Identifying Older Adults with Cancer Who May Benefit from Geriatric Assessment

Current reports estimate that by 2030, approximately 12 million people diagnosed with cancer will be older than 70 years. Many older adults with cancer have multimorbidity and their health status can vary greatly. Therefore, treatment decisions based solely on chronologic age may put some older patients at risk for undertreatment or overtreatment.

Comprehensive geriatric assessment (CGA) can help identify needs and vulnerabilities in older adults by assessing physical functioning, psychologic health, functional status, and social well-being. The findings from CGAs may be used by clinicians to support clinical recommendations to optimize cancer treatment decision-making and follow-up. However, CGAs are not routinely implemented in oncology, often due to the time commitment and lack of available, appropriately trained staff. CGAs require input from multiple clinicians to conduct and interpret results, and sometimes require involvement of geriatricians.

There are several screening tools available to help determine the need for a CGA, but diagnostic accuracy of these tools varies considerably. To appraise recent evidence and identify an optimal screening tool for geriatric assessment, a systematic review of 17 peer-reviewed, primary studies from March 2019 to March 2020 was conducted and published in JAMA Oncology . Most of the studies were prospective cohort studies that included mixed cancer populations; others were specific to hematologic malignant neoplasms, head and neck cancer, and prostate cancer. Among 12 different screening tools identified, the Geriatric-8 (G8), followed by the patient-administered Vulnerable Elders Survey-13 (VES-13), were found to have the most evidence to support their use in clinical practice, with higher sensitivity and specificity, respectively. The authors concluded that implementation of G8 or VES-13 into clinical practice can facilitate a geriatric assessment and assist with identifying potential vulnerabilities and unmet needs of older people with cancer.

Of future interest for trials incorporating CGAs is the method of repeated screenings at routine times, or as prompted by changes in disease progression or other declines in function, to help identify potentially vulnerable patients. The authors suggest that future research should explore the potential benefits of combining the G8 and VES-13 in addressing the needs of the older patient population. Alternatively, different settings could prompt the use of different screening tools, such as the Triage Risk Screening Tool in emergency settings or the OncCOVID model in facilities with limited resources.

High level
Geriatric assessments can provide beneficial support for planning treatment and care goals for older patients, whether they are vulnerable or fit. However, time commitment and workforce availability limit the feasibility of this approach in all patients. The authors of this review recommend screening patients using the G8, with the VES-13 as a potential alternative for settings with fewer available resources. In order for either screening tool to be worthwhile, structures must be in place to enable further detailed evaluation, implementation of appropriate interventions, and provision of follow-up. Additional training or education may be required to ensure clinicians are able to properly administer the tools and interpret the findings, particularly in settings where patients do not have access to geriatric and/or oncologic specialists.

Ground level
Some centers screen all patients on arrival and integrate the data into the medical record, which requires availability of designated nurses to conduct geriatric assessments, as well as a uniform system for recording the data, such as electronic medical records. Regardless of setting, screening tools should always be followed by a clinical response, such as a deeper assessment or appropriate management to address unmet needs.