Expert panel updates cancer and aging guidelines

In an effort to improve treatment outcomes and quality of life for older adults with cancer, researchers from City of Hope, one of the largest cancer research and treatment organizations in the United States, and colleagues across the country today released updated guidelines by the American Society of Clinical Oncology (ASCO) outlining the need to assess and manage vulnerabilities in patients aged 65 and older prior to prescribing chemotherapy, targeted therapy and/or immunotherapy.

The updated recommendations, published in the Journal of Clinical Oncology, urge the clinical use of a validated geriatric assessment (GA)—defined as an evaluation of an older adult's physical and cognitive abilities, emotional health, co-existing medical conditions, medications, nutrition and social circumstances—to guide treatments. The resulting modifications often result in de-escalation or cutting back on some therapies, which reduces side effects, improves quality of life without hurting survival odds, and lowers health care costs.

"Studies continue to prove that patients and families win when care teams ask older adults with cancer the right questions at the outset. A GA can change care choices without making cancer therapy less effective. It's a form of precision medicine: more appropriate dosing of medicine, more supportive care interventions, fewer side effects, higher quality of life and the same great cancer care results. It's a winning formula for patients, families, providers and the system," said William Dale, M.D., Ph.D., lead author of the updated ASCO guidelines and City of Hope's George Tsai Family Chair in Geriatric Oncology in Honor of Arti Hurria, M.D.

While the first-ever geriatric oncology guideline was issued five years ago with input from City of Hope experts, a recent survey of oncologists revealed that only 13% of oncologists in community clinics used a GA for all of their older patients. An alarming 60% of oncologists said they did not use a formal GA for any of their older adult patients. (Advanced age is the most important risk factor for cancer: Half of people first diagnosed with cancer are over 66 years old, according to National Cancer Institute data.)

Older adults who receive GA-guided management are more likely to complete cancer treatment and maintain their independence. Its use improves cancer care satisfaction among older patients and family members, as well as reduces both overtreatment of frail patients and undertreatment of fit patients.

A GA is just one of the many supportive care assessments and specialized services City of Hope, a national leader in supportive care medicine, offers patients.

The updated ASCO cancer and aging recommendations detail an expert panel's review of 26 studies from randomized clinical trials, cohort studies and systematic reviews. The guidelines recommend these best practices:

1. All cancer patients 65 or older should receive a GA and potentially have their cancer therapy modified or receive supportive care interventions to address any identified deficits. Referrals may include geriatrics expertise, counseling, physical therapy, social work assistance, nutritional support and more.
2. Essential aspects of patients, such as physical and cognitive ability, emotional health, nutrition and social circumstances, must be included in the GA. Research indicates that survival benefits are preserved and quality of life is improved when patients receive appropriate GA-guided management.
3. A chart called the Practical Geriatric Assessment is a new tool to help care teams perform GA-guided care.

Among the reasons why a GA is often not performed is that it seems overly burdensome to doctors, especially for oncologists in the community setting as they often have a higher case load. Other obstacles include physicians not knowing that it exists or how to use it, a perceived lack of resources, poor documentation, and system barriers.

"We realized the GA needed to be shorter, more concise and very practical," Dale said. "So, we developed the Practical Geriatric Assessment. It boils the science down to its essence and is easy to use. About 80% of it are questions for patients that can be completed without assistance from care staff. The remaining information about cognition and physical abilities, however, need to be captured in clinic by trained personnel."

Tanyanika Phillips, M.D., M.P.H., is a co-author of the updated guideline, as well as a medical oncologist and hematologist at City of Hope | Antelope Valley. Many residents who live near this clinical network site in Northern Los Angeles are challenged with housing, food insecurity and mental health issues.

"In my experience, if you don't do a geriatric assessment, the patient pays for it later," Phillips said, sharing that if care is prescribed without accurate health information, the result could be serious side effects or even hospitalization, which could lead not only to more costly care but also cancer treatment outcomes that are not the best for patients.

"In a general visit, patients often will say they feel well and are fine because they're incentivized to answer in the affirmative and move forward with treatment, added Phillips, assistant clinical professor in City of Hope's Department of Medical Oncology & Therapeutics Research. "Place this same patient in a different environment where they are answering geriatric assessment questions, and they may be more forthcoming and detailed about their lifestyle and abilities. This candor will help physicians prescribe the most appropriate care for that individual based on their circumstances."