Time for Geriatric Assessments in Cancer Care: William Dale, Mazie Tsang, and John Simmons

Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we’ve got a full house again today.

Alex: We got a full house. We’re delighted to welcome back to the GeriPal Podcast, William Dale, who is Vice Chair for Academic Affairs. And, in the Department of Supportive Care Medicine, and Director of the Center for Cancer and Aging at City of Hope. Welcome back, William.

William: Thanks so much. Delighted to be here.

Alex: And we’re delighted to welcome John Simmons, who is a patient representative and physician. Retired hematologist, oncologist, works for Scoreboard and lives in Oakland, California. Welcome to GeriPal, John.

John: Thank you. This is my first podcast, so I’m ready.

Alex: Terrific. And we are delighted to welcome Mazie Tsang. She did a palliative care fellowship, then she did hematology oncology fellowship at UCSF, and did a T32 research fellowship in aging with us in the division of geriatrics at UCSF. And she’s now a hematologist oncologist researcher at the Mayo Clinic in Phoenix, Arizona. Mazie, welcome to GeriPal.

Mazie: Thank you so much. It’s also my first podcast.

Eric: Well, Mazie, I think you have the honor, we’re going to be talking about geriatric assessment and oncology. But before we do Mazie, I think you got a song request for Alex.

Mazie: Yes, I do. And thank you so much for the honor of selecting a song. So I’d like to choose Hawaiʻi Aloha. So my family is from Maui and were impacted by the wildfires, so I really appreciate this.

Alex: Thank you.

Mazie: Thank you. It’s in honor of all the people in Maui.

Alex: How is your family doing?

Mazie: They’re good, thank you. And we’re very grateful and we’re praying for all the people who still have yet to be found.

Alex: Yeah, yeah. My family’s also from Maui. My full name is Alexander Keliimoeanu O’Haleakala Smith. So for our listeners who don’t know, I’m part native Hawaiian. And my mom, she has Hawaiian on both sides, my mom, from her dad, and from her mom. And her dad’s family, the Makekaus family, which is based in Lahaina, and we actually visited their grave sites there, when we were there a few years ago. And I don’t think any direct relatives live there anymore. And we also know a number of musicians who live in Lahaina, and all of them are safe. One of them lost his house, sounds like he had a terrible time trying to flee in his car with his three-year-old kid. And then the cars weren’t moving, he abandoned it and ran for it, made it away. His whole house burned down, just cast iron pots left behind. So really feel for those impacted in Maui, and thank you so much for choosing this song. My kids, by the way, did a benefit this last weekend, and raised over $1,200.

Eric: Alex, can we have the link to their benefit so listeners could support those dealing with the fire.

Alex: Oh, yeah.

Yeah, we’ll include it in the show notes.

It was for the Red Cross of Hawaii. So this song, Hawaiʻi Aloha, is a traditional closing song for any Hawaiian concert that you go to. People stand up, hold hands, and sing this song together. So here’s a little bit of it.

[Alex singing]

Mazie, thank you for that song selection.

Mazie: It was beautiful. Thank you.

Alex: All right, again, encourage all of our listeners. Go to our show notes, you can have a link to the Hawaiian Red Cross if you’re up for donating to help those in Hawaii.

Well, with that, let’s turn to the topic at hand. Geriatric assessment. So William, I’m going to start with you. What are we trying to achieve with a geriatric assessment in older adults living with cancer, or being treated for cancer?

William: Yeah, the focus of… So some new guidelines came out, so one reason we are talking about this, ASCO made a high priority of bringing in geriatric assessment for older adults.

Alex: And for our listeners, can you remind us what ASCO is?

William: Sure. The American Society for Clinical Oncology, it’s the largest oncology group in the US, 45,000 members.

Alex: Wow.

William: So ASCO decided to make a high priority this year to redo the guidelines, which were originally released in 2018. And there were two large randomized trials that came out that made them say, “It’s time to update the guidelines.” And really they’re focused on older adults starting on systemic therapies for cancer treatments. And they said, “We really need to update them now, the evidence has gotten so strong to do it.”

Eric: But what are we, I guess going back to the question, what are we trying to achieve with this? Is it for those who may not be appropriate for chemotherapy, for not to do chemotherapy of them? Is to reduce toxicity for chemotherapy? What’s ASCO’s hope when they do this type of thing? And yours, too?

John: For people on clinical trials, we want a certain amount, it’d be ideal if there was a certain amount of homogeneity. So that if you’re calling a color red, and someone else is calling it magenta, and someone else is calling it rose, we may have different populations. One of the advantage of a geriatric assessment is that those 65 and older who have gone through it, we can… They’re perhaps not truly homogeneic groups, but they’re more homogeneous than as if we hadn’t done it. That’s one thing, and there are other benefits as well.

Eric: I guess one question with that is that I think more than half of people with cancer are over the age of 65, but if you look at cancer trials, they’re often either excluding or not saying they’re excluding older adults, but due to multiple, multiple exclusions, they’re underrepresented in those clinical trials. Do you worry about that?

