Pilot Study for Feasibility of Onco-Geriatric Intervention Model in Older Patients with Cancer in a Tertiary Academic Hospital
Article information
Abstract
Purpose
Older cancer patients face unique challenges due to age-related physiological changes, increasing their vulnerability to treatment-related toxicities. Geriatric assessment (GA) is a validated tool for optimizing care, yet there is no consensus on integrating geriatric interventions into oncology. This study evaluates the feasibility of a tailored onco-geriatric intervention model incorporating the KG-7 screening tool.
Materials and Methods
This prospective study included 30 patients aged ≥ 70 years with solid tumors undergoing adjuvant or palliative chemotherapy. Patients scoring ≤ 5 of KG-7 were eligible. Tailored interventions incorporating KG-7 included polypharmacy, functional status, mobility, nutrition, cognition, emotional well-being, insomnia, social support, and medical problem. KG-7, GA, and quality of life (QoL) were followed at 12 weeks.
Results
Participants (median age, 79.5 years) had colon (43.3%), pancreatic (23.3%), or gastric cancer (23.3%). At baseline, most patients showed independent activities of daily living (100%)/instrumental activities of daily living (90%). However, 93.3% had abnormal GA. Particularly, 86.7% were either malnourished or at risk of malnutrition. The most frequently identified intervention needs included polypharmacy (70.0%), nutritional support (60.0%), and emotional well-being (50.0%) with high adherence (100.0%, 88.9%, and 46.7%, respectively). At 12 weeks, KG-7 scores improved in 43.8% of patients, and 69.2% of GA domains were improved. QoL analysis revealed modest improvement in Global Health Status (mean difference, 6.3; p=0.176). One-year survival rates were 92.3% and 79.4% for adjuvant and palliative groups, respectively.
Conclusion
The onco-geriatric intervention model incorporating KG-7 demonstrated high feasibility and potential to enhance clinical outcomes. Future studies should validate this approach in randomized trials to optimize care for older cancer patients.
Introduction
Older cancer patients exhibit distinct physical, emotional, cognitive, and nutritional characteristics compared to younger patients. They have reduced resilience to internal and external stressors, making them more vulnerable to adverse events from cancer treatment. Therefore, cancer treatment in older adults presents unique challenges due to age-related physiological changes, including reduced organ function and diminished metabolic reserves [1-5]. These changes increase the risk of chemotherapy-induced toxicities, necessitating a tailored approach to care.
Geriatric assessment (GA) is an objective tool that provides a comprehensive evaluation of the overall health status in older populations. Studies have shown that GA can predict life expectancy, chemotherapy compliance, postoperative mortality, early death, and chemotherapy-related adverse effects in older patients receiving chemotherapy [4-10]. Global guidelines recommend incorporating GA into cancer treatment for older patients to optimize care and improve outcomes [2,11]. Furthermore, geriatric oncology invention trials have been conducted to evaluate clinical efficacy of geriatric intervention and to find effective geriatric intervention model [7,12-17]. However, the results of these trials were not consistent and geriatric models were diverse. There is no consensus on the optimal approach to implement interventions based on GA into routine oncology care, and geriatric intervention models for older cancer patients are scarce. Moreover, geriatric intervention models should accommodate wide variety of healthcare system, necessitating different models according to different healthcare system.
To bridge this gap, we designed a tailored onco-geriatric intervention model incorporating a geriatric screening tool (KG-7) to identify patients in need of comprehensive geriatric assessment (CGA) and focused interventions. These interventions include addressing polypharmacy, functional status, mobility/fall risk, nutritional support, cognitive function, emotional well-being, insomnia, social and family support, and medical problem, with the aim of improving patients’ quality of life (QoL) and survival outcomes. We evaluated the feasibility of this onco-geriatric intervention model with KG-7, suitable for high-volume cancer centers with low resource setting.
