Integration of geriatric assessment into clinical oncology practice: A scoping review

Implementation of a Multi-Disciplinary Geriatric Oncology Clinic in Toronto, Canada

Older adults with cancer tend to face more complex health needs than their younger counterparts. Patients > 65 years of age are recommended for comprehensive geriatric assessment (CGA) to capture and address age-related vulnerabilities. Access to geriatrics services is limited, and our baseline audit of geriatric referrals in 2019 from the cancer program revealed that only 30% of patients referred received a CGA. The aim of this study was to assess the implementation of a geriatric oncology (GO) clinic that employs CGA and determine patient outcomes. We conducted a retrospective cohort study at a single institution. Data collection included baseline characteristics, GO clinic findings and characteristics, recommendations/referrals, and emergency room (ER) visits/hospitalizations within 6 months of CGA. Descriptive statistics were used for analysis. A total of 100 patients were included, with a median (range) age of 80 (63-97) years; 70% were female, and the most common cancer type was breast (31%). Through the GO clinic, patients were seen in a timely manner, with a median of 3 weeks, compared to our historical baseline of 11 weeks. Cognitive decline (32%) and pre-treatment CGA (22%) were the most common reasons for referral, and the most common new diagnosis was cognitive impairment (65%). For pre-treatment CGA, 16 (48%) patients were deemed suitable for treatment and 10 (30%) were recommended for modified treatment; 34 (94%) referring physicians followed the recommendation. In addition, most (68%) patients received an allied health referral. One third of patients visited the ER and 30 (30%) patients were hospitalized. Overall, the GO clinic resulted in greater access to CGA in a timely manner, enhanced access to allied health, and assisted in treatment decision-making.

The Five "Ws" of Frailty Assessment and Chronic Lymphocytic Leukemia: Who, What, Where, Why, and When

Chronic lymphocytic leukemia (CLL) is a disease of the elderly, but chronological age does not accurately discriminate frailty status at the inter-individual level. Frailty describes a person's overall resilience. Since CLL is a stressful situation, it is relevant to assess the patient´s degree of frailty, especially before starting antineoplastic treatment. We are in the era of targeted therapies, which have helped to control the disease more effectively and avoid the toxicity of chemo (immuno) therapy. However, these drugs are not free of side effects and other aspects arise that should not be neglected, such as interactions, previous comorbidities, or adherence to treatment, since most of these medications are taken continuously. The challenge we face is to balance the risk of toxicity and efficacy in a personalized way and without forgetting that the most frequent cause of death in CLL is related to the disease. For this purpose, comprehensive geriatric assessment (GA) provides us with the opportunity to evaluate multiple domains that may affect tolerance to treatment and that could be improved with appropriate interventions. In this review, we will analyze the state of the art of GA in CLL through the five Ws.

Development and implementation of an interdisciplinary telemedicine clinic for older patients with cancer-Preliminary data

BACKGROUND

Frailty assessment is an important marker of the older adult's fitness for cancer treatment independent of age. Pretreatment geriatric assessment (GA) is associated with improved mortality and morbidity outcomes but must occur in a time sensitive manner to be useful for cancer treatment decision making. Unfortunately, time, resources and other constraints make GA difficult to perform in busy oncology clinics. We developed the Cancer and Aging Interdisciplinary Team (CAIT) clinic model to provide timely GA and treatment recommendations independent of patient's physical location.

METHODS

The interdisciplinary CAIT clinic model was developed utilizing the surge in telemedicine during the COVID-19 pandemic. The core team consists of the patient's oncologist, geriatrician, registered nurse, pharmacist, and registered dietitian. The clinic's format is flexible, and the various assessments can be asynchronous. Patients choose the service method-in person, remotely, or hybrid. Based on GA outcomes, the geriatrician provides recommendations and arrange interventions. An assessment summary including life expectancy estimates and chemotoxicity risk calculator scores is conveyed to and discussed with the treating oncologist. Physician and patient satisfaction were assessed.

RESULTS

Between May 2021 and June 2022, 50 patients from multiple physical locations were evaluated in the CAIT clinic. Sixty-eight percent was 80 years of age or older (range 67-99). All the evaluations were hybrid. The median days between receiving a referral and having the appointment was 8. GA detected multiple unidentified impairments. About half of the patients (52%) went on to receive chemotherapy (24% standard dose, 28% with dose modifications). The rest received radiation (20%), immune (12%) or hormonal (4%) therapies, 2% underwent surgery, 2% chose alternative medicine, 8% were placed under observation, and 6% enrolled in hospice care. Feedback was extremely positive.

