The Comprehensive Geriatric Assessment (CGA) is recommended to guide treatment choices in older patients with cancer. Patients ≥ 70 years referred to our oncology service with a new cancer diagnosis are screened using the G-8. Patients with a score of ≤14 are eligible to attend the Geriatric Oncology and Liaison (GOAL) Clinic in our institution, with referral based on physician discretion. Referred patients undergo multidimensional assessments at baseline. CGA domains assessed include mobility, nutritional, cognitive, and psychological status. Chemotherapy toxicity risk is estimated using the Cancer Aging and Research Group (CARG) calculator. We undertook a retrospective analysis of patients attending the GOAL clinic over a 30-month period to April 2021. The objective was to determine rates of treatment dose modifications, delays, discontinuation, and unscheduled hospitalizations as surrogates for cytotoxic therapy toxicity in these patients. These data were collected retrospectively. Ninety-four patients received chemotherapy; the median age was 76 (70–87) and 45 were female (48%). Seventy-five (80%) had an ECOG PS of 0–1. Seventy-two (77%) had gastrointestinal cancer, and most had stage III (47%) or IV (40%) disease. Chemotherapy with curative intent was received by 51% (n = 48) and 51% received monotherapy. From the CGA, the median Timed Up and Go was 11 s (7.79–31.6), and 90% reported no falls in the prior 6 months. The median BMI was 26.93 (15.43–39.25), with 70% at risk or frankly malnourished by the Mini Nutritional Assessment. Twenty-seven (29%) patients had impaired cognitive function. Forty-three (46%) had a high risk of toxicity based on the baseline CARG toxicity calculator. Twenty-six (28%) required dose reduction, 55% (n = 52) required a dose delay, and 36% (n = 34) had a hospitalization due to toxicity. Thirty-nine patients (42%) discontinued treatment due to toxicity. Despite intensive assessment, clinical optimization and personalized treatment decisions, older adults with cancer remain at high risk of chemotherapy toxicity.
Introduction Medication reconciliation as part of a Comprehensive Geriatric Assessment by a specialist pharmacist is a process that has been shown to be beneficial in terms of medication adherence in patients taking oral anticancer medication and potentially cost-effective in cancer patients. Medication review guidelines in older adults with cancer suggest using polypharmacy (≥ 5 medications) as an indication for medication review in older adults with cancer. Case report We present a case where a medication review as part of a Comprehensive Geriatric Assessment in the absence of polypharmacy resulted in two pharmacist interventions when standard care resulted in no intervention. A 71-year-old male prescribed capecitabine for rectal cancer had a medication reconciliation done as standard care before starting an oral anticancer medication. He then proceeded to get a medication review as part of a Comprehensive Geriatric Assessment and was deemed to have a potentially excessive anticholinergic burden and underprescribed gastro protection. This case is interesting as it occurred in a patient who would not have met the current inclusion criteria for a medication review as part of a Comprehensive Geriatric Assessment. Management and outcome As a result of the Comprehensive Geriatric Assessment, a letter was written to the patient's general practitioner, recommending a change to anti-depressant therapy to optimise anticholinergic burden, as well as introducing a proton-pump inhibitor upon completion of the Capecitabine protocol concurrent with radiotherapy, to confer gastro-protection against the antidepressant medication, as per the START criteria. Upon discharge from medical oncology, neither of the changes had been adopted by the patient's general practitioner. This highlights one of the challenges facing clinical pharmacists in an outpatient setting, where evidence-based recommendations are not always implemented as care transitions from tertiary to primary care. Conclusion Comprehensive Geriatric Assessment is a process that identifies potential issues in older adults with cancer that aren’t identified with standard medication review. This is also evident for medication reviews as part of a Comprehensive Geriatric Assessment, and where resources allow, and recommendations are likely to be accepted, it should be offered to all older adults with cancer. Pharmacists are still faced with challenges in implementing recommendations from medication reviews, particularly in healthcare systems where pharmacist prescribing has yet to be introduced.
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