An online survey by the American Society of Clinical Oncology (ASCO), conducted between April 5, 2019 and June 5, 2019, showed that oncology providers familiar with the ASCO guideline on older adults with cancer are two to four times more likely to conduct a geriatric assessment on patients with cancer over the age of 65.[1]

Lori J. Pierce, MD, FASTRO, FASCO, the current president of the American Society of Clinical Oncology (ASCO), is a radiation oncologist, professor, and Vice Provost for Academic and Faculty Affairs at the University of Michigan. Pierce is also director of the Michigan Radiation Oncology Quality Consortium. A national leader in breast cancer research, Pierce was previously a Senior Investigator at the National Cancer Institute, National Institutes of Health, and in 1992, joined the faculty at the University of Michigan where she has focused her career primarily on the treatment of breast cancer. An active ASCO member since 1992, Pierce is a past member of multiple ASCO committees including the Government Relations Committee, Annual Meeting Scientific Program Committee, and the Conquer Cancer Foundation Nominating Committee, and she served as a mentor for the Leadership Development Program from 2015 to 2018. She previously served on the ASCO Board of Directors from 2010 – 2014 and was named a Fellow of ASCO (FASCO) in 2015. Photo courtesy: 2020 ASCO. Used with permission.

The survey, is the first international ASCO survey aimed at determining if and how often cancer providers are using geriatric assessments when treating older adults. Responses from 1,240 providers across the globe who care for older adults with cancer were analyzed for this report. [1]

According to ASCO, the findings are a noteworthy because nearly 70% of patients with cancer in the United States are 65 years of age or older, and globally, the number of new cancer cases per year among older adults will exceed 13 million by 2030.

A disease of Aging
“Cancer is predominantly a disease of aging, and as our population grows older, there’s an urgent need to equip clinicians who treat older adults with cancer with tools to assess the array of factors that may impact care,” noted ASCO President Lori J. Pierce, M.D., FASTRO, FASCO.

“ASCO’s work in this area underscores the importance of cancer care teams understanding the value of geriatric assessments in improving care management decisions for older adults,” she added.

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In 2018, ASCO published a guideline entitled Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy. This guideline recommends that cancer care providers conduct a geriatric assessment on all patients 65 years or older to identify vulnerabilities such as function, comorbidity, falls, depression, cognition, and nutrition. These vulnerabilities may not routinely be captured in standard oncology assessments. The guideline further recommends specific tools providers can use to conduct these geriatric assessments.[2]

The survey results, which was published in JCO® Oncology Practice, found more than half (53%) of respondents were familiar with the ASCO guideline. Of those, 69% used geriatric assessment tools to assess functional status of older adults with cancer, compared to 50% of those who were not familiar with the guideline. [1]

Respondents aware of the guideline noted that the biggest barrier to using geriatric assessment tools was a lack of resources, including time (81.7%) and trained staff (77.0%), while those unaware of the guideline reported a lack of knowledge/training (78.4%), lack of awareness about tools (75.2%), and uncertainty about use of tools (75.0%).

The survey also showed that nearly two-thirds of respondents (63%) reported that they “always” or “most of the time” assess older patients differently than younger patients when making clinical management decisions including using specific validated tools (29%) or using informal assessments based on their own judgment (69%).

Changes in clinical management
Evidence is emerging that geriatric assessment can lead to changes in clinical management and improved outcomes for older adults with cancer. Recent studies have demonstrated that if oncologists were aware of geriatric assessment results indicating a patient had a functional or cognitive impairment, they would be less likely to give full-dose chemotherapy. [3][4][5][6]

Another study, which was presented at ASCO’s Annual Meeting in 2020, found that use of geriatric assessments in routine care of older adults with advanced cancer significantly improved doctor-patient communication about age-related concerns, as well as increased patient satisfaction with the communication.

William Dale, M.D., Ph.D., Co-Chair of ASCO’s Addressing Cancer Health Disparities Among Older Adults Task Force and Director, Center for Cancer and Aging Research, Clinical Professor, Department of Supportive Care Medicine at City of Hope. Photo courtesy: © 2020 City of Hope. Ysed with permission.

“We know that a geriatric assessment gives vital information to support cancer care providers in guiding treatment choices for older adults,” said William Dale, M.D., Ph.D., Co-Chair of ASCO’s Addressing Cancer Health Disparities Among Older Adults Task Force and Director, Center for Cancer and Aging Research, Clinical Professor, Department of Supportive Care Medicine at City of Hope.

