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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)
Older Adult Oncology

Version 1.2020 — February 7, 2020
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Version 1.2020, 02/07/20 © 2020 National Comprehensive Cancer Network® (NCCN®), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
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NCCN Guidelines Version 1.2020 NCCN Guidelines Index

Table of Contents
Older Adult Oncology Discussion
*Efrat Dotan, MD/Chair † Reshma Jagsi, MD, DPhil § Randall W. Rupper, MD, MPH Þ ₪
Fox Chase Cancer Center University of Michigan Rogel Cancer Center Huntsman Cancer Institute
*Louise C. Walter, MD/Vice Chair ₪ Nancy L. Keating, MD, MPH Þ at the University of Utah
UCSF Helen Diller Family Dana-Farber/Brigham and Women’s Lidia Schapira, MD †
Comprehensive Cancer Center Cancer Center Stanford Cancer Institute
Joel Baumgartner, MD ¶ Elizabeth Kessler, MD † Derek L. Stirewalt, MD † ‡
UC San Diego Moores Cancer Center University of Colorado Cancer Center Fred Hutchinson Cancer Research
Ilene S. Browner, MD † ₪ Thuy Koll, MD ₪ Center/Seattle Cancer Care Alliance
The Sidney Kimmel Comprehensive Fred & Pamela Buffett Cancer Center Ishwaria M. Subbiah, MD, MS † £
Cancer Center at Johns Hopkins Beatriz Korc-Grodzicki, MD, PhD ₪ The University of Texas
Peggy Burhenn, MS, RN † ₪ Memorial Sloan Kettering Cancer Center MD Anderson Cancer Center
City of Hope National Medical Center June M. McKoy, MD, MBA, JD, MPH ₪ Þ William P. Tew, MD † Þ
Harvey Jay Cohen, MD † ₪ Robert H. Lurie Comprehensive Cancer Memorial Sloan Kettering Cancer Center
Duke Cancer Institute Center of Northwestern University Noam VanderWalde, MD §
Martine Extermann, MD, PhD † Tracey O’Connor, MD † St. Jude Children’s Research Hospital/The
Moffitt Cancer Center Roswell Park Comprehensive Cancer Center University of Tennessee Health Science Center
Cary Gross, MD Þ Cynthia Owusu, MD, MS ‡ Tanya Wildes, MD † ‡ ₪

Yale Cancer Center/Smilow Cancer Hospital Case Comprehensive Cancer Center/ Siteman Cancer Center at Barnes-
University Hospitals Seidman Cancer Jewish Hospital and Washington
Genevieve Hollis, MSN, CRNP § University School of Medicine
Abramson Cancer Center Center and Cleveland Clinic Taussig
at the University of Pennsylvania Cancer Institute Grant R. Williams, MD † ₪
Ashley Rosko, MD ‡ O'Neal Comprehensive Cancer Center at UAB
Joleen Hubbard, MD †
Mayo Clinic Cancer Center The Ohio State University Comprehensive NCCN
Cancer Center - James Cancer Hospital Jennifer Keller, MSS
Kevin Hughes, MD ¶ and Solove Research Institute Hema Sundar, PhD
Massachusetts General Hospital Griselda Zuccarino-Catania, PhD
Cancer Center
₪ Geriatric medicine £ Supportive care including

‡ Hematology oncology palliative and pain
Þ Internal medicine, including management
Continue family practice and
preventive management
¶ Surgery/Surgical oncology
* Discussion Writing Committee
NCCN Guidelines Panel Disclosures
† Medical oncology Member
§ Radiation oncology

Table of Contents
NCCN Older Adult Oncology Panel Members

Clinical Trials: NCCN believes that
Summary of the Guidelines Updates
the best management for any patient
with cancer is in a clinical trial.
Definition and Purpose of the NCCN Guidelines for Older Adult Oncology (OAO-1) Participation in clinical trials is
Approach to Decision-Making in the Older Adult (OAO-2) especially encouraged.
Pre-Treatment Evaluation (OAO-3)
To find clinical trials online at NCCN
Considerations for Older Adults Undergoing Cancer Treatments (OAO-4) and (OAO-5) Member Institutions, click here:
Considerations for Older Adults and Side Effects for Use of Systemic Therapy (OAO-6) nccn.org/clinical_trials/member_
Upper, Middle, and Lower Quartiles of Life Expectancy for Women and Men at Selected Ages institutions.aspx.
(OAO-A)
NCCN Categories of Evidence and
Optimizing Communication with Older Adults (OAO-B) Consensus: All recommendations
Comprehensive Geriatric Assessment (OAO-C) are category 2A unless otherwise
Geriatric Screening Tools (OAO-D) indicated.
Gait Assessment and Interventions (OAO-E)
See NCCN Categories of Evidence
Assessment of Cognitive Function (OAO-F)
and Consensus.
Assessment of Adherence (OAO-G)
Insomnia (OAO-H) NCCN Categories of Preference:
Medications Commonly Used for Supportive Care that Are of Concern in Older Patients (OAO-I) All recommendations are considered
appropriate.
See NCCN Categories of Preference.
The NCCN Guidelines® are a statement of evidence and consensus of the authors regarding their views of currently accepted approaches to
treatment. Any clinician seeking to apply or consult the NCCN Guidelines is expected to use independent medical judgment in the context of individual
clinical circumstances to determine any patient’s care or treatment. The National Comprehensive Cancer Network® (NCCN®) makes no representations
or warranties of any kind regarding their content, use or application and disclaims any responsibility for their application or use in any way. The NCCN
Guidelines are copyrighted by National Comprehensive Cancer Network®. All rights reserved. The NCCN Guidelines and the illustrations herein may not
be reproduced in any form without the express written permission of NCCN. ©2020.

Table of Contents
Updates in Version 1.2020 of the NCCN Guidelines for Older Adult Oncology from Version 1.2019 include:
General OAO-3
• Terms modified throughout the Guidelines: • Footnote h added: Concerns can come from the patient, family, or
Advance directive/advance care planning document clinician and can be related to the patient's performance status and/
Geriatrician geriatric trained clinician or comorbidities.
Family/caregiver
OAO-4
OAO-1 • General
• A new page was added that includes the definition of the older adult Bullet 1 added: There are data to suggest correlation between
oncology population and the purpose of the NCCN Guidelines for low social support and a higher risk for mortality. In patients with
Older Adult Oncology low levels of social support, consider referral to social work and/
or case management to explore home supports and community
OAO-2 resources.
• Pathway starting point modified: Is the patient at moderate or Bullet 2 added: Patient's wishes should be assessed.
high risk of dying or suffering from cancer a candidate for cancer • Surgery
treatment considering his or her overall life expectancy? Bullet 2 modified by adding: regardless of age
• For patients who do not have decision-making capacity Bullet removed: Assess physiologic status.
Bullet 2 added: Consider family/care coordination meeting • Radiation Therapy
Bullet 3 added: Communicate with patient's primary care provider Bullet 1 modified: Considerations for of older patients undergoing
Bullet 4 modified: Consider consult from social work, psychology, radiation therapy should be informed by the benefits versus risks
palliative care (See NCCN Guidelines for Palliative Care) or ethics based will heavily depend on the anatomic site...
committee Bullet 2 added: Conformal techniques may be helpful to minimize
• Footnotes tissue toxicities.
Footnote a added: Assessment of the patient’s goals and objectives
with regard to his/her cancer diagnosis should be completed OAO-5
prior to any treatment decision. Supportive and palliative care • Systemic therapy
assessment is recommended for any older adult with cancer. Bullet 1 modified: Chemotherapy toxicity risk can be predicted
Footnote c modified by removing: Note that these calculators by parameters that are typically included in a comprehensive
should be used in conjunction with clinical judgment. geriatric assessment (CGA).
Footnote g modified: Harrington SE, Smith TJ. The role of Cancer Aging Research Group (CARG) Chemo Toxicity Calculator
chemotherapy at the end of life: when is enough, enough? JAMA ◊◊Sub-bullet 3 modified by removing: first
2008;299:2667-2678. Massa I, Nanni O, Foca F, et al. Chemotherapy ◊◊Sub-bullet 4 modified by removing: using Jeliffe formula
and palliative care near end-of life: examining the appropriateness Chemotherapy Risk Assessment Scale for High-Age Patients
at a cancer institute for colorectal cancer patients. BMC Palliat Care (CRASH) score link added: https://moffitt.org/eforms/
2018;17:86. crashscoreform
• Immunotherapy
Continued
UPDATES

Table of Contents
Bullet 1 added: Older adults are underrepresented in clinical trials Reference 9 added: Kanesvaran R, Cordoba R, Maggiore
studying immunotherapy across multiple cancers. Most subgroup R. Immunotherapy in older adults with advanced cancers:
analyses and retrospective studies report a similar clinical benefit Implications for clinical decision-making and future research. Am
in older and younger patients, with some concerns for increase in Soc Clin Oncol Educ Book 2018;38:400-414.
toxicity rates.
Bullet 2 added: When considering immunotherapy, be aware that OAO-A
management of immunotherapy-related toxicity with high-dose • Page heading added: Data from United States Life Tables
steroids must be viewed with caution in older patients, as it may • Life expectancy calculation link added: See eprognosis.ucsf.edu
worsen other comorbidities or cognitive function.
OAO-B
OAO-6 • Oral Communication
• Cardiac toxicity Bullet 3 modified by adding: minimize background noise
Sub-bullet 2 modified by adding: See NCCN Guidelines for Bullet 8 modified by adding Teachback link: See Teachback
Survivorship SCARDIO-1, SCARDO-2, and SCARDIO-3 Bullet 10 added: Recognize the presence of, and avoid the use
of, “elderspeak,” a form of communication used with older adults
OAO-7 that is similar to “baby-talk” and may impact clinician-patient
• Reference 1 interactions and result in poor patient outcomes.
Previous version: Chow WB, Rosenthal RA, Merkow RP, et al. • Footnote b added: Corwin AI. Overcoming elderspeak: A qualitative
Optimal preoperative assessment of the geriatric surgical patient: study of three alternatives. Gerontologist 2018;58:724-729.
a best practices guideline from the American College of Surgeons
National Surgical Quality Improvement Program and the American OAO-C 1 of 8
Geriatrics Society. J Am Coll Surg 2012;215(4):453-66. • Comprehensive Geriatric Assessment statement modified: CGA can
Updated version: Geriatric Surgery Verification Program Standards be performed in a number of ways, the most extensive being with
from the American College of Surgeons, July 2019. https://www. a geriatric trained clinician doing a full assessment. Alternatively,
facs.org/quality-programs/geriatric-surgery. there are tools that allow the clinician to administer assessments
• Reference 7 within the oncology clinic setting. See ASCO Guidelines for
Previous version: Inouye SK, Westendorp R, Saczynski JS. Delirium Geriatric Assessment. CGA is a systematic procedure to appraise
in elderly people. Lancet 2014;383(9920):911-922.0. objective health, including multiple comorbidities and functional
Updated version: Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium status, which interfere with cancer prognosis and treatment choices
in older persons: Advances in diagnosis and treatment. JAMA in older adults.
2017;318:1161-1174. • Assessment of patient's goals statement added: A patient's goals
Reference 8 added: Bastiaannet E, Battisti N, Loh KP, et al. and objectives with regard to his/her cancer diagnosis should be
Immunotherapy and targeted therapies in older patients with assessed prior to any treatment decision. Supportive and palliative
advanced melanoma; Young International Society of Geriatric care assessment is recommended for any older adult with cancer.
Oncology review paper. J Ger Oncol 2019;10:389-397. • Reasons to Perform CGA
Continued
UPDATES

Table of Contents
Bullet 2 modified: CGA can predict risk of toxicity/adverse effects Methods to assess comorbidities
from cancer treatment or decrease in quality of life (QOL), enabling ◊◊Sub-bullet added: Adult Comorbidity Evaluation 27 (ACE-27)
more targeted use of supportive care measures. • Cognitive Function
Bullet removed: CGA can influence/improve treatment decisions. Dementia
Bullet 5 added: CGA can be helpful in improving communication. ◊◊Sub-bullet 1 modified: Mini-Mental State Examination (MMSE)
• Heading modified: Collaboration with the Between Geriatric Trained ◊◊Sub-bullet 3 added: Mini-cog (https://mini-cog.com/)
Clinician and Oncologist in the Care of an Older Patient with Cancer ◊◊Sub-bullet 4 added: Short Blessed Test (SBT)
Cognitive impairment
◊◊Sub-bullet 3 modified: Life expectancy, advance directive/ OAO-C 4 of 8
advance care planning, guardianship (See NCCN Guidelines for • Nutritional Status
Palliative Care) Statement modified: Patients with cancer tend to be are at risk for
Bullet 8 added: Caregiver support severe malnutrition that is underdiagnosed.
Bullet 9 added: Assistance with social support resources Malnutrition
◊◊Sub-bullet 1 modified: Unintentional weight loss of greater than
OAO-C 2 of 8 5% over 6 months
• Functional Status ◊◊Sub-bullet 5 modified: Practical suggestions to for evaluation
Bullet removed: CGA includes assessment tools to predict the of and treatment for optimizing nutrition among patients with
functional age of older patients with cancer based on functional cancer:
status, comorbidities that may interfere with cancer treatment, ––Added:
polypharmacy, nutritional status, cognitive function, psychological ▪▪Mini Nutritional Assessment (MNA)
status, and socioeconomic issues. ▪▪Patient-Generated Subjective Global Assessment of Nutrition
Falls and/or unstable gait ◊◊Sub-bullet 5 added: Referral to speech and language pathologist
◊◊Bullet 3, sub-bullet 6 modified: Medications review for at-risk to assess for swallowing issues
medications (eg, benzodiazepines, hypnotics) that put patients at Polypharmacy
risk for adverse outcomes See Medications Commonly Used for ◊◊Bullet 2 modified: Review medications periodically as indicated
Supportive Care that Are of Concern in Older Patients (OAO-I) to identify medication-related problems. Medication review may
• Socioeconomic Issues also be indicated...
Bullet 6 added: Food insecurity
Bullet 7 modified: Financial toxicity (eg, underinsurance and/or OAO-C 6 of 8
high out-of-pocket costs) • Functional Status
Intervention modified: Promote physical activity and exercise
OAO-C 3 of 8 • Social Support/Caregiver Burden
• Comorbidities Intervention added: Financial toxicity
Bullet 1 modified: May affect treatment decisions in 5 several ways • Psychological Status: Anxiety/Depression
◊◊Sub-bullet removed: Comorbidity may modify cancer behavior. Intervention modified: Counseling by a qualified professional
◊◊Sub-bullet 2 modified by adding: Depression, Dementia
Continued
UPDATES

Table of Contents
OAO-C 7 of 8 • Reference 25
• Reference 3 added: Mohile SG, Epstein RM, Hurria A, et al. Previous version: Landi F, Zuccala G, Gambassi G, et al. Body
Communication with older patients with cancer using geriatric mass index and mortality among older people living in the
assessment: A cluster-randomized clinical trial from the National community. J Am Geriatr Soc 1999;47(9):1072-1076.
Cancer Institute Community Oncology Research Program. JAMA Updated version: Winters J, MacInnis R, Wattanapenpaiboon N, et
Oncol 2019;7:1-9. al. BMI and all-cause mortality in older adults: a meta-analysis. Am
• Reference 5 added: de Souza JA, Yap BJ, Wroblewski K, et al. J Clin Nutr 2014;99:875-890.
Measuring financial toxicity as a clinically relevant patient-reported • Reference 27 added: Gabrielson DK, Scaffidi D, Leung E, et al.
outcome: The validation of the Comprehensive Score for financial Use of an abridged scored Patient-Generated Subjective Global
Toxicity (COST). Cancer 2017;123:476-484. Assessment (abPG-SGA) as a nutritional screening tool for cancer
• Reference 9 added: Binder PS, Peipert JF, McCourt CK, et patients in an outpatient setting. Nutr Cancer. 2013;65(2):234-239.
al. Adult Comorbidity Evaluation 27 score as a predictor of • Reference 28 added: Abbott J, Teleni L, McKavanagh D, Watson
survival in endometrial cancer patients. Am J of Obstet Gynecol J, McCarthy AL, Isenring E. Patient-Generated Subjective Global
2016:215(6);766.e1-766.e9. Assessment Short Form (PG-SGA SF) is a valid screening tool in
• Reference 10 chemotherapy outpatients. Support Care Cancer. 2016;24(9):3883-
Previous version: Yesavage JA, Brink TL, Rose TL, et al. 3887.
Development and validation of a geriatric depression screening • Reference 29 added: Bauer J, Capra S, Ferguson M. Use of the
scale: a preliminary report. J Psychiatr Res 1982-1983;17(1):37-49. scored Patient-Generated Subjective Global Assessment (PG-SGA)
Updated version: D’Ath P, Katona P, Mullan E, Evans S, Katona C. as a nutrition assessment tool in patients with cancer.
Screening, detection and management of depression in elderly • Eur J Clin Nutr. 2002;56(8):779-785.
primary care attenders: the acceptability and performance of the 15
item Geriatric Depression Scale (GDS15) and the development of OAO-E
short versions. Fam Pract 1994;11(3):260-266. • Footwear assessment intervention added: Consider referral to
• Reference 13 added: Ketelaars L, Pottel L, Lycke M, et al. Use of the podiatrist
Freund clock drawing test within the Mini-Cog as a screening tool • Footnote added: Lui M, DuMontier C, Murillo A, et al. Gait speed,
for cognitive impairment in elderly patients with or without cancer. J grip strength, and clinical outcomes in older patients with
Geriatr Oncol 2013;2:174-182. hematologic malignancies. Blood 2019;134(4):374-382.
• Referencee 14 added: Katzman R, Brown T, Fuld P, et al. Validation
of a short Orientation-Memory-Concentration Test of cognitive OAO-F 2 of 2
impairment. Am J Psychiatry 1983;140:734-739. • Further evaluation for Dementia and Delirium, link added: See
NCCN Guidelines for Distress Management, DIS-7 and DIS-8
OAO-C 8 of 8
• Reference 24 added: Fearon K, Strasser F, Anker S, et al. Definition OAO-G
and classification of cancer cachexia: an international consensus. • Strategies to minimize non-adherence
Lancet Oncol 2011;12(5):489-495. Bullet 7, first sentence modified: Provide written instructions to
patient/caregiver for taking the medication at the sixth fifth grade
Continued
UPDATES

Table of Contents
level.
OAO-H
• Insomnia
Last bullet added: See sleep medication recommendations (OAO-I)
OAO-I 1 of 5
• Benzodiazepines, Alternative(s)
Bullet 2, links added: See "Insomnia" (OAO-H) and See
NCCN Guidelines for Survivorship (also for OAO-I 2 of 5 Non-
benzodiazepine sedative and First-generation antihistamines)
Bullet 3, link added: See NCCN Guidelines for Antiemesis (also for
OAO-I 3 of 5 Antiemetic, prokinetic and Phenothiazine antiemetic;
OAO-I 4 of 5, Antipsychotics)
OAO-I 5 of 5
• Antiepileptic drugs, Recommendations
Bullet 2 added: Carefully check drug interactions when using these
agents.
Section on Opioids added
UPDATES

Table of Contents
DEFINITION AND PURPOSE
Definition of the Older Adult Oncology Population

Older adults are defined based on functional status rather than chronologic age. Age 65 and older is generally considered the chronologic
definition of an older adult as this is the usual age of eligibility for Medicare benefits.
Purpose of the NCCN Guidelines for Older Adult Oncology

• There are unique issues to consider when caring for an older adult with cancer.
• The biologic characteristics of certain cancers and their responsiveness to therapy may be different in older patients compared to their
younger counterparts.
• The physiologic changes associated with aging may impact an older adult’s ability to tolerate cancer therapy and should be considered in
the treatment decision-making process.
• Advanced age alone should not be the only criterion to preclude effective treatment that could improve quality of life (QOL) or lead to a
survival benefit in older patients.
• These age-related issues form the basis for the development of NCCN Guidelines for Older Adult Oncology that address special
considerations in older patients with cancer.
Note: All recommendations are category 2A unless otherwise indicated.

Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged.
OAO-1

Table of Contents
APPROACH TO DECISION-MAKING
IN THE OLDER ADULTa,b
Is the patient a candidate for Symptom management/supportive care

No See NCCN Guidelines for Palliative Care
cancer treatment considering his
or her overall life expectancy?c,d • Obtain information from:
Patient’s proxy
Yes
Advance directive/advance care planning document
Living will
Health care power of attorney
Does this patient have decision-making No Clinician’s documentation
capacity?e,f • Consider family/care coordination meeting
Patients must have the ability to: • Communicate with patient's primary care provider
• Understand the relevant information about • Consider consult from social work, psychology,
proposed diagnostic tests or treatments palliative care (See NCCN Guidelines for Palliative Care)
• Appreciate their situation (including their or ethics committee
underlying values and current medical
situation)
• Use reason to make a decision Yes
• Communicate a consistent choiceb
Symptom management/supportive
• Assess the patient’s goals and No care (See NCCN Guidelines for
values regarding the management Palliative Care)
of his or her cancer
• Are the patient’s goals and values
consistent with wanting anti-cancer Assessment of risk factors
Yes (See OAO-C)
therapy?g
a Assessment of the patient’s goals and objectives with regard to his/her cancer diagnosis
should be completed prior to any treatment decision. Supportive and palliative care
assessment is recommended for any older adult with cancer. e Sessums LL, Zembrzuska H, Jackson JL. Does this patient have medical decision-making
b See Optimizing Communication with Older Adults (OAO-B). capacity? JAMA 2011;306(4):420-427. Copyright © (2012) American Medical Association.
c Life expectancy calculators are available at www.eprognosis.com. Note that All rights reserved.
these calculators are used to determine anticipated life expectancy f McKoy JM, Burhenn PS, Browner IS, et al. Assessing cognitive function and capacity in
(independent of the cancer). They could be utilized in clinical decision-making to weigh older adults with cancer. J Natl Compr Canc Netw 2014;12(1):138-144.
whether the cancer is likely to shorten the patient's life expectancy or whether the patient is g Massa I, Nanni O, Foca F, et al. Chemotherapy and palliative care near end-of life:
likely to become symptomatic from cancer during his or her anticipated life expectancy. d examining the appropriateness at a cancer institute for colorectal cancer patients. BMC
See histograms for age-specific life expectancy (OAO-A). Palliat Care 2018;17:86.

OAO-2

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PRE-TREATMENT EVALUATIONa
Treat as recommended in disease-specific
treatment guidelines (NCCN Guidelines for
Treatment of Cancer by Site)
Normal
See Geriatric See Considerations for Older Adults Undergoing
No Screening Cancer Treatments (OAO-4) and Side Effects for
Tools (OAO-D)i Use of Systemic Therapy (OAO-6)
Are there any concerns
about the patient's ability Abnormal
to tolerate anti-cancer Comprehensive
therapy?h Yes Geriatic Assessment,
CGA [See OAO-C (1 of 8)]
Modifiable abnormalities identified Non-modifiable abnormalities identified
Are there alternate

Treat abnormalities
treatment options
See Care Process See NCCN Guidelines
that would reduce No
for Older Adults with for Supportive Care
toxicity to an
Cancer OAO-C (6 of 8)
acceptable level?
Yes
See Considerations for Older Adults Undergoing Cancer Treatments (OAO-4), Side Effects
for Use of Systemic Therapy (OAO-6), and NCCN Guidelines for Supportive Care
aAssessment of the patient’s goals and objectives with regard to his/her cancer diagnosis should be completed prior to any treatment decision. Supportive and palliative care assessment
is recommended for any older adult with cancer.
hConcerns can come from the patient, family, or clinician and can be related to the patient's performance status and/or comorbidities.
iMultiple screening tools have been tested and validated in this setting. Selected geriatric screening tools that have been used to determine if a CGA would be beneficial for older patients
with cancer are listed on OAO-D.

OAO-3

Table of Contents
CONSIDERATIONS FOR OLDER ADULTS UNDERGOING CANCER TREATMENTSj

• There are data to suggest correlation between low social support and a higher risk for mortality. In patients with low
General levels of social support, consider referral to social work and/or case management to explore home supports and
community resources.
• Patient's wishes should be assessed.
• In general, age is not the primary consideration for surgical risk.
• Emergency surgery carries increased risk of complications, regardless of age.
• The American Geriatrics Society (AGS) Task Force and American College of Surgeons provided general guidelines for
older adults undergoing surgery.1 These guidelines can be applied to older cancer patients undergoing surgery.
• There are data to suggest that an increased need for functional assistance pre-surgery (measured by activities of daily
living [ADLs], instrumental ADLs [IADLs], and performance status [PS]) predicts postoperative complications, extended
hospital stay, and 6-month mortality in older patients undergoing cancer surgery.2-4
• Impaired cognitive status is a risk factor for postoperative complications, prolonged length of stay, and 6-month overall
Surgery mortality postoperatively.2,5
• In patients undergoing general surgery:k
Older age is a risk factor for postoperative delirium.6
Delirium is a risk factor for functional and cognitive decline.7 See Assessment of Cognitive Function (OAO-F)
• Preventive measures exist for delirium
Yale Delirium Prevention Trial and Hospital Elder Life Program (HELP) for Prevention of Delirium:
http://www.hospitalelderlifeprogram.org/
National Institute for Health and Care Excellence (NICE) Guideline for Prevention of Delirium:
http://publications.nice.org.uk/delirium-cg103
• Considerations of older patients undergoing radiation therapy should be informed by the benefits versus risks based on
the anatomic site being radiated and the dose/fractionation chosen. Use caution with concurrent chemoradiation therapy;
Radiation
dose modification of chemotherapy or chemoradiation may be necessary. See disease-specific NCCN Guidelines for
therapy
Treatment of Cancer by Site.
• Conformal techniques may be helpful to minimize tissue toxicities.
• Nutritional support and pain control are needed if radiation therapy-induced mucositis is present.
jMonitor the patient’s functional status, comorbidities, social circumstances, pain, nutritional status, and distress.
kThe American College of Surgeons and the AGS have provided general guidelines for the preoperative assessment of older patients undergoing surgery. These guidelines could also be
applied to older patients with cancer undergoing surgery. Chow WB, Rosenthal RA, Merkow RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices
guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg 2012;215:453-466.
Continued
See References on
(OAO-7)
OAO-4

Table of Contents
CONSIDERATIONS FOR OLDER ADULTS UNDERGOING CANCER TREATMENTSj
• Chemotherapy toxicity risk can be predicted by parameters that are typically included in a comprehensive geriatric
assessment (CGA).
Cancer and Aging Research Group (CARG) Chemo Toxicity Calculator (http://www.mycarg.org/Chemo_Toxicity_
Calculator). The CARG calculator considers the following domains:
◊◊Patient demographics (ie, age, height, weight, gender)
◊◊Cancer type (gastrointestinal [GI], genitourinary [GU], or other)
◊◊Chemotherapy risk (dosage and number of agents)
Systemic ◊◊Laboratory values (ie, hemoglobin, serum creatinine, creatinine clearance)
therapy ◊◊Functional status: number of falls in the past 6 months, ability to walk one block, ability to participate in social
activities, and ability to take medicines without help
◊◊Hearing is fair, poor, or nonexistent
Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score (https://moffitt.org/eforms/
crashscoreform). The CRASH score considers the following domains:
◊◊Chemotherapy risk according to regimen
◊◊Hematologic risk factors (diastolic blood pressure [BP], IADLs, lactate dehydrogenase [LDH])
◊◊Nonhematologic risk factors (ECOG PS, Mini-Mental State Examination [MMSE], Mini Nutritional Assessment [MNA])
• Older adults are underrepresented in clinical trials studying immunotherapy across multiple cancers. Most subgroup
analyses and retrospective studies report a similar clinical benefit in older and younger patients, with some concerns
Immunotherapy8,9 for increase in toxicity rates.
• When considering immunotherapy, be aware that management of immunotherapy-related toxicity with high-dose
steroids must be viewed with caution in older patients, as it may worsen other comorbidities or cognitive function.
• See NCCN Guidelines for the Management of Immunotherapy-Related Toxicities
Targeted therapy (See NCCN Guidelines for Treatment of Cancer by Site)
Cellular therapy (See NCCN Guidelines for Treatment of Cancer by Site)
jMonitor the patient’s functional status, comorbidities, social circumstances, pain, nutritional status, and distress.
Continued
OAO-5

Table of Contents
CONSIDERATIONS FOR OLDER ADULTS AND SIDE EFFECTS FOR USE OF SYSTEMIC THERAPYj
• Rule out other medical causes of diarrhea before starting anti-diarrhea drugs
Diarrhea • Consider early aggressive rehydration
• Manage with octreotide if oral preparations are ineffective
Constipation See NCCN Guidelines for Palliative Care
Nausea/
See NCCN Guidelines for Antiemesis and NCCN Guidelines for Palliative Care
vomiting
• Early hospitalization is needed for patients with mucositis who also develop dysphagia/diarrhea
Mucositis • Provide nutritional support
• See NCCN Task Force: Prevention and Management of Mucositis in Cancer Care
Bone marrow Prophylactic colony-stimulating factors are needed when dose intensity is required for response
suppression or cure (See NCCN Guidelines for Hematopoietic Growth Factors)
• Monitor hearing loss and avoid neurotoxic agents if significant hearing loss is present
• Monitor cerebellar function if high-dose cytarabine is present
Neurotoxicity
• Monitor for peripheral neuropathy
• Monitor for cognitive dysfunction (See OAO-F)
• Periodic assessment of history of falls, balance, and gait difficulties is recommended for all patients as fall risk may
change over time10 (See Comprehensive Geriatric Assessment OAO-C 2 of 8)
Falls
• The use of early and preventive use of durable medical equipment and in-home safety evaluations is recommended for
patients with neurotoxicities at high risk for falls.
• Monitor for symptomatic or asymptomatic congestive heart failure (CHF)
Caution with use of anthracyclines; consider alternative treatment dosing schedule or treatment as appropriate per
Cardiac toxicity disease site (See NCCN Guidelines for Treatment of Cancer by Site)
Caution with use of trastuzumab (among patients with normal left ventricular ejection fraction [LVEF], risk factors for
CHF include older age, receipt of an anthracycline-based regimen, baseline LVEF of 50%–54%, coronary artery disease,
hypertension, and weekly trastuzumab administration [See NCCN Guidelines for Survivorship SCARDIO-1, SCARDIO-2,
and SCARDIO-3]).11,12,13
Serum creatinine is not a good indicator of renal function in older adults. Calculation of creatinine clearance is
Renal toxicity
recommended to assess renal function and adjust dose to reduce systemic toxicity.
• Benzodiazepines or other sedative-hypnotics should not be used as first-line treatment for insomnia in older
Insomnial adults;14 non-pharmacologic methods such as cognitive behavioral therapy and lifestyle modifications are preferred.
• See Sleep Disorders in NCCN Guidelines for Survivorship, SSD-1.
jMonitorthe patient’s functional status, comorbidities, social circumstances, pain, nutritional status, and distress.
l
See Insomnia (OAO-H).
See References
Note: All recommendations are category 2A unless otherwise indicated. on (OAO-7)
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REFERENCES
1Geriatric Surgery Verification Program Standards from the American College of Surgeons, July 2019. https://www.facs.org/quality-programs/geriatric-surgery.
2Fukuse T, Satoda N, Hijiya K, Fujinaga T. Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly
patients. Chest 2005;127(3):886-891.
3PACE participants; Audisio RA, Pope D, Ramesh HS, et al. Shall we operate? Preoperative assessment in elderly cancer patients (PACE) can help. A SIOG surgical
task force prospective study. Crit Rev Oncol Hematol 2008;65(2):156-163.
4Robinson TN, Eiseman B, Wallace JI, et al. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg 2009;250(3):449-455.
5Robinson TN, Wu DS, Pointer LF, et al. Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly. J Am Coll Surg
2012;215(1):12-17; discussion 17-18.
6Marcantonio ER, Goldman L, Mangione CM, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA 1994;271(2):134-139.
7Oh ES, Fong TG, Hshieh TT, Inouye SK. Delirium in older persons: Advances in diagnosis and treatment. JAMA 2017;318:1161-1174.
8Bastiaannet E, Battisti N, Loh KP, et al. Immunotherapy and targeted therapies in older patients with advanced melanoma; Young International Society of Geriatric
Oncology review paper. J Ger Oncol 2019;10:389-397.
9Kanesvaran R, Cordoba R, Maggiore R. Immunotherapy in older adults with advanced cancers: Implications for clinical decision-making and future research. Am Soc
Clin Oncol Educ Book 2018;38:400-414.
10Tinetti ME. Clinical practice. Preventing falls in elderly persons. N Engl J Med 2003;348:42-49.
11Piccart-Gebhart MJ, Procter M, Leyland-Jones B, et al. Trastuzumab after adjuvant chemotherapy in HER2-positive breast cancer. N Engl J Med 2005;353:1659-
1672.
12Romond E, Perez E, Bryant J, et al. Trastuzumab plus adjuvant chemotherapy for operable HER2-positive breast cancer. N Engl J Med 2005;353(16):1673-1684.
13Chavez-MacGregor M, Zhang N, Buchholz TA, et al. Trastuzumab-related cardiotoxicity among older patients with breast cancer. J Clin Oncol 2013;31:4222-4228.
14American Geriatrics Society: Ten Things Clinicians and Patients Should Question (http://www.choosingwisley.org/doctor-patient-lists/american-geriatrics-society/).

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DATA FROM UNITED STATES LIFE TABLES

UPPER, MIDDLE, AND LOWER QUARTILES OF LIFE EXPECTANCY FOR WOMEN AND MEN AT SELECTED AGES
A Life Expectancy for Women Data from the Life Tables of the United States, 2008. See the life
25.0
expectancy tables in the National Vital Statistics Reports at
22.0 http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_03.pdf.
20.0 For further life expectancy calculations, See eprognosis.ucsf.edu
17.6
16.6
15.0
13.4
Years 12.6
10.3 9.8
10.0 9.1
7.4 6.2 6.8
5.0 4.0 4.6
5.0
3.1 2.6
1.9
1.1
0.0
70 75 80 85 90 95
B Life Expectancy for Men
25.0
20.0 19.4
15.0 15.3
Years 13.9
11.5
10.0 10.4 Top 25th Percentile
8.3
8.0 7.4 5.8 50th Percentile
5.6 5.0
5.0 3.8 3.3 4.0
Lowest 25th Percentile
2.4 1.5 2.2
1.0
0.0 Reprinted and adapted with permission from Walter LC,
70 75 80 85 90 95 Schonberg MA. Screening mammography in older women: a
Age review. JAMA 2014;311(13):1336-1347.

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OPTIMIZING COMMUNICATION WITH OLDER ADULTSa

General:
• Optimize vision – glasses if needed
• Optimize hearing – hearing aid, amplifying device (eg, pocket talker)
• Avoid jargon (eg, instead of “benign” use “not cancer” or instead of “metastasized” use “the cancer has spread”)
Written materials:
• Write materials at the 5th grade level
• Use a large font (14 pt or larger)
• Use pictures that enhance the text
• Use black ink on white paper to optimize contrast
Oral communication:
• Ask the patient how best to communicate, and if hearing is better in one ear or the other
• Have the patient sit with his/her back to a wall (to help reflect sound)
• Speak toward the better ear and use a lower-pitched voice; minimize background noise
• Face the patient when speaking, speak slowly and distinctly; don’t shout
• Rephrase rather than repeat
• Pause at the end of phrases or ideas
• After each key concept, topic, or instruction, stop and ask, “What questions do you have?”
• For major concepts (prognosis, expected side effects, outcomes of treatment, and informed consent) always use the “teach back” (See
Teachback) or “teach goal” method, by querying the patient for understanding. Use questions such as: “I just gave you a lot of information
and that can be confusing or a lot to absorb at once. Can you tell me in your own words what this chemotherapy will do for you/how you will
take your medicine, etc.?”
• Use a black board/white board or written materials to reinforce key concepts.
• Recognize the presence of, and avoid the use of, “elderspeak,” a form of communication used with older adults that is similar to “baby-talk”
and may impact clinician-patient interactions and result in poor patient outcomes.b
aWith permission from Reuben DB, Herr KA, Pacala JT, et al. Geriatrics At Your Fingertips: 2016, 18th Edition. New York: The American Geriatrics Society; 2016.
bCorwin AI. Overcoming elderspeak: A qualitative study of three alternatives. Gerontologist 2018;58:724-729.

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COMPREHENSIVE GERIATRIC ASSESSMENT

CGA can be performed in a number of ways, the most extensive being with a geriatric trained clinician doing a full assessment. Alternatively,
there are tools that allow the clinician to administer assessments within the oncology clinic setting. See ASCO Guidelines for Geriatric
Assessment.
A patient's goals and objectives with regard to his/her cancer diagnosis should be assessed prior to any treatment decision. Supportive and
palliative care assessment is recommended for any older adult with cancer.
Reasons to Perform CGA1,2
• CGA can reveal/detect reversible geriatric problems not found by routine oncology care.
• CGA can predict risk of toxicity/adverse effects from cancer treatment or decrease in quality of life (QOL), enabling more targeted use of
supportive care measures.
• CGA has important prognostic information that can be helpful in estimating life expectancy, which is of paramount importance when making
treatment decisions.
• CGA allows targeted intervention, which can improve QOL and adherence to therapy.
• CGA can be helpful in improving communication.*
Collaboration Between Geriatric Trained Clinician and Oncologist in the Care of an Older Patient with Cancer
Older adults may benefit from a referral to a geriatric trained clinician for assessment of vulnerability prior to cancer treatment, to develop
a coordinated care plan with the oncologist and/or to manage geriatric syndromes that could jeopardize outcomes of cancer treatment. The
geriatric trained clinician thus may be able to assist the oncologist in optimizing the management of the non-cancer aspects of the patient’s
care, which in turn may enable more effective delivery of direct cancer care. Consider consultation to a geriatric trained clinician for the
following:
• Cognitive impairment
Dementia/delirium
Decision-making capacity evaluation
Life expectancy, advance directive/advance care planning, guardianship (See NCCN Guidelines for Palliative Care)
• Functional or physical impairment, mobility issues, or disability
Falls evaluation and/or advice on falls prevention
Promote independent living or supportive living
• Multimorbidity including vision and hearing impairments
• Polypharmacy evaluation
• When considering a high-risk procedure, such as:
Chemotherapy and radiotherapy
Hematopoietic cell transplantation
Complex surgeries (eg, cystectomy)
• Presence of geriatric syndromes such as frailty, osteoporosis, depression, pressure ulcers, urinary incontinence, neglect or abuse, failure to
thrive, or sarcopenia
• Weight loss (≥5% unintentional weight loss in last 3 months) and anorexia
• Caregiver support
• Assistance with social support resources
Continued
Note: All recommendations are category 2A unless otherwise indicated. References
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Version 1.2020, 02/07/20 © 2020 National Comprehensive Cancer Network (NCCN ), All rights reserved. NCCN Guidelines and this illustration may not be reproduced in any form without the express written permission of NCCN.
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Functional Status
• ADL - Self-feeding, dressing, continence, grooming, transferring, using the bathroom
• IADL - Using transportation, managing money, taking medications, shopping, preparing meals, doing laundry, doing housework, using the
telephone
• Physical performance status
• Visual function and/or hearing impairment
• Falls and/or unstable gait
Falls are more common in older adults with cancer than those without cancer
Factors that have been prospectively associated with increased risk of subsequent falls in older adults with cancer include: prior falls,
benzodiazepine use, cancer pain, and neurotoxic chemotherapy
In patients who are at risk, such as those who have experienced a fall in the last 6 months or if the patient is “afraid of falling,” consider the
following evaluations:
◊◊Assessment of gait by evaluating gait speed4 or using the Timed Up and Go (TUG) test: See OAO-E
◊◊Exercise promotion including physical therapy (PT) or occupational therapy (OT) evaluation, as needed
◊◊Checking vitamin D levels and supplementing vitamin D if low
◊◊Referral to geriatrics or primary care physician
◊◊Home safety evaluation and home modifications as indicated
◊◊Medications that put patients at risk for adverse outcomes See Medications Commonly Used for Supportive Care that Are of Concern in
Older Patients (OAO-I)
Socioeconomic Issues
• Poor living conditions
• No family/caregiver or limited social support
• Low income
• Screen for elder abuse
Ask the patient, "Do you feel safe at home?"
Refer to social work
• Transportation barriers/access problems
• Food insecurity
• Financial toxicity (eg, underinsurance and/or high out-of-pocket costs)5
Psychosocial Distress
• Depression
Geriatric Depression Scale (GDS)10,11
See NCCN Guidelines for Distress Management
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Comorbidities
• May affect treatment decisions in 5 several ways:
Cancer treatment may interact with comorbidity to impact functional status or worsen comorbidity. This includes any drug-drug
interactions.
Comorbidities may increase risks from cancer treatment:
◊◊Anemia ◊ Depression ◊◊Neuropathy
◊◊Cardiovascular disease ◊◊Diabetes ◊◊Osteoporosis
◊◊Chronic infections ◊◊Hearing or vision loss ▪▪See NCCN Task Force Report:
◊◊Decubitus or pressure ulcers ◊◊Liver and lung disease Bone Health in Cancer Care
◊ Dementia ◊◊Prior cancer diagnosis and treatment
◊◊Renal insufficiency
Comorbidity may influence life expectancy (independent of the cancer).
Comorbidity may affect treatment outcome.
• Methods to assess comorbidities:

