An oncologist walking into a room in a busy clinic might find an older patient already on the exam table, for instance, and miss the fact that he needed assistance getting out of a chair and getting into a gown – important signs of functional impairment that could be aggravated by chemotherapy, Dr. Hurria said. Or, “a very pleasant older patient might smile kindly at you and agree with everything you’re saying, and she might not have understood a thing you said” because of undetected cognitive impairment that could worsen and interfere with treatment, she explained.
William Dale, MD, a geriatrician and Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope and another cochair of the guideline panel, tells of an 83-year-old woman whom he saw several years ago, with lung cancer metastasized to her brain. Her family requested a consultation because she’d become withdrawn and forgetful – a sign of accelerating cognitive impairment, they suspected.
Should she have chemotherapy and whole brain radiation, or would that worsen her memory lapses, the patient and family wondered?
One result stood out when Dale ordered a geriatric assessment: This older woman wasn’t cognitively impaired, she was psychologically distressed. “She wasn’t eating, she wasn’t interacting with other people, she appeared not to want treatment, but all this was due to depression,” Dr. Dale recalled. With counseling, the patient decided to undergo chemotherapy and radiation treatment, which he called “remarkably successful.”
Just as genetic tests are being used to personalize care for older cancer patients, geriatric assessments can be employed for this purpose – at considerably less expense, said Supriya Gupta Mohile, MD, editor in chief of the Journal of Geriatric Oncology and director of geriatric oncology at the James Wilmot Cancer Institute at the University of Rochester (N.Y.).
She tells of a 78-year-old man with invasive bladder cancer who came in for a consultation. From the medical chart, she learned the patient had hypertension, diabetes, and depression, all reasonably well controlled. From a geriatric assessment, she discovered that he lived alone, had cognitive impairment, relied on his daughter to deliver meals, and was at high risk of falling.
“The patient and his daughter were worried about his safety at home, his cognition getting worse, and fatigue [he was dealing with] and how that might affect his ability to function,” Dr. Mohile said. “His goal was to stay independent, at home, and not be hospitalized or go to rehabilitation.”
The standard of care for this condition was 3-4 months of chemotherapy before surgery, but Dr. Mohile recommended that the older patient skip chemotherapy and have surgery immediately, after reviewing the geriatric assessment with her patient and his family.
Every older patient considering chemotherapy should request an evaluation of this kind, even if your physician doesn’t offer it, said Heidi D. Klepin, MD, associate professor of hematology and oncology at Wake Forest University, Winston-Salem, N.C. “Ask for your doctor to consider your ability to do the things you most care about doing and for care to be individualized to your unique circumstances.”
KHN’s coverage of these topics is supported by John A. Hartford Foundation, Gordon and Betty Moore Foundation, and The SCAN Foundation. Kaiser Health News is a nonprofit national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.