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Integrating a Geriatric Evaluation in the Clinical Setting
Integrating a Geriatric Evaluation in the Clinical Setting Martine Extermann, MD Older cancer patients—which make the majority of cancer patients—present with a highly heterogeneous health status. Therefore, a careful assessment of the individual’s condition is important in the planning of their oncologic care. In this article, a two-step approach is recommended: a short screening test of every patient presenting for treatment, and a multidisciplinary evaluation for patients screening at risk. Several screening tools that have been tested are described, and their relative performance is reviewed: the abbreviated Comprehensive Geriatric Assessment, the G8, the Senior Adult Oncology Program 2 questionnaire, the Triage Risk Screening Tool, the Vulnerable Elders Survey 13 tool, the Groeningen Frailty Index, and the Onco-Geriatric Screening Tool. Indeed, regular multidisciplinary meetings are key to optimal management of elderly patients, as they modify treatment plans in ¼ to ½ of patients. A practical way of implementing a multidisciplinary consultation is reviewed, and future directions are discussed. Semin Radiat Oncol 22:272-276 © 2012 Elsevier Inc. All rights reserved.
Introduction: The Two-Step Approach
I
t is now well established that older cancer patients present a significant prevalence of geriatric problems. Approximately 20% have an Eastern Cooperative Oncology Group performance status (PS) of ⱖ2. An equal proportion of patients have a dependence in basic activities of daily living (ADL). More than half have a dependence in instrumental activities of daily living (IADL). More than 90% have at least 1 comorbidity, and 30%-40% of those comorbidities are severe. Depression is present in 20%40% of older patients, and cognitive impairment in 25%35% of patients. Finally, 30%-50% of patients are at risk of malnutrition or are malnourished.1 The average number of medications taken by older patients is a half-dozen, with a significant potential for interactions.2 This number has risen since the mid-90s, when it was 4 medications,3 and is likely to keep increasing. Therefore, as a population, older patients need to be assessed for more than just their cancer status. This is highly relevant to all oncologic specialities including radiation oncology because radiation is used even in patients of very advanced age. It is the second most frequent modality used in nonagenarians with cancer, afMoffitt Cancer Center, University of South Florida, Tampa, FL. Address reprint requests to Martine Extermann, MD, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612. E-mail: martine.extermann@ moffitt.org
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ter surgery (at Moffitt Cancer Center, 16% and 37% of treatments, respectively, with an additional 2% of patients receiving concomitant chemoradiation).4 Unfortunately, simple clinical judgment is often not a good enough instrument to detect geriatric problems, even when they directly impact the outcome of cancer patients.5-8 Therefore, a specific screening is needed. As a general approach in a busy oncology practice, we suggest a two-step process, illustrated in Figure 1. First, a rapid geriatric screening by the oncology team, and if positive, a combined oncologic and geriatric assessment with an integrated treatment plan. In our experience, very few cancer patients get treated at their first visit, which allows time for a geriatric evaluation in parallel with the final oncology preparations (eg, slides review, port placement, simulation, final staging studies). Several short screening instruments are available in geriatric oncology. They are usually simple to use, and although all the details of their use have not yet been worked out, many of them have some validation. If one chooses a tool designed to assess who needs a more comprehensive multidisciplinary geriatric assessment (MGA), the rapid screening can be done on all new patients, and approximately half of them will need a comprehensive geriatric work-up in parallel with their oncology work-up. Such an approach has been used routinely over the past decade in our clinic at Moffitt with the Senior Adult Oncology Program (SAOP) screening tool (http:// www.moffitt.org/saoptools).
Integrating a geriatric evaluation in the clinical setting
18. Kenis et al14 compared it with the Triage Risk Screening Tool (TRST) and the GFI, and its sensitivity was intermediate between the TRST and the GFI, at 80%. In a large French multicenter trial, the G8 was compared with the VES 13.15 Its sensitivity was 76.6% versus 68.7% for the VES 13, and its specificity was 64.4% versus 74.3%.
Geriatric screening
Negative
273
Positive
The SAOP 2 Screening Tool Oncology workup/ set-up
Treatment plan
Oncology workup/set-up
Geriatric workup/set-up
Integrated treatment plan
Figure 1 General approach to treatment planning in an older cancer patient.
Short Screening Tools These are rapid triage tools taking only a few minutes to answer. This is an area in active development, and the list that follows does not claim to be exhaustive. However, some instruments that were used and tested in recent articles are described in the following sections.
