- Email: [email protected]
Geriatric assessment of older patients with cancer in Australia—A multicentre audit
J O U RN A L OF GE RI A T RI C O NC O L O G Y 6 ( 2 01 5 ) 1 8 5 –19 3
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Geriatric assessment of older patients with cancer in Australia—A multicentre audit Roopa Lakhanpala , Jaclyn Yoongb , Sachin Joshic , Desmond Yipa,d , Linda Mileshkinb , Gavin M. Marxe , Tracey Dunlop f , Elizabeth J. Hovey f , Stephen A. Della Fiorentinag , Lakshmi Venkateswaranh , Martin H.N. Tattersalli , Sem Liewc , Kathryn Fieldj , Nimit Singhalk , Christopher B. Steerc,⁎ a
The Canberra Hospital, Yamba Drive, Canberra, ACT 2605, Australia Peter MacCallum Cancer Centre, 7 St Andrews Place, East Melbourne, Victoria 3002, Australia c Border Medical Oncology, Suite 1, 69 Nordsvan Drive, Wodonga, VIC 3690, Australia d Australian National University (ANU) Medical School, Canberra, ACT, Australia e Sydney Adventist Hospital, 185 Fox Valley Road, Wahroonga, NSW 2076, Australia f Prince of Wales Hospital, Barker Street, Randwick, NSW 2031, Australia g Macarthur Cancer Therapy Centre, 1 Therry Road, Campbelltown, Sydney, NSW 2560, Australia h Westmead Hospital, Corner of Hawkesbury Road and Darcy Road, Westmead, NSW 2145, Australia i Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia j Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia k Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia b
AR TIC LE I N FO
ABS TR ACT
Article history:
Objective: The aim of this study is to determine the frequency of geriatric assessment in
Received 24 October 2014
patients aged over 70 years in Australian medical oncology clinics.
Received in revised form
Material and Methods: This was a multicentre audit in two parts: a retrospective file review of
26 January 2015
initial consultations with an oncologist and prospective audit of case presentations at
Accepted 4 March 2015
multidisciplinary meetings (MDMs). Patients aged over 70 years presenting to a medical
Available online 23 March 2015
oncology clinic or being discussed at an MDM were eligible. Data was collected at six oncology centres in Victoria, NSW and Canberra from October 2009 to March 2010.
Keywords:
Results: Data was collected from 251 file reviews and 108 MDM discussions in a total of 304
Geriatric assessment
patients. Median age was 76 years (range 70–95). The geriatric assessment (GA) domains most
Older adults
frequently assessed during an initial consultation were the presence of comorbidities (92%),
Geriatric oncology
social situation—living alone or with someone (80%), social supports (63%), any mention of at
Medical oncology
least one Activity of Daily Living (ADL) (50%) and performance status (49%). Less frequently
Multidisciplinary meetings
assessed were any Instrumental Activity of Daily Living (IADL) (26%), presence of a geriatric syndrome (24%), polypharmacy (29%) and creatinine clearance (11%). Only one patient had all components of ADLs and IADLs assessed. During MDMs all the geriatric domains were comparatively less frequently assessed. No patients had all ADL and IADL components discussed formally in an MDM.
⁎ Corresponding author. Tel.: + 61 2 60515300; fax: + 61 2 60567663. E-mail address: [email protected] (C.B. Steer).
http://dx.doi.org/10.1016/j.jgo.2015.03.001 1879-4068/© 2015 Elsevier Ltd. All rights reserved.
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Conclusion: This is the first multicentre audit that reveals the low rates of GA in Australian medical oncology practice and describes the GA domains considered important by oncology clinicians. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction The fastest-growing segment of the Australian population is composed of individuals over the age of 65 years. Increasing age is directly associated with increasing rates of cancer.1 It is not surprising therefore that cancer is more common in older Australians. In 2009, 73.5% of new cancer cases were diagnosed in men aged 60 years and over; and 63.6% in women aged 60 years and over.2 The average age at the first diagnosis of cancer in Australia is 65.4 years.3 Together, these statistics outline an increasingly older population of patients with cancer who will require specific management.4 Studies have shown deficiencies in the management of elderly people with cancer, including under-diagnosis and under-treatment. Documented problems include incomplete investigation, decreased utilisation of standard therapy and more dose reductions and delays than younger patients.5–7 The increased incidence of comorbidities in older adults can increase the risk of treatment-related toxicities; however the assumption of frailty based on age alone may lead to inadequate and inappropriate treatment. In addition, evidence-based decisionmaking is limited by the underrepresentation of elderly patients in large cooperative trials.8,9 This is possibly due to some trials limiting the upper age limit and secondly as many clinicians are reluctant to recommend older patients to trials. The adequate assessment of older adults with cancer can also direct supportive care interventions. These services can then be utilised to preserve independence and prevent toxicity regardless of treatment or treatment intent. Established guidelines and position statements recommend that all older adults with cancer undergo some form of geriatric assessment.10 Unfortunately there is no single agreed standard assessment that is both validated and practical to perform in the oncology clinic.11 Despite this, the key domains of a multi-domain geriatric assessment (Table 1) are well recognised and should be determined regardless of the actual tool utilised.12 The frequency at which geriatric assessment domains are measured within Australian medical oncology practice is unknown. At the time of this audit there was only one formal combined geriatric oncology clinic in the country.13 No other formal collaborations between geriatricians and oncologists currently exist in clinical practice. The objectives of this multicentre audit were to determine the frequency of geriatric assessment in patients over the age of 70 years presenting for an initial medical oncology opinion and to explore the degree to which geriatric assessment domains were discussed in multidisciplinary team meetings.
2. Material and Methods The study was a multicentre two-phase audit, conducted at 6 oncology centres in Australia; Albury-Wodonga, Sydney (3 sites), Melbourne and Canberra. Sites chosen were representative of
metropolitan and regional centres. The audit occurred from October 2009 to March 2010 and was performed in two parts; a retrospective file review and a prospective audit of case presentations at multidisciplinary meetings (MDMs). The retrospective file review audited all consecutive new patients aged over 70 years presenting for assessment and treatment at an oncology clinic. The prospective component audited all patients aged over 70 discussed at an MDM. Information was collected by an oncology advanced trainee. A standardised proforma was used to collect information (Appendix 1). None of the sites studied had formal geriatric oncology services. The retrospective file review involved review of the notes and/or correspondence letters during the initial consultation with a medical oncologist. Documentation of GA domains was recorded as well as other variables including tumour type/ stage and treatment recommendations. The second phase of the study involved a prospective audit of the same GA domains mentioned during discussion at multidisciplinary meetings. The MDMs generally comprise representatives from surgical, radiation and medical oncology in conjunction with radiology, pathology and nursing services. Attendance by allied health professionals such as social workers was variable. A geriatrician was not present at these MDMs. Patients were mostly recruited from general oncology clinics; however one site recruited from a genitourinary MDM and clinic only. The auditor was present at these MDMs and entered data during the meetings. MDM participants were not informed that
Table 1 – Geriatric assessment domains audited. Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Performance status (ECOG/Karnofsky) Comorbidities • Any mention of comorbidity • Use of a formal comorbidity index14 Geriatric syndromes • Falls • Cognitive impairment • Spontaneous fracture • Depression/anxiety • Vision and/or hearing impairment Discussion of social situation. • Lives alone or with someone? • Social support • Home services in place? eg “meals-on-wheels”, housekeeping, domiciliary nursing. Polypharmacy a Documentation of creatinine clearance Nutritional assessment eg dietician opinion, Mini-nutritional assessment (MNA) or general comment including body mass index (BMI) a
Polypharmacy defined as ≥5 medications noted in record by the medical oncologist. This does not include medications mentioned only in the general practitioners' referral letter.
