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The Anderson Network is a program of Volunteer Services at MD Anderson Cancer Center
Staging the aging: Geriatricians can help older patients choose cancer treatment by Mary Brolley
People profiles: Angele Romig
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Data Powerhouse
Cancer is far from a one-size-fits-all disease. Each patient reacts to cancer and treatment differently. This is especially true for patients 65 and older, who may be more affected by certain side effects of surgery, chemotherapy, radiation and other cancer treatments. One reason is because they are, on average, more likely to be on medications — in fact, a larger combination of them. They may also be dealing with bone loss and its effects on balance, strength and ability to heal. Or they may be suffering from cognitive losses, dementia or depression.
Enter the geriatrician, a physician who is board certified in internal medicine to treat adults over 65. Holly Holmes, M.D., is one of two geriatricians at MD Anderson. An assistant professor in the Department of General Internal Medicine, she specializes in the care of patients in active treatment. A geriatrician’s goal, she says, is to help older adults remain as functional and independent as possible. Holmes’ research focuses on polypharmacy, or the interaction of medications, and overmedication. She’s also developing a tool physicians can use to help estimate the risks to elders of adverse effects from various treatments. “We want to know who becomes medically frail as a result of certain treatments,” Holmes says. “My goal is to let patients know the likely consequences of choosing certain therapies, and do so more thoroughly. I take into account not just
MD Anderson’s Tumor Registry
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Sex and the female cancer patient
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Sharing hope, support and understanding with anyone diagnosed with cancer, regardless of where treatment is or was received.
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“I tell family practice physicians that it’s hard to plan for survival if you haven’t planned treatment with survivorship in mind. You haven’t done an older person any favors.” Holly Holmes, M.D.
• gait (walking) speed,
osteoporosis, making him at risk for falls, which would endanger his caregiving duties. When Holmes explained these findings, the patient decided to forego the hormone treatment so that he could take care of his wife. “He went through radiation treatment, then took care of her for three more years until she passed away,” Holmes adds. How is he doing now? She smiles. “The last time I saw him, he said he was dating,” she says.
• ability to complete activities of daily living, such as bathing, fixing meals, etc., and
A demographic imperative
• cognitive function and depression.
what’s most effective to treat the cancer, but how the patient will function afterward.”
Predicting medical frailty Geriatricians use well-established tools to assess the patient’s physical and mental state, then recommend which therapies would most benefit them. These include screening tools for assessing:
Through the screening, patients are identified as being very healthy, average or frail. Frail patients are most at risk for adverse effects from cancer treatments. Holmes calls it “staging the aging.” In what she admits is “a sneaky way” of assessing them, Holmes sometimes walks her patients down the hall after a visit. “I see how they’re walking and then talk to them, ask them a question or two. “Walking is a very complicated process, and if they have to stop to answer my questions, I make note of that.”
‘Not every 75-year-old is the same’ A common age-related treatment dilemma involves men diagnosed with prostate cancer. Those older than 75 are often advised that surgery may be hard to recover from, or that the side effects might worsen existing issues, so they often choose radiation. “And there’s a movement to reduce prostate cancer screening in older men, acknowledging that, after a certain age, men are more likely to die with it than of it,” Holmes says. “But not every 75-year-old patient is the same. I want to know if he’s healthy, average or frail.” She recalls a patient who was considering hormone treatments in addition to radiation to treat his prostate cancer. He was the main caregiver for his wife, who suffered from dementia. During the gait speed test, Holmes saw that the man was somewhat unsteady. He was later determined to have
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Holmes is quietly passionate about her work. Noting that there are only 7,000 geriatricians in the United States — that’s just three for every 10,000 adults over 75 — she says that family practice and internal medicine physicians must be aware that an older person might need special attention and screenings before deciding on treatment. “It’s hard to plan for survival if you haven’t planned treatment with survivorship in mind. You haven’t done an older person any favors,” she says. In 2008, Holmes received a grant from the John A. Hartford Foundation, which supports researchers who develop, implement and evaluate model initiatives that integrate geriatrics into surgical and related specialty residency training. To that end, Holmes is happy that all of MD Anderson’s fellows are now required to shadow her for a month’s rotation. She hopes that it will help them consider the special issues of elderly patients. “They sit in on all kinds of consults,” she says. “It’s very interesting to the fellows. And because they’re fresh out of internal medicine residency, I learn so much from them.”
For more information about cancer and aging, check out the American Geriatrics Society (AGS) Foundation for Health in Aging website at www.healthinaging.org.