Charlson Comorbidity Index (CCI)6
Cumulative Illness Rating Scale (CIRS)7
Older Americans Resources and Services (OARS) Multidimensional Functional Assessment Questionnaire8
�Adult Comorbidity Evaluation 27 (ACE-27)9
Cognitive Function (See Assessment of Cognitive Function OAO-F)

• Dementia
Mini-Mental State Examination (MMSE)10,11
Montreal Cognitive Assessment (MoCA)12 (http://www.mocatest.org/)
�Mini-cog13 (https://mini-cog.com/)
�Short Blessed Test (SBT)14
• Delirium
Confusion Assessment Method and/or Memorial Delirium Assessment Scale15,16
See NCCN Guidelines for Palliative Care and NCCN Guidelines for Distress Management
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Nutritional Status17
Patients with cancer are at risk for severe malnutrition that is underdiagnosed.18
• Poor nutritional status is associated with increased mortality and poor chemotherapy tolerance.19,20,21,22
• Malnutrition among hospitalized patients with cancer is associated with increased length of stay.18
Practical consideration to guide further nutritional assessment of at-risk patients includes:
◊◊Unintentional weight loss of greater than 5% over 6 months23,24
◊◊Body mass index (BMI) of 22 or below25
◊◊Weighing less than 80% of ideal body weight26
◊◊Practical suggestions for evaluation of and treatment for optimizing nutrition among patients with cancer:
––Guide to Nutritional Intervention from NCI Nutrition in Cancer Care (PDQ)
––MNA® Mini Nutritional Assessment
––Patient-Generated Subjective Global Assessment of Nutrition27,28,29
◊ Referral to speech and language pathologist to assess for swallowing issues
Polypharmacy
• Reconcile medications at every visit, including prescription and over-the-counter medications, vitamins, and supplements.a,b,c,d
• Medication reviewc may also be indicated with any initiation or change in oncologic treatment, change in comorbid disease management, or
change in clinical condition, and at other times as determined by the clinical team and during transition of care. See Medication Review on
next page.
• Carefully review indications, duration of therapy, and dosage when using these medications or classes of medications that are not
recommended for older adults. See Medications Commonly Used for Supportive Care that Are of Concern in Older Patients (OAO-I).
• Evaluate adherence to therapy (See OAO-G).
aReconciliation and review of medications, and medication changes in particular, should ideally occur in the context of a patient’s oncologic treatment and with the input
from other physicians involved in the patient’s care. The extent to which a patient’s oncologic care occurs in a shared model of care with primary care providers will
guide the extent of involvement of a primary care physician in medication management questions.
bReconciliation refers to the process of developing an accurate list of medications a patient is taking in order to communicate and make care decisions about
medication.
cMedication review refers to the process of providing a structural, critical evaluation of a patient’s medication list in order to optimize care and avoid harm.
dMemorial Sloan Kettering Cancer Center Search About Herbs. Available at: https://www.mskcc.org/cancer-care/diagnosis-treatment/symptom-management/integrative-
medicine/herbs/search.
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Medication Review30
• Does every medication match a known medical problem or chronic condition?
Any deficiencies?31,32,33,34,35
Any duplications?
• Are the dosages appropriate for each medication for the patient’s age, renal function, or liver function?
• Are there potential drug-drug or drug-disease interactions or other adverse effects of the medication?
Drug interactions:36
◊◊http://medicine.iupui.edu/clinpharm/ddis/
◊◊http://www.mskcc.org/cancer-care/integrative-medicine/about-herbs-botanicals-other-products
• Are there any high-risk/low-benefit or inappropriate medications?
Beers criteria:37
◊◊http://geriatricscareonline.org/toc/american-geriatrics-society-updated-beers-criteria-for-potentially-inappropriate-medication-use-in-
older-adults/CL001
STOPP criteria32,33,34,35
Medication Appropriateness Index38
• Could a medication-related problem be responsible for current complaints or presenting problems?
• Can the regimen be simplified?
• Are there any less expensive alternative medications that are of equal utility?
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COMPREHENSIVE GERIATRIC ASSESSMENT / CARE PROCESS FOR OLDER ADULTS WITH CANCER
Impairment in any domain may consider the following:

Domain Impaired Potential Interventions
Functional Status (See OAO-C 2 of 8) Physical therapy referral
Occupational therapy referral
Home safety evaluation/Home health care
Evaluate fall risk
Promote physical activity and exercise
Cognition/Memory (See OAO-C 3 of 8 and OAO-F) Involve family/caregiver
Assess/minimize potentially inappropriate medications (See OAO-I)
Delirium prevention
Assess capacity and ability to consent to treatment (See OAO-2)
Identify health care proxy/collaborative decision maker
Cognitive testing/neuropsychology referral
Social Support/Caregiver Burden Transportation assistance
Financial toxicity5
Home health care
Home safety evaluation
Support groups
Refer to psychiatry/psychology
Spiritual care
Screen for elder abuse; ask the patient, "Do you feel safe at home?"
Refer to social work
Psychological Status: Anxiety/Depression Complementary (non-pharmacologic) modalities such as guided
imagery, meditation, relaxation, acupuncture, etc.
Counseling by a qualified professional
Refer to psychiatry/psychology
Start medications to treat anxiety/depression
Support programs
Spiritual care
Nutrition (See OAO-C 4 of 8) Nutrition consult
Make specific dietary recommendations
Oral care
Supplemental nutrition
Physical/Occupational therapy if function related
Adapted with permission from Mohile SG, Velarde C, Hurria A, et al. J Natl Compr Canc Netw 2015 Sep;13(9):1120-1130.
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REFERENCES
1Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol
2014;32:2595-2603.
2Hamaker ME, Schiphorst AH, ten Bokkel Huinink D, et al. The effect of a geriatric evaluation on treatment decisions for older cancer patients--a systematic review. Acta
Oncol 2014;53:289-296.
3Mohile SG, Epstein RM, Hurria A, et al. Communication with older patients with cancer using geriatric assessment: A cluster-randomized clinical trial from the National
Cancer Institute Community Oncology Research Program. JAMA Oncol 2019;7:1-9.
4Studenski S, Perera S, Patel K, et al. Gait speed and survival in older adults. JAMA 2011;305:50-58.
5de Souza JA, Yap BJ, Wroblewski K, et al. Measuring financial toxicity as a clinically relevant patient-reported outcome: The validation of the Comprehensive Score for
financial Toxicity (COST). Cancer 2017;123:476-484.
6Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis
1987;40:373-383.
7Linn BS, Linn MW, Gurel L. Cumulative illness rating scale. J Am Geriatr Soc 1968;16:622-626.
8Fillenbaum GG, Smyer MA. The development, validity, and reliability of the OARS multidimensional functional assessment questionnaire. J Gerontol 1981;36:428-434.
9Binder PS, Peipert JF, McCourt CK, et al. Adult Comorbidity Evaluation 27 score as a predictor of survival in endometrial cancer patients. Am J of Obstet Gynecol
2016:215(6);766.e1-766.e9.
10Tombaugh TN, McIntyre NJ. The mini-mental state examination: a comprehensive review. J Am Geriatr Soc 1992;40(9):922-935.
11Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the Mini-Mental State Examination by age and educational level. JAMA
1993;269(18):2386-2391.
12Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc
2005;53:695-699.
13Ketelaars L, Pottel L, Lycke M, et al. Use of the Freund clock drawing test within the Mini-Cog as a screening tool for cognitive impairment in elderly patients with or
without cancer. J Geriatr Oncol 2013;2:174-182.
14Katzman R, Brown T, Fuld P, et al. Validation of a short Orientation-Memory-Concentration Test of cognitive impairment. Am J Psychiatry 1983;140:734-739.
15Inouye SK, van Dyck CH, Alessi CA, et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med
1990;113:941-948.
16Lawlor PG, Nekolaichuk C, Gagnon B, et al. Clinical utility, factor analysis, and further validation of the memorial delirium assessment scale in patients with advanced
cancer: Assessing delirium in advanced cancer. Cancer 2000;88:2859-2867.
17The Joint Commission Standards. Available at: http://www.jointcommission.org/standards_information/tjc_requirements.aspx
18Pressoir M, Desne S, Berchery D, et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer
2010;102(6):966-971.
19Aaldriks AA, Maartense E, le Cessie S, et al. Predictive value of geriatric assessment for patients older than 70 years, treated with chemotherapy. Crit Rev Oncol
Hematol 2011;79(2):205-212.
20Aaldriks AA, van der Geest LG, Giltay EJ, et al. Frailty and malnutrition predictive of mortality risk in older patients with advanced colorectal cancer receiving
chemotherapy. J Geriatr Oncol 2013;4(3):218-226.
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REFERENCES
21Alexandre J, Gross-Goupil M, Falissard B, et al. Evaluation of the nutritional and inflammatory status in cancer patients for the risk assessment of severe
haematological toxicity following chemotherapy. Ann Oncol 2003;14(1):36-41.
22Arrieta O, Michel Ortega RM, Villanueva-Rodriguez G, et al. Association of nutritional status and serum albumin levels with development of toxicity in patients with
advanced non-small cell lung cancer treated with paclitaxel-cisplatin chemotherapy: a prospective study. BMC Cancer 2010;10:50. doi: 10.1186/1471-2407-10-50.
23Boleo-Tome C, Monteiro-Grillo I, Camilo M, et al. Validation of the Malnutrition Universal Screening Tool (MUST) in cancer. Br J Nutr 2012;108(2):343-348.
24Fearon K, Strasser F, Anker S, et al. Definition and classification of cancer cachexia: an international consensus. Lancet Oncol 2011;12(5):489-495.
25Winters J, MacInnis R, Wattanapenpaiboon N, et al. BMI and all-cause mortality in older adults: a meta-analysis. Am J Clin Nutr 2014;99:875-890.
26NCI. (2014). Nutrition in Cancer Care (PDQ). Retrieved January 24, 2014, from http://www.cancer.gov/cancertopics/pdq/supportivecare/nutrition/HealthProfessional/
page2/AllPages.
27Gabrielson DK, Scaffidi D, Leung E, et al. Use of an abridged scored Patient-Generated Subjective Global Assessment (abPG-SGA) as a nutritional screening tool for
cancer patients in an outpatient setting. Nutr Cancer. 2013;65(2):234-239.

28Abbott J, Teleni L, McKavanagh D, Watson J, McCarthy AL, Isenring E. Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) is a valid
screening tool in chemotherapy outpatients. Support Care Cancer. 2016;24(9):3883-3887.
29Bauer J, Capra S, Ferguson M. Use of the scored Patient-Generated Subjective Global Assessment (PG-SGA) as a nutrition assessment tool in patients with cancer.
Eur J Clin Nutr. 2002;56(8):779-785.
30Adapted from the Medication Screening Questionnaire: George CJ, Jacobs LG. Geriatrics medication management rounds: a novel approach to teaching rational
prescribing with the use of the medication screening questionnaire. J Am Geriatr Soc 2011;59:138-142.
31Pretorius RW, Gataric G, Swedlund SK, Miller JR. Reducing the risk of adverse drug events in older adults. Am Fam Physician 2013;87(5):331-336.
32Gallagher P, Baeyens JP, Topinkova E, et al. Inter-rater reliability of STOPP (Screening Tool of Older Persons’ Prescriptions) and START (Screening Tool to Alert
doctors to Right Treatment) criteria amongst physicians in six European countries. Age Ageing 2009;38:603-606.
33Gallagher P, O’Mahony D. STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): application to acutely ill elderly patients and comparison
with Beers’ criteria. Age Ageing 2008;37:673-679.
34Barry PJ, Gallagher P, Ryan C, O’Mahony D. START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing
omissions in elderly patients. Age Ageing 2007;36:632-638.
35Gallagher PF, O’Connor MN, O’Mahony D. Prevention of potentially inappropriate prescribing for elderly patients: a randomized controlled trial using STOPP/START
criteria. Clin Pharmacol Ther 2011;89:845-854.
36Riechelmann RP, Saad ED. A systemic review on drug interactions in oncology. Cancer Investigation 2006;24:704-712.
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Medication Use in Older Adults. J Am Geriatr Soc 2015;63:2227-2246.
38Samsa GP, Hanlon JT, Schmader KE, et al. A summated score for the medication appropriateness index: development and assessment of clinimetric properties
including content validity. J Clin Epidemiol 1994;47(8):891-896.

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GERIATRIC SCREENING TOOLS
Abbreviated CGA (aCGA)1,2

Barber questionnaire3
Fried Frailty Criteria4,5
Geriatric (G-8)6-8
Groningen Frailty Index2
Triage Risk Screening Tool (TRST)8
Vulnerable Elders Survey (VES-13)7,9-12
1Overcash JA, Beckstead J, Moody L, et al. The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: scoring
and interpretation. Crit Rev Oncol Hematol 2006;59:205-210.
2Kellen E, Bulens P, Deckx L, et al. Identifying an accurate pre screening tool in geriatric oncology. Crit Rev Oncol Hematol 2010;75:243-248.
3Molina Garrido MJ, Guillen Ponce C. Comparison of two frailty screening tools in older women with early breast cancer. Crit Rev Oncol Hematol 2011;79:51-64.
4Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001;56:M146-M156.
5Biganzoli L, Boni L, Becheri D, et al. Evaluation of the cardiovascular health study (CHS) instrument and the Vulnerable Elders Survey 13 (VES 13) in elderly cancer
patients. Are we still missing the right screening tool? Ann Oncol 2013;24:494-500.
6Bellera CA, Rainfray M, Mathoulin-Pélissier S, et al. Screening older cancer patients: first evaluation of the G-8 geriatric screening tool. Ann Oncol 2012;23:2166-2172.
7Pottel L, Boterberg T, Pottel H, et al. Determination of an adequate screening tool for identification of vulnerable elderly head and neck cancer patients treated with
radio(chemo)therapy. J Geriatr Oncol 2012;3:24-32.
8Kenis C, Bron D, Libert Y, et al. Relevance of a systematic geriatric screening and assessment in older patients with cancer: results of a prospective multicentric study.
Ann Oncol 2013;24:1306-1312.
9Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001;49:1691
-1699.
10Mohile SG, Bylow K, Dale W, et al. A pilot study of the vulnerable elders survey 13 compared with the comprehensive geriatric assessment for identifying disability in
older patients with prostate cancer who receive androgen ablation. Cancer 2007;109:802-810.
11Luciani A, Ascione G, Bertuzzi C, et al. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable
elders survey 13. J Clin Oncol 2010;28:2046-2050.
12Owusu C, Koroukian SM, Schluchter M, et al. Screening older cancer patients for a Comprehensive Geriatric Assessment: A comparison of three instruments. J
Geriatr Oncol 2011;2:121-129.

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GAIT ASSESSMENT AND INTERVENTIONS

Assessment of gait by evaluating gait speed or using the Timed Up and Go (TUG) test1,2
The TUG test is calculated as the time in seconds it takes a patient to stand up from a chair (without using his or her arms), walk 10 feet
straight ahead, turn back, and return to the chair and sit down. The patient may use an assistive device, such as a cane or walker, but may
not have assistance from another person.
A normal TUG test score is less than 13 seconds. For patients with above-normal TUG test scores, consider comprehensive evaluation as
indicated below.
ASSESSMENT INTERVENTIONS
Assess proximal • Diagnose and treat underlying causes
muscle strength • Consider physical therapy evaluation
• Assess for type, condition, usage technique, and fit of mobility aid
Mobility aids assessment
• Consider referral for occupational/physical therapy evaluation
• Diagnose and treat underlying causes
Check orthostatic • Review medications
blood pressure • Address salt intake, adequate hydration, and compensatory strategies (eg, elevating head of
bed, rising slowly, using pressure stockings)
• Diagnose and treat underlying cause of vision changes
Ask about changes in vision • Consider referral to opthalmologist
• Consider neurologic evaluation
Assess for neurologic • Evaluate if cancer or cancer treatment-related and modify treatment if possible
changes • Consider neurologic evaluation
Review medications • See “Polypharmacy” (OAO-C, 4 of 8) and “Medication Review” (OAO-C, 5 of 8)
• Consider home safety evaluation
Environmental hazards • Educate patients to reduce risk
(http://www.cdc.gov/HomeandRecreationalSafety/Falls/CheckListForSafety.html)
• Assess type, condition, and fit of shoes
Footwear assessment • Perform foot exam
• Consider referral to podiatrist
1Pondal M, del Ser T. Normative data and determinants for the timed "up and go" test in a population-based sample of elderly individuals without gait disturbances. J
Geriatr Phys Ther 2008;31(2):57-63.
2Lui M, DuMontier C, Murillo A, et al. Gait speed, grip strength, and clinical outcomes in older patients with hematologic malignancies. Blood 2019;134(4):374-382.

