Download Will my elderly patient be able to tolerate chemotherapy?

ARIZONA GERIATRICS SOCIETY
VOL. 12 NO. 2
REYNOLDS QUESTION
OF THE MONTH
Will my elderly patient be able to tolerate chemotherapy?
What tools, if any, are validated for comprehensive evaluation of the older adult
(>65) with cancer to determine his/her ability to tolerate chemotherapy?
Carol Howe, MD, MLS, Assistant Librarian, Arizona Health Sciences Library, and Informationist, Arizona Reynolds Program of Applied Geriatrics,
University of Arizona College of Medicine
The following is a response by Carol Howe, MD, MLS, on March 12, 2007 to this question submitted by Setsuko Chambers, MD,
Director, Division of Women’s Cancers, Arizona Cancer Center. This series is part of the Arizona Reynolds Program of Applied
Geriatrics at the University of Arizona, established through a grant from the Donald W. Reynolds Foundation .
M
any authors, particularly in articles published
between 2000 and 2005, advocate adopting the
Comprehensive Geriatric Assessment (CGA) to
help clinicians determine the level of care that
would be appropriate to treat elderly patients with cancer.
Balducci and Extermann, for example, state the following:
Aging is highly individualized: chronologic age
may not reflect the functional reserve and life
expectancy of an individual. A comprehensive
geriatric assessment best accounts for the diversities
in the geriatric population. The advantages of the
CGA include:
1.
Recognition of potentially treatable conditions
such as depression or malnutrition, that may
lessen the tolerance of cancer treatment and be
reversed with proper intervention;
2.
Assessment of individual functional reserve;
3.
Gross estimate of individual life expectancy; and
4.
Adoption of a common language to classify older
cancer patients.
The CGA allows the practitioner to recognize at
least three stages of aging:
1.
2.
People who are functionally independent and
without comorbidity, who are candidates for any
form of standard cancer treatment, with the
possible exception of bone marrow transplant.
People who are frail (dependence in one or more
activities of daily living, three or more comorbid
conditions, one or more geriatric syndromes),
who are a candidate only for palliative treatment;
and
3.
People in between, who may benefit from some
special pharmacological approach, such as
reduction in the initial dose of chemotherapy with
subsequent does escalations. 1(abstract)
Chen et al. recognize the potential usefulness of a CGA
model for all patients with cancer as the latter “may
precipitate classic geriatric syndromes such as falls,
malnutrition, delirium, and urinary incontinence” even in
non-elderly patients.2
Extermann has written several articles advocating the
use of the CGA. In Extermann et al’s 2005, article for
example, the authors note:
There is strong evidence that a CGA detects
many problems missed by a regular assessment in
general geriatric and in cancer patients. There is also
strong evidence that a CGA improves function and
reduces hospitalization in the elderly. There is
heterogeneous evidence that it improves survival and
that it is cost-effective… A CGA, with or without
screening, and with follow-up, should be used in
older cancer patients, in order to detect unaddressed
problems, improve their functional status, and
possibly their survival.3 (abstract)
Although their article contains the International Society of
Geriatric Oncology’s (SIOG) “recommendations for the use of
CGA in research and clinical care for older cancer patients”
they note: “The task force cannot recommend any specific
tool or approach above others at this point…”3(abstract).
Other authors recommending the use of the CGA are
Friedrich et al.4; Repetto and Comandini5; Repetto et al.6,
Repetto et al.7, Reuben 8; Wedding et al.9; and Wieland and
Hirth 10 (“Since age itself is not predictive of outcome in an
elderly cancer patient, the CGA helps to distinguish
between elderly patients who should be treated with intent
to cure and those who will benefit from clinical oncologic
and geriatric comanagement.”10 (abstract)
The Comprehensive Geriatric Assessment is itself not a
formalized protocol or tool but more of an interdisciplinary
prototype of ideal geriatric care whose actuality is very
much dependent of the specifics of local resources.
The composition of the CGA team has
traditionally included core and extended team
members. Core members evaluate all patients;
whereas extended team members are enlisted to
evaluate patients on an "as-needed" basis. Most
frequently, the core team consists of a physician
(usually a geriatrician), a nurse (nurse practitioner or
nurse clinical specialist), and a social worker.
The extended members of the team include a
variety of rehabilitation therapists (e.g., physical,
occupational, speech therapy), psychologists or
psychiatrists, dietitians, pharmacists, and other
health professionals (e.g., dentists, podiatrists).
Frequently, the constituency of the team is
determined more by the local availability of
professionals with interest in CGA than by
programmatic needs.11
In the process of a CGA, the following domains are
evaluated:
Functional status
Comorbid medical conditions
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Will my elderly patient be able to tolerate chemotherapy?
