Identifying Geriatric Oncology Competencies for Medical Oncology Trainees: A Modified Delphi Consensus Study

Abstract

Background

Most oncology trainees are not taught about the needs of older patients, who make up the majority of patients with cancer. Training of health care providers is critical to improve the care of older adults with cancer. There is no consensus about which geriatric oncology (GO) competencies are important for medical oncology trainees. Our objective was to identify GO competencies medical oncology trainees should acquire during training.

Materials and Methods

A modified Delphi consensus of experts in oncology medical education and GO was conducted. Experts categorized at what training stage proposed competencies should be attained: internal medicine, oncology, or GO training. Consensus was obtained if two thirds of experts agreed on the training stage at which the competency should be attained.

Results

A total of 78 potential competencies were identified, of which 35 (44.9%) proposed competencies were felt to be appropriate to be acquired during oncology training. The majority of the identified competencies pertained to prescribing of systemic therapy (n = 12) and psychosocial and supportive care (n = 13). No competencies related to geriatric assessment were identified for acquisition during oncology training.

Conclusion

Experts in oncology education and geriatric oncology agreed upon a set of GO competencies appropriate for oncology trainees. These results provide the foundation for developing a GO curriculum for medical oncology trainees and will hopefully lead to better care of older adults with cancer.

Implications for Practice

The aging population will drive the projected rise in cancer incidence. Although aging patients make up the majority of patients diagnosed with cancer, oncologists rarely receive training on how to care for them. Training of health care providers is critical to improving the care of older adults with cancer. The results of this study will help form the foundation of developing a geriatric oncology curriculum for medical oncology trainees.

Short abstract

Training of health care providers is critical to improving the care of older adults with cancer. This article focuses on the geriatric oncology competencies an oncology trainee should possess on completion of training and provides a foundation for development of a geriatric oncology curriculum for medical oncology trainees.

Introduction

The world's population is aging. By 2030, one in five adults in the U.S., or 70 million people, will be aged at least 65 years 1. Older adults already account for 60% of all newly diagnosed cancer cases and 70% of all cancer deaths 2. Aging is one of the principal drivers of the projected increase in cancer burden 3. Older adults with cancer often differ from their younger counterparts in several aspects, including declines in organ function, increased comorbidities, and increased vulnerability to stressors 4, 5, 6, which can affect a patient's ability to tolerate and/or complete treatments, making patient assessment critical and decisions about selecting the appropriate treatment for older adults more complex. Furthermore, aging is a heterogeneous process, making an in‐depth assessment of the older adult critical to determine a patient's “true” age.

There is a shortage of geriatricians to care for the growing population of older adults 7, 8. As a result, it is essential that all oncologists have some knowledge of geriatric principles to better meet the needs of older adults with cancer. Additionally, it has long been recognized that oncology education should include the care of the older person 9, 10. However, about two thirds of oncology trainees report never receiving teaching regarding the needs of older patients with cancer 11, and few oncology programs offer formal training in geriatric oncology 12.

There is no formal consensus as to which geriatric oncology competencies a medical oncology trainee should successfully attain by completion of training. Such a consensus would help to inform the development of a geriatric oncology curriculum, which the majority of hematology‐oncology fellowship program directors in the U.S. said they would use if available 12. Both experts in the content matter and those who understand the total breadth of what is needed to train medical oncologists need to be engaged to identify these competencies to ensure consideration of both the knowledge and context for which the competencies are to be obtained and to improve uptake of a geriatric oncology curriculum through engagement of stakeholders.

We administered a modified Delphi process to a panel of experts in oncology medical education and geriatric oncology to attain consensus as to which geriatric oncology competencies an oncology trainee should possess on completion of training. Based on the geriatric oncology compentencies that meet consensus, a curriculum can be developed aimed at improving medical oncology trainees’ knowledge and skills to care for older adults with cancer.

Materials and Methods

We used a modified Delphi process to attain consensus among a group of experts in geriatric oncology and those involved in medical oncology educational programming. The Delphi method is a well‐established and validated method used to establish consensus through the use of iterative rounds of questionnaires followed by anonymized feedback summarized from the group's responses 13. The participants are then allowed to adjust their response based on the feedback provided. The Delphi methodology allows us to engage the relatively small group of experts in this field despite their geographical dispersion.

