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Geriatric Assessment in Oncology Practice: Podcast with Supriya Mohile & William Dale


Should Geriatric Assessments be part of the routine ontological care for older adults with cancer?   On this weeks podcast we attempt to answer this question with national experts in Geriatric Oncology: Dr. Supriya Mohile from the University of Rochester and William Dale from City of Hope, as well as UCSF's Melissa Wong.

Lucky for us, they also have a little evidence on their side thanks to a recently published JAMA Oncology article that they authored titled "Communication With Older Patients With Cancer Using Geriatric Assessment - A Cluster-Randomized Clinical Trial".  We discuss not only the trial results, but also:
  • reasons why geriatric principles is important in oncology
  • what a geriatric assessment includes
  • who should do a geriatric assessment (including does it need a geriatrician?)
We also talk about these resources if you want to take a deeper dive in geriatric oncology:

by: Eric Widera (@ewidera)




  


You can also find us on Youtube!

 

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TRANSCRIPT

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex there's somebody else in the room with us today.

Alex: We have a guest host with us today, we have Melissa Wong, who's a geriatric oncologist here at UCSF. Welcome to the GeriPal podcast Melissa.

Melissa: Great, thanks for having me.

Alex: Thanks for joining.

Eric: And we have two people on the call, we're going to be talking about geriatric assessments in oncology. Who are these two very special people Alex?

Alex: We have Supriya Mohile who is Director of Geriatric Oncology at the University of Rochester. Welcome to the GeriPal podcast, Supriya.

Supriya: I'm looking forward to this, thank you for having me.

Eric: And we have a voice without a face because we can't get him on a webcam but we've called him in.

Alex: We have William Dale who is the Chair of Supportive Care Medicine at City of Hope down in Los Angeles. Welcome to the GeriPal podcast William.

William: Thank you, delighted to be here from Hollywood land.

Alex: Well, we're going to be talking about a recent paper you published in geriatric oncology, titled Communication With Older Patients With Cancer Using Geriatric Assessment, but before we go into the paper and think about geriatric assessment and oncology, we always start off with a song request, do either of you have a song request for Alex?

William: Absolutely, in honor of my move to the Southern California area, my favorite band the Eagles, Hotel California.

Alex: All right.

Alex: (singing)

Eric: Alex could have gone on the entire podcast singing.

William: That was awesome thank you.

Alex: Well, I got some of the notes, switched around some of the lyrics-

Eric: Hotel California or like stairway to heaven, I'm pretty sure Alex would just sing like the whole song, cause like that's a guitarist song, right?

Alex: Yeah, yeah love it.

Eric: Like every guitar playing person.

Alex: I messed up that that intro though but whatever we just roll with it.

Supriya: I think you did a very nice job.

Alex: It's better in practice.

Eric: You got a second attempt at the end Alex.

Alex: That's right. Yeah.

Eric: So, maybe we'll jump right into the article and the topic, Supriya I'm going turn to you like how did you get interested in this as a topic?

Supriya: So, geriatric oncology's cornerstone is really geriatric assessment, and many of us got interested as fellows when we were in oncology fellowships, taking care of older adults with cancer and wondering how to improve care delivery... and like geriatricians and you see older patients they go through cancer treatment there are functional issues, cognitive issues, even fit older adults may have side effects that interfere with function. And then what we think of is how to adapt geriatric principles to oncology, and one of the tools that can do that is geriatric assessment. And so we now over the last... I would say 10 to 15 years have studied the progression of geriatric assessment through many different kinds of oncology research and have evidence to show that it can impact clinical care.

Eric: The majority of cancer patients, right? They're older is this like a usual part of oncology fellowships where geriatrics is like heavily integrated-

Supriya: We wish.

Eric: A fringe element.

Supriya: That's our job. Melissa, mine, and William's job is to make this the case, but it's not quite the case yet. And unfortunately as we go through training to become doctors, we don't get enough aging related training, oncologist don't get enough aging related training. When we ask oncologists and community practices especially, they really do recognize that their patient population is older and especially for those that are seeing patients and in the community rather than academic centers and they want more training, but they're sort of already out in practice taking care of these older adults without access to geriatricians or palliative care specialists. So, it's really our job as academic geriatric oncologists or geriatricians like... and palliative care doctors like William, who need to teach and educate and do research like this to show how these things can be adaptable and implemented for oncology practices.

