Comprehensive Geriatric Evaluations Improve Care

BOSTON—Elderly cancer patients who are very healthy can usually tolerate cancer treatments. Most elderly patients have comorbidities, however, and oncologists are being urged to conduct a comprehensive geriatric evaluation before deciding on a course of treatment.

The recommendation comes from Martine Extermann, MD, of the Senior Adult Oncology Program (SAOP), H. Lee Moffitt Cancer Center & Research Institute, University of South Florida, Tampa. She told the 14th international meeting of the Multinational Association for Supportive Care in Cancer (MASCC) and International Association for Oral Oncology that many problems affecting prognosis are not currently detected before cancer treatment.

"We have good data that some form of geriatric assessment improves care," she told ONI in an interview. "And now we have several screening tools available . . . they are not perfect, but they can help the busy physician screen for the most important problems with as little as a 5-minute assessment."

Dr. Extermann recommended that physicians use results from a rapid geriatric screening and comprehensive geriatric assessment to place elderly patients in one of three categories (see Figure):

1. Healthy. Patient is in good condition except for cancer and can tolerate high-dose chemotherapy or radiation therapy.
2. Vulnerable. Patient looks healthy but is at increased risk of complications and of dying within the next few years. Treat with tailored, lower-dose treatment regimens that minimize toxicity.
3. Frail. Patient cannot survive aggressive treatment and should be given tailored treatment or palliative care.

"The challenge in oncology is to define and target the vulnerable population," she said. Patients in her program have three comorbidities on average, and 5% take as many as 10 medications each day. "Before you can treat a problem, you need to detect it," she said, warning that malnutrition, depression, and cognitive disorders are often missed if the patient is not screened.

As many as one third of all elderly cancer patients are depressed, but most are not diagnosed because they are more likely to rationalize than to cry about their problems, Dr. Extermann said. "We are not diagnosing depression well, and I think it’s dangerous to act on an inadequate diagnosis," she said. She noted that she has been surprised to find that some patients who seemed fine screened positive for depression while others who appeared depressed screened well and were able to handle chemotherapy.

Available geriatric screening tools include a National Comprehensive Cancer Network (NCCN) instrument that Dr. Extermann said could be completed in 5 minutes during an office visit and MACE, a structured, multidimensional questionnaire developed by Italian researchers.

Her program does a 2½-hour multidimensional geriatric and medical evaluation. Although time consuming, the full assessment "pays for itself in the long run," Dr. Extermann said. She urged oncologists to form alliances with geriatricians who can help assess older patients with more complicated problems.

Various cooperative groups have developed 20-minute assessments for clinical trials, she added, and SAOP is developing a computerized assessment. An International Society of Geriatric Oncology task force is reviewing evidence on comprehensive geriatric assessments, Dr. Extermann said. It is expected to issue more detailed guidelines next year.

Supportive care of the older cancer patient is an increasingly important issue in oncology, according to Paul Calabresi, MD, professor of medicine, Brown University, who served as chairman of a plenary session on the topic. He said that the median age for cancer is 70 in the United States, and many more cases are anticipated as the baby boom generation ages.

"Problems in the elderly are different and unique," he said, warning that drugs act differently in older populations, who are often undergoing immunologic changes that can alter their response to cancer therapies.