Geriatric assessment with management for older patients with cancer receiving radiotherapy: a cluster-randomised controlled pilot study

Abstract

Background: Geriatric assessment and management (GAM) improve outcomes in older patients with cancer treated with surgery or chemotherapy. It is unclear whether GAM may provide better function and quality of life (QoL), or be cost-effective, in a radiotherapy (RT) setting.

Methods: In this Norwegian cluster-randomised controlled pilot study, we assessed the impact of a GAM intervention involving specialist and primary health services. It was initiated in-hospital at the start of RT by assessing somatic and mental health, function, and social situation, followed by individually adapted management plans and systematic follow-up in the municipalities until 8 weeks after the end of RT, managed by municipal nurses as patients' care coordinators. Thirty-two municipal/city districts were 1:1 randomised to intervention or conventional care. Patients with cancer ≥ 65 years, referred for RT, were enrolled irrespective of cancer type, treatment intent, and frailty status, and followed the allocation of their residential district. The primary outcome was physical function measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (QLQ-C30). Secondary outcomes were overall quality of life (QoL), physical performance, use and costs of health services. Analyses followed the intention-to-treat principle. Study registration at ClinicalTrials.gov ID NCT03881137.

Results: We included 178 patients, 89 in each group with comparable age (mean 74.1), sex (female 38.2%), and Edmonton Frail Scale scores (mean 3.4 [scale 0-17], scores 0-3 [fit] in 57%). More intervention patients received curative RT (76.4 vs 61.8%), had higher irradiation doses (mean 54.1 vs 45.5 Gy), and longer lasting RT (mean 4.4 vs 3.6 weeks). The primary outcome was completed by 91% (intervention) vs 88% (control) of patients. No significant differences between groups on predefined outcomes were observed. GAM costs represented 3% of health service costs for the intervention group during the study period.

Conclusions: In this heterogeneous cohort of older patients receiving RT, the majority was fit. We found no impact of the intervention on patient-centred outcomes or the cost of health services. Targeting a more homogeneous group of only pre-frail and frail patients is strongly recommended in future studies needed to clarify the role and organisation of GAM in RT settings.

Keywords: Cancer; Frailty; Geriatric assessment with management; Older patients; Radiotherapy; Randomised controlled trial.

Fig. 1

¹Four municipalities were joined two and two into two randomised units due to sharing a common cancer nurse, ²Pts, patients; ³No patient were included from two control and two intervention municipal units; ⁴PROMS, patient-reported outcomes, here referring to the QLQ-C30 questionnaire; ⁵Performance test, here referring to the Short Physical Performance Battery

Fig. 2

Collaboration across sectors. Municipal cancer contact nurses serving as the main link. *In collaboration with the patients’ oncologist, referrral to other hospital professionals or direct involvement of the patient’s GP if needed

Fig. 3

Results of longitudinal ANCOVA for between-group differences in trend in outcomes (unadjusted) and post hoc analyses assessing between-group differences at each time point presented as p-values. Curves showing mean scores with 95% confidence intervals at each assessment point for the two study groups, ^*higher scores indicate better physical function, global QoL, health index, physical performance, or grip strength, respectively, ^**higher scores indicate more symptoms