November/December 2019

Geriatric Assessments for Older Adult Cancer Patients: What’s Their Value?
By Jamie Santa Cruz
Today’s Geriatric Medicine
Vol. 12 No. 6 P. 18

New guidelines from the American Society of Clinical Oncology recommend geriatric assessments for all adults before the development of treatment plans.

More than two-thirds of individuals with cancer are age 65 or older.1 Older adults frequently have age-related conditions—such as impaired cognition, malnutrition, inability to perform activities of daily living (ADLs), and fall history—that put them at higher risk for adverse outcomes in cancer treatment. However, the standard assessments used in many oncology clinics don’t capture information about these key age-related factors that influence patient risk. Partly for this reason, older adults are vulnerable to both overtreatment and undertreatment of their cancers.2-4

To improve cancer care for older adults and move toward more evidence-based decision making, the American Society of Clinical Oncology (ASCO) issued a new guideline in 2018 recommending that oncologists conduct geriatric assessments on all older adults prior to determining a treatment plan.5 Advocates say the use of geriatric assessments helps physicians better predict outcomes among older patients and helps oncologists know when they should intervene on an age-related vulnerability that might compromise the patient’s ability to tolerate treatment.

Current use of geriatric assessments in cancer care is limited; a 2018 survey of community oncologists found that only 23% of the 305 respondents used geriatric assessment in their clinics.6 Meanwhile, a 2019 survey of members of the Association of Community Cancer Centers found that the rate of use was even lower: Although 95% of respondents agreed or strongly agreed that a comprehensive geriatric assessment would benefit their patients, only 17% said they routinely conduct such assessments.7

“Older people are not the same as younger people,” says Harvey Jay Cohen, MD, Walter Kempner Professor of Medicine at North Carolina’s Duke University School of Medicine and a coauthor of the guidelines. “Older adults are not the same as middle-aged adults. They tend to have a variety of different things—physiological changes, the accumulation of comorbidities, increased prevalence of cognitive decline, increased prevalence of functional difficulties. So it becomes important to evaluate the status of those things when somebody is about to embark on a therapy—be it surgery or radiation or chemotherapy or anything—that may depend on the functional status of these older patients.”

What Are Geriatric Assessments?
Geriatric assessments cover several domains, including functional status, comorbidity, cognition, depression, social activity/support, and nutritional status. Although a portion of a geriatric assessment requires administration by a health care provider, the majority consists of a questionnaire filled out by the patient.

Importantly, geriatric assessments capture information that oncologists typically don’t get through other sources, such as routine histories or physicals. Although oncologists typically make use of assessment tools that measure performance status, such as the Karnofsky Performance Scale or Eastern Cooperative Oncology Performance Status, these tools often miss key aspects of older adult health. This is evident from a study of 363 older cancer patients indicating that geriatric assessments added significant information about functional status even among patients who had a good performance status.8 Another study of 1,820 older cancer patients found that geriatric assessments detected previously unknown problems among 51.2% of patients.9 In other words, geriatric assessments provide insight into older adults’ health that oncologists wouldn’t otherwise have.

The Value of Geriatric Assessments in Cancer Care
There are two ways in which geriatric assessments have value.

Prediction
“If the patient is 85 and you see this 85-year-old sitting in a chair, how do you know—what information can help an oncologist decide—whether this patient should get four months of chemotherapy before surgery?” asks Supriya Mohile, MD, MS, a professor of medicine and surgery at New York’s University of Rochester and a cochair of the ASCO guideline committee. “Right now, what people do is just look at the patient and make an assessment—it’s the eyeball test. We’re trying to say you need more objective information, and that’s where geriatric assessment comes in.”

The various tests included in geriatric assessments were all designed for patients without cancer. However, a body of research in the last few years has demonstrated that the domains included in geriatric assessments can predict oncology outcomes. Specifically, multiple studies have shown that geriatric assessments can predict both chemotherapy toxicity and mortality among older patients receiving chemotherapy.5 Other studies show that specific questions covered in geriatric assessments can predict hospitalization as well as functional decline among older patients on chemotherapy.10-13

Consider, for example, a patient’s ability to perform ADLs such as bathing, toileting, and eating. “We know that when somebody has an ADL deficit, they are highly likely to have an adverse outcome,” Mohile says, “whether it’s death or nursing home admission or chemotherapy toxicity or poor surgical outcome.” It’s a similar situation, she says, with the outcome of the Short Physical Performance Battery (SPPB), which is one of three options recommended in the guidelines for assessing physical performance. “The SPPB test is scored between zero and 12. We know from large data sets that patients who score nine and under on an SPPB have increased risk of future disability, nursing home placement, or death. This is patients without cancer. What we’re learning now in the last three to five years is that many of the geriatric assessment tests predict cancer outcomes too.”

