MD Anderson Cancer Center
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Lisa Garvin: Welcome to Cancer News Line, a podcast series from the University of Texas, MD Anderson Cancer Center. Cancer News Line helps you stay current with the news on cancer research, diagnosis, treatment and prevention providing the latest information on a reduce in your family's cancer risk. I'm your host, Lisa Garvin, today our guest is Doctor Beatrice Edwards she's an Associate Professor of Geriatric Medicine here at MD Anderson and Geriatrics is something that's an emerging field in the oncology field and Dr. Edwards we're going to talk today about what you do and what the scope of your practice is, welcome.
Dr. Beatrice Edwards: Thank you so much, Lisa, it's a pleasure to be here today.
Lisa Garvin: So tell me what is your role in the treatment of a cancer patient?
Dr. Beatrice Edwards: So a few years ago, the NCI and the National Institute on Aging got together to discuss the growing imperative of the rising numbers of seniors; particularly we know that baby boomers are aging. With that we know that there will be more older adults with cancer and so we're facing a double challenge of treating patients with some of the very toxic regiments but patients who have already have a lot of say functional impairment or chronic conditions that may affect their outcome. So the question is how aggressive do we go and treat these patients, how can we improve their outcome, how can we retain their independence in the community, that's a role that geriatricians play very, very significantly in the care of cancer patients.
Lisa Garvin: Now as far as MD Anderson, we're kind of in the forefront of bringing geriatric medicine to a cancer center, is that correct.
Dr. Beatrice Edwards: I would say that there is a great importance given to geriatrics here and anytime we speak with the oncology group or the stem cell transplant group, they seem to completely understand survivorship issues, they tend to understand predicative...we have some scales that we can run on patients, for instance in the senior their functional status predicts more...predicts survival much more than an Karnowski scale for instance. So we can find that they are able to care for themselves, they are able to do their shopping, their transportation, they can do their finances and their medications, they will probably have a very good outcome with chemotherapy given that their initial status is fairly high; however, many times we see patients who were brought to us and we identify that they have some memory loss which we might think is just forgetfulness of aging; however, we need to realize that dementia which is, you know global memory loss and loss of other functions and the brain does rise with aging, for instance at 65 you will see 12 percent of seniors having some dementia by 85 you will see 45 percent of seniors so you have to be careful knowing how they start, where they start, to anticipate what the outcomes are going to be and also to try prevent some of the complications.
Lisa Garvin: Now which sort of conditions are you working with specifically in the older population? Dementia is one you mentioned.
Dr. Beatrice Edwards: Dementia is one; we all deal with balance and gait disorders. Knowing that many seniors even those who do not have cancer develop some degree of neuropathy and develops some aging of the ears, they have to do a lot with balance. So multifactorial balance disorders are very common so we anticipate that, we evaluate their gait and we know that 30 percent of women will fall in a given year and that 10 percent of those will end up in the emergency room; however, their mortality after that fall is 40 times higher than a child.
Lisa Garvin: Wow.
Dr. Beatrice Edwards: So falls are very serious conditions that occur and we have to screen everyone we see for balance and gait disorders knowing full well that there are vitamins if they are deficient in them, we can supplement them and improve their balance. We can send them to physical therapy, we can arrange for glasses and hearing aids which will improve the way they process the environment around them.
Lisa Garvin: Now typically where do you insert yourself in the whole diagnostic and treatment process of the patient, when is a geriatrician called in?
Dr. Beatrice Edwards: Well, in general geriatricians are not called in in emergency cases, they're usually called in...the two big places where geriatricians have been seen very...on a national basis have been in the VA Hospital. The VA Hospital came up with units that were called geriatric evaluation and management units. Where seniors would come in as rehab facility where we would do the comprehensive assessment and have a multi-disciplinary of team of individuals, so it would be the doctor, the nurse practitioner, it would be pharmacist, it would be physical therapist, occupational therapist, speech therapist, and many of these individuals had had a stroke or were having some dementing process or were having malnutrition and it was our job to rehab them as much as possible so they would be able to go back and live independently in the community. So that's an area I think where we able to have a real effect and I think the VA system was able to see that we did save money in the long run.
