- By 2040, it is anticipated that more than 70% of cancers will be diagnosed in patients older than age 65.
- Quality and value remain conceptually difficult when applied to the care of older adults with cancer, particularly those with complex comorbidities, frailty, or other vulnerabilities, as the preferences of older adults with cancer are likely to diverge from a sole focus on the traditional endpoints of survival and toxicity.
- Considering the anticipated shortage of oncology providers and the complexity of care, meeting the needs of the older patient with cancer will rely on a highly integrated patient-centered approach. Training, expanding, and empowering the workforce to care for these vulnerable patients is integral to the delivery of patient-centered care.
Cancer can be considered a disease of aging. By 2040, it is anticipated that more than 70% of cancers will be diagnosed in patients older than age 65.1 This prevalence represents a 10-fold increase in cancer among adults age 75 to 84 and a 17-fold increase among those age 85 and older since 1975.2 Decisions regarding cancer treatment are complicated by lack of evidence, particularly for older adults who have health status conditions, such as multiple chronic conditions and frailty. Attention to personalized medicine has expanded the focus on individual patient factors to be incorporated into treatment decision making. For older adults, these factors include not only the assessment of increasing tumor-related factors (e.g., molecular and genetic information) but also the evaluation of comorbid conditions, health status, and functional independence, among others.
Defining Quality of Care
An Institute of Medicine (IOM) report defined quality of care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.”3 Although this has served as a working definition for many clinical populations, its founding principle is noteworthy here.
“Health care implies a broad set of services, including acute, chronic, preventive, restorative, and rehabilitative care, which are delivered in many different settings by many different health care providers,” the report states. “This broad dimension is particularly important for the elderly, who often receive a wide range of services from different sources.”3
In 2001, the IOM strengthened the definition, adding six specific aims: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability.4 ASCO’s working definition of quality is “the best scientific, evidence-based care delivered in the safest manner to a patient in a specific disease state in a consistent and reproducible manner across multiple settings.”5
Quality is a measurement of adherence to evidence-based guidelines, with a focus on care processes. ASCO has initiated the Quality Oncology Practice Initiative (QOPI®), an oncologist-developed and -led quality-improvement initiative, which provides a robust library of quality measures developed by oncologists and quality experts and is founded on ASCO and nationally recognized practice guidelines and expert consensus. Practices that score above threshold on a defined set of measures can voluntarily apply for QOPI certification, which evaluates the performance of an individual practice in areas that affect patient care and safety and builds on the ASCO QOPI. Of the 196 quality measures that are part of ASCO’s QOPI 2016 set, the vast majority are process measures, with a much smaller number focused on structure, outcome, or the patient experience. Quality is linked conceptually to value in that high-quality care produced at the lowest possible cost is considered to offer maximal value.
The challenge for older patients with cancer is that related evidence is generally limited in this population. A 2013 study found that two-thirds of medications (143/214) relevant to geriatrics that have been approved by the U.S. Food and Drug Administration in the previous 10 years lacked adequate prescribing information about efficacy and safety data in older populations.6 Value is defined by the health outcomes achieved relative to the costs, and it measures the efficiency of health care delivery.7 This construct of value raises important questions for the older patient with cancer, who may prefer quality of life over quantity of life, palliation over survival, or independence over longevity. Moreover, older adults often have multiple comorbid conditions that may contribute to unanticipated complications and subsequent cost (direct and indirect) to the treatment of cancer, obscuring calculations of value for these patients.
Measuring Quality and Value
The rapidly escalating costs of health care, particularly within cancer care, have brought increasing attention to the concept of value. However, moving from volume- to value-based cancer care delivery is made challenging by tenuous consensus on what constitutes value in cancer care and on the relationship between value and quality. Although value measures outcomes per unit cost, it is much more than the simple equation of cost limited to drug costs and outcomes limited to survival and/or treatment toxicity. Such a simple view fails to consider comorbidity (which may compromise treatment and generate even more expense), competing risks, functional outcomes, and indirect costs to patients and families.
Despite significant initiatives over many years to develop measures and standards for both quality and value in health care, only a paucity of research is focused on the older adult with cancer, and, consequently, evidence-based treatment guidelines are inadequate. Furthermore, there is a need to overcome an apparent disconnect in how patients, especially older adult patients, define value and quality and how they are being measured by policymakers. Recent quality initiatives have attempted to set standards for cancer care, and value frameworks have emerged to attempt to evaluate cancer care delivery metrics, often using novel methodologies. Nonetheless, quality and value remain conceptually difficult when applied to the care of older adults with cancer, particularly those with complex comorbidities, frailty, or other vulnerabilities. Tied up in the definitions of quality and value are personal preferences regarding value—the preferences of older adults with cancer are likely to diverge from a sole focus on the traditional endpoints of survival and toxicity.
The multiple recently designed frameworks for assessing value include varying measures and perspectives. The ASCO Value Framework assesses the value of new cancer therapies based on clinical benefit, side effects, and improvements in patient symptoms or quality of life in the context of cost.6 The National Comprehensive Cancer Network’s Value Pathways are designed to help doctors and patients assess the anticipated clinical benefit of certain therapies in the context of cost. Other frameworks, such as the European Society for Medical Oncology Magnitude of Clinical Benefit Scale, the Institute for Clinical and Economic Review Value Assessment Framework, and the Memorial Sloan Kettering Cancer Center DrugAbacus are intended to help payers and/or policymakers ascertain value or the value-based price of treatments.