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ASSESSMENT OF COGNITIVE FUNCTION1,2
When to assess for cognitive function Recommendations

Would impaired cognitive function affect the planning
or delivery of care? (eg, impact life expectancy or risk/ Reassess periodically or
benefit, impact adherence to treatment plan) No (to all) when considering treatment
plan changes
Is the medical team concerned about decision-making
capacity? See OAO-2
Does the patient have a history of recent delirium or late
onset of depression? Consult with a clinician experienced in cognitive
evaluation (ie, geriatrician, neurologist, geriatric
Does the medical team suspect impaired cognitive psychiatrist, neuropsychologist, occupational
function? Yes (to any)
therapist)
Has the patient or patient’s family/caregiver suggested OR
that the patient has impaired cognitive function? Initiate the evaluation yourself (See OAO-F, 2 of 2)
1Cordell CB, Borson S, Boustani M, et al. Medicare Detection of Cognitive Impairment Workgroup. Alzheimer’s Association recommendations for operationalizing the
detection of cognitive impairment during the Medicare Annual Wellness visit in a primary care setting. Alzheimers Dement 2013;9(2):141-150.
2Simpson JR. DSM-5 and neurocognitive disorders. J Am Acad Psychiatry Law 2014;42:159-164.
Continued
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ASSESSMENT OF COGNITIVE FUNCTION1,2,3
Mild Cognitive Impairment Dementia Delirium

Definition An intermediate state between normal A progressive condition characterized by: Disturbance in attention and awareness:
cognition and dementia characterized by: • Evidence of significant cognitive decline • Onset over a short period of time (usually
• Subjective memory impairment from a previous level of performance in hours to days)
• Preserved general cognitive function one or more cognitive domains • Fluctuation during the course of the day
• Intact ability to perform daily functions• Interference with ability to perform daily
functions (ADL/IADL) (See OAO-C)
Distinguishing • Subjective memory complaints and • Progressive (not sudden) loss of multiple • Acute onset
Features awareness of memory changes cognitive abilities • Waxing and waning attention
• Preserved function • Affects the ability to function • Associated with physiologic
independently disturbances
Differential Diagnosis CNS metastases
(confounding factors) Psychiatric disease (depression, anxiety, apathy)
Endocrine dysfunction (thyroid)
Metabolic causes (B12 deficiency)
Drug dependency (including alcohol)
Medication related
Sleep disturbance
Common geriatric conditions (pain, infection, constipation)
Screening Tool Clinical interview with cognitive Clinical interview with cognitive Confusion Assessment Method (CAM)
(Mini-Cog) and functional (ADL/IADL) (Mini-Cog) and functional (ADL/IADL) https://www.hospitalelderlifeprogram.org/
assessment (See OAO-C) assessment (See OAO-C) delirium-instruments/4
Further Evaluation • Reassess periodically and with major • Consult with a clinician experienced in • Evaluate and treat all potential causes of
changes in condition or when cognitive evaluation and treatment delirium
considering changes to treatment plan • Neuropsychological testing may be • If screening is abnormal consult with
• If screening is abnormal consult with indicated a clinician experienced in cognitive
a clinician experienced in cognitive • Evaluation: B12, TSH, brain imaging evaluation
evaluation • See NCCN Guidelines for Distress • See NCCN Guidelines for Distress
Management, DIS-7 and DIS-8 Management, DIS-7 and DIS-8
1Cordell CB, Borson S, Boustani M, et al. Medicare Detection of Cognitive Impairment Workgroup. Alzheimer’s Association recommendations for operationalizing the
detection of cognitive impairment during the Medicare Annual Wellness visit in a primary care setting. Alzheimers Dement 2013;9(2):141-150.
2Simpson JR. DSM-5 and neurocognitive disorders. J Am Acad Psychiatry Law 2014;42:159-64.
3If you have concerns about decision-making capacity, see (OAO-1).
4Confusion Assessment Method. © 1988, 2003, Hospital Elder Life Program. All rights reserved. Adapted from: Inouye SK et al. Ann Intern Med.1990;113:941-948.

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ASSESSMENT OF ADHERENCE
Assess risk of non-adherence whenever considering a treatment regimen that will include an oral agent1
Although older age per se is not a consistent risk factor for non-adherence, several factors may increase the potential for non-adherence
among older adults:
• Decreased propensity of older adults to ask questions about benefits and risks of treatments
• Increased numbers of comorbidities and associated medications leading to regimen complexity
• Side effects adversely affecting comorbidities
• Prior experience with medication side effects
• Drug-drug interactions
• Acquisition barriers, including out-of-pocket costs, mobility/transportation difficulties, and lack of synchronized refill dates
• Cognitive impairment
Strategies to minimize non-adherence

When initiating therapy:
• Ask patient to bring in prescribed, over-the-counter medications and supplements to review
• In collaboration with other medical providers, reduce regimen complexity, if possible
• Take into consideration cost of the medication, including insurance coverage and out-of-pocket cost
• Consult with pharmacist to synchronize medication refills whenever possible2
• Prepare the patient regarding anticipated side effects to avoid inappropriate medication discontinuation
• Ensure that the patient/family/caregiver understands the benefits/rationale for the medication and the risks of not taking it 3,4
• Provide written instructions to patient/caregiver for taking the medication at the fifth grade level.5 Have patient/caregiver repeat back his/her
understanding of how to take the medication, common side effects, and “when to worry” and “what to do if worried”
• Engage family/other caregivers and interdisciplinary team in the process
At each follow-up visit:

• Ask patient to bring in prescribed, over-the-counter medications and supplements to review
• Provide additional cues or reminders (eg, calendars, pill boxes, other reminder techniques)
• Reinforce benefits and ask about side effects: if tolerable, stay the course; if intolerable, select an alternative
• Assess adherence in a non-judgmental way: “How many pills did you take during the past week?” “How did you take them in relation to
meals?” (if applicable)
• Ask the patient if there are any barriers to acquiring the medication. Refer to case manager or pharmacist as applicable.
• If patient agrees, also check with primary caregiver or family member regarding medication adherence and explore any challenges.
1Mislang AR, Wildes TM, Kanesvaran R, et al. Adherence to oral cancer therapy in older 3Steiner JF. Rethinking adherence. Ann Inter Med 2012;157:580-585.
adults: The International Society of Geriatric Oncology (SIOG) taskforce recommendations. 4Viswanathan M, Golin CE, Jones CD, et al. Interventions to improve adherence to self-
Cancer Treat Rev 2017;57:58-66. administered medications for chronic diseases in the United States: A systematic review.
2Agarwal S, et al. Does synchronizing initiation of therapy affect adherence to concomitant Ann Intern Med 2012;157:785-795.
use of antihypertensive and lipid-lowering therapy? Am J Ther 2009;16(2):119-126. 5 Confirm ability to read and comprehend written instructions (eg, vision, literacy).

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INSOMNIA
• The AGS provides recommendations for the diagnosis, evaluation, and management of insomnia.
• Benzodiazepines or other sedative-hypnotics should not be used as first-line treatment for insomnia in older
adults.a
• Non-pharmacologic methods such as sleep hygiene, cognitive behavioral therapy, and lifestyle modifications
are preferred.
• Patient should be cautioned that most over-the-counter sleep medications contain antihistamines and should
Insomnia not be used in older adults.
• If pharmacologic therapy is to be utilized, it is recommended for short-term use only with the lowest dose that
is effective. The risks and benefits of the therapy should be discussed.b
• Please note that if zolpidem is considered, the FDA has advised that the recommended dose of zolpidem for
women should be lowered from 10 mg to 5 mg for immediate-release products and from 12.5 mg to 6.25 mg for
extended-release products.c
• Patient information regarding optimizing sleep is available through the National Institute on Aging.d
• See sleep medication recommendations (OAO-I).
aSee American Geriatrics Society: Ten Things Clinicians and Patients Should Question (http://www.choosingwisely.org/doctor-patient-lists/american-geriatrics-society/).
bSee AGS Geriatrics Evaluation & Management Tools (GEMS): http://www.americangeriatrics.org.
cSee https://www.fda.gov/drugs/drugsafety/ucm334041.htm.
dSee http://www.nia.nih.gov/health/publication/good-nights-sleep.

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MEDICATIONS COMMONLY USED FOR SUPPORTIVE CARE THAT ARE OF CONCERN IN OLDER PATIENTS
Therapeutic Class/ Negative Effects/

Recommendation Alternative(s)
Medication(s) Condition the Drug May Adversely Affect
Corticosteroids (oral):1,2,3,4,5,6 • Weight gain • When used for supportive care, When risk outweighs benefit:
• hydrocortisone • Muscle weakness carefully consider the dose and • For pain, consider other
• methylprednisolone • Agitation duration of therapy. adjuvant pain medications
• prednisone • Hypergylcemia/Diabetes • Use the lowest possible dose ideally (eg, gabapentin,a SNRI
• prednisolone • Cushing syndrome for short-term therapy (1–3 weeks). antidepressants,b
• dexamethasone • Osteoporosis • Short-term use as an adjuvant for lamotrigine,a tramadol,
• Delirium pain or antiemetic, for spinal cord topical lidocaine, as
• Insomnia compression, increased intracranial indicated by type of pain and
• Increased risk of GI bleed, infection, fracture, pressure, and bowel obstruction is response).
thromboembolism appropriate (when benefit outweighs • For nausea, consider
risk). alternative antiemetics
(eg, serotonin antagonists,
aprepitant).
Benzodiazepines:4,5,7,8 • Older adults have increased sensitivity and • Avoid for treatment of insomnia, • For anxiety, consider
• alprazolam slower metabolism of benzodiazepines agitation, or delirium. buspirone, SSRIs,a or
• estazolam • Increased risk for falls, cognitive impairment, • Potentially appropriate for seizures, SNRIs.a
• lorazepam delirium rapid eye movement sleep disorders, • For sleep, use sleep hygiene
• oxazepam benzodiazepine withdrawal, alcohol education, sleep restriction
• temazepam withdrawal, severe generalized anxiety or sleep compression,c or
• triazolam disorders, and end-of-life care. cognitive behavioral therapy.
• clorazepate • Reduce dose and/or lengthen the See “Insomnia” (OAO-H).
• chlordiazepoxide dosing interval when using for See NCCN Guidelines for
• clonazepam supportive care during chemotherapy Survivorship.
• diazepam administration. • For nausea, consider an
• flurazepam alternative agent. See NCCN
• quazepam Guidelines for Antiemesis.
aUnlabeled use.
bNot all medications in this class are labeled for this use.
cSleep compression is an incremental decrease of time spent in bed.
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Non-benzodiazepine sedative • Similar adverse effects to benzodiazepines • Use no more than 2 to 3 days per • Use sleep hygiene
hypnotics:7,8 with minimal improvement in sleep latency and week for up to 90 days. education, sleep restriction
• zolpidem duration • Avoid chronic use. or compression, or cognitive
• eszopiclone • Delirium • If zolpidem is used, the dose in women behavioral therapy. In the
• zaleplon • Falls/fractures should not exceed 5 mg. right setting, if pharmacologic
therapy is deemed
necessary, agents such as
trazodone,a mirtazapine,a
melatonin,a ramelteon, or
other medications could
be considered, keeping in
mind the risks and benefits
of each individual therapy.
See “Insomnia” (OAO-H).
See NCCN Guidelines for
Survivorship - Sleep.
First-generation • Anticholinergic toxicities • Use only for supportive care when • For allergic rhinitis,
antihistamines:4,5,7,8 • Confusion convincing benefit exists. use second-generation
• diphenhydramine • Cognitive impairment • Appropriate for acute treatment of antihistamines (cetirizine,
• hydroxyzine • Delirium severe allergic reactions. desloratadine, fexofenadine,
• promethazine • Dry mouth levocetirizine), intranasal
• brompheniramine • Constipation corticosteroids, intranasal
• carbinoxamine • Urinary retention antihistamines, intranasal
• clemastine • Clearance is reduced anticholinergics, or
• cyproheptadine leukotriene inhibitors.
• dexbrompheniramine • For pruritis, use second-
• dexchlorpheniramine generation antihistamines.
• doxylamine • For sleep, use sleep hygiene
• triprolidine education, sleep restriction
or sleep compression, or
cognitive behavioral therapy.
See “Insomnia” (OAO-H).
See NCCN Guidelines for
Survivorship.
aUnlabeled use.
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Antiemetic, prokinetic: 6,7,8 • May cause extrapyramidal effects • Avoid, unless use for patients with • Consider serotonin
• metoclopramide • Greater risk of falls in older patients gastroparesis. antagonists (ie, dolasetron,
• Can worsen parkinsonian symptoms • If benefit outweighs risk, use the lowest granisetron, ondansetron,
Phenothiazine antiemetic:7 dose possible, and avoid exceeding 5 palonosetron, tropisetron),
• prochlorperazine mg. short-term corticosteroids
(ie, dexamethasone,
prednisone), or other
antiemetics. See NCCN
Guidelines for Antiemesis.
Histamine-2 receptor • Delirium • Avoid in patients at risk for delirium. • Proton-pump inhibitors (eg,
blockers: 7 • Cognitive impairment omeprazole, esomeprazole,
• famotidine • Can worsen dementia pantoprazole, lansoprazole).
• ranitidine
• cimetidine
Selective seretonin • Can induce ataxia, impair psychomotor function • Consider sertraline or citalopram as • For patients with falls,
re-uptake inhibitor • Increase risk for syncope first-line due to a lower propensity for consider SNRIs (eg,
antidepressants: 4,5,7,8,13,14 • Increase risk for falls interactions. venlafaxine, desvenlafaxine,
• fluoxetine • Exacerbate hyponatremia particularly in • Review the need for continued duloxetine) or bupriopion.
• paroxetine older adults by syndrome of inappropriate treatment for depression at least 6 • Consider the use of a
• sertraline antidiurectic hormone secretion (SIADH) months after remission of the episode, gastroprotective medication
• fluvoxamine • Increased risk for GI bleeding, particularly when based on number of prior episodes, (proton pump inhibitors
• citalopram using with NSAIDs, aspirin, or anticoagulation residual symptoms, current medical such as omeprazole,
• escitalopram • Can increase QT interval problems, and psychosocial difficulties. esomeprazole, or
• Consider stopping by gradually misoprostol) if SSRIs must
reducing the dose over a 4-week be combined with NSAIDs,
period in patients who no longer need aspirin, or antiplatelet agents.
antidepressants. • For patients taking warfarin,
• Avoid in patients with falls, unless heparin, or anticoagulants,
alternatives are not available. consider mirtazapine
• Avoid in patients with SIADH. • Consider complementary or
• Avoid paroxetine (and possibly alternative therapy (eg, CBT)
fluoxetine) in patients taking tamoxifen.
• Consider baseline EKG before
initiation of therapy.
Continued
Clinical Trials: NCCN believes that the best management of any patient with cancer is in a clinical trial. Participation in clinical trials is especially encouraged. References
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Antipsychotics: 4,5,7,8,9,10,11,12 • Some agents have anti-anticholinergic effects • In the presence of psychosis and • For delirium, short-term use
• chlorpromazine (especially chlorpromazine, clozapine, loxapine, danger to self/others, use low-dose (no more than 5 days) of one
• fluphenazine olanzapine, thioridazine, and trifluoperazine) non-anticholinergic agent for the of the following at low dose:
• haloperidol • Increased risk of cerebrovascular accident shortest duration possible. Haloperidola (0.25–1 mg
• loxapine (CVA) • May be appropriate for short-duration PO up to q8h)
• molindone • Increased risk of mortality in patients with treatment of refractory chemotherapy- Olanzapinea (2.5–5 mg PO
• perphenazine dementia induced nausea and vomiting. daily)
• pimozide • Hyperglycemia • May be appropriate for short-term Risperidonea (0.25–0.5 mg
• promazine • Increased risk of falls and fractures, especially management of delirium. PO daily)
• thioridazine in patients at risk • With concern for QT prolongation, start For patients with
• thiothixene • Concern for QT prolongation, especially at the lowest dose with slow uptitration. parkinsonism, quetiapinea
• trifluoperazine in combination with serotonin antagonists, Consider baseline EKG before (12.5–25 PO daily or q12h)
• triflupromazine antidepressants, and in patients with underlying initiation of therapy. • If using an antipsychotic,
• aripiprazole cardiac diseases attempt to reduce, taper, or
• asenapine stop other antipsychotics
• clozapine and/or drugs acting on the
• iloperidone central nervous system that
• lurasidone can worsen the risk of falls or
• olanzapine cognitive decline.
• paliperidone • For nausea, could
• quetiapine consider other antiemetics
• risperidone (serotonin antagonists
• ziprasidone such as ondansetron,
dexamethasone, or
aprepitant) if risk outweighs
the benefit of using an
antipsychotic.
• Monitor for extrapyramidal
symptoms; tools such as
the Abnormal Involuntary
Movement Scale are useful.
• See NCCN Guidelines for
Antiemesis.
aUnlabeled use.
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Antiepileptic drugs • Induce multiple cytochrome P450 enzymes, • Avoid for newly diagnosed epilepsy in • Examples of multiple
(AEDs):15,16 resulting in clinically significant drug interactions persons ≥60 years of age not currently AEDs that do not induce
• phenobarbital • Falls on antiepileptic therapy, unless at cytochrome P450 enzymes:
• primidone least two other AEDs have been lamotrigine, levetiracetam,
• phenytoin unsuccessful in stopping seizures or tiagabine, and topiramate.
• carbamazepine have intolerable adverse effects.
• Carefully check drug interactions when
using these agents.
Opioids • Sedation • Start low and escalate slowly, use • Consider using nonopioids
• morphine • Impaired balance and falls longer intervals if possible; NSAIDs,
• codeine • Nausea/vomiting • Start with short-acting agents acetaminophen
• tramadol • Constipation • Make sure patients are on a bowel • Consider radiation or nerve
• hydrocodone • Respiratory depression, especially in patients regimen to avoid severe constipation block in localized pain
• oxycodone with sleep apnea • Caution when prescribing with • For neuropathic pain,
• hydromorphone • Urinary retention underlying dementia consider non-opioids
• fentanyl • Dependence • Half-life may be longer in older adults • See NCCN Guidelines for
• methadone • Long-term use is associated with bone loss who have renal or hepatic dysfunction Adult Cancer Pain.
• Confusion
• Delirium
References
1Vyvey M. Steroids as pain relief adjuvants. Can Fam Phys 2010;56:1295-1297.
2Sturdza A, Millar BA, Bana N, et al. The use and toxicity of steroids in the management of patients with brain metastases. Support Care Cancer 2008;16:1041-1048.
3AGS Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Amer Geriatr Soc 2009;57:1331-1346.
4Hilmer SN, Mager DE, Simonsick EM, et al. A drug burden index to define the functional burden of medications in older people. Arch Intern Med 2007;167:781-787.
5Chew ML, Mulsant BH, Pollock BG, et al. Anticholinergic activity of the 107 medications commonly used by older adults. J Am Geriatr Soc 2008;56:1333-1341.
6Malik I, Moid I, Khan Z, Hussain M. Prospective randomized comparison of tropisetron with and without dexamethasone against high-dose metoclopramide in prophylaxis of acute and delayed cisplatin-induced
nausea and vomiting. Am J Clin Oncol 1999;22:126-130.
7The American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc
2012;60:616-631.
8HEDIS: Health Care Effectiveness Data and Information Set, at http://www.ncqa.org/HEDISQualityMeasurement.aspx.
9Fossey J, Ballard C, Juszczak E, et al. Effect of enhanced psychosocial care on antipsychotic use in nursing home residents with severe dementia: cluster randomised trial. BMJ 2006;332:756-761.
10O’Neil ME, Freeman M, Christensen V, et al. VA-Evidence-based Synthesis Program Reports Project #05-225, Washington (DC): Department of Veterans Affairs; 2011 Mar.
11Porsteinsson AP, Drye LT, Pollock BG, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial. JAMA 2014;311:682-691.
12Hocking CM, Kichenadasse G. Olanzapine for chemotherapy-induced nausea and vomiting: a systematic review. Support Care Cancer 2014;22:1143-1151.
13Kelly CM, Juurlink DN, Gomes T, et al. Selective serotonin reuptake inhibitors and breast cancer mortality in women receiving tamoxifen: a population based cohort study. BMJ. 2010;340:c693.
14Depression in adults with chronic physical health problem: recognition and management. NICE guidelines [CG91]. Published date: October 2009. Available at: https://www.nice.org.uk/guidance/cg91/chapter/
guidance.
15Pugh MJ, Berlowitz DR, Rao JK, et al. The quality of care for adults with epilepsy: an initial glimpse using the QUIET measure. BMC Health Serv Res 2011;11:1.
16Riechelmann RP, Del Giglio A. Drug interactions in oncology: how common are they? Ann Oncol 2009;20:1907-1912.

