IT’S WELL KNOWN that older adults, who make up approximately 60% of cancer patients, are at increased risk of complications related to their cancer, its treatment and other health conditions. Caring for people 65 and older with cancer is often about balancing risks. On one hand, there are the dangers of having a potentially lethal disease. On the other, toxic treatments can come with serious side effects, particularly for older adults who are more likely to have multiple medical conditions and age-related deficits.
“You don’t want cancer to progress, you don’t want to have treatment complications, and you want to be mindful of age-related conditions. It’s optimizing all those factors, and it’s a fine balance in oncology,” says Wee-Kheng Soo, a geriatric oncologist at Eastern Health, based in Melbourne, Australia.
Soo and other geriatric oncologists presented data from clinical trials on the impact of geriatric assessment and intervention at the virtual scientific program of the 2020 American Society of Clinical Oncology (ASCO) Annual Meeting held May 29-31.
Comprehensive geriatric assessment is not a new concept. But its application in oncology dates to the past decade—as evidence continues to suggest standard oncology assessments can miss problems that could jeopardize the health of older adults undergoing cancer treatment. In 2018, ASCO released guidelines endorsing geriatric assessment to help oncologists better identify and address vulnerabilities in older patients. Geriatric assessment can be divided into various domains including physical performance and falls, depression, nutritional status, social support, cognition, medical conditions besides cancer, and functional status, which includes the ability to carry out daily activities like grocery shopping. Other organizations, such as the National Comprehensive Cancer Network and the International Society of Geriatric Oncology, have published similar endorsements for geriatric assessment to help identify factors that can contribute to poor outcomes in patients undergoing cancer treatment.
Talk about geriatric assessment with your oncologist.
People with cancer who are over 65 should ask their oncologists about whether they can take a geriatric assessment, says Daneng Li, a geriatric oncologist at the City of Hope Center for Cancer and Aging, based in Duarte, California. If the treating physician is unfamiliar with doing geriatric assessment, Li suggests the patient can fill out a questionnaire on the Cancer & Aging Research Group (CARG) website and print out the assessment for the doctor. CARG also has a chemotherapy toxicity calculator that predicts the risk of having adverse effects from chemotherapy.
“If you are an older adult who is going through cancer treatment, and especially if you are that older adult’s caregiver, you should just ask the provider: ‘Do you mind if I fill out a geriatric assessment to give you a richer picture of who I am as a patient and to potentially identify those areas that might need to be considered while I’m going through the cancer treatment?’” says Li.
Still, not everybody has embraced this approach. In one 2018 study published in the Journal of the National Comprehensive Cancer Network, just 23% of 305 community oncologists reported performing geriatric assessments with older patients despite 89% agreeing that cancer care of older adults needed to be improved.
“Many of us in specialized centers and academic centers [realize] the value of this assessment. We already know studies show that geriatric assessment is able to predict whether or not someone has a risk of chemotherapy-related toxicity,” says Daneng Li, a geriatric oncologist at the City of Hope Comprehensive Cancer Center in Duarte, California. “Others who maybe have had trouble adopting this might say, ‘OK, you can predict toxicities, but what are you going to do about it?’ Our research was an attempt to answer that question.”
Li presented results from a study that included 600 patients age 65 or older who had solid malignancies. All patients filled out a baseline geriatric assessment survey that asked questions about their function, additional health conditions and cognition. However, in one group of patients, a multidisciplinary team led by a geriatric oncologist reviewed the assessment and sent a report to the treating oncologist with recommended interventions, including physical therapy, occupational therapy, nutritional counseling and pharmacist consultations. Just over half of the patients whose oncologists received the supplemental information had grade 3 to 5 chemotherapy-related toxicity, compared to a little more than 60% of patients whose physicians received the assessments but no intervention recommendations. Grade 3 to 5 toxicities include severe to life-threatening complications. Li’s study did not show significant differences in emergency room visits, hospitalizations or average length of hospital stays between the group that received just the assessment compared to those who received the assessment and intervention recommendations.
The study confirms that oncologists’ knowledge of vulnerabilities paired with practical recommendations help them understand and improve health problems doctors might otherwise have missed in patients, Li says. He notes the reduction in chemotherapy-related toxicity in the study was associated with the recommendation for interventions—such as physical therapy, occupational therapy and nutritional therapy—and not a physician’s decision to reduce chemotherapy doses. (Li did not present data on reduced chemotherapy doses at the conference but is planning to include the data when the study is published.)
