Comprehensive Geriatric Assessment for Older Patients With Cancer
10 May 2007-Journal of Clinical Oncology (American Society of Clinical Oncology)-Vol. 25, Iss: 14, pp 1824-1831
TL;DR: An update on the studies that address the domains of a geriatric assessment applied to the oncology patient, the results of the first studies evaluating the use of a CGA in developing interventions to improve the care of older adults with cancer, and future research directions are provided.
Abstract: Purpose During the last decade, oncologists and geriatricians have begun to work together to integrate the principles of geriatrics into oncology care. The increasing use of a comprehensive geriatric assessment (CGA) is one example of this effort. A CGA includes an evaluation of an older individual's functional status, comorbid medical conditions, cognition, nutritional status, psychological state, and social support; and a review of the patient's medications. This article discusses recent advances on the use of a CGA in older patients with cancer. Methods In this article, we provide an update on the studies that address the domains of a geriatric assessment applied to the oncology patient, review the results of the first studies evaluating the use of a CGA in developing interventions to improve the care of older adults with cancer, and discuss future research directions. Results The evidence from recent studies demonstrates that a CGA can predict morbidity and mortality in older patients with cancer. Acc...
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University of Turin1, Aix-Marseille University2, National Health Service3, University Hospital of South Manchester NHS Foundation Trust4, University of Ljubljana5, Karolinska University Hospital6, Centre Hospitalier Universitaire de Grenoble7, University of Aberdeen8, The Royal Marsden NHS Foundation Trust9, VU University Medical Center10, University of Salamanca11, Katholieke Universiteit Leuven12, University Hospital of Lausanne13
TL;DR: The ESMO Guidelines Committee concluded that current state-of-the-art oncology practices in France, Belgium, and the Netherlands are suitable for frontline use and recommend further research into these practices.
2,349 citations
Cites background from "Comprehensive Geriatric Assessment ..."
...CGA can predict morbidity and mortality in elderly patients with cancer [75] and can help to adapt cancer management to each Systemic progression Disease progression...
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01 Jan 2014
TL;DR: Lymphedema is a common complication after treatment for breast cancer and factors associated with increased risk of lymphedEMA include extent of axillary surgery, axillary radiation, infection, and patient obesity.
1,988 citations
Beckman Research Institute1, City of Hope National Medical Center2, University of Rochester3, Case Western Reserve University4, Wake Forest University5, Yale Cancer Center6, Memorial Sloan Kettering Cancer Center7, State University of New York Upstate Medical University8, Georgetown University9, University of California, Davis10, Cornell University11
TL;DR: A risk stratification schema can establish the risk of chemotherapy toxicity in older adults and Geriatric assessment variables independently predicted therisk of toxicity.
Abstract: Purpose Older adults are vulnerable to chemotherapy toxicity; however, there are limited data to identify those at risk. The goals of this study are to identify risk factors for chemotherapy toxicity in older adults and develop a risk stratification schema for chemotherapy toxicity. Patients and Methods Patients age 65 years with cancer from seven institutions completed a prechemotherapy assessment that captured sociodemographics, tumor/treatment variables, laboratory test results, and geriatric assessment variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status). Patients were followed through the chemotherapy course to capture grade 3 (severe), grade 4 (life-threatening or disabling), and grade 5 (death) as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events. Results In total, 500 patients with a mean age of 73 years (range, 65 to 91 years) with stage I to IV lung (29%), GI (27%), gynecologic (17%), breast (11%), genitourinary (10%), or other (6%) cancer joined this prospective study. Grade 3 to 5 toxicity occurred in 53% of the patients (39% grade 3, 12% grade 4, 2% grade 5). A predictive model for grade 3 to 5 toxicity was developed that consisted of geriatric assessment variables, laboratory test values, and patient, tumor, and treatment characteristics. A scoring system in which the median risk score was 7 (range, 0 to 19) and risk stratification schema (risk score: percent incidence of grade 3 to 5 toxicity) identified older adults at low (0 to 5 points; 30%), intermediate (6 to 9 points; 52%), or high risk (10 to 19 points; 83%) of chemotherapy toxicity (P .001).
1,383 citations
Katholieke Universiteit Leuven1, University of Toronto2, Charles University in Prague3, Maastricht University4, University of South Florida5, Lyon College6, University of Chicago7, Curie Institute8, Catholic University of the Sacred Heart9, University of São Paulo10, University of Liverpool11, University of Rochester12, Drug Abuse Resistance Education13
TL;DR: There is mounting data regarding the utility of GA in oncology practice; however, additional research is needed to continue to strengthen the evidence base.
