Dana-Farber’s Older Adult Gastrointestinal Cancer program specializes in treating patients who are 65 and older and have gastrointestinal cancers, such as colorectal cancer, esophageal and gastric cancer, liver cancer, neuroendocrine and pancreatic cancer.
“Older adults are richly complex and multidimensional,” says gastrointestinal and geriatric oncologist Nadine McCleary, MD, MPH, who leads the program. “They deserve high quality coordinated care.”
McCleary has been working with older patients since the beginning of her medical career. Her research has focused on understanding more about how conditions that are more common in older patients can influence their experiences being treated for cancer.
Attention to the unique needs of older adults is important. While rates of cancer are rising in younger people, older people are much more likely to receive a cancer diagnosis, and they are also much more likely to have other health concerns than younger people.
“We need to be prepared to meet the needs of these patients,” says McCleary, who designed the program based on input from older patients and their caregivers.
The Older Adult Gastrointestinal Cancer program is one of several similarly focused programs at Dana-Farber, such as the Older Adult Breast Cancer Program led by Rachel Freedman, MD, MPH, and the Older Adult Hematologic Cancer Program led by Gregory Abel, MD, MPH. It is currently available at Dana-Farber’s Longwood and Chestnut Hill locations but an expansion to additional Dana-Farber satellite locations is planned.
What needs do older adult patients with gastrointestinal malignancies have?
Older adults often come to Dana-Farber with needs and conditions that are much less common in younger patients. For example:
- Frailty can be physical, mental, or social, and becomes more common with age. Any of these forms of frailty can influence a patient’s experience with treatment for cancer.
- Other medical conditions and related medicines become more common with age. These other medical conditions could distract from cancer treatment or could require special considerations regarding treatment or supportive interventions.
- Unique priorities in terms of treatment goals. Expectations and priorities change with age and can also influence treatment decisions.
In some cases, the needs of an older adult are straightforward. For example, a patient might be physically frail and benefit from a rehabilitation program, such as physical therapy or occupational therapy, prior to treatment.
In other cases, the needs may be complex and layered and require collaborative and coordinated care across specialists in oncology, geriatrics, pharmacy and more.
How does the program evaluate a patient’s needs?
Patients in the program are supported by a team of specialists including a medical oncologist, surgical oncologist, radiation oncologist, geriatrician, and pharmacist. A program manager, Rachel Weitzner, MPH, and program coordinator, Siri Rosenberg, MPH, also support the program, which is funded by the High Pointe Investigatorship in Gastrointestinal Oncology under the direction of Brian Wolpin, MD, MPH, chief of the Gastrointestinal Cancer Center.
The first step for older adults coming to Dana-Farber for gastrointestinal cancer is screening using a well-tested tool that helps assess conditions common in older adults. This geriatric assessment tool can help the care team understand the patient’s support system, risk factors, and medical history. Additional questions assess the patient’s fitness and ability to function.
These evaluations can help the care team match patients to additional support systems that could help them, such as:
- Integrative therapies through the Leonard P. Zakim Center for Integrative Therapies and Healthy Living
- Social work support with the help of Dana-Farber’s Adult Social Work Program
- Physical rehabilitation via a referral to a physical therapist or occupational therapist
In addition, the program’s geriatrician, Tammy Hshieh, MD, MPH, and pharmacist, Shannon Goniwiecha, PharmD, are experts in coordinating care for patients with cancer who have existing medical conditions. This team identifies any conditions or medicines that might prevent a patient from receiving the best possible cancer treatment or preclude them from participating in a clinical trial. Their main goal is to determine if there are ways to address those gaps and improve the treatment the patient can receive.
Benefits of the program
By managing the care of older adults more closely, with coordinated care and attention to physical, mental, and social needs, research shows that providers can reduce treatment toxicities and improve decision-making. McCleary is also conducting research to determine if these interventions also reduce hospitalizations and emergency room visits.
Older adults, regardless of the stage at which their gastrointestinal cancer is diagnosed (for example, early stage or late stage), are more frequently hospitalized and are more likely to visit an emergency room than younger people.
“This likelihood is true even for patients with curable cancers, where we would normally expect nothing more than a surgical intervention and a follow up,” says McCleary. “We’d really like to reduce emergencies and hospitalizations for our patients.”
How to access the program
Every patient over 65 who is being treated for gastrointestinal cancer is assessed to determine any unique needs. Patients who might not need help from the program at first are able to opt in at any time as needs change.
The program has been in operation for two years and has already screened more than 1,400 older adults.
“We’ve found that about a third of the older adults we’re seeing in the gastrointestinal cancer program are frail or pre-frail according to what they are sharing in our assessments,” says McCleary. “That means they might need help with social support, physical function, mental function, hearing or something else.”
Does the program help older adults participate in clinical trials?
Older adults are poorly represented in most clinical trials. That is, the proportion of older patients with cancer in the real world exceeds that of patients who enroll in trials. As a result, doctors like McCleary don’t have as much evidence as they’d like about how to best treat older adults.
Barriers include:
- Eligibility criteria that exclude people with conditions that are more common with age, like chronic kidney disease.
- An assumption that clinical trials are too challenging for older adults – too complicated, too confusing, and too much physically.
But McCleary’s experience with older adults suggests that many patients want to participate in clinical trials, so the Older Adults Gastrointestinal Cancer Program works to find ways for older patients to participate when possible.
“Our patients are telling us to explore innovative approaches to cancer treatment,” she says. “They want to participate in clinical research and benefit from it and from the assessments, the interventions, and the coordinated care we offer.”
Ongoing research and future directions
In addition to offering clinical trials of novel treatments, the program is also collecting tissue samples and clinical data from older adults who want to participate. This data can be used to learn more about older adults with gastrointestinal cancer and could potentially be used to discover biomarkers or patterns that could improve treatment.
About the Medical Reviewer
Dr. Nadine Jackson McCleary earned a Bachelor of Science in Nursing from the University of Pennsylvania in 1998. She went on to earn both a Masters in Public Health (2002) and medical degree (2003) from Johns Hopkins University Bloomberg School of Public Health and School of Medicine, respectively. She completed residency in internal medicine at Johns Hopkins Hospital in 2006 and fellowship in clinical hematology and oncology at Dana-Farber/Partners CancerCare in 2009. Dr. McCleary joined the staff of Dana-Farber Cancer Institute and Brigham and Women’s Hospital in 2009 where she is a medical oncologist and clinical investigator. Her research is focused on improving health and treatment outcomes for older patients with cancer.