Download Geriatric Oncology

Comprehensive geriatric assessment in
older people undergoing cancer treatment
Dr Danielle Harari
Consultant Physician, Senior Lecturer
Guys & St Thomas’ Hospital Foundation
NHS Trust, Kings College London
[email protected]
Improving Cancer Treatment Assessment and Support for Older People Project:
partly funded by the Department of Health and Macmillan Cancer Support
(registered charity no 261017), supported by Age UK (registered charity no
1128267)
What is the problem?
Cancer Reform Strategy, NCEPOD, National Chemotherapy Advisory Group, NICE
'Britain's cancer shame as 15,000 elderly patients
could be saved every year' Daily Mail June 2009
 Overall cancer survival in the UK is improving but not for
older people (National Cancer Intelligence Network 2010)
 Older people (with same cancer & comorbidity profile as
younger) receive less curative or adjuvant treatments
 Lack of evidence to guide treatment in older people
 Clinical trials include small nos. fit older people - benefit
from therapy as much as younger patients (survival,
QOL)
 BUT exclude frailer OP (often those seen in clinical
practice especially in myeloma)
What is needed?
 Risk assessment methods to provide guidance
on appropriate levels of treatment in older
people
 Comprehensive support to optimise outcomes in
frailer patients
 Trials of modified treatment in older and frailer
patients (does dose reduction limit toxicity, but at
a cost to tumour response?)
 DH/Macmillan/AgeUK funded 5 national ‘Older
Persons Pilots’ (including SELCN)
What is Comprehensive Geriatric
Assessment (CGA)?
 STRUCTURED ASSESSMENT of older patients
to identify comorbidities, physical, psychological
and social functional problems plus
 INTERVENTION - addressing these issues
through ongoing patient-centred management
plans (often multidisciplinary)
 Domains covered by variety of tools (not
prescriptive, can be adapted to diff settings)
 Improves outcomes in geriatric literature
Role of CGA in oncology:
current situation
 Oncologists usually use Life Expectancy &
Performance Status
 PS gives little info beyond mobility and does not
assess reasons underlying functional difficulties
 Comorbidities rarely formally assessed
 Life expectancy – meaningless without comorbidity
assessment
 No assessment or support specific to the needs of
older people in NHS cancer services
Role of CGA in oncology:
current situation
 Growing interest (SIOG, DH, Macmillan, NCEPOD) in integrating CGA into pretreatment assessment to
- avoid age-based treatment decision making
- inform treatment choices to optimise outcomes
 Existing oncology studies show CGA
 can predict morbidity and mortality
 is feasible
 cancer outcomes and toxicity can be predicted by CGA domains such
as functional dependency, depression and comorbidity
 Increasing use of brief ‘frailty’ scores (e.g. Balducci) and
prescriptive ‘CGA’ tools to decide if patients are ‘fit’ for
chemotherapy
BUT dangers of using CGA assessment without
intervention…
 Extra issues identified by CGA scores may lead
oncologists to overestimate treatment risk
 Women 70+ breast cancer CGA-screened: Treatment
plan changed by oncologists in 39% to less active
treatment (most influenced by depression and low
weight)
 Use of briefer tools may also overestimate risk
 CGA assessment should aim to accurately:
- identify ‘fit’ patients for full cancer Rx
- identify at risk patients for optimisation by geriatricians
or other providers to improve fitness for cancer treatment
‘POPS-GOLD’ – Improving cancer treatment
in older people
South-East London Cancer Network
Project Lead: Dr Danielle Harari
Project Team: Dr Tania Kalsi (Spr fellow), Gordana Babic-Illman (CNS)
Collaborators (haemoncology): Dr Paul Fields
 Project funding from Department of Health (Health Care
Inequalities, Cancer Strategy), Macmillan, GST Charity
 Observational: what factors (age, comorbidity) influence whether
or not older people are offered evidence-based care?
 Can geriatric-oncology liaison improve (a) appropriate
treatment decisions (b) treatment tolerance (c) patientreported outcomes (QOL) (d) healthcare processes (e.g.
transport to hospital, unplanned admissions, LOS)?
