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The aim of this systematic review is to summarize all available data on the effect of a geriatric assessment in older patients with cancer, for oncologic treatment decisions, the implementation of non-oncologic interventions, patient-doctor communication, and treatment outcome. Additionally, we examined the impact of the type of assessment used.
Methods
Systematic Medline and Embase search for studies on the effect of a geriatric assessment on oncologic treatment decisions, non-oncologic interventions, communication, and outcome.
Results
Sixty-five publications from 61 studies were included. After a geriatric assessment, the oncologic treatment plan was altered in a median of 31% of patients (range 7–56%), with highest change rates in studies using a multidisciplinary team evaluation. Non-oncologic interventions were recommended in over 70% of patients, provided that an intervention plan or specific expertise was in place. A geriatric assessment led to more goals-of-care discussions and improved communication. The geriatric assessment also led to lower toxicity/complication rates (most strongly if the assessment outcomes were considered during decision making), improved likelihood of treatment completion, and improved physical functioning and quality of life in the majority of included studies.
Conclusion
A geriatric assessment can change oncologic treatment plans, leads to non-oncologic interventions, and improve communication about care planning and ageing-related issues. It can decrease toxicity/complications and improve treatment completion and patient-centred outcomes. If multidisciplinary or geriatric input is not available, having a pre-defined non-oncologic intervention plan is important. To maximize the effect on outcomes, the result of the geriatric assessment should be incorporated into oncologic decision-making.
Cancer mostly affects older adults, and the dilemma of the best treatment for this disease in older patients led to the emergence of the field of geriatric oncology over 25 years ago [
]. Early research focused on demonstrating the heterogeneity in the older population, highlighting that this was insufficiently captured by performance status as included in a standard oncologic workup [
]. Next, the concept of frailty was adopted and evaluated with a geriatric assessment – a multidimensional assessment of health status across somatic, functional, and psychosocial domains that is routinely used in geriatric medicine. This led to studies consistently demonstrating an association between baseline geriatric impairments, frailty, and various adverse outcomes, including complications, toxicity, and mortality, across various cancer and treatment types [
In a systematic review on the effect of a geriatric assessment for the care of older patients with cancer published in 2018 in the Journal of Geriatric Oncology [
], we demonstrated that performing a geriatric assessment could alter oncologic treatment decisions in older adults with cancer and provide opportunities for non-oncologic management [
]. A possible explanation could be that these studies demonstrated that a geriatric assessment led clinicians to change the oncological care they provided for their patients, but evidence that this ultimately improves outcomes that are meaningful to both patients and clinicians was lacking at that time [
]. Since 2018, several clinical trials with landmark potential have been published in the field of geriatric oncology. These have compared outcomes for older patients with cancer who underwent a geriatric assessment – with or without subsequent interventions – to the outcomes in a control group without geriatric assessment and/or follow-up. They represent an important missing piece in the framework of geriatric oncology.
Another question still open to debate is the best way of organising the geriatric assessment in daily practice. Studies have used a range of methods including a geriatric consultation, a questionnaire-based assessment of geriatric domains by a health care professional from the oncology team, or a multidisciplinary team evaluation [
]. Some studies take the outcome of the geriatric assessment into account during oncologic decision-making, while others use the assessment primarily for implementing non-oncologic interventions, with or without a pre-defined intervention plan. This choice could be based purely on pragmatism in relation to local circumstances and resources, but in some situations, multiple options for organising the geriatric assessment and subsequent care process may be feasible. As more data have become available since the previous systematic review, it may now be possible to compare these options with regards to the potential impact on decision-making and the subsequent care trajectory. We therefore felt that an update of the 2018 systematic review was warranted.
The aim of this systematic review was to summarize currently available data on the effect of a geriatric assessment on the treatment of older patients with cancer for oncologic treatment decisions, the implementation of non-oncologic interventions, doctor-patient communication, and the impact on treatment outcome. A second aim was to assess differences in impact based on the way the geriatric assessment is implemented.
