second opinionepisode 902 geriatric oncolgytranscript announcer: major funding for "second opinion" is providedby the bluecross and blueshield association,an associationof independent, locally operated, and community-based blue cross and blue shieldcompanies. for more than 80 years,blue cross and blueshield companies have offered health care coverage in everyzip code across the country and supported programs that improvethe healthand wellness
of individual members and their communities.thebluecross and blueshield association's mission is to make affordable health care availableto all americans. news about our innovations is online at bcbs.comand on twitter @bcbsassociation. "second opinion" is produced in associationwith the university of rochester medical center, rochester, new york. salgo: welcome to "second opinion," whereyou get to see, firsthand, how some of the country's leading health care professionalstackle health issues that are important to you. i'm your host, dr. peter salgo, and todaywe're happy to welcome our "second opinion" primary care physician, dr. lisa harris.dr. supriya mohile from the university of
rochester medical center.dr. william dale from the university of chicago. and beverly vaughan, who ishere to share her personal experience.that's an experience, by the way, that our panelists,along with you at home, will be hearing for the first time.so let's get right to work. beverly, thanks for coming. before august of 2010, you thoughtyou were pretty healthy. yeah? vaughan: oh, yes. i was raised in a familywhere my mother was a nurse, so we knew that we had to have continued medical attention,and i had done all of that, led a very active life. my husband had suggested to me thati had failed retirement completely. which was an opinion shared by most of my friends.
salgo: so now it's 2010, august. what changedin august that concerned you? vaughan: for a person who normally feels verygood, um...all of a sudden, i had a stomach ache. salgo: describe the stomach ache to me. vaughan: just like a very dull pain. it wasn'texcruciating, but it was definitely there. salgo: and how long had it gone on? vaughan: well, when i got to day two, i decidedthat i'd better not fool around. salgo: lisa, here's an otherwise healthy womanwho's in your office with two days of vague dull stomach ache. are you worried?
harris: well, not with two days' history.i mean, certainly we do tend to try to find the more common things that occur, so i'dwant to find out if she had any change in her eating habits, has she eaten somewheredifferently, has she been around anyone that was sick, particularly children, grandchildren,great-grands. vaughan: and the answer would be no to allof the questions. salgo: how old were you at the time? vaughan: 77. mohile: any changes in bowel habits at thattime? vaughan: no.
dale: nausea or sick to your stomach at all? vaughan: nothing like that at all. salgo: so you decided with this constellationto contact your primary care physician, and what did your primary care physician's visitentail? vaughan: in retrospect, i'm very happy thati've gone to the same medical team, because they knew me. and after poking around in mystomach for a while and making sure that i wasn't having an allergy reaction, she said,"we need to have you have an mri right now." harris: not even a ct or a plain film, anmri? salgo: now, you sound surprised that theywent right to a scan.
harris: well, they must have found somethingon physical exam that would make them think that she needed to have a scan. had you lostany weight? vaughan: unfortunately, no. [ laughter ] harris: and was your appetite still normal? vaughan: yes. mohile: and what did she tell you that shethought was going on? vaughan: she said, "i really don't know what'sgoing on. we need to have a further check-up on it."
harris: did you have any pain when she feltyour abdomen at all? harris: did she tell you that she felt anythingabnormal? salgo: now, something else happened. you getthis scan, you got the result right away. vaughan: she said to me, "i think you'd betterget to strong hospital right away." salgo: that's of some concern. you went infor a stomach ache, got a scan, and the next thing you know, they're admitting you to thehospital. mohile: with the pain being, you know, with10 being the worst pain you've ever had, was this pain increasing in severity at that point? mohile: it was kind of a dull ache. that wasconstant.
dale: yeah, was it moving anywhere or wasit staying pretty much right where it was? vaughan: no, no. harris: and the only thing they told you was,"there's something on the scan -- go to the hospital right now"? dale: when she's doing the exam, did you noticeany reaction that she had, or a time in the exam where, i don't know, her eyes widenedor something -- harris: or she stayed in the same area? dale: because it's pretty unusual on a physicalexam to have something that bypasses more standard testing of some kind.
