Geriatric Assessments Should Guide Treatment Decisions in Older Patients

Hyman B. Muss, MD

Breast cancer clinicians today are faced with an ever-expanding number of older patients, yet determining the most appropriate treatment for these individuals can be challenging. Conducting a thorough geriatric assessment will aid greatly in making these decisions, and there are tools available that can help today’s busy practitioner, Hyman B. Muss, MD, told attendees at the 30th Annual Miami Breast Cancer Conference® (MBCC) during his presentation on adjuvant therapy for older individuals.

Muss is director of the Geriatric Oncology Program at the Lineberger Comprehensive Cancer Center and Professor of Medicine at the University of North Carolina-Chapel Hill. He chairs an American Society of Clinical Oncology task force on geriatric oncology and also is a co-chair of the Cancer in the Elderly Committee for Cancer and Leukemia Group B, a cooperative group sponsored by the National Cancer Institute.

“What’s most important when talking with older patients is to understand their goals,” said Muss, who noted that when older people with a serious illness are asked what their priorities are, they will typically say that maintaining cognitive function and independent living are most important to them. “When you get to age 78, even though you may be in relatively good health, your concerns are different.”

Thus, clinicians need to accurately estimate the survival of the patient without the breast cancer, estimate the benefit of treatment, and understand the toxicity of the regimen, said Muss. Complicating the latter is the paucity of data comparing treatment risks and benefits in the elderly who are underrepresented in clinical trials. Data are lacking, for example, on how chemotherapy toxicity impacts function in older patients with breast cancer, Muss and coauthors wrote in a recent paper on the topic.¹

To make appropriate treatment decisions for older patients, oncology professionals must go beyond the patient’s age and look at life expectancy. “What we’ve learned is that we’re really not very good at this,” he said. “We didn’t grow up with a lot of geriatric training, and there’s still a lot of age bias.”

Moreover, the need to conduct thorough geriatric assessments is complicated by the current shortage of geriatricians and geriatric-trained nurses, plus the practical difficulty of conducting a full, 2-3 hour comprehensive geriatric assessment (CGA) for each older patient with cancer. “This is just not realistic for all of the cancer patients that we have,” Muss noted in an interview with Oncology Nursing News prior to MBCC. “Right now, 55% of cancer patients are 65 and older, and that number is just going to go up.”

By the Numbers

Breast Cancer in Older Patients¹

Breast cancer incidence per 100,000 women

• <65 years = 82
• ≥65 years = 404

30%-40% of all breast cancer patients are women aged ≥70.

The median age at diagnosis of breast cancer is 61 years.

Among patients aged ≥70, 85% of those with node-negative and 65% of those with node-positive breast cancer die of non-breast cancer—related causes.

A number of tools are now available to help providers conduct an abbreviated CGA in a way that is feasible within the time limitations of today’s busy oncology practices, requiring minimal staff time. The oncology nurse has a crucial role to play in assessing geriatric patients because they are “critical members of the interdisciplinary team,” noted Jeannette Kates, MSN, RN, GNP-BC, a PhD candidate at Duquesne University School of Nursing who is writing her dissertation on cancer treatment— related decision making in older adults. “Nurses are educated to assess patients in a holistic way, which is congruent with comprehensive geriatric assessment in oncology patients.”

“Although comprehensive geriatric assessment can take a variety of forms, the major components should be consistent. It is vital to assess the medical, psychosocial, functional, and environmental aspects of the older adult prior to developing a treatment plan,” Kates continued.

One particularly useful assessment, Muss said, developed by Arti Hurria, MD, director of the Cancer and Aging Research Program at the Duarte, California— based City of Hope Comprehensive Cancer Center, takes, on average, 5-10 minutes of professional time and 20-30 minutes for the patient, who completes a questionnaire in the office. The survey is multidimensional, assessing such factors as the patient’s physical, psychosocial, and cognitive function, medication use, nutritional status, and level of family or caregiver support.

Muss added that the information gathered can help improve a patient’s quality of life beyond the cancer, leveraging community and family interventions in real time, for example, removing risks of falls, and improving nutritional support for patients with weight loss that is often unrelated to their cancer.

The website eprognosis.org is another helpful tool for healthcare professionals, said Muss. He said that he uses it and also encourages his fellows to use it in the clinic. “It has a series of scales— none are perfect—but they’re certainly better than anybody’s guess,” he said. The scales allow practitioners to enter certain clinical and other information, such as body-mass index and history of smoking, other diseases, and cancer, and then use these indicators to estimate survival. The answers to four basic questions are also key, explained Muss: the number of hospitalizations in the last year; self-rated health, which, he noted, is “very, very accurate in predicting how people do”; instrumental activities of daily living such as paying bills and going to the grocery store; and difficulty walking a quarter mile.

Other helpful resources for clinicians include adjuvantonline.com and the Lineberger Comprehensive Cancer Center’s “Core Lectures in Geriatrics.”

Although the movement toward more comprehensive assessments of older patients has been “very slow,” Muss is encouraged by the fact that many of the major, academic medical centers are implementing geriatric oncology programs, and also by the increasing availability of tools which are fast, cheap, simple, and scalable.

“We all need to learn this,” he said, “and just stand up to the plate and do it.”

Reference

1. Jones EL, Leak A, Muss HB. Adjuvant therapy of breast cancer in women 70 years of age and older: tough decisions, high stakes. Oncology (Williston Park). 2012;26(9):793-801.