As our population rapidly ages, the burden of cancer incidence increases accordingly, creating an urgent need for greater and more incisive research on the diagnosis, treatment, and survivorship issues for older adults with cancer. Given the numerous challenges faced by today’s busy oncologists, a team of geriatric oncologists examined whether there is adequate access to geriatric specialty care in community oncology practices across the United States. The ASCO Post recently spoke with the lead investigator of this study, Grant R. Williams, MD, MSPH. As both a geriatrician and oncologist, Dr. Williams has conducted research focused on refining treatment selection and improving the outcomes of older adults with cancer.
Grant R. Williams, MD, MSPH
The Intersection of Aging and Cancer
Please tell the readers about your current position and work.
I am Assistant Professor in the Division of Hematology/Oncology and Gerontology, Geriatrics, and Palliative Care at The University of Alabama at Birmingham (UAB). In my work, I’m a geriatrician/oncologist who studies the intersection of aging and cancer. Clinically, I am a gastrointestinal oncologist and Director of the Cancer and Aging Program at UAB. That said, I predominantly do research, and my goal is to improve the care and outcomes of the growing number of older adults with cancer.
My research involves the use of geriatric assessment and novel biomarkers, such as molecular markers of aging and body composition, to better evaluate functional age and develop interventional clinical trials to improve the tolerance and outcomes of older adults undergoing cancer treatment.
Focus on Community Practice Setting
You and your coauthors recently looked at the capacity to provide specialty care in the community setting for geriatric patients with cancer. Has this issue been examined in other studies?
The issue of capacity for care in the older adult population within the community oncology practice setting has not been well observed in the literature. For one, the geriatric oncology discipline is relatively small, and, unfortunately, there are fewer and fewer people being trained in the field of geriatrics. As I see it, the assumption is that the community setting is lacking properly trained oncologists with expertise in assessing the special needs of the geriatric oncology population, nor do they have easy access to geriatrics specialists for comanagement. However, to my knowledge, there are no solid data to support this assumption.
Study Design and Findings
In a nutshell, please describe the study design and its findings, also shedding light on the National Cancer Institute Community Oncology Research Program (NCORP).
This was a unique opportunity to look at the availability of practitioners in the community setting who have expertise in the special needs of geriatric oncology patients. We used the 2017 NCORP landscape survey, focusing on data from approximately 1,000 community practice locations within the United States.1 Its purpose is to conduct multisite trials essentially centered around cancer prevention, screening, and delivery. The NCORP network comprises 7 research bases and 46 community sites, 14 of which are designated as minority or underserved community sites. The survey was conducted over various years to assess the capacity of care within their network of institutions and practices to further their own cancer care research ability on a more granular level.
If you looked at the 504 community practices as a whole, only about 5% really had access within the oncology clinic to geriatric specialty care.— Grant R. Williams, MD, MSPH
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We were able to use the results from the most recent NCORP study to examine the question of whether community oncology practices have the capacity to provide geriatric specialty care for older adults with cancer. A total of 504 of the approximately 1,000 practices in NCORP responded to our survey.
Our first question centered on whether respondents had access to a dually trained geriatric oncologist at their site. Unsurprisingly, only about 2% of oncology practices had a geriatric oncologist on staff.
Then, we asked whether they had a geriatrician available for consultation or co-management. About 37% of sites noted some availability to geriatric services; we then drilled down a bit more, asking where these providers were available, and we found just 13% of these sites had availability to geriatric services within the clinic. Most had to reach out to an affiliated hospital to have access to geriatric services or only had access within the inpatient hospital setting. So, if you looked at the 504 community practices as a whole, only about 5% really had access within the oncology clinic to geriatric specialty care.
Were there factors that predicted which practices had access to geriatric specialty care?
It turned out to be a size issue. Clinics that had more adult patients with cancer happened to have more access to specialty geriatric resources. However, otherwise, demographic issues around geography and specific factors about the clinic’s functionality were not predictive of whether they had in-service availability to geriatric services. Although the community practices were lacking in specialty geriatric services, we found that they provided a multitude of other key services valuable to older adults with cancer, from such specialists as nurse navigators, social workers, pharmacists, and dieticians.
