review
memo (2021) 14:24–28
https://doi.org/10.1007/s12254-020-00625-w
Geriatric oncology: questions, answers and guidelines
Matthias Unseld · Christine Marosi
Received: 17 April 2020 / Accepted: 18 May 2020 / Published online: 9 June 2020
© The Author(s) 2020
Summary Introduction
Background With the aging of populations, the num-
ber of elderly persons with cancer will increase. Due Raising awareness of the necessity to adapt cancer
to the high individuality of elderly persons and their therapy to the individual needs and resources of
varying patterns of resources and disabilities, cancer elderly cancer patients is the mission for geriatric on-
treatment for elderly cancer patients needs to be indi- cology in the 21st century. Since its beginnings around
vidually adapted. To achieve this, geriatric medicine the turn of the millennium [1], geriatric oncology has
has established the comprehensive geriatric assess- provided tools for the assessment of functioning and
ment (CGA). This short review presents the evidence vulnerabilities in older patients undergoing cancer
of feasibility and impact of CGA on cancer treatment therapies. The International Society of Geriatric On-
in elderly patients, as recommended by the American cology (SIOG) has advocated for many years that
Society of Clinical Oncology (ASCO) in 2018. older adults undergo a geriatric assessment (GA) be-
Methods A systematic review of the literature and fore the start of cancer treatment and that possible
a Delphi Consensus with a panel of experts cooper- findings of this assessment are taken into account to
ated to compile the evidence for choosing the most potentially adapt and assist this therapy. In a seminal
adequate treatment for elderly cancer patients. paper, Hamaker et al. showed that this practice made
Results There is evidence that CGA makes it pos- it possible to detect a previously unknown geriatric
sible to predict the occurrence of complications of syndrome in half of the patients tested and that geri-
chemotherapy and of health deterioration, as well as atric counselling led to an increase in the therapy
death within 1 year. planned in the same number of patients as to an
Conclusion The ASCO has recognized the optimiza- alleviation of therapy [2]. Meanwhile, a lot of expe-
tion of cancer therapy for elderly patients as a priority. rience has been gained by using and optimizing the
assessment tools, as well by evaluating their impact
Keywords Tumor treatment for elderly · Individual in clinical trials.
resources and restrictions · Functional indepence · Although more than two thirds of cancers develop
Chosing endpoints for clinical trials · Non-cancer- in individuals aged 65 years or more [3], older pa-
specific life expectancy tients have been underrepresented in clinical trials
for decades, first due to age limits, and later due to
selective inclusion and exclusion criteria hindering
trial participation of older subjects with age-related
comorbidities. This exclusion has led to a situation in
M. Unseld, MD, PhD · C. Marosi, MD () which evidence-based treatment standards are lack-
Clinical Division of Palliative Care, Department for Internal ing for older patients with cancer, despite this group
Medicine I, Medical University of Vienna, Währinger representing the majority of cancer patients. In the
Gürtel 18–20, 1090 Vienna, Austria US, the Institute of Medicine acknowledged this fun-
damental gap in cancer care and implemented actions
M. Unseld, MD, PhD for change [4].
24 Geriatric oncology: questions, answers and guidelines K
, review
Supriya Mohile coordinated a panel of experts of A CGA is a multidimensional assessment evaluat-
different disciplines that reviewed the literature for the ing physical performance, functional status including
development of an American Society of Clinical On- activities of daily living and instrumental activities of
cology (ASCO) guideline for geriatric oncology pub- daily living (ADL and IADL, respectively), history of
lished in August 2018 in the Journal of Clinical On- falls, comorbidities, depression, cognition, social ac-
cology [5]. Their duty was to evaluate the feasibil- tivities and social support as well as nutritional status.
ity and efficacy of the different tests of a comprehen- There are some validated short screening tools, like
sive geriatric assessment (CGA) to guide the manage- the G8 [6] and the Vulnerable Elders Survey (VES-13)
ment of vulnerabilities in older adult patients receiv- [7], which are able to predict mortality within 1 and
ing chemotherapy. 2 years, respectively, but unable to provide the infor-
The ASCO guideline provides answers to four ques- mation of a full assessment.
tions: There is already strong evidence that a CGA is able
1. Should GA be used in older adults with cancer to to identify older individuals at increased risk of mor-
predict adverse outcomes from chemotherapy? tality. One of the most convincing studies on this topic
2. For older patients that are considering undergoing is the one conducted by Aaldricks et al., describing
chemotherapy, which GA tools should clinicians use a three-item Geriatric Prognostic Index [8]:
to predict adverse outcomes (including chemother- Decreased food intake in the preceding 3 months
apy toxicity and mortality)? Dependence in terms of shopping
3. What general non-cancer-specific life expectancy Use of more than three medications
data for community-dwelling patients should clin-
icians consider to estimate and best inform treat- The score is associated with an increased risk of mor-
ment decision-making for older patients with can- tality of 1.58, 2.32 and 5.58 for one, two or three items,
cer? respectively. The association between abnormal find-
4. How should GA be used to guide the management ings in CGA and mortality has been confirmed by
of older patients with cancer? many studies in geriatric oncology.
