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Caring for older adults with cancer is complex. While many appreciate medical doctors, when it comes to caring for older adults with cancer, Advanced Practice Providers (APPs) are unsung heroes in the field of geriatric oncology. In this episode, we will discuss the great work that some of the APPs in a major comprehensive cancer center is doing to improve care and outcomes of older adults with cancer.
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0:00
Welcome to the deep dive. Today we're
0:02
looking at um a really big challenge in
0:05
medicine right now.
0:06
It's where aging meets cancer care.
0:10
And it's not just a small thing. It's a
0:12
huge demographic shift.
0:13
Yeah. The numbers are pretty staggering,
0:15
right? They're predicting that by 2040
0:19
something like 70% of all cancer
0:21
patients will be over 65.
0:22
Nearly 70%. Yeah. That's a massive
0:25
change. So the big question isn't just,
0:27
you know, can we treat the cancer. It's
0:29
how do we do it while really focusing on
0:32
on quality of life.
0:33
Exactly. Preserving that is key.
0:35
And that's what this deep dive is about.
0:37
We're looking at this group kind of
0:38
unsung heroes.
0:39
Yeah.
0:40
Really geriatric oncology advanced nurse
0:42
practitioners
0:43
really.
0:44
Yeah. For 20 years they've been quietly
0:46
but uh fundamentally changing things
0:49
right from the patient's bedside all the
0:50
way up to like national policy. And
0:53
what's amazing is how they've basically
0:54
built this whole specialty. We're
0:56
focusing on three pioneers. Sincere
0:58
McMillan, Heidi Ulo, and Su Junkim. And
1:01
our sources, they don't just talk about
1:02
one project. They describe it as this
1:04
whole uh meticulously built ecosystem.
1:08
You know, care, education, innovation,
1:11
all linked together.
1:12
An ecosystem. I like that.
1:13
They didn't just tweak things. They
1:15
really redefined compassionate cancer
1:18
care for older adults.
1:19
Okay. So, let's dig into that. Where
1:21
should we start? maybe with direct
1:23
patient care. That seems like where
1:24
you'd feel the impact first.
1:25
Yeah, that makes sense. Let's talk about
1:27
their inpatient geriatric co-management
1:30
program.
1:31
Go management. So, they're working with
1:32
the surgeons
1:32
right alongside them co-managing these
1:35
really complex older patients just after
1:37
they've had major cancer surgery.
1:39
Okay, that sounds different. What makes
1:41
it special? And you know, what are the
1:43
results like?
1:44
Well, the results are um honestly kind
1:46
of jaw-dropping. There was a study
1:48
published in 2020
1:50
that showed when these&ps were involved,
1:52
there was a 57% lower risk of dying
1:55
within 90 days for these patients.
1:58
Wait, 57%.
1:59
57. Yeah. I mean, think about that.
2:01
Usually in medicine, you get excited
2:03
about a 5 or 10% improvement,
2:05
right? That's huge.
2:07
This is it's a whole different level, a
2:09
paradigm shift really.
2:11
So, how how do they achieve that?
2:13
It's because they're managing the whole
2:14
person. They're not just focused on the
2:16
surgical site. They're proactively
2:18
preventing things like delirium,
2:20
which is a huge problem for older
2:22
patients in hospital.
2:23
Huge. And they're carefully managing
2:26
those super long, complicated medication
2:29
lists, making sure nutrition is right,
2:31
getting patients moving safely.
2:34
Basically, they stop those complications
2:36
that can just completely knock a
2:38
patient's recovery off track after a big
2:40
operation.
2:40
Wow. Okay. So, it's like this incredible
2:42
safety net during that really vulnerable
2:45
posttop period. Exactly.
2:46
And this proactive idea, it sounds like
2:49
it goes beyond the hospital stay, too. I
2:51
was reading about their outpatient work,
2:52
these comprehensive geriatric
2:54
assessments.
2:54
Absolutely. That's a really key part of
2:57
it, especially before someone goes into
2:58
a really tough treatment
2:59
like stem cell transplant.
3:00
Yeah.
3:01
Or car.
3:02
Precisely. Treatments like car therapy.
3:04
I mean, they're cutting edge, amazing,
3:06
but they demand so much from a patient
3:10
physically and mentally,
3:11
right? So people like Su Jong Kim, they
3:14
lead these really in-depth assessments
3:16
before treatment starts. They use
3:19
specific tools like the electronic rapid
3:21
fitness assessment, the ERFA.
3:23
ERFA. Okay.
