A new playbook for assessing older patients with cancer in places where resources are scarce

A University of Colorado Cancer Center leader co-chaired an international expert panel that drafted new global guidelines for conducting geriatric assessments of older people with cancer in parts of the world where robust medical resources may be lacking.

The new guidelines were adopted recently by the American Society of Clinical Oncology (ASCO). They are the first to specifically address geriatric assessments of cancer patients older than 65 in “resource-limited settings,” including low- and middle-income countries as well as resource-challenged parts of the United States with marginalized populations.

A geriatric assessment is an assortment of tests and surveys used to evaluate the overall health and well-being of older patients, drawing on information not routinely gathered in a standard clinical workup, with the aim of identifying patients’ vulnerabilities and impairments. The assessment is often followed by various steps – called interventions – to manage health issues identified in the assessment.

The new guidelines offer a playbook to clinicians worldwide who may lack the means to conduct geriatric assessments and interventions as robust as would be available at a well-resourced facility like the CU Cancer Center.

Enrique Soto Pérez de Celis, MD, PhD, appointed as the CU Cancer Center’s associate director for global oncology in 2024, was co-chair of an ASCO expert panel that developed the guidelines. He is an associate professor in the CU Anschutz Department of Medicine’s Division of Medical Oncology and a specialist in geriatric oncology.

Soto and his colleagues worked on the new guidelines for more than a year. They were then submitted to ASCO members and experts in geriatric oncology for review.

Soto calls geriatric assessments “absolutely critical” for older adults with cancer before treatment begins. He says they help clinicians craft individualized treatment plans that patients can tolerate and improves patients’ chances of having “a good quality of life during and after treatment.”

Also, he says, “we now have outstanding evidence from randomized trials in geriatric oncology showing that geriatric assessment works” in improving outcomes for older cancer patients.

→ Developing a Cancer Care Framework That Respects Older Patients’ Values

Bang for the buck

The new guidelines come amid a trend of rising cancer numbers among older adults in resource-limited areas of the world.

Soto co-authored research showing that in 2020, 6.3 million new cancer cases were diagnosed among older adults in low- and middle-income countries, representing 55% of the world’s total cancer-incidence burden. The research projected that new diagnoses in that group are expected to nearly double to 11.5 million per year by 2040, a rate of increase much larger than the expected growth in world population.

“Most people with cancer, and most cancer survivors, are older people,” Soto says. “The issue is that in low- and middle-income countries, as well as in less well-resourced regions of high-income countries like the U.S., there aren’t as many resources to treat people. Even though big cancer centers can implement a lot of interventions, that is not necessarily true for community centers or for hospitals in developing countries. So, in order to implement geriatric assessments in these settings, we needed to think about how to implement them in a stepwise approach – how to prioritize which interventions give you the most bang for the buck.”

Maximal-setting guideline

Soto says geriatricians have been doing geriatric assessments of their patients for several decades, but they are “relatively new” in oncology. In 2018, ASCO issued guidelines stating that all age-65-and-old cancer patients should have a geriatric assessment before starting treatment.

“Everybody’s very different as we age, and so part of what we do in geriatric oncology is to assess all of these domains that we know have a very close relationship with treatment outcomes, and also with overall quality of life and survival,” he says.

In a fully-resourced area, operating under what ASCO calls the “maximal-setting guideline,” a geriatric assessment can include evaluations of fitness, balance, and walking speed; ability to perform daily activities like dressing and bathing; cognition, memory, and concentration; nutrition; levels of anxiety and depression; existing medication; and levels of social activity and support from family and friends. The assessment may also calculate a patient’s life expectancy.

The assessment can lead to interventions to address issues identified in the assessment, such as exercise programs, medication adjustments, home modifications, and social engagement activities.

Basic, limited, enhanced

Soto says that for geriatric assessments, resource-limited areas face a host of challenges, including access to personnel.

“Many of the interventions that are recommended for older adults require a multidisciplinary team – a psychologist, a geriatrician, a physical therapist, a nutritionist, and so on – that may not be available everywhere,” Soto says. “For a sophisticated cognitive screening, a neurologist who specializes in cognition is seldom available in some places. And in places with a lot of resources, if someone is having a lot of falls, you can recommend a home evaluation, or someone can go to their house and install handrails in the bathroom. Those kinds of resources do not exist everywhere in the world. It may be surprising to some people, but even getting a cane or a walker is very difficult in some parts of the world.”

Instead of offering a single, “one size fits all” design for geriatric assessments and interventions that might be better suited for high-resource settings, the new ASCO guidelines recommend three levels of assessment steps based on available resources, ranked as “basic,” “limited,” and “enhanced.” It’s a system called “resource stratification.”

“In these scenarios, you need to equip the clinicians so they’re treating patients with evidence-based interventions that can improve outcomes, even in the absence of more sophisticated resources,” Soto says.

Starting with a screening tool

Soto offered these examples to illustrate the three resource levels:

• In basic-resource settings, there are simple interventions that any doctor can do, such as checking blood pressure for fall risk, adjusting medications that increase fall risk, and giving general fall-prevention advice.
• In limited-resource locations, physical therapy or rehabilitation could be administered, and not necessarily by specialized personnel who might not be available.
• And in enhanced-resource settings, advanced interventions, such as home-based physical therapy, providing assistive devices, and home safety evaluations, might be possible.

At all resource levels, Soto says, “we recommended using at least a brief geriatric screening tool” – a widely used questionnaire called the G8 – “and for patients who are identified as vulnerable, we also recommended the Practical Geriatric Assessment, a self-administered survey that the ASCO geriatric oncology group created. It takes 15 minutes and can be done even in limited resource settings. So those two were relatively straightforward recommendations.”

Getting to the next level

Soto notes that resource-challenged places around the world generally tend to have younger populations than better-resourced areas like the U.S., Canada, and western Europe. But that’s changing.

“Low- and middle-income countries are aging at a very fast pace,” Soto says. “Developing countries need to prepare for that, because that’s going to be a big challenge for them in the future.”

He believes the guidelines will provide a blueprint for under-resourced nations seeking ways to grow their health care systems. “If you already have what you need for the basic level, then these guidelines can help you decide, ‘What do I need to get to the next level and the next level after that?’”

Early indications are that the new guidelines have been gaining traction, Soto says. As of mid-October, they have been downloaded 6,700 times from the ASCO website. Soto has already given four talks about them, and he is slated to talk about them in Brazil in November.

He sees this initiative as one of many examples of how advances in global oncology can help people closer to home as well.

“If we think about Colorado, a physician treating a patient on the Western Slope or in the southern valleys does not have the same resources as we have at CU Anschutz. So even though these guidelines are conceived as something for low- and middle-income countries, they could be used in community settings in the United States, too. That’s exactly why we have a global oncology initiative at the CU Cancer Center, so we can improve the way we treat patients with cancer regardless of where they live.”