In Toulouse University Hospital, a geriatric consultation team including a geriatrician experienced in oncology (with an university degree in geriatric oncology) and a geriatric nurse, can be requested by an oncologist, surgeon or radiation therapist, to provide a geriatric expertize in older patients with cancer in various hospital units (15). They perform a one-hour geriatric assessment at the patient’s bedside and give conclusions about geriatric impairment, subsequent interventions, and if needed they can provide guidance for cancer treatment decision. In complex clinical situations or treatment plans, a more complete geriatric evaluation may be advised so the oncogeriatric patients are referred to the Geriatric Frailty Clinic.
The geriatric frailty clinic (GFC) is a geriatric day hospital of the Gerontopole of Toulouse, France, dedicated to the prevention of disability in frail older patients. It also evaluates patients aged 65 years and older with solid or hematological cancer during a pre-therapeutic evaluation. Its organization and overall activity are well described elsewhere (16). Each patient undergoes a CGA performed by a multidisciplinary geriatric team (including a geriatrist or a general practitioner specifically trained in geriatrics, a nurse, a nurse-aid, an orthoptist (paramedical profession specialized in the eye care sector), and if needed a dietician, a neuropsychologist, and a physical activity teacher). In geriatric oncology patients, a geriatrician specialized in oncology is also consulted.
The first objective of the evaluation is to provide guidance concerning cancer treatment decision. The CGA is a recommended assessment able to: 1/ give helpful information concerning the existence of unidentified health-related problems and geriatric syndromes, 2/ help to estimate life-expectancy in the context of cancer, comorbidities and geriatric status, 3/ predict treatment-related complications and overall survival (5). At the end of the evaluation, during a multi-professional meeting, the geriatric team and the geriatrician specialized in oncology, propose to maintain or change the initial cancer treatment plan, according to the conclusions of the CGA. Changes in cancer treatment may be graded as follow: intensification of cancer treatment, decrease in treatment intensity or change from specific cancer treatment to supportive care. In case of change, the geriatric proposal is discussed with the referring practitioner, who will decide the final treatment. The decision-making process is described in Figure 1.
A second objective of the CGA is to propose therapeutic and non-therapeutic interventions to optimize the patient’s health status before the cancer treatment.
In this analysis, oncogeriatric patients evaluated between October 2011 and January 2016 were included. Ethics approval for this study was obtained from the local ethic committee in Toulouse University Hospital.
Comprehensive geriatric assessment
A CGA was performed for all consecutive patients. Social environment assessment included living conditions and marital status. A medical evaluation recorded the type and stage of cancer. Comorbidities were assessed according to the Charlson Comorbidity Index (17). Polypharmacy was defined as five or more prescribed medications (18). Functional abilities were assessed using Kat’z Activities of Daily Living (ADL) and Lawton’s Instrumental Activities of Daily Living (19,20). Frailty and physical function were measured respectively using Fried’s Criteria (8) and the Short Physical Performance Battery (SPPB) (21). Frailty criteria included 1) unintended weight loss, 2) self-reported exhaustion, 3) low hand-grip strength (as measured by a dynamometer and stratified by BMI and sex), 4) slow walking speed (4 meters usual walk speed stratified by height and sex) and 5) low physical activity. Patients were classified as frail if they met at least three criteria, pre-frail if they met one or two criteria, and robust if they met no criteria. The SPPB consists of three measurements: 1) standing balance test, 2) four meters walking speed and, 3) chair stand. Patients were categorized into three groups according to the SPPB score: high performance (score 10-12), medium performance (score 6-9), low performance (score 0-6). The G-8 geriatric screening tool, which is usually used to determine what patients would benefit from CGA, was also assessed (22). A cut-off less or equal to fourteen is usually admitted to identify vulnerable patients who need a CGA (22).
Cognition was evaluated using the Mini Mental State Evaluation (MMSE) (23). A MMSE score of 24 or less was used to identify cognitive impairment (24). The nutritional status was assessed by the Mini Nutritional Assessment (MNA) (25). A MNA score ≥ 24 indicates a good nutritional status, a score of 17-23.5 indicates a risk of malnutrition and a score less than seventeen indicates malnutrition. The Hearing Handicap Inventory for the Elderly-Screening (HHIE-S), a self-assessment scale, was used to assess hearing loss (26). An ophthalmologic evaluation was performed focusing on near vision (Parinaud chart), distance vision (Snellen chart) and detection of age-related macular degeneration (using Amsler grid). Visual impairment is defined using definitions detailed in a former work (27).
Statistical analysis
We performed a descriptive analysis of the patients, cancers, and treatments characteristics. We performed a bivariate analysis to compare the CGA characteristics of the patients according to the change in cancer treatment plan (change or no change). Chi-square test or Fisher exact test were used for qualitative variables, and Student’s t test (in case of normal distribution) or the Mann-Whitney non-parametric test were used for quantitative variables. A multivariate logistic regression, using backward selection, was performed to test the association between CGA components and change in treatment decision. The multivariate model was built using variables which were associated in the bivariate analysis with a p-value<0.20. Collinear variables were not entered in the final model. Interactions were tested according to clinical judgment. Statistical analyses were carried out using STATA version 11 (STATA Corp., TX USA).