Godelieve Conings

Performance of Two Geriatric Screening Tools in Older Patients With Cancer

PURPOSE To compare the diagnostic characteristics of two geriatric screening tools (G8 and Flemish version of the Triage Risk Screening Tool [fTRST]) to identify patients with a geriatric risk profile and to evaluate their prognostic value for functional decline and overall survival (OS). PATIENTS AND METHODS Patients ≥ 70 years old with a malignant tumor were included if a new cancer event occurred requiring treatment decision. Geriatric screening with G8 and fTRST (cutoff ≥ 1 [fTRST (1)] and ≥ 2 [fTRST (2)] evaluated) was performed in all patients, as well as a geriatric assessment (GA) evaluating social situation, functionality (activities of daily living [ADL] + instrumental activities of daily living [IADL]), cognition, depression, and nutrition. Functionality was re-evaluated 2 to 3 months after cancer treatment decision, and death rate was followed. Functional decline and OS were evaluated in relation to normal versus abnormal score on both screening tools. RESULTS Nine hundred thirty-seven patients were included (October 2009 to July 2011). G8 and fTRST (1) showed high sensitivity (86.5% to 91.3%) and moderate negative predictive value (61.3% to 63.4%) to detect patients with a geriatric risk profile. G8 and fTRST (1) were strongly prognostic for functional decline on ADL and IADL, and G8, fTRST (1), and fTRST (2) were prognostic for OS (all P < .001). G8 had the strongest prognostic value for OS (hazard ratio for G8 normal v abnormal, 0.38; 95% CI, 0.27 to 0.52). CONCLUSION Both geriatric screening tools, G8 and fTRST, are simple and useful instruments in older patients with cancer for identifying patients with a geriatric risk profile and have a strong prognostic value for functional decline and OS.

The influence of clinical assessment (including age) and geriatric assessment on treatment decisions in older patients with cancer

OBJECTIVES The aim of this prospective study in older patients with cancer was to evaluate how clinical assessment (including age) determines the physicians treatment decisions, and how geriatric assessment (GA) further influences these decisions. PATIENTS AND METHODS Patients aged ≥70years old with cancer were included if a new therapy was considered. All patients underwent a GA and results were communicated to the treating physician. After the final treatment decision, a predefined questionnaire was completed by the physician. RESULTS In total, 937 patients with median age of 76years old were included. A total of 902 (96.3%) questionnaires were completed by the treating physicians. In 381/902 patients (42.2%) clinical assessment led to a different treatment decision compared to younger patients without co-morbidities. This difference was most prominent for chemotherapy/targeted therapy decisions. In 505/902 cases (56%) the treating physician consulted GA results before the final treatment decision. In these patients, the treatment decision was influenced by clinical assessment in 44.2%. In 31/505 patients (6.1%) the GA further influenced treatment, mostly concerning chemotherapy/targeted therapy. In eight patients GA influenced the physician to choose a more aggressive chemotherapy. CONCLUSIONS Physicians use different treatment regimens in older versus younger patients, based on clinical assessment, including age. GA results further influence treatment decisions in a minority of patients and may trigger the use of less aggressive as well as more aggressive treatments. GA information is not always utilized by oncologists, indicating the need for better education and sensitization.

Functional decline in older patients with cancer receiving chemotherapy: A multicenter prospective study

OBJECTIVES This study aims to evaluate the evolution of functional status (FS) 2 to 3months after initiation of chemotherapy, to identify factors associated with functional decline during chemotherapy treatment and to investigate the prognostic value of functional decline for overall survival (OS). PATIENTS AND METHODS Patients ≥70years with a malignant tumor were included when chemotherapy was initiated. All patients underwent a geriatric assessment (GA) including FS measured by Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL). FS of patients was followed by repeating ADL and IADL to identify functional decline. RESULTS From 10/2009 until 07/2011, 439 patients were included. At follow-up, ADL and IADL data were available for 387 patients. Functional decline in ADL and IADL was observed in 19.9% and 41.3% of the patients respectively. In multivariable logistic regression analysis, baseline factors associated with decline in ADL are abnormal nutritional status (OR:2.02) and IADL dependency (OR:1.76). Oncological setting (disease progression/relapse vs new diagnosis) (OR:0.59) is the only determinant of decline in IADL. Functional decline in ADL is strongly prognostic for OS (logrank p-value<.0001; Wilcoxon p-value<.0001) with HR 2.34 and functional decline in IADL is also prognostic for OS but less prominent with HR 1.25. CONCLUSIONS Functional decline occurs in about a third of older patients with cancer receiving chemotherapy and is associated with GA components. It strongly predicts survival, the most prominent for ADL. This knowledge can be used to identify older persons with cancer receiving chemotherapy eligible for interventions to prevent functional decline.

A Belgian survey on geriatric assessment in oncology focusing on large-scale implementation and related barriers and facilitators

OBJECTIVES The aim of this study is to describe a large-scale, Belgian implementation project about geriatric assessment (=GA) in daily oncology practice and to identify barriers and facilitators for implementing GA in this setting. Design / setting / participants: The principal investigator of every participating hospital (n=22) was invited to complete a newly developed questionnaire with closed- and open-ended questions. The closed-ended questions surveyed how GA was implemented. The open-ended questions identified barriers and facilitators for the implementation of GA in daily oncology practice. Descriptive statistics and conventional content analysis were performed as appropriate. RESULTS Qualifying criteria (e.g. disease status and cancer type) for GA varied substantially between hospitals. Thirteen hospitals (59.1%) succeeded to screen more than half of eligible patients. Most hospitals reported that GA data and follow-up data had been collected in almost all screened patients. Implementing geriatric recommendations and formulating new geriatric recommendations at the time of follow-up are important opportunities for improvement. The majority of identified barriers were organizational, with high workload, lack of time or financial/staffing problems as most cited. The most cited facilitators were all related to collaboration. CONCLUSION Interventions to improve the implementation of GA in older patients with cancer need to address a wide range of factors, with organization and collaboration as key elements. All stakeholders, seeking to improve the implementation of GA in older patients with cancer, should consider and address the identified barriers and facilitators.