A comprehensive geriatric intervention detects multiple problems in older breast cancer patients

Abstract

Studies of comprehensive geriatric assessment (CGA) have shown the importance of follow-up for effectiveness, but this has not been tested in an oncology clinic. In this pilot study, we enrolled 15 early breast cancer patients, aged 70 and older. They received a multidisciplinary CGA every 3 months and structured follow-up from the SAOP nurse practitioner, dietitian, social worker, and pharmacist according to risk. Total follow-up was 6 months. Median age of evaluable patients was 79 years (range 72–87). Median number of comorbidities by Cumulative Index Rating Scale-Geriatric (CIRS-G) was 5 (3–9) at baseline. Ten patients were at pharmacological risk, five at psychosocial risk, and eight at nutritional risk. Patients presented on average six problems initially, and three new problems during follow-up. The intervention directly influenced oncological treatment in four cases. It ensured continuity/coordination of care in seven cases. Success rate in addressing problems was 87%. Mean Functional Assessment of Cancer Treatment-Breast (FACT-B) scores improved from 110.5 (S.D. 16.7) to 116.3 (S.D. 16.5) (t=0.025). Function and independence were maintained. Conclusions: Older patients with early breast cancer have a high prevalence of comorbidity. A CGA with follow-up has potential for improving the treatment and prognosis of these patients and is feasible in an academic oncology setting.

Introduction

Approximately 50% of cancers occur in people aged 70 and older. Older patients may present multiple problems that may interfere with cancer treatment, including comorbidity, functional dependence, inadequate access to care, cognitive decline and depression. Detection and reversal of these conditions is necessary to assure the benefits as well as the continuity of care. In other areas of geriatrics a comprehensive geriatric assessment (CGA) has proven the most effective venue to manage the multiple problems of older individuals.

For example, in a meta-analysis of 28 geriatric randomized trials, the CGA led to an increased probability of living at home, an improvement in cognitive function, a decrease in hospital admissions, and a decrease in mortality [1]. The latter decrease (14%) compares very well with results obtained by adjuvant chemotherapy in breast cancer patients: 15.2% (S.D. 2.4%) relative risk reduction overall, 8% in patients aged 60–69 [2]. In a recent meta-analysis of in-home CGA interventions, Stuck et al. confirmed an effect on functional status and prevention of nursing home admissions. A beneficial effect on mortality was confirmed in cohorts with a younger average age (72.7–77.5) years: 24%, but not in cohorts with an older average age (80.2–81.6 years) [3].

The direct integration of these interventions in the treatment of cancer patients needs further testing, however. Some unanswered questions are: how many addressable geriatric problems do older cancer patients have? How does their severity compare with that of their cancer? Do these comorbidities interact with the course of cancer or its treatment? What is the best model of intervention? Geriatric studies have demonstrated that two elements were fundamental for the full effectiveness of these comprehensive treatments: medical supervision, and a follow-up by the multidisciplinary team [1], [3], [4]. The present study was built to address these points, in particular the latter one.