Integrated Geriatric/Palliative Care Intervention Promising for Older Adults with Cancer
Key findings
- In this pilot randomized, controlled trial (n=62), usual oncology care was compared with a transdisciplinary intervention designed to address both the geriatric-specific and palliative care needs of older adults with advanced cancer
- Patients in the transdisciplinary intervention group were scheduled for two visits with a geriatrician who had been oriented to the needs of older adults with cancer; the geriatricians reported their findings to the patient's oncology team
- The study did not meet the predetermined feasibility goal of enrolling ≥70% of patients approached, but 56% of patients invited did enroll, and 80% of patients assigned to the transdisciplinary intervention attended both geriatrician visits
- At baseline 73% of the 62 participants reported at least one moderate–severe symptom, 24% had clinically significant depression, 74% had at least one comorbid condition, and only one was independent with all activities of daily living
- The intervention demonstrated encouraging effect size estimates for enhancing patients' quality of life, physical and psychological symptom burden and confidence in their ability to communicate with health care providers
Research suggests older patients with cancer should receive targeted palliative care interventions, as their physiologic, psychological and social support needs differ from those of younger patients with cancer. Along the same lines, geriatricians have developed tools to assess and manage older patients' geriatric-specific concerns, but data are lacking on whether those interventions also address patients' palliative care needs.
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In a pilot randomized, controlled trial, an integrated geriatric/palliative care intervention showed promise for improving symptom burden, mood and quality of life in older patients with advanced cancer. Ryan D. Nipp, MD, MPH, gastrointestinal oncologist and health services researcher, and Jennifer S. Temel, MD, clinical director of thoracic oncology, co-director, Cancer Outcomes Research and Education Program at the Mass General Cancer Center and Hostetter Mass General Research Scholar 2017-2022, and colleagues report the results in the Journal of the National Comprehensive Cancer Network.
Study Design
Patients eligible for the study were 65 or older and had been diagnosed with incurable gastrointestinal or lung cancer less than eight weeks previously. They were enrolled between February 15, 2017, and June 28, 2018, at Mass General.
Before the study began, geriatricians attended four 1-hour orientation lectures by geriatricians, palliative care clinicians and a medical oncologist. These addressed topics such as chemotherapy logistics and adverse effects, cancer-specific symptoms and prognosis, collaborating with the oncology team, symptom management and prognostic disclosure.
1:1 Randomization
- Transdisciplinary intervention: Patients were scheduled for two visits with one of the collaborating geriatricians. Before their first visit, patients completed a brief questionnaire to report their symptom burden, nutrition status and vulnerability. Geriatricians were asked to discuss patients' physical and psychological symptoms, comorbid conditions, polypharmacy, cognitive issues, social support, functional impairments, coping strategies and illness understanding. After each visit, the geriatricians communicated their findings to the patient's oncology team
- Usual care: Patients received routine oncology care but could meet with a geriatrician on request by the oncologist, patient and/or family. (No patient receiving usual care ultimately met with a geriatrician.)
Feasibility
The primary study endpoint was feasibility, predefined as: (a) ≥70% enrollment in the study and (b) completion of study visits and surveys by ≥75% of living patients assigned to the intervention.
56% (62/111) of patients approached agreed to enroll. The most common reasons for refusal were feeling too ill (21%) and not being interested in the research (19%).
Among patients assigned to the intervention:
- 82% attended the first geriatric visit and 80% attended both visits
- 90% completed study surveys at both baseline and week 12
Patient Characteristics
As expected from previous research, 73% of the 62 participants reported at least one moderate–severe symptom at baseline and 24% had clinically significant depression. 74% had at least one comorbid condition, and only one was independent with all activities of daily living.
Improvement in Outcomes
The intervention had small to medium effect sizes for improving many patient-reported outcomes between baseline and week 12, compared with usual care. These included:
- Less decrement in quality of life (Functional Assessment of Cancer Therapy–General)
- Decreased total score on the Edmonton Symptom Assessment System–Revised
- Reduction in the number of moderate to severe ESAS-r symptoms
- Lower score on the Geriatric Depression Scale
- Improvement in confidence about communicating with providers (Perceived Efficacy in Patient–Physician Interactions Questionnaire)
Continued Research Expected
The researchers hope to continue efforts at integrating geriatricians into the Mass General Cancer Center, and they believe a larger trial is warranted to investigate the efficacy of this transdisciplinary intervention. The high rates of symptom burden, comorbidities and functional impairments in this cohort underscore the importance of addressing both the geriatric and palliative care needs of older adults with cancer.
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