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Table 2 – Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) audited in case records and MDM discussions. Activities of daily living (ADL)31 Bathing Dressing Toileting Transferring Continence Feeding Mobility—eg walking, ability to climb stairs, “Get-up-and-go” test
Instrumental activities of daily living (IADL)32 Ability to use telephone Shopping Food preparation—ability to prepare meals. Housekeeping Laundry Transportation—ability to use private/public transport. Responsible for own medications? Ability to handle finances
Fig. 1 – Frequency that activities of daily living were mentioned in file review and MDMs. the audit was being conducted as any awareness could potentially bias the results of the study. The auditor noted any mention of a GA domain during the discussion of the patient's case. All patients over the age of 70 years discussed at an individual MDM during the audit were included for analysis. Apart from 55 patients at a comprehensive cancer centre, patients reported in file review and MDMs differed (see Table 3 & Figs. 1 & 2). The geriatric assessment domains audited in both sections of the study are included in Table 1. The individual components of activities of daily living (ADL) and instrumental activities of daily living (IADL) are documented in Table 2. Human Research Ethics Committee approval was obtained at all sites. The approved protocol stated that it was necessary for clinicians attending MDMs to be unaware that the audit was taking place. Data from all centres was entered onto a master excel spreadsheet for analysis.
MDMs only and there were 55 patients who were audited in both file review and MDM discussion. Median age was 76 years (range 70–95). Approximately two-thirds of patients were married. Prostate cancer (33.5%) was the most common primary site, followed by gastrointestinal (15.7%) and breast cancer (13.4%). Ten patients had a haematological malignancy (CLL, NHL and myeloma). The patient characteristics are summarised in Table 3.
3.2. Treatment Decisions Treatment was recommended in 181 patients (72%) during the initial consultation with a medical oncologist, and in 86 patients (80%) discussed in an MDM. Treatment recommendations are summarised in Table 4. Treatment was withheld on the basis of age alone in 5 patients (file review—3 and MDMs—2). Treatment intent was assessed in 95% of patients and is summarised in Table 4.
3. Results 3.3. Assessment of Geriatric Domains 3.1. Characteristics of the Study Population 3.3.1. File Review Data was collected from 251 file reviews and 108 MDM discussions in a total of 304 patients. One hundred and ninety six patients had a file review only, 53 patients were discussed in
All geriatric domains audited are listed in Table 1. The geriatric domains most frequently documented in an initial
Table 3 – Patient characteristics. File reviews (%) n = 251 Median age—yrs (range) Male/female Marital status
Fig. 2 – Frequency that instrumental activities of daily living were mentioned in file review and MDMs.
Tumour type Gynaecological Gastrointestinal Breast Bladder Prostate Lung Other
Married Single/widowed Unknown
MDMs (%) n = 108
76 (70–95)
76 (70–92)
143/108 (57/43) 159 (65) 71 (27) 21 (8)
70/38 (65/35) 66 (61) 19 (17.7) 23 (21.3)
10 30 28 10 58 14 33
10 (9) 18 (16.5) 13 (12.5) 7 (6.5) 44 (40) 5 (4.5) 11 (10)
(5) (21) (15) (5) (30) (7) (17)
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Table 4 – Treatment intent and type. Treatment intent
File review (%) n = 251
MDMs (%) n = 108
Adjuvant Curative Palliative No active treatment planned Not documented
54 47 80 61 9
(22) (19) (32) (24) (3)
19 30 37 14 8
(18) (28) (34) (13) (7)
Treatment type Surgery Chemotherapy Radiation therapy Chemo radiation Hormonal manipulation Other
23 72 63 26 40 14
(9) (29) (25) (10) (16) (6)
9 20 49 4 21 0
(8) (18) (45) (3) (19) (0)
Fig. 3 – Frequency that individual geriatric syndromes were mentioned in file review and MDMs.
4. MDM Discussion consult with an oncologist (Table 5) were the presence of comorbidities (92%), social situation—living alone or with someone (80%), social support (63%) and any mention of at least one ADL (50%). Specific geriatric domains such as any mention of at least one IADL (26%), presence of one or more geriatric syndromes (24%), polypharmacy (29%) and creatinine clearance (11%) were less commonly documented. A formal comorbidity index, such as the Charlson Comorbidity Index, was never used.14 Only one patient had all components of ADLs and IADLs assessed. When specific ADLs were mentioned, mobility was most frequently documented (36%) followed by continence (23%) (Fig. 1). The most commonly assessed component of IADLs was the availability of transportation (15%) (Fig. 2). The majority of file reviews contained references to the patients' social situation (Fig. 4) however the presence of home services was mentioned in only 13% of files. The performance status was documented in just under half the patients' files (49%) (Fig. 5). An individual geriatric syndrome (as defined in Table 1) was assessed in 24% of patients during file review (Fig. 3). The most commonly assessed item was formal screening for depression/ anxiety (14%). A formal cognitive assessment was only performed in 4% of patients. A nutritional assessment was documented in 20% of patients.
Analysis of the frequency of domains assessed during MDMs (Table 5) showed that the most common was comorbidities (84%), followed by living alone or with someone (30%) and social support (24%). Overall geriatric domains were mentioned much less frequently in this setting (Table 5). The frequency of any item in the ADL domain being mentioned in an MDM was 23% of patients. When ADLs were mentioned the most common were mobility (13%) and continence (13%) (Fig. 1). One or more components of IADL assessment was mentioned in only 6% of patients. The most common IADL referred to was ability to prepare food (6%) (Fig. 2). No patients had all ADL and IADL components considered formally in an MDM. The presence of a geriatric syndrome was mentioned in 10% of MDM discussions. Performance status was mentioned in 19% of MDMs. Polypharmacy issues were discussed in 13% of cases (Fig. 5)
5. Discussion This is the first multicentre audit to document the frequency at which geriatric domains were assessed in Australian medical oncology practice. A formal Comprehensive Geriatric Assessment
Table 5 – Frequency of assessment of geriatric domains. Geriatric domain ADLs (any component) IADLs (any component) Geriatric syndromes (any) Performance status Comorbidities Lives alone/with someone Social supports Home services Polypharmacy Creatinine clearance Nutrition
File review (%) n = 251 125 65 60 123 232 201 159 33 74 27 49
(50) (26) (24) (49) (92) (80) (63) (13) (29) (11) (20)
MDM (%) n = 108 25 7 11 20 91 32 26 5 14 3 10
(23) (6) (10) (19) (84) (30) (24) (5) (13) (3) (9)
Fig. 4 – Frequency that individual social situation domains were mentioned in file review and MDMs.
