Models of Care in Geriatric Oncology

STATE OF HEALTH CARE DELIVERY IN THE UNITED STATES: MAKING THE CASE FOR OLDER ADULTS WITH CANCER

Optimal delivery of health care in the United States faces multiple hurdles related to high cost, logistical inefficiency, and medical errors.^1-3 These pitfalls create risk for all patients but are magnified for older adults with cancer considering the complexity of their care. The rapidly expanding pool of patients over age 65 years being diagnosed with and surviving their cancer is creating a perfect storm—the Silver Oncologic Tsunami.^4,5

CONTEXT

• Key Objective

• Is it possible to develop geriatric oncology models of care delivery to fit all practice sizes and settings? Validated geriatric assessment tools and educational resources are readily available for cancer care team members to use.

• Knowledge Generated

• A clear framework for incorporating best practices in older adult cancer care currently exists to guide programmatic development.

• Relevance

• The rapidly growing number of older adults being diagnosed with and surviving cancer will necessitate education of all cancer team members and caregivers involved in their unique care needs. The successful development and implementation of models of care for these older adults with cancer is required to meet the rising needs of this population.

As the global population ages, the majority of older adults with cancer will live in low-income countries. Providing geriatric assessment (GA) can be resource intensive, so it is not unexpected that most robust geriatric oncology initiatives are found in high-income countries. The specialty of geriatrics struggles with growth within the United States and is not recognized as a specialty in many other countries, resulting in a major barrier to geriatric oncology initiatives. Furthermore, the age definition of geriatrics may vary depending on life expectancy in each respective country making it more difficult to generalize.

Although there has been significant work on the global landscape to address the needs of older adults with cancer, many challenges remain.^6,7 Better recognition, assessment, and management of the unique needs of these patients are a central focus in the delivery of high-quality cancer care in this population. Integral to this process is shared decision making aimed at developing relevant goals of care that clearly reflect the patient and caregiver wants, needs, and preferences. Unfortunately, there is a great shortage of health care providers with geriatric or geriatric oncology expertise to lead the care of older patients.^8,9 Clinical trial enrollment has been hampered for decades by an upper age limit, leading to data that are inadequate to generate the safety and efficacy profiles of many therapeutics in older patients.¹⁰ Financial toxicity remains an unanswered challenge, and although Medicare may add some protection, too many older adults with fixed incomes are forced to choose between therapeutics and necessities such as food or rent.¹¹

The COVID pandemic further unmasked vulnerabilities unique to these older adults including: (1) adherence to complex often risky treatment plans, (2) anxiety and depression because of social isolation and fear of infection, (3) concerns about rationing of care, and (4) malnutrition from inadequate support for food acquisition and preparation.

As part of a call to action, the geriatric oncology community continues to work tirelessly to educate and expand the workforce.¹² National and international society support has led to webinars, training modules, training grants, fellowships, intensive training courses, and web site development with information and tools dedicated to the practice of geriatric oncology. ASCO and the European Society of Medical Oncology have recommended core geriatric training as part of their Global Curriculum for Medical Oncology.¹³ The International Society of Geriatric Oncology (SIOG) continues to promote collaboration and dissemination of education, research, and clinical practice highlighted at their annual meeting.⁷ Additional advocacy has included a global regulatory effort by the US Food and Drug Administration to increase the enrollment of older adults in clinical trials and incentivizing researchers to provide more information on age distribution.¹⁴

The landmark ASCO geriatric oncology guideline published in 2018 recommended the assessment of geriatric domains in all older adults ≥ 65 years before initiating chemotherapy.¹⁵ The four randomized clinical trials (abstracts 12009-12012)^16-19 presented at the May 2020 ASCO meeting, linking GA and interventions to improved clinical outcomes, have further paved the way for widespread geriatric oncology programmatic development. This paper will illustrate models of care and barriers to model implementation and may serve as a How-To Guide for programmatic development.

EVIDENCE SUPPORTING GERIATRIC ASSESSMENT FOR OLDER ADULTS WITH CANCER

Multiple studies have supported the use of GA in identifying noncancer vulnerabilities and assessing the risks of morbidity and mortality in older adults with cancer.^20-22 Benefits of GA have been validated in hematologic malignancies and solid tumors.^23,24 As a result, SIOG, ASCO, and the National Comprehensive Cancer Network now recommend GA for all older adults undergoing chemotherapy.^15,25,26

ASCO's published clinical practice guidelines recommend that an assessment of older adults should evaluate, at a minimum, their functional status, history of falls, psychological health, cognition, nutritional profile, risk of chemotherapy toxicity, and survival estimation. Systematic review of the literature led to specific recommendations for validated tools to use along with additional validated options and possible interventions on the basis of abnormal findings (Table 1).

