How to identify older patients with cancer who should benefit from comprehensive geriatric assessment?

IntroductionAlthough many studies describe benefits from the comprehensive assessment of older patients, the lack of geriatricians combined with the increased number of elderly patients revealed the need for screening tools in order to detect cancer patients presenting with geriatric conditions.Objectives(i) To assess the validity of screening tools to detect patients presenting with geriatric conditions. (ii) To analyze the relative contribution of those tools to detect some characteristics of the geriatric profile and the stage of the tumors.Materials and MethodsTwo hundred eleven consecutive elderly patients were screened for the presence of geriatric conditions using the Identification of Senior At Risk score (ISAR) and the G8 score. Comprehensive geriatric assessment for functional, cognitive, mood, and nutritional status, self-perceived fatigue and comorbidities was performed. Oncological assessment included the Karnofsky performance status (KPS) and tumor staging.ResultsBoth scores detected an average of 80% of frail patients. The PPV and NPV of the scores to detect at least one geriatric condition were respectively 47% and 22% for an ISAR score ≥ 2 and 76% and 10% for a G8 < 15. Area under the ROC curves between ISAR and G8 was not statistically different. In logistic models an ISAR score ≥ 2 was associated with comorbidity and falls whereas a G8 score < 15 was associated with low KPS (< 80) and the presence of generalized cancer.ConclusionsHigh prevalence of geriatric syndromes and comorbidities is associated with positive ISAR and G8 scores but not with the tumor stage.     

What will perioperative geriatric assessment for older cancer patients look like in 2025? Advantages and limitations of new technologies in geriatric assessment

For years, surgeons have explored the relationship between age and surgical outcomes. Over time, it is more widely accepted that frailty and fitness of older patients, rather than their age, should be considered in surgical decision making. The gold standard of frailty assessment is comprehensive geriatric assessment (CGA) which is best performed by geriatricians. In the past decade, Digital Health Technologies that range from electronic solutions for electronic Patient-reported Outcomes to wearables and sensors have emerged. As these solutions are likely to expand and advance in the next years, we will review the history of investigating factors, especially aging-related factors associated with surgical outcomes, and the current supportive data about the potential and challenges of Digital Health Technologies in complementing or replacing some of the components of CGA by 2025.     

Preoperative geriatric assessment and follow-up of patients older than 75 years undergoing elective surgery for suspected colorectal cancer

ObjectivesWe investigated the predictive value of specific tools used in a Comprehensive Geriatric Assessment (CGA) with regard to postoperative outcome in patients 75 years and older undergoing elective colorectal cancer (CRC) surgery. Furthermore, recovery was followed over the first postoperative year using the same assessment tools.Material and MethodsBaseline clinical and CGA variables including functional and nutritional status, pressure sore risk, fall risk, cognition, depression, polypharmacy, comorbidity, and health-related quality-of-life (HRQoL) were prospectively recorded. Outcome variables were postoperative complications and length of stay (LOS). Patients were likewise followed up at one, three and twelve months postoperatively.ResultsForty-nine patients underwent surgery (median age 81 years). Forty-three per cent had ASA (American Society of Anesthesiologists) class 2 47% had ASA class 3. Postoperative complications occurred in 32.7%. Median LOS was eight days. In univariate analyses, none of the parameters tested predicted postoperative complication or LOS. During follow-up, all patients recovered to baseline values apart from HRQoL which was still reduced at three and twelve months (p = .017). Nutritional status had improved twelve months after surgery (p = .011).ConclusionsNo association could be found in this study between the results of a comprehensive geriatric assessment and prolonged length of stay or postoperative complication rate after elective surgery for colorectal cancer. Patients recovered well during the first year after surgery. Quality of life, however, was still lower than prior to surgery.     

Is there a role for specialized geriatric centers in treating geriatric cancer patients?

As the population with colorectal cancer ages, the tailored approach required to manage older patients becomes all the more important for all providers and institutions treating colorectal cancer to adopt and improve the outcomes and well-being of this important and increasingly prevalent population. Joint guidelines from the American College of Surgeons and American Geriatric Association should be followed. Older cancer patients undergoing colorectal cancer surgery should be referred to centers with expertise in minimally invasive surgery. Likewise, older rectal cancer patients should be referred to centers with expertise in treating rectal cancer.     

