Page 27 - Haematologica - Vol. 105 n. 6 - June 2020

Geriatric assessment in older patients with a hematologic malignancy
However, it can be difficult to deliver optimal cancer treatment tailored to individual needs of an older patient, particularly as older patients are frequently excluded from clinical trials.7 Older patients constitute a heterogeneous population due to large differences in comorbidity, func- tional capacity and psychological and physical reserves. As a result, the benefit of treatment can differ and patients with comorbidity or geriatric impairments are particularly at risk of adverse health outcomes. Choosing the optimal treatment for these patients is a challenge.
It is therefore recommended that the degree of frailty of older patients is assessed.8 Frailty is a biological syndrome which can exist alongside age, comorbidity or disease characteristics. Over the years, numerous definitions of frailty have been formulated and there is still no consensus on a definition.9 There are two commonly used approach- es to define frailty. The first defines frailty based on phe- notypic criteria including reduced grip strength, walking speed, physical capacity, level of energy and weight loss. Patients are considered frail if three or more criteria are present.10 The second approach proposes a frailty index which is an accumulation of patient’s deficits. These deficits consist of physical or cognitive symptoms, func- tional impairments, abnormal laboratory values and comorbidities.11,12 In daily practice, frailty is a dynamic state which needs a multidimensional approach and might have various implications in different scenarios.
An appropriate method to assess the level of frailty of older patients is a geriatric assessment.8,13 This consists of a systematic assessment of an older patient’s health status focusing on somatic, psychological, functional and social domains. Different tools can be used to detect geriatric impairments in these domains.14 Moreover, frailty screen- ing tools were developed in order to identify older patients who require a full geriatric assessment.15 Nowadays, some form of geriatric assessment is increas- ingly incorporated in hemato-oncologic care to customize hemato-oncologic treatment.16
In 2014, we published a systematic review on the value of performing a geriatric assessment in older patients with a hematologic malignancy, demonstrating that such an assessment can detect multiple health issues and has pre- dictive value for clinical outcome in older patients with a hematologic malignancy.17 However, evidence was limited, especially regarding clinical outcomes such as treatment- related toxicity, treatment completion or physical function- ing after treatment. Since then, many new studies have been published on this subject. The aim of this present sys- tematic review is, therefore, to give an update of all cur- rently available data on the association between geriatric impairments and hematologic cancer-related outcomes.
Methods
Search strategy and article selection
Our aim was to identify studies concerning patients with a hematologic malignancy in which a geriatric assessment was used to detect geriatric impairments or which addressed the association between baseline geriatric assessment and outcome.
Geriatric assessment was defined as an assessment composed of at least two of the following domains: cognitive function, mood, nutritional status, activities of daily living (ADL), instru- mental activities of daily living (IADL), polypharmacy (using five or more drugs), objectively measured physical capacity (for
instance, gait speed, hand grip strength or balance tests), social support and frailty (assessed with a frailty screening tool or by summarizing the geriatric assessment). As prior medical history/comorbidity and performance status are routine parts of the hematologic work-up, these were not counted as domains of the geriatric assessment for this particular systematic review. The following items were defined as outcomes: prevalence of geriatric impairments, change in oncologic treatment plan, toxicity of chemotherapy, healthcare utilization, physical functioning after treatment, quality of life after treatment and mortality.
The following search was performed on March 4, 2019 and updated on January 20, 2020, in both MEDLINE and EMBASE: ((("Hematologic Neoplasms"[Mesh] OR "Leukemia"[Mesh] OR "Lymphoma"[Mesh] OR "Multiple Myeloma"[Mesh] OR "Myelodysplastic Syndromes"[Mesh] OR leukemia[tiab] OR leukaemia[tiab] OR lymphoma*[tiab] OR hodgkin*[tiab] OR non- hodgkin*[tiab] OR (multiple myeloma[tiab]) OR myelodysplas*[tiab] OR (haematolog* AND malignan*[tiab]) OR (hematolog* AND malignan*[tiab]) OR (myeloid[tiab] OR lym- phoid[tiab] AND neoplas*[tiab]) OR myeloproliferative[tiab] OR (plasma cell neoplas*[tiab]) OR plasma cell dyscrasia*[tiab] OR (myeloid[tiab] AND sarcoma*[tiab]) OR waldenstrom[tiab] OR myelofibrosis[tiab] OR mastocystosis[tiab] OR (polycyth* AND vera[tiab]) OR (essential AND thrombocyt*[tiab]))) AND (("frailty"[All Fields] OR "Geriatric Assessment"[Mesh] OR frail*[tiab] OR vulnerabl*[tiab] OR geriatric assessment*[tiab] OR geriatric*[tiab]))
No age or language limitations were applied. All search results until 2013 were reviewed previously by Hamaker et al.17 We therefore limited our search to studies published after January 1, 2013. The titles and abstracts of all studies retrieved by the search were assessed by one reviewer (ES) to determine which warranted further examination.The full texts of all potentially relevant articles were subsequently screened. We excluded stud- ies that did not focus exclusively on hematologic malignancies. Finally, references of included studies were cross-referenced to retrieve any additional relevant citations. Eligible studies from all searches (2013, 2019, 2020) were subsequently combined to form the final study selection.
Data extraction
For each eligible study, data regarding study design and results were independently extracted by two authors (ES and AV). Extracted items included the type of study, study population (number of patients, median age, malignancy subtype, stage, treat- ment) and the content of the geriatric assessment. Only validated tools from the geriatric assessment were included. If multiple tools were used to assess one geriatric domain, the result of the most commonly used tool was noted. We registered the prevalence of geriatric impairments, and the reported results on the association between the geriatric assessment and outcome measures. If neces- sary, study authors were contacted to obtain additional data.
Quality assessment
The methodological quality of each of the studies was assessed independently by two reviewers (ES and AV), using the Newcastle-Ottawa scale adapted to this subject (Online Supplementary Table S1).18 As our main focus was on older patients with hematologic malignancies, we classified studies of patients with a me(di)an age less than 68 years old, or with more than one third of the patients younger than 65 years old, as not being fully representative of our target population. Disagreements among the reviewers were discussed during a consensus meeting and in the case of persisting disagreement, the assistance of a third reviewer (MH) was enlisted.
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