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Presented by Prof Lore Decoster, medical oncologist (UZ Brussels) and board member and Belgian representative of the International Society of Geriatric Oncology
The ASCO guidelines about the evaluation of geriatric patients undergoing chemotherapy have undergone revisions since their initial publication in 2018.
The original guideline comprised four key recommendations:
1. All patients aged 65 and above should undergo a geriatric assessment to identify vulnerabilities and impairments not routinely captured in standard oncology workups.
2. Geriatric assessments should employ practical and validated tools, covering functionality, falls, comorbidities, nutrition, cognition, and depression. Additionally, the risk of chemotherapeutic toxicity should be assessed using either the CARG tool or the CRASH score.
3. Cancer-unrelated survival should be evaluated using a tool from the ePrognosis website, such as the Lee Schonberg index.
4. The geriatric assessment should culminate in an individualized care plan guiding treatment decisions and directed interventions for the patient.
The necessity for updating these guidelines arose following the publication of two significant randomized controlled trials: the GAP70+ study and the GAIN study. Both trials demonstrated that a geriatric assessment, followed by appropriate therapy management, reduces chemotherapy-related toxicity, particularly severe effects.
The revised ASCO guidelines now advocate for geriatric assessment for all patients over 65 years undergoing systemic treatment, not limited to chemotherapy. The recommendation has been expanded to include an assessment of polypharmacy, crucial for detecting potential drug interactions or facilitating deprescribing. Social support has also been added as a parameter, recognizing its impact on therapy adherence.
ASCO introduces a practical geriatric assessment tool available on their website, or through a link in the recently updated guidelines. Patients can complete this assessment at home, alone or with a caregiver, or in the waiting room. The tool evaluates various domains, enabling physicians to determine whether the patient is frail or fit for further treatment.
The third and fourth recommendations of the guidelines remain unchanged. Based on these ASCO updates, it is now imperative to integrate geriatric assessments into the care of older patients, including in Belgium. While not all individuals over 65 need comprehensive evaluations, a preliminary screening can differentiate fit patients from those requiring further assessment, preventing an undue burden on geriatricians. However, in the case of a patient aged over 70 diagnosed with cancer and scheduled for systemic chemotherapy or any other potentially toxic treatment, both screening and geriatric assessments are deemed essential. This underscores the need for close collaboration between oncological and geriatric departments to ensure optimal treatment outcomes.
References:
Dale W. et al. (2023) Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy: ASCO Guideline Update. Journal of Clinical Oncology 2023 41:26, 4293-4312
Daneng L. (2021) Geriatric Assessment-Driven Intervention (GAIN) on Chemotherapy-Related Toxic Effects in Older Adults With Cancer: A Randomized Clinical Trial. JAMA Oncol. 7(11):e214158.
Mohile SG. (2021) Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study. Lancet 398(10314):1894-1904.
Links to the guidelines and assessment:
https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf