NcXHF

KLEPIN, RODIN, AND HURRIA
plan was prescribed in almost 40% of patients, with less intensive
treatment accounting for two-thirds of these plans. 61
In one French study, GA followed tumor board deliberation
for the initial treatment of 191 patients older than 70. There
was a slight tendency to decrease the intensity of treatment
after reviewing the GA fındings, but it is not clear from this
report how the geriatric consultation was integrated into the
fınal treatment plan. 62 A second French study introduced inpatient
GA for hospitalized older adults with cancer. 63 Of 107
patients, the geriatric consultant agreed with the oncology
treatment plan 68% of the time. When there was disagreement,
approximately half of the time the oncology team ignored
the geriatrics recommendations, whereas, the other
half of the time the oncology team stepped down the treatment
or changed to palliative care in concordance with
geriatrics recommendations. Interestingly, a recent metaanalysis
of the effect of inpatient geriatric consultation in a
general hospital population concluded that the main benefıt
was to be seen in decreased mortality 6 to 8 months after discharge,
not necessarily during the index admission. 64 In
other words, it seems that geriatric inpatient consultation can
help oncologists identify and plan care for the frailest and
sickest patients on the one hand, and help with postacute care
and planning as they do with any other hospitalized older
adult.
In the outpatient setting, where most cancer treatment is
delivered, GA has followed oncology assessment in two recently
published reports. One clinic planned to refer all patients
with gastrointestinal and lung cancer older than age 70
to the geriatrician for a GA. However, the actual referral rate
was only 29%, and only 25% actually completed the appointment.
The GA information affected only those patients for
whom the oncologist had not decided what to do. 65 We see a
different result in a report of geriatric consultation in an outpatient
oncology setting in which patients were already receiving
their fırst-line therapy. 66 Of 161 patients older than
age 70, 49% had their treatment changed based on the geriatricians’
assessment of ADLs, cognitive function, depression,
and malnutrition: 34 had less intense treatment and 45 had
more intensive treatment after consultation.
Why
Geriatricians anticipate, diagnose, and manage syndromes
that do not necessarily involve only one organ, for which
there is no diagnostic test, and for which there is ample evidence
of increased morbidity, mortality, and disablement.
Older patients who have these syndromes, whether at home
or in the hospital, may end their lives in nursing homes or
suffer other preventable losses in dignity and quality of life.
Current evidence supports the value of geriatric medicine
consultation for at least some older adults with cancer. Consultation
should be sought when validated screening tools indicate
a problem with performing daily activities required for
self-care (ADLs) and maintaining a household independently
(IADLs). Consultation should be considered for older
adults with polypharmacy, particularly in the setting of multimorbidity,
frequent falls, and any change in mental status
that could indicate delirium or depression. Before treatment,
older adults can be assessed for decisional capacity formally
or informally. A rapid gait screening should be performed
initially for risk stratifıcation and, subsequently, to monitor
risk for falls.
The timing of consultation remains in the hands of the primary
oncology team. When oncologists have hesitation to
treat and geriatric consultation is easily available, cancer
treatment plans may be adjusted, more often toward less aggressive
treatment. Hospital-based geriatric consultation can
also be benefıcial. The assessment of functional status, cognitive
status, decisional capacity, physical performance, and
emotional well-being should be considered vital signs to be
followed throughout cancer treatment. Involving a geriatrician
can help lessen the demands on the oncology team and
potentially improve treatment outcomes.
THE EVIDENCE GAP BETWEEN RISK ASSESSMENT
AND MANAGEMENT
Although there is increasing evidence that vulnerability to
treatment toxicity can be predicted for older adults receiving
chemotherapy, 17,20,27 there remains an evidence gap between
identifıcation of vulnerability and knowledge of how to best
manage vulnerable older adults. Unfortunately, most randomized
clinical trials are not yet incorporating measurement
of vulnerability or frailty to inform which treatment
modifıcations, if any, would optimize outcomes for a given
older adult. The remaining sections of this chapter will highlight
issues related to chemotherapy dosing and toxicity assessments
among older patients in practice.
DOSE MODIFICATION FOR OLDER ADULTS
RECEIVING CHEMOTHERAPY
Most published models to predict chemotherapy toxicity
among older adults have shown that the risk of grade 3 to
grade 5 toxicity for older adults is approximately 50%, 20 with
vulnerable and frailer patients likely exceeding these estimates.
When considering a treatment decision, the balance
between the risk of treatment and its potential benefıts often
poses a major challenge. Treatment characteristics that have
been shown to influence toxicity risk include use of standarddose
chemotherapy and polychemotherapy. 20 Therefore,
dose modifıcation is often considered to minimize the negative
consequences of therapy on symptoms and quality of life.
Because of a scarcity of clinical trial data there remain more
questions than answers regarding the benefıts and risks of
dose modifıcation strategies, particularly in the setting of
fırst-line treatment for advanced cancer.
DOSE MODIFICATION IS COMMON AMONG OLDER
PATIENTS WITH CANCER
Available evidence suggests that dose modifıcation is common
among older adults treated for cancer. Data from com-
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