In the traditional Delphi methodology, the initial list of statements that compose the survey are generated by the participants during the initial round of the Delphi process. We used a modified Delphi process, in which the initial set of competencies were generated by the research team after a review of the literature and known existing geriatric oncology curricula 14. This list was reviewed for comprehensiveness, readability, and face validity of the questionnaire. These competencies were grouped into six domains: aging and cancer interface; geriatric oncology knowledge base; prescribing systemic therapies in older adults with cancer; geriatric assessment; geriatric syndromes; and psychosocial, supportive care, and survivorship. This was supplemented by competencies from the expert panel in the initial round of the Delphi. This method has been used extensively in other studies and ensures that the initial list is comprehensive and takes into account what is known in the field 15.

We surveyed experts in geriatric oncology and experts in medical oncology training. Experts in geriatric oncology were selected from members of the Cancer and Aging Research Group, a consortium of national leaders in geriatric oncology research in North America. Medical oncology program directors in Canada and the U.S. were invited to participate as experts in oncology training. Additional experts in medical oncology eduation were identified through snowball sampling 16 in which program directors were asked to identify one to three experts in oncology education at their center whom we could approach for participation the modified Delphi process.

Potential participants were contacted prior to administration of the modified Delphi process to introduce the rationale for the study and to determine those physicians who were interested in participating and who were committed to completing the Delphi process. We contacted potential members of each group until we had accrued 15–20 geriatric oncology experts and 10–15 medical oncology education experts who were interested and committed to participating in the study.

The survey was administered electronically via SurveyMonkey. In the first round of the modified Delphi process, the participants reviewed the initial list of competencies for comprehensiveness and wording. Additional potential competencies suggested by the Delphi participants were incorporated into the list of competencies for round two.

In rounds two and three, participants were asked to evaluate and sort the list of potential competencies by the level at which a trainee would be expected to possess the competency (i.e., at completion of internal medicine, medical oncology, or geriatric oncology–specific training). Respondents were also able to rate competencies as not being relevant or important to possess or if they felt the competencies were not specific to older adults. Those competencies in which 50% of respondents ranked as not being important to possess were eliminated. The results were summarized in terms of the percentage of respondents who ranked each competency at the internal medicine, medical oncology, or geriatric oncology level.

In round three of the Delphi, results were fed back to the participants. Participants were asked to review the results and to recategorize the competencies by the level at which they should be achieved. The level at which the majority (at least two thirds of the panel) felt the competency should be achieved were fed back to the panel in round four. Participants were asked to rate if they agreed or disagreed with each competency being correctly classified. If at least 80% of respondents agreed that the competency was correctly classified, consensus about the inclusion of the competency at that level was met. Those in which less than 80% of respondents agreed were classified as not having met consensus. The total number of rounds of ranking in the Delphi was prespecified.

Results

Thirty‐three experts in oncology medical education (n = 15) and geriatric oncology (n = 18) participated. Respondents were trained in oncology (77%), geriatrics (39%), or both (19%); 42% were involved in a geriatric oncology clinical care; 52% were in practice for 5–10 years and 26% for >20 years (Table 1). Respondent characteristics were gathered during the first round of the modified Delphi and are missing for two participants who did not contribute to the first round.

Table 1.

Respondent characteristics

Characteristics	Total (n = 31; 2 missing), %	GO experts (n = 18), %	Oncology medical education experts (n = 13), %
Age, years
<35	0	0	0
35–44	65	67	62
45–54	16	17	15
55–64	13	11	15
65+	6.5	6	8
Female gender	58	61	54
Location of practice
Canada	42	22	69
U.S.	58	78	31
Certification(s)
Oncology	77	67	100
Hematology	32	39	23
Geriatrics	39	67	0
Years in practice
<5	13	17	8
5–10	52	50	54
11–15	6	6	8
16–20	3	6	0
>20	26	22	31
GO clinical care
Involved in GO clinic	42	72	0
Has a GO clinic at center (not involved)	6	6	8
No GO clinic	52	22	92
Role in oncology medical education
Oncology program director	16	0	38
Oncology assistant program director	6.5	5.6	8
Formal role in oncology training program	16	6	31
Primary teaching role in training	48	67	23
Not involved	13	22	0
Time spent in oncology education
<5 hours	55	78	23
5–10 hours	23	6	46
10–15 hours	0	0	0
>15 hours	13	0	31
None	10	17	0

Abbreviation: GO, geriatric oncology.

An initial list of 46 potential competencies was identified by the investigators (Fig. 1). Respondent suggestions, including additional competencies and modifications in wording, were incorporated into the second round of the Delphi. Response rates were 94% (n = 31) for round one, 100% (n = 33) for rounds two and three, and 82% (n = 27) for round four. After three rounds of ranking, 44.9% (n = 35) of proposed competencies were ranked at the oncology level (Table 2). An additional 24 competencies were felt to be more appropriate to obtain during internal medicine training and 2 competencies during geriatric oncology training (Table 3).

