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Geriatric hematology in low-resource settings: Improving care for older people through the implementation of geriatric hematology programs

Oct 25, 2021
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Currently, more than half of the 700 million people aged 65 years or older live in low- and middle-income countries (LMICs).1 This is set to increase to over two thirds by 2050, with the most rapid increases seen in the least developed countries.2 With this rapidly aging population comes a significant chronic disease burden, and hematologic malignancies make up a notable part of this. Significant discrepancy exists in outcomes globally for patients of all ages with a hematologic malignancy. Particularly striking though is the discrepancy between older people who live in areas with a low Human Development Index and those who live in areas with a high Human Development Index; the mortality-to-incidence ratios in these populations are 96% and 61%, respectively.3

Most geriatric hematology clinical and research programs to date have been implemented in cancer centers in high-income countries (HICs); few programs exist in LMICs, though the International Society of Geriatric Oncology (SIOG) has developed recommendations with the aim of improving cancer care for older people globally, including the creation and implementation of geriatric oncology policies, clinics, and training programs. Soto-Perez-de-Celis and colleagues in The Lancet Healthy Longevity provide an overview of the current global landscape of geriatric oncology and hematology, with a particular focus on resource limited settings.4 Broadly, the authors consider clinical practice, research, education, and partnerships, and their findings and recommendations are summarized in this article.

Healthcare systems in LMICs and the burden of hematologic malignancies

Given the significant disease burden of the aging population, LMICs need to be set up not only to treat patients with disease, but to measure and understand the disease itself. Whilst the World Health Organization (WHO) recommends disease registries to appreciate regional needs, the proportion of the population covered by such registries is very low in resource poor settings. More than two thirds of low-income countries do not have a national cancer control plan or cancer registries.5

Healthcare systems in many LMICs fail to meet population needs; this is due in large part to lack of financial expenditure and fragmented healthcare structures that struggle to provide for the poor and unemployed. Other common challenges include lack of social security insurance, lack of resources, poor infrastructure, and inadequately trained healthcare professionals.

Mortality rates due to hematologic malignancies are disproportionately higher in LMICs due to low access to health care.6 Specific barriers to accessing high quality care for hematologic malignancies include the following:

  • Lack of access to advanced diagnostic tests and complex treatments, such as chemotherapy, monoclonal antibodies, or stem cell transplant.
  • Lack of access to specialist hematologists and other trained personnel, who are often centralized to large cities.
  • Limited or undependable blood supply and the unavailability of advanced transfusion medicine, such as irradiated blood products.

Further barriers to high quality care among older patients include a high prevalence of ageism, cancer-related stigma, and the tendency for older people and their families to hold fatalistic views with regard to their cancer and cancer treatment.

Components of a geriatric hematology program

The wide variation in the individual needs of older patients necessitates a comprehensive geriatric assessment such that cancer therapy may be tailored to the individual’s needs. Comorbidities, cognition, psychological status, functional capacity, physical reserve, and social support are critical factors to consider, though currently there is no consensus regarding specific tools to use to make these assessments and provide the best care model, and thus often these choices depend on resource and personnel availability in each center.

Models of care in geriatric hematology

SIOG recommends the use of self-administered screening tools to assess frailty, such as the Geriatric 8 (G8) screening tool or the Vulnerable Elders Survey-13 (VES-13); examples of geriatric assessment tools are shown in Table 1.7-9

Table 1. Examples of geriatric assessment tools used for the evaluation of older people with hematologic malignancies*

Screening tool

Domains

Purpose

Scoring

Type of hematologic malignancy

 Administration

Vulnerable Elders Survey-13

Age, self-rated health status, functional limitations, and functional disabilities

Screens for risk of functional status deterioration, identifies need for complete geriatric assessment, and predicts outcomes

Range 0–10; cutoff ≥3

NHL

Self‑administered; 5 min

Geriatric 8 screening tool

Age, weight loss, BMI, motor skills, psychological status, number of medications, and self-rated health status

Identifies need for complete geriatric assessment and predicts outcomes

Range 0–10; cutoff ≤14

Leukemia, NHL, MDS

Administered by healthcare provider; self-administered version available; 5 min

Geriatric Assessment in Hematology

Number of medications, gait speed, mood, ADL, self-rated health status, nutrition, psychological status, and comorbidities

Identifies frailty among older patients with hematologic malignancies

NA

Leukemia, MDS, MM

Administered by healthcare provider; 1012 min

Elderly Prognostic Index

Age, ADL, instrumental ADL, comorbidity, IPI, and hemoglobin level

Identifies frailty among older patients with DLBCL and predicts OS

Range 0–8; risk groups: low (0–1), intermediate (2–5), and high (6–8)

DLBCL

Administered by healthcare provider; <10 min

ADL, activities of daily living; BMI, body mass index; DLBCL, diffuse large B-cell lymphoma; IPI, International Prognostic Index; MDS, myelodysplastic syndromes; MM, multiple myeloma; NA, not applicable; NHL, non-Hodgkin lymphoma; OS, overall survival.
*Adapted from Soto-Perez-de-Celis et al.4
Overall survival and toxicities.