TABLE 1.

ASCO Geriatric Oncology Clinical Practice Guideline Recommended Assessments^15,27

Recognizing that the GA can be time and resource intensive, research has sought a highly sensitive screening tool to help select patients that may benefit from a more in-depth evaluation. Several screening tools have been evaluated (Table 2). SIOG consensus review found the G8 tool to have the best sensitivity data but noted that the choice of screening tools may depend on context, and therefore, no specific tool is recommended.²⁸

TABLE 2.

Evaluation of Screening Tools^27-29

Although screening tools do not replace a more comprehensive GA, there may be some utility in the brief screen alone as they may provide an objective assessment of overall health status.^27,29 For example, abnormal Geriatric 8 (G8), Vulnerable Elders Survey-13 (VES-13), or Triage Risk Screening Tool (TRST) has been associated with functional decline and poorer survival.^27-29 In addition, the brief screening tools can lead to a more efficient GA by suggesting increased focus on certain domains of concern.²⁷

There is a growing body of literature supporting the value of the GA for surgery in older adults with cancer, with most domains being associated with adverse postoperative outcomes. The systematic review has shown functional status, comorbidity, and frailty to be the most studied and likely the most significant.³⁰ Although not cancer-specific, the American College of Surgeons has recently launched the Geriatric Surgery Verification program to provide a framework for developing centers of geriatric surgery. The Society for Perioperative Assessment and Quality Improvement has published recommendations for perioperative management of frailty.³¹ Both focus on multidisciplinary GA in various ways to improve surgical outcomes in older adults.

Unlike medical and surgical oncology, geriatric data remain limited in the radiation oncology literature. SIOG published evidence-based guidelines for curative radiation therapy in older adults recommending evaluation that includes comorbidities and geriatric syndromes.³² Radiation therapy may provide a viable alternative in older adults whose comorbidities may preclude multimodal therapies or surgery, and more research is needed in this area.

USING IMPLEMENTATION SCIENCE TO CREATE PRACTICE CHANGE

Barriers to Implementation

The oncology community acknowledges the challenges of cancer care in older adults; however, the implementation of clinical principles of geriatric oncology continues to be limited.^15,33 A survey of multidisciplinary professionals by the Association of Community Cancer Centers (ACCC) reported that 95% (n = 332) supported the importance of GA in older adults with cancer, but only 17% were routinely performing it.³⁴ Similar results were noted in a survey by the ASCO Older Adults taskforce which showed that only 29% of the respondents (n = 1,277) were performing assessments of older patients using validated tools.³⁵

One of the most important barriers to geriatric oncology implementation is the limited expertise because of the scarcity of health care providers with geriatric training.⁸ The shortage of geriatricians in the United States is estimated to reach 26,890 full-time equivalents in 2025, and those in practice will likely be needed mostly in primary geriatrics care.³⁶ The establishment of fellowship training programs in combined geriatrics and medical oncology has recently promoted the expansion of the geriatric oncology community, but it is unlikely to fill the gap.³⁷ Among 210 practice groups belonging to the National Cancer Institute Community Oncology Research Program, there were only 2% who had a fellowship-trained geriatric oncologist on staff, and only 37% of the sites had geriatricians available to assist with the care of oncology patients.³⁸ Importantly, most trainees and fellowship program directors in the United States recognize the importance of cancer and aging education, but only a small percentage of fellows have access to geriatrics training or a geriatric oncology clinic.^39,40 The ASCO Older Adults taskforce survey showed that providers who were aware of the ASCO Geriatric Oncology Guidelines were twice as likely to perform specialized assessment of older patients but still faced large barriers that derive from the lack of resources.³⁵ The most reported barriers by the survey respondents (aware v not aware) were limited time (81.7% v 72.5%) and support staff (77.0% v 68.4%). The lack of training and knowledge, uncertainty of which tool to use, and lack of awareness of tools were highly reported barriers by providers who were not aware of the guidelines and, to a lesser degree, by those who were aware. The top three barriers to the use of geriatric screening and assessment reported by the ACCC survey were lack of familiarity with available screening and/or assessment tools, limited time, and limited personnel.³⁴

A practical GA should be efficient in time and resources, and should be framed in a pragmatic fashion that helps both the patient and the primary oncology provider understand its outcomes facilitating the implementation of geriatric interventions. From the health system perspective, geriatric oncology practices are expected to demonstrate cost-effectiveness to ensure financial stability. The strategies for clinical geriatric oncology implementation will need to be developed with a clear understanding of these barriers and incorporated into the daily practice environment without overwhelming an already overloaded system, particularly in the setting of community-based practices where most patients are treated.⁴¹

Strategies for Programmatic Development

Performing GA has been limited to a handful of institutions⁴² and has not reached the wider community. The Patient-Centered Outcomes Research Institute has a funding mechanism to implement major findings from comparative effectiveness trials.⁴³ The goal of this funding mechanism is to move findings from research to regular use in the intended settings and reach the target audiences. This implementation funding mechanism is critical to move the research pipeline to clinical practice.

