Preventing Treatment-Related Functional Decline: Strategies to Maximize Resilience

Cancer is a disease that occurs more commonly in older adults. For example, the total number of cancers is projected to increase by 45% from 2010 to 2030 in the United States, driven largely by the growing number of older adults. By 2030, an estimated 70% of all cancers will occur among adults age 65 and older.1 There is wide variation in the ability of patients of the same age to tolerate cancer therapy. Chronologic age alone is a poor descriptor of heterogeneity in the aging process and is an inadequate indicator to determine responses among older patients to cancer treatment. We need a systematic and evidence-based way to describe this heterogeneity to guide oncology treatment decisions. Geriatric conditions such as functional and cognitive impairments are frequently unrecognized or inadequately addressed in older adults. Rather than chronologic age, patients’ physiologic age or fitness level based on a “fit-to-frail” spectrum is more meaningful. Frailty is an important geriatric syndrome that is characterized by multisystem dysregulation, leading to decreased physiologic reserve and increased vulnerability for adverse health outcomes.2 CGA involves the evaluation of the physical, psychosocial, and environmental factors that impact the well-being of older individuals.3 CGA is a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of an older adult, which should lead to the development of a coordinated and integrated plan for treatment and long-term follow-up to improve outcomes for older patients with cancer.4 Frail older adults may have multiple chronic conditions and may have difficulty maintaining independence. They may be more vulnerable to therapy toxicities and may not have substantial lasting benefits from therapy. CGA may be used as a tool to determine reversible deficits and devise treatment strategies to mitigate such deficits. The CGA has been demonstrated to be superior to clinical judgment, even by experienced clinicians, when used to evaluate the fitness of older patients with cancer.5 Multiple studies have suggested a spectrum of benefits that arise from using CGA for older patients with cancer. For example, a prospective multicentric study on the large-scale feasibility and usefulness of CGA in oncology showed that CGA detected unknown geriatric problems in 51% of patients age 70 and older. When the physician was aware of the assessment results at the time of decision-making, geriatric interventions were planned for 25.7% of patients and the treatment decision was