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Fig. 5 – Frequency of other geriatric domains mentioned in file review and MDMs.
(CGA) is an in-depth, multidisciplinary, multidomain evaluation to assess functional status, life expectancy and risk of morbidity/ mortality that results in formulation of a specific management plan according to the individual's needs. The individual components of the CGA can inform treatment decisions and guide supportive care interventions.10,15 This audit shows that many elements of the CGA are not documented routinely in the assessment of older patients by medical oncologists during their initial consultation or in conjunction with a multidisciplinary case conference. Older adults are more likely to suffer from comorbidities and the risk factors for adverse outcomes from the cancer and its treatment.16 Adequate assessment for these risk factors enables appropriate management and minimises the risk of both over- and under-treatment.17 Although there is no single recommended assessment tool for use in the oncology clinic, international guidelines document the geriatric assessment domains that should be considered.10 These include activities of daily living, comorbidities, social situation and presence of a geriatric syndrome (e.g. cognitive impairment). Despite the documented benefits of adequate assessment, the rate of GA in this audit was generally low. The most commonly assessed geriatric domains were the presence of comorbidities and basic aspects of the patient's social situation. The question of whether the patient had someone else at home with them was documented in 80% of initial consultations and 30% of MDM discussions. A comprehensive GA requires a detailed assessment of the patient's basic and instrumental activities of daily living (ADLs and IADLs). Mobility and continence were the most frequently assessed ADLs. Oncology treatment predominantly involves ambulatory care and regular clinic visits. Clinicians are likely to be interested in mobility to assess if patients can attend for treatment. The ability to transfer and walk unaided is also a factor in the assessment of performance status and is potential surrogate for frailty (gait speed is specifically a measure of frailty).18 Despite the relatively low rate of assessment of continence, this figure is potentially an overestimate as data from 46 patients (18% of consultations and 42% of MDM discussions) was derived from attendance at a specialist urology multidisciplinary clinic. The remainder of the patients were
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discussed in general oncology clinics. As other individual ADL domains were mentioned in <15% of consultations the rate of comprehensive assessment remains low. It is generally accepted that ADL/IADL assessment is a crucial component of a CGA. Dependence on others for ADL and IADL assistance has been shown to be predictive of mortality in geriatric oncology patients.19 Assessing functional status not only predicts for treatment toxicity but also allows targeted supportive care intervention.20 Preservation of functional independence is a key aim of therapy in older adults regardless of treatment intent and adequate functional assessment is vital if this goal is to be achieved. Of the geriatric syndromes audited (Table 1) the most commonly assessed was depression/anxiety (14% of consultations; 3% of MDMs). It could be argued that this is not a true geriatric syndrome; however the rate of routine assessment was low if we accept that it should be considered in all patients regardless of age. The rate of assessment for cognitive impairment was very low (4% of consultations; 3% of MDMs) and questions pertaining to falls occurred just as infrequently. The incidence of geriatric syndromes in patients over the age of 70 with cancer is modest when compared with patients under the care of a geriatrician; however it remains high enough to warrant consideration.21 The potential for these issues to change treatment is substantial. Whilst some attention was paid to the issues of polypharmacy and nutritional assessment these are aspects that would be routinely assessed by a geriatrician during CGA. It could be argued that these assessments should be performed by trained allied health professionals (e.g. pharmacists and dieticians respectively) and require additional resources; however the recognition of these issues during the initial consultation is important.12 As this was a retrospective audit of clinical consultations it is possible that the items audited were discussed but would only be noted in the patient's records if an assessment revealed a problem. The results of this audit establish at the very least that routine specific geriatric assessment was not performed at these centres. Even if a GA was performed routinely and the abnormalities documented, the rate of issues would be expected to be higher. For example, in a study of 500 patients over the age of 65 years participating in a prospective trial of GA the rate of patients requiring assistance with an IADL was 43% and 18% reported at least one fall in the last 6 months.22 The rate of geriatric assessment was higher in clinical consultations than in MDM discussions. This is not surprising as usually oncology MDM discussions are short, involve presentation of a concise history, relevant radiology and histopathology and in the interest of time it is not practically possible to conduct a GA. Utilisation of screening tools prior to MDM discussion will prove to be an effective strategy to identify if a patient is fit or unfit for standard treatment and needs a GA. In general these MDMs were tumour specific, rather than having a geriatric focus. Despite the paucity of GA information presented, binding treatment decisions regarding older patients are often made at an MDM. It is interesting to note that that in the opinion of the auditor, a decision to withhold treatment on the basis of age alone was made in 2 cases during an MDM.
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Given that treatment decisions were made despite the lack of complete assessment, it is likely that clinicians based their treatment decisions on patients' overall health status and level of home support. Despite this, performance status (PS) was documented in only 49% of clinical consultations. This is surprisingly low given the acceptance of PS as being important in treatment decision-making. The design of this audit does not enable us to determine whether this is simply a problem of documentation or if clinicians really did not use performance status in their clinical decisions. A CGA is time consuming and not necessarily required in every elderly patient with cancer.23 Therefore a screening tool is recommended to identify patients in need of further evaluation by GA.17 If abnormal, the screening should be followed by CGA and guided multidisciplinary intervention. Screening tools might also have a prognostic or predictive value for important outcome measures such as treatment toxicity, early discontinuation of treatment, functional decline and survival. If a sensitive screening tool is used, it can identify fit elderly patients who should be treated with standard treatments and avoid under treatment. Since this audit was completed, screening tools have been developed to identify if a patient is fit for standard treatment or unfit and requires further intervention. The three most studied screening tools in older cancer patients are G8, Flemish version of the Triage Risk Screening tool (fTRST) and Vulnerable Elders Survey-13 (VES-13).24–26 The G8 is an 8-item screening tool, which was developed specifically for older cancer patients. The tool incorporates elements of the Mini-Nutritional Assessment (MNA) questionnaire and covering multiple domains usually assessed by the geriatrician when performing the GA. It is user-friendly and takes 2–3 min to complete.24 fTRST includes 5 items and takes less than 1 min to complete.25 Both G8 and fTRST are strongly prognostic for functional decline on ADL and IADL and overall survival.24,25 G8 is also associated with chemotherapy-related toxicity.27 VES-13 is a tool developed for identification of vulnerable elders in the community. It includes 13 items and takes less than 5 min to complete. It is highly predictive of impaired functional status with a sensitivity and specificity of 87% and 62% respectively.26 In Australia, the first Australian geriatric oncology program, based at the Royal Adelaide Hospital, used a screening questionnaire to identify high-risk patients based on the seminal work of Hurria et al.28 Based on the patients' responses, referrals could then be made for appropriate interventions e.g. to dietician, social worker, etc.29 The limitations of our study include the fact that the first part of the audit was retrospective and was conducted at only 5 cancer centres. Whilst the data in the second part of the study was derived prospectively during MDMs and the auditors had a standardised set of geriatric domains to record, data collection was limited to 4 sites. Almost half of the audited MDM discussions occurred in a genitourinary clinic at a comprehensive cancer centre. Continence was mentioned more frequently in the 46 genitourinary MDM discussions audited (21%) than in the 62 non-specialist MDM discussions at other sites. No sites routinely performed a formal CGA or a brief screening test. Notably this audit pre-dates the development and use of screening tools such as the G8, fTRST and VES-13. Lack of standardised guidelines and lack of awareness of the clinical utilities of geriatric assessment tools are the likely
causes for this. Workshops and conferences dedicated to increase awareness in oncology practice are needed. Utilisation of screening tools in daily practice is more practical and time efficient than trying to complete a CGA when seeing new patients. Incorporating screening tools on local websites such as the Cancer Institute NSW eviQ
Disclosures and Conflict of Interest Statements All authors have no conflict of interest to declare.