By applying an implementation science lens through these kinds of funding mechanisms, the potential to promote the wider implementation and sustainability of GA to community cancer centers should be feasible. There are many frameworks, models, and theories that can guide implementation.⁴⁴ The Exploration, Preparation, Implementation, Sustainment framework⁴⁵ delineates the main phases of implementation and includes factors that are likely to influence implementation. The factors are categorized into larger domains, such as the outer context, bridging factors, innovation factors, and inner context. It also highlights the interconnection and linkages between these domains and/or factors.

Exploration.

There are several key steps that an organization can take during the exploration phase to determine need, engagement, and resources. First, review the volume of patients seen who are 65 years and older and receiving chemotherapy. Second, determine the outcomes for these patients and determine the rate of treatment toxicity and hospitalizations. Third, identify key stakeholders and clinical champions including leaders from upper leadership, middle management, frontline clinicians (eg, physicians, advanced practice providers, and nursing), patient coordinators or schedulers, information technology staff, patients, nutritionists, social workers, physical therapists, and occupational therapists. After the key stakeholders are identified, hold outreach meetings and townhalls to share the current state of cancer care for older patients receiving chemotherapy and determine interest or potential barriers.

Preparation.

After it is clear that there is interest and support, at least from one clinic, identify a core quality improvement team to spearhead the initiative. This team will be responsible for checking in with others, monitoring implementation process, and addressing barriers. During this stage, it may also be helpful to determine meaningful clinical data and create a dashboard to monitor improvement (eg, chemotherapy toxicity). The team will need to identify the existing resources (eg, current staffing) and map out the current clinical workflow. During this stage, identify supportive services, such as nutrition, social work, physical therapy, and occupational therapy. Additionally, identify who will be trained and what materials will be used. After training, conduct dry runs of the new workflow to identify patients, conduct the GA, and interpret the GA to inform decision making and identify appropriate referrals.

Multiple models of delivery of geriatric oncology care exist; however, it is clear that one size does not fit all. Historically, specialists often relied on a shared care model, working with a primary care provider to manage nononcologic issues. This model has been limited by the inherent fragmentation of the medical system creating issues with communication and often lacking a geriatric focus. Newer models of care delivery, each with its own resource requirements, are further illustrated in Table 3. For example, embedded geriatric-trained provider models allow for longitudinal follow-up but may limit availability to the specific clinic in which they are embedded. Dual-trained geriatric oncologists can provide comprehensive care, but this model is limited by the few number of qualified providers. It is clear that all oncology clinics should attempt to perform some form of GA, but practices will need unique flexible models of care and guidance in using patient-completed metrics and geriatric screening tools.

TABLE 3.

Models of Delivery for Geriatric Oncology Care^27,46,47

Lack of funding and lack of resources are the typical challenges faced regardless of practice setting. In high resource settings (eg, Academic Medical Centers), a full GA should be attempted using multidisciplinary teams to address all the domains. Teams could include a geriatrician, nutritionist, social worker, pharmacist, physical or occupational therapist, audiologist, and/or nurse navigator. Trained staff can perform the cognitive and physical function assessments. These are often performed under a consultative model, and outcomes often depend on the implementation of the recommendations (Table 3). Assessments can be conducted over multiple visits or in different clinical settings such as the infusion center if being used to help support ongoing treatment.

Community oncology offices with fewer resources can consider using a screening tool with referral to a geriatrician for further assessment. Clinics without resources for geriatrician referral can consider a self-administered GA tool such as the one offered through the Cancer and Aging Research Group.⁴⁸ The tool is based primarily on information reported by patient or caregiver, with only three items completed by a health care professional. The tool delivers a set of recommendations for the oncologist to review and refer to resources as needed (nutrition and social work)⁴⁹ All oncologists should incorporate a chemotherapy toxicity risk calculator (Cancer and Aging Research Group [CARG] or Chemotherapy Risk Assessment Scale for High-Age Patients [CRASH]) to assist with shared decision-making conversations about treatment options.¹⁵

A successful implementation of geriatric interventions into oncological care can be associated with decreased treatment-related toxicity and hospitalizations, and therefore, it is expected to lower health care expenditure.^16-19 Therefore, especially with the increased adoptions of bundled payment models, the hiring of dedicated staff to support the GA can be justified from a financial standpoint because of the expected drop in expenditure.⁵⁰ Figure 1 depicts a potential workflow and the additional time needed for the different components of the GA.

