BEVERLY CANIN DIDN’T WANT CHEMOTHERAPY. She was 66 years old in 2000, recently widowed and diagnosed with stage I breast cancer.
Canin, now 90 and living in Rhinebeck, New York, says that, although treatment guidelines at the time recommended a course of chemotherapy after surgery, the cancer had been caught at a very early stage. Reading the research did not convince her she needed all that treatment.
“I went to the medical oncologist and wanted to question the need for chemotherapy,” Canin says. “Given the diagnosis that I had, statistically, the benefit that I might gain from the chemotherapy was not worth it to me.”
People 65 and older represent 58% of cancer patients, and the risk of receiving a cancer diagnosis rises as a person grows older. These patients also carry a higher risk of comorbidities—having medical conditions besides cancer—than younger patients do. Despite this, older patients and their doctors have to work with treatment standards developed using research done in younger populations that may not be appropriate for their physical health or their goals for care.
Understanding Older Patients
“Chronological age is a very crude first step in understanding people’s medical needs or how you’re going to treat them,” says William Dale, a geriatrician and palliative medicine physician, as well as the director of the Center for Cancer and Aging at City of Hope, a comprehensive cancer center in Duarte, California. “It has some value, but it’s just a starting point.”
Beverly Canin
One challenge for getting beyond that starting point for cancer care is that older adults are largely unrepresented in the clinical trials that guide cancer treatment recommendations, says Supriya G. Mohile, a geriatric oncologist at Wilmot Cancer Institute, part of University of Rochester Medicine in New York.
Despite making up the majority of cancer diagnoses in the U.S., people 65 and older represent about 1 in 3 participants in clinical trials for new cancer drugs. Additionally, Mohile says, people in clinical trials tend to be healthier than the population in treatment. That’s because trials can exclude certain patients with other conditions, such as cardiovascular disease or diabetes, since these conditions can adversely affect the outcomes of drug trials.
“That makes it a challenge when we’re in [the] clinic, when we’re seeing older adults,” Mohile says. Doctors may be concerned that a recommended treatment is more than their patient can tolerate. “But we don’t really have objective evidence to say they can or they can’t based on the clinical trial itself.”
This puts health care providers in a position where they make calls case by case that could lead to giving too little or too much treatment. Mohile says undertreatment can occur when a provider withholds or prematurely reduces the dose of a potentially beneficial treatment because of the patient’s age alone. On the other side, those who provide standard recommended doses with little consideration for factors such as existing health conditions risk toxic side effects.
Geriatric Assessment
Just because two patients are diagnosed with cancer at the same age, it does not mean they will share the same level of fitness, comorbidities, prescriptions or care priorities. In the past 10 years, efforts to better understand how to treat cancer in older adults have led to valuable new tools and treatment recommendations.
One of the main tools researchers have offered to help doctors better understand an older patient’s individual needs is geriatric assessment. The aim is to evaluate several domains that can affect how a person responds to treatment, including physical performance, functional status, comorbidities, other medicines being taken, nutrition, cognition, social support and psychological status. This information is then used to provide evidence-based recommendations to adjust care instead of relying on the judgment of individual doctors.
A study Dale co-authored in JCO Oncology Practice in 2021 found that 69% of cancer care providers surveyed used their own judgments about patients to make decisions about care without performing a formal assessment. He recalls conversations with colleagues who said a patient was fit because they came to their appointment looking put together and nicely dressed, or they drove to the clinic on their own. Dale says a geriatric assessment can help provide a more rigorous way to distinguish problems in cognition and function. “We keep studying this, and the truth is we’re just not good at it,” Dale says about doctors intuiting a patient’s condition without a formal assessment.
A full assessment with a geriatric specialist can involve a battery of tests to measure how a person functions in daily life, their thinking and memory, social supports, nutrition and other factors. Less comprehensive tools have been developed that oncologists can use in centers that do not have access to specialty care. These assessments include short tests to evaluate several health domains using information reported by the patient, simple tests administered in the clinic and reports from other people in the patient’s life.
Older patients are often missed in clinical research, but new efforts aim to better understand treatment in this group.
Clinical trials have eligibility requirements that restrict who is allowed to join in order to more clearly show whether the drug works in cancer and to limit the potential harm to people with other health problems. However, overly broad restrictions have created a gap between the relatively fit and young population included in clinical trials and the real-world population who take these drugs.
“If you think most of the patients with prostate cancer are older … then you should have a similar percentage of older adults in studies for prostate cancer. You shouldn’t have 50-year-olds in those studies,” says medical oncologist Efrat Dotan, the executive medical director of Penn Medicine Lancaster General Health Ann B. Barshinger Cancer Institute in Lancaster, Pennsylvania. “But that’s not what we see.”
Though many trials have moved away from capping eligibility at a certain age, Dotan says restrictions on functional status, organ function, blood counts and other conditions disproportionately affect older patients who remain underserved by research. She says easing these restrictions can open trial participation to more people and provide oncologists with better data to guide treatment decisions in older patients.