Author Contributions The study was designed by C.B. Steer. All authors contributed to the writing of the manuscript and approved the final version of the manuscript.
Role of Funding Source There was no external funding for this project.
Acknowledgements We would like to thank all the clinicians who participated in data collection.
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Appendix 1. CRF
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REFERENCES
1. Ershler WB. Cancer: a disease of the elderly. J Support Oncol Nov-Dec 2003;1(4 Suppl 2):5–10. 2. Australian Cancer Incidence and Mortality (ACIM). Books—All Cancers combined for Australia (ICD10 C00-C97, D45-46, D47.1, D47.3). [Internet] Available from, http://www.aihw.gov. au/acim-books/ [Cited 2014 May 19]. 3. Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2012. Cancer series no. 74. Cat. no. CAN 70. Canberra: AIHW; 2012. 4. Yancik R. Cancer burden in the aged: an epidemiologic and demographic overview. Cancer Oct 1 1997;80(7):1273–1283.
5. Bouchardy C, Rapiti E, Blagojevic S, Vlastos AT, Vlastos G. Older female cancer patients: importance, causes, and consequences of undertreatment. J Clin Oncol May 10 2007;25(14):1858–1869. 6. Extermann M, Aapro M, Audisio R, Balducci L, Droz JP, Steer C, et al. Main priorities for the development of geriatric oncology: a worldwide expert perspective. J Geriatr Oncol Oct 2011;2(4): 270–273. 7. Quipourt V, Jooste V, Cottet V, Faivre J, Bouvier AM. Comorbidities alone do not explain the undertreatment of colorectal cancer in older adults: a french population-based study. J Am Geriatr Soc Apr 2011;59(4):694–698. 8. Monfardini S, Sorio R, Boes GH, Kaye S, Serraino D. Entry and evaluation of elderly patients in European Organization for
J O U RN A L OF GE RI A T RI C O NC O L O G Y 6 ( 2 01 5 ) 1 8 5 –19 3
9.
10. 11.
12.
13.
14.
15.
16. 17.
18.
19.
20.
Research and Treatment of Cancer (EORTC) new-drug-development studies. Cancer Jul 15 1995;76(2): 333–338. Scher KS, Hurria A. Under-representation of older adults in cancer registration trials: known problem, little progress. J Clin Oncol Jun 10 2012;30(17):2036–2038. Hurria A. Management of elderly patients with cancer. J Natl Compr Canc Netw May 2013;11(5 Suppl):698–701. Applegate WB, Blass JP, Williams TF. Instruments for the functional assessment of older patients. N Engl J Med Apr 26 1990;322(17):1207–1214. Hurria A, Wildes T, Blair SL, Browner IS, Cohen HJ, Deshazo M, et al. Senior adult oncology, version 2.2014: clinical practice guidelines in oncology. J Natl Compr Canc Netw Jan 2014;12(1): 82–126. Keefe D, Prowse R. Overview. Geriatric oncology: a medical subspecialty whose time has come [online]. Cancer Forum Mar 2008;32(1):3–5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–383. Extermann M, Hurria A. Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol May 10 2007;25(14): 1824–1831. Balducci L, Extermann M. Management of cancer in the older person: a practical approach. Oncologist 2000;5(3):224–237. Extermann M, Aapro M, Bernabei R, Cohen HJ, Droz JP, Lichtman S, et al. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol Sep 2005;55(3):241–252. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci Mar 2001;56(3): M146–M156. Maione P, Perrone F, Gallo C, Manzione L, Piantedosi F, Barbera S, et al. Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: a prognostic analysis of the multicenter Italian lung cancer in the elderly study. J Clin Oncol Oct 1 2005;23(28):6865–6872. Aparicio T, Jouve JL, Teillet L, Gargot D, Subtil F, Le Brun-Ly V, et al. Geriatric factors predict chemotherapy feasibility: ancillary results of FFCD 2001–02 phase III study in first-line chemotherapy for metastatic colorectal cancer in elderly patients. J Clin Oncol Apr 10 2013;31(11):1464–1470.
193
21. Retornaz F, Seux V, Sourial N, Braud AC, Monette J, Bergman H, et al. Comparison of the health and functional status between older inpatients with and without cancer admitted to a geriatric/internal medicine unit. J Gerontol A Biol Sci Med Sci Aug 2007;62(8):917–922. 22. Hurria A, Togawa K, Mohile SG, Owusu C, Klepin HD, Gross CP, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol Sep 1 2011;29(25):3457–3465. 23. Singhal N, Rao AV. Tools for assessing elderly cancer patients. Cancer Forum 2008;32(1):6–7. 24. Bellera CA, Rainfray M, Mathoulin-Pelissier S, Mertens C, Delva F, Fonck M, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol Aug 2012;23(8):2166–2172. 25. Kenis C, Decoster L, Van Puyvelde K, De Grève J, Conings G, Milisen K, et al. Performance of two geriatric screening tools in older patients with cancer. J Clin Oncol Jan 1 2014;32(1):19–26. 26. Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, et al. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable elders survey-13. J Clin Oncol Apr 20 2010;28(12):2046–2050. 27. Stokoe JM, Pearce J, Sinha R, Ring A. G8 and VES-13 scores predict chemotherapy toxicity in older patients with cancer. J Geriatr Oncol Oct 2012;3(Supplement 1):S81. 28. Hurria A, Lichtman SM, Gardes J, Li D, Limaye S, Patil S, et al. Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice. J Am Geriatr Soc Oct 2007;55(10):1604–1608. 29. To THM, Okera M, Prouse J, Prowse RJ, Singhal N. Infancy of an Australian geriatric oncology program—characteristics of the first 200 patients. J Geriatr Oncol October 2010;1(2):81–86. 30. Clinical Oncological Society of Australia. COSA Geriatric Oncology Workshop: Assessment tools for Australian clinical practice and research [Internet]. [Cited 2014 May 19]. Available from, https://www.cosa.org.au/media/158605/ cosa-geriatric-oncology-workshop-report-_final_.pdf Nov 16 2009. 31. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of Adl: a standardized measure of biological and psychosocial function. JAMA Sep 21 1963;185:914–919. 32. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist Autumn 1969;9(3):179–186.
