Perspectives on Geriatric Oncology Research presented at the 2019 International Society of Geriatric Oncology Annual Meeting: Young International Society of Geriatric Oncology report

1. Introduction

The International Society of Geriatric Oncology (SIOG) held its19th conference, November 14 −16, in Geneva, Switzerland, under the theme: “Integrative oncology – Leaving no one behind.” Attendees also engaged in a joint global policy summit (SIOG and International Federation of Aging), held at the United Nations. This summit sought to address ageism and its impact on older adults with cancer. Figure 1. provides demographic data for meeting attendees. Herein we summarize selected research studies presented at the meeting.

Figure 1.

Conference attendee demographics

2. Geriatric Assessments in cancer management

The comprehensive geriatric assessment (CGA) is a multi-domain tool, integral for the evaluation of age-related vulnerabilities in older adults with cancer [1]. Despite the prognostic and predictive value of the CGA [2], routine use in clinical practice remains largely limited due to resource/practice constraints. Recognition of these implementation barriers has led to increased interest in developing easily adoptable screening tools, capable of identifying the most vulnerable patients. In one study, use of the SAOP-3 (Senior Adult Oncology Program) tool, identified changes in age-related factors in older adults receiving anti-cancer treatment. Decline in functional and nutritional domains were more common within the first 3- months of cancer treatment initiation. Recognizing longitudinal changes in age-related factors in this population could aid with resource allocation and timely interventions to mitigate adverse outcomes, thus improving the patient experience [3].

Rosko et al. presented prospective data on the application of the Cancer and Aging Research Group’s (CARG) geriatric assessment (GA) and chemotherapy toxicity prediction tool, in a population of older adults (n=54) with hematological malignancies. Most patients (94%) had additional comorbidities, with a median hematopoietic cell transplantation-specific comorbidity index score of 6 (range 2–12). 50% of patients were considered mobility impaired, based on an inability to complete the Timed Up and Go test. Short Physical Performance Battery scores were low in 64% (median score=2 (range 2–12), suggesting mobility limitations. Toxicity prediction scores of 10 (range 4–18) identified a population at high risk for grade 3–5 toxicities [4].

Older adults with cancer receiving active treatment may also have concomitant high symptom burden alongside age-related vulnerabilities. In 301 patients with advanced solid tumors, comorbid burden, nutritional and psychological deficits were associated with higher patient reported total symptom severity [5]. Studies also highlighted the importance of an integrated care team for optimal management of older adults with cancer. One study found older adults with geriatric impairments were less likely to address non-cancer related concerns with their oncologist. This finding, highlights the importance of effective communication between patients and their oncologists [6] to ensure patient engagement and satisfaction with care.

The studies outlined, emphasize the importance of the GA in the care of older adults with cancer. Additional studies are needed to evaluate outcomes of a GA-based personalized approach to cancer treatment. In an ongoing randomized controlled multicenter trial (EGeSOR), investigators are evaluating the impact of a GA and geriatrician-guided interventions, on survival, function, and nutritional status amongst older adults with head and neck cancer. Results of this study could be illuminating, as older adults with this disease have historically worse survival outcomes compared to their younger counterparts [7].

3. Keynote oral abstracts

Five keynote oral abstracts were presented (Table 1). Dr. Montroni’s Geriatric Oncology Surgical Assessment and Functional Recovery after Surgery (GOSAFE) project evaluating surgical outcomes and quality-of-life in older adults with advanced cancer [8], received the SIOG 2019 Young Investigator award. The importance of geriatric co-management services was also highlighted by Kim et al. based on the observed significant reduction in 90-day post-operative mortality and higher utilization of supportive services in older adults with cancer [9].

Table 1:

Keynote oral abstracts

Abs tract number/Author	Design/Intervention	Demographics	Results
K01 Montroni et al. (GOSAFE) [8]	Prospective cohort study. Assess surgical outcomes and QOLa (EQ-5D-3L) at day:+30 and + 90 in surgical oncology patients	N = 643, median age 78 (range 70–94 years)	QOLa improved for most by day +90 post-op. 29% remained functionally impaired.
K02 Swinson et al. [19]	Randomized noninferiority study. Determine the optimal dose of OCapb. Determine an individualized GA-guided dose of OCapb to achieve Overall treatment utility (OTU)	N = 512	Oc 78mg/m2 d1, Capd 375mg/m2 bid d1–21 PFS non-inferior to Oc 130mg/m2 d1, Capd625mg/m2 bid d1–21 (HR 1.10, CI 0.90–1.33). Lower dose associated with better OTU.
K03Lund et al. [20]	Secondary analysis of the COACH trial; a community-based cluster randomized trial. Determine the agreement between oncologist- estimated and actual survival. Determine the predictive ability of the GAe for life expectancy.	N = 435, mean age 76 years	Oncologists overestimate life expectancy in older adults with advanced cancer (weighted kappa 0.21, 95% CI 0.15–0.28). Adding GAe measures improved overall discrimination and calibration of life expectancy estimates
K04 Oubaya et al. [21]	Pooled analysis of 3 prospective multicenter trials (ELCAPA, PHRC AQUITANE, ONCODAGE). Determine the prognostic value of CRPf and albumin on one-year mortality	N = 1800, mean age 78.5±5.5 years	CRPf and albumin were independently associated with death and may add valuable prognostic information for the assessment of older adults with cancer
K05 Alam et al. [22]	Retrospective cohort study to evaluate cost savings between the pre- GA treatment proposal and the post-GA actual treatment	N = 119, mean age 81.9 years	GA led to a modification of treatment plans in approximately 30% of cases while 90% had deintensification of treatment. Cost savings associated with the geriatric oncology clinic were $292,202 gCAD, suggesting cost- effectiveness of a geriatric oncology clinic in an academic setting

Abbreviations.

