Five key practice performance gaps and associated needs have been identified from this research; each will be detailed below. As observed in the discussion to follow, many of the gaps overlap, and reflect the importance of staying up-to-date on the most recent clinical data and resources available while treating geriatric patients with cancer. Additionally, the integral role of communication is a theme throughout many of these gaps.

4.1   Key Practice Performance Gaps

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1. Selecting the optimal treatment approach for geriatric patients with cancer and comorbidities

    • Selecting appropriate therapy options
    • Assessing the risks/benefits of treatment options in the geriatric patient population
    • Differentiating therapy options based on the impact of comorbidities
    • Identifying factors that are most predictive of toxicity with treatment
    • Managing side effects appropriately, which may include adjusting or revising the treatment plan

2. Using appropriate tools to assess a patient’s functional, cognitive, and support status

    • Evaluating the patient’s status to ascertain the optimal treatment approach and to identify any additional support they may need
    • Documentation that allows the entire multidisciplinary team to assess changes in these metrics

3. Recognizing and overcoming the barriers that lead to poor compliance in the geriatric patient population

    • Monitor and manage side effects of therapy
    • Engage in effective patient-physician and/or caregiver-physician communication and education
    • Utilize case managers/patient navigators as resources for addressing physical and social barriers that lead to poor compliance

4. Engaging in effective communication with patients’ primary care provider

    • Communicating disease status, anticipated side effects, and recommended management of patients to support continuum of care and possibly improve clinical benefit

5. Articulating in what ways the goals of care for geriatric patients are the same and how they may differ from that of younger patients

    • Recognize the important role quality of life plays in treatment decisions in the geriatric patient population

Each of these gaps is explored in detail below.

4.2   Practice Performance Gap #1: Selecting the optimal treatment approach for geriatric patients with cancer and comorbidities

An unmet need exists in medical oncologists’ ability to select appropriate therapy options for geriatric patients with cancer. They rate their confidence in treating geriatric patients lower than their confidence in treating younger patients with cancer. The majority expressed a desire for more specific guidelines for geriatric cancer patients, rated the utility of various educational platforms for learning about new therapies, and described the types of tools and resources they use in their current practice.

Medical oncologists indicated a high desire for greater competence related to selecting optimal treatment. However, the perceived need, defined as the difference between their desired and present ability, demonstrates that clinicians recognize that their ability to select optimal treatment needs improvement. These findings, along with their reported readiness to change the way they practice in the near future, indicates that physicians are ready and willing to learn in order to change their clinical practice. They also rated the influence of various forces for change—professional, personal, and social [1].

National Comprehensive Cancer Network (NCCN) guidelines are often the most trusted source for treatment recommendations. However, 55% of respondents indicated the desire for more information in the NCCN guidelines, compared with 40% who felt the guidelines provided just the right amount of information. The expert advisory panel agreed that in the geriatric oncology field, far too many physicians rely on “gut knowledge” or “common sense” to guide their treatment decisions. As a medical oncologist stated:

“The important challenge in the geriatric oncology area is convincing [physicians]…that there is actual knowledge, that it’s not just common sense…there are actual ways to assess a patient that are objectively shown to improve your practice or your outcomes.”

The tendency to avoid use of guidelines is likely rooted in the historical practice of underrepresentation of geriatric patients in clinical trials of cytotoxic therapies. A 2004 study found that while patients ≥65 or ≥70 years of age represented 60% and 46%, respectively, of all patients newly diagnosed with cancer, they represented only 36% and 20%, respectively, of patients enrolled in clinical trials [2]. This underrepresentation led to lack of knowledge of the efficacy and toxicity of these agents in the geriatric population [3]. Despite the fact that the past few years have seen a greater focus on the efficacy and safety of cytotoxic therapies in the elderly, many physicians interviewed believed that the guidelines, which include this new information, have little or no utility in their clinical practice. Others indicated they were unaware that NCCN guidelines specific to geriatric patients had been developed. Education on new clinical data focused on geriatric cancer patients, and how these data have been incorporated into recently developed guidelines, is critically needed.

The expert advisory panel did emphasize the importance of not blindly following the guidelines, but tailoring them to each patient. A geriatrician stated:

“The guidelines are a starting point. Individualized care is the end point.”

In other words, the path to truly individualized treatment plans require a firm foundation on current best practices and guidelines.