Integration of geriatric assessment into clinical oncology practice: A scoping review

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Abstract

Sixty percent of newly diagnosed cancers occur in older adults and more complex planning is required to sustain quality care for older populations. Individualized care incorporating geriatric assessment can predict early mortality and treatment toxicity for older cancer patients. We mapped and summarized the available evidence on the integration of geriatric assessment into clinical oncology practice, and ascertained which domains have been implemented. We systematically searched bibliographic databases and trial registries for reports of clinical studies, clinical practice guidelines, systematic and non-systematic reviews, and grey literature published in English. We gathered data on study characteristics, geriatric domains and strategies evaluated, and relevant study objectives and findings. From a total of 10,124 identified citations, 38 articles met our eligibility criteria, 3 of which were clinical practice guidelines. Nearly half of these articles came from the United States. Domains of the geriatric assessment implemented in studies ranged from 1 to 12, with varied combinations. We identified 27 studies on strategies for implementing geriatric assessment and 24 studies on feasibility of implementing geriatric assessment, into clinical oncology practice. We also identified 3 main geriatric assessment models: 2 from the United States and 1 from Australia. Furthermore, we identified 2 reviews that reported varied components of geriatric assessment models. There is increasingly robust evidence to implement formal geriatric assessment in oncology practice. There remains a great deal of variation in the tools recommended to address each of the domains in a geriatric assessment, with only 1 guideline (American Society of Clinical Oncology guideline) settling on a specific best practice.

Protocol registration: Open Science Framework osf.io/mec93.

Introduction

The population of older adults (≥65 years) worldwide has been increasing due to increasing life expectancy. Older age is a leading risk factor for the development of many cancers.1 Adults ≥65 years old account for around 60% of newly diagnosed cancer patients, and cancer incidence in this population is up to 10 times greater compared with younger populations.2,3

Aging introduces changes in health, function, cognition, emotional and social status; it influences the treatment of cancer due to decreased life expectancy, variable tolerance to treatment, changing patient values, and potential inability to obtain treatment due to social barriers.4 Needs become more complex with advancing age, and a more comprehensive approach to care can improve quality of life and reduce the risk of hospitalization.5, 6, 7 It is therefore essential to integrate geriatric principles into oncology, including the importance of geriatric syndromes, incorporation of functional assessment, recognition of multiple chronic conditions, addressing social determinants of health, and integration of palliative care across the care continuum.8 The response to this need has been the advent of the field of geriatric oncology.

Through a variety of cohort studies and randomized trials, evidence has accumulated that geriatric assessment in older adults with cancer receiving chemotherapy predicts prognosis and treatment toxicity, while discovering issues that alter chemotherapy decisions in 25%-30% of patients.9,10 Comprehensive geriatric assessment (CGA) is the most commonly studied and most complete form of geriatric assessment. A CGA is “a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs (p. 149).”11 Implementation of CGA and geriatric principles, in oncology care would seem intuitive, but there are multiple challenges. Completing a CGA in clinical practice requires approximately 30-60 minutes per patient and requires expertise in both conduct and interpretation.12, 13, 14, 15 Most oncologists lack training in geriatrics and the increasing number of cancer patients has been straining existing oncologic resources. These factors have slowed integration of geriatric principles into oncologic care. However, interest in integrating these principles has been increasing.9,10,16,17 Due to this shifting dynamic, it is important to determine the existing evidence for implementing geriatric oncology principles in clinical practice.

We undertook a scoping review to identify and map the available evidence on strategies for integrating geriatric assessment into clinical oncology practice and ascertain which principles have been implemented in clinical oncology practice, while focusing on the main concepts and any gaps in knowledge.

Section snippets

Methods

We followed the Joanna Briggs Institute's methodological framework for the conduct of scoping reviews.18 This framework includes defining and aligning the objective(s) and question(s) for the review, developing and aligning the inclusion criteria with the review objective(s) and question(s), and describing the planned approach to evidence searching. It also includes selecting, extracting and charting of evidence, summarizing the evidence in relation to the objectives and questions, and

Results

Out of 10,124 citations identified from the search results, 38 articles met our inclusion criteria (Fig 1). These articles were for 26 clinical studies,12,13,15,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44 8 reviews,14,45, 46, 47, 48, 49, 50, 51 1 retrospective data analysis,52 and 3 clinical practice guidelines.9,10,16 Seventeen of these studies were conducted in the United States of America (USA),10,12,13,15,24,27,30,33,35,36,39,43, 44, 45, 46, 47,

Discussion

Our scoping review reveals a reasonable literature base for planning strategies and models for implementation of geriatric assessment. The most common manifestation of geriatric assessment in the literature is the CGA, which is the cornerstone intervention in geriatrics and serves to both evaluate and guide interventions for older adults. In older adults with cancer, results of a CGA correlate with finding issues not identified during routine oncologic assessment, survival, likelihood of

Conclusions

Based on the focus of the existing literature, there is increasingly robust evidence to implement formal geriatric assessment in oncology practice. There remains a great deal of variation in the tools recommended to address each of the domains in a geriatric assessment, with the ASCO Guideline providing a good starting point for programs planning to implement geriatric oncology services.

Disclosures

This review was funded through the Underserved Populations Program at CancerCare Manitoba, partially funded by the CancerCare Manitoba Foundation, also partially funded by a grant from the Manitoba Medical Services Foundation. G.N.O is a recipient of the Centre on Aging Betty Havens Memorial Graduate Fellowship Award for health services research. D.E.D has received a research grant from AstraZeneca.

Sponsor's role

The sponsor had no role in the design, methods, data collection, analysis and preparation of this manuscript.

Declaration of Competing Interest

D.E.D has received advisory board honoraria from Merck and AstraZeneca, and educational content honoraria from Boehringer-Ingelheim. T.H has received advisory board honoraria from Ipsen, Apobiologix and Celgene. The other authors declare that they have no competing interests. The primary and corresponding authors had full access to data presented in this study and all the authors had final responsibility for the decision to submit a manuscript for publication.

Authors contributions

Conceptualisation (M.S. and D.E.D.), Study design (G.N.O., M.S., A.M.A.S. and D.E.D.), Protocol development (G.N.O., M.S., A.M.A.S. and D.E.D.), Data acquisition (G.N.O., F.R., O.L.T.L., V.K.R., and L.C.), Data analysis (G.N.O. and D.E.D.), Data interpretation (G.N.O., T.H., A.M.A., D.E.D.), Draft manuscript (G.N.O. and D.E.D.), Final manuscript (G.N.O., M.S., F.R., O.L.T.L., V.K.R., L.C., T.H., A.M.A.S., D.E.D.).

Funding

Received through the Underserved Populations Program at CancerCare Manitoba, partially funded by the CancerCare Manitoba Foundation, also partially funded by a grant from the Manitoba Medical Services Foundation.

Acknowledgments

We thank Tamara Rader, MLIS for the design and execution of the literature search strategy. D.E.D would like to acknowledge the Manitoba Medical Services Foundation, which awarded him a salary award to protect some of his time for research.

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