Once higher risk patients have been identified, an in-depth geriatric assessment should take place using validated tools. Identifying geriatric deficits or syndromes, such as nutritional status, cognitive impairment, and polypharmacy, is an essential part of the assessment. The presence of frailty is particularly significant, as given its association with increased risk of treatment toxicity and higher mortality, identification of frailty can influence treatment decisions. Soto-Perez-de-Celis and colleagues summarize three models of care that can be used to implement a geriatric hematology clinic tailored depending on resources available in each healthcare setting.7,10,11

Geriatric oncology unit model

  • Hematologists acquire the necessary knowledge and skills to perform the comprehensive geriatric assessments, including geriatric screening tools and evaluations.
  • A nurse with geriatric knowledge is an additional option.
  • This model can be used mainly in tertiary cancer centers in HICs or in LMICs with multispecialty hospitals with dedicated hematology clinics.

Geriatric consultation team or co-management model

  • Hematologists and geriatricians with experience in treating hematologic malignancies in older patients collaborate.
  • Comprehensive geriatric assessments are performed by geriatricians with support from a wider team of professionals such as physical therapists and nutritionists.
  • This model can be implemented in any specialized hospitals that have geriatricians available.

Referral model

  • Hematologists obtain geriatric consultations from specialists that may or may not be based in the same medical center or healthcare system.
  • Telemedicine allows for the use of this model in centers where geriatricians are not readily available; however, its use may be limited in LMICs depending on access to internet and mobile technology.

Global geriatrics training in hematology

Lack of availability of geriatricians and geriatric training is a significant barrier for geriatric tailored hematologic care, a problem that is present globally but is worst in LMICs. This is considered in part to be due to lack of training and poor exposure to the field during medical school. 

In 2011, SIOG considered increasing the geriatric training of the cancer workforce a top ten priority.8 Since then, a concerted effort has been made to improve training. SIOG established a yearly course, the Advanced Course in Geriatric Oncology, which has inspired other regional and national organizations to do the same. A group set up by the Spanish Society of Haematology provides virtual workshops in geriatric hematology in Spanish, which are open to attendees from Latin America. Further strategies include initiatives to include geriatric hematology and oncology sessions in local and regional hematology, geriatrics and oncology meetings and seminars. Successful workshops were developed for the annual meeting of the Geriatrics Department of the National Institute of Medical Science and Nutrition in Mexico City, which have been rolled out in other meetings as well.

Table 2 outlines the SIOG recommendations for the development of education. Despite improvements, education will remain a priority in the global advancement of care for older people. Education initiatives need to be tailored and resource-stratified based on setting, and they need to reach the largest number of professionals possible.

Table 2. Recommendations for the development of geriatric hematology in LMICs*

Education

Partnerships

Clinical practice

Research

Hematology training to include geriatric principles.

Geriatric hematology education and activities within larger hematology meetings.

Development of specialized training programs for physicians from LMICs in centers of excellence in HICs.

Strengthen links between international societies and local hematology societies.

Create global funding mechanisms for geriatric hematology.

Develop and implement models of care.

Develop resource-stratified guidelines for assessing geriatric patients.

Establish national centers of excellence in the field.

Improve worldwide availability of clinical trials for older adults with a hematologic malignancy.

Strengthen research collaborations between HICs and LMICs.

Evaluate the benefits of specialist units on the outcomes of patients in LMICs

HICs, high-income countries; LMICs, low-income and middle-income countries.
*Adapted from Soto-Perez-de-Celis et al.4
These recommendations are based on the priorities for the advancement of geriatric oncology from the International Society of Geriatric Oncology.12

Resource stratification in geriatric hematology

Resource stratification, as defined by WHO, is the adaptation of preventative, diagnostic, and therapeutic interventions, without disregarding an evidence-based approach, according to the level of resources available in each country.13 Resource levels are usually considered as basic, core (or limited), enhanced, and maximal, and tailored recommendations can be developed for each of these. Resource-stratified guidelines have been created by the National Comprehensive Cancer Network for the treatment of acute lymphoblastic leukemia and diffuse large B-cell lymphoma, though currently there are no resource-stratified guidelines for geriatric oncology and hematology.

