ASCO SPECIAL ARTICLES
Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy: ASCO Guideline Update
2Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
3University of Alabama at Birmingham, Birmingham, AL
4Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
5CETTRO Cancer Research Hospital in Brasilia, Brazil
6University of Louisville, Kent School of Social Work, Louisville, KY
7Novant Health Cancer Institute/SCOR NCORP, Winston-Salem, NC
8Englewood Health, Englewood, NJ
9City of Hope Comprehensive Cancer Center, Duarte, CA
10University of Rochester Medical Center, Rochester, NY
11University of Texas MD Anderson Cancer Center, Houston, TX
12Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL
13TATA Memorial Hospital Mumbai, Mumbai, India
14Department of Medical Oncology & Therapeutics Research, City of Hope Cancer Center, Duarte, CA
15Ohio State University Comprehensive Cancer Center, Columbus, OH
16WellStar School of Nursing, Kennesaw State University, Kennesaw, GA
17University of California, San Diego Moores Cancer Center, La Jolla, CA
18SCOREboard, Oakland, CA
19MD Anderson Cancer Center, Houston, TX
20Memorial Sloan Kettering Cancer Center, New York, NY
21Wake Forest University Health Sciences, Winston Salem, NC
22SCOREboard, Sharon, CT
23American Society of Clinical Oncology, Alexandria, VA
*W.D., H.D.K., and S.G.M. were Expert Panel Cochairs.
To update the ASCO guideline (2018) on the practical assessment and management of age-associated vulnerabilities in older patients undergoing systemic cancer therapy.
An Expert Panel conducted a systematic review to identify relevant randomized clinical trials (RCTs), systematic reviews, and meta-analyses from January 2016 to December 2022.
A total of 26 publications met eligibility criteria and form the evidentiary basis for the update.
The Expert Panel reiterates its overarching recommendation from the prior guideline that geriatric assessment (GA), including all essential domains, should be used to identify vulnerabilities or impairments that are not routinely captured in oncology assessments for all patients over 65 years old with cancer. Based on recently published RCTs demonstrating significantly improved clinical outcomes, all older adults with cancer (65+ years old) receiving systemic therapy with GA-identified deficits should have GA-guided management (GAM) included in their care plan. GAM includes using GA findings to inform cancer treatment decision-making as well as to address impairments through appropriate interventions, counseling, and/or referrals. A GA should include high priority aging-related domains known to be associated with outcomes in older adults with cancer: physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support. Clinical adaptation of the GA based on patient population, resources, and time is appropriate.
The Panel recommends the Practical Geriatric Assessment as one option for this purpose (https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf; https://youtu.be/jnaQIjOz2Dw; https://youtu.be/nZXtwaGh0Z0).
Additional information is available at www.asco.org/supportive-care-guidelines.
The purpose of this guideline is to update the 2018 ASCO guideline on practical assessment and management of vulnerabilities in older patients undergoing chemotherapy.1 ASCO updates its guidelines at intervals determined by the Expert Panel leadership, based on a literature search and the expertise of ASCO guideline panel members to identify signals in the literature.2 Signals are new, potentially practice-changing data that may translate into major revisions to current practice recommendations.
Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy: ASCO Guideline Update
To improve outcomes for older adults with cancer through recommendations for:
(1) use of validated geriatric assessment (GA) tools and GA-guided interventions, and
(2) management of common age-associated conditions identified through GA that may impact the care of those undergoing chemotherapy and other treatments.
Older adults (65+ years old) with cancer.
Oncologists (medical, radiation, and surgical), geriatricians, palliative medicine specialists, primary care physicians, advanced practice providers, pharmacists, oncology nurses, social workers, physical therapists, occupational therapists, nutritionists, dieticians, patients, and caregivers.
An Expert Panel was convened to update clinical practice guideline recommendations based on an updated systematic review of the medical literature.
See Table 1 for the full list of recommendations.
All patients with cancer age 65 years and over with GA-identified impairments should have GA-guided management (GAM) included in their care plan. GAM includes using GA results to (1) inform cancer treatment decision-making, and (2) address impairments through appropriate interventions, counseling, and/or referrals.
This includes older adults receiving systemic therapy, including chemotherapy, targeted therapy, and/or immunotherapy (Type: Evidence based, benefits outweigh harms; Evidence quality: High; Strength of recommendation: Strong).
A GA should include high priority aging-related domains known to be associated with outcomes in older adults with cancer to include assessment of physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support (Type: Evidence based, benefits outweigh harms; Evidence quality: High; Strength of recommendation: Strong).
The Panel recommends the Practical Geriatric Assessment (PGA) as one option for this purpose. See the PGA tool at: https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf. See how to use the PGA tool at: https://youtu.be/jnaQIjOz2Dw; and https://youtu.be/nZXtwaGh0Z0 (Type: Informal consensus; Evidence quality: Moderate; Strength of recommendation: Weak).
Definitions for the quality of the evidence and strength of recommendation ratings are available in Appendix Table A1 (online only). More information, including a supplement with additional evidence tables, slide sets, and clinical tools and resources, is available at www.asco.org/supportive-care-guidelines. The Methodology Manual (available at www.asco.org/guideline-methodology) provides additional information about the methods used to develop this guideline. Patient information is available at www.cancer.net.
ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care, and that all patients should have the opportunity to participate.
The present update was prompted by the publication of two large randomized clinical trials (RCTs), Geriatric Assessment for Patients 70 Years and Older (GAP70+)3 and Geriatric Assessment-Driven Intervention (GAIN)4 that evaluated whether integration of geriatric assessment (GA) and GA-guided management (GAM) would reduce serious chemotherapy-related toxic effects in older adults with cancer. GAP70+ enrolled patients 70 years old or older who had advanced cancer (solid tumors or lymphoma) with at least one GA-identified vulnerability and were receiving a new treatment regimen; GAIN enrolled patients 65 years old or older with a solid tumor who were receiving a new chemotherapy regimen. Both found clinically significant benefits from GAM in reducing the primary outcome of chemotherapy toxicity.
This guideline update revisits the role of GA in patients age 65 years and older receiving systemic therapy for cancer. We note that the guideline now addresses systemic therapy, including chemotherapy, targeted therapy, and immunotherapy. In addition, based on data demonstrating that the uptake of guideline-recommended GA has been uneven at best,5,6 the update reconsiders the question of which GA tools are best suited for use in everyday clinical oncology practice. In that context, the update highlights and makes the case for the use of a Practical Geriatric Assessment (PGA) instrument designed to address barriers to routine implementation of GA in clinical practice. Clinical adaptation of the GA based on patient population, resources, and time is appropriate. The remaining recommendations from the 2018 guideline are unchanged because there were no new potentially practice-changing data to support other substantive revisions (Table 1). The evidence supporting these unchanged recommendations is reviewed in the previous guideline publication.1
This clinical practice guideline update addresses two overarching clinical questions: (1) What is the role of GA in older adults with cancer to inform specific interventions to improve clinical outcomes? (2) For older patients who are considering undergoing chemotherapy and other systemic treatments, which GA tools and component elements should clinicians use to predict adverse outcomes (including chemotherapy toxicity and mortality) and guide management?
