effect on treatment choice and undesirable effects – BCFI

The elderly and cancer treatment

More than half of patients with a new cancer diagnosis are older than 65 years ¹. Geriatric syndromes (a symptom or symptom complex with several possible underlying causes in the geriatric patient, e.g. malnutrition, dementia or falls) are more common in older people with cancer than in older people without cancer ^{1, 2}.

The elderly are more susceptible to adverse effects of their oncological treatment due to changes in pharmacodynamic and pharmacokinetic properties of drugs. For example, they are more susceptible to the cognitive effects of cancer treatment than young patients. Because polypharmacy is more common in the elderly, there is a higher risk of clinically relevant interactions between the chosen treatment and the medicines they are already taking ¹.
In addition, the elderly often set different treatment goals than younger cancer patients. For example, undesirable effects and quality of life in the elderly are often more important than extending lifespan ².

A geriatric evaluation (or ‘geriatric assessment‘) could therefore help to make a more informed choice in the treatment of cancer in this more vulnerable group. As a result, both over- and under-treatment can be avoided ^{1, 2}.

• An important part of a geriatric evaluation is the screening for polypharmacy, including nutritional supplements and over the counter and on demand medication ¹.
• Before and during treatment, it is important to check compliance, the undesirable effects of the treatment and possible interactions. Discuss treatment goals and potential adverse effects with the patient and caregivers (shared decision making) are an important part of this geriatric evaluation ^2,3.
• Preferably, the geriatric evaluation is multidisciplinary. Good communication through regular consultation between general practitioner, geriatrician and oncologist is essential, both prior to treatment and during the treatment process ^{2, 3}.

Geriatric evaluation: clinical value in cancer treatment

In the cluster randomized study by Mohile et al ²published in The Lancetthe effect of a geriatric evaluation on the occurrence of serious adverse events from cancer treatment in older adults with advanced cancer was investigated.

Prior to treatment, all patients received a geriatric evaluation. In the intervention group, oncologists were given access to the results of the geriatric evaluation and to the accompanying recommendations for adjustments in the patient’s approach. In the control group, the oncologists were only informed of strongly deviating scores on the cognition or depression screening tests.

The primary outcome measure of this study was the number of patients with serious adverse events over 3 months.

• The following eight domains were evaluated in the geriatric evaluation: comorbidities, cognition, nutrition, social support, polypharmacy, psychosocial status, functional status and physical condition. The evaluation was based on objective measurements and patient self-report data.
• Study inclusion criteria were a diagnosis of an incurable solid tumor or lymphoma, age over 70 years, and impairment in at least one domain on geriatric evaluation.
• Only patients who opted for palliative treatment with a high risk of toxicity were included.
• Randomization to the intervention group or control group was done at practice level
  (= cluster randomized). If an oncologist, research nurse or coordinator worked in more than one practice, these practices were clustered together.

The geriatric evaluation resulted in less intensive treatment, fewer serious adverse events, a reduction in polypharmacy and fewer falls in elderly people with advanced cancer. This without difference in survival ².

• Less intensive combination therapy was more often chosen in the intervention group. More often, single-agent chemotherapy, non-chemotherapeutic treatment or chemotherapy in combination with another product were chosen. Patients in the intervention group more often received a lower initial dose.
• There were fewer patients with grade 3 to 5 toxicities in the intervention groups (p National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE).
• The most common adverse events were fatigue, general weakness, electrolyte disturbances, gastrointestinal distress, infection and dehydration. There was no significant reduction in haematological toxicity (p = 0.11). The most common haematological disturbances were neutropenia, lymphopenia and anemia. The number of falls was lower in the intervention group
  (p
• Survival at 6 months (250 (72%) of 349 patients versus 275 (75%) of 369 patients) did not differ between the two groups.

Critical discussion and decision

The study by Mohile et al ² is a well-conducted, large cluster randomized trial investigating the utility of a geriatric evaluation for serious adverse events. The study shows that a geriatric evaluation can support treatment choice, indirectly reduce the toxicity of cancer treatment and thus improve quality of life in older people with cancer without decreasing life expectancy.

This study confirms previous studies showing beneficial effects of geriatric evaluation prior to treatment plan formulation.

• The systematic reviews of Hamaker et al ³ in Van Chuang et al. ⁴ confirm that performing a geriatric evaluation prior to developing the treatment plan can prevent grade 3 adverse events in different types of cancer, at different stages of treatment.
• From a review by Chuang et al ⁴ analyzed six RCTs examining the effect of a geriatric evaluation on grade 3 toxicity in the elderly receiving non-surgical treatment. The included studies examined patients with different types of tumors at different stages of disease, but the studies mostly included more patients with advanced stage cancer. They found that a geriatric evaluation led to fewer toxic adverse events from their treatment and to less frequent dose reduction during treatment.
• The systematic review by Hamaker et al ³ demonstrated the positive effect of a geriatric evaluation on both clinical decisions and clinically relevant endpoints as well as improved doctor-patient communication. The included studies examined patients with different types of cancer and different types of treatment.

Although there are differences in the organization of geriatric oncology care between the United States and Belgium, these results provide additional support for the implementation of geriatric evaluation in oncology. It supports the oncologist in the decision to treat or not, to determine the best treatment with the least toxicity and thus improve the quality of life in older people with cancer.

A geriatric evaluation is best incorporated into the decision-making process of the patient
therapy ^{2, 3}.

Sources

1 Magnuson A, Sattar S, Nightingale G, Saracino R, Skonecki E, Trevino KM. A Practical Guide to Geriatric Syndromes in Older Adults With Cancer: A Focus on Falls, Cognition, Polypharmacy, and Depression. Am Soc Clin Oncol Educ Book. 2019 Jan;39:e96-e109.
2 Mohile SG, Mohamed MR, Xu H, Culakova E, Loh KP, Magnuson A, et al. Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study. Lancet. 2021 Nov 20;398(10314):1894-1904.
3 Hamaker M, Lund C, Te Molder M, Soubeyran P, Wildiers H et al. Geriatric assessment in the management of older patients with cancer – A systematic review (update). J Geriatr Oncol. 2022 Jul;13(6):761-777.
4 Chuang MH, Chen JY, Tsai WW, Lee CW, Lee MC, Tseng WH, Hung KC. Impact of comprehensive geriatric assessment on the risk of adverse events in the older patients receiving anti-cancer therapy: a systematic review and meta-analysis. Age Ageing. 2022 Jul 1;51(7):afac145