In a breakout session at this year’s ASCO Genitourinary (GU) Cancers Symposium, a multidisciplinary panel defined frailty, described geriatric assessment, and highlighted interventions in cancer treatment for older adults.
Sindhuja Kadambi, MD, said that although most patients with GU cancers (of the prostate, kidney, and bladder) are at least 65 years old, current clinical trials don’t adequately inform how to best treat older patients. Chronologic age is often used as a surrogate for life expectancy and fitness for and benefit from treatment, but provides an incomplete picture of overall physiologic age.
Studies show that fit older patients with GU cancers benefit from standard guideline based curative intent treatment, yet these patients are often under-treated. The challenge for oncologists is to identify patients who would benefit from guideline-recommended treatment vs not overtreating those who are at high risk for adverse events (AE).
Dr. Kadambi noted that oncologists are not accurate in identifying fit vs frail patients. This is where geriatric assessments (GA) can help guide treatment and supportive care. She said, “ASCO guidelines recommend the GA should be implemented in our clinical practice for all patients over the age of 65. When we surveyed oncologists, very few actually use it in clinical practice. Obviously there are significant barriers. We hear all the time about limited time, space, expertise. Then we have the question of does it really help?”
There are, she noted, multiple effective models of incorporating the GA into clinical practice that can be done across different systems with varying resources, including simple tools like the Vulnerable Elders Survey (VES)-13 and the Geriatric (G) 8 screening tool.
Dr. Kadambi said all older patients with GU cancer should undergo a GA, which can assist with treatment decision-making and can improve outcomes.
A discussion of rethinking clinical trial endpoints followed. Sarah Psutka, MD, pointed out that some older adults with cancer may prefer less aggressive therapy if it preserved their quality of life (QoL) vs therapy that could increase length of life. Oncology clinical trials focus on outcomes like AE, cancer-specific survival, and other metrics, whereas older adults value non-traditional outcomes like functional recovery, cognitive trajectories, maintaining independence, time spent at home, and QoL, and it’s important to integrate these outcomes into clinical trial designs.
BounceBack, a prospective, observational cohort of patients undergoing radical cystectomy is tracking these kinds of outcomes across episodes of care to help understand predictors of the recovery trajectory.
Dr. Psutka, also discussed challenges presented by frailty, a risk factor that may be addressed by a personalized supportive care pathway to help patients while undergoing therapy. Strategies include prehabilitation, interventions to improve functional capability prior to treatment, and rehabilitation, interventions following treatment to aid in recovering/improving functional capacity, reducing the risk of cancer recurrence and other morbidities.
The 2022 Exercise, Diet, and Weight Management During Cancer Treatment: ASCO Guideline states that oncology providers should recommend aerobic and resistance exercise during active treatment to mitigate side effects of cancer treatment, although uptake is limited among patients in real life.
Dr. Lederman has no conflicts of interest to report.
Illustration by April Brust