Alex: And William you're a geriatrician and palliative care doc, within the sort of geriatrics and palliative care clinicians perspective where do you see the need for this study fitting in?

William: I think as Supriya was commenting most patients, cancer patients who are older aren't seen in academic centers. So, 20% or so are seen in academic centers like City of Hope, UCSF or University of Rochester. But that means 80% are seen out in the community settings, and so what are we going to do? As we all know we're never going to produce enough geriatricians and we're certainly not going to produce enough geriatric oncologists to go out into the communities and populate the place. So, we have to find ways to provide primary geriatrics, primary palliative care or supportive care to communities or communities of oncologists. So, this study shows that you can go out to this network with ENCORE that Supriya is connected with and helps oversee. Get some tools to those community oncologists and then I'd say start talking to their patients, the patients will talk to them and they'll have a high quality conversation that isn't just about cancer, but it's also about the aging issues and the things confronting patients who are older.

Melissa: And William you mentioned the importance of studying geriatric oncology in the community setting not just in academic centers where we might have more geriatricians or palliative care doctors. Can you tell us a little bit more about the ENCORE and what makes this research base so unique?

William: Yeah, I'll say a little bit about it and then I'll do what I usually do, which is kick it back to Supriya who knows far more about it. ENCORE is this network that's out across the country that practices in the community that have decided they want to participate in research, even though they're not at a formal academic center. So, it's been gathered up through the NCI so that they can participate in research studies, and Supriya and her team have done an amazing job to sort of use this network of community oncology practices to do this kind of research. Though I'm sure I haven't done it full justice so I'll let Supriya fix it.

Supriya: Yeah, I know you did a great job William and I'll just echo what William said. The NCI funds community oncology practices across the country to work with seven research bases. Many of those research bases are in cooperative groups with the University of Rochester, have a research base and a geriatric oncology program so we were able to design a study like this. We are a coordinating center the people, the oncologists who spearhead and the staff that spearhead these kinds of studies are in the community, they're in practices. And they're able to enroll patients on to the research base studies, and are very integrated with us. So, they provide input as stakeholders on to all our studies, as do patients and caregivers in our community. So, this study was designed in partnership with community oncologists and patient and caregiver stakeholders.

Eric: While we're talking about the study many of our viewers may not have read it yet so what was the study? What was the question that you're trying to answer here?

Supriya: Yeah, so this is a PCORI funded study, so for people who are not familiar with PCORI it's Patient-Centered Outcomes Research Institute, just got refunded by Congress for another 10 years. It was both PCORI funded and NCI funded, and our question was a PCORI interest which was patient centered outcomes. So, looking at direct communication and patient and caregiver satisfaction with care. And so we designed a study to evaluate if geriatric assessment can improve communication between oncologist patients and caregivers about aging, so not necessarily about the cancer treatment or the risks and benefits of cancer treatment although those are related, but really trying to educate oncologists about aging and have them communicate better with their patients about aging.

Eric: And many of our listeners... well, some of our listeners I should say will be familiar with geriatric assessment but some of them will not. I wonder if you could give us a quick rundown about the kinds of domains and specifics of what's inside of a geriatric assessment?

Supriya: Yeah, we utilized a pretty standard geriatric assessment approach that was originally developed... originally was out being used with older patients without cancer, but Dr. Arti Hurria who was one of our colleagues who passed away in November tragically in a car accident, had studied this geriatric assessment and found it was feasible for older patients with cancer. And then the three of us -- me, William Dale who's on the call with us, and Arti created a toolbox of both the assessment tools plus algorithms for management, and that was really the basis of our geriatric assessment. We evaluated eight domains and let's see if I can... this will test my brain to see if I can remember. So, it's function comorbidity, polypharmacy, social support, objective physical performance, cognition and psychological status and nutrition.

