Comprehensive geriatric assessment for patients with cancer

INTRODUCTION — Approximately 54 percent of new cases and 70 percent of mortality from cancer occur in patients ≥65 years of age [1,2]. As a result, the care of older patients constitutes an important part of the everyday practice for the adult oncologist.

Despite the high incidence of cancer in this group, older patients have been underrepresented in clinical trials that set the standards for care in oncology practice [3-7]. Less data exist regarding the risks and benefits of cancer treatment in this population, and there are few guidelines that specifically address the evaluation and treatment of the older patient.

Older patients are less likely to receive all types of standard cancer therapies compared with younger individuals [8-15]. Possible reasons include concerns regarding increased toxicity, competing causes of morbidity and mortality, lack of access to care, and clinician or patient preference.

Chronologic age alone provides relatively little information regarding an individual's tolerance to cancer treatment. Among patients of the same age, there is wide heterogeneity in the ability to undergo aggressive therapy.

Identifiable comorbid conditions and organ-specific physiologic changes due to aging can limit a patient's ability to tolerate cancer therapy. In addition, the aging process can be associated with decreased physiologic reserve affecting multiple systems. This can be manifested as frailty and can interfere with the functional status of the patient, even in the absence of specific comorbidities. The manifestations of frailty include various components of weight loss, exhaustion, weakness, relative immobility, and a general decrease in physical activity.

There is a need to identify the seemingly frail older individual who is likely to benefit from and tolerate standard therapy, as well as the seemingly fit older individual who is apt to experience undue side effects and requires a modified treatment plan. The evaluation of frailty in older adults (clinical and potential physiologic predictors) is discussed separately. (See "Failure to thrive in older adults: Evaluation", section on 'Frailty'.)

Information about specific issues may guide interventions that can improve the ability to undergo cancer treatment. A comprehensive geriatric assessment (CGA) looking at all of the factors that can influence the outcome of therapy is useful in addressing these needs.

The key components of a CGA as applied to patients with cancer will be reviewed here, along with the different approaches for obtaining this information. A more detailed discussion of the CGA, general aspects of the treatment of cancer in the older adult patients, and the management of older adult patients with specific types of cancer are presented separately. (See "Comprehensive geriatric assessment" and "Systemic chemotherapy for cancer in older adults".)

POTENTIAL BENEFITS — A CGA is a standard part of a geriatrician's baseline evaluation of an older individual. Several studies have suggested a wide range of possible benefits from using a CGA in patients with cancer. These include (see 'Use of CGA results' below):

●Predicting complications and side effects from treatment [16-22]

●Reducing serious side effects from treatment [23-25]

●Predicting functional decline during treatment [26,27]

●Estimating survival [20,21,28-30]

●Assisting in cancer treatment decisions [31-34]

●Detecting problems not found by routine history and physical examination in the initial evaluation [21,33,35-38]

●Identification and treatment of new problems during follow-up care [37,39]

●Improving mental health and well being [40]

●Better pain control [40]

Discussion of supporting evidence is found below. (See 'Supporting evidence' below.)

WHO NEEDS A CGA? — Consensus guidelines from the American Society of Clinical Oncology, the National Comprehensive Cancer Network, and the International Society for Geriatric Oncology (SIOG) recommend the routine use of a geriatric assessment for the older patient with cancer (defined as age 65 or older) [41-44]. However, although a CGA is helpful for clinicians to develop a coordinated plan for cancer treatment and to guide appropriate interventions for specific problems, it can be time consuming and may not be practical for all patients. Nevertheless, in our practice, we utilize a CGA in every patient age 65 and older, using a mainly self-administered CGA assessment tool, as described in more detail below [45]. (See 'Self-administered CGA' below.)

PRE-CGA SCREENING TOOLS — Some, including the SIOG, have suggested the use of a screening tool to identify vulnerable patients for whom a CGA could potentially optimize their cancer treatment [42,46]. Multiple approaches have been made to develop "simplified CGAs" (assessment of autonomy, malnutrition, depression, cognition, and comorbidity), which are intended to be quick screening tools to determine who could benefit from a full CGA [46].

