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J Natl Cancer Inst. Aug 8, 2012; 104(15): 1134–1164.
Published online Aug 7, 2012. doi:  10.1093/jnci/djs285
PMCID: PMC3413614

Use of Geriatric Assessment for Older Adults in the Oncology Setting: A Systematic Review

Abstract

Background

Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult’s medical, psychological, social, and functional capacity. No systematic review of the use of geriatric assessment in oncology has been conducted. The goals of this systematic review were: 1) to provide an overview of all geriatric assessment instruments used in the oncology setting; 2) to examine the feasibility and psychometric properties of those instruments; and 3) to systematically evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes (including the impact on treatment decision making, toxicity of treatment, and mortality).

Methods

We searched Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library for articles published in English, French, Dutch, or German between January 1, 1996, and November 16, 2010, reporting on cross-sectional, longitudinal, interventional, or observational studies that assessed the feasibility or effectiveness of geriatric assessment instruments. The quality of articles was evaluated using relevant quality assessment frameworks.

Results

We identified 83 articles that reported on 73 studies. The quality of most studies was poor to moderate. Eleven studies examined psychometric properties or diagnostic accuracy of the geriatric assessment instruments used. The assessment generally took 10–45min. Geriatric assessment was most often completed to describe a patient’s health and functional status. Specific domains of geriatric assessment were associated with treatment toxicity in 6 of 9 studies and with mortality in 8 of 16 studies. Of the four studies that examined the impact of geriatric assessment on the cancer treatment decision, two found that geriatric assessment impacted 40%–50% of treatment decisions.

Conclusion

Geriatric assessment in the oncology setting is feasible, and some domains are associated with adverse outcomes. However, there is limited evidence that geriatric assessment impacted treatment decision making. Further research examining the effectiveness of geriatric assessment on treatment decisions and outcomes is needed.

In North America and Europe, the majority of persons who receive a cancer diagnosis every year are aged 65 years or older (1–3). Cancer treatment decision making for older adults is often complicated by the presence of comorbidities and psychosocial factors. The US National Comprehensive Cancer Network (NCCN) and the International Society of Geriatric Oncology (SIOG) (4,5) have recommended that some form of geriatric assessment be conducted to help cancer specialists determine the best treatment for their older patients. Despite their recommendations, neither organization has indicated what constitutes the best form of assessment.

Geriatric assessment has been used in geriatric medicine since the 1980s (6). The aim of geriatric assessment in a traditional geriatric population is to identify current health problems and to guide interventions to reduce adverse outcomes and to optimize the functional status of older adults (7–9). A traditional geriatric assessment is not an intervention in itself but rather aims to identify opportunities for intervention. A geriatric assessment conducted in the oncology setting may not have the same goals as a traditional geriatric assessment, because the latter was never intended to help identify the best cancer treatment (10). The SIOG and NCCN recommend that a geriatric assessment be used to help select the best cancer treatment for an older patient with cancer (11–13). Oncology clinics see many more older adults each day compared with clinics that specialize in geriatric medicine, and the concerns of patients attending each type of clinic are often quite different (10). The feasibility and effectiveness of geriatric assessments in the oncology setting might also be very different compared with the geriatric medicine setting. Furthermore, the older cancer population is heterogeneous in terms of cancer type, cancer stage, and disease and treatment trajectories. These factors might affect the feasibility and efficacy of geriatric assessment in the oncology setting.

There has been only one review published to date on the use of geriatric assessment in older cancer patients. That review (4) was based on a literature search of MEDLINE up to February 2003 and was limited to English-language articles. It is not clear which data were abstracted and by whom, and how the quality assessment of the included studies was conducted. Similarly, descriptions of the included studies were not reported. Numerous geriatric assessment studies have been published since the publication of that review.

The objectives of this systematic review were: 1) to provide an overview of all geriatric assessment instruments that have been developed and/or are in use in the oncology setting for older adults with cancer; 2) to examine the feasibility of geriatric assessment instrument use in the oncology setting (ie, time needed to complete, proportion of patients with complete assessments), and the psychometric properties or diagnostic accuracy of the instruments (ie, reliability and validity, sensitivity and specificity); and 3) to systematically evaluate the impact of geriatric assessment instruments on the treatment decision-making process and their effectiveness in predicting cancer and treatment outcomes. The outcomes of interest were chosen a priori as part of the review protocol according to Cochrane review methodology as described in the Cochrane Handbook for Systematic Reviews of Interventions (14) and included mortality, complications and toxicity of treatment, health and functional status (ie, impact on activities of daily living), use of inpatient and outpatient care, use of geriatric assessment to avoid complications of treatment, and the impact on cancer treatment decisions and approaches. Geriatric assessment is typically used to predict functional status, use of care, and mortality (7–9). We included prediction of complications and toxicity of treatment and impact on planned cancer treatment as outcomes of interest in this review based on suggestions by experts and SIOG and NCCN that they may be impacted by the use of a geriatric assessment (11–13).

Methods

Data Sources

This review was based on a systematic comprehensive search of six databases: OVID MEDLINE (1950 to October week 4, 2010); PubMed (January 1, 2008, to November 16, 2010); OVID EMBASE (January 1, 1980, to 2010 week 44); OVID PsycINFO (January 1, 1987, to November week 1, 2010); CINAHL (January 1, 1982, to November 16, 2010); and the Cochrane Library (searched on November 6, 2011). We considered articles in English, Dutch, French, or German that were published or in press between January 1, 1996, and November 16, 2010, for inclusion in this review.

A study was eligible for inclusion if it: 1) reported on older patients (mean or median age of study participants 65 years or older) who were diagnosed with cancer (any type of cancer, including hematological malignancies) and being seen in oncology clinics (outpatient oncology or hematology clinics or inpatient oncology or hematology units); 2) reported on cross-sectional, longitudinal, observational, or interventional studies that either assessed the feasibility of the use of tools or instruments or the effectiveness of geriatric assessment tools on any of the aforementioned outcome measures; and 3) was written in English, French, Dutch, or German. We excluded editorials, case studies, reviews, and expert opinion papers and studies that were published as abstracts only.

The following sets of keywords or free text words were used in combination with subject headings where available: cancer (cancer* or neoplasm* OR oncolog*) AND geriatric assessment (geriatric or elderly or frailty or aged and assessment* or evaluation* or consultation*; or consultation service for senior adults or geriatric oncology module or frailty marker*). The literature search was performed by an experienced university librarian (ES).

Process of Study Selection

The studies were selected in two steps (Figure 1). In the first step, an initial selection based on titles and abstracts was done independently by two authors (MP and JH) using the inclusion and exclusion criteria. When at least one reviewer was uncertain about whether the article fulfilled the inclusion criteria, the abstract was included for full-text review. In the second step, the full text was reviewed independently by the same authors. Disagreements between reviewers were resolved by consensus (this process was used for eight studies). If multiple articles reported similar results, only the article with the most complete information was retained. For all studies identified as abstract only (n = 50), we attempted to contact the authors by e-mail to determine whether the full-text study had been published. For eight abstracts, no e-mail address was found. Of the 42 authors who were contacted, 19 did not respond, six e-mails were undeliverable, 15 authors responded that the studies and/or manuscripts were still in progress, and two authors informed us that their manuscripts were accepted for publication and were included in this systematic review. We also reviewed the reference lists of all selected articles to identify any additional relevant articles, but no additional studies were identified. When an article referred to additional publications for more details on study methods and design, those publications were also obtained.

Figure 1.
Flow chart of study selection.

Data Abstraction

Data were abstracted by the same reviewers using a data abstraction form that was created with Excel software (Microsoft Corporation, Redmond, WA). The abstracted information included the study design, aim of the study, location of the study, sampling method, source of data, recruitment, participant inclusion criteria, the characteristics of included study participants, the name used for the geriatric assessment, the instrument(s) used, instrument feasibility, results of the study, outcomes of the assessment, and details about the statistical analysis. If any aspect of the study design was unclear, we attempted to contact the authors of the study by e-mail. For two of 19 studies, no e-mail address could be found, and for one study, the email was undeliverable, leaving 16 authors that could be contacted. Of the 16 authors contacted, five did not respond whereas 11 responded and provided additional details.

Quality Assessment

The Reporting of Observational Studies in Epidemiology (STROBE), the Meta-analysis of Observational Studies in Epidemiology (MOOSE), and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were used by two reviewers (MP and JH) to assess the quality of the included studies (15–17). Any disagreement, which involved 421 (18%) of 2324 assessed quality items, was resolved though consensus. However, because this is the first systematic review on the use of geriatric assessment in oncology, no study was excluded based on the quality assessment.

Results

A total of 1308 abstracts were initially identified for possible inclusion (Figure 1). Based on the review of the abstracts, 226 citations were included for full-text review. Of those 226 articles, 83 reporting on 73 studies were included. Of the 83 articles included, three were written in French, and 80 were written in English.

Quality Assessment

The quality of most studies was poor to moderate based on MOOSE and PRISMA guidelines for reporting (Supplementary Table 1, available online). Of the 59 studies that were not chart reviews, 51 (86%) did not report a response rate (18–70), and all but one (38) also did not report the reasons for refusal to participate in study. Therefore, the extent of selection bias could not be assessed. Furthermore, of the 73 studies, 13 (18%) did not describe the study design (18,20,27,37,42,53,57,64,65,67,69,71,72), and 12 (16%) did not describe the setting in which the study was conducted (20,22–24,33,42,44,49,51,53,61,70). Among the 28 prospective studies, nine (32%) did not describe the method of follow-up (20,22,23,27,33,35,37,39–41) . The amount of missing data was not described in 41 (67%) of 61 studies (excluding studies that reported having complete data) (20–23,25,27,33–35,39–45,47,51,53,54,60–63,66,68–71,73–84), and 41 of 58 studies (excluding studies that reported no missing data or how missing data were handled) did not describe how the study authors dealt with missing data (20–23,25,27,33,37–39,41–47,49,51,53,54,57,58,60–64,68–72,74–85). For 12 (16%) of the 73 studies, the statistical methods were inadequately described (19,20,37,42,52,59,67,69,72,84,86,87). Three (4%) of the 73 studies did not describe all of the measurement instruments used in the study (ie, geriatric assessment instruments, outcomes, predictors) (20,42,52).

Characteristics of the Included Studies

The characteristics of the 73 studies reported by the included articles are presented in Supplementary Table 2 (available online). Twenty-five studies were conducted in North America: 23 in the United States
(25,30–33,37,38,43,46,52,54,58,62,64,73,74,77,78,80,81,83,85,86, 88–92) and two in Canada (93–95). Forty-three studies were conducted in Europe: 19 in Italy (20,26,34–36,40,42, 44,51,53,57,59,61,63,67,69,70,76,79), 14 in France (19,27–29,39,45,48,72,82,84,87, 96–98), three in Spain (47,55,56), two in Germany (41,68,99), one in the United Kingdom (22,23), one in Norway (71,75), one in Greece (24), one in the Netherlands (18), and one in Austria (65). Two studies were conducted in Asia: one in Japan (100) and one in Korea (50). One study was conducted in Australia (66), and two studies were conducted in multiple countries (21,49,60).

Of the 73 studies that included geriatric assessment, 28 (38%) were prospective observational studies (18–41,71,73–76,94,95,100), 31 (42%) were cross-sectional observational studies (42–68,77,78,85,88–90,93,99), and 14 (19%) were retrospective studies or chart reviews (69,70,72,79–84,86,87,91,92,96–98). None of the reviewed studies was a randomized controlled trial specifically designed to examine the effectiveness of geriatric assessment.

In studies that investigated a new drug or treatment regimen (26,28,30,39,59,67,70), geriatric assessment was employed for the most part to describe study participants. Geriatric assessment was included in seven nonrandomized clinical drug trials (24,26,28,30,59,67,70) and no randomized controlled drug trial.

Most of the studies recruited participants either through convenience sampling (25 studies) (24–26,30–32,36,37,39,51,52,59,65, 67,69,73,74,76–78,84,88–90,93–95,97,99) or by consecutive sampling (32 studies) (18,19,21,27,33–35,40,41,45–48,55,57,58,60–64,66,68,71,75,79,80,82,85,86,91,92,96,98,100) techniques. Three studies used other sampling methods (29,38,54), and in 13 studies the method used for recruitment was not clear or not reported (20,22,23,42–44,49,50,53,56,70,72,81,83,87). However, 11 (15%) of 73 studies failed to report clear and explicit inclusion and recruitment procedures criteria (20,22–24,42,44,53,57,65,67,77,89,90).

Sample sizes ranged from 10 (36) to 12 480 (54) participants. Response rates ranged from 53% (73) to 100% (100). The age range of participants was 65–99 years.

Overview of All Geriatric Assessment Instruments Developed and/or Used in the Oncology Setting for Older Adults with Cancer

Setting of the geriatric assessments. In 61 of the 73 studies, the geriatric assessment was conducted in a hospital (18–21,24,25,27–41,43–8,50–53,55–69,71,72,74–79,81–90,92–100). In 11 studies, patients underwent geriatric assessment during admission or stay at inpatient ward (21,38,41,60,61,63,65,68,69,79,82,86,92), and participants in 11 studies were evaluated during initial or routine clinic visits (33,34,46–48,56,62,64,74,77,88). In four studies, the geriatric assessment took place either at inpatient admission or in the outpatient clinic (57,72,93–95).

