Janine Overcash, RN, ARNP
As the number of older Americans increases,
so will the number of incident cancers.
1 According to the US
Bureau of Census in 1993, projected estimates indicate that 14% of the
total population will be over the age of 65 by the year 2010, with Florida
having the highest percentage of elderly at almost 20%. With this forecasted
increase in the number of older Americans with cancer, it is important
to have an oncology program specially designed for the geriatric oncology
patient.
Some of the problems that often plague the older
cancer patient can be identified with the Comprehensive Geriatric Assessment
(CGA). Results obtained using the CGA in an outpatient oncology setting
are presented. The purpose of this project was to describe the results
of the CGA when used with a senior adult oncology population.
Comprehensive Geriatric Assessment
The CGA was administered upon initial visit to the Senior
Adult Oncology Program (SAOP) at the H. Lee Moffitt Cancer Center &
Research Institute at the University of South Florida in Tampa. The project
included 470 patients who ranged in age from 70 to 91. The CGA is an instrument
commonly used in geriatrics that involves a series of assessments focused
on screening for potential or existing problems that may be experienced
by the older person. The CGA is usually administered by a multidisciplinary
team of professionals, with each team member performing his or her discipline-specific
portion of the instrument. The CGA can be vital to the older cancer patient
in that hidden diagnoses or problems may be found and corrected, which
may promote a positive cancer therapy outcome. The CGA can be administered
in an outpatient setting in an ambulatory clinic or in an inpatient setting.
Some of the issues assessed by the CGA are polypharmacy, malnutrition,
comorbidities, functional status, depression, dementia, and psychosocial
difficulties. These are common problems that affect many older people and
can be a confounding factor to cancer treatment.
The SAOP is composed of a multidisciplinary team
and was developed to offer cancer care to the older cancer patient. The
CGA administered for the project consisted of the Katz Index of Activities
of Daily Living (ADL),2 Lawton Instrumental Activities of Daily
Living (IADL),3 Eastern Cooperative Oncology Group Performance
Status (ECOG PS),4 Folstein Mini-Mental State Examination,5
and Yesavage Geriatric Depression Scale.6 Malnutrition, polypharmacy,
and psychosocial status were assessed by the dietitian, pharmacist, and
social worker, respectively. Demographics such as age, diagnosis, tumor
stage at initial presentation, and tumor stage at presentation to SAOP
were collected. Data collection began in August 1994 and continues as new
patients enter into the SAOP. The average time required to compete the
CGA was 2.5 hours. Each case included in the project was discussed at a
weekly team conference, and further treatment plans were developed when
necessary.
Results
ADL revealed 20% were functionally dependent or required
assistance. IADL showed 55% required assistance. The Yesavage Geriatric
Depression Scale found that 23% of patients screened positively for depression
and 15% screened positively for dementia. Upon assessment of malnutrition,
30% had fair or poor nutritional status. Fifty-seven percent of patients
were taking three or more medications, 35% were taking five or more, and
7% were taking 10 or more. The ECOG PS found that 20% of the subjects had
a poor performance status of 2.0 or more. The mean number of comorbidity
was 3.5. Arthritis was the most common comorbidity, followed by hypertension.
The CGA is a useful tool for assessment and treatment
planning in the older cancer patient. A significant number of patients
present with functional limitations, dementia, and depression that might
not be detected without the use of a CGA.
References
1. Polednak AP. Projected numbers of cancers diagnosed in the US elderly
population, 1990 through 2030. Am J Public Health. 1994;84:1313-1316.
2. Katz S, Ford AB, Moskowitz RW, et al. Studies of illness in the aged.
The index of ADL: a standardized measure of biological and
psychosocial function. JAMA. 1963;185:94-99.
3. Lawton MP, Brody EM. Assessment of older people: self-maintaining
and instrumental activities of daily living. Gerontologist. 1969;9:179-186.
4. Zubrod CG, Scheiderman M, Frei E, et al. Appraisal of methods for
the study of chemotherapy in man: comparative therapeutic trail of nitrogen
mustard and trimethylene thiophosphoramide. J Chronic Dis. 1960;11:7-33.
5. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical
method for grading the cognitive state of patients for the clinician. J
Psychiatr Res. 1975;12:189-198.
6. Yesavage JA, Brink TL, Rose TL, et al. Development and validation
of a geriatric depression screening scale: a preliminary report. J Psychiatr
Res. 1982;17:37-49.
Selected References
Extermann M, Overcash J, Lyman GH, et al. Comparison of the Cumulative
Illness Rating Scale - Geriatric (CIRS-G) with the Charlson Comorbidity
Scale in older cancer patients. J Clin Oncol. 1998. In press.
Overcash J. The case for a geriatric oncology program in a cancer center.
In: Balducci L, Lyman GH, Ershler W, eds. Comprehensive Geriatric Oncology.
London, England: Harwood Academic Publishers; 1997.