Materials and Methods
1. Study design
This single-center, prospective feasibility study was conducted at Seoul National University Bundang Hospital, Korea. The primary objective was to assess the feasibility of an onco-geriatric intervention model tailored for older cancer patients undergoing adjuvant or palliative chemotherapy. This feasibility study evaluates the practicality and impact of this intervention model. Specifically, it aims to (1) identify the types and prevalence of required interventions, (2) assess compliance, and (3) evaluate changes in KG-7, GA, and QoL, and survival. All participants received standard cancer care, supplemented with tailored onco-geriatric interventions based on individual needs identified through screening and assessment of KG-7.
2. Participants
Participants were recruited based on the following inclusion criteria: age ≥ 70 years, histologically confirmed diagnosis of a solid tumor, scheduled for adjuvant or palliative chemotherapy, expected survival of ≥ 3 months for a sufficient follow-up period, able to understand the study and provide written informed consent. Eligible participants were screened using the KG-7, a validated geriatric screening tool developed to predict the need for CGA. Patients scoring ≤ 5 on the KG-7 were finally enrolled. Exclusion criteria included patients younger than 70 years, those diagnosed with non-cancer conditions, and those who did not exhibit the geriatric phenotype to need further GA and geriatric intervention, despite a KG-7 score ≤ 5.
3. Patient assessment
KG-7 questionnaire was always answered before full GA. KG-7 consisted of seven questions evenly distributed to represent each domain of GA. KG-7 scores ranged from 0 to 7, and higher scores indicated better conditions [18,19]. As in our previous studies, GA consisted of an evaluation of medical problems, social support, functional status, cognitive status, emotional status, nutritional status, and mobility [5,9,10,18,19]. Additionally, muscle strength was assessed by the handgrip strength in the dominant hand with the patient in the sitting position with elbows flexed at 90°. Handgrip strength (kg) was measured using the Jamar Plus+ Digital Hand Dynamometer (Sammons Preston) in sitting position; a maximum of two measurements from the dominant hand were recorded. We adopted cut-off values of handgrip strength (< 28.6 and < 16.4 kg in men and women, respectively) for the definition of low grip strength based on data from the Korea National Health and Nutrition Examination Survey VI [20]. The functional status was tested using the activities of daily living (ADL) and Korean instrumental activities of daily living (K-IADL) scores [18,21]. At least one item with dependency in ADL or K-IADL was categorized as ADL-dependent or instrumental activities of daily living (IADL)–dependent, respectively. Timed get-up-and-go test (TUGT) of greater than 20 seconds was defined as impaired mobility [22]. Cognitive function was tested using Mini-Mental Status Examination in the Korean version of the Consortium to Establish a Registry for Alzheimer’s disease Assessment Packet (MMSE-KC), which was categorized into severe cognitive impairment (scores ≤ 16) and mild cognitive impairment (scores 17-24) [23]. For depression, short-form Geriatric Depression Scale (SGDS) scores of 5 to 9 and of 10 or more showed mild depression and severe depression, respectively [24]. In terms of nutritional status, the mini nutritional assessment (MNA) score of less than 17.0 and between 17.0 and 23.5 indicated malnutrition and at risk of malnutrition, respectively [25]. GA was evaluated by clinical research coordinators who underwent appropriate education for the standardization of GA. Abnormal GA was defined as deficits in at least two out of six domains (ADL, K-IADL, MMSE-KC, SGDS, MNA, and TUGT) [5,8,18]. QoL was measured by the European Organisation for Research and Treatment of Cancer QLQ-C30. KG-7, GA, and QoL were assessed at baseline and 12 weeks.
4. Geriatric intervention model
The onco-geriatric intervention model was designed to address specific geriatric domains identified through KG-7 and clinical practice. The interventions were based on a standardized checklist, with the following components (Table 1).
Geriatric intervention checklist
(1) Polypharmacy: Inappropriate medication use was assessed using Beers criteria and New Beers criteria. Recommendations for medication adjustments and counseling were provided to reduce the number of inappropriate medications.
