Comprehensive Geriatric Assessments Key to Treatment Planning in Elderly Patients

Comprehensive geriatric assessment (CGAs) will play an increasingly important role in identifying patient frailty and personalizing geriatric oncology treatment, according to several recently published reviews.[1-3]

CGAs measure baseline patient cognitive function, nutritional status, and physical functional status.[1,2] Both cancer and its treatment can profoundly stress organ and immunologic function in older adults.

“CGA predicts survival in colorectal cancer, identifies high-risk surgical oncology patients, predicts toxicities associated with breast cancer treatment, helps determine cancer treatment decisions, and identifies those individuals who are most likely to tolerate cancer treatment,” reported authors of a review in Seminars in Oncology Nursing.[3]

But the concept of frailty in geriatric oncology is a deceptively simple one, cautioned researchers at Emory University’s Winship Cancer Institute in Atlanta.[1]

“Put simply, frailty is a state of extreme vulnerability to stressors that leads to adverse health outcomes,” wrote Cecilia G. Ethun, MD, and coauthors.[1] “In reality, frailty is a complex, multidimensional, and cyclical state of diminished physiologic reserve that results in decreased resiliency and adaptive capacity and increased vulnerability to stressors.”

More than 70 CGA instruments have been proposed.[1] Better standardization is needed for cut-off score thresholds to identify frailty, the authors concluded.[1]

As the Baby Boomer generation ages and enters high-risk years for cancer diagnosis, oncology nurses will conduct CGAs to inform multidisciplinary clinical geriatric oncology decision-making.[3]

“Objective findings from the CGA can be crucial in developing end-of-life care plans that reflect both the patient’s health status and personal values,” noted authors of another review, published online ahead of print in Current Oncology Reports.[2] CGA can help inform patients about realistic treatment outcomes and spare frail patients toxic side effects from treatments that are unlikely to effectively control their tumors.[2]

Authors of a systematic review of 36 published studies, including 27 prospective studies, concluded that CGA predicts which elderly patients are likely to benefit from chemotherapy and which will suffer adverse events.[4]

Other recently published studies have bolstered the case that frailty predicts worse treatment outcomes.[3] A study of 535 women with advanced ovarian cancer, published in the October issue of Gynecologic Oncology, found that frailty was an independent predictor of postsurgical mortality even after statistically controlling for other known risk factors; overall survival (OS) was significantly shorter among frail patients than non-frail patients (median OS: 26.5 months vs 44.9 months; P < .001).[5]

“Routine assessments of frailty can be incorporated into patient counseling and decision-making for the advanced epithelial ovarian cancer patient beyond simple reliance on single factors such as age,” the authors of the ovarian surgery outcomes study concluded.[5]

References:

1. Ethun CG, Bilen MA, Jani AB, et al. Frailty and cancer: Implications for oncology surgery, medical oncology, and radiation oncology. CA Cancer J Clin. 2017;67:362-77.

2. Baronner A, MacKenzie A. Using geriatric assessment strategies to lead end-of-life care discussions. Curr Oncol Rep. 2017;19:75.

3. Overcash J, Momeyer MA. Comprehensive geriatric assessment and caring for the older person with cancer. Semin Oncol Nurs. 2017 Sep 15. [Epub ahead of print]

4. Janssens K, Specenier P. The prognostic value of the comprehensive geriatric assessment (CGA) in elderly cancer patients (ECP) treated with chemotherapy (CT): a systematic review. Eur J Cancer. 2017;72(suppl 1):S164-5.

5. Kumar A, Langstraat CL, DeJong SR, et al. Functional not chronologic age: Frailty index predicts outcomes in advanced ovarian cancer. Gynecol Oncol. 2017;147:104-9.