Inclusion of Geriatric Assessments Alters Cancer Management in Older Patients

Including an upfront geriatric assessment and input from an onco-geriatric multidisciplinary team (OMT) in the decision-making process for older patients with cancer had a substantial impact on recommendations related to treatment management. The findings from this study were published in the Journal of Geriatric Oncology.

Decisions related to the management of older patients (70 and older) with cancer often involve consideration of competing causes of morbidity and mortality, as well as concerns regarding the potential for increased treatment toxicity. Nevertheless, one-dimensional measures based on age, performance status, or comorbidity have not been shown to adequately assess the diversity of physiologic reserve (ie, level of frailty or fitness) that exists in this group of patients.

Although the Comprehensive Geriatric Assessment (CGA) is a validated geriatric screening method for the assessment of frailty in older persons, it is time-consuming to complete and often performed by a geriatrician, of whom there are limited numbers. Given these restrictions, an alternative geriatric assessment (GA), performed by a trained oncology nurse, in conjunction with an assessment of patient preferences was developed.

In this study, use of this measure followed by standard care (ie, multidisciplinary tumor-specific board meeting) and then an OMT meeting involving active participation by the oncology nurse and a geriatrician in which the GA outcomes and patient preferences were discussed, was compared with standard care alone for older patients with cancer.

This prospective cohort study was performed at a tertiary cancer center in the Netherlands between 2014 and 2016. The GA was conducted within the context of a semistructured interview, and involved an assessment of somatic, social, psychological, and functional domains; patient preferences were assessed using a separate measure. The primary outcome of the study was a comparison of treatment recommendations for older patients evaluated using the 2 decision-making approaches. The secondary outcome was the number of referrals by the OMT to geriatric services.

Of the 197 patients included in the analysis, all of whom had solid-tumor cancers, the median age was 78.0 years, and the standard multidisciplinary tumor board recommended curative-intent treatment for 80.7% of patients. In 27% of cases, the OMT modified the treatment plan proposed by the standard tumor board. Patients with a modified treatment plan were more likely to have differences on functional assessment and degree of polypharmacy compared with patients with an unmodified treatment plan, and most treatment modifications involved recommendations for less intensive therapy.  The OMT recommended subsequent patient referral to a geriatrician in only 12.6% of cases. The authors estimated that, based on frailty screening, more than 50% of these patients would typically have been referred to a geriatrician using standard approaches.

Some of the study limitations noted by the researchers included the possibility of bias due to patient sampling and selection methods, as well as the lack of comparison with the gold-standard comprehensive geriatric assessment measure.

In their concluding statements, the researchers noted that upfront nurse assessments of older patients with cancer may often be excluded from consideration during standard multidisciplinary tumor board meetings. They further noted that incorporation of the GA, assessment of patient preferences, and the OMT into the decision-making process can help ensure that this information is weighed when recommendations for the treatment and additional assessment of older patients with cancer are formulated.

Reference

Festen S, Kok M, Hopstaken JS, et al. How to incorporate geriatric assessment in clinical decision-making for older patients with cancer. An implementation study [published online April 25, 2019]. J Geriatr Oncol. doi: 10.1016/j.jgo.2019.04.006