3:24
Someone described it as the most
3:26
important pre-flight check for a
3:28
patient's life.
3:28
A pre-flight check, that's a great
3:30
analogy. What does it actually check?
3:32
Everything pretty much. physical
3:34
function, cognitive state, um social
3:37
support, like who do they have at home,
3:40
nutritional status, the whole picture.
3:42
And getting that whole picture. Yeah.
3:43
That's what helps with those really
3:45
tough conversations about goals of care.
3:48
Making sure the treatment fits the
3:49
person, not just the disease.
3:51
Exactly. Right. It's not just about
3:53
tweaking dosages. It's fundamental. It
3:55
pushes back against this old way of
3:56
thinking where you either overtreat
3:58
aggressively,
3:59
right?
3:59
Or you just write off older patients
4:01
because of their age. This makes sure
4:03
the plan fits their reality, their
4:04
capabilities, their wishes.
4:06
It avoids both extremes. Giving
4:08
treatment that's too harsh for someone
4:10
frail, but also not denying good
4:12
treatment to someone older but strong.
4:14
Precisely. It stops the overt treatment
4:17
of frail patients who might just suffer
4:19
more from the side effects
4:21
and it stops the under treatment of
4:23
robust older adults who can absolutely
4:26
benefit but get judged just by their
4:29
birth year. It really drives home that
4:31
age is just one factor. Frailty,
4:34
fitness, that's the clinical reality you
4:36
need to tailor care to.
4:38
Okay, so they're clearly amazing
4:40
clinicians, but you know, delivering
4:42
great care is one thing. How do you make
4:43
sure that knowledge, that expertise
4:46
doesn't just stay with a few people,
4:48
right? That's the next crucial piece.
4:50
It sounds like this team really thought
4:51
about sustainability, building for the
4:53
future, and education was key.
4:55
Totally. This is where you see the real
4:57
legacy building work. Sincere McMillan
4:59
and her team, they created the first and
5:02
still the only accredited geriatric
5:04
oncology advanced practice provider
5:06
fellowship in the whole US.
5:07
The only one. Wow.
5:09
Yeah. It's huge. New fields often
5:11
struggle, you know, to get established
5:12
to get a steady stream of trained
5:14
experts.
5:14
Right. You need a formal training
5:16
pathway.
5:16
Exactly. And this fellowship provides
5:18
that. It's a formal structure for
5:20
training highly specialized clinicians,
5:23
usually nurse practitioners, physician
5:25
assistants to become leaders in this
5:26
really complex area and make sure the
5:28
expertise keeps growing.
5:30
That's incredible. Building the pipeline
5:32
and it seems like they also cast a wider
5:34
net with conferences and things training
5:36
more people.
5:37
Oh yeah, like an army as you said. So
5:39
Jung Kim for over 10 years she's led
5:42
this geriatric oncology nursing
5:44
conference.
5:44
Okay. Twice a year, hundreds of
5:47
frontline MSK nurses get trained in key
5:50
geriatric skills. And nurses are
5:52
crucial, right? They're often the first
5:54
ones to spot problems.
5:55
Definitely. They see the subtle changes.
5:57
And then there's Sincere McMillan's
5:59
virtual A symposium that drew over 180
6:02
people from all over the world.
6:03
Oh, global reach.
6:05
Yeah, it really positioned their
6:06
institution as like a world leader in
6:08
this knowledge.
6:09
And didn't their influence start even
6:11
earlier? I saw something about working
6:12
with NP students from places like Yale,
6:15
Colombia,
6:16
and they won a change agent award.
6:18
That's right.
6:18
What does that really mean? Being a
6:20
change agent in a big hospital system.
6:23
That sounds tough.
6:24
It is tough. It means you've
6:25
successfully gone against a grain, you
6:28
know, challenge how things are normally
6:29
done in a big established place,
6:31
right? Bureaucracy and all that.
6:32
Exactly. It means you've built something
6:34
so innovative and strong that it's
6:36
recognized for actually changing how the
6:39
next generation of health care providers
6:41
gets trained. It's not just about having
6:43
a good idea. It's about the grit, the
6:45
tenacity to make it happen.
6:47
Okay. So, they're training the next
6:48
generation, which is vital. But how do
6:50
you weave this geriatric knowhow into
6:54
the daily fabric of a huge hospital?
6:56
Make it part of the culture.
6:57
Yeah. How do you make it stick
6:58
everywhere? That's where their
6:59
grassroots stuff is brilliant. Like the
7:01
geriatric resource nurse program, the
7:03
GRN.
