(Photography by Kevin Van Paassen)
For older patients with cancer, treatment can be challenging. And they may not always get the care they need because of their age. A bold new Sunnybrook program aims to improve outcomes for older patients through a comprehensive team approach and tailored treatment plans.
Twice a week, Nettie Yeoman spends her mornings at Sunnybrook’s W. P. Scott Geriatric Day Hospital. For a few hours each day, she engages in therapies that benefit her body and her brain.
But Nettie doesn’t view these prescribed therapies as stressful or burdensome. In fact, she equates her time at the hospital with being on vacation.
“For years, I was fond of saying that there were two places in the world that I thought were like heaven on earth,” says Nettie, a 71-year-old Toronto resident. “One of those places was Disneyland. Now, I want to include Sunnybrook on my list.”
Nettie’s time at the Geriatric Day Hospital, one of the first programs of its kind in Canada, is filled with physiotherapy that strengthens her muscles and improves her balance, recreation therapy, where she can do activities she loves – like planting seedlings or playing Scrabble – and a lunch where she can socialize with others.
She also meets with her occupational therapist, who challenges her to problem-solving exercises to keep her mind sharp or invites her to bake with other patients.
These enjoyable activities are a far cry from the challenges she faced last year.
In May 2018, Nettie was diagnosed with early stage breast cancer. She underwent a mastectomy in July, followed by a series of chemotherapy and radiation treatments.
Now finished with her treatment, Nettie’s regular visits to the Geriatric Day Hospital are part of a pioneering program at Sunnybrook designed to improve outcomes for older patients with cancer.
It’s an initiative that’s about more than ridding the body of disease. The ultimate goal is to build patients up and provide them with the services and care to keep them active, healthy and happy.
Over-represented and undertreated
According to Canadian cancer statistics, of the more than 200,000 Canadians who are diagnosed with cancer each year, nearly 90 per cent are people aged 50 and over. Seventy per cent of all cancers occur in people older than 60. But while cancer mortality rates have decreased by at least 2 per cent, year over year, some patients may not be getting the treatment they need, simply because of their age.
“Studies have shown that older people with cancer have often been undertreated,” says Dr. Ines Menjak, a medical oncologist at Sunnybrook. “They may not see the appropriate specialists to treat their cancer because someone early on in their care has made the decision that they’re not appropriate for treatment.”
Traditionally, there has been a reluctance to offer aggressive treatment to older patients because it was assumed they would not be able to cope, Dr. Menjak says.
But senior patients are diverse in their general health and fitness, as well as cognitive and physical functioning, Dr. Menjak says.
Nettie is a prime example. Aside from taking a low-dose medication and acetaminophen on occasion, she is healthy and relishes the chance to participate in aqua-fitness classes five times a week.
On the other hand, older patients may have other illnesses for which they take medication, or they may have difficulties with memory or getting around the house. These comorbidities, as they are called, can interact or interfere with standard treatments, not just on a biochemical level, but also in terms of how the patient will deal psychologically during and after treatment.
Oncologists might be fearful of causing harm when making these difficult treatment decisions, and that may lead them to err on the side of caution.
“Because of that concern, oncologists may end up undertreating older patients. They’re giving them modified dosing or regimens that may not benefit them as much,” she says.
Another challenge is that older adults with cancer have been historically under-represented in clinical trials. That means most standard treatments were devised without taking the needs of this group into account.
Instead of trying to fit the diversity of patients into a few treatment types, or not treating at all, Sunnybrook is finding ways to understand older patients’ needs and tailor more personalized treatment plans for them.
Working as a team
To better understand the needs of older patients, Sunnybrook went directly to the source.
Researchers asked older women undergoing breast cancer treatment to tell them what they needed from their care. What came across from the women was a desire for more communication between physicians, more social support networks and to be more involved in deciding their treatment.
For patients’ families, having a geriatric specialist involved and having educational resources tailored for older patients was important.
In response to their findings, Sunnybrook formed an interdisciplinary team of oncologists, geriatricians, occupational therapists, physiotherapists, pharmacists and social workers. The group works together to assess and treat patients in a way that meets their individual diagnoses, as well as their cognitive or social needs.