The Abbreviated Comprehensive Geriatric Assessment Overcash et al9,10 isolated an Abbreviated Comprehensive Geriatric Assessment (aCGA) that correlated with the findings of an MGA in a large database of older patients with cancer who underwent a CGA as part of their oncology evaluation. These 15 items include 3 questions about ADL, 4 questions about IADL, 4 questions from the Mini-Mental Status Exam (MMS), and 4 questions from the Geriatric Depression Scale (GDS). If the patient has any impairment in the ADL or IADL items in the abbreviated CGA, then the full ADL and IADL scales should be administered. If 2 depression items are altered, a full GDS should be administered. A score ⱕ6 in the cognitive screen triggers a full MMS.10 The score can be obtained from Overcash et al’s article.9 Kellen et al11 compared the performance of the aCGA with that of the Vulnerable Elder Survey (VES) 13 and the Groeningen Frailty Index (GFI) in predicting impairments in ADL, IADL, MMS, and GDS. The aCGA was more sensitive than the 2 other indices for functional impairments, with a sensitivity of 97% for ADL and 92% for IADL, but performed less well for depression (69%) and cognitive impairment (23%). In a recent cohort of institutionalized patients, the aCGA was also slightly more sensitive than the VES 13.12
The G8 This index was developed by the Institut Bergonié team in France.13 It consists of 8 items, with a score ranging from 0 to
This empirical tool was developed by the multidisciplinary clinical team of the SAOP at Moffitt to determine when a multidisciplinary team consultation was required in new cancer patients. In addition to function, depression, and cognitive screening, the screen includes questions regarding health-related quality of life, self-rated health, falls, nutrition, sleep, polymedication, and social questions (drug payment and caregiver availability). After ⬎8 years of clinical use in its second version, this screen has demonstrated face validity, showing that 63% of senior cancer patients needed psychosocial counseling, 40% dietary intervention, and 14% medication counseling and assistance (the latter probably underestimated).16 Its performance was validated against a multidimensional geriatric assessment.17 It is a sensitive tool, but there is low internal specificity, meaning that if a question is positive in 1 domain of the questionnaire, it might reflect a problem in another domain, reflecting the importance of a multidisciplinary team approach. The first page is answered directly by the patient, and the second page is administered by the clinic staff. If 1 item is positive, the respective specialist is called in, with possible secondary referral to other members of the team. If several items are impaired, the multidisciplinary team is called in or a geriatric referral is made for a CGA. The tool has been translated in Spanish, French, Italian, Chinese, and Portuguese.
The Triage Risk Screening Tool This tool was developed for geriatric screening in the emergency room setting.18 Patients screening positive underwent a half-hour evaluation by a geriatric nurse practitioner. Its performance was compared with a full CGA in oncology patients.19 It proved sensitive, provided the threshold was lowered from 2 to 1 point. Therefore, any positive item would warrant geriatric evaluation in cancer patients. It was compared with the G8 and the GFI in its ability to detect a “geriatric profile” as defined by a multidisciplinary geriatric oncology team.14 With a cut-off value of 1, its sensitivity was 92%, versus 64% with a cut-off of 2 (the original cut-off), 80% for the G8, and 57% for the GFI. In another series comparing the TRST and the G8, the sensitivity of the TRST was 91.2% versus 86.9%, and the specificity was 42.7% versus 60.8%, compared with a standard geriatric assessment battery.20
The Vulnerable Elders Survey 13 Mohile et al21 analyzed the performance of the VES 13,22 developed in a large geriatric survey cohort, in older prostate cancer patients. Fifty percent of patients were identified as impaired on the VES 13 (score ⱖ3). That cutoff had a sensitivity of 72.7% and a specificity of 85.7% for impairment in
M. Extermann
274 ⱖ2 dimensions on an MGA. The score can be obtained from http://www.usafp.org/Best-Practices.htm. Lucianni et al23 found a high sensitivity of the VES 13 for geriatric problems in their study: 87% compared with a CGA, and 90% compared with ADL/IADLs. However, they “adapted” the tests for patients ⬎85 years of age. Although they do not specify the adaptation, the understanding of this author is that they might have counted all patients aged ⱖ85 years as frail. By contrast, Falci et al24 found 30% of elderly patients with favorable VES 13 scores to be vulnerable or frail at full CGA, and 40% of patients with unfavorable VES 13 scores to be fit. The VES 13 was compared with the G8 in the French multicenter study mentioned previously and was found less sensitive and more specific.15 It was compared with the aCGA in Kellen et al’s11 study but was not as sensitive to impairments in ADL (76%) and IADL (67%). One study argued that the performance of VES 13 was comparable with using an Eastern Cooperative Oncology Group PS ⱖ1 or a Karnofsy PS ⱕ80 for screening.25 By contrast, a small study found a better correlation of the VES 13 with a CGA (intraclass correlation ⫽ 0.814) than that of an instrument popular in Spain: the Barber questionnaire (intraclass correlation ⫽ 0.672).26
The Groeningen Frailty Index This index is a list of 15 screening questions addressing various geriatric domains.27 A score of ⱖ4 indicates frailty. In a screening role in older cancer patients, it underperformed the aCGA and VES 13 in detecting impairments in ADL and IADL (47% and 39%, respectively). Also, it did not fare as well as the TRST and the G8 in detecting a geriatric profile in the study by Kenis et al.14 Therefore, it might be more valuable to use it as a frailty defining tool than as a screening instrument in older cancer patients.
