Feasibility of a Geriatric Oncology Longitudinal End to End (GOLDEN) Program in a Tertiary Cancer Center in Singapore
Globally, the population is aging, with the number of people aged 60 years and older projected to double from 1 billion worldwide in 2020 to 2.1 billion by 2050. The aging population, coupled with the risk of cancer increasing with age, predicts an exponential rise in cases of older adults diagnosed with cancer. Given that the provision of care for older adults with cancer presents the unique challenge of requiring expertise in both oncologic and geriatric issues, most cancer programs are still lacking in terms of meeting the complex needs of these patients. , Consequently, in recent years, there has been an increasing urgency to address that through training and subsequently, the introduction of dedicated geriatric oncologic models of care delivery. Singapore is in a similar predicament with the number of working adults supporting the older population decreasing from 5 young adults to one older adult today, to 2 young adults for one older adult by 2030. Correspondingly, the incidence of cancer in older adults aged 65 years and over is expected to rise from 121,000 in 2020 to 349,000 in 2040. Despite this, a nation-wide survey of oncologists conducted by the National University Cancer Institute, Singapore (NCIS), revealed that most oncologists in Singapore (61%) have never engaged the help of a geriatrician in the decision-making process for cancer treatment and less than half of the participants (47%) were aware that there were geriatric oncology assessment scales available. However, in line with the recommendations of the American Society of Clinical Oncology (ASCO), International Society of Geriatric Oncology (SIOG) and National Comprehensive Cancer Network (NCCN) to perform geriatric assessments (GA) on patients before initiating therapy, , the vast majority of the oncologists surveyed (90%) welcomed the introduction of a geriatric oncology service. With the recognition of the importance of Geriatric Assessment (GA)-directed interventions in guiding and supporting cancer care in older adults, 2 concurrent pilot programs were initiated in the National University Hospital (NUH) and the National University Cancer Institute, Singapore (NCIS) to cater to the needs of patients planned for cancer surgery and those planned for chemotherapy and/or radiation. The Management & Innovation for Longevity in Elderly Surgical patients (MILES) program was started in NUH in 2017 to enhance perioperative care for older adults aged 65 years and above requiring elective major surgery. All patients enrolled into the program are managed by a multidisciplinary team with expertise to meet their complex care needs. All patients will undergo a GA administered by MILES nurses. During the assessment, attention is paid to their functional status, cognition, nutritional status and level of frailty so the patients requiring input by dietitians, physiotherapists and occupational therapists are promptly identified and referred. These patients will receive personalized nutritional intervention and are prescribed exercise regimens tailored to their capacity and needs. They are also provided with strategies and aids to cope with the limitations they are experiencing. Furthermore, patients are referred to a specialist in perioperative medicine should they require medical optimization. These management strategies are geared toward optimizing patients’ health status pre-surgery, thus reducing their operative risks and improving their outcomes from the surgery. To ensure a smooth hospital stay and transition to home or a step-down facility, the multidisciplinary team remains involved in the continuation of care for all patients within the program throughout their journey. The MILES nurses will conduct follow-up calls and visits to patients peri-surgery to ensure that the trajectory of their surgical journey and recovery is keeping to the expected course. The allied health teams involved during the patients’ preoperative period will continue to partner closely with the surgical teams in the postoperative period to expedite the patients’ recovery. This input continues after discharge till the patients are fit to be discharged from their specialized care. This is to ensure that the program restores as many patients as possible to their premorbid level of health and quality of life. A pilot Geriatric Medical Oncology(GO) program supported by the Singapore Cancer Society (SCS) grant was also developed at NCIS in 2017. Similarly, all