Decisions about treatment for adults aged 70 years and older with advanced cancer can be challenging, as this population is often underrepresented in clinical trials that establish standards of care. Many of these patients receive treatments that have greater risks than benefits. Older adults with age-related conditions are at increased risk of toxic effects, lower rates of treatment completion, and early mortality. Falls and polypharmacy are more common in this population and can impact clinical outcomes in older patients with cancer. Age-related comorbidities are also common, so patients often prioritize the minimization of toxicities while maximizing function and quality of life when making treatment decisions.
The Geriatric Assessment for Patients 70 Years and Older (GAP70+) trial was the first nationwide, cluster-randomized study to examine the impact of a geriatric assessment intervention in older adults with advanced cancer (n = 718). The assessment included 8 domains: physical performance, functional status, comorbidity, polypharmacy, cognition, nutrition, social support, and psychological status. In the Lancet publication summarizing the trial, Dr Supriya Mohile, et al determined the geriatric assessment summary provided valuable information about health status that helped improve upfront decision-making for palliative treatment to optimize clinically significant outcomes.
The intervention reduced the risk of serious toxic effects (hematologic and nonhematologic) by over 20% and increased the number of patients with reduced treatment intensity at cycle 1, indicating an effect on treatment decisions. The reduced dose-intensity did not compromise survival, which was similar at 6 months and 1 year between patients who did or did not receive the intervention. These results suggest that providing standard, aggressive cancer care to vulnerable patients may do more harm than good. Patients in the intervention group also had fewer falls and reduced polypharmacy.
The authors concluded that geriatric assessment and assessment-guided management should be standard of care for older patients with advanced cancer and age-related conditions who are starting a new treatment regimen with a high risk of toxicity.
High Level
Dr Supriya Mohile and colleagues established that a geriatric assessment summary with management recommendations could improve clinical outcomes in older adults with advanced cancer through improved decision-making. The GAP70+ study included patients with advanced disease and those with age-related conditions who were at high risk of adverse outcomes from cancer treatment. The question remains whether this approach would have a similar impact on older patients receiving treatment in a curative setting and in those who are less frail, where considerations regarding toxicity might differ. More research is needed to determine the impact of integrating aging-sensitive interventions such as this one in a range of settings and patient populations, and their potential role in standard oncology clinical practices.
Ground Level
Older patients with significant comorbidities or other geriatric impairments are most likely to be treated in a community practice. On the basis of results of the GAP70+ study, clinicians should consider integrating geriatric assessment and geriatric assessment-guided management into standard of care for older patients with advanced cancer and age-related conditions who are starting a new treatment regimen with a high-toxicity risk. This intervention requires little time investment from healthcare providers, allowing the oncologist to retain their decision-making autonomy while also improving clinical outcomes.