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review memo (2021) 14:24–28 https://doi.org/10.1007/s12254-020-00625-w Matthias Unseld · Christine Marosi Received: 17 April 2020 / Accepted: 18 May 2020 / Published online: 9 June 2020 © The Author(s) 2020 Summary Introduction Background With the aging of populations, the num- ber of elderly persons with cancer will increase. Due Raising awareness of the necessity to adapt cancer to the high individuality of elderly persons and their therapy to the individual needs and resources of varying patterns of resources and disabilities, cancer elderly cancer patients is the mission for geriatric on- treatment for elderly cancer patients needs to be indi- cology in the 21st century. Since its beginnings around vidually adapted. To achieve this, geriatric medicine the turn of the millennium [1], geriatric oncology has has established the comprehensive geriatric assess- provided tools for the assessment of functioning and ment (CGA). This short review presents the evidence vulnerabilities in older patients undergoing cancer of feasibility and impact of CGA on cancer treatment therapies. The International Society of Geriatric On- in elderly patients, as recommended by the American cology (SIOG) has advocated for many years that Society of Clinical Oncology (ASCO) in 2018. older adults undergo a geriatric assessment (GA) be- Methods A systematic review of the literature and fore the start of cancer treatment and that possible a Delphi Consensus with a panel of experts cooper- findings of this assessment are taken into account to ated to compile the evidence for choosing the most potentially adapt and assist this therapy. In a seminal adequate treatment for elderly cancer patients. paper, Hamaker et al. showed that this practice made Results Thereis evidencethat CGA makes it pos- it possible to detect a previously unknown geriatric sible to predict the occurrence of complications of syndrome in half of the patients tested and that geri- chemotherapy and of health deterioration, as well as atric counselling led to an increase in the therapy death within 1 year. planned in the same number of patients as to an Conclusion The ASCO has recognized the optimiza- alleviation of therapy [2]. Meanwhile, a lot of expe- tion of cancer therapy for elderly patients as a priority. rience has been gained by using and optimizing the assessment tools, as well by evaluating their impact Keywords Tumor treatment for elderly · Individual in clinical trials. resources and restrictions · Functional indepence · Although more than two thirds of cancers develop Chosing endpoints for clinical trials · Non-cancer- in individuals aged 65 years or more [3], older pa- specific life expectancy tients have been underrepresented in clinical trials for decades, first due to age limits, and later due to selective inclusion and exclusion criteria hindering trial participation of older subjects with age-related comorbidities. This exclusion has led to a situation in which evidence-based treatment standards are lack- M. Unseld, MD, PhD · C. Marosi, MD () ing for older patients with cancer, despite this group Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Währinger representing the majority of cancer patients. In the Gürtel 18–20, 1090 Vienna, Austria US, the Institute of Medicine acknowledged this fun- christine.marosi@meduniwien.ac.at damental gap in cancer care and implemented actions for change [4]. M. Unseld, MD, PhD matthias.unseld@meduniwien.ac.at 24 Geriatric oncology: questions, answers and guidelines K review Supriya Mohile coordinated a panel of experts of A CGA is a multidimensional assessment evaluat- different disciplines that reviewed the literature for the ing physical performance, functional status including development of an American Society of Clinical On- activities of daily living and instrumental activities of cology (ASCO) guideline for geriatric oncology pub- daily living (ADL and IADL, respectively), history of lished in August 2018 in the Journal of Clinical On- falls, comorbidities, depression, cognition, social ac- cology [5]. Their duty was to evaluate the feasibil- tivities and social support as well as nutritional status. ity and efficacy of the different tests of a comprehen- There are some validated short screening tools, like sive geriatric assessment (CGA) to guide the manage- the G8 [6] and the Vulnerable Elders Survey (VES-13) ment of vulnerabilities in older adult patients receiv- [7], which are able to predict mortality within 1 and ing chemotherapy. 