patients aged 70 years and older seen in NCIS undergo a GA on the day of their first visit. All cases are discussed at a multidisciplinary meeting with a geriatric medical oncology (GO) team consisting of a medical oncologist, radiation oncologist, geriatrician, pharmacist and nurse coordinator. The GO team identifies older adults who are pre-frail and frail through the GA and multidisciplinary discussion and synthesizes a summary of treatment recommendations and interventions which can help support patients through their cancer treatment. This summary is then conveyed to the primary oncologist in a memo. The GO team also works with patients’ primary oncologists to design a suitable treatment plan for optimal results, without compromising their independence and quality of life. Patients on the program are monitored closely for treatment-related toxicities during their cancer treatment. With recognition of the need for a program which can provide seamless continuity of care to older adults with cancer in our hospital, the 2 teams merged to form the G eriatric O ncology L ongitu D inal E nd to e N d (GOLDEN) program. This end to end program was the first of its kind in Singapore. Consequently, the combined team was awarded a grant from a philanthropic fund, the Jurong Health Fund, to support the program in NCIS (NUH) and Ng Teng Fong General Hospital (NTFGH), 2 hospitals within the National University Health System (NUHS) cluster. The GOLDEN program commenced in August 2019. The age cutoff was aligned at 65 years and older and the handover workflows were fine-tuned between the surgical MILES program and the geriatric medical oncology program to facilitate a seamless transfer of care for pre-frail and frail patients. All cancer patients aged 65 years and older seen in NCIS would be screened on their first visit with a Geriatric 8 (G8) screening questionnaire , to identify patients who might benefit from a Comprehensive Geriatric Assessment (CGA). For patients who scored 14 or less, an electronic memo would be sent to their primary oncologist through the hospital’s electronic medical records system to highlight their potential suitability for the GOLDEN program. All patients referred to the GOLDEN program will undergo a CGA before their treatment, alongside a consultation with the geriatric medical oncology team in a one-stop geriatric oncology clinic, where they can be seen on the same day by members of the multidisciplinary team including a dietitian, physiotherapist, occupational therapist and a medical social worker if required. The cases are also discussed at a multidisciplinary meeting by the geriatric oncology (GO) team. Patients in the GOLDEN program would be under the supportive care of the geriatric medical oncology (GO) team after surgery until the end of their cancer treatment. For older adults with challenging cancer survivorship issues and geriatric syndromes, the geriatric medical oncology team would continue to follow them up after the completion of their oncological treatment until specialized geriatric oncology care is no longer required. Their care would then be transferred to their primary oncologist and their primary care provider. After establishing the GOLDEN program in NCIS, the program expanded to NTFGH, a hospital within the same healthcare system. A multidisciplinary team was assembled and a parallel GOLDEN program workflow was initiated in NTFGH in November 2019. Geriatric assessment for older adults with hematological malignancies is no less important with many recent papers highlighting the need for a CGA in prognosis and treatment decision. The decision to add the geriatric hematology patients into the GOLDEN program was made after the successful initiation of the program in oncology patients. To successfully initiate the geriatric hematology program, champions in the medical team were identified and feedback from hematologists in the department were sought and incorporated into the workflow to ensure referrals and subsequent consultations. As of December 2021, all patients aged 65 years and older with newly diagnosed hematological malignancy would be referred to the geriatric hematology service. Similar to the GOLDEN framework, a G8 screening would be performed followed by a CGA if required. They would also be discussed at the same GOLDEN multidisciplinary team meeting. With the initiation of the GOLDEN program in our cancer center, we sought to assess the feasibility of our Geriatric Oncology program and evaluate if we have benefited our patients since its introduction. 