William: Yeah, no, I mean that… 50 to 60% of patients with cancer, over 65. So I make the point, they often say, “Oh, you have this special population,” like pediatrics, where it’s 10% or something. We actually have the majority. So Stu Lichtman’s always saying, “Every oncologist is really a geriatric oncologist, because people over 65 are the majority of the patients.” As you said, about 20 to 25% of people, and that has not moved, are enrolled in clinical trials are over 65. So the trials that we base treatment on are for younger people, the people getting the care, getting the chemotherapy, getting immunotherapy are over 65, by and large. So the oncologists are guessing, essentially and much of the time, about what to do.

John: And not just guessing about what to do, guessing how to cope with frail patients.

Alex: Yeah.

William: That’s right.

John: And there’s a difference between a frail patient in the eyes of an oncologist, and a frail patient in the eyes of the patient, and you can envision a certain amount of tension, there.

William: Yeah.

Eric: Well, Mazie, you’re attending now at Mayo in Phoenix, but not too long ago you were a fellow. Is that right?

Mazie: That’s right.

Eric: So 50 to 60% of patients in oncology are older adults. Is the same representative as far as the teaching one gets in oncology fellowships, where it’s 50 to 60% focused on older adults?

Mazie: That’s a really nuanced question. So I would say that a lot of the education we received were on cutting edge research and the latest drugs in clinical trials, the latest cellular therapies that are coming out. And we don’t often talk about how to apply that to older adults. And that’s why I love the guidelines that came out. William, John, I thought you did a fabulous job.

And following these guidelines is really important because geriatric and palliative care related problems are really common. Alex and I did a study on over 2000 community dwelling older adults, and we found that over two thirds of people had geriatric conditions, these geriatric syndromes, and palliative care related problems like pain, difficulty climbing stairs. Half of people couldn’t get up from a chair, or didn’t have an advance directive. And a third had issues with falls in the last couple of years.

And so these are things we’re not really taught about in fellowship, or in training. And it’s with this information from the geriatric assessment that we can really create interventions, and so that’s something that Alex and I strongly believe that we should move forward with. To start with assessing all these syndromes and palliative care related problems and geriatric syndromes, so that we can create interventions that allow people to receive the cutting edge therapies.

Eric: Whose job, though, is it? Is it the oncologist’s job to do this, and worry about falls, worry about these things? Or is it the primary care document, who’s busy doing other things too, who probably won’t have the time to do a comprehensive geriatric assessment? Who’s responsible for this?

William: I just want to tie a little bit of all this together-

Alex: Yeah.

Eric: Please.

William: … sort of what Mazie’s saying.

So one thing that Mazie’s study shows is that people walk in the door to get their oncology treatment, and they already have all of these conditions. And the key to the new guidelines I would say is, “Well, we’re going to assess them systematically and say, ‘Here are the ones that you have, and we’re going to support that with supportive care or palliative care interventions. So the trials tell us we can intervene, and the biggest outcome is your toxicities go down 20% or more from the treatments that you have, when you intervene appropriately.'”

So it really is the bridge between geriatric assessment and supportive care interventions that this guideline tries to emphasize.

Eric: Okay, I’m going to take a big step back, because I don’t think I actually asked this question yet. What is a geriatrics assessment? I probably should have started with that, right, Alex?

William: Well, I’ll take a shot at it, and let everybody else chime in. Comprehensive geriatric assessment scares oncologists. I’m going to start there.

Alex: It sounds like a lot.

William: Sounds scary.

Eric: It has the word comprehensive in it.

William: It’s too long. There’s too many things to do. So I’m going to come back to that, because the guidelines also help-

John: The key word is practical.

William: … yeah, the practical piece we’re going to come back to. Right, John?

Eric: Okay.

William: But to start with, in oncology, we just pick out the key domains. So we tend to talk in terms of a geriatric assessment, the key domains. And Mazie mentioned a few earlier. So falls, mobility concerns, polypharmacy, comorbidities, nutrition, social support, and mental health. And I think I got most of them, but those in combination are a geriatric assessment, with formal tools for oncology. So John, Mazie, did I miss any? Or, what else should be in there? But we’ve tried to make it as short as we can, I know.

John: I thought there were, the way I put it together, there were seven. One was FEDS, like the Federales, the FEDS. Food, emotional health, drugs, and social support. Drugs has to do with polypharmacy. Food is nutrition, and we all at one time or another endured CPCs, clinical path conferences. And so that’s good for comorbid conditions. And then the duo, physical and cognitive function, those are the seven that…

Alex: Oh, that’s a good way of remembering it. I like it, John.

William: Yeah.

Alex: All right, I got to ask a question here.

Eric: Wait, can I ask one question beforehand?

Alex: Yeah, you can go ahead.

Eric: Because it’s on topic. As an outside observer of oncology practice it seems like, historically, some of it was covered… Well, age was covered, and functional status was somewhat covered. Like, you got an ECOG or Karnofsky. What’s wrong with just using an ECOG or Karnofsky, like you’ve done for decades?

