You don’t have to be a geriatrician to properly evaluate and manage older patients with cancer. The wave of older patients with cancer predicted over 30 years ago is now fully upon us. The oncology community finds itself ill-prepared to manage the increased number of older patients. It is not just the age of the patient but the comorbidities, social issues, and cognitive decline that will confront oncologists with complex problems to solve in a short period of time.
Stuart Lichtman, MD, FACP, FASCO
At the same time, we have seen a surge in new modalities of treatment, including immunotherapy and drugs targeting various cell processes and actionable mutations, new radiation therapies, and surgical techniques. However, chemotherapy for most of the common diseases will still be with us for the foreseeable future. It is absolutely incumbent on all oncology practitioners to be able to evaluate older patients for their specific specialty.
Most of the focus of assessing older patients has been on chemotherapy toxicity, with guidance on drug selection and dosing as well as overall cancer outcomes. Studies have yielded a number of validated measures to predict chemotherapy toxicity and functional outcome. They have been published in high-impact journals such as the Journal of Clinical Oncology and have come from reputable research institutions and organizations. Despite the number of patients and the data, why have these evaluations and models not entered general oncology care?
Impediments to Implementing Geriatric Evaluation
In the current busy world of clinical oncology, there is a reluctance to add on more evaluations. Clinicians are often unfamiliar with geriatric issues and terminology due to a lack of training and may find it difficult to interpret the results of testing and incorporate them into decision-making.
One reason for this has been the underrepresentation of older patients in clinical trials. There is not an adequate amount of objective data. Even when trials do include some older patients, they often do not include the baseline data to fully interpret the outcomes in relation to these patients. Clinical trials often inadequately report the outcomes of older patients, particularly in terms of treatment-related toxicity. And most oncologists have no geriatric training. Despite these issues, some clinicians may feel they can still perform the evaluation. However, these issues have led to undertreatment with poor outcomes or overtreatment with unnecessary excessive toxicity. One great impediment to the implementation of a geriatric evaluation is the Comprehensive Geriatric Assessment. How can busy clinicians perform a “comprehensive assessment” in a field of medicine with which they may not be truly familiar? Many may believe it takes a long time to perform it and may wonder how the results will be used. Many busy clinicians, already overwhelmed by patient care, electronic health records, and medical bureaucracy, reject the implementation of the Comprehensive Geriatric Assessment a priori. They may say, ‘I am not a geriatrician. I don’t have the time.’
Key Clinical Issues for Older Patients
But I say emphatically, you don’t have to be a geriatrician. A busy clinician can do a brief, focused, geriatric evaluation depending on the clinical situation. The evaluation can be performed by another health-care professional; much of the evaluation is a geriatric self-assessment. Simple steps such as watching a patient walk and asking about recent falls can influence a decision about potential neuropathy, for example.
“Polypharmacy and drug management issues are key components of geriatric evaluation.”— Stuart M. Lichtman, MD, FACP, FASCO
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Polypharmacy and drug management issues are key components of geriatric evaluation. The ability to take medications correctly is evaluated as part of the Instrumental Activities of Daily Living (managing finances, handling transportation, shopping, preparing meals, using the telephone and other communication devices, managing medications, attending to home maintenance). Deficiencies in components of Instrumental Activities of Daily Living have consistently been associated with increased therapy-related toxicities and poor outcomes.1,2
Standard medical practice now incorporates drug utilization as part of routine patient evaluation. With minor modification, this can be made to focus on older patients. Stopping unnecessary and inappropriate medication can potentially avoid the adverse sequelae mentioned. It can also be used as a teachable moment to focus on the most important issues facing older patients.
Brief, Validated Clinical Tools Available
Clinicians caring for older patients with cancer should not and cannot carry out the traditional Comprehensive Geriatric Assessment performed by geriatricians. The Comprehensive Geriatric Assessment is a tool that geriatricians use to screen for specific problems that will need to be addressed further. It was not developed as an intervention or a predictive tool for cancer therapy. As a result, researchers in geriatric oncology have developed brief, validated tools that aid clinicians in shared decision-making.
