The global population is aging rapidly. Currently, there are more than 703 million people worldwide aged 65 and older, representing 9.1% of the global population. It is estimated that this percentage will grow to 15.9%—1.5 billion people—by 2050.1 And with that growing aging population will come increased incidence of cancer—a disease that occurs in more than 50% of adults older than age 65—requiring tailored treatment and support.1
According to GLOBOCAN 2020, in Portugal, more than 60% of people newly diagnosed with cancer are aged 65 and older, making this population the most commonly seen in an oncology practice in that country.2 Yet in a national survey of health-care providers from various medical specialties treating older patients with cancer in Portugal, 62.6% of the respondents reported the absence of geriatric oncology and/or geriatrics consultations at their institutions, 14.9% reported having guidelines for the management of older patients with cancer, and just 4.5% reported having a physician dedicated to geriatric oncology in their hospitals.3
To help remedy this situation, Filipe Coutinho, MD, a medical oncologist and palliative care physician at the Centro Hospitalar do Médio Ave in Santo Tirso and in Vila Nova de Famalicão, Portugal, launched the Geriatric Oncology Working Group of the Portuguese Society of Oncology in 2020. “Our goals are to promote and raise awareness among all physicians about geriatric oncology practice in Portugal, contribute to the investigation and establishment of consensus and protocols in the field of geriatric oncology, and endorse a multidisciplinary articulation at a national level, with the perspective of the creation of medical centers aimed at geriatric oncology,” said Dr. Coutinho.
In a wide-ranging interview with The ASCO Post, Dr. Coutinho discussed the importance of improving health literacy in geriatric oncology and the use of geriatric oncology screening tools in Portugal, the obstacles in providing early referral to palliative care services to some patients, and the strategies he uses to communicate difficult news to patients with advanced cancer.
Caring for Older Patients With Cancer
Multiple organizations such as ASCO, the National Comprehensive Cancer Network, the European Organisation for Research and Treatment of Cancer, and the International Society of Geriatric Oncology recommend the routine use of a comprehensive geriatric assessment among older patients with cancer before starting treatment. Please talk about the state of geriatric oncology in Portugal. Are there new geriatric assessment tools being developed for patients with cancer?
The population in Portugal is aging, with life expectancy being around 81 years old, and with that aging population comes increasing numbers of patients with cancer. We noticed that at least 21% of the population in Portugal is 65 or older, and together with Spain, Portugal has a higher incidence of cancer than other countries in Ibero-America. We were also aware of the lack of geriatricians compared with the elderly population in Portugal, with a ratio of 31,590 older patients per one geriatrician, compared with about 9,039 older patients per one geriatrician in Spain.4
In Europe, there are countries where geriatrics is a specialty or a subspecialty and other countries where it is a competence. In Portugal, geriatrics is not recognized as a medical specialty but as a competence by the Portuguese Medical Association, and there are few geriatric physicians with training in oncology to care for elderly patients with cancer.
We need a national plan to ensure that geriatric assessment is part of the standard of care for every older patient with cancer.— Filipe Coutinho, MD
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The results from a national survey of health-care professionals in Portugal found that although nearly all those surveyed, 95%, said there is a need for more education regarding geriatric oncology, as well as additional training in this field; 23% of respondents reported using any geriatric scale to assess elderly patients with cancer; and 8% of respondents had never heard about geriatric assessment. So, we have a lot of work to do to improve those percentages.3
Since we launched the Geriatric Oncology Working Group (GTOG) as part of the Portuguese Oncology Society, in 2020, we have partnered with the International Society of Geriatric Oncology (SIOG), Oncogeriatrics Group of the Spanish Society of Medical Oncology, and the Geriatric Study Group of the Portuguese Internal Medicine Society. These collaborations are important to provide training and funding for research in geriatric oncology. And we are starting to see some progress. Over the past year, six Portuguese oncologists have taken part in the SIOG Advanced Course in Geriatric Oncology, in addition to three more who had completed the course previously, and others are being trained throughout Europe in centers with experts in geriatric oncology.
In addition to increasing the number of geriatric physicians to reduce barriers to this care, we need to build in more time in clinical visits for this evaluation and need a national plan to ensure that geriatric assessment is part of the standard of care for every older patient with cancer.
