|ORIGINAL ARTICLE: GERIATRIC ONCOLOGY SECTION
|Year : 2021 | Volume
| Issue : 3 | Page : 492-498
Oncologists' perceptions of the need for assessing individual domains in the geriatric assessment and worthwhile outcomes in treating older patients with cancer: A questionnaire-based survey
Vanita Noronha, Devanshi Kalra, Anant Ramaswamy, Shreya C Gattani, Nandini Menon, Vijay M Patil, Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
|Date of Submission||02-Sep-2021|
|Date of Decision||05-Sep-2021|
|Date of Acceptance||06-Sep-2021|
|Date of Web Publication||08-Oct-2021|
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Although the multidimensional geriatric assessment (GA) is considered the standard of care, it is not uniformly practiced. In older patients with cancer, shared decision-making requires a clear understanding of the goals of therapy.
Objectives: We aimed to understand the perceptions of health-care professionals of the need to assess the various domains in the GA and what would constitute worthwhile outcomes in older patients with cancer.
Materials and Methods: An online questionnaire survey was conducted by the geriatric oncology group of the Department of Medical Oncology at the Tata Memorial Hospital in Mumbai, India. Participants in the survey included various health professionals with an interest in the care of older patients with cancer. Data were collected in Microsoft Excel and basic descriptive statistics were performed.
Results: Between July and August 2020, 234 health-care professionals responded to the survey. The respondents included predominantly medical oncologists (146, 70.9%), practicing in academic centers (148, 65.6%) from India (168, 87%). According to 46% of the respondents, over 30% of the patients in their practices were in the geriatric age group; yet, 144 (73.8%) respondents reported that they referred <10% of their older patients with cancer for a GA. Almost all the respondents agreed that it was important to check for the presence of polypharmacy, inappropriate medications, comorbidities, drug interactions, falls, function, psychological status, cognition, nutrition, social support, and quality of life in the older patients with cancer. Over 95% of the respondents thought that formal training in the GA should be part of the oncology training programs. According to 139 respondents (63%), an improvement in the quality of life or a decrease in toxicity were more important goals of cancer-directed therapy in older patients with cancer, compared to prolongation of overall survival.
Conclusion: There is a recognition of the importance of performing a multidimensional GA in older patients with cancer; however, this has not translated into a widespread performance of the GA in actual practice. It would be important to address the barriers to implementing the GA in the clinic, to help optimize the care of older patients with cancer. The goals of cancer-directed therapy should be clearly discussed with the patients in order for true shared decision-making to occur.
Keywords: Geriatric assessment, geriatric oncology, older, shared decision-making
|How to cite this article:|
Noronha V, Kalra D, Ramaswamy A, Gattani SC, Menon N, Patil VM, Prabhash K. Oncologists' perceptions of the need for assessing individual domains in the geriatric assessment and worthwhile outcomes in treating older patients with cancer: A questionnaire-based survey. Cancer Res Stat Treat 2021;4:492-8
|How to cite this URL:|
Noronha V, Kalra D, Ramaswamy A, Gattani SC, Menon N, Patil VM, Prabhash K. Oncologists' perceptions of the need for assessing individual domains in the geriatric assessment and worthwhile outcomes in treating older patients with cancer: A questionnaire-based survey. Cancer Res Stat Treat [serial online] 2021 [cited 2021 Dec 9];4:492-8. Available from: https://www.crstonline.com/text.asp?2021/4/3/492/327796
| Introduction|| |
Life expectancy has progressively increased; the global life expectancy in 1960 was 52.6 years, that in 2000 was 67.6 years, and currently in 2021, it is 73.2 years. Cancer is a disease of aging, with a steady increase in cancer incidence noted with increasing age. As per the data from the National Cancer Institute of the United States of America (USA), cancer is reported to occur in <25 per 100,000 people below the age of 20 years, in 350 per 100,000 people between the ages of 45 and 49 years, and in over 1000 per 100,000 people aged 60 years and over. Older persons with cancer have a unique set of problems, and management of these patients has to be tailored accordingly.