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Geriatric assessment of older patients with cancer in Australia—A multicentre audit Roopa Lakhanpala , Jaclyn Yoongb , Sachin Joshic , Desmond Yipa,d , Linda Mileshkinb , Gavin M. Marxe , Tracey Dunlop f , Elizabeth J. Hovey f , Stephen A. Della Fiorentinag , Lakshmi Venkateswaranh , Martin H.N. Tattersalli , Sem Liewc , Kathryn Fieldj , Nimit Singhalk , Christopher B. Steerc,⁎ a
The Canberra Hospital, Yamba Drive, Canberra, ACT 2605, Australia Peter MacCallum Cancer Centre, 7 St Andrews Place, East Melbourne, Victoria 3002, Australia c Border Medical Oncology, Suite 1, 69 Nordsvan Drive, Wodonga, VIC 3690, Australia d Australian National University (ANU) Medical School, Canberra, ACT, Australia e Sydney Adventist Hospital, 185 Fox Valley Road, Wahroonga, NSW 2076, Australia f Prince of Wales Hospital, Barker Street, Randwick, NSW 2031, Australia g Macarthur Cancer Therapy Centre, 1 Therry Road, Campbelltown, Sydney, NSW 2560, Australia h Westmead Hospital, Corner of Hawkesbury Road and Darcy Road, Westmead, NSW 2145, Australia i Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW 2050, Australia j Royal Melbourne Hospital, 300 Grattan Street, Parkville, VIC 3050, Australia k Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia b
AR TIC LE I N FO
ABS TR ACT
Article history:
Objective: The aim of this study is to determine the frequency of geriatric assessment in
Received 24 October 2014
patients aged over 70 years in Australian medical oncology clinics.
Received in revised form
Material and Methods: This was a multicentre audit in two parts: a retrospective file review of
26 January 2015
initial consultations with an oncologist and prospective audit of case presentations at
Accepted 4 March 2015
multidisciplinary meetings (MDMs). Patients aged over 70 years presenting to a medical
Available online 23 March 2015
oncology clinic or being discussed at an MDM were eligible. Data was collected at six oncology centres in Victoria, NSW and Canberra from October 2009 to March 2010.
Keywords:
Results: Data was collected from 251 file reviews and 108 MDM discussions in a total of 304
Geriatric assessment
patients. Median age was 76 years (range 70–95). The geriatric assessment (GA) domains most
Older adults
frequently assessed during an initial consultation were the presence of comorbidities (92%),
Geriatric oncology
social situation—living alone or with someone (80%), social supports (63%), any mention of at
Medical oncology
least one Activity of Daily Living (ADL) (50%) and performance status (49%). Less frequently
Multidisciplinary meetings
assessed were any Instrumental Activity of Daily Living (IADL) (26%), presence of a geriatric syndrome (24%), polypharmacy (29%) and creatinine clearance (11%). Only one patient had all components of ADLs and IADLs assessed. During MDMs all the geriatric domains were comparatively less frequently assessed. No patients had all ADL and IADL components discussed formally in an MDM.
⁎ Corresponding author. Tel.: + 61 2 60515300; fax: + 61 2 60567663. E-mail address: [email protected] (C.B. Steer).
http://dx.doi.org/10.1016/j.jgo.2015.03.001 1879-4068/© 2015 Elsevier Ltd. All rights reserved.
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Conclusion: This is the first multicentre audit that reveals the low rates of GA in Australian medical oncology practice and describes the GA domains considered important by oncology clinicians. © 2015 Elsevier Ltd. All rights reserved.
1. Introduction The fastest-growing segment of the Australian population is composed of individuals over the age of 65 years. Increasing age is directly associated with increasing rates of cancer.1 It is not surprising therefore that cancer is more common in older Australians. In 2009, 73.5% of new cancer cases were diagnosed in men aged 60 years and over; and 63.6% in women aged 60 years and over.2 The average age at the first diagnosis of cancer in Australia is 65.4 years.3 Together, these statistics outline an increasingly older population of patients with cancer who will require specific management.4 Studies have shown deficiencies in the management of elderly people with cancer, including under-diagnosis and under-treatment. Documented problems include incomplete investigation, decreased utilisation of standard therapy and more dose reductions and delays than younger patients.5–7 The increased incidence of comorbidities in older adults can increase the risk of treatment-related toxicities; however the assumption of frailty based on age alone may lead to inadequate and inappropriate treatment. In addition, evidence-based decisionmaking is limited by the underrepresentation of elderly patients in large cooperative trials.8,9 This is possibly due to some trials limiting the upper age limit and secondly as many clinicians are reluctant to recommend older patients to trials. The adequate assessment of older adults with cancer can also direct supportive care interventions. These services can then be utilised to preserve independence and prevent toxicity regardless of treatment or treatment intent. Established guidelines and position statements recommend that all older adults with cancer undergo some form of geriatric assessment.10 Unfortunately there is no single agreed standard assessment that is both validated and practical to perform in the oncology clinic.11 Despite this, the key domains of a multi-domain geriatric assessment (Table 1) are well recognised and should be determined regardless of the actual tool utilised.12 The frequency at which geriatric assessment domains are measured within Australian medical oncology practice is unknown. At the time of this audit there was only one formal combined geriatric oncology clinic in the country.13 No other formal collaborations between geriatricians and oncologists currently exist in clinical practice. The objectives of this multicentre audit were to determine the frequency of geriatric assessment in patients over the age of 70 years presenting for an initial medical oncology opinion and to explore the degree to which geriatric assessment domains were discussed in multidisciplinary team meetings.
2. Material and Methods The study was a multicentre two-phase audit, conducted at 6 oncology centres in Australia; Albury-Wodonga, Sydney (3 sites), Melbourne and Canberra. Sites chosen were representative of
metropolitan and regional centres. The audit occurred from October 2009 to March 2010 and was performed in two parts; a retrospective file review and a prospective audit of case presentations at multidisciplinary meetings (MDMs). The retrospective file review audited all consecutive new patients aged over 70 years presenting for assessment and treatment at an oncology clinic. The prospective component audited all patients aged over 70 discussed at an MDM. Information was collected by an oncology advanced trainee. A standardised proforma was used to collect information (Appendix 1). None of the sites studied had formal geriatric oncology services. The retrospective file review involved review of the notes and/or correspondence letters during the initial consultation with a medical oncologist. Documentation of GA domains was recorded as well as other variables including tumour type/ stage and treatment recommendations. The second phase of the study involved a prospective audit of the same GA domains mentioned during discussion at multidisciplinary meetings. The MDMs generally comprise representatives from surgical, radiation and medical oncology in conjunction with radiology, pathology and nursing services. Attendance by allied health professionals such as social workers was variable. A geriatrician was not present at these MDMs. Patients were mostly recruited from general oncology clinics; however one site recruited from a genitourinary MDM and clinic only. The auditor was present at these MDMs and entered data during the meetings. MDM participants were not informed that
Table 1 – Geriatric assessment domains audited. Activities of daily living (ADLs) Instrumental activities of daily living (IADLs) Performance status (ECOG/Karnofsky) Comorbidities • Any mention of comorbidity • Use of a formal comorbidity index14 Geriatric syndromes • Falls • Cognitive impairment • Spontaneous fracture • Depression/anxiety • Vision and/or hearing impairment Discussion of social situation. • Lives alone or with someone? • Social support • Home services in place? eg “meals-on-wheels”, housekeeping, domiciliary nursing. Polypharmacy a Documentation of creatinine clearance Nutritional assessment eg dietician opinion, Mini-nutritional assessment (MNA) or general comment including body mass index (BMI) a
Polypharmacy defined as ≥5 medications noted in record by the medical oncologist. This does not include medications mentioned only in the general practitioners' referral letter.
