Geriatric Oncology has arrived. Yes, Louise Walter has been leading the fight to improve cancer screening in older adults for years. But when it came to geriatricizing the way we assess and treat older adults with cancer, the evidence was thin. In our prior podcast with Supriya Mohile and William Dale on geriatric assessment in oncology, we couldn’t say for certain if a geriatric assessment was helpful for patients with cancer. Well now we can.
We are joined by Melisa Wong, a geriatric oncologist, and Louise Walter, a geriatrician and leader in cancer screening for older adults, to talk about the shifting landscape of geriatric oncology, including:
- How to think about cancer screening in older adults, moving beyond a one-size-fits all age-based approach to individualize cancer screening decisions. We also talk about the importance of thought pieces in driving a field forward.
- 2 landmark trials of the geriatric assessment in oncology, one in JAMA Oncology (first author Daneng Li) and the other in the Lancet (first author Supriya Mohile) (William Dale senior author for both studies). In both studies, grade 3+ toxicity was reduced in the geriatric assessment arm.
- Melisa Wong’s study in JAGS finding a constriction of life space for older adults with cancer, and discussion of patient centered outcomes beyond traditional outcomes such as grade 3+ chemotherapy toxicity.
Links of Interest:
And as a bonus, you get to hear Louise on piano and vocals and I cover Wouldn’t It be Loverly, from My Fair Lady.
Eric: Welcome to the GeriPal Podcast. This is Eric Eric Widera.
Alex: This is Alex Smith.
Eric: And, Alex, who do we have with us today?
Alex: Today, we’re delighted to welcome Melisa Wong, who is Assistant Professor in the Divisions of Hematology/Oncology and Geriatrics at UCSF, and also directs the UCSF Older Adult Cancer Care Program. Welcome to the GeriPal Podcast, Melisa.
Melisa: Thank you so much. Wonderful to be here.
Alex: We’re also delighted to welcome Louise Walter, who is Professor and Chief of the Division of Geriatrics at UCSF and the San Francisco VA. Welcome to the GeriPal Podcast, Louise.
Louise: Thank you so much.
Eric: We’re going to be talking about geriatric oncology. And I just want to say, for the palliative care folks out there, too, this is going to be a lot about palliative care oncology, too, but how to care for older adults who are receiving cancer treatment. We’re also going to be talking a little bit about Louise’s stuff about even before they get diagnosed with cancer, some of the preventative oncological interventions, I’ll say. But before we get into all of that, do you have a song, Louise Walter?
Louise: We do. We picked Wouldn’t It Be Loverly, from the My Fair Lady soundtrack.
Eric: The Cockney version or the …
Louise: Well, it was the one I heard on stage just a week ago, and when Alex reached out to me, thinking, “Well, what’s a life-space song?” I thought, “Well, she talks about one enormous chair and not moving until spring,” so I was like, “That could actually work to talk about life-space.”
Alex: So, we were fortunate that we had Louise, who is a pianist play this on piano and sang it with me. We recorded it a couple days ago, and I’m going to share it with everybody right now. Here we go. (singing).
Alex and Louise: (singing).
Alex: There we go. That was fun. Thank you, Louise.
Eric: Melisa, I’m going to start off with you. What got you interested in geriatric oncology?
Melisa: That’s a great question because there are not that many of us. So, my experience really started during my medicine rotations at the San Francisco VA with a lot of you. So, Louise was one of my attendings, Mike Simon was one of my attendings, and I really learned to enjoy that space of medical oncology that was more difficult, at least from my perspective, where I really didn’t know how to best take care of an older patient. I didn’t know if they would tolerate guideline-recommended treatment. I didn’t know if they wanted guideline-recommended treatment. And so I really found that space, the art of medicine, to be more interesting in that area, and I really found that we needed extra skills, geriatric and palliative care skills to really best take care of that population. Once I started getting interested clinically, I met the geriatric oncology research community, and I love these folks, these are my people, and that’s really what’s made me become a geriatric oncology researcher.
Louise: It’s interesting, I got involved with geriatric oncology because I do a lot on cancer screening, and I was invited to always be the lead-off speaker in some of the geriatric oncology conferences, and I learned a lot about geriatric oncology because I would talk about my screening, and then I’d sit through and listen to the rest of their seminars.
Eric: Louise, you’ve done a lot of work even before someone gets diagnosed with cancer. I think it started off with breast cancer, right? Mammogram screenings in older adults. I’ve heard this story before, but I wonder if you can share with our audience, how did you get interested in this as a topic about screening mammographies in older adults and preventative interventions in older adults?
