Changes in the Use of Comprehensive Geriatric Assessment in Clinical Trials for Older Patients with Cancer over Time

Clinical trials in older patients with cancer - typical challenges, possible solutions, and a paradigm of study design in breast cancer

BACKGROUND AND PURPOSE

While the prevalence of older breast cancer patients is rapidly increasing, these patients are greatly underrepresented in clinical trials. We discuss barriers to recruitment of older patients to clinical trials and propose solutions on how to mitigate these challenges and design optimal clinical trials through the paradigm of IMPORTANT trial.

PATIENTS AND METHODS

This is a narrative review of the current literature evaluating barriers to including older breast cancer patients in clinical trials and how mitigating strategies can be implemented in a pragmatic clinical trial.

RESULTS

The recognized barriers can be roughly divided into trial design-related (e.g. the adoption of strict inclusion criteria, the lack of pre-specified age-specific analysis), patient-related (e.g. lack of knowledge, valuation of the quality-of-life instead of survival, transportation issues), or physician-related (e.g. concern for toxicity). Several strategies to mitigate barriers have been identified and should be considered when designing a clinical trial dedicated to older patients with cancer. The pragmatic, de-centralized IMPORTANT trial focusing on dose optimization of CDK4/6 -inhibitors in older breast cancer patients is a paradigm of a study design where different mitigating strategies have been adopted.

INTERPRETATION

Because of the existing barriers, older adults in clinical trials are considerably healthier than the average older patients treated in clinical practice. Thus, the study results cannot be generalized to the older population seen in daily clinical practice. Broader inclusion/exclusion criteria, offering telehealth visits, and inclusion of patient-reported, instead of physician-reported outcomes may increase older patient participation in clinical trials.

A model for predicting physical function upon discharge of hospitalized older adults in Taiwan-a machine learning approach based on both electronic health records and comprehensive geriatric assessment

Background

Predicting physical function upon discharge among hospitalized older adults is important. This study has aimed to develop a prediction model of physical function upon discharge through use of a machine learning algorithm using electronic health records (EHRs) and comprehensive geriatrics assessments (CGAs) among hospitalized older adults in Taiwan.

Methods

Data was retrieved from the clinical database of a tertiary medical center in central Taiwan. Older adults admitted to the acute geriatric unit during the period from January 2012 to December 2018 were included for analysis, while those with missing data were excluded. From data of the EHRs and CGAs, a total of 52 clinical features were input for model building. We used 3 different machine learning algorithms, XGBoost, random forest and logistic regression.

Results

In total, 1,755 older adults were included in final analysis, with a mean age of 80.68 years. For linear models on physical function upon discharge, the accuracy of prediction was 87% for XGBoost, 85% for random forest, and 32% for logistic regression. For classification models on physical function upon discharge, the accuracy for random forest, logistic regression and XGBoost were 94, 92 and 92%, respectively. The auROC reached 98% for XGBoost and random forest, while logistic regression had an auROC of 97%. The top 3 features of importance were activity of daily living (ADL) at baseline, ADL during admission, and mini nutritional status (MNA) during admission.

Conclusion

The results showed that physical function upon discharge among hospitalized older adults can be predicted accurately during admission through use of a machine learning model with data taken from EHRs and CGAs.

Palliative care and Chinese medicine in a centenarian with primary hepatocellular carcinoma and 27-month follow-up: A case report

The number of centenarians with cancer is increasing as the global population ages. The diagnosis and treatment for centenarians with tumor sometimes are specific, and there are currently less appropriate guidelines as references. We report a 104-year-old man with asymptomatic primary liver cancer (PLC) whose family decided to receive conservative and palliative care. The patient has been followed up for 27 months. He has been mainly received Chinese herbal medicine (CHM), nutritional support and thymalfasin injection intermittently, etc. During the 27-month follow-up, the patient has showed good compliance and tolerance without any complications of the tumor. Conclusion: Individualized palliative care and complementary medicine, based on multidisciplinary evaluation, traditional Chinese medicine, consultation with patients and their families about treatment options, etc., may help improve the life quality of centenarians with end-stage tumors.

