Developing Sustainable Cancer and Aging Programs.

Geriatric assessment (GA) has been shown to decrease toxicity from systemic therapy, improve completion of chemotherapy, and reduce hospitalizations in older adults with cancer. Given the aging of the cancer population, this has the potential to have a positive impact on the care of a large swath of patients seen. Despite endorsement by several international societies, including the American Society of Clinical Oncology, uptake of GA has been low. Lack of knowledge, time, and resources has been cited as reasons for this. Although challenges to developing and implementing a cancer and aging program vary depending on the health care context, GA is adaptable to every health care context from low- to high-resource settings, as well as those in which geriatric oncology is a well-established or just emerging field. We provide an approach for clinicians and administrators to develop, implement, and sustain aging and cancer programs in a doable and sustainable way.

Relationship between polypharmacy and inpatient hospitalization among older adults with cancer treated with intravenous chemotherapy.

OBJECTIVES: Polypharmacy (≥5 concurrent medications) is common among older patients with cancer (48%-80%) and associated with increased frailty, morbidity, and mortality. This study examined the relationship between polypharmacy and inpatient hospitalization among older adults with cancer treated with intravenous (IV) chemotherapy. MATERIALS AND METHODS: The main data source was the Surveillance, Epidemiology, and End Results-Medicare linked files. Patients (≥65 years) were included if they were diagnosed with prostate (n = 1430), breast (n = 5490), or lung cancer (n = 7309) in 1991-2013 and received IV chemotherapy in 2011-2014. The number of medications during the six-month window pre-IV chemotherapy initiation determined polypharmacy status. Negative binomial models were used to assess the association between polypharmacy and post-chemotherapy inpatient hospitalization. The results were presented as incidence rate ratios. RESULTS: We identified 13,959 patients with prostate, breast, or lung cancer treated with IV chemotherapy. The median number of prescription medications during the six-month window pre-IV chemotherapy initiation was high: ten among patients with prostate cancer, nine among patients with breast cancer, and eleven among patients with lung cancer. Compared to patients taking <5 prescriptions, post-chemotherapy hospitalization rate for patients with prostate cancer was 42%, 75%, and 114% higher among those taking 5-9, 10-14, and 15+ medications, respectively. Patients with breast and lung cancer demonstrated similar patterns. CONCLUSION: This large population-based study found that polypharmacy during the six-month window pre-IV chemotherapy is highly predictive of post-chemotherapy inpatient hospitalization. Further studies are needed to evaluate whether medication management interventions can reduce post-chemotherapy inpatient hospitalization among older patients with cancer.

The prevalence of major drug-drug interactions in older adults with cancer and the role of clinical decision support software.

OBJECTIVES: Drug-drug interactions (DDIs) represent an escalating concern for older adults attributed to polypharmacy, multi-morbidity and organ dysfunction. Few studies have evaluated the prevalence of major DDIs and the variability between DDI detection software which confuses management. MATERIALS AND METHODS: Prevalence of major DDIs was examined as a secondary analysis of outpatients aged ≥65 years. Demographic and clinical information was collected from electronic health records including age, sex, race, cancer type, comorbidities, and medications. All DDIs were screened by a clinical pharmacist using Lexi-Interact® and Micromedex®. Major DDIs were defined as Lexi-Interact® category D or X and/or Micromedex® category major or contraindication. Summary statistics of patient characteristics and DDIs were computed. RESULTS: Our cohort included 142 patients (mean age, 77.7 years; 56% women, 73% Caucasian). The mean medications was 9.8 including 6.7 prescriptions, 2.6 non-prescriptions, and 0.5 herbals. Lexi-Interact® identified 310 major DDIs in 69% of patients (n = 98) with an average of 2.2 DDIs per patient. Micromedex® identified 315 major DDIs in 61% of patients (n = 87) with an average of 2.2 DDIs per patient. DDIs mostly involved opioids, antiplatelets, electrolyte supplements, antiemetics, and antidepressants. Variability existed with the severity rating reporting of the clinical decision support software. CONCLUSIONS: There was a high prevalence of major DDIs in older adults with cancer. Utilizing clinical decision support software was beneficial for detecting DDIs however, variability existed with severity reporting. Future studies need to identify the relevant DDIs with clinical implications in order to optimize medication safety in this population.

Implementing a pharmacist-led, individualized medication assessment and planning (iMAP) intervention to reduce medication related problems among older adults with cancer.

