Communication With Older Patients With Cancer Using Geriatric Assessment: A Cluster-Randomized Clinical Trial From the National Cancer Institute Community Oncology Research Program

Supriya G Mohile, Ronald M Epstein, Arti Hurria, Charles E Heckler, Beverly Canin, Eva Culakova, Paul Duberstein, Nikesha Gilmore, Huiwen Xu, Sandy Plumb, Megan Wells, Lisa M Lowenstein, Marie A Flannery, Michelle Janelsins, Allison Magnuson, Kah Poh Loh, Amber S Kleckner, Karen M Mustian, Judith O Hopkins, Jane Jijun Liu, Jodi Geer, Rita Gorawara-Bhat, Gary R Morrow, William Dale, Supriya G Mohile, Ronald M Epstein, Arti Hurria, Charles E Heckler, Beverly Canin, Eva Culakova, Paul Duberstein, Nikesha Gilmore, Huiwen Xu, Sandy Plumb, Megan Wells, Lisa M Lowenstein, Marie A Flannery, Michelle Janelsins, Allison Magnuson, Kah Poh Loh, Amber S Kleckner, Karen M Mustian, Judith O Hopkins, Jane Jijun Liu, Jodi Geer, Rita Gorawara-Bhat, Gary R Morrow, William Dale

Abstract

Importance: Older patients with cancer and their caregivers worry about the effects of cancer treatment on aging-related domains (eg, function and cognition). Quality conversations with oncologists about aging-related concerns could improve patient-centered outcomes. A geriatric assessment (GA) can capture evidence-based aging-related conditions associated with poor clinical outcomes (eg, toxic effects) for older patients with cancer.

Objective: To determine whether providing a GA summary and GA-guided recommendations to oncologists can improve communication about aging-related concerns.

Design, setting, and participants: This cluster-randomized clinical trial enrolled 541 participants from 31 community oncology practices within the University of Rochester National Cancer Institute Community Oncology Research Program from October 29, 2014, to April 28, 2017. Patients were aged 70 years or older with an advanced solid malignant tumor or lymphoma who had at least 1 impaired GA domain; patients chose 1 caregiver to participate. The primary outcome was assessed on an intent-to-treat basis.

Interventions: Oncology practices were randomized to receive either a tailored GA summary with recommendations for each enrolled patient (intervention) or alerts only for patients meeting criteria for depression or cognitive impairment (usual care).

Main outcomes and measures: The predetermined primary outcome was patient satisfaction with communication about aging-related concerns (modified Health Care Climate Questionnaire [score range, 0-28; higher scores indicate greater satisfaction]), measured after the first oncology visit after the GA. Secondary outcomes included the number of aging-related concerns discussed during the visit (from content analysis of audiorecordings), quality of life (measured with the Functional Assessment of Cancer Therapy scale for patients and the 12-Item Short Form Health Survey for caregivers), and caregiver satisfaction with communication about aging-related patient concerns.

Results: A total of 541 eligible patients (264 women, 276 men, and 1 patient did not provide data; mean [SD] age, 76.6 [5.2] years) and 414 caregivers (310 women, 101 men, and 3 caregivers did not provide data; mean age, 66.5 [12.5] years) were enrolled. Patients in the intervention group were more satisfied after the visit with communication about aging-related concerns (difference in mean score, 1.09 points; 95% CI, 0.05-2.13 points; P = .04); satisfaction with communication about aging-related concerns remained higher in the intervention group over 6 months (difference in mean score, 1.10; 95% CI, 0.04-2.16; P = .04). There were more aging-related conversations in the intervention group's visits (difference, 3.59; 95% CI, 2.22-4.95; P < .001). Caregivers in the intervention group were more satisfied with communication after the visit (difference, 1.05; 95% CI, 0.12-1.98; P = .03). Quality of life outcomes did not differ between groups.

Conclusions and relevance: Including GA in oncology clinical visits for older adults with advanced cancer improves patient-centered and caregiver-centered communication about aging-related concerns.

Trial registration: ClinicalTrials.gov identifier: NCT02107443.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Mohile reported receiving a grant from the National Cancer Institute (NCI) and a contract from the Patient-Centered Outcomes Research Institute (PCORI) during the conduct of the study; and receiving grants from Carevive outside the submitted work. Dr Epstein reported receiving grants from NCI and American Cancer Society during the conduct of the study. Dr Hurria reported receiving a contract from PCORI during the conduct of the study; and consulting payments from Celgene, Novartis, GSK, Boehringer Ingelheim, Carevive, Sanofi, GTx Inc, Pierian Biosciences, and MJH Healthcare Holdings LLC outside the submitted work. Dr Canin reported receiving personal fees from the University of Rochester during the conduct of the study. Dr Culakova reported receiving a grant from NCI and a contract from PCORI during the conduct of the study. Dr Gilmore reported receiving grants from the University of Rochester during the conduct of the study. Ms Plumb reported receiving grants from the University of Rochester during the conduct of the study. Dr Lowenstein reported receiving a contract from PCORI during the conduct of the study. Dr Flannery reported receiving a contract from PCORI and a grant from NCI during the conduct of the study. Dr Magnuson reported receiving grants from the University of Rochester during the conduct of the study. Dr Kleckner reported receiving grants from NCI during the conduct of the study. Dr Morrow reported receiving a grant from NCI and a contract from PCORI during the conduct of the study; and grants from NCI outside the submitted work. No other disclosures were reported.

Figures

Figure 1.. CONSORT Flow Diagram for the…
Figure 1.. CONSORT Flow Diagram for the COACH (Improving Communication in Older Cancer Patients and Their Caregivers) Trial of Practice Clusters, Oncologists, Patients, and Caregivers
Follow-up at 4 to 6 weeks included 472 patients, at 3 months included 410 patients, and at 6 months included 348 patients. Follow-up included 348 caregivers at 4 to 6 weeks, 306 caregivers at 3 months, and 261 caregivers at 6 months. HCCQ indicates Health Care Climate Questionnaire. aClusters that maintained institutional review board (IRB) approval but never enrolled any participants. bPractices are no longer associated with their respective National Cancer Institute Community Oncology Research Program (NCORP) affiliate or with the University of Rochester NCORP Research Base. cSigned consent and participated in screening process. dSatisfaction with communication about aging-related concerns. eConversations about aging-related conditions during clinic visit. fIrretrievable, site miscommunication, technical difficulty, or protocol violation.
Figure 2.. Patient and Caregiver Satisfaction
Figure 2.. Patient and Caregiver Satisfaction
A, Patient satisfaction with communication about aging-related concerns. B, Patient satisfaction with overall care. C, Caregiver satisfaction with communication about the patient’s age-related conditions. Scores were derived using modified versions of the Health Care Climate Questionnaire. The telephone assessment was 7 to 14 days after the audio-recorded clinic visit.
Figure 3.. Conversations About Aging-Related Conditions
Figure 3.. Conversations About Aging-Related Conditions
The patient’s visit with the oncologist within 4 weeks of completing the geriatric assessment (GA) was audiorecorded, transcribed, and coded. We used an open coding approach of themes and subthemes to quantify the number of age-related conversations, the number of aging-related discussions with high-quality communication, and the number of conversations of GA-driven recommendations communicated to patients by oncologists.

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