“We hope that by highlighting perceived barriers among providers to using geriatric assessments, they will seek out available guidance, such as the ASCO geriatric oncology guideline, and adopt the simple tools as part of routine cancer care,” Dale added.

Multi-pronged strategy
Despite representing a growing segment of the population of cancer patients, older adults patients are generally underrepresented in cancer clinical trials. As a result, more information is needed to better inform treatment decisions for older adults with cancer.

ASCO has undertaken a multi-pronged strategy to improve the evidence base for treating older adults with cancer, to enhance education and training for oncology providers, and to create guidelines aimed at improving the quality of care for older adults with cancer. ASCO published a set of recommendations focused on ensuring clinicians and patients have the information they need to develop treatment plans for this population.

In 2017, ASCO and the U.S. Food and Drug Administration (FDA) co-hosted a public workshop focused on building collaborations and developing new action items to increase the evidence base for treating older adults with cancer.

FDA guidance
Based on the outcomes of these activitioes, the FDA recently issued draft guidance to encourage inclusion of older adults in cancer clinical trials – an important signal to researchers and sponsors that older adults with cancer should be enrolled in clinical trials when they can do so safely and ethically.[7]

The his draft guidance provides recommendations regarding the inclusion of older adult, age 65 years and older, patients in clinical trials of drugs for the treatment of cancer.

The draft guidance further emphasizes the particular importance of including adults over age 75 years in cancer clinical trials. According to the FDA’s draft guideline, enrolling an adequate representation of the range of older patients in a clinical trial helps to better enable evaluation of the benefit-risk profile of cancer drugs in this population and may, after a novel anticancer drug is approved maximize the generalizability of the trial results in clinical practice. The tresults are also expected to oimprove the the labeling describing use in older adults and may contribute to promote the safe and effective use of these products and better informs treatment decisions in clinical practice.

In the draft guidance, the FDA recommends that sponsors of cancer trials consider the age demographics of their target population early in development and that a strategy for inclusion of older adults be informed by any known information for older adults. The draft guidance includes recommendations for inclusion of older adults related to early clinical development, clinical trials (including considerations for trial design, recruitment, and developing and reporting discrete age subgroups) and the postmarket setting of novel anticancer drugs.

[1] Dale W, Williams GR, MacKenzie AR, Soto-Perez-de-Celis E, Maggiore RJ, Merrill JK, Katta S, Smith KT, Klepin HD. How Is Geriatric Assessment Used in Clinical Practice for Older Adults With Cancer? A Survey of Cancer Providers by the American Society of Clinical Oncology. October 15, 2020. DOI: 10.1200/OP.20.00442 JCO Oncology Practice.
[2] Mohile SG, Dale W, Somerfield MR, Schonberg MA, et al. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol. 2018 Aug 1;36(22):2326-2347. doi: 10.1200/JCO.2018.78.8687. Epub 2018 May 21. PMID: 29782209; PMCID: PMC6063790.
[3] Gajra A, Loh KP, Hurria A, et al. Comprehensive Geriatric Assessment-Guided Therapy Does Improve Outcomes of Older Patients With Advanced Lung Cancer. Journal of clinical oncology: official journal of the American Society of Clinical Oncology 34:4047-4048, 2016
[4] Corre R, Greillier L, Le Caër H, et al. Use of a comprehensive geriatric assessment for the management of elderly patients with advanced non–small-cell lung cancer: The phase III randomized ESOGIA-GFPC-GECP 08-02 study. Journal of Clinical Oncology 34:1476-1483, 2016
[5] Hamaker ME, te Molder M, Thielen N, et al. The effect of a geriatric evaluation on treatment decisions and outcome for older cancer patients–A systematic review. Journal of geriatric oncology 9:430-440, 2018
[6] Mohile SG, Magnuson A, Pandya C, et al. Community oncologists’ decision-making for treatment of older patients with cancer. Journal of the National Comprehensive Cancer Network 16:301-309, 2018
[7] Inclusion of Older Adults in Cancer Clinical Trials. FDA Draft Guidance for Industry, March 2020. Online. Last accessed on October 16, 2020.

Featured image: Diagnosis Cancer.  Photo courtesy: © Fotolia/Adobe 2016 – 2020.

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