Oncologists Reveal Limited Use of Geriatric Assessment in Older Patients

Targeted Therapies in Oncology, May 2022, Volume 11, Issue 7

Research has shown the use of standardized geriatric assessments (GAs) to aid in treatment decisions in older patients with cancer improves quality of life, reduces treatment-related toxicity, and is guideline recommended.1 However, a survey conducted among practicing oncologists and hematologists from the Cardinal Health Oncology Provider Extended Network revealed that most physicians rely on ECOG performance status and comorbidities to inform treatment decisions in older adults with cancer; fewer than a quarter of respondents said they use GAs in clinical practice.2

The survey collected responses from 349 physicians on whether they use GAs to inform treatment decisions in patients with geriatric cancer, and 60% responded that they do not use a formal GA for any older patients. Of the respondents who do use GAs, 13% perform them for all older patients and the rest use GAs for only some older patients.

The most common reasons for not using a GA were that they are “too cumbersome to incorporate into routine practice” (44%) and “add no value beyond the comprehensive history and physical exam” (36%) (TABLE 1).2

Between September 2019 and March 2020, oncologists were recruited from the Oncology Provider Extended Network to attend 1 of 6 live meetings and were asked questions on GAs. Participants were not aware they would be asked questions about GAs during the live meeting.

Regarding level of experience, 23% of survey participants had practiced between 1 and 10 years, 38% between 10 and 20 years, and 39% for more than 20 years. The majority of physicians came from the southern US (40%), followed by the Midwest (22%), Northeast (19%), and the West (18%).

Most participants defined “older” patients as 70 years or older (39%), followed by 75 years (32%), 65 years (22%), and 60 years (3%) as the cutoff (FIGURE).2 For patients 75 years and older, physicians answered that ECOG performance status (88%) and comorbidities (73%) were the 2 most frequently used patient characteristics in determining treatment decisions.2

Participants with fewer years of experience used GA more often than more experienced physicians. Among the 80 oncologists with 10 years or less in practice, 42 (53%) reported using a GA to inform treatment decisions for their older patients—12 (15%) used it for all their older patients, and 30 (38%) used it for some (TABLE 2).2 In the group of oncologists with more than 10 years in practice (n = 269), 100 (37%) reported using a GA, with 32 (12%) using it for all their older patients and 68 (25%) using it for some (P = .0997).

In an interview with Targeted Therapies in Oncology™, lead study author and chief scientific officer at Cardinal Health, Ajeet Gajra, MD, MBBS, FACP, discussed the relationship between oncologist experience level and utilization of GA.

“I think this [difference between more experienced and less experienced oncologists] likely has to do with a greater emphasis and recognition of the importance of geriatric assessment,” Gajra said. “Geriatric oncology is a newer field. As we know, NCCN [National Comprehensive Cancer Network] created their fi rst set of adult oncology guidelines back in 2005. And then, ASCO [American Society of Clinical Oncology] and other organizations have reiterated the importance of geriatric assessment or having their own guidelines. And most recently in 2018, ASCO renewed or gave an update of their own guidelines. So, I feel there’s greater recognition by organizations in more recent times.” 3,4

Investigators also asked which validated GA instruments doctors were aware of. Most knew of the Mini–Mental State Exam (MMSE; 63%), the comprehensive geriatric assessment (37%), and the Cancer and Aging Research Group (CARG) GA tool (22%); however, 19% of participants were not aware of any of these or other GAs listed in the question.

When asked about the specific GAs used outside clinical trials, 54% have used MMSE, 23% have used the comprehensive GA,12% the CARG GA tool, and 9% the Chemotherapy Risk Assessment Scale for High-Age Patients; however, 33% answered that they had never used any validated GA instruments outside a clinical trial.

Investigators posed additional questions to better understand oncologists’ strategies for assessing older adults and potential barriers to GA use. When asked how they usually assess physical function, most answered that they rely on ECOG performance status (82%) and history and physician examination (HPE; 42%). The most frequently used cognitive assessments were HPE (78%) or MMSE (12%). Social support was assessed via HPE (44%) or GA (27%).

Although guidelines recommend the use of a GA for patients 65 years and older, the use of these tools within community oncology practices is unclear. These survey results highlight an important gap between what is being recommended in clinical practice guidelines and what oncologists are routinely performing. These findings beg the question whether increased education of the benefits of GA-directed therapy would alter oncologists’ practices and potentially increase the utilization of GA in their treatment routine for older patients.

When asked how the use of GA could become more widespread, Garjra said, “I think [it] is important, especially [among] practicing community oncologists, to spread the word, and I feel...that perhaps we need to spread the word via different organizations—perhaps partnering with something like...the Community Oncology Alliance [COA]. I think organizations like ASCO or NCCN can partner with COA, which [hosts a conference that] is attended by community oncologists. I think that’s where a major deficit is. Also, a lot of these doctors are older or have been in practice awhile, so I think that is perhaps a way to reach them.”

REFERENCES
1. Kenis C, Bron D, Libert Y, et al. Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study. Ann Oncol. 2013;24(5):1306-1312. doi:10.1093/annonc/mds619
2. Gajra A, Jeune-Smith Y, Fortier S, et al. The use and knowledge of validated geriatric assessment instruments among US community oncologists. JCO Oncol Pract. Published online March 9, 2022. doi:10.1200/OP.21.00743
3. Balducci L, Cohen HJ, Engstrom PF, et al; National Comprehensive Cancer Network. Senior adult oncology clinical practice guidelines in oncology. J Natl Compr Canc Netw. 2005;3(4):572-590. doi:10.6004/jnccn.2005.0032
4. Mohile SG, Dale W, Somerfi eld MR, et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol. 2018;36(22):2326-2347. doi:10.1200/JCO.2018.78.8687