Use of comprehensive geriatric assessment in older cancer patients:: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG)

https://doi.org/10.1016/j.critrevonc.2005.06.003Get rights and content

Abstract

Background:

As more and more cancers occur in elderly people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters in the treatment of their patients.

Methods:

The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted.

Results:

Several biological and clinical correlates of aging have been identified. Their relative weight and clinical usefulness is still poorly defined. There is strong evidence that a CGA detects many problems missed by a regular assessment in general geriatric and in cancer patients. There is also strong evidence that a CGA improves function and reduces hospitalization in the elderly. There is heterogeneous evidence that it improves survival and that it is cost-effective. There is corroborative evidence from a few studies conducted in cancer patients. Screening tools exist and were successfully used in settings such as the emergency room, but globally were poorly tested. The article contains recommendations for the use of CGA in research and clinical care for older cancer patients.

Conclusions:

A CGA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The task force cannot recommend any specific tool or approach above others at this point and general geriatric experience should be used.

Introduction

Persons over the age of 65 years are the fastest growing segment of the population and will account for an estimated 20% of Americans and 25% of Europeans by the year 2030. Cancer incidence is 11-fold higher in persons over the age of 65 years than in younger ones [1]. This increasingly older cancer population will require specific management [1], [2]. Aging being a highly individualized process, geriatricians have developed a thorough assessment method: the comprehensive geriatric assessment (CGA). The CGA is “a multidisciplinary evaluation in which the multiple problems of older persons are uncovered, described, and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed, and a coordinated care plan developed to focus interventions on the person's problems” [3]. Since the mid-1990s, oncologists and geriatricians have tried to integrate CGA approaches in the oncology setting. Several questions arose as to the best form of CGA to use, how to integrate it in current oncology practice, and what parameters to include in oncology studies. The International Society of Geriatric Oncology (SIOG) created a task force to address such questions with a systematic review.

The task force was composed of four oncologists and four geriatric specialists (two geriatricians, a geriatric nurse, and a geriatric epidemiologist). The task force structured its approach into four questions.

  • 1.

    Is there clinically usable biological or other evidence for “degrees of aging”?

  • 2.

    What can CGA detect that cannot be detected by an oncologic assessment?

  • 3.

    What is the evidence for the effectiveness of CGA?

  • 4.

    What screening tools and alternative assessments are available and what is their validity compared to full CGA?

Each question was reviewed by an oncologist and a geriatric specialist, and submitted to the whole task force for review. We used Medline searches for English language literature, linked references and expert knowledge. Articles and abstracts published up to February 2003 were considered. A formatted data collection tool was created. The level of evidence was rated according to the adapted Oxford criteria [4] (Appendix A). The task force met three times in 2002–2003, the last time including international experts from several oncologic and geriatric societies (Appendix B), and the data were presented and debated. A consensus summary was written. The level of agreement was rated as α for unanimous agreement, β for agreement with some divergences, and γ for disagreement among the panel. Given the status of the evidence at present time, we have chosen to publish recommendations, rather than guidelines. More detailed clinical evidence will be required on the majority of points before clinical guidelines can be designed. The recommendations were reviewed and approved by the SIOG board.

Section snippets

Key evidence

A major goal of the review was to determine whether there are simple clinical and biological markers for predicting functional decline and/or mortality and frailty. Overall, there are a number of clinical syndromes and markers that could help the oncologist predict outcome for older persons with cancer. Clinical markers have more evidence than biological markers. Albumin, hemoglobin and summary performance scores appear the most established of these markers. They indicate the reaction of the

Future developments

The efforts of this task force are a starting point. They provide a solid research basis, and some clinical recommendations. Although there is strong general evidence of the effectiveness of CGA, the evidence concerning its specific components is much weaker. Given this weakness, our recommendations should not yet be seen as guidelines for a standard of care. We do believe nevertheless that they represent a progress in that this is the first systematic compilation of evidence concerning the use

Acknowledgments

This task force was sponsored by the International Society of Geriatric Oncology. SIOG was supported in its effort by an unrestricted grant from AMGEN Europe. The initiative, conduct, and results of this task force are the Society's alone.

Martine Extermann is Associate Professor of Oncology at the University of South Florida and Attending physician in the Senior Adult Oncology Division at the H. Lee Moffitt Cancer Center in Tampa, FL, USA. She is the chair of this task force.

References (103)

  • S. Stewart et al.

