A whole person approach to geriatric oncology in the region is urgently needed.
by Dr Ravindran Kanesvaran
Asia is at a critical point in its history when it is crucial to start taking a “whole person view” of cancer care for elderly people. More than half of the world’s population lives in Asia – 2.5 billion people reside in India and China alone. The pace of population ageing is much faster now than in the past.1Cancer is a disease of ageing. In fact, around 60 percent of people living with cancer are aged 65 years or older.2From the first-ever geriatric oncology programme in Southeast Asia at the National Cancer Centre Singapore, it was observed that older patients with cancer are more likely to have comorbidities, polypharmacy, and mental health issues like depression than younger patients.
Despite these differences, there is currently little training or education in Asia on how to take care of elderly patients with cancer. Much of the research and know-how in geriatric oncology originates from North America and Europe, and cross fertilisation to Asia is in the early stages.
During the fourth edition of the ESMO Asia 2018 Congress,34Conducted at the National Cancer Institute, Singapore, the study recruited 136 outpatients aged 70 years and older who underwent GA. The assessment identified 80 patients (59 percent) who required at least one intervention. Compared to patients who did not need an intervention following GA, those who did had worse scores in the physical, role, cognitive and social functioning domains of the EORTC QLQ C30 questionnaire and fared poorer on the symptom scales.5 The authors concluded that without GA, the needs of many of these patients would have remained undiscovered, making it a useful tool to identify gaps in care and optimise treatment.
What is geriatric assessment?
The aim of geriatric assessment (GA) in patients with cancer is to identify issues that might impact their ability to undergo treatment. Patients are divided into three broad groups. First are the very frail patients who would not be able to tolerate treatment of their cancer. At the other end of the spectrum are those who are fit and well, have no comorbidities, and for whom treatment of their cancer would be completely appropriate. Finally, there is a group of patients with a varying number of comorbidities. GA identifies those comorbidities so that appropriate interventions can be implemented to enable these patients to successfully undergo anti-cancer treatment.
“It’s about personalising care for the patient,” said Professor Dorothy Keefe, interim director of the South Australian Cancer Service and professor of cancer medicine at the University of Adelaide, Australia. “Assessment is not based on age per se but on comorbidity and frailty – both of which are more associated with ageing, as is cancer. It’s about making sure that you’re not doing harm to the patient.”
Before conducting GA, it is good practice to conduct screening to identify those who would potentially benefit from the full assessment. The G8 questionnaire6 has been validated in oncology, takes less than 10 minutes to complete, and can be administered by a nurse. It covers nutritional status, weight loss, body mass index, motor skills, psychological status, medications, and self-perception of health and produces a score ranging from 0 (heavily impaired) to 17 (not at all impaired). Patients who score 14 or lower require GA.
GA itself takes around one hour and should evaluate functional status, fatigue, comorbidities, cognition, mental health, social support, nutrition, and geriatric syndromes (e.g. dementia, delirium, falls, incontinence, osteoporosis or spontaneous fractures, neglect or abuse, failure to thrive, constipation, polypharmacy, pressure ulcers, and sarcopenia).
A multidisciplinary approach
Geriatric assessment was discussed in depth during the ESMO Asia 2018 Congress, in a dedicated session entitled ‘Issues for cancer care in the elderly’. Keefe, who was co-chair of the session and co-chair of the supportive and palliative care programme at the congress said, “Assessment of the older patient with cancer is going to be a very big area in Asia and we need to make sure that the things we’ve learned from other populations translate into the Asian population.”
Regardless of age, all patients with cancer should have their case discussed by a multidisciplinary tumour board of medical oncologists, radiation oncologists, radiologists, pathologists, surgeons, and nurses with expertise in the particular type of cancer. For older patients, this multidisciplinary board also needs people who are expert in issues of ageing, such as a social worker, physiotherapist, occupational therapist, and clinical pharmacist. Keefe said, “This is so that all potential comorbidities can be looked at with the aim in older cancer patients of making sure that they are fit and well enough to have the treatment that might be prescribed.”
“Because cancer is a disease of ageing, there is an ever-increasing number of older people who have had cancer, are now survivors, and have suffered true financial hardships,” said Keefe. Financial toxicity is a term coined to highlight the fact that cost of treatment is another side effect of cancer which can impact patients’ standard of living for the rest of their lives.
It is an area healthcare professionals may shy away from raising since they do not have the answers to difficult questions – for example what can be done if a patient cannot afford to pay for their treatment? But there are ways to help, such as keeping travel costs down by giving treatment close to home by minimising the number of appointments, and reducing prescription costs with combination anti-emetic tablets.
Balancing treatment and toxicity was another issue. “This is the art of medicine,” said Keefe. “We know that there are treatments that might kill a cancer but, to be really brutal about it, if they kill the patient as well, you haven’t succeeded. The risk of toxicity depends on the drugs, the tumour, and the patient’s physical state and comorbidities. This is exactly what geriatric assessment looks at.”
One of the risks for older people when it comes to this balance is that some centres reduce the amount of anti-cancer treatment because a patient is old, thus limiting its effectiveness. “We have to be very careful that we make decisions for the right reasons,” said Keefe. “It’s not about chronological age, it’s about comorbidities and frailty, which are identified through comprehensive assessment.”
Unfortunately, ageism is a real issue. Physicians and patients, and their families, have this preconceived notion that at a certain age, you become unfit and should not receive treatment. But that is not true. When patients receive GA, they react very positively. Patients feel better taken care of, and their other issues like diabetes, high blood pressure, depression, and medications are not ignored. They also feel better able to make decisions about their treatment. And it is a win for healthcare systems since costs and side effects are avoided in patients who do not receive treatment inappropriately.
The way forward in Asia
However, geriatric assessment is still underused in Asia, partly due to lack of time, but this can be overcome by employing a nurse to conduct screening, which is relatively quick, followed by the full GA if needed.
Another reason for its underuse in Asia is the lack of awareness. Centres in Japan, South Korea, Singapore, India, and Hong Kong are now starting to get involved. However, awareness about how to provide a geriatric oncology service is growing in the region, with events like the ESMO Asia Congress disseminating knowledge. Cancer care in the elderly is becoming an increasing priority for ESMO, which has just formed a joint working group on cancer in the elderly with the International Society of Geriatric Oncology (SIOG), aimed to teach all oncologists the principles of geriatric oncology and how to conduct geriatric assessment. It is hoped that many oncologists will own these important skills when treating the growing number of older adults with cancer.
- World Health Organisation. Ageing and health key facts. February 2018. Available at <https://www.who.int/news-room/fact-sheets/detail/ageing-and-health>
- Scotté F, Bossi P, Carola E, et al. Addressing the quality of life needs of older patients with cancer: a SIOG consensus paper and practical guide. Ann Oncol. 2018;29:1718–1726. doi: 10.1093/annonc/mdy228.
- ESMO Asia Congress 2018: www.esmoasia.org
- Wang M, Ho F, Ng YS, et al. Abstract 442P: CGA directed interventions in Asian geriatric oncology patients. ESMO Asia Congress 2018, 23 to 25 November 2018, Singapore.
- EORTC QLQ C30: The European Organisation for Research and Treatment of Cancer core quality of life questionnaire version 3.0 measures physical, psychological, and social functions in patients with cancer. Available at <http://www.siog.org/files/public/g8_english_0.pdf>
- G8 questionnaire. Available at <http://www.siog.org/files/public/g8_english_0.pdf>
Dr Ravindran Kanesvaran is a senior consultant, division of medical oncology at the National Cancer Centre Singapore. He is also assistant professor at the Duke-NUS Graduate Medical School in Singapore.