Time to Stop Saying Geriatric Assessment Is Too Time Consuming.

Aging makes us increasingly unique. A group of older patients with cancer of identical chronologic age will demonstrate great heterogeneity with regard to vitality, comorbidity, functional status, physiologic reserves, and psychosocial functioning. Thus, age alone is an insufficient surrogate for biologic aging. Similarly, commonly used unidimensional measures, such as performance status or the American Society of Anesthesiologists classification, cannot fully do justice to this heterogeneity. Despite accumulating evidence regarding the value of geriatric assessment (GA) to encompass the diversity of older patients, it seems almost requisite in literature and presentations on GA in cancer care to state that it is too time consuming to implement in daily oncology practice. In our opinion, this complaint is ill founded and should be retired. With the imminent aging of Western societies, the number of older patients with cancer is rapidly increasing. In fact, almost 70% of the patients sitting in front of you, as a cancer specialist, will be age 65 years or older by the year 2030. This demographic shift mandates a closer look at aging-related issues that older patients face, which persist and coexist with a new cancer diagnosis. In fact, such issues may be exacerbated by cancer symptoms and treatment—for example, increased risk of falls because of chemotherapy-related neuropathy in an older adult with limited mobility. As their patient population ages, cancer specialists increasingly have to make complex treatment decisions in older patients with comorbidities and functional impairment. This requires some familiarity and experience with geriatric care components. To address this demographic development, research on the incorporation of geriatric concepts into oncologic care beganmore than 20 years ago. Cancer specialists adopted the geriatric concept of frailty—a state of decreased physiologic reserve caused by the accumulation of aging processes across multiple organ systems, which affects the patient’s resistance to stressors such as cancer or cancer therapy. In addition, the GAwas adopted for assessing the presence of impairments (eg, in cognition or mobility) and overall health status. Multiple resources now exist for oncologists wanting to implement a GA in clinical practice, such as the Web sites of the International Society of Geriatric Oncology, American Society of Clinical Oncology, Cancer and Aging Research Group, andMoffitt Cancer Center, as well as National Comprehensive Cancer Network older adult oncology guidelines. In geriatric medicine, comprehensive GA (CGA) is “a multi-dimensional, interdisciplinary, diagnostic process to identify care needs, plan care, and improve outcomes of frail older people. ” CGA encompasses multiple domains beyond a traditional medical assessment, including functional status, cognition, psychological health, and socioenvironmental factors. Tailored interventions are subsequently recommended, such as nutritional supplements or home nursing to help with medications. Furthermore, an important aspect of CGA is to discuss the patient’s preferences and treatment goals so that the care plan reflects these crucial aspects of care. Although it is a time-consuming process, CGA has been proven to decrease mortality and care dependence, and is the essence of geriatric medicine. In geriatric oncology, a modified version of CGA, simply named GA, has been proposed and studied extensively in various tumor types and treatment settings. The multidimensional character has been maintained, but with a simplified process, focusing primarily on identifying health issues that may affect treatment tolerance and prognosis. In this form of GA, many of the data are collected by patient or caregiver self-report, sometimes electronically. Only certain components, including the cognitive screen and physical performance tests (eg, Timed Up and Go test), require any health care provider time. Typically, such assessments can be performed by a nurse. Estimates of the total time required are 22 to 27 minutes, with 15 to 23 minutes being completed by the patient and caregiver and only 5 to 6 minutes by the health care provider. Provided that an intervention protocol is in place, there are no differences between assessments performed by a geriatrician or a trained health care worker in the proportion of patients for whom oncologic treatment decisions are altered, nor are there differences in the use of nononcologic interventions to optimize health status. Although completion of a series of screening instruments does not allow for actual clinical diagnosis of an underlying illness, such as depression or dementia, these instruments are quick and valid methods for identifying areas that may be impaired and acquiring an overall impression of a patient’s health status. What do the data show about the utility of GA in oncology? Even in patients with a good performance status, GA can identify multiple geriatric impairments. Additionally, among older patients beginning a course of chemotherapy, GA predicts toxicity. In the Cancer and Aging Research Group model, which includes GA parameters such as mobility and falls, the lowest-risk group had a 25% rate of grade 3 to 5 toxicity, whereas the highest-risk group had an 89% risk of grade 3 to 5 toxicity. The area under the