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Cancer care for older adults

28 November 2022

Jed Isaac Ashman and Thomas Ho Lai Yau :

Cancer rates continue to rise globally with a disproportionate impact on the older population. Individuals aged 70 and above are particularly affected and account for the largest proportion of cancer-related deaths globally. Despite this, the care they receive falls short when compared to other age groups. The misconception that older adults have a lower treatment tolerance contributes to this, leading to under-representation in trial registration.  
Health professionals, researchers, NGOs, governments, and patients are coming together toward a common goal of improving cancer care in the older population. The International Society of Geriatric Oncology, or SIOG, has been at the forefront of addressing the issue since 2000 through education, clinical practice, research, and partnerships. SIOG has shown leadership in the field and served as a platform for partners from over 80 countries to improve older adult cancer care.
In 2019, SIOG gathered global experts for a policy meeting at the United Nations in Geneva and outlined 12 priorities for advancing cancer care in older adults. Since then, the focus has been establishing a road map that transforms these commitments into practical action.
On Oct. 28 this year, SIOG convened its public policy in Geneva, bringing together representatives from organizations including the European Union, the Swiss Group for Clinical Cancer Research, or SAKK, and the U.S. Food and Drug Administration. The aim was to outline steps to measure and monitor the access to quality care and treatment that older adults with cancer receive and how to improve older persons' inclusion in clinical trials.
SIOG's public policy committee is focusing on enhancing treatment of older cancer patients through recommendations for cancer drug development programs and clinical trials for this age group.
There are signs of change at a governmental level. The European Parliament's Special Committee on Beating Cancer Plan has a section recognizing the importance of cancer in older adults. During the meeting, Member of the European Parliament Alessandra Moretti acknowledged SIOG for its contribution to this accomplishment. She also expressed that there is a real political will in Europe and "a growing commitment by the EU in the fight against cancer, with the new policies, the resources and funds dedicated to this."
 "Ahead of us, we have however some decisive years where at the EU and national levels we will need to concretely implement those plans and strategies with regulatory and legislative measures," she said.
FDA has developed guidance for drug developers requiring the inclusion of older adults across all clinical trial phases. The European Medicines Agency has a similar strategy document as well as a Geriatric Expert Group ensuring older patients are well represented in the drug approval process. There is a strong emphasis from regulatory bodies on the need to include patients aged 75 and above. "Yet, very often at the time of registration of new drugs, fewer older cancer patients are enrolled - resulting in skewed output of tolerance in the 'non-fit' older population," said professor Hans Wildiers, SIOG past president and member of EMA's Geriatric Expert Group.
Some research groups have already started taking steps to improve representation. SAKK has removed age as an exclusion criteria in their trials. Patient partnerships are also being formed, recognizing the importance of patient insight in the development of trials. One example is the SCOREboard group, a patient-based committee that provides feedback on the design and protocol of research trials.
There is still work to do. Dr Martine Extermann, chair of the SIOG public policy committee, illustrated a road map from policy-making to implementation. Priorities to simplifying practical guidelines, standardizing cancer care worldwide, removing age as an exclusion criterion, and addressing hidden inclusion criteria that inevitably exclude older adults in randomized control trials, or RCTs, is set. She presented a 2022 KPMG-Sanofi study, "When Cancer Grows Old," highlighting an urgent need for effective geriatric assessment tools to alleviate the socioeconomic burden of cancer in older adults.
More studies that involve the pharmaceutical industry could fast-track research, with corporations becoming key players in fighting these negative socioeconomic impacts.
Globally, SIOG encourages those conducting RCTs to follow SAKK's example in removing the age exclusion criteria. SIOG President Dr. Nicolò Matteo Luca Battisti urged the international community to go beyond this and highlighted key policy actions being undertaken at the European level: collecting data on comorbidities, upskilling the cancer workforce in the principles of geriatrics and geriatric oncology, and fostering the inclusion of older individuals in oncology clinical trials.
SAKK President Miklos Pless suggested open-label trials running in parallel to RCT should be organized for more frail adults; these trials will enable healthcare providers and patients to be aware of the treatment given, and allow for data focusing on life quality. Phase IV trials have been touted as a primary focus for older adult trials for obtaining more accurate real-life data and continual monitoring of toxicity.
The feasibility of operating clinical trials within low- and middle-income countries, or LMICs, due to limitations in infrastructures and resources was discussed. Historically, clinical trials have primarily been based in high-income countries and rarely encounter these limitations. SIOG past-President Dr. Ravindran Kanesvaran raised that policymakers' national cancer care plans improve access to health care services and clinical trials in LMICs.
Education should be used to tackle barriers in cultural, language, misinformation, and cancer stigma. This will raise awareness and improve cancer services for older adults. A strong push to increase exposure to geriatric oncology via training programs for health professionals is warranted. Geographical efforts to spread this are spearheaded by SIOG national representatives changing clinical practice around the world. Patient advocate Ms. Beverly Canin argued that "research training should include how to engage with patients not just as subjects or peripherally but as collaborators and partners."
In terms of research, SIOG CEO Dr. Najia Musolino calls on key opinion leaders to support multi-partner consortiums for systematic geriatric oncology dataset in clinical trials by engaging with target regulatory bodies, cooperative groups, and pharmaceuticals coalitions to further amplify this effort and to reduce the gap between what older cancer patients need and what the current health systems provide.

(Jed Isaac Ashman and Thomas Ho Lai Yau are SIOG medical writers).

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