Louise: Well, there was a couple times. One was when I was a resident and I had to come up with a project, and I remember my mentor saying, “Well, what happened to you in clinic today that bugged you that you couldn’t figure out or that bothered you?” And I was like, “I couldn’t decide about whether recommending,” in this case, it was a colon cancer screening or mammography screening, “for a couple of my patients. And I was being told to do it, but one patient was really ill and had so many other things we should be focusing on. Another person was really healthy, and I was being told I couldn’t do it.” And I was like, “This really bugged me,” I really wanted to learn more. So, that actually launched me during fellowship to really take that on.
Louise: And then during fellowship, I should probably say, I worked at the On Lok, one of these great programs for all-inclusive care of the elderly here in San Francisco, and at the time, they were being told by California state auditors that one of the quality metrics was rates of mammography, and it didn’t matter that 50% of the folks had severe dementia and things like that, they still say, “You have to get this mammogram done or you’re not a good-performing program.” And so I remember taking that on with Dr. Cathy Eng, the medical director, to really understand what happens when you screen very frail folks who have dementia, screen them for cancer, how often does that lead to bad things?
Eric: And how often did it lead to bad things?
Louise: Often. Very often. It was surprising, I hadn’t really thought about the fact that screening, the test itself, one is you have to be able to hold still in a mammogram machine to get a good picture, so if you have dementia and don’t realize you have to hold still, you get bad quality. But, second, they would bind all these clinically-insignificant findings that would never have caused this person a problem, but because we screened them, found this abnormality, it just led to all these extra biopsies and treatments. And because they’re more frail and sick, they had more complications. Anyway, it was really an eye-opening thing to see some of the harms that can happen if you don’t individualize the screening decision.
Alex: Is that when you wrote your landmark thought piece, Individualizing Cancer Screening Decisions in the Elderly in JAMA?
Louise: It was, and that was because it really bugged me that there was this age-cutoff idea, where if you’re 75 and younger, do it no matter what, or if you’re older than 75, forget it, you shouldn’t get screened. Or, at the time, they had all kinds of different age cutoffs, depending what organization you listen to. And, again, I was thinking, one of the mantras of geriatrics is the heterogeneity of the older population. I think that really gets to why geriatric assessment is so important, because you want to detect this heterogeneity and figure out how do you maximize benefits and risks for each individual.
Louise: And that’s certainly true for cancer screening, life expectancy has a big component of whether someone’s going to benefit from a test that you’re doing when someone has no symptoms and no problems, that you’re trying to find something that, years down the road, is going to grow and cause symptoms. It’s important to think about, life expectancy. And, obviously, very important to think about the person’s preferences in terms of risks and benefits and how they weigh those risks and benefits. And that was not being taken into account, it was just being looked at by age. It was kind of viewed like a flu shot. Cancer screening is not like a flu shot.
Alex: And I’ve heard you say things like you’ve cared for patients who are elderly and older and who wouldn’t meet guideline recommendations for screening, but they’re incredibly healthy. They’re, what do you say, running up and down Mount Tam?
Louise: Right, actually hiking to Mount Tam. And I had to go through Herculean efforts to be able to get an 80-year-old woman who was super healthy very active, again, hiking to Mount Tam, trying to get her a mammogram was a challenge at that time because she’s older than the age cutoffs. And, similarly, it was hard to stop the train for someone who was 72, but bed-bound with severe dementia, got to get their mammogram screening.
Eric: So, both over-treatment and under-treatment in older adults.
Alex: And didn’t you go on a similar journey with colorectal cancer screening as well, maybe at the VA?
Louise: Yeah, colon cancer screening, prostate cancer screening, cervical cancer screening, we looked at all that. And it’s always similar, that age tends to be what people focus on more than comorbidities, life expectancy, patient preferences, and really trying to shift that to be more individualized.
Alex: And for our listeners out there, JAMA doesn’t publish full-length articles that are thought pieces anymore, but I know that you were kind of a pioneer and a leader and teacher in how to write thought pieces. Anything for our listeners out there who might be aspiring junior investigators who are interested in putting their stamp on the field like you did and coming up with a new conceptual framework advance? Not necessarily empirical study, but a new way of thinking about things that’s really changed. I read your paper when I was in residency at the Brigham, and it just transformed the way I thought about cancer screening. I was terrible about it before that. I did … I won’t even say, let me just say. It was hugely influential, and it was a thought piece. Anything for our listeners about thought pieces?