For the identification of patients at increased risk
This guideline was developed by a multidisciplinary for chemotherapy toxicity, two composite test tools
expert panel and is conceived as a snapshot of the have already been validated:
state of the art as of August 2018. It is not updated The Chemotoxicity Calculator by the Cancer and
und thus open for progress. The authors claim nei- Aging Research Group (CARG) led by Arti Hurria [9]
ther completeness nor exclusivity. They emphasize combines standard clinical data with GA data on
that new evidence may emerge and should be taken prior falls, ability to walk one block, hearing prob-
into account, as well as the fact that the guideline is lems, social support and IADL. This tool takes less
not intended as a substitute for the individual assess- than 5 min to complete and is freely available at:
ment of a given patient. The recommendations are www.mycarg.org/Chemo_Toxicity_Calculator.
based on the literature available at the time of writing. The CRASH score (Chemotherapy Risk Assessment
The authors compiled data from 68 studies, including Scale for High-Age Patients) was designed by eval-
17 randomized controlled trials (RCTs). uating prospectively recorded toxicity data of 585
These guidelines will now be briefly summarized patients older than 70 years, treated at the Moffitt
and the subjectively most substantial references dis- Affiliate Research Network [10]. It provides esti-
cussed with regard to their respective topics; never- mates for both hematologic toxicity ≥3 and severe
theless, studying the guidelines in full text is strongly non-hematologic toxicity. The CRASH score con-
recommended. tains several elements of CGA such as IADL, Mini
Mental State Examination (MMSE) [11] and Mini
Question 1: Should geriatric assessment be used Nutritional Assessment (MNA) [12, 13]. The CRASH
in older adults with cancer to predict adverse score takes 30 min to complete and is also freely
outcomes from chemotherapy? available at: https://moffitt.org/for-healthcare-
providers/clinical-programs-and-services/senior-
Recommendation 1 CGA should be used in patients adult-oncology-program-tools.
aged 65 years and older in order to identify vulnera-
bilities or geriatric impairments that are not routinely Furthermore, CGA enables a prediction of completion
captured in oncology assessments. of chemotherapy, the risk of hospitalization and the
Strength of recommendation: strong risk of functional decline.
This recommendation is based on literature show-
ing that CGA detects problems that are not routinely
detected by routine history taking, physical examina-
tion and evaluation of the Karnovsky or Eastern Coop-
erative Oncology Group (ECOG) performance scores.
K Geriatric oncology: questions, answers and guidelines 25
memo (2021) 14:24–28
https://doi.org/10.1007/s12254-020-00625-w
Geriatric oncology: questions, answers and guidelines
Matthias Unseld · Christine Marosi
Received: 17 April 2020 / Accepted: 18 May 2020 / Published online: 9 June 2020
© The Author(s) 2020
Summary Introduction
Background With the aging of populations, the num-
ber of elderly persons with cancer will increase. Due Raising awareness of the necessity to adapt cancer
to the high individuality of elderly persons and their therapy to the individual needs and resources of
varying patterns of resources and disabilities, cancer elderly cancer patients is the mission for geriatric on-
treatment for elderly cancer patients needs to be indi- cology in the 21st century. Since its beginnings around
vidually adapted. To achieve this, geriatric medicine the turn of the millennium [1], geriatric oncology has
has established the comprehensive geriatric assess- provided tools for the assessment of functioning and
ment (CGA). This short review presents the evidence vulnerabilities in older patients undergoing cancer
of feasibility and impact of CGA on cancer treatment therapies. The International Society of Geriatric On-
in elderly patients, as recommended by the American cology (SIOG) has advocated for many years that
Society of Clinical Oncology (ASCO) in 2018. older adults undergo a geriatric assessment (GA) be-
Methods A systematic review of the literature and fore the start of cancer treatment and that possible
a Delphi Consensus with a panel of experts cooper- findings of this assessment are taken into account to
ated to compile the evidence for choosing the most potentially adapt and assist this therapy. In a seminal
adequate treatment for elderly cancer patients. paper, Hamaker et al. showed that this practice made
Results There is evidence that CGA makes it pos- it possible to detect a previously unknown geriatric
sible to predict the occurrence of complications of syndrome in half of the patients tested and that geri-
chemotherapy and of health deterioration, as well as atric counselling led to an increase in the therapy
death within 1 year. planned in the same number of patients as to an
Conclusion The ASCO has recognized the optimiza- alleviation of therapy [2]. Meanwhile, a lot of expe-
tion of cancer therapy for elderly patients as a priority. rience has been gained by using and optimizing the
assessment tools, as well by evaluating their impact
Keywords Tumor treatment for elderly · Individual in clinical trials.
