Cancer Assessment and Interventions

Older adults have an increased risk of malignancy (Howlader et al., 2018). Seniors often tolerate cancer treatment as well as younger people, depending on functional and general health status (Droz et al., 2017; Gomez-Millan, 2009; Sastre et al. 2008, Wildiers et al., 2007).

BACKGROUND

Cancer is most often diagnosed in people aged 65 years and over (Howlader et al., 2018). Nurses must be aware of management options and some potential emergencies associated with the diagnosis and treatment of a malignancy.

PRINCIPLES OF CANCER CARE IN THE OLDER PERSON

A.  Assessment of comorbid conditions

  1. Cancer may be one of several chronic conditions.
  2. The more severe the comorbidity, the lower the probability of survival after a diagnosis of cancer (Iversen et al., 2009). The absence of severe comorbidity and good general health allows older people to be considered for more aggressive types of cancer treatments (Banysch et al., 2018; Vitale et al., 2019).

B.  Assess the patient using a comprehensive geriatric assessment.

  1. The CGA is a battery of clinical measures used to assess functional, emotional, and cognitive status; falls; medications; and general health status (Overcash, 2018; Wildiers et al., 2014).
  2. Functional status can be measured using an Activity of Daily Living Scale (Katz et al., 1970), Instrumental Activities of Daily Living Scale (Lawton & Brody, 1969), Gait Assessment Scale (Tinetti, 1986), or Berg Balance Scale (Berg et al., 1992).
  3. Risk of falls can be assessed using the Timed Up and Go Test (Podsiadlo & Richardson, 1991).
  4. Emotional status is often assessed using the Geriatric Depression Scale (Yesavage et al., 1982).
  5. Cognitive status is assessed using the Mini-Cog (Borson et al., 2000).
  6. General health status is assessed with a complete history and physical exam.
  7. Medication is evaluated using the Beers Medication Screen (AGS, 2019).

C.  Assessment of medical emergencies associated with cancer

  1. Hypercalcemia
    • Defined as calcium concentrations greater than 10.2 mg/mL (C. T. Lee et al., 2006)
    • Signs and symptoms are not often noticeable.
    • Gastrointestinal discomfort, lethargy, confusion, anorexia, nausea, constipation, polyuria, and polydipsia are symptoms (Halfdanarson et al., 2006).
    • Treatment depends on severity.
    • Thiazide diuretics should be discontinued.
    • Hydration with intravenous normal saline is recommended.
    • Bisphosphonates are an option (Fallah-Rad & Morton, 2013).
  2. Tumor lysis syndrome (TLS)
    • Caused when a tumor breaks down rapidly (Wagner & Arora, 2014).
    • Causes hyperkalemia, hyperuricemia, and hyperphosphatemia, which can cause renal failure and reduced cardiac function.
    • Signs and symptoms are muscle cramps, anxiety, depression, confusion, hallucinations, cardiac arrhythmia, and seizures (Cantril & Haylock, 2004; Dubbs, 2018).
    • Treatment with hydration, administration of allopurinol, and diuresis are generally the first line of treatment (Cantril & Haylock, 2004).
    • Treatment with rasburicase has been found to be effective in the treatment and prevention of hyperuricemia and TLS (Dinnel et al., 2015).
  3. Spinal cord compression
    • Occurs when metastasis spreads to the vertebral bodies and invades the spinal cord (Campillo-Recio et al., 2019; Halfdanarson et al., 2006).
    • Signs and symptoms are numbness, tingling, and weakness in the extremities; sensory changes; upper thorax and back pain (Lowey, 2006; Tsukada et al., 2015).
    • Pain can radiate or localize and may seem chronic, which may disguise the emergent spinal cord compression and delay critical treatment.
    • Bowel and bladder dysfunction can also occur (Tsukada et al., 2015).
    • Treatment is often initiated with glucocorticoids, followed by radiation therapy and/or surgery (George et al., 2008).
  4. Neutropenia fever
    • Caused by the diminishment of neutrophils by chemotherapeutic agents
    • Neutropenia is defined by an oral temperature of 101°F and an ANC of less than1,500 cells/μL. An ANC of less than 500 cells/μL is considered severe (Freifeld et al., 2011).
    • Generally, fever is the presenting sign; however, skin rashes and mucositis may also be present.
    • Prevention of neutropenia and neutropenic fever should be proactive in the administration of G-CSFs in patients who are considered to be at high risk (Aapro et al., 2011; Dale, 2016).
    • Treatment of neutropenia is to stop chemotherapy until white counts elevate.

PARAMETERS OF ASSESSMENT

A.  Older patients with cancer require comprehensive geriatric assessment and monitoring during diagnosis and treatment of malignancy.

