Geriatric Assessments Help Promote Comorbidity-Related Discussions in Patients With Advanced Cancer

Sap Partners | Schools of Nursing | <b>University of Rochester Wilmot Cancer Institute</b>

A secondary analysis of the COACH study revealed that a geriatric assessment–guided intervention increased the number of comorbidity-related discussions between patients and providers.

Providing oncologists with a geriatric assessment (GA)–guided intervention effectively promoted communication regarding comorbidities in older patients with advanced cancer, according to findings from a secondary analysis recently published in JCO Oncology Practice.1

The study enrolled 541 patients with advanced cancer, all aged 70 years or older, and of whom 94.6% had at least 1 comorbidity. The average number of comorbidities was between 1.9 and 3.2. On average, the intervention increased the number of conversations surrounding comorbidities from 0.52 to 0.99 (P < .01) per patient.

Furthermore, the number of concerns that were communicated by patients to their providers increased from 0.32 to 0.52 (P = .03). Similarly, the odds that a physician would address a comorbidity-related concern via referral, handout, or other modes increased by 2.4 (95% CI, 1.3 to 4.3; P = .004).

Most oncologists (76%) who participated in the study and received the intervention consequently considered comorbidities in regard to treatment plans, and nearly half (41%) adjusted their treatment plans accordingly.

ASCO recommends the GA to evaluate age-related conditions in all patients with cancer who are aged 65 years older. The multidimensional evaluation assesses function, cognitive, psychosocial, and medical needs to identify treatment gaps in a patient’s treatment plan.

Furthermore, some studies, but not all, have demonstrated that the GA improves physical function, quality of life, and even overall survival in community-dwelling older adults.1 Because the assessment provides clinical care teams with the necessary tools to identify and address common health-related needs associated with aging, incorporating the GA often yields more appropriate and specific treatment modifications, facilitated care coordination, and an elimination of potentially in appropriate medications.

“The interaction between cancer, cancer treatments, and specific comorbidities is extremely complex, and management of all conditions simultaneously can be a formidable challenge for care teams,” lead study author Amber S. Kleckner, MD, of University of Rochester Medical Center, and coinvestigators wrote in the study. “Consideration of comorbidities in cancer care is important because it can affect a patient’s prognosis, tolerance of treatment, quality of life, and mortality.”

The findings from this study were based on a secondary analysis of the COACH study (NCT02107443)—a nationwide, multisite cluster-randomized trial, which enrolled patients older than 70 years who had advanced cancer (either solid tumor or lymphoma), and impairment in at least 1 GA domain besides polypharmacy. Thirty oncology practices were randomized to conduct either standard care (no GA intervention) or to provide intervention in the form of the “GA-guided assessment” to understand the GA’s impact on guided decision making.

Researchers audio recorded the post-GA clinic visit. The conversation was transcribed and coded for topics related to comorbidities; linear mixed models were then developed to assess the impact of the intervention.

Researchers assessed comorbidities via the Older Americans Resources and Services (OARS) comorbidity questionnaire. The questionnaire helps identify the presence of 15 comorbidities, including diabetes, depression, and poor eyesight, and queries about the impact of these comorbidities on daily activities. The most commonly reported comorbidities were high blood pressure (55.8%) and arthritis/rheumatism (51.2%). Poor eyesight (56.2%), poor hearing (55.6%), and emphysema or chronic bronchitis (23.9%) were the comorbidities most likely to interfere with daily living activities.

If patients reported 3 or more comorbidities, or 1 comorbidity which greatly interfered with their daily lives, they were considered “impaired.”

Notably, in the non-intervention cohort, patients were responsible for initiating 36% of comorbidity relate conversations while providers initiated 56% of these discussions. In the experimental cohort, however, providers initiated 80% of comorbidities-related conversations, while patients were only responsible for 14%.

“Quality conversations between patients and providers can improve health outcomes in multiple ways, many of which are indirect,” the investigators concluded. “Patients who are satisfied with communication with their providers are more trusting and adhere better to treatments.”

Recommendations for patients who have been categorized as “Impaired” because of their comorbidities are as follows:

  • Initiate direct communication with the patient’s primary care physician about the treatment plan for their disease. This can be either written, electronic, or by telephone.
  • If the patient has a history of diabetes, neurotoxic agents should be avoided, provided there is an equivalent option.
  • If the patient has a history of heart failure, treatments should be administered at a slower infusion rate and the volume of agents should minimized however much possible.
  • If the patient has a history of renal impairment, nephrotoxic agents should either be avoided, if possible, or administered at an adjusted dosage.
  • Dosage schedule should be modified if there is concern regarding show patient will tolerate therapy or if there is concern about worsening comorbidities.
  • If patient currently smokes, smoking cessation counseling should be provided.

The authors acknowledged that, in past studies, nurse-guided interventions have yielded higher quality of life in patients with gynecologic cancers. Future research exploring how various providers can help guide treatment-related decisions post-GA assessments are warranted, particularly in increasing comorbidity-related conversations among people of color and in other minority groups.

“Herein, we showed that patients have a high comorbidity burden and we demonstrated that providing a GA-guided intervention to oncologists doubled the number of conversations that they had about comorbidities, leading to more concerns being acknowledged and appropriately addressed,” the study authors concluded. “These practices have the potential to improve patient satisfaction with cancer care and properly manage comorbidities during treatment of their advanced cancer.”

References

  1. Kleckner AS, Wells M, Kehoe LA, et al. Using geriatric assessments to guide conversations regarding comorbidities among older patients with advanced cancer. JCO Oncol Pract. 2022;18(1):e9-e19. doi:10.1200/OP.21.00196.
  2. Olesen ML, Duun-Henriksen AK, Hansson H, Otteson B, Andersen KK, Zoffman V. A person-centered intervention targeting the psychosocial needs of gynecologic cancer survivors: a randomized clinical trial. J Cancer Surviv. 2016;10(5):832-841. doi:10.1007/s11764-016-0528-5.