Germain D, Mohile S, Hudson MF. Enrolling Older Adults Onto National Cancer Institute-Funded Clinical Trials in Community Oncology Clinics: Barriers and Solutions

In April 2021, the National Cancer Institute (NCI) Division of Cancer Prevention collaborated with the NCI Division of Cancer Treatment and Diagnosis to produce a virtual workshop that developed recommendations for enhancing NCI-sponsored clinical trial accrual of older adults. Prior to the workshop, a multidisciplinary group of stakeholders (eg, community oncologists, advanced practice practitioners, clinic and research staff, and patient advocates) gathered information related to accrual of older adults to clinical trials from the literature. Subsequently, a survey was conducted to detail NCI Community Oncology Research Program members' perspective on accrual barriers for this population; 305 individuals responded to the survey. Barriers to clinical trial accruals included comorbidity-attributed trial ineligibility, transportation and time issues, concern that the proposed regimen is too toxic for older adults, patient or family caregiver declined participation, and lack of trials relevant to older patients. Identified solutions included broadening clinical trial inclusion criteria, increasing the number of clinical trials specifically designed for older adults, simplifying consent forms, improving recruitment materials for older adults and their families, and facilitating transportation vouchers. At the workshop, participants, including stakeholders, used prior literature and survey results to develop recommendations, including interventions to address clinician bias, implement geriatric assessment, and promote clinician and staff engagement as mechanisms to improve accrual of older adults to clinical trials.

Use of geriatric assessment in cancer clinical trials: A systematic review

BACKGROUND

Older adults are underrepresented in cancer clinical trials despite accounting for most of the disease burden. Geriatric assessment (GA) could be used in clinical trials of cancer drugs for older adults to improve the clinical evidence for cancer drug use among older adults.

OBJECTIVE

To examine patterns of use of GA in cancer clinical trials.

METHODS

We undertook a systematic review of the studies reporting use of GA in a clinical trial setting for all cancer types and published between January 2010 and January 2020. Characteristics of GA use were extracted for each study, along with study phase, cancer type, and participant age (PROSPERO: CRD42020170584).

RESULTS

We identified 320 studies and 63 studies met the final inclusion criteria. Among 74 purposes of GA use, the most common was to examine the association between impairments in GA domains and clinical outcomes (28/74, 38%). Among 258 GA domains assessed across 63 studies, physical status (59/258, 23%) and comorbidities (50/258, 19%) were most often evaluated. There was significant heterogeneity in the instruments used to assess physical function (n = 16) and mood disorders (n = 7). Most studies were phase 2 (32/63, 51%).

CONCLUSIONS

GA is most often used in clinical trial settings to examine associations between GA-identified deficits and clinical outcomes. Significant heterogeneity exists in the GA instruments used across trials. Comprehensive and consistent incorporation of GA into future cancer clinical trial designs could help collect more older adult-specific clinical information and adjust trial eligibility criteria to increase representation by older adults.

Exclusion of Older Adults from Cancer Clinical Trials: Review of the Literature and Future Recommendations

In this review, we present the context of older adult (OA) cancer patients within the broader cancer population, including cancer burdens and trial representation. We first describe the proportion of older adults in clinical trials, with studies showing strong evidence that the proportion of OA in cancer trials is much less than the proportion of OA in the overall cancer population. We highlight the lack of generalizability that can lead to challenges in treatment decisions for OA as well as concerns regarding health inequity. We then discuss barriers to OA enrollment related to trial structure and design, physician perspective, and patient and/or caregiver perspective. We expand on this further by outlining these barriers throughout the process of trial design, patient enrollment/trial implementation, and data analysis in post-market settings. We summarize guidelines from national societies, regulatory agencies, and other institutional bodies, then present a compilation of on-the-ground actionable recommendations to address the challenges of clinical trial design, focusing on geriatric assessments and OA-specific trials. We conclude by providing an outline for future directions, noting specifically the potential impact that radiotherapy and radiation oncology may have on clinical trials related to OA patients.

