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Tools to Help Decision Making

Chapter 3 - Evaluation of the Senior Cancer Patient: Comprehensive Geriatric Assessment and Screening Tools for the Elderly

An overall approach to treatment selection is illustrated in the Figure below.

Treatment approach based on levels of geriatric impairment

Some tools have been developed that may assist in decision making. Several are available online (Table below) and cover GA, chemotherapy risk assessment, or life expectancy estimates.

Standard oncology tools, such as Adjuvant! Online, can be helpful but should be used with caution as their data estimates can be skewed in the elderly. In addition, published predictive assessments are available, for example for the risk of post-surgical complications: PACE/PREOP, Kristjansson.

The links provided in the Table below are some of those found to be very useful by the author but in no way is this presented as an exhaustive list as such lists evolve rapidly.

With advancing age and comorbidity, patients may use increasingly diverse criteria to judge which treatment choice is “worth it”, and subjective estimates by both patient and physician become increasingly imprecise as case complexity increases. Therefore, one of the main goals of these tools is to provide accurate estimates of the benefits and risks of cancer and its treatment alternatives for discussion with the patient and other stakeholders.

Useful links to online resources

NameType
CARG scoreChemotoxicity risk prediction
CRASH scoreChemotoxicity risk prediction (the page also contains a low neutropenia risk calculator, CIRS-G calculator, and SAOP2 questionnaires in several languages)
ePROGNOSISGeneral life expectancy
POGOeCollection of free geriatric resources
SIOGGeriatric assessment and cancer treatment guidelines for older patients

Abbreviations: CARG: Cancer and Aging Research Group; CRASH: Chemotherapy Risk Assessment Scale for High-Age Patients; POGOe: Portal of Geriatric Online Education; SIOG: International Society of Geriatric Oncology (Société internationale d’oncologie gériatrique) (Links accessed 10/11/2014)

Practical Tips

Establish relationships with colleagues and think through the referral pathways for positive screening in advance. Use pre-formatted orders when possible to simplify referrals. Integrate referrals and tools which help in onco-geriatric decision making in your clinical pathways. Integrate geriatric assessment recording in your electronic medical record. Seek training and regular input from experienced onco-geriatricians if you are developing a focus group or programme in your institution: this will avoid a lot of pitfalls, as the format of such programmes is still very much context-dependent.

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