2 years, respectively, but unable to provide the infor- The ASCO guideline provides answers to four ques- mation of a full assessment. tions: There is already strong evidence that a CGA is able to identify older individuals at increased risk of mor- 1. Should GA be used in older adults with cancer to tality. One of the most convincing studies on this topic predict adverse outcomes from chemotherapy? is the one conducted by Aaldricks et al., describing 2. For older patients that are considering undergoing a three-item Geriatric Prognostic Index [8]: chemotherapy, which GA tools should clinicians use to predict adverse outcomes (including chemother- Decreased food intake in the preceding 3 months apy toxicity and mortality)? Dependence in terms of shopping 3. What general non-cancer-specific life expectancy Use of more than three medications data for community-dwelling patients should clin- The score is associated with an increased risk of mor- icians consider to estimate and best inform treat- tality of 1.58, 2.32 and 5.58 for one, two or three items, ment decision-making for older patients with can- respectively. The association between abnormal find- cer? ings in CGA and mortality has been confirmed by 4. Howshould GA beusedto guide themanagement many studies in geriatric oncology. of older patients with cancer? For the identification of patients at increased risk This guideline was developed by a multidisciplinary for chemotherapy toxicity, two composite test tools expert panel and is conceived as a snapshot of the have already been validated: state of the art as of August 2018. It is not updated The Chemotoxicity Calculator by the Cancer and und thus open for progress. The authors claim nei- Aging Research Group (CARG) led by Arti Hurria [9] ther completeness nor exclusivity. They emphasize combines standard clinical data with GA data on that new evidence may emerge and should be taken prior falls, ability to walk one block, hearing prob- into account, as well as the fact that the guideline is lems, social support and IADL. This tool takes less not intended as a substitute for the individual assess- than 5 min to complete and is freely available at: ment of a given patient. The recommendations are www.mycarg.org/Chemo_Toxicity_Calculator. based on the literature available at the time of writing. The CRASH score (Chemotherapy Risk Assessment The authors compiled data from 68 studies, including Scale for High-Age Patients) was designed by eval- 17 randomized controlled trials (RCTs). uating prospectively recorded toxicity data of 585 These guidelines will now be briefly summarized patients older than 70 years, treated at the Moffitt and the subjectively most substantial references dis- Affiliate Research Network [10]. It provides esti- cussed with regard to their respective topics; never- mates for both hematologic toxicity ≥3and severe theless, studying the guidelines in full text is strongly non-hematologic toxicity. The CRASH score con- recommended. tains several elements of CGA such as IADL, Mini Mental State Examination (MMSE) [11] and Mini Question 1: Should geriatric assessment be used Nutritional Assessment (MNA) [12, 13]. The CRASH in older adults with cancer to predict adverse score takes 30 min to complete and is also freely outcomes from chemotherapy? available at: https://moffitt.org/for-healthcare- providers/clinical-programs-and-services/senior- Recommendation 1 CGA should be used in patients adult-oncology-program-tools. aged 65 years and older in order to identify vulnera- bilities or geriatric impairments that are not routinely Furthermore, CGA enables a prediction of completion captured in oncology assessments. of chemotherapy, the risk of hospitalization and the Strength of recommendation: strong risk of functional decline. This recommendation is based on literature show- ing that CGA detects problems that are not routinely detected by routine history taking, physical examina- tion and evaluation of the Karnovsky or Eastern Coop- erative Oncology Group (ECOG) performance scores. K Geriatric oncology: questions, answers and guidelines 25 review Question 2: For older patients that are Question 3: What general non-cancer-specific considering undergoing chemotherapy, which life expectancy data for community-dwelling GA tools should clinicians use to predict adverse patients should clinicians consider to estimate outcomes? and best inform treatment decision-making for older patients with cancer? Recommendation 2 At a minimum, assessment of function, comorbidities, falls, depression, cognition Recommendation 3 This question on the probabil- and nutrition, ideally with the validated tools. ity of survival for the next 5–10 years can be answered Strength of recommendation: high using validated tools established for large cohorts Strength for each tool alone: moderate of US citizens aged 50+ or 65+ after 2000, e.g. the In order to avoid repetitions, the above-mentioned Lee Schonberg Index [21, 22], available at https:// tools, such as ADL/IADL, G8 or VES-13, CARG Score eprognosis.ucsf.edu/leeschonberg.php. or CRASH Score, MNA, and MMSE, are not presented Of note, to determine the “non-cancer” probability again. In addition to a complete CGA, a question of death, the question on “presence of cancer” needs on falls during the preceding 6 months, a question to be answered with “no”. The prognosis tools rely on on living situation (alone or with someone else), an data such as age, sex, performance status, mastering evaluation of co-morbidities with the Cumulative Ill- of ADLs and IADLs, comorbidities, life style factors ness Rating Scale for geropsychiatric patients (CIRS- and self-reported health. G) [14] or Charlson Comorbidity score [15], screen- Strength of recommendation: strong ing for depression with the Geriatric Depression Scale In a next step, the probability of survival with opti- [16], screening for impaired cognition with the