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Melanie Cole (Host): For patients aged 65 and older with cancer, there are some unique challenges these patients and their caregivers face. My guest is Dr. Erika Ramsdale, she is a board-certified specialist in internal medicine and geriatric medicine who specializes in geriatric cancer care. Welcome to the show, Dr. Ramsdale. What is geriatric oncology?

Dr. Erika Ramsdale (Guest): Well, thank you very much for having me on, so geriatric oncology is a pretty new field and it combines two different specialties focusing on the care of older adults with a diagnosis of cancer, so geriatric oncologist like myself often have training and certification in both geriatric medicine and oncology.

Melanie: So, what are some of the unique challenges that an older patient with cancer might face different than their younger counterparts.

Dr. Ramsdale: Sure so, as we know, you know, as we age, our physiology changes. I tell patients you don't have the same body at 80 as you did at 20, so we become susceptible to more health problems and that includes cancer. Older adults can be more at risk also for complications from their cancer and from their treatment compared to younger patients, so some are more risk for side effects or they may have other complex health problems affecting them, for example, they may have a mobility issue that makes getting back and forth to the clinic difficult, so I think determining the right treatment plan is sometimes not easy and really requires thinking about the whole person, not just the cancer. On the other hand, I would say aging doesn't happen at the same rate in everyone, so age really is just a number, some healthy and fit older adults are not offered treatment for their cancer because of their age and this is unfortunate because some might really benefit.

Melanie: Well and as you mentioned that they might have other medical problems in addition to cancer, whether it's mobility issues, arthritis, or you know any of these things, they also might not have as easily access to transportation and social support, that sort of thing, so what are some important things that caregivers of these geriatric and elderly patients need to know.

Dr. Ramsdale: The caregivers are critical parts of the cancer care for older adults. They are really important to all patients going through cancer treatment, though maybe especially for older adults and especially as you mentioned for those with complex health problems, mobility problems, memory loss, and things like that, there's a lot of accumulating data that our social support structure is really critical for these patients and does affect the outcomes of treatment in older patients to a very significant degree. On the other hand, caregiving can be really tough on the caregiver and so I would say, he or she needs to know how to access health, so I always encourage patients to have their caregivers present at clinic appointment, so that they can ask questions about what to expect. I also strongly encourage all my patients really at any age to talk about their wishes and goals with their primary caregivers and to also designate a power of attorney for healthcare in case they become unable at some point to make decisions for their healthcare. This really helps the caregivers be better advocates for the patient and especially for older patients if something unexpected happens or the end of life.

Melanie: I think it's also important that the caregivers help with that advocacy because a lot of time, you know, the hearing is even an issue, so that the elderly patient can't even hear the doctor’s instructions or hear their prognosis, you know, those are the kinds of things that that advocate, that caregiver is so important. Now, where do emotions come in Dr. Ramsdale, can depression for example affect treatment and outcomes?

Dr. Ramsdale: Yes, most definitely. There is a lot of data that problems with mood including depression can significantly impact outcomes for cancer patients.

Melanie: And what about the risk factors for elderly patients like their susceptibility to falling maybe if treatment gives them a little bit of nausea, something that they're not that used to. What do you tell them and their caregivers to watch out for?

Dr. Ramsdale: Well, I think you point out that it's true that, you know, older adults have less what we call reserve, so things that might not bother younger patient or might not push them into a serious situation can be sometimes very serious for older adults, so I tell them to speak up and the caregivers to speak up if they experience any side effects because we need to react quickly in many cases to prevent complications like falls which can obviously be very devastating.

Melanie: Where does nutrition play a part in treatment for cancer care for older patients?

Dr. Ramsdale: Well, as you are going through cancer treatment, I always encourage my patients to maintain their weight as much as possible. Often patients have weight loss and then in older patient, they predominantly lose muscle mass when they lose weight and this actually increases the risk of mobility problems, and to falling, and other, you know, adverse health outcomes, so the role of nutrition is particularly important for older adults.

Melanie: Do you like to, you know, recommend some of the nutritional supplements, cans and things that are out there to help them keep up that nutrition while they are going through treatment?

Dr. Ramsdale: I do. I think a lot of patients are obviously scared by a diagnosis of cancer, so they really want to make some changes in their diet, but I tell people the most important thing going through cancer treatment is to again maintain your weight, so that is calories and that is protein, so certainly I often recommend shakes like, you know, Ensure Boost, some of the calories supplementing shakes because these are sometimes easier especially when someone has a lower appetite because of their treatment or because of the cancer, so yes this is something I often recommend.

Melanie: Now doctor, one of the things that kind of goes along with being older and then also having cancer is that you are on so many medications for these other things. How do you work with the patients and the medications that they are on for blood pressure or diabetes or their arthritis or any number of things and what they're going through for their cancer care?

Dr. Ramsdale: Yes, so you are right, older adults are often on many medication for other health problems and also older adults metabolize drugs differently, so I always do a very detailed review of their medication list, what they're taking and how they're taking it and look at potential interactions between those medications and also potential interaction with the cancer treatment itself, so these are very important things to be aware of and their actually criteria out there to help us look at these medications and decide how we should be tailoring therapy.

Melanie: Well, it's such a wonderful field that you're in, this new burgeoning field and tell the listeners why geriatric cancer patients should choose UVA for their care.

Dr. Ramsdale: Well, at UVA, we just started the Geriatric Oncology Clinic, it’s located in the Emily Couric Clinical Cancer Center where the cancer patients receive most of their care, so in that clinic, I am the physician there and we see patients on the request of their treating physician and so the patients can get referred to the clinic for a variety of reasons, not just advanced age because, you know, they have additional concerns about some other conditions we have been talking about and so we do a comprehensive assessment of the older person's functioning, not just their physical functioning, but some of the domains that we have talked about like cognitive status or social functioning, emotional functioning, how their nutrition is. We look at their other health problems in depth and we review their medications as I mentioned and their potential interactions with cancer treatment that allows me to give an individualized summary and recommendation back to the treating physician and this helps with decision making for the patient. For example, what's the right cancer therapy for them, are they likely to tolerate this therapy, what’s likelihood of significant side effects, you know, how will the cancer impact other health problems and these are obviously very important questions in an older adult, so I would say UVA contributes, this is not a clinic that is available at a lot of other sites. Obviously, a diagnosis of cancer requires really multidisciplinary expertise with experts from different fields working together for the patient and UVA, I have really seen how successful the experts are in individualizing care and I've been really impressed by how motivated my colleagues are to work together to find the best plan for the patient because this is what really leads to excellent care, so we have not only the geriatric oncology clinic, but excellent supportive care services, palliative care experts, social workers, nutritionists, physical therapy and I think we really offer comprehensive care for older patients and this is really what we need to ensure the best outcome.

Melanie: Thank you so much Dr. Erika Ramsdale. You are listening to UVA Health Systems Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening.