Geriatric oncology, general practitioners and specialists: Current opinions and unmet needs

doi:10.1016/j.critrevonc.2009.03.002

Critical Reviews in Oncology/Hematology

Volume 75, Issue 1, July 2010, Pages 47-57

https://doi.org/10.1016/j.critrevonc.2009.03.002 Get rights and content

Abstract

Purpose

To describe the patterns of care of elderly cancer patients (ECPs) (>70 years old) and the factors affecting the referral by general practitioners (GPs) of patients to cancer specialists (SPs), in Alsace France.

Methods

A postal mail questionnaire was sent to a total of 2818 physicians including primary care physicians and specialists. The factors possibly responsible for a poor referral rate of ECPs and the factors affecting treatment implementation by specialists were explored. We also searched for unmet needs such as the incorporation of geriatric assessment into routine practice and continuous medical education (CME) programs.

Results

A total of 1217 questionnaires were returned (46.9%) from 1053 GPs and 214 SPs. Patients’ age did not negatively impact referral to SPs as opposed to patients’ performance status, wishes, and co-morbidities. Conversely, a significant decrease in patients’ file presentation by SPs to tumor boards was observed for patients over 80 years old. Neither reimbursement nor SPs’ waiting lists were an issue. The need for CME programs in geriatric oncology was emphasized by both GPs and SPs.

Conclusions

Age was not the governing variable that impacted patient referral. The need for CME in geriatrics was highlighted for both GPs and SPs.

Introduction

As lifespan is continuously growing, a dramatic increase in cancer incidence is anticipated over the next decade, as cancer is a condition that mostly occurs in patients over 50, and that peaks in the 70s. Treatment of elderly cancer patients (ECPs) has progressed over recent years, by the identification of elderly patients characteristics and the use of corresponding guidelines. Moreover, most elderly cancer patients now consider positively both being actively treated and their enrolment onto a clinical trial [1], [2], [3]. However, both oncologists and other specialists (SPs) depend on the general practitioners (GPs) for patient referral. Hence it is of major importance that geriatric oncology is identified by GPs, as patients themselves acknowledge that old age should not be a factor for inadequate treatment [3]. Geriatricians and oncologists have shown that geriatric assessment identifies three subsets of patients, and accordingly three different approaches towards anticancer treatment [4], [5]. Patients in group #1 should be treated as young patients, whereas in group #3, frail patients should mainly be candidates for supportive care. The intermediate (#2) group of patients should be treated, taking into consideration their partial frailty as well as the severity of the disease. Diagnosing the frailty syndrome dramatically impacts a patient's ability to recover from stress, including surgery, chemotherapy or radiation therapy [6], [7]. Additionally, it is important to diagnose vulnerability as a factor that might strongly interfere with treatment toxicity. In France, geriatric oncology has been recognized as a major objective in the “Plan Cancer”, a nationwide effort to promote cancer care. This plan also recommended the set-up of tumor boards, where oncologists, radiotherapists, SPs and possibly GPs gather to establish a treatment plan recommendation for the patients. Within these tumor boards are discussed complex patients’ files that do not fit into usual guidelines, or which require additional expertise from a multidisciplinary point of view. We set up a pilot geriatric oncology unit from the two major academic institutions taking care of cancer patients in Alsace, France. We conducted a study with 2818 physicians, including GPs and SPs. Our primary end-point was to identify the unmet needs of practitioners in the field of geriatric oncology. Secondary end-points were to describe the factors affecting care of elderly cancer patients as well as describing current opinion and practices.

Section snippets

Materials and methods

General practitioners, as well as specialists, in activity throughout the entire region were identified from the ADELI repertoire (a national health professionals database) and crossed with the databases from the regional Medical Association. Data included specialty, mode of practice (private versus paid employee or both), length of service and practice location. Data from the regional social security office (URCAM, Union Régionale des Caisses d’Assurance Maladie) database were used to compare

Results

A total of 2818 questionnaires were sent to a physician population including 2337 GPs and 481 SPs; 1267 questionnaires (1053 GP and 214 SP) were returned (overall response rate of 46.8%). Of these, 420 (362 GP and 58 SP) were returned after the second mail wave. We found that for GPs, the responders’ age did not differ from the entire study target (p = 0.063). Practice location slightly differed mostly due to a higher rate of responders in urban areas (72.3 versus 66.8%, p = 0.0104). These data