The Oncogeriatric Screening Tool This 10-items tool assesses 5 frailty risks.28 It was compared in a prospective cohort study with a geriatric assessment battery performed by a geriatrician. Its sensitivity was 88%, and its specificity 44%. It classified 11% of patients as fit, 81% as vulnerable, and 8% as frail, whereas the geriatric assessments classified 11% of patients as fit, 79% as vulnerable, and 10% as frail. In summary, several short screening tools are available with good sensitivity for geriatric problems. Tools assessing several domains tend to outperform tools assessing functional issues only (such as the VES 13). Sensitivity comes at the price of specificity, and all these instruments have a very moderate specificity. Therefore, these tools by themselves should not serve as a basis for treatment decisions, but should indicate that further evaluation by a geriatric or a multidisciplinary oncogeriatric team is needed.
Step 2: Integrated Geriatric Oncology Management Once a patient screens positive for geriatric problems a combined oncogeriatric approach should be set up. This can take
several formats. The International Society of Geriatric Oncology (SIOG) recently presented its list of the 10 Global Priorities to address the care of older cancer patients.29 Among them is to “Develop interdisciplinary geriatric oncology clinics, especially in academic institutions and comprehensive cancer centers.” We believe that major centers should have geriatric oncology clinics, and this is increasingly the case. There are various formats that can be implemented: A multidisciplinary team coheaded by a geriatrician and an oncologist serving a region (eg, the French Unités Cliniques d’Oncogériatrie), which might have a mobile consultation unit; a team headed by dual trained oncogeriatricians (eg, Moffitt, City of Hope, Roswell Park, and other American cancer centers), with or without geriatric nurse practitioners; or a geriatric team embedded in a cancer center (eg, MD Anderson, Memorial Sloan-Kettering). Smaller hospitals or group practices can set up regular multidisciplinary tumor boards including a geriatrician, or establish a privileged relationship with a geriatric consultant or an academic center with a complete onco-geriatric team, which over time will lead to crosstraining of the participants. Telemedicine consultations might be helpful in this setting. Such multidisciplinary management clearly impacts the oncologic treatment planning of older patients and the management throughout treatment.7,8,30 In the elderly cancer patient (ELCAPA) study, the initial plan of the oncologist was modified in 20.8% of patients, notably those with dependence in ADL and those who were malnourished.8 Eighty percent of the decisions were toward less intense treatment. In the study by Chaïbi et al,7 the geriatric consultation modified the initial treatment plan in 49% of patients. The treatment was delayed in 3%, less intensive in 18%, and more intensive in 28%. In our pilot of 15 breast cancer patients, 6 months of multidisciplinary management modified treatment in 1 patient and influenced treatment management in 3 patients.30
Risk Prediction Models The prediction of treatment outcome in a situation where multidimensional variables occur, as with the older patient, is difficult. Trained oncologists have difficulty integrating in their treatment plan ⬎3 variables at one time.31 Our interpretation of the patient’s desires might be biased by cultural expectations,32,33 and our reading of the literature is selective due to time constraints. Therefore, good quality decision models based on systematic reviews of available data are very valuable. A geriatric evaluation has so far mostly been used as a detection tool to identify problems that might interfere with cancer treatment so that they can then be addressed by the multidisciplinary team or the respective specialists. More recently, however, studies using geriatric parameters as true predictors of oncologic outcome have been published. For example, 2 models predicting the risk of severe side effects from chemotherapy in older patients are available: The Chemotherapy Risk Assessment Scale for High-age patients (CRASH) score,34 and the Cancer and Aging Research Group score.35 None of these scores has yet been validated with
Integrating a geriatric evaluation in the clinical setting chemoradiation regimens, but this would be a logical extension of their use. Also recently published is a simple tool that might help identify patients at very low risk of severe neutropenia and febrile neutropenia after their first cycle of treatment.36 In such patients, weekly blood counts beyond the first cycle might be avoidable. In a different domain, Audisio et al37,38 explored the potential of geriatric instruments to predict complications of surgery with the Preoperative Assessment of Elderly Cancer score. IADL dependence and the number of geriatric domains altered correlate with the risk of complications within 30 days after surgery. These studies represent the future of the use of geriatric instruments in geriatric oncology. We need to harness the now well-established correlation of geriatric instruments with various oncology outcomes to transform this into decision guidelines for integrated onco-geriatric approaches. Other helpful models are general ones that exist, for example, for the adjuvant treatment of breast, colon, and lung cancer (http://www.adjuvantonline.com) or for initial treatment of prostate cancer with radiation or surgery.39 These allow an objective quantification of benefits that can be weighed against potential harms and can be used in the discussions with the individual patients. As it is unlikely for there to be specific therapeutic studies focused only on particular scenarios (eg, older women with lung cancer, diabetes, and coronary artery disease), there is a clear need for more such models in geriatric oncology.
