Economic Evaluation of a Geriatric Oncology Clinic

Round 1

Reviewer 1 Report

This is an extremely important manuscript in the setting of geriatric oncology. It demonstrates clearly that geriatric approach of treatment older patients with cancer is cost saving. Other studies have demonstrated that it could reduce toxicity of medical treatments, increase quality of life and even overall survival. But this is the first demonstration of cost effectiveness.

 

However, it is an experimental model (single institution, tertiary cancer center, with a prestigious geriatric oncology team and based in Ontario Canada). But the authors have extensively described the methods (both in the manuscript body and in supplements), the assumptions and they have tested assumption impact in a sensitivity procedure. Moreover, they have reported the numerous limitations that could be considered. Everything is convincing. Tables and figures are useful, particularly the sample case in Box1.

 

I have three suggestions to help the reader (particularly this outside North America) to understand the study:

• If I understand well. Cost is calculated for all individuals. But as it is a retrospective study of clinical charts, there are many lacking information. Therefore, the cost is based on assumptions on general practice or on a consensus with specialists on a particular procedure. Moreover, there are common assumptions for all patients as duration of chemotherapy (6 months). No problem for that because each assumption was discussed and adhoc sensitivity analysis was performed. But this is difficult to the reader to understand this process before having read the manuscript and supplements completely. I suggest adding a short paragraph at the beginning of the manuscript (simple summary? Abstract? Introduction?) to help the reader to understand the principle of the study.
• However, I know the geriatric oncology practice of this team, but there is no reference on the geriatric assessement procedure (it could be a reference on a general procedure in this institution or individual references on tools). What we know in this manuscript (table 2) is:
  1. ECOG PS: it is not discriminant for frailty
  2. VES-13 is a good screening tool of frailty but not a geriatric assessement
  3. Charlson comorbidity index is a useful prognostic index, but it does not help to perform a diagnosis and indicate a treatment. But “clinical judgement” implies MD clinic
  4. IADL : 7 items?
  5. Abnormal Physical Performance: reference?
  6. Medication Optimization Issues: criteria?
  7. Increased Falls Risk: criteria?
  8. Social Supports (Vulnerable or Poor): criteria?
  9. Nutrition, Mood, Cognition: criteria?
  10. Finally, who is performing the geriatric assessement? Probably a nurse. But several aspects require a MD…
• Then, what is the decision-making process to modify the cancer treatment and to propose the geriatric interventions? Is there a geriatric oncology board?

 

Author Response

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Author Response File: Author Response.docx

Reviewer 2 Report

An interesting original article on the economic feasibility of introducing geriatric oncology is submitted for review. I had several questions for the authors:

1) I am interested in the qualifications of specialists who changed the decision on the treatment. Was it one specialist in each case or a panel discussion? Do physicians for geriatric oncology need special training and education?

2) How will the change in the treatment regimen affect the quality of life of patients in the long term (3-5 years)? Since patients were recruited into the study in 2017-2018, these figures can be estimated.

3) This is not only about the economic effect, but more about the fact that the standard type of treatment in the perspective of the remaining 5-10 years of life and the decrease in the quality of life may not be comparable for a particular patient.

Small remarks: you need to add a caption to the figure on page 6.

Author Response

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Author Response File: Author Response.docx