Cognition
Psychological status
Social functioning and support
Socioeconomic issues
Medication review
Nutritional status12 (Table 75-6)
tertiary care center; already receiving chemo—therefore
possibly pre-selected to be healthier and more capable of
doing the self-administered part of the test—as well as
presenting an inherently biased sample). Nonetheless,
they consider that:
In comparison to the geriatric assessment
performed by these other investigators, the geriatric
assessment proposed in our study includes a more
comprehensive assessment of physical functioning
(including a performance-based functional status
measure and questions regarding higher-order
physical functioning and the ability to perform more
rigorous physical activities) and assessment of
cognition (not included in the assessment by Ingram
et al.) each of these domains is critical in assessing
older patients with cancer. Our goal for future
studies is to determine whether these measures can
be used to predict an older patient’s ability to
tolerate and comply with a rigorous treatment
course.13 (pp.2003-4)
Although Reuben discusses the evolving nature of the
CGA—including the fact that many individual clinicians are
adapting its initial multidisciplinary model to their individual
practices11, the CGA as a whole remains too time
consuming and unwieldy to be a practical tool for
oncologists.
The standard assessment performed by a
geriatrician, requiring up to two hours, may not
address the needs of the oncologist, who requires a
brief assessment to specifically identify the
seemingly fit-appearing older individual whose limited
function reserve places him/her at risk for toxicities
and, perhaps, poorer outcomes overall.13 (p.2003)
Hurria et al. proceeded, therefore, to conduct a pilot
study whose goals “were to develop a brief yet
comprehensive cancer-specific geriatric assessment
measure (CSGA) that would be primarily self-administered
and to establish its feasibility in an oncology practice.”
They created an instrument that measured the following:
Functional Status (using the Activities of Daily Living …
subscale of the Medical Outcomes Study [MOS] Physical
Health, the Karnofsky Physician-Rated Performance
Rating Scale, the Karnofsky Self-Reported Performance
Rating scale, the Timed Up and Go, and the Number of
falls in the last 6 months); Comorbidity (using the OARS
Physical Health Section); Cognition (using the Blessed
Orientation-Memory-Concentration test); Psychologic
(using Hospital Anxiety and Depression Scale); Social
Functioning (using Medical Outcomes Study Social
Activity Limitations Measure); Social Support (using
Medical Outcomes Study Social Support Survey:
Emotional/Information and Tangible subscales and the
Seeman and Berkman Social Ties measure); and
Nutrition (using Body Mass Index and percent
unintentional weight loss in the last 6 months).13
The authors found that “the mean time to completion
of the geriatric assessment was 27 minutes” which
included “patient time to complete the self-administered
portion of the assessment and the interviewer time to
administer the BOMC test and Timed Up and Go, and to
rate the patient’s KPS.” 13(p.2002)
In a second report based on the same pilot study,
Hurria et al. note that the measures used (represented in
the above paragraph in italics) were “chosen based on their
validity, reliability, brevity, adaptability for self-administration,
and ability to prognosticate risk for morbidity or mortality in
an older patient.”14 (abstract) Their “eventual goal is to
determine if this geriatric assessment measure can identify
factors independent of age that predict cancer treatment
morbidity and mortality and result in rational interventions to
optimize oncologic care.”14 (abstract)
Hurria et al. acknowledge the limitations to their
preliminary studies including a primarily homogenous
study sample (mostly white; well educated; from a single
Page 20
In summary, Dr. Chambers’ question appears to be
one that is very much on the mind of many oncologists
and geriatricians. Using the concept of a Comprehensive
Geriatric Assessment as a starting point, several
investigators are actively studying improved protocols for a
screening tool that would be logistically feasible in the
context of a busy oncology practice.
References
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Chen CC, Kenefick AL, Tang ST, McCorkle R. Utilization of comprehensive geriatric
assessment in cancer patients. Crit Rev Oncol Hematol. 2004;49:53-67.
Extermann M, Aapro M, Bernabei R, et al. Use of comprehensive geriatric
assessment in older cancer patients: Recommendations from the task force on CGA
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Friedrich C, Kolb G, Wedding U, Pientka L, Interdisziplinare Arbeitsgruppe der
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Repetto L, Pietropaolo M, Gianni W. Comprehensive geriatric assessment in
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Reuben DB. Geriatric assessment in oncology. Cancer. 1997;80:1311-1316.
Wedding U, Hoffken K. Care of breast cancer in the elderly woman--what does
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Wieland D, Hirth V. Comprehensive geriatric assessment. Cancer Control.
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Reuben DB. Comprehensive geriatric assessment and systems: approaches to
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Hurria, A., Muss, H.B. & Cohen, H.J. Cancer and aging. In: Kufe, D.W., et al., ed.
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