7:04
Exactly. That was initially set up by
7:06
Heidi Ulo. It trains nurses on different
7:09
units, inpatient, outpatient, to be the
7:12
local go-to expert on geriatrics.
7:15
So like champions on each floor,
7:17
kind of like sentinels. They're trained
7:18
to use tools like the CAM, the confusion
7:21
assessment method. It helps nurses
7:23
quickly spot even subtle signs of
7:25
delirium,
7:26
which we said is so important to catch
7:29
early.
7:29
Critically important. Catching it early
7:31
can mean the difference between a quick
7:33
recovery and, you know, a much longer,
7:35
more complicated hospital stay. It's
7:38
like a grassroots movement changing care
7:40
right at the bedside.
7:41
That makes so much sense. And that same
7:43
kind of practical systems thinking seems
7:47
to apply to falls prevention, too. A
7:49
fall for an older cancer patient could
7:51
be disastrous.
7:52
Absolutely catastrophic. It can totally
7:54
derail their cancer treatment. So Jung
7:57
Kim's leadership here is key again. She
8:00
co-leads the hospitalwide fall steering
8:02
committee.
8:02
The whole hospital.
8:04
Yeah. She helps run a specialized clinic
8:06
just for falls and develops patient
8:08
education materials they use across all
8:10
their sites now.
8:11
Wow.
8:11
It's practical. It's visible and it
8:13
genuinely saves lives. It's seeped into
8:15
the whole institution. And they've even
8:17
taken this into the digital world.
8:18
Health informatics. That seems like
8:20
another level entirely.
8:21
Yeah. They're not just clicking boxes in
8:23
the electronic health record. They're
8:25
helping build it. They're epic super
8:27
users.
8:27
Okay.
8:28
They create tools like a dashboard that
8:30
shows falls in real time. But even
8:33
bigger, sincere McMillan was nominated
8:35
for the National Epic Geriatric Steering
8:37
Committee.
8:38
National. So for the software itself.
8:40
Yeah. That means her expertise is
8:43
helping shape the software design that
8:45
millions of doctors and nurses use
8:47
across the country.
8:48
Wa.
8:48
So she's influencing care for patients
8:50
who might never even come to their
8:52
hospital. That's incredible reach.
8:55
That really is profound. And okay,
8:57
finally, there's maybe the deepest level
9:00
of their work tackling agism.
9:03
Yeah, this is maybe the toughest
9:05
barrier.
9:06
That bias sometimes it's not even
9:07
conscious, right? But it's there.
9:09
It's pervasive. So, the team worked
9:11
together to create a national online
9:13
course specifically about agism in
9:15
cancer care,
9:16
an educational module for other
9:17
professionals.
9:18
Exactly. They're directly fighting that
9:20
implicit bias that can mean older adults
9:22
just don't get offered potentially
9:24
life-saving treatments purely because of
9:25
their birth date,
9:26
not based on their actual health or
9:28
ability to handle the treatment,
9:30
right? They're pushing for this culture
9:32
shift. So, every patient is seen as an
9:34
individual, their fitness, their
9:36
resilience, who they are, not just a
9:38
number. It's about seeing the person,
9:40
not the age.
9:41
That's the core of it. And when you step
9:43
back and look at everything they've
9:44
done, Yeah. I mean, from saving one
9:47
person's life after surgery to training
9:49
people all over the world, from changing
9:51
a hospital handout to advising a
9:54
national software. It it's just it's
9:56
remarkable.
9:57
It really is.
9:57
It really gives you a blueprint for how
9:59
you build a whole medical specialty, you
10:01
know, from the ground up and doing it
10:04
with compassion right at the center
10:05
alongside the science. the work these
10:08
three women, sincere McMillan, Heidi
10:09
Ulo, Su Jung Kim have done. It's
10:12
defining what cancer care should look
10:14
like in the future. Making sure that all
10:16
our fancy technology is matched by um by
10:20
wisdom and compassion and how we
10:22
actually care for people.
10:23
A truly inspiring story. You can really
10:25
see the ripple effect of their
10:26
dedication. So something for you our
10:28
listeners to think about here. How does
10:30
this focus on whole person care and
10:33
really fighting agism in cancer
10:35
treatment? How does that resonate with
10:37
your own ideas about personalized
10:38
medicine? And maybe what could this kind
10:40
of holistic approach mean for other
10:42
parts of healthcare even outside of
10:43
cancer?
#Aging & Geriatrics
#Cancer