This systematic review-based guideline product was developed by a multidisciplinary Expert Panel, which included two patient representatives and an ASCO guidelines staff member with health research methodology expertise (Appendix Table A2, online only). One full panel meeting was held and members were asked to provide ongoing input on the quality and assessment of the evidence, generation of recommendations, draft content, as well as review and approve drafts during the entire development of the guideline. ASCO staff met routinely with the expert panel co-chairs and corresponded with the panel via e-mail to coordinate the process to completion. The guideline recommendations were sent for an open comment period of 2 weeks allowing the public to review and comment on the recommendations after submitting a confidentiality agreement. These comments were taken into consideration while finalizing the recommendations. Members of the Expert Panel were responsible for reviewing and approving the penultimate version of the guideline, which was then circulated for external review, and submitted to the Journal of Clinical Oncology for editorial review and consideration for publication. All ASCO guidelines are ultimately reviewed and approved by the Expert Panel and the ASCO Evidence Based Medicine Committee (EBMC) before publication. All funding for the administration of the project was provided by ASCO.
ASCO uses a signals approach to facilitate guideline updating.2 This approach identifies new, potentially practice-changing data—signals—that might translate into revised practice recommendations. The approach relies on the Expert Panel co-chairs to identify potential signals in the literature via formal, annual update assessments of the original ASCO guideline. For this update, two phase III RCTs trials, GAP70+3 and GAIN,4 that evaluated if GAM interventions could reduce chemotherapy-related toxic effects in older adults with cancer, provided the signals. Corresponding electronic literature searches are then conducted to identify additional relevant studies.
The updated recommendations were developed based on a systematic review of evidence identified through electronic searches and, where adequate high-quality evidence was lacking, on the Expert Panel's best clinical experience and opinion. The Expert Panel searched the PubMed database (January 1, 2016–December 11, 2022) to identify any additional phase III RCTs and systematic reviews and meta-analyses of published RCTs, that addressed the update's clinical question regarding GA with management. Articles were selected for inclusion in the systematic review based on the following criteria:
• Population: older adults with cancer (65+ years old) considering undergoing chemotherapy and other systemic (nonsurgical or radiation) therapies.
• Interventions: GAM, GA-driven or -based intervention, GA integrated into oncology care (integrated oncogeriatric care), GA with or without tailored follow-up (TFU).
• Comparisons: standard or usual care (no GA summary or management recommendations provided to clinician).
• Outcomes: mortality, overall survival, chemotherapy completion without dose reductions or delays, treatment-related toxicity, patient satisfaction with communication about aging-related concerns, health-related quality of life, and functional and nutritional status.
• Sample size: ≥100 total patients across study arms.
To inform Clinical Question 2, the Expert Panel conducted an additional systematic literature review to identify articles addressing guideline-recommended1 uptake of GA among clinicians, with a focus on perceived barriers and facilitators12 for GA implementation among patients with cancer in everyday clinical practice. Two broad PubMed searches (January 1, 2017, to December 23, 2022) were conducted to identify systematic reviews, primary studies, and selected narrative reviews concerning GA implementation among adults with cancer.
All electronic searches were supplemented by articles identified by Expert Panel members and by reviews of the bibliographies of relevant articles. Articles were excluded from the systematic review if they were (1) meeting abstracts not subsequently published in peer-reviewed journals; (2) editorials, commentaries, letters, news articles, or case reports; (3) published in a non-English language; or (4) small-scale (<100 total patients) or pilot RCTs.
A guideline implementability review was conducted. Based on the implementability review, revisions were made to the draft to clarify recommended actions for clinical practice. Ratings for type and strength of the recommendation, and evidence quality are provided with each recommendation. The quality of the evidence for the primary outcomes of the nine RCTs informing Clinical Question 1 was assessed using the Cochrane Risk of Bias tool and elements of the GRADE quality assessment and recommendations development process.13 GRADE quality assessment labels (ie, high, moderate, low, and very low) were assigned for each outcome by the project methodologist in collaboration with the Expert Panel cochairs and reviewed by the full Expert Panel.
The ASCO Expert Panel and guidelines staff will work with co-chairs to keep abreast of any substantive updates to the guideline. Based on formal review of the emerging literature, ASCO will determine the need to update. The ASCO Guidelines Methodology Manual (available at www.asco.org/guideline-methodology) provides additional information about the guideline update process. This is the most recent information as of the publication date.
The entire Expert Panel contributed to the development of the guideline, provided critical review, and finalized the guideline recommendations.
The Clinical Practice Guidelines and other guidance published herein are provided by American Society of Clinical Oncology, Inc (ASCO) to assist providers in clinical decision making. The information herein should not be relied upon as being complete or accurate, nor should it be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. With the rapid development of scientific knowledge, new evidence may emerge between the time information is developed and when it is published or read. The information is not continually updated and may not reflect the most recent evidence. The information addresses only the topics specifically identified therein and is not applicable to other interventions, diseases, or stages of diseases. This information does not mandate any particular course of medical care. Further, the information is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients. Recommendations specify the level of confidence that the recommendation reflects the net effect of a given course of action. The use of words like “must,” “must not,” “should,” and “should not” indicates that a course of action is recommended or not recommended for either most or many patients, but there is latitude for the treating physician to select other courses of action in individual cases. In all cases, the selected course of action should be considered by the treating provider in the context of treating the individual patient. Use of the information is voluntary. ASCO does not endorse third party drugs, devices, services, or therapies used to diagnose, treat, monitor, manage, or alleviate health conditions. Any use of a brand or trade name is for identification purposes only. ASCO provides this information on an “as is” basis and makes no warranty, express or implied, regarding the information. ASCO specifically disclaims any warranties of merchantability or fitness for a particular use or purpose. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this information, or for any errors or omissions.
The Expert Panel was assembled in accordance with ASCO's Conflict of Interest Policy Implementation for Clinical Practice Guidelines (“Policy,” found at https://www.asco.org/guideline-methodology). All members of the Expert Panel completed ASCO's disclosure form, which requires disclosure of financial and other interests, including relationships with commercial entities that are reasonably likely to experience direct regulatory or commercial impact as a result of promulgation of the guideline. Categories for disclosure include employment; leadership; stock or other ownership; honoraria, consulting or advisory role; speaker's bureau; research funding; patents, royalties, other intellectual property; expert testimony; travel, accommodations, expenses; and other relationships. In accordance with the Policy, the majority of the members of the Expert Panel did not disclose any relationships constituting a conflict under the Policy.