Recommendations, Perspectives, Research Needed In summary, there is an increasing amount of evidence that geriatric parameters should be considered when planning cancer treatment. We recommend identifying or setting up a local oncogeriatric team in an appropriate format. Even if the volume of consultations might initially be low, the effect is likely to be multiplied by a mutual educational process. We recommend choosing 1 short screening tool assessing several geriatric domains in conjunction with the local geriatric support to optimize referral patterns. Such tools should not be considered diagnostic by themselves. Most of the time, the geriatric work-up can be conducted in parallel with the oncology work-up, as patients rarely initiate treatment at their first oncology visit. Regular multidisciplinary meetings are key to optimal management of these patients, as they modify treatment plans in ¼ to ½ of patients.7,8,30 The integration of geriatric assessments and interventions into oncology decision making is a field in rapid progress, so attention should be paid to that literature. Guidelines, such as the NCCN elderly guidelines or the SIOG guidelines, are a good resource for updates. A SIOG task force is in the process of preparing a specific set of guidelines for radiation oncology. More research is needed, particularly on the topics of combined modality therapy and the influence of advanced age on normal tissue and organ tolerance to radiation. Such research studies will typically need more detailed evaluations than simple screening tools. There are now a reasonable number
275 of multicenter trials that have successfully integrated geriatric instruments packages as part of patient evaluations, demonstrating their feasibility.15,34,35,37,40-42
References 1. Extermann M, Hurria A: Comprehensive geriatric assessment for older patients with cancer. J Clin Oncol 25:1824-1831, 2007 2. Popa M, Wallace K, Brunello A, et al: The impact of polypharmacy on toxicity from chemotherapy in elderly patients: Focus on cytochrome P-450 inhibition and protein binding effects. Proc Am Soc Clin Oncol 26:503s, 2008 3. Corcoran ME: Polypharmacy in the older patient with cancer. Cancer Control 4:419-428, 1997 4. Extermann M, Crane EJ, Boulware D: Cancer in nonagenarians: Profile, treatments and outcomes. J Geriatr Oncol 1:27-31, 2010 5. Tucci A, Ferrari S, Bottelli C, et al: A comprehensive geriatric assessment is more effective than clinical judgment to identify elderly diffuse large cell lymphoma patients who benefit from aggressive therapy. Cancer 115:4547-4553, 2009 6. Wedding U, Ködding D, Pientka L, et al: Physicians’ judgement and comprehensive geriatric assessment (CGA) select different patients as fit for chemotherapy. Crit Rev Oncol Hematol 64:1-9, 2007 7. Chaïbi P, Magné N, Breton S, et al: Influence of geriatric consultation with comprehensive geriatric assessment on final therapeutic decision in elderly cancer patients. Crit Rev Oncol Hematol 79:302-307, 2011 8. Caillet P, Canoui-Poitrine F, Vouriot J, et al: Comprehensive geriatric assessment in the decision-making process in elderly patients with cancer: ELCAPA study. J Clin Oncol 29:3636-3642, 2011 9. Overcash JA, Beckstead J, Extermann M, et al: The abbreviated comprehensive geriatric assessment (aCGA): A retrospective analysis. Crit Rev Oncol Hematol 54:129-136, 2005 10. Overcash JA, Beckstead J, Moody L, et al: The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: Scoring and interpretation. Crit Rev Oncol Hematol 59:205210, 2006 11. Kellen E, Bulens P, Deckx L, et al: Identifying an accurate pre-screening tool in geriatric oncology. Crit Rev Oncol Hematol 75:243-248, 2010 12. Luz L, Santiago MM, Mattos PCA: The abbreviated comprehensive geriatric assessment and the vulnerable elders survey 13 as screening instruments in elders of Brazilian long-stay institutions. J Geriatr Oncol 2:s39, 2011 13. Bellera C, Rainfray M, Mathoulin-Plissier S, et al: Validation of a screening tool in geriatric oncology: the ONCODAGE project. Crit Rev Oncol Hematol 68:S22, 2008 14. Kenis C, Schuermans H, Van Custem E, et al: Screening for a geriatric risk profile in older cancer patients: A comparative study of the predictive validity of three screening tools. Crit Rev Oncol Hematol 72:S22, 2009 15. Soubeyran P, Bellera C, Goyard J, et al: Validation of the G8 screening tool in geriatric oncology: The ONCODAGE project. J Clin Oncol 29: 550s, 2011 16. Johnson D, Blair J, Balducci L, et al: The assessment of clinical resources in a senior adult oncology program. European Oncology Nursing Society Meeting 2006, Innsbruck, Austria, 2006 17. Extermann M, Green T, Tiffenberg G, et al: Validation of the Senior Adult Oncology Program (SAOP) 2 screening questionnaire. Crit Rev Oncol Hematol 69:185, 2009 18. Mion LC, Palmer RM, Anetzberger GJ, et al: Establishing a case-finding and referral system for at-risk older individuals in the emergency department setting: The SIGNET model. J Am Geriatr Soc 49:1379-1386, 2001 19. Kenis C, Geeraerts A, Braesl T, et al: The Flemish version of the Triage Risk Screening Tool (TRST): A multidimensional short screening tool for the assessment of elderly patients. Crit Rev Oncol Hematol 60:S31, 2006 20. Kenis C, Decoster L, Vanpuyvelde K, et al: Comparison of two screening tools (Flemish version of the Triage Risk Screening Tool (TRST) and G8) in older cancer patients. J Geriatr Oncol 2:S39, 2011