    Effects of a multidisciplinary, home-based intervention on unplanned readmissions and survival among patients with chronic congestive heart failure: a randomised controlled study

    Lancet

    (1999)
  • M. Extermann et al.

    A comprehensive geriatric intervention detects multiple problems in older breast cancer patients

    Crit Rev Oncol Hematol

    (2004)
  • J. Close et al.

    Prevention of falls in the elderly trial (PROFET): a randomised controlled trial

    Lancet

    (1999)
  • A.E. Stuck et al.

    Comprehensive geriatric assessment: a meta-analysis of controlled trials

    Lancet

    (1993)
  • A.A. Moore et al.

    Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument

    Am J Med

    (1996)
  • A.A. Moore et al.

    A randomised trial of office-based screening for common problems in older persons

    Am J Med

    (1997)
  • F. Landi et al.

    New model of integrated home care for the elderly: impact on hospital use

    J Clin Epidemiol

    (2001)
  • G. Gambassi et al.

    Management of heart failure among very old persons living in long-term care: has the voice of trials spread? The SAGE Study Group

    Am Heart J

    (2000)
  • R. Yancik

    Cancer burden in the aged: an epidemiologic and demographic overview

    Cancer

    (1997)
  • R. Yancik et al.

    Cancer in the elderly. Approaches to diagnosis and treatment

    (1989)
  • D. Solomon et al.

    National Institutes of Health Consensus Development Conference statement: geriatric assessment methods for clinical decision-making

    J Am Geriatr Soc

    (1988)
  • No authors cited. Table A. Levels of evidence and grades of recommendation. Evidence-based Oncol. 2001; 2:...
  • D.B. Reuben et al.

    Peripheral blood markers of inflammation predict mortality and functional decline in high-functioning community-dwelling older persons

    J Am Geriatr Soc

    (2002)
  • M.C. Corti et al.

    Serum albumin level and physical disability as predictors of mortality in older persons

    JAMA

    (1994)
  • J.H. Cohen et al.

    Coagulation and activation of inflammatory pathways in the development of functional decline and mortality in the elderly

    Am J Med

    (2003)
  • B.J. Ania et al.

    Incidence of anemia in older people: an epidemiologic study in a well defined population

    J Am Geriatr Soc

    (1997)
  • P.H. Chaves et al.

    Looking at the relationship between haemoglobin concentration and prevalent mobility difficulty in older women. Should the criteria currently used to define anemia in older people be reevaluated?

    J Am Geriatr Soc

    (2002)
  • G.J. Izaks et al.

    The definition of anemia in older persons

    JAMA

    (1999)
  • M. Kikuchi et al.

    Five-year survival of older people with anemia: variation with hemoglobin concentration

    J Am Geriatr Soc

    (2001)
  • W.A. Satariano et al.

    The effect of comorbidity on 3-year survival of women with primary breast cancer

    Ann Intern Med

    (1994)
  • C.J. Newschaffer et al.

    Does comorbid disease interact with cancer? An epidemiologic analysis of mortality in a cohort of elderly breast cancer patients

    J Gerontol A Biol Sci Med Sci

    (1998)
  • G. Frasci et al.

    Cisplatin–epirubicin–paclitaxel weekly administration with G-CSF support in advanced breast cancer. A Southern Italy Cooperative Oncology Group (SICOG) Phase II Study

    Breast Cancer Res Treat

    (2000)
  • P.A. Rochon et al.

    Comorbid illness is associated with survival and length of hospital stay in patients with chronic disability. A prospective comparison of three comorbidity indices

    Med Care

    (1996)
  • J.F. Piccirillo

    Inclusion of comorbidity in a staging system for head and neck cancer

    Oncology (Huntingt).

    (1995)
  • L. Wang et al.

    Predictors of functional change: a longitudinal study of nondemented people age 65 and older

    J Am Geriatr Soc

    (2002)
  • L.C. Walter et al.

    Development and validation of a prognostic index for 1-year mortality in older adults after hospitalization

    JAMA

    (2001)
  • M.M. Desai et al.

    Development and validation of a risk-adjustment index for older patients: the high-risk diagnoses for the elderly scale

    J Am Geriatr Soc

    (2002)
  • A.B. Newman et al.

    Weight change in old age and its association with mortality

    J Am Geriatr Soc

    (2001)
  • S.K. Inouye et al.

    Importance of functional measures in predicting mortality among older hospitalized patients

    JAMA

    (1998)
  • D. Saliba et al.

