The multidisciplinary team organisation for older cancer patients

The multidisciplinary team organisation for older cancer patients: portraits of Geriatric Oncology Programmes worldwide Silvio Monfardini, MD Geriatric Oncology Program Istituto Palazzolo, Fondazione Don Gnocchi, Milano

Disclosure Session Chairman at a Meeting sponsored by Cellgene Recipient of a Bristol-Myers Squibb grant for the Project ‘the Italian Road Map for Geriatric Oncology’

What are your projects foreseen following this Course ? A small sample of Your Answers(Pre-event evaluation) • We plan to establish an organised interdisciplinary (geriatrics and oncology) management of the older cancer patients…… • We would like to bring some more methodology and knowledge to this topic……. . ………create a oncogeriatric unit or functional team • ………. designing and having my institution participate in trials geared toward the geriatric population.

This is then the need MULTIDISCIPLINARY TEAMS: A BETTER INTEGRATED APPROACH BETWEEN ONCOLOGY AND GERIATRICS, WORLDWIDE

If You are here 1) You are already convinced of the usefulness of the CGA 2) Most of You probably believe in the interaction Clinical Oncologists-Geriatricians But returnig to Your Institutions…, somebody will not really believe in this approach

Why They should believe You? Caravaggio: Incredulity of St Thomas

One of the best ways to convince them on the usefulness of an integrated approach before the proposition of a multidisciplinary team organisationan To present and discuss with them ( and possibly with Geriatricians) real clinical cases of frail and vulnerable old cancer patients, taken from Your daily activity Unknown painter, Florence

Possible lessons from clinical cases An MGA, better if performed by a Geriatrician, before offering a treatment : 1) Can provide information on: hearing defect, visual deficit and cognitive impairments leading to the lack of understanding of the real meaning of the information 2) The knowledge of these elements can be clinically useful in order to obtain the patients consensus for treatment

Possible lessons from clinical cases Some information obtained with the help of Geriatricians can be useful in order to identify obstacles to cancer treatment: - Limited family and social support, Lower education - Difficulty in: 1. having access to a mean of transport, 2. telephone calls 3. self administration of drugs Monfardini S. et al, ASCO Proceedings 1996, Eur J Cancer 2002

What may in Your Institute Medical Oncologists learn, especially in presence of Geriatricians ? Geriatricians have a better knowledge of the conditions/ diseases affecting elderly patients and interfering with their treatment They are better able to deal with the social problems impeding the management of the neoplastic diseases

What else to be made understandable to Your Medical Oncology Collegues through the discussion of clinical cases with the partecipation of Geriatricians? The role of Geriatricians as partners in - Vunerability prevention - Rehabilitation home - Stopping inappropriate medications - Tumor independent life expectancy evaluation

To have this Orchestra we need Geriatric Oncology Programmes worldwide Clinical Oncol. (Surgical, Medical Oncology, RT) Rehabilitation, pharmacy, nutrition, social services Epidemiology. Clinical and Laboratory Research Geriatrics, Gerontology GERIATRIC ONCOLOGY Palliative care Supportive therapy Primary care Clinical Oncologists, Geriatricians and other partners

GOALS of a dedicated Geriatric Oncology Program (GOP): • To provide comprehensive care through a multidisciplinary approach (age-associated conditions and cancer management) • To conduct clinical trials in representative older pts. • To educate health professionals(, older patients, their families and the public ) • S Monfardini et al: Report of a SIOG task force. Crit Rev Oncol/Hematol, 2006

How difficult is it to transfer such specific approach in the real world? Which is the status of the Geriatric Oncology Programmes worldwide? Bosch, Hieronymus the Ship of Fools

Liberism and happiness In the USA emphasis on training and acquisition of data Geriatrics/Oncology Training Program Development Grant ASCO/The. John A. Hartford Foundation, (2001): Dual Training Grants to NCI-NIA (National Institute of Aging)designated Cancer Centers to study Age integrated aspects (2005): Emphasis on Research The U 13 conference series of Cancer and Aging Research Group NCI, NIA and the Alliance Clinical Trials in Oncology (2010 -2016): Areas of highest research priorities in Geriatric Oncology

Formal Geriatric Oncology fellowships in both the US and Canada Boston University, Mc. Gill University, Montreal , Thomas Jefferson University, Philadelphia University of California, Los Angeles (UCLA), University of Chicago, University of North Carolina, University of Rochester, University of Toronto