The relevance of a geriatric assessment for elderly patients with a haematological malignancy – A systematic review

Background

Geriatric assessment is increasingly used to assess the health status of older cancer patients. We set out to assemble all available evidence on the relevance of a geriatric assessment in the treatment of older patients with haematological malignancies.

Methods

A systematic Medline and Embase search for studies in which a geriatric assessment was used to detect health issues or to address the association between baseline geriatric assessment and outcome.

Results

18 publications from 15 studies were included. The median age of patients was 73 years (range 58–86). Despite generally good performance status, the prevalence of geriatric impairments was high.Geriatric impairments were associated with a shorter overall survival in a relevant proportion of studies (instrumental activities 55%, nutritional status 67%, cognitive capacities 83%, objectively measured physical capacity 100%). Comorbidity, physical capacity and nutritional status retained their significance even in multivariate analyses in 50%, 75%, and 67% of analyses respectively, whereas age and performance status lost their predictive value in most studies. One study found an association between comorbidity and chemotherapy-related non-haematological toxicity. In another study a pronounced association between summarised outcome of geriatric assessment and chemotherapy-related toxicity as well as response to treatment was described.

Conclusion

This review demonstrates that a geriatric assessment can detect multiple health issues, even in patients with good performance status. Impairments in geriatric domains have predictive value for mortality and also appear to be associated with toxicity and other outcome measures and should thus be integrated in individualised treatment algorithms.     

Predictive value of selected geriatric parameters for postoperative outcomes in older patients with rectal cancer – A multicenter cohort study

IntroductionOlder patients have a higher risk for complications after rectal cancer surgery. Although screening for geriatric impairments may improve risk prediction in this group, it has not been studied previously.MethodsWe retrospectively investigated patients ≥70 years with elective surgery for non-metastatic rectal cancer between 2014 and 2018 in nine Dutch hospitals. The predictive value of six geriatric parameters in combination with standard preoperative predictors was studied for postoperative complications, delirium, and length of stay (LOS) using logistic regression analyses. The geriatric parameters included the four VMS-questionnaire items pertaining to functional impairment, fall risk, delirium risk, and malnutrition, as well as mobility problems and polypharmacy. Standard predictors included age, sex, body mass index, American Society of Anesthesiologists (ASA)-classification, comorbidities, tumor stage, and neoadjuvant therapy. Changes in model performance were evaluated by comparing Area Under the Curve (AUC) of the regression models with and without geriatric parameters.ResultsWe included 575 patients (median age 75 years; 32% female). None of the geriatric parameters improved risk prediction for complications or LOS. The addition of delirium risk to the standard preoperative prediction model improved model performance for predicting postoperative delirium (AUC 0.75 vs 0.65, p = 0.03).ConclusionsGeriatric parameters did not improve risk prediction for postoperative complications or LOS in older patients with rectal cancer. Delirium risk screening using the VMS-questionnaire improved risk prediction for delirium. Older patients undergoing rectal cancer surgery are a pre-selected group with few impairments. Geriatric screening may have additional value earlier in the care pathway before treatment decisions are made.     

Our experience of nursing/allied health practitioner led geriatric screening and assessment of older patients with cancer – a highly accessible model of care

ObjectiveComprehensive Geriatric Assessment (CGA) has been proven to assist development of tailored treatment plans for older patients with cancer by identifying health issues affecting their ability to complete systemic therapy or cope with and recover from cancer treatment.Materials and MethodsMetro North Hospital and Health Service (MNHHS) has significant older population with cancer. Geriatric Oncology services were commenced in February 2018 at two facilities of MNHHS [North Lakes Cancer Care Services/Caboolture Hospital (NLCCS/CBH) Cancer services and Redcliffe Hospital (RH) Cancer services]. The Geriatric 8 (G8) screening tool was administered to predict patient vulnerability and need for CGA. A bespoke CGA suite comprising of 16 assessments was used. A clinical nurse or Allied Health (AH) practitioner conducted screening, followed by CGA. Proposed care was discussed at multidisciplinary case conference and AH interventions were provided.ResultsFrom February’2018 to July’2019, the G8 was administered to 1380 patients between the two facilities (918 patients at NLCCS/CBH and 462 patients at RH), comprising oncology and haematology patients. 825 patients (59%) showed impairment on G8 and were recommended for CGA. Another 50 patients were referred for CGA as per clinical assessment despite normal G8. 65% (572) of recommended CGAs were conducted.The most common impairments identified on CGA leading to AH referrals were timed up & go >13 s, malnutrition, polypharmacy and low mood & depression.ConclusionThe nursing/AH practitioner led Geriatric Oncology service is feasible, applicable and beneficial to patients. Further study is planned to assess the impact of the service on patients' health related quality of life and chemotherapy completion rates.     