●An abbreviated CGA was developed by performing a retrospective chart review of 500 patients who underwent a geriatric assessment consisting of an evaluation of functional status (Activities of Daily Living [ADLs] and Instrumental Activities of Daily Living [IADL]), cognition (Mini-Mental State Exam [MMSE]), and psychological state (Geriatric Depression Scale). The authors identified 15 items from these scales that demonstrated the highest item to total correlation [47].

●Another alternative tool is the Vulnerable Elders Survey-13 (VES-13) (table 1) [48-51]. This approach utilizes a function-based scoring system that considers age, self-rated health, physical limitations, and functional disabilities.

●Other instruments include the French G8 tool [52] and the Flemish version of the Triage Risk Screening Tool (fTRST) [53]. One group used both tools to screen 937 patients aged 70 or older with a malignant tumor and a new cancer event requiring a treatment decision [54]. Both tools showed high sensitivity for detecting patients with a geriatric risk profile (as determined by formal geriatric assessment, which was carried out in all patients) and were prognostic for functional decline during therapy and higher mortality rates.

All frailty screening methods, including the VES-13, have a limited power to predict outcome of a CGA. A systematic review of several frailty screening methods, including the VES-13, concluded that they all had limited specificity and that the negative predictive value of the most sensitive screening tool was only 60 percent [55]. Nevertheless, a prospective study of 1021 patients with cancer evaluated four frailty tools (Balducci [56], SIOG 1 and 2 [57,58], and Ferrat [59]) and found that each had good prognostic ability to predict six-month unscheduled admissions and one-year mortality, suggesting that such tools may be helpful in decision-making regarding cancer treatments in older patients [60]. (See "Frailty", section on 'Instruments developed to identify frailty'.)

These tools are not intended to be a CGA or replace the need for one. They do not really identify issues that can be followed up specifically to try to improve outcomes. While they have been used for prognostication and probably work almost as well as a full CGA for that, they do not substitute for a CGA for all purposes.

DOMAINS OF A CGA — The typical domains of a CGA include evaluations of functional status, comorbid medical conditions, cognitive status, psychological state, social support, nutritional status, and a review of the medication list [43,61]. The American Society of Clinical Oncology (ASCO) guidelines provide a minimum dataset for practical assessment of vulnerabilities in older patients with cancer (table 2) [43]. Specific instruments to assess these vulnerabilities include the Instrumental Activities of Daily Living (IADL) for function, a thorough history or validated tool (eg, the Cumulative Illness Rating Scale-Geriatrics [62,63]) to assess comorbidity, a single question for falls (how many falls have you had in the last six months or since your last visit), the Geriatric Depression scale (GDS) to screen for depression, the mini-Cog [64] or the Blessed Orientation-Memory-Concentration (BOMC) test [65] to screen for cognitive issues, and assessment of unintentional weight loss to evaluate nutrition.

The guidelines also include recommendations for specific interventions guided by the geriatric assessment (table 3).

Impaired functional status and significant comorbidity can have significant effects on the ability to administer systemic chemotherapy in the older adult patient. (See "Systemic chemotherapy for cancer in older adults".)

Functional status — Functional status refers to a patient's ability to perform routine daily tasks. Functional disability is common in older patients with cancer. This was illustrated by a national sample of 9745 community-based Medicare beneficiaries, in which older adults had greater health care utilization and more limitations in activities of daily living (ADLs) and instrumental activities of daily living (IADLs) than individuals without cancer [66]. ADLs are the skills that are necessary for basic living, and include feeding, grooming, transferring, and toileting. IADLs are required to live independently in the community and include activities such as shopping, managing finances, house-keeping, preparing meals, and taking medications. Similar results were seen in another study of 303 patients aged ≥65 years with solid tumors or hematologic malignancies, in which limitations in ADLs and IADLs were found in 17 and 59 percent of patients, respectively [67].

The commonly used performance status scores (eg, Karnofsky or Eastern Cooperative Oncology Group [ECOG] scales (table 4 and table 5)) tend to underrepresent the degree of functional impairment in the older patient [36]. A more comprehensive understanding of an older patient's functional state can be obtained by the Activities of Daily Living (ADL) and IADL scales (table 6). In a study of 363 cancer patients aged ≥65 years, an ECOG performance status <2 (table 5) was associated with limitations of ADL and IADL in 9 and 38 percent of patients, respectively [36]. The frequency of IADL limitations was more common in patients aged ≥80 years.