Goals of U 13 Grant : “Geriatric Oncology Research to Improve Clinical Care Care. ” Research Methodology Training & Education 1. To identify the present level of evidence & areas of high research priority in Geri Onc 2. To identify strengths in research methodology, from the fields of Geriatrics and Oncology 3. To foster collaboration between multidisciplinary scholarly teams 4. To foster and promote the research of existing and new investigators in Geriatric Oncology 5. To disseminate findings from this conference grant program with easily adaptable recommendations

Clinical Research helps in developing multidisciplinary clinical and teaching activities Starting up a clinical research activity can help in developing a comprehensive approach because in order to conduct an oncogeriatric study is necessary to build a new team with different competences of the participants This team approach will provide the background for further projects implementation and teaching

Diversity across the US SPECIALIZED ONCOLOGY CARE AND RESEARCH IN THE ELDERLY (SOCARE) ROCHESTER AND CHICAGO UNIVERSITY • Pre-operative setting: evaluation prior to cancer surgery Pre-treatment assessment: evaluation and weight of the risks and benefits of multiple treatment options • Survivorship: assistance through the management of geriatricrelated conditions Magnuson A , Dale W and Mohile S, Curr Geriatr Rep 2014

Who were the first ones: L Balducci, M Extermann, Senior Adult Oncology Program. Tampa CGA performed by a nurse Separate clinic within the center with physicians, nurses, pharmacist, social worker, dietitian and support staff Cases discussed at weekly team meeting

Selected Geriatric Oncology Initiatives in the United States and Canada. Global Geriatric Oncology: Achievements and challenges E. Soto-Perez-de-Celis et al J Ger Oncol 2017

From the American experience: The possible models: Consultative Model Oncologist Refers Patient Ø Reasons for referral: • Geriatric assessment & intervention recommendations • Treatment recommendations Comprehensive Geriatric Assessment Performed by Geriatrician and Multidisciplinary Team Geriatric assessment results and recommendations provided to the oncologist Courtesy of Arti Hurria

Shared Care Model Oncologist Refers Patient Ø Reasons for referral: • Geriatric assessment & intervention recommendations • Treatment recommendations Comprehensive Geriatric Assessment Performed by Geriatrician/Geriatric Oncologist and Multidisciplinary Team Interdisciplinary Meeting to Review the Results and Care Plan Geri-Oncology Team Collaborates with Treating Oncologist & Provides Concurrent Care Across the Disease Trajectory Courtesy of Arti Hurria

Comprehensive Care Model The Geriatric Oncologist is the Treating Oncologist Ø Reasons for referral: • Cases where geriatric oncology expertise is needed Comprehensive Geriatric Assessment Performed Results and Recommendations are Reviewed with the Patient Referrals to the Multidisciplinary Team The Geriatric Oncologist is the Patient’s Treating Physician Throughout the Patient’s Disease Trajectory Courtesy of Arti Hurria

Selected Geriatric Oncology Initiatives in Latin America (E. Soto-Perez-de-Celis et al J Ger Oncol 2017)

Lack of a common European Union Framework : the different national situations ( France……. ) • Belgium, Holland, Norway and Switzerland: successful models of care delivery and cooperation between Clinical Oncologists and Geriatricians developed • Italy: some central funding for research. A dozen of Units with Geriatric Oncology activity, scarce cooperation with Geriatricians. In other EU Nations: no established collaboration with Geriatricians. Monfardini S, J Ger Oncol 2013

The GOP at the Istituto Oncologico Veneto, Padova, Italy (2004 -2008) • All patients > 70 years referred to the Divisione di Oncologia Medica offered an MGE ·In all cases ADL, IADL, MMS, GDS questionnaires administered by a psycologist ( 30 to 45 minutes). · Determination and rating of comorbidity(CIRS) performed afterwards by a Medical Oncologist · All most complex cases evaluated weekly by the Geriatricians.