276 21. Mohile SG, Bylow K, Dale W, et al: A pilot study of the vulnerable elders survey-13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 109:802-810, 2007 22. Saliba D, Orlando M, Wenger NS, et al: Identifying a short functional disability screen for older persons. J Gerontol A Biol Sci Med Sci 55: M750-M756, 2000 23. Luciani A, Ascione G, Bertuzzi C, et al: Detecting disabilities in older patients with cancer: Comparison between comprehensive geriatric assessment and vulnerable elders survey-13. J Clin Oncol 28:2046-2050, 2010 24. Falci C, Brunello A, Monfardini S: Detecting functional impairment in older patients with cancer: Is vulnerable elders survey-13 the right prescreening tool? An open question. J Clin Oncol 28:e665-e666, 2010; author reply e7 25. Owusu C, Koroukian SM, Schluchter M, et al: Screening older cancer patients for a comprehensive geriatric assessment: A comparison of three instruments. J Geriatr Oncol 2:121-129, 2011 26. Molina-Garrido MJ, Guillen-Ponce C: Comparison of two frailty screening tools in older women with early breast cancer. Crit Rev Oncol Hematol 79:51-64, 2011 27. Schuurmans H, Steverink N, Lindenberg S, et al: Old or frail: What tells us more? J Gerontol A Biol Sci Med Sci 59:M962-M965, 2004 28. Valero S, Migeot V, Bouche G, et al: Who needs a comprehensive geriatric assessment? A French Onco-Geriatric Screening Tool (OGS). J Geriatr Oncol 2:130-136, 2011 29. Extermann M, Aapro M, Audisio R, et al: Main priorities for the development of geriatric oncology: A worldwide expert perspective. J Geriatr Oncol 2:270-273, 2011 30. Extermann M, Meyer J, McGinnis M, et al: A comprehensive geriatric intervention detects multiple problems in older breast cancer patients. Crit Rev Oncol Hematol 49:69-75, 2004 31. Loprinzi CL, Ravdin PM, de Laurentiis M, et al: Do American oncologists know how to use prognostic variables for patients with newly diagnosed primary breast cancer? J Clin Oncol 12:1422-1426, 1994
M. Extermann 32. Slevin ML, Stubbs L, Plant HJ, et al: Attitudes to chemotherapy: Comparing views of patients with cancer with those of doctors, nurses, and general public. BMJ 300:1458-1460, 1990 33. Extermann M, Albrand G, Chen H, et al: Are older French patients as willing as older American patients to undertake chemotherapy? J Clin Oncol 21:3214-3219, 2003 34. Extermann M, Boler I, Reich RR, et al: Predicting the risk of chemotherapy toxicity in older patients: The chemotherapy risk assessment scale for high-age patients (CRASH) score. Cancer Nov 9, 2011 [Epub ahead of print] 35. Hurria A, Togawa K, Mohile SG, et al: Predicting chemotherapy toxicity in older adults with cancer: A prospective multicenter study. J Clin Oncol 29:3457-3465, 2011 36. Janssen-Heijnen ML, Extermann M, Boler IE: Can first cycle CBCs predict older patients at very low risk of neutropenia during further chemotherapy? Crit Rev Oncol Hematol 79:43-50, 2010 37. Audisio RA, Pope D, Ramesh HS, et al: Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical task force prospective study. Crit Rev Oncol Hematol 65:156-163, 2008 38. Audisio RA, Ramesh H, Longo WE, et al: Preoperative assessment of surgical risk in oncogeriatric patients. Oncologist 10:262-268, 2005 39. Alibhai SM, Naglie G, Nam R, et al: Do older men benefit from curative therapy of localized prostate cancer? J Clin Oncol 21:3318-3327, 2003 40. Gore E, Bae K, Langer C, et al: Phase I/II trial of a COX-2 inhibitor with limited field radiation for intermediate prognosis patients who have locally advanced non-small-cell lung cancer: Radiation therapy oncology group 0213. Clin Lung Cancer 12:125-130, 2011 41. Soubeyran P, Khaled H, MacKenzie M, et al: Diffuse large B-cell and peripheral T-cell non-Hodgkin’s lymphoma in the frail elderly. A phase II EORTC trial with a progressive and cautious treatment emphasizing geriatric assessment. J Geriatr Oncol 2:36-44, 2011 42. Hurria A, Cirrincione CT, Muss HB, et al: Implementing a geriatric assessment in cooperative group clinical cancer trials: CALGB 360401. J Clin Oncol 29:1290-1296, 2011
Introduction: The Two-Step Approach
I
t is now well established that older cancer patients present a significant prevalence of geriatric problems. Approximately 20% have an Eastern Cooperative Oncology Group performance status (PS) of ⱖ2. An equal proportion of patients have a dependence in basic activities of daily living (ADL). More than half have a dependence in instrumental activities of daily living (IADL). More than 90% have at least 1 comorbidity, and 30%-40% of those comorbidities are severe. Depression is present in 20%40% of older patients, and cognitive impairment in 25%35% of patients. Finally, 30%-50% of patients are at risk of malnutrition or are malnourished.1 The average number of medications taken by older patients is a half-dozen, with a significant potential for interactions.2 This number has risen since the mid-90s, when it was 4 medications,3 and is likely to keep increasing. Therefore, as a population, older patients need to be assessed for more than just their cancer status. This is highly relevant to all oncologic specialities including radiation oncology because radiation is used even in patients of very advanced age. It is the second most frequent modality used in nonagenarians with cancer, afMoffitt Cancer Center, University of South Florida, Tampa, FL. Address reprint requests to Martine Extermann, MD, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL 33612. E-mail: martine.extermann@ moffitt.org
272
