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Geriatric assessments could fine-tune cancer care for older adults


 

In a move to improve cancer care for older adults, the American Society of Clinical Oncology is recommending that all patients aged 65 years and older receive a geriatric assessment when considering or undergoing chemotherapy.

A female doctor comforting an elderly man. FatCamera/Getty Images
The goal is to better identify which patients can tolerate intensive chemotherapy and which patients may need modified treatment regimens because of underlying conditions, such as cognitive impairment, which often go undetected by oncologists.

Fewer than 25% of older cancer patients currently get these assessments, which evaluate a person’s functioning (what he can and cannot do), psychological status, nutrition, cognition, social circumstances, and other, coexisting medical conditions, and which can predict the potential toxicity of chemotherapy.

The new guideline, ASCO’s first in the field of “geriatric oncology,” may have significant potential to change medical practice. “These recommendations will capture the attention of oncologists, I think, and that will be incredibly valuable,” said Corinne Leach, PhD, strategic director of cancer and aging research at the American Cancer Society.

They recognize a shifting demographic reality for cancer specialists, who are treating increasingly older patients as life spans lengthen across the globe. In the United States, 60% of patients newly diagnosed with cancer (an estimated 1.7 million people this year) are aged 65 years or older, as are more than 60% of cancer survivors.

Yet evidence about how best to treat older adults with cancer is weak because older adults are underrepresented in clinical trials. And most oncologists have received little training in how to manage older patients’ unique vulnerabilities.

When researchers asked 305 community oncologists about evaluating older patients, 89% acknowledged “the care of older adults with cancer needs to be improved,” according to a recently published study. Fewer than 25% said they were “very confident” they could identify dementia or accurately assess a patient’s functioning or risk of falling – factors associated with poorer outcomes for cancer treatment.

Still, resistance to change is evident. “We’re all inundated with trying to keep up with new standards of care, and I doubt there will be any broad acceptance of the rigor called for in this guideline,” said Frederick Schnell, MD, medical director of the Community Oncology Alliance.

The burden on physicians shouldn’t be significant, however: The streamlined assessments recommended in the ASCO guideline take only about 20 minutes to complete. Patients fill out surveys during most of that time; about five minutes is required for a nurse or physician assistant to administer several brief tests.

The assessment can identify people at increased risk of experiencing serious side effects from chemotherapy – infections, fatigue, diarrhea, dehydration and other problems that affect more than half of older patients. Physicians can then take steps to address these vulnerabilities, such as prescribing physical therapy for an older patient with muscle weakness or ordering a nutritional consultation for someone who has become malnourished. Also, they can alter chemotherapy regimens to minimize the potential for harm.

Currently, most oncologists decide whether older patients can benefit from chemotherapy by using the “eyeball test,” an assessment that relies primarily on their experience and judgment. “This isn’t enough to understand factors that put older adults at risk; it takes a deeper dive,” said Arti Hurria, MD, director of the Center for Cancer and Aging and professor of medical oncology and therapeutics research at City of Hope, a comprehensive cancer center in Duarte, Calif., and cochair of the panel that produced the new guidelines.

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