Being able to predict outcomes using geriatric assessments can help oncologists make better decisions regarding treatment. In Mohile’s example of the 85-year-old patient with bladder cancer, she has to evaluate whether the patient should be given standard of care—four months of chemotherapy prior to surgery. “I look at function, cognition, physical performance, comorbidities—all of that. I get a toxicity score from the mycarg.org website, and I go into the room and talk to that 85-year-old about risks and benefits. If that patient has a lot of problems on the geriatric assessment—they’re frail, maybe they have cognitive impairment, maybe their chemotherapy toxicity risk is 90% in three months—I’m going to say, ‘Go straight to surgery. And if you do OK, then maybe chemotherapy afterwards,’ because surgery is the most important intervention for that patient. But if the patient is super fit, super active, I might say, ‘OK, you should get standard of care.’

“But I’m not just looking at the patient sitting there and using age, which is not adequate to say whether the patient should get treatment or shouldn’t get treatment.”

Intervention
Geriatric assessments not only predict outcomes but also identify age-related problems that may be helped by intervention. “When I know someone is vulnerable but we still decide to try chemotherapy, I can recommend geriatric interventions that could help improve the ability of that person to tolerate chemotherapy,” Mohile says. A patient who is falling, for example, is at higher risk of chemotherapy toxicity, so Mohile might intervene by having the patient go to physical therapy and start using an assistive device, and she might ask for a home safety evaluation. Alternatively, when patients have cognitive deficits and there’s reason to think they might not be able to communicate well about side effects experienced during chemotherapy, Mohile might explain to their caregivers that the patients need constant supervision.

According to Cohen, there’s not yet definitive evidence about whether identifying vulnerabilities through geriatric assessment and then intervening to address them will improve cancer mortality or quality of life among older patients. (Four separate randomized trials are underway to evaluate those questions, but the results weren’t available at press time.) But it’s “intuitive” to think that geriatric assessments enabling targeted interventions should improve outcomes, Cohen says. Before, there were age-related vulnerabilities that clinicians didn’t know were influencing outcomes, but now that the knowledge base is there, “we have these potential tools that we can use to intervene,” he says.

How to Complete a Geriatric Assessment
A full geriatric assessment in an oncology clinic should cover six domains: function, falls, comorbidity, cognition, depression, and nutrition. According to Mohile, there are a wide variety of tools that can be used to assess each domain, but the specific choice of tool isn’t as important as simply making sure to have one that covers each domain. “Should you use geriatric assessment? Yes, you should do geriatric assessment, and yes, you should look at all the domains. But which tools? The strength of the evidence is less.” She adds, “The way people pick is based on what’s practical for their clinical setting. Or maybe there’s a study that shows a particular tool is more valuable for a particular kind of cancer or for a particular outcome.”

That said, the ASCO guidelines make suggestions of at least one specific tool for each of the six domains, and these suggestions can be beneficial for oncologists who are starting from scratch with geriatric assessments and want a ready-made assessment package at their fingertips. “The tools we selected as the highest-priority options for each domain were the ones that the panel thought were most practical, and when we looked at literature, they had the most evidence of being predictive of cancer outcomes,” Mohile says.

For evaluating the risk of chemotherapy toxicity in particular, the guidelines recommend one of two specific prediction tools: either the Cancer and Aging Research Group tool or the Chemotherapy Risk Assessment Scale for High-Age Patients tool. Neither is a full geriatric assessment, but both incorporate the items from a geriatric assessment that are most predictive of toxicity. “If your question is the likelihood of having toxicity of chemotherapy, you absolutely should use one of those two tools,” says William Dale, MD, PhD, Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope, a comprehensive cancer care center in Duarte, California, and cochair of the ASCO guideline committee.

How Much Time Does It Take?
The biggest concern most oncologists have about giving routine geriatric assessments is time. But according to advocates of geriatric assessment, this shouldn’t actually be a concern. People still associate the process “with the old traditional geriatric assessment done by a geriatrician, which takes multiple personnel, is multidisciplinary, and may take four hours. Though this may be useful in some situations, it’s not what we’re talking about here,” Cohen says. “The physician has to do virtually nothing.”

