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January/February 2019
Clinical Concepts: Guidelines for Geriatric Oncology First of their kind guidelines aim to offer personalized care plans. Age is one of the greatest risk factors for developing cancer, and as the older population continues to age, the health care community faces a serious challenge: a lack of consensus guidelines providing community oncologists the evidence-based tools to manage care for older adults with cancer. According to the American Society of Clinical Oncology (ASCO), approximately 70% of people diagnosed with cancer are older than 65. That number is expected to increase significantly over the next two decades, making it critical for physicians to establish treatment plans for older adults living with this challenging disease. Recent data published in the Journal of the National Comprehensive Cancer Network revealed that approximately 90% of oncologists feel the care of older adults with cancer needs to improve and nearly three-quarters believe that proper training in geriatric treatment is "essential." Studies have also shown that existing oncology assessments used to predict adverse events and survival regardless of age, such as the Karnofsky Performance Status or Eastern Cooperative Oncology Group performance status, don't accurately identify which older cancer patients are at a higher risk of adverse reactions from chemotherapy. With these and other findings in mind, ASCO has produced Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology, available at http://ascopubs.org/doi/full/10.1200/JCO.2018.78.8687. The goal of the geriatric assessment is to determine which patients can tolerate often-intensive chemotherapy and which may need modified treatment regimens due to age-related conditions. About the Geriatric Assessment Supporting our recommendation, our team conducted a study, also published in Journal of Clinical Oncology, which evaluated 542 patients ages 70 and older across 31 community oncology practices. All the patients had incurable, advanced solid tumors or lymphoma and at least one vulnerability in one or more sections of the geriatric assessment. We concluded that patients who did not receive a geriatric assessment were less likely to have high-quality conversations with their physicians and had fewer discussions about noncancer and age-related concerns. However, patients in the geriatric assessment arm reported higher patient satisfaction and, on average, had two or more high-quality discussions with their physicians that led to interventions such as physical therapy or assessments of cognitive impairment. The new guidelines—the first of their kind for ASCO—state that all patients older than the age of 65 who are planning to undergo chemotherapy should receive a geriatric assessment that evaluates various age-related concerns to identify vulnerabilities or impairments that are not normally captured in oncology assessments, including the following: • functional status; The goal of the assessment is to better understand older patients and identify those at risk of having a shorter life expectancy due to noncancer-related health problems and those at an increased risk of side effects from chemotherapy. Recommended tests and tools include the Cancer and Aging Research Group chemo toxicity tool, Mini-Cog, and the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, the Geriatric Depression Scale, and the Instrumental Activities of Daily Living to assess function. Our hope is that physicians can have the geriatric assessment readily available to help them identify an appropriate treatment plan. The assessment is quick—it takes less than 30 minutes to complete—and is easy to follow. Most of the information can be filled out by the patients prior to their appointments. ASCO believes that to improve the quality of care, physicians and patients should carefully weigh the risks and benefits of cancer-directed therapy for patients with a low performance status and for whom there's "no strong evidence supporting the clinical value of standard cancer treatment." What's Next for Geriatric Cancer Care To improve care for older cancer patients, we must have a clear picture of our patients' overall health, including their psychosocial needs, sensory and cognitive function, and day-to-day mobility. That's why City of Hope and other comprehensive care centers across the country offer a wide range of services through integrated care departments. Another significant challenge in treating older patients is geography. Optimal treatment for older patients includes inpatient and outpatient care services. Yet 80% of cancer patients in the United States do not receive care in specialty cancer centers. The question that remains is how do we reach communities with limited health services? Physicians, researchers, and policy makers alike are looking for ways to reach people who don't live near comprehensive cancer centers. Part of the solution will undoubtedly be telehealth options tailored for older adults. Expanding on a study funded by the UniHealth Foundation, Hurria is investigating ways to offer multidisciplinary services through telehealth programs to older patients with cancer who are being treated at small community hospitals with fewer services. Hurria, Mohile, and I recently received a grant from the National Institute of Aging to further our research on cancer and aging. There's limited evidence on how to effectively treat older patients with cancer; a study presented at the 2017 ASCO Annual Meeting found that only 40% of patients enrolled in clinical trials are older than age 65. However, as the life expectancy of older adults increases, the number of older patients with cancer continues to grow. The National Institute of Aging and our teams are working to establish a national research infrastructure that facilitates and supports innovative research projects on cancer and aging so that we can create effective treatment plans for older adults. In my role at City of Hope, I help care for vulnerable patients in my geriatric oncology clinic, the Specialized Oncology Care and Research in the Elderly (SOCARE) clinic, which is part of the Department of Supportive Care Medicine. Patients can visit SOCARE for assessments and work directly with us to come up with a comprehensive treatment plan. We also work closely with family, friends, and caregivers to understand the challenges of caring for older adults with cancer. Whatever the future holds, one thing is certain: We must dig deeper into the lives of our older patients and their families and offer them integrated, specialized services that treat more than their cancer. The recently published ASCO guidelines for geriatric assessment are an important step toward ensuring our older loved ones with cancer receive the same quality care as their younger counterparts. — William Dale, MD, PhD, is the Arthur M. Coppola Family Chair in Supportive Care Medicine at City of Hope in Duarte, California. |
