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American Society of Clinical OncologyMedical Oncology2023advanced

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy

Published by American Society of Clinical Oncology · GRADE

5Recommendations

88References

5Tables

Summary

AI-generated

This update builds upon the 2018 ASCO guideline by recommending the mandatory integration of geriatric assessment (GA) and GA-guided management (GAM) for patients 65 and older receiving systemic cancer therapy. Revisions were driven by large randomized clinical trials demonstrating significant benefits in reducing serious chemotherapy-related toxicity.

geriatric assessmentsystemic cancer therapyASCOmedical oncologyguidelinesolder adultsimmunotherapytargeted therapy

Key Takeaways

1
All older adults (65+) considering or receiving systemic cancer therapy should undergo a Geriatric Assessment (GA).
2
Geriatric Assessment-guided Management (GAM) should be integrated into care plans and significantly reduces serious treatment-related toxicities.
3
GAM improves advanced directive completion and communication around aging-related concerns.
4
The Practical Geriatric Assessment (PGA) offers a streamlined, consensus-based tool for clinical implementation to address known barriers to GA uptake.
5
Recommendations apply to all systemic therapies, newly explicitly expanded to include immunotherapy and targeted therapy.

What's New in This Version

This update expands on the 2018 recommendations by requiring GA-guided management (GAM) for older adults based on new phase III randomized clinical trials (GAP70+ and GAIN) showing significant toxicity reduction. It broadens the scope of systemic therapy beyond chemotherapy to include targeted therapies and immunotherapy, and formally introduces the Practical Geriatric Assessment (PGA) to improve clinical implementation and address widely documented adoption barriers.

Key Recommendations

Clinical Question 1

1.1
All patients with cancer aged 65 and over with geriatric assessment (GA)-identified impairments should have GA-guided management (GAM) included in their care plan. GAM includes using GA results to: (1) inform cancer treatment decision-making, and (2) address impairments through appropriate interventions, counseling, and/or referrals. Amendment 1.1a. This includes older adults receiving systemic therapy, including chemotherapy, targeted therapy, or immunotherapy.
StrongEvidence: HighEvidence based, benefits outweigh harms

Clinical Question 2

2.1
A GA should include high priority aging-related domains known to be associated with outcomes in older patients with cancer to include assessment of physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support.
StrongEvidence: HighEvidence based, benefits outweigh harms
2.2
The Panel recommends the Practical Geriatric Assessment (PGA) as one option for this purpose.
WeakEvidence: ModerateInformal consensus

Table 1. Complete List of Recommendations

3
Based on the best clinical opinion of the Expert Panel, clinicians should use one of the validated tools listed at ePrognosis to estimate life expectancy (LE) greater than or equal to 4 years. The Expert Panel especially recommends either the Schonberg or Lee Index.
Strong that it predicts mortality, Weak that it improves outcomes or improves decision makingEvidence: High that it predicts mortality, Insufficient that it improves outcomes or improves decision makingInformal consensus, benefits outweigh harms
4
The Expert Panel recommends that clinicians apply the results of GA to develop an integrated and individualized plan for patients that informs treatment selection by helping to estimate risks for adverse outcomes and to identify nononcologic problems that may be amenable to intervention. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems.
ModerateEvidence: ModerateInformal consensus

Scope & Objectives

Clinical Topic

Geriatric Oncology

Objectives

To improve outcomes for older adults with cancer through recommendations for: (1) use of validated assessment tools and GA-guided interventions, and (2) management of common age-associated conditions identified through GA that may impact care.

Target Patient Population

Older adults (65+) with cancer considering or receiving systemic therapy

Target Providers

Oncologists (medical, radiation, surgical)GeriatriciansPalliative medicine specialistsPrimary care physiciansAdvanced practice providersPharmacistsOncology nursesSocial workersPhysical therapistsOccupational therapistsNutritionistsDieticians

Patient Criteria & Setting

Therapeutic Area

Systemic Cancer Therapy

Guideline Scope

AssessmentManagement

Inclusion Criteria

Older adults with cancer (65+)
Considering undergoing chemotherapy and other systemic (non-surgical or radiation) therapies

Care Settings

Oncology practicesCommunity oncology settingsAcademic cancer centers

Special Populations

Older adults (65+)Frail older adultsVulnerable older patients

Evidence Grading

System: GRADE

Evidence Levels

LowOur confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.

HighWe are very confident that the true effect lies close to that of the estimate of the effect.

ModerateWe are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

Very LowWe have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

Recommendation Strength

WeakIn recommendations for an intervention, the desirable effects probably outweigh the undesirable effects, but appreciable uncertainty exists. In recommendations against an intervention, the undesirable effects probably outweigh the desirable effects, but appreciable uncertainty exists. Most informed people would choose the recommended course of action, but a substantial number would not.

StrongIn recommendations for an intervention, the desirable effects of an intervention outweigh its undesirable effects. In recommendations against an intervention, the undesirable effects of an intervention outweigh its desirable effects. All or almost all informed people would make the recommended choice for or against an intervention.

Safety & Contraindications

Monitoring Guidance

Consider more frequent toxicity checks (weekly or every other week) depending on risks evaluated by the geriatric assessment.

Authors & Contributors

William DaleMDPhDHeidi D. KlepinMDMSGrant R. WilliamsMDMSPHShabbir M. H. AlibhaiMDCristiane BergerotPhDKarlynn BrintzenhofeszocPhDMSWJudith O. HopkinsMDMinaxi P. JhawerMDVani KatheriaMSKah Poh LohMBBCh BAOMSLisa M. LowensteinPhDJune M. McKoyMDMPHJDMBAVanita NoronhaMDTanyanika PhillipsMDAshley E. RoskoMDTracy RueggPhDANPMelody K. SchiaffinoPhDJohn F. Simmons Jr.MDIshwaria SubbiahMDWilliam P. TewMDTracy L. WebbPA-CMary WhiteheadMark R. SomerfieldPhDSupriya G. MohileMDMS

Guideline Features

Dosing informationBased on systematic reviewMultidisciplinaryPatient involvement

Learning Context

Difficulty

advanced

Learning Paths

Geriatric OncologyGeriatric AssessmentChemotherapy ToxicitySystemic Therapy in Older AdultsClinical Guideline Implementation