Cancer care

‘Staging the ageing’: why all older cancer patients should have geriatric assessments


Geriatric assessments should be a routine part of oncology care for all older patients prior to starting cancer therapy, an Australian randomised controlled trial has shown.

A one hour assessment by a geriatrician and a personalised plan to address patient vulnerabilities when starting treatment led to significant improvements in patient health outcomes and also reduced healthcare utilisation, according to findings presented at ASCO 2020 by Dr Wee-Keng Soo, medical oncologist at Eastern Health and Monash University, Melbourne.

And two US studies also presented at ASCO 2020 showed that geriatric assessments were associated with lower rate of serious adverse events from cancer therapy.

Dr Soo’s study, conducted at three Melbourne hospitals in cancer patients over the age of 70, assessed the impact of a comprehensive geriatric assessment on outcomes over 24 weeks in areas such as physical and social functioning, mobility, burden of illness and anxiety.

The 130 patients who completed the trial had solid cancers (lung or GI) or DLBCL, and underwent an initial assessment by a geriatrician, who looked for under-recognised problems such as cognitive decline, polypharmacy and social isolation and then referred the patient to existing health services for practical support.

For the primary outcome of health related quality of life, patients who were randomised to the geriatric assessment had significantly better Elderly Functional Index (ELFI) scores compared to patients who had usual care. At 12, 18 and 24 weeks the absolute differences in ELFI were 11.1, 13.4 and 8.5 for assessment vs usual care.

Dr Soo said the patients in the control (usual care group) showed a greater deterioration in health-related functioning and had a longer recovery compared to the assessment group.

Patients who had geriatric assessment also had 39% less emergency presentations (equivalent to 1.3 less presentation/patient/year) and 24% less unplanned hospital overnight stays (equivalent to 7 less per patient per year).

The findings provided the first robust evidence from a RCT to support this model of care for older patients, he said.

“In essence we are staging the ageing to provide appropriate care,” said Dr Soo.

“These findings suggest that all older people 70 years and above with cancer who are receiving systemic anti-cancer therapy should receive comprehensive geriatric assessment to optimise their clinical care and help [improve] health outcomes.”

“This supports the wider scale implementation of an integrated geriatric oncology model of care, bringing the future possibilities of improving the health trajectories of vulnerable older cancer patients a step closer.”

A US study also presented at ASCO showed that when oncologists were provided with geriatric assessment information, this reduced the proportion of older patients who experience grade 3-5 toxicity from high-risk palliative cancer treatment (50% vs 71% compared to usual care), without compromising overall survival at six months.

The study involving 718 patients with an average age of 77 also showed that patients who had geriatric assessments were more likely to receive reduced intensity treatment (49% vs 35%) and have fewer dose modifications due to toxicity (42% vs 58%).

Patients who had geriatric assessments were more likely to receive reduced intensity treatment (49% vs 35%) during cycle 1 and have fewer dose modifications due to toxicity (42% vs 58%).

Commenting on the findings Professor Martin Stockler said the trial had shown that geriatric assessments were feasible and had promising results, but the findings were limited by only having outcome data for six month when the impact of dose reductions might not be apparent.

“Further research should focus on longer term outcomes and mechanisms for dissemination and implementation,” he said.

A second US study of geriatric assessments involving 600 cancer patients at a single centre found that when provided by a nurse practitioner, they were associated with a reduction in grade 3-5 toxicity events from 60.4% to 50.5% compared to usual care.

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