Older or frail adults with cancer often have different priorities and goals than healthier, younger patients. Doctors are examining how to guide conversations with these patients to ensure that their treatment plans address not just the cancer but these priorities and goals as well.
Doctors Discuss How Best to Serve Older Patients
If you or a loved one is among the many older individuals with cancer, you were on the minds of a group of doctors at a session entitled “Shared Decision-Making for Older Adults with Cancer Using Available Treatment Tools,” at the 2023 American Society of Clinical Oncology (ASCO) Annual Meeting, held June 2-6 in Chicago and virtually. This moderated discussion reviewed research and tools available to help inform treatment decisions in older patients.
Daniel Richardson, MD, MSc, MA, of the UNC Lineberger Comprehensive Cancer Center moderated the conversation between providers of different specialties. These included geriatrician Clark DuMontier, MD, MPH, of Brigham & Women’s Hospital; geriatric oncologist Kah Poh Loh, MS, MBBCh, of the James P. Wilmot Cancer Institute; and medical oncologist Melisa Wong, MD, of the University of California, San Francisco.
The panel addressed a difficult question: With older adults under-represented in most clinical trials, how can doctors best recommend cancer treatments to these patients?
For this population, the availability of social support and the level of functional and cognitive abilities can make some treatment options better or worse – considerations that usually aren’t as important for the younger patients who fill most trials. To fill this gap, panelists encouraged doctors to use a geriatric assessment, a comprehensive, holistic approach to evaluate an older person’s health, to help base treatment decisions on the patient’s priorities and health. They also stressed the need for clinicians to elicit and for patients and their families to communicate their goals and concerns.
“[The geriatric assessment] rises to the challenge of avoiding both under-treatment and over-treatment of older patients, where we don't have clear evidence on the safety and effectiveness of regimens that were tested on younger trial populations,” Dr. DuMontier said. “If [a patient is] frail and they have multiple aging-related vulnerabilities that may not be helped by the cancer treatment – and might even be exacerbated by an intensive regimen – then they’re at higher risk of toxicity. The harms of the treatment might outweigh the benefits.”
Dr. Loh shared the results of a recent survey of 42 older adults with acute myeloid leukemia (AML). These patients weighed the benefit of survival against other side effects of care, including:
Worsening memory or confusion
Assistance with daily activities
Quality of life
One striking result was that about half of patients would rather live shorter than experience a decrease in quality of life, worsening memory, or confusion.
“These results are striking in the context of our clinical trials, [in] which our primary outcome is almost always overall survival,” Dr. Richardson said. “We have a huge discordance between what patients value most and what is actually measured as the primary outcome for the trials.”
How Doctors Use a Geriatric Assessment to Guide Discussion on Treatment Options
Sometimes oncologists only recommend the guideline recommended standard of care, and patients may not understand that other options are available, Dr. Wong said. Performing a geriatric assessment allows patients to learn their treatment options and allows doctors to learn more about their patients’ values and goals.
To guide the assessment in an efficient, easy-to understand conversation, Dr. Wong uses a four-step process:
She discusses the available treatment choices with the patient and explains that reasonable people would make different decisions based on their circumstances.
She discusses the range of plausible outcomes and treatment goals of each using narrative descriptions. Then, she presents the option that is most likely for that patient to experience.
She engages in a conversation with the patient that compares each option. She stresses that active listening is important to understand what the patient thinks about each option and how each option matches their goals.
She recommends an option to the patient based on the patient’s goals and preferences and explains why this is her recommendation.
“This is about really showing patients and their families that you are there to support them and come to a decision together,” Dr. Wong says. “This is not putting the burden of making the decision on the patients themselves, but really showing them that you are going to offer support and ask about their goals and preferences.”
Advice to Patients About Shared Decision-Making
Not all oncologists use geriatric assessments to guide their discussion with older patients, however. That’s why Dr. Loh encourages patients to feel empowered in starting the conversation with their doctors at any point in their cancer journey, especially during decision-making moments.
“Consider what is important to you and to your family. In the context of making decisions about treatment, expressing values could be something general – such as being able to live longer, maintaining quality of life, or preserving independence – or something more specific such as, ‘I want to make it to my daughter’s wedding in December,’” Dr. Loh said. “You can also be open about sharing your health, whether or not you have challenges with walking, completing activities at home, memory concerns.”
Patients can download the patient version of the geriatric assessment available from the Cancer and Aging Research Group, Dr. Loh recommended. You can then complete the assessment and share it with your care team. Sometimes, completing an assessment or writing questions or ideas down at home and bringing them to appointments can help you engage in shared decision-making with your doctors.
“We know that patients who are being proactive about their care are more likely to be satisfied with their teams and have better outcomes,” Dr. Loh said. “As the medical team, we want to know what is important to the patient and caregiver so we can make the best decision together.”