Should your patient have that oncology intervention?

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Should your patient have that oncology intervention? - #36

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Diagnostic testing and treatment are determined based on ability to improve disease process or quality of life/goals of care.

Assessment

General Geriatric Principles

  • Due to physiologic changes with aging:
    • Many diseases present atypically.
    • Interventions (medical and surgical) may have unintended consequences/effects.
    • Pharmacologic interventions should be adjusted based on renal function, body composition, and side effect profile.
  • Medical problems are frequently multifactorial (physical, cognitive, functional, and social), thus diagnosis/management is best approached through a multifaceted plan of care.
  • Diagnostic testing and treatment are determined based on ability to improve disease process or quality of life/goals of care.

Patient Assessment
1. Gather in-depth information regarding physical, cognitive, and social issues.
2. Evaluate functional status by screening:

  • Activities of Daily Living – Barthel Scale (ADL)
  • Instrumental Activities of daily Living – Lawton Scale (IADL)

3. If there is evidence of cognitive deficits, evaluate cognitive status using screening tools:

  • Mini-Cognitive assessment tool (Mini-cog)
  • Montreal Cognitive Assessment (MoCA)

4. Generate approximate prognosis of life expectancy.

  • In patients with a single primary disease process, prognosis can be estimated with a disease-specific instrument.

  • When multiple diseases alter the patient’s health status, prognosis can be estimated by considering general health (number and severity of co-morbidities), age, cognition, nutritional status, social situation and functional status (eprognosis calculators (Geriatric specific, evidence base prognostic tools)

5. Identify patient goals of care

  • In non-curative disease, treatment is aimed at palliating symptoms and extending disease-related life expectancy.
  • All chemotherapy and targeted therapy regimens have potential side effects which must be taken into consideration in determining whether therapy meets the patient’s care goals.
  • Validated models help predict likelihood of significant toxicities including: Chemotherapy Risk Assessment Scale for High-Age Patients score (CRASH)

(Adapted from Hurria,et al).

Risk Factor Score
Age ≥72 years 2
Cancer type GI or GU 2
Standard dose chemotherapy 2
Polychemotherapy 2
Hemoglobin <11 g/dL (male) or <10 g/dL (female) 3
Creatinine clearance <34 mL/min 3
Hearing, fair or worse 2
≥1 falls in prior 6 mos 3
IADL: taking medications with some help or unable 1
Somewhat limited/limited a lot in walking 1 block 2
Decreased social activity due to physical/emotional health at times 1

Score predicts low (0-5), intermediate (6-9), or high (10-19) risk of Grade 3-5 chemotherapy toxicities.

Context

Elderly patient with oncologic disease considering treatment intervention.

Action

Determine appropriateness of oncologic intervention in the geriatric oncology patient through assessment of their overall physical health, cognition, function and social situation.

Incidence / Prevalence

The NCI SEER Database reports that from 2006-2010, approximately 53% of cancers were diagnosed in patients > 65 years of age, with the median age at diagnosis of 66 years.

Underlying Sciences

The pathophysiology of cancer is complex. Cancer is deregulated cell growth and invasion resulting from genetic alterations that may be inherited or acquired with age. A multistep process of mutations (5-10 estimated mutations) is required for progression from a single mutated cell to metastasis. The most common cancers in the elderly include those arising from the lung, prostate, breast, and colon. Symptoms from malignancy can be related to the primary tumor, metastatic lesions, or paraneoplastic syndromes. Therapy for cancer can range from traditional cytotoxic chemotherapy to supportive care alone. Response rates and survival estimates vary depending upon disease, stage, performance status, and treatment regimen.

Science Principles

Impaired homeostasis

Objectives

• List geriatric assessment tools to help identify patients who may benefit from oncologic intervention.
• Identify factors that may increase morbidity and mortality in older adults with oncologic disease.
• Formulate an appropriate prognosis of life expectancy.

Keywords/Tags

References

  1. Howlader N, Noone AM, Krapcho M, et al (eds.) SEER cancer statistics review, 1975- 2010, National Cancer Institute. Bethesda, MD. Based on November 2012 SEER data submission, posted to the SEER web site 2013.
  2. Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother. 2007; 5(3):263-303.
  3. Walter LC, Lewis CL, Barton MB. Screening for colorectal, breast, and cervical cancer in the elderly: a review of the evidence. Am J Med. 2005; 118(10):1078-86.
  4. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol. 2011; 29:3457-3465.
  5. Karnofsky performance status scale definitions rating (5) criteria.http://www.hospicepatients.org/karnofsky.html
  6. ePrognosis: Estimating prognosis for elders. http://eprognosis.org
  7. Barthel index of activities of daily living. http://www.healthcare.uiowa.edu/igec/tools/function/barthelADLs.pdf
  8. The Lawton instrumental activities of daily living (IADL) scale. http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf
  9. Eastern Cooperative Oncology Group. http://ecog.dfci.harvard.edu/general/perf_stat.html
  10. Montreal Cognitive Assessment. http://mocatest.org
  11. The Mini-Cog test. http://geriatrics.uthscsa.edu/tools/MINICog.pdf
This GFF ___ my competence in geriatrics.

Authors

Gabriel Manzi MD,Thomas Giever MD, Nicholas Dreger, Kathryn Denson MD, Patrick Foy MD

Author Affiliation

Medical College of Wisconsin

Copyright

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