(2) Functional status: For patients dependent in ADL or IADL, interventions included regular telephone follow-ups and, if necessary, referrals to social work services. The goal was to maintain functional independence.
(3) Mobility and fall risk: Patients with a history of falls within the past 6 months or those with delayed mobility responses (TUGT > 20 seconds) were referred to physical therapy for fall prevention strategies and mobility training.
(4) Nutritional status: Malnutrition was assessed using the MNA (≤ 17). Patients with unintentional weight loss of ≥ 5% over the past 3 months were provided with dietary counseling and supplementation.
(5) Cognitive function: Patients scoring ≤ 23 on the Mini-Mental State Examination (MMSE) were identified as having cognitive impairment and referred to psychiatry for further evaluation and management.
(6) Emotional Well-being: Depression was assessed using the Geriatric Depression Scale (GDS-15 ≥ 6). Patients identified with depressive symptoms were referred to psychiatry for management.
(7) Insomnia: When subjectively reported, was managed through counseling, pharmacological treatment, or referrals to psychiatry.
(8) Social and family support: Patients living alone or with insufficient support networks were referred to social work services. Emergency contact networks were also established to enhance treatment adherence and support.
(9) Medical problems: Uncontrolled comorbidities were managed through medication adjustments and specialist referrals as needed.
5. Statistical analysis
Baseline characteristics and intervention prevalence were summarized using descriptive statistics. Baseline and the 12-week follow-up comparisons of KG-7, GA, and QoL were analyzed using paired t tests. Kaplan-Meier survival analysis was used to estimate 1-year survival, with group comparisons performed using the log-rank test.
Results
1. Baseline characteristics and GA
A total of 30 older patients with cancer were enrolled in the study between August 2020 and November 2021. The median age was 79.5 years (range, 71 to 87 years), and 63.3% of the patients were female. The most common cancer type was colon cancer (43.3%), followed by pancreatic cancer (23.3%) and gastric cancer (23.3%). In terms of clinical setting, 60% of patients were receiving palliative chemotherapy, while the remaining 40% were undergoing adjuvant chemotherapy.
Regarding GA, as measured by the KG-7 score, 63.3% and 23.3% of patients scored 4 and 5, respectively. Thirteen patients (43.3%) had low grip strength. Baseline functional assessments revealed that no patients had dependent ADL, while 10% exhibited dependency in IADL. MMSE revealed that 53.3% of participants had mild cognitive impairment (MMSE score 17-24), while 3.3% had severe cognitive impairment (MMSE score ≤ 16). Depression was identified in 53.3% of patients, with 50.0% exhibiting mild symptoms (SGDS score 5-9) and 3.3% showing severe depression (SGDS score ≥ 10). Nutritional assessments indicated that 76.7% of patients were at risk of malnutrition (MNA score 17-23.5), and 10.0% were classified as malnutrition (MNA score < 17). Mobility impairments, assessed by the TUGT test, were present in 46.7% of participants (TUGT > 20 seconds). Additionally, 93.3% of patients showed abnormalities in at least two GA domains, highlighting the high prevalence of vulnerabilities in this cohort (Table 2).
Baseline characteristics and geriatric assessment
2. Intervention need and adherence
The most frequently identified intervention need was polypharmacy, observed in 21 patients (70.0%), all of whom adhered to the recommended medication adjustments. Nutritional support was the second most common need, identified in 18 patients (60.0%) with an adherence rate of 88.9%. Interventions targeting cognitive function and emotional well-being were required in 33.3% and 50.0% of patients, respectively, with varying adherence rates (Table 3). Mobility interventions were necessary for 20.0% of patients, but compliance was lower at 33.3%. Overall, the intervention model demonstrated high feasibility, with adherence rates exceeding 85% in the majority of interventions.
