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Tailoring care for better quality of life

Ageing is a process we all go through. But, getting older also means an increased risk of illness. How do we support ageing with dignity and maintain good quality of life even with illness?

Healthcare teams at the National Cancer Centre Singapore (NCCS), who serve the majority of cancer patients in the public sector consider this question daily. According to the Singapore Cancer Registry’s 2020 Annual Report, more than 43% of patients diagnosed with cancer in Singapore between 2016 to 2020 were aged above 70 years. Cancer is increasingly diagnosed in older adults, with the median age of cancer diagnosis in Singapore of 66 years between 2016 to 2020.

To better serve our elderly population, the NCCS Geriatric Oncology Clinical Service and Research Programme (NCCS GO) was set up to assess the needs of elderly patients and personalise cancer treatment plans to empower them and improve their quality of life.

The multidisciplinary team  who care for patients on the NCCS Geriatric Oncology Clinical Service and Research Programme.
Why do older cancer patients need personalised support?

Geriatric patients are a diverse group from different socioeconomic backgrounds, with varying levels of social support and multiple comorbidities. Some have memory deficits and emotional concerns – which in turn affects their families and caregivers. And many are also less likely to comply with taking required medications due to the large number of medications they may be on.

“Studies have shown that if patients are prescribed four or more medications, they are less likely to take them,” said Associate Professor Ravindran Kanesvaran, Head of NCCS GO, who is also Deputy Chair and Senior Consultant in NCCS’ Division of Medical Oncology.

One of the ways to help manage this is to prescribe less medication, whether for comorbidities or for cancer. This can be done, if the patient is assessed and it is found that they can safely be given less medication with little to no impact to their survival. Polypharmacy, or using five or more medications, is one of a few key domains assessed by the NCCS GO team administering a Geriatric Assessment (GA) to understand the needs of elderly patients.

NCCS GO: Assessing patients’ needs and making meaningful changes
Since its inception in 2007, NCCS GO has been available to all NCCS patients aged above 70 years. Before their first visit to NCCS, patients receive a text message linked to a 3-minute, pre-screening questionnaire with questions on mobility, nutrition and health. From there, the majority are recommended for further assessment, indicating a great need for this service.
On the same day as their first visit, the patients identified for further assessment go through a comprehensive hour-long assessment with the NCCS GO coordinator. The assessment evaluates their ability to perform daily activities, mobility, mental health, medication, comorbidities, nutrition, social support and cognition. The assessment also looks at chemotherapy toxicity, fitness and the patient’s ability to tolerate medication. This helps clinicians in decision-making to reduce medication or chemotherapy dosage for the patient without an adverse impact on their survival. 
After undergoing the assessment, elderly patients are broadly categorised into three groups – fit, vulnerable and frail. Standard-of-care treatment is recommended for fit patients, while it is recommended that frail patients avoid treatment, which may not prolong or improve their quality of life. Patients in the vulnerable group require further assessment and are reviewed at regular meetings by the NCCS GO team, made up of medical oncologists, geriatricians, rehabilitation physicians, nurses, medical social workers and physiotherapists. The multidisciplinary team’s expertise is needed to detect medical, psychosocial and functional issues unidentified by routine evaluations. They recommend holistic interventions by the primary treating oncologist which may include changes to medication regimes and referrals to medical social workers, dieticians, physiotherapists as needed.
A recent study showed that the group who had been assessed had better quality of life, fewer hospital admissions, and lower medication dosage but the same survival as those who not been assessed. 
A multidisciplinary approach ensures comprehensive care

The NCCS GO team is made up of physicians, nurses, and allied health professionals. Two team members, Clinical Psychologist Ms Sandy Tong and Medical Social Worker Ms Lynette Tham, from NCCS’ Department of Psychosocial Oncology (DPO), were quick to take up the invitation to be part of NCCS GO.

Ms Tham, who always had a passion for geriatric work, started her social work journey working with the elderly in the community. She enjoyed engaging with them and gaining insight from their vast experiences and rich perspectives on life. Ms Tong was inspired to join the team after a sharing by Assoc Prof Kanesvaran about how cancer affects the elderly. Both were motivated to support the unique psychosocial needs of the elderly and their families. Both also believe that NCCS GO’s multidisciplinary approach is key to best managing patient care.

“A 75-year-old patient, whose endometrial cancer had relapsed, was uncertain about starting treatment gain because of past experiences with chemotherapy. Through consultation with our multidisciplinary team who considered different treatment options and outcomes, the patient decided that supportive care was the best decision for her,’ said Ms Tham.

“Her children had difficulty accepting the decision. Through providing emotional support and engagement, we helped them understand their mother as a person, beyond her cancer diagnoses and her hope to spend her last days at home. Eventually, we were able to bridge that understanding with them. We planned for discharge, helped secure interim caregivers, necessary home equipment and home caregiving with the support of physiotherapists, occupational therapists, clinicians and nurses, and facilitated the patient’s wish of returning home.”

Overall, the multidisciplinary NCCS GO team is able to coordinate and concentrate efforts in providing comprehensive management of a patient’s care, weigh concerns and start interventions earlier in the patient journey. It also creates the potential for the best outcomes for patients and their families. 

“A multidisciplinary approach also enables us to conduct meaningful research to advance our understanding of cancer management in older adults to improve outcomes and optimise care,” said Ms Tong.

Empowering elderly patients and their families

      Head of the NCCS Geriatric Oncology Clinical Service and Research Programme, Assoc Prof Ravindran Kanesvaran, is a passionate advocate for elderly patients.

Assoc Prof Kanesvaran, who is past-president of the International Society of Geriatric Oncology (SIOG), has always been a passionate advocate for elderly patients. He pursued a Fellowship in Genitourinary Oncology and Geriatric Oncology at the Duke Cancer Institute in 2011 and has been implementing his specialised knowledge and skills at NCCS since.

“When patients are older, they tend to value quality of life over quantity of life,” said Assoc Prof Kanesvaran. “And NCCS GO provides an empirical assessment and evaluation that doctors, family members and patients can use to help optimise the patient’s quality of life.”

“By assessing elderly patients’ physical and emotional states, it starts conversations about their preferences for care that can extend to important discussions about end-of-life care,” shared Assoc Prof Kanesvaran. “This helps families navigate difficult decision-making and can be very empowering.” 



1. Singapore Cancer Registry Annual Report 2020

2. Mohile SG, Mohamed MR, Xu H, Culakova E, Loh KP, Magnuson A, Flannery MA, Obrecht S, Gilmore N, Ramsdale E, Dunne RF, Wildes T, Plumb S, Patil A, Wells M, Lowenstein L, Janelsins M, Mustian K, Hopkins JO, Berenberg J, Anthony N, Dale W. Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study. Lancet. 2021 Nov 20;398(10314):1894-1904. doi: 10.1016/S0140-6736(21)01789-X. Epub 2021 Nov 3. PMID: 34741815; PMCID: PMC8647163.