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Table 2 – Activities of daily living (ADLs) and instrumental activities of daily living (IADLs) audited in case records and MDM discussions. Activities of daily living (ADL)31 Bathing Dressing Toileting Transferring Continence Feeding Mobility—eg walking, ability to climb stairs, “Get-up-and-go” test
Instrumental activities of daily living (IADL)32 Ability to use telephone Shopping Food preparation—ability to prepare meals. Housekeeping Laundry Transportation—ability to use private/public transport. Responsible for own medications? Ability to handle finances
Fig. 1 – Frequency that activities of daily living were mentioned in file review and MDMs. the audit was being conducted as any awareness could potentially bias the results of the study. The auditor noted any mention of a GA domain during the discussion of the patient's case. All patients over the age of 70 years discussed at an individual MDM during the audit were included for analysis. Apart from 55 patients at a comprehensive cancer centre, patients reported in file review and MDMs differed (see Table 3 & Figs. 1 & 2). The geriatric assessment domains audited in both sections of the study are included in Table 1. The individual components of activities of daily living (ADL) and instrumental activities of daily living (IADL) are documented in Table 2. Human Research Ethics Committee approval was obtained at all sites. The approved protocol stated that it was necessary for clinicians attending MDMs to be unaware that the audit was taking place. Data from all centres was entered onto a master excel spreadsheet for analysis.
MDMs only and there were 55 patients who were audited in both file review and MDM discussion. Median age was 76 years (range 70–95). Approximately two-thirds of patients were married. Prostate cancer (33.5%) was the most common primary site, followed by gastrointestinal (15.7%) and breast cancer (13.4%). Ten patients had a haematological malignancy (CLL, NHL and myeloma). The patient characteristics are summarised in Table 3.
3.2. Treatment Decisions Treatment was recommended in 181 patients (72%) during the initial consultation with a medical oncologist, and in 86 patients (80%) discussed in an MDM. Treatment recommendations are summarised in Table 4. Treatment was withheld on the basis of age alone in 5 patients (file review—3 and MDMs—2). Treatment intent was assessed in 95% of patients and is summarised in Table 4.
3. Results 3.3. Assessment of Geriatric Domains 3.1. Characteristics of the Study Population 3.3.1. File Review Data was collected from 251 file reviews and 108 MDM discussions in a total of 304 patients. One hundred and ninety six patients had a file review only, 53 patients were discussed in
All geriatric domains audited are listed in Table 1. The geriatric domains most frequently documented in an initial
Table 3 – Patient characteristics. File reviews (%) n = 251 Median age—yrs (range) Male/female Marital status
Fig. 2 – Frequency that instrumental activities of daily living were mentioned in file review and MDMs.
Tumour type Gynaecological Gastrointestinal Breast Bladder Prostate Lung Other
Married Single/widowed Unknown
MDMs (%) n = 108
76 (70–95)
76 (70–92)
143/108 (57/43) 159 (65) 71 (27) 21 (8)
70/38 (65/35) 66 (61) 19 (17.7) 23 (21.3)
10 30 28 10 58 14 33
10 (9) 18 (16.5) 13 (12.5) 7 (6.5) 44 (40) 5 (4.5) 11 (10)
(5) (21) (15) (5) (30) (7) (17)
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Table 4 – Treatment intent and type. Treatment intent
File review (%) n = 251
MDMs (%) n = 108
Adjuvant Curative Palliative No active treatment planned Not documented
54 47 80 61 9
(22) (19) (32) (24) (3)
19 30 37 14 8
(18) (28) (34) (13) (7)
Treatment type Surgery Chemotherapy Radiation therapy Chemo radiation Hormonal manipulation Other
23 72 63 26 40 14
(9) (29) (25) (10) (16) (6)
9 20 49 4 21 0
(8) (18) (45) (3) (19) (0)
Fig. 3 – Frequency that individual geriatric syndromes were mentioned in file review and MDMs.
4. MDM Discussion consult with an oncologist (Table 5) were the presence of comorbidities (92%), social situation—living alone or with someone (80%), social support (63%) and any mention of at least one ADL (50%). Specific geriatric domains such as any mention of at least one IADL (26%), presence of one or more geriatric syndromes (24%), polypharmacy (29%) and creatinine clearance (11%) were less commonly documented. A formal comorbidity index, such as the Charlson Comorbidity Index, was never used.14 Only one patient had all components of ADLs and IADLs assessed. When specific ADLs were mentioned, mobility was most frequently documented (36%) followed by continence (23%) (Fig. 1). The most commonly assessed component of IADLs was the availability of transportation (15%) (Fig. 2). The majority of file reviews contained references to the patients' social situation (Fig. 4) however the presence of home services was mentioned in only 13% of files. The performance status was documented in just under half the patients' files (49%) (Fig. 5). An individual geriatric syndrome (as defined in Table 1) was assessed in 24% of patients during file review (Fig. 3). The most commonly assessed item was formal screening for depression/ anxiety (14%). A formal cognitive assessment was only performed in 4% of patients. A nutritional assessment was documented in 20% of patients.
Analysis of the frequency of domains assessed during MDMs (Table 5) showed that the most common was comorbidities (84%), followed by living alone or with someone (30%) and social support (24%). Overall geriatric domains were mentioned much less frequently in this setting (Table 5). The frequency of any item in the ADL domain being mentioned in an MDM was 23% of patients. When ADLs were mentioned the most common were mobility (13%) and continence (13%) (Fig. 1). One or more components of IADL assessment was mentioned in only 6% of patients. The most common IADL referred to was ability to prepare food (6%) (Fig. 2). No patients had all ADL and IADL components considered formally in an MDM. The presence of a geriatric syndrome was mentioned in 10% of MDM discussions. Performance status was mentioned in 19% of MDMs. Polypharmacy issues were discussed in 13% of cases (Fig. 5)
5. Discussion This is the first multicentre audit to document the frequency at which geriatric domains were assessed in Australian medical oncology practice. A formal Comprehensive Geriatric Assessment
Table 5 – Frequency of assessment of geriatric domains. Geriatric domain ADLs (any component) IADLs (any component) Geriatric syndromes (any) Performance status Comorbidities Lives alone/with someone Social supports Home services Polypharmacy Creatinine clearance Nutrition
File review (%) n = 251 125 65 60 123 232 201 159 33 74 27 49
(50) (26) (24) (49) (92) (80) (63) (13) (29) (11) (20)
MDM (%) n = 108 25 7 11 20 91 32 26 5 14 3 10
(23) (6) (10) (19) (84) (30) (24) (5) (13) (3) (9)
Fig. 4 – Frequency that individual social situation domains were mentioned in file review and MDMs.
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Fig. 5 – Frequency of other geriatric domains mentioned in file review and MDMs.
