ASCO Statement: Improving the Evidence Base for Treating Older Adults With Cancer
The Silver Tsunami is real and affecting all branches of medicine. People are living longer and staying healthier longer. But cancer incidence is proportional to age so the numbers of cases will go up but the rate will go down. Nonetheless, we know that we know very little, and certainly not enough of whatever are the unique aspects of cancer in the older population and we have relevant and sometime non relevant or thoughtful small enrollment of older patients in clinical trials- not the smartest move when they will be the majority or cases. To the credit of these authors, and soon I suspect the NIH and the American Society Of Clinical Oncology, the majority of the recommendations below will form the framework of growing with and engaging the older population and with probably much better outcomes than at present . This is a great comfort to see scientists stand up and say we have a hole in the whole of us in terms of of knowledge and we need to fix that Dr Kevin Ryan
Older persons are the fastest growing segment of the U.S. population and account for the majority of cancer diagnoses and deaths and the majority of cancer survivors. However, since this population is underrepresented in clinical trials, the evidence base for treating older patients is poor. As reported in the Journal of Clinical Oncology by Hurria et al, ASCO has issued a statement designed to encourage improvement of the evidence base for treating older adults with cancer. The statement includes five basic recommendations and associated action items, as reproduced below.
Recommendation 1: Use clinical trials to improve the evidence base for treating older adults with cancer.
- Regulatory agencies, funders of cancer clinical research, and researchers should carefully consider whether there is evidence supporting limitations to eligibility criteria based on age, performance status, or comorbid conditions. Researchers should provide a rationale, informed by input from experts in aging and geriatric oncology, when trials include eligibility criteria that are restricted based on these factors.
- The National Cancer Institute (NCI), U.S. Food and Drug Administration (FDA), and other organizations that are developing common sets of data elements for researchers to collect in clinical trials should include measures from the geriatric assessment domains.
- Funders of cancer clinical trials in which tumor specimens are studied should require researchers to report the age distribution of samples studied and whether this is reflective of the age distribution of the population enrolled onto the trial and the population with the disease overall.
- The NCI should collaborate with the National Institute on Aging, National Institutes of Health (NIH), and other funders of cancer clinical research to encourage and incentivize research involving older adults.
Recommendation 2: Leverage research designs and infrastructure to improve the evidence base for treating older adults with cancer.
- Researchers and funders of cancer clinical research should use the full range of research designs, including innovative trial designs, to fill knowledge gaps in the treatment of older adults with cancer.
- Funders of comparative-effectiveness research should require researchers evaluating the role of a standard or novel cancer treatment to include a plan to study a population that mirrors the age distribution and health risk profile of patients with the disease.
- Developers of research and clinical databases should ensure that their systems collect geriatric assessment data and have the functionality to support studies designed to improve the evidence base supporting the treatment of older adults with cancer.
- The Centers for Medicare and Medicaid Services (CMS) should use its coverage with evidence development authority to cover the off-label use of marketed drugs in select cancer clinical trials. The CMS should work with the NIH, patients, and researchers to prioritize trials for this additional coverage.
Recommendation 3: Increase the authority of the FDA to incentivize and require research involving older adults with cancer.
- Congress should provide the FDA authority to require a drug or biologic marketing application to contain a plan to gather data and develop recommendations on safety, efficacy, and dosing in older adults.
- Congress should grant the FDA authority to create incentives for companies that conduct clinical trials of new cancer treatments in older adults.
- The FDA should include experts in aging and geriatric oncology on its advisory boards to provide scientific advice on the development and assessment of novel agents and emerging federal policies.
Recommendation 4: Increase clinician recruitment of older adults with cancer to clinical trials.
- Professional societies should develop and promote educational materials for clinicians and researchers to encourage greater recruitment of older adults to clinical trials.
- The American Medical Association should establish new common procedural terminology codes to reimburse clinicians who offer older patients the opportunity to participate in clinical trials, enroll them onto these trials, and conduct management and follow-up of these patients for the additional time and effort involved. These codes should be reimbursed by Medicare, Medicaid, and third-party payers.
Recommendation 5: Use journal policies to incentivize researchers to consistently report the age distribution and health risk profiles of research participants.
- Require authors to submit and report the detailed age distribution (by decade) of the population included in the study, not just the age ranges of population, and data analyses that could potentially yield valuable age-related information, including age-based analyses of response, benefit, and toxicity.
- Include geriatric oncology experts in the pool of editorial board members who serve as peer reviewers of manuscripts.
- Instruct peer reviewers to consider whether the authors have adequately reported the age distribution of the population included in the study, the generalizability of the results to the population with the disease, and data analyses that could potentially yield valuable age-related information.