Successful implementation of the models of care described by the authors—the geriatric oncology unit model, the geriatric consultation team or co-management model, and the referral model—are entirely resource dependent. For example, in basic settings without a geriatrician, hematologists or nurses could use validated geriatric screening tools to help identify patients at increased risk of adverse outcomes with more intensive treatment.

Existing clinical and research geriatric hematology initiatives in LMICs

There are few geriatric oncology and hematology clinics in LMICs (and a lack of information from medical centers regarding their approaches to treating geriatric hematology patients), though the Cancer Care in the Elderly Clinic in Mexico City is a good example of a geriatric consultation model in practice. The clinic has two geriatricians and one medical oncologist on staff, as well as nutrition, physical therapy, palliative care, and social work practitioners to provide care to older patients with lymphomas and solid tumors.

Most of the research in geriatric hematology comes from clinical trials in HICs. Many barriers to conducting clinical trials exist in LMICs, including poor infrastructure, scarce funding, insufficient research expertise, and lack of protected time to conduct it.14 Furthermore, participation of researchers from LMICs in international hematology meetings is also low. Several studies, however, have been conducted in LMICs, including the following:

  • In Peru, a study of 496 older men with cancer, 102 of whom had a hematologic malignancy (55 with multiple myeloma and 47 with leukemia or lymphoma), found both frailty (according to the Fried phenotype) and vulnerability (assessed by VES-13 and G8) were independently associated with an increased risk of chemotherapy toxicity.15
  • In Mexico, a study of 56 older patients with diffuse large B-cell lymphoma found that adjusting chemotherapy according to frailty status (classed as fit, unfit, or frail) allowed a group of unfit patients to tolerate treatment with good results.16
  • Another study from Peru included 253 older patients with aggressive non-Hodgkin lymphoma and compared different geriatric assessment tools; the study found the locally developed Peruvian Abbreviated Comprehensive Geriatric Assessment—which evaluated polypharmacy, physical function, activities of daily living, and social support—to be superior to both VES-13 and G8.17
  • In Turkey, an analysis of frailty in patients of all ages with acute myeloid leukemia found the Eastern Cooperative Oncology Group performance status, G8, and VES-13 predicted survival in both patients younger and older than 65 years.18
  • In Brazil,19,20 two studies analyzed comprehensive geriatric assessments in patients with various hematologic malignancies prior to allogeneic hematopoietic stem cell transplant and in patients with myelodysplastic syndromes (MDS).
    • In the hematopoietic stem cell transplant study, 640 patients aged ≥60 years were analyzed, and comprehensive geriatric assessment was able to identify patients who were independent regarding activities of daily living (90%), had alterations in hand grip strength (66%), had memory loss (38%), were at risk for malnutrition (30%), were considered vulnerable (42%), or were considered frail (19%).
    • In the MDS study, 78% of the 102 patients were ≥65 years old, and in these older patients, 60% had polypharmacy and 38% were frail. The older patients with MDS also reported significantly worse nutritional intake compared with the younger patients in the study.

Geriatric hematology initiatives and research opportunities in community settings of HICs

Whilst strong geriatric hematology programs often exist in academic cancer centers and large university hospitals in HICs, limitations in community settings in HICs may more closely mimic those of LMICs, and therefore may potentially serve as blueprints for clinical practices in such areas.

To bridge the gap between specialist cancer centers and the community, some geriatric hematology programs serve as referral centers. Community clinics may be led by a dual-trained geriatric hematologist, a hematologist with training in geriatrics, or a geriatrician providing consultative care. A multidisciplinary team approach is favored, including, for example, physical therapists, pharmacists, and dieticians, but as in LMICs, the availability of team members in the community setting is resource dependent. Since the COVID-19 pandemic, some clinics can now perform assessments and consultations remotely as well as in person. In addition to treatment decisions, they recommend supportive care interventions and help manage non-cancer comorbidities with the aim of optimizing geriatric-related vulnerabilities.

