Geriatric Assessments Help Guide Meaningful Cancer Treatment

Leana Cabrera Chien, MSN, RN, GCNS-BC, GNP-BC

Nurses are at the forefront of helping connect older patients to individualized care, according to Leana Cabrera Chien, MSN, RN, GCNS-BC, GNP-BC. As the American Society of Clinical Oncology has updated its supportive care guidelines to state that all patients over the age of 65 require a geriatric assessment prior to undergoing systemic therapy, Cabrera Chien asserts that nurses will play a crucial role in guiding them through the practical geriatric assessment (PGA) and ensure that these assessments take place.

“In my opinion, the ASCO recommendation for the PGA is really geared towards the oncology nurse,” Cabrera Chien, who is a nurse practitioner in the Center for Cancer and Aging at City of Hope, told Oncology Nursing News®. “Our older adults have many vulnerabilities such as nutritional and functional deficiencies, and the GA really provides an opportunity to assess geriatric problems that can be optimized or reversed.”

“The PGA largely can be done by patients outside of clinic,” William Dale, MD, PD, vice chair for academic affairs in the Department of Supportive Care Medicine at City of Hope, added. He is also the director of City of Hope’s Center for Cancer and Aging. “It is patient-reported [and] 80% to 85% of the PGA has the patient answering questions, so [it] should not have to disrupt flow.”

William Dale, MD, PD

The 2023 ASCO guideline update piggybacks off of the previous recommendations from 2018, this time with a heavier hand. Previously, the guidelines supported routine GA assessments; however, the new guidelines state that GA assessments are a crucial component of geriatric cancer and must always be conducted. This change largely follows the publications of 2 large randomized clinical trials, the GAP70+ trial (NCT02054741) and the GAIN trial (NCT02517034), which demonstrated that patients who received GA-guided individualized care experience less toxicity and better quality of life while receiving treatment.

Both Dale and Cabrera Chien served as investigators in the GAIN trial, which demonstrated that the rate of grade 3 or worse chemotherapy-related adverse events was 50.5% (95% CI, 45.6%-55.4%) following a GA assessment vs 60.6% (95% CI, 53.9%-67.3%) for patients who received standard-of-care treatment. Overall, the GA was associated with a 10.1% reduction in grade 3 toxicities (95% CI, –1.5 to –18.2%; P = .02) without compromising overall survival.

“In the big picture, the GA can improve outcomes,” Dale said. “[In the GAIN trial], chemotherapy toxicity went down, with no effect on survival. People are living just as long in the intervention arm, but their quality of life is much higher. Advanced directive completion was much higher; falls were lower; patient and family satisfaction were higher; and the use of excessive medications was lower. A whole bunch of outcomes were better for patients and [their] families.”

Implications for Practice

Both Dale and Cabrera Chien underscored that the PGA represents the most concise, easy-to-use tool, which was designed in accordance with nurse and patient feedback, and clinical trial experience. Because the tool is easy to use, Dale is optimistic about its application beyond the academic setting.

“We have evidence that it can be done in the community, and that is where the majority of patients with cancer are,” he said. “So, whether you're at a large, comprehensive cancer center, like we are at City of Hope, or you are at a community-based oncology center, you can apply this [tool].”

Cabrera Chien is also encouraged by the adaption of the PGA. To emphasize the importance of GA, she shared a clinical experience about a patient who benefited from GA intervention.

“The importance of the GA is how it is individualized with each patient,” she said, citing a patient who was so fatigued that on her initial telehealth visit, she did not get out of bed.

“We worked with her,” she said. “We completed her GA and provided supportive care interventions. She received interventions from our supportive care team, including our social worker, our pain management team, and our occupational therapists.”

Through occupational therapy, they were able to create a patient-centered care plan to help improve the patient’s activities of daily living, fatigue, and stress levels. Cabrera Chien stressed that it was important to the care team that the patient continue to engage in meaningful activities and find ways to increase her physical activity levels.

“This is an example of how the several interventions that the patient received was really profound because [by] our last visit she was not only out of her bedroom, [but] she sat in her chair with a big smile on her face,” Cabrera Chien shared. “She was showing off her new haircut, she had new earrings, and she [had] really regained her quality of life. She was performing meaningful activities again, living with her cancer, and receiving treatment.”

During that meeting, the patient told her about how a successful trip she had taken in her RV—being able to return to these sorts of trips was a goal that she and her occupational therapist had been working towards. According to Cabrera Chien, helping the patient return to these normal day-to-day activities gave meaning to the treatment they were providing.

“This was a long way from her initial visit with the patient, where she was in bed and unable to get out her room,” she concluded. “This is just a really great example of how the GA, and now the PGA, can provide this patient-centered, individualized care to meet the needs of our patients.”

References

1. Dale W, Klepin HD, Williams GR, et al. Practical assessment and management of vulnerabilities in older patients receiving systemic cancer therapy: ASCO guideline update. J Clin Oncol. Published online July 17, 2023. doi:10.1200/JCO.23.00933
2. Li D, Sun CL, Kim H, et al. Geriatric assessment-driven intervention (GAIN) on chemotherapy-related toxic effects in older adults with cancer: a randomized clinical trial. JAMA Oncol. 2021;7(11):e214158. doi:10.1001/jamaoncol.2021.4158