Other measures of functional status have been evaluated, including gait speed and grip strength [68-70]. For example, in one study of 314 adult patients aged ≥75 years with blood cancers, decrease in gait speed was associated with higher mortality, odds of unplanned hospitalizations, and emergency room visits, after adjustment for other clinical and disease factors [69]. Decreases in grip strength were associated with worse survival, but not hospital or emergency room use.

Impaired functional status is associated with an increased risk of toxicity due to chemotherapy. This was demonstrated in two multicenter studies that identified predictors of chemotherapy toxicity [17,18]. In both of these studies, the patient's functional status was a key predictor. In the study by the Cancer and Aging Research Group, the functional measures that predicted chemotherapy toxicity risk included falls in the last six months, limitations in walking one block, need for assistance with taking medications, and decreased social activities [18]. The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score identified the need for assistance with IADLs as a predictor of chemotherapy toxicity. Another study of patients aged ≥70 years with ovarian cancer who were receiving carboplatin and cyclophosphamide identified functional dependence (defined as living at home with assistance or living with medical assistance in a specialized institution) and ECOG performance status ≥2 as predictors of chemotherapy toxicity [16].

Comorbidity — Comorbidity represents the extent of an individual's physical and psychological disease in addition to the disease for which they are seeking treatment [71]. As an individual ages, the number of comorbid medical conditions increases [72]. The impact of these comorbid medical conditions on life expectancy and treatment tolerance should be considered when estimating the risks and benefits of treatment [73].

The importance of comorbidity is illustrated by analyses from three large series:

●A longitudinal observational study of 936 women with breast cancer ages 40 to 84 found that patients who had three or more comorbid medical conditions had a 20-fold higher rate of mortality from causes other than breast cancer and a four-fold higher all-cause mortality rate compared with those who had no comorbid medical conditions [74].

●A second report analyzed 1255 patients with non-small cell lung cancer who were enrolled in two randomized trials conducted by the National Cancer Institute of Canada [75]. Patients at least 65 years of age were significantly more likely to have a Charlson Comorbidity Index score ≥1 than younger patients (42 versus 26 percent) (table 7). Although age was not an independent factor influencing survival, comorbidity, as evidenced by a Charlson Comorbidity Index score ≥1, was associated with increased mortality (hazard ratio [HR] 1.28, 95% CI 1.09-1.50).

●A third study analyzed the impact of comorbidity using three different instruments in a series of 496 patients (mean age, 67 years) undergoing surgery for colorectal cancer [76]. Analysis using the Charlson Comorbidity Index, the National Institute on Aging and National Cancer Institute Comorbidity Index, and the Adult Comorbidity Evaluation-27 all found that patients with the highest comorbidity burden had the poorest overall and colon cancer-specific survival.

In addition to its effect on survival, the presence of comorbid medical conditions also affects a patient's ability to tolerate cancer therapy. In a study of patients aged ≥70 years with advanced non–small cell lung cancer, for example, those with a Charlson Comorbidity Index of ≥2 were more likely to discontinue chemotherapy early than patients with a comorbidity score <2 [77].

An assessment of comorbid medical conditions can provide information that is independent of the individual's functional status. This was illustrated by a study of 203 older patients with cancer, in whom there was little or no correlation between comorbidity (as measured by either the Charlson Comorbidity Index or Cumulative Illness Rating Scale – Geriatric) and functional status (as assessed by ECOG performance status or ADLs). Thus it is important to assess comorbidity as well as functional status [78].

Cognitive function — Cognitive function is another important component of the overall assessment of the geriatric patient with cancer. (See "Evaluation of cognitive impairment and dementia".)

ASCO guidelines suggest either the mini-Cog [64] or the BOMC test [65] to screen for cognitive issues.

