Tanya M. Wildes, MD, MSCI
Siteman Cancer Center at Barnes-Jewish Hospital and Washington University in St. Louis School of Medicine
St. Louis, MO
Amid a coming storm of demographic trends signaling a sharp increase in the number of older people diagnosed with cancer in the United States, researchers are developing new geriatric assessment tools to help oncology specialists better manage this patient population.
The Cancer and Aging Research Group, a collaborative effort to design and implement clinical trials for older patients, is seeking to validate tools that will be available online to assist oncology care providers. Currently, oncologists use their best clinical judgment to help their older patient with cancer make an individualized treatment decision.
The need for such tools is pressing. Since cancer is a disease of aging, the number of new cancer cases diagnosed in older adults will increase as the nation’s baby boomers enter their golden years. Between 2010 and 2030, the number of new cases of cancer diagnosed annually in adults over age 65 years is expected to increase by 67%, from 1.0 million to 1.6 million.
Unfortunately, most of what we know about treating cancer comes from studies in younger patients. Older patients are less likely to be enrolled in clinical trials due to criteria excluding other medical conditions, which are common as people age. The researcher may assume the older adult is not interested in participating or worry that the new treatment will be too hard on the patient. This has left gaps in our knowledge about the risks and benefits of new treatments in older adults. Further, chronological age is not the best marker for which older adults are vulnerable to severe side effects of chemotherapy.
Comprehensive geriatric assessment (CGA) is a multidimensional assessment of an older individual’s functional, medical, and psychosocial problems or limitations. In geriatrics, CGA is used to define a multidisciplinary treatment plan aimed to optimize the health in an aging individual. A number of recent studies have applied CGA to the care of older adults with cancer and shown the added value of this information, which is not routinely obtained in oncology practice.
Studies Supporting Assessments
The Cancer and Aging Research Group investigated components of a CGA as predictors of toxicity of chemotherapy in 500 older adults receiving chemotherapy.1
Tools for Evaluating Patients
Cancer and Aging Research Group
Geriatric Assessment Tools
Patient questionnaire—3-page assessment that patients primarily complete covers daily physical activities, number and types of medications, health status, nutritional status, mood, social activities, social support, religious experiences, and overall feelings
Healthcare input—Team member enters Karnofsky performance score, Timed Get Up and Go test score, and memory concentration test result to obtain a score
Prediction tool—Prechemotherapy assessment covers sociodemographics, tumor/treatment variables, laboratory test results (hemoglobin, creatinine clearance), and geriatric assessment variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status)
Before starting treatment, the participants completed a geriatric assessment, which gave information on their daily activities, comorbid medical problems, medications, social support, cognition, stress and depression, and nutrition. Among other factors, patients with hearing impairment, falls, difficulty walking one block, decreased social activity, and needing help with medications had a greater chance of experiencing grade III-V toxicity of chemotherapy. The researchers are confirming these findings in a follow-up study, and plan to make an online tool available for clinical use; a prechemotherapy calculator already is accessible through the group’s website (Table
In another study,2
one in six older adults experienced decline in daily function within the first cycle of chemotherapy, whereby the individual now needed assistance with one or more of their activities of daily living (ADLs) such as dressing, bathing, toileting, transferring, continence, and eating in which they were previously independent. Individuals who were dependent in one or more of their instrumental activities of daily living (eg, finances, taking medications, transportation) prior to initiation of chemotherapy were more likely to experience new dependence in ADLs. Individuals who screened positive for depression prior to chemotherapy were also more likely to experience new dependence in ADLs. CGA can also predict early deaths among older adults receiving first-line chemotherapy.
In a cohort of almost 350 patients receiving chemotherapy,3
patients with poor nutrition or slow walking speed on a physical performance test (the Timed Get Up and Go test) were significantly more likely to die within 6 months than those who were categorized as having good nutrition or normal walking speed. Thus, CGA may help clinicians and patients individualize their treatment decisions by giving greater insight into their prognosis.
Goals of Assessments
In geriatrics, the role of CGA is not only to predict future events, such as functional decline, nursing home placement, or death but also to identify areas in which intervention may decrease the risk of adverse outcomes.