By Fernando Diaz, MD, Anahid Hamparsumian, MD, Melisa L. Wong, MD, MAS, and Grant R. Williams, MD, MPH
By 2030, it is projected that 70% of all cancer diagnoses will occur in older adults.1 Despite the increased incidence of cancer in this age group, older adults are traditionally under-represented in clinical trials and outcome measures such as functional independence are rarely reported.2-4 The paucity of research and real-world data in this area adds to the complexity of decision-making for oncologists eager to avoid undertreating or overtreating their patients.
What is geriatric oncology and why is it important for trainees to know about it?
Geriatric oncology is a subspecialty of oncology dedicated to the diagnosis and treatment of older adults with cancer. In 2013, the Institute of Medicine published a report, Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis, highlighting the importance of increasing attention for older adults with cancer. The committee therein asserts that “the current care delivery system is poorly prepared to address the care needs of this population, which are complex due to altered physiology, functional and cognitive impairment, multiple coexisting diseases, increased side effects from treatment, and greater need for social support.”5
In an effort to develop a workforce prepared to meet this challenge, the Accreditation Council for Graduate Medical Education (ACGME) program requirements for hematology-oncology include competence in the care and treatment of the geriatric patient with malignancy and hematologic disorders.6 However, a study by Maggiore et al. found that while hematology-oncology fellows recognize the importance of this skillset, few are provided adequate exposure to geriatric oncology curricula.7
What geriatric skills should a trainee or practicing oncologist have?
As an oncology trainee or practicing oncologist, it is imperative that we understand how and when to implement a geriatric assessment (GA) into our daily practice when providing care for older adults. GA is recommended by ASCO and the International Society of Geriatric Oncology (SIOG) and is considered the gold standard for informing cancer management by identifying vulnerable older adults at high risk of treatment-related side effects or functional decline that may be amenable to intervention.8,9Validated assessments such as the Geriatric-8 (G8) and the Vulnerable Elders Survey-13 (VES-13) can provide a high-level screening assessment to determine which patients need a full GA.10 Chemotherapy toxicity can also be evaluated using tools developed by the Cancer and Aging Research Group (CARG) and other groups. The 2022 edition of ASCO-SEP (Self-Evaluation Program) is an up-to-date resource that includes a succinct and informative chapter discussing the principles of geriatric oncology, including use of a GA.
Where can a trainee or practicing oncologist learn more about geriatric oncology?
Launched in 2022 as one of ASCO’s three initial Communities of Practice, the ASCO Geriatric Oncology Community of Practice is a forum for clinicians, researchers, and trainees of all stages with an interest in geriatric oncology to learn about current evidence-based recommendations and network with others in the field.11 Led by coauthors Dr. Wong and Dr. Williams, the Geriatric Oncology Community of Practice seeks to provide ASCO members with clinical education, mentorship, and opportunities to discuss challenging geriatric oncology cases from diverse practice settings.
Additional geriatric oncology training can be obtained through focused workshops such as the Advanced Course in Geriatric Oncology organized by SIOG twice a year in Treviso, Italy, and Canberra, Australia, which teaches principles of geriatrics for oncologists and clinical oncology for geriatricians through case-based discussions.12
What if someone is interested in developing expertise in both disciplines?
For those who desire expertise in both disciplines, additional geriatric medicine training can be incorporated into training as part of a combined or sequential fellowship. A combined fellowship in geriatric medicine and medical oncology consolidates training into three years.13 At the conclusion of the combined fellowship, trainees are board-eligible in both medical oncology and geriatric medicine. There are also programs that integrate geriatrics with the traditional hematology-oncology fellowship where trainees are triple board-eligible upon completion of the program. While these combined fellowships are not essential to acquire expertise in geriatric oncology, such training can be advantageous because it affords the opportunity to receive mentorship from geriatric oncologists, participate in a specialized geriatric oncology clinic, and conduct geriatric oncology-focused research.