1053-4296/12/$-see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.semradonc.2012.05.003
ter surgery (at Moffitt Cancer Center, 16% and 37% of treatments, respectively, with an additional 2% of patients receiving concomitant chemoradiation).4 Unfortunately, simple clinical judgment is often not a good enough instrument to detect geriatric problems, even when they directly impact the outcome of cancer patients.5-8 Therefore, a specific screening is needed. As a general approach in a busy oncology practice, we suggest a two-step process, illustrated in Figure 1. First, a rapid geriatric screening by the oncology team, and if positive, a combined oncologic and geriatric assessment with an integrated treatment plan. In our experience, very few cancer patients get treated at their first visit, which allows time for a geriatric evaluation in parallel with the final oncology preparations (eg, slides review, port placement, simulation, final staging studies). Several short screening instruments are available in geriatric oncology. They are usually simple to use, and although all the details of their use have not yet been worked out, many of them have some validation. If one chooses a tool designed to assess who needs a more comprehensive multidisciplinary geriatric assessment (MGA), the rapid screening can be done on all new patients, and approximately half of them will need a comprehensive geriatric work-up in parallel with their oncology work-up. Such an approach has been used routinely over the past decade in our clinic at Moffitt with the Senior Adult Oncology Program (SAOP) screening tool (http:// www.moffitt.org/saoptools).
Integrating a geriatric evaluation in the clinical setting
18. Kenis et al14 compared it with the Triage Risk Screening Tool (TRST) and the GFI, and its sensitivity was intermediate between the TRST and the GFI, at 80%. In a large French multicenter trial, the G8 was compared with the VES 13.15 Its sensitivity was 76.6% versus 68.7% for the VES 13, and its specificity was 64.4% versus 74.3%.
Geriatric screening
Negative
273
Positive
The SAOP 2 Screening Tool Oncology workup/ set-up
Treatment plan
Oncology workup/set-up
Geriatric workup/set-up
Integrated treatment plan
Figure 1 General approach to treatment planning in an older cancer patient.
Short Screening Tools These are rapid triage tools taking only a few minutes to answer. This is an area in active development, and the list that follows does not claim to be exhaustive. However, some instruments that were used and tested in recent articles are described in the following sections.
The Abbreviated Comprehensive Geriatric Assessment Overcash et al9,10 isolated an Abbreviated Comprehensive Geriatric Assessment (aCGA) that correlated with the findings of an MGA in a large database of older patients with cancer who underwent a CGA as part of their oncology evaluation. These 15 items include 3 questions about ADL, 4 questions about IADL, 4 questions from the Mini-Mental Status Exam (MMS), and 4 questions from the Geriatric Depression Scale (GDS). If the patient has any impairment in the ADL or IADL items in the abbreviated CGA, then the full ADL and IADL scales should be administered. If 2 depression items are altered, a full GDS should be administered. A score ⱕ6 in the cognitive screen triggers a full MMS.10 The score can be obtained from Overcash et al’s article.9 Kellen et al11 compared the performance of the aCGA with that of the Vulnerable Elder Survey (VES) 13 and the Groeningen Frailty Index (GFI) in predicting impairments in ADL, IADL, MMS, and GDS. The aCGA was more sensitive than the 2 other indices for functional impairments, with a sensitivity of 97% for ADL and 92% for IADL, but performed less well for depression (69%) and cognitive impairment (23%). In a recent cohort of institutionalized patients, the aCGA was also slightly more sensitive than the VES 13.12
The G8 This index was developed by the Institut Bergonié team in France.13 It consists of 8 items, with a score ranging from 0 to
This empirical tool was developed by the multidisciplinary clinical team of the SAOP at Moffitt to determine when a multidisciplinary team consultation was required in new cancer patients. In addition to function, depression, and cognitive screening, the screen includes questions regarding health-related quality of life, self-rated health, falls, nutrition, sleep, polymedication, and social questions (drug payment and caregiver availability). After ⬎8 years of clinical use in its second version, this screen has demonstrated face validity, showing that 63% of senior cancer patients needed psychosocial counseling, 40% dietary intervention, and 14% medication counseling and assistance (the latter probably underestimated).16 Its performance was validated against a multidimensional geriatric assessment.17 It is a sensitive tool, but there is low internal specificity, meaning that if a question is positive in 1 domain of the questionnaire, it might reflect a problem in another domain, reflecting the importance of a multidisciplinary team approach. The first page is answered directly by the patient, and the second page is administered by the clinic staff. If 1 item is positive, the respective specialist is called in, with possible secondary referral to other members of the team. If several items are impaired, the multidisciplinary team is called in or a geriatric referral is made for a CGA. The tool has been translated in Spanish, French, Italian, Chinese, and Portuguese.
