Grace Christ, DSW - Columbia University, School of Social Work
Although chronic illnesses in older adults have predictable psychological and social impacts, the specific characteristics of any disease influence the adaptive challenge it presents. To be effective the social work role, interventions, and service delivery models need to be designed and developed to take account of the particular characteristics of an illness and its affect on patients, families, and communities. Such defining characteristics for the biopsychosocial assessment and interventions include, for example:
Presented here is the example of cancer, a disease that has high prevalence in older adults, is life threatening, is increasingly becoming chronic (but may have periods of remission and exacerbation), often requires decision making about the use of complex high technology treatments. Both cancer and its treatment have a broad range of impacts on patient functioning, and only recently has it been viewed as a disease that should be treated in older adults. The use of care coordination models with older adults with cancer is just emerging and has included primarily interdisciplinary team care, patient and caregiver education and support, and care/system navigator programs to improve access and continuity for multiple populations.
The burden of cancer is considerable in older adults and as the population ages it will continue to grow. Based on cancer incidence rates and U.S. census department population projections the number of cancer patients 65 years and older will double over the next 30 years and in those 85 years and older it is expected to increase four fold from 2000 to 2050 (Edwards et al., 2002).
For many individuals long-term disease-free survival is now possible (IOM, 2006). In the past two decades the 5-year survival rate for the 15 most common cancers has increased from 43% to 64% for men and from 57% to 64% for women (Jemal et al., 2007). With survivors living longer, often with more than one chronic condition, some types of treatable cancer can be seen less as a terminal disease and more as a manageable chronic condition. This new trajectory is especially important for older populations to learn about as they may have perceived a cancer diagnosis as a death sentence given their early life experiences prior to the current advances in cancer control. Despite advances, cancer does remain a group of diseases that represent both acute life-threatening illnesses and serious chronic conditions (Maramaldi & Lee, 2006).
As a result, cancer is now classified as a disease of older adults (Cohen, 2003; Deimling, Kahana, Bosmon, & Schaefer, 2002; Ershler, 2003).
1) They are at higher risk of a diagnosis of most cancers. Cancer rates are 10 times higher for people age 65 and older.
2) They have a higher rate of cancer deaths.
3) They are more likely to have concomitant health problems associated with advancing age.
4) Sixty percent of cancer survivors are over the age of 65.
Even if diagnosed at an earlier age, they are now living as survivors into their older years. Approximately 14% of the 10.5 million estimated cancer survivors were diagnosed over 20 years ago. That often means they are living with the late effects of treatments that were more radical and more toxic than the treatments of today (IOM, 2007b).
The five most commonly diagnosed cancers in women age 65 and older are cancer of the lung, breast, colon, rectum, and pancreas. In older men the five most common cancer sites are lungs, prostate, colon, rectum, and pancreas (Maramaldi & Lee, 2006; Sacks & Abrahm, 2003).
Table 1 shows the median ages of patients at diagnosis for both sexes. With the exception of non-Hodgkin’s lymphoma (NHL), the median age in men for these common cancer sites is uniformly above the age of 65, and in some cases above 70 years. For women the situation is similar.
As shown in Figure 1, for several tumor types the proportions are even higher.
Figure 2 shows age-adjusted incidence and death rates for all cancer sites combined. The age-adjusted incidence per 100,000 population is 10 times greater for individuals 65 and older compared to the rate for younger persons. And, in all cancer sites age-adjusted death rates are 17 times greater for this age than for those aged less than 65. This is important because for many years health care researchers/providers believed that older people did not die of cancer. The presumption was that they would die from other co-morbid diseases and that cancer progressed more slowly than those diseases did. Therefore, both screening and treatment were often not recommended. As people began to live longer, however, it became clear that they can live long enough to die from cancer, and over the past decade new guidelines have been developed such that more screening and treatment now occurs in older people.