William: You did it.

Supriya: ... validated tests and there were algorithmic management recommendations that were provided to the teams in the intervention. William had a lot to do with the development of the intervention because we worked with experts to make sure our algorithms were sound in the geriatrics and palliative care literature before implementation.

Eric: So, let me get this straight. So, there's a geriatric assessment... geriatric assessment didn't include a geriatrician, it was a set of assessment tools, and then what did you exactly do with those? Like-

Supriya: Yeah, that's exactly right. So, everybody in both are... it was a cluster randomized study. So, we actually randomize the practices to one model of care over the other. When the patients were enrolled they filled out the geriatric assessment.

Eric: Everybody got the geriatric assessment?

Supriya: Everybody got the geriatric assessment. In the usual care arm... so the arm that the practices that were randomized not to the intervention, the oncologists only got information about screening positive for depression or cognition that's it, and they got kind of a trigger. So, ethically we felt that we had to at least tell the oncologist those things, but in the intervention arm we had a web based summary that was printed out, plus a list of recommendations for each domain impairment, and it was tailored for each patient. So, for example if a patient had a fall, it would print out in the summary your patient had a fall, this is why falls are bad for older patients with cancer, and here's what you can do about falls. That summary was provided to the oncologist and the oncologist could choose what they did with a summary or the recommendations because we can't really tell... I mean they're the doctor for that patient, so we couldn't tell them you had to do X, y and Z. But they had the information at their fingertips to decide what to do next.

Eric: Alright, so you gave information to oncologists, they screened positive, these are why it's important and these are some things you could do about it. Did the caregivers or the patient get any information too or is it just the oncologist?

Supriya: Yeah, they got the printout also in intervention arm. So, they would get their summary plus the recommendations.

Eric: And for those folks in the usual care arm, screened positive for depression or cognition did they-

Supriya: In fact that's usual care.

Eric: But they got... your patient screened positive, did they get any recommendations? Like hey you screened positive for cognition.

Supriya: No.

Eric: It was just you screened positive.

Supriya: Yeah, we told the clinicians that your patient screened positive for cognition and depression, and it was usual care and that's what happened. I mean honestly in oncology most patients aren't screening anyway, so they knew at least ethically that people had that information that had those problems.

Melissa: And then Supriya and William, what were your primary outcomes? What did you compare between the two groups?

William: I'll just mention some of them. The main thing was... this is designed to get people talking to each other, make the communication intervention right. So, most of the time as Supriya said, you can get all this information but nothing happens. These are busy practices and clinicians who are there. So, the goal was just to have conversations and to have conversations about these aging issues if possible. So, one of the main outcomes was did that happen? And that did happen. Officially 3.5 more discussions in the intervention group than the non intervention group is was discovered and about these aging discussions. The next thing would be sort of were the conversations of quality or was it just passing mention? Oh, they failed. Okay, great we'll let somebody know, but not with more in depth. And there was a way to assess this, I believe from expert analysis that this was a "high quality conversation." So, on average there was two more of those in the intervention arm, so not only were there more conversations, they were more in depth and had a more strength to the conversations.

William: And the last main finding was about satisfaction so that the patients on a standard scale were much happier as were the caregivers I believe, with the direction that they had with the doctor. So, in this world of patient satisfaction to perhaps to people surprise they're actually happier that somebody spent time on these things in those busy clinics where they tend not to. So, Supriya I think I got those right.

Supriya: Yeah. And what we did just to assess the communication, was we audio recorded one clinic visit after the geriatric assessment was done in both arms. So, we had 540 audio recorded clinic visits which we still have, and we transcribed them and we had blinded coders go through and look for conversations about aging as William said. Did they talk more about cognition and memory? Do they talk more about balls? And if they did, did they also mention interventions? Did they say we're going to get PT and home safety involved? Or do alert... happen alert wrist... necklace if you're on chemotherapy and you're at risk for falling. So, they did talk more about those things and in addition as William said, both patients and caregivers are more satisfied with that one interaction, three months after that audio recorded clinic visit up to three months later.

