The decision-making process in older patients with cancer is challenging. In our study population, the initial cancer treatment plan was deemed inappropriate for 16.6% of patients. A low MMSE score, malnutrition, and low physical performances were independently associated with the risk to judge the treatment inappropriate.
In previous studies exploring the impact of geriatric evaluations on treatment decisions in older patients with cancer, the oncologic treatment was modified in 8 to 54% of all patients (with a median of 28%) (14). In our study, the initial treatment was judged inappropriate and modified in only 14.6% of patients. This difference may be difficult to compare with previous studies because of the populations heterogeneity, the various types of cancer, the various geriatric evaluations and different settings (14). Nevertheless, oncogeriatric evaluation has been implemented in clinical routine for a few years in our clinical setting (25), and may have influenced and improved decision-making in this discipline. In addition, geriatric treatment recommendations were closely followed-up by the oncologist when the initial treatment plan was judged inappropriate (in 91.1% of patients).
Malnutrition is significantly associated with the risk to judge the treatment inappropriate. In cancer treatment, malnutrition is a substantial parameter to consider, because of its association with treatment toxicity and mortality (26). Our results are consistent with past studies exploring CGA parameters associated with cancer treatment changes. In two studies, a low BMI under 21 kg/m2 was associated with a modification of the cancer treatment plan (27,28), and according to Caillet et al. malnutrition evaluated by MNA, BMI, weight loss or low serum albumin was also associated with changes in cancer treatment (mainly a decrease in treatment intensity) (29). In our analysis, malnutrition was defined only with the MNA score, which may have underestimated the prevalence of malnutrition in this population.
Another CGA parameter significantly linked with cancer treatment change is a MMSE score under 24. Even if there is evidence that cognitive impairment is associated with cancer mortality or the probability of not completing chemotherapy (30–32), the impact of cognitive impairment or dementia on chemotherapy tolerance, hospitalizations or patient-reported outcome measures remains quite unclear (33). In our knowledge, only one study concluded that a low MMSE score (<26) was associated with cancer treatment change, specifically in lung cancer (34). The impact of pre-existing cognitive-impairment on cancer-related outcomes needs to be clarified to improve cancer decisions and care in older adults.
In this study, low physical performances defined by a SPPB score less or equal to six, are associated with an increase risk to judge the treatment inappropriate. Physical performances tests reflect well frailty in oncogeriatric patients and are easy and rapid to use in clinical settings. In previous studies exploring the effect of CGA on treatment decisions, physical performances were not systematically tested or were sometimes limited to the number of falls (27,28,35). According to Farcet et al., the number of Fried’s criteria was significantly associated with a modification of the initial cancer treatment plan (36). In our study, frailty according to the same definition, was not significantly associated with change in treatment plan. As most of the patients were frail or prefail (only 8% were robust), it is possible that clinicians did not use this information to judge the initial treatment decision, but based their judgment mainly on the results of the SPPB which seems to offer a better discrimination of subjects with poor physical performances. This is the first time that the SPPB score is identified as a test that could be useful to modify treatment decision in oncogeriatric patients. Its use in routine should be considered when evaluating oncogeriatric patients.
This study presents some limitations. First, some parameters usually assessed in a geriatric evaluation (such as mood, BMI, or weight loss), were not systematically recorded in our dataset and were not exploitable in this analysis. Then, the geriatric assessment was operated in only one hospital, by the same medical team, which may prevent reproducible research in other clinical settings. Moreover, oncologists referred patients to the frailty clinic without using an identified screening tool, but mainly according to their clinical judgment (if the patient seems frail or not); nevertheless the evaluation of the G-8 score during the day hospital assessment shows that their clinical impression was good. Finally, our population cancer type was heterogeneous: specific studies should be planned in the most prevalent cancers and according to the type of treatment. This study has also several strengths: this is one of the few studies to evaluate the role of physical performances defined by frailty, SPPB or gait speed in treatment decision in oncogeriatric patients. We used only international validated tools to assess domains of the CGA, as part of a multidisciplinary evaluation (5), and the median age was relatively high compared to other studies (83 years).