The Triage Risk Screening Tool This tool was developed for geriatric screening in the emergency room setting.18 Patients screening positive underwent a half-hour evaluation by a geriatric nurse practitioner. Its performance was compared with a full CGA in oncology patients.19 It proved sensitive, provided the threshold was lowered from 2 to 1 point. Therefore, any positive item would warrant geriatric evaluation in cancer patients. It was compared with the G8 and the GFI in its ability to detect a “geriatric profile” as defined by a multidisciplinary geriatric oncology team.14 With a cut-off value of 1, its sensitivity was 92%, versus 64% with a cut-off of 2 (the original cut-off), 80% for the G8, and 57% for the GFI. In another series comparing the TRST and the G8, the sensitivity of the TRST was 91.2% versus 86.9%, and the specificity was 42.7% versus 60.8%, compared with a standard geriatric assessment battery.20
The Vulnerable Elders Survey 13 Mohile et al21 analyzed the performance of the VES 13,22 developed in a large geriatric survey cohort, in older prostate cancer patients. Fifty percent of patients were identified as impaired on the VES 13 (score ⱖ3). That cutoff had a sensitivity of 72.7% and a specificity of 85.7% for impairment in
M. Extermann
274 ⱖ2 dimensions on an MGA. The score can be obtained from http://www.usafp.org/Best-Practices.htm. Lucianni et al23 found a high sensitivity of the VES 13 for geriatric problems in their study: 87% compared with a CGA, and 90% compared with ADL/IADLs. However, they “adapted” the tests for patients ⬎85 years of age. Although they do not specify the adaptation, the understanding of this author is that they might have counted all patients aged ⱖ85 years as frail. By contrast, Falci et al24 found 30% of elderly patients with favorable VES 13 scores to be vulnerable or frail at full CGA, and 40% of patients with unfavorable VES 13 scores to be fit. The VES 13 was compared with the G8 in the French multicenter study mentioned previously and was found less sensitive and more specific.15 It was compared with the aCGA in Kellen et al’s11 study but was not as sensitive to impairments in ADL (76%) and IADL (67%). One study argued that the performance of VES 13 was comparable with using an Eastern Cooperative Oncology Group PS ⱖ1 or a Karnofsy PS ⱕ80 for screening.25 By contrast, a small study found a better correlation of the VES 13 with a CGA (intraclass correlation ⫽ 0.814) than that of an instrument popular in Spain: the Barber questionnaire (intraclass correlation ⫽ 0.672).26
The Groeningen Frailty Index This index is a list of 15 screening questions addressing various geriatric domains.27 A score of ⱖ4 indicates frailty. In a screening role in older cancer patients, it underperformed the aCGA and VES 13 in detecting impairments in ADL and IADL (47% and 39%, respectively). Also, it did not fare as well as the TRST and the G8 in detecting a geriatric profile in the study by Kenis et al.14 Therefore, it might be more valuable to use it as a frailty defining tool than as a screening instrument in older cancer patients.
The Oncogeriatric Screening Tool This 10-items tool assesses 5 frailty risks.28 It was compared in a prospective cohort study with a geriatric assessment battery performed by a geriatrician. Its sensitivity was 88%, and its specificity 44%. It classified 11% of patients as fit, 81% as vulnerable, and 8% as frail, whereas the geriatric assessments classified 11% of patients as fit, 79% as vulnerable, and 10% as frail. In summary, several short screening tools are available with good sensitivity for geriatric problems. Tools assessing several domains tend to outperform tools assessing functional issues only (such as the VES 13). Sensitivity comes at the price of specificity, and all these instruments have a very moderate specificity. Therefore, these tools by themselves should not serve as a basis for treatment decisions, but should indicate that further evaluation by a geriatric or a multidisciplinary oncogeriatric team is needed.