William: Well, I know the oncologists are going to say this, but I’ll just tell an anecdote, which is the eyeball test is what was used for so long along, with a little bit of a Karnofsky or an ECOG. And our founder, in some ways, Arti Hurria showed, it’s really bad. The eyeball test is really bad, and Karnofsky is very little better, in predicting the kind of things we care about for older adults.

John: I’ve come up with an anecdote, and that is, in going to our tumor boards on occasion we would have an 83, 84 year old person who looked just so great. I mean he or she could pass for mid 60s. And my comment was, “Well, I know they look 60, 65, but some part of them is 82.” And that’s the part we couldn’t always assess, that’s why earlier I said frailty is something that is so very subjective.

Alex: Yeah. John, I want to go back to another word you used earlier, and that’s practical. Do you or William want to talk about Practical Geriatric Assessment, and how that might differ from a comprehensive geriatric assessment?

William: So John, why don’t you go first, and then I’ll follow up with what we’re doing with the formal PGA, or Practical Geriatric Assessment.

John: The more comprehensive is one with, requiring greater time, resources, and support. And because, it’s a little kid in a candy store, so many different choices for quote, unquote, “community oncologists,” and perhaps even for academic oncologists. It was intimidating, because there were not always time, resources, et cetera.

So one of the, when you read the guidelines, and I’d encourage each and every one of you to read the guidelines. When you read the guidelines, you’ll see that there are a lot of barriers that the practical part was able to address. The talking stick is yours.

William: Yeah, no. So after we did the initial studies for geriatric assessments, we went to the oncologists. We said, “Hey look, we’ve got this great tool, we want you guys to use it.” And they were like, “It’s too long, we won’t do it.” Literally they’d say, “We’re just going to throw it in the garbage, it’s too much.” So they pushed us over and over and over again, in focus groups and everywhere else. It was too hard, in two ways, they said. One, they said, “It’s too much resources, it’s too much time.” But they also said, “We don’t know what to do with it. I understand, I see these things, but I don’t know what to do with it. How am I supposed to follow up?”

Alex: So like if somebody had a fall, “Like, okay, what do we do?”

William: “What do I do with this? Or what if I find there’s some nutrition I can… What do I do with it?” So what we tried to do with this was address those two concerns.

So along with the guidelines, there’s some links which we’d love to show, of a video. Some training, showing people what to do in the clinic. For resources, 80 to 85% of it does not require the oncologist to do anything. It can be their patient reported tools, or their assessments that can be done in the clinic by an MA, a nurse, someone else with just a digested version. Talk about it, we want like a CBC for them, for a GA, so that the oncologist can just walk in with this really practical thing, and a simple action chart that, “If this is true, do this.” So the Practical Geriatric Assessment tries to do that.

Alex: So what you said, I went biking. One of my good friends, Jerome Kim, is a community oncologist. He’s at Kaiser San Rafael and he’s joined some of these calls, and he was one of those community oncologists who was like, “Nope, too long. Throw it in the trash.”

William: That’s funny.

Alex: “Throw it in the trash, too long. I’m not going to do this.” So I really admire and appreciate your efforts to make this more practical. And I watched the YouTube videos that you link to, and we’ll have links to those in the show notes associated with this podcast. And one is about what is a geriatric assessment, and how do you do it, practically? And the idea that this can be done beforehand, patients can fill it out in advance. And the other video is about what to do with the geriatric assessment, which is really, really key.

But now I want to bring Mazie back in and say, Mazie. Okay, brass tacks, I think you’re the only practicing oncologist in this group, or on this call right now. Is that right? I think?

William: That’s right.

Alex: What do you do?

Mazie: I think I am.

Eric: What do you do?

Mazie: I’m very grateful, I was actually just going to chime in, because I’m very grateful for the Practical Geriatric Assessment. Because a lot of my colleagues, who are like transplant coordinators for example, are asking, “Can you help us better screened for which older adults would be fit enough to go for transplant? And by the way, we don’t have any resources and it’s just us doing everything. And there are only two of us.”

And we’re trying to figure out… Well, I typically like to at least get an assessment of their daily activities. I have people walking, like the time’s up and go, sometimes I assess grip strength. So I actually do these assessments, and my colleagues, these transplant coordinators are saying, “We don’t have time for that. That’s too resource intensive.” And so the Practical Geriatric Assessment, I think we’re going to start implementing. I’m going to try to do it as a QI project because basically, the patient or caregiver can complete it at home, and bring it in. There’s really no added extra resource or time that the coordinators really need to put to doing the screening, themselves. And that way they can just give me the results, and I could help interpret them, and then we can start getting different people involved based on the results.

So I will say that it’s challenging, because we don’t have, unlike City of Hope, we don’t have a big team like they do of geriatricians and palliative care physicians, who can screen these older adults or help with management. It’s really up to the oncologist. So this goes back to your question, Eric, who does it? Well, I do it personally. Fortunately, I am at an institution where they value patient-centered care and they give us that extra time. But I think if I were under normal constraints of the healthcare system, I wouldn’t have that time. So the Practical Geriatric Assessment is just this beautiful tool, and it’s so simple and so clear, I think that a lot of people could really use it. It’s very practical.