In the general geriatric population, dementia is an independent prognostic factor for survival. The presence of dementia influences the likelihood of both cancer diagnosis and treatment [79]. In a population cohort study using the Surveillance, Epidemiology and End Results (SEER) Medicare database, patients with invasive colon cancer and dementia were more likely to have a cancer diagnosis reported after death based upon either an autopsy or death certificate than patients who did not have dementia [80]. In addition, patients with dementia were less likely to have a biopsy-proven diagnosis of cancer and were less likely to receive surgery or chemotherapy. In another study using the SEER database, patients with Alzheimer disease and breast cancer were more likely to be diagnosed with a later stage of breast cancer and were less likely to receive treatment for their malignancy [81].

From a practical standpoint, an assessment of cognitive status is important prior to beginning cancer treatment in order to ensure that the patient can comply with instructions regarding supportive medications or oral chemotherapy, and in order to understand and remember to seek medical attention if side effects develop.

Nutrition — Nutritional status is an important prognostic factor in all geriatric patients. (See "Dietary assessment in adults".)

In the general older population, there are several reports demonstrating the adverse impact of weight loss or low body mass index (BMI) even when subjects do not have cancer (figure 1) [82-86]. The importance of weight loss was illustrated by a study of 4714 community-dwelling adults age ≥65 years, in which weight loss ≥5 percent was associated with an increased risk of mortality [82]. Similar results were seen in another study of 7527 individuals age ≥70 years, in which a BMI <19.4 kg/m² (the lowest 10 percent of the population) was associated with an increased risk of mortality [83].

Among patients with cancer, the deleterious effect of weight loss on survival was demonstrated in a study of 3047 patients enrolled in 12 ECOG chemotherapy protocols [87]. In this analysis, weight loss was an independent prognostic factor for survival and was associated with a lower performance status. Furthermore, weight loss was associated with a decrease in chemotherapy response rates in women with breast cancer, although this correlation was not present in other tumor types. Even a limited weight loss (0 to 5 percent) can be clinically significant in patients with cancer.

In a retrospective study of 454 older adults with cancer who underwent a CGA and clinical exam, 42 percent were clinically diagnosed with malnutrition [88]. The Mini-Nutritional Assessment [89] had the highest validity and reliability to detect malnutrition compared with clinical exam followed by weight loss then BMI [88]. Older adults with malnutrition were more likely to have major depression and frailty [90].

Thus, the adverse effects of weight loss and low BMI have been demonstrated in all older patients including those with cancer. Future studies are needed to determine whether nutritional intervention can decrease these risks. (See "Pathogenesis, clinical features, and assessment of cancer cachexia" and "Management of cancer anorexia/cachexia".)

Psychological state and social support — Although the incidence and severity of psychological distress are reported to be less than that observed in younger patients [91,92], approximately one-third of older patients with cancer experience psychological distress. (See "Patients with cancer: Overview of the clinical features and diagnosis of psychiatric disorders".)

This most typically takes the form of depression. The prevalence of clinically significant depression is estimated to be 3 to 25 percent in the older population with cancer [91]. ASCO guidelines suggest the GDS to screen for depression [43].

The consequences of depression in this group include an increased risk of subsequent functional decline and with increased utilization of healthcare resources [93]. This was illustrated in a survey of 6649 patients aged >70 years, in which the presence of increasing numbers of depressive symptoms was associated with a need for more hours of informal caregiving [94].

The patients who are most vulnerable to psychological distress are those with inadequate social support. This was illustrated by a study of breast cancer survivors, in which older age was associated with less distress [95]. However, patients with less adequate social support experienced increased distress. In addition, social isolation is also an independent predictor of mortality in the geriatric population [96].

Medication review — For older patients with cancer, careful review of medications is an important component of a CGA. Regular and comprehensive review of all medications (both prescription and over the counter) is needed to remove any unnecessary or potentially inappropriate medications and to assess for potential drug interactions [97-99]. As an example, the diagnosis of terminal cancer should prompt the discontinuation of certain drugs that are no longer potentially beneficial, such as lipid-lowering medications [100]. Details about specific interactions may be obtained by using the Lexicomp drug interactions tool included within UpToDate.

Physiologic changes associated with aging can have a major impact on drug pharmacokinetics and pharmacodynamics. With aging, body fat increases, total body water and renal function decrease, and hepatic mass and blood flow decrease. In addition, the number of medications that an individual takes also increases. This combination of age-related changes in physiology and polypharmacy is associated with an increased risk of adverse drug events in the older patient. (See "Drug prescribing for older adults".)