Supriya: And I think clinically we know... especially us in the geriatric oncology world that our older adults and their caregivers are concerned about these issues. When the oncologist is saying you need this chemotherapy, what they're thinking is, is this going to affect my memory? Am I going to fall down more or am I going to need more help in the home but they are not sure... patients and caregivers are not sure that those are relevant concerns so they don't bring them up on their own. And what the intervention did was guide those conversations so that everybody was sort of talking about it more, the concerns were being elicited and discussed in a high quality way that inform patients and caregivers and made them more satisfied with care.

Eric: So, can I ask you when I see scales like this, the modified healthcare climate questionnaire with a scale of zero to 28. I have a hard time trying to figure out like is this a clinically meaningful change in satisfaction?

Supriya: That's a great question-

Eric: This is what I see -- survival or mortality or some other kind of harder outcome I can say, It's not that big of a difference. So how big of a difference was this in the satisfaction? Is that even a reasonable question to ask?

Supriya: Yeah, no it absolutely is. The JAMA oncology viewers asked it, so for sure it's reasonable, and I think... when we think about patient centered outcomes, what's important to patients. So certainly survival is important and that is something that oncologists care about too, but when you ask patients who are older about survival, only about 50% of them say that survival is their most important endpoint, and that's guided our discussions about clinical trial endpoints. So, when we think about what patients want and caregivers want, when we were designing the study we asked them so we have a board called scoreboard it's led by patients. It's part of... I can let William talk about this but part of our infrastructure grant for the cancer and aging research group.

Supriya: They told us that they care about what's talked about in the room, like this is what... they want a good conversation with their doctors about aging when they're thinking about high risk treatments. And so that was why we picked satisfaction, there aren't great tools for satisfaction they all have sealing effects. But in addition to the small difference in the scale and between arms, we also look the proportion of perfect scores versus less than perfect scores, and that was also clinically significant by quite a bit. So, I think almost 15% of patients difference between the arms, more patients had perfect scores completely perfect scores in the intervention arm than they did in the usual care arm. And so we do think that it's hard to move satisfaction scores actually in studies, and we think that because we were able to move it even that much that there was some value there.

Supriya: In addition, it's hard to change physician behavior even in the intervention arm, if the oncologist didn't care about the summary they wouldn't have used it, like they would have just thrown it. Like we didn't tell them what they had to do, they could have just thrown it on the desk and walked away. But the fact that they actually took it into the room and used it, I think showed that they cared about it because we can't make doctors do anything they don't want to do.

Alex: Right, right. Well, so my question is... I want to commend you first of all for doing this study in community settings with people who are not only older but older and have cancer and their caregivers, incredible and doing this intervention collecting outcomes. It seems to me like that the communication... and it's terrific that they had an improvement in discussions around aging related concerns, high quality conversations and improved satisfaction. But if you could wave your magic wand and say like, here's Eric's magic wand going. Like here's what I really want to know, like does this do x? Does it do Y? What are those sort of downstream outcomes that you care about most? Or Melissa, you might want to chime in here. What are you looking to see that's going to come convince people that hey, this makes a difference in patients lives. What would those outcomes be?

William: Can I say a couple things I definitely want to hear what the outcome of choices from my colleagues, but you said something really important and I just want to make sure I double down and say this to Supriya and she knows it. One of the big objections to doing this kind of research is you can't enroll people over 70 years old which is what the group was, you can't enroll people with disabilities into cancer clinical trials which is why we don't have enough of these kinds of trials. And if this study did nothing else to enroll 500, 600 patients and their families into the trials who were 70 with a disability, they did that in under PCORI grant in three years, maybe a little more. And that alone I think just proves the case, it's not that people who are in these categories don't want to be in trials, that's really on us and that we need to do that more and whatever answer we got, and this is a good answer in my opinion, that alone is important and needs to be propagated especially through places like NCI where we do too many studies with the patients who don't get these diseases.

