This year we had several very important advances in medical oncology in the field of geriatric oncology. I had the pleasure of discussing some of those advances at this year’s annual meeting of the International Society of Geriatric Oncology which was held virtually for the first time. Although there have been many interesting papers and novel concepts in geriatric oncology during the year, I think that the most relevant information was presented at the ASCO annual meeting of the year. There was a session which was dedicated entirely to geriatric oncology and in which four randomised clinical trials looking at the implementation of the geriatric assessment and of geriatric assessment based care in the care of older adults with cancer was discussed. These randomised clinical trials represent for the first time hard evidence showing that geriatric assessment based care can actually lead to improved outcomes for older adults with cancer and these outcomes include improved quality of life, reduced hospitalisation and emergency room utilisation and a decrease in severe toxicity and all of these without affecting survival. So, for me, those were the most important advances of the year.
During the annual meeting I talked about three of those trials. The first trial was the GAP-70 trial which was led by the University of Rochester and conducted in 41 community sites in the US. They looked at the effect of providing GA-guided recommendations to oncologists working in community practices. What they saw was that providing oncologists with geriatric assessment based recommendations actually led to a reduction in toxicity. This was partly due because oncologists who were given the geriatric assessment were more likely to reduce the dosing of chemotherapy for older patients.
The interesting thing is that even though patients got dose reductions, this did not affect their survival. So it seems that actually for some patients adjusting dosing and monitoring treatment plans actually may lead to improved quality of life without affecting survival and this is something that we knew before but this is the first time it has been shown in a randomised clinical trial.
The second trial, which was presented by Dan Li and colleagues, was conducted at City of Hope and they looked at the effect of a multidisciplinary team and geriatric assessment guided interventions in patients with solid tumours. What they found was that actually having a geriatric team which assists and performs some interventions in the patients actually led to a reduction in toxicity, to an increase in advanced directed completions. There were no changes in other outcomes such as hospitalisations but this actually showed that having a multidisciplinary team can improve the outcomes of older patients who are getting chemotherapy.
The third trial, which was also very interesting and was conducted in Australia, it’s called INTEGERATE by Soo and colleagues. What they saw was they studied the effect of having co-management by a geriatrician and an oncologist on older patients who were getting treatment. What they found was that having a geriatrician co-managing patients with the oncologist actually led to improved quality of life or to a reduction in the decline of quality of life and also, very importantly, to a decrease in hospital utilisation.
So this year we have three trials of different forms of geriatric assessment based interventions that actually show improvement in hard oncological outcomes. So we have two that show that geriatric assessment improves toxicity; we have one that shows that it improves hospital utilisation and quality of life and we have seen that this does not seem to detrimentally affect survival. One of the important things about this is that these studies can be implemented across several settings. So if you have an academic institution where you have all the resources available and a multidisciplinary team with geriatric training, you can actually implement some of the things they did in the GAIN trial. If you are working in an institution where geriatricians are available but perhaps you don’t have a specific geriatric oncology team, you can still get help from the geriatricians to co-manage patients and this can lead to improved outcomes such as in INTEGERATE.
And if you are working in a community clinic or in a hospital network, you can actually have patients get their geriatric assessment somewhere else and then get those recommendations and follow them and this can also lead to improved toxicity such as they did in GAP-70. So it’s very interesting because we have these trials that can adapt to different healthcare systems and different resource settings.
I think that what we have to work on from now on is actually doing some implementation science to show how these different strategies can be implemented across countries. Because, of course, all of these trials were conducted in countries with a high income and it’s difficult to extrapolate these results to other settings. But I think that these models can be tailored and adapted to work anywhere in the world.
These papers will be very impactful for the future. Although these results are, in itself, practice-changing, I also think that they lay the foundation for more work. So we need, as I said before, we need to work on how to actually implement this in everyday clinical practice. We need to provide tools to oncologists who are working all around the world to perform these assessments and to undertake the different interventions that need to be done in order to improve the outcomes of patients.
So this is a great trial for geriatric oncology and it lays the foundation for the next set of studies. We no longer need to prove that doing a geriatric assessment or that geriatric oncology is useful, now we have to actually do it in a way such that every older adult in the world can get this type of care.