ASCO States That All Older Adults With Cancer Should Receive Geriatric Assessments

William Dale, MD, PhD

All patients with cancer who are 65 years or older should receive a geriatric assessment (GA) to identity vulnerabilities or impairments that ordinarily are not caught with routine oncology assessments, according to an American Society of Clinical Oncology (ASCO) guideline update.

Findings from the GA should be used to inform cancer treatment-making and boost appropriate interventions, counseling, or referrals.¹

The GA should query about high priority aging-related domains, such as physical and cognitive function, comorbid conditions, polypharmacy, nutrition, and social support. The expert panel behind the recommendation supports the Practical Geriatric Assessment (PGA) as a GA tool that addresses these concerns and that can feasibly be integrated into clinical practice.

The recommendation from the panel reiterates the overarching recommendation published in the prior guidelines that GA should be used for all older patients. A total of 26 publications, published between January 2016 and December 2022, support the recommendation. The body of evidence includes recently published data from randomized control trials (RCTs) demonstrating that patients achieve significantly improved clinical outcomes following systemic therapy informed by GA-identified deficits.

Patients who are included in this recommendation are those who are receiving systemic therapy, including chemotherapy, targeted therapy, and/or immunotherapy.

“It is essential to do a GA for older adults with cancer to provide appropriate care when considering systemic therapy,” William Dale, MD, PhD, physician and George Tsai Family Chair in Geriatric Oncology at City of Hope, and co-panelists, wrote in the guideline update. “When GA is compared with SOC, it clearly leads to significantly less chemotherapy toxicity and improves adherence to chemotherapy. It also improves important patient-centered outcomes and communication, particularly patient and caregiver satisfaction with care, communications about aging concerns, and completion of advanced directives.”

Learn more: Leana Cabrera Chien and William Dale Underscore The Value of Geriatric Assessments in Optimizing Cancer Care

Two large RCTs served as the catalyst for the current update. These 2 trials were the GAP70+ trial (NCT02054741) and GAIN trial (NCT02517034), both of which demonstrated that GA-informed treatment led to reduced chemotherapy-related toxicities in older patients with cancer. ^2,3

GAP70+ assessed patients with solid tumors or lymphomas who were 70 years or older and whose diseases did not have any known curative regimens. Patients were randomly assigned 1:1 to either receive a tailored geriatric assessment (n = 349), with management recommendations provided afterword, or usual care (n = 369), with no geriatric assessment or individualized care recommendations. Over a 3-month span, 51% of patients (n = 177) in the intervention group developed grade 3 or worse AEs. In comparison, 71% of patients who received usual care developed grade 3 or worse AEs (relative risk, [RR]; 0.74; 95% CI, 0.64-0.86; P = .001). The findings were published in The Lancet in 2021.²

Similarly, the GAIN trial, whose findings were published in JAMA Oncology in 2021, enrolled 605 patients with cancer who were 65 years or older. These patients were diagnosed with a solid malignant neoplasm and were about to start a new chemotherapy regimen. All patients received evaluation with a GA. However, patients were randomly assigned 2:1 to either receive the GA intervention (n = 402) or standard of care (n = 203). Those who were in the intervention group had a multidisciplinary team review their GA results and tailor their care based on the findings. The multidisciplinary team included an oncologist, nurse practitioner, social worker, physical/occupation therapist, nutritionist, and pharmacist. For patients in the SOC arm, the treating oncologist evaluated the GA results.³

Ultimately, the incidence of grade 3 or worse chemotherapy-related AEs was 50.5% (95% CI, 45.6%-55.4%) among patients in the intervention group and 60.6% (95% CI, 53.9%-67.3%) among in the SOC arm. Investigators concluded that the 10.1% reduction was clinically significant (95% CI, –1.5 to –18.2%; P = .02).³

Of note, a total of 15 publications met the inclusion criteria for the guideline update and served as an evidentiary basis to support the clinical benefit of GA in older patients. This included 9 primary reports of RCTs and 4 secondary analyses of RCTs. One publication was a systemic review of GA-related studies and 1 was a systematic review of GA studies with a meta-analysis. A range of different end points were assessed across the 9 RCTs, including chemotherapy completion rates, grade 3-5 AE occurrences, quality-of-life outcomes, functional impairment, overall survival, weight loss, and patient satisfaction about aging-related concerns.¹

Eleven publications were assessed to identify the optimal GA tool. These included 7 clinician surveys, 1 systemic literature review, and 3 narrative literature reviews.These articles measured or addressed barriers to implementing GA in oncology practice. The literature suggests that time restraints, inadequate staffing or financial support, and a lack of relevant knowledge or training, are key factors in the inconsistent GA uptake since the 2018 recommendation.¹

To that end, the panel suggests the PGA to promote GA uptake. They state that the PGA is the most concise version of the GA that is both evidence-based and aligned with the available data. They also suggest that it is a less burdensome tool compared to other common interventions in oncology care. To address barriers to in relevant knowledge and training, the ASCO Older Adults Task Force, along with the International Society of Geriatric Oncology and the Cancer and Aging Research Group, has created a companion article which highlights how to use the PGA and interpret the scores. ASCO also has guidelines on how to apply the information generated through the PGA on their website.^1,4

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. Published online July 17, 2023. doi:10.1200/JCO.23.00933
2. 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. 2021;398(10314):1894-1904. doi:10.1016/S0140-6736(21)01789-X
3. 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. 2021;7(11):e214158. doi:10.1001/jamaoncol.2021.4158
4. Practical assessment and management of vulnerabilities in older patients receiving systemic cancer therapy: ASCO guideline questions and answers. J Clin Oncol. Published online July 17, 2023. doi:10.1200/OP.23.00263