What is Comprehensive Geriatric Assessment?
UK national policy now advocates comprehensive assessments for older people at the time of cancer treatment decision making.1 Comprehensive Geriatric Assessment (CGA) is a 'multidimensional interdisciplinary diagnostic process focused on determining a frail older person's medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long-term follow-up'.2 CGA involves a review of comorbidities, geriatric syndromes (e.g. frailty, falls, incontinence), mental health, functional difficulties and social circumstances. Although the term CGA implies it is an assessment, it is in fact a four-part clinical process (Figure 7.1).
It is essential to ask about the patient's own goals for the treatment experience (e.g. 'to go to my granddaughter's wedding in a month'). Randomized controlled trials, meta-analyses and a 2011 Cochrane review3 have shown that CGA reduces mortality and institutionalization. Studies of geriatrician-delivered CGA in orthopaedics and surgery have shown reduced length of stay, mortality and postoperative complications.4,5 Based on such evidence, the International Society of Geriatric Oncology (SIOG) recommends CGA in cancer patients over the age of 70 years.6,7
Studies in cancer patients have demonstrated that the four-stage CGA process influences oncological treatment decision making,8,9 impacts clinical care by resulting in a number of intervention plans,8,9 increases postoperative survival,10 and, for geriatrician-led CGA, improves chemotherapy tolerance.11 Studies of one-stage CGA (i.e. screening alone without follow-through) have identified that patient factors such as function, nutrition, comorbidity and falls are associated with lower survival, postoperative complications and chemotherapy toxicity.12-14 Caution should be applied to interpreting these factors as definitive predictors of poor outcome in cancer treatment, however, because these studies crucially lack the key element of intervention and clinical optimization that may impact the associations (e.g. diabetes care, dietary supplementation, referring to falls strength and balance programmes).
What does CGA include and how can we apply this to cancer care?
CGA covers multiple domains that ideally are all screened for but that can also be sub-selected to best assess particular patient needs (e.g. bladder and bowel function for those undergoing pelvic irradiation). Relevant domains can also be added, so for cancer patients this would include cancer-related symptoms and how these impact independent functioning and quality of life, e.g. European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), potential risks of treatment toxicity and optimization to reduce those risks, and preoperative assessment for those undergoing surgery, e.g. American Society of Anesthesiologists (ASA) score. Table 7.1 summarizes these domains with clinical scenarios illustrating referral pathways and optimization if abnormalities are detected through screening. Patients with single-organ comorbidities can be appropriately referred for specialist review (e.g. cardiology or GP). More ...