Domains included in the geriatric assessment. Table 1 presents an overview of the domains included in geriatric assessments, and Supplementary Table 3 (available online) presents the detailed content and domains of the geriatric assessment used in each study. Of the 73 studies, 68 included measures of basic activities of daily living (18–41,41,42,44–51,53–63,65–67,69–72,74–83,85–100), and 65 included instrumental activities of daily living (18–28,30–39,41,44–63,65–72,74–95,97–99).

Table 1.
Domains of geriatric assessment included in the 73 studies that examined geriatric assessment in the oncology setting

A total of 58 studies included a comorbidity domain (18–25,27–32,34,35,38–48,50,51,54,55,57,59–61,63,65–68, 71–77,79,80,82,84–87,89–91,93–100). Cognitive functioning was evaluated in 53 studies (18–21,25,27–29,31,32,34–36,38,39,41,44, 45,47,49–58,60–62,64–67,69,71,72,74–77,79–84,86–88,91–95,97–100). Assessment of depression, anxiety, or general mood was a component of geriatric assessment in 52 studies (19–23, 26–33,36,39,42,44,47–50,52,53,57,58,60–67,69,71–77,79–85, 87–95,97,98).

A nutritional assessment was conducted in 40 studies (18–20, 25,27–29,32–36,38,39,43,45,47,48,50,51,53,55–57,63,65,66,71, 74–76,79,82,84,87–90,92–97,99,100), and 27 studies assessed the risk of falls (19,25,27,38,42,43,45,47,48,50,52,54,58,61,63,66,
72,76–78,80,82,84,88–96,98,99). Performance status was assessed in 37 studies (20,21,24,30–32,34,35,39,41,44, 46–48,
50,51,53,55,56,60–71,74,75,86–90,93–98,100).

Information about the use of prescription medications was collected from patients in 22 studies (19,25,28,29,39,47,48,50–52,55,56,63,66,71,72,75,78,82,84,85,92,98,99), and in 14 of these 22 studies, the information obtained included the total number of prescriptions (25,29,39,47,48,51,52,63,66,
71,75,78,82,84,85,92). In 24 studies (19,22,23,25,28,38,48,50–52,55,56,63,65,66,72,73,78,84–86,88–90,93,97,98), geriatric assessment included the availability of social support and living arrangements, such as the availability of a caregiver. The most commonly used objective measure of physical function was gait speed, which was included in 15 studies (25,29,43,45,50,52,61,64,65,72,78,84,87,88,93–95). Patient characteristics that were less often incorporated into geriatric assessments included symptoms [assessed using a symptom inventory, two studies (22,23,85); fatigue or energy levels, seven studies (21,25,37,43,60,85,93–95); pain, three studies (37,66,85); quality of life, seven studies (22,23,31,32,37,50,65,68,74); grip strength, five studies (43,64,87,93–95); distress, three studies (66,85,89,90); and self-rated health, two studies (54,73)].

In 30 of 73 studies, the results of geriatric assessment were summarized in a summary score (18,20,24,26,34,40,42,43,47,49–51,54,55,66,70,72–76,78,79,84,93–96,98,99). In 12 of those studies (20,24,40,47,50,54,75,79,84,96,98,99), the summary score used was the classification of fit, vulnerable, and frail developed by Balducci and Stanta (101). In this classification, frail refers to patients who are generally unfit for cancer treatment (defined as those with any of the following characteristics: older than 85 years, more than two disabilities, multiple comorbidities, or the presence of geriatric syndromes) and should receive best supportive care or palliative treatment; fit (defined as patients who are independent and have no clinically significant comorbid conditions) indicates patients who should receive standard therapy; and vulnerable (defined as patients with one or two clinically significant comorbid conditions and/or instrumental activities of daily living disability but no activities of daily living disability) refers to patients for which the standard treatment should be adjusted.

Feasibility and Psychometric Properties of Geriatric Assessment

Feasibility of geriatric assessment. Thirty studies reported some aspect of the feasibility of the geriatric assessment, such as time needed to complete the assessment and/or who (study author, patient themselves, or others) conducted the assessment (21,25,26,32,36,37,40,45,46,50,52,55–58,60,66,69,73–75,77,78,84,85,87–89,93,94,99). In most of these studies, the assessment was done through a face-to-face interview and generally took 10–45 minutes. Among studies that reported how many participants refused the assessment (26,74,78,94,95), only a small number of participants refused the assessments (Table 2). In six studies (33,66,69,85,88,89), geriatric assessment was done using self-administered surveys. However, only four of those studies (66,85,88,89) reported on feasibility, and each showed that it was acceptable (more than 75% of participants could complete the survey without assistance, and participants were satisfied with length of questionnaires and content).

