Comprehensive geriatric assessment in older people undergoing cancer treatment

Dr Danielle HarariConsultant Physician, Senior Lecturer

Guys & St Thomas’ Hospital Foundation NHS Trust, Kings College London

danielle.harari@gstt.nhs.uk

Improving Cancer Treatment Assessment and Support for Older People Project: partly funded by the Department of Health and Macmillan Cancer Support (registered charity no 261017), supported by Age UK (registered charity no

1128267)

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 peopleClinical 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)

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)

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

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 assessedLife expectancy – meaningless without comorbidity

assessmentNo assessment or support specific to the needs of

older people in NHS cancer services

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

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 riskCGA 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

‘POPS-GOLD’ – Improving cancer treatment in older people South-East London Cancer NetworkProject Lead: Dr Danielle HarariProject 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 CharityObservational: 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)?

Patients aged 70+ being considered for cancer treatment

Complete CGA/comorbidty questionnaire

Observational ‘pre’ groupUsual care

POPS-ONCOLOGYLow-risk patients identified as ‘fit’ At risk patients assessed for comorbidity optimisation pre-treatmentCGA ‘holistic’ supportFollow-through during treatment including liaison on oncology wards

OUTCOMES% undergoing treatment with curative intentTreatment tolerance (toxicity, completion of planned protocol, decompensation of chronic conditions)Hospitalisations (emergency, length of stay)Patient reported quality of life, function, mood

Findings from observational work (‘pre’ group) – all patients

completed GOLD-CGA questionnaire:

Why may older people be ‘under-treated’

GOLD-CGA questionnaire

All questions source-referencedComorbidities questions nuanced e.g. is

BP usually high when checked, breathless on walking on flat surfaces

Evidence-based functional scoresEORTC-QLQ-C30 (cancer-specific QOL

tool validated in older people)

CGA screening in patients with lymphoma BSH 2012

o 74 older patients (aged ≥65) attending lymphoma clinic (mean age 74) o Mean questionnaire completion time was 11.5 + 7.4 minutes.o Comorbidities included: BP usually high when checked 23%, diabetes 21% (6%

poorly controlled), angina/previous MI 11%, breathless on flat surfaces 27%o Cognition: confusion episodes 12%, significant memory problems 11%o Polypharmacy ( 4 medications) 30%o Function: Difficulties with 1 basic activity of daily living (ADL) 48%, with 1

instrumental ADL 53%, fatigue 71%, pain 38%, incontinence 26%o 34% lived alone, 14% had noone to look after them for a few days if needed

o Questionnaire responses were used to categorise as low or high risk:o Low risk = no functional difficulties, no active comorbidity, mild QOL difficultieso High risk = functional difficulties &/or active comorbidity &/or severe QOL difficulties.

o 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

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.

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 (kappa=0.25)

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.

Low grade toxicity in older people undergoing chemotherapy ECCO 2013

N=108 patients aged 65+ recruited at start of chemotherapy

Research questionTo 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

Results: treatment modifications due to toxicity N=60 (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)

Results: Toxicity grade trigger to treatment modification (N=60) by comorbidity

Few Comorbidities (<4) N=41

Multiple comorbidities (4+)N=19

Low grade toxicity57.9%(N=11)

High grade toxicity42.1%(N=8)

High grade

toxicity75.6%(N=31)

Low grade toxicity24.4%(N=10)

Statistically significant: p=0.011, 2=6.41

Results: Early discontinuation due to toxicity N=23 (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 n=3 Most common grade 2 toxicities: fatigue

(5) and haemotological toxicity (4)

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?

Fatigue in older people undergoing chemotherapy SIOG 2013

Baseline fatigue is rarely documentedFatigue toxicity was cited by treating oncologists

in 69.1% (n=75) of all patients during chemotherapy, with grade 2+ occurring in 36.1% (39) and grade 3+ occurring in 11.1% (11)

Fatigue severity from EORTC-Q30 as part of CGA-GOLD questionnaire

Improved fatigue % (N)

No change % (N)

Fatigue worse % (N)

At 2 months follow up (n=89) 14.6 (13) 71.9 (64) 13.5% (12)

At 6 months follow up (n=68) 14.7 (10) 76.5 (52) 8.8 (6)

Findings from interventional work (‘post’ group) :

Impact of geriatric-oncology liaison in outpatients and

inpatients (oncology wards)

GOLD PATHWAYS DEVELOPEDOLDER PATIENT WITH CANCER

SELF REPORTING CGA SCREENING QUESTIONNAIRE

IN DEPTH REVIEW BY GERIATRICIAN TO

OPTIMISE/REVERSE CGA

INFORM ONCOLOGY

HIGH RISKLOW RISK

TREATMENT DECISION

CONTINUED GERIATRICS SUPPORT & RE-REVIEW AS NEEDED

ONCOLOGY REFERRAL

NO CGA REQUIRED

SERVICE DEVELOPMENT – CLINIC PATHWAYS

Tailor CGA intervention to cancer treatment Optimise in relation to tx and plan proactively

for anticipated cancer treatment toxicityDeveloped to fit in within existing oncology

pathwaysTailor 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

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 folateDiabetes management with steroidsNutritional supportPain and mobility optimisation (osteoarthritis)Fatigue investigation and management plan –

protocolised fatigue pathway developedManaging continence (QOL)Transport assistance esp for people having outpatient

chemo/RT

Screening QuestionnaireRECRUITED n=177

BEXLEY GP GROUP n = 31

GSTT GROUP n=146

SCREENING QUESTIONNAIRE NOTE REVIEW AND TELEPHONE CLINIC FOR CGA NEED

IN DEPTH CGA CLINICN=73 (50%)