Discussion

In France, the life expectancy in 2007 was 84.4 and 77.5 years for males and females, respectively, whereas the 2005 cancer mortality accounted for 155,407 deaths as compared to 149,839 deaths from cardiovascular diseases [8]. From 1980 to 2005, the incidence of cancer cases in France increased by 89%, and population ageing accounted for 24% of this number [9]. In our study, patients were considered as elderly beyond 70 years old. Treatment decisions in geriatric oncology rely on several

Conclusion

We have investigated the patterns of elderly cancer patients’ care at the scale of the entire region of Alsace, France. To our knowledge, such a study has not been conducted so far in Europe, but our data were consistent with the patterns of care shown in Canada [18]. All physicians emphasized the need for developing social/logistic aids to the patients, as well as facilities dedicated to medium-term geriatric hospitalization. It is now on health authorities and executives to take

Reviewers

Professor Marc Bonnefoy, Chef de Service, Centre Hospitalier Lyon Sud, Department of Geriatric Medicine, Pavillon 5 E Médecine Générale, 165, Chemin du Grand Revoyet, F-69495 Pierre Benite, France.

Professor Jean-Pierre Droz, Centre Léon Bérard, Dept. Medical Oncology, 28 rue Laennec, F-29008 Lyon, France.

Acknowledgements

The authors are indebted to all the physicians who voluntarily participated in the study. The study was supported in part by the association AGIRA (Alsace Gérontologie Information Recherche Action) and the Ligue Régionale contre le Cancer.

Jean-Emmanuel Kurtz, MD, Ph.D. is professor of medical oncology at the University of Strasbourg. He is author of many articles in the field of oncology, and has been involved in the early development of geriatric oncology in the Hôpitaux Universitaires de Strasbourg. At the present time, he is engaged in both clinical and translational research projects.

References (18)

I. Carreca et al.
Cancer in the older person
Cancer Treat Rev
(2005)
L. Ferrucci et al.
The frailty syndrome: a critical issue in geriatric oncology
Crit Rev Oncol Hematol
(2003)
L. Repetto et al.
Geriatric oncology: a clinical approach to the older patient with cancer
Eur J Cancer
(2003)
A. Belot et al.
Cancer incidence and mortality in France over the period 1980–2005
Rev Epidemiol Sante Publique
(2008)
L. Fratino et al.
Global health care: the role of the geriatrician, general practitioner, and oncology nurse
Crit Rev Oncol Hematol
(1998)
C. Terret et al.
Statements on the interdependence between the oncologist and the geriatrician in geriatric oncology
Crit Rev Oncol Hematol
(2004)
M.S. Mano et al.
Colon cancer: update on adjuvant therapy
Clin Colorectal Cancer
(2008)
L.A. Siminoff et al.
Factors that predict the referral of breast cancer patients onto clinical trials by their surgeons and medical oncologists
J Clin Oncol
(2000)
M. Extermann et al.
Are French older patients as willing as older American patients to undertake chemotherapy?
J Clin Oncol
(2003)

There are more references available in the full text version of this article.