Sequential training entails completion of a hematology-oncology fellowship and then a geriatric fellowship, or vice versa. Current hematology-oncology fellows and practicing oncologists interested in a formal geriatric medicine fellowship will find multiple programs eager to train physicians in geriatrics and opportunities to curate a fellowship focused on developing the skills of a geriatric oncologist. Fellowship in geriatric medicine is a year-long immersive experience providing care for a heterogeneous population of older adults in a wide variety of settings. During geriatrics training, you learn how to approach the management of multimorbidity in older patients by comprehensively assessing function, cognition, and resilience, rather than relying on chronologic age alone. Moreover, you become comfortable recognizing geriatric syndromes (e.g., frailty, falls) and identifying opportunities to intervene for patients whose functional or cognitive status limits their ability to adhere to their care plan. Humbly, you also learn when to alter the plan when additional interventions offer no additional benefit. You learn to differentiate physiologic and pathologic changes that occur with age, and to account for commonly atypical presentations for a variety of conditions in the older adult. Additionally, you develop a better understanding of pharmacodynamics of potentially harmful medications that are used without issue in younger adults. These skills and knowledge allow you to better navigate an older adult’s care grounded in what matters most to them, and advocate on their behalf in multidisciplinary team meetings. Ultimately, a geriatric medicine fellowship provides an opportunity for trainees to build a foundational framework for how to provide the best care for older adults.
Can you describe your motivation for pursuing geriatric oncology?
AH: As a physician, I’m driven by the unique relationship I have with each of my patients and the complexity involved in personalizing their treatment to obtain the best possible outcome in alignment with their goals. As a medical student and then an internal medicine resident, I found it disconcerting that many of my older adult patients who had been previously independent were struggling with disability due to complications of cancer or their cancer treatment. It was also not uncommon for me to conduct family meetings where newly diagnosed patients were finding it difficult to make a decision on what to do next based on survival data alone. Unfortunately, other than treatment-related toxicity, research on outcomes relevant to older adults with cancer, such as disability, hospitalization, and institutionalization, is limited. It was later in residency that I learned of the field of geriatric oncology. Recognizing the opportunity to help older adults with cancer to live fuller lives, and the need for further research in this area, I decided to pursue geriatrics fellowship with the plan to apply to hematology-oncology fellowship afterwards. This led me to Duke University, where I had the honor to train with Dr. Harvey Cohen, one of the earliest proponents of geriatric oncology. Now I am an advanced fellow in geriatric medicine, engaged in research related to the use of digital technology for remote symptom monitoring with the hope that implementation of these technologies will allow us to follow the trajectory of our patients more closely over the course of their treatment, to help us in identifying which patients are more vulnerable to treatment-related toxicities and in detecting changes in function earlier, so that we can tailor their treatment appropriately. I will apply to hematology-oncology fellowship this year.
FD: I began my hematology-oncology fellowship intently focused on becoming a health services researcher with the goal of advancing our understanding of cancer disparities in the Hispanic population. One particular subgroup I found to be poorly represented in my review of the literature was the population of geriatric Hispanic patients with cancer. It is estimated that by 2060, the Hispanic population, including both foreign- and U.S.-born individuals, will make up 21% of the older population living in the U.S., with approximately 20 million people.14 The degree to which Hispanics have acculturated and acquired English language proficiency impacts their interaction with the U.S. health care system and ultimately shapes their health outcomes. Understanding the role of nuanced social determinants in the context of an aging Hispanic patient with cancer is challenging from both a clinical and a research perspective.
I shared my disquietude with Dr. Hyman Muss, director of the Geriatric Oncology Program at the University of North Carolina (UNC) at Chapel Hill, who shared that he, too, was concerned that we know so little about the aging U.S. Hispanic population. This prompted us to begin a study looking at this issue in greater detail and ignited a personal desire to sharpen my clinical acumen in the older adult population. I consequently made the decision entering my final year of hematology-oncology fellowship to apply for geriatrics fellowship, matching at my home institution of UNC Chapel Hill.
The foremost priority in oncology is to provide high-quality, evidence-based care that aligns with our patients’ stated goals. With an overwhelming proportion of patients with cancer older than age 65, it is essential that oncologists are familiar with the principles of geriatric oncology. As presented, there are a wide array of options available to trainees and clinicians to cultivate competency in this field. By doing so, we will be able to deliver higher quality care to all our patients, including the most vulnerable. The geriatric oncology community, much like the geriatric population, is growing. We welcome trainees and practicing oncologists eager to learn more
Dr. Diaz is a hematology-oncology fellow at the University of North Carolina at Chapel Hill, where he will begin his geriatric medicine fellowship in July 2023. He is a member of the ASCO Trainee & Early Career Advisory Group. Follow Dr. Diaz on Twitter @FernandoDiazMD1. Disclosure.
