Erika Ramsdale, MD
Supriya Mohile, MD
An inspiring case series of fit patients aged 98 and older who recovered from hospitalization for COVID-19, published by Huang et al, reminds us that older age may not be a barrier to recovery.1 On behalf of the Cancer and Aging Research Group, we do not support “ageism” in the care of older adults with cancer, and we will extend the fight against ageism to advocate for older adults with cancer during the COVID-19 pandemic.
In situations of expansive local health emergencies and pandemic, some essential services and resources are in far greater demand than can be supplied. In such events, rationing and intentional resource allocation (and sometimes reallocation) strategies may be required. American medicine has traditionally
functioned by maximizing resource allocation to the patient sitting in front of us, with little need to account for any impact upon society as a whole. The pandemic requires that the underlying philosophical principles of American medicine—particularly prioritizing patient autonomy—are shifting in a way that more closely models European practice, ie, a more utilitarian consideration of the reality of limited resources that must be used in a consistent, transparent, and responsible way to do the most good possible for the greatest number of people (a “distributive justice” priority).2,3
Health systems around the country are mobilizing to design and implement their own responses, and as they do so, they should remain mindful of including not only health-care professionals but also community members, especially those known from the history of medicine to be most at risk of experiencing bias in the process of resource allocation.4 Input from groups that are underrepresented, such as from the Black, Latinx, Asian, sexual/gender minority, and deaf communities in addition to representation for older adults should be sought by groups guiding plans for resource allocation. Clear and accurate communication from leadership within the health system, but also to community partners and the wider public, is essential to ensure full participation and buy-in of any allocation process, which—no matter how aspirational its intent—will remain imperfect.
Approaches to Resource Allocation
Given the data indicating the increased risks for severe illness and mortality in older adults with COVID-19,5,6 it is important to consider whether and how a health system will make unbiased decisions about allocating resources in situations where there are potential shortages. As an example, guidance issued from New York State explicitly prohibits consideration of age in any resource allocation process, following a “most lives saved” approach.7 Other institutions are incorporating the idea of “highest life-years saved” approach, using age, comorbidities, or measures of life expectancy as a “tie-breaker” in cases where multiple patients are designated into the same triage categories.8
Triage based on the Single Organ Failure Assessment (SOFA) score9 is, at the time of this writing, recommended by New York State policy; it has not been extensively validated in COVID-19–positive cohorts or older patients with cancer,10 and it fails to account for preexisting comorbidities or frailty that might limit life expectancy. Additionally, organ dysfunction differentially affects older and younger adults; older and younger adults with the same SOFA scores may not have similar survival rates due to the interactions among age, frailty, and illness that influence prognosis.11
A similar trade-off between the ethical tenets of patient autonomy and distributive justice arises when considering whether to offer cardiopulmonary resuscitation (CPR) to patients who are positive for the COVID-19 virus. Although specific data about postresuscitation survival are not widely available, outcomes from CPR are poor in older adults with COVID-19. CPR is an aerosolizing procedure, and, given the potential for scarcity of available personal protective equipment and the potential risk posed to health-care providers, the traditional American approach to CPR may need to be reconsidered in this setting as an “opt-in” instead of “opt-out” procedure. This would be equivalent to setting a default do-not-resuscitate order for all COVID-19–positive patients, which would represent a sea change in policy and practice for American health care. Given the variation across communities in patient demand, available resources, and institutional policies, we agree with ASCO’s recommendation that oncologists become familiar with their institution’s allocation plans and use best practices for health communication so they can have informed conversations about them with their patients.12
Broader Challenges for Older Patients With Cancer
Ethically, oncologists will face broader challenges in selecting appropriate therapy for their older patients with cancer. Immunosuppressive antineoplastic therapies expose patients to a higher risk of severe or fatal COVID-19 infection, as do repeated trips to medical settings for treatment or toxicity evaluation. Even antineoplastic therapies that are not immunosuppressive can cause adverse effects that weaken an older adult’s physiologic resilience, creating more susceptibility to adverse outcomes from COVID-19. The benefit-to-risk ratio of therapy is therefore shifted at this time, and in particular, therapies for metastatic disease that offer only small incremental benefits to survival should be reconsidered, and a supportive care approach should be prioritized.
“[W]e do not support ‘ageism’ in the care of older adults with cancer, and we will extend the fight against ageism to advocate for older adults with cancer during the COVID-19 pandemic.”— Erika Ramsdale, MD, Supriya Mohile, MD, and colleagues
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This situation also represents a potential shift away from patient autonomy, as some patients and their families express hesitancy to “give up.” For patients with nonmetastatic disease, decisions may be challenging as well, due to deferral of surgeries, considerations of exposure frequency with infusions or radiation treatments, and strict prohibitions on visitors, which will all complicate treatment decision-making and may compromise outcomes in older adults who are “fit.” Telemedicine software should be used where possible, to allow for involvement by family members and other caregivers, and life expectancy should be estimated to assess competing risks for mortality and impact on the overall benefit of curative-intent therapies. Early and frank discussions about goals of care and specific risks and benefits are more necessary than ever.
