Page 170 - Haematologica May 2022

C. DuMontier et al.
Table 2. Multivariable analyses assessing effect of geriatric consulta- tion on overall mortality rate through 1 year of follow-up, acute care utilization, and goals-of-care discussions.
Table 3. Survey results of oncologists’ opinions regarding value of geri- atric consultation.a
Overall mortality rate through 1 year
Intent-to-treat vs. control Per-protocol vs control
ED visits
Intent-to-treat vs. control Per-protocol vs. control
Hospitalizations
Intent-to-treat vs. control Per-protocol vs. control
Days in hospital
Intent-to-treat vs. control Per-protocol vs. control
EOL GOC discussions
Intent-to-treat vs. control Per-protocol vs. control
Hazard ratio (95% CI)
0.93 (0.45 - 1.95) 0.70 (0.30 - 1.66)
Incidence rate ratio (95% CI)
0.89 (0.33 - 2.42) 0.77 (0.26 - 2.23)
Incidence rate ratio (95% CI)
0.91 (0.30 - 2.71) 0.74 (0.24 - 2.32)
Incidence rate ratio (95% CI)
1.05 (0.29 - 3.79) 0.82 (0.20 - 3.38)
Odds ratio (95% CI)
3.12 (1.03 - 9.41) 3.58 (1.13 - 11.35)
P value 0.85
0.42
P value 0.82
0.62
P value 0.86
0.61
P value 0.94
0.78
P value 0.05
0.03
Domains of care
Evaluating cognition
Connecting patients to resources Diagnosing frailty
Managing non-oncologic comorbidities Tailoring end-of-life care
Informing treatment decisions
Management of age-related issues
Functional status Falls
Depression Mood disorders Insomnia Nutrition
Pain
Number of responses
35 35 35 35 35 35
Number of responses
35 35 35 34 35 35 35
% who answered 4 or 5 (95% CI)
85.7 (69.7 - 95.2) 80.0 (63.1 - 91.6) 77.1 (59.9 - 89.6) 77.1 (59.9 - 89.6) 71.4 (53.7 - 85.4) 62.9 (44.9 - 78.5)
% who answered 4 or 5 (95% CI)
88.2 (72.6 - 96.7) 85.7 (69.7 - 95.2) 80.0 (63.1 - 91.6) 79.4 (62.1 - 91.3) 77.1 (59.9 - 89.6) 62.9 (44.9 - 78.5) 62.9 (44.9 - 78.5)
All models for the multivariable analyses were adjusted for age, sex, disease aggres- siveness, and frailty. Separate models were run for per-protocol analysis. 95% CI: 95% confidence interval; ED: emergency department; EOL GOC: end-of-life goals of care.
above). Future trials in older adults with blood cancers should investigate not only the effectiveness of different models of geriatrics-driven interventions in terms of mortal- ity, but also their impact on treatment decisions and patient-centered outcomes such as function and quality of life, which are outcomes often valued by older patients just as much as, if not more than, survival.38-41 Reducing toxicity and optimizing function and quality of life - all while main- taining similar survival in comparison with standard onco- logic care - constitute a net benefit for complex older patients.42
To this end, our finding that geriatric consultation increased the likelihood of having documented EOL goals- of-care discussions is clinically relevant to pre-frail and frail older adults with blood cancers, many of whom have a high risk of death regardless of intervention.4,43 Discussing preferences regarding place of death and resuscitation sta- tus is of paramount importance in frail older patients with blood cancers; doing so early in the outpatient setting can reduce intensive care use in the days before death while increasing hospice enrollment.44 Moreover, a geriatrician’s evaluation of age-related vulnerabilities (e.g., functional and cognitive impairment) and their potential reversibility bet- ter informs these goals-of-care discussions.42 Many frail older patients may have other advanced conditions that limit their prognosis independently of their cancer or its treatment, diminishing the benefits and increasing the harms of intensive chemotherapy. Indeed, our trial popula- tion had high rates of cognitive, functional, and mobility impairment, more representative of patients aged ≥75 years treated in practice than the small number of patients in this age group enrolled in clinical trials.4,45
Beyond aligning EOL care with patients’ preferences, the geriatricians’ expertise in evaluation and management of age-related vulnerabilities was highly valued by surveyed hematologic oncologists and other clinicians at Dana- Farber. Most rated geriatric consultation to be useful in the
aFor each question, responses were rated on a Likert scale ranging from 0 = not at all useful to 5 = very useful. CI: confidence interval.
evaluation of cognition, management of non-oncologic comorbidities, and management of functional status and falls. Fewer clinicians found geriatric consultation to be use- ful in informing oncologic treatment decisions and the man- agement of nutrition and pain. The latter might in part be due to the comfort of hematologic oncology teams in treat- ing these problems themselves, with support from nutri- tionists and other allied healthcare services.
Our study has limitations other than those related to the geriatric consultation model listed above. Our study took place at a large, academic, tertiary care center that may limit generalizability of its findings to community practices. However, GA-driven interventions have been shown to be feasible and improve outcomes in other settings, including community hematologic oncology clinics.14,28 Competing risk of mortality may have hindered observation of hospi- talizations and other secondary outcomes; three patients in the consultation arm died before they could even receive the intervention. Although we did not detect a difference in care utilization between study arms, the study may have been underpowered to investigate these secondary out- comes. Indeed, our overall event rates for deaths and care utilization were low, likely because many of our patients were on observation for less aggressive disease. Future trials could further minimize heterogeneity in patients’ character- istics by limiting enrollment to patients with one or two types of blood cancer on active treatment. Along with investigating patient-centered outcomes, future trials should also investigate the impact of GA-guided care on treatment toxicity, treatment discontinuation, and progres- sion free survival.
In conclusion, our randomized trial of embedded geriatric consultation for pre-frail and frail older patients with blood cancers did not show an improvement in survival or health- care utilization, but did increase EOL goals of care discus- sions and was valued by hematologic oncology clinicians. Lessons learned from our trial complemented by the results emerging from others suggest that ensuring earlier delivery and more longitudinal co-management may be necessary to have an impact on outcomes such as survival and hospital- izations. Such models should be investigated in older adults with blood cancers, along with their impact on patient-cen- tered outcomes such as function and quality of life. Future
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