People profiles ‘There’s a little Forrest Gump in me’: New Orleans executive tackles colon cancer with energy, humor by Mary Brolley
Been putting off that colonoscopy? Angele Romig would like a word with you. “Do it. Get it over with. Move forward,” the New Orleans native says with characteristic directness. “You blink, and it’s over.” In January 2007, Romig woke from her first colonoscopy to learn there was a large tumor in her colon. She was just 44. Diagnosed with stage IV colon cancer, she had surgery to remove tumors in her colon and liver, followed by chemotherapy. She’d had symptoms of gastrointestinal distress for a while, but chalked them up to the stress of her challenging job, raising three children and life in general. After other tests turned up nothing, her physician suggested a colonoscopy. Since her diagnosis in 2007, she’s had three major surgeries and 20 rounds of chemotherapy. And at one point, daily shots administered by her husband Greg that “added a new dimension to our relationship,” she jokes.
She makes light of the surgeries that have taken her uterus, gallbladder, parts of her lungs, colon and liver, saying, “I have the fewest organs of anyone I know.” She deadpans that it’s been her lifelong goal “to be the centerfold in an MD Anderson magazine.” And she confides that despite the difficulties she’s faced, “I have a little Forrest Gump in me.”
Planning, humor prove essential
Move forward. Be optimistic.
Initially treated at a hospital in New Orleans, she came to MD Anderson when she was diagnosed with tumors in her lungs in 2009. She credits Greg, her children and family with having been with her every step of the way. Greg took over appointment scheduling and ran interference so that his very social wife wouldn’t get too tired by well-meaning callers and visitors during treatment. Through it all, Romig kept working — as she has for 24 years — as the chief administrative officer at GCR Associates, a well-respected New Orleans consulting company. It’s clear that humor plays a large role in Romig’s resilience and strength.
Although no one would choose to get cancer, Romig has weathered this health crisis with good humor and common sense. “In hindsight, it’s hard to believe it’s been four years now,” she says. “While you’re in the moment, it seems overwhelming.” “I’ve had setbacks, but every time I took two steps back, it’s propelled me forward. “Cancer treatment became a part of my life. I thought of it as if I were enrolling in medical school.” To newly diagnosed patients, her advice is simple. “Set a schedule and follow it. As you complete parts of your treatment, celebrate. It marks you on the path to recovery.”
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Doctor, Doctor Focus on advanced practice nurses and patient care Advanced practice nurses, also called “mid-level providers,” act as a bridge between physicians and patients. We asked Jane Williams, advanced practice nurse and manager of midlevel providers in MD Anderson’s Department of Genitourinary Medical Oncology, to give us the basics, including how they help improve patient care. What is an advanced practice nurse? Advanced practice nurses (APNs) are registered nurses who have advanced education and advanced knowledge, skills and scope of practice. There are several categories of APNs at MD Anderson. The two most common are nurse practitioners and clinical nurse specialists. Nurse practitioners (NPs) are advanced practice nurses who provide high-quality health care services directly to patients, similar to those of a doctor. NPs diagnose and treat a wide range of health problems, and many are trained to perform advanced procedures. NPs also focus on health promotion, disease prevention, health education and counseling. Clinical nurse specialists (CNSs) focus on a specific patient population. Five general duties make up their daily routine: clinical practice, teaching, research, consulting and management. CNSs work primarily with other nurses to advance their nursing practices, improve outcomes and provide clinical expertise to effect system-wide changes to improve care.
How does this advanced training and education improve patient care? Unit-based CNSs assist clinic nurses with care at an advanced level of practice. They also serve as educators and consultants to improve clinical care. Nurse practitioners provide a blend of nursing and medical care. Whether clinic-based or hospital-based, they might:
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order, perform and interpret diagnostic tests such as lab work and diagnostic imaging;
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evaluate the effects of cancer treatment and help patients manage side effects;
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diagnose and treat acute and chronic conditions such as diabetes, high blood pressure, infections and injuries;
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prescribe medications and other treatments; and
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counsel patients on a variety of issues, including nutrition and physical activity, physical symptoms, coping strategies, sexuality and end-of-life decisions.
By having an extension of the usual physician-delegated services, patients may experience shorter wait times, receive comprehensive care and have time to discuss other issues that affect their overall health that the physician may not have time to offer.
What is the future for advanced practice nursing at MD Anderson and beyond? We have many clinics at MD Anderson that are APN-run, such as survivorship, fatigue, coagulation, prevention and others. As the demand on the health care delivery system increases, the numbers and types of APN-run clinics will increase. APNs will work closely with their physician colleagues to expand such key service areas. We’re expanding our 24-hour hospital coverage by staffing nurse practitioners who are skilled in internal medicine from 6 p.m. to 6 a.m. We will also see many more APNs acquiring doctoral degrees.
