Doctors stress importance of getting to know patients | ASCO 2024

Aging is a disparity

Older adults are 10% of the world’s population, but 57% of cancer cases occur in older adults. Across continents, older adults with cancer do worse than their peers with similar cancers. The healthcare system does not support the needs of older adults well. Enrique Soto Perez de Celis, MD, PhD of the University of Colorado noted these inequities:

• Ageism in the healthcare system
• Older adult patient underrepresentation in clinical trials
• Lack of geriatric medicine training for healthcare professionals
• Reluctance to give older adults the standard treatment even when it fits with the diagnosis

Oncologists can use two strategies to make care more equitable for older adults:

• Perform a geriatric assessment. ASCO guidelines recommend asking older adults about functional status, depression, nutrition, falls, other ailments, and cognition. Responses to these questions can help connect patients to resources, predict risks, and help in shared decisionmaking.
• Recognize that older adults are unique individuals. Ask about priorities and preferences. In a study in which older adults were asked to rank their priorities, nearly one-third ranked staying independent as their most important outcome. Sixty-one percent said their priority was staying alive as long as possible and 8% prioritized reducing symptoms. Responding to a separate question, 83% would rather die than lose their cognitive abilities. Dr. Soto advises colleagues to “ask, ask, and keep asking patients about their preferences,” because they can change over time.

An additional strategy: Researchers can enroll more older adults in clinical trials. Specifically:

• Enroll more frail and vulnerable older adults in trials
• Design trials in new ways
• Include clinical trial endpoints that people care about
• Incorporate geriatric assessments into trials

Culture matters

Serious illness and end-of-life care in the U.S. are based on white, middle-class, Christian culture and values, according to Ronit Elk, PhD, of the University of Alabama. Understanding this is key to improving care for Black people with cancer. Culture influences care preferences, communication patterns, decision making approaches, and how we define illness. Research shows that community-based partnerships can improve supportive care for minority groups, yet they are seldom used by hospitals and cancer centers.

Dr. Elk’s team worked with a rural southern Black community to create a training called “African-American Communities Speak to Healthcare Providers.” The goal: train healthcare providers in how to provide culturally appropriate care to Black people with serious illness or at the end of life. The advisory board, made up mostly of religious leaders, produced video skits to demonstrate ineffective and effective ways to provide community care. An educator incorporated the videos into a three-hour workshop offered to healthcare providers on Zoom or in person.

The results of the program were positive. Clinicians had a better understanding of African-American cultural values and more confidence to change their approach to care. Six-month follow-up showed that they were using what they learned—including involving family members, emphasizing hope when discussing serious news, assuring patients that they are receiving the best care, and planning in advance to have clergy present for serious news.

The team is now continuing this research. Their approach can serve as a model for other minority groups.

Talk about prognosis

New cancer therapies bring hope, but they don’t work for everyone. Oncologists are not trained in communication, yet their job requires talking with people facing very serious illness in a sensitive, culturally appropriate, and realistic way. Research shows that most patients do not discuss prognosis—the future or outcome of their cancer treatment—with their doctor. This gap leaves some people with hard-to-treat cancers mistakenly thinking that the goal of their treatment is cure.

Ramy Sedhom, MD, of the University of Pennsylvania strives to have balanced conversations with patients. He recommends “hope–worry” statements, using the example, “I hope that this therapy would work for you and that we can measure your life in years, but I worry that, for many of our patients, we see unexpected toxicities, and survival is less than we’d hope. Is this something you’d like to discuss?”

Palliative care is not just for end of life

One way to improve communication with patients is to bring in palliative care early on. ASCO guidelines call for palliative care to be integrated into cancer care from the time of diagnosis. People who receive palliative care early report better moods, milder symptoms, and better quality of life. Their caregivers are also more satisfied. Palliative also costs the healthcare system less and decreases the need for intense end-of-life care.

“We need to move to precision palliative care,” says Dr. Sedhom. “In a perfect world, every patient who walks into every cancer clinic will have a thorough assessment of their needs—physical, psychological, spiritual, emotional—and also their caregivers’ needs.” These conversations will lead to referrals to social workers, chaplains, and other specialists.

Where do we go from here?

These presentations emphasized getting to know patients and their culture. The speakers acknowledged these challenges in the U.S. healthcare system can make this difficult.

• Lack of time: doctors do not have enough time to spend with each patient due to the U.S. healthcare financing structure
• Lack of staffing
• Limited resources for referrals to help patients once their needs are known

There are many ways for patient advocates to continue to push the conversation forward with solutions to ensure more equitable care, including:

• Partnering with community advisory boards to create culturally appropriate services Talking with patients about their prognosis and their preferences
• Introducing palliative care early
• Using geriatric assessments
• Addressing disparities in clinical trials