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Assessment of the interest of the geriatric oncology consultation among French general practitioners
2016, Journal of Geriatric Oncology
Citation Excerpt :
The response rate (44.4%) of GPs in our study was satisfactory and comparable with those for most surveys of this type. Indeed, this response rate is similar to that found in the study by Kurtz et al. (46.9%),8 and better than the mean response rate reported in the literature for this kind of study.9 We regret the fact that the chase-up phone call (following our paper questionnaire) did not improve the response rate among GPs.10
We assessed the interest of the geriatric oncology (GO) consultation (GOC) among general practitioners (GPs).
We conducted a survey among GPs whose patients had had a GOC in 2012. A questionnaire was sent to GPs. The 1st part collected GPs' characteristics including medical education in geriatrics and GO, and knowledge of GOC. The following parts concerned the GOC and included the cancer type, GOC report and care plan.
One-hundred twenty-six questionnaires corresponding to 94 GPs were collected. Concerning the GPs' characteristics, age range 50–59 (44.7%), men (62.8%) and urban practice (79.8%) were the most represented, 80.8% had no expertise in geriatrics, 60.6% knew of the existence of GOCs, and 14.9% had received medical education in GO. The most frequent cancer location was gynecological (40.7%) (82.6% were breast cancers). Of the GPs, 69.8% had received a GOC report and 92% were (very) satisfied with the delivery time. A care plan was proposed after the GOC in 83% of cases. It was satisfactory in 96.4% of cases, and applied by 74.7% of GPs. Sixteen percent of GPs were called by the GO team. The less the GP was satisfied with the GOC, the more he or she wanted phone contact (p = 0.02); 94% of GPs considered the GOC (very) satisfactory. Sixty-seven percent of GPs wanted to be trained in GO.
Very few GPs had been trained in geriatrics and/or GO. They were mostly satisfied with GOC and expressed a wish to be trained in GO.
From suboptimal to optimal treatment in older patients with cancer
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Referral of elderly cancer patients to specialists: Action proposals for general practitioners
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In the two studies involving all types of cancer and specifically among elderly patients, the factors found to be predictive of patient referral to specialist care were linked to the desires or reluctance of the elderly patients (OR = 1.26, 95%CI[1.01–1.56])36 with 75% of GPs judging this to be ‘very important’,24 to the stage of the disease (OR = 1.69, 95%CI[1.38–2.07])36 with 62% of GPs judging this to be very important,24 and to the presence of comorbidity (OR = 1.56 95%CI[1.26–1.94]).36 In terms of organizational factors, physicians who had received specific training in geriatrics were more likely to refer their patients.24,36 The location where the GP was practicing was also noted, but the direction of influence not always clear.11,36
Many studies have identified advanced age as a barrier to accessing specialized oncological care.
To identify elements from the literature influencing general practitioners (GPs) in their decisions to refer elderly patients with cancer to oncology teams, and propose focused actions to improve referral processes.
Eligible articles published up to July 2010 identifying factors associated with referral decisions for elderly cancer patients were selected. A quality assessment of each article was performed. All factors identified were considered for possible interventions classified by the Effective Practice and Organisation of Care (EPOC) taxonomy and development of recommendations for referral of elderly patients.
Thirty eligible articles were found with only 18 articles specifically exploring factors influencing physicians in the referral of their patients with cancer. Twelve focused on delay to treatment and only two uniquely on elderly patients. Patient age was the main factor associated with referral decisions, but this factor can influence GP’s differently depending on the type of cancer. The small size of these studies, heterogeneity of study populations, and diversity of outcome measures used meant that compilation of guidelines based on high-quality evidence was not possible. However, organizational factors hindering decisions to refer are identified and highlighted as crucial for inclusion in intervention programs, specifically to reach GPs in smaller locations or with less experience in collaborating with specialists. For patient-related factors, professional and organizational interventions are necessary, aimed at both GPs and patients to update knowledge of the non-linear relationship between chronological age and a patient’s ability to tolerate treatment.
First and foremost, this article highlights the scarcity of literature specific to elderly patients with cancer. It also identifies the public health need for better knowledge of the factors for referral of elderly patients. Focussed action proposals are presented to improve knowledge and consequently, optimize the referral process.
Therapeutic strategies in elderly and very elderly patients
2012, Best Practice and Research: Clinical Haematology
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Furthermore, participation of patients is often altered with frequent occurrence of under-diagnosed depression which may lead to refusal of treatment [9]. Finally, but this list is not exhaustive, the attitude of physicians and relatives may be biased and may lead to misconduct of diagnosis, work-up or even treatment [11–14]. This first part of the management of patients is crucial and will allow for a thorough evaluation of the patient and his/her problems which will be then gathered with the results of the lymphoma pre-treatment work-up to help the hematologist decide about the adequate treatment.