Figure 1.

Competencies for each round of modified Delphi process (N refers to number of competencies).

Table 2.

Geriatric oncology competencies categorized at the oncology training level

Aging and cancer interface Describe biological and psychosocial changes that occur with aging and their implications regarding cancer and cancer care Describe how the association between aging and cancer will affect cancer incidence Recognize the heterogeneity of aging in older adults with cancer Describe changes in the immune system that occur with aging and how these changes impact on cancer growth and/or the effect of treatments

Geriatric oncology knowledge base Describe key findings of randomized phase III studies that are specific to older adults with cancer Evaluate, interpret, and determine the applicability of results of a clinical study to an older patient with cancer Describe reasons for underrepresentation of older adults in clinical trials

Prescribing systemic therapies in older adults with cancer Use a validated assessment tool to calculate the risk of chemotherapy toxicity in older adults with cancer Describe age‐related changes in physiology by organ system and their impact on the dosing of and tolerance to cancer therapy in older adults Elicit an older adult's goals of care including his or her preference for treatments, including chemotherapy and clinical trial involvement Describe factors that may affect an older person's preferences with respect to cancer therapy Propose treatment alternatives for patients who may not be candidates for surgery or chemotherapy Identify factors that can influence the prescription of cancer therapy among older adults with cancer, such as comorbidity, functional status, cognitive function, psychosocial status, social support, and patient preference Assess for adherence with oral systemic therapy. Recognize barriers and identify solutions to improve adherence in older adults with cancer Identify risk factors for chemotherapy toxicity in older adults with cancer and manage treatment accordingly Weigh potential risks and benefits of anticancer therapy in an older adult with cancer. Identify scenarios in which risks outweigh potential benefits and vice versa Identify older patients who may be less willing to undergo frequent monitoring (e.g., computed tomography scans, biopsy) to assess response to treatment Describe the impact of social supports on decision making in the older adult with cancer Assess and incorporate patient goals of care and preferences into the decision‐making process regarding cancer care

Geriatric syndromes Identify how cancer and its treatment may increase the risk of or interact with geriatric syndromes List common potential drug interactions among older adults with cancer Identify and evaluate comorbidities that may directly influence cancer therapy in older patients

Psychosocial, supportive care, and survivorship Evaluate the need for supportive care (e.g., hydration, home care, etc.) for older adults with cancer and refer to appropriate services as indicated Describe psychosocial issues affecting older patients with cancer, their caregivers, and their families (i.e., transportation, personal care, homemaking, legal affairs, finances, etc.) Explain the difference between religion, education, language, and social class as modifiers of the cancer experience Explain prognosis to the patient and determine the patient's goals of care if cure or prolongation of life is not possible Recognize when early referral to hospice or palliative care is appropriate based on the presence of other life‐limiting illnesses in an older adult with cancer Describe differences in different care facilities (e.g., independent living vs. assisted living vs. subacute care vs. long‐term care) and the ramifications of the available care for supporting an older adult receiving cancer treatment Identify specific considerations unique to end‐of‐life care in older patients Identify at least three nonpain symptom complexes frequently affecting patients with cancer and describe palliative treatment modalities appropriate to each Describe the role of primary care providers in caring for older adult with cancer Recognize the importance of supporting caregivers of older adults in all phases of the cancer continuum Identify a designated caregiver who can assist the older patient with cancer with their health care during their treatment for cancer Identify challenges associated with being a caregiver of an older patient with cancer Assess and address the psychosocial and caregiver needs of an older adult throughout all phases of the cancer continuum

Table 3.

Geriatric oncology competencies ranked at the internal medicine and geriatric oncology training levels

Internal medicine

Aging and cancer interface 1. Distinguish between the concept of functional vs. chronologic age 2. Identify modifiable and nonmodifiable factors that influence a patient's life expectancy or noncancer prognosis 3. Identify and use an existing instrument to evaluate the life expectancy of an older patient

Geriatric assessment 1. Identify available tools to assess a patient's nutritional status 2. Identify available tools to assess a patient's psychosocial status

