City of Hope Guides ASCO’s New Geriatric Cancer Recommendations

June 8, 2018 | by Saundra Young

We are living in an aging society. And with that undeniable truth comes sobering statistics.
Age is one of the greatest risk factor for developing cancer. According to the American Society of Clinical Oncology (ASCO), about 70 percent of those diagnosed with the disease are over 65 years old.
Unfortunately, experts say those numbers are expected to increase significantly over the next 20 years, making treatment decisions for this population imperative. The good news is a large percentage of those patients are cancer survivors. 
Now ASCO has released new recommendations designed to help doctors assess and manage care for these older adults.
“Geriatric assessment tools can help identify frailty and resilience in older cancer patients and inform shared decision-making,” ASCO Chief Medical Officer Richard L. Schilsky, M.D. said. “This guideline provides recommendations on the appropriate implementation of such tools and decision-making models for this vulnerable population. It also provides recommendations for managing common age-related conditions that may impact the care of older patients with cancer undergoing chemotherapy.”
City of Hope physicians Arti Hurria, M.D., a geriatric oncologist, and William Dale, M.D., Ph.D., a geriatrician and palliative care physician, co-chaired the panel that developed the new guidelines.

A New Assessment

Hurria-Arti Arti Hurria, M.D.
Establishing a geriatric assessment was at the top of the list.
“A geriatric assessment really is a fancy way of saying ‘get to know your patients as a whole individual beyond their chronological age,’” said Hurria, the George Tsai Family Chair in Geriatric Oncology. “So in addition to the patient’s age, understanding how active are they in their daily life. What other medical problems do they have? What’s their social support? Are they feeling anxious and depressed? What’s their nutritional status and what’s their memory like?”
All things that should be taken into consideration when making treatment decisions and so important that Hurria says the panel determined all patients over 65 planning to have chemotherapy should get this assessment, which would include tests to evaluate function, comorbidity, depression, cognition, falls, nutrition and even social activity and support.
“The assessment might pick up things like an individual is falling, and if they are, we should consider a physical therapy assessment," Hurria said. "If they have been losing weight, we should have a nutritionist involved. If they don't have family support, we would think about getting our social worker involved and providing additional support for the patient during treatment. If they have other medical problems, we would think about how that might influence the treatment and the types of drugs that we get. So there's so much value that we can get from this assessment that might tell us about who this individual is, and also what are certain interventions that we can do to help them through their cancer therapy?”
“This guideline is timely due to the rapidly aging and growing cancer population,” said Corinne Leach, strategic director for cancer and aging research at the American Cancer Society. “Clinicians will now be able to refer to this guideline for the essential steps they can take to improve the care of their older cancer patients receiving chemotherapy.”
Tests include the Geriatric Depression Scale, the Instrumental Activities of Daily Living, Blessed Orientation-Memory-Concentration test and the Chemotherapy Risk Assessment Scale for High-Age Patients.
The panel felt the assessment would help predict who might experience severe side effects from treatment, help the physician understand how risky a treatment is for a particular patient, and help determine prognosis based on general health.

A Better Prognosis

William Dale, M.D. Ph.D. William Dale, M.D., Ph.D.
“Another part of the recommendation is to establish life expectancy or prognosis for patients, and it's something that everybody would like to know,” added Dale, the Arthur M. Coppola Family Chair in Supportive Care Medicine. “Often the best information we have is about prognosis related to the cancer. But from a geriatric assessment perspective, knowing prognosis for all of the other conditions that someone has, all of those things identified by geriatric assessment can be used to accurately predict what people's other risks are and what their prognosis is from things separate from the cancer.”
Dale feels it’s important for patients to initiate these conversations with their doctor; discussions that must include the entire care team. The first step?
“Make sure a patient has a clear understanding of what their care plan is from their oncologist. But then to turn quickly to their geriatric assessments and to talk about them, about what's most important to them in their lives, to establish what their goals are personally, and how we can use this discussion and the formal assessments to help them achieve those goals, whether that's to supplement their cancer-directed therapy with other kinds of therapies, or whether it's to have them have a more detailed conversation with their oncologist about what to do about their chemotherapy choices.”
“The really hard part,” Hurria said, “is to make sure you're doing the right thing for the right individual at the right time, and that it’s what the patient really wants. And so what I find is that as I go through the assessment findings and really get to know this individual, and then look at the chemotherapy toxicity tool with them, I get a sense of, 'Do they feel that this treatment is worth it? Is this in line with what their goals are?'"
She looks at the assessment as a springboard for getting to know her patients and starting a meaningful dialogue.
 “It becomes a very integral part of my conversation with an older adult.”

Daunting Statistics

ASCO believes another integral part of the conversation must be cancer clinical trial participation where elderly patients are under-represented. 
“Our knowledge of how to care for older patients with cancer,” Schilsky said, “Is limited as they are often excluded from participation in clinical trials.”
According to ASCO less than 25 percent of patients enrolled in trials at the National Institutes of Health are 65 to 74 years of age and less than 10 percent are over 75, which means vital information needed to make sound medical decisions is lacking. Elderly minority populations are the most vulnerable.
The panel also recommends physicians use established tools found at ePrognosis to estimate life expectancy. In this archive, doctors can find information on patient prognosis and mortality outcomes.
Dale says the geriatric assessment takes less time and money than many of the tests they currently do. 
Another timesaver? Most of it can be filled out by the patient before they actually see their oncologist. Patients can find the assessment online at the Cancer and Aging Research Group website.
“I love the idea of the patient taking the initiative on this,” Dale said. “I think the one fear patients have sometimes is not knowing what to bring up with the doctors.”
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