ASCO Urges Geriatric Assessments for Older Cancer Patients

Updated recommendations from the American Society of Clinical Oncology (ASCO) re-emphasized the importance of conducting geriatric assessment (GA) for older cancer patients and promoted a new tool to streamline their use.

The guideline update was prompted by the publication of two large randomized clinical trials that found an advantage to their use: Geriatric Assessment for Patients 70 Years and Older (GAP70+) and Geriatric Assessment-Driven Intervention (GAIN).

New Evidence

The GAP70+ trial found that older patients with advanced cancer who underwent a geriatric assessment intervention were less likely to experience grade 3-5 toxic effects, had fewer falls, and had more medications discontinued compared with patients who received usual care with no GA summary of management recommendations. There was no difference in overall survival (OS) at 6 and 12 months between the two groups.

In the GAIN trial, integration of the geriatric assessment intervention resulted in significantly reduced grade 3 or higher chemotherapy-related toxic effects in older adults with cancer. Again, there was no difference in OS between groups or in other outcomes such as emergency department visits, unplanned hospitalizations, or average length of stay.

“We know we can lower chemotherapy toxicity by up to 20%, and we know we can prevent people from having falls,” said William Dale, MD, PhD, director of the Center for Cancer and Aging at City of Hope National Medical Center in Duarte, California, and co-chair of the ASCO expert panel that updated the guidelines.

“All of these things we know will happen from doing these assessments,” he told MedPage Today. “The evidence is overwhelming that anybody over 65 benefits from this way of taking care of patients.”

The guidelines continued to recommend that all cancer patients 65 or older should receive a GA, which could potentially result in modifications to therapy, supportive care interventions, and referrals to counseling, physical therapy, social work assistance, nutritional support, geriatrics specialists, and more.

Furthermore, the GA should include “high priority” aging-related domains known to be associated with outcomes in older patients, such as physical and cognitive ability, emotional health, nutrition, and social circumstances.

Importantly, the panel noted that while the recommendations were strongest for adults receiving chemotherapy, the guideline now also addresses targeted therapy and immunotherapy.

Getting Oncologists to Conduct GAs

Despite the fact that ASCO first issued GA guidelines 5 years ago, the evidence suggests that many oncology teams have resisted conducting these assessments.

For example, a survey study published last year showed that among 349 oncologists in community practice settings, 60% reported they did not use a GA tool to guide treatment decisions for older cancer patients. The most common reasons given were: “Too cumbersome to incorporate into routine practice” and “Adds no value beyond the comprehensive history and physical exam.”

By failing to identify conditions among older adults that are not found in routine examinations, “you risk things like higher rates of toxicities from treatments that could lead to other complications, like admission to the hospital, or failure to complete therapy,” Dale said. But the recent studies have proven that GA use “allows us to intervene appropriately with supportive care interventions to avoid those toxicities, or to target those interventions appropriately to avoid problems of being older — like falls, cognitive impairment, functional loss — and prevent them from happening.”

In order to encourage more oncology teams to conduct GAs, the panel recommended the use of the Practical Geriatric Assessment (PGA).

“We need to make these [GA] tools ones that oncologists can easily use in their clinic settings,” Dale said, adding that the PGA “boils the science down to its essence” and makes the assessment shorter, more concise, and practical.

Moreover, about 80% of the PGA consists of questions for patients that can be answered without any input or assistance from clinical care staff, with the remaining information about cognition and physical function captured by trained personnel.

After that, Dale said, an oncologist can use the information to make individualized choices about therapy or make referrals for physical therapy, nutritional support, pain specialists, or supportive care.

“So, the idea that this is too hard to do, or takes up too much time, is just not true,” he said. “Here’s a way to do it within the parameters of any oncology practice. And this is much easier than anything else you have to do in your practice — but the benefits are really high.”