ASCO has updated a guideline on the practical assessment and management of age-associated vulnerabilities in older patients receiving systemic cancer therapy.1 Among the updates, the guideline adds more detail to domains that should be evaluated in geriatric assessments (GAs) and expands patient populations who should be receiving GA-guided disease management based on treatment.
Updated Recommendations
Similar to the 2018 ASCO guideline on vulnerabilities in older adults receiving systemic cancer therapy,2 the most recent 2023 guideline update endorses the use of management guided by a geriatric assessment in all patients with cancer aged 65 and older who have GA-identified impairments.
However, Expert Panel Co-Chair Heidi D. Klepin, MD, of Wake Forest University School of Medicine, said that one of the key differences with the new guideline is that the recommendations are “broader” when compared with the 2018 iteration. “They’re more specific, they incorporate actions, they’re based on clear evidence of the benefits of geriatric assessment for patients,” she explained, “but they’re broader than the initial guidelines from the standpoint of extending the recommendation for a GA to be conducted for patients receiving varied types of systemic therapy and not just restricted to chemotherapy.”
In contrast to the 2018 guideline, which recommends GA-guided management of disease in patients receiving chemotherapy, the new guideline recommendation encompasses all older adults receiving systemic therapy comprising chemotherapy, targeted therapy, or immunotherapy.
Heidi D. Klepin, MD
Supriya G. Mohile, MD
Expert Panel Co-Chair Supriya G. Mohile, MD, of the University of Rochester Medical Center, added that the new guideline provides improved clarity on what works to improve outcomes in older, vulnerable patients with cancer. “In the first guideline, we knew that geriatric assessment was important to help us identify older adults who are at risk, but now we know what to do, because the interventions work, and we tested the interventions in trials,” she said.
Additionally, the guideline update recommends a GA that includes high-priority, age-related domains that are associated with outcomes in older patients with cancer. They include evaluation of comorbid conditions, emotional health, nutrition, physical and cognitive function, polypharmacy, and social support.
The 2023 guideline panel recommends the Practical Geriatric Assessment as the GA tool clinicians can use to predict outcomes in older patients receiving systemic cancer therapy. According to the guideline panel, findings from the tool may better inform cancer treatment decision-making and help clinicians address impairments with appropriate counseling, interventions, and/or referrals.
A recommendation that aligns with the 2018 guideline includes the use of either the Schonberg or Lee Index to estimate life expectancy of 4 years or more. Furthermore, the 2018 guideline and the 2023 updated guideline both recommend that clinicians apply GA findings to construct an individualized and integrated management strategy for patients; the strategy not only informs treatment selection by estimating adverse outcome risks, but also identifies nononcologic issues that may be receptive to interventions.
Data Spur New Recommendations
According to Expert Panel Co-Chair William Dale, MD, PhD, of City of Hope, the updated recommendations are centered around data from two large, randomized trials. The GAP70+ (Geriatric Assessment for Patients 70 years and older) and GAIN (Geriatric Assessment-Driven Intervention) trials assessed the effects of GAs and GA-guided management on reducing serious chemotherapy-related toxic effects in older adults with cancer.3,4 The findings from these trials, Dr. Dale said, showed that the use of GAs “and acting on them with specific interventions, could lower toxicity for chemotherapy by 20% or more as its primary outcome.”
William Dale, MD, PhD
One study, according to Dr. Dale, showed that the use of GAs in these older patients receiving systemic therapy was associated with reduced falls and polypharmacy. In the GAIN study, researchers also found that advanced directive completion went up more than 25% with the use of GAs in this population.
Guideline in Practice
Improving uptake of the recommendations is critically important to ensure optimal outcomes for patients, Dr. Dale said. “When we first put out the original guidelines, we saw there wasn’t a lot of uptake of it,” he said. The development of the Practical Geriatric Assessment has “really streamlined” the process of GAs, he added, helping to overcome barriers to incorporating these assessments into routine clinical practice.
Dr. Klepin added that although there are some barriers to the uptake of GAs, the guideline panel hopes the information provided in the new updated guideline will serve to educate providers on many of the key outcomes that are positively impacted using GA.
“Things like decreasing treatment toxicity, improving decision-making and communication, and improving patient and caregiver satisfaction have all been shown to be positively impacted with conduct of GA for older patients,” Dr. Klepin said. “We hope that providing a practical GA to guide management strategies will empower clinicians and providers to incorporate the assessments in their workflow, both in academic settings, where we know some centers have already done this, but also more routinely in community practice..., [and] even low-resource community settings.”
REFERENCES
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. July 17, 2023 (early release online).
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. Li D, Sun CL, Kim H, et al: Geriatric assessment-driven intervention (GAIN) on chemotherapy-related toxic effects in older adults with cancer: A randomized clinical trial. JAMA Oncol 7:e214158, 2021.
Originally published in ASCO Daily News. © American Society of Clinical Oncology. ASCO Daily News, August 9, 2023. All rights reserved.
