Geriatric Assessment May ImproveCancer Prognosis in the Elderly

TAMPA, Florida-Clinicians 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, MD, PhD. "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 patients. "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 of 75." 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 risks identified. 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 (median, five). Findings Reported 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(Drug information on 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- up. While preliminary, these results suggest that a geriatric assessment plus multidisciplinary intervention could improve treatment and possibly prognosis in elderly cancer patients, Dr. Extermann said. 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.