Geriatric Assessment and More Inclusive Clinical Trials Needed for Older Adults with Lung Cancer

Older patients can benefit from supportive care and geriatric assessments before undergoing cancer treatment, especially as 60% of cancer incidence and 70% of cancer mortality occurs in patients over the age of 65, according to an expert at the CURE® Educated Patient® Lung Cancer Summit.

Dr. Efrat Dotan, associate professor and director of the hematology/oncology fellowship training program at Fox Chase Cancer Center in Philadelphia, spoke about the importance of supportive care in older adults with lung cancer and the challenges oncologists face when caring for them.

In an interview with CURE®, Dotan explains that it is more complicated to care for an older patient than a younger patient, partly due to psychologic changes but also because there aren’t much data on how to take care of these patients. Dotan says that these changes affect how oncologists can treat a patient, what drugs to use and what benefits could be seen from therapy.

“One thing I didn’t mention (in my presentation) is comorbidities,” Dotan said. “Older patients typically have other medical issues in addition to their cancer. So that means on top of giving them chemotherapy, they’re also on five or six other medications, and there might be interactions between the medications and the chemotherapy that you’re giving them.”

Personalized medicine can work in this patient population; Dotan noted that it should not just be personalized for the tumor but also for the patient who is receiving it by using a patient-centric approach to geriatric assessment.

“A geriatric assessment is a way to understand a patient’s overall health and fitness for therapy. Geriatric assessment is just a general term that encompasses evaluation of multiple domains that can affect outcomes,” Dotan said. This includes independent predictors of morbidity and mortality such as a patient’s functional status, comorbid medical conditions, cognitive function, psychological state, social support, nutritional status and geriatric syndrome (dementia, depression, falls, neglect and failure to thrive).

In her presentation, Dotan highlighted results from two studies that compared patients who received usual care with those who received treatment guided by geriatric assessment. In other words, patients in the assessment-guided treatment group underwent a geriatric assessment, had intervention based on abnormalities detected and then were treated. Both studies demonstrated a benefit for patients who received a geriatric assessment and a significantly improved rate of toxicities from chemotherapy.

In a study conducted by researchers at Fox Chase, results demonstrated that providers lack understanding around social support needs and cognitive function of patients, both of which have a direct impact on care. The study highlighted a need for a third geriatric assessment among oncology patients over the age of 85, Dotan said.

“When you address not just the cancer but also the other factors, your patient is much better equipped to go through therapy and tolerate treatment. … We believe this is practice-changing data, and every patient that is seen with cancer and is planning to undergo therapy should have this intervention,” Dotan said.

The top three reasons for geriatric assessment not being done in all patients from community oncologists were time constraints (60%), limited familiarity with tools (49%) and limited personnel (46%). A few screening tools have now been implemented to help with these problems such as the G8 tool (helps identify a patient’s risk for geriatric issues) and the chemotherapy prediction toxicity tool, both of which take a few minutes to complete. Guidelines have also been released to show how to manage older patients from American Society of Clinical Oncology, National Comprehensive Cancer Network and the Society of Geriatric Oncology.

Dotan explained that as a medical community, there should be a “push” for more clinical trials that include the type of patients that clinicians are seeing so when they do treat them, they have data to guide them. Previous trials were conducted on much younger patients, so results may be different in an older population.

Some ways to improve this disparity are the design of the trials, enrolling patients and also changing the culture, which includes collecting more data specific to older patients such as comorbidities and functional status. Trials must also have adjustments in eligibility criteria to include patients who are fit, which is a big push from the Food and Drug Administration and other committees, Dotan said.

She also noted that it is not just about including patients in studies but also reporting on data that would be significant to them. She said older adults would value data from trials on rates of hospitalizations or effects on independence, functional status and quality of life rather than data on survival.

“It’s not just a matter of prolonging life, but prolonging life with good quality of life and focusing on other factors that are really critical for an older adult,” she said.

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