Eric: Well, I think it’s, two things are interesting.

John: And the other thing that perhaps we could add-

Eric: Oh, go ahead John. No, no, please.

John: … is that, and I think William can help me more. By completing the Practical Geriatric Assessment, we’re able to feed in and get a result of the probable toxicity that patients will experience. And that’s another important feature. So you’ve taken something very subjective and been able to quantify it, so you can have a tangible, palpable guesstimate about of outcome. Would you say, William?

William: Yeah, I mean, I’m sitting here with the ePrognosis guys, so I’m going to compliment them here, for a moment. Which is, they really did show us, and we’ve in some ways pointed people directly from our GA to the ePrognosis team. In which we say, “If we could cure your cancer, what would your prognosis still be?” And the reason I call it out is, not only could we do it and they bring it into the clinic, you could just do it online. So through our CARG, or Cancer and Aging Research Group website, we have the PGA posted, you can go there. We have the chemo talks tool posted, so people can go there and click and immediately get the information about this.

Eric: What’s the chemo talks tool?

William: Yeah, I’m sorry. Before we had this PGA, there’s a very specific chemotherapy toxicity tool, that you punch in just like ePrognosis and it comes up with, “The chances of you’re having serious chemotherapy toxicity is this,” just gives you a number and a beautiful chart that says low, medium, and high. That was what we used in the trials to say, “Can we lower that likelihood, from what we found in the assessment, down to something else?” And we can by targeting these supportive care interventions. So pretty soon, I hope, we’ll be able to do this all electronically by anyone who wants to. So there is no paper and pencil at all.

Eric: And just for our listeners, you probably caught this. PGA is Practical Geriatric Assessment. This is terrific. I love the link to the practicalities and the next steps. And I just want to push a little bit more on this for the practicing oncologists out there, who might be listening to this podcast who are interested in geri onc or palli onc. What do they do with this information? I know you have the video, and you’ve talked a little bit about you could see their predicted risk for toxicity, for high grade toxicity. But what are the sort of practical steps that they can do once they have assessed the patient using the GA?

William: Yeah, go ahead Mazie. I know what you guys do. I’m just going to say we did create an action chart. So we have an action chart also, that we’ve also tried to boil down to, “If this is this, here’s the follow-up actions to take.” Whether it’s referrals that need to be made, or whether they’re specific actions that the person at home needs to take, like a home safety change. They’re all going to be the things that we palliativists tell people, but they’re really boiled down to, “If this happened, physical therapy needs to do a balance assessment,” and tells them what to do for that.

Mazie, I know it changes locale to locale, because your referral sources are going to be different.

Mazie: Yes. So what I’ve done as a practicing oncologist is sometimes I’ll substitute chemotherapy drugs that might have increased side effects. So for example, I’m thinking of a patient of mine who I absolutely loved. He had a very aggressive lymphoma, highly aggressive, with a lot of different medical conditions. And by geriatric assessment, he was not fit to receive highly intensive chemo, but I did end up giving him a good regimen. I substituted an agent that would possibly cause heart failure, and I gave him some dose reductions as well, just as tolerated and would adjust. I slowly introduced higher doses as he recovered from his medical conditions that were acute. So he had COVID for example, and it really caused a lot of issues for him.

And he did beautifully. He had six extra months. He was so grateful, he had a nice interim remission. And at the end though, he relapsed, and I gave him again lower doses because of biologic function. And I ended up, even despite the lower doses, completely ruining his kidneys. His kidneys couldn’t tolerate this chemo drug, even though it was like a baby dose. It was 25% of the standard dose of chemo for his relapse disease. And he ended up in the cardiac unit because, even though this wasn’t a cardiotoxic agent, he didn’t have the ability to maintain his blood pressures. And he was bradycardic.

And at one point he was just like, “I don’t want to do any more treatments, and I’m so grateful that you gave me six months of quality time with my family, where I was feeling well enough to spend time with them. And had you given me that stronger chemo,” I mean, all his family told me this. “If you gave me that stronger chemo, I probably would’ve been dead within a month,” because again, I gave him very low doses of this treatment for CNS disease, which he was at very high risk for. And he would’ve needed prophylaxis, anyway.

William: I feel like I want to jump in. I mean, it’s the ideal case when you have someone who’s an oncologist with geriatrics and palliative care training. We don’t always have that. So that’s the challenge. But we have told people, they say, “I can’t do this stuff.” There’s two big buckets of things people can do, and Mazie just gave the one, which is, you can always make a different decision. Now that I know that a person has these circumstances, and oncologists can dose reduce, change the dose, decide not to give chemotherapy because it’s so risky that we’re just going to not do that and focus on the other parts of their health. So there’s always decision making things to do, wherever they are, whatever they do. We even did this in Brazil with a mentee of mine in remote clinics, and they loved being able just to get information.