resources and restrictions · Functional indepence · Although more than two thirds of cancers develop
Chosing endpoints for clinical trials · Non-cancer- in individuals aged 65 years or more [3], older pa-
specific life expectancy tients have been underrepresented in clinical trials
for decades, first due to age limits, and later due to
selective inclusion and exclusion criteria hindering
trial participation of older subjects with age-related
comorbidities. This exclusion has led to a situation in
M. Unseld, MD, PhD · C. Marosi, MD () which evidence-based treatment standards are lack-
Clinical Division of Palliative Care, Department for Internal ing for older patients with cancer, despite this group
Medicine I, Medical University of Vienna, Währinger representing the majority of cancer patients. In the
Gürtel 18–20, 1090 Vienna, Austria US, the Institute of Medicine acknowledged this fun-
damental gap in cancer care and implemented actions
M. Unseld, MD, PhD for change [4].
24 Geriatric oncology: questions, answers and guidelines K
, review
Supriya Mohile coordinated a panel of experts of A CGA is a multidimensional assessment evaluat-
different disciplines that reviewed the literature for the ing physical performance, functional status including
development of an American Society of Clinical On- activities of daily living and instrumental activities of
cology (ASCO) guideline for geriatric oncology pub- daily living (ADL and IADL, respectively), history of
lished in August 2018 in the Journal of Clinical On- falls, comorbidities, depression, cognition, social ac-
cology [5]. Their duty was to evaluate the feasibil- tivities and social support as well as nutritional status.
ity and efficacy of the different tests of a comprehen- There are some validated short screening tools, like
sive geriatric assessment (CGA) to guide the manage- the G8 [6] and the Vulnerable Elders Survey (VES-13)
ment of vulnerabilities in older adult patients receiv- [7], which are able to predict mortality within 1 and
ing chemotherapy. 2 years, respectively, but unable to provide the infor-
The ASCO guideline provides answers to four ques- mation of a full assessment.
tions: There is already strong evidence that a CGA is able
1. Should GA be used in older adults with cancer to to identify older individuals at increased risk of mor-
predict adverse outcomes from chemotherapy? tality. One of the most convincing studies on this topic
2. For older patients that are considering undergoing is the one conducted by Aaldricks et al., describing
chemotherapy, which GA tools should clinicians use a three-item Geriatric Prognostic Index [8]:
to predict adverse outcomes (including chemother- Decreased food intake in the preceding 3 months
apy toxicity and mortality)? Dependence in terms of shopping
3. What general non-cancer-specific life expectancy Use of more than three medications
data for community-dwelling patients should clin-
icians consider to estimate and best inform treat- The score is associated with an increased risk of mor-
ment decision-making for older patients with can- tality of 1.58, 2.32 and 5.58 for one, two or three items,
cer? respectively. The association between abnormal find-
4. How should GA be used to guide the management ings in CGA and mortality has been confirmed by
of older patients with cancer? many studies in geriatric oncology.
For the identification of patients at increased risk
This guideline was developed by a multidisciplinary for chemotherapy toxicity, two composite test tools
expert panel and is conceived as a snapshot of the have already been validated:
state of the art as of August 2018. It is not updated The Chemotoxicity Calculator by the Cancer and
und thus open for progress. The authors claim nei- Aging Research Group (CARG) led by Arti Hurria [9]
ther completeness nor exclusivity. They emphasize combines standard clinical data with GA data on
that new evidence may emerge and should be taken prior falls, ability to walk one block, hearing prob-
into account, as well as the fact that the guideline is lems, social support and IADL. This tool takes less
not intended as a substitute for the individual assess- than 5 min to complete and is freely available at:
ment of a given patient. The recommendations are www.mycarg.org/Chemo_Toxicity_Calculator.
based on the literature available at the time of writing. The CRASH score (Chemotherapy Risk Assessment
The authors compiled data from 68 studies, including Scale for High-Age Patients) was designed by eval-
17 randomized controlled trials (RCTs). uating prospectively recorded toxicity data of 585
These guidelines will now be briefly summarized patients older than 70 years, treated at the Moffitt
and the subjectively most substantial references dis- Affiliate Research Network [10]. It provides esti-
cussed with regard to their respective topics; never- mates for both hematologic toxicity ≥3 and severe
theless, studying the guidelines in full text is strongly non-hematologic toxicity. The CRASH score con-
recommended. tains several elements of CGA such as IADL, Mini
Mental State Examination (MMSE) [11] and Mini
Question 1: Should geriatric assessment be used Nutritional Assessment (MNA) [12, 13]. The CRASH
in older adults with cancer to predict adverse score takes 30 min to complete and is also freely
outcomes from chemotherapy? available at: https://moffitt.org/for-healthcare-
providers/clinical-programs-and-services/senior-
Recommendation 1 CGA should be used in patients adult-oncology-program-tools.
aged 65 years and older in order to identify vulnera-
bilities or geriatric impairments that are not routinely Furthermore, CGA enables a prediction of completion
captured in oncology assessments. of chemotherapy, the risk of hospitalization and the
Strength of recommendation: strong risk of functional decline.
This recommendation is based on literature show-
ing that CGA detects problems that are not routinely
detected by routine history taking, physical examina-
tion and evaluation of the Karnovsky or Eastern Coop-
erative Oncology Group (ECOG) performance scores.
K Geriatric oncology: questions, answers and guidelines 25