William: So, it's really important that that enrollment be propagated forward. I know there's more to come on sort of outcomes of choice for Supriya, and I want to put my money down on that older people care about functional outcomes, and that's what they care about as much as survival. If you have to choose something, people want to be functionally independent. And if these conversations lead to more people who are functionally independent, that's what I would love to know. I'll stop there and let Melissa or Supriya weigh in on their favorite.

Alex: That's good William because you only had one magic wand so you've just used yours.

Supriya: I have for a different one so I'll let Melissa talk.

Melissa: Well as someone who studies functional status in older adults with lung cancer, I think function is a very important outcome for older adults as well. We've heard that in a lot of our qualitative studies, but I think cognition is also a very important outcome, and it really is required to help patients live independently. So, I would say preserving their function and then also preserving their cognition are two very important outcomes.

Supriya: So, I'll do mine. I agree with both William and Melissa. We hear this over and over. In fact I just had two or three patients this morning and I asked, "What do you want? Would you take treatment that would help you live longer but it would impact your function or cognition negatively?" and both of them said no. And it was with their families who heard that for the first time even though they've seen multiple doctors previous to my appointment. And so it is very important to patients and we know this from a lot of studies. One of the goals of this PCORI funded study was to get patients and caregivers asking more about geriatric assessment. So, there was actually quite a bit of news around this study and I think if a patient saw a news article about this and said, well, this improves conversations and people are more satisfied, they might go to their oncologist and say, "Why aren't you doing this with me?" So, I actually think that might be very powerful in our community to get patients and caregivers starting to ask for it.

Supriya: But to get clinicians, to get oncologists onboard I think we do need clinical outcomes and there... as William hinted out there's several ongoing large or randomized clinical trials looking at geriatric assessment and the effects of geriatric assessment on chemotherapy toxicity. We know that using geriatric assessment can help us identify patients at highest risk for serious toxicity from chemotherapy or post operative complications. But in medical oncology it would be can you lower chemotherapy toxicity without compromising survival when you use geriatric assessment, and if we can show that perhaps oncologists would buy in more because those are the things they look at.

Alex: Yep, that's terrific. And I also don't want to downplay the importance of communication, Of course in geriatrics and palliative care communications is an incredibly important outcome. So, to the extent to which we can activate patients and caregivers and get them talking with their oncologist about geriatric issues that's all to the good. Eric you had something?

Eric: So, I guess like another question is, what's the right way to do the geriatric assessment?

Supriya: Oh, that's a good question.

Eric: When you're thinking about this in like a working clinical practice outside of research, like who's doing the geriatric assessment? Should a geriatrician or a palliative care doctor or NP or somebody from the team be involved in either the assessment or kind of the outcomes? Again I'm giving you more like those magic wands right now, like if you had to think about what it should look like, Like what should it look like?

Supriya: I'm going to let William take this one cause he's done working.

William: Yeah, this a perfect question and a very challenging one, I'll say maybe I'll think of Aladdin's lamp and get like three choices.

Eric: I'm going to give you three. I'm going to give you three. It's your lucky day.

William: Instead of just the one magic wand, I know we're in the Harry Potter World but I'm going to shift to Aladdin a little bit. So I would... some of this is dependent on where you are, but the truth is we're in a world in oncology. They are very busy and they are admittedly trying to jam a lot of things into a small amount of space. So, the right person to do this sort of standardized validated tests is not a doctor in the clinic. It has to be done preferably before the clinic whether it's in the waiting area, or even on a tablet computer someplace else, as long as the tools are validated tools ... most of the information I'll say 80 to 90% should be gotten in some other way.

William: That can then be used to stratify things in a number of ways. And while we could talk later but to translate this into guidelines is something we've done through ASCO and published like, here's what you should do if you're an oncologist in the community, these are the high yield screening tests to do and that should be done by somebody else, and it can largely be self reported. Within that my other wish would be, you need a little bit of performance assessment because PRO's alone and these are basically PROs.

Alex: What's a PRO?

William: Patient Reported Outcome.

Alex: All right.

