Use of Comprehensive Geriatric Assessment in Oncology Patients to Guide Treatment Decisions and Predict Chemotherapy Toxicity
Purpose: Our objective was to review the utility of pretreatment comprehensive geriatric assessment (CGA) and its impact on decision making regarding choice and intensity of oncologic therapeutic regimens for older, frail, or poor-functional-status patients, as well as using this prospective assessment to predict chemotherapy-related toxicities. Database searches were conducted in Medline, PubMed, and Ovid for clinical studies, review articles, and journal publications. Search terms included geriatric assessment , medical oncology , chemotherapy , frailty , toxicity , and functional status . Thirty-seven pertinent articles were retrieved and serve as the basis for this clinical review.
Observations: CGA is an important tool for examining aspects of frailty and functional status that are not captured by traditional performance status measures. These findings may then be used in selection of appropriate therapeutic regimens for a given patient that are efficacious and tolerable. Such pretreatment assessments also have been used in predicting therapy-related toxicities.
Conclusions: Frail and older patients are common in oncology practices and are at high risk for therapy-related toxicities because of comorbidities and physiologic changes, presenting a considerable clinical challenge. CGA establishes evidence-based strategies to better assess the functional status of such patients and is predictive for chemotherapy-related toxicities in this vulnerable group. Despite publications on these measures in the oncology literature, there is limited evidence-based research to demonstrate the utility of CGA by practicing oncology providers and how to implement it into practice.
Psychological and Social Status
A cancer diagnosis has a major impact on the mental and emotional state of patients and family members. Clinically significant anxiety has been reported in approximately 21% of older patients with cancer, and the incidence of depression ranges from 17 to 26%.22 In older patients with, psychologic distress can impact cancer treatment, resulting in less definitive therapy and poorer outcomes.23 All patients with cancer should be screened for psychologic distress using standardized methods, such as the Geriatric Depression Scale or the General Anxiety Disorder-7 scale.24 A positive screen should lead to additional assessments that evaluate the severity of depression and other comorbid psychological problems and medical conditions.
Social isolation and loneliness are factors that can affect both depression and anxiety. Older patients with cancer are at risk for decreased social activities and are already challenged with issues related to home care, comorbidities, functional status, and caregiver support.23 Therefore, it is important to assess the social interactions of an older and/or frail patient with cancer and use social work assistance to address needs for supportive services.
Nutrition
Nutrition is important in any patient with cancer undergoing chemotherapy treatment. However, it is of greater importance in older adults, as malnutrition and weight loss are negative prognostic factors that correlate with poor tolerance to chemotherapy treatment, decline in quality of life, and increased mortality.25 The Mini-Nutritional Assessment is a widely used validated tool to assess nutritional status and risk of malnutrition.11 This tool can help identify those older and/or frail patients with cancer with impaired nutritional status and aid in instituting corrective measures to treat or prevent malnutrition.
Effectiveness of CGA
Multiple randomized controlled clinical trials assessing the effectiveness of CGA have been conducted over the past 3 decades with overall positive outcomes related to its value.26 Benefits of CGA can include overall improved medical care, avoidance of hospitalization or nursing home placement, identification of cognitive impairment, and prevention of geriatric syndrome (a range of conditions representing multiple organ impairment in older adults).27
In oncology, CGA is particularly beneficial, as it can identify issues in nearly 70% of patients that may not be apparent through traditional oncology assessment.28 A systematic review of 36 studies assessing the prognostic value of CGA in elderly patients with cancer receiving chemotherapy concluded that impaired performance and functional status as well as a frail and vulnerable profile are important predictors of severe chemotherapy-related toxicity and are associated with a higher risk of mortality.29 Therefore, CGA should be an integral part of the evaluation of older and/or frail patients with cancer prior to chemotherapy consideration.
Several screening tools have been developed using information from CGA to assess the risk of severe toxicities. The most commonly used tools for predicting toxicity include the Cancer and Aging Research Group (CARG) chemotoxicity calculator and the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH).30,31 Although these tools are readily available to facilitate CGA, and despite their proven beneficial outcome and recommended usage by national guidelines, implementation of these tools in routine oncology practice has been challenging and slow to spread. Unless these recommended interventions are effectively implemented, the benefits of CGA cannot be realized. With the expected surge in the number of older patients with cancer, hopefully this will change.