FIG 1.

Proposed workflow for GA implementation. A proposed workflow is outlined in this figure from when a patient checks in for the visit. Italicized text is part of routine clinic workflow. We have indicated the additional time needed to integrate the GA into an existing clinical workflow. GA, geriatric assessment; PROs, patient-reported outcomes.

An autonomous GA can process the collected information using preconfigured pathways and protocols to produce clinically meaningful actionable outcomes. The automatization of the GA can be a key maneuver to overcome barriers to geriatric oncology implementation. The development of this format of GA relies on significant geriatric or geriatric oncology expertise but ultimately leads to a scalable assessment that could be performed without direct involvement of the expert. Using this approach, health care providers of any background can be trained to perform the GA, which would facilitate a wider dissemination of geriatric oncology practices that is not restricted by the availability of geriatric expertise.^51,52

An efficient technical platform is critical for the success of this strategy. A certain level of artificial intelligence is needed to facilitate the automated processing of the geriatric data and to ensure the replicability of the GA. Multiple smart versions of the GA and other geriatric oncology tools such as chemotherapy toxicity predictors are currently available online, but their use remains limited.^27,53 This is largely due to their institute-specific platform or lack of compatibility with the daily clinical workflow. There are ongoing efforts aimed at incorporating the GA into the electronic medical record to facilitate wide scale dissemination.⁵⁴ Furthermore, the increased use of telehealth, propelled by the COVID-19 pandemic, is one of many technology-based strategies that can be used to expand the reach of geriatric oncology practices, particularly in situations where a central GA unit can offer geriatric services to multiple care locations.⁵⁵

Implementation.

A staged implementation process is recommended, where one clinic starts implementing and others follow in a sequential roll-out. During implementation, the quality improvement team should use tools associated with continuous quality improvement, such as the Plan-Do-Study-Act⁵⁶ approach. This approach includes reviewing key data and providing feedback to the clinical teams. As implementation progresses, the clinical team will need to determine the who and how for the following steps: (1) identify eligible patients, (2) complete patient-reported outcomes, (3) alert the clinical team about the eligible patient, (4) conduct the administered sections of the GA, (5) score the GA, (6) share the results with the treating clinician, (7) determine which referrals are needed and make decisions about treatment, (8) place orders for the referrals, if needed, and (9) follow up on the completion of the referrals. Barriers will likely arise during implementation, as outlined in Table 4 with possible solutions.

TABLE 4.

Implementation Solutions to Known Barriers of GA

Sustainment.

Once the GA has been successfully piloted, the quality improvement team can take steps to sustain GA implementation. The new workflow will need to be baked into the existing clinical processes by modifying clinical flow sheets or algorithms. The electronic medical record can be leveraged to sustain the changes by creating smart phrases and/or order sets. A key is to determine whether more time is needed for the clinical appointments (or not) and identify appropriate billing processes. Continuing to monitor outcomes and conducting quality checks will ensure that implementation will continue smoothly. To sustain the implementation, ongoing education will be needed for new staff and leaders will need to incorporate the training process during onboarding. Engaging with patients and referral sources will be needed to continue to drive the demand for specialized cancer care for older patients.

SUPPORT AND DISSEMINATE GERIATRIC ONCOLOGY MODELS OF CARE

Cancer and Aging Research Group Core

The Clinical Implementation Core (CIC) of the Cancer and Aging Research Group⁵⁷ was developed as an ongoing effort aimed at disseminating geriatric oncology care concepts and facilitating clinical program development.

The core was formed as part of the CARG National Institute of Health/National Institute of Aging (NIH/NIA) R21/R33 grant to develop a national geriatric oncology research infrastructure (R21/R33 AG059206).⁵⁸ CARG is a platform that connects cancer and aging investigators from multiple disciplines and career stages with the goal of improving the care of older adults with cancer by fostering geriatric oncology research efforts.⁵⁹ The development of CARG's infrastructure is based on seven cores: leadership, aging measures, analytics, clinical implementation, communication, health services, and supportive care.

The fundamental focus of the CIC is to facilitate the implementation of geriatric oncology evidence-based principles. The core provides guidance to health care professionals interested in the integration of geriatric principles into the clinical care of older adults with cancer and promotes their growth as cancer and aging leaders within their institutions. The CIC supports investigators with their strategic planning, business model design, and the development of geriatric oncology clinical programs (Fig 2).