Geriatric syndromes 1. Define frailty and identify an older adult who is frail 2. Describe the impact of frailty on outcomes of mortality (life expectancy) and morbidity (such as falls, hospitalization, etc.) 3. Distinguish between cognition and capacity 4. Perform a semistructured interview to assess decisional capacity in an older adult; include the four major components of capacity 5. Assess a patient's capacity for decision making and identify when a surrogate decision maker is needed for decision making 6. Identify potential barriers to communication with older adults 7. List common geriatric syndromes (falls, urinary incontinence, delirium, depression, cognitive impairment, malnutrition, polypharmacy) 8. Recognize the presence of a geriatric syndrome in a patient 9. Diagnose and initially manage common geriatric clinical syndromes 10. Identify delirium in an older patient with cancer 11. Diagnose, manage, and prevent delirium in an older patient with cancer 12. Screen for falls in a patient with cancer and institute appropriate management 13. Identify potentially inappropriate medication use in an older adult with cancer 14. Identify tools available to assess for potentially inappropriate medication use 15. Define polypharmacy and identify it in an older adult with cancer

Psychosocial, supportive care, and survivorship 1. Recognize how culture may affect patient and family perceptions of older adults and provide culturally sensitive care with this in mind 2. Demonstrate competence in using a medical interpreter. Explain why family interpreters are not optimal 3. Describe the advantages and disadvantages of using a family interpreter 4. Conduct a brief initial assessment of patient advance directives including establishing durable power of attorney for health care and goals of care

Geriatric oncology

Geriatric assessment 1. List and describe the domains of a comprehensive geriatric assessment 2. Identify instruments that are available to assess common domains of the comprehensive geriatric assessment

The majority of geriatric oncology competencies were felt to be appropriate for medical oncology trainees to obtain by the end of training related to prescription of systemic therapies for older adults (n = 12) and psychosocial and supportive care (n = 13). None of the competencies relating to geriatric assessment was ranked as being appropriate for oncology trainees to obtain. The respondents felt that the majority of competencies regarding geriatric syndromes should be obtained by the completion of internal medicine training, whereas competencies related to performing a comprehensive geriatric assessment were felt most appropriate for trainees pursuing focused training in geriatric oncology. Finally, no consensus was attained for 17 proposed competencies (supplemental online Table 1). The majority of these were related to geriatric assessment (n = 9) and included the use of screening tools, identifying who needed a geriatric assessment, performing a comprehensive geriatric assessment, interpretation of results, and identifying the added value of geriatric assessment.

Discussion

With the aging of the population, all oncologists need to be able to care for older adults with cancer. Despite this, oncology trainees receive little training in geriatric oncology. Training of health care providers is critical to improving the care of older adults with cancer. We identified and reached consensus for 35 geriatric oncology competencies to be attained by the end of oncology training. The majority of these competencies related to the administration of systemic therapy and supportive care with no competencies related to geriatric assessment identified for medical oncology trainees.

The competencies identified differ somewhat from the American Society of Clinical Oncology (ASCO)–European Society of Medical Oncology curriculum 17, which was used to generate the initial list of competencies. In particular, the panel felt that knowledge about domains of geriatric assessment and about geriatric syndromes were not competencies relevant to be acquired during oncology training. This may reflect the relatively short training period and breadth of knowledge that needs to be attained during oncology training or the fact that this knowledge spans all disciplines. Alternatively, assessment and management of geriatric syndromes may be a core skill set that was felt to be important to learn early on in training. These findings highlight the importance of having broad input from stakeholders in the development of competencies and the importance of reviewing these in the broader context of the educational continuum rather than at a set stage of training. Although our results suggest that teaching in oncology should focus on knowledge and skills specific to caring for older adults with cancer, this should integrate and build on knowledge learned in prior stages of training and suggests that an overarching approach to educating health care professionals about geriatrics, which spans all stages of training and beyond, is needed. If, however, geriatric competencies have not been adequately taught in prior stages of training, then teaching these knowledge and skills may then fall to educators to provide during oncology training, as many of the identified competencies may depend on this prior knowledge and training.

The preponderance of competencies related to systemic therapy and supportive care likely reflect the inherent nature of the oncology discipline, in which care planning involves assessing the overall supportive care needs and priorities of patients with respect to systemic therapy options. This may also be partially reflective of the oncologist's particular interest in identifying those older adults at higher risk of toxicity from systemic therapy and to better identify the optimal treatment approach for each individual patient. It may also reflect the fact that older adults are more likely to have functional impairments and may have differences in values and preferences compared with their younger counterparts 6, 18. This may result in a higher proportion of older adults being managed with best supportive care measures alone.

There is inherent overlap between the competencies identified with respect to supportive care and palliative care. In planning a geriatric oncology–focused curricula, it is thus important to understand which supportive care competencies are applicable to all patients and may already be taught in the existing curriculum. It may be prudent to compare where palliative care and geriatric oncology overlap and how they differ in teaching. Furthermore, as palliative care is also often inadequately taught in oncology 19, 20, there is potential for geriatric oncology and palliative medicine to learn from each other about how to best integrate successfully within oncology and/or to collaborate synergistically to advance their respective agendas.