Older adults with cancer are particularly prone to medication errors attributed to medication changes, complex regimens, and incomplete information handoff between providers [101]. Cancer-related therapy adds to the use of multiple medications and/or the consumption of potentially inappropriate medications and compounds the risk for adverse drug effects, drug-drug interactions, and nonadherence as a result of increased pill burden and regimen complexity [102,103]. In one pharmacist-led medication review of 248 ambulatory older adults with cancer who received a geriatric oncology assessment, the mean number of medications used was 9.23, and 43 percent were receiving more than 10 medications [103]. The prevalence of potentially inappropriate medication use (as assessed by 2012 Beers criteria, Screening Tool of Older Person's Prescriptions [STOPP], and the Healthcare Effectiveness Data and Information Set [HEDIS]) was 51 percent. (See "Drug prescribing for older adults", section on 'Inappropriate medications'.)

OBTAINING PATIENT DATA — Although consensus guidelines recommend that older patients with cancer undergo a CGA, there is no consensus regarding an optimal tool [41,44]. The various approaches that have been studied recognize the limited resources available in an oncology practice, and several different methods of obtaining this information have been explored. These screening tools can potentially identify older adults who would benefit from a more thorough evaluation or collaborative care with a geriatrician. Here we will briefly review several assessment methods.

Mailed CGA — A self-reported, mailed CGA was evaluated in a population of male oncology patients (mean age 68, range 42 to 87) at the Durham, North Carolina Veterans Administration Medical Center [104]. The assessment evaluated functional status, pain, financial wellbeing, social support, psychological state, spiritual wellbeing, and quality of life (table 8).

The CGA was sent to participants prior to their initial clinic visit, and 76 percent of patients kept their clinic visit and returned the assessment. The mailed CGA was effective in capturing salient information about the different assessment domains. For example, 58 percent of patients required assistance with one or more instrumental activities of daily living (IADLs), 61 percent required assistance with one or more activities of daily living (ADLs), the mean number of comorbid medical conditions was five, and the mean number of medications was six.

Self-administered CGA — Investigators from the Cancer and Leukemia Group B (CALGB), Cancer in the Older Adult Committee (formerly Cancer in the Elderly Committee), developed a CGA that is primarily self-administered [45]. This assessment is a compilation of well-validated instruments that evaluate functional status, comorbidity, cognition, nutritional status, psychological state, social support, and medication use (table 9).

Three of the instruments are performed by the healthcare provider: the Blessed Orientation-Memory-Concentration Test (a measure of cognition), Timed Up and Go (a performance-based measure of functional status), and Karnofsky performance status (table 4). The remainder of the assessment is self-administered by the patient.

Pilot data demonstrate that the mean time to complete the assessment is 27 minutes, and 78 percent of participants could complete the self-administered portion on their own. Overall, 90 percent of participants were satisfied with the length of the questionnaire, 83 percent reported that it was easy to understand, and 100 percent stated that there were no upsetting items [45]. The CALGB, Cancer in the Older Adult Committee evaluated the feasibility of including this primarily self-administered assessment in CALGB trials [18]. The median time to complete the geriatric assessment tool was 22 minutes. The majority (87 percent) of patients completed the assessment without assistance. Furthermore, patient satisfaction with the questionnaire was high (92 percent reported satisfaction with the questionnaire length, 95 percent reported no difficult questions, and 96 percent reported no upsetting questions). The assessment met the feasibility criteria specified in the protocol for inclusion in future cooperative group studies.

Electronic CGA — Administration of the CGA electronically has become increasingly common [105]. In a prospective study of 100 older adults with cancer, a computer-based CGA was feasible, reliable, and valid with 67 percent of participants preferring a computer-based CGA to a paper assessment [106]. The Memorial Sloan Kettering Cancer Center Geriatric Service developed the Electronic Rapid Fitness Assessment (eRFA), which is performed during preoperative evaluations of older adults considering cancer surgery. The eRFA assesses function, cognition, social support, emotional status, nutrition, sensory deficits, and polypharmacy with a median time to completion of 11 minutes [107]. Integration of electronic CGA results into the electronic medical record may help promote implementation of CGA clinically and facilitate interpretation of results with targeted interventions.

