Up next in 10
Many times, care for older adults with cancer goes beyond what the " evidence" written in the textbooks suggests. Often, you need to assess the patient as a whole and then discuss various options with the patient and their family members to determine which treatment option aligns with the patient's wishes and goals. Such a process should lead to a meaningful "informed decision making". We will take a deep dive into a real case to make an informed decision.
Other Podcasts for Deep Dive into Geriatric Oncology
https://youtube.com/playlist?list=PLYGS6iJ2qRQn9Daebd7tj_XGegwjHZfvz&si=Wj5WeJucPFUSrEeV
------
Follow or reach out:
https://x.com/GeriOncologist?t=CUzyZGLoJi3HTr5eR851FQ&s=09
or
https://www.linkedin.com/in/arminshahrokni?utm_source=share&utm_campaign=share_via&utm_content=profile&utm_medium=android_app
Show More Show Less View Video Transcript
0:05
welcome to the deep dive you've shared
0:06
some uh really interesting sources with
0:09
us focusing on well complex medical
0:11
decisions specifically in geriatric
0:14
cancer care yeah it's definitely an area
0:16
where you know the textbook answer
0:18
doesn't always fit the actual patient
0:19
sitting there you have to balance things
0:21
carefully exactly and that's our mission
0:23
for this deep dive to really unpack
0:26
these sources pull out the key insights
0:28
on how medical teams manage that balance
0:30
you know standard treatments versus the
0:32
individual patients risks their overall
0:34
health and crucially what they want and
0:37
we're going to tackle this mostly by
0:38
looking at the core of your source
0:40
material which is a discussion built
0:42
around a real world case study an
0:44
81-year-old patient uh the source calls
0:47
her Jane Smith okay great let's dive in
0:49
then yeah so the source introduces Jane
0:51
Smith 81 years old diagnosed with ductal
0:53
carcinoma in C2DCIS in her left breast
0:56
right and the source makes sure to
0:58
highlight a couple of key things about
1:00
her DCIS it's high-grade and it's triple
1:03
negative now DCIS is technically
1:06
non-invasive but those features well the
1:10
source flags them as potentially
1:11
indicating a more aggressive biology
1:13
underneath got it so even though it's in
1:15
situ those details matter for the team's
1:18
thinking now the source is clear despite
1:21
her age and um other health issues we'll
1:24
get to the goal for Miss Smith was
1:26
curative intent treatment they were
1:28
aiming for a cure absolutely not just
1:30
managing it and that clear goal really
1:32
framed the choices they had to discuss
1:33
okay so the source talks about two main
1:36
treatment options they went over with
1:37
her option A was cryoblation yeah the
1:40
source describes that as uh less
1:41
invasive basically freezing the cancer
1:43
cells the big plus as the source puts it
1:46
is lower procedural risk kind of the
1:48
safer path at least in terms of the
1:49
immediate procedure safer path okay
1:51
compared to option B lumpctomy the
1:54
traditional surgery right removing the
1:55
lump exactly and the source calls this
1:57
the gold standard for definitive local
1:59
control so highest chance of clearing
2:01
that specific area but it comes with
2:03
those higher risks of surgery anesthesia
2:05
all that so there's the dilemma the
2:07
source lays out the um the apparently
2:10
safer less invasive way versus the
2:13
traditional more definite way that has
2:15
bigger upfront risks and the source
2:17
really stresses you can't just look at
2:19
the cancer to make this call no you
2:21
absolutely have to look at the whole
2:22
person which brings us to the geriatric
2:25
assessment the source goes into detail
2:26
here and it's critical what did that
2:29
assessment show about Jane Smith it
2:31
placed her as prefrail to frail right
2:34
and the value in the source is how it
2:36
breaks that down listing the specific
2:38
things contributing to her frailty and
2:40
her overall risk picture it's quite a
2:41
list when you lay it out um complex
2:44
medical history high blood pressure
2:46
she's got insulin dependent diabetes
2:48
stage 3b chronic kidney disease which
2:51
means functionally her kidneys are only
2:52
working at about 37% capacity that's
2:55
pretty significant very and then there's
3:00
eliquis a blood thinner and that elquis
3:03
is a perfect example the source uses for
3:04
that highwire act right if she has
3:07
surgery you've got this major bleeding
3:09
risk during the operation but if you
3:11
stop the elitequiz you risk a stroke
3:13
yeah a tough balancing act then the
3:15
source adds polyfarm
3:17
pharmacy basically she's at a lot of
3:20
different medications daily more
3:21
variables more potential interactions
3:23
and functionally what did the source say
3:25
about her mobility that's another big
3:27
piece severe spinal stenosis painful
3:30
neuropathy she uses a walker her gate
3:34
how she walks is described as slow and
3:37
antalgic meaning slow because it hurts
3:39
exactly so you can see the worry
3:41
highlighted in the source that a major
3:43
surgery could really knock back her
3:44
mobility maybe permanently okay so you
3:47
put all that together and the source
3:48
spells out the risks for the lumpctomy
3:50
pretty clearly yeah it's stark high GH
3:52
anesthesia risk high GH bleeding risk
3:55
and elevated risk for posttop
3:57
complications things like poor wound
3:58
healing infection maybe kidney injury
4:01
and uh a big one in older folks
4:03
post-operative delarium or confusion wow
4:06
okay looking just at that list I mean it
4:08
seems almost obvious to say "Let's go
4:10
with the cryoablation it's too risky."
