original articles

Annals of Oncology

Annals of Oncology 24: 1306–1312, 2013 doi:10.1093/annonc/mds619 Published online 4 January 2013

Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study C. Kenis1, D. Bron2, Y. Libert3, L. Decoster4, K. Van Puyvelde5, P. Scalliet6, P. Cornette7, T. Pepersack8, S. Luce9, C. Langenaeken10, M. Rasschaert11, S. Allepaerts12, R. Van Rijswijk13, K. Milisen14,15, J. Flamaing14,16, J.-P. Lobelle17 & H. Wildiers18,19* 1 Department of General Medical Oncology and Geriatric Medicine, University Hospitals Leuven, Leuven; Departments of 2Hematology; 3Psycho-oncology, ULB Institut Bordet, Brussels; Departments of 4Medical Oncology, Oncologisch Centrum; 5Geriatric Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels; Departments of 6Radiotherapy; 7Department of Geriatric Medicine, Cliniques Universitaires Saint-Luc, UCL, Brussels; Departments of 8Geriatric Medicine; 9Medical Oncology, University Hospital Erasme, Université Libre de Bruxelles (ULB), Brussels; 10Department of Medical Oncology, Iridium Cancer Network Antwerp, AZ Klina, Brasschaat; 11Department of Medical Oncology, Iridium Cancer Network Antwerp, St. Augustinus, Wilrijk; 12Department of Geriatric Medicine, Centre Hospitalier Universitaire Sart Tilman, Liege; 13Department of Medical Oncology, ZNA Stuivenberg, Antwerpen; 14Department of Geriatric Medicine, University Hospitals Leuven; 15 Centre for Health Services and Nursing Research, KU Leuven, Leuven; 16Department of Clinical and Experimental Medicine, KU Leuven, Leuven; 17Consultant in Statistics, Beernem; 18Department of General Medical Oncology, University Hospitals Leuven, Leuven; 19Department of Oncology, KU Leuven, Leuven, Belgium

Received 27 August 2012; revised 16 October 2012; accepted 17 October 2012

Background: To evaluate the large-scale feasibility and usefulness of geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions. Patients and methods: Eligible patients who had a malignant tumour were ≥70 years old and treatment decision had to be made. Patients were screened using G8; if abnormal (score ≤14/17) followed by Comprehensive Geriatric Assessment (CGA). The assessment results were communicated to the treating physician using a predefined questionnaire to assess the topics mentioned above. Results: One thousand nine hundred and sixty-seven patients were included in 10 hospitals. Of these patients, 70.7% had an abnormal G8 score warranting a CGA. Physicians were aware of the assessment results at the time of treatment decision in two-thirds of the patients (n = 1115; 61.3%). The assessment detected unknown geriatric problems in 51.2% of patients. When the physician was aware of the assessment results at the time of decision making, geriatric interventions were planned in 286 patients (25.7%) and the treatment decision was influenced in 282 patients (25.3%). Conclusion: Geriatric screening and assessment in older patients with cancer is feasible at large scale and has a significant impact on the detection of unknown geriatric problems, leading to geriatric interventions and adapted treatment. Key words: cancer, elderly, geriatric assessment, treatment decision

introduction About 50% of cancer cases and two-thirds of cancer deaths occur in patients of 65 years and older. Hence, there is a great need to deliver qualitative cancer care for older persons [1]. Older patients with cancer are less likely to be treated *Correspondence to: Prof H. Wildiers, Department General Medical Oncology, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium. Tel: +32-16-34-69-00; Fax: +3216-34-69-01; E-mail: [email protected]

according to recommended treatment guidelines and as a consequence, under-treatment may have a strong negative impact on survival [2, 3]. Older patients with cancer represent a very heterogeneous group, where the biological or functional age can differ significantly from chronological age. A Comprehensive Geriatric Assessment (CGA) is considered to be the most appropriate way to obtain a better view on the global health and functional status and reserve capabilities of older individuals. CGA is a multidimensional, interdisciplinary

© The Author 2013. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: [email protected].