Patients aged 70+ being considered for cancer treatment
Complete CGA/comorbidty questionnaire
Observational ‘pre’
group
Usual care
POPS-ONCOLOGY
Low-risk patients identified as ‘fit’
At risk patients assessed for comorbidity
optimisation pre-treatment
CGA ‘holistic’ support
Follow-through during treatment including
liaison on oncology wards
OUTCOMES
% undergoing treatment with curative intent
Treatment tolerance (toxicity, completion of planned
protocol, decompensation of chronic conditions)
Hospitalisations (emergency, length of stay)
Patient reported quality of life, function, mood
Findings from observational
work (‘pre’ group) – all
patients completed GOLD-CGA
questionnaire:
Why may older people be
‘under-treated’
GOLD-CGA questionnaire
All questions source-referenced
Comorbidities questions nuanced e.g. is
BP usually high when checked, breathless
on walking on flat surfaces
Evidence-based functional scores
EORTC-QLQ-C30 (cancer-specific QOL
tool validated in older people)
CGA screening in patients with lymphoma
BSH 2012
o
74 older patients (aged ≥65) attending lymphoma clinic (mean age 74)
Mean questionnaire completion time was 11.5 + 7.4 minutes.
Comorbidities included: BP usually high when checked 23%, diabetes 21% (6%
poorly controlled), angina/previous MI 11%, breathless on flat surfaces 27%
Cognition: confusion episodes 12%, significant memory problems 11%
Polypharmacy ( 4 medications) 30%
Function: Difficulties with  1 basic activity of daily living (ADL) 48%, with  1
instrumental ADL 53%, fatigue 71%, pain 38%, incontinence 26%
34% lived alone, 14% had noone to look after them for a few days if needed
o
o
o
Questionnaire responses were used to categorise as low or high risk:
Low risk = no functional difficulties, no active comorbidity, mild QOL difficulties
High risk = functional difficulties &/or active comorbidity &/or severe QOL difficulties.
o
64% of patients aged 70+ and 48% of those aged 65-70 were high risk, often
with a combination of comorbidities, functional difficulties & QOL issues
o
o
o
o
o
o
Frailty- a comparison of diagnostic criteria
SIOG 2013
 108 patients judged fit for chemotherapy by usual clinical
oncological practice, had frailty categorisation assigned
retrospectively. This enabled a comparison between clinical
judgement of fitness and the 2 frailty criteria for fitness.
 Participants were defined as "fit" or "frail" using the Balducci
criteria and a frailty index:
 The Balducci criteria defined frail:
age 85+ &/or functional deficit (≥1 ADL dependency)
&/or serious comorbidity (serious cardiovascular, respiratory or cerebrovascular
disease or 3+ comorbidities)
&/or presence of any geriatric syndrome
• The frailty index was derived from 43 items from the CGAGOLD screening questionnaire using methodology as described
by Rockwood.
Frailty- a comparison of diagnostic criteria
SIOG 2013
 The frailty index classified 33.0% (35/106) as frail compared
with 72.6% (77/106) by the Balducci criteria
 There was poor agreement in who was fit or frail between the 2
diagnostic criteria (kappa=0.25)
 The use of Balducci criteria to define frailty to aid treatment
decision-making may risk under-treatment of older people with
cancer. Frailty indices (based on CGA screening data) may provide
a more comprehensive approach.
 Chemotherapy treatment decision-making should not be based on
the result of frailty scores whilst existing tools do not reliably
agree on who is “frail” in this setting. The optimal measure of
frailty to apply to clinical practice with proven abilities to
accurately detect frailty has yet to be identified.
Low grade toxicity in older people
undergoing chemotherapy ECCO 2013
N=108 patients aged 65+ recruited at start of
chemotherapy
Research question
To identify which level of toxicity (and how many
toxicities) trigger
a) treatment modification
• defined as dose reductions, delays or drug omissions
b) early discontinuation of chemotherapy
Results: treatment modifications due to
toxicity N=60 (55%)
 35% (21/60) had no greater than
grade 2 toxicity
 Of these 21:
 Mean 2.19+/-1.33 grade 2 toxicities
 7 patients had only one grade 2 toxicity
 Range of G2 toxicity types

