Geriatric Assessment: ASCO Global Guideline

General Note. The following recommendations (strong or weak) and terminology (Data Supplement) represent reasonable options for patients depending on clinical circumstances and in the context of individual patient preferences. Recommended care should be accessible to patients whenever possible

• Recommendation 1.1Basic, Limited, Enhanced: All patients with cancer aged 65 and over receiving systemic therapy and 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, telemedicine, and/or referrals.Evidence quality: Moderate-High; Strength of recommendation: Strong
• Recommendation 2.1Basic: A geriatric evaluation should include at a minimum the use of a brief geriatric screening tool (G8 tool with a cutoff of ≤14 points is recommended). (Evidence quality: Moderate; Strength of recommendation: Strong)Recommendation 2.1. Limited, Enhanced: 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.Evidence quality: High; Strength of recommendation: Strong
• Recommendation 2.2Basic: For patients who are identified as potentially vulnerable using a screening tool, the Panel recommends the PGA as one option for conducting a GA. See the PGA tool [https://cdn.bfldr.com/KOIHB2Q3/as/fr5tbfs65q37wzkqhnn3fn7/2023Practical-Geriatric-Assessment]16 and associated videos (How to Do A GA [https://youtu.be/jnaQIjOz2Dw],17 What to do with the Results of a GA [https://youtu.be/nZXtwaGh0Z0]18). (Evidence quality: Moderate; Strength of recommendation: Weak)Recommendation 2.2. Limited and Enhanced: The Panel recommends the PGA as one option for this purpose. See the PGA tool [https://cdn.bfldr.com/KOIHB2Q3/as/fr5tbfs65q37wzkqhnn3fn7/2023Practical-Geriatric-Assessment]16 and associated videos (How to Do a GA [https://youtu.be/jnaQIjOz2Dw],17 What to do with the Results of a GA [https://youtu.be/nZXtwaGh0Z0]18).Evidence quality: Moderate; Strength of recommendation: Weak
• Recommendation 2.3(all levels): Although the tools available in the PGA are available and validated in multiple languages, other similar tools may be more appropriate for some settings and languages, and those could be used if they include the relevant domains mentioned in Recommendation 2.1.Evidence quality: Moderate; Strength of recommendation: Strong
• Recommendation 2.4(all levels): Cutoffs for GA-identified impairments have traditionally been developed in Maximal-resource settings of high-income countries. Therefore, differing cutoffs may be informed by locally validated research and practice.Evidence quality: Moderate; Strength of recommendation: Weak
• Recommendation 3.1(all levels): In settings not adequately represented in the validated tools listed at ePrognosis,19 clinicians may use actuarial life-expectancy tables, with preference given to those that consider quartiles of overall health status.Evidence quality: Moderate; Strength of recommendation: Weak
• Recommendation 3.2(all levels): Based on the best clinical opinion of the Expert Panel, clinicians should use one of the validated tools listed at ePrognosis to estimate life expectancy ≥4 years.a. For settings outside the United States and Canada, the Expert Panel especially recommends the Suemoto Index. The most common variables considered in these indices include age, sex, comorbidities (eg, diabetes, COPD), functional status (eg, ADLs, IADLs, mobility), health behaviors and lifestyle factors (eg, smoking status, body mass index), and self-rated healthb. Several indices have “presence of cancer” as a relevant variable, answering “no” to this question will allow for noncancer life expectancy, to consider competing risks of mortality.Evidence quality: Moderate; Strength of recommendation: Strong that it predicts mortality; Weak that it improves outcomes or improves decision making
• Recommendation 4.1Basic: Delphi consensus panels of experts have established approaches for implementing GA-guided care processes in older adults with cancer. The Expert Panel recommends that clinicians apply the results of GA to develop an integrated and individualized plan for patients that informs treatment selection by helping to estimate risks for adverse outcomes and to identify nononcologic problems that may be amenable to intervention. Based on clinical experience and the results of formal expert consensus studies, the Expert Panel suggests that clinicians consider G8 screening tool plus or minus GA results and when recommending treatment and that the information be provided to patients and caregivers to guide decision making for treatment. In addition, clinicians should implement targeted, GA-guided interventions to manage nononcologic problems (Table 2)Qualifying statement for Recommendation 4.1. Basic: Most of these processes have been developed in Maximal-resource settings. Therefore, the implementation of GA-guided care may need to be adapted to the local context following the interventions listed in Table 2. A model of care utilizing the GA to inform clinicians to adapt treatment decisions for older patients with cancer may be reasonable in Basic settingsRecommendation 4.1. Limited: Delphi consensus panels of experts have established approaches for implementing GA-guided care processes in older adults with cancer. The Expert Panel recommends that clinicians apply the results of GA to develop an integrated and individualized plan for patients that informs treatment selection by helping to estimate risks for adverse outcomes and to identify nononcologic problems that may be amenable to intervention. Based on clinical experience and the results of formal expert consensus studies, the Expert Panel suggests that clinicians consider GA results when recommending treatment and that the information be provided to patients and caregivers to guide decision making for treatment. In addition, clinicians should implement targeted, GA-guided interventions to manage nononcologic problems (Table 2)Qualifying statement for Recommendation 4.1. Limited: Most of these processes have been developed in Maximal- or Enhanced-resource settings. Therefore, the implementation of GA-guided care may need to be adapted to the local context following the interventions listed in Table 2. A model of care which uses the GA to inform oncologists about adapting treatment decisions, along with appropriate referrals and comanagement for older patients with cancer may be reasonable in Limited settingsRecommendation 4.1. Enhanced: Delphi consensus panels of experts have established approaches for implementing GA-guided care processes in older adults with cancer. The Expert Panel recommends that clinicians apply the results of GA to develop an integrated and individualized plan for patients that informs treatment selection by helping to estimate risks for adverse outcomes and to identify nononcologic problems that may be amenable to intervention. Based on clinical experience and the results of formal expert consensus studies, the Expert Panel suggests that clinicians consider GA results when recommending treatment and that the information be provided to patients and caregivers to guide decision making for treatment. In addition, clinicians should implement targeted, GA-guided interventions to manage nononcologic problems (Table 2)Rating for all settings:Evidence quality: Moderate; Strength of recommendation: Weak