Comprehensive geriatric assessment (CGA) is recommended for older adults before starting cancer-directed therapy, explains Justin J. Cheng, MD. “Specifically, within the realm of systemic therapy, CGA reduces chemotherapy toxicity without dose reduction and can improve QOL for older patients with cancer,” Dr. Cheng says. “However, implementation of CGA remains a barrier in a busy oncology practice, so identifying a point-of-care tool to quickly and efficiently assess an older adult’s vulnerability is crucial.”

One way to do that, he says, is to assess frailty via an EHR-based frailty index (eFI). “Capturing an older adult’s frailty can help guide oncologists in deciding who may or may not benefit from systemic therapy, and what type of therapy they should receive. This is especially true in a hematological malignancy setting, specifically acute myeloid leukemia (AML), where the acuity of the disease prompts immediate treatment without unnecessary delays in care.”

Assessed Proportion of Frailty Status by Chemotherapy Type

For a study published in the Journal of Geriatric Oncology, Dr. Cheng and colleagues conducted a retrospective cohort study of older adults (n=106; aged >60) with a new AML diagnosis who received some form of leukemia-directed therapy, either intensive therapy (ie, anthracycline-based chemotherapy) or less-intensive therapy (ie, hypomethylating agents, low-dose cytarabine, and/or venetoclax). “We wanted to determine if the primary care–derived embedded eFI built into our institution’s EHR could be assessed in an older population with AML,” Dr. Cheng says. “Data were abstracted from our cancer registry, as well as additional information from each individual’s chart.” The primary outcome was proportion of frailty status (fit, pre-frail, or frail) by chemotherapy type.

The study team found that the eFI was associated with type of chemotherapy received (Figure). “Specifically, patients who were categorized as frail by the eFI did not receive intensive chemotherapy,” Dr. Cheng notes. “Only patients who were fit or pre-frail received intensive chemotherapy. The eFI includes an assessment of major comorbid conditions that are also heavily weighted in clinical practice, which may help to explain why the eFI was linked with treatment choice.”

Future Research Includes Adapting the eFI to AML Care

Dr. Cheng and colleagues believe that the eFI may be an effective tool to help determine the appropriateness of intensity of therapy for older adults with AML. “While the eFI was not associated with survival or number of chemotherapy cycles, it may help identify older adults who are more vulnerable than initially perceived,” Dr. Cheng says. “For patients who are categorized as pre-frail or frail by the eFI, this may help to identify those who would benefit from a comprehensive geriatric assessment to identify vulnerabilities prior to initiation of treatment.”

A future area of interest, he adds, is the adaptation of the eFI to an AML setting, including incorporating inpatient laboratory results and potentially modifying the outpatient requirement to accommodate the acute hematological malignancy setting. “Acutely ill patients are often transferred to the tertiary care cancer center when AML is suspected, whereas patients with solid malignancies typically have already established care within the healthcare system prior to their diagnosis,” he says.