VA considerations

Assess the relevance of lung cancer to a growing elderly population, the challenges associated with eldercare, and the importance of emotional care—particularly among veterans, who have a higher rate of significant depressive symptoms than the general population.1,2

ELDERLY POPULATION

Lung cancer is primarily a disease of the elderly1

  • Although patients may be diagnosed with lung cancer at any age, the majority are aged 65 years or older1

*Includes lung and bronchus.

Source: Howlader N, et al, eds. SEER Cancer Statistics Review 1975-2012. Bethesda: MD; National Cancer Institute; 2014.
http://seer.cancer.gov/csr/1975_2012/results_merged/sect_15_lung_bronchus.pdf. Accessed July 28, 2015.

 

The United States is projected to experience rapid growth in its elderly population4

  • Number of people aged ≥65 years is expected to almost double between 2012 and 2050
  • Veterans, on average, are older than the general population5
    – In 2011, the median age of male veterans was 64 years old and the median age of males in the general population was 41 years old

Source: US department of Veterans Affairs, Profile of Veterans: 2011.
http://www.va.gov/vetdata/docs/specialreports/profile_of_veterans_2011.pdf

References: 1. National Cancer Institute. SEER stat fact sheets: lung and bronchus cancer. http://seer.cancer.gov/statfacts/html/lungb.html. Accessed March 31, 2015. 2. Zivin K, Kim HM, McCarthy JF, et al. Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics. Am J Public Health. 2007;97(12):2193-2198. 3. Howlader N, et al, eds. SEER Cancer Statistics Review 1975-2012. Bethesda: MD; National Cancer Institute; 2014. http://seer.can-cer.gov/csr/1975_2012/results_merged/sect_15_lung_bronchus.pdf. Accessed July 28, 2015. 4. Ortman JM, Velkoff VA, Hogan H. An aging nation: the older population in the United States. United States Census Bureau. Issued May 2014. https://www.census.gov/prod/2014pubs/p25-1140.pdf. Accessed August 5, 2015. 5. U.S. Census Bureau, American Community Survey PUMS, 2011. Prepared by the National Center for Veterans Analysis and Statistics: http://www.va.gov/vetdata/docs/specialreports/profile_of_veterans_2011.pdf. Published March 2013.

ELDERCARE

There are special challenges associated with elderly patients

Elderly patients often present with medical and physiological challenges1-3
  • Higher frequency of comorbidities2
  • Higher prevalence of polypharmacy2
  • Reduced hepatic, renal, and bone marrow reserve2,3
  • Greater susceptibility to toxicity from treatment regimens3
The Comprehensive Geriatric Assessment (CGA) is helpful in managing the complex needs of elderly patients
  • CGA utilizes an interdisciplinary healthcare team and multiple standardized assessment scales examining1:
    – Functional Status
    – Comorbidities
    – Polypharmacy
    – Nutritional status
    – Socioeconomic issues
    – Geriatric syndromes
    – Mental status and emotional conditions
Effective communication is key to caring for elderly patients
  • Recommendations from the National Institute on Aging4
    – Speak respectfully
    – Establish rapport
    – Use active listening
    – Show empathy
    – Don’t rush or interrupt
    – Avoid jargon
    – Reduce barriers to communication
    – Assess and compensate for hearing and visual deficits
    – Ensure understanding
    – Keep cultural differences in mind
    – Establish a plan for next steps
The medical and physiological challenges of elderly patients may contribute to poor performance status (PS)
  • PS is commonly used to determine appropriateness of treatment5
  • PS is measured most often by ECOG and KPS scores6
  • Prevalence of poor PS is quite high in lung cancer patients7,8
    – 35% to 40% to total NSCLC population present with ECOG ≥2
  • Low PS predicts lower response, higher toxicity, and worse survival5
  • Providers tend to underestimate the number of patients with poor PS9

ECOG = Eastern Cooperative Oncology Group Performance Status.
KPS = Karnofsky Performance Status.

Monitoring adverse effects is particularly important in elderly patients
  • Elderly patients are less able to tolerate treatment than younger individuals2,3,10
  • Prognostic functional and clinical risk factors must be identified to prospectively identify those at high risk for severe treatment-associated toxicity10
Patients with lung cancer may experience complications from their disease and benefit from palliative, or
supportive care, aimed at relieving symptoms and improving quality of life11
  • A pleural effusion—a buildup of fluid in the chest outside of the lungs-can press on the lungs and cause trouble breathing11
    – Thoracentesis, pleurodesis, or placement of a chest catheter may be used to drain fluid and provide relief to the patient
  • A pericardial effusion—fluid buildup inside the sac around the heart—can press on the heart, affecting how well it works11
    – Pericardiocentesis or creation of a pericardial window may be used to drain fluid away from the heart
  • If the cancer is growing into an airway in the lung, it can block the airway and cause problems like pneumonia or shortness of breath11
    – Photodynamic therapy (PDT) or laser therapy may be used in early stages of the disease
    – Sometimes a stent may be placed in the airway to help keep it open

