Evaluation of cancer-specific comprehensive geriatric assessment (CGA) tools
Prof Arti Hurria - City of Hope, Duarte, USA
You are looking here specifically, one of the many things you’re very interested in is chemotherapy toxicity and how oncologists should view this in the context of older patients. What’s the main point that you’re trying to get over here?
The main point is that we know that with increasing age there is an increasing risk of toxicity from chemotherapy but now we have excellent tools to be able to identify if an individual is at low, intermediate or high risk of toxicity. One of those tools has been developed by the Cancer and Aging Research Group and it’s an online tool that oncologists can use. They can ask eleven questions and they can really identify where is their patient in terms of that risk.
So how is that used? Is it the patient filling it in or the does the doctor go through it or what?
So there are some parts of it where the patient could complete the questions. Five of the eleven questions are ones that the patient could complete but the remainder are ones that the doctor would put in information about what sort of treatment they’re thinking about. So it’s a combination.
And typically what sort of chemotoxicity could you avoid by applying that tool and similar approaches?
The idea behind it is that you can identify who is at high risk for toxicity and then implement interventions that can really be personalised to the patient. So a very practical one, maybe, is if a patient says ‘I have difficulty taking my medicines at the right doses and at the right time,’ then you might get a visiting nurse to come at home and assist that patient to make sure they get the appropriate medicines. So it’s really to get to know where your patients’ risk is and then to do a more thorough assessment so that you can intervene and try to decrease that risk.
Cognitive function comes into this and we hear about things like chemo brain, don’t we? Is that a factor?
Well, cognitive function is a very important factor when thinking about prescribing treatment to an older adult - it’s critical to evaluate cognitive function. Chemo brain is a little bit of a different concept, it’s a concept where a patient who is undergoing treatment might feel foggy, they describe, they don’t feel like they’re as quick in terms of their cognitive function. But the field in that, we do research in that, is still early in trying to understand exactly what’s happening from the patient perspective and then typically it’s a fraction of patients that are experiencing that and we’re trying to understand it better.
So what are the key factors that doctors need to bear in mind in their decision making for older patients with cancer?
We always think about things like the tumour stage and the risk of the cancer coming back but in addition we need to think about what’s the patient’s preference for treatment, what’s their risk of side effects. So weighing that risk and benefit for the individual and then placing that decision in the patient’s goals and their values and their preferences, so what does the patient really want to do. So it’s a comprehensive look at who this patient is, what’s their risk of side effects, what’s the benefit of the treatment and then placing it in the context of their own belief system.
Is that the CGA, the comprehensive geriatric assessment?
A comprehensive geriatric assessment is a way of understanding factors other than age that can identify a patient’s functional age. So it’s things like what’s the individual’s functional status, what are their other medical conditions, what’s their memory like, what’s their social support, what’s their psychological state and nutritional status? If you put that all together you get a much better picture of who someone is in terms of their functional age rather than what their passport age is. So that’s what a CGA is, it’s actually a really good history and physical, it’s asking about who is that patient and what are the factors other than age then that might predict the risk for side effects from treatment and how can we best help and tailor that therapy?
How much of an improvement can you get, potentially, by doing the CGA?
I think it can really assist in, one, predicting who is at risk for side effects; two, identifying how you can intervene to try to decrease that risk, how can you really help that patient. It can also help you to understand where that person’s life expectancy is. So if you’re worried, for example, is this tumour going to come back during the patient’s life expectancy you’re able to get a much better sense of where is that patient right now in terms of their life expectancy through doing a CGA. So there are many, many different benefits from doing a geriatric assessment and that literature is emerging right now in the oncology realm.
I know you’ve published recently on research needs and looking at the gaps that need to be filled, would you pinpoint one or two for me please?
Absolutely. So even though the vast majority of individuals with cancer are those that are older adults, they’ve been under-represented on clinical trials to date. So despite the fact that it’s a disease of aging, the vast majority of our studies have been performed in younger adults. There has been a real call to action now to try to change that. The American Society of Clinical Oncology just put out a working statement about ways in which we can try to fill that knowledge gap. And one of the key things that we really need to do is study our drugs in older adults so that we know how do we dose the drug, what’s the side effect, what’s the potential impact of that therapy on the patient’s function and ability to live independently. Those are some of the questions that are really at the forefront right now.
In the field of practical medicine in the present time, how do you counsel doctors, briefly to sum up, to take account of all of these effects concerning older patients with cancer?
We counsel them in saying it’s a tool that can be helpful to them, that’s the goal of it. It can help them to really personalise therapy for their older adult and assist in that decision-making process, decreasing the side effects. So it’s one of those things that we hope these tools will actually be helpful to the practising physician and hence that they will adopt their use.
In a nutshell, what are the key tools and the key messages that you’d like to leave people with?
The key message is that we really need to tailor therapy based upon an individual’s functional age rather than chronological age. There’s huge heterogeneity in the aging process so understanding that as you’re making a treatment decision is really important. And most importantly to make the decision with the patient in the context of what they want, their goals, their values, their preferences. So it’s really taking into account the whole person when you make a treatment decision, not just an age.