The effect of a geriatric evaluation on treatment decisions and outcome for older cancer patients – A systematic review

Aim

The aim of this systematic review is to summarise all available data on the effect of a geriatric evaluation on the multidisciplinary treatment of older cancer patients, focussing on oncologic treatment decisions, the implementation of non-oncologic interventions and the impact on treatment outcome.

Presence of HER4 associates with increased sensitivity to Herceptin™ in patients with metastatic breast cancer

Introduction  

HER2 overexpression, or rather HER2 gene amplification, is indicative for Herceptin therapy in both metastatic and pre-metastatic breast cancer patients. Patient's individual sensitivity to Herceptin treatment, however, varies enormously and spans from effectual responsiveness over acquired insensitivity to complete resistance from the outset. Thus no predictive information can be deduced from HER2 determination so that molecular biomarkers indicative for Herceptin sensitivity or resistance need to be identified. Both ErbB receptor-dependent signalling molecules as well as HER2-related ErbB receptor tyrosine kinases, known to mutually interact and to cross-regulate each other are prime candidates to be involved in cellular susceptibility to Herceptin.     

Geriatric assessment in the management of older patients with cancer – A systematic review (update)

AimThe aim of this systematic review is to summarize all available data on the effect of a geriatric assessment in older patients with cancer, for oncologic treatment decisions, the implementation of non-oncologic interventions, patient-doctor communication, and treatment outcome. Additionally, we examined the impact of the type of assessment used.MethodsSystematic Medline and Embase search for studies on the effect of a geriatric assessment on oncologic treatment decisions, non-oncologic interventions, communication, and outcome.ResultsSixty-five publications from 61 studies were included. After a geriatric assessment, the oncologic treatment plan was altered in a median of 31% of patients (range 7–56%), with highest change rates in studies using a multidisciplinary team evaluation. Non-oncologic interventions were recommended in over 70% of patients, provided that an intervention plan or specific expertise was in place. A geriatric assessment led to more goals-of-care discussions and improved communication. The geriatric assessment also led to lower toxicity/complication rates (most strongly if the assessment outcomes were considered during decision making), improved likelihood of treatment completion, and improved physical functioning and quality of life in the majority of included studies.ConclusionA geriatric assessment can change oncologic treatment plans, leads to non-oncologic interventions, and improve communication about care planning and ageing-related issues. It can decrease toxicity/complications and improve treatment completion and patient-centred outcomes. If multidisciplinary or geriatric input is not available, having a pre-defined non-oncologic intervention plan is important. To maximize the effect on outcomes, the result of the geriatric assessment should be incorporated into oncologic decision-making.     

Delivering tailored surgery to older cancer patients: Preoperative geriatric assessment domains and screening tools – A systematic review of systematic reviews

The onco-geriatric population is increasing and thus more and more elderly will require surgery; an important treatment modality for many cancer types. This population's heterogeneity demands preoperative risk stratification, which has led to the introduction of Geriatric Assessment (GA) and associated screening tools in surgical oncology.Many reviews have investigated the use of GA in onco-geriatric patients. Discrepancies in outcomes between studies currently hamper the implementation of a preoperative GA in clinical practice. A systematic review of systematic reviews was performed in order to investigate assessment tools of the most commonly included GA domains and their predictive ability regarding the adverse postoperative outcomes.All domains – except polypharmacy – were, to a varying degree, associated with different adverse postoperative outcomes. Functional status, comorbidity and frailty were assessed most frequently and were most often significant. The association between domain impairments and adverse postoperative outcomes appeared to be greatly influenced by the study population characteristics and selection bias, as well as the type of assessment tool used due to possible ceiling effects and its sensitivity to detect domain impairments.Frailty seems to be the most important predictor, which underpins the importance of an integrated approach. As it is unlikely that one universal GA will fit all, feasibility, based on the time, expertise, and resources available in daily clinical practice as well as the patient population to hand, should be taken into consideration, when tailoring the ‘optimal GA’.     

