As the oncology community braces for an anticipated 36 percent increase in breast cancer diagnoses among women older than 65 by 2030 (J Clin Oncol 2009;27(17):2758-2765), an essential question is emerging: What is the best way to treat these patients and preserve the best possible quality of life?
The answer is multifaceted of course. But research and clinical experience are showing that at the center should be an action that is powerful in its simplicity and effect: a geriatric assessment at the time of diagnosis.
Arti Hurria, MD, Director of the Cancer and Aging Research Program at City of Hope Comprehensive Cancer Center, Duarte, Calif., is working to demonstrate the importance of incorporating a geriatric assessment into the care of older patients with cancer. Through conference presentations, research, and via the Cancer and Aging Research Group (CARG; http://www.mycarg.org), Hurria and colleagues are performing research that will help oncologists better care for older women with breast cancer.
The Landscape
Age is the No. 1 risk factor for breast cancer, and the highest rates of this cancer occur among women between the ages of 75 and 79, according to http://Breastcancer.org. Following closely behind is the incidence in women 80 to 84 and older-almost 250 cases per 100,000. While many women in their 80s are healthier than their counterparts of the past, the variation in health and functional status can be dramatic. The percentage of today's Americans older than 85 who have diminished or impaired ability to perform activities of daily living is more than 6 times the rate among 65- to 74-year-olds (Health Serv Res 2002;37(4):849-884). Such deficits can play an instrumental role in a patient's treatment course after a breast cancer diagnosis, fueling complications and accelerating functional decline.
"We need to understand the whole person, what their risk factors are, and how we might decrease those risk factors," Hurria said in an interview with Oncology Times. "We get very little of that when we look at chronological age alone."
Individualizing care requires a more thorough understanding of patient circumstances than a traditional intake involves. This understanding can be built through the implementation of geriatric assessment as a standard of care in older adult patients.
Basics of Geriatric Assessment
The geriatric assessment asks key questions about functional status that help inform the care plan. The findings also can be utilized to identify patients at risk for severe chemotherapy toxicity. "Oncologists can ask 11 simple questions to understand the patient's risk."
To arrive at conclusions about toxicity risk, the geriatric assessment analyzes domains outside of chronological age that are known to be predictive of the risk of morbidity and mortality in older patients with cancer:
* functional status;
* comorbidity;
* nutritional status;
* cognition;
* psychological state;
* social support;
* medication therapies (polypharmacy).
To facilitate widespread use of geriatric assessment in oncology practice, an assessment has been developed that can be primarily self-administered by patients (J Clin Oncol 2011;29(10):1290-1296, Cancer 2005;104(9):1998-2005). This free questionnaire is linked with a tool that calculates a score to indicate a patient's level of risk for chemotherapy-induced toxicity. The questionnaire is available at the CARG website, http://www.mycarg.org/SelectQuestionnaire, and the results can be printed for interpretation and use by treating physicians.
Evolving Research
CARG seeks to foster collaboration among geriatric oncology researchers to produce studies that will lead to improved care for older adults with cancer. To that end, Hurria and fellow CARG researchers are in the final phases of a study assessing the effectiveness of the geriatric assessment questionnaire. The goal is to use the data to develop a breast cancer-specific predictive model. Hurria presented preliminary information about the design of the study at the 2016 San Antonio Breast Cancer Symposium (SABCS) and during this interview.
The trial followed 700 older women across 15 institutions. Five hundred of the women had been treated for breast cancer and received adjuvant chemotherapy, 100 had been treated for breast cancer but received no adjuvant chemotherapy, and 100 were healthy controls. The researchers performed geriatric assessments and collected blood draws at two points during the study, prior to adjuvant chemotherapy and upon completion of adjuvant chemotherapy. A subset of the participants is being followed into the survivorship years, 2-3 years post-completion of adjuvant chemotherapy. The research team is analyzing the results and hopes to present and publish the findings within the next 6-12 months, Hurria noted.
"The goal of this study is to produce a calculator that can quantify an individual's unique risk of chemotherapy side effects," Hurria explained. "It will allow patients and their doctors to more accurately weigh the benefits and risks, and to use this information in shared decision-making."
At SABCS, Hurria offered the theoretical case of an 80-year-old woman with breast cancer who was diagnosed after an abnormal mammogram result and the detection of a palpable lump. The patient underwent lumpectomy and sentinel lymph node dissection, and the results were a T2 (4-cm tumor) that was ER/PR-positive, HER2-negative, with a high-risk oncotype recurrence score.
The geriatric assessment findings for this patient showed she needed assistance taking medications and had fallen once in the prior 6 months (functional status); she had diabetes, arthritis, and osteoporosis (comorbidity status); she reported no cognitive impairment (cognitive status); she had experienced no unintentional weight loss (nutritional status); she reported no depression or anxiety (psychological state); and family support was available to her (social support).
Using the CARG geriatric assessment tool, this patient's risk score is 10, with an estimated risk of grade 3-5 chemotherapy toxicity of approximately 72 percent, placing the patient in high risk for chemotherapy toxicity.
Follow-up discussion with this patient should focus on the potential benefits of adjuvant chemotherapy and the risks associated with potential chemotherapy toxicity. It should also include exploration of other available treatment options. The oncologist and patient discussed these issues together and decided to forgo chemotherapy after weighing the risks and benefits, and opted for endocrine therapy and radiation.
Scope of Need
The need for widespread clinical attention to geriatric risk assessment is considerable because older cancer patients are not typically assessed for the complex factors that affect their day-to-day functioning.
"[Geriatric assessment] is not routinely done in clinical practice," Hurria stated. "Very few oncologists are geriatric oncologists, and most oncologists haven't been trained in geriatrics.
"Hence, we've tried to make it easier for the health care team to get the geriatric information they need, so that they can spend more time sitting with the patient and thinking about it together when formulating a treatment plan."
Referring to the CARG questionnaire for geriatric assessment, Hurria said the ability to capture patient self-report in a way that is reportable to the provider should go a long way toward addressing the barrier of time to complete the geriatric assessment.
"We, as a field, need to continue to prove the utility of what we are recommending," she concluded. "We have shown that a geriatric assessment can be utilized to identify the risk of chemotherapy side effects. The next steps in our research are to determine how we can utilize a multidisciplinary geriatric oncology team to lower that risk."
Michelle Perron is a contributing writer.