2. Methods
2.1 Search strategy and article selection
For this systematic review, ethics review was not required. The following search was performed on December 16, 2021 in both Medline and Embase: (frailty[tiab] OR frail[tiab] OR geriatrics[MeSH] OR “Geriatric Assessment”[MeSH] OR geriatric*[tiab] OR elderly care[tiab] OR elderly medicine[tiab]) AND (neoplasm[MeSH] OR cancer[tiab] OR tumour[tiab] OR tumour[tiab] OR tumours[tiab] OR tumours[tiab] OR neoplasm[tiab] OR malignan*[tiab] OR oncol*) AND (multidisciplin*[tiab] OR interdisciplin*[tiab] OR team*[tiab] OR tumour board*[tiab] OR tumour board*[tiab] OR conference*[tiab] OR meeting*[tiab] OR decision*[tiab] OR decision making[tiab] OR decision-making[tiab] OR treatment choice*[tiab] OR intervention*[tiab] OR management[tiab] OR prehabilitation[tiab] OR communication[tiab] OR discussions[tiab] OR conversation*[tiab]). MeSH refers to medical subheading, tiab refers to title and abstract. As this was an update of an earlier search, publication date was truncated at December 2017. No limits in age or language were applied.
For this systematic review, a geriatric assessment could consist of a geriatric consultation, an assessment by the oncology team, or a multidisciplinary team evaluation. We defined a geriatric consultation (C) as a consultation with a geriatrician or specialist in elderly medicine. An assessment by the oncology team (O) was defined as a questionnaire-based assessment performed by a cancer specialist or a health care provider (such as a nurse) working with the cancer specialist, focussing on at least three geriatric domains (cognition, mood/depression, nutritional status, activities of daily living, instrumental activities of daily living, comorbidity, polypharmacy, mobility/falls, or frailty), investigated with validated assessment tools. A multidisciplinary team evaluation (M) was defined as an assessment of at least three geriatric domains performed by two or more (para)medical health care professionals (e.g., physiotherapist, nutritionist, social worker).
Studies were included if they fulfilled the inclusion criteria for one or more of four outcome measures. The first outcome measure was any alteration in oncologic treatment plan after the geriatric assessment. For this outcome measure, studies were included if a treatment plan was determined both prior to and after the geriatric assessment or if a comparison was made between treatment choice in patient cohorts with and without a geriatric assessment. The second outcome measure was the number and type of recommendations for non-oncologic interventions directly resulting from the findings of the geriatric assessment. The third outcome measure was the effect of the geriatric assessment on patient-doctor communication, for example differences in the content of doctor-patient conversations, care planning, or patient satisfaction with the communication process. The final outcome measure was the effect of the geriatric assessment on outcome of treatment, i.e., toxicity or treatment-related complications, treatment completion, quality of life or physical functioning, mortality, and health care utilisation (such as hospitalisation, length of stay). For both effect on communication and on outcome of treatment, studies were only included if they had a control group which did not undergo a geriatric assessment, and/or if the study had a control group that did not receive geriatric interventions or follow-up whilst the intervention group did. The control groups had to be either based on randomisation or historic/matched cohorts. Studies using a control group that was likely to be subject to confounding or selection bias were excluded (for example, if only vulnerable patients were referred for a geriatric assessment and the control group consisted of non-vulnerable patients). These studies could still be included for other outcome measures.
The titles and abstracts of all studies retrieved by the search were assessed by one reviewer (MH) to determine which warranted further examination. All potentially relevant articles were subsequently screened as full text by two authors (MH and CL/SR). Studies were excluded if they were not written in English or Dutch. If only an abstract was available, an effort was made to find the final report of the study by searching Embase and Medline using the names of the first, second, and/or final author as well as key words from the title. If multiple publications were available from one study, the primary publication was included. If a secondary manuscript contained relevant outcomes that were not included in the primary publication, both were included together. Finally, references of included publications were cross-referenced to retrieve any additional relevant citations.