Table 2.
Overview of the results of the feasibility of the assessments as reported in the article*

Psychometric properties and diagnostic accuracy of geriatric assessment instruments. Eleven studies (19,37,46,49,51,55,57,65,78,81,83,99) reported psychometric properties or diagnostic accuracy of the geriatric assessment (ie, validity, reliability, and/or sensitivity and specificity) (Table 3). Most of these studies examined diagnostic accuracy of one or more short geriatric assessment tools with those of a full geriatric assessment. However, because these studies compared different screening instruments with different forms of full geriatric assessment or used the same instruments but with different cutoffs, it was not possible to summarize the results in a quantitative manner. Nevertheless, two main findings emerged from our review of these studies. First, shorter forms of geriatric assessment generally had good diagnostic accuracy compared with a full geriatric assessment. For example, Aparicio et al. (19) found that concordance between individual domain scores from mini-geriatric assessment and from comprehensive geriatric assessment ranged from 66% to 83%. Second, four studies that compared the Vulnerable Elder Survey-13 items (VES-13) with a full geriatric assessment found that the former had excellent diagnostic accuracy, with an area under the curve that ranged from 0.83 to 0.90, sensitivity that ranged from 54% to 87%, and specificity that ranged from 70% to 89% (49,51,55,78).

Table 3.
Psychometric properties and/or diagnostic accuracy reported*

In addition, one study (49) compared the Groningen frailty indicator to a full geriatric assessment; one study (55) compared the Barber questionnaire to a full geriatric assessment; and one study (99) compared expert physician judgment to the Balducci classification.

Effectiveness of Geriatric Assessments in Predicting Cancer and Treatment Outcomes

Thirty-seven studies (51%) examined at least one of the four a priori specified outcomes presented below. The outcomes use of geriatric assessment (followed by interventions) to avoid complications of treatment and health and functional status were not studied in the included studies. Below, the results for each of the studied outcomes are described.

Geriatric assessment and treatment decision. An important goal of geriatric assessment is to distinguish between older patients who are fit to undergo standard cancer treatments and frail older patients who would benefit from modified treatment or best supportive care. Only four studies (19,27,48,98), all conducted in France, examined the impact of geriatric assessment before the start of treatment on the cancer treatment plan (Table 4). In two studies (19,98), geriatric assessment did not influence the treatment decision, whereas in the other two studies (27,48), geriatric assessment led to changes in the treatment plan for 40%–50% of patients, mostly consisting of changes in the chemotherapy regimen. Of note, in the study by Girre et al. (48), the final treatment decision (which took into account the results of the geriatric assessment) was made by a doctor or team that was not the original doctor or team that conducted the geriatric assessment. In the study of Chaibi et al. (27), patients were rediscussed at tumor board, where the multidisciplinary team decided to change their treatment recommendation based on the results of the geriatric assessment.

Table 4.
Impact of geriatric assessment on cancer treatment decision-making process or treatment delivery*

In a small pilot study of 15 breast cancer patients, Extermann et al. (74) reported that assessment and interventions influenced the oncological treatment, but it was not clear how or how often they influenced the outcome. The impact of geriatric assessment on the treatment decision was examined by Marenco et al. (34) in a prospective study with a variety of cancers and stages (n = 571), and by To et al. (66) in a cross-sectional study with diverse cancers and stages (n = 200). However, it is not clear how treatment decisions were specifically impacted (eg, increase in treatment dose or dose reduction was not reported) in these two studies. Three studies (27,74,84) have shown that geriatric assessment led to geriatric interventions, such as nutritional interventions and treatment of depression before the start of treatment.

Geriatric assessment and complications or toxicity of treatment. Table 5 lists all studies that examined complications or toxicity of treatment as an outcome of geriatric assessment. Nine studies (21,30–33,35,71,73,75,95,100) that examined the impact of geriatric assessment on complications of any type of cancer treatment did not use multivariable analysis techniques. Complications were generally defined as grade 3 or 4 treatment-related toxicity, treatment interruptions, and postoperative complications, such as wound infections. In five studies with mixed cancer diagnoses and stages and sample sizes that ranged from 60 to 660 participants (21,33,35,71,75,100), impairments in basic and instrument activities of daily living, comorbidity, poor mental health, poor social support, and cognitive functioning were associated with treatment complications. In a prospective observational study that included mixed cancer diagnoses and stages (n = 112), Puts et al. (95) reported that low grip strength was the only frailty marker (of seven measured) to predict treatment toxicity. Two other studies (30–32) with sample sizes of 20, 28, and 49 participants (most with breast cancer) showed no difference in treatment toxicities with regard to geriatric assessment variables. These studies may have lacked statistical power to detect statistically significant associations.