Louise: Thought pieces, we should do more in medicine, and we should encourage our junior faculty or our trainees, they’re bringing new eyes, and they ask, “Why are we doing it that way? Why couldn’t we do it a different way?” Talk about that. And thought pieces aren’t simply editorials where you just … Literally, it’s I looked at the literature, grounded it in facts, looked at data that was already out there to really make the case. It’s more like a thesis in a way, where you’re bringing in evidence to build your case for why something could be better if we looked at it a different way.
Alex: And you, importantly, link to life tables so that you could categorize the population into best top quartile, bottom quartile, middle quartiles of life expectancy.
Louise: Yeah. I remember talking to the National Health Center for Health Statistics because, at the time, and actually even to this day, they only give the median. And I was like, “Well, that just means you’re lumping everybody into the median.” So, I worked actually with them on the phone to figure out how I could, from the data that was already out there, develop what are the top 25th percentile life expectancy, what’s the bottom 25th percentile life expectancy, to really show the range, that there’s, again, this huge heterogeneity in how long people live, even if they’re at the same age.
Alex: Right. Isn’t there a clinical pearl that you do when you’re teaching residents in the wards, where you ask them, “We have this patient who’s X age …” Could you relate that for our listeners, how long do you think-
Louise: Well, I actually ask people, “What is the average life expectancy of an 80-year-old woman?” or the person sitting in front of us, and it’s always really eye-opening to hear. Usually, people underestimate how long older people live because they think, “Well, if you’re born today, average life expectancy is 82, it’s two years.” It’s like, “Oh, no, if you make it to 80, you actually have a 50/50 chance of making it to 90.” So, really, the longer you live, the longer you live. I think it’s just important because, again, if you underestimate how long people live, you maybe offer them less than what they should be getting.
Eric: And the time-to-benefit to see, let’s say from a mammogram, what is it, about nine to 10 years?
Louise: Exactly. Most cancer screening, it’s around 10 years. This lag time from when you get the test to, on average, when you see a reduction in mortality, about one in a thousand, [crosstalk 00:13:07].
Eric: For that 80-year-old, if they’re hiking around Mount Tam, don’t have a lot of comorbidities, maybe something to consider.
Louise: Absolutely. Definitely.
Eric: Melisa, when you’re thinking about this as an oncologist, you also see it from a select group, people who now have cancer.
Melisa: Most often. Although, we do sometimes see patients who have … I’m a thoracic oncologist, so we see patients who have pulmonary nodules on CT scans that pulmonary has been following over time. And, sometimes, they let us know before they discuss intervention or they discuss biopsy, whether or not the patient might even be a candidate for cancer treatment if it does turn out to be cancer, because if they really are too frail for treatment, then we have a discussion with the patient, would it be helpful to know this information for your planning to know how to prioritize other things in your life. And if they don’t want to know and they wouldn’t be eligible for treatment because they’re too frail, then sometimes we don’t biopsy these folks and we just continue to watch or we stop monitoring.
Eric: When you think about this as an oncologist, how important is that pre-treatment, I guess even pre-screening, assessment? I guess we’re now talking about the geriatric assessment. What do we know about it and how important is it to do?
Melisa: So, in oncology, a geriatric assessment is an assessment of a patient, typically an older patient, although I think it is relevant for younger, frailer patients as well, that covers a series of domains about the patient beyond their cancer characteristics. So, we often will evaluate function, cognition, their nutritional status, their mental health or mood, their medications, to look for polypharmacy. And you can evaluate these things in many different ways. If you have the luxury of having a geriatrician that you collaborate very closely with, like I do here at UCSF, then the geriatrician can do that assessment, but most oncologists will not have that access or have that availability so quickly.
Melisa: So, the geriatric oncology community has developed surveys that are patient-facing, so really trying to have the patients answer questions that give us information about these domains. And it’s often paired with either a cognitive screen, like a Mini-Cog, or a physical performance test in person, like a Timed Up & Go test, where the patient stands up, walks, turns around and sits back down. And that really helps us understand so much more about the patient before we even get to talking about cancer treatment. And I find it really critical and invaluable. I can’t practice without it.
Eric: One question for you is the majority of cancer occurs in adults over the age of 65. The vast majority of deaths occur in older adults. Is geriatric oncology a big part of oncology training?
