Geriatric Assessment May ImproveCancer Prognosis in the Elderly

TAMPA, Florida-Clinicianscould improve the prognosis of elderlycancer patients with a comprehensivegeriatric assessment (CGA) andappropriate follow-up based on theresults, according to Martine Extermann,MD, PhD."Older cancer patients have healthproblems that influence prognosis andare underdetected," said Dr. Extermann,assistant professor at the H. LeeMoffitt Cancer Center, University ofSouth Florida, Tampa. "A CGA mayinfluence the prognosis of these patients."According to Dr. Extermann, usingthe geriatric assessment is just oneway that taking a "geriatric oncologyapproach" could benefit elderly cancerpatients."Geriatric assessment uncovers alot of functional problems that wouldbe missed by ECOG (Eastern CooperativeOncology Group) performancestatus," she said. "On average, our patientshave three comorbid diseases inclinic...you will find that half of themhave five comorbid diseases by the ageof 75."Dr. Extermann and her colleagueshave completed a small pilot studydesigned to determine the value ofcomprehensive geriatric assessmentplus appropriate follow-up in olderbreast cancer patients. The 6-monthprotocol included a multidisciplinaryCGA every 3 months and a call from anurse practitioner once monthly; specialistsprovided additional follow-upbased on pharmacy, dietary, and psychosocialrisks identified.Of the 15 patients enrolled, 10 completedall assessments, and an 11thpatient completed the 3-month assessment.Patients ranged in age from70 to 87 years (mean age, 80 years)and had as many as nine comorbidities(median, five).Findings ReportedGeriatric assessment revealed thatsix patients were at high pharmacyrisk and two were at moderate pharmacyrisk. During the study period,patients presented with an average ofnine problems that required some sortof intervention; often, multiple teammembers collaborated to solve thesenewly arising problems.For one patient, an 83-year-oldwith memory problems, the geriatricassessment findings altered the oncologist'schemotherapy decision, accordingto Dr. Extermann. In addition,the findings improvedcompliance with hormone therapy fortwo patients. In another notable intervention,one member of the multidisciplinaryteam detected an error inthe filling of a paroxetine (Paxil) prescription.In seven cases, the assessmentand follow-up ensured that patientsreceived continuity orcoordination of care.Patients maintained independenceand function, investigators reported.Despite two new depressions screenedby the Geriatric Depression Scale,mean scores on the functional assessmentof cancer therapy-breast (FACTB)scale improved from 110.5 (SD ±16.7) to 116.3 (SD ± 16.3) (P = .02).One patient needed major multidisciplinaryintervention throughout follow-up.While preliminary, these resultssuggest that a geriatric assessment plusmultidisciplinary intervention couldimprove treatment and possibly prognosisin elderly cancer patients, Dr.Extermann said.In a 1993 meta-analysis of 28 controlledtrials (Lancet 342:1032-1036),investigators reported a 26% relativerisk reduction in institutionalizationfor 4,959 subjects who received CGAvs 4,912 controls.This 26% reduction in risk is com-parable to the benefit of adjuvant breastcancer chemotherapy in preventingrelapse, or the benefit of beta-blockersin preventing new myocardial infarctions,according to Dr. Extermann.More recent studies and meta-analyseshave shown that geriatric assessmentis cost-effective and has a "consistentbeneficial effect" on functionalstatus, although the results regardingmortality benefit have been ambiguous,said Dr. Extermann. In The Lancetmeta-analysis, there was a 14% relativerisk reduction in mortality forthe geriatric assessment group.Specialized home-care interven-tions utilizing geriatric nurses couldalso improve prognosis for elderly cancerpatients. In one randomized controlledstudy including 375 dischargedolder cancer patients (60 to 92 years ofage), a month of home visits and telephonecalls from advanced-practicenurses was associated with a survivalbenefit on follow-up, at least for latestagepatients. The 2-year survival forlate-stage cancer patients was 67%, vs40% for controls."I think this is definitely a strikingresult that suggests we are really changingthe survival of our cancer patients,"Dr. Extermann said.