She points to recommendations published in the Journal of Clinical Oncology in 2017 for ways clinical trial eligibility requirements can be safely loosened to establish a more representative sample of the treatment population. These recommendations from a working group organized by the American Society of Clinical Oncology and Friends of Cancer Research, a nonprofit advocacy group, include easing restrictions on kidney function for drugs that aren’t cleared by the kidneys and don’t pose a risk to them. They also suggest allowing some people with previous cancer diagnoses to participate where it makes sense. “Somebody in their 80s may have had breast cancer resected 20 years ago. Who cares about that if they’re now being treated for colon cancer?” Dotan says.
The Food and Drug Administration established Project Silver to improve the evidence base for cancer treatment in older adults and issued guidance in 2022 for researchers to include people over the age of 65, especially people over the age of 75, in clinical trials. This guidance included suggestions for recruitment and accommodations for older patients, as well as trial designs that are stratified by age to understand how different groups do with the treatment.
“There’s still a long way to go, but I think we see slow and steady steps towards getting to a better place,” says Dotan.
The GAP70+ study, published in the Lancet in 2021 and including both Mohile and Dale as co-authors, looked at cancer patients 70 and older whose care was guided by a geriatric assessment compared with patients getting usual care. It found that those in the assessment group were less likely to experience severe (grade 3 to 5) treatment side effects and had fewer falls over three months of study. People who received geriatric assessment also were more likely to receive lower-intensity treatment—for example, a chemotherapy combination that leaves off one of the standard drugs or is given at a lower dose from the start—and required fewer dose adjustments.
Dale and Mohile were authors on the 2023 updated guideline put out by the American Society of Clinical Oncology (ASCO) recommending geriatric assessment for all patients over 65. Dale also helped develop the Practical Geriatric Assessment, a further abbreviated way to test the domains included in other tools in 10 minutes or less. The practical assessment uses mostly patient-reported information to make it as easy as possible for time-crunched doctors in community cancer clinics.
Widespread uptake of formal geriatric assessments has been slow. The 2021 JCO Oncology Practice study found that fewer than 30% of cancer care providers reported using validated geriatric assessment tools. The most common barriers to offering geriatric assessment cited by doctors who were aware of the ASCO recommendation were not having enough time and not having enough staff.
Yet testing older patients with geriatric assessment pays off, says Efrat Dotan, a medical oncologist and the executive medical director at Penn Medicine Lancaster General Health Ann B. Barshinger Cancer Institute in Lancaster, Pennsylvania. One of the most important things doctors can learn from geriatric assessment, Dotan says, is the risk of chemotherapy toxicity. “I think what the geriatric assessment identifies for you is those patients that look OK when you see them in [the] clinic, then you give them chemo, and somehow the glue that keeps them together melts away and then they fall apart.”
Older patients may be susceptible to severe toxicities, or side effects from treatment that require medical attention. Dotan gives the example of diarrhea, a common side effect. Diarrhea could lead to dehydration and put an older person at risk of kidney failure and a hospital stay. “That’s what you try to avoid—those really high-risk toxicities that are not worth it,” Dotan says. Geriatric assessment tools can flag when patients are likely to have severe side effects so doctors can discuss dose adjustments and other treatment options before a crisis.
The past 15 years have seen an explosion in the number of cancer treatments, including approvals of new immune checkpoint inhibitors, antibody-drug conjugates, bispecific T-cell engagers and CAR T-cell therapies. Many of these treatments have side effects that are different and sometimes less severe than chemotherapy that make them attractive to people who may not be fit enough or would prefer to avoid toxicities from chemo. Dotan says immunotherapy in particular has made it possible to treat many patients for whom chemotherapy would be too toxic.
But the rush to embrace treatments seen as less toxic brings its own potential for overtreatment. Mohile says with older patients still underrepresented on clinical trials, doctors are again trying to judge appropriate treatments without enough data, leading some to prescribe therapies to more frail patients while underestimating the risks.
Identifying Goals for Care
Another benefit of a geriatric assessment is that it can prompt more discussion about a person’s goals for care, Dale says. One patient may want to do everything possible to increase their chance of survival and reduce the risk of cancer returning. That might mean surgery, the full standard dose and schedule of chemotherapy, and radiation therapy, among other options. Another patient may not want to trade quality of life now for a reduction in the risk of cancer returning. They may prefer to get a less intense treatment or to completely avoid certain treatments.
Such was the case for Canin, whose breast cancer diagnosis predated many of the geriatric assessment tools available today. Of her decision to forgo chemotherapy, she says, “I didn’t want to compromise my immune system unnecessarily. I knew that chemotherapy was toxic.”
Dotan says side effects can affect an older person’s ability to perform the tasks necessary in daily living, and that can affect their independence. “Those may be factors that carry much more weight in terms of decisions, over just ‘How long am I going to live?’ or ‘How much longer am I going to gain?’” she says.
