(UroToday.com) The 2024 SUO annual meeting included a health services session, featuring a presentation by Dr. Sindhuja Kadambi discussing genitourinary cancer care among geriatric patients. Dr. Kadambi started by highlighting a typical geriatric oncology consult: A 72 year old with newly diagnosed stage II muscle invasive urothelial carcinoma with a history of myocardial infarction s/p drug-eluting stents, emphysema, sleep apnea, hypertension, hyperlipidemia, and BPH. Is he a candidate for neoadjuvant chemotherapy and radical cystectomy?
Among the three main organ sites we treat, bladder cancer patients are typically the oldest, however, most patients, in general, are older than 65 years of age:
Importantly, all older patients with genitourinary cancer are not the same: we may undertreat fit, older patients, and over-treat many elderly frail patients. Dr. Kadambi emphasized that age is just a number, as highlighted in the following examples of a 72 year old man’s life expectancy:
- Excellent health, no medical issues, independent: life expectancy is 17-21 years
- Poor health, COPD, cognitive impairment, needs assistance with ADLs/IADLs: life expectancy is 4-5 years
- Good health, CHF, difficulty with physical activities: life expectancy is 9-10 years
Chronic conditions are highly prevalent in older patients. Among Medicare beneficiaries, the 10 most common co-occurring chronic conditions are highlighted:
Work from Dr. Kadambi’s group has shown that geriatric syndromes affect cancer outcomes. This includes increased:
- Symptom burden
- Treatment of adverse events
- Risk of post-operative complications and increased length of hospital stay
- Functional decline
- Morbidity and mortality
Physicians also tend to underestimate vulnerability and impairment of their patients. Bergerot et al.2 showed that 92% of physicians classified a patients’ ECOG performance status as 0 versus only 64% of patients themselves (p = 0.001). Clinicians have tended to focus on physical and functional well-being. Dr. Kadambi summarized that geriatric oncology is essentially balancing the importance of survival with the importance of quality of life:
The benefits of the geriatric assessment are several, including (i) prediction of toxicity and mortality, (ii) guiding decisions and care management, (iii) fostering communication, and (iv) improving clinical outcomes. A comprehensive geriatric assessment includes many domains:
Presented at ASCO 2020, Mohile et al. demonstrated that prospective randomized trials have shown that incorporating a geriatric assessment versus usual care:
- Detects unidentified geriatric syndromes
- Decreases grade 3-5 chemotherapy adverse events
- Decreases ED visits
- Decreases unplanned hospitalizations
- Decreases treatment discontinuation
- Improves quality of life
- Increases referrals for supportive care
The utility of geriatric assessment in older adults is for risk prediction, cancer treatment modification, intervention, and communication:
Dr. Kadambi notes that ACS NSQIP Surgical Risk Calculator is an excellent, quick way to assess geriatric patients for their surgical risk. This calculator highlights several outcomes (including death), predicts length of stay, as well as geriatric outcomes such postoperative delirium. Specific to assessing the risk of chemotherapy toxicity, Dr. Kadambi emphasized the tool provided by the Cancer and Aging Research Group (CARG), which more accurately predicts chemotherapy toxicity compared to Karnofsky performance status.
Shahrokni et al.3 previously assessed the associations of geriatric co-management of care for older patients undergoing cancer-related surgical treatment with 90-day postoperative mortality, rate of adverse surgical events, and postoperative use of inpatient supportive care services. Among 1,892 patients, geriatric surgical co-management was provided for 1,020 patients, leading to a lower 90-day probability of death (4.3% versus 8.9%, p < 0.001), a higher proportion receiving inpatient supportive care services (ie. PT, OT, nutrition), and a higher proportion discharged home with home supportive services (ie. visiting RN).
Depending on the type of practice, the model of geriatric care may differ. This may include a geriatric oncology unit in an academic cancer center, a geriatric consultation team in larger hospitals, or community/smaller hospitals having no geriatric expertise available4:
Dr. Kadambi concluded this presentation by discussing genitourinary cancer care among geriatric patients with the following take home messages:
- All older patients with genitourinary cancer should undergo a geriatric assessment
- The geriatric assessment can assist with treatment decision making and can improve outcomes
- A geriatric assessment can be done across various settings with differing resources and infrastructure
- Early integration of geriatric specialists into cancer care is recommended
- ‘Geriatricized’ trials are much needed
Presented by: Sindhuja Kadambi, MD, MS, University of Rochester, Rochester, NY
Written by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Associate Professor of Urology, Georgia Cancer Center, Wellstar MCG Health, @zklaassen_md on Twitter during the 2024 Society of Urologic Oncology (SUO) annual meeting held in Dallas, between the 3rd and 6th of December, 2024.
References:
- Kadambi S, Loh KP, Dunne R, et al. Older adults with cancer and their caregivers – current landscape and future directions for clinical care. Nat Rev Clin Oncol. 2020 Dec;17(12):742-755.
- Bergerot CD, Philip EJ, Bergerot PG, et al. Discrepancies between genitourinary cancer patients’ and clinicians’ characterization of the Easter Cooperative Oncology Group performance status. Cancer 2020 Oct 2 [Epub ahead of print].
- Shahrokni A, Tin AL, Sarraf S, et al. Association of Geriatric Comanagement and 90 Day Postoperative mortality among patients aged 75 years and older with cancer. JAMA Netw Open. 2020 Aug 3;3(8):e209265.
- Soto-Perez-de-Celis E, Aapro M, Muss H. ASCO 2020: The Geriatric Assessment Comes of Ages. Oncologist. 2020 Nov;25(11):909-912.