Melisa: It is not at most places, although it is improving across the nation. We typically give one lecture to the oncology fellows, and I’d love for that to be more. We are having oncology fellows rotate with us, so I have a fellow right now who’s rotating with me, and she learns a lot about geriatric assessment. In my clinic, she may not learn a lot about third or fourth-line lung cancer treatment, but she learns how to assess patients, how to have goals of care conversations, how to really have more nuanced treatment discussions where we really don’t know if the treatment might benefit the patient, and so their current functional status is really important, having them really understand the goals of the treatment is really important as well. Because a lot of patients and caregivers and families might assume that cancer treatment will cure their cancer and, unfortunately, in a lot of cases, it will not.
Louise: And I think Melisa really led the charge here at UCSF, where we actually have a lot of our oncology fellows do what’s called a T32 Aging Researcher Fellowship. We’ve had a number of people, five or six folks. So, really trying to meld geriatrics and oncology together.
Eric: Melisa, when we think about doing a geriatric assessment, is it anybody older than 65? Who needs it?
Melisa: So, the American Society of Clinical Oncology guideline is for patients who are 65 and older, particularly if they’re considering chemotherapy. That’s just where the data is the strongest. But I do think it could be relevant for older adults with cancer for any treatment type or any disease type. But some of the guidelines are based more on what the available evidence says. I think an age cutoff is really more to operationalize a program. So, for UCSF Screening Program, we start at age 70, and that’s simply because we don’t have the capacity to screen everyone, but I think everyone could benefit. Even a 50-year-old who has multi-morbidity, has a lot of functional impairment, is on dialysis, that patient would benefit from a geriatric assessment as well.
Louise: Yeah, I really look at geriatric assessments as really drilling down on the characteristics of the patient, which is the geriatric lens, and then I know we are really much better at drilling down on the characteristics of the cancer. And so, now, if we really bring in both of those, I think we will … again, we’re trying to maximize benefits and reduce risk.
Alex: And I’ve heard you say this is like the precision medicine of geriatric oncology. There’s the precision medicine, as you were saying, of targeting the molecules and the DNA or whatever of the cancer itself, the molecular footprint, but we also need to understand … The precision in geriatrics is understanding what can the patient do, how is their function, how is their cognition, what’s going on in their social lives, do they have geriatric syndromes? Thoughts about that?
Louise: Exactly. And how do we optimize? Because, again, that’s the idea, you identify these things, and then you figure out what can we change, what can we modify, whether that’s modifying the environment or something about the person and making sure their other diseases are better controlled, or is it changing how we do the treatment? So, that’s the precision part of it. Melisa, I’ll turn it over to you.
Melisa: Yeah, I completely agree. It’s useful for both helping patients get through treatment, to help support them with their toxicities, to help make sure they’re really optimized as best as they can. I took care of an older woman who had metastatic lung cancer, and she was so short of breath at first, she was on six liters of home O2 because she also had underlying ILD. And in caring with her very closely with Dr. Natalie Young, who’s a geriatrician and palliative medicine physician, we were able to get her through chemotherapy treatment, and she did pretty well, much better than either of us expected at the beginning.
Melisa: And that was really in part through a close partnership, where Natalie could aggressively manage her symptoms, could help get her DME at home to really help her be more functional at home. And she says that she feels so much better than when she did initially at her lung cancer diagnosis. And geriatric assessment also helps with decision-making, as Louise said. There was a French study of patients who were 70 and older who showed that geriatric assessment results changed the oncologist’s treatment plan about half the time. And in half of that, it increased the treatment, and then in half of it, it decreased it. So, it has the ability to both help reduce over-treatment and reduce under-treatment for the patients.
Eric: Are there not just process-related outcomes, but patient-centered outcomes? Do we know if geriatric assessment not only changes what oncologists do, but actually does it help with mortality, side effects, anything that patients actually may care about?
Melisa: Yeah, that’s a great question. A couple of years ago, we would have said those studies are ongoing, but, in the last couple of months, there have been two landmark papers published. The first one was out of City of Hope and JAMA Oncology, led by Dan Lee, William Dale, and this was [inaudible 00:21:17] study. And they looked at a geriatric-driven intervention that was multidisciplinary, primarily with their research NP guiding the results of the geriatric assessment to lead to interventions and referrals.
Eric: And who did the geriatric assessment?
Melisa: I believe the patients answered the questions, but this multidisciplinary team reviewed the results and then took action on that, and they shared the results with the oncologist, but the oncologist wasn’t responsible for all of the nitty-gritty, determining what should be done next.
Eric: What did it do? What was the outcome?
