Community Oncologists' Decision-Making for Treatment of Older Patients With Cancer

Abstract

Background This study’s objectives were to describe community oncologists’ beliefs about and confidence with geriatric care and to determine whether geriatric-relevant information influences cancer treatment decisions. Methods Community oncologists were recruited to participate in two multi-site geriatric oncology trials. Participants shared their beliefs about and confidence with caring for older adults. They were also asked to make a first-line chemotherapy recommendation (combination vs. single-agent vs. no chemotherapy) for a hypothetical vignette of an older patient with advanced pancreatic cancer. Each oncologist received one randomly-chosen vignette that varied on three variables: age (72/84 years), impaired function (yes/no), and cognitive impairment (yes/no). Other patient characteristics were held constant. Logistic regression models were used to identify associations between oncologist and vignette-patient characteristics with treatment decisions. Results Oncologist response rate was 61% (n=305/498). The majority of oncologists agreed that “the care of older adults with cancer needs to be improved” (89%) and that “geriatrics training is essential” (72%). However, less than 25% were “very confident” in recognizing dementia or conducting a fall risk or functional assessment, and only 23% reported using the geriatric assessment (GA) in clinic. Each randomly varied patient characteristic was independently associated with the decision to treat: younger age (adjusted OR: 5.01; 95% CI: 2.73–9.20), normal cognition (5.42; 3.01–9.76), and being functionally intact (3.85; 2.12–7.00). Accounting for all vignettes across all scenarios, 161 (52%) said they would offer chemotherapy. All variables were independently associated with prescribing single-agent over combination chemotherapy (older age: 3.22; 1.43–7.25; impaired cognition: 3.13, 1.36–7.20; impaired function: 2.48; 1.12 –5.72). Oncologists’ characteristics were not associated with decisions about providing chemotherapy. Conclusion Geriatric-relevant information, when available, strongly influences community oncologists’ treatment decisions.

Cachexia and Sarcopenia in Older Adults with Cancer: A Comprehensive Review

“…One fundamental strategy is the use of a GA in the oncology clinic, which is recommended for all older adults with cancer by the American Society of Clinical Oncology (ASCO), the National Comprehensive Cancer Network, and the International Society of Geriatric Oncology [43,[48][49][50]. Despite these recommendations, the implementation of the GA in daily oncology practice has been slow; this is, in part, due to the perception that it is time consuming [51]. However, the ASCO guideline notes that the GA is feasible to complete in both clinical trials and in the oncology clinic, takes about 20-30 minutes to complete, and can be obtained via a paper or electronic record [43].…”

Geriatric Assessment in Older Patients with Acute Myeloid Leukemia

“…Both aforementioned studies demonstrated that a geriatric assessment could be helpful in guiding treatments. When relevant geriatric information is available to oncologists, it has been shown that treatment decision-making does change [ 38 , 39 ]. While geriatric assessment-guided AML studies are lacking, available data from varied settings do suggest that if geriatric assessment information is available to oncologists, decisions to treat more or less aggressively are altered; some patients receive more aggressive treatment based on evidence of fitness and others receive less aggressive therapies once existing vulnerabilities or frailty are demonstrated.…”

First person profile: Supriya G. Mohile, MD, MS

“…Dr. Mohile and Dr. Dale are currently examining how GAs can be further integrated into oncology clinics to improve patient care. “Community oncologists want to do these assessments, but we found that less than 25% were using them,” Dr. Mohile says. “We have to change the practice structure so it's amenable to doing GAs.”…”