Most common: Fatigue (8), haem (8), GI (6) &
infections (5)
Results: Toxicity grade trigger to treatment
modification (N=60) by comorbidity
Few Comorbidities (<4)
N=41
Low grade
toxicity
24.4%
(N=10)
High grade
toxicity
75.6%
(N=31)
Multiple comorbidities (4+)
N=19
Low grade
toxicity
57.9%
(N=11)
Statistically significant: p=0.011, 2=6.41
High grade
toxicity
42.1%
(N=8)
Results: Early discontinuation due to
toxicity N=23 (21%)
 39.1% (9/23) had no greater than
grade 2 toxicity.
 Of these 9:
 Mean 1.78+/-1.2 grade 2 toxicities
 One grade 2 toxicity n=3
 Most common grade 2 toxicities: fatigue
(5) and haemotological toxicity (4)
Key questions & future research in low
grade toxicity
Truly have a greater clinical impact on
older people?
Is this related to differences in the clinical
interaction between dr & older patient?
Lower threshold for modifying/discontinuing
treatment in older people? If so, why?
Reporting behaviour?
Additional support (e.g. geriatrician
liaison) improve treatment tolerance?
Fatigue in older people undergoing
chemotherapy SIOG 2013
Fatigue severity from EORTC- Improved
Q30 as part of CGA-GOLD
fatigue
questionnaire
% (N)
No change Fatigue worse
% (N)
% (N)
At 2 months follow up (n=89) 14.6 (13)
71.9 (64)
13.5% (12)
At 6 months follow up (n=68) 14.7 (10)
76.5 (52)
8.8 (6)
 Baseline fatigue is rarely documented
 Fatigue toxicity was cited by treating oncologists
in 69.1% (n=75) of all patients during
chemotherapy, with grade 2+ occurring in 36.1%
(39) and grade 3+ occurring in 11.1% (11)
Findings from interventional
work (‘post’ group) :
Impact of geriatric-oncology
liaison in outpatients and
inpatients (oncology wards)
GOLD PATHWAYS DEVELOPED
OLDER PATIENT WITH CANCER
SELF REPORTING CGA
SCREENING QUESTIONNAIRE
LOW
RISK
ONCOLOGY
REFERRAL
HIGH RISK
NO CGA
REQUIRED
IN DEPTH REVIEW BY
GERIATRICIAN TO
OPTIMISE/REVERSE CGA
INFORM ONCOLOGY
TREATMENT DECISION
CONTINUED GERIATRICS SUPPORT & REREVIEW AS NEEDED
SERVICE DEVELOPMENT – CLINIC
PATHWAYS
 Tailor CGA intervention to cancer treatment
 Optimise in relation to tx and plan proactively for
anticipated cancer treatment toxicity
 Developed to fit in within existing oncology
pathways
 Tailor to individual needs of the tumour groups
bladder cancer - joint clinic with a walk-in CGA
colorectal and prostate cancer - fast track review
typically within 1 week of referral
Examples of targeted interventions
 Cardiac and cardiac risk optimisation in patients
receiving anthracyclines
 Improving renal function in those to receive platin based
chemo – polypharmacy etc
 Treating pre-existing anaemia – iv iron, B12 and folate
 Diabetes management with steroids
 Nutritional support
 Pain and mobility optimisation (osteoarthritis)
 Fatigue investigation and management plan –
protocolised fatigue pathway developed
 Managing continence (QOL)
 Transport assistance esp for people having outpatient
chemo/RT
Screening Questionnaire
RECRUITED n=177
BEXLEY GP GROUP
n = 31
GSTT GROUP
n=146
SCREENING QUESTIONNAIRE  NOTE REVIEW AND
TELEPHONE CLINIC FOR CGA NEED
IN DEPTH CGA CLINIC
N=73 (50%)
NO CGA CLINIC AS PER NEED OR
WISHES N=73 (50%)
Questionnaire Validity & Reliability
(EUGMS 2013, BGS 2103)
 Inter-rater reliability
 Subgroup of 71 patients, 2 clinicians (SPR & CNS) review same
screening questionnaires
 Same decision in 87.3% (n=62/71) of questionnaires
 Reliability: against clinical notes review
 Clinician 1 (SPR): notes changed decision of CGA need in
10.9% (n=9/82) patients
 Clinician 2 (CNS) notes changed decision in 9.6% (n=8/83)
patients
 Acceptability: patient responses
o 80.2% (n=142) did not need help to complete
o Mean time to complete: 14.5 mins +/- SD 9.3
Outpatients - Comorbidities
LOW
RISK
NO CGA
REQUIRED
COMORBIDITIES
MEDIAN 3.0
MEAN 2.51 +/- SD 1.9.
HIGH RISK
IN DEPTH REVIEW BY
GERIATRICIAN TO
OPTIMISE/REVERSE CGA
COMORBIDITIES
MEDIAN 6
MEAN OF 5.75 +/- SD 2.4
Did POPS-GOLD influence oncology
treatment decision-making BGS 2012
 60% (n=24) of oncologists responded to semistructure questionnaire
(21% consultants, 63% registrars, 17% clinical nurse specialists)
 All respondents had read the CGA assessment letter at the patient’s
next cancer appointment.
 63% (n=15) reported the assessment had influenced their
decision-making.
 Of these, 67% (n=10) reported CGA assisted the evaluation of
fitness for treatment, more often in favour of active treatment (8
versus 2 patients).
 Common themes reported as beneficial were:




medical review (n=5)
increased information (n=3)
facilitated communication (n=2)
increasing confidence (n=3).
Did POPS-GOLD influence oncology
treatment decision-making BGS 2012

“it was so helpful.....we thought he might have had a cardiac problem related to the chemo but you
have identified the culprit drug. Based on your consultation, we decided to continue chemotherapy
without any dose reductions”

“Overall, POPS review was a very helpful and precise holistic assessment of the patient”

“Partly......altering medications had improved her symptoms. But balance is to control disease vs
toxicity and she was relatively symptom free”

“Confirmed impression that not fit for further systemic therapy and that efforts should be palliative. It
was really useful to confirm co-morbidities and their impact on symptoms. Also useful to clarify
modifiable factors...”

“No. We knew what treatment the patient needs to be on. However, the pt did mention he found the
POPS review helpful particularly with respect to medications”

“increased confidence in proceeding with chemo with knowledge of optimal medical management”

Of the 9 who reported no influence on decision-making, 5 found it useful for other reasons:

“the reduction in antihypertensives is likely to mean he will tolerate radiotherapy”
Did POPS-GOLD influence oncology
treatment decision-making BGS 2012
 To impact on decision-making, CGA needs to be delivered within a
tight timeframe to fit in with existing cancer targets. This could be a
challenge for an already busy geriatric medicine department.
However, the CGA screening questionnaire allowed us to assess for
CGA need. This meant clinic time could be utilised effectively to
enable rapid CGA delivery for those that needed it most.
 Within limitations, this evaluation highlights the potential benefits of
geriatrician-led CGA, more often in favour of more actively treating
older people
o Early CGA can influence oncology decision-making.
o Feedback suggests this relates not only to improved medical
support and the information provided, but by increasing
confidence to actively treat older people with cancer.
Patient & Carer Feedback
 “Nice to know GOLD are there to give advice and help with
possible problems.”
 “There is time to talk and the Doctor looks at you as a person and
how you can cope with the medical problems”.
 “The clinic is very relaxed and you feel there is time to talk, whereas
other clinics are so busy and the Doctor is catching up with
information on the computer.”
 ‘They saw my mother a few weeks ago and did a fantastic job in
sorting her out for chemo. Consultant haematologist
In-patient Liaison
Service & Pathway Development for
geriatric liaison on oncology wards
 Identified patients
morning board rounds (CNS)
MDT (CNS/SPR)
Case note review (CNS/SPR)
Patients were stratified according to risk- pathways
 Clinical Review
For patients in need
Optimised in a similar way to in the CGA clinic.
Discharge planning
GOLD Intensity of Input
GOLD Intensity of Input
Not involved
Light touch
Medium touch
Heavy
Very heavy
N = 113
% (n)
37% (42)
25% (28)
11% (13)
20% (22)
7% (8)
Impact on quality of information across to
primary care and community and coding
Oncology Discharge letter
GOLD ENHANCED
PRINCIPAL DIAGNOSIS
1. AML
PRINCIPAL DIAGNOSIS
1. Neutropenic Sepsis
2. Anaemia secondary to UGI (gastric ulcers) and
AML - needing blood transfusion
3. Pancytopenia
4. AML - end of life - fast-tracked to hospice
5. Pulmonary oedema
COMORBIDITIES
1. MDS
2. AML
3. Gastric ulcers
4. Barrett Oesophagus
5. Hypertension
6. B12 deficiency
7. Folate deficiency
