Comprehensive geriatric assessment in older people undergoing cancer treatment

1. Comprehensive geriatric assessment in older people undergoing cancer treatment Dr Danielle Harari Consultant Physician, Senior Lecturer Guys & St Thomas’ Hospital Foundation NHS Trust, Kings College London danielle.harari@gstt.nhs.uk Improving Cancer Treatment Assessment and Support for Older People Project: partly funded by the Department of Health and Macmillan Cancer Support (registered charity no 261017), supported by Age UK (registered charity no 1128267)

2. What is the problem? Cancer Reform Strategy, NCEPOD, National Chemotherapy Advisory Group, NICE 'Britain's cancer shame as 15,000 elderly patients could be saved every year'Daily Mail June 2009 • Overall cancer survival in the UK is improving but not for older people (National Cancer Intelligence Network 2010) • Older people (with same cancer & comorbidity profile as younger) receive less curative or adjuvant treatments • Lack of evidence to guide treatment in older people • Clinical trials include small nos. fit older people - benefit from therapy as much as younger patients (survival, QOL) • BUT exclude frailer OP (often those seen in clinical practice especially in myeloma)

3. What is needed? • Risk assessment methods to provide guidance on appropriate levels of treatment in older people • Comprehensive support to optimise outcomes in frailer patients • Trials of modified treatment in older and frailer patients (does dose reduction limit toxicity, but at a cost to tumour response?) • DH/Macmillan/AgeUK funded 5 national ‘Older Persons Pilots’ (including SELCN)

4. What is Comprehensive Geriatric Assessment (CGA)? • STRUCTURED ASSESSMENT of older patients to identify comorbidities, physical, psychological and social functional problems plus • INTERVENTION - addressing these issues through ongoing patient-centred management plans (often multidisciplinary) • Domains covered by variety of tools (not prescriptive, can be adapted to diff settings) • Improves outcomes in geriatric literature

5. Role of CGA in oncology:current situation • Oncologists usually use Life Expectancy & Performance Status • PS gives little info beyond mobility and does not assess reasons underlying functional difficulties • Comorbidities rarely formally assessed • Life expectancy – meaningless without comorbidity assessment • No assessment or support specific to the needs of older people in NHS cancer services

6. Role of CGA in oncology:current situation • Growing interest (SIOG, DH, Macmillan, NCEPOD) in integrating CGA into pre-treatment assessment to - avoid age-based treatment decision making - inform treatment choices to optimise outcomes • Existing oncology studies show CGA • can predict morbidity and mortality • is feasible • cancer outcomes and toxicity can be predicted by CGA domains such as functional dependency, depression and comorbidity • Increasing use of brief ‘frailty’ scores (e.g. Balducci) and prescriptive ‘CGA’ tools to decide if patients are ‘fit’ for chemotherapy

7. BUT dangers of using CGA assessment without intervention… • Extra issues identified by CGA scores may lead oncologists to overestimate treatment risk • Women 70+ breast cancer CGA-screened: Treatment plan changed by oncologists in 39% to less active treatment (most influenced by depression and low weight) • Use of briefer tools may also overestimate risk • CGA assessment should aim to accurately: - identify ‘fit’ patients for full cancer Rx - identify at risk patients for optimisation by geriatricians or other providers to improve fitness for cancer treatment

8. ‘POPS-GOLD’ – Improving cancer treatment in older peopleSouth-East London Cancer NetworkProject Lead: Dr Danielle HarariProject Team: Dr Tania Kalsi (Spr fellow), Gordana Babic-Illman (CNS)Collaborators (haemoncology): Dr Paul Fields • Project funding from Department of Health (Health Care Inequalities, Cancer Strategy), Macmillan, GST Charity • Observational: what factors (age, comorbidity) influence whether or not older people are offered evidence-based care? • Can geriatric-oncology liaison improve (a) appropriate treatment decisions (b) treatment tolerance (c) patient-reported outcomes (QOL) (d) healthcare processes (e.g. transport to hospital, unplanned admissions, LOS)?