Melisa: Their primary outcome was severe toxicity from chemotherapy, and the intervention arm had a lower rate of toxicity, so these patients were actually able to receive cancer treatment and do better because they had lower severe side effects. The second paper was in The Lancet recently, and that was led by Dr. Mohile out of University of Rochester, also with William Dale. And this intervention was very similar, although it didn’t require multidisciplinary team, and it was done in community oncology clinics throughout the nation. This is the GAP70 study.
Melisa: And they also found that it reduced grade 3 or higher severe toxicities from chemotherapy or other similar treatments, and it had a number needed to treat of just five. So, if you did a geriatric assessment and provided those results with recommended interventions to the oncologist, you were actually able to reduce one severe toxicity. And that’s pretty tremendous for our field. They also saw fewer falls in that population, more discontinuation of medications, and there was no compromise of overall survival, both arms had the same survival overall. But the patients in the intervention arm with the geriatric assessment with intervention did better during their treatment.
Louise: If this was a drug, everybody would do it. What’s the resistance or what do you think the barriers are to doing more geriatric assessment in the oncology sphere?
Eric: You got to call a geriatric assessment a “mab”.
Alex: And there it is, the aducanumab reference for today.
Melisa: I think for folks in the geriatric oncology field who really drink this Kool-Aid already, it’s hard for me to understand why an oncologist wouldn’t want this. What I’ve heard from folks who have been a little hesitant about us at least at UCSF rolling out the program to their patients is, “Well, my patients are very busy already, they’re quite overwhelmed. Do they want to do another assessment? Will this be of actual benefit to my patients?” Some people also think they already do a geriatric assessment with their eyeball test. And study after study have shown that among patients who have a good performance status as judged by the oncologist, there are still many, many uncovered geriatric impairments among those patients when you do a formal geriatric assessment.
Melisa: I think, also, culturally, it’ll just take a little bit of time for people to see the results in their own patients. I think that is really how we’re going to convince people. I don’t think more and more data will necessarily convince people, I think it’s the stories of how this really helps. And I joke with Natalie Young that I would never leave practice where she’s not going to come with me because I can’t practice where I don’t have that support anymore because I’ve just seen how much it can help my patients.
Alex: We’re talking about older adults with cancer, often advanced cancer, and so you’re talking about the need to work as a geriatric oncologist with a palliative care geriatrician specialist, so co-management. And the other piece that we haven’t brought in as much here is the role of palliative care and palliative oncology, and partnering with them in geriatrics. Any thoughts about that landscape and need?
Melisa: Yeah, I think it’s a really interesting area to have a coordinated, essentially, GeriPal/Onc program is what I’ve been trying to do here at UCSF for our older lung cancer patients. And I think it is so valuable, even more so than just having a Geri/Onc program because a lot of the medications that palliative medicine physicians use to manage side effects or symptoms from the cancer can have side effects in older adults that may be more severe, delirium from high-dose steroids or from opiates or other medicines. And so it’s been really helpful to have the geriatrician lens combined with the palliative medicine lens for my patients.
Melisa: It’s also been really nice because the patient can go to one additional center or clinic and not necessarily have to be followed longitudinally by a geriatrician and a palliative medicine physician, so it’s been helpful to reduce treatment burden for the patients as well. Most places are not going to have a GeriPal/Onc program, and I don’t think we necessarily, and I don’t think we necessarily need that, but it sure is nice to have that available to the patients here.
Eric: Yeah, I feel like reading The Lancet study, the palliative care side of me thinks, “Man, we should actually be incorporating geriatric assessment more into outpatient palliative care clinics, making sure that we’re not just assessing symptoms, but we’re assessing function, polypharmacy, comorbidity, cognition.” I think most palliative care clinics are assessing psychosocial issues, maybe nutrition. I think I hit all the big domains. And that Lancet study, for me, was a wake-up of saying, “Hey, we should be doing this in palliative care as well.”
Louise: As a division chief, it’s also brought me a new model of thinking about how we bring geriatrics or geriatricize everything is instead of having a clinic of our own off to the side, which is very important and we do in primary care, but to really embed geriatricians in palliative medicine, in oncology. We’re in the bone marrow transplant clinic, we’re in pulmonary. And I think that’s a way to bring geriatric expertise and combine, have geriatric/oncology, geriatric/pulmonary, where the patient doesn’t have to go to multiple places and they get that dual interaction, and you also probably get the education of the whole clinic. I don’t know, Melisa, if you think, is Natalie being there a way to geriatricize even beyond you, other people in the clinic?