It is important to recognize that despite the high incidence of cancer in older adults little is known about the intersection of cancer and aging (Marimaldi & Lee, 2006). Interaction between these two specialty areas, gerontology and oncology, has been quite limited. In a June 2001 a workshop convened by the National Institute on Aging and the National Cancer Institute (NCI) expert participants acknowledged that geriatric and cancer research have developed separately with little interaction. A cross-institute initiative was subsequently implemented with the goal of bringing aging and cancer research together. In 2006, an Institute of Medicine workshop on Cancer in Elderly People presented information documenting gradual improvements in survival of older people with cancer, although such improvements lag far behind those made in pediatric oncology, until recently another age group for which cancer was insufficiently studied (IOM, 2007b). Yet, older cancer patients still do not receive the appropriate standard of care, in spite of near universal health coverage of this population under Medicare. Specifically, older patients continue to be underrepresented in clinical trials. Referrals to hospice occur late in the course of this illness. Because of the outpatient locus of most cancer treatment and the increasing complexity of care over longer periods of time, an increasingly high burden falls on the families who care for older adults (IOM, 2007b).
Even when treatment is completed and no cancer remains, there are frequently permanent, and serious residua of cancer and/or of chemotherapy, radiation, hormone therapy, surgery, and other treatments. These can permanently impair cardiac, neurological, kidney, lung, and other body functioning, necessitating ongoing monitoring of cancer survivors’ health. Cancer survivors report a broad range of functional limitations as well as mental health problems, such as depression and anxiety disorders. Regardless of age, an individual with a cancer history must be diligently monitored for recurrence of a previous cancer or the occurrence of a new form of cancer.
Older cancer patients may require a longer period of rehabilitation from treatment and experience more severe or longer-lasting treatment side effects. There may be setbacks after initial treatment. Restoration to pre-illness functioning may not be possible. The same physiological processes that slow down the progression of cancer in older adults may also delay the recovery process (Balducci & Yates, 2000).
Three critical challenges for older adults with cancer are concurrent diseases with the cancer diagnosis, the lack of a workforce trained to treat older adults with cancer, and the increasing need for family caregivers for older adults.
The major diseases and conditions common to older persons include heart-related conditions, diabetes, hypertension, chronic obstructive pulmonary diseases (COPD), cerebrovascular diseases, urinary tract problems, and subcategories of each of these. Using these conditions, one study of breast cancer patients found that the number of co-morbidities ranged from 0-13 per patient and that the numbers increased with age. (Yancik et al., 2007, as cited in Institute of Medicine, 2007b).
Co-occurring conditions limit the ability to determine prognosis, minimize treatment options, and increase the risk of death from multiple causes. Co-morbidity is frequently assessed in the context of an index disease (e.g., a newly diagnosed cancer). Some researchers/practitioners have suggested that focusing only on the index disease is insufficiently comprehensive to be used in a primary care setting. Alternatively, they encourage an approach that would define co-morbidity as the total burden of biological dysfunction. A recent article that contributes to developing the research structure in this area proposes that co-morbidity be assessed in a way parallel to the World Health Organization’s (WHO, n.d.) International Classification of Functioning, Disability, and Health. Functioning of each system is assessed on a continuum from high-functioning, protective zones to early subclinical changes, to overt disease of increasing severity, to end-stage disease. It does not rely solely on clinically diagnosed diseases and explores the full range of performance in each system (positive and negative) instead of measuring only negative aspects.
Both researchers and practitioners are advocating greater attention to the research interface of aging and cancer treatment. Further they recommend stronger ties between geriatric medicine and medical oncology to meet the current and future needs of the older age segment of the population (IOM, 2007b; Maramaldi & Lee, 2006).
For example, when deciding what screening and treatment to offer geriatric patients, professionals still focus on the particular age of the individual rather than considering their functional level, co-occurring conditions, and symptoms. Until recently individuals over 70 years of age were routinely restricted from participation in clinical trials because it was believed that none could tolerate aggressive treatments or would live long enough to benefit from them. In fact, older adults are quite heterogeneous in relation to their physical condition, depending upon their functional status, co-morbidities, and symptoms. Therefore, specific age is not sufficient to rule in or out many treatments. Their limited representation in clinical trials makes it difficult to predict older adults’ reaction to newer treatments. What are the potential risks in terms of morbidity and mortality, and what are the potential benefits in relation to longer active life time? Many patients ask this question. Often older adults are not offered screening and treatment that would improve their survival and quality of life, and conversely, they may receive treatments in the advanced stages of an illness that are futile and prolong suffering (IOM, 2007b). Providing a better informed workforce that understands how to assess strengths and protective factors as well as co-morbidities and that appreciates the continuing expansion of active life time in older adults is a current challenge.
