Evaluation of the Radiation Oncologists" Awareness and Needs about Geriatric Oncology: TROD-13-001 Study

Introduction

Methods

The survey was pretested among a sample of 5 radiation oncologists from the member of TROD to ensure reliability and understanding of the survey content. The required changes were done according to pretest results. The electronic survey was finalized and distributed to all of the TROD members nationwide, through a survey link from Google Forms. TROD society had been contacted in advance and agreed to facilitate survey distribution to their members. The survey was accompanied by an introductory e-mail which explained the study rationale and invited the members to participate and to fill the survey. The survey was available in Turkish only.

Descriptive statistics were used to analyze the Likert scale and multiple choice questions. The percentage of respondents for each of the Likert scale options was calculated. Opinions expressed in open-ended questions were compiled and analyzed for common themes or topics.

Results

Table 1 Characteristics of the participants

As expected, 99.5% of the participants stated that they encountered the geriatric group in their daily practice. Considering the distribution of tumor localization areas of this geriatric patient group, 56.3% were thoracic cancers, 53.3% were genitourinary cancers, 39.1% were breast cancers, and 31% were head-andneck cancers. The most commonly seen diagnosis for geriatric group was given lung cancer in our survey. They stated that geriatric patients constitute 40.9% of their daily practice. It was observed that 62.4% had difficulty in making decisions in geriatric patient group, with whom they had such intense communication in daily clinic practice. Despite this, 85.4% of them pointed out that they make the treatment decision independent of the patient's age.

It was seen that 62% of the participants did not use any special evaluation tool for geriatric cancer patients in their treatment decisions. The most used scale for geriatric patients was Karnofsky Performance Scale (KPS) (13.5%). Therefore, 85% of them stated that it would be appropriate to evaluate geriatric patients from the perspective of an experienced physician in the field of geriatric age. While 47.7% of them did not have a specialist in geriatric age in their institution, only 34.3% of them had a geriatrician in their institution. The interesting thing was that 18% of them did not know whether there was a geriatrician in their institution even though it was needed. It was found necessary by 75% of the participants to include geriatric training in their RO residency training program. In geriatric patients, 71.6% of the participants stated that they had difficulties in the management of side effects. This could be the first reason that they stated to need a residency training program about geriatric age. In addition, the most difficult issues in geriatric patient management were comorbid diseases (73.1%), care support (64%), systemic treatment side effects (59.9%), and compliance with treatment (48.2%). 98.5% of the responders thought that a comprehensive evaluation was necessary before starting the treatment. Again, 99% considered that the geriatric patient group would take place more in our daily practice in the coming years. Therefore, 86.3% concluded that they need a guide to manage geriatric patients (Table 2).

Table 2 The distribution of the paticipants according to the questions regarding geriatric oncology

Discussion

It is undisputed that making the right treatment decision in a geriatric cancer patient should start with a serious general performance assessment by a geriatrician perspective. Therefore, we asked TROD members which assessment scale they use commonly in their practice when making treatment decisions in geriatric cancer patients. We have encountered a serious problem that needs to be resolved. In our survey, where 85.4% of the participants stated that they made decisions independent of age, it was seen that 63.5% of the participants did not use any special performance scales for geriatric cancer patients. Regardless of that, the commonly used evaluation scale was KPS is able to identify the patient functional status; however, it is lack the sensitivity to detect geriatric syndromes and to be a useful prediction tool assessing patients" suitability for oncology treatment. The KPS allows patients to be classified according to their functional impairment, which helps to assess the prognosis in individual patients and compares the efficiency of various therapies. The lower the KPS score, the lower the chances of survival for severe illnesses. [] Although KPS indicates degree of functional performance status, it is not specific to geriatric patients and do not evaluate geriatric syndromes specifically.

