A Geriatrician's Insight Into Cancer Care
Lines Between Medical, Geriatric Oncology Blur
Elba Circelli is a sharp, energetic 86-year-old living in Friendswood, a Houston suburb.
Five years after chemotherapy and radiation treatment for breast cancer, she’s a feisty survivor who jokes good-naturedly about cooking for her Italian husband of 40 years.
Her visit to MD Anderson’s Internal Medicine Center in July put her in rare company, because her physician is a geriatrician.
Holly Holmes, M.D., is the only practicing geriatrician at the institution. An assistant professor in the Department of General Internal Medicine, she specializes in the care of elders who are long-term survivors, as well as those in active treatment.
Unique concerns of aging cancer patients
Cancer is a disease of aging, and our society is aging. This presents problems in decisions about the best treatment choices.
Elders 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 healing. Or they may be suffering from cognitive losses, dementia or depression.
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A physician who is board certified in medicine and geriatrics, a geriatrician tries to help older adults remain as functional and independent as possible.
A geriatrician’s area of expertise, Holmes says, is taking care of frail elders.
Geriatric oncologists use well-established tools to assess the patient’s physical and mental state — called “staging the aging” — 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, cognitive function and depression.
Patients are identified as being very healthy, average or frail. Frail patients are most at risk for adverse effects from cancer treatments, Holmes says.
Research explores medication
A pharmacist before she went to medical school, Holmes also conducts research, which makes up 70% of her work and centers on polypharmacy — the interaction of medications — and on overmedication.
She’s also helping to create a tool any physician can use as an aid to estimate the risks to elders of adverse effects from stem cell transplantation.
“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 thoroughly. I take into account not just what’s most effective to treat the cancer, but also how the patient will function afterward.”
Too much or too little
The balance most difficult to strike — and the crux of what oncologists treating the elderly face daily — is between under-treatment and over-treatment.
Relatively few elders participate in clinical trials, though that is changing, and some treatments may be considered too harsh for those with co-morbid health conditions or physical or cognitive deficits.
For frail elders, maintaining function and comfort may be more important than attempting lengthy or harsh treatments, Holmes says.
“If you have mobility issues, balance problems, a history of falls, or cognitive or memory deficits, cancer treatment is not going to improve them.”
Not enough geriatricians
Because there are only 7,000 geriatricians in the United States — three for every 10,000 adults older than 75 — Holmes says that family practice and internal medicine physicians must be aware that an older person diagnosed with cancer might need special attention and screenings before deciding on treatment.
She also considers it essential for geriatricians to educate oncologists on the special needs of elderly patients.
Fortunately, the Accreditation Council of Graduate Medical Education, which accredits post-medical-degree training programs in the United States, recently mandated that oncology fellows receive training in geriatric oncology.
Data: U.S. Census Bureau's2008 national populationprojections
Van Morris, M.D., a hematology and oncology fellow, shadowed Holmes as she saw patients on a recent Friday. Although Morris will focus on research, he understands the importance of the rotation with Holmes.
“As the U.S. population gets older, we’ll see more people in the geriatric population. It’s important for us to understand the co-morbidities that affect treatment,” he says.
Coordinating care with patience, humor
During her visit, Circelli reports that she’s recently had symptoms of a urinary tract infection and some mild back pain. She went to her primary care physician for treatment, she says.
Soon Holmes is on the phone with this physician, finding out which tests he’s run and what he’s found. “This is what I spend a lot of time doing,” she explains to Morris. “Coordinating care.”
Data: Experience Corps' "Fact Sheet on Aging in America," statistics from the Center for Disease Control and Prevention's National Center for Health Statistics Bureau
At the end of the call, she offers to send the primary care physician an email on the visit so he can keep Circelli’s chart up-to-date.
Holmes has a disarming bedside manner that is patient, yet direct. It’s obvious that she relishes her practice and sees her patients as distinct individuals.
And Circelli, whom Holmes calls “snazzy,” clearly adores the Internal Medicine Center — and Holmes. “I love her,” she says. “I feel I can tell her anything … like she’s my niece, maybe. They take good care of me here.”