Clinical interview — A fourth approach, using a clinical interview for the CGA, was evaluated in 30 patients aged 65 and older with a variety of tumor types [108]. The Multidimensional Assessment Protocol for Cancer (MACE) includes an evaluation of the socioeconomic status, cognitive status, depression, physical performance, disability, and tumor characteristics (table 10). The mean time for administering the MACE was 27 minutes.

Multidisciplinary geriatric oncology clinics have been developed in several cancer centers, where geriatricians or geriatric oncologists are available to perform in-person geriatric assessments [109-113]. For example, the Specialized Oncology Care and Research in the Elderly (SOCARE) clinics at the University of Chicago, University of Rochester, and City of Hope combine a self-administered CGA with in-person assessments including the Short Physical Performance Battery, Blessed Orientation-Memory-Concentration (BOMC), and Mini-Nutritional Assessment as needed [109]. A geriatric oncology-trained nurse, physical therapist, occupational therapist, social worker, pharmacist, and nutritionist are available to provide CGA-guided interventions to address any impairments identified. Additionally, integration of geriatric nurse practitioners and physician assistants into multidisciplinary geriatric oncology care can help expand the limited geriatrics clinician workforce [114].

USE OF CGA RESULTS — The information from the CGA can be used in a number of ways to assist in decision-making regarding overall management of the older patient with cancer. As examples:

●Some authors have classified the older population into specific groups for the purpose of selecting the treatment strategy, based upon their functional status, rehabilitative potential, life expectancy, and tolerance of stress (table 11 and algorithm 1) [115-118].

●Others have developed tools such as prognostic indices and nomograms based upon domains and elements of the CGA that predict the probability of one-, two- and three-year overall survival for older adult patients with cancer [119,120].

●A frailty index derived from information gleaned from the CGA has been used to predict the likelihood of discontinuing chemotherapy and hospitalization in older patients [121].

●In older adults with lung cancer, chemotherapy treatment allocation based on CGA results is associated with reduced treatment toxicity and treatment failures compared with treatment allocated based on performance status and age alone [22].

●The information obtained from the CGA has also been combined with other information, including the proposed chemotherapy regimen, hematologic and renal function, hearing impairment, and cancer type, to derive a model used to predict chemotherapy toxicity in the older adult population (table 12 and table 13) [18]. This predictive model was developed (studying a cohort of 500 patients) [18] and validated (in a cohort of 250 patients) in a prospective multicenter trial [122]. (See "Systemic chemotherapy for cancer in older adults", section on 'Models predicting chemotherapy toxicity and early death'.)

●A cohort of geriatric oncology experts developed algorithms for geriatric assessment-guided care processes and developed geriatric assessment-guided interventions. Impairment in a specific geriatric assessment domain could influence cancer treatment decision-making [123].

SUPPORTING EVIDENCE — Randomized trials have shown that CGA-driven interventions and integrated oncogeriatric care can reduce chemotherapy toxicity, improve quality of life, reduce unplanned hospitalizations, improve patient and caregiver satisfaction with communication about aging-related concerns and satisfaction with overall care, reduce falls during cancer treatment, and increase advance directive completion, all while preserving overall survival.

As examples of available data [22-24,124-130]:

●In a multicenter, cluster-randomized clinical trial comparing CGA summary and management recommendations provided to oncologists versus usual care (COACH trial), among adults age ≥70 years with advanced solid tumor or lymphoma with ≥1 impairment in a CGA domain, patients in the CGA intervention group reported higher satisfaction with communication about aging-related concerns and higher satisfaction with overall care than the usual care group [127]. The intervention group also had a higher number of age-related conversations, higher-quality age-related conversations, and a higher number of conversations with CGA-driven recommendations. In addition, caregivers also reported higher satisfaction with communication about the patient's aging-related concerns. There were no differences in patient or caregiver quality of life.