“This is a group of patients who require really a team-based approach,” says radiation oncologist Dr. Ewa Szumacher. She leads the Senior Women’s Breast Cancer Clinic at Sunnybrook, where the initiative is being piloted before rolling out across all areas of oncology.
“There is an awareness of the problem that these patients have specific needs,” Dr. Szumacher says. “We know exactly who the people are who can offer services to the patients, [and] we try to utilize those services as much as we can.”
“We’re trying to dig deeper and identify those people who may run into significant problems during treatment.”
– Dr. Ines Menjak, medical oncologist at Sunnybrook
Occupational therapists, for example, take a holistic view of a patient’s ability to function in everyday life: how they get dressed, buy groceries and cook for themselves or take their medications. Their ability to do these things reflects their cognitive, physical and mental status, and the treatment and supports they need to maximize their ability to function safely in their home and in the community.
“The most important question I ask always my patients is, ‘What is the biggest challenge in your daily life?’ It’s not only about what they can and can’t do; it’s about what concerns them most,” says Sunnybrook occupational therapist Beverley Moskovic, who works with Nettie.
Moskovic and her colleagues also provide emotional support to patients who have received a medical diagnosis, faced hospitalization or have declined in their ability to fulfill the roles in their life that gave them a sense of value. Sitting together, listening and talking about how they feel strengthens patients emotionally.
As of December 2018, all older Sunnybrook patients with breast cancer are screened at their first visit using a self-reporting questionnaire that assesses how frail or vulnerable they are. If the survey indicates the patient may need extra care, the patient is referred to a geriatrician who can do a more thorough assessment of their needs.
“We’re trying to dig deeper and identify those people who may run into significant problems during treatment,” Dr. Menjak says. “We try to address that upfront.”
During the pilot phase of the screening initiative, close to 40 per cent of patients who completed the questionnaire had some vulnerability, such as a previously undiagnosed cognitive impairment or a new medical condition.
Looking at the broader picture
Geriatricians work with older patients across the hospital, including the oncology centre, and collaborate with other physicians and allied health professionals to form comprehensive treatment plans.
“A geriatrician’s job is to look at the broader picture of functioning and cognition, and then put that into context of someone’s cancer or proposed therapy,” says head of geriatric medicine Dr. Rajin Mehta, who leads the geriatric oncology initiatives at Sunnybrook.
For women with breast cancer, for example, the plan takes into account the stage of the cancer, any comorbidities and the patient’s cognitive and physical abilities. If a patient is dizzy or off-balance, they could have their medication adjusted, for example, or see a physiotherapist to strengthen their muscles.
Details of the comprehensive care plan are then shared with the oncologist, surgeons, family members or anyone involved with a particular patient, so everyone is on the same page.
According to surveys conducted by Sunnybrook researchers, both patients and physicians felt more confident in a treatment plan when a geriatric assessment had been done. Of note, the nature of the treatment plan changed by close to one-third after such assessments.
Overall, patients felt more informed, more supported and less uncertain about their decisions for treatment, says Dr. Menjak, who led the research project.
Sunnybrook’s efforts in geriatric medicine reflect a growing trend across Canada and worldwide to provide more inclusive oncology care.
The American Society of Clinical Oncology now advocates for this, including assessments of function, comorbidity, falls, depression, cognition and nutrition in older patients receiving chemotherapy.
“I think it speaks great volumes [about] where this field has come [from] and where it’s going,” Dr. Menjak says.
The aim is to foster a comprehensive approach to patient care both across the hospital and throughout the profession as a whole.
“The hope is that this field will continue to grow, and the next generation of oncologists and geriatricians will help to develop it even further,” Dr. Mehta says.
For Nettie, the kind of care she’s received at Sunnybrook has been a great boon to her recovery post-cancer – and likely the reason it’s one of her favourite places.
“The professionals and volunteers at the Geriatric Day Hospital are so kind, courteous and helpful,” she says. “You don’t necessarily receive that kind of treatment out there in life.”