Research shows geriatric assessments for older adults with cancer that identify pre-existing comorbidities and health status outside of their cancer improve outcomes. In 2014, researchers launched a cluster randomized clinical trial to compare a geriatric assessment intervention with what was then usual care for reducing cancer treatment toxicity in older patients that spread. The primary analysis found that patients who underwent geriatric assessment had fewer serious toxic effects from treatment than patients without an assessment (Lancet 2021; doi: 10.1016/S0140-6736(21)01789-X).
A secondary analysis showed that patients who had geriatric assessment also reduced patient-reported symptom toxicity (J Clin Oncol 2022; doi: 10.1200/JCO.22.00738). This data confirms these types of assessments in routine cancer care for older adults benefit patients. In 2018, ASCO published a recommendation that adults ages 65 and older diagnosed with cancer and receiving chemotherapy should undergo a geriatric assessment to identify vulnerabilities not routinely captured in oncology assessments (doi: 10.1200/JCO.2018.78.8687). The authors of the recent analysis hope the new evidence helps fuel the implementation of such assessment into routine cancer care. Marie Flannery, PhD, RN, Director of the PhD Program in Nursing & Health Science and Associate Professor of Nursing at the University of Rochester, and Eva Culakova, PhD, MS, Research Assistant Professor in the Department of Surgery at University of Rochester Medical Center, shared details on their work.
1 Are geriatric assessments being routinely done for older adults?
Flannery: "When older adults are diagnosed with cancer, they're more likely to already have other diagnosed comorbidities or medical illness. They're also more likely to experience issues related to aging than people who get cancer at younger ages-having difficulty hearing, change in vision, or having arthritis or heart disease. These can make the treatment of cancer more challenging. There's an expression that you need to 'stage the aging and you have to stage the cancer.' You can't always tell just by looking at an individual how many of these changes related to the aging process are present. The geriatric assessment is a tool that includes formal evaluation of multiple domains that can be affected by aging. It includes standardized patient questionnaires...shown to be validated and helpful in a population.
"The geriatric assessment used in our study looked at eight different domains. There's physical status, functional status, comorbidities (whether they're present, as well as whether they interfere with daily living), polypharmacy, social support, psychologic status, nutrition, and cognition.
"Geriatric assessment for older adults initiating cancer treatment is recommended as best practice by ASCO. Then after the assessment is done, the recommendation is that clinicians take these findings into account when recommending the type of chemotherapy the individual will receive. They also consider implementing plan-of-care changes based on the assessment findings and discuss with the patient and any of their caregivers or family members.
"We know that there's increasing evidence on the effectiveness, acceptability, and feasibility of geriatric assessment. We also know it is not always implemented in every oncology practice. Sometimes there is a shortage of geriatricians or oncologists to complete the assessments, or sometimes there's a lack of knowledge that they should be done. When this study was initiated, the guideline was not out from ASCO."
2 What were the key study findings?
Culakova: "Primary findings support that, in the population of older adults with advanced cancer and aging-related impairments, implementing the geriatric assessment-guided intervention can reduce clinician-rated toxicity based on the Common Terminology Criteria for Adverse Events. The results of this secondary analysis show that geriatric assessment intervention also reduced overall symptomatic toxicity reported by patients using the Patient-Reported Outcome version of the Common Terminology Criteria for Adverse Events. However, the effect of geriatric assessment intervention on patient-reported symptomatic toxicity was not as large on clinician-rated toxicity.
"In summary, these patients start with high levels of symptoms, such as pain, sleep, or appetite problems. During the treatment, there may be symptoms that actually get worse and new symptoms may develop. Geriatric assessment intervention provided at treatment initiation helped in reducing the overall occurrence of toxicities. However, there may be a further need for implementing symptom assessment and symptom management strategies in addition to geriatric assessment-guided interventions for older adults with advanced cancer."
3 What are the main implications of these findings for clinical practice?
Flannery: "This paper provides further evidence on the importance of incorporating aging-specific information into the management of older adults being treated for cancer. This study specifically looked at individuals diagnosed with advanced cancer. Traditionally, older adults with cancer have been underrepresented in clinical trials. This is the population that is growing and many older adults with advanced cancer are experiencing treatment for a period of time. This study entirely enrolled adults who were over the age of 70, so it gave us a lot of specific information about what the experience is like for older adults with advanced cancer.
"The take-home message is that this paper further provides evidence on the effectiveness of geriatric assessment-based interventions. And it expands that to knowing those geriatric assessment interventions can help with patient-reported symptomatic toxicities during the treatment of their cancer. It further reinforces...the importance of ongoing symptom assessment and management strategies being delivered to these individuals along with their oncology treatment. There is frequently a delay in the time that findings come out from research and when those findings are routinely integrated into practice. The more we get these results out there, the more clinicians will know they're important, but also patients and families will know they're important and they'll seek out care where they can find it."