Oncologist Ubaldo Martinez doesn't have enough time to address all the special needs of the growing number of elderly cancer victims who seek his help, even though he spends 90 minutes with patients the first time and 30 during subsequent visits.
It's all he can do to explain their disease and its treatments to them, but so many other things can affect how they'll do.
How many drugs are they taking? Are they frail? Or robust enough to race their grandkids up a hill? Do they have dementia? Are they eating right? What kind of help can they get at home? How much do they want to live? Are they worried about money?
That's why he recently sent Bill Schooley, 74, a West Deptford man with multiple myeloma, to Thomas Jefferson University Hospital's Senior Adult Oncology Center. Martinez wanted to know if Schooley, a former smoker with diabetes and high blood pressure, could survive a stem-cell transplant.
A transplant is considered the best treatment for an aggressive cancer like Schooley's, but it gets riskier with age. It also requires a long hospitalization, more than two weeks, and that can also be especially hard on older patients. Schooley, who was on chemo and in remission, was too tired to help his wife Pat around the house. He was hoping a transplant would give him enough energy to do some chores and maybe go on a trip.
Because senior citizens may be denied care because of their age or suffer from overzealous treatment, Jefferson's Kimmel Cancer Center started the senior program 19 months ago to help doctors like Martinez and older patients like Schooley analyze the risks and benefits of treatments. Martinez now sends almost all of his older patients there.
"Their multidisciplinary approach is something I don't have the ability to do in my own practice," he said.
During Schooley's all-morning visit, he stayed in one exam room and was seen one-on-one by a parade of specialists: Andrew Chapman, who codirects the program, geriatrician Kristine Swartz, and a social worker, a dietitian, and a pharmacist.
Although cancer disproportionately strikes people over 65, efforts like this one that focus on the elderly are still rare.
Chapman, who recently helped host a national meeting on geriatric oncology at Jefferson, said the special needs of elderly cancer patients are getting more attention. Nationally, more hospitals are starting programs. Locally, Fox Chase Cancer Center received a grant from the National Institutes of Health to start a geriatric oncology research and treatment program. One of its nurse practitioners, who specializes in geriatric oncology, began evaluating patients in December. Pennsylvania Hospital started a program that focused on the social needs of older cancer patients, such as transportation to appointments or access to healthy food, in 2004.
"Nationally, this is clearly catching on," said Chapman, who argues that older patients are as distinctive a group as children with cancer. Some cancers are more aggressive in the elderly. Some are less. Some are more responsive to chemotherapy than they are in younger patients. Some are more resistant.
But David Mintzer, an oncologist who developed Pennsylvania Hospital's program, thinks there's still a long way to go. Interest in geriatric oncology, he said, "is disproportionately low when you look at the demographics. You don't see a lot of hospitals and health systems investing in this."
The big thing driving interest in older people with cancer is demographics. Cancer is a disease of aging: Sixty percent of cancer is in people 65 and older. A huge wave of people, the baby boomers, is getting old.
"We're really facing an oncologic tsunami," Chapman said.
In addition, there are more cancer treatments and more ways to control side effects. More older patients can tolerate the treatments now and more want to fight the disease aggressively.
"When I started in this field, people didn't send me 80- to 85-year-olds," said Mintzer, who began practicing in 1984. Now he sees patients that age every day.
There's also growing recognition that chronological age is no way to make medical decisions about the elderly. Some 80-year-olds are so strong and healthy they're likely to live another dozen years, so it makes sense to fight their cancer. Some are frail and have dementia, conditions that put them at greater risk.
The special geriatric programs spend most of their time on a middle group, older people like Schooley who take a lot of drugs and have chronic health problems.
Even when older people are in great shape, they can't handle hospitalizations, surgeries, and chemo quite as well as their children and grandchildren would.
"There's a much narrower margin for error," Chapman said. "There's much less resilience in elders than there is in their younger counterparts."
One big problem is that most clinical trials are done in younger people. "I know exactly what to do if you are 50 years old, because that's where we have all the data," said Efrat Dotan, a Fox Chase oncologist. In many cancers, there's not enough evidence to know whether reducing doses or increasing the time between treatments would curb the cancer while sparing the elderly some nausea and fatigue.
"Nobody knows," she said. "It's a work in progress."
Some older patients want to fight for every extra week. "I am so surprised," Dotan said, "when an 85-year-old man sits in front of me and says, 'No. I want to do everything. I want to live another 10 years.'"
Others may not realize how sick they are. Then she has to say, "I know you came here to get the most aggressive treatment, but, really, it's not in your best interest."
Some give up quickly because they remember how horrible cancer treatment was for family members 20 years ago. Swartz said patients should also consider how untreated cancer will make them feel. Patients in this age range all have Medicare and coverage of their medical bills is generally not a problem, but Chapman said some worry about the cost of their illness. The social worker tries to help.
Schooley's cancer, multiple myeloma, is incurable. If a transplant works, Martinez said, patients can live longer and have better quality of life. They don't have to take many other drugs, so they're exposed to fewer toxic side effects. The treatment, which costs $37,000 to $53,000, is considered standard of care and Medicare covers it.
But a transplant is risky. For a patient who is around 50, the risk of death over the next six months is 1 to 2 percent. For someone like Bill Schooley, it's 2 to 5 percent.
Schooley is younger and healthier than many patients the Jefferson team sees, but he had many typical problems. He has lost 50 pounds since he got sick, but still has an ample belly. The weight loss improved his high blood pressure and diabetes. He's still having trouble regulating his blood sugar. He wears hearing aids and has recently started using a cane.
He brought 12 pill bottles with him. He showed the pharmacist that he could open them easily and that he knew why and when he should take the medicines. Problems with these skills are a warning sign because cancer treatments are complicated and can further impair thinking.
Swartz, the geriatrician, spent a lot of time talking with Schooley about why he was taking an anti-anxiety medicine. Schooley had come with his wife of 52 years. They had met at a dance when he was 21 and Pat was 19. He hated that he couldn't help her around the house anymore. It upset him so much to watch his children do things for him that he took the medicine before they arrived. Just talking about it made him cry. "I'm just a boarder," he said.
Swartz checked his memory. Cancer patients with dementia don't do as well as those who still think well. She asked him the usual questions: Can you spell world backwards? What season is it? Remember these three words: apple, table, and penny. He did it all easily. She handed him a note pad and asked him to write a sentence. When he handed it back, it said "I love my wife."
Swartz gave him a depression test. Asked if he felt hopeless, he said no. "I look around and I think I am so lucky," he said, on the verge of tears again. He came out normal.
He told Swartz he'd like to be able to go to the gym. "I'm just hoping to get back to normal or almost normal."
After lunch, the Jefferson team convened.
Swartz was worried that Schooley could become depressed during a hospital stay that averages 16 days. They'd try to find ways to keep him busy. Delirium, or sundowning, is always a worry in older patients, and they'd want to take measures to prevent it. He might need physical therapy.
Swartz put data about Schooley into a couple of online life expectancy tools. Without cancer, someone in his condition could expect to live 10 to 12 years, she told the team. With cancer, any cancer, another tool estimated his four-year mortality at 45 percent.
The team considered him vulnerable to the side effects of treatment, but saw no reason to nix the transplant.
Martinez talked it through with Chapman and then with the Schooleys.
Bill Schooley entered Jefferson for his transplant last week.