Do patients with weight loss have a worse outcome when undergoing chemotherapy for lung cancers?

To examine whether weight loss at presentation influences outcome in patients who received chemotherapy for lung cancer or mesothelioma. Multivariate analysis of prospectively collected data 1994-2001. Data were available for age, gender, performance status, histology, stage, response, toxicity, progression-free and overall survival. The outcomes of patients with or without weight loss treated with chemotherapy for small cell lung cancer (SCLC; n=290), stages III and IV non-small-cell lung cancer (NSCLC; n=418), or mesothelioma (n=72) were compared. Weight loss was reported by 59, 58 and 76% of patients with SCLC, NSCLC and mesothelioma, respectively. Patients with weight loss and NSCLC (P=0.003) or mesothelioma (P=0.05) more frequently failed to complete at least three cycles of chemotherapy. Anaemia as a toxicity occurred significantly more frequently in NSCLC patients with weight loss (P=0.0003). The incidence of other toxicities was not significantly affected by weight loss. NSCLC patients with weight loss had fewer symptomatic responses (P=0.001). Mesothelioma patients with weight loss had fewer symptomatic (P=0.03) and objective responses (P=0.05). Weight loss was an independent predictor of shorter overall survival for patients with SCLC (P=0.003, relative risk (RR)=1.5), NSCLC (P=0.009, RR=1.33) and mesothelioma (P=0.03, RR=1.92) and an independent predictor of progression-free survival in patients with SCLC (P=0.01, RR=1.43). In conclusion, weight loss as a symptom of lung cancer predicts for toxicity from treatment and shorter survival.     

Changes in the place of death for older adults with cancer: Reason to celebrate or a risk for unintended disparities?

BackgroundPlace of death is important to patients and caregivers, and often a surrogate measure of health care disparities. While recent trends in place of death suggest an increased frequency of dying at home, data is largely unknown for older adults with cancer.MethodsDeidentified death certificate data were obtained via the National Center for Health Statistics. All lung, colon, prostate, breast, and pancreas cancer deaths for older adults (defined as >65 years of age) from 2003 to 2017 were included. Multinomial logistic regression was used to test for differences in place of death associated with sociodemographic variables.ResultsFrom 2003 through 2017, a total of 3,182,707 older adults died from lung, colon, breast, prostate and pancreas cancer. During this time, hospital and nursing home deaths decreased, and the rate of home and hospice facility deaths increased (all p < 0.001). In multivariable regression, all assessed variables were found to be associated with place of death. Overall, older age was associated with increased risk of nursing facility death versus home death. Black patients were more likely to experience hospital death (OR 1.7) and Hispanic ethnicity had lower odds of death in a nursing facility (OR 0.55). Since 2003, deaths in hospice facilities rapidly increased by 15%.ConclusionHospital and nursing facility cancer deaths among older adults with cancer decreased since 2003, while deaths at home and hospice facilities increased. Differences in place of death were noted for non-white patients and older adults of advanced age.     

Questionnaires and instruments for a multidimensional assessment of the older cancer patient: What clinicians need to know?

Due to the ageing of the population in the Western world, a significant increase in the number of older patients diagnosed with neoplastic diseases is observed. Hence, there is an emerging need for tools to efficiently evaluate older patients’ functional and global status. These tools can allow treating oncologists to better select patients, to propose treatment modifications, implement supportive measures and develop interventions to decrease the risk of toxicity and in general better tailor the treatment plan on an individual level. Currently significant uncertainty exists about the optimal tools and strategy for geriatric assessment, but on the other hand there is more than enough evidence that (some form of) geriatric assessment detects many previously unrecognised problems, and allows directed intervention which can improve outcome and compliance of proposed treatments. In the present paper, we discuss the most commonly used and studied tools for the assessment of functional status of older cancer patients.