9. Patients aged 70+ being considered for cancer treatment Complete CGA/comorbidty questionnaire Observational ‘pre’ group Usual care POPS-ONCOLOGY Low-risk patients identified as ‘fit’ At risk patients assessed for comorbidity optimisation pre-treatment CGA ‘holistic’ support Follow-through during treatment including liaison on oncology wards OUTCOMES % undergoing treatment with curative intent Treatment tolerance (toxicity, completion of planned protocol, decompensation of chronic conditions) Hospitalisations (emergency, length of stay) Patient reported quality of life, function, mood

10. Findings from observational work (‘pre’ group) – all patients completed GOLD-CGA questionnaire: Why may older people be ‘under-treated’

11. GOLD-CGA questionnaire • All questions source-referenced • Comorbidities questions nuanced e.g. is BP usually high when checked, breathless on walking on flat surfaces • Evidence-based functional scores • EORTC-QLQ-C30 (cancer-specific QOL tool validated in older people)

12. CGA screening in patients with lymphoma BSH 2012 • 74 older patients (aged ≥65) attending lymphoma clinic (mean age 74) • Mean questionnaire completion time was 11.5 + 7.4 minutes. • Comorbidities included: BP usually high when checked 23%, diabetes 21% (6% poorly controlled), angina/previous MI 11%, breathless on flat surfaces 27% • Cognition: confusion episodes 12%, significant memory problems 11% • Polypharmacy ( 4 medications) 30% • Function: Difficulties with  1 basic activity of daily living (ADL) 48%, with  1 instrumental ADL 53%, fatigue 71%, pain 38%, incontinence 26% • 34% lived alone, 14% had noone to look after them for a few days if needed • Questionnaire responses were used to categorise as low or high risk: • Low risk = no functional difficulties, no active comorbidity, mild QOL difficulties • High risk = functional difficulties &/or active comorbidity &/or severe QOL difficulties. • 64% of patients aged 70+ and 48% of those aged 65-70 were high risk, often with a combination of comorbidities, functional difficulties & QOL issues

13. Frailty- a comparison of diagnostic criteria SIOG 2013 • 108 patients judged fit for chemotherapy by usual clinical oncological practice, had frailty categorisation assigned retrospectively. This enabled a comparison between clinical judgement of fitness and the 2 frailty criteria for fitness. • Participants were defined as "fit" or "frail" using the Balducci criteria and a frailty index: • The Balducci criteria defined frail: age 85+ &/or functional deficit (≥1 ADL dependency) &/or serious comorbidity (serious cardiovascular, respiratory or cerebrovascular disease or 3+ comorbidities) &/or presence of any geriatric syndrome • The frailty index was derived from 43 items from the CGA-GOLD screening questionnaire using methodology as described by Rockwood.

14. Frailty- a comparison of diagnostic criteria SIOG 2013 • The frailty index classified 33.0% (35/106) as frail compared with 72.6% (77/106) by the Balducci criteria • There was poor agreement in who was fit or frail between the 2 diagnostic criteria (kappa=0.25) • The use of Balducci criteria to define frailty to aid treatment decision-making may risk under-treatment of older people with cancer. Frailty indices (based on CGA screening data) may provide a more comprehensive approach. • Chemotherapy treatment decision-making should not be based on the result of frailty scores whilst existing tools do not reliably agree on who is “frail” in this setting. The optimal measure of frailty to apply to clinical practice with proven abilities to accurately detect frailty has yet to be identified.

15. Low grade toxicity in older people undergoing chemotherapy ECCO 2013 • N=108 patients aged 65+ recruited at start of chemotherapy Research question • To identify which level of toxicity (and how many toxicities) trigger • a) treatment modification • defined as dose reductions, delays or drug omissions • b) early discontinuation of chemotherapy

16. Results: treatment modifications due to toxicity N=60 (55%) • 35% (21/60) had no greater than grade 2 toxicity • Of these 21: • Mean 2.19+/-1.33 grade 2 toxicities • 7 patients had only one grade 2 toxicity • Range of G2 toxicity types • Most common: Fatigue (8), haem (8), GI (6) & infections (5)

17. Results: Toxicity grade trigger to treatment modification (N=60) by comorbidity Multiple comorbidities (4+) N=19 Few Comorbidities (<4) N=41 Low grade toxicity 57.9% (N=11) High grade toxicity 42.1% (N=8) Low grade toxicity 24.4% (N=10) High grade toxicity 75.6% (N=31) Statistically significant: p=0.011, 2=6.41

18. Results: Early discontinuation due to toxicity N=23 (21%) • 39.1% (9/23) had no greater than grade 2 toxicity.  • Of these 9: • Mean 1.78+/-1.2 grade 2 toxicities • One grade 2 toxicity n=3 • Most common grade 2 toxicities: fatigue (5) and haemotological toxicity (4)

19. Key questions & future research in low grade toxicity • Truly have a greater clinical impact on older people? • Is this related to differences in the clinical interaction between dr & older patient? • Lower threshold for modifying/discontinuing treatment in older people? If so, why? • Reporting behaviour? • Additional support (e.g. geriatrician liaison) improve treatment tolerance?