    The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community

    J Am Geriatr Soc

    (2001)
  • D. Hamerman

    Toward an understanding of frailty

    Ann Intern Med

    (1999)
  • L.P. Fried et al.

    Frailty in older adults: evidence for a phenotype

    J Gerontol A Biol Sci Med Sci

    (2001)
  • R. Hebert

    Functional decline in old age

    CMAJ

    (1997)
  • J.I. Wallace et al.

    Involuntary weight loss in older outpatients: incidence and clinical significance

    J Am Geriatr Soc

    (1995)
  • K.M. Fox et al.

    Markers of failure to thrive among older hip fracture patients

    J Am Geriatr Soc

    (1996)
  • R.B. Verdery

    Failure to thrive in older people

    J Am Geriatr Soc

    (1996)
  • J.K. Hildebrand et al.

    Use of the diagnosis “failure to thrive” in older veterans

    J Am Geriatr Soc

    (1997)
  • W.J. Evans

    What is sarcopenia?

    J Gerontol A Biol Sci Med Sci

    (1995)
  • K.K. Brody et al.

    A comparison of two methods for identifying frail Medicare-aged persons

    J Am Geriatr Soc

    (2002)
  • J.R. Lunney et al.

    Profiles of older medicare decedents

    J Am Geriatr Soc

    (2002)
  • Cited by (0)

    Martine Extermann is Associate Professor of Oncology at the University of South Florida and Attending physician in the Senior Adult Oncology Division at the H. Lee Moffitt Cancer Center in Tampa, FL, USA. She is the chair of this task force.

    Matti S. Aapro is Dean of the Multidisciplinary Oncology Institute, Genolier, Switzerland. He chairs the EORTC Cancer in the Elderly Task Force, is Executive Director of the International Society for Geriatric Oncology (SIOG) and President of the Multinational Association for Supportive Care in Cancer (MASCC).

    Roberto Bernabei is Director of the Department of Geriatrics at the Catholic University of Rome. He is the executive vice-president of interRAI, a non profit corporation for the standardisation of assessment instruments in the elderly care and president elect of the Italian Society of Gerontology and Geriatrics.

    Harvey Jay Cohen is Professor of Medicine, Chief of the Division of Geriatrics and Director of the Center for the Study of Aging at Duke University and the Director of the Geriatric Research Education and Clinical Center at the VAMC in Durham, NC. He Co-chairs the Cancer in the Elderly Committee for CALGB and the Task Force on Cancer and Aging for the AACR. He is current President of the International Society for Geriatric Oncology (SIOG).

    Jean-Pierre Droz is Professor of Medicine, Chief of the Medical Oncology Department of the Centre Léon Bérard, Lyon, France. His main research areas are G-U malignancies and geriatric oncology.

    Stuart M. Lichtman is an Associate Attending, Memorial Sloan Kettering Cancer Center, New York; member of the Pharmacology and Experimental Therapeutics Committee and the Cancer in the Elderly Committee of the Cancer and Leukemia Group B; chemotherapy taskforce leader of the International Society of Geriatric Oncology (SIOG); Board of Directors and the Scientific Advisory Board of the Geriatric Oncology Consortium.

    Vincent Mor, Ph.D. is Professor and Chair of the Department of Community Health in the Brown Medical School. His research focuses on the determinants of care quality in the nursing home setting in the US and abroad.

    Silvio Monfardini, MD, is Chief of the Division of Medical Oncology. Azienda Ospedaliera- Università, Padova (Italy). His works concern the main fields of medical oncology with particular reference to non Hodgkin's lymphomas, Hodgkin's lymphomas, chronic myeloid leukemias, solid tumors (in particular cancer of the testis) and phase I-II studies. He is the immediate past president of SIOG and has served as President of the European Society for Medical Oncology and of the Italian Association of Medical Oncology.

    Lazzaro Repetto, is a Senior Investigator at the National Institute of the Care of the Elderly, Rome, Italy. He is the treasurer of SIOG.

    Liv Sørbye, RN, works at the Diakonhjemmet University College in Oslo, Norway, where she has focused on health services research. She is the project leader of the Norwegian part of the Ad HOC project on home care.

    Eva Topinková is Chair of Department of Geriatrics at Charles University in Prague, Director of postgraduate training program in geriatrics, Institute of Postgraduate Medical Education in Prague. Professor Topinková is Secretary general of International Association of Gerontology -European Region, and board member of other European bodies (Geriatric Medicine Section of UEMS, European Union of Geriatric Medicine Society).

    View full text