^aQOL: quality-of-life,

^bOCap: oxaliplatin and capecitabine

^cO: oxaliplatin,

^dCap: capecitabine,

^eGA: geriatric assessment,

^fCRP: c-reactive protein,

^gCAD^: Canadian dollar

4. Modern diagnostics and therapeutics

Immune checkpoint inhibitors (ICIs) are increasingly utilized in solid tumor malignancies; however, a paucity of data exists about the safety and tolerability of these agents in older adults. Two studies reported tolerability of ICIs in those age 70 and older. Peters et al. reported ICIs were well tolerated, noting fatigue as the most commonly reported immune-related adverse effect (IrAE). No higher-grade toxicities were identified [10]. Mebarki et al., evaluated the efficacy and safety of ICIs in 42 octogenarians. IrAEs were most often mild, with severe IrAEs occurring less commonly. Findings suggest ICIs may be appropriate for select octogenarians with a manageable toxicity profile [11].

Baldini et al. reported on the safety profile of combination therapy with ICIs and vascular endothelial growth factor (VEGF) inhibitors for older adults with solid tumor malignancies. In this single institution, retrospective study conducted in France, adults age > 70 years had no increased risk of Grade 2 or higher toxicities compared to their younger counterparts [12].

Older adults with cancer may be at risk for orthopedic conditions with advancing age. These conditions could potentially impact tolerance of therapies such as radiotherapy, due to positional requirements. McDonald et al. proposed a novel lateral decubitus treatment position for stereotactic body radiation (30 Gy in 5 fractions to the gross disease with up to 40 Gy in the tumor vessel interface), in older adults with pancreatic cancer previously treated with systemic therapy. This position was associated with less surrounding field organ toxicity and a higher proportion 90.9% (n=10) of patients achieving R0 resection and significant partial tumor response. Additionally, this position was viewed to be more tolerable especially for those, who due to functional and physical limitations (e.g. lower back pain, shoulder or rotator cuff injuries) would otherwise be intolerant to the supine position [13].

5. Addressing barriers to clinical trial participation

Underrepresentation of older adults in cancer-related clinical trials remains a major challenge, with approximately 25% of USA clinical trial enrollees aged ≥ 65 years [14]. This has led to knowledge gaps about therapeutic options for this population, due to a lack of robust data to support treatment decisions. To address these gaps, novel clinical trial designs, using modified eligibility criteria, as well as evaluation of the outcomes most valued by older adults are needed.

Increasingly, registry data is utilized in an attempt to provide real-world evidence of treatment related disease- specific and patient-related outcomes. Rodriquenz et al. compared the characteristics and treatment recommendations of participants enrolled in 95 randomized clinical trials (RCTs) (identified using the National Comprehensive Cancer Network’s (NCCN) guideline, for the treatment of locally advanced pancreatic cancer), to a real-world population of 707 adults age ≥ 70 years, in the Moffitt database. Thirty-seven of the eighty-six patients (43%), received adjuvant chemotherapy and 13/37 (35.1%) received radiosensitizer chemotherapy. These treatments were chosen, despite a lack of evidence supporting their use in age-matched, clinical trial participants [15]. Using the Moffitt dataset, Battisti et al compared the characteristics and treatment recommendations of octogenarians with non-small cell lung cancer, to clinical trial participants who form the basis of the NCCN and European Society of Medical Oncology’s recommendations. There was limited to no evidenced-base recommended treatment strategies in this population of octogenarians [16].

6. Solid malignancies

This year’s meeting introduced four multispecialty panels. Using a case-based approach, the potential challenges of addressing the complex care needs of older adults with breast, lung, prostate and gastrointestinal malignancies were reviewed. These discussions highlighted the importance of an integrative care model for older adults with cancer

Several studies focused on treatment-related toxicites in older adults with cancer. Pondé et al. evaluated serious adverse events among adults age ≥ 65 years enrolled in the ALTTO trial (a study of trastuzumab vs. trastuzumab and lapatinib). Serious adverse events (SAEs) defined as AEs resulting in hospitalization, occurred in 24.7% of patients (n=106), these were more common in the combination therapy arm [OR=1.84, 95% CI = 1.17–2.90, p=0.008]. Both comorbidity [OR=1.24, 95% CI = 0.72–2.11, p=0.439] and polypharmacy [OR=1.65, 95% CI = 0.98–2.79, p=0.060] were associated with an increased likelihood of SAEs [17].

Using the Surveillance, Epidemiology and End Result-Medicare dataset, men receiving abiraterone and prednisone for prostate cancer, had a higher rate of post-treatment hospitalizations due to septicemia, compared to pre-treatment (IRR 3.18, 95% CI 2.07–4.87) [18].

7. Updates from CARG, European Organization for Research and Treatment of Cancer (EORTC) and Instituto Nacional de Câncer (INCa)

These sessions, focused on improving care of older adults with cancer through best clinical practices and research. During a joint presentation by Dr. Supriya Mohile and Dr. William Dale we learned of the continued growth of CARG, to >300 members across 20 institutions nationally and internationally. The reach of the CARG group was felt to extend further, based on an estimated 16,000 website hits per month, with 45 % originating from international sources. This continued growth suggests an increased awareness about the challenges of aging and its relationship to cancer.

8. Conclusions

The field of geriatric hematology-oncology continues to expand, in an attempt to meet the projected needs of the aging population. Highlighted in this year’s conference, was the integrative approach to the care of older adults with cancer, through multispecialty models of care. Studies presented here, though spanning the research continuum, convey important messages around risks of treatment related toxicities, the role of the GA in older adults, as well as novel treatment modalities in surgical and radiation oncology related fields. Continued efforts geared toward promoting clinical trial accessibility and inclusivity for older adults are needed.