Research continues to focus on improving the identification of age-related vulnerabilities and their relationship to outcomes, longitudinal changes in age-related vulnerabilities, and the development of interventions and models of care to improve outcomes. Several studies in the US, in which older patients with hematologic malignancies and other cancers received a geriatric assessment, found that compared to usual care, patients were more likely to have discussions about goals of care and aging-related concerns and to report greater satisfaction with communication about age-related issues. Given funding for clinical trials in LMICs may be lacking, research programs such as these that focus on interventions to improve shared decision making and patient-centered care could be implemented.

Conclusion

Geriatric hematology remains a relatively new field even in the highly specialized cancer centers in Western Europe and the US. Soto-Perez-de-Celis and colleagues set out recommendations based on the SIOG priorities for the advancement of geriatric oncology; however, given the significant hematologic disease burden and challenges that are present regarding LMICs, international collaboration will be essential for the ongoing development of this field.

  1. The World Bank. Data bank. Population ages 65 and above, total. https://data.worldbank.org/indicator/SP.POP.65UP.TO?view=chart. Accessed Mar 1, 2021.
  2. United Nations Department of Economic and Social Affairs. World population ageing 2019. https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Report.pdf. Accessed Aug 24, 2021.
  3. Ferlay J, Ervik M, Lam F, et al. World Health Organization International Agency for Research on Cancer. Global Cancer Observatory: Cancer Today. https://gco.iarc.fr/today. Accessed Mar 1, 2021.
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  8. Bellera CA, Rainfray M, Mathoulin-Pélissier S, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol. 2012;23(8):2166-2172. DOI: 1093/annonc/mdr587
  9. Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc. 2001;49(12):1691-1699. DOI: 1046/j.1532‑5415.2001.49281.x
  10. Magnuson A, Dale W, Mohile S. Models of care in geriatric oncology. Curr Geriatr Rep. 2014;3(3):182-189. DOI: 1007/s13670-014-0095-4
  11. Loh KP, Soto-Perez-de-Celis E, Hsu T, et al. What every oncologist should know about geriatric assessment for older patients with cancer: Young International Society of Geriatric Oncology Position Paper. J Oncol Pract. 2018;14(2):85-94. DOI: 1200/JOP.2017.026435
  12. Extermann M, Brain E, Canin B, et al. Priorities for the global advancement of care for older adults with cancer: an update of the International Society of Geriatric Oncology Priorities Initiative. Lancet Oncol. 2021;22(1):e29-e36. DOI: 1016/S1470-2045(20)30473-3
  13. Hunter N, Dempsey N, Tbaishat F, et al. Resource-stratified guideline-based cancer care should be a priority: historical context and examples of success. Am Soc Clin Oncol Educ Book. 2020;40:1-10. DOI: 10.1200/EDBK_279693
  14. Gyawali B, Bouche G, Crisp N, et al. Challenges and opportunities for cancer clinical trials in low- and middle-income countries. Nat Can. 2020;1:142-45. DOI: 10.1038/s43018-020-0030-x
  15. Runzer-Colmenares FM, Urrunaga-Pastor D, Roca-Moscoso MA, et al. Frailty and vulnerability as predictors of chemotherapy toxicity in older adults: a longitudinal study in Peru. J Nutr Health Aging. 2020;24(9):966-972. DOI: 1007/s12603-020-1404-6
  16. Lastra-German IK, Navarrete-Reyes AP, Mejía-Domínguez NR, et al. Adjusted chemotherapy according to frailty status in elderly patients with diffuse large B-cell lymphoma: experience from a single referral center in Mexico City. Clin Lymphoma Myeloma Leuk. 2019;19(2):e98-e106. DOI: 1016/j.clml.2018.11.013
  17. Beltrán B, Gamarra MP, Carbajal JC, et al. Comparison of different geriatric screening methods in elderly patients with aggressive non-Hodgkin lymphoma in Peru. Poster #EP1765. 25th European Hematology Association (EHA) Annual Congress. Jun 12, 2020; Virtual.
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  19. Rodrigues M, de Souza PMR, de Oliveira Muniz Koch L, et al. The use of comprehensive geriatric assessment in older patients before allogeneic hematopoietic stem cell transplantation: a cross-sectional study. J Geriatr Oncol. 2020;11(1):100-106. DOI: 1016/j.jgo.2019.05.022
  20. Aguiar APN, Mendonça PDS, Ribeiro-Júnior HL, et al. Myelodysplastic syndromes: an analysis of non-hematological prognostic factors and its relationship to age. J Geriatr Oncol. 2020;11(1):125-127. DOI: 1016/j.jgo.2019.06.021

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