Intervention need and adherence
3. Correlation between intervention need and GA deficit
Among the 17 patients identified with MMSE deficits, seven (41.2%) required interventions to address cognitive function. Similarly, 10 out of 16 patients (62.5%) with GDS deficits were identified as needing support for emotional well-being. In 16 out of 26 patients (61.5%) presenting MNA deficits, nutritional interventions were required. Lastly, two out of 14 patients (14.3%) with mobility deficits required targeted interventions of mobility and fall risk to improve their physical function and reduce fall risk (Fig. 1). Patients with deficits in cognitive function (MMSE), depression (GDS), nutritional status (MNA), and mobility (TUGT) were more likely to require multiple interventions. For instance, patients with MNA deficits also required polypharmacy intervention, emotional intervention, cognitive function, insomnia, mobility/fall risk as well as nutritional status, highlighting the link between nutritional status and other geriatric domain.
The correlation between intervention need and geriatric assessment deficit. ADL, activities of daily living; GDS, Geriatric Depression Scale; IADL, instrument activities of daily living; MMSE, Mini-Mental Status Examination; MNA, Mini Nutritional Assessment; TUGT, timed get-up-and-go test.
4. Changes in KG-7, GA, and QoL between baseline and the 12-week follow-up
Among the total cohort of 30 patients, 14 patients were lost to follow-up, resulting in incomplete data at the 12-week assessment. The reasons for drop-out included consent withdrawal (6), follow-up loss (2), inability to visit (2), early death before 12-week assessment (2), refuse for chemotherapy (1), and transfer to hospice (1). All 16 patients who remained in the study at the 12-week follow-up were still receiving chemotherapy. Consequently, 16 patients were included in the analysis of changes in KG-7, 13 in the analysis of GA, and 16 in the evaluation of QoL. The analysis of changes in KG-7 scores showed that, among 16 patients, one patient (6.3%) demonstrated a +3-point improvement, two patients (12.5%) showed a +2-point improvement, and four patients (25.0%) had a +1-point improvement. Meanwhile, eight patients (50.0%) showed no change, and one patient (6.3%) experienced a –2-point decline. These results indicate that most patients either maintained or improved their KG-7 scores. The detailed information regarding the changes in KG-7 scores is presented in Fig. 2.
KG-7 score change between baseline and the 12-week follow-up (F/U).
The analysis of changes in GA between baseline and the 12-week follow-up revealed varying contributions to GA deficit decreases and increases (Fig. 3). No changes were observed in ADL, while one patient showed additional deficit in IADL. For MMSE, two patients demonstrated improvement, whereas one patient showed additional deficit at the 12-week follow-up. Similarly, one patient had additional deficit in SGDS domain. In terms of MNA, three patients exhibited improvement, while two showed additional deficit. Mobility, as assessed by TUGT, indicated improvement in two patients and new deficit in one. Finally, grip strength showed improvements with two patients and no new deficit at the 12-week follow-up. Overall, nine domains of 13 patients were improved, while six domains were worse.
Geriatric assessment deficit change between baseline and the 12-week follow-up (F/U). GDS, Geriatric Depression Scale; IADL, instrumental activities of daily living; MMSE, Mini-Mental State Examination; MNA, Mini Nutritional Assessment; TUGT, timed get-up-and-go test.
In QoL change analysis involving 16 patients, Global Health Status/QoL improved from a baseline mean of 53.7 (±13.6) to 59.9 (±20.9) by a mean difference of 6.3 (±17.6), though this was not statistically significant (p=0.176) (Fig. 4). Physical functioning showed a decline with a mean difference of –8.8 (±20.9) (p=0.115), while role functioning dropped by –10.4±26.4 (p=0.136). Emotional functioning exhibited a minor improvement (2.6±30.7, p=0.739), but cognitive functioning and social functioning declined slightly (–7.29±26.5, p=0.289, –4.17±40.1, p=0.684, respectively). While most symptoms such as fatigue (4.51±21.8, p=0.420), nausea/vomiting (4.2±34.7, p=0.638), pain (7.3±27.2, p=0.300), dyspnea (4.2±26.9, p=0.545), insomnia (10.4±35.9, p=0.264), appetite loss (4.17±38.3, p=0.669), and constipation (16.67±38.5, p=0.104) were worse, diarrhea was improved (–4.17±29.5, p=0.581) and financial difficulties showed the most significant reduction (–10.42±26.4, p=0.136). Despite observed changes, no domain reached statistical significance due to low number of patients.
