SIOG has established a COVID-19 working group because obviously there is a substantial risk of under-treatment and over-treatment in older patients with cancer and there is a substantial risk of treatment variation within the context of the COVID-19 pandemic has become even more important to assess, establish, and also to tackle.
The problem with managing cancer in older patients during COVID-19 is that the pandemic can really pose a significant barrier to equal and evidence-based care in this setting. So the society, SIOG, has decided to group together a number of specialists, including medical oncologists, radiation oncologists, geriatricians, surgeons, pharmacists, nurses, allied healthcare professionals in general, to really try and understand how we could set out a set of recommendations that clinicians all over the world could consider to try and minimise the risk of managing this population of patients with suboptimal care, essentially.
Another issue with older patients is obviously that they have a more limited life expectancy which obviously makes survival benefits of anti-cancer treatment less relevant in this patient population compared to, for example, other endpoints like quality of life, functional status and treatment tolerability. Again, during the COVID-19 pandemic this becomes an even more important problem.
So, what we did is essentially publishing a set of recommendations that are now available in paper format in the Journal of Geriatric Oncology which is the SIOG official journal. In these recommendations we outline suggestions regarding the management of surgical aspects or radiation treatment or, again, systemic treatments for cancer in the coronavirus pandemic. We also stressed the importance of using geriatric assessment to determine who are the patients that are more likely to not have any adverse outcomes on some specific anti-cancer treatments and also to better estimate survival and add benefit also, or less detrimental impact, on quality of life outcomes.
The issue with geriatric assessment at the moment is that obviously they are more difficult to conduct in the context of COVID-19 because we are relying much more on telemedicine, for example, phone and video consultations. In our paper we stress the importance of the possibility of essentially using telemedicine also to deliver geriatric assessment. This is something that, for example, the University of Rochester [??] SIOG care team in the States have showed us that it’s feasible, it’s feasible to deliver geriatric assessment remotely, even in this context.
There are also self-administered tools that we can use, that we can implement within our clinics, such as the G8, the VES13, that are available in formats in questionnaires that patients can complete themselves and then we can use to screen them for frailty vulnerabilities and discuss in the clinic.
Were there any ethical issues discussed in this working group?
Given that the benefits of anti-cancer treatment are maybe different in older patients, this has a particular implication with regards to ethical considerations because obviously in younger patients they may be more sensitive about survival outcomes and survival benefit whereas in older patients I need to consider also other endpoints such as quality of life and functional endpoints and treatment tolerability. So it is absolutely critical to determine which are those patients that may be seemingly frail but actually do benefit from anti-cancer treatment, standard cancer treatment, as opposed to those that are seemingly fit but actually are quite prone to develop undue adverse outcomes on standard treatment that require obviously adjusted treatment plans.
There is a substantial risk in this context that older patients may be denied very effective treatment in terms of efficacy outcomes, in terms of survival and response rates, while they may also be safe, also in the older patient population. This is the most important dilemma that obviously clinicians have to consider in the context of what is going on with the COVID-19 situation.