In addition, all studies from the 2018 systematic review [
] were checked to assure that the most recent/complete version was included in the current review.
2.2 Data extraction
For each eligible study, the following data were independently extracted by two investigators (MH, CL): type of study, study setting, study population (age, sex, cancer type), method of patient selection, the type of control group if present, type of geriatric assessment, the frequency and types of changes in treatment after the geriatric assessment, the number and type of (recommended) non-oncologic interventions, whether or not the study used a pre-defined protocol for non-oncologic interventions, changes in communication/care planning, and finally, the change in treatment outcomes, i.e., toxicity or treatment-related complications, treatment completion, quality of life or physical functioning, mortality, and health care utilisation (hospitalisation, readmissions, length of stay). For studies assessing change in treatment outcomes, we also extracted whether or not the geriatric assessment was taken into account during oncologic treatment decisions, and whether or not the study included interventions or follow-up with regards to geriatric impairments highlighted by the geriatric assessment.
2.3 Quality assessment
The methodological quality of each of the studies was independently assessed by two reviewers (MH, CL), using the Newcastle-Ottawa Scale adapted to this subject (Appendix 1a) [
]. Disagreement among the reviewers was discussed during a consensus meeting.
2.4 Data synthesis and analysis
We summarized the study results to describe our main outcomes of interest. Data on the proportion of patients for whom the oncologic treatment plan was changed after a geriatric assessment, and on the proportion of patients with one or more non-oncologic recommendations, were pooled according to the three models of geriatric assessment: geriatric consultation, assessment by the oncology team performed by a cancer specialist or a health care provider working with the cancer specialist, or multidisciplinary team evaluation, as detailed in the section on study selection. Organisation parameters were presence/absence of a predefined intervention plan, and whether the outcome of the assessment was included in the decision making. Pooled data were subsequently compared using a validated online chi-square calculator [
For studies assessing treatment outcomes and course of treatment, intervention methodology was too heterogenous to permit pooling of data; descriptive statistics were used instead. To account for the potential impact effect of study size and possible power issues with regards to outcomes, sensitivity analyses using descriptive statistics were performed to assess subgroups based on the size of the study population (above or below the median study size).
3. Results
3.1 Study characteristics
The 2021 literature search identified 5202 citations (1758 from Medline and 3444 from Embase), of which 1243 were duplicates. Details on the search and reasons for exclusion can be found in Fig. 1. After exclusion of 3933 publications, 26 publications from 25 studies were included [
Communication with older patients with Cancer using geriatric assessment: A cluster-randomized clinical trial from the National Cancer Institute Community oncology research program.
Geriatric assessment in older people with myelodysplasia is predictive of azacitidine therapy completion and survival: A prospective interventional study at the royal Adelaide hospital.
Implementation of a preoperative multidisciplinary team approach for frail colorectal cancer patients: influence on patient selection, prehabilitation and outcome.
A prospective study to evaluate the utility of geriatric assessment and intervetnion in patients with lymphoproliferative disorders in a tertiary hospital.
Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non-small cell lung cancer: the Phase III randomized ESOGIA-GFPC-GECP 08-02 Study.
Frennet M Kjcphylv de SHM Impact of comprehensive geriatric assessment (CGA) during oncologic treatment in frail elderly patients. Eur Geriatric Med 2011;(2):S35.
Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly Cancer patients: report on a multicentre, randomized, controlled trial.
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
Pattinson J. SA, CA, MT, MR. Does comprehensive geriatric assessment affect decision-making & outcomes for older adults treated for upper gastro-intestinal cancer. Eur Geriatric Med 2016;7:S101.
Health status, emergency department visits, and oncologists’ feedback: an analysis of secondary endpoints from a randomized phase II geriatric assessment trial.