Ageism and stereotyping of older adults as “having lived long enough” or being unable to tolerate the burden of treatment, or no longer needing cancer screening because they will die of another disease before the cancer reaches a fatal stage are attitudes that also contribute to the failure to meet the correct standard of care for older adults in many situations. Contrary to earlier notions that older adults would not die of their cancer illness, but would die of organ failure first, current data document a high mortality rate from cancer among this age group.
The trend in U.S. health care towards “de-hospitalization,” in combination with advances in cancer treatment makes it possible for many elderly cancer patients to be managed on an outpatient basis and remain in the community while in treatment.
Diagnostic testing, surgical treatments, complex chemotherapies, and radiation treatments previously performed on an inpatient basis are increasingly administered in physicians offices or outpatient treatment facilities.
We have not often thought of cancer as a long-term caregiving situation in comparison with, for example, the care of patients with dementia. However, with medical advances the disease progression can now extend over many years resulting in increasing needs for family care. Consider the length of time from initial diagnosis through therapy, potential progression, possible recurrence, perhaps even a second cancer, and then palliative and end-of-life care. With a second cancer or late recurrence, family members report already being involved for 4.6 years on average. (Cannuscio et al., 2002; Hayman et al., 2001). So, caregiving can go on for a considerable period of time, and as survival time lengthens to 15 or 20 years, caregiving also stretches out for many years.
In 2004, calculated at $9.92 per hour, the value of family care was estimated to be $306 billion dollars (Hayman et al., 2001; Rabow, Hauser, & Adams, 2004). This is substantially more than we are currently spending on nursing home care or other professional services provided in home care. It is a major contribution and a major resource to the health-care system.
Families play different roles in helping patients at different stages of the illness process and have varying abilities and skills for fulfilling these roles. Different judgments and different expectations of families occur during diagnostic phases, treatment phases, maintenance phases, rehabilitation phases, recurrence and metastasis, and palliative care at the end of life. The range of tasks they may have to fulfill in caring for the patient with cancer is quite broad and demands considerable skill and knowledge. These tasks include:
a. medication dispensing and monitoring
b. symptom management
c. monitoring of side effects and adverse events
d. meal preparation and nutritional balance
e. care decisions and problem solving
f. skin care and infection control
g. management of highly technical equipment
h. management of medical procedures such as catheters and wound care
i. bill paying
j. transportation and errands
k. advocacy with health professionals and within the health care system.
The general roles and functions assumed by informal caregivers are shown in Table 2.
a. Relationship to patient: Adult children caregivers experience distress and anxiety related to role change (from taking care to giving care) and task overload with multiple role demands from their work and family life. Older spouses, on the other hand suffer from role changes in the relationship, the loss of support, and anticipation of future loss and change.
b. Caregiver illness and depression: Disabilities and health and mental health conditions of caregivers affect their caregiving capacity.
c. Specifics of the caregiving situation: Research shows that it is not so much the amount of physical care that is the stress; it is the transitioning from more care to less care or less to more. Also the number and severity of the patient’s symptoms create varying stress for the caregiver, especially the management of pain and fatigue. The experience of caring for a person with advanced disease and terminal illness is a time of high stress for everyone involved (Greenberg, Seltzer, & Brewer, 2006).
Importantly, studies show that caregiver stress can be very high up to 18 months after care is completed. Caregivers describe being distressed by fear of the future, worrying about the patient’s death, problems of managing pain and fatigue, and in older adult spouses, feeling the absence of respite assistance. They are also distressed by conflicts with the patient and inconsistency among providers, by the hours of care, and the level of vigilance required (Cameron, Franche, Cheung, & Stewart, 2002; Greenberg et al., 2006; Rabow et al., 2004; Schulz, Tompkins, Wood, & Decker, 1987).
Studies have documented a variety of emotional consequences of caregiving for the older cancer patient, including increased levels of depression and anxiety, helplessness hopelessness, emotional exhaustion, low morale, distress, feelings of isolation, guilt, and anger. The emotional distress centers around helplessness, loss of control, insecurity about the course of illness, and the fear of losing the family member. The physical, psychological, and economic impact of caregiving is substantial (Hauser & Kramer, 2004). Schultz and colleagues (2001) showed that older spousal caregivers had a mortality risk that was 63% higher than non caregiver controls and had an increased number of physical symptoms. Patients and caregivers also have an impact on each other. Patients who lose their caregiver have higher mortality rates and caregivers have more chronic illnesses and increased mortality when they become bereaved (Hauser & Kramer, 2004; Schulz & Beach, 1999; Schulz et al., 2001)
An overview of current research on the stresses of older adult cancer patients reported few studies that also included the specifics on impairments among relatives of older cancer patients; however, the authors highlighted the following (Kotkamp-Mothes, Slawinsky, Hindermann, & Strauss, 2005):