CONCLUSIONS

The successful development of the CAIT clinic model provides strong support for the potential dissemination across services and institutions.

An evaluation of the Index4 tool for chemotherapy toxicity prediction in cancer patients older than 70 years old

Chemotherapy, although beneficial for improving outcomes in both localized and metastatic cancers, may be associated with significant adverse effects, especially for patients with decreased functional reserves. Prediction of patients who will not tolerate well chemotherapy treatment may help in modifying treatment plans and in reallocating resources to vulnerable patients. One hundred seventeen consecutive cancer patients over the age of 70 scheduled for chemotherapy treatment in a single cancer center were included in the study. Prediction of adverse chemotherapy outcomes were calculated using a prediction tool proposed and validated from the Cancer and Aging Research Group (CARG) and a prediction tool proposed by us, called Index4. The 2 tools were compared for their ability to predict grade 3 and 4 toxicities, Emergency Department (ED) and hospital admissions and chemotherapy discontinuation. The accuracy of both predictive tools was suboptimal. A high CARG score had a sensitivity of 46.3% and a specificity of 82% and an Index4 of 1 or above had a sensitivity of 53.7% and a specificity of 60% in predicting grade 3-4 adverse effects. The performance of the 2 tools in predicting ED and hospital admissions and chemotherapy discontinuation was comparable. An Index4 score of 0 was superior in predicting absence of grade 3-4 toxicities than a low CARG score (p = 0.002, McNemar's test). The CARG tool for chemotherapy adverse effect prediction in geriatric cancer patients and the Index4 were able to predict adverse outcomes with moderate accuracy. Given its ease of calculation Index4 may be an alternative to CARG tool, suitable for a busy oncology practice.

Addressing the Needs of Older Adults With Cancer in Low- and Middle-Income Settings

The number of older adults in the world is projected to increase steeply over the next 30 years; most older adults will live in low- and middle-income countries. This will have a direct impact on the global cancer burden, as cancer is largely a disease of aging. A revolution in the way we care for older adults in low- and middle-income settings is needed to meet rapidly rising demands. Regardless of a nation's relative wealth or resources, implementing the geriatric assessment in cancer care has presented a challenge because of omission of the principles of geriatric oncology from formal training and continuing education, lack of time, and a shortage of qualified personnel. To meet the challenge of caring for older adults globally, we must: (1) re-imagine aging-focused training for providers and nurses, (2) create and strengthen collaborations/partnerships between geriatric oncology teams and aging-service organizations, and (3) increase advocacy for age-friendly health care policy. By harnessing technology, the reach of specialized oncology education and care can be extended even-or especially-to low- and middle-income settings.

Integration of geriatric assessment into clinical oncology practice: A scoping review

Sixty percent of newly diagnosed cancers occur in older adults and more complex planning is required to sustain quality care for older populations. Individualized care incorporating geriatric assessment can predict early mortality and treatment toxicity for older cancer patients. We mapped and summarized the available evidence on the integration of geriatric assessment into clinical oncology practice, and ascertained which domains have been implemented. We systematically searched bibliographic databases and trial registries for reports of clinical studies, clinical practice guidelines, systematic and non-systematic reviews, and grey literature published in English. We gathered data on study characteristics, geriatric domains and strategies evaluated, and relevant study objectives and findings. From a total of 10,124 identified citations, 38 articles met our eligibility criteria, 3 of which were clinical practice guidelines. Nearly half of these articles came from the United States. Domains of the geriatric assessment implemented in studies ranged from 1 to 12, with varied combinations. We identified 27 studies on strategies for implementing geriatric assessment and 24 studies on feasibility of implementing geriatric assessment, into clinical oncology practice. We also identified 3 main geriatric assessment models: 2 from the United States and 1 from Australia. Furthermore, we identified 2 reviews that reported varied components of geriatric assessment models. There is increasingly robust evidence to implement formal geriatric assessment in oncology practice. There remains a great deal of variation in the tools recommended to address each of the domains in a geriatric assessment, with only 1 guideline (American Society of Clinical Oncology guideline) settling on a specific best practice. Protocol registration: Open Science Framework osf.io/mec93.