In this issue of the journal, Magnuson et al. provide a comprehensive review of available geriatric assessment (GA) tools and their impact on outcomes for solid tumors and hematologic malignancies. In addition, the authors provide a clear guide for clinicians to help understand the importance of GA and management.¹

An assumption inherent in the GA is that improvement in outcomes is driven by modifications in treatment delivery or implementation of features to make activities of daily living safer. In other words, GA-guided management² or GA-driven intervention,³ rather than simply performing the GA, is what leads to outcome improvement. These modifications are implemented using a multidisciplinary team of geriatric trained specialists. Examples include occupational therapists to improve home safety, physical therapists to improve gait and balance, pharmacists to review home medications and adjust based on anticipated adverse drug interactions, dietitians to improve nutrition, etc. Most of the studies included showed benefit, either in survival, reduced toxicity, improved quality of life, or cost effectiveness.

These observations led to the development of an American Society of Clinical Oncology guideline recommending GA-guided management of cancer treatment in elderly adults.⁴ However, it is widely recognized that this tool is underused by practicing oncologists.⁵ The whys have been explored by Magnuson et al. and others^{5, 6} and included the belief that the GA was too cumbersome in addition to the perception that it added little or no value. Based on these assumptions, making assessment tools more efficient and educating providers about their evidence-generated benefits have been the focus of efforts to improve GA use. To encourage greater uptake of the tool, Magnuson and co-authors detail ways to educate providers and simplify the GA.

What is not discussed that may be an important root cause of poor uptake of GA is resource scarcity, which takes two forms. The first is the lack of available services to support GA-modified treatment. Substantial numbers of communities, particularly in rural sites, do not have consistent—if any—access to the specialists required to modify treatment in a GA-guided manner. These practices almost certainly do not have geriatricians or geriatric-trained nurse practitioners; and they may not have physical therapists, occupational therapists, chemotherapy-dedicated pharmacists, or even social workers. Rural sites particularly often have one oncology provider whose job is to meet all the needs of every oncology patient in their practice. This distributive inequity of resources⁷ has always existed and will continue to plague rural communities. In this context, even if one performed a GA, opportunities to make care delivery safer or less toxic would be challenging in the absence of necessary ancillary services.

The second resource scarcity comes from the constraints on the oncologist's time, which is more universal. Williams et al. suggested that more frequent toxicity checks would help improve GA-based outcomes even in resource-limited communities.⁴ However, this overlooks the finding that the centrally important resource, oncologist time, is already in short supply everywhere, particularly in underserved communities. The numbers of those requiring cancer care continue to increase because of an aging US population and the increasing incidence of cancer in young adults. Meanwhile, the number of oncologists in the workforce is not increasing to keep up with demands. In an environment in which oncologists are asked to address pain at every visit, manage distress, mitigate financial toxicity, and actually treat the cancer, adding another requirement to oncologist visits is likely to generate much resistance. As the saying goes, you can only get so much blood from a stone. The integration of geriatric principles into oncology will face problems of inertia, especially in busy clinics. However, short cuts will probably not work. Simple, easily administered GA screens might seem attractive in resource-limited areas, but results have been inconsistent.⁷ In addition, resource-limited areas will not have the support systems that the GA may require to realize optimal care of the elderly oncology patient.

The important question then becomes: How do we help improve the ability of resource-challenged practitioners to implement the changes required by GA? Writing guidelines and encouraging GA use without addressing this fundamental problem will leave GA underused. If you cannot act on test results, why perform them? And writing guidelines without addressing this fundamental resource problem will leave patients with disappointed expectations and may expose oncologists working in resource-challenged communities to liability.

This is not to say that we should abandon GA. Telehealth has been successful in many aspects of oncology, from surveillance to toxicity monitoring, and could be used for geriatric consultation and management. Our national organizations (e.g., the American Society of Clinical Oncology and the American Cancer Society) could help create a panel of nationally credentialed geriatricians available for teleconsultation that would address this aspect of GA. However, this assumes that there are enough geriatricians who are willing and able to meet the expanding needs of an ever-growing elderly population. A more difficult problem to solve is how to assemble a multidisciplinary team to actualize GA recommendations, including broader access to occupational and physical therapy evaluation and management, which require in-person, hands-on visits. Perhaps a novel solution to this manpower issue would be to help create a new paraprofessional field, geriatric assessment implementation technicians (GAITs). Such GAITs would be lay people who undergo a relatively brief, focused training period followed by certification, similar to lay navigators. These individuals could be trained to do in-home evaluations and make changes necessary for the safe implementation of chemotherapy and could be deployed to underserved and rural communities. Designed correctly, this could be an attractive and useful career option in communities that are lacking economic opportunities and could provide a solution to the growing need represented by our aging population. These two elements, telehealth geriatrics supporting local physicians and GAITs complimenting telehealth occupational therapy/physical therapy, will require additional funding and would require implementation studies to determine whether and/or how these enhancements improve outcomes. Envisioning the resources needed to support these initiatives may seem daunting. However, ignoring the problem will not make it go away.

If we want to improve the use of GA in all oncology practices, educating oncologists and simplifying the tool is not enough. We must help enable under-resourced practices to implement GA-based changes, and we need to bring the required specialty practices to the rural environment. Remembering the needs of underserved communities will be vital to the success of any and all guidelines that continue to roll out.

