A dedicated geriatric oncology clinic set up at Monash Health in Melbourne has proved to be of great value in identifying and dealing with issues for older frail patients including vulnerability, falls, malnutrition, and undiagnosed cognitive impairment.
Reporting on their experience with the first 220 patients referred to the clinic, clinicians at Monash Health say the service has been of great value in tailoring treatment to suit an individual’s condition and enabling access to non-oncology services such as memory clinics and community support.
Set up in 2017, the service was run on very limited resources, staffed by an oncologist and a trainee, and designed to accept referrals of patients over the age of 70 if they had multiple comorbidities, fragile social circumstances, or were facing intensive treatment.
The service, which acted as an adjunct to regular tumour-based oncology clinics, offered patient a geriatric assessment including tools to assess vulnerability, cognitive function, physical functioning and malnutrition risk.
Over half the patients had high scores for vulnerability, 22% had cognitive dysfunction, and a fifth had high scores for malnutrition.
With input from a geriatrician, the geriatric oncology clinic was able to provide onward referrals for patient to services including palliative care, Oncology Nurse Practitioner, My Aged Care, Advanced Care Planning and Community Health Services.
“The geriatrician assisted in identifying and managing any geriatric syndromes. Where necessary, the geriatrician conducted detailed chart reviews to identify past and ongoing geriatric issues with the potential to impact the cancer journey …The geriatrician’s knowledge of local council services, home care packages, and waiting times for fulfilment was used to assist patients and families with their care needs, the authors led by Dr Claire Taylor wrote in the Journal of Geriatric Oncology.
Information obtained from patients at the clinic also allowed a Chemotherapy Toxicity Score to be calculated that was used to inform the intensity of the chemotherapy regime.
The setting up of the clinic also highlighted the fact that many patients came from non-English speaking backgrounds and needed help from family, carers or support services during their cancer treatment, the report authors noted.
“Another issue identified was the high prevalence of falls. It is important to identify a falls history and physical function as these have been shown to be predictive of chemotherapy toxicity,” they wrote.
“Cancer treatment often results in a further decline in a person’s physical function and the maintenance of function is of greater importance to the majority of unwell older adults than the prolongation of life.”
Although the geriatric oncology clinic review did not have a control group, based on other such interventions it was likely to have led to changes in treatment plans and facilitate non-oncological interventions and referrals, the report authors said.
“Chemotherapy tolerance is improved not just by modifications to chemotherapy intensity, it is also improved by other [geriatric assessment] interventions. Patients who undergo a geriatric assessment are also more likely to complete cancer treatment and require fewer treatment modifications,” they noted.
However a key issue for the geriatric oncology clinic was lack of resources, as it was dependent on the goodwill of staff to support it. As a minimum a clinic should have nurse support to ensure follow up of recommendations, and also funding for a geriatrician to be present in meetings, they suggested.
“Our study highlighted the heterogenous nature of the older adult with cancer … Potential benefits of a geriatric oncology clinic include early identification and management of geriatric syndromes and anti-cancer treatment recommendations that more closely reflect the patient’s overall health status,” they concluded.