LONG-TERM CARE THREEStati Generali dell’Assistenza a lungo termine

Roma, 11 e 12 luglio 2018 Ministero della Salute

Silvio MonfardiniProgramma Oncologia GeriatricaIstituto Palazzolo,Fondazione Don Gnocchi,Milano

IL PAZIENTE ONCOLOGICO E I “LONG SURVIVORS”: BISOGNI INEVASI PER UNA CORRETTA PRESA IN CARICO

Disclosure

Session Chairman at a Meeting sponsored by Cellgene

Giotto. Evil exorcism in Arezzo

Quanti sono gli italiani che vivono dopo una diagnosi di tumore?

*Nel 2017, oltre 3 milioni e trecentomila (3.304.648) gli italiani

che vivono dopouna diagnosi di tumore ( 5,4% della popolazione italiana ,1/19 italiani)

*I NUMERI DEL CANCRO IN ITALIA 2017 AIOM-AIRTUM

Survivorship by Age

• Survivorship includes not just patients in remission but where cancer is a chronic disease

46% of cancer survivors are 70 years and older

Survivorship includes not just patients in remission but where cancer is a chronic disease

Estimated number of personswith a history of cancer from 1971 to 2008, by age group, projected through to the year 2030.

Rowland J. H., and Bellizzi K. M. JCO 2014; 32:2662-2668

©2014 by American Society of Clinical Oncology

2014 prevalence by age, sex, and durationamong cancer survivors age ≥ 65 years

1)Focus on screening for physical impairments (from mild to severe) as they need to be identified and treated

2)refer cancer survivors who have problems amenable to rehabilitation interventions to the appropriate health care

How to improve survivors' physical and psychological outcome?

From Giuseppe Colloca 2018,Treviso advancedcourse of Geriatric Oncology

General Physical Impairments

•Difficulty returning to premorbid activities•Joint pain, diffuse (e.g., arthralgias)•Musculoskeletal pain (e.g., myalgias)•Neuropathic pain•Somatic pain•Visceral pain•Weakness•Fatigue•Deconditioning

And Specific (organ or treatment related in each neoplasia)Physical Impairments

Common amenable Impairments

“medical care that should be integrated throughout the oncology carecontinuum and delivered by trained rehabilitation professionals

to diagnose and treat patients’ physical, psychological and cognitive impairments

to maintain or restore function,in a multidisciplinary approach reduce symptomburden, maximize independence and improve quality of life

Whatis then CancerRehabilitation?

From Giuseppe Colloca 2018,Treviso advanced course of GeriatricOncology

Arco temporale di attuazione della riabilitazione in oncologia

“La riabilitazione deve occuparsi del paziente oncologico per tutto

l’iter della malattia, dalla diagnosi all’intero percorso terapeutico, fino alla fase

ultima della vita “Progetto finanziato dal Ministero Salute -Riabilitazione in oncologia-: dalla diagnosi alle cure palliative,2006. Istituto Nazionale TumoriMilano-FAVO

M.P. Schieroni, M.R. Strada, P. Varese in Libro Bianco sulla

riabilitazioneoncologica

La Riabilitazione Oncologica non è purtroppo stata inclusa nei Lea

“la riabilitazione oncologica continuerà a essere inclusa in modo frammentato all’interno di diverse tipologie riabilitative riferite ad altri gruppi di patologie

Si tratta di una soluzione inaccettabile che condanna il paziente a un percorso riabilitativo discontinuo, frammentato, ma soprattutto parziale,

perché focalizzato esclusivamente sul recupero della funzione fisica lesa dalla malattia e non

sul completo recupero cognitivo, psicologico, sessuale, nutrizionale e sociale

FAVO .Quotidiano Sanita’ 2016

Ministero della salute Quaderno n. 8 del 2011

“La centralità della Persona in riabilitazione: nuovi modelli organizzativi e gestionali”

“un’efficace terapia antitumorale non può prescindere da una precoce presa in carico riabilitativa globale che prevede una completa integrazione con chi si occupa

del piano terapeutico strettamente oncologico e chi si occupa della terapia di supporto e delle cure di

sostegno”

Rehabilitation in older cancerpatients

The rehabilitative program should be tailored to single-out elderly patients after an attentive

evaluation of their needs and the assessment of clinical(impairments for each type of cancer and

comorbidities), psychological and social conditions through a Comprehensive Geriatric Assessment

E Morello,G Giordano,C Falci,S Monfardini. Aging Health 2009

● In elderly cancer survivors an assessment of persistentand coexisting health problems should be carried out

● In this field issues are still open concerning deliveringoptimal post-treatment care

● Dialogue between oncology and geriatric specialistsother than cross-training of clinical researchersshould be encouraged