A total of 15 publications met eligibility criteria and form the evidentiary basis for the guideline recommendation pertaining to Clinical Question 1.3,4,14-24 The identified publications include the respective primary reports of nine RCTs evaluating GAM3,4,14-20; four reports of secondary analyses of data from the primary RCTs23-26; one systematic review of GA studies22; and one systematic review of GA studies with meta-analysis.21
The identified RCTs were published between 2020 and 2022. The RCTs evaluated comparable GA with management interventions. For the clinical question concerning the role of GA in older adults with cancer to suggest specific interventions to improve clinical outcomes, the primary outcomes of the nine RCTs included completion of planned chemotherapy (n = 2)14,19; the proportion of patients with grade 3-5 toxicity (n = 2)3,4; quality of life (n = 2)16,17; overall survival (n = 1)20; a composite criterion of 6-month mortality, functional impairment (fall in the Activities of Daily Living [ADL] score ≥2), and weight loss (≥10%; n = 1)18; and patient satisfaction with communication about aging-related concerns (n = 1).15 Table 2 presents the characteristics of the nine included RCTs. Evidence tables are provided in the Data Supplement (online only).
A total of 11 publications were identified by the systematic review and form the evidentiary basis for the Clinical Question 2 guideline recommendations concerning which GA tools should be used to predict outcomes,5,6,12,27-34 and help inform the development of the PGA. The identified publications include reports published between 2018 and 2022 of seven clinician surveys,5,6,12,30,32-34 one systematic literature review,27 and three narrative literature reviews.28,29,31
The quality of evidence was assessed for each outcome of interest. This rating includes factors such as study design, consistency of results, directness of evidence, precision, publication bias, and magnitude of effect, assessed by one reviewer. Refer to Appendix Table A2 (online only) for definitions for the quality of the evidence, and the Methodology Manual for more information.
What is the role of geriatric assessment in older adults with cancer to suggest specific interventions to improve clinical outcomes?
The 2018 guideline recommended that, in patients ≥65 years receiving chemotherapy, GA should be used to identify vulnerabilities or other geriatric impairments that are not routinely captured in oncology assessments.1 The Panel reiterates that key recommendation here. For this update, the Panel expands on and strengthens the 2018 guideline's informal consensus-based recommendations for GA with management in light of recently published data on GAM from several key trials that had not yet been completed in 2018. Finally, the guideline update offers recommendations for use of a more clinically practical GA tool that streamlines the GA with a management approach that is now supported by data from seminal RCTs.
All patients with cancer age 65 years and over with GA-identified impairments should have GAM included in their care plan. GAM includes using GA results to (1) inform cancer treatment decision-making, and (2) address impairments through appropriate interventions, counseling, and/or referrals.
This includes older adults receiving systemic therapy, including chemotherapy, targeted therapy, or immunotherapy (Type: Evidence based; Benefits outweigh harms; Evidence quality: High; Strength of recommendation: Strong).
The systematic literature review identified nine RCTs3,4,14-20 that investigated the efficacy of GA with management for a range of primary endpoints in older patients with cancer (the results of RCTs identified by the systematic review are summarized in the Data Supplement). The GAP70+ and GAIN trials evaluated whether integration of GA and GAM would reduce serious (grade 3-5) chemotherapy-related toxic effects. GAP70+, a cluster randomized trial, enrolled 718 patients from 40 community oncology practice clusters; patients were 70 years old or older, had incurable cancer (solid tumors or lymphoma) with at least one identified vulnerability other than polypharmacy, and were receiving a new treatment regimen.3 Patients were randomly assigned to either a usual care group (n = 369) in which the treating oncologists received no GA summary or management recommendations, or to an intervention group (n = 349) in which oncologists received a tailored GA summary and management recommendations. The proportion of patients who had any grade 3-5 toxic effect within 3 months of starting a new high-risk treatment regimen was the primary endpoint of the trial; secondary endpoints included falls and polypharmacy. Analyses revealed that a lower proportion of patients (51%) in the intervention group experienced grade 3-5 toxic effects than patients in the usual care group (71%; relative risk [RR] 0.74 [95% CI, 0.64 to 0.86]; P = .0001). Over 3 months, patients in the intervention group also had fewer falls (12%) than patients in the usual group (21%; adjusted RR, 0.58 [95% CI, 0.40 to 0.84]; P = .0035), and had more medications discontinued (mean adjusted difference, 0.14 [95% CI, 0.03 to 0.25]; P = .015). Two recently published secondary analyses of data from GAP70+ reported, respectively, a significantly lower proportion of stage III and IV patients with lung cancer who experienced grade 3-5 toxicity in the intervention arm versus usual care (53.1% v 71.6%; P = .01)24; and, among 623 patients from GAP70+ with follow-up Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE) data, fewer patients in the GA intervention arm reported grade ≥2 symptomatic toxicity compared to usual care patients (overall: 88.9% v 94.8%; P = .035; core symptoms: 83.4% v 91.7%; P = .001).25
The GAIN randomized trial enrolled 613 patients from a National Cancer Institute (NCI)–designated cancer center. Patients were 65 years old or older with a solid tumor of any stage (71.4% had stage IV disease) who were receiving a new chemotherapy regimen; all patients had a completed GA. Patients were randomly assigned (2:1) to either a standard of care (SOC) arm (n = 203) or to a GAIN arm (n = 402). GA results were provided to treating oncologists for their review within 2 weeks of study enrollment for patients in the SOC arm. In the GAIN arm, a multidisciplinary team reviewed GA results and implemented interventions and referrals based on predefined GA thresholds. Both the patient and the treating oncologist were informed of the plan. The incidence of ≥grade 3 chemotherapy-related toxic effects was the primary endpoint; secondary endpoints included emergency department visits, advance directive completion, average length of stay, unplanned hospitalizations, unplanned hospital readmissions, and chemotherapy dose modifications and early discontinuations. An analysis of overall survival was done up to 12 months after the start of chemotherapy. In the GAIN arm, the ≥grade 3 chemotherapy-related toxic effects was 50.5% (95% CI, 45.6 to 55.4); in the SOC arm, the incidence was 60.6% (95% CI, 53.9 to 67.3), representing a significant 10.1% reduction (95% CI, −1.5 to −18.2; P = .02). With GAIN, there was a significant increase in advance directive completion of 28.4% compared to 13.3% with SOC (P < .001). There were no other differences observed between the two groups in the secondary endpoints evaluated. The reduction in the incidence of grade 3-5 toxicity with comprehensive geriatric assessment (CGA) versus standard care observed in the GAIN and GAP 70+ RCTs is supported by the systematic review and meta-analysis of six RCTs of CGA in older patients with cancer conducted by Chuang and colleagues.21
Two of the nine GAM RCTs identified by the guideline update systematic review investigated the effect of GAM on the completion of scheduled chemotherapy. Lund et al14 reported the results of GERICO, a phase III RCT of comprehensive GA-based interventions (n = 71) versus standard care (n = 71) in vulnerable (Geriatric-8 [G-8] questionnaire ≤14 points) patients ≥70 years old who were receiving 3-6 months of adjuvant or first-line palliative chemotherapy for stage II-IV colorectal cancer. Patients in the intervention group received the GA at or around the start of chemotherapy; the GA consisted of an assessment of comorbidity, a medication review, determination of psychocognitive function and nutritional, functional, and physical status with corresponding interventions such as referral to a dietitian, and a program of physical exercise. The primary endpoint of the trial was completion of planned chemotherapy without later dose modifications or delays; secondary endpoints included toxicity, quality of life, and survival. Compared with standard care patients, more patients in the GA intervention group completed scheduled chemotherapy (45% v 28%; P = .0366). Aspects of quality of life improved versus controls, with decreased burden of illness (P = .048) and improved self-reported mobility (P = .008) observed among intervention group patients.
