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Slide1
Screening, Geriatric Assessment and Interventions
Pierre Soubeyran and Siri Rostoft
Slide2Disclosure
Research Support/P.I.
Roche, TEVA
Employee
No relevant conflicts of interest to declare
ConsultantNo relevant conflicts of interest to declareMajor StockholderNo relevant conflicts of interest to declareSpeakers BureauNo relevant conflicts of interest to declareHonorariaSPECTRUM, Pierre FabreScientific Advisory BoardTEVA, CELGENE
Slide3Disclosure
No conflicts of interest to declare
Slide4Mrs
A, aged 94Admitted to the acute geriatric ward because of fatigue and dizziness
Work up revealed severe iron-deficiency anemia (she was bleeding)
Colonoscopy revealed right sided large colon cancer, narrow passage
Surgery?
Slide5Decrease in capacity - heterogeneity
Muravchik, Anesthesia 5th
ed
, 2000
Slide6What factors to consider?
Discuss for 2-3 minutes with the person next to you
Slide7Screening
tools
Relevance for the management
of cancer patients
Pierre Soubeyran, MD,
PhDInstitut Bergonié, Université Bordeaux
Slide8What
is the final goal ?
Better
treat
patientsEnsure tumor control, as much as possibleLimit the risk of adverse events which may lead to dependencies or even deathMaintain quality of lifePatient is still leaving at homeStill autonomous with no sequellaeCancer is controlled (cured ?)
Slide9Available data for screening
Standard evaluation
Performance
status
At
baselineA few months beforeOrgan functionCreatinine clearanceLiver tests…Nutritional statusWeight, albumin…Geriatric assessmentDesigned for the oldestTo be implemented in oncology9
Slide10How
many Risk Groups ?
Heterogeneous
population
Three
groups (or even more) FitIntermediateFrail
Slide11How to design screening
tools ?
Various
solutions
Identify
a specific vulnerable profile Vulnerable geriatric profile Questionnaires, Fried criteriaNon feasibility of a specific treatmentOr Identify predictors of unacceptable events Early death, functional decline, toxicity
Slide12Oncologists
’ approach
Feasibility
of
chemotherapy
>70 and at least one factorPoor performance status (WHO 3-4)Cardiac contra-indication to doxorubicinLow creatinine clearance (<50 ml/mn)Neutropenia or thrombocytopeniaSevere comorbiditiesSoubeyran P, J Ger Oncol 2011;2:36-44
Slide13Another
approach
Predictors
of
unacceptable
eventsEvents which would have changed your initial decision, would you have known it may occur later…Early deathFunctional declineHospitalization for toxicity
Slide14P
Soubeyran, J Clin Oncol 2012; 30: 1829-34
MNA and TGUG
add
to
Stage and Sex for prediction of early deathAnother approachPredictors of early death
Slide15S Hoppe, J Clin
Oncol 2013; 31: 3877-82IADL and GDS15 are the
only
predictors
of early functional declineAnother approachPredictors of functional decline
Slide1616
Arti Hurria,
J Clin
Oncol
2011;29:3457-65
Martine Extermann, Cancer 2012;118:3377-86IADL, MMS, MNA and MAX2orIADL and physical activitiespredict severe toxicityAnother approachPredictors of toxicity
Slide1717
Thrombocytopenia and Malnutrition
predict
severe
toxicityOR95% CIP-valueMNA <244.1941.7 - 10.30.0018Platelets3.7631.3 - 10.80.0140Treatment strategy 0.5090.26 - 0.990.0465T Warkus, Proc SIOG 2011Another approachPredictors of hospitalization for toxicity
Slide18Too
many patients
to
evaluate
Need
for Screening toolsCGA is time-consumingMost CGA tools are useful
Slide19G8 questionnaire
Eight
questions
Performed
by a nurse
5 to 10 minAppetite, weight loss, BMIMobilityMood and cognitionNumber of medicationsSelf-related healthAgeAbnormal if ≤14Preliminary analysisSe: 89.6% ; Sp: 60.4%Carine Bellera, Ann Oncol 2012;23:2066-72
Slide20The ONCODAGE
study
20
Setting:
Patients >70
with cancerImpaired MGA if ≥ one abnormal questionnaireCIRS-G : at least one grade 3ADL : score ≤ 5IADL : score ≤ 7Timed Get up and Go : > 20 sMNA : score ≤ 23,5MMSE : score ≤ 23GDS-15 : score 6Gold standard: Impaired Multidimensional Geriatric Assessment (MGA)Pierre Soubeyran, Proc ASCO 2011
Slide21What
does G8
detect
?
