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Sep 27, 2018

Erika E. Ramsdale, MD is a board-certified specialist in geriatric medicine and medical oncology at the University of Rochester Medical Center who measures value in cancer care and links it with patient-reported outcomes for older adults with cancer.

ASCO Daily News

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.

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Welcome to the ASCO Daily News podcast. I'm Lauren Davis, and joining me today is Dr. Erika Ramsdale, a board certified specialist in geriatric medicine and medical oncology at the University of Rochester Medical Center. Dr. Ramsdale, welcome to the podcast.

Thank you so much for having me.

So advancing age is the largest risk factor for cancer overall. One quarter of new cases are diagnosed in people aged 65 to 74 years, yet many oncologists do not have geriatric training. Could you walk me through a geriatric assessment? How long does one take?

Sure, so a geriatric assessment looks at an older adult's functioning from a lot of different perspectives. So for example, physical, emotional, social, nutritional, and cognitive functioning, and it also typically includes an assessment of the health problems that the person might have and medication burden, or what we call polypharmacy. Geriatric assessment uses a set of validated tools that you can combine in various ways, depending on the time you have and the resources you have available.

I would say, ideally it's delivered in a multidisciplinary setting with input not only from the geriatrician but also nurses, social workers, physical, occupational therapists, pharmacists, nutritionists, and other team members. And you can do a geriatric assessment-- sort of a mini geriatric assessment, I should say-- in as little as a few minutes, just do some screening questions and things like that, but a more extensive evaluation could take 30 to 45 minutes or sometimes even longer. So here at the University of Rochester, we have a multi-disciplinary geriatric oncology clinic, where our oncology colleagues can refer patients for geriatric assessments and targeted recommendations, and we actually do a pretty lengthy assessment within that clinic. So we have one of the largest programs here, but these sorts of clinics are showing up at a lot of other centers as well across the country.

That's great.

And geriatric assessment is now-- yeah, it's pretty exciting. Geriatric assessment is now part of the ASCO guidelines for all older cancer patients who are going to receive cancer therapy. So if you look in those guidelines, there's also some guidance about initial screening questions that can help the oncologist determine who needs more extensive evaluation, for example, in a [? geriant ?] clinic, and this can help busy oncologists sort of streamline their daily workflow.

That's great. It sounds very comprehensive. So I'm wondering, how do you measure quality of care and quality of life in this patient populations? And also, what is known about patient reported outcomes in older patients?

Quality of care and quality of life seem like they're pretty tightly intertwined concepts, but I think they're talked about quite differently in the literature. So quality of care, when I read about quality of care in the literature, this deals with following guidelines and using evidence-based care. But what we have to remember is that for older adults, we don't have necessarily as much evidence. The evidence available is usually obtained from younger adults, and it may not be generalizable or applicable to older adults. But quality of care measures are really trying to standardize a process for selecting the next right step, and so this is more of an algorithmic way of thinking in a lot of cases.

Quality of life, on the other hand, is obviously very subjective, and it does not mean a standardized thing. You can't apply an algorithm to tell you what's important to someone or how you should modify their treatment based on that. So I think it's a very different type of thinking. I think you have to create a story about what is important to patients and how your recommendations will fit with what they prioritize.

So this is kind of more narrative thinking. It's very hard to do, I think. It takes experience, it takes talking to the patient, and it takes doing a broad assessment like the geriatric assessment. So the patient reported outcome sort of fit into and are part of that story, looking at how are they feeling and how are they functioning at home.

Good point. How do you communicate prognosis and treatment plans to caregivers and adult children?

Again, this is a learning process, but personally my experience has been that patients and caregivers also prefer direct and straightforward communication about prognosis. I think it's always important to ask what they want to know because some patients and caregivers will want to know more details, and more numbers, more statistics, and some will want less of that. But when you're communicating about treatment options, I also think you have to strike a balance between just giving patients a recommendation, telling them what you think they should do on one hand, and then on the other hand is an information dump where you just give them all the options and tell them to make a choice.

So I see my role as the experienced advisor. I give them the information on all the treatment options, but I also interpret them in light of the patient's story, and I recommend things based on their lives, their preferences, and also what we get from the geriatric assessment that may tell me what they're likely to handle treatment-wise.

So let's talk about cost of care. By the year 2020, the annual cost to treat cancer in the United States is projected to rise to 173 billion. This means that older adults with cancer will face increasingly high costs for needed medical care. In the wake of ever increasing costs, how do you communicate to patients the value of treatment when they face a financial burden?

I think this is a really tough one because I think most physicians, and myself included in that, are still pretty unaware of the cost differentials between different treatment options. And I think whether or not cost consideration should even come into play with how we recommend therapies is a tricky ethical question, and it's open to debate. So I feel on safer ground talking about value which is a broader concept that fits into what we were sort of talking about before, which is quality of life and what someone wants for herself.

So value is more about outcomes and what we get out of whatever decisions we make, and the outcomes that we've traditionally been most focused on are things like how long someone lives and survival outcomes. I think, for older adults, we know this is often not their priority. They may prioritize, instead of living a long time-- they prioritize remaining independent in their own home, for example, or preserving dignity, or avoiding severe side effects from treatment. And what we also know is that talking about what people want for themselves throughout their treatment course, and starting these conversations really early, leads organically to decisions that tend to both improve the outcomes that people care most about and also to save money. So to give you an example, most people don't want to be hospitalized at the end of their lives or go through really heroic measures that may not help them achieve their goals, but this is often what happens when there's not a lot of upfront discussion and advanced planning.

