Frailty, Oncology, and the Geriatric Assessment
Frailty in older adults with cancer is associated with poor outcomes such as mortality (Augustin et al., 2016; Soubeyran et al., 2012), functional decline (Hoppe et al., 2013) and toxicity from chemotherapy (Hurria et al., 2011). Major organizations like the American Society of Clinical Oncology recommend using a comprehensive geriatric assessment (CGA) to identify vulnerabilities such as functional impairment, comorbidities, and cognition as well as institute CGA-driven interventions like exercise or nutritional rehabilitation (Mohile et al., 2018) that have been shown to significantly reduce the risk of high-grade toxicity without compromising survival in vulnerable cohorts with geriatric impairments (Mohile et al., 2020).
Importantly, geriatric assessment improves outcomes even when implemented by physicians other than geriatricians (Moreno et al., 2022). However, surveys of oncologists in 2019 (Dale et al., 2021) and again in 2020 (Gajra et al., 2022) show poor uptake of CGA tools by oncologists, with about 50% being aware of national guidelines (Dale et al., 2021) and 40% using a CGA to inform treatment decisions (Gajra et al., 2022). Better solutions are needed now and beyond to ensure the equitable delivery of guideline-based care; Digital Health Technology (DHT) is poised to be that solution in the coming decade.
Digital Health Technologies
According to the FDA, DHTs include computing platforms, connectivity, software, and sensors for health care and related uses. Examples of DHTs range from mobile applications apps for wellness from generally accessible platforms like Headspace - which aims to provide meditation and stress management to users across the globe – to more specialized applications like Cankado, an electronic patient-reported outcome (ePRO) application that facilitates symptom survey collection for both clinicians and researchers in advanced cancer.
Using tablets or computers to facilitate symptom and CGA survey data collection in older adults has proven feasible (McCleary et al., 2013). Thus, DHT provides an opportunity to increase the use of CGA assessments by non-geriatricians and decrease the burden of collecting such data during time-limited clinical visits. DHT-based ePRO collection could even improve longevity in patients with cancer by more rapidly alerting providers to high-risk situations that patients may not recognize as such, as well as improving the response times and rates by clinical staff providing targeted symptom care (Denis et al., 2019). Wireless sensors and wearable devices could provide clinicians and researchers with surrogate markers of frailty (Razjouyan et al., 2018) as well as cognitive impairment (Razjouyan et al., 2020), and other markers of vulnerability such as falls (Warrington et al., 2021). However, much more work needs to be done to realize a comprehensive vision of a usable and feasible “smart medical home” for older adults with cancer and frail older adults generally.
Barriers to Digital Health Adoption
Equally important is the tremendous potential of such tools, in combination with telehealth conferencing applications, to deliver multidisciplinary CGA interventions to underserved and rural populations (DiGiovanni et al., 2020). With Pew Research data showing that in the past decade, the gap in smartphone adoption between adults in their 60s compared to those in their 20s has shrunk, tablet adoption by older adults has grown to 44%, and in 2022 75% of older adults identify themselves as internet users, DHT seems like an obvious choice for many data collection and communication challenges.
However, a “digital divide” by location and aging impedes the adoption and implementation of DHTs in geriatric oncology. Over 30 million Americans do not have broadband infrastructure access, many of whom are located on Tribal lands. Without access to adequate internet, the ability of DHT to facilitate communication between patients and clinicians is vitiated.
Age-related changes in visual, motor, and cognitive function also act as barriers to the implementation of technological tools for older adults, in particular the “screen”-based delivery of many DHT applications (Loh et al., 2018). Navigating websites, compactly spaced keyboard buttons, long sets of instructions, and a sense of medical information overload are commonly reported barriers to the adoption of DHTs by this population (Hasnan et al., 2022). When confronted by surveys that are long or include jargon, older patients are therefore at risk of under-reporting due to mental fatigue or cognitive impairment (Kotronoulas et al., 2021).
Most patients and caregivers report low self-perceived electronic health literacy and less confidence in evaluating online health information for cancer decision-making (Verma et al., 2022). There also exists a complex interaction between the older patients’ sense of well-being and their own assessment of their cognitive abilities, which plays a key role in the adoption of wearable use among older adults (Farivar et al., 2020).
Enhancing Digital Health Equity for Older Adults
Interesting design suggestions to optimize uptake and engagement with DHT by older adults include using image or voice prompts, large font sizes, and more pictures/symbols than words for those with literacy issues (Loh et al., 2018). Perceived usefulness could also be improved by providing recommendations of when to visit the ER, medication lists or physical activity reminders, and access to up-to-date, user-friendly cancer disease status and treatment information (Hasnan et al., 2022). Methods incorporating the patient perspective into DHT development through Human-Centered Design is another important concept. By interviewing older users, and examining all aspects of usability, cyclic user testing, and iterative design, developers of DHT can promote applications with better equity and applicability to the diverse components of this heterogeneous population (Harte et al., 2014).
Unobtrusive monitoring is another potential solution, allowing clinicians to obtain patient data without requiring the direct engagement of the participant. This field has been exploring the feasibility of ambient smart sensors that are already integrated with commonly used home items to provide automated measures of health status (Bokharouss et al., 2007; Rashidi et al., 2010). Testing such solutions and designing them with the needs and values of the intended population is critical to bridging this divide and developing truly equitable solutions.
One of the goals of geriatric oncology is to enhance older adult clinical trial participation so that we may expand the evidence base in this rapidly evolving field. DHTs again have the potential to act as monitors of patient-centric outcomes and thereby enhance the interpretability and generalizability of clinical treatment trials. DHTs can provide a longitudinal health status assessment by reliably collecting measures of well-being, function, and nutrition in addition to ePROs.
The Geriatric Remote Initiative (GeRI), led by myself and mentors from both Drug Development and Gero-Tech at the University of Chicago and supported by the Conquer Cancer Foundation’s Young Investigator Award in Geriatric Oncology, is co-designing a cloud-enabled connected-systems platform with startup Prosilient Systems, composed of a tablet, a wearable, and a scale. There has been some preliminary work on sensor-based assessments of frailty (Blinka et al., 2021; Bian et al., 2022). A key feature of this initiative is the participation of key stakeholders, including older patients with cancer, cancer survivors, and caregivers of those with cancer. Thus, our platform will be a novel, technology-based data collection platform, iteratively improved with user feedback and vetted by patients from diverse oncology environments as well as human-centered design specialists able to be adapted and integrated into any geriatric oncology research setting.
Excitingly, there are over 100 recruiting Digital Health Studies in Oncology currently registered on ClinicalTrials.gov, ranging from Digital Biomarker discovery to health coaching and symptom management. However, few of these cater to frail adults specifically. As we have seen, barriers to adoption and lack of data supporting DHTs predictive or prognostic capacities in a frail population persist. Such issues need to become a focus of DHT research, given the major effect of frailty on outcomes.