Table 5.
Predictive validity of geriatric assessment for treatment complications*

Geriatric assessment and prediction of mortality. Table 6 lists all studies that examined mortality as an outcome of domains of geriatric assessment. Sixteen studies examined the ability of geriatric assessment domains to predict mortality: 13 studies were prospective (18,20,23,24,29,34,35,39–41,71,73,95), two were cross-sectional (79,80), one was retrospective (97), and all studies included a variety of cancer diagnoses and stages. The following geriatric assessment variables were associated with increased mortality across multiple studies (18,23,29,34,35,41,71,80): older age, inadequate finances, mental health, comorbidity, high medication use, high Groningen frailty indictor score, low Mini Nutritional Assessment score, and impairments in activities of daily living. The majority of these studies adjusted for important confounders, such as sex, age, type of malignancy, stage of cancer, and comorbidity. However, three studies with sample sizes of 54 to 182 reported that none of the geriatric assessment variables were independent predictors of mortality (71,95,97).

Table 6.
Predictive validity of geriatric assessment for mortality*

Six studies (20,24,40,42,76,79) examined the survival of patients categorized as frail, vulnerable, or fit rather than according to individual components of the geriatric assessment. These studies used tests such as χ2 or log rank tests but did not examine predictive validity using multivariable analytic techniques.

Three studies examined overall survival, progression-free survival, and/or response to treatment in relation to geriatric assessment in univariate analyses only. Bamias et al. (24) found no associations between the VES-13 score and overall survival, progression-free survival, or response to treatment. Basso et al. (79) found that the incidence of treatment interruption was higher and had less benefit in terms of response in patients classified as frail according to the Balducci classification. Massa et al. (76) reported better response in fit patients compared with frail patients (how the patients were classified as fit, intermediate, and frail was not described), but it is not clear what analysis was conducted.

Geriatric assessment and the use of care and other outcomes. Two studies (23,94) examined the association between domains of geriatric assessment and the use of care (Supplementary Table 4, available online). In a prospective study with 337 colorectal cancer patients that adjusted for age and sex but not for illness severity and comorbidity, Bailey et al. (23) found that patients who were older and had poorer mental health had greater use of social resources. In a prospective study that used seven markers of frailty markers and included a wide variety of cancers and stages, Puts et al. (94) reported that only one frailty marker, cognitive impairment, predicted visits to the emergency department after adjustment for confounders such as cancer type, cancer stage comorbidity, age, and sex. Five studies (22,23,34,66,91,98) reported that components of the geriatric assessment, such as age and functional status, were associated with the receipt of certain treatment modalities or regimens, such as surgery only.

Other outcomes studied included changes in functional status, distress, clinical response, and discharge to usual place of residence after hospital admission (Supplementary Table 4, available online).

Discussion

This is the first review, to our knowledge, to systematically summarize all available evidence with regard to the use and effectiveness of geriatric assessment in the oncology setting. The evidence summarized in this review suggests that it is feasible to conduct a geriatric assessment in a hospital setting in older patients with cancer. The use of a geriatric assessment in the hospital setting can identify many health and functional status issues that might not otherwise be known by the treating oncologist. In addition, several domains of geriatric assessment are associated with oncological outcomes, such as toxicity of treatment and mortality, even in heterogeneous study populations. The factors consistently associated with these outcomes include impairments in activities of daily living, comorbidity, and poor mental health. Because most of the studies included heterogeneous study populations and featured small sample sizes, they had limited ability to conduct subgroup analyses. Thus, it was not possible to compare the results for solid tumors vs hematological malignancies or for cancers with different prognoses or treatment trajectories (eg, adjuvant vs metastatic settings). Future studies in more homogeneous populations are needed to identify populations where geriatric assessment might be particularly useful in helping a physician select the cancer treatment, preventing adverse outcomes of cancer and its treatment.

We found that although many studies have incorporated some form of geriatric assessment to describe the patient population, fewer studies have examined the usefulness of geriatric assessment in terms of its ability to identify older adults at risk for adverse outcomes of cancer and its treatment. To date, no randomized controlled trial has been conducted to evaluate the effectiveness of geriatric assessment for distinguishing between fit and frail older adults to improve outcomes of cancer treatment compared with usual care in oncology. Nevertheless, experts in the field and SIOG (13,102) expect that by distinguishing between fit and more vulnerable and frail patients, treatment regimens can be adjusted to maximize the treatment effectiveness and avoid complications; however, this expectation still needs to be proven in a randomized controlled trial setting.