Lisa Garvin: So say at MD Anderson or a Cancer Center are you consulting with these patients during active treatment or post treatment or just any where along...
Dr. Beatrice Edwards: At any point, right now we have a program called the Impact Clinic which basically does pre-operative assessment, risk assessment of patients going for surgery and what we have spoken with Doctor [inaudible] who is the director there is that he will try to refer seniors to us knowing that we will do a more comprehensive screening for cognitive and functional disorders, malnutrition, gait all that will be screened in addition to the medical conditions. So we have the ability of caring for all the comorbidities, like diabetes, high blood pressure, high cholesterol, in addition to all the geriatric syndromes. So what we present to the oncology at that point is a more, let's say a more comprehensive approach, a better diagnostic tool to predict how well they're going to do through surgery and what they can expect on the other end. Because what we don't want to do is, you know perform aggressive therapy on someone who will be disabled at the end and that's what we're trying to prevent and in some seniors we may opt for more conservative management if their risk is extremely high and then we talk about things like palliative care exams, advanced directives, but we try to work in concert with the family at all times.
Lisa Garvin: Is there a certain age break point where cancer treatment just is not recommended at all?
Dr. Beatrice Edwards: Unfortunately, we do not know that yet, we know in general that seniors have not been included in many of the clinical trials or if the seniors are treated for cancer, they are treated at lower doses and shorter regiments. So we don't know their outcomes as compared to the young people because they're treated in two different fashions. In terms of survival, aging is not so much an age or chronologic age as it's a functional age, so we have some master athletes who are still running at 85 and 90 versus there are people who are 66 and they are already frail because they've been very sedentary or you know they've had an accident and they are disabled for some reason, so we have to see the individual and assess the individual in order to see how well they are going to do to therapy.
Lisa Garvin: Now is the geriatric consult standard of care yet?
Dr. Beatrice Edwards: No, there are not geriatricians in the country for the number of growing seniors. So we know that we unfortunately will not be able to be primary care physicians because of that; our job is to educate physicians around us to disseminate the knowledge of geriatrics, so say an internist will be able to do cognitive assessment or screen individuals for depression and screen for functional status as a regular part of their care because we'll not be able to be everywhere and the numbers are just growing.
Lisa Garvin: And how much did your advice weigh on the treatment that's eventually chosen for that patient?
Dr. Beatrice Edwards: I think with the two of us here now, my self and Doctor Holmes there's more of mass of geriatricians available, it was hard for her and she has made a lot inroads, okay but now that there's two of us we will be able to see a larger number of patients and one of her jobs is prediction of outcome and there are some studies that show, you know functional status is a better predictor of outcome than comorbidities; we already know that. So how active is the patient, how well they're doing in the community is very, very important too we'll be able to know if some complications that will occur in the hospital and try to prevent them. For instance, we know that seniors as they enter the hospital, even if they are cognitively intact, no memory loss at all. Just by having lost their glasses and the hearing aids which they do as soon as they come into the hospital, they will have some sensory problems trying to orient themselves and this increases the risk of deliria or acute confusional state which has been shown to be a significant complication extending the length of stay, increasing complications, those are two elements that oncologists don't want there and neither do the surgeons. So we can prevent this with very simple measures, educating the family and the nursing staff. We'll be able to shorten the stay and discharge them in better condition.
Lisa Garvin: I guess a question I have is why did it take so long for geriatrics as practice to infiltrate the cancer setting, I mean most patients tend to be over the age of 50 when they get cancer?