harris: that's correct. vaughan: the only answer i could give youis that she knows me. salgo: that makes a big difference. salgo: when you got to strong, what happened?they took me right into one of those examining rooms. salgo: okay. vaughan: and two or three people appearedand checked me all over, and then we had the blood draw. and the doctor who was there said,"we'll be operating on you in about an hour." harris: now, has shock and surprise set inyet for you?
vaughan: um, i was wondering, you know, howi was going to get in touch with my husband to let him know -- dale: i was just going to ask, where was yourfamily? were they with you? vaughan: i drove myself to the hospital. dale: just by yourself in the car? mohile: from the doctor's office? vaughan: because i didn't think there wasanything particularly wrong with me. harris: wow. salgo: and then they said, "you're goingtothe operating room."
vaughan: they said, "you're going to the operatingroom." harris: and you still don't know what's wrong? vaughan: no. i don't think they did, either,but they knew that something was. salgo: after the surgery was over, what didyou think was wrong? vaughan: the doctor came in and, of course,said, "well, we think what it is is, there was some turning over in your colon." salgo: a twist in the -- vaughan: a twist, yes. a twist. salgo: let's get this straight -- you havea twisted colon. you've had surgery. but then
the question, of course, i'm sure, on everyone'smind here is, "why did you have the twisted colon?" they're on the edge of their seat.what did they tell you? vaughan: the final result was that there wasa loop in the colon and a descending mass. dale: i see. salgo: and what did the doctor say? vaughan: she said, "we think it's cancerous." salgo: what did you think when you heard thatdiagnosis? vaughan: um, i was very surprised. cancerwas not something that ran in my family. salgo: you have this diagnosis now. you're77 years old. is that a common age for someone
to have this diagnosis? dale: yeah, i mean, cancer is much more prevalentin older adults. there’s sort of two epidemics go hand in hand. people are getting older,and cancer comes along with it. salgo: well, beverly, once you left the hospital,you get this diagnosis, you met with an oncologist, and what options did you have? vaughan: they spoke to me very softly, andsaid, "we have several alternatives as to how we're going to treat you. and this iswhat we suggest you should do." they knew that i was in a tough situation. and...thefirst couple of encounters were very emotional. salgo: okay, and what were the options theyoffered you?
vaughan: well, once we were sure that i wasnot going to have to have radiation, they suggested a medicine that i would take. salgo: well, they offered you medication.did they offer ever just do nothing? vaughan: oh, no, oh, no, they were adamanton that. "there is an option for you, and this is what we suggest." salgo: and did your age -- 77 -- enter intothis decision tree at all? vaughan: nobody asked me how old i was. salgo: but they knew, they knew.
vaughan: they knew, and i certainly didn'tmention it. salgo: now, nobody asked her about her age.they knew her age, and it doesn't sound like -- it doesn't sound to me as if they weremodulating their suggestions based upon the fact that you were 77. but that's not alwaysthe case, is it? dale: no, for sure, we --in many cases, peopleare taking "age is age," as if there's some threshold by which, "oh, maybe we should takeit easy, maybe we should do less therapy than we would for other people, because you'retoo fragile to undergo the therapies." salgo: well, let me thrust this out in boldrelief. cancers occur in older people more often, statistically, than in younger people.and with the aging of our population, we're
seeing more and more cancers in more and morepeople. and yet people are saying, "oh, these older people, maybe they don't get the treatmentthe same as younger people." harris: that's such a problem. we're reallytalking about, not so much age as a number, but what's the functional status of the person?and whether or not they are really actively engaged in their quality of life, in theirliving. that's much more important than the actual number. salgo: so what is behind all this? why areolder folks not getting as aggressive therapy as perhaps they might? mohile: there's a challenge, i think, whenoncologists see patients who are 75 and over,
in determining the right approach, becauseour clinical trials that are run by the nih – national institutes on health – andlarge groups of medical centers that do clinical trials together, clinical trials are whatgive us information on what drugs to give, how safe and effective they are for differentstages of cancer -- historically have not enrolled many patients who are 70 and over. salgo: i want to stop you right there, becausethat's critical. we hear about evidence-based medicine -- that means there's got to be evidenceout there. and yet, if you're not enrolling older people in these treatment trials, whatevidence do you have? dale: i think it's a real challenge for ourfield to extrapolate from the existing data
