Impact of Geriatric Assessment on Treatment Decisions and Follow-Up in Older Colorectal Cancer Patients

Abstract

Background: This study aims to investigate the influence of a geriatric assessment (GA) on cancer treatment decisions in older colorectal cancer (CRC) patients ( pts). We also studied the evolution of functionality during treatment and the development of chemotherapy related severe toxicity and looked at predictive markers for functional decline and toxicity Methods: This subanalysis is part of a study on GA in elderly cancer patients in 6 tumor types in 2 Belgian university hospitals. We selected the CRC cohort for this presentation. Pts aged 70 years or older with a newly diagnosed or progressive CRC were evaluated at baseline using a uniform GA including geriatric screening with G8 and Flemish Triage Risk Screening Tool (TRST), pain, social data, Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), presence of falls, Mobility-Tiredness Test (MOB-T), Mini Mental State Examination (MMSE), Geriatric Depression Scale (GDS-15), Mini Nutritional Assessment (MNA), ECOG-Performance Status (ECOG-PS), Charlson Comorbidity Index (CCI) and polypharmacy assessment. GA results were communicated to the treating physician and after treatment decision, the physician was interviewed using a predefined questionnaire focusing on unknown geriatric problems revealed by GA and impact on cancer treatment decisions. At 2-3 months follow-up, functionality was reassessed and severe toxicity in patients receiving chemotherapy was recorded. Predictors for functional decline (ADL increase of > 2 points and IADL decrease of > 1 point compared to baseline) and chemotherapy toxicity were identified by multivariate analysis. Results: 193 pts with CRC were included with a median age of 77 years old (range 70-89) and 67.4% stage IV. At baseline, 48.2% of pts were dependent on at least one ADL and 57.5% on at least on IADL. 40.4% of physicians consulted the GA results before final treatment decision. GA revealed unknown geriatric problems in 37.8% of cases, leading to a geriatric intervention in 4.6%. Treatment was modified according to standard clinical assessment (including age) in 34.7%. GA led to an additional change of treatment in 1 pt: palliative care instead of chemotherapy in a stage IV CRC. At follow up (n = 164), 44.5% of pts were dependent on ADL and 59.8% on IADL. A functional decline was observed in 17.7% for ADL and in 36.6% for IADL. A decline in ADL was predicted by baseline MOB-T (p = 0.0398) and MMSE (p = 0.0283). No predictors for a decline in IADL could be identified. Grade III-IV toxicity occurred in 26/109 (23.9%) of pts treated with chemotherapy, mostly non-hematological. Radiotherapy (p = 0.0016) was predictive for hematological toxicity and MNA (p = 0.03) for non-hematological toxicity. Conclusion: In older patients with CRC, GA revealed previously unknown information in 37.8% but led to geriatric intervention and change in treatment decision in a minority of patients. Baseline screening for fatigue and cognition was found to be predictive for functional decline in ADL at 2-3 months. Severe chemotherapy toxicity was predicted by baseline nutritional assessment and previous radiotherapy.