Updated ASCO guideline reiterates value of geriatric assessment with guided interventions
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ASCO has issued updated guidelines on evaluation and management of vulnerabilities in patients aged 65 years and older prior to initiating systemic cancer treatment.
The updated recommendations, published in Journal of Clinical Oncology, emphasize the need to use a validated geriatric assessment to guide treatments.
A validated geriatric assessment examines an older adult’s physical and cognitive abilities, emotional well-being, coexisting medical conditions, medications, nutrition and social situation. These assessments often lead to de-escalation or reduction of some cancer treatments to minimize adverse events and an increase in supportive care interventions to improve quality of life without compromising survival.
“One thing we want everyone to know is that this is not difficult,” William Dale, MD, PhD, director of the Center for Cancer and Aging at City of Hope, told Healio. “This is not harder than most of the things we do for patients who have cancer, who come in and need biopsies, lab tests, imaging studies and examinations. We’ve also found, through a study called COACH, that patients’ and families’ satisfaction with the cancer care they receive goes up when we do these kinds of assessments. This is personalized care that will improve the experience of patients.”
Dale spoke with Healio about the impetus for this update, its key points and the potential for these new recommendations to improve care for older patients with cancer.
Healio: What motivated this update to the guidelines?
Dale: The original guideline ASCO released in 2018 was influenced by two events.
Some large, randomized controlled trials of geriatric assessment with management, presented at ASCO as oral sessions, were well-received a few years ago and have been published recently. In particular, two randomized trials, one in The Lancet and one in JAMA Oncology, assessed geriatric assessment with management (GAM) — the GAIN study and the GAP70+ study. Those studies came to the same conclusion, that GAM was associated with a 10% to 20% decrease in the primary outcome of chemotherapy toxicity, with no reduction in survival probability. That means it achieved the same survival but with less toxicity and better quality of life. That led to ASCO recognizing the need to update these guidelines and making it a priority.
Healio: What are the updates to the guidelines?
Dale: The guidelines are based on an expert panel’s review of 15 studies. First, they state that the evidence is now strong enough to recommend GAM testing as a standard of care for any patient aged older than 65 years who is on systemic therapy. We recommend a new tool called the practical geriatric assessment for evaluating these patients prior to starting therapy. The third big area is that we recognize the need for appropriate supportive care intervention follow-ups for any patient getting any systemic therapy, including immunotherapy and others. That is new — previously, we had only recommended this for patients undergoing chemotherapy.
Healio: A recent survey of oncologists showed 60% did not use a formal geriatric assessment for any of their older adult patients. Why do you think geriatric assessments are so underused?
Dale: We have done large follow-up studies talking to oncologists, as well as conducted focus groups through ASCO, trying to determine the challenges to doing these assessments. It has fallen into two buckets of perceived challenges. First, although clinicians recognize that these assessments are important, some have said they don’t have the knowledge or training to use these tools. One of the goals of the practical geriatric assessment was to make it really concise and straightforward.
The other concern is that these busy clinicians who are already doing so much might feel that they can’t do this with their current resources. Again, we have tried to boil these assessments down to a tool that can be done easily and quickly with patients. Eighty percent of the practical geriatric assessment can be done as a report from a patient or family. It can be done without clinic personnel having to administer it. They can do it online, on the phone, or before going to the clinic. When they get to the clinic, there is a summary sheet called an Action Chart that the clinician can look at and digest quickly. They can have a nonphysician administer a physical performance test walking, standing and balancing, as well as a simple cognitive assessment that can’t be done by self-report. We have taken clinicians’ two main concerns, boiled them down into this practical geriatric assessment, and we’re providing additional tools, a training video and some other information to help.
Healio: What do you hope will be the long-term impact of this update?
Dale: When the research is conducted, it’s done in a high-intensity way at academic centers, and that sets a high bar. What we really want in practice is for this information to be seen and read by community providers outside of large cancer centers, because that is where 80% of older patients with cancer are seen. We hope these practices will see this information, integrate it into their workflow, and use it to benefit these patients and families.
Another big goal would be to have older patients and families themselves hear the message and wonder why these concerns aren’t being addressed in their cancer management. We want to set them up for advocacy. There is a push to get some policy changes in place, to establish a structure where if an older patient comes into the clinic, that information will be there. We want this to become a routine part of care. We also want to start to build infrastructure and, frankly, attach reimbursements to this important practice that will now essentially be a standard of care, based on the evidence. Our hope is that in the future, clinicians can talk to patients about this and address their personalized concerns in the same way we do precision medicine for their genetics.
Healio: You mentioned potentially modifying medication dosage based on a patient’s age. What other aspects of supportive care medicine might be personalized based on the patient’s profile?
Dale: In many ways, this approach would be the same as the approach for patients with cancer of any age. We would do a very careful assessment before starting treatment of the essential domains and the challenges in these areas. The classics for what we’re doing here are functional status, cognition, emotional problems, nutrition, polypharmacy, social support and comorbidities. Each of these domains then leads to a potential course of action. If there’s a problem with polypharmacy, for example, we would need to go through the patient’s medications and start to pare it down. That’s good practice in any setting for any patient. Supportive care medicine is the right group of providers to address all of these concerns — mood issues, symptom management, goals of care conversation. It’s the marriage of all of this for the patient population aged older than 65 years.
References:
- Dale W, et al. J Clin Oncol. 2023;doi:10.1200/JCO.23.00933.
- Li D, et al. JAMA Oncol. 2021;doi:10.1001/jamaoncol.2021.4158.
- Mohile SG, at al. JAMA Oncol. 2020;doi:10.1001/jamaoncol.2019.4728.
- Mohile SG, et al. Lancet. 2021;doi:10.1016/S0140-6736(21)01789-X.
For more information:
William Dale, MD, PhD, can be reached at City of Hope, 1500 E. Duarte Road, Duarte, CA 91010; email: wdale@coh.org.
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