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Textbook vs. Reality in Elderly Cancer Care
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Jul 4, 2025
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
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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
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cancer care yeah it's definitely an area
0:16
where you know the textbook answer
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doesn't always fit the actual patient
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sitting there you have to balance things
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carefully exactly and that's our mission
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for this deep dive to really unpack
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these sources pull out the key insights
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on how medical teams manage that balance
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you know standard treatments versus the
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individual patients risks their overall
0:34
health and crucially what they want and
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we're going to tackle this mostly by
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looking at the core of your source
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material which is a discussion built
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around a real world case study an
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81-year-old patient uh the source calls
0:47
her Jane Smith okay great let's dive in
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then yeah so the source introduces Jane
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Smith 81 years old diagnosed with ductal
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carcinoma in C2DCIS in her left breast
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right and the source makes sure to
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highlight a couple of key things about
1:00
her DCIS it's high-grade and it's triple
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negative now DCIS is technically
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non-invasive but those features well the
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source flags them as potentially
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indicating a more aggressive biology
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underneath got it so even though it's in
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situ those details matter for the team's
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thinking now the source is clear despite
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her age and um other health issues we'll
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get to the goal for Miss Smith was
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curative intent treatment they were
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aiming for a cure absolutely not just
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managing it and that clear goal really
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framed the choices they had to discuss
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okay so the source talks about two main
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treatment options they went over with
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her option A was cryoblation yeah the
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source describes that as uh less
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invasive basically freezing the cancer
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cells the big plus as the source puts it
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is lower procedural risk kind of the
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safer path at least in terms of the
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immediate procedure safer path okay
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compared to option B lumpctomy the
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traditional surgery right removing the
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lump exactly and the source calls this
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the gold standard for definitive local
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control so highest chance of clearing
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that specific area but it comes with
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those higher risks of surgery anesthesia
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all that so there's the dilemma the
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source lays out the um the apparently
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safer less invasive way versus the
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traditional more definite way that has
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bigger upfront risks and the source
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really stresses you can't just look at
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the cancer to make this call no you
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absolutely have to look at the whole
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person which brings us to the geriatric
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assessment the source goes into detail
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here and it's critical what did that
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assessment show about Jane Smith it
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placed her as prefrail to frail right
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and the value in the source is how it
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breaks that down listing the specific
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things contributing to her frailty and
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her overall risk picture it's quite a
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list when you lay it out um complex
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medical history high blood pressure
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she's got insulin dependent diabetes
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stage 3b chronic kidney disease which
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means functionally her kidneys are only
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working at about 37% capacity that's
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pretty significant very and then there's
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eliquis a blood thinner and that elquis
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is a perfect example the source uses for
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that highwire act right if she has
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surgery you've got this major bleeding
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risk during the operation but if you
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stop the elitequiz you risk a stroke
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yeah a tough balancing act then the
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source adds polyfarm
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pharmacy basically she's at a lot of
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different medications daily more
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variables more potential interactions
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and functionally what did the source say
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about her mobility that's another big
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piece severe spinal stenosis painful
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neuropathy she uses a walker her gate
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how she walks is described as slow and
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antalgic meaning slow because it hurts
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exactly so you can see the worry
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highlighted in the source that a major
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surgery could really knock back her
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mobility maybe permanently okay so you
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put all that together and the source
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spells out the risks for the lumpctomy
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pretty clearly yeah it's stark high GH
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anesthesia risk high GH bleeding risk
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and elevated risk for posttop
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complications things like poor wound
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healing infection maybe kidney injury
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and uh a big one in older folks
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post-operative delarium or confusion wow
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okay looking just at that list I mean it
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seems almost obvious to say "Let's go
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with the cryoablation it's too risky."