The other part of it is you can optimize the precision of their care by making them stronger, by having people get the non-cancer directed therapies, can also be done. So it’s really decision making, and interventions with supportive care, that can be done at some level in almost any situation.

Eric: Well, I guess-

Mazie: Exactly.

Eric: … going to John, as a patient representative, right? So you’re an oncologist, but you’re also a patient representative for these guidelines. Is that right, John?

John: I’m also a cancer survivor.

Eric: Cancer survivor.

John: Right.

Eric: So let me ask you this. Because I could imagine, as a patient, you get this form mailed to you. Or electronically, to fill out, right? Part of this can be filled out by the patient.

William: Most of it, yeah.

Eric: 80%?

William: 80%.

Eric: 80% that, I work with a lot of cancer patients, sometimes they have a lot of hope, maybe not a lot of trust in the medical system. And they think, “You know what, if I don’t say I’m perfectly healthy, they’re not going to treat me.” Is that something that you worry about? Or even to, either of you, this is qualitative data around this? How does that fit in?

John: You know, Eric, I think it’s a definite possibility. I mean, as you’ve laid it out, it’s a possibility. But I mean, I would also add that not all of the responses to the PGA, and to the provider part that is completed, are coming from the patient. So it’s not just the patient says, “I walk on water,” but you’re seeing, having to keep throwing them life preservers. It’s not like that. And I think that as we in geriatrics, geriatric oncology, palliative care, get more comfortable with the PGA, the Practical Geriatric Assessment, there’s probably some revisions along the way. And more importantly, there’s dissemination to other fields. Mazie brought up transplant medicine. So I mean, it’s very, very important.

William: Yeah, I was going to say, I mean Mazie knows we have a transplant clinic too, at City of Hope, and so they come to us specifically for these assessments. And the patients have exactly what you were saying. They come in, arms crossed, they’re like, “I’m here to see the geriatrician, and they’re here to tell me I can’t get a transplant.” That’s what they’re thinking.

Eric: They’re going to City of Hope, these people-

William: They’re there to get a transplant.

Eric: They’re there for a reason.

William: They’re there to get a transplant.

Alex: Yeah, City of Hope bought Cancer Treatment Centers of America, didn’t they?

Eric: Oh, really?

William: That’s correct.

Eric: All right.

William: It’s now City of Hope, Atlanta, Chicago and Phoenix. There is no Cancer Treatment Centers of America. But yes, we did, so now a national system. But I did want to seriously address this. I mean, they come in, and are there in part to give information. And the first thing I tell them is, “I am not here to tell your oncologist what to do for your care. That is not my job. My job is to help you have the best possible outcome from whatever decision you and your oncologist make.”

And I tell them, “We’re here to make a decision,” and tell them, “If you’re at high risk, I’m going to tell you and them you’re at high risk. And what high risk means is, you might end up in an ICU, or you might end up with this. Has anyone talked to you about that?” And I can tell you, in many cases, nobody has talked to them. They’ve talked a lot about survival, but they haven’t talked a lot about the other outcomes. And to be honest, I think the patients appreciate someone who’s directly telling them, “These are the risks.”

Eric: Well, Mazie, I’m going to you. We brought up your JAGS article, which we’ll link to our show notes about some of the geriatric needs, falls. Where does palliative care fit into all of this, even in your own practice as an oncologist?

Mazie: Yes. So this podcast is GeriPal. For me, they’re really, it’s so highly integrated. I think geriatrics and palliative care, Alex had this really nice Venn diagram that he had created for an article he wrote, where it’s overlapping. And I really think of using geriatrics and palliative care principles for my older adults with cancer. And so, in our finding, we actually were the first study to look at both geriatrics and palliative care related problems in older adults who have these poor prognosis cancers, which means that their survival is less than one year.

And we find that there is that high need, as well, to address some of the palliative care related problems. And what I like about the geriatric assessment, so in the guidelines that they wrote, there are at least two studies that they’ve included, such as the GAIN study, which William led, and Clark de Montiere’s study as well, where they found that using the geriatric assessment actually improved some of these palliative care related concerns, such as advanced care directive completion, discussing goals of care. And so, for me, that’s really important because my goal as an oncologist is to deliver care that is in line with patients’ goals and their values, so that they could live the way that they want to live for the rest of their life. And I think that the geriatric assessment does that, and I’ll let William talk more about his study, but I thought that was really powerful. That geriatric assessment can improve some of these points that we try to address as palliative care physicians as well.

Eric: It’s well said. But William, does the geriatric assessment include questions about advanced care planning and goals of care?

William: Well, what I will say in the GAIN study is, it increased the chances of completing advance directive in the randomized study by 25%. So having those conversations about aging related concerns leads people to do the advance directive. So it definitely changes the dynamic on goals of care, and increases that. It doesn’t specifically ask people, “Have you completed the advance directive?” So it’s not part of the geriatric assessment. What I like about it is it indirectly gets at, “Are we really doing the right thing? Is this really the approach we should take?” And leads naturally to, “Maybe we should complete those advance directives.”