1. Age-related impairments in the healthy partner add considerable stress and limit their caregiving capacity.
2. A cancer diagnosis disrupts continuity of relationships and requires change in future plans.
3. Older adults have already experienced losses that may increase their fear of loss.
4. The older caregiver is stressed by the physical demands of caregiving.
5. Positive experiences of caregiving are reported to include an increase in self-esteem, the experience of competence, positive feedback from patients and other social partners, existential factors, and improved family relationships(Koop & Strang, 2003; Nijboer, Tempelaar, Sanderman, Triemstra, & van den Bos, 1998).
Interventions have been slower to be developed for families caring for members with cancer than for those caring for members with dementia, where the cognitive impairment creates disruptive behaviors and an obvious urgent and demanding role for caregivers. Another difference is that in families with cancer patients, changes in role and in daily activities start immediately after identification of the cancer, whereas changes in cognitively impaired patients develop gradually. Diagnostic procedures and treatments for cancer can be arduous and have multiple reactions and side effects. The predominant responses of relatives of cancer patients are reported to be anxiety and unassertiveness, depressive reactions, hopelessness, feelings of guilt and psychosomatic symptoms such as sleep disorder, gastrointestinal disorders, headache, and fatigue (Raveis, 2007).
Families are rarely included in the development of a care plan with cancer patients, and they are often given very little guidance, counseling or direction about what to do and the range of expectations. Emerging interventions are aimed at improving the direction and communication between the physician and other members of the interdisciplinary team through family conferencing (Rabow et al., 2004). Psychoeducation, coping skills training, and multidisciplinary interventions have shown some effectiveness with families of older cancer patients with advanced illness. (Greenberg et al., 2006; McMillan et al., 2006; Rummans et al., 2008).
Older adults bring strengths of life experience and established coping patterns to the event of a cancer diagnosis. While social workers validate and build on these strengths, they must also recognize the special needs of older adults with cancer. They may require different kinds of help with understanding and processing the diagnosis and complex treatment options offered to them. Explaining the opportunities for remission and the risks of complications from the treatment itself can create difficult decision challenges. Age cohort and cultural differences complicate understanding of the situation. The functional level of elderly people may be impaired by the total burden of chronic conditions they have been living with in addition to a cancer illness. The treatments may be more difficult for their bodies to accommodate. Emotionally they may be exhausted by recent losses of family and peers and their own functional challenges. As a consequence the elder’s social network is often strained and unable to provide the physical and emotional support they need for cancer treatment. The major caregiving challenges for families of older adults are described above.
Both psychological and social problems are accentuated with cancer because of the arduous treatment procedures used to achieve control or cure of the disease, including multiple surgeries, radiation, and a broad range of chemotherapies. These problems are also exacerbated by late effects of treatment and the long period of surveillance to detect recurrence or metastasis.
Psychosocial health needs vary by the type of cancer, the time since diagnosis, degree of functional and role impairment, the amount of pain and discomfort, and the prognosis. Physical stresses include degree of impairment and disability related to disease or treatment, fatigue, and pain. Psychological distress can include depression, anxiety, guilt, loss of control, anger, sadness, confusion, and fear. Patients may experience mood disturbances, fear of recurrence, and concerns about body image.
Relational concerns of patients include distress about the impact their illness is having on their family, their role changes within family relationships, and changes in sexual function and intimacy. They may have feelings of isolation, loneliness, and diminished self-esteem. Older adults are found to have special vulnerability to loss of self-esteem related to functional impairments and loss of autonomy. As noted previously their combined burden of chronic illnesses in addition to cancer may be quite high. Because of the rigorous treatments, side effects of treatments, fears of recurrence, and constant monitoring, families and support networks can experience severe strain over time.
Patients also experience spiritual and existential concerns. While cancer in many situations can be managed as a chronic illness today, it is life-threatening and older adults may have experienced the deaths of other from this disease. Therefore, they confront fears of death and a dying process that includes uncomfortable symptoms and pain. They may ponder the meaning of their illness, their suffering, their relationship to God, and their possible death.