Dr. Beatrice Edwards: Correct. And I think it would seem that the initial wave of geriatricians very much focused on the frailest of the frail which is the group over 85. And unfortunately that group is heading into nursing homes and retirement homes so the long term care arm of geriatrics grew in that direction so as the demographics have changed, the federal government is seeing what's going to happen and they're trying to anticipate, alert the specialty bodies to, you know kind of stir your members and see if we can create this kind of a panel to work; like right now they're working on systems of care, delivery of care very much in concert with what's going to be the health care reform but we have seen specific groups of patients who are growing. You know there was a study done by the CDC of the CR Data Base and they see...this is the first generation of cancer survivors and they're about 11 million cancer survivors and of those 70 percent are women. And of those the most common cancer survivors are breast, so breast cancer women are like, you know we calculate about 7 million or so. So the numbers are definitely growing and they're living a long time afterwards too. So I think the demographic imperative is very pertinent to this particular group of patients.
Lisa Garvin: What should...maybe not the patients but perhaps their family and caregivers, what do they need to know about a geriatric consult?
Dr. Beatrice Edwards: Well, they need to know that geriatrics does not only apply to the very frail elderly who are heading into a nursing home, on the contrary, what they, if they see a robust senior whose heading into cancer therapy and cancer therapy is very hard on the body, they can think, you know let's assess dad or mom about this and we can prevent a lot of complications that could land them in some type of disability but if we see a specialist at the beginning of a therapy, he or she can guide us through it and tell us what to anticipate in the next step and how to prevent it. For instance, we know that many seniors enter chemotherapy in a state of malnutrition and they tend to eat a lot of sweets and not a lot of proteins. So it's been shown, especially after a hip fracture, that if you feed the patient high protein meals, their length of stay is shorter, their recovery is better, so we would extrapolate to say that if you, you know preemptively are given that individual nutrition as they are heading into chemo and post op too you might expect better outcomes than if you don't. So we tend to liberalize diets saying let's worry about the low cholesterol diet on the other end when you are fully on your feet and totally functional.
Lisa Garvin: So it sound like there's a bottom line aspect here. Have there been studies or surveys that have shown that this kind of care or this kind of intervention actually does save costs down the line?
Dr. Beatrice Edwards: Yes, there have been comprehensive geriatric assessment clinics that hospitals would set up for a time and the argument was do they save money. At first it costs more to set it up but in the long run they do save money to the individuals and society and the individuals tend to have a better quality of life and be more...use more community resources than those individuals who do not see a geriatrician. And the number of medicines they use is also a smaller number preventing drug, drug interaction or side effects.
Lisa Garvin: So, Doctor Edwards, it seems to me just based on my own life experience that geriatrics was kind of bad word, do you find patients reacting negatively to that?
Dr. Beatrice Edwards: It is unfortunate but the term has been stigmatized and often times we're in the office waiting for a patient to come in and we hear them on the outside registering and suddenly the senior says, geriatrics, I'm not that old and they just stomp off and so we've tried to come up with other terms so we'll be happy if, you know callers or listeners want to come up with ideas, but we know that golden years is something we're not going to use and the silver lining, we're not going to use either so we're just trying to come up with a term senior care or senior care and cancer that will in a way open the doors to more individuals making use of our services.
Lisa Garvin: With the last wave of baby boomers approaching retirement, where do you see actually the field of geriatrics oncology going it sounds to me like an emerging discipline?
Dr. Beatrice Edwards: I would definitely agree with you, Lisa it's an area that will definitely have to grow, the need is there, and we know that this group of seniors is a very vocal group who will demand what they need and this is an area that they definitely are going to need more and more. And this is the groups that's going to want to stay functional, this is not a group that, you know I turned 50, I dress in black and I just stay at home, they're out there, they're dancing, they're going to discos, they want to stay young so the best way to do that is education knowing where to go and what to ask for and then preventive practices along the way.
Lisa Garvin: Great, thank you very much an interesting topic.
Dr. Beatrice Edwards: Thank you.
Lisa Garvin: If you have questions about anything you've heard today on Cancer News Line contact ask MD Anderson at 1-877-MDA6789 or online at MD Anderson.org /ask. Thank you for listening to this episode of Cancer News Line, tune in for the next podcast in our series.
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