Detection
ofAbnormal MNA 94,4%Abnormal ADL 93,6%Abnormal TGUG 91,3%Abnormal GDS15 84,8%Abnormal IADL 84,5%Abnormal MMS 80,5%CIRS-G grade 3 – 4 77,4%
Slide22What
does G8
detect
?
False
negative characteristics53,1% with only one abnormal quest. median : 118,4% for true positives median : 3136 patients with grade 3-4 comorbiditiesVascular 49,3% Cardiac 15,4% Respiratory 14% Metabolic 11,8%
Slide23Confirmation
Kenis
C et al. J Clin
Oncol
2014, 32: 19-26
937 patientsAt least two abnormal tests among:Live alone, ADL, IADL, MMS, GDS15, MNA, CCI
Slide24Confirmation
Kenis
C et al. J Clin
Oncol
2013 In
Press
Slide25What
to do when the screening tool
is
positive ?
Slide2626
Consultation
Screening G8
Pretreatment
work-upGeriatric evaluationGeriatric synthesisTreatment feasibilityAdaptation of non specific treatmentAdverse events to avoidMultidisciplinary Oncology meetingTreatment planAfter Screening
Slide27Geriatric
assessment
(GA)
1
Functional status
ComorbidityPolypharmacyCognitive function/ dementiaNutritional statusDepressionSocial supportRemaining life expectancyDetection of unidentified problemsOptimization before treatmentPrediction of adverse outcomesTreatment planningBaseline informationShared decision-makingFRAILTY1Wildiers et al, JCO, 2014
Slide28Slide29Studies
included in review
CGA and ability to detect health problems: n=29
CGA and prediction of outcomes: n=17
CGA and tailored interventions: n=3
Slide30Results
All CGA types identified - large numbers of geriatric problems
- multiple comorbidities likely to interfere with
cancer treatment and to compete with cancer as a
cause of death
Some CGA domains may influence treatment decisionsfunctional status and nutritional status may have the strongest effect
Slide31Results cont.
Each CGA domain was associated with chemotoxicity and survival in at least one study
The domains most often predicting mortality and
chemotoxicity
:
functional impairmentmalnutritioncomorbidities
Slide32Slide33Methods and results
10 studies included in the reviewChange in oncologic treatment:
the initial treatment plan modified in
39% of patients
after geriatric evaluation
two thirds resulted in less intensive treatmentImplementation of non-oncologic interventionsinterventions were suggested for more than 70% of patientsmost frequently social interventions and pharmacological interventions
Slide34Conclusion
A geriatric evaluation has significant impact on oncologic and non-oncologic treatment decisions in older cancer patients
Slide35Journal of Surgical Research 193 (2015) 265-272
Slide36Results
Elective surgery only10 publications from 6 studiesGA domains predicting overall and major complications
dependency in ADLs and IADLs (functional status)
higher ASA score
decreased mini-mental state examination score
worse geriatric depression scoreworse frailty scoresfatigueJournal of Surgical Research 193 (2015) 265-272
Slide37Results cont.