A CGA was performed for all patients enrolled in the GOLDEN program to determine the older adults’ health state, classifying them as fit, pre-frail or frail. It covered domains including functional status, falls, cognition, sensory impairment, social support, nutrition, psycho-emotional status, and assessment of comorbidity and polypharmacy. Patients with one to 4 domains of concern were categorized as pre-frail, while those with 5 or more domains of concern were frail. Functional status was assessed using the Katz’s Activities of Daily Living (ADL) Index, , Lawton instrumental ADL (IADL), and Karnofsky Performance Status (KPS). Comprehensive fall history and Timed Up and Go (TUG) were taken to assess fall risk. Presence of visual and hearing impairment were noted. The Mini-Cog was used to assess for cognitive impairment. Social support and activity was assessed using Medical Outcomes Study—Social Support Survey (MOS-SSS-4) and Medical Outcome Study—Social Activities Survey (MOS-SAS-4) respectively. Nutritional status was assessed via changes in weight over 6-month duration, psycho-emotional status was assessed using the Distress Scale and Geriatric Depression Scale (GDS-4) and polypharmacy was assessed through a thorough medication review by a trained pharmacist. Comorbidities were assessed using a patient-reported version of the Older Americans Resources and Services Questionnaire (OARS) Physical Health comorbidity subscale. We measured the incidence of geriatric syndromes picked up on performing a CGA in these patients, and the number of patients had issues of concern requiring targeted allied health interventions after a CGA. In order to assess the impact of the GOLDEN program on the referring physicians’ practice, we also measured the percentage of patients who had a change in treatment plans after the GA. Lastly, we measured patient related outcome measures (PROMs) such as their satisfaction rate with a patient satisfaction survey and their quality of life using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) questionnaire. As there was limited time for the older adults planned for prehabilitation prior to surgery, only the patients who were enrolled in the geriatric medical oncology component of the GOLDEN program were further evaluated for these outcomes. This study was approved by the National University Hospital (NUH) Institutional Ethics Review Board. 

A total of 1347 older adults with cancer were screened with G8 in NCIS from August 2019 to August 2021, of which 1,139 were suitable to be enrolled in the GOLDEN program and 777 were referred by their primary oncologists and enrolled into the GOLDEN program. Five hundred and sixty-nine (73%) patients were enrolled in the surgical prehabilitation program, while 308 (40%) patients were enrolled in the geriatric medical oncology program and 100 (12.8%) patients were enrolled in both. shows the characteristics of all the patients referred to the GOLDEN program. There were 442 (56%) females and the median age was 73 (ages ranged from 65 to 95). The ethnic make-up of the cohort was 85.8% Chinese, 8.2% Malay, 3.1% Indians, and 2.8% were of other ethnicities. The most common cancer types in our program are lower gastrointestinal cancers ( n = 398; 51.2%), hepatobiliary cancers ( n = 187; 24.1%), upper gastrointestinal cancers ( n = 48; 6.2%), genitourinary cancers ( n = 43; 5.5%) and thoracic cancers ( n = 40; 5.2%). 86.6% of the patients had early stage cancers while 13.4% had advanced stage cancers. Based on the CGA, 44.9% of our whole population of 777 patients was fit, 43.4% was pre-frail and 11.7% was frail. Further Analysis of Patients Enrolled in the Geriatric Medical Oncology Arm Of the 308 patients enrolled in the geriatric medical oncology arm, 265 patients (86.0%) were identified to have geriatric syndromes with a CGA, as detailed in . A hundred and forty-five (47.1%) patients were at risk for frequent falls with a Timed Up and Go test (TUG) of more than 12 seconds, and 65 (21.1%) of them had more than one fall in the past 6 months. Ninety-five (30.8%) of the patients scored less than 3 on the mini cog screening test, suggesting a likelihood of cognitive impairment, while 51 (16.6%) patients scored 2 or more on the Geriatric Depression Scale 4 questionnaire, which was concerning for low mood. Thirty-one (10%) patients had self-reported urinary incontinence issues. One hundred ninety 4 patients (63.0%) had polypharmacy, defined as the use of at least five chronic medications, of which 111 (36.0%) required deprescribing or dose adjustments. One hundred and eighty-seven (60.8%) of the patients had a change in their treatment plans after the patients were seen by the geriatric medical oncology team. 205 (66.6%) of the patients were treated with curative intent for their cancer diagnosis. Of the 231 patients who completed the EORTC QLQ-C30 questionnaire, 97 patients (31.5%) reported an overall improvement in their global health status, while 118 patients (38.3%) maintained their global health status after being enrolled in the GOLDEN program.Of the 233 patients who completed the patient satisfaction survey, 226 (73%) responded that they had benefited from the program. 

