All Adult Oncologists Are Geriatric Oncologists
The data developed over the past few years have overwhelmingly favored geriatric assessment as part of the routine care for older patients with cancer. It has become the standard of care. ASCO has recently published a Practical Geriatric Assessment to aid in the implementation of this vital evaluation tool.1 For patients to fully benefit from this evaluation, a clear understanding of the issues among physicians, patients, and caregivers is crucial. This understanding encompasses therapeutic options and care goals.
A successful therapeutic partnership in medicine hinges on effective communication between physicians and patients. This is especially vital in the treatment of cancer among older patients. This largest group of patients with cancer typically faces more complex issues. This is the result of frequent issues with multiple comorbidities, polypharmacy, social support, and possibly cognitive impairment. The goals of treatment are often much different from those for a younger patient. Treatment modifications may be necessary based on these issues. The ability to effectively treat cancers in older patients has improved over the recent decades.
Big Benefits but Little Implementation
In the past few years, there has been a large increase in publications documenting the benefit of geriatric assessment and geriatric assessment–guided management. The benefits comprise reduced toxicity, maintained or improved quality of life, and enhanced overall survival.2-5 Many of these studies are randomized trials with large numbers of patients and sufficient power to make a very strong case for its benefits. Despite this, the implementation of geriatric assessment has been slow. There have been complaints about a lack of education, time-consuming to conduct, and difficulties in interpreting and implementing recommendations. These issues, I feel strongly, are moot.
Many organizations, including ASCO, SIOG (International Society of Geriatric Oncology), ESMO (European Society for Medical Oncology), ACCC (Association of Community Cancer Centers), and others, have provided extensive educational materials to adequately address these issues. Most of the assessment is self-administered by the patient and family; the functional components are done by the office staff, which can be performed while taking vital signs.6-11 The components of the geriatric assessment are being incorporated into electronic health record platforms.
“The data developed over the past few years have overwhelmingly favored geriatric assessment as part of the routine care for older patients with cancer.”— STUART M. LICHTMAN, MD, FACP, FASCO
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ASCO updated its 2018 geriatric assessment guideline in July 2023 by recommending use of the Practical Geriatric Assessment tool. This tool makes this evaluation more direct and user-friendly. No more excuses!
The implementation of these assessments is critical for routine patient care and clinical trials. The aging of the population is self-evident and is affecting various aspects of society including medicine. These older individuals will be most patients for the foreseeable future, our most important stakeholders. We must adapt to their needs.
Support From Clinical Trials
As clinicians, we must adequately discuss these issues with our patients and their families. How can this be accomplished? Several clinical trials have shed light on this issue.
Mohile et al conducted a cluster-randomized trial through the NCI Community Oncology Research Program.3 Sites were randomly assigned to conduct a geriatric assessment vs routine care. There were more aging-related conversations in the intervention group. Caregivers in the intervention group were more satisfied with communication after the visit. They concluded that including the geriatric assessment in clinical visits improved patient-centered and caregiver-centered communication about aging-related issues.
Another cluster-randomized trial evaluated whether a geriatric assessment intervention could reduce serious toxic effects in older patients with advanced cancer receiving high-risk treatment.12 The primary outcome was the proportion of patients who had any grade 3 to 5 toxicity based on the Common Terminology Criteria for Adverse Events (CTCAE) version 4. A total of 718 patients were enrolled, with a mean age of 77.2 years. The patients were randomly assigned to the intervention group, where oncologists received a tailored geriatric assessment summary and management recommendations or provided usual care. The results showed that fewer patients in the intervention group experienced toxic effects, reduced fever incidence, and more discontinued medications.
PRACTICAL GERIATRIC ASSESSMENT TOOL
The Practical Geriatric Assessment, or PGA, is a concise and complete tool for assessing older adults with cancer in any setting. The PGA tool was designed to address the barriers to implementing geriatric assessment in clinical practice, making it simpler for oncologists to assess high-priority, age-related issues associated with older adults with cancer.
In the cancer clinical trial area, the Patient Centered Outcomes Research Institute has helped to develop the PRO-CTCAE measurement. The impetus was to capture toxicities and adverse events that were not assessed by the standard CTCAE used in trials. The PRO-CTCAE was to be used as a companion instrument to the CTCAE. It includes 124 items representing 78 symptomatic toxicities. It can be used to supplement clinical assessments of tumor response and toxicity. The instrument can help assess the tolerability of treatment regimens. It bridges the gap between physician and patient symptom reports by evaluating frequency, severity, and interference with daily life. This latter category is particularly important and patient-centric; it is best for subjective symptoms such as nausea and painful neuropathy. A recently published study evaluated PRO-CTCAE and a geriatric assessment intervention. A geriatric assessment also resulted in fewer patients reporting grade 2 or higher symptomatic toxicity during treatment.13
These analyses address important gaps in understanding the symptom experience of older adults with advanced cancer receiving systemic therapy. Gap70+ is the first nationwide cluster-randomized trial to demonstrate that a geriatric assessment intervention may decrease patient-reported symptomatic toxicities.3 The findings establish a high baseline symptom burden and a significant prevalence of developing new or worsening asymptomatic toxicities over 6 months. It is the first study to systematically describe baseline symptom burden as measured by the patient-reported outcomes version of CTCAE -(PRO-CTCAE) in older adults with advanced cancer. This study is one of a very few to focus on patient-reported symptomatic toxicities as an outcome of a randomized controlled trial. Previously, PRO-CTCAEs were evaluated in trials examining the efficacy of therapeutic agents in advanced prostate and non–small cell lung cancers. The results reinforce the feasibility of collecting PRO-CTCAE data longitudinally from an older adult with advanced cancer and aging-related conditions.
