Strongest Evidence Backs Two Tools For Evaluating Older People With Cancer

A systematic review and meta-analysis has pinpointed the Geriatric-8 and VES-13 as assessment tools with the strongest evidence for use with older adults with cancer.

The study was undertaken as part of the University of Technology Sydney's work with the Clinical Oncology Society of Australia to develop online geriatric oncology guidelines for cancer care clinicians, said principal author Dr. Jane Phillips. A geriatric assessment is recommended for older people newly diagnosed or with recurrent cancer, she said, but "time and funding constraints and workforce issues have limited its uptake in Australia, as well as elsewhere."

"The clinician-administered Geriatric-8 is the most suitable tool at this time to use," she said. "However, in resource-poor settings, the patient-administered VES-13 is a potentially suitable alternative."

"Like all screening tools," she added, "there is always some trade-off between specificity and sensitivity and there may be benefits of combining these tools in clinical practice, but this requires further investigation."

As reported in JAMA Oncology, Dr. Phillips and colleagues conducted a systematic review of the literature from 2000 to 2019 for studies reporting on the diagnostic accuracy and use of validated screening tools to identify older adults with cancer who need a geriatric assessment.

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Seventeen studies reporting on 12 screening tools were included. Most (11) were prospective cohort studies; only one was a randomized clinical trial. The median sample size was 108 patients. Only five reported follow-up duration (30 days-12 months).

Ten studies included mixed cancer populations, five reported on hematological malignant neoplasms, one on head and neck cancer and one prostate cancer.

Older adults were defined as either 65 and older or 70 and older.

The Geriatric-8 (G8) (12 studies) and the Vulnerable Elders Survey-13 (VES-13; nine studies) were the most frequently evaluated screening tools.

The G8 scored better in sensitivity and the VES-13 in specificity.

Other screening tools evaluated in two studies each include the Groningen Frailty Index, abbreviated comprehensive geriatric assessment, and Physical Performance Test. All other screening tools were evaluated in a single study each.

The authors state, "Future research needs to further validate or improve current screening tools and explore other factors that can influence their use, such as ease of use and resourcing."

Dr. Marleen Meyers, Director of Survivorship at NYU Langone's Perlmutter Cancer Center in New York City, commented in an email to Reuters Health, "I very much agree with the importance of this paper but wonder about the practicalities. Historically, older patients tend to be undertreated and this may have led to poorer outcomes. On the other hand, as oncologists, we must be mindful of added risks in the geriatric population, including decreased organ function and lack of support."

"The Comprehensive Geriatric Assessment can uncover vulnerabilities related to age, estimate chemotherapy completion rate and identify patients with increased risk of chemotherapy toxicity," she said.

"My greatest concern is that the use of these tools is time- and workforce- dependent, both scarce commodities; without a clear decision as to the optimal screening tool and how the results directly affect treatment recommendations, I would not expect these tools to be used widely," she said.

"In addition," she noted, "these tools need to be updated frequently to reflect changing standards of care for each cancer type and need to be used not once as in the review, but throughout a patient's treatment."

Dr. Nicole Fowler of the Regenstrief Institute and Indiana University School of Medicine in Indianapolis also commented by email. "This is a significant article that points to the importance of and infrequent practice of conducting a geriatric assessment in the process of caring for older adults with cancer."

"Geriatric assessments are key to helping providers understand areas of vulnerability, predict survival, and facilitate shared treatment decision making in cancer care," said Dr. Fowler, who is also principal investigator of the US National Institute on Aging-funded DECAD (Decisions About Cancer Screening in Alzheimer's Disease). "This requires information about the 'big' picture for a patient, including more than just their age; it is an understanding of medical, psychosocial, and functional and cognitive problems in older patients with cancer, including goals of care and preferences for care." Family members can also be included, she noted.

One way to incorporate the assessment into routine cancer care, she suggested, "is through passive digital geriatric assessment that uses a patient's documented health history along with very brief patient-reported outcome prior to the start of treatment."

—Marilynn Larkin

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