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Comprehensive geriatric assessment in older people undergoing cancer treatment

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Title: Geriatric Oncology Author: tkalsi Last modified by: Wendy Notowicz Created Date: 10/17/2011 3:26:07 PM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: Comprehensive geriatric assessment in older people undergoing cancer treatment


1
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
  • danielle.harari_at_gstt.nhs.uk

2
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)

3
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)

4
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

5
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

6
Role of CGA in oncology current situation
  • Growing interest (SIOG, DH, Macmillan, NCEPOD) in
    integrating CGA into pre-treatment 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

7
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

8
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) patient-reported outcomes (QOL) (d)
    healthcare processes (e.g. transport to hospital,
    unplanned admissions, LOS)?

9
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
10
Findings from observational work (pre group)
all patients completed GOLD-CGA questionnaire
Why may older people be under-treated
11
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)

12
CGA screening in patients with lymphoma BSH 2012
  • 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
  • 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.
  • 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

13
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 CGA-GOLD screening questionnaire using
    methodology as described by Rockwood.

14
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 (kappa0.25)
  • 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.

15
Low grade toxicity in older people undergoing
chemotherapy ECCO 2013
  • N108 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

16
Results treatment modifications due to toxicity
N60 (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)

17
Results Toxicity grade trigger to treatment
modification (N60) by comorbidity
Multiple comorbidities (4) N19
Few Comorbidities (lt4) N41
Low grade toxicity 57.9 (N11)
High grade toxicity 42.1 (N8)
High grade toxicity 75.6 (N31)
Low grade toxicity 24.4 (N10)
Statistically significant p0.011, ?26.41
18
Results Early discontinuation due to toxicity
N23 (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 n3
  • Most common grade 2 toxicities fatigue (5) and
    haemotological toxicity (4)

19
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?

20
Fatigue in older people undergoing chemotherapy
SIOG 2013
  • Baseline fatigue is rarely documented
  • Fatigue toxicity was cited by treating
    oncologists in 69.1 (n75) of all patients
    during chemotherapy, with grade 2 occurring in
    36.1 (39) and grade 3 occurring in 11.1 (11)

21
Findings from interventional work (post group)
Impact of geriatric-oncology liaison in
outpatients and inpatients (oncology wards)
22
GOLD PATHWAYS DEVELOPED
23
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

24
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

25
Screening Questionnaire
RECRUITED n177
BEXLEY GP GROUP n 31
GSTT GROUP n146
SCREENING QUESTIONNAIRE ? NOTE REVIEW AND
TELEPHONE CLINIC FOR CGA NEED
NO CGA CLINIC AS PER NEED OR WISHES N73 (50)
IN DEPTH CGA CLINIC N73 (50)
26
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 (n62/71) of
    questionnaires
  • Reliability against clinical notes review
  • Clinician 1 (SPR) notes changed decision of CGA
    need in 10.9 (n9/82) patients
  • Clinician 2 (CNS) notes changed decision in 9.6
    (n8/83) patients
  • Acceptability patient responses
  • 80.2 (n142) did not need help to complete
  • Mean time to complete 14.5 mins /- SD 9.3

27
Outpatients - Comorbidities
LOW RISK
HIGH RISK
IN DEPTH REVIEW BY GERIATRICIAN TO
OPTIMISE/REVERSE CGA
NO CGA REQUIRED
COMORBIDITIES MEDIAN 3.0 MEAN 2.51 /- SD 1.9.
COMORBIDITIES MEDIAN 6 MEAN OF 5.75 /- SD 2.4
28
Did POPS-GOLD influence oncology treatment
decision-making BGS 2012
  • 60 (n24) of oncologists responded to
    semistructure questionnaire (21 consultants, 63
    registrars, 17 clinical nurse specialists)
  • All respondents had read the CGA assessment
    letter at the patients next cancer appointment.
  • 63 (n15) reported the assessment had influenced
    their decision-making.
  • Of these, 67 (n10) 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 (n5)
  • increased information (n3)
  • facilitated communication (n2)
  • increasing confidence (n3).

29
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

30
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
  • Early CGA can influence oncology decision-making.
  • 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.

31
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

32
In-patient Liaison
33
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

34
GOLD Intensity of Input
GOLD Intensity of Input N 113 (n)
Not involved Light touch Medium touch Heavy Very heavy 37 (42) 25 (28) 11 (13) 20 (22) 7 (8)
35
Impact on quality of information across to
primary care and community and coding
Oncology Discharge letter GOLD ENHANCED
PRINCIPAL DIAGNOSIS 1. AML COMORBIDITIES 2. Myelodysplasia 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
36
Impact on length of stay
37
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

38
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 16 doi
    10.1038/bjc.2013.204
  • Survey currently being considered in the revision
    of the national medical oncology curriculum

39
  • 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 (n18)
  • polypharmacy (n17)
  • discharge planning (n7).

40
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
    patients understanding

41
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

42
Macmillan/DOH/Age UK report Cancer Services
Coming of Age, Dec 2012
  • http//www.macmillan.org.uk/Aboutus/Healthprofessi
    onals/Improvingservicesforolderpeople/Pilots/Pilot
    Sites.aspx

43
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-co
    ming-of-age-report-published/

44
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

45
Thank you
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