For more information on advanced practice nurses as mid-level providers, click on www.mdanderson.org/publications/network. 4
Data powerhouse: MD Anderson’s Tumor Registry
by Mary Brolley
Sure, it’s a club you never meant to join. But if you’ve ever been an MD Anderson patient, chances are you’re a member. “It” is MD Anderson’s Tumor Registry, a massive database of information on more than 800,000 patients registered at the institution since March 1, 1944. About four months after a patient’s first appointment, his or her medical information is entered — abstracted — into the registry. Most of the information gathered is basic: demographic, type of cancer, stage, key dates and treatments received. Why does the registry staff wait four months? “By that time we have a definitive diagnosis and treatment is under way,” says Sarah Taylor, informatics manager for the Department of Tumor Registry.
More than a snapshot Taylor draws a distinction between MD Anderson’s and most other tumor registries. The institution’s registry contains data on every patient who’s received a medical record number since March 1944, including those who have a non-cancer diagnosis (e.g., aplastic anemia). “This makes it a true hospital registry,” she says. “Most other hospitals’ tumor registries only collect information on cancer patients. We collect complete data on each patient’s cancer history, including prior treatments and prior primary cancers.” Dozens of MD Anderson departments receive data from the registry. The information is used most often to identify study populations, compare treatment outcomes and conduct survival analyses. “Our financial departments also use the database when determining resource needs. In fact, it was used to determine the size of the Mays Clinic,” Taylor says. A crucial department responsibility is annual contact with patients. To this end, last contact date in the registry is automatically updated when a patient visits the institution. They also send letters to patients who don’t come in, followed by a phone call if there’s no response.
‘Thanks for giving me another 15 years of life’ In the letters, patients are asked just two questions: • Have you been free of cancer for the last 12 months? • Have you been treated for cancer in the last 12 months? “That’s it,” Taylor says. “But we also ask them to write anything they’d like on the back. Often we get questions or requests. And, of course, we follow through. “Sometimes patients ask us to pass on a thank-you message to their doctors or clinics. ‘Thank Dr. Smith and her staff for giving me another 15 years of life.’ ” Taylor, who’s been at MD Anderson for 22 years, says that when the institution committed to computerizing the registry in the 1970s, employees painstakingly entered 30 years’ worth of existing data so the database would be complete. When the American College of Surgeons visits MD Anderson every three years to review its accreditation, the registry is included. And, as required by state law, data is regularly submitted to the Texas Cancer Registry. “I continue to be impressed with the registry, and that MD Anderson gives us the resources, the staff and a dedicated information technology specialist to keep it running,” she says.
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Sex and the female cancer patient: Treatments may affect desire and function by Mary Brolley
Cynthia Cargill is OK with “the new normal.” As long as it includes sex. “I’ve been through a lot, and I’m happy to be alive,” Cargill says, then pauses. “But my husband and I are too young to give up sex.” Cargill, 35, was treated for a recurrence of acute myelogenous leukemia (AML) with a cord blood transplant in 2008. She received heavy doses of chemotherapy that have wreaked havoc on her sex drive and ability to enjoy sex. Not surprisingly, this has caused problems in her marriage of 12 years. Cargill is not taking this lightly. “Fix me,” she jokes about her plea to her medical team. The alkylating agent used in her transplant protocol attacked rapidly growing cells, exactly what was needed to kill leukemia cells. Unfortunately, it was also toxic to her ovaries, causing premature menopause. The effects of this early menopause made intercourse extremely painful, Cargill says, and not surprisingly, her sex drive plummeted.
Gynecological researcher, therapist offers help Though her cancer treatment is complete, this loss of intimacy and sexual health has hampered Cargill’s full recovery. Andrea Bradford, Ph.D., psychologist and instructor in the Department of Gynecologic Oncology at MD Anderson, counsels cancer patients having sexual difficulties.
For pain during intercourse, Bradford suggests patients use a combination of techniques: for a start, women can use a vaginal moisturizer several times a week and a lubricant for sex. If pain persists, low-dose vaginal estrogen can often help. She also recommends the use of relaxation techniques to reduce tension and ease into sex. Patients should also give themselves time to re-establish intimacy and sexual activity, she says. “Cancer puts stress on even the strongest relationships. Shifting to the roles of caregiver and patient adds to the strain.” She advises women suffering sexual side effects to rethink old habits and expectations, perhaps even “taking intercourse off the table” while the couple rekindles their romantic relationship.
