William Dale, MD, PhD
William Dale, MD, PhD is Associate Professor of Medicine and Chief, Section of Geriatrics & Palliative Medicine at the University of Chicago Medicine.
A geriatrician with a doctorate in health policy and extensive experience in oncology, Dr. Dale has devoted his career to the care of older adults with cancer -- particularly prostate cancer. Dr. Dale has a special interest in the identification and treatment of vulnerable older patients who have complex medical conditions, including cancer. He is actively researching the interactions of cancer therapies with changes associated with aging.
Dr. Dale established and co-directs the Specialized Oncology Care & Research in the Elderly (SOCARE) clinic at the University of Chicago in 2006. This unique program offers interdisciplinary, individualized, and integrated treatment for older adults with cancer. In the SOCARE clinic, Dr. Dale and his colleagues give special consideration to the needs of older cancer patients and survivors, and address specific issues relevant to older cancer patients and their loved ones.
Dr. Dale’s clinical research projects are integrated into the SOCARE clinic. With expertise in medical decision-making, quality of life, and frailty, he is studying the role of emotions in decisions about screening, diagnosis, and treatment. He also collaborates widely on interdisciplinary research that integrates the clinical and social sciences.
Dr. Dale teaches and mentors medical students, residents, and fellows in the multidisciplinary concerns of older adults with cancer. He is a founding editor of the Journal of Geriatric Oncology. He is widely published in prominent journals, such as the Journal of Clinical Oncology, Journal of the National Cancer Institute, Cancer, and Medical Care.
Hospice / Palliative Care
University of Chicago
University of Pittsburgh Medical Center, PA
University of Pittsburgh Medical Center, PA
University of Pittsburgh Medical Center, PA
The University of Chicago Medicine
5841 S. Maryland Avenue
Practice phone number:
ADT, which lowers testosterone levels to the undetectable range, is a stalwart in the treatment of metastatic prostate cancer and in combination with radiation therapy for localized disease. It slows the growth of prostate cancer by “starving” the cancer of its main “food” – androgens. However, it can have many side effects that can lower quality of life and shorten life for older men. The effects of ADT are the opposite of the effects of “performance enhancing drugs” for sports athletes. They cause significant fatigue, muscle weakness, lean muscle loss, increased adipose tissue, and slowed gait – in essence, they lead to frailty in older men. In addition, they cause osteoporosis and can lead to falls and fractures as a consequence. Other diseases can be influences as well. For example, it increases the chances of getting diabetes and making existing diabetes worse. Similarly, it can worsen cholesterol and worsen heart disease in men with pre-existing disease. Finally, ADT can cause a number of uncomfortable, quality of life lowering side effects including hot flashes (seehttp://talkabouthealth.com/for-men-experiencing-hot-flashes-from-androgen-deprivation-therapy-adt-what-options-are-there-to-manage-these-effects
), growth of breast tissue, loss of sexual desire, and impotence. Each of these are important considerations for men starting this therapy.
Given all of the potential side effects of ADT, it is important for patients to discuss these possible consequences with their physician in choosing when to start on this therapy. The increasing recognition of these problems by physicians has led to efforts to minimize the use of ADT to circumstances that absolutely require it to control the cancer. For example, many men now use ADT intermittently – interspersing “vacations” from therapy with on-going therapy – in order to minimize the toxicities and maximize quality of life. Recent rigorous studies support this use of ADT for appropriately selected patients with less aggressive forms of prostate cancer.
The hot flashes are more intense early in therapy, as they are more likely as the hormonal levels are shifting. Once they equilibrate, they tend to gradually disappear. Because of this, I usually recommend that patients wait to see if they will decrease a lot on their own and treating symptomatically with cool compresses until the resolve. If they are excessively bothersome, especially if they interfere with sleep, there are several medication options, each with some risk of side-effects. Hormonal therapies, such as progesterone, are an option; they are effective, but carry a risk of blood clots and increase of appetite. The anti-depressants venlafaxine is another effective option, although not in men with significant cardiovascular disease. The anti-depressant medication clonidine can also prevent hot flashes by blunting the body’s response to stress. Each of these has to be checked against a patient’s current medications.
I would break “comfort measures” into two types of care in patients with advanced disease: palliative care and hospice care. The two overlap, but they are not identical. Hospice care is when people have a prognosis of less than 6 months, and the care is directed at supporting patient and their loved ones through the dying process to maximize their comfort and quality of life. This includes treating their physical, emotional, functional, and spiritual/existential needs as they move through the last stages of life. It also includes support for their loved ones, even after the patient dies in the form of bereavement services for the year following death. Palliative care is appropriate throughout the course of cancer care. It is defined as multidisciplinary care focused on treating the symptoms, pain, and stress of serious illness of any cause to enhance the quality of life. Early in the course of serious illness, palliative care plays a smaller role to curative care; as the disease progresses, a greater proportion of care is palliative in nature. When all of the care is palliative in nature and a person nears the end of their lives, all of the care is palliative, and this is then hospice care.
In order for a patient to enroll in hospice, a physician has to judge a patient’s remaining life expectancy as being less than 6 months. Beyond this legal requirement, I prefer the term “palliative care” and “end of life care” to the term “comfort measures” in describing cancer care for advanced disease. When it comes to treating older patients with cancer, we should ALWAYS be providing support and comfort, whether a person is receiving aggressive, curative therapy early in the disease course or palliative treatments later in the disease course. When the benefits of treating with aggressive treatment (such as chemotherapy) no longer exceed the burdens of receiving it, based on the medical facts and the patient’s values, that is the time to transition to “end of life”, i.e. hospice, care.