Quality of life (QoL) change between baseline and the 12-week follow-up (F/U).
5. Survival
At the 1-year follow-up, the overall survival rate was 92.3% in the adjuvant group and 79.4% in the palliative group (S1 Fig.).
Discussion
This study assessed the feasibility and potential efficacy of an onco-geriatric intervention model incorporating KG-7 for older cancer patients receiving chemotherapy. The model utilized the KG-7 screening tool to identify intervention needs, with effects evaluated over a 12-week follow-up period. Given the current lack of conclusive evidence on geriatric interventions, this study provides meaningful insights into their implementation and impact. Pre-planned intervention needs in this study included polypharmacy, functional status, mobility/fall risk, nutritional support, cognitive function, emotional well-being, insomnia, social and family support, and medical problem, consistent with findings from previous studies [12,17,26,27].
By including only patients with KG-7 scores ≤ 5, nearly all participants (93.3%) exhibited abnormal GA results, reflecting their frailty and vulnerability. Polypharmacy management (70%), nutrition support (60%), and emotional well-being management (50%) were frequently identified as intervention need. This finding is in accordance with previous studies [12,27]. Regarding compliance and adherence of interventions, high compliance rates for certain interventions, such as polypharmacy (100%) and nutritional support (88.9%). However, compliance with mobility (33.3%) and emotional well-being interventions (46.7%) was relatively lower. In previous studies, lower adherence rates were also reported, with only 46% of the geriatric recommendations adhered to or adherence rates as low as 52% in some patients [12,28]. Notably, low adherence and compliance may be attributed to the complexity of geriatric syndromes and the variability in intervention feasibility and availability.
In this study, among 17 patients with MMSE deficits, seven (41.2%) required cognitive interventions. Of 16 with SGDS deficits, 10 (62.5%) needed emotional support. Nutritional interventions were necessary for 16 of 26 patients (61.5%) with MNA deficits, while only two of 14 (14.3%) with mobility deficits required targeted mobility interventions. These findings suggest a weak correlation between intervention needs based on KG-7 and clinical practice and GA deficits. Furthermore, the correlations between GA deficits and required interventions underscore the complexity of geriatric syndrome. For instance, patients with nutritional deficits (76.7%) often required additional interventions, such as emotional support and cognitive function management. Similarly, patients with mobility impairments frequently exhibited deficits in other domains, highlighting the cascading impact of physical limitations on emotional well-being. This implicates the interconnected nature of GA domains, where some, like MNA, may reflect multiple symptoms requiring multiple intervention.
At the 12-week follow-up, KG-7 and GA scores showed trends toward improvement. Despite the small sample size and short follow-up duration, QoL analysis demonstrated a slight improvement in Global Health Status (mean difference, 6.3; p=0.176). While most patients maintained their QoL during chemotherapy, some domains, including Role Functioning, insomnia, and constipation, showed worse. These findings highlight the challenges of sustaining QoL in this population. Conversely, financial difficulties improved significantly. Additionally, because all analyzed patients for the 12-week follow-up were still undergoing treatment, potential biases due to chemotherapy discontinuation affecting KG-7 or GA improvements are unlikely. Given the small sample size, these results should be interpreted with caution.