Melisa: Yes, definitely. And I think it goes both ways, where if someone is embedded in an oncology clinic, they understand our treatments much better, they understand what that experience might be, and then they can then better advise patients or help manage those symptoms as they come out. I think what’s really nice about The Lancet paper with the community oncology research sites was that they didn’t have these embedded geriatricians or palliative medicine physicians. It really was a geriatric assessment that the patient did, and it followed an algorithm to then spit out very detailed tailored interventions and recommendations to the oncologist. And even just that intervention, without a whole bunch of bells and whistles of a multidisciplinary team, that was able to reduce toxicity in the older adults in the study. And I think that that’s really valuable because most of cancer care in the U.S. is done in community oncology clinics, not in big cancer centers like ours.
Louise: That’s one of the things I’ve heard is a barrier is like, “Oh my gosh, am I going to identify cognitive impairment, and now what do I do? Where’s my support to help?” So, I don’t know if there was any comment about that, but I hear that sometimes as well, “If I do this, and I don’t have the geriatric support, what do I do?”
Melisa: And I think that that can be a real concern, especially in more rural areas where the community may not even have a geriatrician. And I think each oncology clinic has to really do a landscape assessment and see what it is available, so maybe it’s not a geriatrician, but it’s another type of primary care physician who has more expertise because they’ve essentially built up a panel of patients with more cognitive impairment or dementia. So, I think it’ll look a little different for each clinic, but it doesn’t necessarily have to be this Rolls-Royce model of geriatric/pal care to get started.
Eric: Yeah. In The Lancet study, when you look at what they did for cognition, three-quarters was, in addition to just telling people about appointments and medications and treatments, they wrote it down. There was a medication review in two-thirds of the patients. You think about decision-making capacity, like does this person need somebody else there? In other domains, the majority was reducing the dose, and that, I think, for people with cognitive issues, half of them had some modification of their treatment regimens.
Alex: Reducing the dose, you mean reducing chemotherapy dose?
Eric: Yeah. So, some type of modification of their treatment.
Alex: I think it’d be important for our listeners just to hear … I admit, the major outcome here was grade 4 toxicity, is that right?
Melisa: Three or higher, which is serious, requiring some sort of intervention.
Alex: Even though I’ve been doing this for a while and I’ve been taught what this is, I can’t remember. Could you explain for our listeners what that is, and I know you’ve done a lot of work in thinking about is this the most important outcome in older adults, or are there other important outcomes we should attend to?
Melisa: Yes, that’s a great point. So, grade 3 or higher toxicities are graded in oncology by a very specific scale, and that’s really what a lot of clinical trials will report. Sometimes, clinical trials don’t even collect milder symptoms because it’s hard to do that systematically in big studies. But a lot of my research has really focused on how do we expand this definition of toxicity in oncology to include other things that is not typically included? So, functional status is not typically included, whether or not the patient can perform their ADLs or their IADLs. Their impact of treatment on cognition is not usually measured at all for most studies.
Melisa: And so a lot of my work has really been thinking about how do we broaden this definition to include other outcomes that are really important to older adults? And one of those measures is called “life-space mobility,” and life-space is a measure of where a patient goes in their environment, so it includes a lot of different things. If a patient has a functional impairment, that might decrease their life-space, but also if they have visual impairment and can’t drive, it includes whether or not their social network has the ability to help them get out and about in their environment.
Melisa: And so I was really interested in life-space after hearing it presented at a UCSF geriatric grand rounds back in 2017 during my fellowship, when Cynthia Brown, at that time, of UAB, where it was developed, came to talk about it. And I thought, “Wow, this is a really interesting measure of how patients are doing really in the community,” that, a lot of times, when patients come to clinic, if they’re able to walk around the exam room, I have no sense of how they’re able to get around their community. And so I really liked that aspect of this measure and included it in one of my lung cancer studies.
Alex: Published in JAGS, and we’ll have a link to that in the show notes associated with this podcast. Could you give a sense of what you found in that JAGS study as far as the impact of cancer-directed treatments on life-space for older adults?
Melisa: Yeah. So, this was a prospective cohort study of older adults with lung cancer, 65 and older, who were starting a new systemic cancer treatment that included chemotherapy, immunotherapy, and/or targeted therapy. We were interested to understand what their life-space mobility was at baseline before they started the treatment, and then really how it changed during treatment. And we found that, at baseline, the average life-space in our population was 67, and life space is a scale that goes from 0 to 120, 120 being the best mobility. 60 is considered a cutoff for restricted, so if you’re less than 60, you really don’t get around your community very much. And so our patients were barely above that cutoff at the start.
