Given new research regarding the vulnerabilities of older adults undergoing systemic cancer treatment, the American Society of Clinical Oncology (ASCO) convened an expert panel to identify and review relevant studies to determine whether updates were needed to their
cancer treatment guidelines for older adults. The findings of this panel were published in the Journal of Clinical Oncology. The lead
author of these updated guidelines and an ASCO expert, William Dale, MD, PhD, spoke with Physician’s Weekly regarding the significance of the panel’s findings.
Why did you feel these guidelines were needed?
William Dale, MD, PhD: The very first guidelines from ASCO for caring for older adults with cancer came out in 2018. At that time, the evidence for using a specialized assessment called the geriatric assessment (GA) was recommended for older adults starting chemotherapy based on strong observational studies led by my colleague, the late Arti Hurria, MD, done at City of Hope Comprehensive Cancer Center.
In 2021, two large randomized control trials (RCTs) were published: one in JAMA Oncology, the GAIN study, and one in Lancet, the GAP70+ study. Both showed that GA-guided supportive care interventions substantially decreased chemotherapy toxicities in older adults on systemic therapies for cancer without compromising survival.
GA-guided interventions have also decreased falls, decreased polypharmacy, increased completion of advanced directives, and improved patient and family satisfaction with care. This overwhelming evidence led ASCO to request that our task force update the guidelines to reflect this new evidence. GA is now considered the standard of care for older adults starting systemic cancer therapy (Table).
What are the most important findings of this reassessment for physicians to understand?
By far, the most important finding is that conducting a GA and implementing supportive care interventions based on the GA is a new standard of care for older adults with cancer who start any systemic therapy. The most important updates include:
- The use of GA-guided care is the new standard of care for older adults with cancer starting therapy.
- This guideline includes chemotherapy and other systemic therapies such as immunotherapy, targeted therapy, and hormonal therapy.
- The Practical Geriatric Assessment (PGA) is a new, concise tool that can be used to assess the essential domains with minimal time.
- Combined with the PGA, supportive care interventions can decrease toxicities from cancer treatment without compromising survival.
How can physicians incorporate these updated guidelines into practice?
The new PGA tool, available on the Cancer & Aging Group (CARG) website (mycarg.org), can be easily used in clinical practice. Combined with the Action Chart, which outlines how to interpret the PGA tools and recommends specific interventions based on the GAIN and GAP70+ trials, oncologists can apply the guidelines in practice. The PGA is 85% patient-reported outcomes, which patients or families can answer before visiting the clinic; non-physician practitioners can conduct the additional 15% in the clinic without disrupting clinical workflow. The supportive care interventions are largely referrals to others, such as physical therapy, nutrition, and social work.
What still needs to be explored?
Future research will be focused on further refinements of the GA to incorporate it into different clinical contexts. For example, we and others are working on ways to incorporate GA into practice through telehealth. Another challenge is to provide this care in less-resourced environments, whether in rural or inner-city circumstances or countries with less infrastructure. Another area is understanding in greater detail the specific ways GA-guided care benefits patients.
Is there anything else you feel Physician’s Weekly readers would benefit from knowing about your research?
This work—creating an evidence base for guidelines with the PGA—will allow systemic collection of data in the real-world setting of community oncology practices. We invite others to use the PGA in their setting and to contact us through the CARG website to collaborate on this important work. City of Hope, supported by funding from the Rising Tide Research Foundation, currently leads the Geriatric Oncology Treatment Optimization (GOTO) study, which uses the PGA in five linked RCTs across five different tumor types. This study will help answer how PGA-guided care works in multiple contexts, including community practice.