As COVID-19 poses unparalleled clinical challenges, collaborative and innovative research strategies are required to understand the burden of this disease in older adults with cancer. Early reports of COVID-19 have focused on age as a risk factor for morbidity and mortality. A tremendous body of work over the past 2 decades has demonstrated the pivotal role of geriatric assessment to inform risk-stratification, prognosis, and decision-making in older adults with cancer, beyond chronologic age alone. Similarly, to fully understand the impact of this pandemic on the morbidity and mortality of older adults with cancer, using the lens of aging-associated vulnerabilities rather than age alone will be an essential research strategy.
To understand which older adults with cancer are at greater risk for morbidity associated with COVID-19, data regarding patients’ function, cognition, comorbidities, and other domains of a geriatric assessment will be crucial. As clinicians struggle to meet the clinical demands of caring for patients with COVID-19, any variables collected during this process will need to be both high-yield and feasible, given the constraints of physical distancing and limited staff availability.
Baseline factors such as age, comorbidities, cancer subtype, and stage are likely already being collected in routine oncologic practice. Additional high-yield tools that may identify important geriatric impairments include functional inquiry such as activities of daily living/instrumental activities of daily living along with brief geriatric screening tools. While physical performance measures are known to hold prognostic value, alternative and innovative strategies may need to be developed, allowing for remote monitoring of these variables given the transition to telemedicine visits.
Along with practical and innovative research strategies, multicenter collaborations will likely emerge as a powerful research tool in understanding the effect of COVID-19 on older adults with cancer. Taking into account the prevalence and the morbidity/mortality of COVID-19, large cohorts of patients will be required to understand the independent impact of specific geriatric variables in the outcomes of older adults with cancer. Data-sharing among various sites, both nationally and internationally, will be essential to achieve large sample sizes. Linkages to additional administrative data sets such as the Surveillance, Epidemiology and End Results–Medicare database (which now includes a novel ICD-10 code for COVID-19),13 Center for International Blood and Marrow Transplant Research registry, and various other insurance claim databases will also be important resources for fully understanding the impact of COVID-19 in various disease-specific or treatment-specific subgroups.
“[T]o fully understand the impact of this pandemic on morbidity and mortality of older adults with cancer, using the lens of aging-associated vulnerabilities rather than age alone will be an essential research strategy.”— Erika Ramsdale, MD, Supriya Mohile, MD, and colleagues
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Lastly, to ensure research findings are communicated in a timely manner during this pandemic, novel methods of research dissemination need to be considered. Although the peer-review process remains a robust tool for academic knowledge transfer, it inherently leads to delays in the timely transfer of important information to the appropriate audience. Alternative strategies such as social media and prepublication manuscript sites (eg, medRxiv.com) are emerging as powerful tools to rapidly disseminate research findings in the face of rapidly evolving clinical scenarios facing clinicians during the pandemic. However, individual practitioners will need to carefully evaluate and critically appraise any new information prior to the implementation of such findings.
Challenge of a Lifetime
As we face the challenge of a lifetime, research strategies built on collaborative and inventive platforms will allow us not only to meet the difficulties posed by this pandemic, but may also yield innovative approaches, advancing our knowledge base for caring for older adults with cancer beyond the pandemic.
As we have written this perspective together, we reflect on how the older adults in our lives—our grandparents, parents, relatives, friends, patients, and caregivers—have inspired us and will continue to inspire us to learn from them, and we grieve together for those who have died of this illness.
DISCLOSURE: Dr. Ramsdale reported no conflicts of interest. Dr. Mohile has received research funding from Carevive.
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Adapted from Mohile S, Dumontier C, Mian H, et al: Perspectives from the Cancer and Aging Research Group: Caring for the vulnerable older patient with cancer and their caregivers during the COVID-19 crisis in the United States. J Geriatr Oncol 11:753-760, 2020. The complete article can be viewed at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7172832/pdf/main.pdf.
Members of the Cancer and Aging Research Group include Supriya Mohile, MD, MS, FASCO, University of Rochester Medical Center, Rochester, New York; Clark Dumontier, MD, Brigham and Women’s Hospital, Marcus Institute for Aging Research, Boston; Hira Mian, MD, McMaster University, Ontario, Canada; Kah Poh Loh, BMedSci, MBBCh, BAO, University of Rochester Medical Center; Grant R. Williams, MD, University of Alabama at Birmingham; Tanya M. Wildes, MD, MSCI, Washington University School of Medicine, St Louis; Kevin Boyd, MD, University of Rochester Medical Center; Erika Ramsdale, MD, University of Rochester Medical Center; Sonia Pyne, MD, University of Rochester Medical Center; Allison Magnuson, DO, University of Rochester Medical Center; William Tew, MD, Memorial Sloan Kettering Cancer Center, New York, Heidi D. Klepin, MD, Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, North Carolina; William Dale, MD, City of Hope National Cancer Center, Duarte, California; and Armin Shahrokni, MD, MPH, Memorial Sloan Kettering Cancer Center..
Disclaimer: This commentary represents the views of the author and may not necessarily reflect the views of ASCO or The ASCO Post.