Melisa: Then they declined about 10 points, on average, at the one-month mark, and then really didn’t recover, for the most part, at six months. It was pretty stable from one month to six months. And a change of 10 is significant. We think of a change of five as being clinically-significant, so that means this patient was no longer able to either go around their town independently or didn’t do it as frequently. And so those were really important things to understand about our patients because those aren’t aspects of their lives that we see in clinic.
Alex: And this was a mixed-method study, right? Sometimes, the quotes really illustrate in the way that the numbers don’t. Any key hard-hitting quotes for our listeners, given that we are a podcast?
Melisa: Yes. In our paper in JAGS, we have a figure, called a “joint display,” where we put the patient’s quantitative life-space score on a graph, along with quotes from them that describe how they were doing at the time. So, for example, this is a 68-year-old man receiving chemoimmunotherapy. And before he started treatment, his life-space score was 70, which is a little bit above the restricted cutoff, and he said, “I just do household chores, I lay around the couch and watch television.” So, does a little bit, but not too much.
Melisa: But then, at the one-month mark, his life-space score dropped to 30, which is quite limited, and he said, “After the last treatment, I had these muscles that were really weak. I live in a townhouse, and one flight up the stairs to my bedroom was like walking five miles. I was exhausted.” And, luckily for him, his life-space did improve by the end of the six months, and his score increased back up to 70, and he said, “Occasionally, I take a nap in the afternoon, but not every day.” And so you really saw how his experience of treatment changed during that and it matched really well with what his life-space score was doing.
Alex: Right. And if you could contrast that, could you give some concrete examples of what grade 3 or 4 toxicity is, the standard outcome that you pointed out from clinical trials, including the two trials of geriatric/oncology that we discussed earlier?
Melisa: Yeah. So, grade 3, for lab abnormalities, like hyponatremia or pancytopenia, will have a specific cutoff where you have to essentially do something at a grade 3, you can’t just continue treatment, you have to either stop a dose, dose-reduce it, or actually intervene. A grade 4 is when a patient typically has to be hospitalized for that complication, so that gives you a sense of how severe it is. And a grade 5 is actually dying from the treatment. And so these are impairments interview patient’s daily lives that will affect their quality of life that may not necessarily translate to a grade 3 or higher toxicity, but it really impacts him as he wasn’t able to even go up the stairs to his bedroom on the second floor.
Alex: So, Louise, does Melisa need a thought piece that challenges the dominate paradigm of what toxicity is for older adults?
Melisa: I thought you were going to say that. I will add it to the list of the many things I still need to do.
Alex: For our listeners, just to clue you in, Louise is Melisa’s primary mentor.
Melisa: Yes, and Alex is one of my co-mentors.
Eric: Melisa, I guess for the geriatric assessment, too, should we also be thinking about including life-space in that? We’re doing some physical function, performance status, and function as far as ADLs and IADLs? Is that enough? Or would including life-space, and how would you include it, would that be important to do?
Melisa: Yeah, I actually really do think it’s a promising measure in oncology and could be added to geriatric assessments. We’re always trying to make geriatric assessment small enough to be feasible and quick enough for the patient to not be overly-burden, but in a study we’re doing right now, we looked at patients’ description of their functional decline during treatment, and we compared it with IADLs, a commonly-used quality-of-life metric that has a functional subscore, and life-space, and we found that the most sensitive measure compared to the gold standard of the patient’s own description of functional decline was actually life-space. So, we would see patients whose IADLs scores stayed great the whole time, but their qualitative descriptions of their function really decreased over time, and life-space was sometimes the only measure that captured that. So, I think it could be a great addition to geriatric assessment. Right now, with COVID and the pandemic, all of our life-space has changed a lot. Before this podcast, I calculated my own life-space, it’s 40 in the last four weeks, because I’m not really getting out and about.
Eric: How do you calculate life-space?
Melisa: It looks at where you go, across different life-space levels. So, outside your bedroom, but within your home, to your surrounding home area, to your neighborhood, and then to your town, and then beyond your town. It looks at how often you go to each of those levels, and then also whether or not you needed assistance with an actual physical aid or with a person to assist you, And you multiply it out, and that’s how you get your life-space score.
Eric: And that’s the life-space assessment?
