A Geriatric Assessment Intervention to Reduce Treatment Toxicity Among Older Adults With Advanced Lung Cancer: A Subgroup Analysis From a Cluster Randomized Controlled Trial

Abstract

IntroductionMore older adults die from lung cancer worldwide than breast, prostate, and colorectal cancers combined. Current lung cancer treatments may prolong life, but can also cause considerable treatment-related toxicity.ObjectiveThis study is a secondary analysis of a cluster-randomized clinical trial which evaluated whether providing a geriatric assessment (GA) summary and GA-guided management recommendations can improve grade 3-5 toxicity among older adults with advanced lung cancer.MethodsWe analyzed participants aged ≥70 years(y) with stage III & IV (advanced) lung cancer and ≥1 GA domain impairment starting a new cancer treatment with high-risk of toxicity within the National Cancer Institute’s Community Oncology Research Program. Community practices were randomized to the intervention arm (oncologists received GA summary & recommendations) versus usual care (UC: no summary or recommendations given). The primary outcome was grade 3-5 toxicity through 3 months post-treatment initiation. Secondary outcomes included 6-month (mo) and 1-year overall survival (OS), treatment modifications, and unplanned hospitalizations. Outcomes were analyzed using generalized linear mixed and Cox proportional hazards models with practice site as a random effect. Trial Registration: NCT02054741.Results & ConclusionAmong 180 participants with advanced lung cancer, the mean age was 76.3y (SD 5.1), 39.4% were female and 82.2% had stage IV disease. The proportion of patients who experienced grade 3-5 toxicity was significantly lower in the intervention arm vs UC (53.1% vs 71.6%, P=0.01). More participants in the intervention arm received lower intensity treatment at cycle 1 (56.3% vs 35.3%; P<0.01). Even with a cycle 1 dose reduction, OS at 6mo and 1 year was not significantly different (adjusted hazard ratio [HR] intervention vs. UC: 6mo HR=0.90, 95% CI: 0.52-1.57, P=0.72; 1 year HR=0.89, 95% CI: 0.58-1.36, P=0.57). Frequent toxicity checks, providing education and counseling materials, and initiating direct communication with the patient’s primary care physician were among the most common GA-guided management recommendations. Providing a GA summary and management recommendations can significantly improve tolerability of cancer treatment among older adults with advanced lung cancer.

Association Between Age and Survival Trends in Advanced Non–Small Cell Lung Cancer After Adoption of Immunotherapy

“…Second, future work should incorporate a comprehensive geriatric assessment as part of standard practice before initiating treatment and collect patient-reported outcomes afterward . This can assist in making treatment decisions more patient centered and substantially decrease treatment-related toxic effects . Our study focused on survival; however, it is also critical to assess temporal trends in QOL, including physical and financial burden.…”

Frailty assessment to individualize treatment in older patients with lymphoma

“…Other studies, such as Corre et al [44], have demonstrated similar results in advanced non-small-cell lung cancer, with CGA-based individualized treatment failing to improve treatment outcomes but slightly reducing treatment toxicity. Mohile et al [45] report that older patients with advanced cancer undergoing CGA (incurable solid tumors or lymphoma) experience less grade 3-5 toxicity than their non-CGA counterparts. These studies highlight the importance of CGAguided interventions to improve outcomes, although more speci c studies are needed to determine how CGA-tailored treatment can reduce toxicity for older individuals with lymphoma.…”

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Systemic Cancer Therapy: ASCO Guideline Update

“…Over 3 months, patients in the intervention group also had fewer falls (12%) than patients in the usual group (21%; adjusted RR, 0.58 [95% CI, 0.40 to 0.84]; P = .0035), and had more medications discontinued (mean adjusted difference, 0.14 [95% CI, 0.03 to 0.25]; P = .015). Two recently published secondary analyses of data from GAP70+ reported, respectively, a significantly lower proportion of stage III and IV patients with lung cancer who experienced grade 3-5 toxicity in the intervention arm versus usual care (53.1% v 71.6%; P = .01) 24 ; and, among 623 patients from GAP70+ with follow-up Patient-Reported Outcomes Common Terminology Criteria for Adverse Events (PRO-CTCAE) data, fewer patients in the GA intervention arm reported grade ≥2 symptomatic toxicity compared to usual care patients (overall: 88.9% v 94.8%; P = .035; core symptoms: 83.4% v 91.7%; P = .001). 25…”

“…A total of 15 publications met eligibility criteria and form the evidentiary basis for the guideline recommendation pertaining to Clinical Question 1. 3,4,[14][15][16][17][18][19][20][21][22][23][24] The identified publications include the respective primary reports of nine RCTs evaluating GAM 3,4,[14][15][16][17][18][19][20] ; four reports of secondary analyses of data from the primary RCTs [23][24][25][26] ; one systematic review of GA studies 22 ; and one systematic review of GA studies with meta-analysis. 21 The identified RCTs were published between 2020 and 2022.…”