Yes.

So I think we do need to know more about how we make decisions, effects, costs, and also value. And one of my main research interests is informatics implementation and these decision support tools for older adults with cancer, so I've taken the geriatric assessment and built it into our electronic medical records so it's integrated. And we can start streamlining data capture, and then looking at geriatric assessment, how it changes over time, and linking it with outcomes in unique ways within this, you know, EMR within the database. I think we need to go beyond just survival metrics, and look at other measures of value, and what patients say is worthwhile to them.

In addition to cost, we are anticipating a silver tsunami of older people with cancer. Are there enough oncologists to treat patients, or is there still a shortage?

I think, you know, all the numbers I've seen have indicated that there's a severe shortage not only of geriatricians and things like that but oncologists also. So as I mentioned before, ASCO guidelines are now recommending geriatric assessment for all adults older than 65 who are going to receive some sort of cancer therapy because we know that the standard oncologic assessment can miss things that are a part of the older adults' story. But I think there are some problems actually delivering on this because oncologists are in shortage. They're already overburdened, and very many of them likely don't have the time, and space, resources to do at least a full geriatric assessment on every patient who needs one.

And I think there's also the question, once you have this data, what do you do with it? You need some expertise to fit this information into the treatment and recommendations, and I think this is true even if you're an oncologist very used to seeing and treating older adults. So this is one of the main reasons I'm looking at EMR-integrated decision support to help when an oncologist may not have geriatrician available.

And so I think also you need not only physician resources but other medical team resources. So if something comes up, an issue is found by the geriatric assessment, you may need other resources. We can't think just in terms of cancer treatment like chemo. We may need physical therapy. We may need social work. We may need cognitive rehabilitation, pharmacist counseling, and I think there's really a shortage of those resources as well.

So let's talk about clinical trials for a moment. Age is a factor for clinical trial participation. Do you think we've moved the needle on this in recent years?

I hope so. I think awareness is growing that we need to enroll more older patients and get more data, but I think older adults are still very under-represented in clinical trials. So I think the awareness is causing people to question putting in an age cut-off into clinical trial eligibility, but I think frailty is still a big issue because those who do get enrolled, if they're older, are the fittest of the fit. And so a lot of us are advocating for more clinical trials for the more frail patients, and I don't think the needle has moved as much on this.

I'd say it's a really complex problem. Our gold standard is a randomized clinical trial, but this is really a problem on several levels in an older, frailer population. It's really hard to randomize patients when they're-- you know, older adults are so different in so many different ways, and this makes it really hard to interpret the statistical data. There's a lot of confounding aspects to looking at data that you get.

So my personal opinion is we may have to really look at more novel trial designs, look at new statistical methods, and sort of incorporate big data sets, things like that to look at the data in new ways. But bottom line, we need to keep drumming up awareness that there are still so many knowledge gaps when it comes to how to treat and how to follow an older adult with cancer. And the last point I'd say, there are some phenomenal patient advocates that I've worked with who are also critical to moving the needle on this.

That's great.

And as an expert in this field, what are some key takeaways that you would suggest for oncologists who are treating older patients with cancer?

Yeah, so I actually had the opportunity to talk to a number of oncologists across the country. I did some interviews with them. So I asked them about their approach to assessing older adults, what they think about the geriatric assessment, what resources they might need, some questions like that.

And what surprised me the most, I think, is that a lot of them were still not convinced that geriatric assessment was necessary or would add anything for their care of older adults. So I think there's still a pretty prevalent belief that-- you know, and indeed these oncologists see a lot of older cancer patients. They're the biggest population that we see, and I think there's a sense that I know frailty when I see it, and that this so-called eyeball test is all that is needed. And so I would personally like to increase awareness that the geriatric assessment is important and really is worth the time to do. It will uncover things that are really otherwise invisible during the standard assessment, and certainly to the eyeball test.

So I think the other takeaway based on what we've talked about is to start talking to your patients about preferences and quality of life at the first visit and keep on talking about it. Something that one of my mentors said that has really stuck with me is that people don't want to know how long they have to live. They want to know what exactly is going to happen to them.

And I've found this to be particularly true for my older patients. I would say on average they care more about symptoms, independence, dignity, all the things that go into quality of life, and they care more about than they do their life expectancy. So it's the story, and it really guides how I treat them and interact with them.

So just to close with an example, I had a patient recently whose main goal was to stay in her home, and it was to take care of her elderly dog at the end of his life. And we talked through it, and we actually decided not to do a more aggressive treatment regimen because I thought, and we discussed, that it would probably hasten her move to an assisted living facility, and she would have to give up her dog. So we did a potentially less effective regimen against her cancer, but one that was much, much less toxic and would allow her to live out her goal, and she was she was happy with that choice.

Again, my guest has been Dr. Erika Ramsdale from the University of Rochester Medical Center. Thank you so much, Dr. Ramsdale for your time today.

Well, thank you for the opportunity to talk to your listeners.

And to our listeners, thank you for tuning in to the ASCO Daily News podcast. If you're enjoying the content, we encourage you to rate us and review us on Apple podcast.

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