●In a separate multicenter, cluster-randomized trial comparing CGA summary and management recommendations provided to oncologists versus usual care (GAP70+ trial), among patients age >70 with incurable solid tumors or lymphoma starting a new systemic therapy, the CGA intervention significantly reduced grade ≥3 adverse events (51 percent) compared with usual care (71 percent; relative risk 0.74, 95% CI 0.64-0.86) [24]. Reduced dose intensity at cycle 1 was more common in the CGA intervention group with a lower relative dose intensity over three months compared with usual care. This lower relative dose intensity in the CGA intervention group did not negatively impact survival as survival between the two groups was comparable (HR 1.13, 95% CI 0.85-1.50). Older adults in the CGA intervention group also had fewer falls (12 versus 21 percent) and more medications discontinued compared with usual care.

●Similarly, in a single-center randomized trial of a multidisciplinary geriatric assessment-driven intervention (GAIN) versus standard care, adults age >65 years with a solid malignancy starting a new chemotherapy regimen underwent a CGA prior to chemotherapy initiation [23]. In the intervention arm, a multidisciplinary team including an oncologist, nurse practitioner, social worker, physical/occupational therapist, nutritionist, and pharmacist reviewed CGA results and recommended interventions and referrals, which were placed by the study nurse practitioner, who also informed the treating oncologist and patient. In the standard-care arm, treating oncologists received CGA results without input from the multidisciplinary team. Patients in the intervention arm had a lower incidence of grade >3 chemotherapy-related adverse events (50.5 percent) compared with the standard-of-care arm (60.6 percent). There was also higher completion of advance directives in the intervention arm. There were no differences in overall survival, emergency department visits, unplanned hospitalizations or readmissions, or chemotherapy dose modifications or discontinuations.

●In a pragmatic trial of integrated oncogeriatric care (geriatric assessment with longitudinal geriatrician consultation) compared with usual care (INTEGERATE), adults age >70 with solid cancer or diffuse large B-cell lymphoma starting chemotherapy, immunotherapy, or targeted therapy in the intervention arm reported better quality of life scores over 24 weeks, fewer unplanned hospitalizations, and fewer emergency room presentations [130]. There were no differences in overall survival.

However, some data are conflicting. For example, a Canadian randomized trial in 350 patients in older adults with cancer found that use of geriatric assessment and management resulted in similar patient-reported quality of life, functional status, severe toxicities, satisfaction, cancer treatment plan modification, and overall survival as usual oncologic care [131]. However, in this trial, geriatric assessment was frequently conducted on or after treatment initiation so geriatric assessment results were not incorporated into treatment selection. In addition, the COVID-19 pandemic may have affected the quality of life outcome and intervention delivery.

SUMMARY AND RECOMMENDATIONS

●Cancer is an important and disproportionate cause of morbidity and mortality in the geriatric population. A comprehensive geriatric assessment (CGA) can help achieve the required balance between the potential benefits and side effects of therapy. (See "Comprehensive geriatric assessment".)

●The key domains that are included in the CGA are the functional status, comorbidity, cognition, nutrition, psychological state, social support, and medication review. Various approaches to gathering this information have been used including a mailed or self-administered assessment. (See 'Domains of a CGA' above.)

●For oncology patients age ≥65 years, we incorporate a CGA. Randomized trials have shown that CGA-driven interventions can improve patient and caregiver satisfaction with communication about aging-related concerns and satisfaction with overall care, reduce chemotherapy toxicity, reduce falls during cancer treatment, increase advance directive completion, and for patients with colorectal cancer, improve completion of scheduled chemotherapy. (See 'Who needs a CGA?' above.)

●We utilize a CGA that is primarily self-administered [45]. This assessment is a compilation of well-validated instruments that evaluate functional status, comorbidity, cognition, nutritional status, psychological state, social support, and medication use (table 9). Three of the instruments are performed by the healthcare provider: the Blessed Orientation-Memory-Concentration Test (a measure of cognition), Timed Up and Go (a performance-based measure of functional status), and Karnofsky performance status (table 4). The remainder of the assessment is self-administered by the patient. (See 'Self-administered CGA' above.)

●The information from a geriatric assessment can be used to anticipate and manage toxicity from treatment, predict survival, uncover unexpected health problems, improve mental health and wellbeing, and improve pain control. (See 'Potential benefits' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Arti Hurria, MD, now deceased, who contributed to an earlier version of this topic review.