Abstract: Purpose To update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on geriatric assessment (GA) in older patients with cancer. Methods SIOG composed a panel with expertise in geriatric oncology to develop consensus statements after literature review of key evidence on the following topics: rationale for performing GA; findings from a GA performed in geriatric oncology patients; ability of GA to predict oncology treatment–related complications; association between GA findings and overall survival (OS); impact of GA findings on oncology treatment decisions; composition of a GA, including domains and tools; and methods for implementing GA in clinical care. Results GA can be valuable in oncology practice for following reasons: detection of impairment not identified in routine history or physical examination, ability to predict severe treatment-related toxicity, ability to predict OS in a variety of tumors and treatment settings, and ability to influence treatment choice and intensit...
1,266 citations
Cites background from "Comprehensive Geriatric Assessment ..."
...However, these benefits have primarily been noted in acute geriatric care units.(8,11) Data on the utility of GA in the older (often ambulatory) cancer population have emerged only more recently....
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03 Feb 2014
TL;DR: A committee of experts to examine the quality of cancer care in the United States and formulate recommendations for improvement presents the committee’s findings and recommendations.
Abstract: In the United States, approximately 14 million people have had cancer and more than 1.6 million new cases are diagnosed each year. However, more than a decade after the Institute of Medicine (IOM) first studied the quality of cancer care, the barriers to achieving excellent care for all cancer patients remain daunting. Care often is not patient-centered, many patients do not receive palliative care to manage their symptoms and side effects from treatment, and decisions about care often are not based on the latest scientific evidence. The cost of cancer care also is rising faster than many sectors of medicine--having increased to $125 billion in 2010 from $72 billion in 2004--and is projected to reach $173 billion by 2020. Rising costs are making cancer care less affordable for patients and their families and are creating disparities in patients' access to high-quality cancer care. There also are growing shortages of health professionals skilled in providing cancer care, and the number of adults age 65 and older--the group most susceptible to cancer--is expected to double by 2030, contributing to a 45 percent increase in the number of people developing cancer. The current care delivery system is poorly prepared to address the care needs of this population, which are complex due to altered physiology, functional and cognitive impairment, multiple coexisting diseases, increased side effects from treatment, and greater need for social support. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis presents a conceptual framework for improving the quality of cancer care. This study proposes improvements to six interconnected components of care: (1) engaged patients; (2) an adequately staffed, trained, and coordinated workforce; (3) evidence-based care; (4) learning health care information technology (IT); (5) translation of evidence into clinical practice, quality measurement and performance improvement; and (6) accessible and affordable care. This report recommends changes across the board in these areas to improve the quality of care. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis provides information for cancer care teams, patients and their families, researchers, quality metrics developers, and payers, as well as HHS, other federal agencies, and industry to reevaluate their current roles and responsibilities in cancer care and work together to develop a higher quality care delivery system. By working toward this shared goal, the cancer care community can improve the quality of life and outcomes for people facing a cancer diagnosis.
997 citations
References
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TL;DR: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition, and finds that there is an intermediate stage identifying those at high risk of frailty.
Abstract: Background: Frailty is considered highly prevalent in old age and to confer high risk for falls, disability, hospitalization, and mortality. Frailty has been considered synonymous with disability, comorbidity, and other characteristics, but it is recognized that it may have a biologic basis and be a distinct clinical syndrome. A standardized definition has not yet been established.
Methods: To develop and operationalize a phenotype of frailty in older adults and assess concurrent and predictive validity, the study used data from the Cardiovascular Health Study. Participants were 5,317 men and women 65 years and older (4,735 from an original cohort recruited in 1989-90 and 582 from an African American cohort recruited in 1992-93). Both cohorts received almost identical baseline evaluations and 7 and 4 years of follow-up, respectively, with annual examinations and surveillance for outcomes including incident disease, hospitalization, falls, disability, and mortality.
Results: Frailty was defined as a clinical syndrome in which three or more of the following criteria were present: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity. The overall prevalence of frailty in this community-dwelling population was 6.9%; it increased with age and was greater in women than men. Four-year incidence was 7.2%. Frailty was associated with being African American, having lower education and income, poorer health, and having higher rates of comorbid chronic diseases and disability. There was overlap, but not concordance, in the cooccurrence of frailty, comorbidity, and disability. This frailty phenotype was independently predictive (over 3 years) of incident falls, worsening mobility or ADL disability, hospitalization, and death, with hazard ratios ranging from 1.82 to 4.46, unadjusted, and 1.29-2.24, adjusted for a number of health, disease, and social characteristics predictive of 5-year mortality. Intermediate frailty status, as indicated by the presence of one or two criteria, showed intermediate risk of these outcomes as well as increased risk of becoming frail over 3-4 years of follow-up (odds ratios for incident frailty = 4.51 unadjusted and 2.63 adjusted for covariates, compared to those with no frailty criteria at baseline).