Even though no randomized controlled trial has examined the effectiveness of geriatric assessment in the oncology setting, the general principles of geriatric medicine and geriatric assessment are thought to apply to all older adults, including those with cancer. Published guidelines and the recommendations of groups such as the NCCN and the SIOG suggest that most clinicians accept the applicability of geriatric assessment in the oncology setting. However, we found no high-quality evidence (ie, from randomized controlled trials) that conducting a geriatric assessment and tailoring interventions based on its findings altered important patient outcomes in older cancer patients. Thus, based on the results of this systematic review, firm recommendations for implementing geriatric assessment and the type of geriatric assessment in routine clinical practice await additional study because the effectiveness of geriatric assessment in improving patient outcomes remains unclear. Geriatric assessment is not an intervention in and of itself. Rather, interventions that can improve patient outcomes are identified based on the geriatric assessment. The aim of the traditional geriatric assessment is to predict functional decline and falls in an older population with cognitive and functional impairments. Therefore, it is not surprising that in many of the reviewed studies, geriatric assessment was not useful in predicting oncology outcomes, such as treatment toxicity. Ceiling effects (ie, when most participants score the maximum score possible on a test because the test is unable to distinguish between individuals at the higher score range of the test), as reported by Hurria et al. (32), could explain the null effect of geriatric assessment in predicting outcomes in many of the studies that were included in this review. However, experts have recommended using geriatric assessment in clinical oncology practice because it is expected to improve care for older oncology patients by helping improve treatment selection, avoiding toxicity, and identifying undetected medical problems that can interfere with treatment (11,12,13). Future studies should carefully consider which outcomes are most relevant in this population and how the geriatric assessment can be used to identify opportunities for effective interventions. The necessary next step in geriatric oncology requires intervention studies based on geriatric assessment. A recent meta-analysis of 22 randomized controlled trials that evaluated the effect of geriatric assessment vs usual care on independence and discharge to usual residence after hospital admission for older adults admitted to the hospital showed those who received geriatric assessment prior to interventions were more likely to be alive and in their own homes at the 6-month follow-up and less likely to suffer death or deterioration (103). However, few of these patients had cancer.

This review has several strengths. We used systemic methods to identify all relevant studies, and two reviewers independently assessed the titles and abstracts by following the PRISMA statement. We also used various published quality assessment criteria to take into account different study designs included in this review. We attempted to synthesize the results in an unbiased and reproducible way. Our search strategy was inclusive: We did not exclude any study based on the methodological quality because this is the first systematic review providing a comprehensive overview of the use of geriatric assessment in the oncology setting.

This review also has several limitations. A meta-analysis was not possible because the studies were heterogeneous with respect to geriatric assessment instruments, methods, study populations, and outcomes. Furthermore, the findings are limited by the heterogeneous scientific quality of the studies included. Although we tried to contact all study authors if there were questions regarding the study , we were not successful in contacting all study authors, especially because some studies were published 15 years ago. It is thus possible that we rated some quality criteria of each of the individual studies during the quality assessment as unsatisfactory simply because they were not reported or because reporting guidelines such as STROBE and MOOSE for different study types were published more recently than some of the studies. In addition, cancer treatment options for older adults have changed because more elder-friendly treatments are being developed with less toxicity. These changes may have impacted the predictive validity results of the geriatric assessments reviewed in this systematic review. In addition, we did not examine the feasibility or effectiveness of geriatric assessment by cancer type or stage. Moreover, study participants ranged in age from 65 to 99 years. The results of this systematic review might be different for different patient populations. As more studies are conducted, future systematic reviews should take cancer type and stage into account to examine the effectiveness of geriatric assessment in improving patient outcomes for different tumor types and stages.

There are four fundamental barriers to advancing the field of geriatric oncology as identified through this systematic review. First and most important is the conceptual issue of the clinical value of a gold standard for geriatric assessment in the oncology setting. There is also no consensus regarding which domains should be included in geriatric assessment and how the instruments should best be designed and used in the oncology setting. The ability to compare newly developed, abbreviated, or otherwise-modified instruments with an idealized geriatric assessment is limited because the value of geriatric assessment in terms of predictive validity and impact on cancer treatment or patient outcomes is unclear. For example, the value of geriatric assessment has not been rigorously compared with usual care in the oncology setting, particularly with respect to the impact on treatment decision making or patient outcomes.