ABBREVIATIONS

ANC         Absolute neutrophil count

CGA         Comprehensive geriatric assessment

G-CSF       Granulocyte-colony stimulating factor

----

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 37:  Overcash, J. (2021) Cancer Assessment and Intervention Strategies in the Older Adult.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 683-695).   New York: Springer.

REFERENCES

Aapro, M. S., Bohlius, J., Cameron, D. A., Dal Lago, L., Donnelly, J. P., Kearney, N., … Zielinski, C. (2011). 2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours. European Journal of Cancer, 47(1), 8–32. doi:10.1016/j.ejca.2010.10.013. Evidence Level V.

American Geriatrics Society. (2019). The American Geriatrics -society 2019 updated AGS Beers criteria for potentially i-nappropriate medication use in older adults. Journal of the American Geriatrics Society, 67(4), 674–694. doi:10.1111/jgs.15767

Banysch, M., Akkaya, T., Gurenko, P., Papadakis, M., Heuer, T., Kasim, E., … Kaiser, G. M. (2018). Surgery for colorectal cancer in elderly patients: Is there such a thing as being too old? Giornale di Chirurgia, 39(6), 355–362. doi:10.11138/gchir/2018.39.6.355. Evidence Level IV.

Berg, K. O., Wood-Dauphinee, S. L., Williams, J. I., & Maki, B. (1992). Measuring balance in the elderly: Validation of an instrument. Canadian Journal of Public Health, 83(Suppl. 2), S7–S11. Evidence Level IV.

Borson, S., Scanlan, J., Brush, M., Vitaliano, P., & Dokmak, A. (2000). The Mini-Cog: A cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Internal Journal of Geriatric Psychiatry, 15(11), 1021–1027. doi:10.1002/1099-1166(200011)15:11<1021::AID-GPS234>3.0.CO;2-6. Evidence Level IV.

Campillo-Recio, D., Jimeno Ariztia, M., Flox Benitez, G., Marco Martinez, J., Vicente Martin, C., & Plaza Canteli, S. (2019). Metastatic spinal cord compression: Incidence, epidemiology and prognostic factors. Revista Clinica Española, 219, 386–389. doi:10.1016/j.rce.2018.10.012. Evidence Level IV.

Cantril, C. A., & Haylock, P. J. (2004). Emergency. Tumor lysis syndrome. American Journal of Nursing, 104(4), 49–52; quiz 52. doi:10.1097/00000446-200404000-00017. Evidence Level V.

Dale, D. C. (2016). How I diagnose and treat neutropenia. Current Opinion in Hematology, 23(1), 1–4. doi:10.1097/MOH.0000000000000208. Evidence Level IV.

Dinnel, J., Moore, B. L., Skiver, B. M., & Bose, P. (2015). Rasburicase in the management of tumor lysis: An evidence-based review of its place in therapy. Core Evidence, 10, 23–38. doi:10.2147/CE.S54995. Evidence Level V.

Droz, J. P., Boyle, H., Albrand, G., Mottet, N., & Puts, M. (2017). Role of geriatric oncologists in optimizing care of urological oncology patients. European Urology Focus, 3(4/5), 385–394. doi:10.1016/j.euf.2017.10.012. Evidence Level VI.

Dubbs, S. B. (2018). Rapid fire: Tumor lysis syndrome. Emergency Medicine Clinics of North America, 36(3), 517–525. doi:10.1016/j.emc.2018.04.003. Evidence Level VI.

Fallah-Rad, N., & Morton, A. R. (2013). Managing hypercalcaemia and hypocalcaemia in cancer patients. Current Opinion in Supportive and Palliative Care, 7(3), 265–271. doi:10.1097/SPC.0b013e3283640f5f. Evidence Level V.

Freifeld, A. G., Bow, E. J., Sepkowitz, K. A., Boeckh, M. J., Ito, J. I., Mullen, C. A., … Wingard, J. R.; Infectious Diseases Society of America. (2011). Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clinical Infectious Diseases, 52(4), e56–e93. doi:10.1093/cid/ciq147. Evidence Level IV.

George, R., Jeba, J., Ramkumar, G., Chacko, A. G., Leng, M., & Tharyan, P. (2008). Interventions for the treatment of metastatic extradural spinal cord compression in adults. Cochrane Database of Systematic Reviews, (4), CD006716. doi:10.1002/14651858.CD006716.pub2. Evidence Level I.

Gomez-Millan, J. (2009). Radiation therapy in the elderly: More side effects and complications? Critical Reviews in Oncology/Hematology, 71(1), 70–78. doi:10.1016/j.critrevonc.2008.11.004. Evidence Level V.