20. Fatigue in older people undergoing chemotherapy SIOG 2013 • Baseline fatigue is rarely documented • Fatigue toxicity was cited by treating oncologists in 69.1% (n=75) of all patients during chemotherapy, with grade 2+ occurring in 36.1% (39) and grade 3+ occurring in 11.1% (11)

21. Findings from interventional work (‘post’ group) : Impact of geriatric-oncology liaison in outpatients and inpatients (oncology wards)

22. OLDER PATIENT WITH CANCER SELF REPORTING CGA SCREENING QUESTIONNAIRE ONCOLOGY REFERRAL LOW RISK HIGH RISK IN DEPTH REVIEW BY GERIATRICIAN TO OPTIMISE/REVERSE CGA NO CGA REQUIRED INFORM ONCOLOGY TREATMENT DECISION CONTINUED GERIATRICS SUPPORT & RE-REVIEW AS NEEDED GOLD PATHWAYS DEVELOPED

23. SERVICE DEVELOPMENT – CLINIC PATHWAYS • Tailor CGA intervention to cancer treatment • Optimise in relation to tx and plan proactively for anticipated cancer treatment toxicity • Developed to fit in within existing oncology pathways • Tailor to individual needs of the tumour groups • bladder cancer - joint clinic with a walk-in CGA • colorectal and prostate cancer - fast track review typically within 1 week of referral

24. Examples of targeted interventions • Cardiac and cardiac risk optimisation in patients receiving anthracyclines • Improving renal function in those to receive platin based chemo – polypharmacy etc • Treating pre-existing anaemia – iv iron, B12 and folate • Diabetes management with steroids • Nutritional support • Pain and mobility optimisation (osteoarthritis) • Fatigue investigation and management plan – protocolised fatigue pathway developed • Managing continence (QOL) • Transport assistance esp for people having outpatient chemo/RT

25. Screening Questionnaire RECRUITED n=177 BEXLEY GP GROUP n = 31 GSTT GROUP n=146 SCREENING QUESTIONNAIRE  NOTE REVIEW AND TELEPHONE CLINIC FOR CGA NEED NO CGA CLINIC AS PER NEED OR WISHES N=73 (50%) IN DEPTH CGA CLINIC N=73 (50%)

26. Questionnaire Validity & Reliability (EUGMS 2013, BGS 2103) • Inter-rater reliability • Subgroup of 71 patients, 2 clinicians (SPR & CNS) review same screening questionnaires • Same decision in 87.3% (n=62/71) of questionnaires • Reliability: against clinical notes review • Clinician 1 (SPR): notes changed decision of CGA need in 10.9% (n=9/82) patients • Clinician 2 (CNS) notes changed decision in 9.6% (n=8/83) patients • Acceptability: patient responses • 80.2% (n=142) did not need help to complete • Mean time to complete: 14.5 mins +/- SD 9.3

27. Outpatients - Comorbidities LOW RISK HIGH RISK IN DEPTH REVIEW BY GERIATRICIAN TO OPTIMISE/REVERSE CGA NO CGA REQUIRED COMORBIDITIES MEDIAN 3.0 MEAN 2.51 +/- SD 1.9. COMORBIDITIES MEDIAN 6 MEAN OF 5.75 +/- SD 2.4

28. Did POPS-GOLD influence oncology treatment decision-making BGS 2012 • 60% (n=24) of oncologists responded to semistructure questionnaire (21% consultants, 63% registrars, 17% clinical nurse specialists) • All respondents had read the CGA assessment letter at the patient’s next cancer appointment. • 63% (n=15) reported the assessment had influenced their decision-making. • Of these, 67% (n=10) reported CGA assisted the evaluation of fitness for treatment, more often in favour of active treatment (8 versus 2 patients). • Common themes reported as beneficial were: • medical review (n=5) • increased information (n=3) • facilitated communication (n=2) • increasing confidence (n=3).

29. Did POPS-GOLD influence oncology treatment decision-making BGS 2012 • “it was so helpful.....we thought he might have had a cardiac problem related to the chemo but you have identified the culprit drug. Based on your consultation, we decided to continue chemotherapy without any dose reductions” • “Overall, POPS review was a very helpful and precise holistic assessment of the patient” • “Partly......altering medications had improved her symptoms. But balance is to control disease vs toxicity and she was relatively symptom free” • “Confirmed impression that not fit for further systemic therapy and that  efforts should be palliative. It was really useful to confirm co-morbidities and their impact on symptoms. Also useful to clarify modifiable factors...” • “No.  We knew what treatment the patient needs to be on.  However, the pt did mention he found the POPS review helpful particularly with respect to medications” • “increased confidence in proceeding with chemo with knowledge of optimal medical management” • Of the 9 who reported no influence on decision-making, 5 found it useful for other reasons: • “the reduction in antihypertensives is likely to mean he will tolerate radiotherapy”

