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Integrated management of older cancer patients changes outcomes

June 1st 2020, Report from Dr Martine Extermann, Moffitt Cancer Center, Tampa, USA

This year at ASCO brought excellent news for older cancer patients (OCPs). For a long time geriatric oncologists and guidelines such as ASCO and NCCN’s have recommended a geriatric assessment for older patients with cancer. We have known for several years that a geriatric screening or assessment changes treatment decision for 1 in 4 OCPs. The question was: does it change outcomes? This year, at the Annual ASCO meetings, four randomized studies were presented that addressed that question (abstracts 12009 to 1012).  The 3 studies that addressed chemotherapy patients uniformly showed a reduction in severe toxicity from chemotherapy. The INTEGRATE study, from Australia, which included an integrated oncogeriatric management, showed in addition an increase in quality of life (its primary endpoint), and a reduction in unplanned hospitalizations. The GAIN study, from City of Hope, which explored multidisciplinary team recommendations implemented by the primary team supported by a geriatric nurse practitioner, also showed an increase in the completion of advanced directives, but no change in unplanned hospitalizations, ER visits, or length of stay. The study by Mohile et al, conducted in 41 private oncology practices, included an initial geriatric assessment, with recommendations sent to the primary oncologist.  It noticed that initial treatments were more frequently decreased in the intervention group, but subsequent dose reductions were more frequent in the control group, with overall similar 6 months survival. There was heterogeneity between practices.

The final study was a Massachusetts General Hospital study of perioperative oncogeriatric management for patients undergoing surgery for gastric cancer. The Intent to treat results showed a better ESAS score and less depression symptoms. However, only half of the patients received the intervention fully as planned. The main issue was that the geriatrician had an office in a different site than the surgeons, which reduced the number of patients who received the preoperative component of the intervention. In a per protocol analysis, the intervention decreased the length of stay and ICU admissions.

These 4 randomized studies constitute a major progress in understanding how an integrated geriatric oncology approach changes outcomes for older patients with cancer. We now have consistent and convincing evidence that oncogeriatric management decreases severe toxicity from chemotherapy and decreases early treatment interruptions. These results are further supported by a parallel cohort study by Kalsi et al. (BMJ 2015) that also showed better chemotherapy completion as planned, with similar 6 months survival in the geriatric intervention arm. These studies also support the fact that easy access for the patient to an integrated intervention at the site of their oncology treatment is the most effective approach. Outside of academic centers, the study by Mohile et al. provides an example of intervention applicable in private practice oncology. Several other randomized studies are in progress and we are eagerly waiting their results. In summary, these randomized studies provide major evidence to address one of SIOG’s Top Priorities for the Global Development of Geriatric Oncology: Develop models to provide optimal care for older adults with cancer.

Download the table summarising the 4 studies