Ørum et al19 similarly investigated the effect of GA on the completion of planned treatment among frail and vulnerable older (≥70 years) patients with cancer. In a single-center, randomized phase III trial, Ørum et al compared GA with a TFU intervention by a geriatric multidisciplinary team (gMDT; n = 152) to GA without (n = 149) a TFU intervention. The control group received a baseline GA with recommendations for interventions but with no TFU in the subsequent 90 days on any interventions that were initiated. The intervention group received a baseline GA with recommendations for interventions, and TFU on GA-guided interventions initiated. The form of the TFU varied among intervention group patients, but could involve multiple telephone or in-person contacts (home visits or at-hospital visits) between the patient and the gMDT. The primary outcome was the ability to complete initially proposed cancer therapy within 90 days; daily life activities, functional status, and need for hospitalization were secondary outcomes. There were no statistically significant differences between the study group in the proportion of patients who completed planned treatment: 61% of patients in the intervention group and 52% of patients in control group completed treatment (risk rate, 1.16 [95% CI, 0.95 to 1.4]; P = .14). There were also no differences between the groups observed in daily life activities, 90 days physical performance, or hospital admissions (55% of controls v 47% of intervention group patients; risk rate, 0.86 [95% CI, 0.69 to 1.07]; P = .19).
Two identified studies evaluated whether GA can improve quality-of-life outcomes in older patients receiving cancer treatment. In the multicenter, open-label, INTEGERATE (Integrated Geriatric Assessment and Treatment Effectiveness) phase III RCT, Soo et al16 randomly assigned (1:1) 154 patients to integrated oncogeriatric care (n = 76) or usual care (n = 78). Patients were ≥70 years old and had solid cancer or diffuse large B-cell lymphoma for which they planned to receive systemic anticancer treatment (chemotherapy, targeted therapy, or immunotherapy). The integrated oncogeriatric care intervention consisted of GA (review of medications, comorbidities; physical, cognitive, psychological, and social functioning, falls, frailty, nutrition, sensory impairment, advanced care planning, chemotherapy toxicity risk, and immunization status) followed by geriatrician consultation and implementation of GA-guided interventions. In 96% (68/71) of cases, patients in the intervention group received the GA after treatment initiation (median time to CGA was 14.5 days [IQR, 6-21] after the start of treatment). Participants in the usual care group did not receive the study-specific GA but could be referred to a geriatrician by their clinician. The primary endpoint of the trial was change in health-related quality of life (HRQOL) over 24 weeks; HRQOL, measured with the Elderly Functional Index (ELFI), was assessed at baseline, at week 12, at week 18, and at week 24. A range of secondary endpoints was included that assessed additional measures of functioning, mood, nutrition, treatment modification, health care utilization outcomes, and overall survival. Soo et al found that, compared to usual care, integrated oncogeriatric care resulted in improved HRQOL (overall main effect of group: t = 2.1, df = 213; P = .039; effect size = 0.38); the maximal between-group differences in HRQOL were observed at week 18 (mean difference in change, 9.8 [95% CI, 2.4 to 17.2]; P = .010, corrected P = .030, effect size = 0.48). There were also fewer unplanned hospital admissions (multivariable-adjusted incidence rate ratio, 0.60 [95% CI, 0.42 to 0.87]; P = .0066) with integrated oncogeriatric care versus usual care. No difference between the two groups in overall survival was observed.
In the two-group parallel (1:1) single-blind, multicenter (eight involved hospitals), 5C phase III RCT, Puts et al17 investigated the effectiveness of GA and management (GAM; n = 173) at 6 and 12 months versus usual oncologic care (n = 177) on quality of life (QOL) in older (≥70 years) patients diagnosed with solid tumor, lymphoma, or myeloma, and referred for first- or second-line palliative or adjuvant, curative (>54% of patients) chemotherapy, targeted therapy, or immunotherapy. The GAM intervention consisted of completion of a GA (functional status, cognition, mood, medications, mobility and falls, nutritional status, social support, and comorbidity) at baseline on or after treatment initiation for most patients; followed by GA-guided, evidence-based management interventions; and at least monthly follow-up calls from the intervention team registered nurse. The global QOL subscale of the European Organisation for the Research and Treatment of Cancer QOL Questionnaire core version 30 items (QLQ C30)35 was the primary endpoint. Overall survival, functional status, grade 3-5 treatment toxicity, satisfaction, cancer treatment plan modification, and health care use were the secondary endpoints. Analyses indicated that GAM intervention did not improve QOL (difference in global QOL of 4.4 points [95% CI, 0.9 to 8.0] favoring the control arm); and there were no differences between the two groups in change in treatment plan, overall survival, treatment toxicity, or unplanned hospitalization and/or emergency department visits.
