By Guest Writer - May 31, 2020
Many older cancer patients feel limited in their pursuit of cancer treatments. For geriatric oncology patients, the pros and cons of anti-cancer therapies must be weighed more carefully for proper treatment assessments. A wider range of factors must be considered when building their care plans, such as psychosocial concerns, physical limitations, cognitive issues, nutritional restrictions and other underlying health conditions associated with aging.
Although aging is the highest risk for developing cancer and over half of all cancer patients in the United States are over the age 70, there is little representation of older adults in clinical trials because of underlying health conditions. As the global population of senior adults grows rapidly with prolonged life spans, the need for whole body, comprehensive geriatric assessments is urgent.
For a long time, geriatric oncologists and widely used guidelines have recommended a geriatric assessment for older patients with cancer. We have known for several years that a geriatric assessment changes treatment decision for one in four older cancer patients. However, do these integrated onco-geriatric assessments ultimately change outcomes?
This year, at the annual meeting for the American Society of Clinical Oncology (ASCO), four randomized studies were presented that addressed that question. Three of the four studies addressed chemotherapy patients and uniformly showed a reduction in severe toxicity from chemotherapy.
- INTEGRATE study: this study, from Australia, showed integrated onco-geriatric management increased quality of life and reduced unplanned hospitalizations.
- GAIN study: this study, from City of Hope, explored multidisciplinary team recommendations implemented by a primary care team and supported by a geriatric nurse practitioner. While it showed an increase in the completion of advanced directives, there was no change in unplanned hospitalizations, emergency room visits or length of stay.
- University of Rochester study: this study was conducted in 41 private oncology practices and included an initial geriatric assessment with recommendations sent to the primary oncologist. It noticed that initial treatments were more frequently decreased in the intervention group, but subsequent dose reductions were more frequent in the control group, with overall similar survival rates of six months.
- Massachusetts General Hospital study: this study explored perioperative onco-geriatric management for patients undergoing surgery for gastric cancer. The results showed a better Edmonton Symptom Assessment System score, which is a method of assessing nine symptoms in cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, wellbeing and shortness of breath. Most notable, this study showed much lower depression symptoms. However, only half of the patients received the intervention fully as planned. The main issue was that the geriatrician had an office in a different site than the surgeons, which reduced the number of patients who received the preoperative component of the intervention. In a per protocol analysis, the intervention decreased the length of stay and intensive care unit admissions.
These four randomized studies constitute major progress in understanding how an integrated geriatric oncology approach changes outcomes for older patients with cancer. We now have consistent and convincing evidence that onco-geriatric management decreases severe toxicity from chemotherapy and decreases early treatment interruptions. These studies also support the fact that easy access to an integrated intervention at the site of a patient’s oncology treatment is the most effective approach. Several other randomized studies are in progress and we are eagerly waiting their results.
This is the approach we have favored at Moffitt Cancer Center with our Senior Adult Oncology Program. Moffitt has been a global leader in geriatric oncology for nearly 30 years. Established in 1993, the Senior Adult Oncology program is one of the oldest, largest and most advanced programs in the country. We continue to make advancements in areas that most affect geriatric patients with survival rates often exceeding national averages leading to an overall increased quality of life.
Moffitt has as a key priority to provide personalized cancer care to our patients. The evidence from the ASCO studies are a great addition to help us develop such care for our senior patients. The results will support out institutional efforts to make integrated onco-geriatric interventions available to all senior Moffitt patients.
This article was written by Dr. Martine Extermann, chair of Moffitt's Senior Adult Oncology Program