4.2.1 Implications for future CME
Education on this performance gap is perceived as important and necessary and should be well attended/subscribed. Physicians in our survey demonstrated they are open to changing the way they practice based on education on current data and treatment trends, with high levels of agreement with the statements “I may need to examine one or more of my clinical practices in this area” and “I plan to change the way I practice in this area in the near future.”
Specifically, education should focus on using guidelines and the most recent clinical data for selecting appropriate therapy options in the geriatric patient population, including how to assess the risks and benefits of these options accurately and how they may impact comorbidities. Additionally, identifying factors that predict toxicity and the best practices for managing side effects should be detailed. “Lack of data specifically for geriatric patients” and “Unknown effects of comorbidities” were rated as high barriers to best practices by 78% and 68% of survey respondents, respectively.
Learning from senior oncologists regarding their experience with treatment selection in different settings, including side effect profiles, would be a fruitful approach to education. A modeling forum or patient case scenarios is a suggested approach to communicating these concepts; learning via a clinical vignette may make it easier to absorb, as integration of patient scenarios makes concepts more recognizable and relevant.
4.3 Practice Performance Gap #2: Using appropriate tools to assess a patient’s functional, cognitive, and support status
Chronological age correlates poorly with functional status; as such, the use of geriatric assessments to determine a patient’s so-called “functional” or “physiologic” age may be a more appropriate consideration for treatment decisions . These assessments take chronological age into consideration, but also include variables like risk of falling, kidney and liver function, activity levels, and cognitive abilities [12,13].
Despite the fact that use of status tools may play an important role in treatment decisions, the results of our inquiries demonstrate a low use of these tools. While physicians in the survey largely agreed with the statement “I regularly use formal tools to assess performance status,” when questioned more deeply if they use formal tools to assess cognitive status and identify risk for chemotherapy intolerance, agreement scores fell below the midway point of 3.0. Based on the telephone interviews and comments from the advisory panel, the feeling was that many clinicians use the content of formal tools in an informal manner to assess patients’ performance status—in other words, they size up their patients mentally instead of using the actual tool as specified. However, physicians do recognize that this approach is not best practice, with “Assess health status (comorbidities, physical function, cognition, social status, etc.)” scoring highly as a perceived need.
A lack of knowledge around tools that are particularly useful in the geriatric population may lead to their underutilization. The expert panel surmised that most clinicians are likely to use tools specific for cancer, such as the Eastern Cooperative Oncology Group (ECOG) or Karnofsky scale, but not scales that are tailored to evaluate geriatric patients. For instance, in the Practice Assessment portion of the survey, only 39% of respondents chose to use the Cancer and Aging Research Group (CARG) or Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) tools in response to question 5, despite the fact the patient clearly should be evaluated with one of these tools given the history of multiple recent falls. Further, in question 7, only 39% of respondents recognized that the most appropriate approach for a patient with possible cognitive decline is to administer the Mini–Mental State Examination (MMSE) or Mini-Cog assessment as a screening tool. Additionally, 19% of respondents chose the Confusion Assessment Method (CAM) screening tool as an appropriate approach, despite the fact that it is more appropriate for assessing sleepiness or delirium rather than memory issues. These results highlight the need for education on tools that are most appropriate for assessing the functional, cognitive, and support status of geriatric patients and how they are best utilized.
The need for these tools to be used for formal documentation purposes was reiterated across the multiple platforms of our analysis. The need for baseline measurements is of utmost importance, so that any documented change in metrics can be assessed to determine if the treatment approach needs to be modified in any way or if additional support is needed. As a geriatrician stated:
“[Clinicians] need to realize that evaluating [cognition is important] because [the elderly] need a healthcare proxy even more than a 50-year-old, because, from your treatment, it’s entirely possible they’ll get delirious.”
Moreover, use of standardized tools and accurate documentation of the results will result in better communication across the multidisciplinary care team to assess any changes in metrics. As simply stated by an oncology clinical nurse educator:
“[Use of tools] are [ideal] for better documentation and better communication.”
Clinicians are keenly aware of the need for better communication and collaboration with the remainder of the healthcare team, as “Collaborate with the multidisciplinary team about the care of the geriatric patient” was the second-highest perceived need.