Aging is the result of the accumulation of molecular and cellular damage over time, eventually leading to a loss of physiological reserve across multiple organ systems. In contrast, frailty describes a state in which — irrespective of age — physiologic reserve is depleted to the point that even small stressors can result in poor outcomes, including delirium, falls, disability, or death.
Evidence of frailty is very common in older patients with hematologic malignancy. For example, over one-half of patients diagnosed with hematological malignancies have some evidence of malnutrition, and more than a third have impaired physical function. Frailty in this population has been associated with advanced disease at diagnosis, increased chemotherapy-related toxicity, and poor response to therapy. On the other hand, robust (non-frail) older patients with blood cancers might appropriately receive full-dose treatment despite their advanced age.
Dana-Farber’s Older Adult Hematologic Malignancy (OHM) Program is a unique research and clinical service that addresses the specialized needs of older patients with blood cancers. It was first established in 2012 with a geriatrician embedded in the leukemia service, and expanded to include the lymphoma and myeloma services in 2015. Patients with geriatric needs receive collaborative care from both their Dana-Farber oncologist and a geriatrician from the Brigham and Women's Hospital Division of Aging.
Since 2015, OHM has had a screening program that uses a cumulative deficit/phenotype measurement to assess all new Dana-Farber patients 75 years or older with blood cancers. After informed consent, all patients who agree undergo a 20-minute in-person geriatric screening with a clinic assistant, and are subsequently categorized as “robust,” “pre-frail,” or “frail.” To determine if added services improve outcomes, “pre-frail” and “frail” patients are randomized to comprehensive geriatric management with an embedded geriatrician in addition to standard oncology care, or standard care alone. Over 350 patients have been screened so far, and 83 randomized. For those randomized to geriatric management, visits occur on-site at Dana-Farber.
An exciting new component of the program is to assess how personalized genomics correlate with frailty in this population. In early 2017, we added a pilot study to evaluate the association of novel peripheral blood genetic and molecular markers with frailty status. The molecular markers have the potential to contribute to truly patient-centered care by elucidating the association between objective measures of frailty and disease genetics.
Providers who are referring patients for hematologic malignancy consultation can also request that they see one of our embedded geriatricians on the same day, regardless of the patient’s age or frailty. Such an evaluation would include management of current non-oncologic conditions, minimizing the impact of polypharmacy, assessment of functional status, help in maximizing physical and psychological health, and assessment of family and social support. If you have a patient that would benefit from geriatric management in addition to hematologic oncology consultation, please contact our new patient office at 617-632-6028.