Most community-based oncologists don’t use, don’t see value in geriatric assessment
Click Here to Manage Email Alerts
Cancer is a disease that disproportionately affects the elderly, and current guidelines recommend a comprehensive geriatric assessment for older patients with cancer.
However, older patients are often underrepresented in cancer clinical trials, and geriatric assessment appears to be underused in clinical practice.
“The vast majority of patients fighting cancer are older — there is a projection that by 2030, 70% of all cancers will affect patients aged 65 years and older,” Ajeet Gajra, MD, FACP, medical hematologist/oncologist at Hematology-Oncology Associates of Central New York and senior medical consultant at Cardinal Health, said in an interview with Healio. “I call them the ‘silent majority,’ because most of clinical trials are conducted in younger, healthier folks due to strict inclusion and exclusion criteria largely excluding the typical older patients from participation.”
Gajra and colleagues at Cardinal Health conducted a survey study, published in JCO Oncology Practice, to assess the use of geriatric assessments in clinical practice. He discussed his findings, their implications and the need for increased focus on the needs and functional status of older patients with cancer.
Healio: Why is it important to conduct geriatric assessments of older patients with cancer?
Gajra: Geriatric assessment is a tool that’s been used by geriatricians for a long time, but subspecialists like oncologists have not used it often or consistently. Geriatric assessment is a multidimensional assessment that evaluates multiple domains in an older person. It includes physical function, comorbidity, cognitive function, mood, social support, nutrition and medications. All of these have an impact on outcomes among older adults with cancer. Additionally, an accumulating body of evidence demonstrates that by utilizing geriatric assessment before initiating treatment, we can give older patients with cancer more tailored treatments to suit their needs.
In recent years, major organizations such as ASCO have put out guidelines for management of cancer in older adults. There are also National Comprehensive Cancer Network guidelines and guidelines from organizations dedicated to the cause, such as the International Society of Geriatric Oncology (SIOG). The question is, do we really utilize these guidelines? Have we made progress in this area?
Healio: What inspired you to conduct this study?
Gajra: A study conducted under the auspices of an ASCO task force investigated awareness of the ASCO geriatric oncology guidelines among oncologists. It showed that about 50% of oncologists were aware of the guidelines. However, that study was skewed more toward academic oncologists practicing at large centers. That got me thinking — much of the cancer care in this country is delivered in the community setting. Older patients in particular might be more often treated in community hospitals due to transportation and access issues. They cannot necessarily travel several hours to go to large, tertiary care centers. That was part of the impetus to find out whether community oncologists have the same, less or greater awareness of the principles of geriatric assessment. After all, they are largely the ones providing care to older patients with cancer.
Healio: How did you conduct the study?
Gajra: This was an online questionnaire answered by 349 community-based medical oncologists and hematologists engaged in clinical care. The oncologists answered the survey and then came to a live meeting — during the pandemic, the meetings were virtual. At the meetings, various topics were discussed, including clinical updates and practice-related issues, and it was a great opportunity for us to capture these oncologists’ views and opinions.
Healio: What did you find?
Gajra: A significant proportion — 60% — did not use any type of formal geriatric assessment to inform their treatment decisions in the care of patients with cancer. That was quite dramatic. Almost half did not use geriatric assessment because they thought it was too cumbersome to incorporate into their routine practice. Another third felt that it added no value beyond a good history and a comprehensive physical exam.
We also wanted to assess how many geriatric assessment screening instruments they would be aware of. We found that just over half were aware of the Mini-Mental State Exam (63%), which is a measure of cognitive function. Other instruments the respondents recognized included Comprehensive Geriatric Assessment, which 37% recognized, and Cancer and Aging Research Group (CARG) tool, which 22% recognized. Nineteen percent of participants were not aware of any of the geriatric assessment instruments, and 33% had not used any outside the setting of a clinical trial. Basically, we found that the awareness was rather low. Most programs are now training new oncologists in geriatric assessment, but a generation ago, that might not have been the case.
I think our takeaway was that these are very busy oncologists — they’re seeing multiple patients a day. They have many patients who are older, but may feel as though they don’t have the time. So, they don’t realize the value that a simple geriatric assessment can add to their decision-making. Our key takeaway was that we need to create more awareness, not only among the academics, but especially in the community, where many of these patients are being treated.
Practicing community oncologists have to keep up with a lot — there’s new data emerging every month, even every week. Half of these oncologists [in the study] were running their own practices, so they were independent. It’s like running a small business, so they are also concerned about keeping their practices afloat. I think it’s understandable that something like a geriatric assessment may not be on their radar or might feel peripheral to what they’re engaged in.
Healio: What approaches might be effective in raising awareness of geriatric assessment in the community oncology setting?
Gajra: Oncology societies can help spread the word. Most medical oncologists are engaged with organizations like ASCO or NCCN. Even if they don’t go to the meetings, they will often get emails or publications from ASCO. I think simple modules or messaging targeted toward these community-based oncologists would be worthwhile.
There are other opportunities, as well — the Oncology Care Model is just ending, but the Enhanced Oncology Model is just being formulated. That’s an opportunity for a value-based care program to include some version of geriatric assessment that essentially serves as a quality metric in the care of older patients with cancer. If geriatric assessment were included as part of that or another broad initiative, it could increase both awareness and utilization.
Incorporating geriatric assessment has been shown to significantly reduce chemotherapy-associated toxicity, reduce the number of hospitalizations and improve quality of life among these patients. Decreased hospital admissions should cause everyone to take notice, because that is often a key quality indicator. I think linking these things together and integrating geriatric assessment into value-based care could be a nice way to bring it to the forefront.
References
- Dale W, et al. JCO Oncol Pract. 2020;doi:10.1200/OP.20.00442.
- Gajra A, et al. JCO Oncol Pract. 2022;doi:10.1200/OP.21.00743.
For more information
Ajeet Gajra, MD, FACP, can be reached at agajra@hoacny.com.
Collapse
Read more about
Click Here to Manage Email Alerts