THEORIES AND DIFFERENT MODELS OF INTERPLAY H. Wildiers et Al : J. C. O. 2014 1)Creation of Geriatric Oncology Units (Geriatric Oncologist alone? ) 2)Bring Geriatric consultation teams to patients 3) In settings where geriatric expertise is not nearby GA can be performed (by the Clinical Oncologist) to identify high-risk patients who could be referred to Geriatricians H. Wildiers et Al : SIOG Consensus on Geriatric Assessment in Older Patients With Cancer. J. C. O. AUGUST 2014

(Advantage and)Disadvantage of a Geriatric Oncology Unit 1. potential patient withdrawal from familiar treating oncologist 2. financial incentives might drive general oncologists not to refer patients; 3. only limited No. of patients can be reached 4. general geriatric oncologists might miss detailed, rapidly evolving knowledge of broad field of oncology s, JCO r H. Wildiers et Al : J. C. O. 2014

Empty area Empty area Selected Geriatric Oncology Initiatives in Asia and the Middle East, modified (E. Soto-Perez-de-Celis et al J Ger Oncol 2017)

Empty area Selected Geriatric Oncology Initiatives in Australia and New Zealand(E. Soto-Perez-de-Celis et al J Ger Oncol 2017)

Emerging problems: The strategy of the interaction should be probably rethought in the GOPs according to 1) organ involved(eg breast ca. ) 2) phase of management: - Initial therapeutic decision - Support after initial therapy -Follow up

Medical Oncologists: the trend toward various subspecialties in Cancer Research Institutions, but also in the Surgical Oncology activity • Breast, Gyn, Gi, GU Lung, HN Ematol. , Soft tissue, • Brain, • Etc • Where and how an Interaction with Geriatricians ? • How should be the GOP work be organized?

Phase of management: consider also an integrated approach during the follow up The 3 rdrd U 13 Conference in 2016 focused on improving the quality of life and survivorship of older and frail adults with cancer(S. G. Mohile et al, . Cancer 2016)

FOLLOW-UP OF ELDERLY PATIENTS WITH UROGENITAL CANCERS: EVALUATION OF GERIATRIC CARE NEEDS AND RELATED ACTIONS MGA items collected at the beginning after Radiotherapy or Surgery in 453 patients >70 years > 60% of patients with prostate cancer and > 70% of patients with renal and bladder cancers were frail or vulnerable but only one case was referred to a Geriatrician Of 16 patients with ADL impairment and 63 with IADL impairment, only 4 (25%) and 6 (10%), respectively, were referred to a rehabilitation service. . Conclusion: should older patients with urological neoplasia be seen by a Geriatrician at the initial follow up ? S Monfardini et al J. GER. ONCOL: 2017

Problems in implementing specific activities for cancer in the elderly in some countries within cancer institutes, universities and general hospitals Open issues Geriatrics does not exist in some region or a country Geriatric Units in other cities nearby Oncology and Geriatrics in different hospitals of the same city

POSSIBLE SOLUTIONS ● Geriatrics does not exist in some region or a country ● Geriatric Units in other cities nearby ● Oncology and Geriatrics in different hospitals of the same city Open issues ● Geriatric Oncologist, multidisciplinary meetings, teleconferences ● Geriatric consultations

One last recommendation to the Medical Oncologists embarking into an interdisciplinary game… ● Geriatricians shortfall, professionals difficult to recruit ● Geriatrician's tools and know-how often perceived ambiguously: Oncologists unclear as to the Geriatricians role ● Geriatricians may: 1. feel confined to the periphery of organisation of cancer treatment, 2. be involved with other multiple role within their Institutions 3. Suffer from a time constraint: overhelming number of elderly cancer patients Bruegel, Pieter the Elder The Peasant Dance Sifer-Riviere L. et al, Ann Oncol, 2011 Holmes HM. and Allbrand G. In Cancer and aging Ed by M Extermann M. , 2013

No uniform universal model of the Geriatric Oncology Program can be proposed Different characteristics in various Countries, on the basis of the local health organization and available resources. The models can vary depending on the needs of the individual patient, family and caregiver, the availability and expertise of the involved professionals and support services. And You should find Your Way!

The possible next step for You: after establishing a GOP think of promoting this activity in smaller hospitals treating cancer patients An example: A small Italian Task Force-One Medical Oncologist and one Geriatrician- to ask all Specialists : What is done now in this hospital for older cancer patients and what do You plan for the future? In the year 2017 -2019 metings in Avellino Catania Firenze IOV, Padova Torino Bergamo INT, Milano CRO Aviano UNModena INT Napoli FBF Roma UN Palermo