to apply them to these particular patientsthat we have. even the patients that are older that enroll in the trials are not your typicalolder person who's out in the world. so even where we have the data, it's even thinnerthan we think, in many cases. but also, the outcomes aren't so clear. we tend to focuson mortality, mortality, mortality. but quality of life is at least as important. and especiallyfor older patients, quality of life is so important. we hardly ever measure it in thestudies. salgo: the studies always look for an endpoint to measure, right, and it's usually just, "how long did the person live?" mohile: clinical trials in oncology, overallsurvival is the most -- one of the most important
things, but they'll look at tumor responsesand that kind of thing. quality of life is usually very secondary. we don't do clinicaltrials well that look at quality of life and functional capacity and impact on independence,as beverly was working, and taking care of her needs, and, you know, those kinds of thingsaren't studied as well, so the impact of cancer treatment -- we don't know what the impactof cancer treatment is on those things, often. dale: one thing about that, though, that weforget, is not just that you can tolerate the therapies, but you need to get back tothis independent role, and are our therapies going to allow you to return to that role,is more important, in a way, than the sort of mortality numbers, and so i think we forgetthat piece, that what we're really trying
to do is make sure you can go back to doingwhat you need to do. we need to tell people up front whether that's going to be the case. mohile: so i think you have to balance thefact that there's limited data with the patient that's sitting in front of you. salgo: and let me, if i may, throw a smallhand grenade on the floor. mohile: go ahead. salgo: that is economics, right? we're inthe midst of this decades-long debate about health care costs, and you have this awfulstatistic about cost per year of life added. and what i've heard is, "old people? well,they don't have that much life left. and it's
going to be expensive, so the cost per yearis enormous. that's why we're not going to treat them." you've heard that. dale: for sure. i think that many of our commonmetrics for benefit to cost disadvantage older people in the calculation. the classic onebeing productive life years, meaning how much money are you going to earn between now andthe end of your life? that's the benefit to society of your life. i'm not sure we wantthat as our outcome for people, and we just -- that too often, i think, does enter intothis sort of calculus for any particular person. harris: maybe we need to include in our metricsnot just the productivity with respect to income generated, but also a term called "saging"-- what is the benefit that older adults can
bring with respect to their experiences andtheir wisdom and things that they can share withyounger people? salgo: is chronological age, which is whatyou told me -- "i'm 77 years old" -- is that the best metric, or is there another way tomeasure age? harris: functional status. salgo: what's functional status? dale: right, i mean, i would say age correlateswith many things, and so it's a very rough proxy for things, like, how many other diseasesdo you have? how functional are you in your daily life? all those sorts of things. buti'd say age as a number is pretty crummy.
it gives us a starting point. salgo: why don't we call one of these chronologicalage, and another one physiological age -- the age that your body seems to be, which is notthe same. and that being the case, it makes sense to estimate that, how do you estimatethat? dale: so i want to say something about estimation,first, having -- anyways, thought a lot about this -- one thing we know about how doctorsestimate life expectancy is, if we just ask you, "how long are they going to live" andwe give a guess, we overestimate. so we often overstate how long we think it's going tobe. then, when we go in to talk to the patient, we actually tell them an even larger numberthan we believe, when we come and calculate
it on our own. so that's one direction thatwe make a lot of poor estimates. unfortunately, the other one is, with an older person, weway underestimate people who have much more life to live. salgo: how would you measure that? harris: well, it's a series of questions thatyou really want to ask the patient -- what do you do every day? how much exercise doyou get? what activities are you involved with? how independent are you, you know, withyour life? and how do you feel about your life in general? so we want to know all ofthose things that they're involved with in their day-to-day living.
