Geriatric Assessment is Critical for Treating Older Adults with Cancer

J Clin Pathways. 2021;7(6):24-25.

The nation’s demographics are dramatically shifting. The number of Americans aged >65 years is projected to nearly double from 52 million in 2018 to 95 million in 2060, bringing the 65-and-older age group from 16% to 23% of the total US population.¹ Because older adults are more likely to be diagnosed with cancer than any other age group, the population of cancer survivors is increasing as well. While 64% of cancer survivors in the US are currently aged >65 years, researchers estimate that by 2040, 73% of US cancer survivors will fall into that age range.²

In addition to being associated with an increased risk of cancer, advanced age is often accompanied by certain age-related health problems and chronic illnesses that can have adverse effects on independent living, rates of disability, and quality of life.³ Previous research in community cancer centers has shown a significant prevalence of comorbid conditions among older patients with cancer, with 69% to 92% of patients reporting at least one such condition.⁴ 

A Valuable Process

Conducting a geriatric assessment can help uncover the comorbidities and age-related vulnerabilities that can impact cancer treatment in older adults. In a geriatric assessment, providers use diagnostic tools that provide multidimensional, multidisciplinary evaluations of multiple health domains, including functional status, cognition, psychological health, and nutritional status. When used to evaluate an older adult with cancer prior to initiating therapy, a geriatric assessment can help oncologists inform treatment decision-making, predict morbidity and mortality, guide supportive care interventions, improve patient and caregiver satisfaction, reduce treatment-related toxicity, improve quality of life, and reduce health care use.

In 2018, the American Society of Clinical Oncology (ASCO) issued clinical practice guidelines for using validated and standardized clinical assessment tools to evaluate and manage age-related conditions not routinely captured in oncology assessments and associated with adverse outcomes in older patients with cancer.⁵ An ASCO expert panel found strong evidence that traditional oncology performance measures—such as the Karnofsky Performance Status—do not accurately predict which older adults are at highest risk of adverse outcomes after receiving chemotherapy. 

Need for Training in Geriatric Oncology

In 2018, the Association of Community Cancer Centers (ACCC) conducted an online survey of a diverse group of 332 multidisciplinary oncology professionals. This survey uncovered striking differences between respondents’ ideas about quality cancer care and the practices of the cancer programs in which they work. For example, 95% of respondents said they either “strongly agree” or “agree” that older adult cancer patients would benefit from a comprehensive geriatric assessment, in addition to an oncology assessment before the start of treatment. However, only 17% of survey respondents reported that they routinely conduct comprehensive geriatric assessments with their older adult patients. Very few respondents (26%) said they currently used screening tools to identify at-risk patients who are candidates for a comprehensive geriatric assessment.⁶ 

ACCC provides resources to help cancer programs and practices identify barriers to conducting a geriatric assessment, use validated tools for screening and assessing older adults, and develop models for effectively addressing the needs of the growing number of older adults diagnosed with cancer. Among those resources is the Practical Application of Geriatric Assessment: A How-To Guide for the Multidisciplinary Care Team, published in 2021 in collaboration with The Gerontological Society of America, the Oncology Nursing Society, and the International Society of Geriatric Oncology.

The easy-to-use guide gives cancer programs and practices a compact resource on how to address essential domains of care related to the unique needs of older adults without over-burdening staff or budgets. Coauthored by a series of leading clinician experts in geriatric oncology, the guide describes multiple assessment tools and offers instruction on how to conduct them. The guide is divided into seven sections that describe how specific resources can help assist patients in the domains of:

1. Screening;
2. Functional status;
3. Cognition;
4. Comorbidities;
5. Pharmacy and medication management;
6. Psychological health; and
7. Nutrition.

Guidance also is provided on how to best use the results of the assessment—whether the cancer program or practice has in-house or more limited resources.

In ACCC’s 2018 survey of multidisciplinary oncology professionals, providers often cited time limitations as the reason they do not perform a geriatric assessment (Figure).

In practice, the task of conducting geriatric assessments does not have to take up significant time during patient visits, and the responsibility for conducting these assessments does not have to fall to a single health care provider. The task can be adequately assumed by several members of the multidisciplinary care team, including nurses, physical therapists, social workers, pharmacists, and/or patient care technicians. These tools can also take the form of self-assessments, which can be completed by patients prior to clinic visits or in waiting rooms. 

In addition to the how-to guide for conducting geriatric assessments, ACCC developed a series of resources to improve care for older adults with cancer. If you are uncertain where to begin, start by evaluating your program with ACCC’s gap assessment tool, which will assign a score to your program’s performance and provide helpful recommendations related to critical care areas. Available at accc-cancer.org/geriatric, additional resources include a 6-part webinar series of expert presentations on topics relevant to caring for older adults with cancer; a convenient summary of how to ensure that quality geriatric oncology care is implemented in a thoughtful way; and a resource library that includes more than 100 tools and resources specific to treating and caring for older adults with cancer.

Practical Application of Geriatric Assessment: A How-To Guide for the Multidisciplinary Care Team is downloadable and available free on ACCC’s website at: accc-cancer.org/geriatric-how-to-guide. Distribute the guide to the members of your cancer care team to give them access to the information they need about how to efficiently conduct a geriatric assessment in busy practices and programs. 

References

1. Population Reference Bureau. Fact Sheet: Aging in the United States. July 15, 2019. Accessed August 3, 2021. https://www.prb.org/resources/fact-sheet-aging-in-the-united-states/

2. National Cancer Institute Division of Cancer Control & Population Sciences. Statistics, Graphs and Definitions. Updated December 9, 2020. Accessed August 3, 2021. https://cancercontrol.cancer.gov/ocs/statistics. 

3. Bellizzi KM, Rowland JH. Role of comorbidity, symptoms, and age in the health of older survivors following treatment for cancer. Aging Health. 2007;3(5):625-635. doi:10.2217/1745509X.3.5.625

4. Williams GR, Mackenzie A, Magnuson A, et al. Comorbidity in older adults with cancer. J Geriatr Oncol. 2016;7(4):249-257. doi:10.1016/j.jgo.2015.12.002

5. Mohile SG, Dale W, Somerfield MR, et al. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol. 2018;36(22):2326-2347. doi:10.1200/JCO.2018.78.8687

6. Association of Community Cancer Centers. Growing Need Demands New Approaches to Caring for Older Adults with Cancer. 2019. Accessed August 3, 2021. https://www.accc-cancer.org/docs/Documents/oncology-issues/articles/so19/so19-growing-need-demands-new-approaches-to-caring-for-older-adults-with-cancer