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Staging the Aging: Geriatricians Help Older Patients Choose Cancer Treatment

Network - Spring 2011

By Mary Brolley

Cancer is far from a one-size-fits-all disease. Each patient reacts to cancer and treatment differently.

This is especially true for patients 65 and older, who may be more affected by certain side effects of surgery, chemotherapy, radiation and other cancer treatments.

One reason is because they are, on average, more likely to be on medications — in fact, a larger combination of them. They may also be dealing with bone loss and its effects on balance, strength and ability to heal. Or they may be suffering from cognitive losses, dementia or depression.

Enter the geriatrician, a physician who is board certified in medicine and in geriatrics.

Holly Holmes, M.D., is one of two geriatricians at MD Anderson. An assistant professor in the Department of General Internal Medicine, she specializes in the care of patients in active treatment.

A geriatrician’s goal, she says, is to help older adults remain as functional and independent as possible.

Holmes’ research focuses on polypharmacy, or the interaction of medications, and overmedication. She’s also developing a tool physicians can use to help estimate the risks to elders of adverse effects from certain cancer treatments.

“We want to know who becomes medically frail as a result of certain treatments,” Holmes says.

“My goal is to let patients know the likely consequences of choosing certain therapies, and do so more thoroughly. I take into account not just what’s most effective to treat the cancer, but how the patient will function afterward.”

Predicting medical frailty

Geriatricians use well-established tools to assess the patient’s physical and mental state, then recommend which therapies would most benefit them.

These include screening tools for assessing:
• gait (walking) speed,
• ability to complete activities of daily living, such as bathing, fixing meals, etc., and
• cognitive function and depression.

Through the screening, patients are identified as being very healthy, average or frail. Frail patients are most at risk for adverse effects from cancer treatments.

Holmes calls it “staging the aging.”

In what she admits is “a sneaky way” of assessing them, Holmes sometimes walks her patients down the hall after a visit.

“I see how they’re walking, and then talk to them, ask them a question or two.

“Walking is a very complicated process, and if they have to stop to answer my questions, I make note of that.”

‘Not every 75-year-old is the same’

A common age-related treatment dilemma involves men with prostate cancer. Those older than 75 are often advised that surgery may be hard to recover from, or that side effects might worsen existing issues, so they often choose radiation.

“And there’s a movement to reduce prostate cancer screening in older men, acknowledging that, after a certain age, men are more likely to die with it than of it,” Holmes says.

“But not every 75-year-old patient is the same. I want to know if he’s healthy, average or frail.”

She recalls a patient who was considering hormone treatments in addition to radiation to treat his prostate cancer. He was the main caregiver for his wife, who was very disabled due to her medical conditions.

During the gait speed test, Holmes saw that the man was somewhat unsteady. He was later determined to have osteoporosis, making him more at risk for breaking a bone if he were to fall, which would endanger his caregiving duties.

When Holmes explained these findings, the patient decided to forego the hormone treatment that could worsen frailty, so that he could take care of his wife.

“He went through radiation treatment, then took care of her for two more years until she passed away,” Holmes adds.

How is he doing now?

She smiles. “The last time I saw him, he said he was dating,” she says.

A demographic imperative

Holmes is quietly passionate about her work.

Noting that there are only 7,000 geriatricians in the United States — that’s just three for every 10,000 adults over 75 — she says that family practice and internal medicine physicians must be aware that an older person might need special attention and screenings before deciding on treatment.  

“It’s hard to plan for survival if you haven’t planned treatment with survivorship in mind. You haven’t done an older person any favors,” she says.

In 2008, Holmes received a grant from the John A. Hartford Foundation, which supports researchers who develop, implement and evaluate model initiatives that integrate geriatrics into surgical and related specialty residency training.

To that end, Holmes is happy that all of MD Anderson’s oncology fellows are now required to shadow her for a month’s rotation. She hopes that it will help them consider the special issues of elderly patients.

“They’re each with me for four clinic days, and they sit in on all kinds of consults,” she says.  

“It’s very interesting to the fellows. And because they’re fresh out of internal medicine residency, I learn so much from them.”

© 2015 The University of Texas MD Anderson Cancer Center