Timing of geriatric assessment may impact benefit for older patients with cancer
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Although a study on the benefits of geriatric assessment in older patients with cancer did not demonstrate significant improvements to quality of life, researchers said it yielded valuable insights about how to optimize this intervention.
“In our study, our geriatric assessment intervention did not impact any treatment plans, but it was conducted during the COVID-19 pandemic — that’s why we think it turned out to be a negative study,” lead author Martine Puts, RN, PhD, FAAN, associate professor in the Lawrence S. Bloomberg Faculty of Nursing at University of Toronto, told Healio. “Other trials that previously reported on this intervention were all completed prior to COVID. They have all had several positive endpoints.”
Puts spoke with Healio about how COVID impacted the study and discussed some of the findings that surprised her.
Healio: What inspired you to conduct this study?
Puts: A long time ago, we conducted one of the first pilot trials of geriatric assessment, because many studies indicated it is helpful. It is also recommended by organizations such as ASCO. When we got the grant for this study, no large randomized, controlled trials had been completed. Thus, the recommendations to conduct geriatric assessments for all adults with cancer were based on evidence from geriatric medicine settings from trials conducted 30 years ago. Geriatric medicine patients differ from oncology patients because, typically, they have dementia and a lot more disability. Their clinic circumstances are very different — older patients typically have longer appointments. So, we wanted to test this in the older oncology patient population. First we did a small, randomized controlled pilot study of 60 patients, 30 in each arm. We showed an improvement in quality of life, enough to warrant a larger study. So, we submitted a grant proposal to the Canadian Cancer Society to conduct this large study. We did the intervention for all adults aged 70 years or older referred for cancer treatment.
Prior to our study, the optimal timing of geriatric assessment was not very clear. The guidelines recommend doing it before treatment, and that is typically when oncologists do it. However, that is not always possible if a geriatric team does it.
Our study clearly shows that if you don’t do the assessment before treatment, there are no changes to the treatment plan. So, we hypothesized that this is a crucial component of this intervention — we need to do the geriatric assessment before the oncologist decides on treatment to have benefit. Some large trials, like the one by Supriya G. Mohile, MD, did the intervention prior to treatment and then showed reductions in treatment toxicity.
So, that seems to be a key component — that the geriatric assessment should be done before treatment selection. Our study clearly helped future studies in showing that logistical need.
One problem with our study is that the COVID-19 pandemic occurred while we conducted it. Sixty percent of our patients were surveyed during COVID, and we couldn’t deliver the intervention because we couldn’t do the face-to-face geriatric assessment. Even if we did the assessment by telephone and recommended, for example, physiotherapy for patients at fall risk, patients didn’t seem to want to follow up on these recommendations. In some cases, these community services weren’t available anymore, or patients didn’t want to see extra health care providers because they were afraid of getting COVID.
Healio: What did the geriatric assessment intervention in your study entail?
Puts: We used a standardized geriatric assessment looking at functional status, ability to do daily activities, fall risk, mobility, nutritional status, cognitive status, mental health, mood and social support. A nurse and a geriatrician asked questions and did some testing, such as grip strength. Based on that, we identified several more issues and developed an intervention plan to address those issues. If the patients had multiple falls, the geriatrician looked at the potential causes of the falls — was it orthostatic hypertension? Were they on too much medication? Depending on what was identified, they offered different interventions to the patient. Then the nurse followed up with at least a monthly phone call for 6 months.
Healio: What was your study’s unexpected finding?
Puts: Something strange happened, and other studies have now reported this, too. Among the group in the study during COVID, many reported a higher quality of life than those who completed the study before COVID. So, we weren’t able to do our intervention, but they were reporting a higher quality of life during the pandemic.
Healio: Why do you think this occurred?
Puts: We have several hypotheses. If we think about it from the perspective of the patient with cancer, certainly they didn’t have to go to treatment as many times — everything was done by telephone or virtual appointment. There was no commute for the adult children. So, we are hypothesizing that the reduced burden of frequently coming to the hospital for blood tests, imaging and follow-ups improved quality of life for patients and their caregivers.
Healio: What is next for your research on this?
Puts: We saw a lot of issues with falls. About a quarter to a third of patients had falls before even coming in for the assessment. We also saw a quarter to a third falling during treatment. So, that is clearly an issue, because we know that patients with cancer who have falls are more likely to have injurious falls because of the risk [for] cancer to the bones.
We think the next step needs to be some intervention not only in terms of geriatric assessment, but combined with some kind of exercise or nutrition intervention during treatment to reduce that fall risk. We received a grant to do a pilot study on that, and others are on the way to combining a geriatric assessment with other components to make it a more active intervention.
References:
For more information:
Martine Puts, RN, PhD, FAAN, can be reached at Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College St., Suite 130, Toronto, Ontario, M5T 1P8, Canada; email: martine.puts@utoronto.ca.
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