1. Goodwin, Peter M.

Article Content

CHICAGO-A "cluster randomized controlled trial" of treatment for patients with advanced cancers found that the use of standardized geriatric assessments (GAs) significantly increased the number and quality of discussions about age-related concerns in comparison with usual care and also resulted in higher scores of patient satisfaction-which the investigators regarded as paramount among therapy outcomes (Abstract LBA10003).


In a media briefing about the study held at the 2018 ASCO Annual Meeting, lead author Supriya Gupta Mohile, MD, MS, Professor of Medicine and Surgery at the James Wilmot Cancer Institute at the University of Rochester and Director of the Geriatric Oncology Clinic, emphasized the pivotal role of GA when treating older patients for their late-stage cancers.


With few cancer doctors specifically trained at caring for older patients in addition to their standard oncology training, Mohile said her group's study found that integrating those two specialties was important. "Older patients with cancer have more than just cancer going on. They have other issues that they care about.


"If an oncologist is going to meet an older patient and think about treatment for cancer-especially in the palliative setting for advanced cancer-understanding these other issues [is] important," she told Oncology Times.


Historically, when GA had not been used, there had been poorer outcomes, she noted. And in the real world, oncologists generally made their decisions by using data derived from phase III clinical trials such as those reported at ASCO.


"These patients aren't enrolled in phase III clinical trials. They're older. They have comorbidities. They have disability. They are frail. Yet they are prevalent in our community and oncologists are faced every day in shared decision-making issues with patients and caregivers about what to do," said Mohile.


Since oncologists commonly take factors such as age, comorbidity, and "how the patient looks" into consideration when making treatment decisions, this could lead to big variations in care, she stated.


Doctors often resorted to using "gestalt" to decide on a course of action with an individual patient. And one doctor's gestalt might be different from another's. So older patients could easily be over- or under-treated. "A geriatric assessment is standard. So it can standardize [the] approach to an older patient," Mohile noted.


GA included validated measures that assessed age-related health domains such as function and cognition that were known to influence outcomes, said Mohile. So it was not surprising that the GA-guided interventions used in the study were found to have improved communication about age-related concerns for older patients with cancer.


Study Details

Study patients were at least 70, had advanced solid tumors or lymphoma, and also had one or more impaired GA domain. They were randomized to intervention (in which their oncologists received GA summaries) or usual care (with no summary provided).


"Cluster randomization" was achieved by randomly assigning 31 entire community oncology practice sites to the GA intervention or usual care. Doing this-rather than randomizing individual patients within the same practice-eliminated the risk that clinicians would inadvertently use newly acquired knowledge of geriatric assessment among patients allocated to usual care.


The two primary outcomes were the number of discussions about age-related concerns and findings from telephone surveys assessing patient satisfaction by means of a modified "Health Care Climate Questionnaire" (HCCQ).


Out of a total of 544 patients enrolled, 295 had GA. There were no demographic differences between the two study arms. Mean age was 77. Half of the patients were female. Slightly more of the patients randomized to usual care had impaired physical performance (96% compared with 92%) and a greater number of them had social support (33% compared with 25%).


An average of 6.3 discussions about age-related concerns were conducted in both study arms put together. But patients allocated to have GA included with their care had a mean of 3.5 more discussions than those on usual care.


On average, 2.0 more discussions were categorized as "higher quality communication" among patients who had GA and 1.9 more discussions led to interventions. Not surprisingly, patients in the GA arm of the study had significantly more discussions for almost all GA domains.


The mean score of HCCQ was 22.9 (both arms together). It was 1.12 points higher for patients in the GA arm.


"Examples of age-related concerns were things like: How will cancer treatment affect my blood pressure? How will cancer treatment affect my heart disease?" noted Mohile. And she also listed worries among family and caregivers as well as by patients themselves about whether cancer drugs could interact with any of the medicines they were already taking.


Poor and faulty compliance-as well as the concern that cancer treatment might exacerbate cognitive issues-were also prominent among the age-related issues discussed.


And Mohile said some patients worried that, despite the possible benefit of a treatment for their cancer, they were concerned that it could make it more difficult for them to take care of other family members more needy than themselves.


"These are things that older people care about. All the time in my clinics I hear: Can I stay in my home?" Mohile said these questions were problematic since they were not addressed in clinical studies. "I don't know what to tell my patients. But these are things that are important to discuss.


"There were more discussions in the geriatric assessment intervention arm-about 7.7 on average compared to 4.2 on average [with usual care]," she reported. "This was highly statistically significant. In addition: it wasn't just talked about. The doctors actually probed more. They had conversations that were meaningful. They had higher-quality conversations. And they also did something about it."


Practice Implications

Given the paucity of geriatric oncologists, Mohile regarded the education of oncologists as a paramount need in the U.S. and possibly elsewhere.


"If we are concerned about providing high-value care to older patients, we have to recognize that older patients and their caregivers care about these kinds of concerns and not neglect them when we're talking about cancer and their treatment," she said.


"Geriatric assessment is known to identify older patients at highest risk for adverse outcomes. We think we can improve care delivery by improving communication about age-related health concerns if geriatric assessment is used."


ASCO expert Joshua A. Jones, MD, MA, Assistant Professor of Clinical Radiation Oncology at the Perelman Center for Advanced Medicine, Perelman School of Medicine in the University of Pennsylvania, Philadelphia, commented on the findings: "As a society we often think about the value of cancer treatments in terms of survival. But for older patients we need to look beyond that.


"Geriatric assessments are clearly an effective tool to help us treat the whole patient," he concluded. "It's a conversation starter that informs and empowers both patients and oncologists as we make decisions about their cancer care and overall health care together."


Peter M. Goodwin is a contributing writer.