Two RCTs evaluated the effect of GA with management on short-term (6-month, 1-year) survival outcomes. In a phase III RCT, DuMontier et al20 compared the impact of consultation with a geriatrician combined with standard oncologic care (n = 60) to standard oncologic care alone (n = 100) for older (≥75 years), prefrail or frail, transplant-ineligible adults with hematologic malignancies (lymphoma, leukemia, or multiple myeloma). Intervention group patients received embedded geriatric consultation, including a GA with individualized management and interventions, with a licensed geriatrician; the patient's hematologic oncologist provided standard oncologic care. One-year overall survival was the primary outcome; documented end-of-life (EOL) goals-of-care discussions and unplanned care utilization within 6 months of follow-up were the secondary outcomes. Forty-eight of the 60 patients (80%) in the intervention group completed ≥1 visit with a geriatrician. Consultation with a geriatrician combined with standard oncologic care did not improve 1-year overall survival compared to standard oncologic care (difference: 2.9% [95% CI, –9.5 to 15.2]; P = .65), and did not significantly reduce the incidence of hospital admissions, days in the hospital, or emergency department visits. The consultation intervention did, however, improve the odds of having EOL goals-of-care discussions (odds ratio, 3.12 [95% CI, 1.03 to 9.41]).
The EGeSOR (Effectiveness of Geriatric Assessment-Driven Interventions on Survival and Functional and Nutritional Status in Older Patients with Head and Neck Cancer) open-label, multicenter, randomized, parallel-group, controlled trial evaluated the efficacy of GA-driven intervention and follow-up in older (≥65 years old) patients with head and neck squamous cell carcinoma.18 Patients were randomly assigned (1:1) to receive GA-driven interventions and follow-up (n = 238) or SOC (n = 237). The intervention consisted of a pretreatment GA conducted by a geriatrician with oncology expertise, involvement of the geriatrician in shaping the cancer treatment plan, GA-driven intervention recommended by the geriatrician, and standardized geriatric follow-up for 2 years. The primary endpoint of the trial was a composite outcome that included 6-month overall survival, functional status, and nutritional status. There was no statistically significant differences between the study groups in the primary, composite outcome (41.0% v 38.0%; P = .53), or in any of the individual, component outcomes of death (31 [13%] v 27 [11.4%]; P = .48), weight loss (69 [29%] v 65 [27.4%]; P = .73), or functional status (fall in ADL score ≥2; 9 [3.8%] v 13 [5.5%]; P = .35).
The systematic literature review identified one trial that assessed whether providing a GA summary and corresponding GA-guided recommendations to oncologists could enhance communication about aging-related concerns. COACH (Improving Communication in Older Cancer Patients and Their Caregivers),15 a cluster-randomized trial, enrolled 131 oncologists, 541 patients, and 414 caregivers from 31 community oncology practices; patients were age 70 years or older with an advanced solid malignant tumor or lymphoma who had at least one impaired GA domain and were receiving cancer treatment with palliative intent. In addition, patients chose one caregiver to participate in the study. Community oncology practices were randomized to receive either the intervention (n = 17 practice sites) or usual care (n = 14 practice sites). The intervention involved providing a tailored GA summary with GA-guided recommendations to treating oncologists for each enrolled patient; usual care provided alerts to oncologists only if patients met criteria for cognitive impairment or depression. Patient satisfaction with communication about aging-related concerns, measured after the initial oncology visit, was the primary outcome. The number of aging-related concerns discussed during the visit, QOL, and caregiver satisfaction with communication about aging-related patient concerns were the secondary outcomes. Compared to the usual care group patients, intervention group patients were more satisfied with communication about aging-related concerns after the visit (difference in mean score, 1.09 points [95% CI, 0.05 to 2.13 points]; P = .04); and satisfaction with communication about aging-related concerns continued to be higher among intervention group patients over 6 months (difference in mean score, 1.10 [95% CI, 0.04 to 2.16]; P = .04). The intervention group's visits included more aging-related conversations than the usual care group's visit (difference, 3.59 [95% CI, 2.22 to 4.95]; P < .001). Finally, in the intervention group, caregivers were more satisfied with communication after the visit (difference, 1.05 [95% CI, 0.12 to 1.98]; P = .03). Two recently published secondary analyses of data from COACH reported that, compared to usual care, providing oncologists with a GA summary with tailored recommendations was associated, respectively, with an increase in oncologist-initiated conversations concerning physical performance and functional status with corresponding recommendations to address these concerns36; and with an increased number of conversations regarding comorbidities per patient, with having a greater number of concerns acknowledged, and with a greater chance of having those comorbidity concerns addressed.26
Clinically, the most important conclusion is that it is essential to do a GA for older adults with cancer to provide appropriate care when considering systemic therapy; when GAM is compared with SOC, it clearly leads to significantly less chemotherapy toxicity and improves adherence to chemotherapy. It also improves important patient-centered outcomes and communication, particularly patient and caregiver satisfaction with care, communications about aging concerns, and completion of advanced directives. These benefits are especially strong for patients who are older and are most vulnerable. These recommendations are strongest for older adults receiving chemotherapy, but the panel still recommends them for any systemic therapy, based on early evidence of similar benefits. We note that the GAP70+ study included patients who received immunotherapy in combination with chemotherapy as they were being treated in the NCORP sites. The Soo et al trial summarized in the guideline manuscript also included patients who received immunotherapy, which was 6 of the 154 total patients (4%; three patients per arm). A nonrandomized study of older adults receiving immunotherapy, while not including a GA, notes that such therapies were discontinued due to adverse events more than twice as often among patients age 90 years or older compared to others, suggesting some possible safety concerns that would benefit from GA.37 An observational study comparing older (70+ years) with younger (<70 years) patients receiving immunotherapy showed that older adults who screened positive for frailty using the G-8 (60%) experienced higher hospitalization rates and shorter survival.38 Other rigorous studies specifically including immunotherapies are ongoing. While the data for GAM are growing, it is reasonable to consider GAM recommendations as relevant for all older adults receiving systemic therapy since they are developed from geriatrics guidelines (eg, fall prevention for older adults who are falling). Questions regarding other systemic therapies, such as the rapidly growing field of immunotherapy,39 are still being developed. Many patients who are older will receive immunotherapies, and they are also likely to benefit from a GA to identify management needs.40 There is mixed evidence that GAM can improve QOL as well, although this is inconsistent across studies, depending on the interventions. Overall survival is not adversely impacted by GAM care, although the GA-guided interventions reduced toxicity rates and improved patient-reported outcomes. In these higher-resourced settings over the time intervals studied, GAM does not seem to consistently alter other outcomes, such as hospitalizations or emergency department visits. The evidence is sufficient that GAM, using formal GA tools, provides significant benefits to older patients with cancer and caregivers, especially the most vulnerable patients, and that GA should be conducted in such patients.
