Gobind Tarchand is a Physician Assistant, and Mark Klein is a Medical Oncologist, both in the Hematology-Oncology Section, Primary Care Service Line at the Minneapolis VA Health Care System in Minnesota. Vicki Morrison is Professor of Medicine in Medical Oncology and Infectious Diseases, and Mark Klein is Associate Professor of Medicine, both in the Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota in Minneapolis. Elyse Watkins is Associate Professor for the Lynchburg DMSc program at the University of Lynchburg in Virginia. Vicki Morrison is a Geriatric Oncologist in the Division of Hematology/Oncology, Department of Medicine at Hennepin County Medical Center in Minneapolis, Minnesota. Correspondence: Gobind Tarchand (gobind.tarchand@va.gov)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
A cancer diagnosis has a major impact on the mental and emotional state of patients and family members. Clinically significant anxiety has been reported in approximately 21% of older patients with cancer, and the incidence of depression ranges from 17 to 26%.22 In older patients with, psychologic distress can impact cancer treatment, resulting in less definitive therapy and poorer outcomes.23 All patients with cancer should be screened for psychologic distress using standardized methods, such as the Geriatric Depression Scale or the General Anxiety Disorder-7 scale.24 A positive screen should lead to additional assessments that evaluate the severity of depression and other comorbid psychological problems and medical conditions.
Social isolation and loneliness are factors that can affect both depression and anxiety. Older patients with cancer are at risk for decreased social activities and are already challenged with issues related to home care, comorbidities, functional status, and caregiver support.23 Therefore, it is important to assess the social interactions of an older and/or frail patient with cancer and use social work assistance to address needs for supportive services.
Nutrition
Nutrition is important in any patient with cancer undergoing chemotherapy treatment. However, it is of greater importance in older adults, as malnutrition and weight loss are negative prognostic factors that correlate with poor tolerance to chemotherapy treatment, decline in quality of life, and increased mortality.25 The Mini-Nutritional Assessment is a widely used validated tool to assess nutritional status and risk of malnutrition.11 This tool can help identify those older and/or frail patients with cancer with impaired nutritional status and aid in instituting corrective measures to treat or prevent malnutrition.
Effectiveness of CGA
Multiple randomized controlled clinical trials assessing the effectiveness of CGA have been conducted over the past 3 decades with overall positive outcomes related to its value.26 Benefits of CGA can include overall improved medical care, avoidance of hospitalization or nursing home placement, identification of cognitive impairment, and prevention of geriatric syndrome (a range of conditions representing multiple organ impairment in older adults).27
In oncology, CGA is particularly beneficial, as it can identify issues in nearly 70% of patients that may not be apparent through traditional oncology assessment.28 A systematic review of 36 studies assessing the prognostic value of CGA in elderly patients with cancer receiving chemotherapy concluded that impaired performance and functional status as well as a frail and vulnerable profile are important predictors of severe chemotherapy-related toxicity and are associated with a higher risk of mortality.29 Therefore, CGA should be an integral part of the evaluation of older and/or frail patients with cancer prior to chemotherapy consideration.
Several screening tools have been developed using information from CGA to assess the risk of severe toxicities. The most commonly used tools for predicting toxicity include the Cancer and Aging Research Group (CARG) chemotoxicity calculator and the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH).30,31 Although these tools are readily available to facilitate CGA, and despite their proven beneficial outcome and recommended usage by national guidelines, implementation of these tools in routine oncology practice has been challenging and slow to spread. Unless these recommended interventions are effectively implemented, the benefits of CGA cannot be realized. With the expected surge in the number of older patients with cancer, hopefully this will change.
