Long-Term Care Survey Alert

Published on Fri Apr 13, 2007 PDF

Does your facility use this 3-step approach for each resident?

A one-size-fits all approach to detecting and treating cancer is out of vogue, especially for frail elders in a nursing home. Instead, consider three pivotal decision-making steps to individualize cancer screening and treatment.

Step 1: Develop a framework for deciding whether to screen a resident for the most common types of cancer: breast, colon, prostate and cervical.

"You want to be able to show surveyors that you have a process for screening," says Matthew Wayne, MD, CMD, chief medical officer, Eliza Jennings Senior Care Network in Cincinnati.

"A lot of people fall into the trap of thinking surveyors want to see action in the form of screening. But [facilities] get in trouble for not thinking about it and just providing it or not," Wayne cautions.

Invest your resources wisely: Doing some of the cancer screening, such as mammography or colonoscopy, on a very frail, elderly nursing home population can sometimes detract from interventions that will help residents in the near term, cautions Louise Walter, MD. Examples include "fixing vision or hearing or focusing on falls or depression," says Walter, assistant professor of medicine, geriatrics, at the University of California in San Francisco, who has published on cancer screening in elderly people.

Consider these factors in deciding whether to screen an individual resident, suggests Wayne:

•  A review of the literature to assess whether a person is a candidate for cancer screening based on his estimated life expectancy and his other health issues.

•  A discussion with the resident and his family, if appropriate, about the risks and benefits of the screening and the person's decision to proceed or not. (For more information, see the American Medical Directors Association's clinical practice guideline chart on health screening.)

If the person has a life expectancy of two to three years, screening could probably do more harm than good, advises Lodovico Balducci, program leader of the Senior Adult Oncology Program at H. Lee Moffitt Cancer and Research Center at the University of South Florida in Tampa, FL.

Do a breast exam: A breast exam can be as effective as mammography in some cases in finding cancerous lumps. "The elderly woman tends to have less fat in the breast, which means you can palpate nodules much better," explains Balducci. "The person should have a breast exam when she sees the doctor," he says. And "the nurse in the nursing home could check for nodules as part of an assessment during the bath, for example, with the patient's permission."

Step 2: If the resident does have cancer, work with the resident's oncologist or physician to find the best treatment approach.

Wayne notes that geriatric oncology programs "cropping up" around the country look at the elder cancer patient's medical problems, recommended intervention, such as chemotherapy--and how that will affect the individual. "Each malignancy is unique," he says. "But before you go down the road of providing chemo, you have to look at the potential benefits and its potential impact," he says.

Best: Look at the patient's life expectancy--and whether he will be able to tolerate the treatment, says Balducci. Also look at the resident's comorbidities, functional status and "medications in terms of potential for complications due to polypharmacy and the chemotherapy."

Watch out: Providers "can get focused on giving chemotherapy ... but then the person's congestive heart failure worsens, etc.," cautions Walter.

Thus, "if the person has a lot of other medical illnesses, he may want to pick something that's the least invasive but addresses the cancer," adds Walter (see "Help Physicians, Elderly Breast Cancer Patients, Physicians Weigh Rx Options," contained within the next article).

Key point: "The person or his decision-making surrogate should know what the treatment is going to offer the person--is it a cure, a few weeks or a few months of life?" emphasizes Walter.

If you're talking about metastatic disease, then chemotherapy or radiation is going to be palliative, providing symptom relief, Walter says.

Step 3: Emphasize the resident's right to make treatment decisions, advises Walter. "The resident/family should know they can get second opinions," she says.

Time to listen: "If the resident says, 'This is really making me sick or I don't want to do it,'" staff should pay attention, emphasizes Walter. "Providers sometimes think that treatment can only do good things and patients should at least try it, but that's not always true," she counsels. "There's no treatment that just has a beneficial effect--everything has side effects. So it's always reasonable for a patient to say, 'I don't want this ... I will take my chances,' especially if the cancer cannot be cured."