Halfdanarson, T. R., Hogan, W. J., & Moynihan, T. J. (2006). Oncologic emergencies: Diagnosis and treatment. Mayo Clinic Proceedings, 81(6), 835–848. doi:10.4065/81.6.835. Evidence Level V.

Howlader, N., Noone, A. M., Krapcho, M., Miller, D., Brest, A., Yu, M., … Cronin, K. A. (2018). Seer cancer statistics review (CSR) 1975-2016. Bethesda, MD: National Cancer Institute. Retrieved from https://seer.cancer.gov/csr/1975_2016. Evidence Level IV.

Iversen, L. H., Nørgaard, M., Jacobsen, J., Laurberg, S., & -Sørensen, H. T. (2009). The impact of comorbidity on survival of Danish colorectal cancer patients from 1995 to 2006—A population-based cohort study. Diseases of the Colon and Rectum, 52(1), 71–78. doi:10.1007/DCR.0b013e3181974384. Evidence Level IV.

Katz, S., Downs, T. D., Cash, H. R., & Grotz, R. C. (1970). Progress in development of the index of ADL. The Gerontologist, 10(1), 20–30. doi:10.1093/geront/10.1_Part_1.20. Evidence Level IV.

Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. The Gerontologist, 9(3), 179–186. doi:10.1093/geront/9.3_Part_1.179. Evidence Level IV.

Lee, C. T., Yang, C. C., Lam, K. K., Kung, C. T., Tsai, C. J., & Chen, H. C. (2006). Hypercalcemia in the emergency department. American Journal of the Medical Sciences, 331(3), 119–123. doi:10.1097/00000441-200603000-00002. Evidence Level V.

Lowey, S. E. (2006). Spinal cord compression: An oncologic emergency associated with metastatic cancer: Evaluation and management for the home health clinician. Home Healthcare Nurse, 24(7), 439–446; quiz 447. doi:10.1097/00004045-200607000-00007. Evidence Level V.

Overcash, J. (2018). Comprehensive geriatric assessment: Interprofessional team recommendations for older adult women with breast cancer. Clinical Journal of Oncology Nursing, 22(3), -304–315. doi:10.1188/18.CJON.304-315

Podsiadlo, D., & Richardson, S. (1991). The Timed “Up & Go”: A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39(2), 142–148. doi:10.1111/j.1532-5415.1991.tb01616.x. Evidence Level IV.

Sastre, J., Puente, J., García-Saenz, J. A., & Díaz-Rubio, E. (2008). Irinotecan in the treatment of elderly patients with advanced colorectal cancer. Critical Reviews in Oncology/Hematology, 68(3), 250–255. doi:10.1016/j.critrevonc.2008.05.008. Evidence Level IV.

Tinetti, M. E. (1986). Performance-oriented assessment of mobility problems in elderly patients. Journal of the American Geriatrics Society, 34(2), 119–126. doi:10.1111/j.1532-5415.1986.tb05480.x. Evidence Level IV.

Tsukada, Y., Nakamura, N., Ohde, S., Akahane, K., Sekiguchi, K., & Terahara, A. (2015). Factors that delay treatment of symptomatic metastatic extradural spinal cord compression. Journal of Palliative Medicine, 18(2), 107–113. doi:10.1089/jpm.2014.0099. Evidence Level IV.

Vitale, S. G., Capriglione, S., Zito, G., Lopez, S., Gulino, F. A., Di Guardo, F., … Lagana, A. S. (2019). Management of endometrial, ovarian and cervical cancer in the elderly: Current approach to a challenging condition. Archives of Gynecology and Obstetrics, 299(2), 299–315. doi:10.1007/s00404-018-5006-z. Evidence Level III.

Wagner, J., & Arora, S. (2014). Oncologic metabolic emergencies. Emergency Medicine Clinics of North America, 32(3), 509–525. doi:10.1016/j.emc.2014.04.003. Evidence Level V.

Wildiers, H., Heeren, P., Puts, M., Topinkova, E., Janssen-Heijnen, M. L., Extermann, M., … Hurria, A. (2014). International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. Journal of Clinical Oncology, 32(24), 2595–2603. doi:10.1200/JCO.2013.54.8347. Evidence Level V.

Wildiers, H., Kunkler, I., Biganzoli, L., Fracheboud, J., Vlastos, G., Bernard-Marty, C., … Aapro, M. (2007). Management of breast cancer in elderly individuals: Recommendations of the International Society of Geriatric Oncology. Lancet Oncology, 8(12), 1101–1115. doi:10.1016/S1470-2045(07)70378-9. Evidence Level V.

Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17(1), 37–49. doi:10.1016/0022-3956(82)90033-4. Evidence Level IV.

Protocols

Symptoms

More Information