Second, there is no uniform approach to classifying patients in different risk groups. The most frequently used classification scheme is the fit–vulnerable–frail classification developed by Balducci and Stanta (101). This classification approach recommends standard therapy for fit patients, adjusted therapy for those classified as vulnerable, and best supportive care or palliative treatment for those classified as frail. Other studies have developed their own standards for classifying patients into different risk groups. Most authors have defined impairments in two or more domains of the geriatric assessment as criteria for classifying a patient as frail. These approaches are not necessarily in agreement with the concept of frailty as it is used in the geriatric medicine setting (104). In the latter context, frailty is not considered to be the endpoint of the continuum of fit to completely dependent; rather, it represents a state where an individual is independent but at high risk for developing disability. This inconsistent use of the concept of frailty by oncology and geriatric medicine may lead to confusion and hinder the translation of knowledge from research into clinical practice across different settings. In addition, this varied usage hampers research because study results cannot be compared across studies, both within geriatric oncology and across disciplines.

The third barrier is the lack of information about the psychometric properties of the tools used in the geriatric assessment. Most studies have used instruments that have been validated in the traditional geriatric medicine setting. The properties of these instruments may be different in the oncology setting because the psychometric properties are determined by the clinical population studied. The clinical population in the oncology setting might be different from the one in the geriatric medicine setting where the psychometric properties of these tools were studied. Older persons with moderate to severe disability or cognitive impairment are less likely to be referred to oncology clinics due to referral bias (105). Thus, most likely, the population in the oncology setting has less cognitive impairment and better functional status than the population in which these tools were developed and tested. Therefore, the psychometric properties of geriatric assessment instruments should be examined within the geriatric oncology setting. This would better allow clinicians and researchers to select or develop the most appropriate and effective tools to include in their geriatric assessment in the oncology setting.

Finally, the quality of reporting for studies in the field of geriatric oncology should be improved. Our quality assessment of the published studies suggests that researchers conducting future studies need to report more details on the study design, setting, response rates, and follow-up so that other researchers and clinicians can better evaluate the generalizability of the findings to their own settings.

Randomized controlled trials comparing the effectiveness of conducting geriatric assessment with standard oncological care on relevant oncology outcomes are urgently needed to move the field of geriatric oncology forward. Two studies (27,48) showed an impact of geriatric assessment on the cancer treatment decision, whereas two others did not (19,98); however, none of these studies was a randomized controlled trial. Several studies were published after the search for this systematic review was conducted (106–112). Two studies examined the impact of geriatric assessment on the treatment decision and showed that for the majority of patients geriatric assessment had no impact on the treatment decision (108,112). In addition, four studies that evaluated the predictive validity of geriatric assessment showed that geriatric assessment domains were predictive of cancer treatment outcomes, such as chemotherapy (106,109–112).

Although geriatric assessment is recommended to be used in clinical settings for older adults with cancer by both NCCN and SIOG (11,12,13), in a public health care system with finite resources to allocate to competing health care interventions, showing the (cost-) effectiveness of a geriatric assessment in improving oncology outcomes for older adults is necessary for it to become standard of care. Given that geriatric assessment has been recommended as the standard of care, the broad implementation of geriatric assessment in clinical settings is likely to improve oncology outcomes for older adults affected by cancer.

There is a dearth of studies examining the impact of geriatric assessment on the use of care, and this outcome should be included in future studies. In addition, no study has examined the impact of geriatric assessment on quality of life, which, for older adults with cancer, is an important consideration (113,114).

Thus, there is a need for studies with improved methodological quality, larger sample sizes, and longitudinal design to obtain evidence for the use of geriatric assessment in older patients who are seen in diverse oncology settings. Furthermore, given the costs of conducting multidisciplinary geriatric assessments and the large number of older adults being seen in oncology, there is a need for a short screening tool with good psychometric properties to identify older adults that can benefit from a more in-depth geriatric assessment. Several such tools have been developed for the geriatric oncology setting, including the G-8 (115) and the instrument developed by Hurria et al. (107), all of which are currently being investigated for this purpose. The effectiveness of such an approach—a screening tool for all older patients followed by an in-depth assessment of those deemed to be at risk—is not established and needs to be validated in randomized controlled trials. Of course, such screening tools will only be of value once randomized controlled trials have clearly demonstrated that resource-intensive comprehensive geriatric assessment is effective in improving outcomes compared with usual care in the oncology setting. Furthermore, organizations such as SIOG and NCCN that advocate for some form of geriatric assessment should articulate more clearly the current state of knowledge with regard to the benefits and impact of geriatric assessment on specific outcomes along with highlighting the current large gap in evidence.

Supplementary Material

Supplementary Data:

Funding

This study was funded by the Canadian Institutes for Health Research, grant number KRS-103278 (to MTEP).

Notes

The funder had no role in the study. The authors report that they have no conflicts of interest.

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