How does GAM improve these important outcomes without adversely impacting overall survival? The primary GAM interventions are care optimization in response to GA.41,42 One is changes in decision making, primarily changes in treatments. For example, clinicians may choose to change their approach to management choices, such as decreasing chemotherapy doses,3 helping improve adherence to treatment, or more clearly defining care goals. There is evidence supporting each of these strategies being used successfully. Another consequence is a significant increase in the number of multidisciplinary interventions enacted based on the GA. These interventions include referrals to physical therapy, supportive care, social work, or nutrition when appropriate thresholds from validated tests are met. Clearly, there are interactions between these two optimization strategies; for example, adherence might be improved through dosing adjustments combined with a referral to nutrition to improve weight. In short, GAM results in improved decision-making, better targeting of interventions, and improved communications with patients and families, who are more satisfied with their care. In this regard, the updated systematic review of 65 publications (61 studies) conducted by Hamaker et al22 demonstrated that GA can lead to changes in cancer treatment plans and nononcologic interventions and improve communication about care planning and aging-related concerns. The specific mechanisms and details of how GAM works in different contexts and circumstances continue to be investigated.
As the evidence strengthens supporting the value of GAM for patients, families, and providers, the lack of uptake5,6 remains a primary barrier to realizing the benefits. Implementation barriers to GAM include lack of understanding about available GA tools, perceived lack of resources, need for training, poor documentation, and system barriers.43 Further improvements in the use of these tools require addressing these remaining barriers.
We note that, while the evidence is there for conducting GA in all older adults over 65 years old receiving systemic therapy, this may not be feasible in certain settings or certain populations. We, therefore, leave to the judgment of providers and practices how to adapt the GA to their own specific practice, based on volume, resources, and personnel. As described below, we take seriously these implementation barriers, and the Panel has developed tools, training materials (https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf; https://youtu.be/jnaQIjOz2Dw; https://youtu.be/nZXtwaGh0Z0), and an updated ASCO website to aid in making the implementation as easy as possible.
For older patients who are considering undergoing chemotherapy and other systemic treatments, which GA tools should clinicians use to predict adverse outcomes (including chemotherapy toxicity and mortality)?
Addressing the widespread use of these GA tools was a focus of the panel. The specific tool offered, the PGA, is based on a process to create one practical way to bring the benefits of the GA into widespread use. It is the product of an iterative process with content experts to reach consensus, with input from community oncologists and patient partners, and with a focus on an efficient and easily used approach to conducting GA in many settings. As a composite tool, it has not been psychometrically validated, although the specific items are all validated for use in older patients with cancer. The Panel supports the PGA as one potential strategy to facilitate implementation of GAM into clinical practice (Table 3).
A GA should include high priority aging-related domains known to be associated with outcomes in older patients with cancer to include assessment of physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support (Type: Evidence based, benefits outweigh harms; Evidence quality: High; Strength of recommendation: Strong).
The Panel recommends the PGA as one option for this purpose. See the PGA tool at: https://old-prod.asco.org/sites/new-www.asco.org/files/content-files/practice-patients/documents/2023-PGA-Final.pdf. See how to use the PGA tool at: https://youtu.be/jnaQIjOz2Dw; and https://youtu.be/nZXtwaGh0Z0 (Type: Informal consensus; Evidence quality: Moderate; Strength of recommendation: Weak).
Studies of clinical uptake of GA and GA implementation barriers. Because guideline-recommended GA use has been inconsistent,43 the Expert Panel revisited the question from the 2018 guideline1 of which GA tools clinicians should use to predict adverse outcomes in older patients who are receiving systemic treatment for cancer. The corresponding literature search and associated inclusion criteria were broad, designed to capture articles addressing the uptake by clinicians of GA implementation and perceived barriers to GA use in everyday clinical practice. The review identified 11 relevant publications.5,6,12,27,29-34 This research has consistently shown that the uptake of GA is generally modest. Thus, in a study of the use and knowledge of GA instruments among US community-based oncologists, Gajra et al6 found that just 13% of the 349 oncologists surveyed used GA for all of their older patients; 60% of oncologists did not use a formal GA for any of their geriatric patients; and 19% of oncologists reported that they were not aware of any validated GA instruments. Dale et al,5 based on the results of a survey of 1,277 providers (70% US-based, 63% in academic medicine, and 35% in private practice) who treated adults with cancer, reported that just 21% of respondents indicated that they performed a multidimensional GA using validated tools always or most of the time; 22% performed multidimensional GA some of the time; and 57% performed multidimensional GA rarely or never. A greater frequency of using a multidimensional GA with validated tools was associated with awareness of the 2018 ASCO GA guideline (aware of the ASCO guideline v unaware: 55% v 31%; P < .01). Fifty-three percent of respondents had indicated that they were aware of the ASCO guideline. In a web-based survey, Mishra et al33 assessed the use of GA among transplantation physicians and the barriers to routine GA implementation in clinical practice to help determine candidacy for allogeneic hematopoietic cell transplantation among older (≥60 years) patients. The most common barriers to GA use in this study were uncertainty about which GA instruments to use and the lack of training in or knowledge of GA assessment tools. Other barriers included lack of time and a lack of adequate clinical support to implement routine GA.
Surveys of oncology providers in Australia, Canada, the Netherlands, and Mexico revealed similarly low or variable levels of GA use. In a survey of members of the Medical Oncology Group of Australia (N = 69), To et al32 found that GA had been requested by just 56% of respondents; 71% of respondents perceived that GA added value to clinical assessment alone. Puts et al34 conducted an online survey of Canadian health care professionals' geriatric oncology learning needs and reported on the biggest challenge these clinicians faced in caring for older adults with cancer. These included a lack of resources (eg, a lack of geriatricians) and challenges related to pretreatment assessment and decision-making (eg, lack of knowledge regarding how to conduct a needs assessment of older adults with cancer). Comprehensive GA was used infrequently (n = 3) across centers in the study. Driessen et al30 conducted a survey of GA practices among pulmonologists and radiation oncologists who treated older patients with non–small-cell lung cancer in the Netherlands, and they reported that use of GA in clinical practice varied widely across centers (n = 15) included in their study. All agreed that GA added value for treatment decision-making. Finally, in the study by Verduzco-Aguirre et al,12 a sequential mixed-methods study of Mexican oncology professionals (N = 196) consisting of an online survey to cancer specialists followed by semistructured interviews of respondents based on their reported GA use, just 37 physicians or 18.9% of respondents reported routinely performing a GA.
The 11 articles identified by the literature search for this clinical question all addressed perceived or measured barriers to implementation of GA in oncology clinical practice. The most commonly cited barriers were the time required to perform GA,5,6,12,27,29-32 the lack of adequate resources (qualified staff and financial support) to integrate GA into routine clinical practice,5,27-29,32 and the lack of relevant knowledge or training.5,12,29,30 The growing understanding of barriers to GA implementation in everyday practice gleaned from this research has naturally led to calls for innovative and more practicable approaches to GA and GAM. The PGA that is recommended by the Expert Panel as an option for GAM is one such approach.
