Dr Vanita Noronha, a leading medical oncologist and researcher spoke on the PatientsEngage Podcast on the value of Geriatric Cancer Care and how Geriatric Assessment can help personalize treatment for older persons.
What is Geriatric Oncology or Geriatric Cancer Care?
Given that cancer is predominantly considered a disease of aging, why do we need a special focus on geriatric cancer care?
Geriatric means older and Geriatric oncology means Cancer in older people. There is a greater chance of getting Cancer as you age. As you age the body ages and the organ systems age with increase in multiple vulnerability to falls, weakness, illnesses/ lowered immunity. Though not obviously visible like wrinkles, the muscles, the liver, kidneys, heart and other internal organs are also ageing. Hence, any kind of medical treatment is different in older people and the associated need of managing Geriatric Cancer differently. Any existing vulnerabilities need to be given specific attention in addition to the cancer. This helps to take care of the cancer better and also enables the patient to live better.
When does Geriatric Cancer kick in and what are the factors considered
Age is a moving target though the standard age defined by WHO is 65 years, (65-70 years in US and Europe), when cancer in people of age and above is categorised as Geriatric Oncology and the age cut off varies country wise, which in turn is determined by retirement age and life expectancy of the population. India life expectancy is 71 years, retirement is 60 years and the social circle changes for an individual and anyone above 60 years is considered an older person. However, this is the chronologic age and it is the physiologic age which is used to asses a person with cancer - for example, a person who is at a younger age than 60 years and who is frail, has a chronic illness, paraplegic, had an accident, could be much higher in physiologic age than his chronologic age. The assessment for cancer is done using the physiologic age - how is the patient functioning vs a healthy patient of that age and this is done via a Geriatric Assessment Test or GAT.
What is the Geriatric Assessment Test ?
Geriatric Assessment Test or GAT is a test that considers multiple domains other than the cancer and assesses a patient by his physiologic age vs his chronologic age. This test assesses the non-cancer domains that are required to live independently and have a quality of life, which include co-morbidities - other illnesses like hypertension, diabetes, and related medication consumed or polypharmacy (which includes consumption of 5 or more medicines)to understand the whole slew of interactions between the medications they take.
Assessment is also done to understand how well they can function independently in society, and perform daily activities, for example, the muscle strength, risk of falls, social support system needed for hospitalisation, buying and paying for medication, cooking, caring. All this is part of the GAT and we get to understand all the vulnerabilities based on a group of questions. We categorise a person as frail, depending on the answers to these questions using various validated questionnaires. Based on these answers we recommend and act on this like suggesting a home exercise program, provide support in terms of any physiotherapist or occupational therapist need, even suggest installing handles in the bathroom, use a walking gate.
We focus on understanding these vulnerabilities and if the deficit exists in at least 2 of the domains, the person is categorised as Frail. This helps decide the kind of the treatment needed.
What is the referral system for Geriatric Assessment? When should Geriatric Assessment Test be administered?
Unfortunately, there is NOT a lot of understanding in India on geriatric cancer. Doing the GAT helps improve the patient’s quality of life and decreases side effects of chemotherapy. GAT is not well known in India and no well-established formal educational program exists, with only a few physicians who are able to do the assessment and almost no patients currently get referred. However, this is changing in the last couple of years.
Tata Memorial Hospital has a multi-disciplinary geriatric oncology clinic and patients who are planned for cancer directed therapy are referred here prior to therapy, and hence any deficiency or vulnerability can be caught and plugged as required. These are checked for any change that has happened during the follow-up, especially when there is a change in treatment.
Can you share a couple of examples of how the assessment is more accurate than the typical clinical examination that a patient goes through? Is it more applicable for people diagnosed with some cancers rather than others?
The Geriatric Assessment Test is not Cancer specific, but age specific and is recommended for any stage. Any patient with cancer, who is 60 years and older should be recommended for GAT. Some cancers like prostate or genito-urinary cancer are predominantly a disease of older people for which GAT should be done.
The Assessment should not be done via an Eyeball test to make a quick decision, as clinics are so busy and GAT takes time. Using the eyeball assessment physicians make a decision if the patient can or cannot take the treatment. 50% of the time such assessments are wrong vs actual GAT. Some vulnerabilities are obvious and helps in the assessment, for example, if they have had a fall and their mobility is impaired /functionally deficient. However, some aspects are not obvious especially when there is cognitive impairment, mental health issues like depression, or there is lack of social or financial support.
