Patient-Centric Strategy Is Key to Managing Toxicities in Older Patients With Cancer
Key Takeaways
- Clinical trials often do not reflect the older patient demographics seen in community oncology, necessitating a patient-centric approach.
- Comprehensive Geriatric Assessment is ideal but impractical in busy settings; practical assessments are recommended.
Shifting from a tumor-centric to a patient-centric approach is crucial for older patients with cancer, focusing on functional capacity over age to reduce toxicity.
The majority of clinical trials target patient cohorts whose median age ranges from 50 to 60 years, yet community oncologists often see patients whose median age is 80 years or older. This discrepancy represents a challenge when considering the promising new regimen shared at a recent medical conference or published in the latest journal. Navigating this landscape requires a shift in mindset from a tumor-centric to a patient-centric approach, where biological age plays a lesser role and functional capacity becomes paramount.
According to Efrat Dotan, MD, a gastrointestinal medical oncologist and executive medical director at the Ann B. Barshinger Cancer Institute at Penn Medicine Lancaster General Health, who chairs the National Comprehensive Cancer Network (NCCN) Older Adult Oncology Guidelines, the first and most critical step is abandoning age as a sole criterion.
“You can have somebody who is 60 years old who is much more frail than an 80-year-old,” Dotan said during an interview with Targeted Therapies in Oncology. “It really boils down to function and the composite of domains that we evaluate to understand how an older adult can tolerate treatment.”
Comprehensive Geriatric Assessment
The gold standard for this evaluation is a Comprehensive Geriatric Assessment, a multidisciplinary diagnostic process that scrutinizes functional status, comorbidities, cognition, nutrition, psychological state, social support, and polypharmacy.1
Although ideal, its thorough nature is often prohibitive in a busy community practice. This has led to the development of practical screening tools like the G82 and VES-13,3 though Dotan cautions that these are imperfect. “The challenge with these screening tools is that they’re very limited in what they find. A lot of them are age dependent…that’s not true for every 80-year-old person.”
The solution, championed by both the American Society of Clinical Oncology4 and the NCCN,5 is a “Practical Geriatric Assessment.” This streamlined approach focuses on key evaluations—a brief functional, nutritional, and cognitive assessment—to provide a sufficiently detailed snapshot of a patient’s fitness without consuming a clinic’s entire schedule.
The investment of time up front, Dotan argues, pays significant dividends downstream. “If you look at the data from trials like GAIN (NCT02517034)6 and GAP70+ (NCT02054741),7 they have shown a significant decrease in grade 3 or higher toxicities with treatment if you [adopt] geriatric assessment–driven care.”
Gaps in Community Practice
Implementing this strategy reveals the most significant gaps community oncologists face. The first is simply having the time and personnel to conduct even a brief assessment. The second is a profound lack of data.
“We don’t have good data on a lot of these new drugs…[especially about] how older patients will tolerate them. We don’t have data to guide dosing,” Dotan said. This forces clinicians into a difficult position of extrapolating data from younger, fitter populations onto their vulnerable older patients.
The third gap is one of resources. Identifying a problem is valuable only if you can fix it.
“If you identify something, do you have the resources to support the patient?” Dotan asked. Access to physical therapy, nutritionists, social workers, and palliative care is not uniform across all community settings, leaving oncologists with a diagnosis but no prescription for the underlying vulnerabilities they uncover.
Toxicity Management
When managing specific toxicities, the principles of heightened vigilance and nuanced application apply across treatment modalities.
For immunotherapy, while the overall incidence of immune-related adverse events may be similar to that of younger patients, the management of those toxicities requires greater care.
“Putting an older adult on high-dose steroids can be problematic, for example,” Dotan explained, citing risks of exacerbated diabetes, muscle weakness, and functional decline. For newer immunotherapies like chimeric antigen receptor T cell and bispecific antibodies, a frank acknowledgment of the unknown is necessary due to a sheer lack of data in older populations.
This principle extends to monitoring frequency, as well. Dotan advocates for more frequent check-ins, potentially leveraging telemedicine, especially early in treatment.
“I typically in older patients prefer [shorter infusion intervals]…because I think there’s a lot of unknowns.…Older patients are less likely to call [if they’re experiencing safety issues]. They don’t want to be a burden.” Cardiac and pulmonary monitoring also require a lower threshold due to higher baseline risks.
The guidelines wisely avoid rigid rules for holding or discontinuing treatment. This decision, Dotan explained, is deeply personal and must be guided by the patient’s goals. “There are many studies…showing that older patients are more likely to value quality of life, maintaining their independence rather than survival.” The oncologist’s role is to provide the tools and information for a shared decision that aligns with those values.
Polypharmacy and Supportive Care
One of the most actionable areas for immediate improvement is the management of polypharmacy.
“This is a very low-hanging fruit,” Dotan asserts. A thorough review of a patient’s medication list can identify duplicates, unnecessary prescriptions, and high-risk interactions that could compromise adherence and increase toxicity. Engaging a pharmacist, even periodically, can yield significant benefits.
In supportive care, a proactive stance is paramount. Given the reduced bone marrow reserve in older adults, Dotan is “very quick to use growth factors” to prevent hospital admissions caused by neutropenic fever. While hydration must be balanced against cardiac function, optimizing antiemetics and, crucially, integrating early palliative care are emphasized. Palliative care’s proven benefits in quality of life and even survival make it an essential partner in managing the complexities of cancer care for older adults.
A Paradigm Shift
The central message from Dotan is one of urgent priority. The aging demographic is not a future concern; it is the present reality of every oncology clinic.
By adopting a practical geriatric assessment, creatively addressing resource gaps, and fiercely maintaining a patient-centric focus, community oncologists can ensure their oldest and often most vulnerable patients receive the thoughtful, effective, and dignified care they deserve.