Supriya Gupta Mohile, a geriatric oncologist and director of the Geriatric Oncology Clinic at the University of Rochester James Wilmot Cancer Institute in New York, presented data showing that geriatric assessment and intervention that was integrated into 41 community practices across the U.S. could also reduce grade 3 to 5 toxicities. Mohile presented data from 718 patients who were 70 or older and had incurable cancer. The clinical oncology teams at these community practices were trained to use measures that assessed physical performance, nutrition, and depression and mental status. Then the care team entered geriatric assessment scores into an online tool that provided intervention recommendations. Forty-nine percent of the patients whose oncologists received the assessment and recommendations received a reduced chemotherapy dosage at their first treatment, compared to 35% of patients whose physicians did not receive geriatric assessment information and intervention recommendations. Overall survival in both groups remained comparable at six months even with the lower starting chemotherapy dose. In addition, 50% of patients whose physicians received the recommendations experienced grade 3 to 5 toxicity over three months, compared to 71% of patients whose physicians did not receive the recommendations.
For Mohile, who was also the lead author of the 2018 ASCO guidelines on assessing and managing older cancer patients, these findings confirm the value of geriatric assessment in helping older people with cancer. “There was enough research to inform our guidelines [even then], but now with the randomized controlled data, geriatric assessment should be the standard of care,” she says.
Soo’s study showed that geriatric assessment and intervention were able to reduce unplanned hospitalizations in 154 cancer patients age 70 and older who were receiving chemotherapy, targeted therapy or immunotherapy. The patients were divided into two groups. Both groups received usual care, but one group also received comprehensive geriatric assessment and management recommendations by a geriatrician. The researchers noted 1.3 fewer emergency room visits and 1.2 fewer unplanned hospital admissions per person per year in the group that visited with a geriatrician. In addition, patients who received geriatric assessment were less likely to stop their initial treatment early (32.9% stopped treatment, compared to 53.2% in the usual-care group).
Implementing geriatric assessment measures is not difficult, the presenters noted while discussing their findings with Cancer Today after the ASCO virtual meeting. “The assessment part can be done through self-report for the most part of it. It does take effort to implement it,” says Soo, who notes that data can be collected via a computer, but needs to be put in context by a medical professional. “Once you’ve identified the problem, you need to act on it.” These studies, Soo adds, show that it is feasible and worthwhile to do both.
“I think the studies all add value because they kind of show no matter what you do, it’s helpful,” says Mohile. “Doing nothing is not an option anymore. You can screen. You can do an assessment where you are hitting the highest-priority domains and intervening on those, which is in the ASCO guidelines, or you can do a more heavily resourced intervention, if you are interested, with trained personnel, or you can send patients to do the full geriatric assessment at a facility like ours. People say doing a couple [of] questionnaires or performing an objective measure that takes 10 to 15 minutes is too hard to do. I don’t buy it anymore. We know it’s predictive. We know it improves outcomes.”
Li is working with others in the field to determine the best way to bill Medicare for these assessments for patients in the U.S. He notes that the Centers for Medicare and Medicaid Services (CMS) does not have a specific code for geriatric assessment that oncology practices can use for reimbursement, although geriatricians are able to bill for these services. CMS is the federal agency that administers Medicare and other federally funded health care programs.
Soo, meanwhile, hopes his efforts will convince his facility to open a geriatric oncology clinic in Australia. He estimates there are only a handful of centers that focus on geriatric oncology services in the country. Soo believes the data from his study showing geriatric assessment and intervention reduce hospitalizations could help convince his facility—and other facilities in the country—of the cost savings.
Soo also points out that patients who received the assessment and intervention had improvements in measures of quality of life, such as physical and social functioning, mobility, burden of illness and future worries, compared to those who were in the usual-care group. These measures have an inherent value to older cancer patients, he adds, stressing the importance of long-term follow-up care and rehabilitation after treatment, as well as having conversations about the end of life. In the study at City of Hope, 24.1% of patients in the geriatric assessment and intervention arm completed advance directives compared to 10.4% in the standard-of-care group. In addition, a study published Nov. 7, 2019, in JAMA by Mohile and her colleagues showed that geriatric assessment could improve patient-centered and caregiver-centered conversations about age-related concerns.
“It’s not only health outcomes, it’s about care outcomes,” says Soo. “Health outcomes are what we like to look at in oncology. We like to say the patient is reporting a benefit in having less toxicity or to ask, ‘Did they complete treatment or did they survive longer?’ Care outcomes are slightly different measures. Are we having the advance care planning conversations? It’s a different viewpoint, but no less important in terms of where the patient is in context of their journey.”
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