salgo: exercise tolerance part of that? harris: absolutely. salgo: heart rate, blood pressure? harris: yes. mohile: so, for functional side, i mean, geriatricianstypically use -- there's the standard activities of daily living and instrumental activitiesof daily living. so activities of daily living are the ability of a person to take care oftheir own self-needs. and then instrumental activities of daily living are ability ofa person to live independently in the community. harris: do you drive, do you have a license,do you take the bus, who takes you to your
doctor's appointments, how do you do yourgrocery shopping, you know, how do you get to church, and what do you do with friendsand family, are you the care giver for other family members? those are the questions thatwe have to know about you to try to get an assessment. salgo: i want to pause just for a minute.we've covered a lot of ground. i want to sum up a little bit of what we've been talkingabout. when it comes to cancer, there is no "one size fits all" for treatment for theolder patient. and if your age is a consideration, it should be in terms of your physiologic,not chronological, age. the important thing to remember is that, no matter what your age,you should know that there are options for
you and what those options are. beverly, inaugust of 2010, you had surgery, you were diagnosed with colon cancer, and you decidedto begin chemotherapy. what were your concerns about the chemo? vaughan: well, first i asked if i would losemy hair. and the response was, "no, we don't think so." i knew nothing about cancer medicine,absolutely nothing at all. and dr. khorana suggested we try a drug called xeloda. i thoughtthat was the most exotic name i had heard for a medicine. and i was advised at whatkind of reactions i might have to it. and i said, "fine, go ahead." mohile: so did your doctor give you otheroptions for chemotherapy? or did he say, "this
is what you should do"? vaughan: he said, "i would think that thiswould be the best one for you." and again, i'm in an area that i don't know that muchabout. so i have to rely on the doctor. salgo: what is a doctor's responsibility here,other than, let's say, picking a chemotherapeutic agent? what sort of choices do you give topeople, and what choices do you think are forced? dale: yeah, so i think we need to separatepreferences or values from medical expertise. and i think the biggest mistake i see is whenpatients are sort of given the, "we can do whatever you want," and what we really aregiving back to them is some technical decision
about, "what medicines do you want to choose,"when that's the last thing they can actually tell us about, right? i mean, what we reallywant them to tell us is, "what kind of person are you?" "what kind of things are you goingto need to do?" and once we know that, then we can say, "these medicines do this, andi would recommend this." mohile: there are options for chemotherapy-- this is what we call "adjuvant treatment," so it's to prevent the cancer from comingback. it's like an insurance policy to reduce the risk of the cancer coming back. and thereare options, and your doctor modified it, whether you knew it or not, based on our standardof options, and then told you, based on his assessment of his talk with you about yourgoals and your values, what you would want.
so what -- do you remember what you talkedabout with him, in terms of how you wanted your life to go on treatment? vaughan: two weeks after i got home, we hadan emergency trip with my husband to the hospital. and the doctor there said --i'm never goingto get over this -- he just said to us, "this man has 30 days to live." [ gasps ] oh, my god. dale: this was when, two weeks after what? salgo: two weeks after they told you you hadcancer. vaughan: yeah.
harris: oh, my goodness. vaughan: and so the doctor for my husbandwas quite correct -- within 30 days, we, mercifully, were able to get him into hospice, but hedied within 30 days. so i was into this major, major change inmy life. i'd never lived by myself. either at home or in a sorority house, or i had beenmarried for 53 years. so all of this was happening all at once. salgo: but it just fell on you like a tonof bricks. you have cancer, your husband is ill, he's going to hospice. dale: can i ask you what his condition was,or is that something you'd rather not talk
about? vaughan: he'd had cancer. vaughan: but he had also been in declininghealth for some time. so it wasn't as if it was a total surprise. salgo: but by the same token, you were active-- vaughan: oh, yeah. salgo: you were in control, dealing with allof this, and had decided to be aggressive about your cancer therapy. mohile: and there's a balance here. you know,we like to start our chemotherapy treatment
within eight weeks of surgery, or you losebenefit. so this is -- all the timing was difficult for her, you know, she had to startchemotherapy soon, and had to manage the life situation. salgo: but let's turn this over supposingshe didn't want to do that? and there are people who choose not to do that. not to havethe adjuvant therapy, or whatever. what is your role as a physician for people who choosethe other way than beverly did? dale: for me, i think you have to explorethe reasons why people decide they do or don't want to do something, and feel comfortablethat the reasoning lines up with what the medical facts are in a clear way. but if,for example, you thought, "she's really depressed
