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

Publication Date: July 17, 2023
Last Updated: July 17, 2023

Management

Recommendation 1.1

(Updated) All patients with cancer aged 65 and over with GA-identified impairments should have GA-guided management (GAM) included in their care plan.M 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. ( EB , H , B , S )
3336

Recommendation 2.1

(Updated) 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. ( EB , H , B , S )
3336

Recommendation 2.2

(Updated) The Panel recommends the Practical Geriatric Assessment (PGA) as one option for this purpose. See the PGA tools here: (Evidence Quality: Weak). ( IC , , , M )
3336

Recommendation 3

Based on the best clinical opinion of the Expert Panel, clinicians should use one of the validated tools listed at ePrognosis (eprognosis.ucsf.edu) to estimate life expectancy (LE) greater than or equal to 4 years.
  1. The Expert Panel especially recommends either the Schonberg or Lee Index (eprognosis.ucsf.edu/leeschonberg.php). The most common variables considered in these indices include age, sex, comorbidities (e.g., diabetes, chronic obstructive pulmonary disease [COPD]), functional status (e.g., the Activities of Daily Living [ADLs], Instrumental Activities of Daily Living [IADLs], mobility), health behaviors and lifestyle factors (e.g., smoking status, body mass index), and self-reported health.
  2. Several indices have “presence of cancer” as a relevant variable, answering “no” to this question will allow for non-cancer life expectancy, in order to consider competing risks of mortality.
that it predicts mortality; ( IC , H , B , S )
3336
that it improves outcomes or improves decision making. ( IC , Ins , B , W )
3336

Recommendation 4

Delphi consensus panels of experts have established approaches for implementing GA-guided care processes in older adults with cancer.

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.

Based on clinical experience and the results of formal expert consensus studies, the Expert Panel suggests that clinicians take into account GA results when recommending treatment and that the information be provided to patients and caregivers to guide decision making for treatment. In addition, clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. (Evidence Quality: Moderate) ( IC , , , M )
3336

Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

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

Authoring Organization

Publication Month/Year

July 17, 2023

Last Updated Month/Year

March 11, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

The ASCO Clinical Practice Guidelines Committee (CPGC) convened an Expert Panel with multidisciplinary representation in cognitive science, community oncology, exercise physiology, geriatric oncology, internal medicine medical oncology, oncology nursing, and patient/advocacy representation. This clinical practice guideline for older patients with cancer provides recommendations on the appropriate implementation of validated and standardized clinical assessment tools and decision-making models for this vulnerable and prevalent demographic group. It provides information on how these tools can be integrated into clinical oncology care to efficaciously evaluate and manage age-related conditions associated with adverse outcomes in older patients with cancer.  While geriatric assessment has been shown to potentially be beneficial for older patients undergoing different cancer treatments (e.g., surgery, radiation), this guideline focuses on evidence for patients undergoing chemotherapy due to the robustness of data in this area.

Target Patient Population

Vulnerable older patients with cancer

Target Provider Population

Oncologists, pharmacists, nurses, palliative care, geriatricians, social workers, physical therapists, occupational therapists, nutritionists/dieticians

Inclusion Criteria

Male, Female, Older adult

Health Care Settings

Ambulatory, Home health, Hospice, Hospital, Long term care, Outpatient

Intended Users

Dietician nutritionist, healthcare business administration, nurse, nurse practitioner, occupational therapist, community pharmacist, health systems pharmacist, physical therapist, physician, physician assistant, social worker

Scope

Counseling, Assessment and screening

Diseases/Conditions (MeSH)

D020497 - Problems and Exercises, D000066492 - Cognitive Aging, D017079 - Exercise Tolerance

