For many clinicians working in oncology today, most of their patients are likely to be older.  As for most types of cancer, the risk of developing cancer increases with age. Currently, the median age at diagnosis of any cancer is 66 years in the United States, with slight differences for each type of cancer.1 

The older population of patients often have other medical comorbidities that contribute to their overall health, as well as other challenges due to their age.2 Chronological age is not necessarily an accurate indicator of a patient’s ability to tolerate chemotherapy, and cancer treatment is not one-size-fits-all. Age is just one factor to consider with treatment planning. Performing a comprehensive geriatric assessment (CGA) prior to and after treatment can be an effective way to monitor the older patient. A recently published observational study evaluated the use of a standardized geriatric assessment, the Geriatric 8 (G8), as well as CGA to determine how these tools could be used to evaluate functional status and quality of life before and after chemotherapy.3 

Comprehensive Geriatric Assessment

The CGA is not one standardized test administered to patients. It is generally made up of multiple tests and evaluations that assess different factors for each person. Low scores in these areas have been associated prognostically with decreased survival. As it is comprehensive, CGA may take a significant amount of time to adequately perform a thorough evaluation for every patient. The following are systems that are reviewed during a CGA.4 

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Comorbidities Various comorbid conditions can potentially affect how one will deal with the prescribed cancer therapy. Certain conditions may be more likely to lead to increased toxicity from treatment or may potentiate the need to have to eliminate certain treatments altogether. 

Polypharmacy When elderly patients use multiple medications, this puts them at risk for potential interactions between medications and increases their risk for toxicity. Polypharmacy is typically defined as the use of at least 5 daily medications. 

Psychosocial function The presence of preexisting depression can impact how well a patient with cancer reacts to their diagnosis and adheres to the prescribed treatment plan. The Geriatric Depression scale can be used to determine depression score.  

Cognitive function The Mini Mental State test is used to screen for cognitive function. This can help alert the oncology team to difficulties with cognition and memory that may contribute to a patient’s nonadherence to their treatment plan. 

Functional status Assessing functional status can evaluate not only the activities of daily living (ADL), such as feeding, dressing, and toileting, but also instrumental activities of daily living (IADL). IADL assesses the ability to perform tasks to live independently, such as preparing meals, doing laundry, housekeeping, and managing finances. 

Nutritional status Malnutrition and nutritional deficiencies can be common among the elderly. The Mini Nutritional Assessment (MNA) can be used to determine those who are deficient or are at risk. 

The Geriatric 8

The G8 screening tool was developed to allow for screening patients more quickly and identifying areas that may need further evaluation with a full CGA. The G8 tool is a questionnaire with 8 questions, each scored individually. The total score ranges from 0 to 17. Answers to the questions are scored, and a patient is determined to be either high or low risk. The questions asked on the G8 include5:

  • Has food intake decreased over the last 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties?
  • Weight loss during the last 3 months?
  • Mobility?
  • Neuropsychological problems?
  • BMI?
  • Takes more than 3 prescription drugs per day?
  • In comparison with other people of the same age, how does the patient consider their health status?
  • Age?

Those whose score finds them to be at risk for specific impairments are suggested to undergo full CGA testing.5

Outcomes of the Study

In the recently published study, a total of 291 patients were administered the CGA and G8 tests before starting chemotherapy, immediately after finishing chemotherapy, and again 1 year later. Patients included those being treated for curative and palliative intents and had a variety of solid tumor and hematologic malignancies.3 

The use of the CGA consisted of the Charlson comorbidity index, polypharmacy, ADL, IADL, geriatric depression scale-15, Mini-Mental State evaluation, and minimal nutrition assessment. Using these tools, patients were classified as either fit, vulnerable, or frail depending upon the results.3

The G8 screening tool referenced above was used, and patients with scores of 14 or less were high risk, and those with scores greater than 14 were low risk.3 

The study found that patients who had a high-risk G8 score before starting chemotherapy were at higher risk for progressive disease or decline in IADL 1 year after treatment. They were also found to have shorter overall survival and stopped chemotherapy prematurely due to toxicity. These results were mostly seen in patients being treated with neoadjuvant or adjuvant chemotherapy for solid tumor malignancies. The CGA classification of fit, vulnerable, or frail didn’t show association with the same outcomes. The study also found that in at least half of the patients studied, the quality of life, IADL independence, and functional status were maintained following chemotherapy.3 

Conclusions

The results of this study showed that using the G8 can provide a practical way for clinicians to help decision making about chemotherapy, especially for those patients who are being treated with neoadjuvant or adjuvant chemotherapy for solid tumors.3 

References

  1. Age and cancer risk. National Cancer Institute. Updated March 5, 2021. Accessed September 15, 2022. 
  2. Mohile SG, Epstein RM, Hurria A, et al. Communication with older patients with cancer using geriatric assessment: a cluster-randomized clinical trial from the National Cancer Institute Community Oncology Research Program. JAMA Oncol. 2020;6(2):196-204. doi:10.1001/jamaoncol.2019.4728
  3. Rier HN, Meinardi MC, van Rosmalen J, et al. Association between geriatric assessment and post-chemotherapy functional status in older patients with cancer. Oncologist. Published online July 21, 2022. doi:10.1093/oncolo/oyac131
  4. Owusu C, Berger NA. Comprehensive geriatric assessment in the older cancer patient: coming of age in clinical cancer care. Clin Pract (Lond). 2014;11(6):749-762. doi:10.2217/cpr.14.72 
  5. Bellera CA, Rainfray M, Mathoulin-Pélissier S, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol. 2012;23(8):2166-2172. doi:10.1093/annonc/mdr587.

This article originally appeared on Oncology Nurse Advisor

Topics:

Cancer Geriatrics