right now, for understandable reasons, butreally depressed, and doesn't want to pursue other therapy for that reason," i think wewould all say, we should treat her for that depression before you revisit that conversation. harris: and this is where i want to jump in,where i really want to just hit on the subspecialists just a little bit. you guys forget about theprimary care physicians, and once the diagnosis of cancer comes in, it becomes all-consumingwith that subspecialist, as if there's nothing else going on with that patient, and i wouldjust say, when things like that are happening, just call the primary care doctor. she hada relationship for years with that person. salgo: so, taking this as a whole global picture,what's it like, and what do you need to consider,
working with the older patient with cancer? mohile: so, william and i do this in our clinics,so we have one of the few -- we partner with our clinics -- so we have a clinic, it's multidisciplinary,where we do sort of a very comprehensive assessment of an older patient. it's called comprehensivegeriatric assessment. it's used in geriatrics a lot, where they estimate, you know, function,cognition, social support, psychological status, nutrition, and that can help not only estimatelife expectancy, but predict chemotherapy toxicity and help develop interventions tohelp people get through treatment in a way that they come out of it being more indep--as independent as they started. salgo: you mentioned social support. how importantis that? i mean, she lost some of her social
support with her husband. dale: yeah, this is a super-difficult situation,so, i mean, i can only commend you for, you know, how chaotic that must have been, becauseit's like -- you had the very unusual circumstance of going from incredibly functioning personand a well-functioning social circumstance, and just pulled both rugs out from under youat the same time, which is sort of, the fundamentals of what we do, when you were talking earlierand i said, you know, "it's not just that they're independent, it's what kind of supportdo they have that the independence interacts with," right? salgo: beverly, i was very quick to say that,"oh, your husband died, and your social support
went away." that's not necessarily true. salgo: tell me about that. vaughan: well, of course, i had my familyin town, small as it is, but at least they were there. and i have been active in severalgroups -- syracuse university alumni, my church was really spectacular, american associationof university women. i did two jobs – volunteer jobs -- with children. and those things weregoing on, and so i needed to go on. mohile; oncologists do a reasonable job atassessing, you know, what your doctor saw, you were active, you know, in all these activities,you were taking care of your husband, you know, and then you had a lot of things thatyou needed to take care of during chemotherapy.
and so i think what your doctors rightfullydid was kind of use all this information that's been happening to you to say, you know, "youdon't have time to spend half a day every two weeks in the infusion center and weara pump, and we have reasonable data in using xeloda, which is a pill chemotherapy, andthat may work better for you, you may be able to get through that and finish that treatmentin a more likely way than infusional chemotherapy, and i think that probably was related to socialsupport. dale: my baseline attitude is, if they can-- if they're functioning and can tolerate it and have the right social circumstance,they should get the same treatment anybody else gets. that's the baseline. the data works,and older people and younger people, we should
make no other distinctions. salgo: all right, you know, beverly, you mentionedthat you learned a few things. what else have you learned from this journey? vaughan: i learned that all the plans thati had made for my husband to have a care giver – i neglected to think about a care giverfor myself. salgo: let me pause just for a moment. whetheryou're 65, 80, whether you're 100, a host of factors -- medical, practical, emotional-- need to be taken into account to devise a therapeutic plan. no matter whatplan of action you choose, a partnership with your health care team can help you bettermanage your care. and that team should include
your friends and your whole social network.so, beverly, how are you doing? vaughan: i'm doing fine. i'm approaching amajor birthday. and so the plans are in for that. i continue in all my other activities. salgo: what's your advice for folks of yourage? vaughan: i think many of us are not preparedfor the fact that we're going to be told that we have a serious illness. and i think weneed to prepare ourselves and our families better. salgo: this has been a great, great discussion,but unfortunately, we're out of time. but we hope you continue the conversation on ourweb site. there, you will find the entire
video of this show, as well as the transcriptand links to resources. our address is secondopinion-tv.org. i want to thank you all for watching. i wantto thank you all for being here, thank my uncle abe, who just left us at the age of101 and taught me a lot about older people and sickness. i'm dr. peter salgo, and i'llsee you next time for another "second opinion. major funding for "second opinion"is providedby the bluecros and blueshield association, an association of independent, locally operated,and community-based blue cross and blue shield companies. for more than 80 years, blue crossand blue shield companies have offered health care coverage in every zip code across thecountry and supported programs that improve the health and wellness of individual membersand their communities.the bluecross and blueshield
association's mission is to make affordablehealth care available to all americans. news about our innovations is online at bcbs.comand on twitter @bcbsassociation.
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