If you’re really worried about being in an ICU, or attached to machines and someone’s like, “I don’t ever want that.” Now we can address the issues. So advance directives is closely tied to the whole goals of care conversation. I feel like, there’s so many times I’ve been in those conversations after the referrals to me, again at City of Hope. And they’ll say, “Oh, you mean something bad might happen if I take these treatments?” And you’re like, “Well, maybe. But has someone talked to you?” And just to get that picture, just to show the chemotherapy toxicity. Like, “Here’s the risk of you having toxicities,” just changes the way people talk to each other. So the kinds of conversations you have with oncologists changes from seeing all those other concerns about being older.

Eric: That’s great. Again, we’ve had a whole series of podcasts about advance care planning, Sean Morrison’s article with colleagues about advance care planning. And so I love the focus on the conversations that arise, rather than the completion of the directives. I do have another question. I know, is it all right if I… What about why the geriatric assessment, and not the four Ms? Four Ms, which is, see if I can do it from the top of my head. Multi morbidity, mind and mentation, medications, polypharmacy, what matters most to the patient. There’s the sort of what matters most goals of care domain. And other people add in a fifth, like multi complexity, something like that.

William: Yeah. Sometimes they throw mobility in there, too.

Eric: Oh, mobility.

Alex: Mobility.

William: Actually, mobility is the one. All right, I was close.

Eric: Close.

Alex: That was close. 80%.

Eric: That was pretty awesome.

William: That was pretty good. I would say they’re bundled into the assessment that we have. Those four or five Ms, however many there are. They’re bundled in there. The tradition comes from very specifically picking these formal tools, and building them into these oncology assessments, in a way that honestly, that oncologists can sort of quickly scan them and get at the information. But the what matters most component really is this part.

Eric: All right, brass tacks. This comes at a cost. Even if 80% is done by a patient, it still takes time. Is there any evidence, I think Mazie alluded to this, that it actually does anything? I think John alluded to it, too. So William, summarize where we are with the evidence base for comprehensive geriatric assessment. What does it do?

William: So the two large trials, I’ll mention the GAIN study and the GAP study, large randomized trials, primary outcome predetermined was chemotherapy toxicity reduction. So in that setting, somewhere between 10 to 20 plus percent reduction in grade three chemotherapy toxicity. That is by far the strongest evidence we have of what the geriatric assessment does.

I do want to say, there’s another study called COACH, led by Supriya Mohile, and I was involved, which was attached to the GAP study. And it showed, in the same randomized setting, that the chances that you’ll talk about aging related concerns goes up threefold from doing a geriatric assessment. So just the fact conversations are going to be had, goes up two to three times. That’s substantial. Secondary outcomes also in those randomized studies include, advance directive completion goes up, for sure. Falls goes down, for sure. And here’s a really interesting one. Patient and caregiver satisfaction goes up after you’ve had a geriatric assessment in your oncology visit.

So in all those quality improvement, patient satisfaction metrics, that’s a big one. It goes up when you’ve had those conversations that people have been avoiding. So those are kind of at the top of the list. Polypharmacy for non-cancer drugs also goes down in the GAP study.

Eric: So hypothetically, for an organization something like City of Hope, but it’s hypothetical. Which of those do you think are the most important, if you’re an organization and you’re thinking about implementing a comprehensive geriatric assessment?

William: Yeah.

John: I would say, as hopefully a setup to William, getting caregivers involved at the… I don’t want to use the word grunts, because that sounds like you’re just doing what you’re told. But as important parts of the team, the caregiver is there in the clinic with the patient, the caregiver sees the exam being complimented, or parts of it done. The caregiver has access to these tools. So they are an important part of developing a relationship where one of the manifestations clearly is, “Well, yeah, I felt good about that. I really did, and I was really fearful. And I’m not as fearful now, because I have more control, I have more hope.” And patients who have hope, and less fear, are going to do better.

Eric: I also feel like, from a caregiver perspective, we don’t really think about caregivers until we need caregivers. Which puts a lot of burden on caregivers, instead of including them very early on.

John: It’s called COVID, we learned that from COVID.

Alex: Yeah.

Eric: Yeah.

William: I did want to supplement what John said. So I do think that having caregivers as partners from the beginning is key, they fill out a lot of these assessments, they’re the ones who are going to do a lot of the work to be honest. And to be honest, they want to. I tell the patients this who are often like, “I don’t want to burden the people around me.” They want you to burden them. They want you to sort of reach out, and it helps bring that together.

But I did want to address the organizational prerogative of, why would an organization want to do this? It seems like it’s just extra work. So first of all, we are now able to bill, there are CPT codes that are built into, and billable, through the geriatric assessment. We’re just getting started. I’m not sure if they pay for each other, but several hundred dollars per assessment is possible, and we’re putting those in place. Can’t underestimate taking the sting out of the costs, would make an organization pay attention.