Most of the assessment is based on patient self-report, and front desk staff can mail this portion out to be completed at home prior to the clinic visit. The cognition and physical performance portions of the assessment must be administered in the clinic by a health care provider, but these can be done by a nurse or other staff without taking up the physician’s time. Administration requires only very simple tools (such as a stopwatch, a chair, and a couple of distance markers in a hallway), and it’s estimated that the nurse-administered portion of the assessment takes only five to six minutes.14

It’s true that the self-reported portion of the assessment puts a somewhat greater burden on patients—the estimate of the time required to complete the patient-reported portion of the assessment is 15 to 23 minutes.14 Clinicians are sometimes afraid that patients will be annoyed by such extensive paperwork, but the opposite is actually true, according to Mohile. A randomized trial led by Mohile and presented at the 2018 ASCO Annual Meeting found that use of geriatric assessments resulted in better patient-physician communication about age-related concerns, and that patients reported greater satisfaction with that communication.15

“Our experience is that when we actually do geriatric assessment, patients and caregivers tell us that they’re happy that someone asked those questions,” Mohile says. “These problems identified in a geriatric assessment are concerns that patients and caregivers already have. They just don’t bring them up because they don’t know that they’re relevant in an oncology setting.”

For oncologists who remain concerned about the time it takes to do a complete geriatric assessment for every geriatric patient, one option is to start with only a geriatric screening tool. Options for screening tools include the Geriatric 8 and Vulnerable Elders Survey 13, both of which are abbreviated tests that provide only a quick snapshot of each of the domains covered in a full assessment. Oncologists can then move to a full geriatric assessment only if the initial screen indicates that a full assessment is necessary.

But while starting with a screen is a reasonable approach, Cohen prefers to skip screens and go straight to a full geriatric assessment for all older patients. “The problem is the concordance between findings on a screening tool and the findings on a full assessment is not perfect by any means. Sometimes you don’t find things on a screening tool but they’re there on a full assessment.” And since the majority of a geriatric assessment is self-administered, the full assessment simply doesn’t take that much more physician time, Cohen says.

Now What? Acting on the Results of a Geriatric Assessment
A key aspect of performing a geriatric assessment is knowing what to do with the results. According to Dale, it’s common for oncologists to say, “‘I just found out that [this patient] has cognition issues, but I don’t have a geriatrician. I don’t know what to do with them now that I have this cognition issue identified.’ So some of the work to do is [figure out] what resources do you currently have that you can make use of, so that if you discover something, you have a plan.”

To help oncologists handle the results of geriatric assessments, the ASCO guidelines provide a table of common problems that come to light on assessments plus a list of high-priority interventions for each. For instance, if a geriatric assessment uncovers a history of falls, the guidelines recommend a referral to physical or occupational therapy for strength and balance training. They also suggest evaluating the patient for an assistive device, starting the patient on a home exercise program, initiating a fall prevention discussion, and lining up a home safety evaluation.

To make meaningful use of the assessments, oncologists must first review the resources they already have available as well as what resources they need to line up in order to be able to intervene effectively when problems arise. Is physical therapy available for people with gait problems, for instance? What psychiatry, psychotherapy, and nutrition counseling services are available?

Beyond using the results of a geriatric assessment to guide interventions, Dale suggests that clinicians also use the results to organize and stratify their clinic. If a clinic has 40 patients, eight of whom are complex older adults, those frail older patients should be on a different track than younger, less complex patients. “Screen them and sort them into different care pathways,” Dale says. “Take [the eight] out of the full clinic flow and treat them … with a little more dedicated time and a little longer appointments.” Not only will the patients receive better care but also stratification and organization based on patient complexity will help the clinic run more efficiently, Dale says.

Looking Toward the Future
Oncologists vary widely in terms of their views about how treat older adults with cancer. Specifically, they vary in the decisions they make about chemotherapy for older adults and in terms of how they intervene on patient health conditions that are negatively affected by chemotherapy. Geriatric assessments can reduce some of this variation by helping oncologists better understand which patients are best suited for chemotherapy and which may need interventions to address comorbid conditions.16-22

Although making geriatric assessment a routine part of an oncology clinic may require some upfront legwork, Dale encourages clinicians to take the plunge. It’s the right thing to do for patients whose quality of life hangs in the balance. “We fit all kinds of things—bone marrow biopsies, imaging, testing—into the middle of clinics, and somehow that, which takes way more time and energy, gets done. We can do this,” he says.

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

Resources
ASCO guideline for geriatric oncology: www.ncbi.nlm.nih.gov/pmc/articles/PMC6063790

Cancer and Aging Research Group Geriatric Assessment and Chemo-Toxicity Calculator: www.mycarg.org/tools   

Chemotherapy Risk Assessment Scale for High-Age Patients: https://moffitt.org/for-healthcare-providers/clinical-programs-and-services/senior-adult-oncology-program/senior-adult-oncology-program-tools  

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