Conclusions: This study provides a potential standardized definition for frailty in community-dwelling older adults and offers concurrent and predictive validity for the definition. It also finds that there is an intermediate stage identifying those at high risk of frailty. Finally, it provides evidence that frailty is not synonymous with either comorbidity or disability, but comorbidity is an etiologic risk factor for, and disability is an outcome of, frailty. This provides a potential basis for clinical assessment for those who are frail or at risk, and for future research to develop interventions for frailty based on a standardized ascertainment of frailty.
16,255 citations
TL;DR: The prognostic effect of weight loss prior to chemotherapy was analyzed using data from 3,047 patients enrolled in 12 chemotherapy protocols of the Eastern Cooperative Oncology Group and increased with increasing number of anatomic sites involved with metastases, but within categories of Anatomic involvement, weight loss was associated with decreased median survival.
2,178 citations
TL;DR: The number of participants who said they would choose treatment declined as the likelihood of an adverse outcome increased, with fewer participants choosing treatment when the possible outcome was functional or cognitive impairment than when it was death.
Abstract: Background The questions patients are asked about their preferences with regard to life-sustaining treatment usually focus on specific interventions, but the outcomes of treatment and their likelihood affect patients' preferences. Methods We administered a questionnaire about treatment preferences to 226 persons who were 60 years of age or older and who had a limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease. The study participants were asked whether they would want to receive a given treatment, first when the outcome was known with certainty and then with different likelihoods of an adverse outcome. The outcome without treatment was specified as death from the underlying disease. Results The burden of treatment (i.e., the length of the hospital stay, extent of testing, and invasiveness of interventions), the outcome, and the likelihood of the outcome all influenced treatment preferences. For a low-burden treatment with the restoration of current hea...
1,243 citations
"Comprehensive Geriatric Assessment ..." refers background in this paper
...8% of patients stated that they would not choose the treatment if the outcome was survival but severe cognitive impairment.(27) In a study of older patients with breast cancer, approximately half perceived a decline in cognitive function from before chemotherapy to 6 months after chemotherapy, most pronounced in patients who perceived pre-existing cognitive problems....
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TL;DR: Comorbidity is an important independent prognostic factor for patients with cancer and the inclusion of comorbidities in hospital-based cancer registries will increase the value and use of observational research.
Abstract: Context Patients with cancer often have other medical ailments, referred to as comorbidity. Comorbidity may impact treatment decision-making, prognosis, and quality of care assessment. Objective To assess whether comorbidity information can provide important prognostic information in a hospital-based cancer registry. Design, setting, and participants An observational prospective cohort study using comorbidity data collected by trained hospital-based cancer registrars. Comorbidity was obtained through medical record review using the Adult Comorbidity Evaluation 27, a validated chart-based comorbidity instrument. A total of 17,712 patients receiving care between January 1, 1995, and January 31, 2001, for the primary diagnosis of new cancer of the prostate, lung (nonsmall cell), breast, digestive system, gynecological, urinary system, or head and neck were included. Main outcome measure Duration in months of overall survival. Results A total of 19,268 patients were included in the study; median duration of follow-up was 31 months. Of these patients, 1556 (8.0%) were excluded due to missing or unknown data. Severity of comorbidity strongly influenced survival in a dose-dependent fashion and the impact of comorbidity was independent of cancer stage. Compared with patients without comorbidity, the adjusted hazard ratio associated with mild comorbidity was 1.21 (95% confidence interval [CI], 1.13-1.30), moderate comorbidity was 1.86 (95% CI, 1.73-2.00), and severe comorbidity was 2.56 (95% CI, 2.35-2.81). Adjusted Kaplan-Meier survival curves revealed that at any point in time the patients with more severe levels of comorbidity had worse survival (partial chi2(3) due to comorbidity, 523.54; P Conclusions Comorbidity is an important independent prognostic factor for patients with cancer. The inclusion of comorbidity in hospital-based cancer registries will increase the value and use of observational research.
1,091 citations