Of the 308 patients enrolled in the geriatric medical oncology arm, 265 patients (86.0%) were identified to have geriatric syndromes with a CGA, as detailed in . A hundred and forty-five (47.1%) patients were at risk for frequent falls with a Timed Up and Go test (TUG) of more than 12 seconds, and 65 (21.1%) of them had more than one fall in the past 6 months. Ninety-five (30.8%) of the patients scored less than 3 on the mini cog screening test, suggesting a likelihood of cognitive impairment, while 51 (16.6%) patients scored 2 or more on the Geriatric Depression Scale 4 questionnaire, which was concerning for low mood. Thirty-one (10%) patients had self-reported urinary incontinence issues. One hundred ninety 4 patients (63.0%) had polypharmacy, defined as the use of at least five chronic medications, of which 111 (36.0%) required deprescribing or dose adjustments. One hundred and eighty-seven (60.8%) of the patients had a change in their treatment plans after the patients were seen by the geriatric medical oncology team. 205 (66.6%) of the patients were treated with curative intent for their cancer diagnosis. Of the 231 patients who completed the EORTC QLQ-C30 questionnaire, 97 patients (31.5%) reported an overall improvement in their global health status, while 118 patients (38.3%) maintained their global health status after being enrolled in the GOLDEN program.Of the 233 patients who completed the patient satisfaction survey, 226 (73%) responded that they had benefited from the program. 

While most cancer physicians recognize the importance of a geriatric assessment for the provision of holistic care for older adults with cancer, there were barriers to the uptake of the GOLDEN program by oncologists and patients during the initiation of the program. Screening with G8 (using a cutoff of 14) has identified 84% ( n = 1139) of the population to be potentially suitable for the GOLDEN programme, but only 58% ( n = 777) of the cohort were referred on by their primary physicians . We sought to understand the barriers to referral amongst the oncologists by interviewing some of them. These include the treating physicians would rather prioritize patients’ cancer treatment, instead of “peripheral geriatric issues”, concerns of the burden of additional clinical consults to the patients, fear of delaying patients receiving urgent cancer treatment, and some felt that they had sufficient experience to address issues in older adults. In our patient cohort who had received a CGA, the percentage of pre-frail and frail patients was 55.1% of the patient population which is lower compared to that of 84% of the population identified by the G8. This is consistent with the G8 screen being more sensitive, rather than specific as a screening tool for frailty in the older adults with cancer. In our center, we are currently evaluating if the cutoff of 14 is suitable for our population, or a lower cutoff should be used for a better specificity. The relative urgency of cancer surgery and reluctance of both surgeons and patients alike for adjustments in the surgical schedule to allow prehabilitation has also posed a challenge for its uptake and the execution of the recommendations by the team. We intend to evaluate and fine tune our work processes to improve the uptake of surgical prehabilitation in older adult cancer patients. As such, we had to limit some of the interventions and assessment of patient related outcome measures (PROMs) to the patients who were accrued into the geriatric medical oncology (GO) arm of the program, as they had more time to undergo the interventions, and be interviewed for the PROMs. Close to 70% of the patients enrolled in the geriatric medical oncology arm had geriatric syndromes that would have been missed if a GA was not performed. These may be overlooked when the focus is solely on treating the cancer. This represents lost opportunity for management and treatment, especially when geriatric syndromes have well been associated with adverse outcomes including poorer quality of life, hospitalization, functional decline, institutionalization, and increased healthcare costs. While we understand the concern of their treating oncologist, the importance of an in-depth understanding of an older adult’s overall state of health cannot be undermined when treating individuals with competing medical and physiological challenges which will impact their cancer care. With the appropriate interventions, we believe that it would optimize care for our older patients with cancer. Furthermore, GA-directed interventions have been shown to reduce treatment related toxicities , and improve quality of life in studies done in tertiary cancer centers with geriatric oncology services, as well as in community oncology practices with tailored geriatric assessment and management recommendations. More than half of the patients (60.7%) had a change in their treatment plans after going through the program, with the majority receiving an attenuated treatment regimen in view of their risk of treatment related toxicities. As this may potentially result in under treatment of cancer in these patients, a long term evaluation of their cancer related outcomes