Up next in 10
Give me 20 minutes and I tell you 20 YEARS of Advances in Geriatric Oncology
0 views
Jul 18, 2025
Geriatric Oncologists (doctors specialized in caring for older adults with cancer) have made significant advances in the care, assessment, and outcomes of older adults with cancer. These 20 minutes will review more than 2 decades of advances in this field. Connect with me via LinkedIn https://www.linkedin.com/in/arminshahrokni?utm_source=share&utm_campaign=share_via&utm_content=profile&utm_medium=android_app X https://x.com/GeriOncologist?t=QMpM6F9KTB9_2W66OiEOzw&s=09 Instagram https://www.instagram.com/aging_cancer/profilecard/?igsh=MXI3eTBieTNhNjJucg== Google Scholar https://scholar.google.com/scholar?hl=en&as_sdt=0%2C33&q=armin+shahrokni+&btnG=
View Video Transcript
0:05
okay let's dive into this stack of
0:06
sources you've brought us we're taking a
0:09
deep look at well a really important
0:11
shift in healthcare haven't we we have
0:13
indeed it's about how doctors are
0:15
approaching the care of older adults who
0:17
get diagnosed with cancer mhm for I mean
0:19
for a long time it felt like those
0:21
treatment decisions were often pretty
0:23
heavily weighted maybe even you know
0:26
dominated by just one number someone's
0:28
age and that was really the core problem
0:30
wasn't it relying mainly on
0:32
chronological age and perhaps a basic
0:34
measure of how active someone is like uh
0:36
the carnowski or econ performance status
0:39
right those scores basically just look
0:41
at how much help someone needs dayto-day
0:43
exactly and the critical insight that
0:45
began to emerge is just how incredibly
0:47
diverse older adults are you know age
0:50
alone is just a very poor predictor of
0:52
someone's underlying health the
0:54
resilience or critically how they'll
0:56
tolerate cancer treatment so this deep
0:59
dive is specifically into the evolution
1:01
of what's called geriatric assessment or
1:03
GA in cancer care that's right GA we're
1:06
going to trace that journey what it is
1:10
why it became well essential how the
1:12
evidence built up to support it and sort
1:14
of where we are now our mission really
1:17
is to unpack the key stages of this
1:19
evidence right from just recognizing
1:21
there was a problem yeah the initial aha
1:24
moment to actually proving that taking
1:26
this different approach using GA makes a
1:29
real difference in care and outcomes
1:32
exactly it's a story of moving from a
1:34
kind of one-sizefits-all mentality based
1:37
largely on age to something far more
1:39
nuanced and uh ultimately much more
1:42
effective for the patient all right
1:43
let's start where your sources do back
1:45
in the 1990s this period uh they often
1:49
call it the awakening seems fitting yes
1:52
the '9s were absolutely fundamental cuz
1:54
this was the time when the medical
1:55
community really started I think
1:58
acknowledging the severe limitations of
2:00
the existing system the agebased system
2:02
yeah they saw that just looking at age
2:04
and that basic performance status it
2:06
just wasn't capturing the whole picture
2:08
for older cancer patients not even close
2:10
and what specifically were they missing
2:12
what wasn't being captured they were
2:14
missing that heterogeneity we talked
2:15
about the simple fact that you know an
2:17
80-year-old marathon runner and an
2:19
80-year-old with multiple chronic
2:21
conditions maybe some frailty they need
2:24
vastly different approaches makes sense
2:27
the standard tools just weren't designed
2:29
to pick up the complex sort of
2:31
multi-layered health issues that are
2:33
common in older age things often lumped
2:36
together as geriatric syndromes okay
2:38
like what kind of things fall under that
2:39
umbrella we're talking about stuff like
2:42
um significant medical problems besides
2:44
the cancer itself that maybe aren't well
2:46
controlled or being on a whole bunch of
2:48
medications that's polyfarm pharmacy
2:50
right lots of pills which you know
2:52
dramatically increases the risk of drug
2:54
interactions also subtle declines in
2:57
physical function that aren't obvious
2:59
from just asking are you active maybe
3:01
poor nutrition or even mild cognitive
3:04
impairment that hasn't been formally
3:05
diagnosed and the evidence back then
3:07
what did it look like the evidence
3:09
emerging then was largely observational
3:12
you know descriptive studies they were
3:13
simply documenting how common these
3:15
issues were just counting them up
3:17
basically kind of yeah and crucially how
3:21
often they were going completely
3:22
unrecognized in older cancer patients
3:24
who were just getting the standard
3:26
assessment so the big takeaway from the
3:28
'90s wasn't that they had fixed anything
3:30
yet but more like they were just shining
3:32
a really bright light on the problem
3:34
itself saying "Hey look over here."
3:36
Exactly it was about saying "Look this
3:38
system is fundamentally broken because
3:40
it's missing so much critical
3:41
information about these patients real
3:43
capacity and their vulnerabilities."