Geriatric assessment is considered an essential component of assessing older adults with cancer to determine fitness for treatment and to identify areas of vulnerability that are amenable to intervention to improve tolerance for treatment and/or quality of life. Geriatric assessment has been recommended by several international societies, including the National Comprehensive Cancer Network, International Society of Geriatric Oncology, and ASCO 21, 22, 23. However, in our study there was little consensus by experts as to when these skills should be acquired. A minority of the proposed geriatric assessment–focused competencies were felt to be appropriate for trainees pursuing training in geriatric oncology with no proposed competencies appropriate for acquisition during core oncology training. The reason for this lack of consensus and a gap between recommendations and implementation is unclear but may be due either to lack of knowledge or buy‐in about its value or to confusion about who should be in charge of implementation of such recommendations—the oncologist or the geriatric oncologist. This suggests that further dialogue is needed between those with geriatric oncology expertise—who are typically involved in guideline development—and those who are not. This is necessary to better define what should be the domain of the general oncologist versus a geriatric oncologist, how to establish overall best practices in cancer care for older adults, and also to determine when these competencies are best taught—as an oncology trainee, in postoncology training fellowships, or as part of continuing professional development.

A strength of this study is the inclusion of participants with expertise in geriatric oncology (content expertise) and experts with knowledge of the breadth of knowledge oncology trainees need to acquire during their training. This hopefully will increase the likelihood that these results resonate with both trainees and the oncology educational community. Furthermore, we had high consistent response rate from experts through the Delphi, which is important in ensuring the validity of the results. A limitation of our study is that we did not test for stability of the rankings across Delphi rounds to establish consensus. However, we were limited in the number of rounds in which we could feasibly engage the physician participants, and there was no standard method of establishing consensus 15. Although we did not include oncology trainees in this study, this study sought to complement prior study results conducted predominantly in trainees by gaining the perspective of other stakeholders to achieve a more holistic view of this topic.

Conclusion

In summary, 35 geriatric oncology competencies were felt to be appropriate for oncology trainees to acquire. These results will form the groundwork for developing a geriatric oncology curriculum for medical oncology trainees. This will hopefully improve the utility of such a curricula leading to better care of older adults with cancer. Further engagement of stakeholders, in particular, oncology trainees, will be important to optimize uptake of curricula. The lack of competencies related to geriatric assessment, a pillar of the discipline of geriatric oncology, was unexpected. The reason for this is not entirely clear and requires further evaluation, particularly given the recent release of geriatric oncologic practice guidelines by ASCO for the inclusion of geriatric assessment in oncology practice 23. Better understanding of this discrepancy will be of the utmost importance to facilitate the uptake of these guidelines.

Author Contributions

Conception/design: Tina Hsu, Arti Hurria

Collection and/or assembly of data: Tina Hsu, Elizabeth R. Kessler, Ira R. Parker, William Dale, Ajeet Gajra, Holly M. Holmes, Ronald J. Maggiore, Allison Magnuson, June M. McKoy, Arti Hurria

Data analysis and interpretation: Tina Hsu, Elizabeth R. Kessler, Ira R. Parker, William Dale, Ajeet Gajra, Holly M. Holmes, Ronald J. Maggiore, Allison Magnuson, June M. McKoy, Arti Hurria

Manuscript writing: Tina Hsu, Elizabeth R. Kessler, Ira R. Parker, William Dale, Ajeet Gajra, Holly M. Holmes, Ronald J. Maggiore, Allison Magnuson, June M. McKoy, Arti Hurria

Final approval of manuscript: Tina Hsu, Elizabeth R. Kessler, Ira R. Parker, William Dale, Ajeet Gajra, Holly M. Holmes, Ronald J. Maggiore, Allison Magnuson, June M. McKoy, Arti Hurria

Disclosures

Tina Hsu: Celgene, Apobiologix, Ipsen (H); Ajeet Gajra: ICON plc, Cardinal Health (E); Allison Magnuson: NIH National Institute on Aging (RF). The other authors indicated no financial relationships.

(C/A) Consulting/advisory relationship; (RF) Research funding; (E) Employment; (ET) Expert testimony; (H) Honoraria received; (OI) Ownership interests; (IP) Intellectual property rights/inventor/patent holder; (SAB) Scientific advisory board

Supporting information

See http://www.TheOncologist.com for supplemental material available online.

Supplemental Table