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GENERAL PRINCIPLES

With the rapidly growing number of older adults in the United States, an estimated 70% of all new cancer diagnoses will be in adults age 65 and older by 2030. Similarly, by 2040, the number of older cancer survivors is expected to increase to 19.1 million. Caring for older adults with cancer provides a unique challenge for clinicians, whether the goals of care are curative or palliative. Curative therapy may require more aggressive and potentially morbid treatment with surgery, radiation, systemic therapy (eg, chemotherapy, immunotherapy, targeted therapy), or a multimodality approach. Such aggressive approaches are often more likely to cause toxicity in older patients, who tend to be less tolerant of current therapies.

Older adults, especially those who are frail, remain underrepresented in cancer clinical trials, resulting in a lack of robust data on the safety, tolerability, and efficacy of cancer treatments in this vulnerable population. While most cancer clinical trials no longer have a formal upper age limit for participation, persistent barriers to enrollment include strict performance status and organ function eligibility criteria (eg, creatinine clearance >60 mL/min in a trial of a drug that is not renally excreted), physician bias (ie, ageism) in not presenting trial options based on chronologic age, and patient lack of social support or ability to travel to meet rigorous trial requirements. The 2017 American Society of Clinical Oncology (ASCO) and Friends of Cancer Research joint research statement outlines consensus recommendations to safely broaden trial eligibility criteria to optimize the generalizability of results. The need for alternative trial end points to capture more than the gold standard of overall survival and to focus on issues important to older adults such as quality of life and the maintenance of functional capacity is detailed in a 2013 joint position paper from two cancer cooperative groups (the European Organization for Research and Treatment of Cancer and Alliance for Clinical Trials in Oncology) and the International Society for Geriatric Oncology.

In 2018, ASCO published its first guidelines on the practical assessment and management of vulnerabilities in older patients receiving chemotherapy. An expert panel developed these clinical practice guidelines through a systematic review of the medical literature. While the guidelines primarily focused on older adults receiving chemotherapy, many of the recommendations are applicable to a broad range of therapies and cancer care issues. ASCO recommends that all patients age 65 and older receiving chemotherapy undergo a geriatric assessment (GA; see Chapter 2: “Overview of Geriatric Assessment”) to identify impairments that are often missed in traditional oncology assessments. The feasibility of conducting GAs in older adults with cancer has been well established in both routine clinical care and the clinical trial setting. Assessment of physical function, falls, multimorbidity, medications, psychological health, cognition, nutrition, and social support can help risk-stratify older adults to determine their risk of treatment toxicity, inform shared decision making, and provide an opportunity to implement GA-guided interventions to optimize non–cancer-related ...

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