4:13
And that's exactly the point the source
4:14
makes if you only focus on those risks
4:17
those numbers on paper you could easily
4:20
undertreat her cancer you might steer
4:23
her away from the best cancer treatment
4:24
just because of her age and these other
4:26
issues but the source argues that's only
4:28
half the equation right precisely that's
4:29
the vulnerability side but then the
4:31
source pivots to Jane Smith's strengths
4:34
and this is really important okay so
4:36
what are the strengths the source
4:37
highlights well first her cognition is
4:40
intact she's described as alert oriented
4:44
and pleasant that's huge when you're
4:46
talking about making complex decisions
4:48
and getting through recovery makes sense
4:50
and her goals you mentioned they were
4:52
clear crystal clear the source actually
4:54
quotes "The patients goal remains
4:56
curative intent treatment she has chosen
4:59
lumpctomy to achieve the highest chance
5:01
of local control so her values her
5:03
desired outcome they line up perfectly
5:06
with the more aggressive option." So she
5:07
wasn't ambiguous about wanting the best
5:09
shot at a cure not at all and then
5:12
there's what the source calls a massive
5:14
asset in geriatric care her social
5:17
support her son and daughter were right
5:19
there with her really involved committed
5:21
to helping that feels like it could be a
5:24
gamecher having that kind of support
5:26
system at home the source implies that
5:28
really boosts the chances of a good
5:30
outcome doesn't it oh absolutely strong
5:32
social support isn't just you know nice
5:35
to have clinically it can make a huge
5:37
difference especially after surgery for
5:39
older adults it's a real resource so
5:41
you've got this patient significant
5:43
risks yes but also clear goals she can
5:46
make her own decisions and she has
5:48
fantastic family support how does the
5:50
source say the team brought all that
5:51
together well this is where shared
5:53
decision-making according to the source
5:55
becomes the absolute key it wasn't just
5:57
a quick chat after really extensive
5:59
conversations weighing everything the
6:02
cancer details the procedure risks her
6:04
health her function her goals and her
6:06
support Miss Smith and her family
6:08
elected the surgery that word elected
6:11
really stands out it means she was
6:12
driving the decision yes exactly the
6:16
source emphasizes she fully understood
6:18
the risks weighed them against the
6:20
benefits she valued and made an informed
6:22
choice she was the active participant
6:25
not just being told what to do or pushed
6:27
into something potentially too risky
6:29
without understanding right and once she
6:31
made that choice the source explains the
6:33
medical team's job changed changed from
6:36
deciding for her to figuring out how to
6:39
make her choice happen as safely as
6:41
possible you got it the source details
6:43
this in the plan section it's like a
6:45
blueprint for tackling every single risk
6:47
they'd identified okay give me an
6:48
example like that high anesthesia risk
6:51
what was the plan the source says they
6:53
recommended mitigating that with a
6:55
regional block instead of general
6:56
anesthesia so numbing the specific area
6:59
not putting her fully under less
7:01
systemic impact and the bleeding risk
7:03
with the elquis that needed really
7:05
careful precise coordination with her
7:07
cardiologist the source describes a
7:09
detailed plan for managing the blood
7:10
thinner around the surgery time a very
7:13
tricky balance okay what about her
7:15
diabetes specific plan laid out in the
7:17
source to adjust her insulin carefully
7:20
before during and after and those
7:22
broader geriatric issues the frailty the
7:25
risk of confusion that's where that
7:26
massive asset her family really came in
7:29
the plan as described in the source
7:31
involved leveraging their support for
7:33
roundthe-clock help right after surgery
7:36
educating them on spotting delirium
7:38
early ways to prevent it and uh planning
7:41
for pain control that used fewer opioids
7:43
to cut down on confusion and side
7:45
effects so it sounds like they didn't
7:46
shy away from the high-risisk option she
7:48
chose instead they built this like
7:50
safety net around it exactly high risk
7:53
wasn't a stop sign it was as the source
7:55
suggests a trigger for incredibly
7:57
detailed patient- centered planning okay
8:00
so let's wrap this up what are the big
8:02
lessons the main takeaways from this
8:03
case study according to the source's
8:05
conclusion the source boils it down to a
8:07
few really key points first a number
8:10
whether it's age or kidney function or
8:12
BMI it's never the whole story you need
8:14
that deep dive that holistic view
8:16
strengths support goals the works right
8:19
look at the whole person what else
8:21
second labeling someone high risk
8:23
shouldn't mean no treatment it should
8:25
mean plan meticulously it's a road map
8:28
not a dead end okay makes sense third
8:31
and this really came through the source
8:33
champions shared decision-making he uses
8:36
great analogy the patient the Smith she
8:39
was the pilot it was her flight her
8:41
choice based on her values the medical
8:43
team and the family they were the
8:45
essential flight crew using their
8:47
expertise and support to help her
8:49
navigate the journey she chose i like
8:51
that the pilot and the flight career
8:52
really shifts the perspective it does
8:54
and finally the source basically
8:56
concludes this case is a perfect example
8:58
of the art of medicine you know finding
9:01
the treatment that works for the cancer
9:03
yes but also fits the patients life
9:05
their priorities their ability to
9:07
actually get through it and live well
9:09
afterwards that's a really powerful
9:10
takeaway navigating these complex
9:12
choices especially with older adults who
9:14
often have multiple health issues it
9:16
really forces you to look beyond the
9:18
charts and scans it demands that uh that
9:21
deep dive into the individual balancing
9:23
the hard data with the person's own
9:26
goals and the support they have around
9:28
them that balancing act yeah that's
9:29
where truly patient centered care
9:32
happens it really is so based on this
9:34
case we've just unpacked here's
9:35
something for you the listener to think
9:37
about how much weight do you think a
9:39
patient's personal goals and maybe their
9:41
family support system how much should
9:43
that weigh against the cold hard
9:46
clinical risk factors when everyone's
9:47
trying to make these incredibly tough
9:49
healthcare decisions definitely
9:50
something worth considering
10:02
[Music]
#Aging & Geriatrics
#Cancer