Geriatric Assessments: Enhancing Decision-Making in Older Cancer Patients
Conference:
2024 West Oncology Virtual Conference for Advanced Patient Practicioners
Presented by:
Lauren Albertine, FNP, Nurse Practitioner, West Cancer Center
At the 2024 West Oncology Virtual Conference for Advanced Patient Practicioners (APP), Nurse Practicioner Lauren Albertine from West Cancer Center discussed the topic of Geriatric Assessments in oncology, emphasizing the value of systematically evaluating older cancer patients to guide more individualized treatment strategies. She highlighted the essential components of geriatric assessments (GA), how they may be integrated into oncology practice, and their ability to empower patients and providers through tailored decision-making.
Introduction to Geriatric Assessments
A geriatric assessment is a structured tool designed to evaluate areas where older adults may commonly face vulnerabilities. These include such domains as functional status, emotional well-being, nutrition, mobility, fall risk, cognition, comorbidities, polypharmacy, and level of social support. By identifying deficits in these areas, GA can help providers tailor oncology treatments and optimize patient outcomes.
The 2018 ASCO Guidelines recommend GA for all cancer patients aged 65 and older, performed both at the start of treatment, and throughout the care continuum. Despite this endorsement, GA remain underutilized due to perceived logistical barriers, time constraints, and resource limitations.
Ms Albertine emphasized that chronological age alone is not a reliable measure of patients’ overall resiliency. For example, a 90-year-old who is in excellent health may be better able to tolerate aggressive cancer treatment better than a 66-year-old with significant comorbid conditions. In this regard, geriatric assessments can provide objective data to distinguish these two cases, ensuring a more nuanced and appropriate care plan.
The Role of Geriatric Assessments in Oncology
Geriatric assessments have wide-ranging applications, including:
Guiding Treatment Decisions: GA help to stratify patients by their overall ability to tolerate specific cancer treatments, enabling a more shared decision-making process between patients, families, and providers.
Tailoring Interventions: Early identification of impairments through GA allows for targeted referrals (e.g., physical therapy, nutritional counseling) to help mitigate risks and enhance treatment outcomes.
Supporting Aggressive or Palliative Approaches: GA can be used to advocate for more aggressive treatments in fit older adults, and can also helps justify dose modifications and/or alternative therapies in frail patients.
Empowering Patients: By better personalizing care, GA can foster enhanced patient engagement and greater confidence in their treatment plan.
Ms Albertine also noted that GA benefits extend beyond medical oncology, and can aid decision-making in surgical and radiation oncology. Surgeons, for instance, often use GA to evaluate candidates for higher-risk surgical interventions.
Components of a Geriatric Assessment
MS Albertine described some of the comprehensive patient-specific data collected during GA, which includes:
1. Cognitive Assessment (MiniCog)
The MiniCog, a brief, validated tool, screens for cognitive impairment, providing a score out of 5. It is critical for ensuring that patients have the capacity to make informed decisions about their care.
2. CARE Survey
This patient-reported survey captures:
The patient’s medical history and recent hospitalizations.
Their perceived health and ability to perform activities of daily living (ADLs).
Social support parameters, patient’s nutritional status, and mood.
Patient’s functional capacity, including mobility and independence.
3. Calculators
GA integrates two key predictive tools:
Chemotherapy Toxicity Risk Calculator: This measure quantifies the likelihood of toxicity based on therapy type (i.e., poly- drug therapy vs. monotherapy) and dosing (i.e., standard dosing vs. reduced).
Life Expectancy Predictor: This measure provides an overall estimate of survival, which can aid in discussions about aggressiveness of treatment.
By combining these tools, GA can deliver actionable insights that help to better inform on key parameters and individualize care plans.
Case Studies: Geriatric Assessments in Action
Ms Albertine shared two real-world examples to illustrate the merit of performing GA:
Case 1: 75-Year-Old Male with Muscle-Invasive Bladder Cancer (MIBC)
This patient faced a decision about the need for neoadjuvant chemotherapy followed by cystectomy. Despite his significant comorbidities, his GA revealed:
MiniCog: 4/5 (cognitively intact).
Chemotherapy Toxicity Risk: 90% likelihood of toxicity with standard-dose polytherapy.
Life Expectancy: 8.9–10 years.
In view of these findings, the patient opted for more aggressive treatment. In addition, to mitigate potential toxicity, the provider implemented split-dose chemotherapy, which improved tolerance and allowed the patient to complete four cycles of treatment before surgery. Post-treatment, the patient achieved excellent outcomes, underscoring the utility of GA in guiding and supporting more aggressive, yet still feasible clinical interventions for the patient.
Case 2: 92-Year-Old Male with Metastatic Muscle-Invasive Bladder Cancer
This patient was seeking aggressive therapy, despite his advanced age and metastatic disease. His GA showed:
MiniCog: 4/5 (cognitively intact).
Chemotherapy Toxicity Risk: 86% with standard-dose polytherapy, which could be reduced to 78% with dose-modified regimens.
Life Expectancy: 3.8–5.1 years.
The provider initiated treatment with a 25% dose reduction and maintained a low threshold for changing therapy if necessary. After three cycles of chemotherapy, the patient transitioned to maintenance immunotherapy, achieving improved tolerance and quality of life.
Challenges in Implementing Geriatric Assessments
Despite their proven benefits as exemplified above, GA is often underutilized due to perceived barriers:
Time and Resource Constraints: Comprehensive assessments do require dedicated time, personnel, and logistical planning.
Provider Awareness: Some clinicians may underestimate GA’s value and/or may be unfamiliar with GA tools.
As such, Ms Albertine advocated taking steps to better integrate GA into oncology workflows by:
Delegating data collection (e.g., MiniCog and CARE survey) to non-provider team members.
Scheduling GA appointments separate from initial consults so as to minimize clinic disruptions.
Utilizing digital GA calculators for a more streamlined risk assessment.
Implications for Clinical Practice
Ms Albertine emphasized the transformative potential and benefits of using GA in oncology care:
Improved Outcomes: GA can enhance treatment tolerability, reducing complications, and empowering patients to make more informed decisions.
Evidence-Based Decision-Making: Providers can gain robust data to justify treatment modifications, and enable a more personalized care plan.
Interdisciplinary Value: Beyond medical oncology alone, GA can help support surgical and radiologic procedures by assessing patient fitness for specific interventions.
Conclusions and a Call to Action
Geriatric assessments offer a critical framework for optimizing care in older adults with cancer. By identifying patient-specific risks and tailoring treatment, GA can improve patient outcomes, support shared decision-making with the patient, and empower providers to deliver more compassionate and evidence-based care. Ms Albertine concluded with a call to action, urging oncology teams to adopt GA as a part of standard clinical practice. Whether integrated into routine visits, or conducted by specialized teams, GA ensures that older adults receive the personalized care they deserve.
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Speaker Disclosure Information: Ms Albertine reported no relevant disclosures for this presentation.
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See the full presentation on Geriatric Assessments by Lauren Albertine, FNP here.