Multiple studies have reported that there is a poor correlation between clinical judgment and a multidimensional geriatric assessment (GA) to diagnose frailty.,, The GA is considered the gold standard for assessing an older patient with cancer. The International Society of Geriatric Oncology (SIOG), the American Society of Clinical Oncology (ASCO), and the National Comprehensive Cancer Network (NCCN) recommend that all older patients with cancer should undergo a GA prior to planning therapy.,, One aspect of the GA involves assessing vulnerabilities in various domains including function, falls, comorbidities, cognition, nutrition, medications, psychological status, social support, geriatric syndromes, and quality of life. Assessing all the domains is considered time-, labor-, and resource-intensive, and hence, older patients with cancer often do not undergo a multidimensional GA using validated tools and are managed based on the treating physician's clinical judgment. There are little data available regarding which of these domains are considered important by oncologists who care for older patients with cancer.
Deciding the optimal therapy in an older patient with cancer is complex. There are competing risks for death due to comorbidities, and there may be an increased risk of treatment-related toxicities, cognitive dysfunction, impaired quality of life, and loss of independence as a result of cancer-directed therapy. Most of the evidence that we base our treatment decisions on has been generated in clinical studies done in a younger fitter cohort of patients., In oncology trials, prolongation of survival has traditionally been considered the most important endpoint., However, there are sufficient data that patients with serious illnesses, including cancer, make treatment decisions based on the complexity of the treatment, and the chance of functional and cognitive impairment that could result from treatment.,, In order to enable our patients to make the right treatment decisions, it is essential that treating oncologists have a clear understanding of the goals and outcomes of cancer-directed therapy in older patients.
We therefore performed an online questionnaire-based survey to study what domains are considered important in the GA and what outcomes are considered important in cancer-directed therapy.
| Methods|| |
General study details
This was an online cross-sectional survey, conducted for a period of 1 month from July to August 2020. The survey was conceptualized in the geriatric oncology group of the Department of Medical Oncology at the Tata Memorial Hospital, a tertiary cancer center in Mumbai, India. Implied consent was obtained as part of the survey. No individual identifiable patient information was collected, and therefore, no clearance was obtained from the ethics committee. The study was conducted according to the principles of the Declaration of Helsinki. There was no funding used for the study.
The survey was administered to various health-care professionals who cared for or had an interest in the care of older patients with cancer. The survey was open to anyone who was interested in participating, without limitation. There were no financial incentives offered for participating in the survey.
The primary goal of the survey was to evaluate what percentage of health-care professionals with an interest in the care of older patients with cancer thought it was important to assess each separate domain in the GA, including function, falls, comorbidity, polypharmacy, the use of potentially inappropriate medicines, drug interactions, cognition, nutrition, psychological status, social support, and quality of life. Secondary endpoints included the proportion of oncologists who thought that formal training in GA should be part of the oncology training program. We also sought to evaluate in a descriptive manner what would be considered worthwhile goals of administering cancer-directed therapy in older patients with cancer.
A comprehensive search was carried out using PubMed to search the published literature for oncologists' perceptions and the practice of the GA. A list of relevant articles was identified; additionally, a discussion was carried out among various oncologists to understand their perceptions about the practice of the GA. Then, a list of questions was formulated and finalized.
The final questionnaire [Appendix 1] consisted of 23 questions in 3 sections; all questions had to be answered in each section prior to proceeding to the next section. Section 1 consisted of the general information about the participants and GA; Section 2 consisted of questions related to the importance of various domains of the GA; and Section 3 included questions regarding the benefits that would be considered worthwhile for delivering cancer-directed therapy to an older patient with cancer.
The survey was circulated among the various health-care professionals via an online portal (main website: https://docs.google.com/forms) and was distributed by email (to various medical, surgical, and radiation oncologists, and to the Heads of Department of the Medical Oncology units in the teaching programs across India, and through social media (Twitter, Facebook, and WhatsApp). The survey was also presented during an online meeting and responses were recorded live. Each participant was allowed to complete the survey only once.