Treatment Paradigms for Older Adults with Pancreatic Cancer: a Nuanced Approach

Pancreatic cancer is increasing in incidence in the USA. This disease disproportionately affects older adults, and as the percentage of adults > 65 years old increases with the aging of the baby boomers, the prevalence is expected to rise over the coming decade. These patients are often more susceptible to disease-related symptoms and have less ability to withstand both cancer and treatment-related side effects. Therefore, it is imperative that treating physicians thoughtfully consider their recommended treatment approach towards this vulnerable patient population. This review focuses on the current state of research of older adults with pancreatic adenocarcinoma, highlighting deficiencies in the representation of this patient population in clinical trials. It is vital that the treating physicians take a nuanced approach towards therapy of localized and metastatic disease in geriatric patients. A one size fits all treatment algorithm is no longer appropriate in any cancer patient, let alone the elders who are particularly vulnerable to developing treatment-related toxicities. To help guide therapy decisions, it is important to perform a comprehensive geriatric assessment which may uncover unexpected frailty and lead to a change in the recommended treatment approach. In this way, we can support older adults during therapy for this aggressive malignancy and provide optimal care.

Nutritional Assessment in Older Adults : MNA® 25 years of a Screening Tool and a Reference Standard for Care and Research; What Next?

A tool to assess nutritional status in older persons was really needed. It took 5 years to design the MNA® (Mini Nutrition Assessment) tool, complete the first validations studies both in Europe and in the U.S. and to publish it. After the full MNA®, the MNA® short form and the self-MNA® have been validated. As well as Chinese and other national MNA® forms. Now more than 2000 clinical research have used the MNA® all over the world from community care to hospital. At least 22 Expert groups included the MNA® in new clinical practice guidelines, national or international registries. The MNA® is presently included in almost all geriatric and nutrition textbook and part of the teaching program for medicine and other health care professional worldwide. The urgent need is to target the frail older adults more likely to have weight loss and poor appetite and to prevent frailty and weight loss in the robust. We present in this paper the review of 25 years of clinical research and practice using the MNA® worldwide.

Pharmacotherapeutic considerations for elderly patients with colorectal cancer

Introduction: Oncology care in the elderly presents a dilemma. The majority of cancer cases are diagnosed in the elderly yet they are underrepresented in clinical trials. In addition to limited evidence-based medicine, the elderly is a heterogeneous population filled with pharmacotherapeutic challenges and barriers. Elderly metastatic colorectal cancer (mCRC) treatment decisions encompass these challenges.Areas covered: Treatment based solely on chronological age is an unacceptable practice. Physiologic factors such as function, cognition, comorbidities, polypharmacy, among others must be considered. Oncology guidelines emphasize using a geriatric assessment (GA) as opposed to traditional oncology performance status measures to best identify risks. Our review shines light on these issues as they pertain to elderly unresectable metastatic colorectal cancer (mCRC).Expert opinion: The practical use of GA tools in oncology remain to be determined. Current barriers are the lack of a consistent tool to unify decision-making, provider education, and evidence-based use/outcomes in specific cancers. mCRC antineoplastic data surrounding GAs are scarce, and current mCRC national treatment algorithms are not stratified to encompass GA-driven therapy. Therefore, providers lack clear guidance or practicality of use. We hope mCRC trial designs will abandon age cutoffs and instead place more focus on GAs for inclusion and outcomes.

Comprehensive Geriatric Assessment as a Versatile Tool to Enhance the Care of the Older Person Diagnosed with Cancer

The comprehensive geriatric assessment (CGA) is a versatile tool for the care of the older person diagnosed with cancer. The purpose of this article is to detail how a CGA can be tailored to Ambulatory Geriatric Oncology Programs (AGOPs) in academic cancer centers and to community oncology practices with varying levels of resources. The Society for International Oncology in Geriatrics (SIOG) recommends CGA as a foundation for treatment planning and decision-making for the older person receiving care for a malignancy. A CGA is often administered by a multidisciplinary team (MDT) composed of professionals who provide geriatric-focused cancer care. CGA can be used as a one-time consult for surgery, chemotherapy, or radiation therapy providers to predict treatment tolerance or as an ongoing part of patient care to manage malignant and non-malignant issues. Administrative support and proactive infrastructure planning to address scheduling, referrals, and provider communication are critical to the effectiveness of the CGA.