Page 168 - Haematologica May 2022

C. DuMontier et al.
received geriatric consultation responded to the survey evaluating the perceived value of geriatric recommenda- tions. The majority found embedded geriatric consultation to be valuable in managing several age-related domains of care (Table 3). Domains of care in which consultation was found to be most valued included evaluation of cognition, connecting patients to resources, diagnosing frailty, and managing non-oncologic comorbidities. Specific areas of management found to be most useful included optimizing functional status, treating falls, and treatment of depression and other mood disorders.
Discussion
We found that in pre-frail and frail older patients with hematologic malignancies, embedded geriatric consultation did not improve 1-year overall survival or acute care utiliza- tion. However, consultation significantly increased the like- lihood of having EOL goals-of-care discussions. Moreover, hematologic oncology clinicians highly valued the services provided by geriatrics in the care of their older patients. Our trial addresses a critical gap regarding the effectiveness of geriatric-driven interventions in older patients with hema- tologic malignancies, complementing emerging evidence from other studies predominantly including older adults with solid tumors.15-17,27-31
Few prior studies have investigated GA-driven interven- tions for patients with blood cancers. Artz and colleagues recently reported that in patients with a median age of 67 years undergoing hematopoietic stem cell transplantation for blood cancers, GA-driven interventions implemented by a multidisciplinary geriatrics team improved 1-year overall survival in comparison with conducting a GA alone with- out a multidisciplinary team to manage any detected vul- nerabilities.32 While provocative, a limitation of this non- randomized study was its use of a historical control group for comparison. In our randomized trial of transplant-ineli- gible patients aged ≥75 years undergoing geriatric consulta- tion versus standard oncologic care, we did not find evi- dence of an effect on 1-year overall survival, even in the frail subgroup.
Care for frail older adults is often complex and fragment- ed.33 A significant strength of our consultative model is that our geriatricians - trained specialists in frailty and complex care - were embedded in our center, caring for patients alongside their hematologic oncologists in the same clinic. On the other hand, certain aspects of our model may have limited its effectiveness in both reducing mortality and acute care utilization. First, although 80% of patients assigned to receive consultation ended up completing the consultation, our challenges in enrolling and assigning patients to the consultation arm reflected the limited capac- ity of geriatricians in our clinic. Relatedly, we found the time to have the initial visit with a geriatrician varied across patients, with a median of 36 days. Delays were largely a function of the patients’ busy schedules and the fact that our geriatrics clinics only occurred twice per week. Second, the geriatricians worked within the established referral structures existing at Dana-Farber rather than with a dedi- cated multidisciplinary team (e.g., including pharmacists, social workers, and allied health specialties), which may have limited the breadth and timeliness of any geriatrics- recommended interventions.34,35 Lastly, the utilization of our geriatric consultation service evolved over the study period,
with more clinicians requesting longitudinal co-manage- ment, rather than a single consultation, later in the study. We implicitly intended more longitudinal management for all patients assigned to the geriatrics intervention but found that just over half received additional follow-up visits.
The effectiveness of longitudinal geriatric co-manage- ment models delivered earlier in follow-up, with or without multidisciplinary support, warrants further investigation in frail older adults with blood cancers. Preliminary findings from such a geriatrician-led model in older adults with mostly solid tumors are encouraging, showing - in contrast to our study - a significant reduction in emergency presen- tations and unplanned hospitalizations in comparison to usual care.36 Important distinctions between this model and ours are worth noting. Patients’ initial visit with the geria- trician occurred upon enrollment in the study, which ensured earlier delivery of any GA-driven interventions. Additionally, although the intervention design, like ours, allowed for individualized management tailored by the geriatrician, standardized interventions were provided to all patients assigned to the geriatrics arm that included sup- portive care information and optimization of physical activ- ity and nutrition. Lastly, more longitudinal co-management occurred than in our study’s consultative model, with patients receiving reassessments at multiple points in their follow-up period. Although we did not find an association between number of visits and mortality, our study was underpowered to formally analyze this association. Moreover, the geriatrician may have elected to see sicker patients more often, confounding the association. Earlier delivery, more integration, and more longitudinal follow-up
Table 1. Baseline characteristics of the study population.
Characteristic
Age, mean (SD)
Male, n. (%)
Disease type, n. (%) Lymphoid
Myeloid Myeloma
Aggressive disease, n. (%)
Frailty, n. (%) Pre-frail
Frail
Gait speed, n. < 0.8 m/s (%) Declined/missing
All (n=160)
80.4 (4.2) 104 (65.0)
50 (31.3) 48 (30.0) 62 (38.8)
60 (37.5)
124 (77.5) 36 (22.5)
97 (60.6) 4 (2.5)
Standard oncologic care (n=100)
80.3 (3.9) 64 (64.0)
36 (36.0) 28 (28.0) 36 (36.0)
37 (37.0)
75 (75.0) 25 (25.0)
60 (60.0) 3 (3.0)
16 (16.7) 4 (4.0) 38 (40.9) 7 (7.0)
18 (18.0)
34 (34.0)
Geriatric consultation + standard care (n=60)
80.5 (4.7) 40 (66.7)
14 (23.3) 20 (33.3) 26 (43.3)
23 (38.3)
49 (81.7) 11 (18.3)
37 (61.7) 1 (1.7)
9 (15.0) 0 (0.0) 22 (37.3) 1 (1.7)
9 (15.0) 23 (38.3)
Cognition, n. with impairmenta (%)
Delayed recall Declined/missing
Executive function Declined/missing
25 (16.0) 4 (2.5) 60 (39.5) 8 (5.0)
Function, n. with impairmentb (%)
ADL 27 (16.9) IADL 57 (35.6)
aDelayed recall was assessed using the five-word delayed recall component of the Montreal Cognitive Assessment, with probable impairment defined as the ability to recall two or fewer words after 5 minutes.5 Executive function was assessed using the Clock-in-the-Box test, with probable impairment defined as scoring five or less. bImpairment of basic activities of daily liv- ing (ADL) and instrumental activities of daily living (IADL) was defined as patients reporting requiring assistance or being dependent on others to complete one or more of six ADL or five IADL, respectively. SD: standard deviation; ADL: basic activities of daily living; IADL: instrumental activities of daily living.
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