Data were maintained in Microsoft Excel and analyzed in the Statistical Package for the Social Sciences, version 25 (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.). A descriptive analysis was performed, with absolute numbers and percentages. No sample size calculation was performed.
| Results|| |
Between July and August 2020, 234 health-care professionals from various disciplines and from various parts of the world responded to the survey [Table 1].
|Table 1: Demographic and practice profile of the respondents (Section 1)|
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Most of the respondents (146, 71%) were medical oncologists, practicing in academic medical centers (148, 66%). There was a good mix of seniorities, with a quarter of the participants still in training (61, 28%) and a quarter who had completed training over 10 years prior (59, 27%). Most of the respondents were practicing in India (168, 87%). Of the Indian respondents (n = 168), there were 83 participants (49.4%) from West India, 50 (29.8%) from South India, 23 (13.7%) from North India, 10 (5.9%) from East India, and 2 (1.2%) from Central India.
There were 101 respondents (45.9%) who reported that over 30% of the patients seen routinely in their clinics were in the geriatric age group. Of a total of 195 respondents who reported how often they referred patients for a GA, 144 (73.8%) stated that they referred <10% of their older patients with cancer for a GA.
Over 97% of the respondents felt that it was important to assess for polypharmacy, the use of potentially inappropriate medicines, drug interactions, falls, function, comorbidities, nutrition, cognition, social support, and quality of life [Figure 1] and [Supplementary Table 1]. The only parameter that was considered important by <95% of the respondents was assessment of the psychological status, which was considered important by 94% of the respondents. Two hundred and thirteen of 221 survey participants (96.4%) thought that formal training in GA should be a routine part of oncology training programs.
|Figure 1: Responses of the survey participants regarding the importance of assessing various domains in older patients with cancer|
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The responses to the question, “What improvement in patient outcomes would make the GA worthwhile in the clinic?,” are provided in [Table 2]. Overall, outcomes that were considered important enough to justify performing a GA included an improvement in the quality of life by 199 (90%), a decrease in toxicity by 145 (65.6%), and an improvement in overall survival by 95 (42.9%).
|Table 2: Survey responses regarding what would be desirable outcomes that would make the performance of a geriatric assessment worthwhile (Section 3)|
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In response to the question regarding what improvement in median overall survival in the palliative setting would be considered worthwhile for performing a GA (n = 222 responses), 49 (22%) replied that their goal in performing a GA was not prolongation of survival, 70 (31.5%) replied a prolongation of at least 6 months, 13 (5.9%) responded at least 4 months, 57 (25.7%) desired a prolongation of at least 3 months, 16 (7.2%) replied at least 2 months, 15 (6.8%) replied at least 1 month, 1 (0.5%) responded that any prolongation in survival would be good, and 1 (0.5%) responded that at least 2 years prolongation in survival would be desirable. In response to the question regarding what improvement in 2-year overall survival in the curative setting would make the GA worthwhile (n = 221 responses), 53 (24%) replied at least 5%, 14 (6.3%) replied at least 7%, 71 (32.1%) expected at least 10%, 41 (18.6%) stated at least 15%, and 1 each (0.5%) wanted an improvement of 30% and 50%. In response to the question regarding how much of a decrease in toxicity would be needed to make the GA worthwhile (n = 224 responses), 23 (10.3%) stated a reduction of at least 5%; 74 (33%) wished a reduction of at least 10%; 26 (11.6%) wanted a reduction of 15%; 86 (38.9%) wanted a reduction of at least 20%; 1 each (0.4%) wanted a reduction of at least 25%, at least 30%, over 50%, and reduction to grade 1; and 11 (4.9%) replied that they did not expect a reduction in toxicity from the GA.
