Impact of Geriatric Consultation in Care for Older Patients with Blood Cancer

According to a randomized controlled trial published in Haematologica, geriatric consultation did not improve survival or reduce hospitalization among older patients with hematologic malignancies when compared to standard care. However, these consultations were highly valued among clinicians.

Patients over the age of 75 with transplant-ineligible blood cancers were enrolled into this trial. They were treated between February 2015 and May 2018 at the Dana Farber Cancer Institute. Malignancies included lymphoma, leukemia, or multiple myeloma.

For randomization, patients were classified as pre-frail or frail based on phenotypic and deficit accumulation approaches. Then, these two cohorts were randomized to standard oncological care with, or without consultation with a geriatrician. The primary endpoint was overall survival at one year. Secondary outcomes included unplanned care utilization within six months of follow-up, and documented end of life (EOL) goals of care discussions. Clinicians were also surveyed regarding their impressions of the geriatric consultation.

In total, 160 patients were enrolled. Sixty patients received geriatric consultation and 100 received standard care alone. The median age was 80.4 years. Eighty percent (n = 48) of patients randomized to geriatric consultation completed at least one session with the geriatrician.

The researchers noted that consultation did not have a significant impact on survival compared with standard care. The difference in overall survival at one year was 2.9% in favor of consultation (2.9%, 95% confidence interval (CI), -9.5–15.2, P=0.65). Geriatric consultation was also not associated with improvements with hospitalizations. The consultation cohort did not have significantly reduced rates of emergency department visits, hospitalizations, or length of stay.

However, geriatric consultations were associated with a greater likelihood of patients discussing their EOL care goals with their clinician (odds ratio=3.12; 95% CI, 1.03-9.41). Additionally, between 62.9% and 88.2% of clinicians rated these consultations as “useful in the management of several geriatric domains.”

“Beyond aligning EOL care with patient preferences, the geriatricians’ expertise in evaluation and management of age-related vulnerabilities was highly valued by surveyed hematologic oncologists and other clinicians at Dana-Farber. Most rated geriatric consultation to be useful in the evaluation of cognition, management of non-oncologic comorbidities, and management of functional status and falls,” wrote the authors. “Fewer clinicians found geriatric consultation to be useful in informing oncologic treatment decisions and the management of nutrition and pain. The latter might in part be due to the comfort of hematologic oncology teams in treating these problems themselves, with support from nutritionists and other allied health services.”

Limitations of this study, according to the author, was the location of the study being at a large academic tertiary care center, which may limit generalizability. Additionally, competing risk of mortality may have impacted observations of secondary outcomes. The authors noted that three patients in the consultation arm died prior to receiving the intervention.

“Future trials can further minimize heterogeneity in patient characteristics by limiting to one or two blood cancer types on active treatment,” the authors noted. “Along with investigating patient-centered outcomes, future trials should also investigate impact of geriatric assessment–guided care on treatment toxicity, treatment discontinuation, and progression free survival.”