Comprehensive,Geriatric,Assessment, - - PowerPoint PPT Presentation

Comprehensive,Geriatric,Assessment,

Achieving)pa,ent.centered)cancer)care) Pierre,Soubeyran,

Medical)Oncology,)Bordeaux,)France)

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Health,status9adapted,cancer,care,

Balance)of)risks)and)benefits)

• Benefits,iden=cal,whatever,age,

– Response)to)treatment)and)disease)control) – Quality)of)life)improvement)

• Risks,higher,in,the,elderly,
• Heterogeneity,of,problems,encountered,

– Age.related)physiological)problems) – Elderly.specific)problems)at)baseline))

• cogni(on,"nutri(on,"func(onal"impairment,"social"problems,"…"

– Elderly.specific)outcome)during)treatment))

• confusion,"loss"of"weight,"func(onal"decline,"…"

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How,to,design,treatment,, with,appropriate,, efficacy,/,toxicity,ra=o,?,

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In9depth,evalua=on,of,health,status,

• Standard,evalua=on,

– Performance)status) – Organ)func,on)

• Crea(nine"clearance"
• Liver"tests…"

– Nutri,onal)status)

• Weight,"albumin…"
• Geriatric,assessment,

– Designed)for)the)oldest) – To)be)implemented)in)oncology)

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Which,tools,to,be,used,?,

• Domains,to,be,explored,

– Comorbidi,es:) )CIRS.G) – Cogni,on:) )MMSE) – Nutri,on:) )weight,)albumin,)MNA) – Dependencies:) )BADL,)IADL) – Mood:) )GDS) – Falls: )Timed)Get)up)and)go) – Geriatric)syndroms)

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Which,tools,to,be,used,?,

• Domains,to,be,explored,

– Comorbidi,es:) )CIRS.G) – Cogni,on:) )MMSE) – Nutri,on:) )weight,)albumin,)MNA) – Dependencies:) )BADL,)IADL) – Mood:) )GDS) – Falls: )Timed)Get)up)and)go) – Geriatric)syndroms)

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To,which,purpose,?,

Which,events,to,predict,?,

Soubeyran)JCO)2012) Soubeyran)ASCO2012) Warkus)SIOG2011) 364 patients Early death < 6 m.

Odd ratio (95% CI)

Functional decline

Odd ratio (95% CI)

Hospitalization for toxicity

Odd ratio (95% CI)

Events 59/339 50/299 47/354 Extension (M+ vs M-) 4.1 (1.65-10.1) Sex 2.62 (1.31-5.28) Platelet count <150 G/l 3.8 (1,3-10,8) Clinician opinion ns 0.51 (0,26-0,99) PS ns ns MNA ≤,23.5 2.91 (1.31-56.48) ns 4.19 (1,7-10,3) Get up and go > 20 s 2.51 (1,31-4,82) ns IADL ≤)7 ns 3 (1,13-8,09) GDS15 ≥6 2.4 (1,23-4,66) MMS ns ns ADL ns CIRS-G

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Predic=on,of,toxicity,

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Arti Hurria, J Clin Oncol 2011;29:3457-65 Martine Extermann, Cancer 2012;118:3377-86

Predic=on,of,toxicity,

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Arti Hurria, J Clin Oncol 2011;29:3457-65 Martine Extermann, Cancer 2012;118:3377-86

Geriatric,assessment,tools, can,be,useful,to,manage, elderly,pa=ents,

CGA,is,=me9consuming,:,screening,tools,

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CGA,is,=me9consuming,:,screening,tools,

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SeMng:,Pa=ents,>70,with,cancer,

Impaired,MGA,if,,

≥,one,abnormal,ques=onnaire,

– CIRS.G):) )at)least)one)grade)≥) 3) – ADL):) )score)≤) 5) – IADL):) )score)≤) 7) – Timed)Get)up)and)Go):) )>)20) s) – MNA):) )score)≤) 23,5) – MMSE):) )score)≤) 23) – GDS.15):) )score)≥) 6)

Gold,standard:,Impaired,Mul=dimensional,Geriatric,Assessment,(MGA),

CGA,is,=me9consuming,:,screening,tools,

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SeMng:,Pa=ents,>70,with,cancer,

Impaired,MGA,if,,

≥,one,abnormal,ques=onnaire,

– CIRS.G):) )at)least)one)grade)≥) 3) – ADL):) )score)≤) 5) – IADL):) )score)≤) 7) – Timed)Get)up)and)Go):) )>)20) s) – MNA):) )score)≤) 23,5) – MMSE):) )score)≤) 23) – GDS.15):) )score)≥) 6)

Gold,standard:,Impaired,Mul=dimensional,Geriatric,Assessment,(MGA),

Se Sp PPV NPV K Time

(mn)