Establishing Palliative Care as a Health-Care Right
How is palliative care used in Portugal for patients with cancer? Is it considered at diagnosis to reduce side effects from treatment and provide psychosocial care if needed?
Palliative care is used to provide the highest possible quality of life for patients after a diagnosis of cancer. However, although palliative care is more and more recognized as an integral part of oncology care, especially in the advanced-care setting, there are many obstacles to accessing this care in early-stage disease. Some of the barriers include hesitancy by oncologists to refer patients to this type of supportive care, because there are misperceptions that palliative care should be delivered only in the later stage of disease.
In addition, oncologists worry that offering palliative care to patients denotes a sense of hopelessness because it is often associated with end-of-life hospice care. Another barrier is the lack of time during a clinic visit to discuss palliative care with patients and the lack of reimbursement for these consultations.
In my opinion, medical oncologists must integrate health communication strategies and basic knowledge of palliative care services in their assessment of patients with advanced disease, so they can provide these services to patients and their families. In Portugal, we have a strategic plan for palliative care that was prepared by the Portuguese National Commission for Palliative Care, in 2016, and that established palliative care as a citizen’s right and called for the full integration of palliative care into the Portuguese National Healthcare System in all levels of care, including primary health care, hospital health care, and integrated continuous care.
I am part of a palliative care support team in my hospital, so I drive two cars. I’m a medical oncologist and have specialized training in palliative care. Palliative care teams here must include at least a physician and a nurse with advanced training, a social worker, and a psychologist with training in palliative care. It is projected that more than 81,000 people in Portugal will need palliative care in the future, and our goal is to increase the number of hospital palliative care beds as well as the number of home and hospital palliative care support teams to accommodate these patients.
Effectively Communicating Bad News
You have an interest in medical education focusing on delivering serious news and in the patient decision-making process. Please talk about the communication strategies you use to deliver bad news to patients and how you help patients become more active in shared decision-making.
Effective communication between patients and their providers is the key to improving physical, emotional, and other health outcomes. In my opinion, medical oncologists must integrate health communication strategies and basic palliative care into their oncologic assessment of patients with cancer, especially for those patients with advanced disease.
I use the ASCO guideline on patient-clinician communication5 to have honest, effective communication with my patients and their family members. I also follow the “ask-tell-ask” principle to assess what the patient already knows about his or her situation before giving additional information. I use the six communication steps described in the mnemonic SPIKES listed here:
Setup—The physician is prepared with the patient’s medical facts and has a plan for delivering the news.
Perception—Find out what the patient’s understanding is of the medical situation and how much information the patient wants.
Invitation—Ask permission about whether now is a good time to discuss the news.
Knowledge—Be direct in explaining the medical situation and use language that matches the patient’s level of education.
Empathize—Use empathic statements to respond to a patient’s emotions. For example, “I know this must be disappointing for you.”
Summarize and Strategize—Summarize the clinical information and make a plan for the next step, which may include further testing or a discussion about treatment options.
After each transition point, for example, when changing treatment or when there is a change in prognosis, I ask the patient what his or her expectation is for outcome and what the patient understands about the current medical situation. If the cancer is progressing and active treatment is no longer effective, I establish the prognosis that allows the patient to prepare for end-of-life care and communicate the benefits of palliative and hospice care to alleviate symptoms, pain, and anxiety. The goal is to improve the quality of life for patients as much as possible until the end of life.
DISCLOSURE: Dr. Coutinho reported no conflicts of interest.
1. Union for International Cancer Control: Cancer and ageing. Available at www.uicc.org/what-we-do/areas-focus/cancer-and-ageing. Accessed June 5, 2023.
2. Sung H, Ferlay J, Siegel RL, et al: Global cancer statistics 2020: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 71:209-249, 2021.
3. Marinho J, Custódio S: Geriatric oncology in Portugal: Where we are and what comes next—A survey of healthcare professionals. Geriatrics 7:91, 2022.
4. Soto-Perez-de-Celis E, Cordoba R, Gironés R, et al: Cancer and aging in Ibero-America. Clin Transl Oncol 20:1117-1126, 2018.
5. Gilligan T, Coyle N, Frankel RM, et al: Patient-clinician communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol 35:3618-3632, 2017.