Like most geriatricians and palliative care doctors, I ALWAYS consider quality of life as the most important consideration. Sometimes, that includes aggressive, invasive therapy to extend life, and sometimes that means forgoing aggressive therapy to avoid the toxicities. In the most basic terms, one has to weigh the likelihood of significantly extending life against the dangers of the toxicities from therapy. Another way to think about this is: what is a patient’s remaining life expectancy WITH treatment compared to their remaining life expectancy WITHOUT it? If there is little difference between the two, then quality of life is by far the most important consideration. It is the physician’s job to give as accurate a prognosis, including QOL considerations, to patients as possible. The final decision about making the tradeoffs rests on a clear understanding of the patient’s values, since patients (and their families) ultimately decide what is most important to them.
In helping older patients understand these tradeoffs, I consider their overall health. Do they have many other (life-limiting) conditions? Are they frail? Do they have sufficient social support to handle the rigors of therapy away from the hospital? Do they have cognitive impairments? Patients with these conditions are much less likely to benefit from the rigors of chemotherapy and other aggressive treatments. Sometimes, there are therapy choices that are somewhat less likely to extend life, but that have far fewer side-effects. It’s important for patients to ask about ALL of the options available to them and the side-effects associated with each of them. If patients decide to forgo aggressive treatments, they still need to receive the very best “supportive” or palliative treatments for their symptoms; patients should never be told “there is nothing more we can do for you” – we can always help maximize patients’ quality of life.
Considering conventional testing like imaging (e.g x-rays, ct-scans) or laboratory tests, any patient undergoing chemotherapy should receive the same, appropriate testing. However, it is important for certain tests to be scrutinized a bit more for older adults due to physiological changes that occur with aging. For example, kidney function – measured with a blood test called creatinine – should be carefully considered for older patients. Also, it is important to consider malnutrition in older adults with cancer; it might be important to consider a blood test for this such as albumen or pre-albumen (both blood proteins).
Another important consideration for older adults who are receiving hormone therapy (men with prostate cancer; women with breast cancer) is bone health. Osteoporosis is much more common in older adults, and there are good treatments for it. Given the dangers of a hip fracture for an older adult, this is important to protect against.
A different sort of “test” to consider is a Geriatric Assessment, as there are benefits from a GA before starting chemotherapy (seehttp://talkabouthealth.com/what-are-some-of-the-special-needs-of-older-adults-who-are-going-through-cancer-treatments
). It can identify those who are more vulnerable to toxicity from therapy, it can identify those who would benefit from pre-habilitation prior to therapy, and it can identify those with cognitive difficulties who are prone to delirium with therapy.
It’s important to keep in mind that there is a wide variety of “older adults”. In fact, studies show that there is greater heterogeneity among older adults and among younger ones. Nevertheless, there are some age-associated characteristics that are important to consider when treating older adults for cancer, whether it’s with surgery, radiation, hormone therapy or chemotherapy. While a complete list of such needs is not possible here, five important and common ones include:
1) Dehydration is more likely. Older adults have less overall body water, and they are at greater risk of dehydration from poor fluid intake, vomiting or diarrhea. It is very important to encourage fluid intake while being treated for cancer
2) Fatigue is very common. Both cancer itself and treatments for cancer drain energy from people, so fatigue is a common side-effect. Older adults have a lower threshold for being fatigued, which can prevent them from carrying out their usual activities such as cleaning the house or shopping for food. Careful monitoring for fatigue – and offering to help with tasks – is very important.
3) Muscle weakness is dangerous. This risk of a dangerous fall – especially going up or down stairs or climbing in or out of a bathtub – are heightened when older adults are weakened during cancer treatments. Especially combined with osteoporosis, a fall can be life-threatening if it results in a hip fracture or concussion.
4) The risk for an infection is higher. Especially for older adults on chemotherapy, a fever can be life-threatening if not identified early and treated aggressively with antibiotics.
5) Social isolation can easily occur. Older adults are often living alone, or with an impaired spouse, so they can become easily isolated when being treated for cancer. They may need to stay with someone while undergoing treatment to avoid a significant accident while undergoing therapy.
Even more concerning is when older adults have several of these conditions simultaneously. This is an indication of frailty, which is the lowered ability of a person to handle stress – like cancer treatments.
The most important concerns for older adults considering cancer treatments can be broadly divided into two areas. Both are aspects of individualizing care. The first I’ll call “staging the cancer”, and the second I’ll call “staging the aging.” The first requires a skilled oncologist to characterize the extent of disease, the aggressiveness of the disease, and (increasingly) the genetic profile of the disease in order to pick the best therapy with the fewest likely toxicities. The second requires a skilled geriatrician to characterize health status, remaining life-expectancy, performance status, comorbidities, and social circumstances. This “patient profile” is best assessed through a Comprehensive Geriatric Assessment or CGA.
Once both have been assessed, it is important to integrate the two assessments together. This requires a shared and informed decision making process. During this process, a trusted physician talks with a patient and his loved ones to determine their values, preferences, and goals. Then, the physician matches those values to the options available in selecting a treatment. Ultimately, of course, the patient chooses the treatment option that he or she feels is best, and the physician supports it 100%.