Op-Med is a collection of original articles contributed by Doximity members.
Dr. Shabbir M.H. Alibhai presented at ASCO "How to Bring Geriatric Assessment to Your Practice." Below is a transcript of the full interview.
Alibhai: Geriatric assessment is feasible to do. It can significantly detect more issues that the average oncologist would not have appreciated during the routine assessment and some of these issues can impact management. It can help to predict the risk of treatment toxicity, as well as the prognosis of patients using geriatric information from the assessment. It can also impact on treatment decision-making: A systematic review of 10 studies showed that you can change on average 39 percent of treatment decisions with a geriatric assessment compared to before and after.
But I think the biggest challenge is finding high-level evidence that we can impact on the cancer treatment journey, in terms of reducing mortality or treatment toxicity. That area remains to be tested on the basis of large randomized trials which are currently ongoing.
Doximity: How do you suggest physicians approach the subject of barriers to physical activity with their patients?
I would start with asking patience what's their current level of physical activity and some of the barriers to being able to do further activity. Are the barriers knowledge based in which we could try and intervene by teaching them the importance of exercise? Are they lack of access to appropriate facilities? Are they uncertainties around safety? Or are there other factors, for example cancer related fatigue?
Based on when we figure out what they're currently doing and where the gaps are we can start to intervene by targeting those gaps, whether they are knowledge gaps, prescription gaps or safety gaps. That's the beginning of exploring physical activity with older adults because they can benefit just as much as younger people with exercise and more older people tend to be sedentary compared to younger people. There are even more gaps in terms of what we know and what we should be doing.
Doximity: A new cohort study showed that “PSA testing, prostate biopsy, prostate cancer incidence, and local definitive treatment for prostate cancer decreased between 2008 and 2014, most notably after 2011.” Have you seen this clearly in your practice?
Alibhai: Absolutely, I've seen it in two groups. In middle-aged patients, let's say in the 50 to 70 age range, where there's strong push to reducing screening, I have seen fewer people coming in who are being diagnosed, and I have seen more people coming in with later stage disease.
Where I'm seeing even more reduction in definitive treatment is in the older adults who don't have very aggressive prostate cancer, let's say Gleason 6 or 7. More and more of them are being managed with an active surveillance or conservative management approach and fewer of them are getting definitive therapy in the early stages of the disease.
Doximity: What is your take home message about geriatric assessments?
Alibhai: I guess one of the things that I want to emphasize is the issue of geriatric assessment in practice. I think that there are many opportunities, even though we have imperfect knowledge, to be able to implement some kind of screening or some kind of assessment that can be tailored to different environments. Some environments may have a lot of resources like geriatric oncologists or geriatricians with an interest in oncology, and some may have much less. But I think depending on the center you're in, we can always do better in terms of at least some kind of screening to figure out whether some older adults are vulnerable and may need us to think carefully about the treatment plan versus others where it's a green light we can go ahead and be aggressive because the patients are fit and likely to benefit from full therapy.