‘We have a much closer bond’ Cargill knows there’s a strong psychological and emotional component to this situation. She consulted Phyddy Tacchi, an advanced practice nurse in the Department of Psychiatry, during and after her treatment. Tacchi saw Cargill alone and with Cargill’s husband Reagan. “In our joint sessions, Phyddy helped me see that Reagan had some resentment of how much he’d had to take on. He’d had no time to himself. “And I’d felt like, ‘Hey, I got cancer, and my treatment caused these problems,’ ” Cargill says. “ ‘It’s not like I got leukemia to spite you!’ ” Two years later, the couple is much more patient and open with each other, she says. “We say, let’s work around it. We actually have a much closer bond after the cancer and treatment.” As a result of the heavy doses of chemotherapy, Cargill entered menopause in her 30s. But since the Cargills already had two young children when she was diagnosed, she wasn’t too concerned about the treatment effects on her fertility.
Join the Tendrils program and renew your sex life
Are you a female cancer survivor dealing with sexual problems? Do you live near MD Anderson’s main campus in Houston? A National Cancer Institute-funded program at MD Anderson is recruiting women who’ve been treated for cancer and want to: • recover sexual function and satisfaction, and if relevant, • find answers to concerns about fertility and pregnancy after cancer treatment. Tendrils is a free 12-week research program that involves using a website providing sexual education and counseling as well as filling out online questionnaires concerning emotional adjustment, sexual function and quality of life. Half the participants will also come to MD Anderson for three 60-minute counseling sessions during the 12 weeks. For more information, call Pamela Lewis at 713-745-5535 or e-mail her at plewis@mdanderson.org.
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Address your fertility concerns with your medical team For many other women patients, though, treatment effects on their ability to have children are of great concern. Experts like Bradford advise them to be as proactive and honest as possible when talking to their physicians before treatment begins. The physician and medical team can explain which treatment effects are short-term and which are permanent. It may be possible to tailor treatment to be less harmful to the reproductive system. If not, at least patients will know exactly what to expect and how to maximize their chances of maintaining fertility. Whether or not a woman can get pregnant after cancer treatment depends on a number of factors, including: • her age at the time of treatment, • the type(s) of treatment, • the kind and dose(s) of chemotherapy, if applicable, and • the amount and target area of radiation, if applicable.
Andrea Bradford, Ph.D., says female cancer survivors suffering from sexual difficulties should consider seeking expert help from: • a gynecologist, who can rule out any other reason for pain during sex, • in certain cases, a physical therapist who specializes in treating pelvic floor conditions, and/or • a counselor or therapist who can help resolve negative thoughts or recurring worries and, if indicated, use sex therapy to help resolve sexual problems.
In the summer issue of Network, we’ll explore the effects of cancer and treatment on male sexuality and fertility.
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The University of Texas MD Anderson Cancer Center Communications 600784/18050661 – Unit 700 P.O. Box 301439 Houston, TX 77230-1439
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network The Anderson Network is a program of Volunteer Services at MD Anderson Cancer Center. Address changes should be sent to: Mary Brolley The University of Texas MD Anderson Cancer Center Communications Office – Unit 700 6900 Fannin St. Houston, TX 77030-3800 Phone: 713-792-0658 Fax: 713-563-9735 E-mail: mbrolley@mdanderson.org Articles and photos may be reprinted with permission. Susan French, Executive Director, Volunteer Services Debbie Schultz, Assistant Director, Volunteer Services/ Anderson Network Mary Brolley, Writer/Editor, Network Gini Reed, Graphic Design Pat McWaters, Chair, Anderson Network © 2011 The University of Texas MD Anderson Cancer Center
Page 8 Briefs Mendelsohn to step down, change role John Mendelsohn, M.D., president of MD Anderson through an incredibly productive period of nearly 15 years, recently announced plans to relinquish his leadership position when a new president is recruited and in place. He will remain on the MD Anderson faculty, returning to clinical and translational research as co-director of the Sheikh Khalifa Bin Zayed Al Nahyan Institute for Personalized Cancer Therapy. “I’ve had the best job imaginable,” Mendelsohn says. “So much has been accomplished, but more remains to be done. I’m confident MD Anderson will maintain its lead in translational and clinical research as well as continuing to be the nation’s number one hospital for cancer patients.” Mendelsohn is only the third full-time president of MD Anderson in a history that spans 70 years. R. Lee Clark, M.D., served as president from 1946 to 1978, and was followed by Charles A. LeMaistre, M.D., who was president from 1978 to 1996, when Mendelsohn arrived to take charge. Ernst W. Bertner, M.D., was initial acting director, from 1942 to 1946.
www.mdanderson.org/network Save the date: The Cancer Survivorship Conference, presented annually by the Anderson Network, Department of Volunteer Services, is Sept. 16-17. 713-792-2553; 800-345-6324