Page 33 - Haematologica - Vol. 105 n. 6 - June 2020

Geriatric assessment in older patients with a hematologic malignancy
require very different intensities of treatment; geriatric impairments that were associated with outcome in one setting may not retain their predictive value in another disease entity. In addition, the content of geriatric assess- ments, including the definition of frailty (assessed by sum- marizing the geriatric assessment), was not consistent. Moreover, geriatric impairments were mainly assessed with screening tools (for example, the Mini-Mental State Examination for cognition), and it should be realized that the ensuing results are not the same as an actual diagnosis made by a comprehensive geriatric assessment. Given this heterogeneity, a meta-analysis or a meaningful subgroup analysis (for example, by type of malignancy) could not be performed; and interpretation and extrapolation of results should be done with caution. Another limitation of this review is the procedure used to select the literature. We decided to select only those studies for which a full text is available and which performed a geriatric assessment with validated tools covering at least two geriatric domains. Studies which focused on a single impairment and its relation to outcome were not included, meaning some information on individual associations may have been missed.
Despite these limitations, this review provides a thor- ough update and overview of all currently available evi- dence on the relevance of a geriatric assessment for older patients with a hematologic malignancy. At the time of the previous systematic review, by Hamaker et al.,17 the evi- dence was limited because of a lack of published studies. In the last 5 years, the number of publications concerning the association of geriatric assessment with outcomes in patients with hematologic malignancies has increased greatly, enabling a useful update on the available data.
Performing a geriatric assessment could have an additive value to clinical judgment, treatment allocation and the implementation of non-oncological interventions.
In daily practice, oncologists are able to detect obviously frail patients by clinical judgment. However, estimating the reserve capacity and resilience of the remaining older patients by clinical judgment is difficult, as demonstrated by the discrepancy between performance status and geri- atric assessment. In addition, it can be challenging to dis- tinguish whether the detected vulnerabilities are disease- related or patient-related. This may require a more thor- ough evaluation of the patient’s overall health status, including consultation of a geriatrician.
The impact of performing a geriatric assessment on treat- ment allocation has already been demonstrated in older patients with solid malignancies.73,74 In a systematic review, the oncological treatment plan was altered in 28% of patients after geriatric assessment, primarily resulting in a less intensive treatment option. This review showed that using a geriatric assessment to guide treatment decisions
appeared to have a positive effect on clinical outcome, resulting in less treatment-related toxicity, fewer complica- tions, and increased treatment completion.75 For example, in patients with cognitive impairments, treatment decisions should be made with great care because of the higher risk of chemotherapy-related progression of cognitive dysfunc- tion, treatment non-compliance and death.52,71
In order to tailor cancer treatment to individual needs, it could be interesting to incorporate patient-reported out- come measures (PROMS) into the treatment decision-mak- ing process. PROMS, such as physical functioning and qual- ity of life during and after treatment, were hardly assessed in the studies included in this review, despite quality of life being of primary importance to many older patients.76 It is, therefore, highly relevant that future studies address the association between geriatric impairments and PROMS.77
In addition to clinical judgment and treatment allocation, a geriatric assessment can be used to introduce non-onco- logical interventions before and during treatment in the hope of improving the patient’s health status, resilience and treatment tolerance. However, evidence concerning the effectiveness of such non-oncological interventions is limited. Previous research suggests that perhaps physio- therapy78,79 as well as nutritional counseling80-82 can improve survival, physical functioning and quality of life. Non- oncological interventions in older patients undergoing chemotherapy can improve treatment completion and treatment modifications.83 The process by which a patient’s condition can be enhanced before starting treat- ment is called prehabilitation. Although results of the first studies assessing the effectiveness of prehabilitation in patients with solid malignancies are promising,84,85 the level of evidence is weak, making it too early to draw definitive conclusions. Currently, according to clinicaltrials.gov (searched February 5, 2020), there are 29 ongoing trials in which the effect of non-oncological interventions on clin- ical outcome measures in older cancer patients is being assessed; six out of these 29 trials focus on hematologic malignancies.86 Based on these numbers, further data will follow in the coming years.
In conclusion, this review demonstrates the relevance of performing a geriatric assessment in older patients with a hematologic malignancy. Although the results should be interpreted and extrapolated carefully, our review shows that even in patients with a good performance status, a geriatric assessment can detect geriatric impairments that might be predictive of mortality. Moreover, geriatric impairments seem to be associated with a higher risk of treatment-related toxicity, treatment non-completion and utilization of healthcare services. Future research is need- ed to extend these findings with a focus on reserve capac- ity, resilience, quality of life and the effectiveness of non- oncological interventions.
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