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And that's exactly the point the source
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makes if you only focus on those risks
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those numbers on paper you could easily
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undertreat her cancer you might steer
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her away from the best cancer treatment
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just because of her age and these other
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issues but the source argues that's only
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half the equation right precisely that's
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the vulnerability side but then the
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source pivots to Jane Smith's strengths
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and this is really important okay so
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what are the strengths the source
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highlights well first her cognition is
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intact she's described as alert oriented
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and pleasant that's huge when you're
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talking about making complex decisions
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and getting through recovery makes sense
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and her goals you mentioned they were
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clear crystal clear the source actually
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quotes "The patients goal remains
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curative intent treatment she has chosen
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lumpctomy to achieve the highest chance
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of local control so her values her
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desired outcome they line up perfectly
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with the more aggressive option." So she
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wasn't ambiguous about wanting the best
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shot at a cure not at all and then
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there's what the source calls a massive
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asset in geriatric care her social
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support her son and daughter were right
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there with her really involved committed
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to helping that feels like it could be a
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gamecher having that kind of support
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system at home the source implies that
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really boosts the chances of a good
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outcome doesn't it oh absolutely strong
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social support isn't just you know nice
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to have clinically it can make a huge
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difference especially after surgery for
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older adults it's a real resource so
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you've got this patient significant
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risks yes but also clear goals she can
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make her own decisions and she has
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fantastic family support how does the
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source say the team brought all that
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together well this is where shared
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decision-making according to the source
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becomes the absolute key it wasn't just
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a quick chat after really extensive
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conversations weighing everything the
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cancer details the procedure risks her
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health her function her goals and her
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support Miss Smith and her family
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elected the surgery that word elected
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really stands out it means she was
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driving the decision yes exactly the
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source emphasizes she fully understood
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the risks weighed them against the
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benefits she valued and made an informed
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choice she was the active participant
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not just being told what to do or pushed
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into something potentially too risky
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without understanding right and once she
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made that choice the source explains the
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medical team's job changed changed from
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deciding for her to figuring out how to
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make her choice happen as safely as
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possible you got it the source details
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this in the plan section it's like a
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blueprint for tackling every single risk
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they'd identified okay give me an
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example like that high anesthesia risk
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what was the plan the source says they
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recommended mitigating that with a
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regional block instead of general
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anesthesia so numbing the specific area
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not putting her fully under less
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systemic impact and the bleeding risk
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with the elquis that needed really
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careful precise coordination with her
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cardiologist the source describes a
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detailed plan for managing the blood
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thinner around the surgery time a very
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tricky balance okay what about her
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diabetes specific plan laid out in the
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source to adjust her insulin carefully
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before during and after and those
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broader geriatric issues the frailty the
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risk of confusion that's where that
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massive asset her family really came in
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the plan as described in the source
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involved leveraging their support for
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roundthe-clock help right after surgery
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educating them on spotting delirium
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early ways to prevent it and uh planning
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for pain control that used fewer opioids
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to cut down on confusion and side
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effects so it sounds like they didn't
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shy away from the high-risisk option she
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chose instead they built this like
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safety net around it exactly high risk
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wasn't a stop sign it was as the source
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suggests a trigger for incredibly
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detailed patient- centered planning okay
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so let's wrap this up what are the big
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lessons the main takeaways from this
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case study according to the source's
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conclusion the source boils it down to a
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few really key points first a number
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whether it's age or kidney function or
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BMI it's never the whole story you need
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that deep dive that holistic view
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strengths support goals the works right
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look at the whole person what else
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second labeling someone high risk
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shouldn't mean no treatment it should
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mean plan meticulously it's a road map
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not a dead end okay makes sense third
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and this really came through the source
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champions shared decision-making he uses
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great analogy the patient the Smith she
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was the pilot it was her flight her
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choice based on her values the medical
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team and the family they were the
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essential flight crew using their
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expertise and support to help her
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navigate the journey she chose i like
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that the pilot and the flight career
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really shifts the perspective it does
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and finally the source basically
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concludes this case is a perfect example
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of the art of medicine you know finding
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the treatment that works for the cancer
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yes but also fits the patients life
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their priorities their ability to
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actually get through it and live well
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afterwards that's a really powerful
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takeaway navigating these complex
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choices especially with older adults who
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often have multiple health issues it
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really forces you to look beyond the
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charts and scans it demands that uh that
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deep dive into the individual balancing
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the hard data with the person's own
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goals and the support they have around
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them that balancing act yeah that's
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where truly patient centered care
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happens it really is so based on this
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case we've just unpacked here's
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something for you the listener to think
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about how much weight do you think a
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patient's personal goals and maybe their
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family support system how much should
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that weigh against the cold hard
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clinical risk factors when everyone's
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trying to make these incredibly tough
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healthcare decisions definitely
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something worth considering
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[Music]
#Aging & Geriatrics
#Cancer