The responses to the question, “In older patients with cancer, what is the relative importance of a decrease in toxicity or an improvement in quality of life as compared to an improvement in overall survival” (n = 222 responses), are illustrated in [Figure 2].
|Figure 2: Survey responses regarding the differential importance of various outcomes of cancer-directed therapy in older patients with cancer|
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| Discussion|| |
In our global survey to assess the attitudes and expectations of health-care professionals who care for older patients with cancer, 46% of the respondents reported that at least 30% of their patients were in the geriatric age group. Yet, 74% of the respondents performed a GA in <10% of their older patients with cancer. Almost all the participants agreed on the importance of assessing the various domains as part of the GA, including function, falls, nutrition, comorbidities, cognition, social support, polypharmacy, the use of potentially inappropriate medications, drug interactions, quality of life, and psychological status. There was also a consensus regarding the need to incorporate training in GA in oncology training programs. Almost two-third of the survey respondents opined that an improvement in quality of life or a decrease in toxicity were more important goals of cancer-directed therapy than a prolongation of survival; one-third opined that these were as important and only 0.5% felt that prolongation of survival was a more important endpoint.
Official guidelines suggest that all older patients with cancer undergo a GA.,, However, this is not uniformly practiced. We had earlier conducted a survey to evaluate the knowledge and practice of the management of older patients with cancer. We found that although almost all the oncologists surveyed cared for older patients with cancer, 70% used their clinical judgment to manage these patients and only 9% used validated tools (part of a GA) for assessment. The most common barriers to implementation of the GA in the clinic included lack of time, lack of clinical staff, uncertainty regarding which tools were to be used, and lack of resources for referral. To et al. reported that Australian medical oncologists felt that a GA was worthwhile, but also that there was a lack of access to resources to perform a GA. Honecker et al. from Germany reported that 95% of oncologists considered the GA meaningful, but 30% considered it impracticable. Recently, the Geriatric Oncology Task Force of ASCO conducted a survey to assess the use of the GA in the clinic for older patients with cancer. Over 70% of the 1277 respondents were from the USA; similar to our survey respondents, 71% were medical oncologists and 63% were from academic centers. 47% of the survey respondents were not aware of the official ASCO recommendations for assessing an older patient with cancer. About 55% of those aware of the official ASCO guidelines and 31% of those unaware of the guidelines reported that they performed multidimensional GA using validated tools. The barriers to performing a GA were reported to be limitations in time, support staff, and knowledge/training regarding the GA.
Although a GA is standard and should be performed in all older patients with cancer, the actual benefit in terms of cancer-related outcomes is uncertain. However, various other benefits have been proven to result from the performance of the GA. The GA leads to the detection of hitherto unrecognized vulnerabilities in the domains tested. The GA resulted in an improvement in communication, as demonstrated by Mohile et al. in the COACH study. In a systematic review of 35 studies by Hamaker et al., treatment plans were altered in a median of 28% of cases; most of the changes were de-intensification. In the ESOGIA trial, GA-guided management for older patients with advanced lung cancer led to a 7.8% reduction in all grade toxicities, without impacting the survival. In the CRCT study, Mohile et al. reported that performing a GA and providing management recommendations to the treating oncologists led to a 21% reduction in grade 3 and higher toxicities. In our survey, 66% of the respondents reported that a lowering of toxicity would be a worthwhile goal for performing a GA, and 93% of respondents reported that they expected a 20% or less reduction in toxicity. In the INTEGERATE study presented by Soo et al. at ASCO 2020, performance of the GA and GA-guided management led to improvement in the health-related quality of life in older patients with cancer planned for systemic therapy. In our survey, 90% of the respondents reported that if the GA led to an improvement in the QOL of their patients, they would consider it worthwhile.
Almost all (99.5%) of the survey respondents reported that decreasing toxicity or improving the QOL were at least as important goals in older patients with cancer, as compared to prolongation of survival. This should be emphasized, both in the clinic when managing older patients with cancer, as well as while designing clinical studies that evaluate the optimal therapy for this cohort of patients. The GO2 study reported by Hall et al. proved elegantly that frail older patients with advanced gastroesophageal junction cancer benefitted from lower intensity chemotherapy without a detraction in survival. Unfortunately, the primary endpoints for almost all clinical trials in oncology remain survival; patient-centric outcomes such as QOL or maintenance of independence are either considered of secondary importance or not measured at all., Hamaker et al. reported that of 1207 clinical trials in patients with hematological malignancies, QOL and functional capacity were assessed in 8% and 0.7% of the trials, and even in the trials planned particularly for older patients, the primary endpoints remained survival, efficacy and toxicity with patient-centric outcomes included in <20% of the studies. Thus, making sound evidence-based decisions in older patients with cancer is challenging. Shared decision-making between the patient and the treating oncologist becomes very important. The results of the GA can help facilitate this process.
