Comprehensive Geriatric Assessment May Predict Survival Based on Frailty in Hematologic Malignancies

In patients with hematologic malignancies, comprehensive geriatric assessment could be used to predict treatment complications, identify candidates for intensive chemotherapy, and even predict mortality, according to a paper published in Blood Research.

In 2018 in Korea, a total of 61.8% of newly diagnosed cases of multiple myeloma, 59.3% of myelodysplastic syndrome cases, 47.0% of myeloproliferative disorder cases, and 46.7% of non-Hodgkin lymphoma cases were diagnosed in patients who were older than 65 years. In light of the heterogeneity of health status associated with this older population, investigators indicated that a sufficient standard oncological performance evaluation was necessary to identify candidates for intensive chemotherapy. Investigators defined health status as frailty, age-related syndrome of physiological decline, and increased vulnerability, all of which were associated with adverse health outcomes.

Investigators defined frailty as decreased physiological reserves and marked vulnerability to adverse outcomes after stressful events. In Korea, those who resided within a community setting had frailty ranging from 7.7% to 17.0% based on the frailty phenotype assessment, and 17.5% to 26.3% based on the frailty index assessment. The investigators explained that these assessments help to lower treatment-related morbidity and death. Additionally, frailty was associated with shorter survival in patients with multiple myeloma and those who are undergoing allogeneic hematopoietic cell transplantation.

Comprehensive geriatric assessment, a multidimensional interdisciplinary diagnostic tool, could be used to determine a patient’s psychological, functional, social, and environmental capabilities as well as to help create an individualized treatment plan. The assessment reviews whether patients have acute or chronic disease, their medications, and their nutrition status, as well as conducting a functional and psychological assessment.

Adverse drug reactions are more notable in older populations, with the risk increasing with age. Drugs that yield a higher risk of adverse effects (AEs) have been labeled as potentially inappropriate medications for geriatric patients. The functional assessments assessed the activities of daily living, instrumental activities of daily living, and physical functions. This is of particular importance, as 78.2% of older adults in Korea live in single households, alone, or with a spouse. In particular, the population should be entered into a long-term care facility or hospital if their functional capacity decreases due to treatment-related AEs, the investigators stated.

Socio-economic status was also assessed to identify the patients’ primary caregiver, decisionmaker, and financial/insurance status. This determines how to treat the patient and at what treatment intensity. Investigators also evaluated cognitive function and emotional status, as confusion or delirium could be an adverse effect of treatment. Assessing the nutritional status of a patient is also important because malnutrition is a frequent occurrence in older patients and could negatively affect treatment progress and quality of life.

Investigators also reported geriatric impairments in 17% to 68% of patients despite the population having a positive performance status. These assessments allow for additional decision making, treatment allocation, and implementation of non-oncologic geriatric interventions before and during intensive chemotherapy to help improve resilience and tolerance.

In 13 previously reported studies, with the median prevalence estimate was 26% for activities of daily living, 44% for instrumental activities for daily living, 19% for cognitive impairment, 32% for depressive symptoms, and 39% for impaired objective physical capacity.

Previous studies found that those with aggressive B-cell lymphoma who had impaired functional status and summary scores were more likely to be non-responders, and a majority died before the median follow-up for intensive chemotherapy. Patients who had a comprehensive geriatric score associated with baseline dose reductions, which were associated with lower progression-free and overall survival in those with diffuse large B-cell lymphoma (DLBCL). Additionally, very old patients with DLBCL had a low completion rate for therapy.

It is necessary determine a patient’s chronological age and physiologic age to help balance treatment intensity and disease control, the authors stated. Overall, this assessment helps to guide personalized supportive care.

Reference

Choi JY, Kim KI. Assessing frailty using comprehensive geriatric assessment in older patients with hematologic malignancy. Blood Res. 2022;57(S1):1-5. doi:10.5045/br.2022.2021218