Coronavirus Diary (17): Geriatric Oncology during COVID-19

Here’s a press release from an old friend that I’ve mentioned here a couple of times before, William Dale MD, the Arthur M. Coppola Family Chair in Supportive Care Medicine at the City of Hope in Duarte, California. William specializes in geriatric oncology, the treatment of cancer in older patients, which for obvious reasons presents severe challenges during an event like the COVID-19 pandemic. His pushback against the repulsive ageism that has recently come to the surface of our discourse is an enormous relief to read.

William has been in the forefront of the movement to change the term “social distancing” to “physical distancing,” in order to stress the fact that while physical distancing is crucial to stop or slow the spread of coronavirus, social connection is a vital need in dealing with the pandemic. In these comments below, however, he discusses the more general issues having to do with his work in geriatric oncology.  I’ve copied the entire press release verbatim, in block quotes (the added hyperlinks are mine, not in the original). Here’s a link to William’s extremely informative Twitter feed.

William Dale, M.D., Ph.D., Shares His Vision for the Center of Cancer and Aging, and What We’re Doing for Our Older Patients with Cancer During the Ongoing COVID-19 Pandemic.

William Dale, M.D., Ph.D., the Arthur M. Coppola Family Chair in Supportive Care Medicine, is facing unprecedented challenges in treating older patients with cancer, the most vulnerable population facing the current Coronavirus Disease (COVID-19) pandemic.

“As physicians caring for cancer patients, we are well versed in overseeing patients who are immunosuppressed,” Dale said. “But this pandemic represents a new dynamic, clinical challenge that seems to be changing daily. We are being diligent in screening all patients for symptoms and exposure, but our older patients with cancer are at the highest risk.”

Heightened Anxiety
Older patients with cancer in active treatment are considerably more susceptible to infection and complications from infection. “They are very anxious and worried about COVID-19,” Dale said. “While we have answers, we don’t have all.”

“If you are older with other conditions, you have to be scrupulous about avoiding COVID-19–you are at highest risk of dying from the disease, just like if you are facing chemotherapy or surgery. We can use the same tools and the same approach; the principles are the same.”

“I want to grow our elder awareness and treatment model to every City of Hope location in Southern California,” Dale said. “We’re going to take the wisdom and vision from the past and translate it into the future. City of Hope should be known as the place for geriatric oncology research and care.”

Dale points to a new role for the Geriatric Assessment, to screen older patients for high risk from COVID virus. “How can we better support our vulnerable patients?” he said. “The first step is to think of their health, not their age–healthy older adults should receive the exact same care as younger ones. It’s about their health, not their age.”

More Older Adults in Clinical Trials
Realizing that vision means more participation among older patients in risk assessments so that cancer treatment can be more precise, more targeted. Just as we have ‘targeted medicine’ based on genetics, we can have ‘personalized care’ based on the person..

“We need to protect our older patients with evidence,” Dale said. “Many clinical trials, for example, exclude older patients for enrollment, and that doesn’t make any sense. We’re testing new drugs on younger patients or healthier older patients instead of those older patients who are less fit and need the treatment the most. In order to know which drugs we can use, we need to test them on those patients most likely to get the disease, those over 65.”

Dale’s Strategy
His strategy is three-fold:

  1. Enroll more healthy older patients in standard clinical trials.
  2. Design different clinical trials for less healthy older patients, and
  3. Take care to extend enrollment to those who are in-between.

“With older patients, genetics plays a smaller role in health than in younger patients,” he explained of cancer diagnoses and treatment. “It could be a number of factors, such as your lifestyle choices over many years or the places you lived. And of course, everyone is different. Two 65-year-olds can be very different from each other in terms of health, so there’s a chronological age versus physiological age to consider. We need to focus more on the latter.”

Dale also points out that, for older adults seeking treatment or who are participating in a clinical trial, we need to think about more than just surviving their disease. How will that survival be?

And right now, we need to make this special group a priority to be embraced, not pushed away.

“Not (Only) About Surviving Cancer”
“Eighty percent of my patients want to maintain their cognition–mental acuity–and their independence more than anything. I can tell them there’s a 60% chance of toxicity with a given treatment, and they will tell me ‘Prolong my life if you can, but please let me keep my memory and living in my home.'”

To better recognize and treat the cognitive decline and functional losses that often impact older adults getting cancer treatments, Dale said he would like every department at City of Hope to add supportive care medicine to their treatment plans, to meet the needs discovered with geriatric assessments. And he’d like to purge terms of ageism from our vernacular, including “elderly” and “senior moments.”

“Let’s embrace older people, our elders, and focus on competence and experience, not just on numbers of years on the calendar. No one is necessarily ‘too old’ for something just because of their age: there are gymnasts in their 80s and marathoners over 100. And right now, more than ever, we need to make this special group a priority to be embraced, not pushed away.”

More About Dale’s Passion for Caring for Older Patients
“The work that Dr. Dale and the entire team is doing at the Center of Cancer and Aging is critically important, especially during these extraordinary circumstances,” said Michael Caliguri, M.D., president, City of Hope National Medical Center and the Deana and Steve Campbell Physician-in-Chief Distinguished Chair. “Sixty percent of all people with cancer are 65 years or older and 70% of survivors are 65 years and older. I myself will be 65 this year. Under the leadership of Dr. Dale, four deputy directors and the rest of the team in the Center for Cancer and Aging, I am confident the center will remain vigilant and stable during this time and provide the very best of care for these most vulnerable of our patients.”

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