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NCCN Categories of Evidence and Consensus

Category 1 Based upon high-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2A Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate.
Category 2B Based upon lower-level evidence, there is NCCN consensus that the intervention is appropriate.
Category 3 Based upon any level of evidence, there is major NCCN disagreement that the intervention is appropriate.
All recommendations are category 2A unless otherwise indicated.
NCCN Categories of Preference

Interventions that are based on superior efficacy, safety, and evidence; and, when appropriate,
Preferred intervention affordability.
Other recommended Other interventions that may be somewhat less efficacious, more toxic, or based on less mature data;
intervention or significantly less affordable for similar outcomes.
Useful in certain
Other interventions that may be used for selected patient populations (defined with recommendation).
circumstances
All recommendations are considered appropriate.
CAT-1
NCCN Guidelines Version 1.2020

Socioeconomic Issues .............................................................................. MS-8

Discussion This discussion corresponds to the NCCN Guidelines for
Older Adult Oncology. Last updated on 09/25/18.
Geriatric Syndromes ................................................................................. MS-8
NCCN Categories of Evidence and Consensus
Application of CGA for Older Patients with Cancer ................... MS-12
Category 1: Based upon high-level evidence, there is uniform NCCN
Geriatric Screening Tools Before Using CGA ............................. MS-13
consensus that the intervention is appropriate.
Approach to Decision Making in Older Patients with Cancer ... MS-13
Category 2A: Based upon lower-level evidence, there is uniform
NCCN consensus that the intervention is appropriate. Surgery ................................................................................................... MS-15
Category 2B: Based upon lower-level evidence, there is NCCN Radiation Therapy .................................................................................. MS-15
consensus that the intervention is appropriate.
Chemotherapy ........................................................................................ MS-16
Category 3: Based upon any level of evidence, there is major NCCN
Targeted Therapy ................................................................................... MS-22
disagreement that the intervention is appropriate.
Adherence to Therapy ............................................................................ MS-22
All recommendations are category 2A unless otherwise
indicated. Disease-Specific Issues ................................................................ MS-24
Summary ........................................................................................ MS-24
Table of Contents Table 1. Examples of Cancer Types Included in Studies to Validate

Geriatric Screening Tools as Prescreening Instruments for Cancer
Therapy ........................................................................................... MS-25
Overview ........................................................................................... MS-2
Table 2. Examples of Cancer Types Included in Studies to Validate
Literature Search Criteria and Guidelines Update Methodology . MS-2
Geriatric Screening Tools as Prescreening Instruments for Surgery
Comprehensive Geriatric Assessment .......................................... MS-3 ......................................................................................................... MS-26
Functional Status ..................................................................................... MS-3 References ..................................................................................... MS-27
Comorbidities ........................................................................................... MS-4
Cognitive Function ................................................................................... MS-5
Nutritional Status ..................................................................................... MS-5
Polypharmacy .......................................................................................... MS-6
Version 1.2020 © 2020 National Comprehensive Cancer Network© (NCCN©), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
MS-1

Overview significant survival benefit should be avoided. The physiologic changes

Cancer is the leading cause of death in women and men aged 60 to 79 associated with aging may impact an older adult’s ability to tolerate cancer
years.1 More than 50% of all cancers and more than 70% of therapy and should be considered in the treatment decision-making
cancer-related deaths in the United States occur in patients who are ≥65 process. The NCCN Guidelines® for Older Adult Oncology address
years.2 It is estimated that by 2030 approximately 70% of all cancers will specific issues related to the management of cancer in older adults,
be diagnosed in adults aged ≥65 years.3 Aging in the U.S. population including screening and comprehensive geriatric assessment (CGA),
and greater life expectancy mean that cancer in older adults is becoming assessing the risks and benefits of treatment, preventing or decreasing
an increasingly common problem. Furthermore, older patients with complications from therapy, and managing patients deemed to be at high
cancer are under-represented in clinical trials for new cancer therapies.4 risk for toxicity from standard treatment.
Therefore, less evidence-based information exists to guide the treatment
Literature Search Criteria and Guidelines Update
of these patients. Methodology
The challenge of managing older patients with cancer is to assess whether Prior to the update of this version of the NCCN Guidelines for Older Adult
the expected benefits of treatment are superior to the risks in a population Oncology, a literature search was performed to obtain key literature in
with decreased life expectancy and decreased tolerance to stress. There Older Adult Oncology using the following search terms: older patients and
are unique issues to consider when caring for an older adult with cancer. cancer, treatment, allogeneic stem cell transplantation, adherence,
The biologic characteristics of certain cancers and their responsiveness to comprehensive geriatric assessment, toxicity and chemotherapy,
therapy are different in older patients compared to their younger polypharmacy, comorbidities, functional status, cognitive status, nutritional
counterparts.5 In addition, older patients also have decreased tolerance to status, falls, frailty, geriatric syndromes, delirium, dementia, depression,
anticancer therapy. Nevertheless, advanced age alone should not be the and distress. The PubMed database was chosen as it remains the most
only criterion to preclude effective treatment that could improve quality of widely used resource for medical literature and indexes only
life (QOL) or lead to a survival benefit in older patients.6,7 The available peer-reviewed biomedical literature.11
data suggest that older patients with good performance status are able to
The search results were narrowed by selecting studies in humans
tolerate commonly used chemotherapy regimens as well as younger
published in English. Results were confined to the following article types:
patients, particularly when adequate supportive care is provided.8-10
Clinical Trial, Phase II; Clinical Trial, Phase III; Clinical Trial, Phase IV;
However, there have been few studies that have addressed patients at
Guideline; Randomized Controlled Trial; Meta-Analysis; Systematic
the extremes of age or those with poor performance status.
Reviews; and Validation Studies.
Together, these age-related issues form the basis for the development of
The PubMed search resulted in 44 citations and their potential relevance
guidelines that address special considerations in older patients with
was examined. The data from key PubMed articles selected by the panel
cancer. Proper selection of patients is the key to administering effective
for review during the Guidelines update meeting as well as articles from
and safe cancer treatment. Treatment that diminishes QOL with no
additional sources deemed as relevant to these Guidelines and discussed
Version 1.2020 © 2020 National Comprehensive Cancer Network© ©
(NCCN ), All rights reserved. NCCN Guidelines® and this illustration may not be reproduced in any form without the express written permission of NCCN.
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by the panel have been included in this version of the Discussion section. Functional Status
Recommendations for which high-level evidence is lacking are based on Functional status in older patients with cancer can be evaluated using
the panel’s review of lower-level evidence and expert opinion. self-reported or performance-based measures. Self-reported measures
include the individual’s ability to complete activities of daily living (ADLs)
The complete details of the Development and Update of the NCCN
and instrumental activities of daily living (IADLs).15,16 ADLs encompass
Guidelines are available at www.NCCN.org.
basic self-care skills required to maintain independence at home and
Comprehensive Geriatric Assessment IADLs encompass complex skills that are necessary for maintaining
independence in the community. The need for assistance with IADLs has
CGA is a multidisciplinary, in-depth evaluation to assess the objective
been associated with decreased treatment tolerance and poorer survival in
health of a patient while assessing multiple domains, which affect cancer
older patients with cancer.17-20 Physical performance-based measures
prognosis and treatment choices in older adults. CGA includes
such as gait speed (also known as walking speed) and the Timed Up and
assessment tools to predict the functional age of older patients with cancer
Go (TUG) test are also used to assess functional status in older patients.
based on functional status, comorbidities that may interfere with cancer
treatment, polypharmacy, nutritional status, cognitive function, Gait speed has been used to assess functional status and health
psychological status, socioeconomic issues, and geriatric syndromes. outcomes in older adults.21,22 Some reports have also identified gait speed
as an indicator of survival and mortality in older adults.23,24 In a pooled
CGA can reveal and/or detect reversible geriatric problems that are not
analysis of individual data from 9 large cohort studies that included more
found by routine oncology care, and predict toxicity from cancer treatment
than 30,000 participants (≥65 years) living in the community, Studenski et
enabling a more targeted use of supportive care measures that can
al reported that gait speed was associated with survival in older adults.23
improve QOL and ensure compliance with adherence to therapy.12-14 In
In this analysis, with 0.8 meter/second as the cutoff, gait speed faster than
addition, CGA can provide important prognostic information that can be
1.0 meter/second suggested a better-than-average life expectancy and
helpful in estimating life expectancy, which is of paramount importance
gait speed above 1.2 meters/second suggested exceptional life
when making treatment decisions.
expectancy. White et al reported that decline in gait speed (slow,
Older adults may benefit from a referral to a geriatrician for risk moderate, and fast) could predict mortality in well-functioning older adults.
stratification prior to their cancer treatment, to develop a coordinated plan A fast decline in gait speed was associated with a 90% greater risk of
of care with the oncologist and/or to manage geriatric syndromes that mortality than a slow decline.24 The predictive value of gait speed has also
could jeopardize outcomes of cancer treatment. The geriatrician thus may been evaluated in older patients with cancer.25,26 In the Health, Ageing and
be able to assist the oncologist in optimizing the management of the Body Composition study that included 429 older patients with cancer,
non-cancer aspects of the patient’s care, which in turn may enable more faster gait speed (time taken to cover a 20-m course) was associated with
effective delivery of direct cancer care. lower risk of death (hazard ratio [HR] = .89) in patients with metastatic
cancer and lower 2-year progression to death or disability in patients with
non-metastatic cancer.25 In the Physical Frailty in Elder Cancer patients
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study that included 190 patients (mean age 80.6 years) with cancer during Specific comorbidities have been shown to have an impact on prognosis
the first 6 months following a CGA, a gait speed <0.8 m/s (HR = 5.6; 95% and treatment outcome in patients with cancer.34-36 In a randomized
CI, 1.6–19.7, P = .007) was significantly associated with early death.26 Gait adjuvant chemotherapy trial of 3,759 patients with high-risk stage II and
speed could be helpful in identifying older patients with a longer expected stage III colon cancer, patients with diabetes mellitus experienced a
life expectancy and who may be candidates for preventive interventions significantly higher rate of overall mortality and cancer recurrence. At 5
that are associated with long-term benefit. years, the disease-free survival (DFS; 48% vs. 59%), overall survival (OS;
57% vs. 66%), and relapse-free survival (RFS; 56% vs. 64%) were
The TUG test is a quick screening test to assess mobility and overall significantly worse for patients with diabetes compared with patients
motor function in older adults.27,28 The TUG test score is calculated as the without diabetes.34 In another series of 5077 men (median age, 69.5
time in seconds it takes a patient to get up from an armchair without using years) with localized or locally advanced prostate cancer, neoadjuvant
his or her arms, walk 10 feet forward at his or her usual pace, turn around, hormonal therapy was significantly associated with an increased risk of
walk back to the chair, and then sit down again. The patient may use an all-cause mortality (26.3% vs. 11.2%) among men with a history of
assistive device, such as a cane or walker, but may not have assistance coronary artery disease, CHF, or myocardial infarction after a median
from another person. The TUG test score has been shown to predict the follow-up of 5.1 years.35 In the SEER-Medicare database analysis of older
risk of falls in older adults.29,30 In a preliminary prospective study, the TUG patients (≥66 years) diagnosed with stages I-III breast cancer, those with
test was also associated with good sensitivity and specificity in the diabetes had an increased rate of hospitalizations for any chemotherapy
assessment of falls in older patients with cancer.31 A TUG test score of 13 toxicity and higher all-cause mortality.36
seconds or greater is associated with an increased risk of falls. For these
patients, a comprehensive evaluation should be considered. See In older patients with cancer, comorbidity may modify the disease course.
Assessment of Gait and Treatment Recommendations in the algorithm. The interaction of cancer treatment with comorbidity may impact functional
status or worsen the comorbidity. Cancer treatment may be too risky due
Comorbidities to the type and severity of comorbidity. Furthermore, comorbidity may
Older adults have an increased prevalence of comorbidities that can influence life expectancy (independent of cancer). In one study that
impact cancer prognosis and treatment tolerance.32,33 Cardiovascular evaluated the association between comorbidity, toxicity, time to relapse,
problems including congestive heart failure (CHF), diabetes, renal and OS in older women with good performance status receiving adjuvant
insufficiency, dementia, depression, anemia, chronic infections, chemotherapy for early-stage breast cancer, comorbidity was associated
neuropathy, anemia, liver and lung disease, hearing or vision loss, with shorter OS, but was not associated with increased treatment-related
osteoporosis, decubitus or pressure ulcers, and prior cancer diagnosis and toxicity or relapse.37 The effect of comorbidity on life expectancy should be
treatment are some of the frequently encountered comorbid conditions in evaluated prior to initiation of treatment.
older patients with cancer.
Charlson Comorbidity Index (CCI),38 the Cumulative Illness Rating Scale
(CIRS),39 and the Older Americans Resources and Services (OARS)
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Multidimensional Functional Assessment Questionnaire40 are commonly evidence-based tool for assessing the effect of medications on physical
used to determine the risk of mortality associated with comorbidity in older and cognitive performance in older adults.53 Special considerations for
patients. CCI41 and CIRS42,43 have also been used to determine treatment over- or under-use, duration of therapy, and dosage should be in place
tolerance in older patients with cancer. In a study of 310 older patients with the use of these classes of medications.
(≥70 years) with head and neck cancer, comorbidity as measured by the
ACE-27 index was an indicator of OS.44 In a randomized trial that For patients with suspected impaired cognitive function that could
compared vinorelbine alone or in combination with gemcitabine in older potentially interfere with their decision-making capacity, the guidelines
patients with locally advanced non-small cell lung cancer (NSCLC), a CCI recommend consultation with a clinician experienced in cognitive
of greater than 2 was associated with a higher risk of early treatment evaluation (geriatrician, neurologist, geriatric psychiatrist, or
suspension (82% vs. 30%, respectively).41 In a phase III trial comparing neuropsychologist) or initiation of further evaluation to determine the
platinum-doublet therapy as first-line treatment in patients with appropriate diagnosis (eg, mild cognitive impairment, dementia,
advanced-stage NSCLC, patients with severe comorbidities (as measured delirium).54 In addition to the clinical observation by the medical team, any
by CIRS) benefited from and tolerated platinum-doublet chemotherapy as concerns reported by the patient or the patient’s family suggestive of an
well as patients with no comorbidities.42 However, the former group had a impaired cognitive function should also trigger further evaluation. The
higher risk of neutropenic fever and death from neutropenic infections. NCCN Guidelines recommend periodic reassessment of cognitive function
or when considering changes to treatment plan for all patients, including
Cognitive Function those with no cognitive impairment.
Older patients with cancer who are cognitively impaired have an increased
See the section on Geriatric Syndromes for the assessment of dementia
risk of functional dependence, a higher incidence of depression, and are at
and delirium in older patients with cancer.
greater risk of death. Cognitive function is also predictive of medication
nonadherence across diagnoses, regardless of the complexity of Nutritional Status
regimen.45 Cognitively impaired patients should be cared for by an
Nutritional deficiency or malnutrition is a common and serious condition
experienced multidisciplinary geriatric oncology team along with good
that is underdiagnosed in older patients with cancer. Poor nutritional
supportive care throughout the treatment.46 In addition, the association
status is associated with an increased risk of severe hematologic toxicity,
between cognitive impairment and the ability to weigh the risks and
an increased mortality risk, poor chemotherapy tolerance, and an
benefits of cancer treatment decisions needs to be considered.
increased length of stay among hospitalized patients with cancer.55-58
The use of certain classes of medications (anticholinergics, antipsychotics, While some of the malnutrition is attributed to the underlying illness, in
benzodiazepines, corticosteroids, and opioids) has also been associated most of the patients it is due to inadequate intake of calories. Nutritional
with cognitive impairment in older adults.47-49 Antipsychotic drugs are also parameters would help to identify patients who are at risk for individualized
associated with higher mortality rates in patients with dementia.50-52 Hilmer or advanced intervention. There are many scales for nutritional
and colleagues have developed a drug burden index, which is a useful assessment and no clear definition as to the appropriate scale. The
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malnutrition universal screening tool uses cutoffs such as a body mass polypharmacy and their association with chemotherapy tolerance.69 The
index (BMI) of ≤22 kg/m2 and unintentional weight loss of >5% in the results of this study demonstrated that PDIs may contribute to severe
previous 6 months.59 Special attention should also be devoted to vitamin non-hematologic toxicities, whereas there was no association between
D deficiency since that may be related to osteoporosis and fractures.60 PDIs and hematologic toxicities. Further research regarding PDIs and
chemotherapy toxicity is warranted in order to develop interventions and
Polypharmacy
optimize clinical outcomes in older patients receiving chemotherapy.
Polypharmacy can be defined in various ways, including the use of
increased number of medications (5 or more), more than is clinically The use of one or more potentially inappropriate medications among older
indicated; the use of potentially inappropriate medications; medication patients has also been documented in several studies.70-72 In one study,
underuse; and medication duplication.61 Although polypharmacy can be an the use of inappropriate medications increased from 29% to 48% among
issue across all age groups, it can be a more serious problem in older patients with cancer in the palliative care setting.71 In a more recent study
patients due to the presence of increased comorbid conditions treated with of 500 older patients with cancer (≥65 years) starting a new chemotherapy
one or more drugs. In this patient population, the use of drugs for the regimen, polypharmacy (≥4 drugs) was observed in over 60% of patients
management of cancer-related symptoms or side effects can result in and the use of potentially inappropriate medications was commonly seen
polypharmacy.62-64 in ≤29% of patients.73 Polypharmacy did not increase the risk of
chemotherapy-related toxicity in this cohort, frequency of hospitalization,
The use of multiple medications can lead to increased incidences of or early discontinuation of chemotherapy.72 The use of potentially
adverse drug reactions (which can lead to functional decline and geriatric inappropriate medications (especially hypnotics, sedatives,
syndromes), drug-drug interactions, and non-adherence.65,66 Among antidepressants, long-acting benzodiazepines and other inappropriate
patients with cancer receiving systemic anticancer therapy for solid
psychotropics, and medications with anticholinergic properties) is also
tumors, one or more drug-drug interactions were observed in 27% of associated with an increased risk of falls in older adults (≥65 years).74,75
patients, which increased to 31% among patients with cancer receiving
palliative care only.67 Older patients, those with comorbid conditions, brain Evaluation of Polypharmacy
tumor patients, and those taking many medications are at greater risk of The guidelines recommend evaluation of adherence to therapy and
drug interactions.67 periodic medication review to check for medication duplication, appropriate
use, availability of less expensive alternative medications, and PDIs.
Alterations in pharmacokinetics and pharmacodynamics of drug Although the optimal polypharmacy cut-point for predicting clinically
metabolism in the older population can also contribute to adverse drug important adverse events in older people with cancer is unclear, the
interactions.68 Most of the commonly prescribed medications such as common definition of ≥5 medications is reasonable for identifying patients
opioids, antidepressants, antibiotics, and antipsychotics as well as for medication review.76 Medication review may be indicated prior to
anticancer drugs induce or inhibit cytochrome P-450 enzymes. In a initiation or change in treatment, change in comorbid disease
retrospective analysis of 244 older patients (≥70 years), Popa et al management or in clinical condition, and at other times as determined by
assessed the impact of potential drug interactions (PDIs) from
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the clinical team and during transition of care. A careful review of the patients required specific interventions and the use of potentially
indication for treatment, duration of therapy, and dosage should be inappropriate medication was identified in 11% of patients, following
performed when using specific medications or classes of medications that geriatric management evaluation.80
are not recommended for older adults. See the section on Medications
Commonly Used for Supportive Care that are of Concern in Older Patients The Beers’ Criteria were updated by the American Geriatrics Society
in the algorithm for specific recommendations. (AGS) in 2012 to improve monitoring of drug use, e-prescribing,
interventions to decrease adverse events in older adults, and patient
Beers criteria and the Medication Appropriateness Index (MAI) are two of outcomes.81 In the updated criteria, medications that are used in older
the most common approaches used to evaluate potentially inappropriate adults are divided into three categories: 1) potentially inappropriate
medication use in older patients. The Screening Tool of Older Persons’ medications to avoid in older adults; 2) potentially inappropriate
Prescriptions (STOPP) and the Screening Tool to Alert doctors to Right medications to avoid in older adults with certain diseases and syndromes
Treatment (START) criteria have been recently developed to evaluate that the listed drugs can exacerbate; and 3) medications to be used with
drug interactions, medication duplication, and medication underuse. caution in older adults.
Beers Criteria Medication Appropriateness Index