Rowland J. and Bellizzi K., J ClinOncol.20142014

Unmet needs of old cancer survivors

Follow-up of elderly patients with urogenitalcancers: Evaluation of geriatric care needs and related actions (Supported by the Italian Ministry of Health (RF -2009-1502045 )

(Comparison of a modeled geriatric management to usual care in elderly patients firstly treated urogenital neoplasms )

S.Monfardini1, S.Morlino2, R.Valdagni2, M.Catanzaro3, A.Tafa4, B.Bortolato5, G.Petralia6, E.Bonetto7, E.Villa8, S.Picozzi9, M.C. Locatelli10, G.Galetti1, E.Bianchi11,A.Millul11, Y.Albanese11, C.Panzarino1, F.Gerardi1 and E.Beghi11

Journal of Geriatric Oncology,2017

S.Monfardini1, S.Morlino2, R.Valdagni2, M.Catanzaro3, A.Tafa4, B.Bortolato5, G.Petralia6, E.Bonetto7, E.Villa8, S.Picozzi9, M.C. Locatelli10, G.Galetti1, E.Bianchi11,A.Millul11, Y.Albanese11, C.Panzarino1, F.Gerardi1and E.Beghi11

Results

CGA was performed in 459 pts, >70 years

Prostate cancer : 291 pts (median age 75 y)Bladder cancer :126 (median age 77 y) Kidney cancer :37 (median age 77 y).

Clinical care patterns

• Home & follow-up• Home & caregiver• Home & general

practitioner• Integrated home assistance• Specialist consultation

• Integrated home assistancefor rehabilitation

• Geriatric rehabilitation• General & focused

rehabilitation• Nursing home

Distribution of Fit,Frail,Vulnerable Pts

•prostate ca:40% Fit, 47% Vulner, 13% Frail.

• bladder ca: 21% Fit, 42% Vulner, 37% Frail.

•renal ca: 22% Fit, 43% Vulner, 35% Frail.

Conclusions of this Study•Vulnerable and Frail were over 75% of both renal and bladder cancer pts, and 60% of prostate cancer pts. •During the follow up only a minority of pts was seen by a specialist in case of severe comorbidities. Only few pts with functional deficits received rehabilitation. •A Geriatric consultation was almost unexistent.

An integrated approach also duringthe follow up has to be considered

The U13 conference series of Cancer and Aging Research Group NCI,NIA and the Alliance Clinical Trials in Oncology (2010-2014):

Areas of highest research priorities in Geriatric Oncology

The 3rdrd U13 Conference in 2016 focused on improving the quality of life

and survivorship of older and frail adults with cancer(S.G. Mohile et al,

Cancer 2016)

We need this Orchestra also for older cancersurvivors

GERIATRICONCOLOGY

Primary care

Clinical Oncol. (Surgical,Medical

Oncology, RT)

Epidemiology. Clinical and LaboratoryResearch

Geriatrics, Gerontology

Palliative careSupportive therapy

Rehabilitation, pharmacy, nutrition,

social services

Clinical Oncologists, Geriatricians and other partners

How difficult is it to transfer such specificapproach in the real

world throughout the entire Patient’s Disease

Trajectory?

Bosch, Hieronymus the Ship of Fools

We need to develope dedicated Geriatric OncologyProgrammes (GOP)

• A comprehensive care through a multidisciplinary approach (age-associatedconditions and cancer management) should be provided

• These programmes should take care of the initial diagnostic and therapeuticapproach

• But also provide Survivorship assistance through the management of General and Specific Physical Impairments related to cancer and its treatment as well as of the geriatric-related conditions,

during all the disease trajectory

• S Monfardini et al: Report of a SIOG task force.Crit Rev Oncol/Hematol,2006

CONCLUSIONI• I pazienti oncologici anziani sono la maggior parte dei 3 milioni di

italiani che vivono dopo una diagnosi di tumore ed il loro numero è in aumento

• Le menomazioni legate al cancro ed alla terapia oncologica,comeanche quelle connesse alla eta’dovrebbero essere oggetto dellaRiabilitazione Oncologica e di quella Geriatrica durante tutto l’arcodella malattia( dalla fase iniziale a quella della malattia avanzata)

• E’ necessario pensare per il futuro ad una Valutazione GeriatricaMultidimensionale ed un approccio integrato(Oncologo,Geriatra,Fisiatra,Psicologo,Medico di MedicinaGenerale,ecc)

• Ad oggi molte di queste necessita’ sono inevase ,la prima sfida e’ di ordine culturale:occorre pensare anche per gli Oncologi che ilprocesso di geriatrizzazione della Medicina richiede nuovi tipi di organizzazione :Programmi di Oncologia Geriatrica