would be equally crucial. A recent randomized controlled trial by Li et al had shown that the integration of multidisciplinary geriatric assessment-driven interventions (GAIN) significantly reduced the incidence of grade 3 or higher chemotherapy- related toxicities with no negative impact on their overall survival over a period of 12 months. While some physicians were reluctant to refer their patients to the program, the ones who did have been accepting of the recommendations by the team. With a team specializing in care for older adults with cancer, the GOLDEN program can provide “geri-confidence” to less experienced doctors in this area, such as surgeons and oncology trainees and provide them with guidance in their care of older adults. This is especially so when caring for frail older adults who are at higher risk of developing treatment related toxicities. Most of the patients (69.8%) had at least maintained or shown an improvement in their global health status while undergoing treatment with chemotherapy. This is especially important for older adults to maintain their quality of life during their cancer treatment to strike a balance between the challenges of physiological aging and appropriate treatment of their cancer. A majority of the patients (73.4%) who had completed the patient satisfaction survey felt that they had benefited from the program. On further understanding, what most patients and their loved ones appreciated was the time spent to hear about their concerns, assistance in navigating the system and provision of a one-stop clinic for interventions provided after an explanation of the rationale of prehabilitation. In the small developed nation of Singapore, most older adult cancer patients are treated in public tertiary cancer centers where geriatric oncology services are available. However, there are older adults who are managed in community oncology practices who may benefit from GA directed interventions. We hope to be able to extend a referral service to community oncologists who may wish to refer their patients to the GOLDEN program, as it has been shown by Mohile et al to be beneficial for older adult patients to receive GA directed interventions in community practices. We envisioned the GOLDEN program to be positioned as the sherpa or guide in the older patient’s cancer journey by helping to guide appropriate treatment for older adults and to be a dependable companion to patients and their caregivers to provide necessary information and care navigation during this process. This is especially crucial given the increasing complexity of cancer treatment, which can often be overwhelming especially for older adults. The GOLDEN program provides valuable geriatric assessment of older adults to the referring primary oncologist. We hope to be able to intervene as early as possible, as a pretreatment assessment. The further upstream the patient is in their cancer journey, the more useful this information would be to the treating physicians, as it allows them to take into consideration the additional information a GA provides prior to formulating a suitable cancer treatment for their patients. The program also assesses, monitors and subsequently gives recommendations and supports an older adult’s entire cancer journey. This not only provides a continuous care plan, and is also holistic because the GOLDEN program is not just focused on the cancer treatment, but also care of the older adult and environment as a whole. 

Our study was not designed to assess the statistical feasibility of the program, but rather to gauge how the recipients of our service viewed the program. With future studies, it would be ideal to plan to assess the tangible benefits of the program such as a reduction in unplanned hospitalizations, shortened hospitalization stays and reduction in treatment related toxicities. There is still a significant proportion of oncologists who do not refer their patients to our geriatric oncology program. It would be beneficial to have a better understanding of the factors contributing to this relatively low referral rate and how we could add value to their management of their older adult patients. With compelling evidence supporting the importance of GA directed interventions in older adults and improved outcomes seen in our patients, we hope that this will encourage more cancer physicians to have a mindset shift and consider referring their vulnerable older adult patients to our program. 

In this paper, we shared the evolution of the GOLDEN geriatric oncology program in our tertiary cancer center. With early beginnings consisting of 2 small pilot programs, the GOLDEN program now covers the entire older adult cancer journey and has broadened to include older adults with hematological cancers. With promising benefits felt by patients and increasing appreciation of the program by referring physicians, we hope to further evaluate our program for cancer related outcomes and sustainability of a geriatric hematology-oncology program like this in major tertiary cancer centers. By doing so, we hope to be able to provide some insights to others who are seeking to do the same for their older adults with cancer. 