William: So, you ask the patient directly and they tell you this is what it is, I'm feeling this way, I'm not... my mood isn't so good. I'm not functioning well at home. But it highlights why that alone might be of concern, if they have cognitive impairments they may not be able to report as accurately and you would need other information say from the caregiver. And another thing we're advocating is some performance assessment in clinic, some physical functioning in clinic like a gate speed test, or somebody walks and we time them and see how fast they can walk, or a standing test where you can see can they stand up and sit down in a good way and time them and get information, because I know I've had this experience and you guys can tell me if you do or where you ask the patient, "Hey, how you doing at home? You able to do what you need to do?" And I'll say he says, "Absolutely no problem." And whoever is sitting behind them is shaking their head no, no, no, because they know they can't do those things.

William: And so the accuracy of their reporting is something we have to ensure with some more objective testing. So, that would require a little more training, again most nurses or even nursing assistants can do it.

Eric: And that's what you did in the study, right? Cognition and function were not patient reported right?

Supriya: Correct. We did a mini-cog for the cognition test and we did both TUG and SPPB. We timed up and go in short physical performance battery and we trained... we offered to train clinical staff but most of it was... they get research staff funded through the NCI, most of it was research staff. Now that the study is done they're knocking on our doors. Honestly, a lot of the clinicians and sites want either another study or they want us to train their advanced practice clinicians to do this. William and I get emails every week like how do we do this? And so we're really trying to figure out how to implement, it's challenging.

Eric: And do you have... can we access what tools you actually use for your assessment? Like what did you do for nutrition? What did you do for-

Supriya: Yeah, it's in the supplement for the paper but there's also... I think William through ASCO is putting together some education materials that will be available to oncologists through ASCO. I don't know William if you wanted to speak about that?

William: If it's okay I'll just say it briefly so it would be as a consequence of this as Supriya said, we get asked all the time, like what tools and what are the shortest ones? And what can we get from this? So one will certainly send the guidelines in the guidelines that Supriya lead and that Arti and I were... and many other people were part of. We sort of say here's the domains and here's the tools you should use, and we picked them based on practicality in the clinic. And I'm not sure they're exactly what was in the study, but they're pretty close to them.

William: And so we've done that much, and then this summer at ASCO we're going to do an actual workshop at the request of ASCO in which we show them how easy it is to do these tests in a short amount of time. And if you guys want them we'll send you that information because we think it can and it would be great to get more people who know about it, not only to use them but to kind of use the same ones. So, we can learn the same thing from different places.

Eric: Great and we'll have links to that on our Geripal website, both the supplement and the ASCO recommendations.

Melissa: And supriya and William, for geriatricians and palliative care clinicians who are listening perhaps who are taking care of older adults with cancer in the community and they don't have an established geriatric oncology collaboration with their colleagues, what would be a good first step for them to learn a little bit more about how geriatric assessment can help with the care of older adults with cancer?

Supriya: There's a lot of resources and I'll let William talk about our cancer and aging research group William, which is a huge resource for people interested in just learning more and we can put them in the right place to get more information and actually teach the oncologist where they're working about geriatrics, which is really what's important here.

William: But we always try to make the card or cancer and aging group website available, so there's a lot of resources posted there, and we're going to continue to enhance that. So, that as Melissa knows is a great place to start. Again the guidelines as we mentioned... there's also a group that I'm increasingly referring people to if they just want a starting place, which is what's called the ACCC, it's the Association of Community Cancer Centers. And they have a really nice website too and that's quite practical. So, those are all places people can go. I feel like this is also the place, Melissa, to say, in your local community before you start screening people and doing these things, I think it's great to talk about... but you do have to do a bit of an assessment at your local location, so that you can see that if you discover these things, you actually have a response.

William: I think it's disservice for patients if we do this and we say, "Hey, by the way in addition to cancer, here's some other things that are really a problem but we don't have a way to help you very much, including identifying community resources." So, when I go in and talk local community sites, I'm like What do you have here? Let's focus our screenings on what we can help you with, and not on things that are just going to generate frustration.

Eric: It's a very important point. We don't want to screen for things where we don't have treatments for. Are we at the stage now where we can recommend targeted geriatric assessment for all older adults with advanced cancer? I say targeted based on what you just said William, about needing to have a plan that you can execute at your local community oncology practice, or do we need more information before making such a recommendation?