I’ll say it this way, I’ve been working my whole life to stop over treating and under treating older people with cancer. And organizations, in the name of efficiency, should also want to not over treat and not under treat. Overtreatment leads to hospitalizations, undertreatment leads to disease progression. So if the geriatric assessment, and I’ll go say it, as part of a precision medicine approach that isn’t just about genetics, but is about other parts of patients. That would be the big bottom line to me is, organizations should be interested in this because it would direct their resources, and make the patients happier.

Eric: And Mazie, it’s really interesting, because there are a whole lot of tests that happen, often before giving somebody chemotherapy. We have tons of labs and you never hear, “I don’t want to order a CBC because I don’t know what to do.” Or a compound, or a LFTs. “I’m not a GI doctor, I don’t know what to do with liver abnormalities.”

But there seems to be something special when we move from something that we can just check box like, “I’ve done this,” like a lab order or imaging study. I don’t know, some type of barrier when it comes to, even a patient reported 80% of the time, reported comprehensive geriatric assessment or a Practical Geriatric Assessment. Does that resonate with you at all?

William: It’s a great point.

Mazie: Well, it’s tough, right? Because I’m drinking the Kool-Aid here. They know it’s not challenging at all.

Eric: But even when you said, transplant.

Mazie: Right.

Eric: People going for transplant, that’s not a small little thing. The resources involved in transplant oncology is huge, right? And for some of them, the stays in hospitals are a month long. But what we can’t figure out is, how do we do this comprehensive geriatric assessment? We can figure out how to keep them in the hospital for a month, or do all these other imaging tests, but we can’t do this one thing.

Mazie: Yes. I mean, there are a lot of studies out there that survey oncologists nationwide. I will say from experience, it is challenging, because we’re asked to speak about so many other things in our visit. And it’s a very time limited visit. I’m sure, John, you have a lot of experience with this. And so, we can only cover so much, and there’s a lot… Especially if you’re thinking about allo transplants. Like getting a donor, doing all the different tests, making sure there’s not going be an interaction.

Eric: But if the Practical Geriatric Assessment was a lab test, everybody would get it.

Mazie: Oh, for sure.

William: I can’t resist, Mazie’s probably heard this rant. So they catch me on a bad day, and I get on this rant too. And they’re like, “Oh, it’s too hard. I can’t do it. It takes too much time,” whatever. And I’m like, “Yeah. And when’s that bone marrow biopsy coming up? And when is the MRI being scheduled? And when is the X, Y, Z being planned?” I’m like, “Could I have five minutes of that? How about if I just take five minutes from it? You just make that five minutes easier.”

There’s a great article, I have to say, it’s one of my favorites in JCO. I didn’t write it. It’s called, It’s Time to Stop Saying the Geriatric Assessment Takes Too Much Time. And it actually puts on a chart the geriatric assessment done by nurses, versus a bunch of other things that we do for patients, how expensive they are, how much time they take. And I can tell you, it’s a very good comparison for us. And I do think if we can take the cost out of it, it’s essentially a cost-free way to improve patient’s care. It’s really absurd. It’s really absurd. It’s absurd that we say we can’t do this, at this point.

John: I think a lot in terms of analogies. A surgeon who is seeing a patient and detects diabetes out of control is not going to say, “Damn the diabetes, get them to the OR now.” He’s going to send the patient someplace, diabetologist, endocrinologist, general internist, whatever, to address that issue to make the patient better able to qualify for the intended surgery. Or if you want to think of it personally, to keep a fatality out of the book of the surgeon. So this is, what do you say, pennies wise and pounds foolish.

Eric: Well, can I ask you, and again, I’m going to get personal here for a second, John. Feel free to not …

John: I’ll mute you. Don’t worry.

Eric: As a patient, as somebody who has had cancer, did you get a geriatric assessment? And if not, how would you feel about getting one?

John: I think now I would certainly embrace it and encourage it, because the incompatibility of being a proponent for it and then when it comes to me, the answer is no. My cancer was a while ago, was through the UC system. And so, be careful what you ask. I’ll turn it back on you.

Eric: Well said.

John: And I think that we can’t just work for here and now, we’ve got to plan and work for the future. And geriatricians, I mean look at… Our birth rate just plummeted a little bit, right? We’re growing older, collectively. And so these are the kind of things that can be used to provide quality care that is agreed to by both the health community and the patients receiving it, and along the way, help to control our costs.

William: Not the future, but the present. Right? I want to throw out one fact for you guys. For the first time in history of the world, there are more people over 65 than there are children under five. First time ever, about two years ago.

Eric: Okay. Given that, given the population of older adults is increasing, my last question is, who should get a practical or comprehensive geriatric assessment? Is it everybody over the age of 50, 65, 75? Is there a screen to get comprehensive? Like, “Oh, this person screens positive, they get a practical comprehensive geriatric assessment.” How does that work in real life?

William: Wow, that’s good. I’ll take my first crack at it. So the guidelines say everyone over 65 should get some version of a geriatric assessment if they’re contemplating systemic therapy.

Alex: And what is systemic therapy?