OBJECTIVES: Medication-related problems (MRP) affecting older adults are a significant healthcare concern and account for billions in medication-related morbidity. Cancer therapies can increase the prevalence of MRP. The objective of this study was to test the feasibility and effectiveness of implementing a pharmacist-led individualized medication assessment and planning (iMAP) intervention on the number and prevalence of MRP. MATERIALS AND METHODS: This prospective pilot study enrolled oncology outpatients aged ≥65years. Intervention feasibility encompassed recommendation acceptance rate and intervention delivery time. The intervention was facilitated by pharmacists where patients received comprehensive medication management at baseline and at the 30- and 60-day follow-up. RESULTS: Forty-eight eligible patients enrolled and 41 patients (85.4%) were included in the analysis. Mean age was 79.1years [range 65-101]; 66% women, 83% Caucasian, mean comorbidity count was 7.76. Forty-six percent of the pharmacist recommendations were accepted and the prevalence of MRP at baseline versus 60-day follow-up decreased by 20.5%. The average time to conduct the initial session was 22min versus 15min for the follow-up sessions. Resources needed included a tracking system for scheduling follow-up calls and a database for tracking acceptance of recommendations. A total of 123 MRP were identified in 95% of patients (N=39) with a mean of 3 MRP per patient. The mean reduction in number of MRP (3 at baseline versus 1.6 at 60-day follow-up) was 45.5%. CONCLUSIONS: The pharmacist-led iMAP intervention was feasible and effective at reducing MRP. Additional inter-professional medication safety based interventions measuring patient-reported outcomes are still needed.

Telemedicine and Palliative Care: an Increasing Role in Supportive Oncology.

With the emergence of telemedicine as a routine form of care in various venues, the opportunities to use technology to care for the most vulnerable, most ill cancer patients are extremely appealing. Increasingly, evidence supports early integration of palliative care with standard oncologic care, supported by recent NCCN guidelines to increase and improve access to palliative care. This review looks at the use of telemedicine to expand access to palliative care as well as provide better care for patients and families where travel is difficult, if not impossible. When telemedicine has been used, often in Europe, for palliative care, the results show improvements in symptom management, comfort with care as well as patient and family satisfaction. One barrier to use of telemedicine is the concerns with technology and technology-related complications in population that is often elderly, frail and not always comfortable with non-face-to-face physician care. There remain significant opportunities to explore this intersection of supportive care and telemedicine.

A pharmacist-led medication assessment used to determine a more precise estimation of the prevalence of complementary and alternative medication (CAM) use among ambulatory senior adults with cancer.

OBJECTIVES: The prevalence of complementary and alternative medication (CAM) use in senior adult oncology (SAO) patients is widely variable and little is known about whether polypharmacy (PP) and potentially inappropriate medication (PIM) use influences CAM use given the increased number of comorbidities and polypharmacy. One approach to optimize medication management is through utilization of pharmacists as part of a team-based, healthcare model. MATERIALS AND METHODS: Prevalence of CAM and factors influencing CAM use was examined in a secondary analysis of 248 patients who received an initial comprehensive geriatric oncology assessment between January 2011 and June 2013. Data was collected from electronic medical records. CAM was defined as herbal medications, minerals, or other dietary supplements, excluding vitamins. Patient characteristics influencing CAM use (e.g. comorbidities, PP and PIM use) were analyzed. RESULTS: Only 234 patients (evaluated by pharmacists) were included in the final analysis. Mean age was 79.9 years [range 61-98]; 64% women, 74% Caucasian, 87% with a solid tumor, mean comorbidities, 7.69. CAM prevalence was 26.5% (n=62) and median CAM use was 0 (range 0-10). The proportion of CAM use (1, 2, and 3) was 19.2%, 6.4%, and 0.4%, respectively. Associations with CAM use (versus no-CAM) were polypharmacy (P=0.045), vision impairment (P=0.048) and urologic comorbidities (P=0.021). CONCLUSIONS: A pharmacist-led comprehensive medication assessment demonstrated a more precise estimation of CAM prevalence in the ambulatory SAO population. CAM use was associated with polypharmacy, ophthalmic and urologic medical conditions. Integrating pharmacists into team-based (geriatric and oncology) care models is an underutilized yet viable solution to optimize medication use.

Evaluation of a pharmacist-led medication assessment used to identify prevalence of and associations with polypharmacy and potentially inappropriate medication use among ambulatory senior adults with cancer.