(CGA) is an in-depth, multidisciplinary, multidomain evaluation to assess functional status, life expectancy and risk of morbidity/ mortality that results in formulation of a specific management plan according to the individual's needs. The individual components of the CGA can inform treatment decisions and guide supportive care interventions.10,15 This audit shows that many elements of the CGA are not documented routinely in the assessment of older patients by medical oncologists during their initial consultation or in conjunction with a multidisciplinary case conference. Older adults are more likely to suffer from comorbidities and the risk factors for adverse outcomes from the cancer and its treatment.16 Adequate assessment for these risk factors enables appropriate management and minimises the risk of both over- and under-treatment.17 Although there is no single recommended assessment tool for use in the oncology clinic, international guidelines document the geriatric assessment domains that should be considered.10 These include activities of daily living, comorbidities, social situation and presence of a geriatric syndrome (e.g. cognitive impairment). Despite the documented benefits of adequate assessment, the rate of GA in this audit was generally low. The most commonly assessed geriatric domains were the presence of comorbidities and basic aspects of the patient's social situation. The question of whether the patient had someone else at home with them was documented in 80% of initial consultations and 30% of MDM discussions. A comprehensive GA requires a detailed assessment of the patient's basic and instrumental activities of daily living (ADLs and IADLs). Mobility and continence were the most frequently assessed ADLs. Oncology treatment predominantly involves ambulatory care and regular clinic visits. Clinicians are likely to be interested in mobility to assess if patients can attend for treatment. The ability to transfer and walk unaided is also a factor in the assessment of performance status and is potential surrogate for frailty (gait speed is specifically a measure of frailty).18 Despite the relatively low rate of assessment of continence, this figure is potentially an overestimate as data from 46 patients (18% of consultations and 42% of MDM discussions) was derived from attendance at a specialist urology multidisciplinary clinic. The remainder of the patients were
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discussed in general oncology clinics. As other individual ADL domains were mentioned in <15% of consultations the rate of comprehensive assessment remains low. It is generally accepted that ADL/IADL assessment is a crucial component of a CGA. Dependence on others for ADL and IADL assistance has been shown to be predictive of mortality in geriatric oncology patients.19 Assessing functional status not only predicts for treatment toxicity but also allows targeted supportive care intervention.20 Preservation of functional independence is a key aim of therapy in older adults regardless of treatment intent and adequate functional assessment is vital if this goal is to be achieved. Of the geriatric syndromes audited (Table 1) the most commonly assessed was depression/anxiety (14% of consultations; 3% of MDMs). It could be argued that this is not a true geriatric syndrome; however the rate of routine assessment was low if we accept that it should be considered in all patients regardless of age. The rate of assessment for cognitive impairment was very low (4% of consultations; 3% of MDMs) and questions pertaining to falls occurred just as infrequently. The incidence of geriatric syndromes in patients over the age of 70 with cancer is modest when compared with patients under the care of a geriatrician; however it remains high enough to warrant consideration.21 The potential for these issues to change treatment is substantial. Whilst some attention was paid to the issues of polypharmacy and nutritional assessment these are aspects that would be routinely assessed by a geriatrician during CGA. It could be argued that these assessments should be performed by trained allied health professionals (e.g. pharmacists and dieticians respectively) and require additional resources; however the recognition of these issues during the initial consultation is important.12 As this was a retrospective audit of clinical consultations it is possible that the items audited were discussed but would only be noted in the patient's records if an assessment revealed a problem. The results of this audit establish at the very least that routine specific geriatric assessment was not performed at these centres. Even if a GA was performed routinely and the abnormalities documented, the rate of issues would be expected to be higher. For example, in a study of 500 patients over the age of 65 years participating in a prospective trial of GA the rate of patients requiring assistance with an IADL was 43% and 18% reported at least one fall in the last 6 months.22 The rate of geriatric assessment was higher in clinical consultations than in MDM discussions. This is not surprising as usually oncology MDM discussions are short, involve presentation of a concise history, relevant radiology and histopathology and in the interest of time it is not practically possible to conduct a GA. Utilisation of screening tools prior to MDM discussion will prove to be an effective strategy to identify if a patient is fit or unfit for standard treatment and needs a GA. In general these MDMs were tumour specific, rather than having a geriatric focus. Despite the paucity of GA information presented, binding treatment decisions regarding older patients are often made at an MDM. It is interesting to note that that in the opinion of the auditor, a decision to withhold treatment on the basis of age alone was made in 2 cases during an MDM.
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Given that treatment decisions were made despite the lack of complete assessment, it is likely that clinicians based their treatment decisions on patients' overall health status and level of home support. Despite this, performance status (PS) was documented in only 49% of clinical consultations. This is surprisingly low given the acceptance of PS as being important in treatment decision-making. The design of this audit does not enable us to determine whether this is simply a problem of documentation or if clinicians really did not use performance status in their clinical decisions. A CGA is time consuming and not necessarily required in every elderly patient with cancer.23 Therefore a screening tool is recommended to identify patients in need of further evaluation by GA.17 If abnormal, the screening should be followed by CGA and guided multidisciplinary intervention. Screening tools might also have a prognostic or predictive value for important outcome measures such as treatment toxicity, early discontinuation of treatment, functional decline and survival. If a sensitive screening tool is used, it can identify fit elderly patients who should be treated with standard treatments and avoid under treatment. Since this audit was completed, screening tools have been developed to identify if a patient is fit for standard treatment or unfit and requires further intervention. The three most studied screening tools in older cancer patients are G8, Flemish version of the Triage Risk Screening tool (fTRST) and Vulnerable Elders Survey-13 (VES-13).24–26 The G8 is an 8-item screening tool, which was developed specifically for older cancer patients. The tool incorporates elements of the Mini-Nutritional Assessment (MNA) questionnaire and covering multiple domains usually assessed by the geriatrician when performing the GA. It is user-friendly and takes 2–3 min to complete.24 fTRST includes 5 items and takes less than 1 min to complete.25 Both G8 and fTRST are strongly prognostic for functional decline on ADL and IADL and overall survival.24,25 G8 is also associated with chemotherapy-related toxicity.27 VES-13 is a tool developed for identification of vulnerable elders in the community. It includes 13 items and takes less than 5 min to complete. It is highly predictive of impaired functional status with a sensitivity and specificity of 87% and 62% respectively.26 In Australia, the first Australian geriatric oncology program, based at the Royal Adelaide Hospital, used a screening questionnaire to identify high-risk patients based on the seminal work of Hurria et al.28 Based on the patients' responses, referrals could then be made for appropriate interventions e.g. to dietician, social worker, etc.29 The limitations of our study include the fact that the first part of the audit was retrospective and was conducted at only 5 cancer centres. Whilst the data in the second part of the study was derived prospectively during MDMs and the auditors had a standardised set of geriatric domains to record, data collection was limited to 4 sites. Almost half of the audited MDM discussions occurred in a genitourinary clinic at a comprehensive cancer centre. Continence was mentioned more frequently in the 46 genitourinary MDM discussions audited (21%) than in the 62 non-specialist MDM discussions at other sites. No sites routinely performed a formal CGA or a brief screening test. Notably this audit pre-dates the development and use of screening tools such as the G8, fTRST and VES-13. Lack of standardised guidelines and lack of awareness of the clinical utilities of geriatric assessment tools are the likely
causes for this. Workshops and conferences dedicated to increase awareness in oncology practice are needed. Utilisation of screening tools in daily practice is more practical and time efficient than trying to complete a CGA when seeing new patients. Incorporating screening tools on local websites such as the Cancer Institute NSW eviQ
Disclosures and Conflict of Interest Statements All authors have no conflict of interest to declare.