In response to data from the 2019 ASCO provider survey showing that GA use among oncology providers often is not concordant with guideline recommendations,5 the Older Adults Task Force of ASCO's Health Equity and Outcomes Committee identified the need for a simplified GA tool to help increase uptake. The Task Force employed a consensus development approach and drew from existing published, formal consensus development work on GA domains and specific measures in collaboration with the Cancer and Aging Research Group (CARG)69 to identify essential domains from multiple validated GA tools. To this end, the Task Force first compiled multiple validated tools for each domain and reviewed the strengths and concerns of each tool with a focus on practical clinical use. The Task Force then conducted a consensus exercise using a modified Delphi process with predetermined levels of consensus to identify one tool for each domain. For tools that earned consensus, but received similar support for a given domain, members were asked to vote again after further discussion to select a final measure. The tools identified during the Delphi process were compiled to create the PGA. The PGA was presented to CARG's Measures Core for further input and feedback; after reviewing the PGA content, the Measures Core endorsed the PGA on behalf of CARG. The PGA was also presented to and reviewed by the CARG full membership for additional feedback. In addition, the tool was presented to the Science and Education Committee of the International Society of Geriatric Oncology (SIOG) and received endorsement.
A GA is a multidimensional assessment to identify patient risks, prognosticate for outcomes, and identify targets for interventions. In order to perform these functions, a GA must include a sufficient number of domains, which minimally include physical and cognitive function, emotional health, comorbid conditions, polypharmacy, nutrition, and social support. The PGA is an attempt to translate the evidence that has been generated for the GA, and adapt it for use by most oncologists, with an emphasis on the practical considerations for its widespread adoption. The Panel recognizes that there is no perfect one-size-fits-all solution to the adoption of a GA in specific practices, as different practices settings will have different resources, different personnel, and different comfort levels for conducting GA.
Having said this, the Panel wanted to offer a potential solution to the challenge of adoption that could be integrated into variably resourced clinical settings. The tools chosen through the Delphi process69 provide usable information on which to act. The ASCO Older Adults Task Force, in conjunction with SIOG and CARG, has also created additional resources, including a companion article91 detailing the PGA with scoring instructions, suggestions for actions to take based on the scoring, video guidance on how to conduct the PGA, and references for evidence to support its use. Through ASCO's website, there are updated details on how to use the information generated. Finally, if there is widespread adoption of the PGA in multiple locations, the opportunity for real-world data collection and evidence based on a consistent measurement will ensure continued refinement of the PGA into the future.
The Panel recognizes the challenges of feasibility, including of the PGA. The PGA represents the cumulative wisdom from two groups of cancer and aging experts from ASCO and CARG. It is the most concise version of the GA that is evidence-based and aligns with the available data. It has been shown that the GA is less burdensome than other common interventions to oncology practice.70 Given that clinical judgment has not proven reliable in assessing frailty, the PGA is recommended to be used as the appropriate evaluation for older adults. Specific questions on the use of the PGA are also contained in a companion article by Williams et al91 in JCO Oncology Practice. The Panel acknowledges the challenges of adopting a new practice, and recognizes that judgment will be exercised by individual practices on how best to incorporate these assessments as much a possible into their practices.
Patients 65 years and older and their families should be empowered to expect to receive a GA when considering the initiation of therapy for cancer treatment; the panel is hopeful that patients and families will themselves become advocates for the use of the GA. The use of the GA to guide therapy for cancer treatment improves prognostication of toxicity outcomes, improves prediction of life-expectancy, helps improve communications about aging-related concerns, improves satisfaction for patients and families with their care, and improves outcomes when used to guide care. The decision making for choosing the most appropriate therapy can be impacted through the use of a GA, including specific information about goals of care, the choices of interventions used to prevent aging-related outcomes (such as falls and polypharmacy), and the likelihood of receiving goal-concordant care. This also leads to care that avoids both the overtreatment of frail patients and the undertreatment of fit patients. Shared decision making should include input from patients and families about the results of a GA, which has been shown to increase the satisfaction of both patients and families in their care.
The specific tools to include in the GA have been identified that are practical in nature, including input based on patient partners on the ASCO Older Adults Task Force. Being practical means that they take the minimal amount of time possible, can be completed outside of the time spent with a provider in clinic, and can be easily learned and conducted by clinic personnel. This emphasis on the practical nature of the proposed PGA minimizes one implementation barrier for patients with cancer in the community setting. An important consideration in uptake of the GA is the knowledge and training for staff in clinical practice settings. There are tools for use addressing this concern, such as videos from ASCO (https://youtu.be/jnaQIjOz2Dw; https://youtu.be/nZXtwaGh0Z0). The goal is to make it as easy as possible for community oncologists to provide this care for all of their older patients with cancer.
The draft, revised recommendations were released to the public for open comment from November 14, 2022, to November 28, 2022. Response categories of “Agree as written,, “Agree with suggested modifications” and “Disagree. See comments” were captured for each proposed recommendation, with a total of 25 written comments received. The most common theme reflected in the comments addressed the validity, content, and clinical application (eg, scoring and administration of the instrument and interpretation of the PGA results) of the PGA. Of the 40 respondents, 95% (38/40) either agreed or agreed with slight modifications with each of the three recommendations; 5% (2/40) of the respondents disagreed. In addition, members of the ASCO Supportive Care Guideline Advisory Group reviewed the full guideline. Expert Panel members reviewed comments from all sources and determined whether to maintain original draft recommendations, revise with minor language changes, or consider major recommendation revisions. All changes were incorporated before EBMC review and approval.
ASCO guidelines are developed for implementation across health settings. Each ASCO guideline includes a member from ASCO's Practice Guideline Implementation Network (PGIN) on the panel. The additional role of this PGIN representative on the guideline panel is to assess the suitability of the recommendations to implementation in the community setting, but also to identify any other barrier to implementation a reader should be aware of. Barriers to implementation include the need to increase awareness of the guideline recommendations among front-line practitioners and survivors of cancer and caregivers, and also to provide adequate services in the face of limited resources. The guideline Bottom Line Box was designed to facilitate implementation of recommendations. This guideline will be distributed widely through the ASCO PGIN. ASCO guidelines are posted on the ASCO website and most often published in the Journal of Clinical Oncology.
This guideline update encompasses the most recent evidence supporting the use of GA and GAM as the basis for optimal care for older adults with cancer. From an evidence perspective, the field of geriatric oncology has truly come of age,71 and the guideline recommendations are a complement to a recent Special Series in the Journal of Clinical Oncology, which provides a number of state-of-the-science articles on cancer and aging evidence for older adults with cancer. Still, looking ahead, there is much work to be done to fill many gaps.