The Beers' Criteria identify inappropriate medications that have potential MAI was developed to measure appropriate prescribing based on a
risks that outweigh potential benefits based on the risk of toxicity and the 10-item list and a 3-point rating scale.82 Samsa and colleagues
presence of potential drug-disease interaction in older patients with subsequently modified the MAI to include a single summated MAI score
cancer.77,78 The criteria are appropriate for persons older than 65 years of per medication that demonstrated acceptable reliability in assessing
age and provide a rating of severity for adverse outcomes as well as a medication appropriateness among 1644 medications prescribed to 208
descriptive summary of the prescribing information associated with the older veterans from the same clinic.83 This modified MAI appears to be a
medication. The updated 2003 Beers Criteria have been used to evaluate valid and relatively reliable measure to detect medication appropriateness
polypharmacy in older patients with cancer both in an oncology-specific and inappropriateness in the community pharmacy setting as well as in
acute care unit (Oncology-Acute Care for Elders [OACE]; n = 47 with a ambulatory older patients on multiple medications.84,85 MAI scores were
median age 73.5 years) and in the outpatient setting (n = 154 with a significantly lower for medications with a high potential for adverse effects
median age 74 years). 79,80 The Beers Criteria-based polypharmacy was compared with those with a low potential (1.8 vs. 2.9; P < .001).84 Higher
observed in 21% and 11% of patients, respectively. Both of these studies MAI scores were also associated with lower self-related health scores in
had implemented medication review and pharmacist-based interventions older adults.86 MAI has not been evaluated extensively in older patients
to improve the appropriateness of prescribing. In the OACE study, 53% with cancer.
had a subsequent alteration in their medication regimen and 28% had a
potentially inappropriate medication discontinued, after implementation of STOPP/START Criteria
recommendation by the OACE team.79 In the outpatient study, 50% of STOPP/START criteria were established using the Delphi consensus and
an 18-member expert panel from the academic centers of Ireland and the
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United Kingdom.87 The STOPP criteria are comprised of 65 indicators for cancer.94 Older patients with cancer experience a higher prevalence of
potentially inappropriate prescribing, including drug-drug and drug-disease geriatric syndromes than those without cancer. In an analysis of a national
interactions, therapeutic duplication, and drugs that increase the risks of sample of 12,480 community-based elders, 60.3% of patients with cancer
geriatric syndromes, whereas the START criteria incorporate 22 reported one or more geriatric syndromes compared with 53.2% of those
evidence-based indicators to identify prescribing omissions in older without cancer.95 In this cohort, the prevalence of hearing trouble, urinary
people.88,89 In a randomized trial of 400 hospitalized patients (≥65 years), incontinence, depression, and osteoporosis were significantly higher in
unnecessary polypharmacy, the use of drugs at incorrect doses, and patients with cancer than in those without cancer.
potential drug-drug and drug-disease interactions were significantly lower
Falls
in the group assigned to screening with STOPP/START criteria with
recommendations provided to their attending physicians compared to the Falls are more common in older adults with a cancer diagnosis than those
control group assigned to routine pharmaceutical care.90 Significant without cancer. Cancer diagnosis (especially in the first 6 months after
improvements in prescribing appropriateness were sustained for 6 months diagnosis) and chemotherapy are also associated with a high risk of
after discharge. falls.96-98 In a prospective study of 185 patients with advanced cancer, 93
(50.3%) patients experienced falls associated with a high risk of physical
Socioeconomic Issues injury, regardless of age: 35 patients were <65 years of age and 58
The lack of social ties has been identified as significant predictors of patients were ≥65 years of age.96 The median time to a fall was 96 days.
mortality in older adults. 91,92 In a study of 2,835 women diagnosed with In a multivariate analysis, the diagnosis of a primary brain tumor or brain
breast cancer, socially isolated women had an elevated risk of mortality metastasis, number of falls in the preceding 3 months, severity of
after a diagnosis of breast cancer.93 An evaluation of social support is an depression, benzodiazepine dose, and cancer-related pain were identified
integral part of geriatric assessment. The patient’s treatment goals should as independent risk factors.96 Another study also reported that the risk of
be discussed with them. In addition, the patient’s living conditions, falls increases with each cycle of chemotherapy, and patients treated with
presence, and adequacy of caregiver and financial status should also be taxane-based chemotherapy may be at a greater risk of falls than those
taken into consideration. Furthermore, information should be sought as to treated with platinum-based chemotherapy.97 In a recent study that
whether the patient is a caregiver for someone else and whether cancer evaluated the occurrence of falls in 937 older adults with cancer, during
treatment may impact their ability to provide this care. Consultation with a the follow-up of 2 to 3 months after cancer treatment decision, a fall was
social worker should be encouraged. Consultation with a financial expert reported by 142 patients (17.6%), of whom 51.4% fell more than once. Fall
to discuss the cost and coverage options of treatment would also be history in the past 12 months, fatigue, ADL dependency, geriatric risk
beneficial. profile by Geriatric 8 (G8), and living alone were identifed as independent
predictors of 1 or fewer fall within 2 to 3 months after cancer treatment
Geriatric Syndromes decision.99 These findings suggest that falls are important problems in
Falls, dementia, delirium, depression, distress, osteoporosis, fatigue, and older patients with cancer and that geriatric assessment can identify
frailty are some of the most common syndromes in older patients with patients at risk for falls.
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Multifactorial risk assessment and management, exercise, vitamin D quantitatively assesses the severity of cognitive impairment and
supplementation, withdrawal of psychotropic medications, and documents cognitive changes occurring over a period of time.109,110
environmental modifications have been shown to be effective in reducing However, MMSE is not adequate for mild cognitive impairment and does
the risk and/or rate of falls in older patients.100-105 The guidelines not predict future decline. MoCA is a brief screening tool with high
recommend periodic assessment of history of falls, balance, and gait sensitivity and specificity for detecting mild cognitive impairment in
difficulties for all patients, as fall risk may change over time. The use of patients performing in the normal range on the MMSE.111 MoCA has been
early and preventative use of durable medical equipment and in-home shown to be a superior prognostic indicator to the MMSE in patients with
safety evaluations are recommended for patients with neurotoxicities at brain metastases.112,113 In a feasibility study of MoCA in patients with brain
high risk for falls. Assessment of gait by evaluating gait speed23 or using metastases, cognitive impairment was detected in 80% of the patients by
the TUG test, evaluation for physical or occupational therapy, vitamin D the MoCA compared with 30% by the MMSE.112 Among the 28 patients
supplementation (in patients with low levels of vitamin D), or referral to with a normal MMSE, 71% had cognitive impairment according to the
geriatrics or a primary care physician can be considered for patients who MoCA.
have experienced a fall in the last 6 months or if they are afraid of falling.
Clinical interview with cognitive and functional assessment to screen for
Dementia mild cognitive impairment or dementia is recommended for all patients,
Dementia is a progressive condition characterized by impairment of since there is a strong correlation between decline in cognitive status and
memory and at least one other cognitive function (such as aphasia, the loss of functional independence in older adults.114 The guidelines have
apraxia, agnosia, or executive function) that would interfere with the ability included Mini-Cog as a screening tool for the assessment of mild cognitive
to perform daily functions independently. Dementia is often present in impairment and dementia in older patients with cancer. Mini-Cog is a
older patients as a comorbid condition. In a SEER database analysis, 5-point test (consisting of a three-word recall and clock drawing test) used
older patients with colon cancer (≥67 years) and dementia were less likely for screening cognitive impairment in the older population.115,116
to receive invasive diagnostic methods or therapies with curative intent.106 Assessment of cognitive function can also be confounded by fatigue,
Preexisting dementia was also associated with high mortality, mostly from depression, anxiety, underlying brain tumors, endocrine dysfunction,
noncancer causes in patients ≥68 years diagnosed with breast, colon, or nutritional deficiency, alcohol use, and sleep disturbances.117 Therefore, if
prostate cancer.107 Mild cognitive impairment is an intermediate state dementia is suspected, further evaluation including brain imaging,
between normal cognition and dementia. It is characterized by subjective neuropsychological testing, and evaluation for vitamin B12 deficiency and
memory impairment, preserved general cognitive function, and intact thyroid dysfunction may be indicated. For patients with mild cognitive
ability to perform daily functions.108 impairment, the guidelines recommend periodic reassessment of cognitive
function or when considering changes to the treatment plan.
The Mini-Mental State Exam (MMSE) and the Montreal Cognitive
Assessment (MoCA) are recommended for the assessment of cognitive
function in older adults.109-111 MMSE is an 11-item screening test that
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Delirium Depression
Delirium is an acute decline in attention and cognition over a short period The Geriatric Depression Scale (GDS) is a reliable and valid tool for
of time (usually hours to days) and is characterized by the disturbance of screening for depression in older patients with no cognitive impairment
consciousness with reduced ability to focus, sustain, or shift attention.118 It and in patients with mild to moderate cognitive impairment.129 GDS was
is an under-recognized problem in older adults and can contribute to originally developed as a 30-item scale.129 Shortened versions of GDS
poorer clinical outcomes, functional decline, and impaired communication have been found to be equally accurate and less time consuming in
between the patient and physicians in patients with advanced cancer.119 screening for depression in older adults.130,131 Cancer-related fatigue and
Dementia is the leading factor for delirium and about two thirds of cases of depression frequently occur together; therefore, patients reporting fatigue
delirium occur in older patients with dementia.118 should probably be assessed for depression.132-134
Confusion Assessment Method (CAM) is a screening and diagnostic tool In the prospective ELCAPA cohort study, the overall prevalence of clinical
based on 4 important features of delirium: acute onset and fluctuating depression was 28% among older patients with cancer that had not yet
course, inattention, disorganized thinking, and altered level of been treated.135 In a multivariate analysis, geriatric assessment findings
consciousness.120,121 The Memorial Delirium Assessment Scale is a including impaired mobility and functional status, ADL, inadequate social
10-item validated instrument developed for repeated use to quantify the support, cognitive impairment, polypharmacy, multimorbidity, and cancer-
severity of delirium symptoms in patients with advanced cancer.122 The related pain were independently associated with clinical depression.
Nursing Delirium Screening Scale is an observational 5-item scale and
Distress
has been validated in the oncology inpatient setting and is associated with
high sensitivity and specificity.123 Psychological distress is common among patients with cancer. Hurria and
colleagues reported that significant distress was identified in 41% of
The Hospital Elder Life Program (HELP) includes interventions for the patients ≥65 years with cancer and poorer physical function was the best
management of 6 risk factors for delirium (ie, cognitive impairment, sleep predictor of distress.136 Screening tools have been found to be effective
deprivation, immobility, dehydration, vision or hearing impairment).124 In and feasible in reliably identifying distress and the psychosocial needs of
the Yale Delirium Prevention Trial (852 patients), the HELP interventions patients.137-139 The NCCN Distress Thermometer (DT) and the
resulted in a significant reduction in the development of delirium, total accompanying 36-item problem list is a well-known screening tool,
number of days with delirium, and the total number of delirium episodes in specifically developed for patients with cancer by the NCCN Distress
hospitalized patients ≥70 years.125 Management Panel.140,141 The NCCN DT has been validated by several
studies in patients with different types of cancer and has revealed good
The NCCN Guidelines have included CAM as a screening tool for delirium. correlation with the more comprehensive Hospital Anxiety and Depression
Evaluation and treatment of all potential causes of delirium is Scale.139 Patients can quickly fill out this distress assessment tool in the
recommended for all patients with delirium. Medications that can waiting room and the tool can alert the physician to potential problems.
contribute to delirium should be used with caution in older patients with This tool identifies whether patients with cancer have problems in five
cancer.126-128
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different categories: practical, family, emotional, spiritual/religious, and Frailty

physical. See the NCCN Guidelines for Distress Management available at Frailty is a biologic syndrome of decreased reserve and resistance to
www.NCCN.org for more information on the use of DT as a screening tool stressors, causing vulnerability to adverse outcomes.149 Frail patients are
in patients with cancer. at risk for falling, disability, hospitalization, and death. Fried Frailty Criteria
and the Balducci Frailty Criteria are the two most common measures used
Fatigue to identify frail patients.150,151 A recent study showed that very few
Cancer-related fatigue is a persistent, subjective sense of tiredness patients were classified as frail based on the oncologist’s clinical
related to cancer or cancer treatment that interferes with usual judgment, and the use of a modified geriatric assessment can aid the
functioning.142 In advanced cancer, the prevalence of fatigue is greater oncologists to better identify frail patients.152
than 50% to 70%.143 In a study that evaluated the prevalence of common
symptoms in patients with advanced cancer, fatigue was independently According to Fried Frailty Criteria, frailty is defined as a clinical syndrome
associated with chemotherapy, hemoglobin level, and other symptoms with three or more of the following conditions: unintentional weight loss
such as pain and depression.144 Patients perceive fatigue to be one of the (≥10 lb in the past year), self-reported exhaustion, weakness (grip
most distressing symptoms associated with cancer and its treatment; strength), slow walking speed, and/or low physical activity.150 In a
fatigue is more distressing than pain or nausea and vomiting.145,146 In prospective, observational study of 5317 men and women (≥65 years),
contrast to normal fatigue, cancer-related fatigue is refractory to sleep and frailty status based on these criteria was found to be predictive of incident
rest, perhaps because patients with cancer have aberrant sleep patterns. falls, worsening mobility or ADL function, incidence of hospitalization, and
It is reasonable to expect that fatigue may precipitate functional death.150
dependence, especially in patients who are already dependent in
IADLs.31,147,148 The Balducci Frailty Criteria are based on the components of CGA
(dependence in one or more ADLs, three or more comorbid conditions,
Multiple factors can contribute to fatigue, including pain, emotional and one or more geriatric syndromes).151 These CGA-frailty criteria have
distress, anemia, comorbidities, and/or sleep disturbance; many of them been found to be more useful in identifying frail patients with cancer. In a
are treatable. Certainly, the best strategy is avoidance of any fatigue that prospective study that compared the Balducci Frailty Criteria and the
may precipitate functional dependence in older adults. Energy modified version of Fried Frailty Criteria in 176 patients (aged 70–94
conservation, exercise programs, stress management, sleep therapy, and years) who underwent elective surgery for colorectal cancer, although both
psychostimulants are some of the interventions that have proved valuable. frailty measures were predictive of OS, the Balducci Frailty Criteria were
Screening for fatigue can be done using a brief screening questionnaire more useful than the modified version of the Fried Frailty Criteria in
that would enable patients to rate the severity of their fatigue on a scale of predicting postoperative complications.153
0 (no fatigue) to 10 (worst fatigue). See the NCCN Guidelines for
Osteoporosis
Cancer-Related Fatigue available at www.NCCN.org.
Osteoporosis and its associated increased risk of fracture is a major risk
factor in patients with cancer, especially in women receiving
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chemotherapy or hormonal therapy for breast cancer and in men receiving severe chemotherapy toxicity and hospitalization in older patients with
hormonal therapy for prostate cancer. Osteoporosis can be prevented with metastatic colorectal cancer.161 Similarly, among older patients receiving
appropriate screening, lifestyle interventions, and therapy. The diagnosis induction chemotherapy for acute myeloid leukemia (AML), OS was
of osteoporosis is based on assessment of bone density by a dual-energy significantly shorter for patients with impaired cognitive and physical
x-ray absorptiometry (DEXA) scan. Management of bone health has function.162 CGA has also been reported to be an efficient method to
become an integral part of comprehensive cancer care. Older patients identify older patients with diffuse large B-cell lymphoma (DLBCL) who
should be made aware of the impact of cancer therapies on bone health can benefit from anthracycline-based chemoimmunotherapy.20,165
and should adhere to treatment recommendations for maintaining bone
health.154 The NCCN Task Force Report on Bone Health in Cancer Care Although CGA is helpful for physicians to develop a coordinated plan for
discusses effective screening and therapeutic options for optimizing bone cancer treatment as well as to guide appropriate interventions to the
health in patients with cancer.155 patient’s problems, it can be time-consuming and may not be practical for
all patients. Multiple geriatric screening tools have been tested and
Application of CGA for Older Patients with Cancer validated to identify patients at risk who would benefit from a CGA. See
The feasibility of CGA has been demonstrated in older patients with Geriatric Screening Tools Before Using CGA for more details. Some
cancer151,156,157 and the components of CGA (comorbid conditions, investigators have developed a brief but CGA specific for older patients
functional status, cognitive function, geriatric syndromes, polypharmacy, with cancer.166-168 The Cancer-Specific Geriatric Assessment (CSGA)
and nutritional status) have been associated with survival and developed by Hurria and colleagues includes the assessment of older
chemotherapy toxicity.18-20,158-164 cancer patients across seven domains (functional status, comorbidity,
polypharmacy, cognitive function, psychological status, social functioning
For example, in women ≥65 years diagnosed with stage I-III primary and support, and nutritional status) using validated measures.166 The
breast cancer, the all-cause and breast-cancer-specific death rate at 5 and feasibility of CSGA was demonstrated in a pilot study of 43 patients with
10 years was consistently approximately two times higher in women with 3 cancer (median age of 74 years), the majority of whom had
or more cancer-specific CGA deficits, regardless of age and stage of advanced-stage disease. This brief geriatric assessment is largely
disease.158 In another prospective study of 375 consecutive older patients self-administered and can be completed by the majority of older patients
with cancer (ELCAPA study), in a multivariate analysis, a lower ADL score without assistance.166 Results from the CALGB 360401 study also
and malnutrition were independently associated with cancer treatment demonstrated the feasibility of including CSGA in future cooperative group
changes.159 In a prospective multicenter study of 348 previously untreated clinical trials.167 The Senior Adult Oncology Program 2 (SAOP2) screening
cancer patients older than 70 years, poor nutritional status, impaired tool developed by Extermann and colleagues is aimed at identifying older
mobility, and advanced tumors were identified as risk factors predictive of patients who would benefit from a multidisciplinary evaluation by a
early death (<6 months) after initiation of chemotherapy.160 In a phase III geriatric oncology team.168 The SAOP2 screening tool includes the
study (FFCD 2001-02), impairment in functional status and cognitive assessment of older cancer patients across the following domains using
function (as assessed by IADL and MMSE, respectively) were predictive of
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validated measures: self-rated health, cognitive function, nutritional status, While all of the screening tools included the assessment of functional
comorbidity, ECOG performance status, and functional status. status, the assessment of other domains such as psychosocial status,
nutritional status, comorbidities, and polypharmacy varied widely. For
Geriatric Screening Tools Before Using CGA example, aCGA, Fried Frailty Criteria, and the VES-13 had a stronger
Abbreviated CGA (aCGA),169,170 Barber questionnaire,171 Fried Frailty predictive value for impairment of functional status (ADL and IADL) and
Criteria,150,172 G8,173-175 Groningen Frailty Index,170 Triage Risk Screening G8 had a strong predictive value for nutritional status, but not for other
Tool (TRST),175 Vulnerable Elders Survey (VES-13),174,176-179 and Lachs’ geriatric conditions. As a result, none of the screening tools were
screening test180 have been used to identify patients who would benefit successful in identifying impairments across all of the domains included
from a CGA. Some examples of cancer types that have been included in in CGA. Given the lack of data supporting the use of any one screening
studies evaluating these geriatric screening tools, which have been tool for predicting outcome of a CGA, screening tools should not replace
predictive of frailty, functional decline, survival, or, more importantly, the CGA in the management of older patients with cancer. However,
need for further screening using CGA, are listed in Table 1. These screening tools could be used to identify those patients who would
studies included patients with all types of solid tumors (including breast, benefit from a CGA prior to initiation of therapy.184,185
gastrointestinal, lung, ovarian, and many other cancers) and hematologic
malignancies. The studies validating geriatric screening tools as
Approach to Decision Making in Older Patients with
Cancer
prescreening instruments for patients with cancer who are undergoing
surgery are listed in Table 2. G8 and aCGA were developed specifically Older patients can be classified into three categories: 1) young old
for older patients with cancer. In a systematic review, Hamaker et al patients are 65 to 75 years of age; 2) old patients are 76 to 85 years of
assessed the sensitivity and specificity of frailty screening methods that age; and 3) oldest old patients are older than 85 years of age.5
could potentially be useful in the selection of patients for CGA.181 G8 and Chronologic age by itself is not reliable in estimating life expectancy,
TRST had the highest sensitivity (87% and 92%, respectively) and aCGA functional reserve, or the risk of treatment complications.186 While it is not
had the highest specificity (97%) for predicting frailty on CGA. A modified possible for a physician to predict the exact life expectancy of an individual
six-item version of the G8 screening tool, which was recently evaluated patient, it is possible to provide an estimate of whether a patient is likely to
in a prospective cohort of older patients with cancer from the ELCAPA live longer or shorter than an average person of similar age.22-24,187-190
study, exhibited better diagnostic performance with 89% sensitivity and
79% specificity.182 In the ONCODAGE prospective multicenter cohort Life expectancy at a given age can be estimated using life table data as
study, which evaluated the diagnostic accuracy of G8 and VES-13 as a suggested by Walter and Schonberg.191 For example, about 25% of the
predictive screening tool to identify older patients who would require healthiest 75-year-old women will live more than 22 years, 50% will live at
CGA, G8 was more sensitive and VES-13 was more specific. Abnormal least 17 years, and 25% will live less than 10 years. Lee and colleagues
G8 score, advanced stage, male sex, and poor performance status were
developed and validated a potentially useful tool for clinicians to estimate
independent prognostic factors of 1-year survival.183
the 4-year mortality risk.189 Patients can be stratified into three groups of
varying risk of mortality (high, intermediate, or low) based on the
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prognostic index, which incorporates demographic variables (age and understand. See Optimizing Communication with Older Adults in the
sex), self-reported comorbid conditions, and functional measures.189 Carey algorithm. Sessums et al evaluated a variety of instruments used to
and colleagues also developed a similar functional morbidity index based assess medical decision-making capacity in adult patients without any
on self-reported functional status, age, and gender to stratify elders into mental illness and concluded that Aid to Capacity Evaluation (ACE) is the
varying risk groups for 2-year mortality.188 best available instrument to assist physicians in making assessments
about a patient’s medical decision-making capacity.193 Irrespective of age,
The risk of morbidity from cancer is generally established by the stage at a person who is functionally independent without serious comorbidities
diagnosis, the aggressiveness of the tumor, and risk of recurrence and and has the decision-making capacity should be a good candidate for
progression. More generally, a useful collection of tools to estimate the most forms of cancer treatment. In patients without decision-making
general mortality risk in the older adult can be found online at capacity, the guidelines recommend considering consultation from an
http://eprognosis.ucsf.edu/. Life expectancy calculators available at this ethics committee or social worker. Additional information can be obtained
website could be utilized to determine anticipated life expectancy from the patient’s proxy, advance directive, health care power of attorney,
(independent of the cancer) and in clinical decision-making to assess or clinician’s documentation.
whether the cancer is likely to shorten the patient's life expectancy or
whether the patient is likely to become symptomatic from cancer during Functionally independent patients with contraindications to treatment and
the anticipated life expectancy. These calculators should be used in patients with major functional impairment with or without complex
conjunction with clinical judgment. comorbidity should be managed according to the appropriate NCCN
Following initial screening and CGA, patients with a low risk of dying or Guidelines for Supportive Care. Patients who are dependent in some
suffering from cancer during their lifetime can receive symptom IADLs, with or without severe comorbidities, are at increased risk of
management and supportive care as detailed in the appropriate NCCN treatment complications. For these patients with intermediate functional
Guidelines for Supportive Care. Patients in the moderate or high-risk impairment who have milder problems (such as dependence in one or
group can be further evaluated to assess their functional dependency, more IADLs, milder comorbidity, depression, minor memory disorder, mild
decision-making capacity, overall goals, and desire for proposed dementia, and inadequate caregiver), treatment may still be administered
treatment.192,193 with special individualized precautions.5
A patient’s decision-making capacity is generally evaluated based on the The potential benefits of cancer treatment include prolonged survival,
patient’s ability to understand the relevant information about the diagnosis maintenance, and improvement of QOL and function, as well as palliation
and proposed diagnostic tests or treatment; appreciate his or her of symptoms. For patients who are able to tolerate curative treatment,
underlying values and current medical situation; use reason to make a options include surgery, radiation therapy (RT), chemotherapy, and
decision; and communicate his or her choice. It is essential that key targeted therapies. Symptom management and supportive care as
concepts and information regarding the diagnosis of cancer and treatment detailed in the appropriate NCCN Guidelines for Supportive Care is
should be communicated to older patients in a way that they will be able to recommended for all patients.
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Surgery Health and Clinical Excellence (NICE) guidelines202 provide

