Comprehensive Geriatric Assessment and Caring for the Older Person with Cancer

Prevalence and health outcomes in community-dwelling older adults with comorbid cancer and dementia: a longitudinal analysis

OBJECTIVES

To examine health outcomes in community-dwelling older adults with: dementia only, cancer only, and comorbid cancer and dementia.

METHODS

Longitudinal analysis was conducted using data from 2010 to 2016 waves of the Health and Retirement Study. Health outcomes included mortality, limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL), nursing home utilization, hospital stay, homecare use, self-rated health, and out-of-pocket medical expenditure. Panel regression was used for statistical analysis.

RESULTS

The prevalence of comorbid cancer and dementia ranged from 2.56% to 2.97%. Individuals with comorbid cancer and dementia demonstrated a higher likelihood of nursing home utilization and poorer self-rated health but a lower likelihood of hospital stay, homecare use, and out-of-pocket expenditures, compared to the cancer only or dementia only groups. The differences in mortality and ADL and IADL limitations were not statistically significant.

CONCLUSION

Comorbid cancer and dementia predicted longer nursing home utilization and poorer self-rated health. The results help guide care planning for individuals with comorbid cancer and dementia.

Exploring Cost-Effectiveness of the Comprehensive Geriatric Assessment in Geriatric Oncology: A Narrative Review

Simple Summary

The Comprehensive Geriatric Assessment is a multidimensional and multidisciplinary evaluation designed for elderly patients with the goal of structuring tailored care and follow-up. Despite the known benefits of this approach, the Comprehensive Geriatric Assessment is not universally applied to elderly cancer patients due to economic and practical barriers. This narrative review aims to investigate the cost-effectiveness of the Comprehensive Geriatric Assessment adopted in geriatric oncology. The results revealed a lack of research on the topic, but recurrent cost-saving effects of this approach in geriatric oncology settings were highlighted—suggesting a positive cost-effectiveness ratio. Further structured research with comprehensive economic evaluations is needed to confirm these findings.

Abstract

The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.

Perceptions of Older Adult Care Among Ambulatory Oncology Nurses

BACKGROUND

Most cancer treatment is provided in the ambulatory setting; thus, it is important to know what issues ambulatory oncology nurses identify in their practice with older cancer patients as well as resources that are helpful or are needed.

OBJECTIVE

The aim of this study was to capture ambulatory oncology nurses' perceptions of the unique aspects of caring for older patients and to present the development process, content validity testing, and psychometric evaluation of a survey designed to denote nurse perceptions of older adult care.

METHODS

An expert panel and 2 focus groups informed the development of a 34-item survey scored on a 5-point Likert-type agreement scale and 2 open-ended questions. Psychometric testing and descriptive statistics summarized the quantitative responses. Using thematic analysis, we identified the themes from the open-ended responses.

RESULTS

The survey demonstrated good psychometric qualities. A total of 401 participants, mostly staff from large, academic cancer centers, reported an average total score of 3.76, indicating generally positive perceptions of older adult care. The 269 (67%) open-ended responses were categorized into 4 main themes: concerns over medical issues, the need for specialized services, adequate support systems, and appropriate communication.

CONCLUSIONS

Although most perceived their geriatric practice environment favorably, nurses recognized the complexity of caring for older adults with cancer. They identified gaps in care, such as the need for geriatric specialists and better community resources, paid by insurance.

IMPLICATIONS FOR PRACTICE

Nurses need more time in the clinic to address complex advanced care planning, symptom burden and home services of older adults with cancer. Each institution should seek feedback from nurses to guide resource allocation.

Physical function measurement in older long-term cancer survivors

OBJECTIVE

To establish reliability, validity, and minimal detectable change in measures of function in older long-term cancer survivors.

METHODS

Older cancer survivors were recruited to perform functional measures; 5 Times Sit-to-Stand (5xSTS), 30-second Timed Chair Rise (30sTCR), Short Physical Performance Battery (SPPB), Physical Performance Test-7 (PPT-7). Two testing sessions were completed two weeks apart. Test-retest reliability was examined using the intraclass correlation coefficient (ICC2,1), convergent and discriminant validity using Spearman's rho and Minimal Detectable Change (MDC95) was calculated.

RESULTS

Forty-seven older long-term cancer survivors participated. Test-retest reliability was good for 5xSTS (ICC2,1=0.86), 30sTCR (ICC2,1=0.89), and SPPB (ICC2,1=0.85) and poor for PPT-7 (ICC2,1=0.48). Both convergent and discriminant validity was established.