Geriatric evaluation scales, used for determining geriatric patients, were used to inform participants concerning geriatric evaluation tools for this study. Decoster et al.[] evaluated 17 developed screening tools for multidimensional health problems providing a geriatric assessment in geriatric cancer patients. They concluded that screening tools do not replace geriatric assessments, but they are recommended in a busy practice to identify patients who require a full geriatric assessment. In addition, Korc-Grodzicki et al.[] pointed out that the geriatric assessment evaluations could be used to create treatment strategies to alleviate reversible deficits and assist clinicians to stratify patients before any potentially high-risk treatment.

In this current evaluation, most commonly used assessment tool specific for geriatric cancer patients was the G8 screening scale. The G8 screening scale is presented to evaluate geriatric cancer whether those are suitable for intensive treatment by giving a score related with the vulnerability of the geriatric patients. Hamaker et al.[] examined the G8 screening scale with regard to select fragile geriatric patients with hematologic cancers that require to tailor their treatment plan. They concluded that the G8 scale seems to predict prognosis effectively and could be useful for future treatment managements in terms of geriatric oncology.

Additional geriatric screening tools including the VES-13, gait speed, and others are in use in clinical geriatric oncology clinics.[] The literature, however, is unclear which of these instruments is superior and should be recommended in clinical settings. It was seen our evaluations results that those kind of different geriatric screening scales were not known widely among our society members. As a result of 62.4% of participants indicated that they have difficulty making a decision for geriatric patients, geriatric assessment tool must find a place in the curriculum of RO residency. There seems to have more important place in our clinic life, so we have to fill this gap with geriatric oncology education.

Another important issue regarding geriatric oncology is managing the adverse effects of the treated patients. Now, we know for sure that ROs are commonly deal with geriatric patients and those are mostly vulnerable to treatment than the young adults.[] In these presented data, 71.6% of the participants stated that they were forced into the adverse effect management while treating geriatric patients. Considering that it was stated that the 84% of treatment decisions were made independent of age, selection of the right patient for treatment and education on issues specific to the geriatric patient group are of critical importance. [] Rostoft et al.[] emphasized that better geriatric assessment results better treatment management. We need to organize joint interdisciplinary courses which should include all the members dealing with geriatric patient health. Closer collaboration with the geriatric teams in multidisciplinary clinical models including the nurses, physiotherapists, and geriatricians could facilitate the decision-making for treatment of geriatric patients undergoing RT.[] As we saw our survey results that 48.5% of the participants did not have a geriatric specialist in the institution where they worked, while 16.7% did not have knowledge on this subject. Similar problem was emphasized in the paper written by Morris et al., recently.[] We need to organize more courses and to attend more seminars to educate our society concerning the problems and issues of geriatric patients. Lester et al.[] described physiologic changes in older adults, historical trends in geriatric training, and propose solutions for this looming crisis. This crisis could affect our geriatric cancer management during RT treatment. As stated by 73.1% of the participants, the most common problem in treating geriatric patients was the management of comorbidities during treatment. If we want to have a geriatrician perspective and to get used to looming crisis, we should enrich our training programs on geriatric patient needs and management.[] There is no standard training in geriatric medicine in RO programs across the worldwide; it would be beneficial to clarify how these geriatric oncology curriculum programs could better be process through the formal or informal education.

As with all survey methodology, there some limitations of this current research. Although the number of patients participating in the study seems relatively limited (n=201), it can be though appropriate if we consider that the number of our association members is not high (not more than 600). In addition, the participants were representing an important proportion of those potentially eligible for treating geriatric patients in different part of Türkiye. Thus, the results could be generalizable to RO in Türkiye as a whole.

Conclusion

Peer-review: Externally peer-reviewed.

Conflict of Interest: All authors declared no conflict of interest.

Ethics Committee Approval: The study was approved by the Biruni University Non-interventional Research Ethics Committee (no: 2021/62-5, date: 25/11/2021). Financial Support: None declared.

Authorship contributions: Concept - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Design - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Supervision - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Funding - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Materials - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Data collection and/or processing - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Data analysis and/or interpretation - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Literature search - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Writing - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.; Critical review - F.S., E.M., E.Y.E., G.A., B.H.B., G.Ö.

References