PURPOSE: The use of multiple and/or inappropriate medications in seniors is a significant public health problem, and cancer treatment escalates its prevalence and complexity. Existing studies are limited by patient self-report and medical record extraction compared with a pharmacist-led comprehensive medication assessment. PATIENTS AND METHODS: We retrospectively examined medication use in ambulatory senior adults with cancer to determine the prevalence of polypharmacy (PP) and potentially inappropriate medication (PIM) use and associated factors. PP was defined as concurrent use of five or more and less than 10 medications, and excessive polypharmacy (EPP) was defined as 10 or more medications. PIMs were categorized by 2012 Beers Criteria, Screening Tool of Older Person's Prescriptions (STOPP), and the Healthcare Effectiveness Data and Information Set (HEDIS). RESULTS: A total of 248 patients received a geriatric oncology assessment between January 2011 and June 2013 (mean age was 79.9 years, 64% were women, 74% were white, and 87% had solid tumors). Only 234 patients (evaluated by pharmacists) were included in the final analysis. Mean number of medications used was 9.23. The prevalence of PP, EPP, and PIM use was 41% (n = 96), 43% (n = 101), and 51% (n = 119), respectively. 2012 Beers, STOPP, and HEDIS criteria classified 173 occurrences of PIMs, which were present in 40%, 38%, and 21% of patients, respectively. Associations with PIM use were PP (P < .001) and increased comorbidities (P = .005). CONCLUSION: A pharmacist-led comprehensive medication assessment demonstrated a high prevalence of PP, EPP, and PIM use. Medication assessments that integrate both 2012 Beers and STOPP criteria and consider cancer diagnosis, prognosis, and cancer-related therapy are needed to optimize medication use in this population.

Development of a comprehensive multidisciplinary geriatric oncology center, the Thomas Jefferson University Experience.

BACKGROUND: The proportion of older patients with cancer is expected to grow exponentially in the next two decades. This population has large heterogeneity and it is well known that chronologic age is a poor predictor of outcomes. Research has shown that these patients are best served with a Comprehensive Geriatric Assessment (CGA) to formulate individualized treatment plans for better outcomes. However, the best model for CGA has yet to be determined. MATERIALS AND METHODS: Our objective was to develop a highly functional model for the establishment of a comprehensive multidisciplinary geriatric oncology center in the setting of a university based NCI-designated cancer center. Each patient is evaluated by medical oncology, geriatric medicine, pharmacy, social work and nutrition. Expert navigation is provided to enhance the patient experience. At the conclusion, the inter-professional team meets to review each case and formulate a comprehensive treatment plan. The patient is classified as Fit, Vulnerable, or Frail based on the complete CGA. RESULTS: The average age of patients seen was 80.7 with the most common diagnoses being breast, colorectal and lung cancers. Twenty four percent of patients were determined to be Fit, 47% Vulnerable, and 29% Frail. Twenty one percent of patients determined to be Frail by CGA received an ECOG score of 0-1 by the oncologist. Our pharmacists made specific recommendations in over 75% of patients and social work provided assistance in over 50% of patients. CONCLUSIONS: We were able to observe some interesting trends such as potential discordance with ECOG score and assessment of Fit/Vulnerable/Frail but due to limitations in the data, this paper is not able to illustrate definitive correlations. Several challenges with the development of the clinic include 1) patient related issues, 2) navigation, 3) financial reimbursement, 4) referral patterns, and 5) coordination of care during office hours. We feel that we have been able to establish a model for a comprehensive multidisciplinary geriatric oncology evaluation center in the setting of a university based cancer center.

Caregiver care.

In 2009, nearly 66 million Americans (three in 10 U.S. households) reported at least one person providing unpaid care as a family caregiver. More adults with chronic conditions and disabilities are living at home than ever before, and family caregivers have an even higher level of responsibility. Caring for loved ones is associated with several benefits, including personal fulfillment. However, caregiving is also associated with physical, psychological, and financial burdens. Primary care physicians can aid in the identification, support, and treatment of caregivers by offering caregiver assessments-interviews directed at identifying high levels of burden-as soon as caregivers are identified. Repeat assessments may be considered when there is a change in the status of caregiver or care recipient. Caregivers should be directed to appropriate resources for support, including national caregiving organizations, local area agencies on aging, Web sites, and respite care. Psychoeducational, skills-training, and therapeutic counseling interventions for caregivers of patients with chronic conditions such as dementia, cancer, stroke, and heart failure have shown small to moderate success in decreasing caregiver burden and increasing caregiver quality of life. Further research is needed to further identify strategies to offset caregiver stress, depression, and poor health outcomes. Additional support and anticipatory guidance for the care recipient and caregiver are particularly helpful during care transitions and at the care recipient's end of life.