Cancer Care in the Older Adult: Think of Geriatric Assessment as 'Staging the Age'
Older patients may require special consideration during decision-making for cancer treatment.
Outcomes in older adults with cancer are highly variable, and therefore management decisions should consider the likelihood of benefit, the likelihood of harm, and the patient’s values and preference, said Grant Williams, MD.
The median age at cancer diagnosis in the U.S. is 67 years. Most cancer survivors are ≥65 years, and this proportion is expected to grow.
Assessing cancer in older adults remains a clinical challenge. “There’s a lot of subjectivity and variability in how one assesses an older adult. Chronological age and performance status alone are insufficient,” said Dr. Williams, assistant professor, Director of the Cancer and Aging Program, University of Alabama, Birmingham. “Better ways to assess older adults are needed.”
Geriatric oncology can be viewed as an iceberg, at which the assessment tip are age, performance status, tumor characteristics, and organ function. These variables are part of the traditional assessment in oncology. Other factors under the surface of the iceberg that must also be assessed are polypharmacy, comorbidities, falls, psychologic dysfunction, function deficits, cognitive impairment, nutritional deficits, sarcopenia, and social support. “[These] are critically important to developing personalized cancer treatment plans for older adults,” he said. “This brings us to the concept of a geriatric assessment.”
A geriatric assessment is a multidimensional, interdisciplinary approach to the evaluation of an older adult, leading to the identification and treatment of areas of vulnerabilities.1 It requires a systematic evaluation of the aforementioned domains that are under the surface, and it involves both evaluation and management.
The inherent challenges to a geriatric assessment are the time involved and the specialized personnel and expertise required. The National Cancer Institute Oncology Research Program landscape survey of community oncology practices reveals that only 2% of community oncology sites have fellowship-trained geriatric oncology providers, and 34% indicated that they had a geriatrician available for consultation, but only 13% had a geriatrician available in the oncology clinic.2
A brief geriatric assessment instrument developed by Hurria et al that incorporates several domains take 30 minutes or less.3
“It’s important to think of the geriatric assessment as staging the age,” he said. Patients with no functional impairment, no significant comorbidity, and no geriatric syndromes would be staged as “fit,” who are able to undergo traditional oncology treatment similar to that of their younger counterparts.
In contrast, those with dependence in activities of daily living (ADL), three or more comorbidities or at least one life-threatening comorbidity, or a clinically significant geriatric syndrome would be staged as “frail.” “Most of these patients will not benefit from traditional oncology care,” he said. A symptom-based or palliative approach may make more sense in this group.
Those staged as “vulnerable” may have dependence in instrumental ADL but not ADL, some comorbidities but none that are life threatening, and no geriatric syndromes other than mild memory disorder or mild depression. This group represents the majority of older adults, and is the subject of ongoing research in an attempt to improve decision-making and outcomes.
A geriatric assessment in oncology can uncover problems not found routinely, allow for an accurate estimate of life expectancy, and can predict treatment-related toxicity and other outcomes. The ePrognosis website (www.eprognosis.org) can be used to estimate life expectancy and uses some geriatric assessment data. The survival benefit of adjuvant treatment can be estimated by entering variables into www.adjuvantonline.com. The risk of chemotherapy toxicity can be estimated using the Chemo-Toxicity Calculator (“CARG TOOLS” at www.mycarg.org).
Many impairments via geriatric assessment have found beneficial interventions available to improve function, reduce chemotherapy toxicities, and improve outcomes. The geriatric-derived frailty index has been found to predict mortality4 and treatment tolerability and toxicity from treatment.5
Beyond prediction of outcomes, the geriatric assessment “is an intervention tool as well,” he said. The tool can be used for modification of cancer treatment (ie, dose reductions, choice of agents) and modification of supportive care (ie, medication review, measures to reduce the risk of falls) to improve tolerance to treatment.
Disclosure
Honoraria: Carevive Systems, Cardinal Health
References
- Mohile SG, Dale W, Somerfield MR, et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 2018;36:2326-47.
- Williams G, Weaver KE, Lesser G, et al. Capacity to provide geriatric specialty care for older adults in community oncology practices. Oncologist 2020;25:1032-8.
- Hurria A, Gupta S, Zauderer M, et al. Developing a cancer-specific geriatric assessment: a feasibility study. Cancer 2005;104:1998-2005.
- Guerard EJ, Deal AM, Chang Y, et al.
- Hurria A