The one-year survival rates were 92.3% in the adjuvant group and 79.4% in the palliative group for a cohort with a median age of 79.5 years and significant geriatric impairment. The one-year survival rate of 79.4% in the palliative group is consistent with survival rates reported in similar general populations with colorectal cancer and Eastern Cooperative Oncology Group scale of performance status 1-2, which was the majority of this study. These outcomes suggest that tailored geriatric interventions may enhance clinical outcomes, consistent with recommendations from organizations like American Society of Clinical Oncology and International Society of Geriatric Oncology, which advocate for incorporating CGAs into routine oncology practice to better stratify patients by risk, predict treatment tolerance, and optimize outcomes [2,29]. Nonetheless, the further studies are needed to validate their impact on long-term survival.
However, this study has some limitations. The small sample size, lack of randomization, and difficulty in objectively measuring intervention compliance limit the generalizability of the findings. Additionally, the short follow-up period restricts the ability to draw conclusions about long-term effects. The improved outcome was challenging to interpret, as it could have resulted from either the interventions or the effectiveness of chemotherapy. In the further study, exploring the causal relationships between GA domains and intervention outcomes could help refine intervention strategies. Another area for improvement involves the development of standardized, scalable protocols to ensure consistency in intervention delivery across diverse clinical settings. Nonetheless, given the increasing need for multidisciplinary approaches in the treatment of older cancer patients, this study highlights the feasibility of an onco-geriatric intervention model tailored to address geriatric-specific vulnerabilities. The positive impact in this trial suggests that structured interventions could enhance clinical outcomes, reinforcing the necessity for integrated oncology and geriatrics care.
In conclusion, this study demonstrates that an onco-geriatric intervention model using the KG-7 tool is practical and effective for identifying required intervention in older cancer patients. It provides an onco-geriatric intervention model for integrating geriatric care into routine oncology practice, emphasizing the importance of a personalized, multidimensional approach to improving both clinical outcomes and QoL for this vulnerable older patients receiving chemotherapy. In the further study, this onco-geriatric intervention model incorporating KG-7 should be evaluated and validated through randomized clinical trials.
Electronic Supplementary Material
Supplementary materials are available at Cancer Research and Treatment website (https://www.e-crt.org).
Notes
Ethical Statement
This prospective study was approved by the Institutional Review Board (No. B-1602-336-701) of Seoul National University Bundang Hospital (Seongnam, Korea). The trial was designed and conducted in accordance with the Helsinki Declaration and the Ethical Guidelines for Clinical Studies. All participating patients provided written informed consent.
Author Contributions
Conceived and designed the analysis: Kim JW (Jin Won Kim), Kim JH.
Collected the data: Kim JW (Jin Won Kim), Kim JH.
Contributed data or analysis tools: Kim JW (Jin Won Kim), Choi JY, Park W, Kang M, Seo J, Jung EH, Suh KJ, Kim JW (Ji-Won Kim), Kim SH, Kim YJ, Lee KW, Kim SA, Lee JY, Lee JO, Bang SM, Kim KI, Kim JH.
Performed the analysis: Kim JW (Jin Won Kim), Kim JH.
Wrote the paper: Kim JW (Jin Won Kim), Choi JY, Park W, Kang M, Seo J, Jung EH, Suh KJ, Kim JW (Ji-Won Kim), Kim SH, Kim YJ, Lee KW, Kim SA, Lee JY, Lee JO, Bang SM, Kim KI, Kim JH.
Conflicts of Interest
Conflict of interest relevant to this article was not reported.
Funding
This study was fully supported by Seoul National University Bundang Hospital (SNUBH) grant No. 02-2015-0027. This research was partly supported by a grant of Patient-Centered Clinical Research Coordinating Center (PACEN) funded by the Ministry of Health & Welfare, Republic of Korea (grant number: RS-2020-KH095186).
Acknowledgments
This study utilized the assistance of AI-based technology (ChatGPT), provided by OpenAI, for statistical analysis, figure generation, and language editing. All content was reviewed and edited by the authors to ensure scientific accuracy and originality.