8. Angiodysplasia,
9. Lives alone
COMORBIDITIES
2. Myelodysplasia
Impact on length of stay
LOS WITH AND WITHOUT POPS
NOV 11 NO POPS
DEC 11 NO POPS
JA N 12 NO POPS
MONTH WITH/WITHOUT POPS
FEB12 POPS - CNS MA INLY
Mar 12 POPS CNS MA INLY
A PRIL 12 NO POPS
(HOLIDA Y /CONFERENCES)
MA Y 12 POPS -CNS
MA INLY
JUN 12 POPS CNS & SPR
JULY 12 POPS CNS & SPR
A UG 12 POPS CNS & SPR
SEPT 12 POPS CNS & SPR
OCT 12 NO POPS
5
6
7
8
9
10
11
12
13
LOS IN DAYS
Series1
OCT
12 NO
POPS
SEPT
12
POPS
A UG
12
POPS
JULY
12
POPS
JUN 12
POPS
CNS &
MA Y
12
POPS -
A PRIL
12 NO
POPS
Mar 12
POPS
CNS
FEB12
POPS CNS
9.8
7.2
7.2
9.4
8.7
10.6
11.5
9.1
9.5
JA N 12 DEC 11
NO
NO
POPS
POPS
11.7
11.5
NOV
11 NO
POPS
12.5
Impact on LOS
 LOS in patients aged 65+ reduced with GOLD
 Pre-GOLD LOS: 11.7-14.0 days (Oct 11-Jan 12)
 Partial GOLD LOS: 9.1 - 9.5 days (Feb 12 – March 12)
 GOLD LOS: 7.2 - 9.4 days (Jun – Aug)
 In addition, a number of younger patients with complex
needs and lengthy hospitalisations would benefit from
this approach.
 Our scoping would suggest that at least half of all
inpatients fall into the category of requiring GOLD input
Dissemination to oncology training bodies
 Survey of medical oncology trainees
 Kalsi T, Payne S, Brodie H, Wang Y, Mansi JL,
Harari D. Are UK oncology trainees adequately
informed about the needs of older people with
cancer? British Journal of Cancer 1–6 | doi:
10.1038/bjc.2013.204
 Survey currently being considered in the revision
of the national medical oncology curriculum
 Geriatric Oncology Training During Specialist
Training
66.1% never received any training on the needs of
older people with cancer
19.4% had only ever received this training once
 Training in geriatrics specific issues common in
oncology patients (eg delirium, falls)
Of those who had received training, the majority
received it 3 years ago
Want training
 cognitive impairment/delirium (n=18)
 polypharmacy (n=17)
 discharge planning (n=7).
Practice in cognitive impairment
Cognitive assessments
45.9% rarely/never assessed
Consent and Mental Capacity Assessment
27.3% never consent patients with cognitive
impairment
50.9% would rarely consent
38.9% MCA never/rarely used to decide about
the patient’s understanding
Confidence in risk assessment
81.4% confident for younger pts
27.1% for older patients
10.2% for older patients with dementia
25.4% confident/extremely confident managing
multiple comorbidities
Macmillan/DOH/Age UK report:
Cancer Services Coming of Age, Dec 2012
http://www.macmillan.org.uk/Aboutus/Healthprofessionals/
Improvingservicesforolderpeople/Pilots/PilotSites.aspx
Department of health recommendations
 improving survival rates in the population aged
75 years and over
 to deliver high quality services to increasing
numbers of older patients with cancer, including
age appropriate assessment, for example the
Comprehensive Geriatric Assessment (CGA)
 involvement of elderly care specialists
http://cno.dh.gov.uk/2012/12/20/cancer-services-coming-ofage-report-published/
How can oncologists, surgeons and geriatricians work
together?
 CGA / comorbidity screening with identification of low and
at risk patients can be done in oncology clinic
 In-depth CGA for at risk patients (outpatient) – ideally
joint oncology/geriatric clinics
 Assessment is part protocolised so could also be done by
oncology with geriatrician support
 Inpatient liaison – medical optimisation, rehabilitation
goal setting, early discharge planning – dedicated
geriatric liaison team is preferred model (if funded…)
 Could be done by oncologists with consultative support
and geriatrician sitting in on ward MDM