] with new information for two of these 35 studies, which were also included. Thus, the combined result of the 2018 review and the 2021 update was 65 publications from 61 studies (Fig. 1) [
Communication with older patients with Cancer using geriatric assessment: A cluster-randomized clinical trial from the National Cancer Institute Community oncology research program.
Geriatric assessment in older people with myelodysplasia is predictive of azacitidine therapy completion and survival: A prospective interventional study at the royal Adelaide hospital.
Implementation of a preoperative multidisciplinary team approach for frail colorectal cancer patients: influence on patient selection, prehabilitation and outcome.
A prospective study to evaluate the utility of geriatric assessment and intervetnion in patients with lymphoproliferative disorders in a tertiary hospital.
Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non-small cell lung cancer: the Phase III randomized ESOGIA-GFPC-GECP 08-02 Study.
Frennet M Kjcphylv de SHM Impact of comprehensive geriatric assessment (CGA) during oncologic treatment in frail elderly patients. Eur Geriatric Med 2011;(2):S35.
Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly Cancer patients: report on a multicentre, randomized, controlled trial.
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
Pattinson J. SA, CA, MT, MR. Does comprehensive geriatric assessment affect decision-making & outcomes for older adults treated for upper gastro-intestinal cancer. Eur Geriatric Med 2016;7:S101.
Health status, emergency department visits, and oncologists’ feedback: an analysis of secondary endpoints from a randomized phase II geriatric assessment trial.
The characteristics of these 61 studies are summarized in Table 1. Twenty-eight studies used a geriatric consultation; 17 used an assessment by the oncology team, and in 16 studies the geriatric assessment was performed by a multidisciplinary team. The complete study population consisted of 16,819 patients, of which 74% were included in the studies published between 2018 and 2021. Median sample size was 123 patients (range 15–5631). Mean or median age of the patient populations ranged from 68 to 83 years. Study populations were heterogeneous, with 24 focusing on patients with a specific type of cancer, while the remainder included patients with various cancer types.
Table 1Included studies.
Publication
Study method
Patients
Outcome
Author
Publication year
Abstract (A) or full text (F)
Study population
Patient selection
No. of patients
% male
Me(di)an age in years (range)
Change in cancer treatment plan
Non-oncologic interventions
Effect on communication
Effect on treatment outcome*
Studies using a geriatric consultation performed by a geriatrician (C)
Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly Cancer patients: report on a multicentre, randomized, controlled trial.
Geriatric assessment in older people with myelodysplasia is predictive of azacitidine therapy completion and survival: A prospective interventional study at the royal Adelaide hospital.
Health status, emergency department visits, and oncologists’ feedback: an analysis of secondary endpoints from a randomized phase II geriatric assessment trial.
A prospective study to evaluate the utility of geriatric assessment and intervetnion in patients with lymphoproliferative disorders in a tertiary hospital.
Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non-small cell lung cancer: the Phase III randomized ESOGIA-GFPC-GECP 08-02 Study.
Frennet M Kjcphylv de SHM Impact of comprehensive geriatric assessment (CGA) during oncologic treatment in frail elderly patients. Eur Geriatric Med 2011;(2):S35.
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
Communication with older patients with Cancer using geriatric assessment: A cluster-randomized clinical trial from the National Cancer Institute Community oncology research program.
Pattinson J. SA, CA, MT, MR. Does comprehensive geriatric assessment affect decision-making & outcomes for older adults treated for upper gastro-intestinal cancer. Eur Geriatric Med 2016;7:S101.
Implementation of a preoperative multidisciplinary team approach for frail colorectal cancer patients: influence on patient selection, prehabilitation and outcome.
Overall, 29 studies addressed the comparison between the oncologic treatment plan before and after geriatric assessment, of which 21 described the change in treatment plan for individual patients [
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
Pattinson J. SA, CA, MT, MR. Does comprehensive geriatric assessment affect decision-making & outcomes for older adults treated for upper gastro-intestinal cancer. Eur Geriatric Med 2016;7:S101.