NO CGA CLINIC AS PER NEED OR WISHES N=73 (50%)

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% (n=62/71) of questionnaires

Reliability: against clinical notes review Clinician 1 (SPR): notes changed decision of CGA need in

10.9% (n=9/82) patients Clinician 2 (CNS) notes changed decision in 9.6% (n=8/83)

patients

Acceptability: patient responses o 80.2% (n=142) did not need help to completeo Mean time to complete: 14.5 mins +/- SD 9.3

Outpatients - Comorbidities

IN DEPTH REVIEW BY GERIATRICIAN TO

OPTIMISE/REVERSE CGA

HIGH RISKLOW RISK

NO CGA REQUIRED

COMORBIDITIES MEDIAN 3.0

MEAN 2.51 +/- SD 1.9.

COMORBIDITIESMEDIAN 6

MEAN OF 5.75 +/- SD 2.4

Did POPS-GOLD influence oncology treatment decision-making BGS 2012

60% (n=24) of oncologists responded to semistructure questionnaire (21% consultants, 63% registrars, 17% clinical nurse specialists)

All respondents had read the CGA assessment letter at the patient’s next cancer appointment.

63% (n=15) reported the assessment had influenced their decision-making.

Of these, 67% (n=10) 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 (n=5) increased information (n=3) facilitated communication (n=2) increasing confidence (n=3).

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”

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

o Early CGA can influence oncology decision-making.

o 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.

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

In-patient Liaison

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 ReviewFor patients in need Optimised in a similar way to in the CGA clinic. Discharge planning

GOLD Intensity of Input

GOLD Intensity of Input N = 113% (n)

Not involvedLight touchMedium touchHeavy Very heavy

37% (42)25% (28)11% (13)20% (22)

7% (8)

Impact on quality of information across to primary care and community and coding

Oncology Discharge letter GOLD ENHANCEDPRINCIPAL DIAGNOSIS1. AML

COMORBIDITIES2. Myelodysplasia

PRINCIPAL DIAGNOSIS1. Neutropenic Sepsis 2. Anaemia secondary to UGI (gastric ulcers) and

AML - needing blood transfusion3. Pancytopenia4. AML - end of life - fast-tracked to hospice 5. Pulmonary oedemaCOMORBIDITIES1. MDS2. AML3. Gastric ulcers4. Barrett Oesophagus5. Hypertension 6. B12 deficiency7. Folate deficiency8. Angiodysplasia,9. Lives alone

Impact on length of stay

5 6 7 8 9 10 11 12 13

LOS IN DAYS

OCT 12 NO POPS

SEPT 12 POPS CNS & SPR

AUG 12 POPS CNS & SPR

JULY 12 POPS CNS & SPR

JUN 12 POPS CNS & SPR

MAY 12 POPS -CNSMAINLY

APRIL 12 NO POPS(HOLIDAY/CONFERENCES)

Mar 12 POPS CNS MAINLY

FEB12 POPS - CNS MAINLY

JAN 12 NO POPS

DEC 11 NO POPS

NOV 11 NO POPS

MO

NT

H W

ITH

/WIT

HO

UT

PO

PS

LOS WITH AND WITHOUT POPS

Series1 9.8 7.2 7.2 9.4 8.7 10.6 11.5 9.1 9.5 11.7 11.5 12.5

OCT 12 NO POPS

SEPT 12

POPS

AUG 12

POPS

JULY 12

POPS

JUN 12 POPS CNS &

MAY 12

POPS -

APRIL 12 NO POPS

Mar 12 POPS CNS

FEB12 POPS -

CNS

JAN 12 NO

POPS

DEC 11 NO

POPS

NOV 11 NO POPS

Impact on LOSLOS 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

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 1–6 | doi: 10.1038/bjc.2013.204

Survey currently being considered in the revision of the national medical oncology curriculum

Geriatric Oncology Training During Specialist Training66.1% never received any training on the needs of

older people with cancer19.4% 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 (n=18)polypharmacy (n=17) discharge planning (n=7).

Practice in cognitive impairment

Cognitive assessments45.9% rarely/never assessed

Consent and Mental Capacity Assessment27.3% never consent patients with cognitive

impairment50.9% would rarely consent38.9% MCA never/rarely used to decide about

the patient’s understanding

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

Macmillan/DOH/Age UK report: Cancer Services Coming of Age, Dec 2012

http://www.macmillan.org.uk/Aboutus/Healthprofessionals/Improvingservicesforolderpeople/Pilots/PilotSites.aspx

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-coming-of-age-report-published/

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