Melissa (Kah Poh) Loh, BMedSci, MBBCh, BAO, discusses the challenges of utilizing geriatric assessment in oncology and steps that the ACCC resources can provide to institutions that want to incorporate geriatric assessment into practice.
Comprehensive geriatric assessment can identify age-related vulnerabilities, determine patient fitness, and confirm physiological age through multidisciplinary evaluations of multiple health domains, said Melissa (Kah Poh) Loh, BMedSci, MBBCh, BAO. Although geriatric assessment is not utilized routinely, the new Association of Community Cancer Centers (ACCC)’s how-to guide for practical application of geriatric assessment could provide a valuable tool to providers looking to standardize and build a geriatric assessment program at new institutions.
“The first step [in developing a geriatric assessment protocol] is trying to figure out what kind of support and infrastructure [an institution] has locally and then build from there,” said Loh, an ACCC advisory committee member. “This resource from ACCC can serve as a first step to figure that out and [guide] the next steps to build.”
In an interview with OncLive, Loh, a senior instructor in the Department of Medicine, Hematology/Oncology at the University of Rochester Medical Center, discusses the challenges of utilizing geriatric assessment in oncology and steps that the ACCC resources can provide to institutions that want to incorporate geriatric assessment into practice.
Loh: Geriatric assessment is a set of validated tools that we can use to assess individual components or domains, such as functional status and nutritional status. There are usually between 6 and 8 domains that we look at and [we] assess each of those domains with several tools. Also, each of those domains are correlated with outcomes in older adults with cancer.
The assessment doesn’t take age into account unless the validated tool has age as a question. For example, one screening tool we commonly use is called Geriatric 8 and it has the best specificity and sensitivity. The first question [of Geriatric 8] is patient age, so that would be how age is factored into the assessment. However, for the most part, age isn’t factored into geriatric assessment itself, at least when we administer the different questionnaires.
We use the information from the geriatric assessment and the actual age [of the patient] to make a decision.
Medical oncologists or hematologists are usually trained in chemotherapy, but they are not as well trained in determining the underlying fitness or physiologic age [of a patient]. Chronological age may not represent [a patient’s] biological age; a 95-year-old patient can [present like a] 65-year-old patient if they are fit, and vice versa.
Geriatric assessment can help oncologists figure out [a patient’s] physiologic or biologic age. We know that biologic age correlates with better outcomes compared with chronological age. Being able to deeply assess physiological age can help to determine treatment or introduce interventions to optimize health before, during, or after cancer treatment.
It depends on what we define as new. For [a provider] who hasn’t done [geriatric assessment], it is new. Several guidelines have recommended [geriatric assessment], such as the International Society of Geriatric Oncology, the American Society of Clinical Oncology, and the National Comprehensive Cancer Network.
Having said that, the implementation and dissemination [of geriatric assessment] is still relatively low. At least 3 or 4 years ago, about 1% of community oncologists [reported using geriatric assessment]. That number may be a little higher now, but it is still less than 50%.
In general, [geriatric assessment] is not being used routinely in practice for several reasons. One [reason] is that even though [the assessment] can be done in a half hour before the clinic visit, [a practice] still needs personnel and workflow in place to make the [assessment] process work; it requires commitment from the institution. [Plus], some [providers] in general are slow in adopting [new protocols]. That is getting better, but it requires time.
A third barrier is geriatric assessment itself. It [requires patients] to fill out questionnaires on paper. It’s not as [concrete] as doing lab tests, figuring out what mutations [are present, or evaluating] exciting drugs. Sometimes [geriatric assessment] doesn’t generate interest from the community because it doesn’t sound as exciting as drug development or immunotherapy. However, we know [geriatric assessment] improves outcomes. It takes time and it has taken the last 15 to 20 years to get to where we are now [in terms of implementing geriatric assessment]. A lot of work still needs to be done in terms of getting this [screening process] up and running in different practices.
ACCC developed a guideline-based gap assessment tool. Many experts in geriatric oncology broke down geriatric assessment into a few domains as I mentioned. Each of these domains are for oncologists or geriatricians, as long as [the provider] has worked a lot within the [geriatric] population.
[The experts from ACCC] come together to discuss what tools we think are good to use and which are feasible based on supportive evidence. Then, we recommend those tools; if the tools show that domains are impaired, [we discuss] what the next steps can be for the oncology team.
There are around 9 domains, so 9 separate small groups work on [determining which tools are feasible]. That is pretty good because it is laid out in a very simple way. [We can determine] what tools should be used and what should be done at the minimum if there are impairments, such as [lack of] resources. [If an institution] has a lot of resources, [we can determine] more things that can be done [based on] stepwise guidance depending on the resource infrastructure.
ACCC came up with a how-to guide [regarding geriatric assessment] that I have personally not used because our center already had a geriatric oncology infrastructure. This resource is mainly for providers who are thinking about starting geriatric assessment but are not sure where to start or what to use. [Interested providers] complete the [gap assessment] and input information in terms of [resources] they have and what they want to do. From that report, [the providers receive] a step-by-step, personalized report for things they can start instituting, scores in each domain, and a total score. Then, the programs can use the report to create or customize short- and long-term goals for improvement according to the individual infrastructure, commitment, and support [of the institution].
Every center is different, so we have to account for what is available. The important thing is to figure out what is available at [one’s] practice and go from there. For example, if there isn’t geriatric oncology expertise at a particular institution or if [an institution] has geriatricians, [the ACCC platform] can help. If [an institution] doesn’t have any [geriatric assessment infrastructure in place], we can [identify] things to start with that can be built up from there. [The ACCC platform] can help figure out who in the team can [take charge of the new measures], such as nurses, medical oncologists, advanced professionals in the medical system, and even receptionists because some of the tools are pretty straightforward.
The goal is to identify patients who are at a higher risk of [developing] AEs. The two common calculators of risk scores can identify patients who are at higher risk, specifically if they are receiving chemotherapy. There aren’t a lot of [risk scores] for immunotherapy or other targeted therapies because when they were developed, immunotherapy and targeted agents weren’t commonly used.
By identifying high-risk patients for AEs, we can provide information to oncologists to tailor treatment. When patients have already developed AEs, it is difficult to act upon them at that time. They might get toxicity from chemotherapy, and then functionally, be unable to do things at home or become less independent. Sometimes we [add in] physical therapy or occupational therapy, but it might be too late [to mitigate the AE]. It is always better to prevent AEs or identify AEs and modify treatment up front vs waiting until the AE happens and then treat it. It is difficult for older patients to bounce back when they have already experienced something serious.