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Geriatric assessment improves oncologists’ communication with older patients
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CHICAGO — Use of geriatric assessment during routine care of older individuals with advanced cancer significantly improved physician-patient communication about age-related concerns, according to randomized study results presented at ASCO Annual Meeting.
The effort also improved patient satisfaction with communication.
“As oncologists, we care so much about personalized medicine,” Supriya Gupta Mohile, MD, MS, Wehrheim professor of medicine at University of Rochester, told HemOnc Today. “Among older patients, there is such heterogeneity in health status, the geriatric assessment is a way to standardize the process to assess health status.”
Geriatric assessment is intended to assess age-related concerns that often are not identified during routine oncology visits or physical exams.
The assessment — which encompasses mental and physical health, nutrition and social support — can identify older adults at risk for side effects from cancer treatment, as well as those who are at risk for earlier mortality due to noncancer-related health problems.
“As a geriatrician, I can’t tell which patient has cognitive impairment just by looking at them,” Mohile said. “I can’t tell a person sitting on a chair is at risk for falls just by looking at them. We need these tests to be able to do that.”
An ASCO guideline recommends geriatric assessment be conducted for all patients aged 65 years and older who receive chemotherapy. However, geriatric assessment is used most commonly at major cancer centers that have geriatric oncology programs. It is rarely used in other practice settings, according to study background.
The study by Mohile and colleagues included 542 patients (mean age, 77 years; 49% women) aged 70 years or older with incurable advanced solid tumors or lymphoma. The patients received treatment between 2014 and 2017 at one of 31 community oncology practices affiliated with University of Rochester’s NCI Community Oncology Research.
Mohile and colleagues randomly assigned these practices to a geriatric assessment group or usual care group.
All patients underwent geriatric assessment at study enrollment.
Trained coordinators administered objective tests that measured physical performance (eg, balance, falls or physical health) and cognition. These tests took about 10 minutes. Validated questionnaires that took about 30 to 45 minutes to complete assessed function (activities of daily living), nutrition, social support, depression and comorbidities.
All patients in the analysis had an impairment in at least one measure on the assessment they completed at enrollment.
Under the study design, oncologists whose practice was assigned to the geriatric assessment group received a web-based summary of results from patient assessments, along with recommendations for appropriate interventions. Oncologists whose practices were assigned to the usual care group were told if a geriatric assessment indicated one of their patients had depression or significantly impaired cognition; however, they received no overall summary of the results or intervention recommendations.
Clinic visits took place within 4 weeks of geriatric assessment. Investigators used transcribed recordings of the conversation during one clinic visit for each patient included in the study to evaluate the content and quality of physician-patient communication.
Researchers defined quality communication as conversations in which physicians obtained more information about age-related concerns and thoroughly addressed patients’ concerns.
Results showed clinicians who received geriatric assessment results prior to meeting with their patients appeared more likely to talk about age-related concerns and recommend interventions to alleviate them.
Among all patients, the overall mean number of discussions was 6.3 (standard deviation, 4). Physicians whose practice was assigned the intervention conducted a mean 3.5 (95% CI, 2.28-4.72) more discussions about age-related concerns during clinic visits than physicians whose practice was assigned usual care (P = 10-6; intraclass correlation coefficient [ICC] = 0.24).
In the geriatric assessment group, an average of two (95% CI, 1.2-2.69) more conversations had higher quality communication, and 1.9 (95% CI, 1.14-2.73) more led to interventions.
These interventions included reduction or elimination of high-risk medications for a patient taking more than five prescription medications; physical therapy evaluation for patients with history of falls; and decisional capacity assessment for a patient with significant cognitive impairment.
Results showed patients in the intervention arm had significantly more discussions about nearly all age-related concerns measured by geriatric assessment (P = .027; ICC = .02).
Researchers used a telephone questionnaire after the clinic visit to assess patient satisfaction with physician-patient communication. Patients treated at a practice assigned the geriatric assessment intervention reported significantly greater patient satisfaction, leading researchers to conclude patients valued the discussions about age-related concerns.
Mohile and colleagues are evaluating whether the interventions that resulted from geriatric assessments had a positive effect on patient quality of life and function, or caregiver quality of life and satisfaction.
A separate study already underway is designed to assess whether geriatric assessment can reduce chemotherapy side effects by improving decision-making among older patients with advanced cancer.
Utilization of geriatric assessment in clinical practice should increase with more education, Mohile said.
“In medical school and residency, aging-related issues and geriatrics is not highlighted as an important issue,” she told HemOnc Today. “In addition, we’re talking about community oncology practices that are extremely busy. However, the message we’re trying to communicate is, this is not that hard. Anybody can do it. It’s a model of care, so it’s a matter of learning it, initiating it and then understanding how to use the results.” – by Mark Leiser
For more information:
Mohile SG, et al. Abstract LBA10003. Presented at: ASCO Annual Meeting; June 1-5, 2018; Chicago.
Disclosures: The researchers report funding from Patient Centered Outcomes Research Institute and NCI. Mohile reports consultant or advisory board roles with Seattle Genetics. Please see the abstract for all other authors’ relevant financial disclosures.
Perspective
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Afsaneh Barzi, MD
Most oncology providers are not geriatricians, and we do not do formal assessments of the specific needs in this population. This paper shows that, by using geriatric assessment, we can improve health outcomes in this unique population.
Those of us who are not geriatricians and have not reached that same age don’t always recognize some of the tasks we perform so easily each day may not be so easy for these patients. In oncology, we focus so much on the disease that we sometimes forget we actually are treating individuals. These kinds of studies bring into perspective the importance of thinking about the person. Our treatments are designed to target the disease, but placing an emphasis on the individuality of the patient’s case enhances the potential for the treatment.
The time required to perform these assessments will be portrayed as a barrier. However, we don’t consider it a barrier when we have to fill out a hundred forms to get a tumor analysis. There are ways we can do these assessments more systematically, perhaps by incorporating them into nursing intake. Finding better ways to do these assessments is absolutely a correct approach, but the time it takes to perform these assessments — or the challenges they pose to a provider or health care system — should not a justification for not doing them.
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