G8 76.6%

(74-79)

64.4%

(58.6-70)

89.6%

(87.6-91.5)

40.7%

(36.1-45.4)

0.65 4.4 +/- 2.9 VES13 68.7%

(65.9-71.4)

74.3%

(68.8-79.3)

91.5%

(89.4-93.3)

37.1%

(33.2-41.3)

0.64 4.3 +/- 4.6

CGA,is,=me9consuming,:,screening,tools,

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SeMng:,Pa=ents,>70,with,cancer,

Impaired,MGA,if,,

≥,one,abnormal,ques=onnaire,

– CIRS.G):) )at)least)one)grade)≥) 3) – ADL):) )score)≤) 5) – IADL):) )score)≤) 7) – Timed)Get)up)and)Go):) )>)20) s) – MNA):) )score)≤) 23,5) – MMSE):) )score)≤) 23) – GDS.15):) )score)≥) 6)

Gold,standard:,Impaired,Mul=dimensional,Geriatric,Assessment,(MGA),

Se Sp PPV NPV K Time

(mn)

G8 76.6%

(74-79)

64.4%

(58.6-70)

89.6%

(87.6-91.5)

40.7%

(36.1-45.4)

0.65 4.4 +/- 2.9 VES13 68.7%

(65.9-71.4)

74.3%

(68.8-79.3)

91.5%

(89.4-93.3)

37.1%

(33.2-41.3)

0.64 4.3 +/- 4.6

CGA,is,useful, And,screening,of,feasible,

How,to,organize,?,

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Standard Management

Evaluation and cautious management

G8 Screening >14 ≤ 14

How,to,organize,?,

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Standard Management

Selection procedure

MGA ? CGA ? Other ?

G8 Screening >14 ≤ 14

Cautious Management

Oncologist + Geriatrician

CHU,H,Mondor ,

CHU,La,Pi=é/C,Foix,

Lille, , CHU/CLCC,

Dijon, CHU/CLCC/ CH/, Cl,Privées,

Lyon, CHU/CLCC/Cl, Privées,

Marseille, CLCC/CDG,,

Toulouse, CHU/CLCC,

CHU/CLCC/CH,, Clermont, Ferrand,

Limoges, CHU/Cl., Privées,

Bordeaux, CHU/CLCC,

CHU/ CLCC, Rouen,

Str CHU

Nantes/Angers, CHU/CLCC, CH,La,Roche/Yon,

How,to,organize,?,

The)French)UCOG)model)

• Geriatric,Oncology,Coordina=ng,Units,

– 15)already)created)since)2006) – A)few)more)to)be)accredited)soon)

• Main,goals,of,the,UCOG,in,each,region,

– Organize)cancer)care)for)older)pa,ents) – Par,cipate)to)teaching)and)training) – Perform)research)in)the)geriatric)oncology)field) – Inform)pa,ents)and)public)

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How,to,organize,?,Other)proposals)

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Age,,CIRS9G,,ADL, Geriatric,syndromes,

Diffuse,large,B9cell,lymphomas,

Hide,the,results, And,observe,84,,cases,

Unfit, Fit,

CIRS9G,,ADL,,IADL,

Classify, Use,the,results,to,adapt,chemo,, And,treat,100,cases,

Unfit, Fit, Frail, Geriatric,assessments,superior, To,clinical,judgment,, Geriatric,assessments,may,, help,treatment,planning,

Michele'Spina,'The'Oncologist'2012" Alessandra'Tucci,'Cancer'2009'

Classify,

Any,cancer,

Pascal'Chaibi,'CROH'2010' Philippe'Caillet'J'Clin'Oncol'2011'

What,to,do,with,the,results,?,

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• Geriatric,interven=on,

– Laurence)Rubenstein,)N)Engl)J)Med)1984)

• 123"frail"elderly"inpa(ents,"78"y"median"age"
• Randomized"controlled"trial"
• Geriatric"evalua(on"unit"
• Reduced"mortality"at"1"y:"48.3%"to"23.8%"

– Ruth)McCorkle,)JAGS)2000)

• 375"postMsurgical"cancer"pa(ents,"60"to"92"
• Randomized"controlled"interven(on"study"
• Home"care"interven(on"by"advanced"prac(ce"nurses"
• NonMstra(fied"analysis"not"significant"
• Risk"of"death"decreased"in"the"interven(on"group"

– ASer"adjus(ng"for"stage"and"length"of"stay"

Conclusion,

• S=ll,a,lot,to,do,!,
• SIOG,CGA,Task,Force,2012,

– Screening)tools) – CGA)in)geriatric)oncology) – Geriatric)interven,on) – Frailty)

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