FIG 2.

Function of the CARG CIC. A list of objectives of the CIC including some that are provider- or patient-care focused and others that aim to achieve a wide impact on the health care system. CARG CIC, Cancer and Aging Research Group Clinical Implementation Core.

An inquiry form on CARG's web site serves as the first point of contact for interested health care professionals. The purpose is to collect information about the investigator's intent with the aim of providing them with focused expert guidance. The CIC invites ad hoc participants to assist when the investigator's inquiry requires expertise that is not available within the core. The core provides longitudinal support as proposals move through the following development phases: (1) concept creation, (2) plan development, (3) implementation, (4) growth, and (5) interval practice assessment. Throughout this process, the CIC can help investigators identify barriers and facilitate solutions.

The CIC aims to serve as a hub for clinical health care professionals with expertise in geriatric oncology models of care who advocate for the integration of cancer and aging principles into the standards of daily care. The goal of the CIC is to foster the development of geriatric oncology practices with the intent of creating a global geriatric oncology clinical network. This structure will serve as a center for collaborations focused on the implementation of clinical practices, quality improvement, and research.

The CIC serves as a liaison between the other CARG cores and clinical geriatric oncology programs aiming to develop their scholarly profile as it recognizes this interaction is essential for the development of the research profile of the clinical geriatric oncology network.

Sustainability of the CIC is based on a pay it forward strategy that is essential to maintain the core's activities and disseminate the principles of clinical geriatric oncology. As the clinical network grows and the structure matures, participating practices will be asked to support the logistical structure of the core.

ACCC Educational Programming

Efforts are underway in the community to support the implementation of geriatric screening and assessment processes in daily oncological care with consideration for the limitations imposed by setting, size, region, or unique infrastructure. In an ACCC survey,³⁴ many providers reported use of certain assessment tools to fulfill components of the GA, such as the National Comprehensive Cancer Network Distress Thermometer to evaluate psychological health, in their evaluation of older adults, although it is not in a formalized, coordinated approach specific to an older adult population.

To simplify access to available screening and assessment batteries for oncology providers, ACCC has curated a resource library of over 100 recommended tools with a variety of options in each key domain of GA along with other resources for staff training, patient education, and other relevant articles and sources.⁶⁰ Provided in tandem with case studies of programs of varying sizes and regions, a cancer program can begin to formulate a plan to incorporate these tools according to their infrastructure.⁶¹

In addition, ACCC has created an online evidence-based gap assessment tool.⁶² This initiative was developed on the basis of the input of an international group of geriatric oncology experts that participated in a Delphi process to determine the tools and practices that make up the interactive levels of the gap assessment.⁶³ The tool generates, in addition to an aggregate score, an individual evaluation of the strengths and weaknesses in each domain of geriatric cancer care. Teams can use this evaluation to conduct small or large quality improvement programs. A multidisciplinary effort is encouraged, with roles available for medical oncologists or hematologists, pharmacists, social workers, nurses, advanced practice providers, navigators, medical assistants, geriatricians, nutritionists, physical or occupational therapists, psychologists, palliative care specialists, administrators, primary care providers, chaplains, and more. Individual departments or clinics are encouraged to take the assessment separately as practice may vary across functional areas or providers.

“Practical Application of Geriatric Assessment: A How-To Guide for the Multidisciplinary Cancer Team,” available online and in print, offers detailed solutions in each domain that can be implemented without burdening staff or budgets.⁶⁴ Each section details why the featured domain is a critical part to older adult care, offers a suggested or featured tool to assess the domain, explains how to perform the tool along with who can perform it and when, and, most importantly, offers suggestions for follow-up actions once the tool is performed. Alternate tools are also offered in each section to allow for variations in care models and patient management strategies.

In conclusion, a clear framework is available for incorporating best practices in older adult cancer care. Awareness on the part of cancer care team members of the key challenges in caring for older adults is the first step. For any oncology care provider, regardless of practice setting, size, or organizational structure, this education can be pivotal to changing long-defined protocols that need updating. Many tools have been validated, specific to older adults, in various settings. National and international groups have streamlined resources and offered free, evidence-based education in multidisciplinary formats. Cancer programs must work to educate all their staff and implement these practices to accommodate for the growing number of older adults being diagnosed with cancer, as well as the rapidly expanding pool of cancer survivors over the age 65 years.

AUTHOR CONTRIBUTIONS

Conception and design: All authors

Collection and assembly of data: All authors

Data analysis and interpretation: All authors

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Models of Care in Geriatric Oncology

The following represents disclosure information provided by the authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO’s conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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