在本期杂志中，Magnuson 等人全面回顾了可用的老年评估 （GA） 工具及其对实体瘤和血液系统恶性肿瘤结果的影响。此外，作者为临床医生提供了明确的指南，以帮助理解 GA 和管理的重要性。¹

GA 中固有的一个假设是，结果的改善是由治疗实施的修改或功能的实施驱动的，以使日常生活活动更安全。换句话说，GA 指导的管理² 或 GA 驱动的干预^，3 而不是简单地执行 GA，才能改善结果。这些修改是由受过老年病学培训的专家组成的多学科团队实施的。例如，职业治疗师改善家庭安全，物理治疗师改善步态和平衡，药剂师审查家庭药物并根据预期的不良药物相互作用进行调整，营养师改善营养等。纳入的大多数研究都显示出益处，无论是在生存率、降低毒性、改善生活质量还是成本效益方面。

这些观察结果导致了美国临床肿瘤学会指南的制定，推荐 GA 指导的老年人癌症治疗管理。⁴ 然而，人们普遍认为，这种工具并未被执业肿瘤学家使用。⁵ Magnuson 等人和其他人^{5， 6} 已经探讨了其中的原因，除了认为 GA 太麻烦之外，还认为它几乎没有增加价值。基于这些假设，提高评估工具的效率并教育提供者了解其循证产生的益处一直是改进 GA 使用的重点。为了鼓励更多人使用该工具，Magnuson 和合著者详细介绍了教育提供者和简化 GA 的方法。

没有讨论的可能是 GA 吸收不良的重要根本原因是资源稀缺，它有两种形式。首先是缺乏支持 GA 改良治疗的可用服务。大量社区，尤其是农村地区的社区，无法始终如一地（如果有的话）获得以 GA 指导的方式修改治疗所需的专家。这些诊所几乎可以肯定没有老年病学家或受过老年病学培训的执业护士;他们可能没有物理治疗师、职业治疗师、化疗专职药剂师，甚至没有社会工作者。农村站点通常特别有一名肿瘤学提供者，其工作是满足其实践中每位肿瘤患者的所有需求。这种资源分配不均⁷ 一直存在，并将继续困扰农村社区。在这种情况下，即使一个人进行了 GA，在没有必要的辅助服务的情况下，使护理提供更安全或毒性更小的机会也将是具有挑战性的。

第二个资源稀缺来自对肿瘤学家时间的限制，这更为普遍。Williams 等人建议，即使在资源有限的社区，更频繁的毒性检查也有助于改善基于 GA 的结果。⁴ 然而，这忽略了这样一个发现，即核心重要的资源，即肿瘤学家的时间，在任何地方都已经供不应求，尤其是在服务不足的社区。由于美国人口老龄化和年轻人癌症发病率的增加，需要癌症护理的人数持续增加。与此同时，劳动力中的肿瘤学家数量没有增加以满足需求。在一个要求肿瘤学家在每次就诊时解决疼痛、管理痛苦、减轻经济毒性并实际治疗癌症的环境中，在肿瘤学家就诊时增加另一个要求可能会产生很大的阻力。俗话说，一块石头只能流这么多血。将老年学原则整合到肿瘤学中将面临惰性问题，尤其是在繁忙的诊所中。但是，捷径可能不起作用。在资源有限的地区，简单、易于管理的 GA 筛选可能看起来很有吸引力，但结果并不一致。⁷ 此外，资源有限的地区将不具备 GA 可能需要的支持系统，以实现对老年肿瘤患者的最佳护理。

那么重要的问题就变成了：我们如何帮助提高资源匮乏的从业者实施 GA 要求的变革的能力？在不解决这个基本问题的情况下编写指南和鼓励使用 GA 将使 GA 得到充分利用。如果您无法根据测试结果采取行动，为什么要执行它们？在不解决这一基本资源问题的情况下编写指南将使患者的期望落空，并可能使在资源匮乏社区工作的肿瘤学家承担责任。

这并不是说我们应该放弃 GA。远程医疗在肿瘤学的许多方面都取得了成功，从监测到毒性监测，可用于老年病会诊和管理。我们的国家组织（例如，美国临床肿瘤学会和美国癌症协会）可以帮助创建一个由国家认证的老年病学家组成的小组，可用于远程会诊，以解决 GA 的这一方面。然而，这假设有足够的老年病学家愿意并能够满足不断增长的老年人口不断扩大的需求。一个更难解决的问题是如何组建一个多学科团队来实施 GA 建议，包括更广泛地获得职业和物理治疗评估和管理，这需要面对面的实践访问。也许这个人力问题的新解决方案是帮助创建一个新的辅助专业领域，即老年评估实施技术员 （GAIT）。这样的 GAIT 将是非专业人士，他们接受相对简短、集中的培训期，然后获得认证，类似于非专业导航员。这些人可以接受培训进行家庭评估并为安全实施化疗做出必要的改变，并且可以部署到服务不足的农村社区。设计得当，在缺乏经济机会的社区中，这可能是一个有吸引力且有用的职业选择，并且可以为我们老龄化人口所代表的日益增长的需求提供解决方案。 这两个要素，即支持当地医生的远程医疗老年病学和补充远程医疗职业治疗/物理治疗的 GAIT，将需要额外的资金，并且需要实施研究以确定这些增强是否和/或如何改善结果。设想支持这些计划所需的资源似乎令人生畏。但是，忽视问题并不会让它消失。

如果我们想改善 GA 在所有肿瘤学实践中的使用，那么教育肿瘤学家和简化工具是不够的。我们必须帮助资源不足的实践实施基于 GA 的变革，并且我们需要将所需的专业实践引入农村环境。记住服务不足社区的需求对于继续推出的任何和所有指南的成功都至关重要。