William: Yeah, great question. It used to be just chemotherapy, because we didn’t have the evidence. Systemic therapy is now chemotherapy, immunotherapy, targeted therapies, hormonal therapies.

Eric: And what’s not systemic therapy?

William: So we took surgery off. Surgery’s not in there. Radiation therapy is not officially in there, and we don’t have enough evidence for a few things, like CAR T therapies. But most things that a medical oncologist would do are kind of in there, right, Mazie? There’s not much we left off, anymore.

Alex: Yeah. She’s nodding her head, for those listening.

Eric: And Mazie-

Mazie: Oh, that’s right. That’s right.

Eric: … as a practicing oncologist, does that feel right to you, too? Anybody over 65 with systemic therapy?

Mazie: I think that sounds really consistent with all the evidence out there. And I would add that, if one had to choose, some of the research out there shows that people who have higher risk cancers, like poor prognosis cancers or advanced cancers, people who are in underrepresented groups, like people who are Black or of lower socioeconomic status, that they tend to be impacted more with these conditions as well. And so, at least making sure that we target all those groups that are at risk for higher geriatric syndromes and these palliative care related problems.

Eric: And it sounds like, while you did say that this is for people who are receiving some form of systemic chemotherapy and you named some things that are not, it also strikes me that people are having oncologic surgery who are older, probably should also receive some sort of geriatric assessment. And the reason you didn’t include it, it’s just because the evidence isn’t there yet?

William: Yeah. So this is something I have with oncology all the time. We’re always going back and forth like, “What’s the evidence, what’s valid?” All this stuff. And they really insist that it doesn’t matter how many older adults we have shown that this is a good approach for, if they don’t have cancer, I somehow don’t have evidence that it’s good enough for that. So I would say there’s plenty of reason to think that these assessments for anybody who’s older, including those with cancer, provides benefits. Even if you’re not going to give chemotherapy, you’re going to target interventions for falling down, and for advance directive completion and for other things. And, prognosis. You’re actually going to get some prognostic information that should be acted on for anybody.

So I feel comfortable saying anybody over that age. If, for practical reasons, it’s too difficult. There’s an active debate now, maybe 75, because people, 65 to 75 is so many people that we need a somewhat different approach as people have more and more age associated concerns, as they get older. So I think that’s legit if you’re just… Mazie might be overwhelmed if it was everybody over 65, with the amount of resources they have. So you might choose a higher age cutoff just for practical reasons.

Eric: Okay. My last question-

John: Before you wind down.

Alex: Yeah?

Eric: Yeah?

John: A quick comment, namely that, when you talk about DEI you tend to think, evoke this thought of people of color. And I think it’s noteworthy to point out that there were men and women of color, older adults, cancer survivors, and many others that would fit under the umbrella of DEI on this expert panel.

Alex: Great.

John: Notwithstanding that fact, look at the last section of the screening, of the guidelines. And you’ll see how important it is to remember the vast number of people who are not included in clinical trials. And that is, I mean, the people of color that’s just patina.

Alex: Yeah.

Eric: Not just oncological trials, but all trials.

John: Right. I think it’s important to bring that up.

Alex: Yeah. Thank you for bringing that up, John.

William: Thanks, John.

Eric: And thinking about moving forward, John, I’m going to start with you. If you had a magic wand, you’ve been a practicing oncologist, a physician, you’ve been part of these ASCO guidelines. If you had a magic wand, what’s one thing you want our listeners or oncologists or healthcare systems… You only got one thing. One thing you’d want to use that magic wand for? Around this issue.

John: Around this issue? I think I’ve already planted a few little seeds, earlier. I think it has to do with using more fully and dynamically the patient advocate slash caregiver. I mean, it all comes back to money, unfortunately, but we cannot afford what we’re doing. And we have people, that was one of the benefits of COVID experience, who are able and willing to learn and participate. So, my one chance for a Lotto ticket, I would play that number.

Eric: Wonderful. Thank you. John. Mazie, what’s your one?

Mazie: I would focus on, that we’re a team. This is an interdisciplinary team. To take care of people who have a lot of complicated issues requires a team approach, and there’s a thing at our institution that no person is big enough to be independent of others. And I truly believe that. I hope people take that away, that’s what I love about geriatric oncology, palliative care, it’s all interdisciplinary. And that’s what our patients deserve.

Eric: Wonderful. William?

William: I would ask that every person over 65 would be required to have a geriatric assessment before they were allowed to get these treatments, or they would be reimbursed in some way for the trouble.

Eric: Wow. Before we end, Alex, this is the traditional ending song, right? When you go to Hawaii, you want to give us a little bit more of… What’s the title, Mazie?

Mazie: Hawaiʻi Aloha.

Alex: (singing)

Eric: John, William, Mazie, thank you for coming on this podcast with us.

John: Thank you.

William: Thanks for having us. This is great.

Eric: And to all of our listeners, thank you for your support. And again, if you would like, we’ll have the donation site on our GeriPal website if you’d like to contribute to the Hawaiian Red Cross.