Should your patient have that oncology intervention? - #36Take Quiz
Diagnostic testing and treatment are determined based on ability to improve disease process or quality of life/goals of care.
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.
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).
|Age ≥72 years||2|
|Cancer type GI or GU||2|
|Standard dose chemotherapy||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.
Elderly patient with oncologic disease considering treatment intervention.
Determine appropriateness of oncologic intervention in the geriatric oncology patient through assessment of their overall physical health, cognition, function and social situation.
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.
• 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.
Review of Systems (ROS)
- 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.
- Bowie MW, Slattum PW. Pharmacodynamics in older adults: a review. Am J Geriatr Pharmacother. 2007; 5(3):263-303.
- 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.
- 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.
- Karnofsky performance status scale definitions rating (5) criteria.http://www.hospicepatients.org/karnofsky.html
- ePrognosis: Estimating prognosis for elders. http://eprognosis.org
- Barthel index of activities of daily living. http://www.healthcare.uiowa.edu/igec/tools/function/barthelADLs.pdf
- The Lawton instrumental activities of daily living (IADL) scale. http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf
- Eastern Cooperative Oncology Group. http://ecog.dfci.harvard.edu/general/perf_stat.html
- Montreal Cognitive Assessment. http://mocatest.org
- The Mini-Cog test. http://geriatrics.uthscsa.edu/tools/MINICog.pdf
Users are free to download and distribute Geriatric Fast Facts for Informational, educational, and research purposes only. Citation: Gabriel Manzi MD, Nicholas Dreger, Kathryn Denson MD, Patrick Foy MD, Thomas Giever MD, Fast Facts and Concepts #36 Should your patient have that oncology intervention?
Disclaimer: Geriatric Fast Facts are for informational, educational and research purposes only. Geriatric Fast Facts are not, nor are they intended to be, medical advice. Health care providers should exercise their own independent clinical judgment when diagnosing and treating patients. Some Geriatric Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.