Age was not an independent predictor of morbidity in any studiesNo GA domains predicted postoperative mortality (low mortality rates in elective surgery)Frailty predicted readmissionsFunctional status and frailty predicted discharge to a nursing home
Journal of Surgical Research 193 (2015) 265-272
Slide38Categorization
Slide39Geriatric assessment
Overall assessmentMultidisciplinaryAreas where older patients often have problemsCGA – assessment with interventions
Implementing GA in older hospitalized adults increases likelihood of being alive and living in their own home
1
1
Ellis Cochrane Rev 2011
Slide40GA in oncology
Delphi study1: All cancer patients > 70 years
Younger with age-related issues
Most important domains:
Functional status
ComorbiditiesCognitive function1O´Donovan et al 2015
Slide41Mrs
A – Geriatric Assessment
Functional status: Dependence in IADL. Needed help shopping. Problems walking, uses a cane. TUG > 20 sec
Comorbidity: Heart failure – but is the diagnosis correct? She can walk one flight of stairs without being out of breath. Stroke in 2008, no apparent
sequela
. Reduced vision and reduced hearing.Polypharmacy: beta blocker and diuretics
Slide42Nutritional status: No appetite last month (due to
tumour), weight loss, at risk of malnutrition
Cognitive function: MMSE 27/30, she appeared adequate in conversation, she could discuss treatment options
Emotional status: No symptoms of depression
Slide43Recommendation
She had some frailty indicators, risk of post-operative complications highComplications from tumour
at present
(anemia, weight loss)
Risk in emergency surgery much higher than elective surgery
Operated electively, had some complications, survived, discharged home
Slide44A FEW WORDS ABOUT FUNCTIONAL STATUS
Slide45“
She Was Probably Able to Ambulate, but I’m Not Sure”
Failure to assess functional status in hospitalized patients is the norm
Basic: ADL-function, mobility, and cognition
1/3 of patients 70+ encounter hospitalization-associated disability (even when acute illness is effectively treated)
Covinsky JAMA 2011
Slide46How to
measure functional status
ADL
= a
ctivities
of daily livingsurvive (eat, go to the toilet)IADL = instrumental ADLlive independently (manage money, shop, medication use)Performance measures: Gait speed, TUG (timed up and og test), grip strengthAsk about falls
Slide47Walter et al, JAMA,
2001
Slide48Stanaway, BMJ, 2011
Grim reaper´s maximum speed: 1.36 m/s
Slide49“HAVE YOU FALLEN?”
Jones et al, JAMA Surgery, 2013
Slide50COMORBIDITY
Slide51Why is comorbidity
relevant?
Discuss with the person next to you for a few minutes
How do you assess comorbidity in your clinical practice?
Slide52Barnett et al, Lancet 2012
Chronic disorders by age-group
Slide53Optimization
of comorbidities
Geriatrician?
Internal medicine specialist?
Subspecialist, i.e. cardiologist?
Core activity in the acute geriatric wardCompeting risks
Slide54Polypharmacy
Specific talk
Slide55Cognitive function
Mild cognitive impairmentDementia
Screening instruments, MMSE, MOCA, Mini-Cog
Why important?
Slide56Slide57Clock-drawing
test
Slide58Why important?
ConsentPrognosis
Treatment planning
Baseline -
chemobrain
Slide59NUTRITIONAL STATUS
Slide60Malnutrition
Differs between countries – in Norway malnutrition is the dominant problemHome dwelling: 6%, hospitals 40%, nursing homes 14%Tool: mini nutritional assessment (MNA)
Definite risk factor – but do interventions help?
How to intervene?
Slide61EMOTIONAL STATUS
Slide62Emotional function
Depression, anxiety and distressCommon among older peopleCommon among cancer patients
Risk factors are pain and physical distress
Fear of impeding mortality
Protective: Attachment security, self-esteem, sense of meaning and purpose
Treatment options?
Slide63Study (depression)
1Older cancer patients (>70) receiving chemotherapy (n=344)
45% depressed
Risk factor: malnutrition at baseline
1
Duc et al. Psychooncology, 2016
Slide64SOCIAL SUPPORT
Slide65Social support
Fundamental for treatment planningPopulation level – sociodemographic factors strong predictors for receiving treatment and survival
Slide66GA COMPLETED – WHAT NOW?
Slide67Geriatric assessment (GA)
1
Remaining life expectancy
Detection of unidentified problems
Optimization before treatment
Prediction of adverse outcomesTreatment planningBaseline informationShared decision-making1Wildiers et al, JCO, 2014
Slide68SUMMARY
The heterogeneity increases with increasing ageWe need to assess frailty rather than looking at chronological age alone when deciding treatmentGeriatric assessment provides a practical approach to older patients
GA is necessary in many older cancer patients for a number of reasons
Slide69THANK YOU FOR YOUR ATTENTION
QUESTIONS?