Functional status is an important factor to consider when evaluating the overall health of older patients, especially those with cancer.
However, because the amount of time they spend with patients is limited, oncologists sometimes fail to broach the topic in their assessments of older patients with cancer.
“There is an expectation that the oncologist will focus on the patient’s cancer treatment and the associated health care needs and not as much on other issues that an older adult might bring up to their primary care provider, like having trouble walking or falling,” Marielle Jensen-Battaglia, PT, DPT, research assistant at University of Rochester’s Wilmot Cancer Institute and geriatric clinical care specialist, said in an interview with Healio. “There is some research showing that not all oncologists receive much training on how to assess physical function and activities of daily living, so they may not be sure which measure to use or how to assess it. Older patients have complex needs and many comorbidities. Things that happen gradually may sometimes go unnoticed.”
To address the need for better communication around functional status, Jensen-Battaglia and colleagues conducted a secondary analysis of the Improving Communication in Older Cancer Patients and Their Caregivers (COACH) trial. The analysis included 541 patients aged 70 years or older with an advanced solid malignant neoplasm or lymphoma undergoing treatment with palliative intent at one of 31 community oncology practice sites.
The researchers randomly assigned participating practices to either usual care (n = 14) or geriatric assessment intervention (n = 17). All patients received geriatric assessments at baseline, and oncologists in the intervention group received a full geriatric assessment summary and list of management recommendations to address functional status or physical performance impairments.
Results showed 86% of oncologists in the intervention group introduced the topic of functional status with patients, compared with only 59% in the usual care group.
Jensen-Battaglia spoke with Healio about the importance of geriatric assessment in the care of these patients, how functional impairments can be addressed, and the need for oncologist awareness regarding functional status of older patients with cancer.
Healio: Why is functional status of older patients with cancer underassessed?
Jensen-Battaglia: Many things can be going on during cancer treatment, and it is easy to lose track of issues like physical performance and functional status. In the context of cancer treatment, these ultimately may be more important than survival benefit among older adults. So, it is important to make sure we are helping these older adults to optimize these essential aspects of their health.
It isn’t necessarily just the oncologist impeding communication in this area. Some of these topics can be quite awkward for patients, as well. Part of the assessment of functional status includes asking questions like, “Can you bathe and toilet yourself?” That is fairly intimate and may be out of flow with the rest of the conversation. However, I think the main problems are restraints on time and lack of knowledge of how important functional status is for these patients.
Healio: How did the geriatric assessment improve oncologist-patient communication about functional status?
Jensen-Battaglia: As part of the intervention, patients not only went through a geriatric assessment, but their results were provided to their treating oncologist. We also provided oncologists with a list of management recommendations that are valid and reliable for addressing any deficits that were identified on the geriatric assessment. These include things like referrals to physical or occupational therapy, modification of treatments or treatment dosing, and conducting checks for toxic effects of cancer treatments. The combination of the results and the recommendations gave the oncologists the information they needed to prioritize what they would discuss with patients.
For example, if they saw a patient who had fallen twice in the past 6 months, one of the things they could do is send them for a referral or go for physical or occupational therapy. That helps to connect the dots and make the communication more effective during that office visit vs. having to ask a patient whether they had fallen and not being sure what to do with that information.
Healio: Other than referrals, what actions might an oncologist take to help an older patient with cancer deal with functional impairments?
Jensen-Battaglia: It really should reflect the patient’s needs. A referral to physical therapy might be helpful if the source of the fall is weakness or trouble with balance. However, if the patient is also on medication that puts them at risk for orthostatic hypotension, maybe the solution is to check them for that. Having all the necessary information available is very helpful.
Healio: What impact does geriatric assessment and functional status have on quality of life for older patients with cancer?
Jensen-Battaglia: The primary analysis of this trial focused on the outcome of communication satisfaction about aging-related concerns between patients and their oncologists. Although the intervention improved satisfaction with communication, there was no benefit in terms of quality-of-life outcomes. However, in a follow-up study that I’m not directly involved in — the GAP trial — a similar intervention did help to decrease grades 3 to grade 5 toxic events of treatment and also showed that patients in the intervention group had fewer falls in the 3-month follow-up period. They also had more medications discontinued, so there is some meaningful benefit to geriatric assessment interventions.
Healio: Should all oncologists receive a geriatric assessment report on their patients undergoing cancer treatment?
Jensen-Battaglia: This is a complicated question. The simple answer is yes. In an ideal world, we want oncologists to have all the information they need about these aging-related domains. Typically in a geriatric assessment, these include not only physical performance and functional status, but also comorbidities, cognition, nutrition, social support, polypharmacy and psychological status. When you put all that together, it really helps us to get a picture of the patient’s health as a whole and how you can support them through their cancer care process.
On the other side of the argument, it isn’t easy to get all this within 2 or 3 minutes of an office visit. Geriatric assessment takes time for the patient and for the clinician administering the assessment. There is definitely some burden associated with it. I would argue that the benefit outweighs the burden, but I can’t deny that there are some practical realities to getting through all those pieces. There is a lot of good literature out there on trying to understand what is feasible and how to optimize geriatric assessment.
Healio: Is there anything else you’d like to mention on this topic?
Jensen-Battaglia: One of the traditional ways to assess functional status is with the Karnofsky Performance Scale. This was collected in our study, but we found it wasn’t as sensitive in detecting some of the deficits that we found through the short physical performance battery, or just through asking patients about their experience with daily living. This has been shown in other literature, but our findings appear to confirm it. It is important to ask patients these types of questions and use measures that are sensitive to change.
For more information:
Marielle Jensen-Battaglia, PT, DPT, can be reached at University of Rochester, 265 Crittenden Blvd., Rochester, NY 14542; email: email@example.com.