original articles

Annals of Oncology

patient evaluation that leads to the identification of the general health status including medical, functional, cognitive, social, nutritional and psychological parameters [4]. There are at least four good reasons for an oncologist to obtain a CGA [5]: (i) CGA has important prognostic information that can be helpful in estimating life expectancy, which is of paramount importance when making treatment decisions; (ii) CGA can predict toxicity or decrease in quality of life (QoL) enabling a more targeted use of preventive measures; (iii) CGA can reveal previously unknown geriatric problems [6–8]; (iv) CGA allows targeted interventions, which can improve QoL and compliance to therapy. CGA is therefore recommended in all older patients with cancer, as mentioned in guidelines from the National Cancer Center Network (NCCN) and the International Society of Geriatric Oncology (SIOG) [9]. Despite all these arguments, CGA is not routinely implemented in clinical care due to several barriers. These include CGA being a time-consuming realization for busy clinicians, the lack of trained staff even in large academic hospitals and poor financial rewarding for performing the CGA by the health insurance system. To focus on frail patients, those who benefit most from CGA, there is an increasing interest in the use of shorter screening tools to detect older persons with a geriatric profile, such as the Flemish Triage Risk Screening Tool (TRST) [10], Vulnerable Elders Survey-13 (VES-13) [11], Groningen Frailty Indicator (GFI) [12] or G8 [13,14], the latter being validated in older oncology patients in a large French prospective study. It is generally recommended to start with a screening tool and to continue with a CGA only in case of an abnormal screening score. The present study was set up to assess the feasibility and usefulness of a geriatric screening and assessment in the clinical care of older patients with cancer in academic and non-academic centres in Belgium. The primary objective was to assess how many unknown geriatric problems are detected in older patients with cancer. Other objectives were to assess whether the detection of these problems led to a geriatric intervention and influenced treatment decisions.

patients and methods patient population This prospective, multi-centre, non-interventional study was carried out in 10 hospitals in Belgium, including six academic and four non-academic hospitals. Patients 70 years and older with a malignant tumour were included at diagnosis or at disease progression, when a change in therapeutic strategy was considered. Inclusion was limited to six tumour types: breast, colorectal, ovarian, lung, prostate cancer and haematological malignancies. The study was approved by the Ethical Committee of each participating hospital. Informed consent was obtained from all patients or their caregiver.

screening and CGA In each centre, a trained health care worker (usually a nurse, attached to the oncology and/or geriatric department) was appointed to detect eligible patients and to perform a screening with G8. If G8 (range: 0–17) demonstrated a geriatric profile (score ≤14), a CGA was carried out. The CGA was established in collaboration with the Belgian Society of

Volume 24 | No. 5 | May 2013

Gerontology and Geriatric Medicine (BVGG) [15] (supplementary Table S1, available at Annals of Oncology online). The results from the assessment (=screening with/without CGA) were recorded in the medical file of the patient and were delivered (on paper or electronically) to the treating physician, before the (final) treatment decision. It was at the treating physician’s discretion to use the information obtained by the assessment when setting up a treatment plan for the older patient.

questionnaire for the treating physician Within a month after the final treatment decision, the trained health care worker contacted the treating physician. The results from the assessment were presented (again) to the treating physician, who completed a questionnaire. This predefined questionnaire contained four questions: (i) were you aware of the assessment results at the time of treatment decision? (ii) Did the assessment reveal any new information for you in the following fields: pain, social problems, functionality, falls, self-perceived fatigue, cognition, depression, nutrition, other? (iii) When you were aware of the results of the assessment, was any action undertaken to deal with the detected problems (=geriatric interventions that would not have been undertaken if assessment was not carried out)? Possible interventions were the involvement of other health care workers or referrals: geriatrician, geriatric liaison team, social worker, occupational therapist, physiotherapist, geriatric day clinic, fall clinic, geronto-psychiatrist, dietician, other. (iv) Did the assessment influence your oncological treatment decision?

statistical analysis Descriptive statistics were carried out for both continue and discrete values using SAS v9.2. 95% confidence limits were calculated where appropriate. A chi-square test for trend was carried out on the physician’s awareness during three consecutive time periods: first period (10/2009–05/2010), second period (06/2010–12/2010) and last period (01/2011–07/2011).