Chuck O’Shea has experienced how treatment can change a life. When O’Shea, of Long Beach, California, was diagnosed with non-Hodgkin lymphoma in 2008 at 61, he was fit and active. He and his wife, Eileen, were operating a small business together, and he was a runner who had completed some 30 marathons. Within eight weeks of starting treatment, he had stopped running altogether.
O’Shea was on a combination of three chemotherapies plus the steroid prednisone and the targeted therapy rituximab for 16 weeks. “I didn’t feel great. I felt weak. I felt fatigued. I couldn’t sleep,” O’Shea says. Determined to get some activity, he walked every day. After chemotherapy ended, he says a PET scan showed that the cancer had responded well to treatment, but his doctor recommended continuing the rituximab for another year to be safe, and O’Shea went with her recommendation.
Eileen and Chuck O’Shea
With chemotherapy behind him, O’Shea began running again but struggled to get back to the same level of fitness he enjoyed before treatment. After finishing, he and Eileen flew to Paris to run a marathon in 2010. “And that was the last marathon I ran,” O’Shea says.
Now 77 and a patient advocate with the Cancer and Aging Research Group (CARG), a consortium that brings together geriatric oncology experts to implement more cancer research in older adults, O’Shea spreads the word about geriatric assessment to make informed decisions about care. “My quality of life is so much more important to me now than it was. In fact, I think I probably took it for granted when I was 61,” O’Shea says. “I can’t run marathons anymore, but I can still stay pretty active. And that has really grown in importance to me.”
Practical Measures
Not all the interventions that come out of geriatric assessment relate directly to treatment decisions. Some involve what Dale calls “optimizing”—getting care and support for the patient so they are in the best shape to handle treatment.
Many older patients are classified as vulnerable, according to Mohile. That means they are not so fit that they can be treated without any concerns, nor are they so frail that they are at high risk for adverse events from treatment.
“That’s where the test can be very helpful because it can be very nuanced,” Mohile says. “This person seems fit, but maybe they’re on 10 meds that they’re not taking correctly. Or maybe they have mild memory problems and need extra support. We can recommend treatment for the people in the middle, but they [may] need extra support through interventions that are geriatrics based.”
Resources are available to help patients and doctors identify age-related concerns in cancer care.
Multiple tools have been developed to help understand potential risks faced by older patients about to start cancer treatment when a comprehensive exam by geriatric specialists may not be available. Here are a few validated assessment options that can be completed by an oncologist:
Practical Geriatric Assessment: The American Society of Clinical Oncology has the Practical Geriatric Assessment available as a PDF. Patients can access and fill out most of the questionnaire at home and then bring it to a doctor to complete the assessment and discuss the findings.
CARG Geriatric Assessment: The Cancer and Aging Resource Group (CARG) has resources for older cancer patients and providers, including a geriatric assessment tool. The patient form can be completed online to generate a report you can bring to your next appointment.
CRASH: The Chemotherapy Risk Assessment Scale for High-age Patients (CRASH) is an assessment for oncologists that can be completed in under 30 minutes. It predicts severe chemotherapy toxicity in older adults according to four risk categories.
Geriatric Screening: The G8 and the Vulnerable Elders Survey (VES-13) are short screening tools used by doctors to identify people who may benefit from a more comprehensive geriatric assessment.
Interventions can include referrals to physical therapy or a social worker. Mohile says she might recommend an emergency call button for someone who is at risk for falls. These practical measures are not just about making someone more comfortable but can be important for the success or even the possibility of treatment.
For some patients, a little assistance can go a long way. Dotan says, “If you identify things that are related that are fixable, then maybe that opens the door for treatment.”
Empowering Patients
With guidelines already encouraging geriatric assessment, advocates for assessment tools are now appealing directly to patients. If older patients demand cancer care that takes into account their age and physical condition, providers will use assessments and other tools to better meet those needs, Dale says. Canin and O’Shea, co-chairs for SCOREboard, a patient oversight board for CARG, say they and others have discussed how to get the word out to patients that they can and should ask for assessment tools to help guide their care.
Patients can start by visiting the CARG website, which provides assessment forms that patients can complete themselves and bring to their doctors. Researchers and patient advocates both say that assessments can open up conversations about treatment goals and the needs and values patients bring to their health care. O’Shea and Canin say people should feel comfortable participating in their own care, and a big part of that is growing the confidence to ask questions of their doctors. “There are no wrong questions. There are no bad questions,” Canin says.
In the 24 years since Canin was first diagnosed with cancer, she has put a lot of time into patient advocacy and working with doctors and researchers, but she says the fundamentals of decision-making have remained consistent. It starts with understanding that each case is different and gathering as much information as possible. A geriatric assessment is a tool designed to do just that, and she hopes it becomes standard for every older patient who needs cancer treatment.
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