What are the takeaway points from the study and their practical application in community practices?
Given that only a small minority of community practices across the country have access to geriatric specialty care, we need to develop models of care that use patient-reported measures and other geriatric screening tools to evaluate and guide interventions for older adults with cancer. Since geriatric consultations require specialists, who are currently absent in the community, for the most part, the use of properly crafted tools and expanded education to the oncology team is probably the most practical way to ensure better care for this vulnerable population. The bottom line on a clinical level is that we need to develop better ways for practitioners to comprehensively assess these older adults and personalize their care in the absence of a specialty geriatrician, without putting undo stress on the community oncology team.
COVID-19 and Older Patients With Cancer
The COVID-19 pandemic has created access challenges for patients with cancer, none more so than in the geriatric population. What do we know about this issue? Has telecommunications helped this population keep older patients connected with providers?
Since the risk of serious health effects from COVID-19 are greatly heightened in older patients with cancer, we’re seeing a lot of routine care such as mammography and colonoscopy being deferred. Necessary care in the treatment scheme is also being affected, and, in time, I think we’ll have the data to quantify the results.
That said, over the past decade, telecommunications have really advanced. A lot of our patients who travel for an hour or more for their routine visits can now have many of those services handled by phone or online video conferencing. There are, however, issues regarding connectivity in our rural populations that need to be addressed. However, on the bright side, because of the COVID-19 pandemic, what we’ve accomplished in telecommunication services for our older patients with cancer over a few weeks would have normally taken a few years.
What we’ve accomplished in telecommunication services for our older patients with cancer over a few weeks would have normally taken a year or so.— Grant R. Williams, MD, MSPH
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The Geriatric Oncology Community
Our population is aging, which will burden an already-stressed cancer care system. Any thoughts about dealing with this challenge moving forward?
The geriatric oncology community is relatively small; in fact, I probably know nearly everyone in the field. In large part, that closeness is due to the efforts of the late Arti Hurria, MD, FASCO; she worked to create the Cancer and Aging Research Group, which connects geriatric oncology researchers across the nation in a collaborative effort to improve care for our older patients with cancer. Her untimely death was a huge loss to the community. We are trying to use her memory as a reason to continue the things she began, such as biweekly calls to keep us connected, with the goal of actualizing her goal of improved and personalized care for the growing number of older adults with cancer.
The science is getting better; we’re past the geriatric 101 phase. At the 2020 ASCO Annual Meeting, four randomized trials were presented examining various aspects of geriatric focused interventions that demonstrated improvements in quality of life and reduced chemotherapy toxicities. We now know that to improve outcomes in this older population, we need to look at the existing models of care and take steps to improve them. Since we’re a small field, we have to use our resources wisely, and building better, easy-to-access assessment tools is vital.
One concern is that the geriatric field is not expanding enough to address the growing needs of our aging population. ASCO and other organizations are making an effort to address this issue. I am Co-Chair of the ASCO task force on older adults. We recently published an article in JCO Oncology Practice2 highlighting a large survey, including more than 1,000 providers, to evaluate how oncology providers report caring for older adults with cancer, with a focus on the use of a validated geriatric assessment. We drilled down into the major concerns, and I think the most important takeaway from the survey was that guideline awareness was associated with a two to four times increased use of geriatric assessment and differing perceived barriers. There’s work ahead, but it’s a great field to be in, especially now when the need for geriatric specialists is more pressing than ever.
DISCLOSURE: Dr. Williams has received honoraria from Cardinal Health and Carevive Systems.
1. Williams GR, Weaver KE, Lesser GJ, et al: Capacity to provide geriatric specialty care for older adults in community oncology practices. Oncologist 25:1032-1038, 2020.
2. Dale W, Williams GR, MacKenzie AR, et al: How is geriatric assessment used in clinical practice for older adults with cancer? A survey of cancer providers by the American Society of Clinical Oncology. JCO Oncol Pract. October 15, 2020 (early release online).