Providing GOLDEN care for patients in their golden years
Published on 15 May 2023
The NCIS Geri-Onco GOLDEN programme brings together expertise from oncology, geriatric medicine, and allied health to address the complex needs of elderly cancer patients.
It was just last year when Madam Tan Yong Yuat was left fearing for her life, as she was diagnosed with stage 4 colorectal cancer.
To make matters worse, the cancer had spread to her liver. She was subsequently advised to undergo open surgery to remove the cancerous parts of her colon and liver in one sitting.
Given that Madam Tan was already in her late 90s, however, such a major surgery posed its own set of risks, and her family decided not to proceed with the procedure.
Instead, they sought a second opinion at National University Hospital (NUH). There, Madam Tan was referred to the National University Cancer Institute, Singapore (NCIS) GOLDEN (Geriatric Oncology Longitudinal End to eNd) programme.
Started in 2019, the unique GOLDEN programme taps on the expertise of a multidisciplinary team of healthcare professionals – including oncologists, geriatricians, dietitian, physiotherapists, occupational therapists, and more – to provide holistic end-to-end clinical care for cancer patients aged 65 and above.
Adjunct Associate Professor Francis Ho, Head and Senior Consultant, Department of Radiation Oncology, NCIS, said, “One of the common questions that patients, especially the older ones, ask are if they are fit to undergo cancer treatment…as they are worried it might end up affecting their quality of life.
“The GOLDEN programme therefore aims to support such older patients at each stage of their cancer journey and recommend interventions, such as physiotherapy, whenever required.”
Patients under the GOLDEN programme will first undergo a comprehensive geriatric assessment to determine their state of health. This covers aspects such as their functional status, cognition, sensory impairment, social support, nutrition, and medication review, among others.
Based on the results of the assessment, the patient will be meet the relevant members of the GOLDEN multidisciplinary team to go through the interventions needed pre- and post-treatment.
Dr Matthew Chen, Consultant, Division of Geriatric Medicine, Department of Medicine, NUH, elaborated, “As a multidisciplinary team, we adopt a comprehensive approach that considers not just the physical health of the older person with cancer, but also their psychosocial and functional needs.
“This helps to identify and manage potential health risks or previously undiagnosed health conditions. The outcome of our assessment is not just meant to aid oncologists in their decision making when it comes to treatment, but to kick-start conversations on how to better battle cancer together.
Dr Nydia Camelia Mohd Rais, Consultant, Division of Geriatric Medicine, Department of Medicine, Ng Teng Fong General Hospital (NTFGH), further emphasised the importance of personalising treatment for each patient.
“Tailoring treatment to the older person’s health status, taking into consideration their values and preferences, is crucial to ensure good outcomes for our patients,” she said.
“In addition, pre-emptive interventions can also help to improve their physical and mental function and enable the older adults to better tolerate and complete cancer treatments successfully.”
This was the case for Madam Tan. Given that surgery was still necessary to remove the cancerous cells from her colon and liver, she eventually agreed to go along with the operation. However, it would be done as two separate procedures, rather than at one go.
To prepare her for the surgeries, Madam Tan – who was found to be at risk of nutritional decline – was advised by a dietitian on how to optimise her calorie intake, while a physiotherapist prescribed her various strengthening exercises.
The grandmother of seven eventually underwent successful liver surgery in August last year with Associate Professor Alfred Kow, Head and Senior Consultant at NUH’s Division of Hepatobiliary & Pancreatic Surgery.
Three months later, Madam Tan had colorectal surgery with Associate Professor Tan Ker Kan, Head and Senior Consultant at NUH’s Division of Coloretal Surgery, Department of Surgery.
As a result of the preparation and care from the GOLDEN programme, Madam Tan was able to recover well from both surgeries, and is today able to enjoy a good quality of life.
Madam Tan’s eldest son, Mr Wee Kay Kee, said, “There have been no complications after the surgery, and it’s so far so good as far as her health is concerned.
“My mother is now able to walk on her own, and even continues to do the exercises that her physiotherapist prescribed for her. This was surprising to us because we expected her to maybe be a little weaker after the surgeries.
“I believe that the work she did with her physiotherapist, as well as the nutritional advice that we followed closely, has greatly helped with her recovery.”
Madam Tan is just one of over 1,400 patients who have benefitted from the GOLDEN programme over the past 3.5 years.
According to a feasibility study of the programme which was published in February this year, 61% of the 777 patients enrolled in the GOLDEN programme had a change in their cancer treatment plans after being through its comprehensive assessments.
“Older patients are generally at higher risk of developing frailty and that increases the complications after surgery,” said A/Prof Kow, who is also the clinical lead for the Management & Innovation for Longevity in Elderly Surgical Patients (MILES) programme, which aims to enhance perioperative care for older adults requiring elective major surgery.
“Careful evaluation of pre-operative frailty and prehabilitation in the form of nutritional support, prescribed exercise regimens, and psychosocial support have been shown to reverse frailty pre-surgery, and can help such patients to achieve optimal post-surgery recovery.
“Our MILES nurses, who are specially trained to care for geriatric surgical patients, are central to the success of the programme as they do the initial evaluation of the patient and coordinate the whole care process from the pre-operative to post-operative period.”
Ms Sow Bao Yin, Dietitian, Department of Dietetics and Nutrition at NTFGH, shared dietary tips for cancer patients at the Singapore Geriatric Cancer Symposium 2023 in May.
- Before undergoing any cancer treatment, aim for weight maintenance to buffer against likely weight loss during treatments. If you are underweight, gaining some weight before the treatment can be beneficial.
- Avoid unnecessary diet restrictions and non-evidence- based fad diets. Discuss with your dietitian and doctor if you have any concerns.
- Remember the mantra: Patients with cancer need protein and calories (PC need PC). Maximising your protein and caloric intake while going through cancer treatment may help with weight maintenance and to increase treatment tolerance. Calories come from carbohydrate (including starch and sugar), protein and fat. Some common protein sources in your diet include meat, fish, chicken, egg, tofu, nuts and seeds and dairy products.
- Food fortification can help to increase calorie intake without adding too much volume in your diet. E.g. adding extra gravy or cheese into your dishes or sesame oil to your porridge or soup.
- You can also fortify your food by using sugar. E.g. replacing the intake of plain water with sweetened drinks and adding condensed milk or honey into drinks. If you have poorly controlled diabetes, do focus on using fats instead of sugar to increase your calorie intake.
In consultation with A/Prof Francis Ho, Head and Senior Consultant, Department of Radiation Oncology, NCIS, A/Prof Alfred Kow, Head and Senior Consultant, Division of Hepatobiliary & Pancreatic Surgery, NUH, Dr Matthew Chen, Consultant, Division of Geriatric Medicine, Department of Medicine, NUH, Dr Nydia Camelia Mohd Rais, Consultant, Division of Geriatric Medicine, Department of Medicine, NTFGH, Ms Sow Bao Yin, Dietitian, Department of Dietetics and Nutrition, NTFGH