Keywords

chemotherapy, Geriatric Oncology, Older Patients, Vulnerabilities

Source Citation

DOI: 10.1200/JCO.23.00933 Journal of Clinical Oncology

Supplemental Methodology Resources

Data Supplement

Methodology

Number of Source Documents
259
Literature Search Start Date
January 1, 2016
Literature Search End Date
December 11, 2022
Description of External Review Process
The ASCO Clinical Practice Guidelines Committee (CPGC) convened an Expert Panel with multidisciplinary representation in cognitive science, community oncology, exercise physiology, geriatric oncology, internal medicine medical oncology, oncology nursing, and patient/advocacy representation. The external and public review process were targeted to outpatient community oncology settings.
Description of Public Comment Process
An additional review focused on practical considerations for use of the guideline in outpatient community oncology settings.
Specialties Involved
Family Medicine, Geriatric Medicine, Hospice And Palliative Medicine, Internal Medicine General, Oncology, Pain Medicine, Physical Medicine And Rehabilitation, Post Acute And Long Term Care, Medical Oncology, Oncology
Description of Systematic Review
Described in Detail in Methodology Supplement
List of Questions
Should geriatric assessment (GA) be used in older adults with cancer to predict adverse outcomes from chemotherapy? For older patients who are considering undergoing chemotherapy, which GA tools should clinicians use to predict adverse outcomes (including chemotherapy toxicity and mortality)? What general (ie, noncancer-specific) life expectancy (LE) data for community-dwelling patients should clinicians consider to estimate mortality and best inform treatment decision making for older patients with cancer? How should GA be used to guide management of older patients with cancer?
Description of Study Criteria
ASCO guidelines are based on systematic reviews of the literature. A protocol for each systematic review defines parameters for a targeted literature search. Additional parameters include relevant study designs, literature sources, types of reports, and pre-specified inclusion and exclusion criteria for literature identified.
Description of Search Strategy
The systematic review involved searches of PubMed to identify systematic reviews and randomized clinical trials (RCTs) of GA-based allocation of chemotherapy and treatment outcomes for elderly individuals with cancer; RCTs of geriatric evaluation and management (GEM) of age-related medical conditions, psychological morbidity, and functional abilities among community dwelling older individuals; prospective cohort studies that evaluated the association of GA-based tools with outcomes of older patients with cancer receiving chemotherapy; and studies of life expectancy.
Description of Study Selection
Articles were excluded if they were (1) meeting abstracts not subsequently published in peer-reviewed journals; (2) editorials, commentaries, letters, news articles, case reports, and narrative reviews; or (3) published in a non-English language. Among candidate prospective cohort studies, articles were included if they addressed chemotherapy, included greater than or equal to 100 patients, and focused on outpatient GA or factors that are associated with treatment and/or functional outcomes among older persons with cancer. Similar inclusion criteria were applied to studies of life expectancy. Studies were included that had a sample size of at least 100 patients, included older individuals/patients in the nonhospitalized setting (either outpatient or community), and had overall mortality as the primary outcome of interest.
Description of Evidence Analysis Methods
Literature search results were reviewed and deemed appropriate for full text review by ASCO staff in consultation with the Expert Panel Co-chairs. Data were extracted by staff. Evidence tables are provided in both the Data Supplement and manuscript. The guideline recommendations were crafted, in part, using the principles of the GuideLines Into DEcision Support (GLIDES) methodology.
Description of Evidence Grading
High: High confidence that the available evidence reflects the true magnitude and direction of the net effect (i.e., balance of benefits v harms) and that further research is very unlikely to change either the magnitude or direction of this net effect. Intermediate: Moderate confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research is unlikely to alter the direction of the net effect; however, it might alter the magnitude of the net effect. Low: Low confidence that the available evidence reflects the true magnitude and direction of the net effect. Further research may change either the magnitude and/or direction this net effect. Insufficient: Evidence is insufficient to discern the true magnitude and direction of the net effect. Further research may better inform the topic. The use of the consensus opinion of experts is reasonable to inform outcomes related to the topic.
Description of Recommendation Grading
Evidence Based: There was sufficient evidence from published studies to inform a recommendation to guide clinical practice. Formal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. Therefore, the Expert Panel used a formal consensus process to reach this recommendation, which is considered the best current guidance for practice. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). The results of the formal consensus process are summarized in the guideline and reported in the Data Supplement (see the Supporting Documents" field). Informal Consensus: The available evidence was deemed insufficient to inform a recommendation to guide clinical practice. The recommendation is considered the best current guidance for practice, based on informal consensus of the Expert Panel. The Panel agreed that a formal consensus process was not necessary for reasons described in the literature review and discussion. The Panel may choose to provide a rating for the strength of the recommendation (i.e., "strong," "moderate," or "weak"). No recommendation: There is insufficient evidence, confidence, or agreement to provide a recommendation to guide clinical practice at this time. The Panel deemed the available evidence as insufficient and concluded it was unlikely that a formal consensus process would achieve the level of agreement needed for a recommendation.
Description of Funding Source
ASCO provides funding for Guideline Development.
Company/Author Disclosures
Author Disclosures of Potential Conflicts of Interest are documented in the Guideline.
Percentage of Authors Reporting COI
100