Geriatric Assessment in Oncology

Today, in practice of an oncologist almost 54% new cases and 70% of the patients who die due of cancer are above 65years.[1] Thus, geriatric oncology is a very important aspect for all the oncologist. Lung cancer, prostate cancer, breast cancer, and many other common cancers have median population in geriatric age. Elderly patients are different from young and young adults in many significant ways; these include physiological changes, increased prevalence of cancers, varied presentation of common diseases, and variable responses to treatment and the interactions of the drugs due to multiple comorbidities. The elderly patients are usually not included in the clinical trials due to their comorbidities, and hence, these patients require comprehensive assessment before starting the treatment. There are few guidelines that address the evaluation process and treatment in elderly patients.

Oncologists face issues for assessing the patients, whom to be chosen for treatment and for whom to provide best supportive care. The definition of elderly patients differs among various study groups starting from 60 to 70 years. The chronological age of a person can help assessing the physiological status but does not still define it completely about the tolerance to the cancer treatment. There exists wide heterogenicity among the patients of the same age to any aggressive therapy to cancer.

The elderly patient has lesser chances to get the standard treatment as provided to the younger adults due to their comorbidities, varied toxicities due to physiological status, and access to health-care facilities.[2] [3] [4] [5] [6] [7] [8] The aging process decreases the physiological reserve of multiple organs and increases the chances of frailty and increased chances of toxicity even without comorbidities, manifesting as weight loss, fatigue, and decreased activity. Hence, it is important to identify the frail patients and recognize the potential benefits and adverse effects of treatment.

Geriatric Assessment: It is a multidisciplinary process involving the functional, psychological, nutritional, and medical assessment of an elderly patient before starting the cancer treatment, and it helps in finding the problems not found by routine evaluation.[9]

Initially, it was developed for the assessment of general geriatric population for detecting aging-related issues slowly rolled over to oncology clinics. The initial approaches in clinics included assessment of functional, psychological and mental, nutritional and cognitive, and economic status of the patient, but these were time consuming. Then came the assessment by a questionnaire form by Hurria[10] and now recently shifted to electronic models of assessment with various algorithms. As it is very time consuming, hence came the role of screening assessment for patients who needs comprehensive geriatric assessment (CGA).[10] The major and important domains of CGA are as follows:

1. Demography and social status

2. Comorbidities

3. Functional status

4. Cognition

5. Polypharmacy

6. Nutrition

7. Geriatric syndromes

How do a complete geriatric assessment help us?

1. Predicts response to treatment and toxicities—several tools like chemotherapy risk assessment scale for high age patients (CRASH) and cancer and aging research group (CARG) score use geriatric assessment data for predicting toxicities of chemotherapy.

2. Predicts patient's vulnerability—helps in identifying abnormalities in almost 50% of population that are not found by routine evaluation. Most common among them are poor functional status (40.1%), poor nutrition (37.6%), depression (27.2%), and cognitive impairment (19%).

3. Helps in treatment decisions.

4. Helps on survival.

5. Helps to assess functional decline due to treatment.

6. Better assessment of dosages of drugs in view of comorbidity status.

7. Helps in planning interventions for the management of specific issues involving nutrition, social support, economic support, and physical therapy.[10]

Optimum cutoff age for patients for whom genetic assessment has to be done is not recommended clearly, but guidelines recommend that all elderly patients have to undergo CGA. The problem with CGA is that it is very time and resource consuming; hence, certain screening tools are used to decide who to go for CGA. The screening tools available are as follows:

1. Geriatric 8—best sensitivity and highly studied.

2. Senior Adult Oncology Program-2.

3. Abbreviated CGA includes geriatric depression assessment and Mini-Mental State Examination (MMSE).

4. Vulnerable Elderly Survery-13.

5. Fried Frailty Criteria.

6. Triage Risk Screening Tool (TRST).

None of these tools are better or preferred over the other. The specificity for abnormal CGA is highest for abbreviated CGA (97%); maximum sensitivity is given by SAOP-2 or TRST criteria. The patients who are positive on screening test should be taken up for CGA. This can be completed by patient or caregiver within 20 minutes and the electronic tools with algorithm provide details of interventions necessary for improvement in patient condition. Even if the CGA cannot be performed, the screening tools provide useful information required for the management of cancer in elderly.

Other ways of assessment include:

1. Time Up and Go (TUG): it provides assessment of patient's mobility and balance and ability to avoid falls. TUG >13 seconds is associated with increased risk of falls and poor balance. It is done using a chair, stopwatch, and 3-minute walkway.

2. Geriatric Depression Scale-15 (GDS-15): It helps predicting the functional decline of the patient on cancer treatment. A score of >5 in a self-assessment 15-point tool is considered abnormal.

For predicting the toxicities among patients, following tools are used:

1. Chemotherapy risk assessment scale for high age patients (CRASH)

2. Cancer and aging research group (CARG)

These tools are validated by various prospective studies and they recommend either of them can be used in clinical practice.

Collection of suitable data for assessment is the most important tool for GA. This data for patients can be collected either by:

1. Mailed CGA—It was used at Durham for male oncology patients to evaluate their pain, quality of life, functional status, financial and spiritual well-being, social support, and psychological status.

2. Self-administered CGA—It was developed by CALGB and Cancer in Older Adult committee. Most of them are self-evaluation by the patient, but three domains—functional, cognition, and performance status—are evaluated by the clinician.

3. Electronic CGA—Memorial Sloan Kettering Cancer Center (MSKCC) developed electronic rapid fitness assessment for preoperative evaluation.

4. Clinical assessment—This method involves assessment with the help of Multidimensional Assessment Protocol for Cancer, which includes an evaluation of the socioeconomic status, cognitive status, depression, physical performance, disability, and tumor characteristics. Time taken is 27 minutes.

Assessment of frailty and other domains of GA is discussed in the following text.[11]

Publication History

Article published online:
13 December 2021

• References

• 1 Surveillance, Epidemiology, and End Results (SEER) Cancer Statistics Review, 1975–2015. http://seer.cancer.gov/archive/csr/1975_2015/ . Accessed July 05, 2021
• 2 Christman K, Muss HB, Case LD, Stanley V. Chemotherapy of metastatic breast cancer in the elderly. The Piedmont Oncology Association experience [see comment]. [see comment] JAMA 1992; 268 (01) 57-62
• 3 Hurria A, Leung D, Trainor K, Borgen P, Norton L, Hudis C. Factors influencing treatment patterns of breast cancer patients age 75 and older. Crit Rev Oncol Hematol 2003; 46 (02) 121-126
• 4 Mandelblatt JS, Hadley J, Kerner JF. et al. Patterns of breast carcinoma treatment in older women: patient preference and clinical and physical influences. Cancer 2000; 89 (03) 561-573
• 5 Newcomb PA, Carbone PP. Cancer treatment and age: patient perspectives. J Natl Cancer Inst 1993; 85 (19) 1580-1584
• 6 Merchant TE, McCormick B, Yahalom J, Borgen P. The influence of older age on breast cancer treatment decisions and outcome. Int J Radiat Oncol Biol Phys 1996; 34 (03) 565-570
• 7 Bergman L, Dekker G, van Leeuwen FE, Huisman SJ, van Dam FS, van Dongen JA. The effect of age on treatment choice and survival in elderly breast cancer patients. Cancer 1991; 67 (09) 2227-2234
• 8 Bergman L, Kluck HM, van Leeuwen FE. et al. The influence of age on treatment choice and survival of elderly breast cancer patients in south-eastern Netherlands: a population-based study. Eur J Cancer 1992; 28A (8-9): 1475-1480
• 9 Loh KP, Soto-Perez-de-Celis E, Hsu T. et al. What every oncologist should know about geriatric assessment for older patients with cancer: young International Society of Geriatric Oncology position paper. J Oncol Pract 2018; 14 (02) 85-94
• 10 Cohen HJ. Evolution of geriatric assessment in oncology. J Oncol Pract 2018; 14 (02) 95-96
• 11 Korc-Grodzicki B, Holmes HM, Shahrokni A. Geriatric assessment for oncologists. Cancer Biol Med 2015; 12 (04) 261-274
• 12 Golchin N, Frank SH, Vince A, Isham L, Meropol SB. Polypharmacy in the elderly. J Res Pharm Pract 2015; 4 (02) 85-88