Geriatric assessment in older people with myelodysplasia is predictive of azacitidine therapy completion and survival: A prospective interventional study at the royal Adelaide hospital.
Implementation of a preoperative multidisciplinary team approach for frail colorectal cancer patients: influence on patient selection, prehabilitation and outcome.
A prospective study to evaluate the utility of geriatric assessment and intervetnion in patients with lymphoproliferative disorders in a tertiary hospital.
Frennet M Kjcphylv de SHM Impact of comprehensive geriatric assessment (CGA) during oncologic treatment in frail elderly patients. Eur Geriatric Med 2011;(2):S35.
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non-small cell lung cancer: the Phase III randomized ESOGIA-GFPC-GECP 08-02 Study.
Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly Cancer patients: report on a multicentre, randomized, controlled trial.
The results of the quality assessment can be found in Fig. 2; detailed results per study are listed in Appendix 1b. The overall quality of the studies appeared good, but the risk of bias was unclear or high for about 50% of studies for the outcome ‘adequacy of follow-up’. This is partially due to the fact that for 25 studies, only a conference abstract was available, providing only limited data on the methodology. Seven studies assessing the effect on treatment outcome used matched or historic comparisons [
Pattinson J. SA, CA, MT, MR. Does comprehensive geriatric assessment affect decision-making & outcomes for older adults treated for upper gastro-intestinal cancer. Eur Geriatric Med 2016;7:S101.
Outcomes of a geriatric liaison intervention to prevent the development of postoperative delirium in frail elderly Cancer patients: report on a multicentre, randomized, controlled trial.
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
]. The median proportion of patients in which the treatment plan changed was 31% (range 6–56%), primarily in favour of a less intensive treatment option (median 73% of changes, Appendix 2a).
For the eleven studies using a geriatric consultation [
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
Pattinson J. SA, CA, MT, MR. Does comprehensive geriatric assessment affect decision-making & outcomes for older adults treated for upper gastro-intestinal cancer. Eur Geriatric Med 2016;7:S101.
Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non-small cell lung cancer: the Phase III randomized ESOGIA-GFPC-GECP 08-02 Study.
]. Lung cancer patients in this intervention arm received significantly more combination chemotherapy (45% vs. 35% of patients randomised to usual care), less mono-chemotherapy (31% vs. 65% respectively) and more best supportive care (23% vs. 0%, respectively; overall p-value<0.001). In three other randomised trials comparing patients with and without a geriatric assessment, two found no significant differences between study arms [
]. This trial used an intervention protocol tailored to the outcome of the geriatric assessment, in which reducing dosage was one of the predefined intervention options.
Four studies using historic or matched controls found varying results, with one reporting no difference between geriatric assessment and control patients [
Pattinson J. SA, CA, MT, MR. Does comprehensive geriatric assessment affect decision-making & outcomes for older adults treated for upper gastro-intestinal cancer. Eur Geriatric Med 2016;7:S101.
Geriatric assessment in older people with myelodysplasia is predictive of azacitidine therapy completion and survival: A prospective interventional study at the royal Adelaide hospital.
Implementation of a preoperative multidisciplinary team approach for frail colorectal cancer patients: influence on patient selection, prehabilitation and outcome.
A prospective study to evaluate the utility of geriatric assessment and intervetnion in patients with lymphoproliferative disorders in a tertiary hospital.
Frennet M Kjcphylv de SHM Impact of comprehensive geriatric assessment (CGA) during oncologic treatment in frail elderly patients. Eur Geriatric Med 2011;(2):S35.
The ELAN-ONCOVAL (ELderly heAd and Neck cancer-Oncology eValuation) study: Evaluation of the feasibility of a suited geriatric assessment for use by oncologists to classify patients as fit or unfit.
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