It is important to note that data over the past decade have shown that the ability to predict some important clinical outcomes need not be time-consuming nor require highly specialized geriatric knowledge. Dependency in one or more Instrumental Activities of Daily Living is predictive of poor tolerance to treatment and adverse outcomes.1,2 These questions, which take only a few minutes, can be incorporated into basic history-taking or answered by patients in the waiting room.
“Using one of the accepted guidelines to evaluate polypharmacy is one way for clinicians to begin to feel comfortable with geriatric evaluation...”— Stuart M. Lichtman, MD, FACP, FASCO
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The Cancer and Aging Research Group has developed a clinical tool to predict grade 3 or 4 chemotherapy toxicity.3 It has been shown to be superior to clinical judgment and requires minimal physician time. Its components are easily obtainable. Patients with multiple adverse factors may have at least an 80% chance of developing severe toxicity. Patients without significant adverse factors still have an approximately 25% chance of excessive toxicity, emphasizing the vulnerability of the well elderly. The CRASH score (chemotherapy risk assessment scale for high-age patients) can distinguish several risk levels of severe chemotherapy toxicity.4
The importance of adding specific geriatric components to the evaluation of older patients has been recognized by several organizations. ASCO has a number of initiatives, including a Geriatric Special Interest Group, which has recently published guidelines; ASCO University; sessions at the Annual Meeting; a Geriatric Oncology component of the Cancer Education Committee; and the BJ Kennedy Award for Excellence in Geriatric Oncology.5 The Gynecologic Oncology Group’s elderly task force has incorporated the Cancer and Aging Research Group evaluation. The International Society of Geriatric Oncology has educational initiatives and treatment recommendations. The National Comprehensive Cancer Network® (NCCN®) Guidelines for Older Adult Oncology have an extensive discussion of polypharmacy and assessment tools.
Using one of the accepted guidelines to evaluate polypharmacy is one way for clinicians to begin to feel comfortable with geriatric evaluation and to make a tangible impact on patient care. Reducing unnecessary medications can help to optimize drug therapy, reduce costs, increase compliance, and decrease adverse drug events and toxicity. Other aspects of geriatric evaluation can be gradually introduced into their practice, so the value of each component can be appreciated.6
‘Current Status Quo Is Unacceptable’
With all of the information and guidelines available, why hasn’t there been a large-scale uptake of geriatric evaluation? Maybe it’s just inertia, a resistance to change. It could be that adding another thing to do is just overwhelming. Whatever the reason, the current status quo is unacceptable.
Clinicians should not fear the words “geriatric assessment.” The dramatic rise in the number of older patients with cancer makes the incorporation of a geriatric-specific evaluation a requirement to provide high-quality, safe, and cost-effective cancer care. As older patients will become the majority of the patients we evaluate and treat, they need to become the focus of our endeavors. They deserve nothing less. ■
Dr. Lichtman is Attending Physician, Memorial Sloan Kettering Cancer Center; Professor of Medicine, Cornell University Medical College; and Immediate Past President, International Society of Geriatric Oncology, Geneva.
DISCLOSURE: Dr. Lichtman has served as a consultant or advisor for Magellan Health and Remedy One.
REFERENCES
1. Overcash J: Assessing the functional status of older cancer patients in an ambulatory care visit. Healthcare (Basel) 3:846-59, 2015.
2. Korc-Grodzicki B, Sun SW, Zhou Q, et al: Geriatric assessment as a predictor of delirium and other outcomes in elderly patients with cancer. Ann Surg, 2014.
3. Hurria A, Togawa K, Mohile SG, et al: Predicting chemotherapy toxicity in older adults with cancer. J Clin Oncol 29:3457-65, 2011.
4. Extermann M, Boler I, Reich R, et al: The chemotherapy risk assessment scale for high-age patients (CRASH) score: design and validation. ASCO meeting abstracts 28:9000, 2010.
5. Mohile SG, Dale W, Somerfield MR, et al: Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 36:2326-2347, 2018.
6. Lichtman SM: Polypharmacy: geriatric oncology evaluation should become mainstream. J Clin Oncol 33:1422-3, 2015.