In general, age is not the primary consideration for surgical risk, although recommendations for the management of delirium in hospitalized patients
the physiologic status of the patient needs to be assessed.194 Performance ≥70 years.
status and comorbidities of the patient are more important factors than
Radiation Therapy
patient’s age when considering surgical treatment options for older
adults.195 The American College of Surgeons and the AGS have provided RT (external beam RT or brachytherapy) can be offered either in the
general guidelines for the preoperative assessment of older patients curative or palliative setting.203,204 Available data from the literature indicate
undergoing surgery. These guidelines could also be applied to older that RT can be highly effective and well tolerated, so that age alone need
patients with cancer undergoing surgery.128 not be a limiting factor in older patients with cancer.205,206 Radiation
oncologists, like all other clinicians caring for older patients with cancer,
The Surgical Task Force report from SIOG (International Society of must be careful of the potential to overtreat older adults with substantial
Geriatric Oncology) reported that in many malignancies (breast, gastric, competing risks of non-cancer death, as well as the potential to undertreat
and liver) the surgical outcomes in older patients with cancer were not older adults because of an underestimation of life expectancy in patients
significantly different from their younger counterparts.196 Preoperative with advanced age but few significant comorbid conditions.
Assessment of Cancer in the Elderly (PACE) was developed to determine
the suitability of older patients for surgical intervention.197 PACE It is important to consider several general principles when developing an
incorporates CGA, brief fatigue inventory, performance status, and individualized treatment plan with RT in older patients.204 The decision to
American Society of Anesthesiologists (ASA) grade. In an international offer RT to older patients with cancer should be based on the following
prospective study, 460 consecutive older patients completed PACE prior factors: 1) evaluation of the benefits and risks associated with RT; 2)
to surgery.198,199 In a multivariate analysis, moderate-to-severe fatigue, a careful consideration of the patient’s underlying functional reserve; and 3)
dependent IADL, and an abnormal performance status were identified as an understanding of the differences in the biology of cancers and their
the most important independent predictors of postoperative complications. responsiveness to therapy in this patient population. Nutritional support
Disability assessed by ADLs, IADLs, and performance status were and pain control for treatment-induced mucositis are recommended for
associated with an extended hospital stay. patients receiving RT. Considerations for older patients undergoing RT will
heavily depend on the anatomic site being radiated and the
Patients should be made aware that emergency surgery carries increased dose/fractionation chosen. See disease-specific NCCN Guidelines for
risk of complications. Following surgery, physical and/or occupational Treatment of Cancer by Site available at www.NCCN.org. Concurrent
therapy should be considered to expedite the patient’s return to their chemoradiation, however, should be used with caution; dose modification
preoperative functional level. Impaired cognitive function is also a risk of chemotherapy may be necessary to reduce toxic side effects.
factor for postoperative complications, prolonged hospital stay, and
6-month overall postoperative morbidity.200,201 Older age is also a risk Incomplete and interrupted courses of RT can compromise the efficacy of
factor for postoperative delirium. The HELP124,125 and National Institute for treatment as well as the ability to deliver higher doses of RT in the future.
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Therefore, it is important to consider alternative approaches in patients • Only a few patients were ≥80 years; therefore, minimal information is
with extreme functional limitations and ensure maximal supportive care. available on the oldest patients.
Advanced RT techniques (eg, intensity-modulated RT [IMRT], • The older patients involved in these studies were highly selected by the
image-guided RT [IGRT] and stereotactic body RT [SBRT] or stereotactic eligibility criteria of the cooperative group protocols and were not
ablative radiotherapy [SABR]) facilitate the delivery of large doses of representative of the general older population, because they were
radiation to small target volumes while limiting the risk of radiation-induced probably healthier than most older patients.
damage to normal surrounding tissues and organs at risk (OARs).206 • Many of the treatment regimens used in these trials had lower dose
Judicious application of these techniques may also help to assuage intensity than those in current use.
concerns about the risks of RT in older adults. Hypofractionated RT may
also help to improve treatment tolerability by limiting overall treatment time Nevertheless, these studies are important, because they demonstrate that
without compromising clinical outcomes in some patients.207 Since the age, by itself, is not a contraindication to cancer chemotherapy.
biologic characteristics of certain cancers are different in older patients Therefore, patient selection is extremely important to maximize the
compared to their younger counterparts, and partly because of the benefits of adjuvant chemotherapy in older patients with cancer.
decreased tolerance of treatment by older patients, treatment should be Increased age has been associated with changes in the pharmacokinetics
individualized based on the nature of the disease and the performance and pharmacodynamics of cancer therapy and increased susceptibility of
status of the patient. normal tissues to toxic complications.214 Pharmacodynamic changes of
interest include reduced repair of DNA damage and increased risk of
Radiation therapy, though administered locally, can produce systemic side
toxicity. Pharmacokinetic changes of major concern include decrease in
effects such as fatigue, depression, anorexia, nausea, vomiting, alteration
the glomerular filtration rate (GFR) and volume of distribution of
in the taste, sleep disturbance, headache, anemia, dry skin, dermatitis,
hydrosoluble drugs. Although the hepatic uptake of drugs and the activity
and constipation. Late complications of these therapies also include
of cytochrome P450 enzymes also decrease with age, the influence of
pharyngitis, esophagitis, laryngitis, persistent dysphagia, fatigue,
these changes on cancer chemotherapy is not clear. Intestinal absorption
cardiovascular disease, mucositis, hepatotoxicity, and cognitive
may decrease with age, but it does not appear to affect the bioavailability
deficits.208,209
of anticancer agents. The pharmacokinetics of antineoplastic drugs is
Chemotherapy unpredictable to some extent; thus, drug doses should be adjusted
according to the degree of toxicity that develops. However, adequate
Several retrospective studies have reported that the toxicity of
dosing is necessary to ensure the effectiveness of therapy.
chemotherapy is not more severe or prolonged in persons older than 70
years of age.210-213 However, the results of these studies cannot be Extermann and colleagues have devised the MAX2 index for estimating
generalized for the following reasons: the average per-patient risk for toxicity from chemotherapy.215 In a
retrospective analysis, Shayne et al identified advanced age (≥65 years),
greater body surface area, comorbidities, anthracycline-based regimens, a
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28-day schedule, and febrile neutropenia as independent predictors of Side Effects of Chemotherapy
reduced dose intensity among patients with early-stage breast cancer In older patients undergoing chemotherapy, the most common
receiving adjuvant chemotherapy.216 In another retrospective analysis of complications include myelosuppression resulting in neutropenia, anemia,
older patients (≥65 years) with invasive breast cancer, the type of adjuvant or thrombocytopenia; mucositis; renal toxicity; cardiac toxicity; and
chemotherapy regimen was a better predictor of toxicity than increased neurotoxicity. Older patients appear to be at special risk for severe and
age or comorbidity score.217 Anthracycline-based regimen resulted in prolonged myelosuppression and mucositis, increased risk for
greater grade 3 or 4 toxicity, hospitalization, and/or febrile neutropenia, cardiomyopathy, and increased risk for central and peripheral neuropathy.
whereas treatment delays due to myelosuppression were more frequent In addition, they are also at risk for infection (with or without neutropenia),
with the cyclophosphamide-containing regimen. Among older patients with dehydration, electrolyte disorders, and malnutrition either as a side effect
ovarian cancer, those receiving standard-dose chemotherapy were more of the chemotherapy or directly from the tumor. Chemotherapy can also
likely to experience cumulative toxicity and delays in therapy.218 affect cognition, function, balance, vision, hearing, continence, and
mood.222 The combination of these complications enhances the risk of
Other investigators have developed tools incorporating components of delirium and functional dependence. It is essential to detect and correct
CGA to assess the individual risk of severe toxicity from chemotherapy in these complications (that may interfere with treatment) in order to achieve
older patients.219-221 Hurria and colleagues have developed CSGA for maximum benefit from chemotherapy. Prevention and/or amelioration of
predicting treatment-related toxicity in older patients with cancer, which some of the common chemotherapy-related complications are discussed
has also been validated in an independent cohort study of 250 older adults below.
(≥65 years) with a solid tumor.219,220 The following factors were predictive
of grade 3 to 5 toxicity: age ≥72 years; type of cancer (gastrointestinal or Cardiovascular Toxicity
genitourinary); standard-dose chemotherapy; polychemotherapy; Anthracyclines are associated with increased cardiac toxicity resulting in
hemoglobin (male: <11g/dL; female: <10 g/dL); creatinine clearance <34 left ventricular dysfunction (LVD) and CHF.223,224 Other antineoplastic
mL/min; hearing impairment described as fair or worse; one or more falls drugs associated with significant cardiovascular complications include
in the last 6 months; limited in walking one block; the need for assistance alkylating agents, antimetabolites, and microtubule-stabilizing agents.
with taking medications; and decreased social activities due to physical or These drugs may have an additional effect on anthracycline-induced
emotional health. Extermann et al have developed the chemotherapy risk cardiovascular toxicity. Risk factors for anthracycline-induced
assessment scale for high-age patients (CRASH) score, which could be cardiovascular toxicity include an existing or history of heart failure or
useful in predicting significant differences in the risk of severe toxicity in cardiac dysfunction, hypertension, diabetes and coronary artery disease,
older patients with cancer starting a new chemotherapy.221 In this model, older age (independent of comorbidities and performance status), prior
diastolic blood pressure, IADL, lactate dehydrogenase, and the type of treatment with anthracyclines, higher cumulative doses, and short infusion
treatment were the best predictors of hematologic toxicity. Performance duration.225 Age is also a significant risk factor for CHF in patients
status, cognitive function, nutritional status, and the type of therapy were receiving anthracycline-based regimens.224 HER2 status, hypertension,
the best predictors of non-hematologic toxicity. and coronary artery disease have also been identified as significant
MS-17