Author Contributions The study was designed by C.B. Steer. All authors contributed to the writing of the manuscript and approved the final version of the manuscript.
Role of Funding Source There was no external funding for this project.
Acknowledgements We would like to thank all the clinicians who participated in data collection.
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Appendix 1. CRF
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REFERENCES
1. Ershler WB. Cancer: a disease of the elderly. J Support Oncol Nov-Dec 2003;1(4 Suppl 2):5–10. 2. Australian Cancer Incidence and Mortality (ACIM). Books—All Cancers combined for Australia (ICD10 C00-C97, D45-46, D47.1, D47.3). [Internet] Available from, http://www.aihw.gov. au/acim-books/ [Cited 2014 May 19]. 3. Australian Institute of Health and Welfare & Australasian Association of Cancer Registries. Cancer in Australia: an overview, 2012. Cancer series no. 74. Cat. no. CAN 70. Canberra: AIHW; 2012. 4. Yancik R. Cancer burden in the aged: an epidemiologic and demographic overview. Cancer Oct 1 1997;80(7):1273–1283.
5. Bouchardy C, Rapiti E, Blagojevic S, Vlastos AT, Vlastos G. Older female cancer patients: importance, causes, and consequences of undertreatment. J Clin Oncol May 10 2007;25(14):1858–1869. 6. Extermann M, Aapro M, Audisio R, Balducci L, Droz JP, Steer C, et al. Main priorities for the development of geriatric oncology: a worldwide expert perspective. J Geriatr Oncol Oct 2011;2(4): 270–273. 7. Quipourt V, Jooste V, Cottet V, Faivre J, Bouvier AM. Comorbidities alone do not explain the undertreatment of colorectal cancer in older adults: a french population-based study. J Am Geriatr Soc Apr 2011;59(4):694–698. 8. Monfardini S, Sorio R, Boes GH, Kaye S, Serraino D. Entry and evaluation of elderly patients in European Organization for
J O U RN A L OF GE RI A T RI C O NC O L O G Y 6 ( 2 01 5 ) 1 8 5 –19 3
9.
10. 11.
12.
13.
14.
15.
16. 17.
18.
19.
20.
Research and Treatment of Cancer (EORTC) new-drug-development studies. Cancer Jul 15 1995;76(2): 333–338. Scher KS, Hurria A. Under-representation of older adults in cancer registration trials: known problem, little progress. J Clin Oncol Jun 10 2012;30(17):2036–2038. Hurria A. Management of elderly patients with cancer. J Natl Compr Canc Netw May 2013;11(5 Suppl):698–701. Applegate WB, Blass JP, Williams TF. Instruments for the functional assessment of older patients. N Engl J Med Apr 26 1990;322(17):1207–1214. Hurria A, Wildes T, Blair SL, Browner IS, Cohen HJ, Deshazo M, et al. Senior adult oncology, version 2.2014: clinical practice guidelines in oncology. J Natl Compr Canc Netw Jan 2014;12(1): 82–126. Keefe D, Prowse R. Overview. Geriatric oncology: a medical subspecialty whose time has come [online]. Cancer Forum Mar 2008;32(1):3–5. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40(5):373–383. Extermann M, Hurria A. Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol May 10 2007;25(14): 1824–1831. Balducci L, Extermann M. Management of cancer in the older person: a practical approach. Oncologist 2000;5(3):224–237. Extermann M, Aapro M, Bernabei R, Cohen HJ, Droz JP, Lichtman S, et al. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol Sep 2005;55(3):241–252. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, et al. Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci Mar 2001;56(3): M146–M156. Maione P, Perrone F, Gallo C, Manzione L, Piantedosi F, Barbera S, et al. Pretreatment quality of life and functional status assessment significantly predict survival of elderly patients with advanced non-small-cell lung cancer receiving chemotherapy: a prognostic analysis of the multicenter Italian lung cancer in the elderly study. J Clin Oncol Oct 1 2005;23(28):6865–6872. Aparicio T, Jouve JL, Teillet L, Gargot D, Subtil F, Le Brun-Ly V, et al. Geriatric factors predict chemotherapy feasibility: ancillary results of FFCD 2001–02 phase III study in first-line chemotherapy for metastatic colorectal cancer in elderly patients. J Clin Oncol Apr 10 2013;31(11):1464–1470.
193
21. Retornaz F, Seux V, Sourial N, Braud AC, Monette J, Bergman H, et al. Comparison of the health and functional status between older inpatients with and without cancer admitted to a geriatric/internal medicine unit. J Gerontol A Biol Sci Med Sci Aug 2007;62(8):917–922. 22. Hurria A, Togawa K, Mohile SG, Owusu C, Klepin HD, Gross CP, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol Sep 1 2011;29(25):3457–3465. 23. Singhal N, Rao AV. Tools for assessing elderly cancer patients. Cancer Forum 2008;32(1):6–7. 24. Bellera CA, Rainfray M, Mathoulin-Pelissier S, Mertens C, Delva F, Fonck M, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol Aug 2012;23(8):2166–2172. 25. Kenis C, Decoster L, Van Puyvelde K, De Grève J, Conings G, Milisen K, et al. Performance of two geriatric screening tools in older patients with cancer. J Clin Oncol Jan 1 2014;32(1):19–26. 26. Luciani A, Ascione G, Bertuzzi C, Marussi D, Codecà C, Di Maria G, et al. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable elders survey-13. J Clin Oncol Apr 20 2010;28(12):2046–2050. 27. Stokoe JM, Pearce J, Sinha R, Ring A. G8 and VES-13 scores predict chemotherapy toxicity in older patients with cancer. J Geriatr Oncol Oct 2012;3(Supplement 1):S81. 28. Hurria A, Lichtman SM, Gardes J, Li D, Limaye S, Patil S, et al. Identifying vulnerable older adults with cancer: integrating geriatric assessment into oncology practice. J Am Geriatr Soc Oct 2007;55(10):1604–1608. 29. To THM, Okera M, Prouse J, Prowse RJ, Singhal N. Infancy of an Australian geriatric oncology program—characteristics of the first 200 patients. J Geriatr Oncol October 2010;1(2):81–86. 30. Clinical Oncological Society of Australia. COSA Geriatric Oncology Workshop: Assessment tools for Australian clinical practice and research [Internet]. [Cited 2014 May 19]. Available from, https://www.cosa.org.au/media/158605/ cosa-geriatric-oncology-workshop-report-_final_.pdf Nov 16 2009. 31. Katz S, Ford AB, Moskowitz RW, Jackson BA, Jaffe MW. Studies of illness in the aged. The index of Adl: a standardized measure of biological and psychosocial function. JAMA Sep 21 1963;185:914–919. 32. Lawton MP, Brody EM. Assessment of older people: self-maintaining and instrumental activities of daily living. Gerontologist Autumn 1969;9(3):179–186.