Our study had several limitations. Most of the respondents were Indian, medical oncologists, and practicing in academic centers. The results of the survey reflect only the views and practices in the institutions of the respondents and may not be generalizable to oncology practice everywhere. Although we found that most of the respondents considered all the domains of the GA important to perform, 74% referred <10% of their patients for a GA. Thus, clearly, there are very real barriers that prevent the performance of a GA on a routine basis in the clinic-our survey did not address these barriers. In addition, our survey did not include information regarding how different oncologists conducted the GA at their centers, the time taken to perform a GA and which tools were actually used by them for the GA. As the survey was publicized through social media, we were unable to calculate the response rate. It is possible that our study was limited by selection bias, i. e., those who responded were more likely to have an interest in geriatric oncology which may have affected the results of the survey.
| Conclusion|| |
Although there is a consensus on the need to perform a multidimensional GA, less than a quarter of oncologists surveyed perform a GA in even 10% of older patients with cancer. Almost all oncologists want training in GA to be incorporated into oncology teaching programs. In older patients with cancer, improvement in QOL and decrease in treatment toxicity are considered at least as important as prolongation of survival by 99.5% of oncologists.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Appendix|| |
Appendix 1: Survey
What is your E-mail ID? ___________________________________________
1. What is your terminal or primary professional degree?
- Medical oncology/hematology
- Radiation oncology
- Surgical oncology
- Palliative medicine
- Other (specify)________________________________________
2. How do you describe your primary work setting?
- Academic medical center/university
- Community/private practice
3. How long have you been practicing oncology?
- I am still in training
- Completed training 0–5 years ago
- Completed training 6–10 years ago
- Completed training >10 years ago
4. In your regular practice, what percentage of your cancer patients belong to the geriatric age group?
5. How often do you do (or refer) your patients for a comprehensive geriatric assessment?
6. Where do you practice: Name of your institution or hospital with geographic location (city, state, country) or if in private practice, geographic location (city, state, country)?
7. Is it important to check for polypharmacy in geriatric oncology patients?
8. Is it important to check for potentially inappropriate medications in geriatric oncology patients?
9. Is it important to check for drug interactions in geriatric oncology patients?
10. Is it important to ask about falls in geriatric patients?
11. Is it important to assess the functional status in geriatric patients beyond checking the ECOG or Karnofsky performance status?
12. Is it important to check comorbidities in geriatric patients?
13. Is it important to perform a psychological evaluation for depression and/or anxiety in geriatric patients?
14. Is it important to assess cognition in geriatric patients?
15. Is it important to perform a nutritional evaluation in geriatric patients?
16. Is it important to assess social support in geriatric patients?
17. Is it important to evaluate the quality of life in geriatric patients?
18. Do you think formal training in geriatric assessment should be a part of oncology training programs?
19. Which improvement in patient outcome will make a geriatric assessment worthwhile to use in clinic? (may choose more than one option)
- Improvement in overall survival
- Decrease in treatment toxicity
- Improvement in quality of life
- Other improvement (specify) ___________________________________________
20. If the answer to Q.19 is improvement in overall survival, what improvement in median overall survival would you consider worthwhile in the palliative setting?
- At least 1 month
- At least 2 months
- At least 3 months
- At least 4 months
- At least 6 months
21. If the answer to Q.19 is improvement in overall survival, what improvement in survival at 2 years would you consider worthwhile in the curative setting?
- At least 5%
- At least 7%
- At least 10%
- At least 15%
22. If the answer to Q.19 is a decrease in toxicity, how much of a decrease would you consider worthwhile?
- At least 5%
- At least 10%
- At least 15%
- At least 20%
23. In geriatric oncology patients, what is the relative importance of a decrease in toxicity or an improvement in quality of life as compared to an improvement in overall survival?
- As important
- Less important
- More important
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[Figure 1], [Figure 2]
[Table 1], [Table 2]