Simple obvious questions are asked on how patients are feeling, details on symptoms which are easily answered, most often by the care givers. There is no way to tell if the patient has any of the above impairments by visual or functional assessment, or by asking simple questions or even evaluating their nutrition. Especially in cases with rural patients, those working in farms, where body weight could be low, who appear under nourished and actually are not. When patients themselves cannot visit the doctor, then the evaluation has to be done by the relative or via a video. Such an assessment changes when you actually examine the patient and go into details of their activity and their weight profile, etc.
Another aspect is the kidney function - blood test for Creatinine measurement is done as part of the blood test and with age the creatinine could be low which does not indicate the kidneys are functioning well till further functional scans are done. Since muscle mass also reduces with age and creatine being low, creatinine excreted also will be low.
How can a patient or a family member ascertain if they need a Geriatric Assessment Test? And how can they find a healthcare professional who can do this assessment in India ?
There are centres that conduct GAT - Tata Memorial has a Geriatric Oncology Clinic that does assessments in Mumbai, Varanasi. There is also a hospital in Chennai. Ideally all centres need to have this because if awareness is increased for GAT, it is not difficult to learn. It is not necessary for the doctors to do this, it can be administered by a trained health care professional (HCP) or a nurse. Geriatric Oncology Fellowship Training Program exists in Tata Memorial Hospital.
How is the Geriatric Assessment Test administered? Can it be self-administered?
This ideally cannot be self-administered. An app is in the process of being developed where there are a series of questions where a large part can be filled by the patient and there is a part that needs to be filled by the Health care professional or the HCP. Once the HCP part is filled, interpretation is also important which needs to be done by a GAT trained professional.
Should the GAT be conducted with both the patient and family present? How do you ensure patient autonomy?
Initially an attempt is made to give the questionnaire to the patient and caregiver and try and get the patient to fill it themselves, but also care is taken not to try and isolate the patient from the caregiver, as ultimately they are the patient’s support system. At times, attempt is made not to speak to the patient directly at the request of the caregiver, which is difficult.
There is a concept of shared decision making in medical care. If someone is old and frail, that person has the right to decide on the type of treatment which may increase longevity at the same time detract from a quality of life. Attempt is made to put this in a softer manner with the facts being shared. This is specifically so for advanced and palliative care situation where the intent is meant to palliate or ease the situation prolonging survival but not curing. The discussion is different if the patient is younger and has different priorities, responsibility and certain aspirations.
What happens after the assessment? How does the line of treatment change? How do you work with the treating oncologist on this modification?
Once scores are done post GAT, a decision is made on the status of the patient based on whether the patient is cognitively impaired, functionally impaired with co-morbidities and then the patient is classified as Frail. The patient and caregiver are further counseled on intervention needed to improve the vulnerabilities, like suggestions are made for physiotherapy, occupational therapy, health care proxy for cognitive impairment, review of medicine list etc.
Assessment is made on what the chances are for the patient to develop severe toxicity needing hospitalisation and this is then discussed with the patient/caregiver. This is passed on to the treating oncologist who then suggests needed changes in dose of treatment. 35-40% of plans of treatment change post GAT and in most cases it results in reducing chemotherapy doses. Most trials that have proven benefits of GAT have been associated with chemotherapy. Not much data in the other areas like radiation therapy, surgery. Prehabilitation is also looked into to evaluate fitness of the person for surgery.
How should the prehab/ rehab and other supportive care change? Can you share an example.
The outcome of the GAT assessment drives the prehab or rehab care. We try and introduce directed exercises like cognitive or physical exercises, smoking cessation.
What role does palliative care play in your management of elderly cancer patients, and when do you introduce it?
There is a palliative care physician as an integral part of the multidisciplinary Geriatric
oncology team who need to be part of the initial conversations for pain management and multiple other areas like social and functional support, that are needed to improve the patient’s quality of life.
Are there any cultural or socioeconomic factors in India that significantly affect cancer care for the elderly?
