medwireNews: Incorporating geriatric assessment-guided management into the care of older patients receiving anticancer therapy could reduce the risk for treatment toxicity and falls as well as polypharmacy, suggests a cluster randomized controlled trial.
“This study shows that simply providing information about health status through a geriatric assessment summary tied to management recommendations can improve upfront decision making for treatment and optimise clinically significant outcomes,” write the investigators in The Lancet.
They continue: “Geriatric assessment and geriatric assessment-guided management should be considered the standard of care for older patients with advanced cancer and ageing-related conditions who are starting a new treatment regimen with a high risk of toxicity.”
Marije Hamaker (Diakonessenhuis Utrecht, the Netherlands) and Siri Rostoft (University of Oslo, Norway) say in a related commentary that the study “represents a leap forward in geriatric oncology.” But highlighting that the study focused on the palliative setting, they question whether “the geriatric assessment-based intervention has a similar impact on older patients receiving chemotherapy in a curative setting, where considerations regarding benefit and willingness to accept toxic effects might differ.”
For the GAP70+ study, 40 community oncology practice clusters across the USA enrolled 718 patients aged 70 years or older, with advanced solid cancer or lymphoma and at least one geriatric assessment domain impairment (mean 4.5), who were initiating a new treatment regimen with a high toxicity risk.
The majority (87%) of participants had stage IV disease and a third (34%) had gastrointestinal cancer, with lung (25%), genitourinary (15%), and breast cancer (8%) the next most common tumor types in the study population.
In all, 16 practice clusters were randomly assigned to the intervention, which involved the provision of a tailored geriatric assessment summary and management recommendations to the oncologist, and 24 to usual care.
Adverse events (AEs) of grade 3–5 were experienced by 51% of 349 patients from practices receiving the intervention during the initial 3 months of treatment, which was significantly lower than the rate of 71% among the 369 patients treated in practices assigned to usual care, and equated to an adjusted risk ratio (RR) of 0.74 in favor of the intervention.
The geriatric assessment intervention was also associated with a reduced incidence of new falls over the 3-month study period, at 12% versus 21% with usual care, which corresponded to a significant RR of 0.58 after adjusting for a history of falls.
And a significantly greater number of medications were discontinued in the intervention than usual care group, with a mean adjusted difference of 0.14 medications, report Supriya Mohile (University of Rochester Medical Center, New York, USA) and collaborators.
Of note, there was no significant difference in survival between the groups at either 6 months or 1 year, even though participants in the intervention group were significantly more likely to receive treatment at a reduced dose intensity in the first cycle than their counterparts in the usual care group, and had a significantly lower relative dose intensity over the 3-month period.
The researchers caution, however, that “[s]ince survival was a secondary aim and only captured for 1 year, the study was not designed to examine non-inferiority between the study groups.” Therefore, “further research is required to evaluate the effects of geriatric assessment interventions on survival as a primary aim and for tumour control,” they add.
Speaking to medwireNews, Mohile said that “the GAP70+ study adds support to a previously published clinical trial, the GAIN study, to show that geriatric assessment and management lowers toxicity for older patients with cancer.”
She noted that the GAP70+ and GAIN studies differed with regard to the design (multicenter vs single center) and the model of care, but “both studies show that older patients with cancer benefit from an aging-sensitive approach to oncology care delivery and thus geriatric assessment and management should be integrated into oncology care as a standard.”
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Lancet 2021; doi:10.1016/S0140-6736(21)01789-X
Lancet 2021; doi:10.1016/S0140-6736(21)01998-X