predictors for heart failure in patients with breast cancer treated with efficacy with lower rates of cardiac events in patients with early-stage as
anthracycline.226 well as metastatic HER2-positive breast cancer.236-238 The subgroup
analysis of the randomized trial that evaluated trastuzumab in combination
Cardiac toxicity has also been a concern in patients receiving with docetaxel and pertuzumab in patients with HER2-positive metastatic
trastuzumab.227-230 In a single-center, retrospective analysis of older breast cancer (808 patients; 127 patients were ≥65 years) did not show
patients (≥70 years; n = 45) with breast cancer, Serrano et al reported an any increase in the risk of cardiac dysfunction associated with
increased incidence of cardiotoxicity among patients with a history of trastuzumab, and there was also no evidence of late or cumulative cardiac
cardiac disease and/or diabetes treated with trastuzumab.230 toxicity.238 In addition, the results also showed no significant correlation
Asymptomatic cardiotoxicity was observed in 12.5% of patients with between age and the development of left ventricular systolic dysfunction in
early-stage breast cancer; 24% of those with advanced breast cancer and older patients. Additional data are needed regarding the tolerability of
8.9% of all patients with advanced breast cancer developed symptomatic these regimens in older patients.
CHF. Trastuzumab has been associated with cardiac dysfunction and
CHF in patients with HER2-positive metastatic breast cancer, especially Renal Toxicity
when used in combination with anthracyclines.227,231,232 However, in the The GFR decreases with age, which in turn delays elimination of many
long-term follow-up of the HERA trial the incidence of severe CHF, LVD, drugs. Delayed renal excretion may enhance the toxicity of drugs whose
and discontinuation of trastuzumab as a result of cardiac disorders parent compounds are excreted by the kidneys (ie, carboplatin, oxaliplatin,
remained low (0.8%, 9.8%, and 5.1%, respectively) in patients who methotrexate, bleomycin) and drugs that are converted to active (ie,
received trastuzumab.233 A combined review of cardiac data from the idarubicin, daunorubicin) or toxic metabolites (ie, high-dose cytarabine).5
NSABP-31 and NCCTG N9831 clinical trials also showed that the Dose adjustment to the measured GFR should be considered for these
incidence of symptomatic heart failure events was 2.0% in patients treated drugs to decrease systemic toxicity.
with adjuvant trastuzumab and the majority of these patients recovered
with appropriate treatment.234 In a large, population-based, retrospective Renal insufficiency is common in older patients with cancer, particularly in
study of older patients with stage I-III breast cancer (≥66 years; 9,535 patients receiving nephrotoxic drugs, patients with genitourinary cancers,
patients; 2,203 patients received trastuzumab), the use of trastuzumab or patients with multiple myeloma. In patients with preexisting renal
resulted in a CHF rate of 30%, which is substantially higher than that problems who are at a greater risk of renal impairment, the use of
reported in clinical trials. Among patients treated with trastuzumab, older nephrotoxic drugs should be limited or avoided. Serum creatinine is not a
age (≥80 years), hypertension, coronary artery disease, cardiac good indicator of renal function in older adults. Calculation of creatinine
comorbidities, and weekly administration of trastuzumab were associated clearance is recommended to assess renal function and adjust dose to
with increased risk of CHF.235 reduce systemic toxicity.
Emerging data from clinical studies suggest that trastuzumab, when used Neurotoxicity
in combination with non-anthracycline–based chemotherapy, has similar Neurotoxicity is also a dose-limiting toxicity associated with
chemotherapy.239 Vinca alkaloids, platinum-based therapies, and taxanes
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induce peripheral neurotoxicity. Methotrexate, cytarabine, and ifosfamide (cyclophosphamide, doxorubicin, vincristine, and prednisone)
are associated with central neurotoxic side effect. Purine analogs (eg, chemotherapy, the incidences of fever and neutropenia were significantly
fludarabine, cladribine, pentostatin) are associated with life-threatening higher for patients aged ≥70 years (42% vs. 8% for patients aged 61–69
neurotoxicity at significantly higher doses than the recommended clinical years; P < .0001).251 In patients ≥60 years receiving induction or
dose.240 High-dose cytarabine can cause an acute cerebellar syndrome. consolidation chemotherapy for AML, the prophylactic use of
Patient’s age (greater than 60 years), drug dose and schedule, and renal hematopoietic growth factors results in faster recovery of neutrophil and
and hepatic dysfunction are the most important risk factors for shorter hospitalization, but it does not impact OS.252,253
cytarabine-induced cerebellar toxicity.241,242
Meta-analysis of controlled clinical trials on the prophylactic use of
Management of neurotoxicity mainly consists of dose reductions or lower recombinant granulocyte colony-stimulating factors (G-CSF) has
dose intensities. Older patients are particularly susceptible to the toxicity of confirmed their effectiveness in reducing the risk of febrile neutropenia.254
cytarabine-based regimens due to decreased renal excretion of the toxic Some concerns have been expressed that the combination of growth
metabolite ara-uridine, and increased vulnerability of the cerebellum. factors and topoisomerase II inhibitors may be associated with increased
Particular attention should be paid to the use of cytarabine in high doses, risk of acute leukemia; however, these data are controversial.255,256
especially in patients with renal insufficiency. Dose reductions are Despite these caveats, the use of growth factors appears to be the best
necessary in patients with reduced GFR. The guidelines recommend established strategy to improve treatment in this group of patients.257 The
monitoring for cerebellum function, hearing loss, and peripheral EORTC has issued similar recommendations for the prophylactic use of
neuropathy. The risk of falls due to peripheral neuropathy is of particular G-CSF in older patients with cancer.258 The NCCN Guidelines for Myeloid
concern in older patients.97 Growth Factors address the use of G-CSFs in patients with solid tumors
and non-myeloid malignancies.
Myelosuppression
Available data from various studies have shown that the risk of Anemia
myelosuppression increases substantially by age 65 years.243-247 The risk Anemia has been shown to be a risk factor for chemotherapy-related
of myelosuppression is decreased by 50% when using growth factors.248- toxicity and is one of the factors responsible for the reduction in volume of
250
Dose reductions may compromise the effectiveness of treatment. The distribution, which may result in increased peak concentration and
use of growth factors in these circumstances does not appear to be increased toxicity of drugs.259 Anemia is also associated with
associated with increased cost and may even be cost saving if it prevents cardiovascular disease, CHF, coronary death, and dementia.260-263 Anemia
lengthy hospitalizations from neutropenic infections in older persons. is also significantly associated with multidimensional loss of function
(mobility limitations, impaired cognition, and dysphagia) in individuals ≥70
Neutropenia years and higher rates of functional disability in individuals ≥65 years with
Neutropenia is the major dose-limiting toxicity associated with cancer.264,265
chemotherapy, especially in older patients. Among older patients with
aggressive non-Hodgkin’s lymphoma treated with CHOP
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In patients with severe anemia, blood transfusions are necessary to chemotherapy-induced anemia and neutropenia can be managed with
prevent serious clinical consequences. There is increasing controversy hematopoietic growth factors, safe and effective treatment of CIT is still a
regarding the use of erythropoiesis-stimulating agents (ESAs). ESAs have significant problem. Recombinant interleukin-11 is the only currently
been demonstrated to decrease the need for transfusion in patients approved treatment of CIT in patients with nonmyeloid malignancies.270
receiving chemotherapy.266 It also appears to be beneficial to complement However, it is toxic and of minimal clinical benefit. A phase II clinical trial
the administration of erythropoietin with oral or parenteral iron, although demonstrated significant efficacy of thrombopoietin-like agents such as
this is not specific for older patients. However, randomized studies have romiplostim and eltrombopag for the treatment of CIT; however, the
reported decreased survival and poorer tumor control among patients with settings for which these agents will provide clinical benefit are important
cancer receiving erythropoietic drugs for correction of anemia and target and not yet fully defined.271,272
hemoglobin levels 12 g/dL.267 The use of ESAs in patients with cancer is
Nausea and Vomiting
also associated with increased risks of venous thromboembolism and
Chemotherapy-induced nausea and vomiting (CINV) is a debilitating side
mortality.268,269 The risks of shortened survival and disease progression
effect that can significantly affect a patient’s QOL and compliance with
have not been excluded when ESAs are dosed to a target of hemoglobin
treatment. Serotonin (5-HT3)–receptor antagonists, neurokinin-1-receptor
levels of less than 12 g/dL.
antagonists, and corticosteroids are the most effective antiemetic drugs
In July 2008, based on the results of these trials, the FDA strengthened its used for the management of CINV.273 Older patients may have an
warnings to alert physicians of increased risk of tumor progression and increased risk of toxicity from antiemetic drugs due to age-related
shortened survival in patients with advanced breast, cervical and head and physiologic changes in drug absorption, distribution and excretion, drug
neck cancers, lymphoid neoplasms, and NSCLC. Physicians were advised interactions, and polypharmacy used to treat comorbidities.274,275
to use the lowest dose necessary to avoid transfusion. In addition, the use Therefore, the selection of appropriate antiemetic therapy in older patients
of ESAs is restricted to the treatment of anemia specifically related to should be based on individual patient characteristics, prior history of CINV,
myelosuppressive chemotherapy without curative intent. ESAs should be the emetogenic potential of the specific chemotherapeutic agent, and most
discontinued once the course of chemotherapy has been completed and importantly the side effect profile of the antiemetic agent. For example,
the anemia has resolved. The panel recommends that anemia in older QTc prolongation has been reported as a class effect of 5-HT3–receptor
patients with cancer should be managed as outlined in the NCCN antagonists, especially dolasetron, tropisetron, and palonosetron, and
Guidelines for Cancer- and Chemotherapy-Induced Anemia. these should be used with caution in older patients with cardiovascular
complications.274 CINV should be managed as described in the NCCN
Thrombocytopenia Guidelines for Antiemesis and the NCCN Guidelines for Palliative Care
Chemotherapy-induced thrombocytopenia (CIT) is a common available at www.NCCN.org.
hematologic toxicity associated with cytotoxic and myeloablative
chemotherapy. Dose reductions and/or interruptions of chemotherapy Diarrhea
regimens are necessary in patients with severe thrombocytopenia. While Diarrhea is a well-recognized side effect associated with a number of
chemotherapeutic agents, particularly fluorouracil and irinotecan. Loss of
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fluids and electrolytes associated with persistent and severe diarrhea can Oncology have detailed recommendations for the management of
lead to dehydration, renal insufficiency, and electrolyte imbalance.276 mucositis secondary to cancer therapy.282 Once mucositis has occurred,
Furthermore, chemotherapy-induced diarrhea can lead to dose reductions, patients should be kept well hydrated with intravenous fluids. Early
delay in therapy, or discontinuation of chemotherapy, which ultimately hospitalization may be necessary for patients with mucositis who also
affect clinical outcomes.277 Based on the results from various clinical trials, develop dysphagia or diarrhea.
the ASCO guidelines for the comprehensive evaluation and management
of cancer treatment-induced diarrhea recommend loperamide as the Insomnia
standard therapy for mild-to-moderate diarrhea.276 Octreotide Insomnia is characterized by difficulty falling or staying asleep, waking up
(subcutaneous or intravenous if the patient is severely dehydrated) may too early, or experiencing poor-quality nonrestorative sleep associated
be beneficial for patients with severe diarrhea or diarrhea that is refractory with daytime impairment (fatigue, poor concentration, daytime sleepiness,
to loperamide therapy. or concerns about sleep).283 The incidence of insomnia in patients with
cancer has been reported to be three times higher than that reported in
The NCCN Guidelines recommend early aggressive rehydration and the general population and ranges from 25% to 69%, depending on the
management with octreotide (if oral treatments are ineffective) for older type of cancer.284,285 In a longitudinal study that assessed the prevalence
patients with chemotherapy-induced diarrhea. and natural course of insomnia in patients with cancer during an 18-month
period, Savard et al reported higher rates of insomnia in patients with
Mucositis breast (42%–69%) and gynecologic (33%–68%) cancer and lower rates
Oral and gastrointestinal mucositis are significant complications of among men with prostate cancer (25%–39%).285
radiotherapy and chemotherapy. The risk of mucositis increases with age.
In a phase III randomized study of 212 patients with hematologic cancers Insomnia is more prevalent in older adults, and older patients with cancer
undergoing high-dose chemotherapy and total body irradiation followed by should be screened for sleep disturbances prior to the initiation of
autologous hematopoietic stem-cell transplant, palifermin (human treatment and at regular intervals during the course of treatment. The AGS
keratinocyte growth factor) was associated with a significant reduction of has provided recommendations for the diagnosis, evaluation, and
oral mucositis compared to placebo (20% vs. 62%).278 Palifermin is management of insomnia in older adults.283 The recently published
approved for the treatment of oral mucositis in patients with hematologic Pan-Canadian practice guidelines also provide recommendations for the
malignancies receiving myeloablative therapy requiring hematopoietic prevention, screening, assessment, and treatment of sleep disturbances in
stem cell support. A few studies have reported that palifermin is also well older patients with cancer.286
tolerated and effective in the prevention of oral mucositis in patients with
metastatic colorectal cancer treated with fluorouracil-based chemotherapy Cognitive behavioral therapy (CBT) and lifestyle modifications are the
and in patients with head and neck cancer treated with postoperative or preferred first-line treatment options for the management of insomnia in
definitive chemoradiation therapy.279-281 The 2014 Multinational older patients.283,286 The effectiveness of CBT with multicomponent
Association of Supportive Care in Cancer and International Society of Oral interventions (stimulus control, sleep restriction, cognitive therapy, sleep
hygiene, and fatigue management) for the management of insomnia in
MS-21

patients with cancer has been demonstrated in randomized clinical There are limited but growing data available on the safety and efficacy of
trials.287-290 Adherence to CBT has been shown to yield greater sleep targeted therapies in older patients with cancer. Prospective clinical trials
improvements among women following primary treatment for breast that include a sufficiently large number of older patients are needed to
cancer.291 accurately determine the efficacy and tolerability of targeted therapies in
this cohort of patients. In patients who are not able to tolerate cytotoxic
Pharmacologic therapy may be necessary for some patients until CBT chemotherapy, the risk-benefit ratio should be considered prior to initiation
takes effect.283,286 Benzodiazepines, non-benzodiazepines, and of targeted therapy and the use of targeted therapies should be
melatonin-receptor agonists are the FDA-approved classes of drugs for individualized.
the treatment of insomnia.292,293 However, due to some of the severe
adverse effects associated with these benzodiazepines and See Disease-Specific Issues for the efficacy and tolerability of specific
non-benzodiazepines (eg, impaired postural stability, fractures, cognitive targeted therapies in older patients with cancer.
impairment),292 these drugs are not recommended as first-line therapy for
the treatment of insomnia in older adults.283,286 If pharmacologic therapy is Adherence to Therapy
to be utilized, it is recommended only for short-term use, with the lowest Adherence to the prescribed regimen, especially oral therapy, is essential
dose that is safe and effective to address the particular type of sleep to derive maximal clinical benefit. While older age per se is not a
disturbance in an individual patient. consistent risk factor for non-adherence, older adults are at an increased
risk for non-adherence for a variety of reasons including cognitive
Targeted Therapy impairment, increased number of comorbid conditions, polypharmacy,
The emergence of targeted therapies (monoclonal antibodies and small higher risk of side effects adversely affecting comorbidities, increased
molecules targeted against specific molecular pathways required for the likelihood of drug interactions, limited insurance coverage, social isolation,
development of a particular malignancy) has significantly improved and inadequate social support.301
outcomes in a variety of malignancies. The use of targeted therapies in
older patients appears to be promising in view of their better efficacy and Discontinuation and nonadherence to adjuvant hormonal therapy is well
toxicity than conventional chemotherapeutic agents.294,295 However, these documented in women with early-stage breast cancer.302 In studies that
drugs are also associated with some unique and severe toxicities.296 For have evaluated adherence to adjuvant hormonal therapy among older
example, cardiovascular complications such as LVD are associated with women (≥55 years) diagnosed with early-stage breast cancer, the reported
HER2 inhibitors (trastuzumab) and hypertension and arterial rates of nonadherence or discontinuation range from 15% to 49%.303-306 In
thromboembolic events (ATEs) are associated with vascular endothelial a cohort of 961 women (≥65 years) diagnosed with early-stage estrogen
growth factor receptor (VEGFR) inhibitors (bevacizumab),297-299 whereas receptor-positive or indeterminate breast cancer, Owusu et al reported a
dermatologic toxicities (acneiform rash and hand-foot skin reaction) are discontinuation rate of 49% before the completion of 5 years. Women
the major adverse effects of epidermal growth factor receptor (EGFR) aged ≥75 years, those with an increase in the CCI, those with an increase
inhibitors (ie, erlotinib, sunitinib, sorafenib, cetuximab).300 in the number of cardiopulmonary comorbidities at 3 years from diagnosis,
MS-22

those with an indeterminate estrogen receptor status, and those who had non-adherence was associated with poorer response to imatinib in
received breast-conserving surgery without RT were at higher risk of patients with chronic myeloid leukemia (CML); non-adherence rates were
discontinuation.306 Women with estrogen receptor-negative and significantly higher for patients with suboptimal response compared to
node-positive disease, those who report severe initial side effects those with optimal response to imatinib (23% and 7%, respectively).311
(depression, nausea, visual complaints, and vaginal bleeding), and women Marin and colleagues also identified adherence as the only independent
with neutral or negative beliefs about the value of hormonal therapy are predictor for achieving complete molecular response on standard-dose
also more likely to discontinue therapy.303-305 imatinib in patients with CML.312 Poor adherence to imatinib therapy has
also been identified as the most important factor contributing to
Adherence to adjuvant chemotherapy has also been evaluated in older cytogenetic relapse and imatinib failure.313
patients with early-stage breast cancer.307-309 In the randomized study
(CALGB 49907) that evaluated adjuvant chemotherapy with oral Treatment-related adverse events, complexity of regimens, poor
capecitabine vs. standard chemotherapy in 161 women (≥65 years) with understanding of the need for treatment, and the consequences of
early-stage breast cancer, 25% of the patients took fewer than 80% of the non-adherence are some of the common barriers to adherence. In a
planned doses.308 Non-adherence was more likely among women with multicenter, prospective, open-label, randomized trial of exemestane vs.
node-negative disease and mastectomy. Adherence was not related to letrozole (n = 503), 32.4% discontinued initial therapy within 2 years due
age, tumor stage, or hormone receptor status. However, in other studies, to adverse effects and the median time to treatment discontinuation was
poor adherence to adjuvant chemotherapy was more frequent in older 6 months.314 In a survey of women taking oral hormonal therapy for breast
patients (≥65–75 years).307,309 cancer, prior knowledge about the impact of adherence on clinical
outcomes and better management of treatment-related side effects were
Although nonadherence to adjuvant chemotherapy was not associated indicated as most important factors for increasing compliance.315
with shorter RFS in the CALGB 49907 study (may be due to limited
sample size), other studies have reported inferior clinical outcomes in Few studies have determined the actual adherence to oral therapies in
patients with non-adherence to cancer therapy.310-313 Among 8,769 women patients with cancer, but clinical trials in a variety of cancer types attribute
treated with adjuvant hormone therapy for stage I-III breast cancer, reduced adherence in older patients to toxicity. A task force report from
Hershman et al identified early discontinuation and non-adherence to SIOG that reviewed the impact of age-related factors on adherence to oral
adjuvant hormonal therapy as independent predictors of increased therapy in older adults recommends careful patient selection (using CGA,
mortality.310 At a median follow-up of 4 years, the estimated 10-year mentioned above, or other geriatric screening tools) and close monitoring
survival rates were 80.7% and 73.6%, respectively, for women who of adherence to oral therapy.316 The task force report summarizes all
continued hormonal therapy and those who discontinued therapy (P < potential determinants of adherence in older adults as attributed to factors
.001). For those who continued, the 10-year survival rate was higher for that may be patient-related, age-specific, socioeconomic, disease-related,
women with adherence to therapy than for those with non-adherence therapy (toxicity)-related, or health care team-associated. Since non-
(81.7% and 77.8%, respectively; P < .001). In the ADAGIO study, adherence is a complex issue associated with increased mortality and
MS-23

health care costs, the task force has also compiled a corresponding set of Summary
health care-led and patient-driven intervention strategies to promote Cancer is the leading cause of death in women and men aged 60 to 79
adherence and overcome the barriers to adherence. years. The biologic characteristics of certain cancers are different in older
patients compared to their younger counterparts, and older patients also
In older patients with cancer, assessment of risk factors for non-adherence
have decreased tolerance to chemotherapy. Nevertheless, advanced age
is recommended when considering a treatment regimen that will include
alone should not be the only criteria to preclude effective cancer treatment
an oral agent. Close monitoring of patient adherence; reduction of regimen
that could improve QOL or lead to a survival benefit in older patients.
complexity (if possible); interventions designed to educate older patients
Treatment should be individualized based on the nature of the disease,
about the risks and benefits of oral therapy and the importance of
the physiologic status of the patient, and the patient’s preferences.
adherence to therapy; adequate and appropriate management of side
effects; and scheduling of follow-up visits at regular intervals to review side Chronologic age is not reliable in estimating life expectancy, functional
effects are some strategies that may be helpful to minimize reserve, or the risk of treatment complications. The best guide as to
non-adherence to therapy. whether cancer treatment is appropriate may be provided by careful
assessment of the older patient. CGA can be utilized to assess life
Disease-Specific Issues
expectancy and risk of morbidity from cancer in older patients. CGA in turn
Since the biologic characteristics of certain cancers are different in older can enable physicians to develop a coordinated plan for cancer treatment
patients compared to their younger counterparts, and partly because of as well as guide interventions tailored to the patient’s problems.
the decreased tolerance of treatment by older patients, treatment should
be individualized based on the nature of the disease and the performance
status of the patient. Disease-specific issues related to age in some
cancer types are currently being incorporated into the relevant NCCN
Guidelines for Treatment of Cancer by Site, available at www.NCCN.org.
MS-24

Table 1. Examples of Cancer Types Included in Studies to Validate Geriatric Screening Tools as Prescreening
Instruments for Cancer Therapy
Geriatric Screening Geriatric Assessment Cancer Types Included in Study Populations
Tool Domains Evaluated
• Functional status
Breast cancer, prostate cancer, colon cancer,169,170 lymphoma, leukemia, head and
Abbreviated CGA • Psychological status
neck, carcinoid, cervical cancer, hepatic cancer, cancer of unknown origin, pancreatic
(aCGA) (depression) cancer, gastric cancer, and esophageal cancer.169
• Cognition
• Geriatric syndrome Breast cancer171
Barber questionnaire
(frailty)
Fried Frailty Criteria • Geriatric syndrome Breast, colorectal, gastric, and other cancers.317
(frailty)
• Geriatric syndrome Lung,173,175,183,318,319 breast, colorectal,175,183,319,320 prostate,173,175,183,319,320
(frailty) lymphoma,183,319 ovarian,173,175,319 hematologic malignancies,175,319 head and
neck,174,183,319,321,322 colon, stomach, pancreatic, bladder cancers; non-Hodgkin's
• Depression
Geriatric 8 (G8) lymphoma (NHL), cancer of unknown primary origin,173 urinary tract, upper GI/liver, and
• Psychological state other cancers.320
• Nutrition
• Comorbidities However, G8 performance varied by tumor site and metastatic status.320
• Polypharmacy
Groningen Frailty • Geriatric syndrome Gastric cancer,323 NHL,324 malignancies of GI tract or hematologic tumors,325 or
Index (GFI) (frailty) colorectal cancer.326
Triage Risk Screening

Tool (TRST) • Functional status Breast, colorectal, lung, ovarian, prostate, or hematologic malignancies.319
• Functional status Prostate,170,177 breast,170,171,178,179,317,327,328 colorectal, gastric,170,178,179,317 head and neck,

Vulnerable Elders
Survey (VES-13) • Geriatric syndrome lung,178,179 and advanced NSCLC;329 malignant lymphoma or multiple myeloma;330 and
(frailty) other cancers.317
MS-25

Table 2. Examples of Cancer Types Included in Studies to Validate Geriatric Screening Tools as Prescreening
Instruments for Surgery
Geriatric Screening Geriatric Assessment Cancer Types Included in Study Populations
Tool Domains Evaluated
Abbreviated CGA • Geriatric syndrome

Any patient with cancer who qualified for elective abdominal surgery.331
(aCGA) (frailty)
Fried Frailty Criteria • Geriatric syndrome Any patient with cancer who qualified for elective abdominal surgery.331
(frailty)
• Geriatric syndrome
(frailty)
Any patient with cancer who qualified for elective abdominal surgery331 or older
Geriatric 8 (G8) • Functional status
patients with hepatocellular carcinoma who qualified for elective liver resection.332
• Nutrition
• Comorbidities
MS-26

Association experience [see comment]. JAMA 1992;268:57-62. Available

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NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®)

Older Adult Oncology

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

Cary Gross, MD Þ Cynthia Owusu, MD, MS ‡ Tanya Wildes, MD † ‡ ₪

₪ Geriatric medicine £ Supportive care including

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

NCCN Older Adult Oncology Panel Members

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

DEFINITION AND PURPOSE

Definition of the Older Adult Oncology Population

Purpose of the NCCN Guidelines for Older Adult Oncology

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

Is the patient a candidate for Symptom management/supportive care

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

Modifiable abnormalities identified Non-modifiable abnormalities identified

Are there alternate

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

CONSIDERATIONS FOR OLDER ADULTS UNDERGOING CANCER TREATMENTSj

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

CONSIDERATIONS FOR OLDER ADULTS UNDERGOING CANCER TREATMENTSj

Targeted therapy (See NCCN Guidelines for Treatment of Cancer by Site)

Cellular therapy (See NCCN Guidelines for Treatment of Cancer by Site)

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

DATA FROM UNITED STATES LIFE TABLES

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

OPTIMIZING COMMUNICATION WITH OLDER ADULTSa

Note: All recommendations are category 2A unless otherwise indicated.

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

COMPREHENSIVE GERIATRIC ASSESSMENT

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

COMPREHENSIVE GERIATRIC ASSESSMENT

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

COMPREHENSIVE GERIATRIC ASSESSMENT

• Methods to assess comorbidities:

Cognitive Function (See Assessment of Cognitive Function OAO-F)

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

COMPREHENSIVE GERIATRIC ASSESSMENT

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

COMPREHENSIVE GERIATRIC ASSESSMENT

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

Impairment in any domain may consider the following:

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

COMPREHENSIVE GERIATRIC ASSESSMENT

NCCN Guidelines Version 1.2020 NCCN Guidelines Index

COMPREHENSIVE GERIATRIC ASSESSMENT

cancer patients in an outpatient setting. Nutr Cancer. 2013;65(2):234-239.

₪ Geriatric medicine £ Supportive care including