Supriya: I would strongly say that Melissa, William and I think all patients who are older... 65 and older who are considering any cancer treatment should be considered for geriatric assessment, and we've designed practical ways to do that. Again thinking through locally what would work of the ASCO guidelines, American Society of Clinical Oncology guidelines, the highest evidence of data is in patients receiving chemotherapy. So, even stronger recommendation is for anybody... any older adult considering chemotherapy should definitely get a geriatric assessment given the data.

William: I would agree with the targeting as well, I don't think we can say given the practical constraints we're not quite ready to say everybody needs a complete geriatric assessment. But I think targeted assessments, these tools everybody essentially should get that the evidence is there now for that.

Eric: So, my last question is... I guess this one's for William, William you've done a lot about like integrating geriatrics, like actually having a geriatrics practice within oncology. Is there a role for that? Or is this really where we're heading where you don't need a geriatrician, you give people the tools, the assessments to do this and that's good enough.

William: Yeah, I'm going to say that and I'd throw palliative care in there as well. I think there's always going to be a role for specialized attention to older adults and people with advanced disease, but that those practitioners who are the specialists who really are best at that in my clinic, I say these are the patients I want. We are the best people to take care of them just like any other specialist. So, primary geriatrics, primary palliative care I think can be done in many ways using these other tools, but when it comes down to taking care of people who need the specialized attention from a geriatrician, that's what I would call in my Aladdin's lamp last wish, is that we had a system that got patients to those specialized practitioners who really can help them and a system that allows it to happen just like we'd send them to a specialized surgeon or a specialized cancer doctor who knows the most about that particular thing.

William: So, I think there's always going to be a place for that. It's just we need a much better way to get the right patients in the right place at the right time.

Alex: Melissa has got the last question here.

Melissa: Yeah, now that we have seen the geriatric assessment with this intervention is able to improve some very important Patient Centered outcomes. What are your next steps? What are we looking forward to in geriatric oncology, for either other outcomes to study or for ways to help community practices implement this?

Supriya: As I mentioned earlier, there are probably... there's two United States studies that have finished accrual that should be... data should be disseminated within the next year. And then there... and these are large studies looking at other outcomes like chemotherapy toxicity, functional outcomes, quality of life for patients receiving high risk cancer treatment, and then there's also several international randomized studies. There's one in Canada, one in France and I believe there's another one that I'm probably forgetting about but also looking at outcomes like chemotherapy toxicity and quality of life. Interestingly, the models are different in these different studies based on healthcare system in the United States. Given that there's no geriatricians in the community are very few that the oncologists have access to, still kind of giving stuff to the oncologist but there are other models where nurse practitioners are used, and in Canada for example geriatric oncology specialists aren't going to be the interventionalist.

Supriya: So, we'll learn something about from all of these studies that will come out hopefully in the next few years.

William: From my side I just want to say it's going to be intervention... it's going to be intervention research, wide interventions work and implementation research, which care models do we need to put in place to make a difference once we've discovered these issues, and the new data will help define those interventions and implementation issues, that's the future for geriatric oncology.

Supriya: Yeah.

Alex: That's great, it's very encouraging. I'm glad we're already moving in that direction. Dissemination, implementation, how do we tailor it for community practices etc. What does the team look like? All these important questions.

Eric: Yeah and I think it has this huge implications for geriatrician and palliative care teams like thinking about integrating geriatric assessments, that's why I really love this study. So, I want to thank Supriya, William, Melissa for joining us.

Alex: Thank you so much.

Eric: But before we leave Alex-

Alex: A little bit more?

Eric: I know you've been eager.

Alex: I'll try this. Attempt number two.

Alex: (singing)

Supriya: Nice job.

Alex: Thanks.

William: That's awesome you guys.

Eric: Thank you again for joining us. Thank you to all our listeners for joining us on the podcast as well.

Alex: Thank you to Arch Stone Foundation.

Eric: And with that, goodbye everybody.

Alex: Bye folks.

Melissa: Thank you.



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