The strongest evidence supporting the use of GA and GAM comes from studies enrolling patients with solid tumors or lymphomas receiving chemotherapy, and less is known about other populations. While the evidence is strongest for GAM for those with solid tumor malignancies, there is evidence supporting them in those with hematologic malignancies in addition to patients with lymphoma.72-74 Additionally, as pointed out in the clinical implications section, the value of GA for identifying aging-associated concerns and communicating with patients and families is important for all older adults with cancer and is well established. The questions regarding other systemic therapies, such as the rapidly growing field of immunotherapy, are still being developed.40 Many patients who are older will receive immunotherapies, and they are also likely to benefit from a GA to identify management needs.16 More is known about the benefits of traditional chemotherapy and less is established regarding the use of novel therapies, targeted agents, immunotherapies, bone marrow transplants, or other cellular therapies; it is clear that more rigorous studies of these therapies are needed.20 Although the evidence for use of GAM in hematologic malignancies remains limited,20 the GAM approach has been shown in nonrandomized settings to improve clinical outcomes.75
Another area where additional work is needed is the timing of GA. Most studies have shown its value as a risk-assessment tool, to be used to identify and (hopefully) avoid adverse outcomes. But less is known regarding repeating the GA, and when it is most valuable to reassess patients. Perhaps there are better times in the course of disease—times of recurrence or when a therapeutic change is considered or after toxicity—that would also be important.76
Additionally, the strongest evidence supporting the use of GA and GAM is not fully representative of those who most often get cancer. The accrual of older adults into clinical trials remains well below their representation as patients with cancer.77 Another consequence of the lack of enrollment is the nonrepresentative nature of the enrollment that does exist. Most of those enrolled in current trials are White, more highly educated, with greater access to care, and of greater functional capacity. Just as older adults have been systematically excluded from clinical trials, so have many other vulnerable groups based on race, sex, gender, country of origin, disability status, non-English language use, and other forms of discrimination. Many of these intersect with age to create multiple types of systemic exclusions for older adults. Much more work and different strategies are needed to improve accrual of older adults, as a recent NCI workshop demonstrated.78-80 The GA has been shown to improve communications and patient and family satisfaction with care, suggesting a mechanism to improve outcomes for vulnerable groups. Thus, utilization of the GA and facilitating GAM care should improve health equity in clinical trial evaluation and may help to narrow the gap that exists in health care decision making and considerations for trial inclusion for vulnerable populations with cancer. Structural changes to address these systematic exclusions, such as economic support and transportation provision, are needed to have truly representative evidence upon which to base our next guidelines.81 Beyond trial exclusion, the widespread adoption of GA and GAM, which depends on having the necessary resources to implement and act upon them, would enhance the clinical care for those most in need of it, which is the ultimate goal for a more equitable care system for older adults and everyone.
ASCO believes that cancer clinical trials are vital to inform medical decisions and improve cancer care, and that all patients should have the opportunity to participate.
More information, including a supplement with additional evidence tables, slide sets, and clinical tools and resources, is available at www.asco.org/supportive-care-guidelines. Patient information is available at www.cancer.net.
ASCO is committed to promoting the health and well-being of individuals regardless of sexual orientation or gender identity.84 Transgender and nonbinary people, in particular, may face multiple barriers to oncology care including stigmatization, invisibility, and exclusiveness. One way exclusiveness or lack of accessibility may be communicated is through gendered language that makes presumptive links between gender and anatomy.85-88 With the acknowledgment that ASCO guidelines may impact the language used in clinical and research settings, ASCO is committed to creating gender-inclusive guidelines. For this reason, guideline authors use gender-inclusive language whenever possible throughout the guidelines. In instances in which the guideline draws upon data based on gendered research (eg, studies regarding women with ovarian cancer), the guideline authors describe the characteristics and results of the research as reported.
Listen to the podcast by Dr Mohile et al at guideline.libsyn.com
This American Society of Clinical Oncology (ASCO) Clinical Practice Guideline provides recommendations, with comprehensive review and analyses of the relevant literature for each recommendation. Additional information, including a supplement with additional evidence tables, slide sets, clinical tools and resources, and links to patient information at www.cancer.net, is available at www.asco.org/supportive-care-guidelines.
Conception and design: All authors
Administrative support: Vani Katheria, Mark R. Somerfield
Collection and assembly of data: All authors
Data analysis and interpretation: All authors
Manuscript writing: All authors
Final approval of manuscript: All authors
Accountable for all aspects of the work: All authors
The following represents disclosure information provided by authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.
Open Payments is a public database containing information reported by companies about payments made to US-licensed physicians (Open Payments).
Heidi D. Klepin
Patents, Royalties, Other Intellectual Property: UptoDate contributor
Grant R. Williams
Honoraria: Cardinal Health
Speakers' Bureau: Cardinal Health
Shabbir M.H. Alibhai
This author is a member of the Journal of Clinical Oncology Editorial Board. Journal policy recused the author from having any role in the peer review of this manuscript.
Stock and Other Ownership Interests: ResMed
Honoraria: Astellas Scientific and Medical Affairs Inc, Pfizer
Kah Poh Loh
Consulting or Advisory Role: Pfizer, Seagen
Lisa M. Lowenstein
Research Funding: AstraZeneca (Inst), Blue Cross Blue Shield (Inst)
June M. McKoy
Consulting or Advisory Role: Medscape
Research Funding: Dr Reddy's Laboratories (Inst), Intas (Inst)
Travel, Accommodations, Expenses: American Society of Clinical Oncology
Ashley E. Rosko
Honoraria: OncLive/MJH Life Sciences, Curio Science, Curio Science, Medscape, i3 Health
Honoraria: Horizon CME
Consulting or Advisory Role: MedImmune
Research Funding: Bayer, Novartis, GlaxoSmithKline, NanoCarrier, Celgene, Northwest Biotherapeutics, Incyte, Fujifilm, Pfizer, Amgen, AbbVie, Multivir, Exelixis, Loxo, Blueprint Medicines, Takeda
Travel, Accommodations, Expenses: Bayer, PharmaMar, Novartis, MedImmune
No other potential conflicts of interest were reported.
Evidence Based Medicine Committee approval: April 21, 2023
The Expert Panel wishes to thank Dr Alicia Morgans and Dr Marlana Orloff and the Evidence-Based Medicine Committee for their thoughtful reviews and insightful comments on this guideline. The Expert Panel is also grateful to Sweatha Kata, Janette Merrill, and members of the Older Adults Task Force of ASCO's Health Equity and Outcomes Committee and the Cancer and Aging Research Group for their consensus work on and review of GA domains and specific measures completed as part of the Practical Geriatric Assessment development. Finally, the Expert Panel is grateful to members of ASCO's Supportive Care Guideline Advisory Group and to those who participated in external review of the draft recommendations via the Open Comment solicitation.
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