30. Did POPS-GOLD influence oncology treatment decision-making BGS 2012 • To impact on decision-making, CGA needs to be delivered within a tight timeframe to fit in with existing cancer targets. This could be a challenge for an already busy geriatric medicine department. However, the CGA screening questionnaire allowed us to assess for CGA need. This meant clinic time could be utilised effectively to enable rapid CGA delivery for those that needed it most. • Within limitations, this evaluation highlights the potential benefits of geriatrician-led CGA, more often in favour of more actively treating older people • Early CGA can influence oncology decision-making. • Feedback suggests this relates not only to improved medical support and the information provided, but by increasing confidence to actively treat older people with cancer.

31. Patient & Carer Feedback • “Nice to know GOLD are there to give advice and help with possible problems.” • “There is time to talk and the Doctor looks at you as a person and how you can cope with the medical problems”. • “The clinic is very relaxed and you feel there is time to talk, whereas other clinics are so busy and the Doctor is catching up with information on the computer.” • ‘They saw my mother a few weeks ago and did a fantastic job in sorting her out for chemo. Consultant haematologist

32. In-patient Liaison

33. Service & Pathway Development for geriatric liaison on oncology wards • Identified patients • morning board rounds (CNS) • MDT (CNS/SPR) • Case note review (CNS/SPR) • Patients were stratified according to risk- pathways • Clinical Review • For patients in need • Optimised in a similar way to in the CGA clinic. • Discharge planning

34. GOLD Intensity of Input

35. Impact on quality of information across to primary care and community and coding

36. Impact on length of stay

37. Impact on LOS • LOS in patients aged 65+ reduced with GOLD • Pre-GOLD LOS: 11.7-14.0 days (Oct 11-Jan 12) • Partial GOLD LOS: 9.1 - 9.5 days (Feb 12 – March 12) • GOLD LOS: 7.2 - 9.4 days (Jun – Aug) • In addition, a number of younger patients with complex needs and lengthy hospitalisations would benefit from this approach. • Our scoping would suggest that at least half of all inpatients fall into the category of requiring GOLD input

38. Dissemination to oncology training bodies • Survey of medical oncology trainees • Kalsi T, Payne S, Brodie H, Wang Y, Mansi JL, Harari D. Are UK oncology trainees adequately informed about the needs of older people with cancer? British Journal of Cancer 1–6 | doi: 10.1038/bjc.2013.204 • Survey currently being considered in the revision of the national medical oncology curriculum

39. Geriatric Oncology Training During Specialist Training • 66.1% never received any training on the needs of older people with cancer • 19.4% had only ever received this training once • Training in geriatrics specific issues common in oncology patients (eg delirium, falls) • Of those who had received training, the majority received it 3 years ago • Want training • cognitive impairment/delirium (n=18) • polypharmacy (n=17) • discharge planning (n=7).

40. Practice in cognitive impairment • Cognitive assessments • 45.9% rarely/never assessed • Consent and Mental Capacity Assessment • 27.3% never consent patients with cognitive impairment • 50.9% would rarely consent • 38.9% MCA never/rarely used to decide about the patient’s understanding

41. Confidence in risk assessment • 81.4% confident for younger pts • 27.1% for older patients • 10.2% for older patients with dementia • 25.4% confident/extremely confident managing multiple comorbidities

42. Macmillan/DOH/Age UK report: Cancer Services Coming of Age, Dec 2012 http://www.macmillan.org.uk/Aboutus/Healthprofessionals/Improvingservicesforolderpeople/Pilots/PilotSites.aspx

43. Department of health recommendations • improving survival rates in the population aged 75 years and over • to deliver high quality services to increasing numbers of older patients with cancer, including age appropriate assessment, for example the Comprehensive Geriatric Assessment (CGA) • involvement of elderly care specialists http://cno.dh.gov.uk/2012/12/20/cancer-services-coming-of-age-report-published/

44. How can oncologists, surgeons and geriatricians work together? • CGA / comorbidity screening with identification of low and at risk patients can be done in oncology clinic • In-depth CGA for at risk patients (outpatient) – ideally joint oncology/geriatric clinics • Assessment is part protocolised so could also be done by oncology with geriatrician support • Inpatient liaison – medical optimisation, rehabilitation goal setting, early discharge planning – dedicated geriatric liaison team is preferred model (if funded…) • Could be done by oncologists with consultative support and geriatrician sitting in on ward MDM

45. Thank you