For Ashley Rosko, MD, a hematologist and clinical physician at the Cancer and Aging Resiliency (CARE) Clinic at The Ohio State University Comprehensive Cancer Center, treatment recommendations for patients with cancer should be more than just a number. Rosko, who is part of a seven-member team that provides comprehensive care to older adults with cancer, urges clinicians to view patients for total health-not simply age.
Identifying Biologic Markers
"When working with older patients with cancer, it's important to be able to identify factors that influence treatment outcomes," Rosko said. "By looking at age-related factors, we know the criteria to estimate risk and prognosis. There are many factors related to aging that influence outcomes, and it may not always be easy to quantify as an oncologist."
At the CARE Clinic, Rosko is just one member of a team that works to look at a variety of factors that could impact a patient's ability to tolerate treatments that have traditionally been identified as too harsh for the older population, such as chemotherapy, radiation, or surgery.
"By taking a clinical approach to aging to estimate and gauge physiologic fitness and biologic fitness, we can explore and identify markers that predict tolerance for therapies for cancer care," she stated. "It's important as cancer doctors to be able to estimate patient and individual risk of tolerance and toxicity for each treatment independent of chronologic age."
In the current literature, Rosko noted the definition of older adults is arbitrary. For example, a 50-year-old patient in the U.S. with leukemia may be considered "older," while a patient in Germany with lymphoma may not be considered "older" until age 80.
"In the literature, the term 'older' is often centered around age 65, but that doesn't make sense as there is not necessarily a large difference between ages 66 or 64-it is simply a way of society to place emphasis on aging."
Rosko instead recommends abolishing those antiquated age-based decisions in clinical trials and clinical decision-making. "Age 65 does not define being older," she reiterated. "The important piece of the work is being able to focus on an individual, independent of age, to assess risks of treatment tolerance."
To do so, Rosko collaborates with a lab that focuses on molecular markers of age, such as peripheral blood T-cell markers and changes in molecular markers over the course of time.
"Biomarkers of age, such as telomeres, nutritional markers, and inflammatory markers, have been commonly evaluated in the past as indicators of age. But importantly, when it comes to biomarkers of aging, the standard definitions have to be reproducible, independent of the disease process itself, and testable," she said. "Specific molecular markers are able to better characterize someone's physiologic age, and we must continue to explore those factors to quickly, consistently, and more predictably identify a patient's physiologic age through blood tests."
Providing Comprehensive Care
At the CARE Clinic, the multidisciplinary care team, including Rosko, provides a one-stop shop of sorts for patients entering the clinic. Patients remain in one room for an approximately 2-hour appointment, where they are visited by a rotating team of seven care providers.
A physician speaks with patients about how cancer has impacted their lives as a whole, including quality-of-life assessments such as related syndromes like fatigue, insomnia, and falls. A physical therapist is able to examine patients in the clinic to quantify fitness such as level of strength and balance impairment using reliable and validated tests that are independent of the typical "How are you doing at home?" question that is commonplace at clinics, Rosko said. An in-clinic audiologist in a sound booth provides an assessment to test and identify if there are hearing deficits, ensuring patients are able to hear and understand their providers and care teams.
In the same room, a nutritionist completes full testing of nutritional barriers to determine if a patient requires supplements or appetite stimulants. A case manager focuses on access to care, including travel, transportation, financial limitations, medicine assistance, and an interview with caregivers to discuss possible declines in patient cognition or other conditions the patient may not have reported. A pharmacist reconciles medicines quickly and reliably, with a common focus on changing or deprescribing medicines that are no longer indicated, are incorrectly dosed, or may be a duplicate of another medication. Finally, a nurse specializes in cognitive testing that may affect language, processing, anxiety, or depression.
"Together as a team, we approach patient care in a unique way where we are in the same room at the same time, rotating among patients, to avoid sending a patient to seven different places," Rosko said. "Under one single roof, in one single visit, we provide a complete assessment that is then sent to the patient's doctor, while ensuring that if someone needs something, such as physical therapy, occupational therapy, nutritional intervention, or medicines for anxiety or depression, it's taken care of at the clinic."
Undertreatment of Older Adults
By taking a comprehensive assessment of a patient's whole health, Rosko and her team are able to make recommendations based on the individual patient, not simply the patient's age.
"Treatment recommendations that are based on biologic markers help afford treatment to patients who didn't think they could be tolerated otherwise," Rosko said. "There are a lot of older adults who are either undertreated or never treated for their cancer. Something that is becoming increasingly relevant as the number of older adults continues to grow and expand is that we don't treat patients based upon their age alone. Instead, we find those patients who can tolerate therapies, but based on age alone would not have been previously thought able to do so."
For clinicians who treat older adults with cancer and wish to embrace a more comprehensive picture of a patient's physiologic age, Rosko recommends reconsidering institutional guidelines.
"If you are participating in clinical trials and there are upper age limits, really question that and see if the patient as an individual is reasonably able to tolerate treatments," she said. "Given the aging demographic in the U.S., being able to improve patients' quality of life and help in ways that are age-related is important to the field [of oncology]."
Kelly Wolfgang is a contributing writer.