Importance of Assessing Symptomatic Adverse Events
Why is this type of assessment and communication tool important? The assessment of symptomatic adverse events may be of increasing importance as we enter a new therapeutic era in malignant hematology and oncology. An expanding number of mechanistic drug classifications—such as targeted therapy and immunotherapies—have produced a more diverse range of potential toxicities. Many of the molecularly targeted agents are administered orally, often require prolonged treatment duration, and may produce less severe—but more chronically bothersome—side effects.
A systematic longitudinal assessment of relevant symptomatic adverse events using a patient-reported outcome measure may provide informative patient-centered data on symptomatic side effects that may otherwise have been considered low grade by standard clinician reports. In 2022, Watson et al evaluated the PRO-CTCAE in phase I trials. The study showed that interference scores may reflect the most accurate representation of the true impact of an intervention on patients’ quality of life, which is particularly relevant in early-phase trials.14
Oncologists now have the tools to evaluate all our older patients. These tools are validated and have been confirmed in prospective randomized trials. They are applicable to patients in the clinical trial setting and in routine office practice. The Practical Geriatric Assessment should be conducted on patients before making a final treatment decision. Although clinical judgment is essential, it should not be relied upon in isolation.
Editor’s Note: An expert panel1 recommends the Practical Geriatric Assessment should be used to identify vulnerabilities or impairments not routinely captured in oncology assessments for all patients older than age 65 with cancer as one option for this purpose. To view the Practical Geriatric Assessment, visit https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf. Further, to learn how to use the Practical Geriatric Assessment and what to do with the results, see these videos https://youtu.be/jnaQIjOz2Dw and https://youtu.be/nZXtwaGh0Z0. Additional information is available at www.asco.org/supportive-careguidelines.
DISCLOSURE: Dr. Lichtman reported no conflicts of interest.
1. Dale W, Klepin HD, Williams GR, et al: Practical assessment and management of vulnerabilities in older patients receiving systemic cancer therapy: ASCO guideline update. J Clin Oncol 41:4293-4312, 2023.
2. Mohile SG, Dale W, Somerfield MR, et al: Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 36:2326-2347, 2018.
3. Mohile SG, Mohamed MR, Xu H, et al: Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): A cluster-randomised study. Lancet 398:1894-1904, 2021.
4. Mohile SG, Velarde C, Hurria A, et al: Geriatric assessment–guided care processes for older adults: A Delphi consensus of geriatric oncology experts. J Natl Compr Canc Netw 13:1120-1130, 2015.
5. Sedrak MS, Freedman RA, Cohen HJ, et al: Older adult participation in cancer clinical trials: A systematic review of barriers and interventions. CA Cancer J Clin 71:78-92, 2021.
6. Hurria A, Lichtman S, Priyadarshi S, et al: Feasibility of a self-administered geriatric assessment tool for older patients with cancer. 2006 ASCO Annual Meeting. Abstract 18519.
7. Hurria A, Lichtman SM: Clinical pharmacology of cancer therapies in older adults. Br J Cancer 98:517-522, 2008.
8. Hurria A, Lichtman SM, Gardes J, et al: Identifying vulnerable older adults with cancer: Integrating geriatric assessment into oncology practice. J Am Geriatr Soc 55:1604-1608, 2007.
9. Hurria A, Mohile S, Gajra A, et al: Validation of a prediction tool for chemotherapy toxicity in older adults with cancer. J Clin Oncol 34:2366-2371, 2016.
10. Hurria A, Mohile S, Lichtman S, et al: Geriatric assessment of older adults with cancer: Baseline data from a 500-patient multicenter study. 2009 ASCO Annual Meeting. Abstract 9546.
11. Hurria A, Togawa K, Mohile SG, et al: Predicting chemotherapy toxicity in older adults with cancer: A prospective multicenter study. J Clin Oncol 29:3457-3465, 2011.
12. Mohile SG, Mohamed MR, Culakova E, et al: A geriatric assessment intervention to reduce treatment toxicity in older patients with advanced cancer: A University of Rochester Cancer Center NCI community oncology research program cluster randomized clinical trial. 2020 ASCO Annual Meeting. Abstract 12009.
13. Culakova E, Mohile SG, Peppone L, et al: Effects of a geriatric assessment intervention on patient-reported symptomatic toxicity in older adults with advanced aancer. J Clin Oncol 41:835-846, 2023.
14. Watson GA, Veitch ZW, Shepshelovich D, et al: Evaluation of the patient experience of symptomatic adverse events on phase I clinical trials using PRO-CTCAE. Br J Cancer 127:1629-1635, 2022.
Dr. Lichtman is a consultant for UR Medicine’s Wilmot Cancer Institute Geriatric Oncology Research; Attending Physician (retired) at Memorial Sloan Kettering Cancer Center, Commack, New York; Professor of Medicine at Weill Cornell Medical College, New York; and Past President of the International Society of Geriatric Oncology (SIOG).
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.