Mini- mal cancer treatment needs to be estimated. Consid- Cog [17, 18] instead of MMSE and evaluation of phys- ering both results allows the best counselling for pa- ical function with the Timed Up and Go Test (TUG) tients and potentially draws attention to other health [19] are suggested. conditions that should be taken into account, regard- For the quantification of comorbidities, the CIRS-G less of whether anti-cancer treatment is initiated or is available online at https://www.mdcalc.com/cumu not. lative-illness-rating-scale-geriatric-cirs-g,whereas the less detailed Charlson Co-morbidity Index is available Question 4: How should GA be used to guide the at: https://www.mdcalc.com/charlson-comorbidity- management of older patients with cancer? index-cci. The geriatric depression scale is a 15- item self-administered questionnaire that can usually Recommendation 4 There are two parts to this rec- be completed in less than 5 min (Sheik) and avail- ommendation: The first is that a GA will impact treat- able in German at https://www.geriatrie-bochum.de/ ment decisions, e.g. in choosing therapeutic regi- assessment/geriatrische-depressions-skala-gds.php. mens with a low burden of side effects and in adapt- The Mini-Cog test can be administered in less than ing dosage of chemotherapies to the individual organ 3 min and consists of a three-item recall and a clock- functions of the patients, while respecting the guide- drawing test (https://mini-cog.com/) and is easier to lines for the application of growth factors for elderly perform than the MMSE but as informative. The TUG patients. The second aspect is to consider interven- measures the time required for getting up from a chair tions able to address the vulnerabilities identified by with armrests, going 3 m, turning, going back to the a GA in order to improve the condition of elderly per- chair and sitting down. This simple test provides in- sons. formation on a person’s mobility, balance and risk of In fact, there are no completed RCTs to prove that falls and is completed within a few seconds. There are GA-guided therapies improve the outcomes of elderly cut-off values for different age groups. cancer patients. However, there is already wide expe- It has been repeatedly shown that the majority of rience that GA-guided interventions improve the out- these tests can be done as self-administered question- comes of many non-cancer issues. naires and that patients are able to complete them ei- A Delphi consensus was elaborated by the panel ther themselves or with assistance from their proxies that the two recommendations outlined above should during the waiting time in an outpatient unit. Using be implemented in cancer care for the elderly. In Eu- hand-held touch screen computers is reliable and of- rope as well as in the US and Canada, several RCTs ten preferred [20]. Of course, functional tests such as are currently underway to assess the feasibility and the TUG and the screening for cognitive function need impact on the outcomes of elderly cancer patients. to be administered by trained personnel. This can be The endpoints of the studies are mostly composite achieved in less than 15 min. endpoints, focusing on duration of survival and dura- tion of progression free survival, quality of life, rates of severe chemotherapeutic toxicity, rate of hospital- ization, health care utilization, change in functional status, as well as change in psychological status and caregiver quality of life and caregiver satisfaction. 26 Geriatric oncology: questions, answers and guidelines K review 3. Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buch- Strength of the recommendation: as long as the re- holz TA. Future of cancer incidence in the United States: sults of these trials are not available, moderate burdens upon an aging, changing nation. J Clin Oncol. The implementation of GA-guided interventions 2009;27(17):2758–65. necessitates rethinking the workflow of therapeutic 4. Levit LBE, Nass S, Ganz PA. Delivering high-quality cancer decision-making for elderly cancer patients. On the care: chartinganewcourseforasystemincrisis. Committee other hand, it is anticipated that integrating GA and on improving the quality of cancer care: addressing the challenges of an aging population. Washington: Institute of GA-driven interventions prevents chemotherapeu- MedicineoftheNationalAcademies;2013. BoardonHealth tic toxicities, avoidable infectious complications and CareServices. complications related to functional decline, meaning 5. Mohile SG, Dale W, Somerfield MR, Hurria A. Practical that the expenditure of time and resources used for assessment and management of vulnerabilities in older pa- the GA is amply compensated. tientsreceivingchemotherapy: ASCOguidelineforgeriatric This ASCO guideline was released in July 2018 and oncologysummary. JOncolPract. 2018;14(7):442–6. is continuously implemented in the US. 6. Bellera C, Soubeyran P. [How to identify frailty in older patients with cancer? Available tools]. 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memo - Magazine of European Medical Oncology – Springer Journals
Published: Mar 1, 2021
Keywords: oncology; medicine/public health, general
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