CONCLUSIONS

SPPB, 5xSTS, and 30sTCR are reliable and valid tools to measure function in older long-term cancer survivors. MDC95 values were larger than those reported in geriatrics and should be interpreted with caution. Residual effects of cancer treatment, comorbidity, and physical inactivity may contribute to decreased physical function in older long-term cancer survivors, therefore valid and reliable measures like SPPB and the timed chair rise tests should be used objectively measure function throughout the survivorship spectrum.

Perspectives on functional status in older adults with cancer: An interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG

Most adults with cancer are over 65 years of age, and this cohort is expected to grow exponentially. Older adults have an increased burden of comorbidities and risk of experiencing adverse events on anticancer treatments, including functional decline. Functional impairment is a predictor of increased risk of chemotherapy toxicity and shorter survival in this population. Healthcare professionals caring for older adults with cancer should be familiar with the concept of functional status and its implications because of the significant interplay between function, cancer, anticancer treatments, and patient-reported outcomes. In this narrative review, we provide an overview of functional status among older patients with cancer including predictors, screening, and assessment tools. We also discuss the impact of functional impairment on patient outcomes, and describe the role of individual members of an interprofessional team in addressing functional impairment in this population, including the use of a collaborative approach aiming to preserve function.

Prevalence and predictors of depressive symptoms in older adults with cancer

INTRODUCTION

Older adults with cancer are at risk of developing depressive symptoms. However, little is known about the prevalence and predictors of depressive symptoms in older adults with cancer.

MATERIALS AND METHODS

This study examined the prevalence and predictors of depressive symptoms among older adults with cancer in the United States using the data from the 2012 and 2014 wave of the Health and Retirement Study. This analysis included 1799 older adults aged 65 and over with a self-reported diagnosis of cancer. Multivariate regression analysis was used to examine the predictors of depressive symptoms. The main predictors included age, gender, race, education, marital status, chronic conditions, and functional limitations.

RESULTS

Results revealed that the prevalence of depressive symptoms in older adults with cancer was 14.9%. Results of Poisson regression revealed that greater age, belonging to a race other than White or African American, not being married, presence of more chronic conditions, and higher levels of functional limitations were associated with higher levels of depressive symptoms.

DISCUSSION

The prevalence of depressive symptoms is high in older adults with cancer and several factors predict depressive symptoms in this population. Individuals who are at high risk of developing depressive symptoms should be identified and appropriate timely interventions should be initiated to reduce the rates of depressive symptoms in older adults with cancer.

Surgical-only treatment of pancreatic and extra-pancreatic metastases from renal cell carcinoma - quality of life and survival analysis

Background

Treatment of pancreatic metastases (PM) from renal cell carcinoma (RCC) is still an issue between surgeons and oncologists, in the era of target-therapy.

Methods

Data from 26 patients undergoing resection of PM and extra-PM from RCC, with R0 intention were retrospectively analysed. No one received adjuvant chemotherapy. Patients were divided into two groups; Group A comprehends 14 patients who developed synchronous (5) or methacronous (9) extra-PM. Group B comprehends 12 patients that developed PM only.

Results

No intraoperative mortality was recorded. Complications occurred in 14 patients (53.8%), all but 2 (7.26%) were graded I and II according to Clavien-Dindo classification.

Recurrences occurred in 8 patients (30.8%), of whom, 5 (62.5%) were submitted for further resections in other sites.

Three-, five- and ten-year observed overall survival were respectively 88,5% [95%CI: 0,56 – 1,33], 76,9% [95%CI: 0,47 – 1,19] and 50% [95%CI: 0,20 – 1,03]. Disease-free survival was 65,4% [95%CI: 0,38 – 1,05], at 3 years, 57,7% [95%CI 0,323 – 0,952] at 5 years and 42,9% [95%CI 0,157 – 0,933], at 10 years. QoL analysis, through WHOQOL-BREF questionnaire, assessed at last available follow up revealed a mean score of 75,9 ± 11,6 on 100 points.

Conclusion

Despite no significant differences in survival between patients affected by Pancreatic or Extra-Pancreatic metastases, PM patients seems to show better outcome when managed surgically. mRCC patients, eligible for radical metastasectomy, tend to have long survival rates, reduced recurrence rates and good QoL.

Study registration

This paper was registered retrospectively in ClinicalTrials.gov with Identification number: NCT03670992.

Managing older patients with cancer

With the growing population of adults over age 70 years, clinicians must know how to care appropriately for the increasing number of older patients with cancer. Although older adults have higher rates of surgical complications and chemotherapy-related toxicity, they should not be excluded from treatment opportunities based on age alone. Rather, patients should be assessed for fitness, or functional age, for a more accurate estimation of how they will tolerate treatment. This article discusses considerations clinicians should take into account when developing effective treatment plans that do not compromise quality of life for older patients with cancer.