The Practice Assessment portion of the survey indicates variability in medical oncologists’ ability to choose appropriate therapy options. Fifty-four percent of respondents did not choose the most appropriate treatment regimen in the clinical vignette presented in question 1. This was also highlighted in question 2, where 13% of respondents chose an adjuvant therapy (ie, FOLFOX) associated with significant toxicity, despite the fact that oxaliplatin does not provide survival benefit to patients aged >70 years with colon cancer . This demonstrates a gap in accurately assessing the benefits and risks of certain treatment options in the geriatric patient population. In particular, physicians struggle with differentiating therapy options based on impact on comorbidities. For example, in question 2 most respondents chose capecitabine, despite the fact that it may not be an ideal therapy choice given the patient has moderate renal impairment . The gap in appropriate treatment choice with regards to comorbidities is also highlighted in question 4. Only 45% of respondents chose what is considered the best treatment choice, with 28% choosing ibrutinib for this patient with cardiovascular complications, despite its association with potential bleeding and cardiac risks .
Significant gaps were identified in the ability of physicians to predict and manage treatment toxicity in the geriatric patient population. In question 6, 51% of respondents were unable to identify that multiple recent falls is the factor most predictive of chemotherapy toxicity. In question 9, 50% of respondents were unable to accurately identify the correct response to a question on a toxicity that is particularly prevalent in the geriatric cancer patient population. Finally, in question 8, only 52% of respondents were able to correctly identify which supportive medication has the least risk of significant negative effects in older patients. Further, respondents reported that they generally do not use formal tools to identify patients at risk for chemotherapy intolerance.
Physicians do seem cognizant of the need to better identify and manage side effects. Present ability was dramatically lower than the desired ability for the competency “Manage side effects.” One way many physicians attempt to address toxicity and side effects in the geriatric patient population is by empirically reducing the dose of cytotoxic agents. However, many studies have determined a wide variability in the need for dose reductions in this patient population [7-10]. Once again, physicians seem cognizant of this gap, with “Adjust treatment options for geriatric patients based on health status” and “Revise treatment plan when necessary” both showing high perceived needs. There is additionally disagreement between medical oncologists and geriatric specialists with this approach, as a geriatrician stated:
“In geriatrics, our saying is, ‘Start low and go slow in everything.’ And we’re trying to get the oncologists to think that way, instead of, ‘Start high. If they can’t take it, okay, we’ll cut it down a little bit.’”
A distinct possible means of addressing cytotoxicity in geriatric cancer treatment includes the use of increasingly available targeted treatments aimed at particular cellular pathways that are typically associated with fewer debilitating side effects. Clinical trials of these agents have enrolled a higher proportion of older patients compared with historical cytotoxic therapy trials and thus are more likely to have study populations that are more representational of the overall patient population; however, only a few agents have been specifically evaluated in geriatric patient populations. Similar to cytotoxic therapies, these agents demonstrate wide variations in their relationships between age and drug-related toxicity . However, the busy schedules of medical oncologists leave little time for learning about these new treatments, as highlighted by the barrier “Lack of time to learn about new therapies” receiving high ratings as a barrier to best practice.