Melisa: Mm-hmm (affirmative).
Louise: I was going to say, you might get more buy-in now because everybody realizes the importance of a limited life-space and how that has such an effect.
Eric: I guess the other question is my phone tracks how many steps I do a day. My son, yesterday, was able to track me driving home. He goes, “You’re underneath the Golden Gate Bridge.”
Alex: Why are you driving underneath the Golden Gate Bridge? Nevermind.
Eric: You have to go under … Yeah, anyways. I’m sure our podcast listeners want to hear that. But, anyways. Is there a role for using technology instead of questionnaires?
Melisa: Yeah. A lot of folks are looking at technology or mobile health and how that can add to geriatric assessment as well. I’m a little bit more old-school, I like the paper/pencil, I think it’s very easy to ask people questions, and it doesn’t take very much time, and you don’t have the start-up cost of having a piece of technology required.
Alex: And the potential technologic barriers. Eric may have his phone on him, his teenage son may have his phone on him, but the older adults we care for may not.
Eric: All right, my last question, I’m not sure if Alex has more questions, but my last one is you got a magic wand right now, you have two great studies using geriatric assessment, improved outcomes in older adults, what do you do with this? You got a magic wand, you can use it once, what would you use it on?
Melisa: I think we would implement geriatric assessment across the nation and even internationally. A lot of other countries are actually ahead of the U.S. in this already, where they have country-wide geriatric assessment for their older adults already in very [crosstalk 00:40:52]-
Eric: And using this magic wand, could we be specific, what does that geriatric assessment look like to you?
Melisa: I think it would be something that is easily disseminable, I don’t know if that’s a word, and in a way that clinics or other centers can do it without a lot of resources, so even low/middle-income countries can do it.
Eric: Do you think The Lancet study hit that mark?
Melisa: I think it could, yeah. It was a very simple intervention, but that was almost the beauty of it, that it didn’t require a lot of additional personnel. Of course, that was done in a research setting, so not in the clinics with their clinical personnel, so there are ongoing studies to look at how to best implement this. And the Association of Community Cancer Center, the ACCC, actually has a great initiative to try to help cancer clinics embed geriatric assessment in their workflow, and so they have great resources on their website for that.
Louise: Can I use my magic wand to cause it to be reimbursed at a good level as a skilled procedure? Because I think that would also really help it be implemented at a greater amount.
Eric: You just need it to be an infusion so you can use Medicare Part B. Again, geriatric [inaudible 00:42:15].
Melisa: Yeah, it’s much cheaper than some other very expensive tests that we do on the tumor to understand the characteristics, and I would argue it actually provides just as valuable information for oncologists to take care of their older adults better.
Eric: Yeah, not many things have a number at five.
Alex: It’s incredible.
Eric: So, that’s all you want?
Melisa: Well, I do want a lot more if I have some more time. Personally, Louise mentioned at the beginning that she studies things that bothered her in clinic or she really wanted to make better in clinic. Some areas that I would love to see is not just geriatric assessment, but then being able to use that information to predict which patients might have more functional decline, to predict which patients will actually do really well, and then to also use all of this information to help present options to patients in better ways to help them understand what the options’ pros and cons are, to understand, “In the best case, this is what it might look like. In the worst cases, if things don’t go as well as we’d hope, here’s what we might be see. And based on everything I know about you, here’s the most likely scenario that we might be in.” And I think really adding the geriatric assessment information, plus a different way of communicating with patients, really might help improve care beyond what we’re already doing.
Eric: Well, maybe if I try that transition one more time, Alex will pick it up. I’m going to use a Cockney accent. Alex, Cockney accent, that’s all you want? You do it better than I do. All I want … No.
Alex: All I want is a room somewhere. My wife forbade me from singing that way when I sang with Louise. But we did have fun with it, right, Louise?
Louise: We did.
Eric: Let’s hear some more of it, Alex.
Louise: You get the muffled mask sound, too.
Alex: Here’s a little bit more of Wouldn’t It Be Loverly, our outro. Here we go.
Eric: Excellent. Thank you, Alex, Louise, for that wonderful song. Melisa, thank you for joining us on the GeriPal Podcast.
Melisa: Thank you so much for having us.
Louise: It was really fun. Thank you.
Eric: Thank you, Archstone Foundation, for your continued support. And for our listeners, if you want to support our GeriPal Podcast, check out our Donate button on our GeriPal website and see how you can support our podcast, or go to your favorite podcasting app and leave a review. Bye, everybody.