Step 2: Integrated Geriatric Oncology Management Once a patient screens positive for geriatric problems a combined oncogeriatric approach should be set up. This can take
several formats. The International Society of Geriatric Oncology (SIOG) recently presented its list of the 10 Global Priorities to address the care of older cancer patients.29 Among them is to “Develop interdisciplinary geriatric oncology clinics, especially in academic institutions and comprehensive cancer centers.” We believe that major centers should have geriatric oncology clinics, and this is increasingly the case. There are various formats that can be implemented: A multidisciplinary team coheaded by a geriatrician and an oncologist serving a region (eg, the French Unités Cliniques d’Oncogériatrie), which might have a mobile consultation unit; a team headed by dual trained oncogeriatricians (eg, Moffitt, City of Hope, Roswell Park, and other American cancer centers), with or without geriatric nurse practitioners; or a geriatric team embedded in a cancer center (eg, MD Anderson, Memorial Sloan-Kettering). Smaller hospitals or group practices can set up regular multidisciplinary tumor boards including a geriatrician, or establish a privileged relationship with a geriatric consultant or an academic center with a complete onco-geriatric team, which over time will lead to crosstraining of the participants. Telemedicine consultations might be helpful in this setting. Such multidisciplinary management clearly impacts the oncologic treatment planning of older patients and the management throughout treatment.7,8,30 In the elderly cancer patient (ELCAPA) study, the initial plan of the oncologist was modified in 20.8% of patients, notably those with dependence in ADL and those who were malnourished.8 Eighty percent of the decisions were toward less intense treatment. In the study by Chaïbi et al,7 the geriatric consultation modified the initial treatment plan in 49% of patients. The treatment was delayed in 3%, less intensive in 18%, and more intensive in 28%. In our pilot of 15 breast cancer patients, 6 months of multidisciplinary management modified treatment in 1 patient and influenced treatment management in 3 patients.30
Risk Prediction Models The prediction of treatment outcome in a situation where multidimensional variables occur, as with the older patient, is difficult. Trained oncologists have difficulty integrating in their treatment plan ⬎3 variables at one time.31 Our interpretation of the patient’s desires might be biased by cultural expectations,32,33 and our reading of the literature is selective due to time constraints. Therefore, good quality decision models based on systematic reviews of available data are very valuable. A geriatric evaluation has so far mostly been used as a detection tool to identify problems that might interfere with cancer treatment so that they can then be addressed by the multidisciplinary team or the respective specialists. More recently, however, studies using geriatric parameters as true predictors of oncologic outcome have been published. For example, 2 models predicting the risk of severe side effects from chemotherapy in older patients are available: The Chemotherapy Risk Assessment Scale for High-age patients (CRASH) score,34 and the Cancer and Aging Research Group score.35 None of these scores has yet been validated with
Integrating a geriatric evaluation in the clinical setting chemoradiation regimens, but this would be a logical extension of their use. Also recently published is a simple tool that might help identify patients at very low risk of severe neutropenia and febrile neutropenia after their first cycle of treatment.36 In such patients, weekly blood counts beyond the first cycle might be avoidable. In a different domain, Audisio et al37,38 explored the potential of geriatric instruments to predict complications of surgery with the Preoperative Assessment of Elderly Cancer score. IADL dependence and the number of geriatric domains altered correlate with the risk of complications within 30 days after surgery. These studies represent the future of the use of geriatric instruments in geriatric oncology. We need to harness the now well-established correlation of geriatric instruments with various oncology outcomes to transform this into decision guidelines for integrated onco-geriatric approaches. Other helpful models are general ones that exist, for example, for the adjuvant treatment of breast, colon, and lung cancer (http://www.adjuvantonline.com) or for initial treatment of prostate cancer with radiation or surgery.39 These allow an objective quantification of benefits that can be weighed against potential harms and can be used in the discussions with the individual patients. As it is unlikely for there to be specific therapeutic studies focused only on particular scenarios (eg, older women with lung cancer, diabetes, and coronary artery disease), there is a clear need for more such models in geriatric oncology.
Recommendations, Perspectives, Research Needed In summary, there is an increasing amount of evidence that geriatric parameters should be considered when planning cancer treatment. We recommend identifying or setting up a local oncogeriatric team in an appropriate format. Even if the volume of consultations might initially be low, the effect is likely to be multiplied by a mutual educational process. We recommend choosing 1 short screening tool assessing several geriatric domains in conjunction with the local geriatric support to optimize referral patterns. Such tools should not be considered diagnostic by themselves. Most of the time, the geriatric work-up can be conducted in parallel with the oncology work-up, as patients rarely initiate treatment at their first oncology visit. Regular multidisciplinary meetings are key to optimal management of these patients, as they modify treatment plans in ¼ to ½ of patients.7,8,30 The integration of geriatric assessments and interventions into oncology decision making is a field in rapid progress, so attention should be paid to that literature. Guidelines, such as the NCCN elderly guidelines or the SIOG guidelines, are a good resource for updates. A SIOG task force is in the process of preparing a specific set of guidelines for radiation oncology. More research is needed, particularly on the topics of combined modality therapy and the influence of advanced age on normal tissue and organ tolerance to radiation. Such research studies will typically need more detailed evaluations than simple screening tools. There are now a reasonable number
275 of multicenter trials that have successfully integrated geriatric instruments packages as part of patient evaluations, demonstrating their feasibility.15,34,35,37,40-42
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