Managing Systemic Cancer Therapy in Older Patients: Practical ASCO Guideline Update

The latest update of the American Society of Clinical Oncology (ASCO) guideline aims to revise and enhance the 2018 guideline on assessing and managing vulnerabilities in older cancer patients undergoing chemotherapy. It was prompted by two significant clinical trials, GAP701 and GAIN, which explored the integration of geriatric assessment (GA) and GA-guided management (GAM) to reduce chemotherapy-related toxic effects in older adults with cancer. The update now encompasses systemic therapy, such as chemotherapy, targeted therapy, and immunotherapy, and recommends using a Practical Geriatric Assessment (PGA) instrument to overcome barriers to implementing GA in everyday clinical oncology practice. Other recommendations from the 2018 guideline remain unchanged due to the absence of new practice-changing data.¹

Recommendations¹

• Recommendation 1.1: For all patients aged 65 years and above with cancer and identified impairments, it is recommended to include GA-guided care as a part of their treatment plan. The GA should be utilized to (1) inform cancer treatment decisions and (2) address impairments through appropriate interventions, counselling, and referrals. This recommendation extends to older adults receiving systemic therapy, including chemotherapy, targeted therapy, or immunotherapy.
  
  Amendment 1.1a: Older adults undergoing systemic therapy, such as chemotherapy, targeted therapy, or immunotherapy, should also include GA-guided care in their treatment plan.
   
• Recommendation 2.1: The GA should encompass high-priority ageing-related domains known to be associated with outcomes in older patients with cancer. These domains should include physical and cognitive function assessments, emotional health, comorbid conditions, polypharmacy, nutrition, and social support.
   
• Recommendation 2.2: The Panel recommends using the Vulnerable Elders Survey-13 (VES-13) to conduct the GA. The VES-13 tool can be found at: https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf. Instructions on how to use the VES-13 tool can be accessed through the following links: https://youtu.be/jnaQIjOz2Dw and https://youtu.be/nZXtwaGh0Z0.
   
• Recommendation 3: Based on the best clinical opinion of the Expert Panel, clinicians should use validated tools listed at ePrognosis89 to estimate a life expectancy (LE) of four years or more. The Expert Panel particularly recommends considering the Schonberg or Lee Index. These indices commonly take into account variables such as age, sex, comorbidities (e.g., diabetes, COPD), functional status (e.g., ADLs, IADLs, mobility), health behaviours, and lifestyle factors (e.g., smoking status, body mass index), as well as self-reported health. Several indices also account for the presence of cancer as a relevant variable, allowing for the consideration of competing mortality risks.
   
• Recommendation 4: Delphi consensus panels of experts have established approaches for implementing GA-guided care processes in older adults with cancer. The Expert Panel recommends that clinicians utilize GA results to develop an integrated and individualized plan for patients, aiding in treatment selection by estimating risks for adverse outcomes and identifying non-oncologic problems amenable to intervention.
   
• Based on clinical experience and formal expert consensus studies, clinicians should consider GA results when recommending treatment options and communicate this information to patients and caregivers to facilitate treatment decision-making. Additionally, clinicians are encouraged to implement targeted, GA-guided interventions to manage non-oncologic problems effectively.

Literature Gaps and Prospects for Future Research¹

• The guideline update provides evidence supporting the use of GA and GAM for optimal care of older adults with cancer. The field of geriatric oncology has progressed significantly.
• The strongest evidence for GA and GAM comes from studies involving patients with solid tumours or lymphomas receiving chemotherapy. There is limited evidence for other populations, such as those receiving immunotherapy or novel therapies.
• The timing of GA needs further investigation. It has been valuable as a risk-assessment tool, but there is a need to determine the most appropriate time for reassessment.
• Clinical trials often lack representation of older adults and other vulnerable groups based on race, sex, gender, disability status, etc. Efforts are needed to improve the inclusion of these populations in trials.
• GA and GAM can improve communications and patient satisfaction, promoting health equity in clinical trial evaluation and narrowing gaps in healthcare decision-making for vulnerable populations.
• Structural changes, such as economic support and transportation provision, must address systematic exclusions and achieve representative evidence for future guidelines.
• Widespread adoption of GA and GAM would enhance clinical care for older adults and contribute to a more equitable care system for all patients.

Conclusion

The latest ASCO guideline highlights the importance of employing GA-guided care in older cancer patients undergoing chemotherapy. This approach aims to decrease treatment-related toxicity while improving overall treatment outcomes. It recommends validated tools for impairments, comorbidities, and social support. Further research is needed to explore GA timing and representation in trials for equitable healthcare. The adoption of GA and GAM would improve clinical care and equity.

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References

1. Dale W, Klepin HD, Williams GR, Alibhai SMH, Bergerot C, Brintzenhofeszoc K, Hopkins JO, Jhawer MP,  Katheria V, Loh KP, Lowenstein LM, McKoy JM, Noronha V, Phillips T, Rosko AE. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy: ASCO Guideline Update. Journal of Clinical Oncology 2023; JCO2300933. DOI: 10.1200/JCO.23.00933.