A 2023 update to the ASCO guidelines focuses on practical assessment and management of age-associated vulnerabilities in older adults undergoing cancer therapy.
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.
PW: Why did you feel the updates to these guidelines were needed?
Dr. Dale: These updates were primarily needed because the evidence is now overwhelming that the use of a geriatric assessment (GA) should be required for older adults considering cancer treatment. ASCO felt it was important to upgrade the guidelines as a result.
The first-ever guidelines for older adults from ASCO were issued in 2018. Over the past year, two large randomized studies were published, one in the Lancet from the University of Rochester and one in JAMA Oncology from City of Hope. Both showed that GA-guided care with supportive care interventions for older adults with cancer actually reduced chemotherapy toxicity while preserving survival. They also showed that falls decreased, fewer medications were used, more advanced directives were completed, and patients’/families’ satisfaction with care went up. These trial results led to ASCO’s desire to update its guidelines due to the strength of the evidence.
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 it is a new standard of care for older adults with cancer who are starting any systemic therapy (Table). This includes chemotherapy, immunotherapy, and targeted therapies. It also defines the essential domains to be included in a GA: comorbidities, mobility, nutrition, daily function, cognition, social support, mood (anxiety/depression), and polypharmacy.
How can these updated guidelines be incorporated into practice?
We recommend a specific tool, the Practical Geriatric Assessment, that boils down the GA to its most essential elements. The one-page tool gives a specific test to use for each essential domain, and it can be found on the Cancer & Aging Research Group website (https://www.mycarg.org/). This can be matched to the Action Chart that describes the specific evidence-based recommendations, found here, in Table 1: https://ascopubs.org/doi/full/10.1200/OP.23.00263. Together, these guidelines can be enacted in any oncology practice.
What would you like future research to focus on?
The goal is now to improve the uptake of these guidelines into oncology clinical practices, especially in the 80% of clinics outside of academic cancer centers. Hopefully, the Practical Geriatric Assessment and the Action Chart will make this easier. Also, we need to learn how GA-guided care works in different cancers (eg, breast, prostate, hematology). Finally, increasing the enrollment of older adults in clinical trials is essential since we need to improve the representativeness of the evidence in trials where only 25% include older adults.
Is there anything else that you feel Physician’s Weekly readers would benefit from knowing about your research?
We must see systematic changes in how cancer care is delivered for the more than 50% of patients with cancer over age 65. Older adults and their loved ones need to ask for these assessments from their providers. Policies need to change to allow the necessary time and resources to conduct these assessments. People need to be trained in how to use these assessments effectively, and payments need to be made to support these assessments.