Dr. Hamparsumian is a research fellow in the VA Advanced Fellowship in Geriatrics Program at the Greater Los Angeles Veterans Affairs Medical Center. She completed her clinical geriatrics fellowship training at Duke University. Her research is in collaboration with geriatric oncologist Dr. Arash Naeim and the UCLA Center for SMART Health. She is a member of the Cancer and Aging Research Group (CARG) and the American Geriatrics Society (AGS). She will apply for a hematology-oncology fellowship in 2023. Follow Dr. Hamparsumian on Twitter @AHamparsumianMD. Disclosure.
Dr. Wong is a thoracic medical oncologist and geriatric oncology researcher at the University of California, San Francisco. During her medical oncology fellowship, Dr. Wong pursued research training through a National Institute on Aging-funded Aging Research T32 Fellowship. Dr. Wong’s research aims to improve the delivery of goal-concordant cancer care for older adults through development of risk stratification and communication tools. Dr. Wong co-leads the ASCO Geriatric Oncology Community of Practice and serves on the ASCO Geriatric Oncology Education Committee. Follow Dr. Wong on Twitter @melisawongmd. Disclosure.
Dr. Williams is a geriatrician and gastrointestinal oncologist at the University of Alabama at Birmingham. He completed a combined geriatric, medical oncology, and research fellowship at the University of North Carolina at Chapel Hill. His research involves the use of geriatric assessment and novel biomarkers, such molecular markers of aging and body composition, to better evaluate functional age and developing interventional clinical trials to improve the tolerance and outcomes of older adults undergoing cancer treatment. Dr. Williams chairs the ASCO Taskforce on Disparities in Older Adults, co-leads the ASCO Geriatric Oncology Community of Practice, and is president-elect of SIOG. Follow Dr. Williams on Twitter @GrantWilliamsMD. Disclosure.
- Smith BD, Smith GL, Hurria A, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27:2758-65.
- All Cancer Sites Combined SEER 5-Year Relative Survival Rates, 2012-2018. National Cancer Institute. Accessed Dec 1, 2022.
- Cancer Stat Facts: Cancer of Any Site. SEER. National Cancer Institute. Accessed Dec 1, 2022.
- Sedrak MS, Ji J, Tiwari A, et al. Clinical Trial Enrollment, Ineligibility, and Reasons for Decline in Older vs Younger Patients With Cancer in the National Cancer Institute Community Oncology Research Program. JAMA Netw Open. 2022;5:e2235714.
- Committee on Improving the Quality of Cancer Care: Addressing the Challenges of an Aging Population; Board on Health Care Services; Institute of Medicine. Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis. Levit L, Balogh E, Nass S, et al, eds. Washington (DC): National Academies Press (US); 2013 Dec 27.
- ACGME Program Requirements for Graduate Medical Education in Hematology and Medical Oncology. Jul 1, 2022. Accessed Dec 1, 2022.
- Maggiore RJ, Dale W, Hurria A, et al. Hematology-Oncology Fellows’ Training in Geriatrics and Geriatric Oncology: Findings From an American Society of Clinical Oncology-Sponsored National Survey. J Oncol Pract. 2017;13:e900-e908.
- Mohile SG, Dale W, Somerfield MR, et al. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology. J Clin Oncol. 2018;36:2326-47.
- Hurria A, Mohile SG, Dale W. Research priorities in geriatric oncology: addressing the needs of an aging population. J Natl Compr Canc Netw. 2012;10:286-8.
- Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations. Ann Oncol. 2015;26:288-300.
- Curzio J. ASCO Communities of Practice Provide Opportunity for Specialized Collaborative Experience at Annual Meeting and Beyond. ASCO Connection. Apr 1, 2022. Accessed Dec 1, 2022.
- International Society of Geriatric Oncology. SIOG Advanced Course in Geriatric Oncology. Accessed Dec 1, 2022.
- ASCO. Geriatric Oncology Resources. Accessed Dec 1, 2022.
- Administration for Community Living. U.S. Department of Health and Human Services. 2020 Profile of Hispanic Americans Age 65 and Older. Accessed Dec 1, 2022.