Socially patients are stressed by the arduous treatment procedures used to achieve control or cure of the disease. The long period of treatment and rehabilitation and continuing surveillance can also exhaust insurance and require significant out-of-pocket expenses. It may cause the loss of employment for patients or severely impede functioning and imperil family finances.
Obstacles to managing psychosocial stressors include lack of information, insufficient logistical resources, lack of transportation, strained social support, and inattention and lack of support from the health care system. Established approaches to informing and educating patients and caregivers may not be effective with older adults. Specifically they may not have access to internet resources of other cohorts, or be able to process information given in group format. Their understanding of the potential effectiveness of current treatments may be outdated and based on earlier life experiences.
Table 3 presents seven domains of biopsychosocial health needs assessed by social workers and the psychosocial health services social workers use to meet these needs for cancer patients and their families. The domains include:
Fewer coordinated care approaches have been evaluated with cancer patients than with other diseases, and even fewer have focused explicitly on older adults with cancer. Until recently many questioned whether cancer patients’ behaviors could have any impact on the progression of their illness. A recent IOM report challenged that assumption and recommended that more patient self-management approaches be used to lengthen and improve the quality of life of cancer patients as they are helped to access information and services in a more timely and effective way (IOM, 2007a). Care coordination approaches with some evidence base with cancer patients have included improving interdisciplinary communication; screening to identify patients with high distress and unmet needs; implementing case management, on-site collocation, and clinical integration of services (e.g., mental health and primary care); developing a broad range of information and education approaches that link patients with available services and teach problem-solving skills. After reviewing the evidence base for these models for cancer patients, the authors of the IOM consensus report adopted the following standard of care that they believed was warranted by the majority of study findings.
“All cancer care should ensure the provision of appropriate psychosocial health services by:
Psychosocial screening and patient navigator programs are two elements of care coordination that have particular importance to the social work role, although social work is involved in implementing almost all care models with this patient population. These programs present excellent opportunities for social workers to demonstrate their knowledge and skill base in assessment, communication, and problem solving in order to improve patient/family satisfaction, quality, and quantity of life within larger health care systems. An example presented here is a model that is currently supported for study by both the National Cancer Institute and the American Cancer Society.
The available instruments cover a broad range of needs in multiple domains. More research is recommended to clarify reliable and valid measures with minimal patient/family burden (IOM, 2007a). No guidance currently exists to clarify which tools should be used for different types of patients seen in various clinical settings. Psychosocial screening instruments must address a broad range of problems patients encounter, beyond assessing for depression and anxiety (Wen & Gustafson, 2004). For example, one such approach recommended by National Comprehensive Centers Network (NCCN) and reported to be used by three cancer centers, includes both a distress thermometer and a problem list. The distress thermometer is a visual analogue scale displayed on a picture of a thermometer and used to screen for any type of psychological distress. Individuals are instructed to circle the number (from zero [no distress] to 10 [extreme distress]) that best describes their experience over the past week (NCCN, 2006). This assessment takes the patient less than a minute and the results are concordant with other more extensive and time consuming measures of psychological distress: e.g., the Brief Symptom Inventory (BSI) and the Hospital Anxiety and Depression Scale (HADS) (Jacobsen et al., 2005; Zabora, 1998). In guidelines issued by the NCCN, a 35-item Problem List provided on the same page as the thermometer covers a range of psychosocial problems (e.g., financial, emotional, work-related, spiritual, family, physical symptoms). The list does not include inquiries about behaviors that could interfere with illness management education such as smoking, alcohol or drug use, exercise, diet, or cognitive problems. Three cancer centers report having used this approach (Jacobsen & Ransom, 2007).
These programs in cancer care were developed initially to help low-income patients participate in screening for the detection of cancer and to obtain diagnostic and treatment services when indicated. The concept and implementation of such programs has developed over the past decade (IOM, 2007a).
Initially, patient navigators were local community residents without professional credentials, but more recently nurses and social workers have filled the navigator role because of the complexity of cancer treatment approaches. Some of these programs include patient education and patient advocacy roles in addition to helping patients overcome barriers to receiving effective services (Dohan & Schrag, 2005).