All assessments done for the GAT have come from the Western countries, none were originated or devised in India. There may be cultural nuances to consider, or elements that could be culturally inappropriate.. We look at IADL or Instrumental Activities for Daily Living - laundering clothes, cooking, cleaning, managing money. IADL has 8 questions where a female needs to do all 8 and men do 5. When there is a daughter-in-law in the house, all these activities almost stop for a woman, so it is difficult to assess the then and now situation in such instances. Very few are even aware of the clock drawing test used to assess cognitive functions.
Some of the adapted social support questions are irrelevant in an Indian context, like “do you have someone to share your problems with” which in the West adds value but doesn’t apply in the Indian context. Hence an Indian specific one is needed and is being developed.
How do co-morbidities like diabetes, hypertension, frailty or cognitive decline impact treatment planning and outcomes?
Co-morbidity is a crucial domain in geriatric patients not necessarily just controlled ones, the controlled ones are not a cause of worry. However geriatric patients have all these medications interfering with treatment and causing side effects. Hence this is a key factor. This impacts older patients with cancer and are a competing cause of death. For example, Heart Failure is a advanced and life limiting comorbidity vs a low grade prostate cancer. For a patient with both these conditions, their cancer may not needed to be treated, as the cancer may not be so life limiting as the existing comorbidity of their heart.
Hence a tool /calculator like Non Oncologic Life Expectancy is used where all the data is entered and the results indicate how the existing condition and not cancer is going to affect life expectancy, which is very important in the decision making.
Gaps and Challenges in India (medical, social, or systemic)
Do you believe the Indian healthcare system is equipped to address the unique needs of geriatric oncology patients?
GAT is available in English and translated into Hindi, Marathi and Bengali as these are the common languages of patients that are seen at Tata Memorial Hospital, but a whole validated system in all local languages does not yet exist.
What improvements—resources, training, policy, or infrastructure—do you think are most urgently needed to support geriatric oncology in India?
There is no local website available in India . There is a European Geriatric Oncological body called SIOG - International Society of Geriatric Oncology, based in Geneva and an American one called CARG - Cancer and Ageing Research Group and both these have a lot of information.
Tata Memorial Hospital has an online geriatric cancer support group that has a meeting once a month on topics like diet, yoga followed by a question and answer session. Any older person or older person with cancer is open to join. There is a doctor available for advice and to answer any questions.. They don’t do it currently but are also open to try an online assessment if possible.
Geriatricians and Geriatric Oncology advocacy and Mainstreaming
Geriatricians are limited but lately there are a good number of Geriatric programs that exist across India due to which there is an increasing number of Geriatricians, though not enough. There is almost no Health Care Practitioner, who has expertise in Geriatrics and Oncology.
Attempt is being made to bridge the gap via training programs but the crux is funding. This is propagated through research on issues that exist with older people, raising funding for training program and for those who are trained to go and spread this knowledge to other centres. At Tata Memorial Hospital, a fund has been initiated through wealthy patients to indigent patients via a patient supported fund.
Lack of robust evidence is another problem. Clinical trials are the corner stone of cancer treatment options and evidence-based medicines. The enrolled patients are younger and therefore any treatment for older patients are not evidence based. Funding is needed for such studies with older patients. Advocacy and Funding are the 2 big needs for Geriatric Oncology.
In India the population is ageing, number of people more than 60 years is roughly 10%, but the number of people with cancer and more than 60 years is 36-45%, which is a huge gap and this is increasing vs 60% in the US.
Every second or third person who comes to the clinic with cancer is older. Hence there is a big need to develop Geriatric oncology to give optimal treatment to these patients.
Key Takeaway Message
- If you are older person with cancer or a care giver, or know somebody who is an older person with cancer, try and see a Geriatric Oncologist at least once for a Geriatric assessment.
- Advocate to your hospital to start a Geriatric clinic
- Help is needed in funding for geriatric patient care and research.
Dr. Vanita Noronha is a leading medical oncologist and researcher with extensive expertise in the management of head-and-neck, thoracic, genitourinary cancers, precision medicine, and geriatric oncology. She is a Professor in the Department of Medical Oncology at Tata Memorial Hospital, Mumbai. Her academic work spans clinical trials, translational research, and the development of cost-effective cancer treatment protocols tailored to resource-constrained settings.
