A comprehensive geriatric assessment can improve the quality of life of older cancer patients about to receive anti-cancer therapy, according to a new study. The prospective, randomized, open-label INTEGERATE trial, the first randomized clinical trial in geriatric oncology to show that an integrated approach involving geriatricians and oncologists working in partnership, helped improve quality of life and also reduced hospital admissions and early discontinuation of treatment due to adverse events.
With the aging global population, oncologists are faced with the challenges of managing the health care and needs of older cancer patients. "Older people with cancer are a vulnerable group. We need to optimize their health, especially when they are receiving treatments with high side effects, such as chemotherapy," said lead author Wee-Kheng Soo, MBBS, FRACP, a geriatrician and medical oncologist at Eastern Health in Melbourne, Australia.
Soo presented the findings of the study at a press briefing before the 2020 ASCO Annual Meeting (Abstract 12011).
Geriatricians have a holistic way of assessing the health of an older person, called a comprehensive geriatric assessment. It provides a powerful framework to assess an older person's health profile and enables a coordinated person-centered approach to care.
"Comprehensive geriatric assessment is simply a comprehensive health assessment that focuses on vulnerabilities commonly seen in older people, things like difficulty with functional activities, medical issues, polypharmacy, poor nutrition, memory problems, depression, and social isolation. By recognizing these problems early on, we can apply practical interventions to support them. In essence, we are staging the aging to enable appropriate care," Soo explained.
Currently, cancer patients are typically referred to a geriatrician only in the later stages of illness when they experience significant problems with completing everyday tasks. However, an integrated approach involving comprehensive geriatric assessment and early geriatrician involvement can help create a coordinated plan to optimize the older person with cancer.
"The comprehensive geriatric assessment is a powerful tool because it helps optimize care for older cancer patients," said Soo.
About the Study
The prospective, randomized, parallel-group, open-label study involved 154 patients with cancer older than 70 years who were going to receive chemotherapy, targeted therapy, or immunotherapy treatment. Patients were randomized to receive integrated oncogeriatric care or usual care.
The study's primary outcome, quality of life, was measured using a validated assessment tool called the Elderly Functional Index (ELFI) score. Quality of life was also assessed using the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life of Questionnaire.
Patients in the intervention group reported significantly better ELFI scores at 12, 18, and 24 weeks of follow-up as compared with the group receiving usual care. The greatest difference was seen at week 18 (estimated marginal mean ELFI score 72.0 in the intervention group vs. 58.7 in the group receiving usual care).
"In addition, the intervention group saw significant improvements in other quality-of-life measures, including functioning, mobility, burden of illness, and future worries," Soo noted.
The intervention resulted in improvement in more objective measures as well, including unplanned hospital admissions and reduced early treatment discontinuation due to adverse events. There were 1.3 fewer visits to the emergency department per person per year (39% lower than the usual care group), and 1.2 fewer unplanned hospital admissions per person per year (43% lower). The number of overnight stays also decreased by 7 days per person per year (24% lower). The proportion of patients discontinuing treatment early due to adverse events was lower than the group receiving usual care (32.9% vs. 53.2%). This decline appears to be driven by reduced treatment-related toxicity, said Soo.
Next Steps
The researchers plan to implement an oncogeriatric model of care in a large, multi-center implementation study comparing different care models in geriatric oncology (e.g., geriatrician-led, nurse-led, or oncologist-led) and different cancer settings (e.g., surgical oncology, radiation oncology, inpatient).
In conclusion, Soo said: "Integrated oncogeriatric care in older people with cancer about to receive anti-cancer therapy led to significant improvements in health outcomes at patient level and quality of life, as well as system levels outcomes such as hospitalization and treatment delivery. These findings suggest that all older people 70 and above should receive a comprehensive geriatric assessment to optimize their clinical care and health outcomes."
ASCO President Howard A. Burris III, MD, Chief Medical Officer and President of Sarah Cannon Research Institute, commented: "The number of people worldwide over the age of 65 is expected to continue to grow, making the need for more rigorous research to help optimize the quality of care we provide to older patients an urgent priority. This study shows that geriatric assessments lead to clear improvements in quality of life and better care planning for older patients with cancer."
Mark L. Fuerst is a contributing writer.