Geriatric Assessments:
Standard Care and The Best Unused Tool
By @Lorinda Coombs, PhD, CNS, FNP-BC, AOCNP®, University of North Carolina Chapel Hill School of Nursing and Lineberger Comprehensive Cancer Center
Advancing age is the single greatest factor associated with a cancer diagnosis. Approximately 60% of all cancers occur in adults 65 years and older (Estapé, 2018). Older adults diagnosed with a malignancy have additional challenges compared with younger adults.
Performing a geriatric assessment (GA) as part of the workup prior to a treatment plan has been shown to offer predictive utility, avoid unnecessary toxicity, and improve patient experience of care across the malignancy spectrum (Klepin, 2019; Goodwin, 2018; Rostoft et al., 2021). A GA evaluates multiple domains, including physical function, comorbidities, mood, social support, nutrition, and medication. However, despite evidence-based guidelines in place since 2018 recommending a GA, it is rarely done in clinical practice.
Use of Geriatric Assessments
Gijra and colleagues (2022) helped shed some light on the reason in a study of 349 community practicing oncologists. The authors identified that most oncologists thought that the GA was too cumbersome to incorporate into practice and added no value beyond the initial comprehensive history and exam. A significant portion of the sample (19%) was not aware of any validated instruments, despite clinical practice guidelines from the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network (NCCN), and the International Society of Geriatric Oncology (SIOG) recommending the use of a GA to guide treatment decisions for older adults.
Before any of us in academic settings become too enthusiastic about pointing fingers at our community colleagues, another survey by ASCO’s Addressing Cancer Health Disparities Among Older Adults Task Force surveyed oncologists primarily in an academic setting and found that over half rarely or never performed a GA (Dale et al., 2021). Clearly, all oncology clinicians are in a position to improve the care of older adults by using validated GA tools (Dale et al., 2021).
Addressing the Gap in Practice
The gap between national clinical practice guidelines and routine practice is known, and we, as advanced practitioners (APs), are well positioned to address this gap. The first step is to educate and train our colleagues about the benefits of GA in guiding care. Becoming more comfortable with using tools that are available online, such as the Cancer & Aging Research Group (CARG) Geriatric Assessment or the Association of Community Cancer Centers (ACCC) Practical Application of Geriatric Assessment, will help address this (CARG, n.d.; ACCC, 2024). Currently used global assessments, such as the Eastern Cooperative Oncology Group (ECOG) performance status, do not pick up vulnerabilities present in older adults, as identified by Madureira and colleagues (2024).
We are not using the best, evidence-based tool available to improve outcomes for our geriatric patients. Sharing tools and resources to educate colleagues is the first step to moving the needle on adhering to guidelines and improving outcomes for our geriatric patients. Developing a quality improvement project examining the implementation of GA tools can provide insight into their use in clinical practice.
References
Association of Community Cancer Centers. (2024). Practical application of geriatric assessment: A how-to guide for the multidisciplinary care team. https://www.accc-cancer.org/docs/projects/geriatric-patients-with-cancer/practical-application-of-geriatric-assessment_a-how-to-guide.pdf?sfvrsn=71c40f98_0&
Cancer & Aging Research Group. (n.d.). Tools: CARG Geriatric Assessment. https://www.mycarg.org/?page_id=898
Dale, W., Williams, G. R., MacKenzie, A. R., Soto-Perez-de-Celis, E., Maggiore, R. J., Merrill, J. K.,…Klepin, H. D. (2021). How is geriatric assessment used in clinical practice for older adults with cancer? A survey of cancer providers by the American Society of Clinical Oncology. JCO Oncology Practice, 17(6), 336–344. https://doi.org/10.1200/OP.20.00442
Estapé, T. (2018). Cancer in the elderly: Challenges and barriers. Asia Pacific Journal of Oncology Nursing, 5(1), 40–42. https://doi.org/10.4103%2Fapjon.apjon_52_17
Gajra, A., Jeune-Smith, Y., Fortier, S., Feinberg, B., Phillips, E., Jr, Balanean, A., & Klepin, H. D. (2022). The use and knowledge of validated geriatric assessment instruments among US community oncologists. JCO Oncology Practice, 18(7), e1081–e1090. https://doi.org/10.1200/OP.21.00743
Goodwin, P. M. (2018). Geriatric assessment improved outcomes for older patients. Oncology Times, 40(15), 39. https://doi.org/10.1097/01.COT.0000544346.15991.6c
Klepin, H. D. (2019). Ready for prime time: Role for geriatric assessment to improve quality of care in hematology practice. Hematology, ASH Education Program, 2019(1), 53–58. https://doi.org/10.1182/hematology.2019001299
Madureira, T., Magalhães, J., Vilas, P., Campôa, E., Luz, P., & Coutinho, F. (2024). Geriatric screening and comprehensive geriatric assessment during initial oncology appointments. BMJ Supportive and Palliative Care. Advance online publication. https://doi.org/10.1136/spcare-2024-004822
Rostoft, S., O’Donovan, A., Soubeyran, P., Alibhai, S. M. H., & Hamaker, M. E. (2021). Geriatric assessment and management in cancer. Journal of Clinical Oncology, 39(19), 2058–2067. https://doi.org/10.1200/jco.21.00089
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