could improve the prognosis of elderly
cancer patients with a comprehensive
geriatric assessment (CGA) and
appropriate follow-up based on the
results, according to Martine Extermann,
"Older cancer patients have health
problems that influence prognosis and
are underdetected," said Dr. Extermann,
assistant professor at the H. Lee
Moffitt Cancer Center, University ofSouth Florida, Tampa. "A CGA may
influence the prognosis of these patients."
According to Dr. Extermann, using
the geriatric assessment is just one
way that taking a "geriatric oncology
approach" could benefit elderly cancer
"Geriatric assessment uncovers a
lot of functional problems that would
be missed by ECOG (Eastern Cooperative
Oncology Group) performance
status," she said. "On average, our patients
have three comorbid diseases in
clinic...you will find that half of them
have five comorbid diseases by the age
Dr. Extermann and her colleagues
have completed a small pilot study
designed to determine the value of
comprehensive geriatric assessment
plus appropriate follow-up in older
breast cancer patients. The 6-month
protocol included a multidisciplinaryCGA every 3 months and a call from a
nurse practitioner once monthly; specialists
provided additional follow-up
based on pharmacy, dietary, and psychosocial
Of the 15 patients enrolled, 10 completed
all assessments, and an 11th
patient completed the 3-month assessment.
Patients ranged in age from
70 to 87 years (mean age, 80 years)
and had as many as nine comorbidities
Geriatric assessment revealed that
six patients were at high pharmacy
risk and two were at moderate pharmacy
risk. During the study period,
patients presented with an average of
nine problems that required some sort
of intervention; often, multiple team
members collaborated to solve these
newly arising problems.
For one patient, an 83-year-old
with memory problems, the geriatric
assessment findings altered the oncologist's
chemotherapy decision, according
to Dr. Extermann. In addition,
the findings improved
compliance with hormone therapy for
two patients. In another notable intervention,
one member of the multidisciplinary
team detected an error in
the filling of a paroxetine (Paxil) prescription.
In seven cases, the assessment
and follow-up ensured that patients
received continuity or
coordination of care.
Patients maintained independence
and function, investigators reported.
Despite two new depressions screened
by the Geriatric Depression Scale,
mean scores on the functional assessment
of cancer therapy-breast (FACTB)
scale improved from 110.5 (SD ±16.7) to 116.3 (SD ± 16.3) (P = .02).
One patient needed major multidisciplinary
intervention throughout follow-
While preliminary, these results
suggest that a geriatric assessment plus
multidisciplinary intervention could
improve treatment and possibly prognosis
in elderly cancer patients, Dr.
In a 1993 meta-analysis of 28 controlled
trials (Lancet 342:1032-1036),
investigators reported a 26% relative
risk reduction in institutionalization
for 4,959 subjects who received CGA
vs 4,912 controls.
This 26% reduction in risk is com-parable to the benefit of adjuvant breast
cancer chemotherapy in preventing
relapse, or the benefit of beta-blockers
in preventing new myocardial infarctions,
according to Dr. Extermann.
More recent studies and meta-analyses
have shown that geriatric assessment
is cost-effective and has a "consistent
beneficial effect" on functional
status, although the results regarding
mortality benefit have been ambiguous,
said Dr. Extermann. In The Lancet
meta-analysis, there was a 14% relative
risk reduction in mortality for
the geriatric assessment group.
Specialized home-care interven-tions utilizing geriatric nurses could
also improve prognosis for elderly cancer
patients. In one randomized controlled
study including 375 discharged
older cancer patients (60 to 92 years of
age), a month of home visits and telephonecalls from advanced-practice
nurses was associated with a survival
benefit on follow-up, at least for latestage
patients. The 2-year survival for
late-stage cancer patients was 67%, vs
40% for controls.
"I think this is definitely a striking
result that suggests we are really changing
the survival of our cancer patients,"
Dr. Extermann said.