results patient and clinical characteristics For participation in the study, 2259 patients were approached. Of these patients, 151 refused to participate and 141 did not meet the inclusion criteria (mostly not being progressive, no invasive tumour diagnosed or primary origin of the tumour different from the six selected tumour types). Written informed consent was given by 1938 patients and 29 caregivers, resulting in 1967 patients included. Patient characteristics are listed in Table 1. The median age was 76 (range: 70–96) years, and 64.1% were female. Breast cancer was the most common diagnosis, accounting for 40.5% of the patients, followed by colorectal cancer (21.5%) and haematological malignancies (12.8%). Within the haematological malignancies, non-Hodgkin lymphoma was the most common subtype (49.6%), followed by multiple myeloma (16.7%). At the moment of evaluation, 68.2% had a newly diagnosed cancer, whereas 31.8% had disease progression. Considering comorbidities, 24.9% had score 1 and 38.8% had score ≥2 on the CCI. The most common comorbidities were congestive heart failure (19.4%), peripheral vascular disease (16.2%), secondary malignancy (13.1%) and diabetes mellitus without complications (12.6%).

doi:10.1093/annonc/mds619 | 

original articles

Annals of Oncology

Table 1. Patient and clinical characteristics Age, years [median (range)] (n = 1967) Gender (n = 1967) Female Male Tumour type (n = 1967) Carcinoma Breast Colorectal Lung Ovaries Prostate Haematological malignancies Time point of assessment New diagnosis At progression Carcinoma (n = 1715) Stage I II III IV Treatment received Surgery Chemotherapy Radiotherapy Hormonal therapy Haematologic malignancies (n = 252) Setting Curative Palliative Treatment received Surgery Chemotherapy Radiotherapy Comorbidity CCI (0–37) (n = 1959) No comorbidities (score 0) Comorbidity score 1 Comorbidity score ≥2 Performance status ECOG-PS (0–5) (n = 1952) Score 0 = asymptomatic Score 1 = symptomatic but completely ambulatory Score 2 = symptomatic, 50% in bed, but not bedbound Score 4 = bedbound Pain VAS (0–10) (n = 1941) No pain: score = 0 Mild pain: score = 1–3 Pain to treat: score ≥4 Polypharmacy [mean, (SD)] [median (range)] (n = 1903)

76 (70–96) n

%

95% CI

1261 706

64.1 35.9

62.0–66.2 33.8–38.0

797 422 236 98 162 252

40.5 21.5 12.0 5.0 8.2 12.8

38.3–42.7 19.6–23.3 10.6–13.4 4.0–5.9 7.0–9.5 11.3–14.3

1341 626

68.2 31.8

66.1–70.2 29.8–33.9

256 386 303 770

14.9 22.5 17.7 44.9

13.2–16.6 20.5–24.5 15.9–19.5 42.5–47.3

897 711 553 626

52.3 41.5 32.2 36.5

49.9–54.7 39.1–43.8 30.0–34.5 34.2–38.8

115 137

45.6 54.4

39.5–51.8 48.2–60.5

8 201 14

3.2 79.8 5.6

1.0–5.3 74.8–84.7 2.7–8.4

711 488 760

36.3 24.9 38.8

34.2–38.4 23.0–26.8 36.6–41.0

790 582 266 284 30

40.5 29.8 13.6 14.5 1.5

38.3–42.7 27.8–31.8 12.1–15.2 13.0–16.1 1.0–2.1

966

49.8

47.5–51.9

18.7 31.6

16.9–20.4 29.5–33.7

362 613 4.86 (±3.2) 4 (0–22)

CCI, Charlson Comorbidity Index; ECOG PS, Eastern Cooperative Oncology Group Performance Status; VAS, Visual Analogue Scale.

 | Kenis et al.

Volume 24 | No. 5 | May 2013

original articles

Annals of Oncology Table 2. Results of the screening SCREENING

Instrument

Score

n

%

95% CI

Geriatric profile

G8 (0–17) (n = 1967)

Absence of a geriatric profile: score >14 Presence of a geriatric profile: score ≤14

576 1391

29.3 70.7

27.3–31.3 68.7–72.7

Table 3. Results of the CGA CGA

Instrument

Score

n

%

95% CI

Demographic data (n = 1377)

Living situation

Home: alone Home: with partner Home: with family member Service flat Institution Other Single Married Divorced Widow-er Legally cohabiting Other Primary education Lower secondary education Higher secondary education Higher education University education Other Missing Independent: score 6 Dependent: score ≥7 Independent: score 8 (female) or 5 (male) Dependent: score