As the number of elderly patients with cancer continues to rise — and geriatricians remain in short supply — primary care providers and community oncologists need to incorporate formal geriatric assessment into routine practice, a geriatric oncologist said during a presentation at the American College of Physicians annual Internal Medicine meeting.
A 2020 ASCO survey, which the speaker, Grant R. Williams, MD, coauthored, found that 9 out of 10 community oncologists assessed at least some older patients differently than younger patients. But only 1 out of 3 did so in a formal manner, Williams, director of the cancer and aging program at the University of Alabama at Birmingham, said during presentation at virtual meeting.
In most cases, informal geriatric assessment considers only the tip of the 'geriatric oncology iceberg,' including chronological age, performance status, tumor characteristics, and organ function, Williams noted.
In contrast, formal geriatric assessment dives deeper, measuring a series of additional outcome-associated factors: polypharmacy, comorbidities, falls, psychosocial dysfunction, social support, sarcopenia, nutritional deficits, cognitive impairment, and functional issues.
"All these other factors under the surface are critically important to developing a personalized and individualized cancer treatment plan for older adults," Williams said.
He went on to explain that elderly cancer patients can be sorted into three broad categories: fit, vulnerable, and frail. Fit and frail patients are relatively easy to identify, but most elderly patients fall into the vulnerable category, Williams noted.
"It's really more challenging to identify those individuals across the spectrum than those at the extremes," Williams said, noting that formal geriatric assessment can detect problems not found routinely.
Formal Geriatric Assessment's Value
Geriatric assessment can be used for risk modeling and making life-expectancy calculations. It can also be used as an interventional tool, guiding cancer treatment selection, he said. Furthermore, it can open doors to general health interventions, such as occupational therapy, to reduce fall risk.
Beneficial interventions identified by geriatric assessment have been shown to improve function, reduce chemotherapy toxicities, improve quality of life, and extend survival, Williams noted.
Formal geriatric assessment may be particularly useful for primary care providers considering referral to an oncologist, he said.
"I think performing a geriatric assessment [prior to referral] would be a great idea. And that's twofold: Even before you send them to the oncologist, it gives you an idea of how they may tolerate treatment, and frankly, it may give you an idea that they don't need a referral to the oncologist if they're particularly frail," noted Williams.
Alternatives to Formal Assessments
When asked how providers can incorporate formal assessments into a busy day at the clinic, Williams encouraged the use of abbreviated formal assessments, then adding further testing if needed.
"Given known time and support staff restraints, modified geriatric assessment tools have been developed that are either mostly or completely patient-reported," he said in an interview, referring to the Cancer and Aging Research Group (CARG) Geriatric Assessment and the Cancer and Aging Resilience Evaluation (CARE), respectively.
"[These assessments] can easily be completed before clinical visits or while in the waiting room," Williams noted. "The additional objective tests, such as Timed Up and Go, and Mental Status Exam, can be completed if deemed necessary based on these initial assessments."
Martine Extermann, MD, PhD, provided her suggestions in an interview for what physicians can do to get better outcomes for this patient group.
"The secret of successful anti-cancer treatment in an older person is to be proactive with supportive care," said Extermann, leader of the senior adult oncology program at H. Lee Moffitt Cancer Center & Research Institute, Tampa, Fla. "You have to really plan ahead, identify the support gaps, identify the potential problems, and prevent them thoroughly. The upfront work of good patient evaluation will save you a lot of trouble down the line," she added.
Extermann also mentioned the challenges to providing care to geriatric patients with cancer, including a lack of financial incentive for physicians to specialize in geriatrics.
Gerontology Remains a Practice Gap
Oncologists who don't perform geriatric assessments are probably missing more than they think, Extermann said in an interview.
"Many oncologists don't fully realize the importance of [geriatric assessment] yet," Extermann said. "They kind of think that their internal medicine training will carry through, and they'll be able to identify everything; actually, we know very well we miss half of what is found by geriatric assessment clinically."
Gerontology remains a practice gap, Extermann said, not only within oncology, but across specialties.
"One of the big problems with the U.S. health care system is we don't have enough geriatricians, and the reason we don't have enough geriatricians is because we don't pay them," she said.
"Geriatrics is the only specialty where you do more training to be paid less, because Medicare doesn't reimburse geriatric assessment, [and] it doesn't reimburse geriatric consultation. [This] doesn't motivate universities to create geriatric clinics and geriatric programs because they will lose money, basically, doing that. If we want to really solve the problem, we have to solve the reimbursement problem up front," she explained.
Williams disclosed financial relationships with Carevive Health Systems, Cardinal Health, the National Cancer Institute, and the American Cancer Society. Extermann reported no conflicts of interest.
This story originally appeared on MDedge.com, part of the Medscape Professional Network.
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Cite this: Formal Geriatric Assessment Should Be Routine - Medscape - May 05, 2021.