Influence of geriatric consultation with comprehensive geriatric assessment on final therapeutic decision in elderly cancer patients

Abstract

Elderly patients represent a heterogeneous population in which decisions on cancer treatment are often difficult. The present study aims to report a 2-year period of the activity of geriatric assessment consultations and the impact on treatment decisions. Since January 2007, we have systematically carried out geriatric consultations, using well-known international scales, for elderly patients in whom treatment decisions appear complex to oncologists.

From January 2007 to November 2008, 161 patients (57 men, 104 women; median age 82.4 years, range 73–97) were seen at geriatric consultations. Most of the patients (134/161) were undergoing first-line treatment and cancer was metastatic in 86 patients (53%). Geriatric assessment found severe comorbidities (grade 3 or 4 in CIRS-G scale) in 75 patients, dependence for at least one activity of daily living (ADL) in 52 patients, cognitive impairment in 42 patients, malnutrition in 104 patients (65%) and depression in 39 patients. According to the oncologists’ prior decisions, there were no changes in treatment decisions in only 29 patients. Cancer treatment was changed in 79 patients (49%), including delayed therapy in 5 patients, less intensive therapy in 29 patients and more intensive therapy in 45 patients. Patients for whom the final decision was delayed or who underwent less intensive therapy had significantly more frequent severe comorbidities (23/34, p < 0.01) and dependence for at least one ADL (19/34, p < 0.01).

In this study, we have found that comprehensive geriatric evaluation did significantly influence treatment decisions in 82% of our older cancer patients.

Introduction

Increased life expectancy has led to an increased number of older cancer patients and thus the need to provide appropriate cancer care [1], [2]. Usually, it is well accepted that cancer survival is mainly influenced by age, comorbidities, histological type, initial stage, the location of cancer and the treatment related to the cancer [3]. Clearly, further improvements in overall survival may be anticipated as a result of better geriatric and general medical management as much as better cancer management. One must keep in mind that the behaviour of elderly cancer patients is driven by the complexity of this particular population [4] and, as demonstrated by Cohen et al., in a prospective North American randomised trial, in which geriatric interventions were or were not undertaken, the subgroup analysis of elderly cancer patients consists of analysis of the sole group of patients who improved their outcomes according to initial geriatric management [5].

Oncogeriatry is the clinical discipline concerned with the management of elderly cancer patients. It is based on a global oncological and geriatric approach to the health status of patients. Oncogeriatry has been widely adopted throughout the world, but the approaches used and the organisational solutions provided are complex and varied. Geriatricians, who commonly handle the highly heterogeneous process of ageing, have devised a comprehensive multidisciplinary assessment tool called ‘comprehensive geriatric assessment (CGA)’, in which all aspects of older patients are considered and all resources and abilities are listed. The CGA is a reliable and reproducible tool used to discriminate between different groups of patients with different frailty levels. Based on this appraisal, geriatricians can elaborate and co-ordinate an effective care plan with interventions tailored to each individual's problems. In order to offer high quality of care to the elderly patients, one must keep in mind that the two principal characteristics of cancer in the elderly are late diagnosis and comorbidity, which require specific geriatric assessment and cooperation between the oncologist and the geriatrician.

The use of gerontological concepts to explain the age-related impact of cancer will benefit both research and clinical practice by providing a means to target intervention more effectively by taking into account the psychological and social changes that often accompany aging. Taken together, these aspects strengthen the possible impact of geriatric consultation for older patients, particularly those in whom decisions appear to oncologists to be complex.

The aim of the present study was to analyse the change in initial multidisciplinary treatment decisions in cancer patients aged over 75 years after using a CGA, consultation with a geriatrician and the interventions of the specific oncogeriatric board.