Evidence to date for the effectiveness of patient navigator programs has documented their ability to accrue more patients for cancer screening. One of the few randomized trials of this type of program (Jandorf, Gutierrez, Lopez, Christie, & Itzkowitz, 2005) found that patient navigators increased the prevalence of screening for colorectal cancer. Other studies suggest that such programs increase screening rates and may increase the proportion of patients detected with early-stage disease (Dohan & Schrag, 2005). Patient navigators are found to increase patients’ ability to overcome logistic and attitudinal barriers to obtaining screening. Their role in helping patients after diagnosis is less clear. A recent randomized trial evaluating the impact of a patient navigation program on follow-through with diagnosis among women with abnormal mammograms found that the intervention significantly increased the percentage of women achieving diagnostic resolution (Ell, Vourlekis, Lee, & Bin, 2007).
These programs appear to aid in engaging low-income patients to participate in cancer screening and diagnosis. Studies of their broader application in linking a diverse population to appropriate cancer services are currently receiving considerable research support. How they differ from more traditional case management functions remains uncertain. The American Cancer Society (ACS) and NCI have both launched major initiatives to implement and evaluate patient navigator programs. The ACS program places trained ACS staff in selected health care facilities to provide patients and families with personalized and reliable information about the disease, referral to ACS resources, and timely follow-up. NCI has launched a Patient Navigation Research Program to develop interventions to reduce the time required for delivery of the standard of care services in cancer diagnosis, and treatment after an abnormal finding. Patient navigators in this program will help patients and their families throughout the period of care by, for example, arranging various forms of financial support, scheduling transportation to appointments, and organizing child care during appointments. NCI and ACS are working together to develop evaluations of these programs.
Defining action steps: Action steps from a recent IOM (year 2007a) consensus panel are listed under resources in the 10-point action plan noted below. The participants, including several social workers, expressed frustration with the lack of implementation of previous reports and recommendations for integrating psychosocial and medical services that would improve quality of life of patient and family survivors of this complex disease and treatment process. Although people are able to live longer with this often chronic disease and in some situations are cured, they are struggling to cope with the challenges of later cancers, later affects of the treatments, and a health care system that is fragmented and often unresponsive to their human needs. The consensus panel report recommended a new standard for cancer care, a standard that incorporates acknowledgement, treatment, and management of psychosocial (social work) problems.
They identified a range of psychosocial needs of cancer patients from information about their therapies and the potential physical side effects, to treatment for depression, stress, or other mental and emotional conditions; assistance with daily activities that they can no longer perform independently; and assistance with transportation, prosthetics, medications, and other supplies they cannot afford or to which they do not have ready access. These specific needs encompassed seven domains of psychosocial need as presented above in Table 3.
Psychosocial health services are defined as “psychological and social services and interventions that enable patients, their families, and health care providers to optimize biomedical health care and to manage the psychological/behavioral and social aspects of illness and its consequences so as to promote better health” (p.6). The panel found that while cancer therapies save and prolong many lives, they and the tumors they target can exact a debilitating toll on patients’ mental and emotional well being and cause health problems that are not dealt with during oncology treatment.
Neglect of psychosocial services: Issues and evidence of system neglect of psychosocial services included the following:
Other barriers to addressing psychosocial care needs included the following:
The IOM panel (2007a) participants developed a ten-point plan for how to achieve a higher standard of care:
Due to medical advances over the last four decades cancer has become a chronic, though still life threatening, illness for many individuals including older adults. While previously cancer often went untreated in elders since it was believed they would die of other conditions before their cancer advanced to end-stage, that is no longer a valid assumption according to mortality statistics. The social work role and function in cancer has therefore expanded and changed from helping people dealing with dying from their disease to a greater emphasis on helping individuals get appropriate treatment and live with a disease that in many situations can be controlled if not cured. The treatment of cancer in older adults is complex because of co-existing illnesses and conditions, the nature of the treatment, and individual frailty. There is also insufficient research on cancer treatment in older adults that can guide treatment decisions and predict outcomes. Older patient and family needs are often psychosocial in nature, requiring effective care coordination and supportive interventions to maintain an acceptable quality of life. As a consequence, there is a newly recognized need for the development of comprehensive disease management programs for older adults with cancer. Providers acknowledge that they have been slow to incorporate these approaches within the cancer protocols of treatment centers and hospitals. Social workers by virtue of their professional training and expertise are well positioned to use the findings from needs assessment and interventions with older adults to take leadership in developing social work care coordination models that can address the biopsychosocial needs of patients more fully. Specific ways social workers can address some of these needs include the following:
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