Personalized interventions reduce chemotherapy-related toxicity among older adults
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Use of personalized interventions significantly reduced grade 3 or higher chemotherapy-related toxicity among patients with cancer aged 65 years or older, randomized trial results showed.
The findings support widespread implementation of a multidisciplinary geriatric assessment-driven intervention (GAIN) for older adults receiving chemotherapy, researchers concluded.
“By integrating [GAIN] into the care of older adults with cancer, we can decrease chemotherapy-related toxicity and hopefully allow older adults to continue to do the things they enjoy in life by tolerating therapy better,” Daneng Li, MD, assistant professor in the department of medical oncology and therapeutics research at City of Hope, told Healio.
“The impact of widespread implementation of GAIN into oncology clinical practice is really to provide a more patient-centric form of precision medicine that allows us to detect each patient’s own vulnerabilities,” Li added. “Thereby, GAIN allows us to better care for our older adults with cancer effectively.”
Prior research showed GAIN improves patient-centered outcomes; however, its effect on chemotherapy-related toxic effects had not been established.
“Our previous research had demonstrated that, by performing an outpatient cancer-specific geriatric assessment, physicians and care teams were able to better detect vulnerabilities and predict chemotherapy-related toxicity among older adults with cancer receiving chemotherapy,” Li said. “The current GAIN clinical trial was the next pivotal step to determine if offering geriatric assessment-driven interventions can actually help older adults reduce chemotherapy-related toxicity.”
Li and colleagues conducted a randomized clinical trial to evaluate whether GAIN could reduce chemotherapy-related toxic effects among older adults with cancer.
The trial included 613 people (median age, 71 years; range, 65-91; 59% women) with cancer treated at an NCI-designated cancer center from 2015 to 2019. All study participants were starting chemotherapy for solid malignant neoplasms, the most common of which were gastrointestinal (33.4%), breast (22.5%), lung (16%), genitourinary (15%) or gynecologic (8.9%) cancers. The majority (71.4%) of study participants had stage IV disease.
Researchers followed patients until chemotherapy completion or until 6 months after chemotherapy initiation.
Researchers randomly assigned patients 2:1 to GAIN or standard of care.
In the GAIN group, a geriatrics-trained multidisciplinary team that included an oncologist, nurse practitioner, nutritionist, physical/occupation therapist, social worker and pharmacist reviewed geriatric assessment results and incorporated interventions based on prespecified thresholds incorporated into specific geriatric assessment domains.
In the standard-of-care group, treating oncologists received geriatric assessment results for consideration.
Grade 3 or higher chemotherapy-related toxic effects served as the primary outcome. Secondary outcomes included advance directive completion, ED visits, unplanned hospitalizations, average length of stay, unplanned hospital readmissions, chemotherapy dose modifications and early discontinuation.
Researchers analyzed OS up to 12 months after chemotherapy initiation.
Li and colleagues reported a significantly lower rate of grade 3 or higher chemotherapy-related toxic effects in the GAIN group (50.5% vs. 60.6%), equating to a difference of 10.1 (95% CI, –1.5 to –18.2) percentage points.
A significantly higher percentage of patients in the GAIN group completed advance directives (28.4% vs. 13.3%; P < .001).
“The completion of advance directives is very important to older adults with cancer given that it allows the patients to reflect on their own desires of care should they become incapacitated,” Li told Healio. “For patients who did not have an advanced directive on file at the start of the study, GAIN led to a significant increase in the number of patients completing an advanced directive by the end of the study, which truly helps with advanced care planning by allowing patients to voice their wishes with care.”
Results showed no differences in ED visits, unplanned hospitalizations, length of stay, unplanned readmissions, chemotherapy dose modification or discontinuation, or OS.
“Prior and recent randomized clinical trials in older adults with various cancer types have really only been able to show a reduction in toxicity during treatment when initial dose reductions in chemotherapy treatment occurred,” Li said. “The current GAIN study is truly unique in that it is the only large randomized clinical trial to show a significant reduction in chemotherapy-related toxicity without any significant differences between the treatment and control groups with regard to the number of chemotherapy agents received, primary myeloid growth factor prophylaxis and initial dose reductions. This really highlights the positive effects of multidisciplinary geriatric-driven intervention in reducing chemotherapy-related toxicity rather than just chemotherapy modifications or dose reductions leading to this positive outcome.”
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