A City of Hope-led panel of experts have used new evidence to update ASCO guidelines on the management of vulnerabilities in older people undergoing cancer treatment, urging clinicians to carry out geriatric assessments (GA) on these patients.
The updated guidelines place a stronger emphasis on the need for GA—an evaluation of an older adult’s physical and cognitive abilities, emotional health, co-existing medical conditions, medications, nutrition, and social circumstances—than the original 2018 guidance, which suggested its use. They also recommend a simple tool with which the assessments can be carried out.
The update was largely triggered by the publication of two randomized controlled trials (GAP70+ and GAIN) which showed that GA-guided management interventions could reduce chemotherapy-related toxic effects in older adults with cancer, explains William Dale M.D. Ph.D., director of the Center for Cancer and Aging at City of Hope, an academic cancer research and treatment organization. Reduced toxicity can then lead to improved adherence and treatment completion rates without impacting survival.
In addition, GA-guided management improves cancer care satisfaction among older patients and family members and reduces both over-treatment of frail patients and under-treatment of fit patients.
“Now that we have intervention level data, it justifies saying anybody over the age of 65 really ought to have assessments done,” says Dale, who co-led the ASCO task force for both the initial and updated guidelines.
The first recommendation states: “All patients with cancer age 65 years and over with GA-identified impairments should have GA-guided management (GAM) included in their care plan. GAM includes using GA results to (1) inform cancer treatment decision-making, and (2) address impairments through appropriate interventions, counseling, and/or referrals.” This reflects the original guideline but now includes an amendment to cover patients receiving all systemic therapy, rather than just chemotherapy.
The second part of the update addresses some of the barriers to the implementation of GA that Dale and colleagues identified during a review of relevant publications. One study showed that just 13% of the 349 oncologists surveyed used GA for all their older patients; 60% did not use a formal GA for any of their geriatric patients; and 19% reported that they were not aware of any validated GA instruments.
The most common barriers to GA use were uncertainty about which GA instruments to use and the lack of training in or knowledge of GA assessment tools. Other barriers included lack of time and a lack of adequate clinical support to implement routine GA.
Given this information, the Older Adults Task Force of ASCO’s Health Equity and Outcomes Committee identified the need for a simplified GA tool to help increase uptake. The Task Force worked together with the Cancer and Aging Research Group to identify essential GA domains from multiple validated GA tools.
This resulted in updated recommendation 2.1: “A GA should include high priority aging-related domains known to be associated with outcomes in older patients with cancer to include assessment of physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support.”
And updated recommendation 2.2: “The Panel recommends the PGA [Practical Geriatric Assessment] as one option for this purpose.”
Dale explained to Inside Precision Medicine that “the creation of this new practical geriatric assessment was a response to making it accessible to a community oncologist, for example, by making it precise and concise enough to be done within current clinic flow that’s reasonable for people who are busy.”
He said that the PGA takes around 10 minutes to complete and 85% of it can be carried out by patients either at home or while they are in the clinic. Only two domains—a mini cognitive assessment and a gait speed test—need to be carried out by someone else and that person does not necessarily need to be a physician or a nurse practitioner.
The guidelines also provide two suggestions for clinicians who may not be able to implement the PGA: A chemotherapy toxicity-specific calculator and a 3-minute screening test (Geriatric-8) that helps identify higher-risk patients who really need to complete the full PGA.
Dale is optimistic that the new guidelines will increase the uptake of GA in older patients with cancer but acknowledges that clinicians need time to connect their resources. He is also hopeful that insurers will see the benefit of the PGA and make it reimbursable, and that patients and policy advocates become aware of the tool and push for its use.
Increasing the uptake of GA will ultimately improve personalized medicine for older patients with cancer by creating an integrated and individualized plan that informs treatment selection and can incorporate shared decision-making.