Although value should be defined in a patient-centric way, the assessment of value in current frameworks may not capture constructs of importance to older adults with cancer. The exclusive focus on traditional measures of efficacy, such as overall survival and progression-free survival, may not provide sufficient information for the older patient with cancer. Although all the value frameworks account, in some measure, for toxicity of cancer treatment, they don’t consider the risk of serious toxicity because of underlying health status conditions. It has been established that measures within a geriatric assessment can help identify older patients most at risk of serious toxicity from cancer treatment8,9; these measures include issues such as falling, decreased social activity, and deficits in functional abilities to manage medications. Not all frameworks incorporate symptom management, palliation, and quality of life—outcomes highly prioritized by patients. None of the value frameworks incorporate outcomes specific to the preferences of older adults, such as functional independence and aging in place. A recent survey by AARP revealed that 81% of older individuals prioritize staying in their current home and community.10
Changing Care Delivery
As the number of older patients with cancer continues to rise, changes in care delivery are needed to keep pace with patient needs, undergirding and giving structure to the quality and value of care delivered. Older adults with cancer are likely to have comorbidities with varying severity and a significant number of medications (i.e., polypharmacy) to manage these conditions. Geriatric syndromes, such as delirium and frailty, are also common and may affect treatment decisions. Older adults require supportive interventions, such as psychosocial support, physical rehabilitation, and caregiver support, far more than their younger counterparts with cancer. Thus, older adults require an expanded and interdisciplinary care team. And without intentional collaboration, fragmentation of care could lead to confusion, frustration, compromised quality and safety, and a poor patient experience.
The paradigm of patient-centered care offers a roadmap for provision of high-quality care of the older patient with cancer by optimizing the care processes linked to quality indicators. Extrapolating from the successful application of this paradigm to other complex patient populations, patient-centered care in geriatric oncology require: (1) multidisciplinary input; (2) clear and consistent communication between providers, and between providers and patients/caregivers; (3) an informed and engaged patient; (4) shared decision making; and (5) seamless transitions along the care continuum, including into survivorship. In a patient-centered environment, the care team rallies around the patient and closely attends to their wants, needs, and preferences.
Initiatives focused on patient-centered care and care coordination, such as the National Committee for Quality Assurance Patient-Centered Medical Home and Patient-Centered Specialty Practice accreditation programs, may offer opportunities for capturing measures of value prioritized by the older adult patient with cancer, along with the quality indicators. These programs recognize that patient-centered care requires collaboration to address patients’ comprehensive needs. ASCO has developed ASCO COME HOME, a community oncology medical home model that supports coordinated oncology care. The program is now being expanded nationally after successful pilot implementation in seven U.S. practices.
As information technology and electronic medical records (EMRs) overcome obstacles—such as lack of software interoperability between systems, initial costs for installation and training, and general dissatisfaction by physicians—they can become effective tools for promoting patient engagement in shared decision making and identifying special needs and individual values of older adults with cancer. Currently, EMRs sometimes actually serve as an impediment to patient centeredness, increasing the time allocated to data entry at the expense of time spent with the patient in shared decision making and elicitation of goals and preferences.
No initiatives or models of quality or value can be maximized for the benefit of older adults with cancer unless this population is more highly recognized by policymakers. Although the “silver tsunami” and cancer as a disease of aging are both widely acknowledged, the special needs of this population go unrecognized at the highest levels. For example, the U.S. Department of Health and Human Services (HHS) website lists cancer as a chronic disease on its educational pages, but it prominently displays a picture and link to the White House Conference on Aging Final Report, which, notably, does not include cancer in a list of chronic diseases—despite that, by the year 2020, about 20 million Americans will be living with a cancer diagnosis. Resources cited for the list of chronic diseases in the policy brief include the HHS’s “Multiple Chronic Conditions: A Strategic Framework” and the Centers for Disease Control and Prevention’s “Healthy Brain Initiative” (developed in association with the Alzheimer’s Association and the Administration for Community Living). Of the 28 members of the Cancer Moonshot Blue Ribbon Panel, only one lists expertise in geriatric health, even though many members specialize in cancer types most prevalent among the elderly. Furthermore, ASCO’s recently published Clinical Cancer Advances 2017 includes only one editor with geriatric health expertise out of 21.
Together, patients and caregivers, in conjunction with the health care team, can determine the best course of treatment that is relevant to the patient’s goals. It is critical to understand that patients are not happy with actuarial figures such as “risk/harm versus benefit” or “value equals cost over outcome.” Patients are already struggling to overcome the indignities of cancer therapy and are frightened by the high cost of care. They often see any efforts to define and quantify concepts of quality and value as de-humanizing. Patients want to be seen, communicated with, and treated as individuals. Timely exchange of information longitudinally across all members of the health care team is paramount to the success of the care delivered. This information needs to be shared with the patients and caregivers in a manner that is understandable and meaningful to them in order to facilitate shared decision making at every step. Considering the anticipated shortage of oncology providers and the complexity of care, meeting the needs of the older patient with cancer will rely on a highly integrated patient-centered approach. Training, expanding, and empowering the workforce to care for these vulnerable patients is integral to the delivery of patient-centered care.
For more information on this topic, please watch the “Improving Quality and Value of Cancer Care for Older Adults” Education Session on ASCO’s Meeting Videos and Slides or refer to the 2017 ASCO Educational Book for an article by Ramsdale et al. with the same title.
About the Authors: Dr. Mohile is an associate professor at the University of Rochester Medical Center. Ms. Canin is a patient advocate who leads SCOREBoard, an advisory group of older patients, caregivers, and advocates. Dr. Ramsdale is an assistant professor at the University of Rochester Medical Center.