References: 1. Repetto L, Venturino A, Fratino L, et al. Geriatric oncology: a clinical approach to the older patient with cancer. Eur J Cancer. 2003;39:870-880. 2.Quoix E. Therapeutic options in older patients with metastatic non-small cell lung cancer. Ther Adv Med Oncol. 2012;4(5):247-254. 3. Vora N, Reckamp KL. Non-small cell lung cancer in the elderly: defining treatment options. Semin Oncol. 2008;35(6):590-596. 4. National Institute on Aging. Talking with your older patient. https://www.nia.nih.gov/sites/default/files/talking_with_your_older_patient.pdf. Published October 2008. Accessed July 6, 2015. 5. Salloum RG, Smith TJ, Jensen GA, Lafata JE. Survival among non-small cell lung cancer patients with poor performance status after first line chemotherapy. Lung Cancer. 2012;77(3):545-549. 6. ECOG-ACRIN Cancer Research Group. http://ecog-acrin.org/resources/ecog-performance-status. Accessed July 16, 2015. 7. Vardy J, Dadasovich R, Beale P, Boyer M, Clarke SJ. Eligibility of patients with advanced non-small cell lung cancer for phase III chemotherapy trials. BMC Cancer. 2009;9:130. 8. Somer RA, Sherman E, Langer CJ. Restrictive eligibility limits access to newer therapies in non-small cell lung cancer: the implications of Eastern Cooperative Oncology Group 4599. Clin Lung Cancer. 2008;9(2):102-105. 9. Lilenbaum RC, Cashy J, Hensing TA, Young S, Cella D. Prevalence of poor performance status in lung cancer patients: implications for research . J Thorac Oncol. 2008;3(2):125-129. 10. Zauderer MG, Sima CS, Korc-Grodzicki B, Kris MG, Krug LM. Toxicity of initial chemotherapy in older patients with lung cancers. J Geriatr Oncol. 2013;4(1):64-70.11. American Cancer Society. Lung cancer (non-small cell). http://www.cancer.org/acs/groups/cid/documents/webcontent/003115-pdf.pdf. Last medical review August 15, 2014. Last revised March 11, 2016. Accessed March 14, 2016.

EMOTIONAL CARE

There are numerous psychosocial aspects associated with lung cancer diagnosis

  • A diagnosis of lung cancer may leave patients feeling isolated and facing social stigma
    – Lung Cancer is sometimes called the “invisible cancer” due to lack of public attention1
    – Patients may be blamed, rejected, and/or discriminated against by those around them2
    – The result can be stigmatizing1

There are recommended interventions to help patients with cancer cope with emotional disturbances

  • The prevalence of significant depressive symptoms among US veterans are 2 to 5 times higher than among the general population4

 

It’s important to help patients and their caregivers understand the goals of therapy

  • Many advanced or metastatic cancer patients do not understand treatment goals9
  • A 2013 study showed that 69% of patients with metastatic lung cancer did not understand that the chemotherapy they were receiving was not at all likely to cure their cancer, despite discussing this treatment with at least 1 physician10
  • Patients and their caregivers should clearly understand9,11:
    – Prognosis
    – Treatment and care options
            — Goals of treatment
            — Cost of treatment
            — Expected toxicities

It’s important to provide support for caregivers, who often fail to take care of themselves

  • While providing support for their partners of family members with cancer, caregivers often fail to address their own needs and feelings12,13
    – Caregivers are at a high risk of a wide spectrum of mental, physical, and social morbidities13
            — Distress
            — Depression
            — Anxiety
            — Poorer health
            — Lower marital satisfaction
            — Lower social support

References: 1. American Lung Association. Addressing the stigma of lung cancer. Chicago, IL: American Lung Association. http://www.lung.org/as-
sets/documents/lung-disease/lung-cancer/addressing-the-stigma-of-lung-cancer.pdf. Accessed July 28, 2015. 2. Westmass JL. Stigma presents an extra burden for many lung cancer patients. American Cancer Society. http:/twww.cancer.org/cancer/news/expertvoices/posV2013110/28/
stigma-presents-an-extra-burden-for-many-lung-cancerpatients.aspx. Published October 28, 2013. Accessed May 4, 2015. 3. National Cancer Institute. Feelings and cancer. http://www.cancer.gov/cancertopics/coping/feelings. Accessed July 9, 2015. 4. Zivin K, Kim HM, Mccarthy JF, et al.
Suicide mortality among individuals receiving treatment for depression in the Veterans Affairs health system: associations with patient and treatment setting characteristics . Am J Public Health. 2007;97(12):2193-2198. 5. Smith PR, Cope D, Sherner TL, Walker Dk. Update on research-based interven- tions for anxiety in patients with cancer. Clin J Oncol Nurs. 2014;18(6):5-16. 6. Fulcher CD, Kim HJ, Smith PR, Sherner TL. Putting evidence into practice: evidence-based interventions for depression. Clin J Oncol Nurs. 2014;18(6):26-37. 7. Page MS, Berger AM, Johnson LB. Putting evidence into practice: evidence-based interventions for sleep-wake disturbances. Clin J Oncol Nurs. 2006;10(6):753-767. 8. Mitchell SA, Hoffman AJ, Clark JC, et al. Putting evidence into practice: an update of evidence–based interventions for cancer–related fatigue during and following treatment. Clin J Oncol Nurs. 2014;18(6):38-58. 9. Smith TJ, Dow LA, Virago EA, Khatcheressian J, Matsuyama R, Lyckholm LJ. A pilot trail of decision aids to give truthful prognostic and treatment information to chemotherapy patients with advanced cancer. J Support Oncol. 2011;9(2):79-86. 10. Weeks JC, Catalano PJ, Cronin A, et al. Patients’ expectations about effects of chemotherapy for advanced cancer. N Engl J. Med. 2012;367(17):1616-1625. 11. Shockney LD. Fulfilling hope: supporting the needs of patients with advanced cancers. New York, NY: Nova Science Publishers, Inc; 2014. 12. Lopez V, Copp G, Molassiotis A. Male caregivers of patients with breast and gynecologic cancer: experiences from caring for their spouses and partners. Cancer Nurs. 2012;35(6):402-410. 13. Li Q, Loke AY. A spectrum of hidden morbidities among spousal caregivers for patients with cancer, and differences between the genders: a review of the literature. Eur J Oncol Nurs 2013;17(5):578-587.

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