Management of the elderly with lymphoma needs specific attention. This means supplementary evaluation as regards to younger patients. The objective is to identify specific weaknesses of the patients and thus to foresee potential unexpected toxicities which may endanger patients’ outcome. With this information, the hematologist will be able to propose an optimized treatment strategy i.e. with an adapted efficacy/toxicity ratio.
These general principles are consensual but it remains to determine what the practical content of this approach is. Recent results suggest some specific tools for the pre-treatment evaluation. Some specific indexes have been proposed to categorize patients but the ultimate approach remains to be outlined. Finally, while geriatric intervention has demonstrated its capacity to improve survival in the general elderly population, no such demonstration has been made in cancer patients including lymphoma.
Adjuvant chemotherapy in elderly patients with early breast cancer. Impact of age and comprehensive geriatric assessment on tumor board proposals
2011, Critical Reviews in Oncology/Hematology
Elderly breast cancer (EBC) patients are often denied adjuvant chemotherapy because of age. Breast cancer is among the most frequent cancer in Western Countries and recent data suggest that adjuvant chemotherapy could be active in selected elderly patients. We investigated the impact of age and comprehensive geriatric assessment (CGA) among other variables taken into account in tumor boards to recommend adjuvant chemotherapy in EBC patients.
We retrospectively reviewed breast cancer tumor board records of all consecutive EBC patients (over 70 years old) discussed from July 2006 to July 2009 in our institution. The recorded variables included age, comorbidities, tumor stage, grade, ER/PR and HER2 status, treatment characteristics and CGA conclusions. Agreement with breast cancer treatment guidelines was verified. Reasons for deviations were recorded.
A total of 192 early EBC patients files (mean age 76.7 years, range 70–98) were analyzed. Elderly patients were less likely to receive adjuvant chemotherapy even when deemed appropriate by guidelines (p < .001). Out of 118 patients with ≥1 risk factors (pT2–4, N+, RH−, SBR III), 70 were proposed adjuvant chemotherapy. In multivariate analysis, age >80 years, but not CGA result, was an independent variable associated with a decreased likelihood to receiving adjuvant chemotherapy. Moreover, 93 patients (48.4%) underwent CGA, of whom no Balducci's class III patient received adjuvant chemotherapy. An appropriate treatment was administered in only 69% and 42% of Balducci's class I and II patients, respectively.
Our results suggest that age remains an independent variable associated with a decreased use of adjuvant chemotherapy. However, in our series systemic adjuvant chemotherapy was probably underused in “fit” patients. Further efforts are needed to better integrate CGA into tumor boards proposals for early EBC patients.
Nutritional aspects of the cancer/aging interface
2011, Journal of Geriatric Oncology
Citation Excerpt :
Quite recently, Kastritis et al.49 found that weight loss was a significant predictor of outcome in multivariate analysis of patients receiving platinum-based chemotherapy for cervical cancer. Although tolerant, toxicity and efficacy of different chemotherapeutic regimens are comparable in adult and elderly patients despite the presence of comorbidity,50–53 only a limited proportion of elderly patients is routinely treated54–58 with few exceptions.59 Moreover, elderly patients tend to be under-represented in clinical trials,60 since physicians usually avoid to enroll aged patients in prospective investigations.61
The progressive aging of populations coupled with the increasing prevalence of cancer in elderly people, due to their long exposure to potential oncogenic factors, represents a formidable challenge for the health system. Moreover, whereas in many adult cancer patients, malignancy represents the primary basic target to be treated, in the elderly patients a concurrent status of sarcopenia multiplies the risk of aggressive therapies and forces the clinician to maintain a holistic view of his patient.
A common problem for the elderly cancer patient is the progressive malnutrition which is due to coexistence and/or potentiation of the metabolic alterations related to sarcopenia with underlying cancer cachexia. Both processes lead to loss of body weight, lean body mass, and muscle function, as well as a progressive deterioration of function of many organ/systems, a poor quality of life and finally to a poor adaptation to any stress event.
Although neither sarcopenia nor cancer cachexia may be reduced to a condition of simple starvation, an adequate nutritional intake is the conditio sine qua non which can make possible any attempt of aggressive oncologic therapies which are validated in adult subjects.
This paper, after a short review of topics including the interaction between sarcopenia and cancer cachexia, the nutritional status as a component of geriatric assessment tools, the prevalence of malnutrition and the negative prognostic role of malnutrition, focuses on the theoretical and practical aspects of the nutritional support of the elderly cancer patient.

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Geriatric oncology, general practitioners and specialists: Current opinions and unmet needs

Abstract

Purpose

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Conclusion

Reviewers

Acknowledgements

Cancer Treat Rev

Crit Rev Oncol Hematol

Eur J Cancer

Rev Epidemiol Sante Publique

Crit Rev Oncol Hematol

Crit Rev Oncol Hematol

Clin Colorectal Cancer

Factors that predict the referral of breast cancer patients onto clinical trials by their surgeons and medical oncologists

J Clin Oncol

Are French older patients as willing as older American patients to undertake chemotherapy?

J Clin Oncol