3:46
That recognition that was huge it proved
3:49
the need for something better for a more
3:51
comprehensive assessment tool okay so
3:53
armed with that understanding from the
3:54
'90s that realization that the old way
3:56
wasn't working what came next your
3:58
sources point to the 2000s as the time
4:01
for building prediction right this was a
4:03
really crucial step forward the key
4:05
question evolved from you know what are
4:08
we missing to something more proactive
4:10
can identifying these issues these
4:12
geriatric syndromes actually predict
4:14
future outcomes uh okay so could a
4:16
detailed geriatric assessment tell us
4:18
which patients were at higher risk
4:21
higher risk of what specifically higher
4:23
risk of things like severe complications
4:25
from the cancer treatment itself like
4:27
really bad toxicity ending up in the
4:29
hospital unexpectedly or even
4:31
unfortunately not surviving the
4:33
treatment how did they go about trying
4:35
to prove that connection that predictive
4:37
power well they moved into more rigorous
4:40
study designs specifically prospective
4:43
cohort studies became really important
4:45
here okay how did those work basically
4:47
they would perform a comprehensive GA on
4:49
a group of older adults before they
4:51
started their cancer treatment then
4:53
they'd follow these patients closely
4:54
over time to see who actually developed
4:56
those severe problems we talked about
4:58
and were there key players in this
5:00
research absolutely a really key group
5:02
driving this work was the cancer and
5:04
aging research group or a quirk um
5:07
notably led by the late Dr arty Hura who
5:10
was just a pioneer in this field okay cr
5:12
key and what did their research and
5:14
others during that decade actually find
5:17
were specific parts of the GA really
5:19
predictive yes and this is where it gets
5:21
really interesting because they found
5:23
that certain elements of the geriatric
5:25
assessment were actually more predictive
5:28
of severe chemotherapy toxicity we're
5:31
talking grade 3 to five toxicity the
5:33
kind that can be really serious even
5:34
life-threatening okay they were more
5:37
predictive than the patient's age or
5:38
that standard performance status score
5:40
alone wow hang on more predictive than
5:43
someone's actual age that feels pretty
5:44
significant which parts of the
5:46
assessment stood out the most yeah it
5:48
was a big deal key factors that
5:50
consistently popped up included uh
5:52
functional status especially difficulty
5:55
with what are called instrumental
5:56
activities of daily living or IADLs
5:59
iadls what are those exactly they're
6:01
these slightly more complex tasks
6:03
required for living independently things
6:05
like managing your own medications
6:07
handling finances using transportation
6:10
shopping for groceries preparing meals
6:12
stuff that requires more complex
6:14
thinking and planning gotcha so
6:16
difficulty with those tasks was a red
6:18
flag what else also critical were um the
6:21
number and the severity of a patient's
6:24
other medical conditions their
6:25
coorbidities nutritional status
6:27
indicators like if they'd lost weight
6:29
unintentionally or had low albumin
6:31
levels in their blood and again polyfarm
6:33
pharmacy that burden of being on many
6:35
different medications so they went from
6:36
just describing these problems in the
6:38
'90s to actually in the 2000s being able
6:40
to put data behind predicting the risk
6:43
of severe side effects for individual
6:45
patients based on these GA factors
6:47
precisely and this research wasn't just
6:49
academic it directly led to the
6:51
development and importantly the
6:53
validation of practical tools tools like
6:55
the krg chemtoxicity tool ah you
6:58
mentioned kara arg earlier so this tool
7:00
uses GA data yes it takes specific
7:02
inputs from the geriatric assessment and
7:05
calculates an objective personalized
7:07
risk score for severe toxicity it gives
7:10
the doctor and patient a percentage
7:11
likelihood so the significance of the
7:13
2000s was really establishing the
7:15
scientific validity of GA showing it
7:17
wasn't just you know a holistic approach
7:19
but a tool that could actually forecast
7:21
trouble using real data it gave
7:22
oncologists datadriven insights
7:25
absolutely it provided a clear
7:28
evidence-based reason why looking deeper
7:30
truly mattered it showed this wasn't
7:33
just nice to know information it was
7:35
prognostic it could help predict the
7:37
future in a way that must have really
7:39
changed the conversation around treating
7:40
older patients okay let's fast forward
7:42
another 10 years into the 2010s
7:46
your source material calls this the
7:48
intervention era mhm this feels like the
7:51
ultimate question then right can
7:53
actually using the results from the GA
7:55
identifying those risks and
7:56
vulnerabilities can using that
7:59
information to change how we manage
8:00
patients actually improve their outcomes
8:03
compared to just standard care this was
8:04
the critical pivot yes and it demanded
8:07
the highest level of evidence we have in
8:09
medicine randomized control trials or
8:11
RCTs gold standard exactly it wasn't
8:14
enough anymore just to show GA could
8:15
predict risk you had to prove
8:17
head-to-head that acting on those
8:20
predictions addressing the
8:21
vulnerabilities found by the GA made a
8:23
measurable positive difference for
8:25
patients compared to just doing what was
8:27
usually done were there specific
8:28
landmark trials during this time that
8:30
really moved the needle yes absolutely
8:33
several trials came out in the 2010s
8:35
that were really practice changing uh
8:37
the gain trial conducted in the US was a
8:40
major one okay the gain trial what did
8:42
they do they took older patients aged 65
8:45
plus who are about to start chemotherapy
8:47
they randomized them into two groups one
8:49
group just got the usual standard
8:50
oncology care okay the other group the
8:52
intervention group had a geriatric
8:54
assessment done and if vulnerabilities
8:57
were found like poor nutrition risk of
8:59
falls polyfarm pharmacy they received
9:01
targeted interventions often coordinated
9:04
by a geriatric team things like
9:06
medication adjustments referrals to
9:08
physical therapy or nutritionists
9:10
cognitive strategies that kind of thing
9:11
based specifically on their GA results
9:13
and the results of that gain trial what
9:16
did they find they were really quite
9:17
compelling the group that received the
9:19
GA guided interventions had
9:21
significantly less severe chemotherapy
9:23
toxicity how much less it was a pretty
9:25
dramatic reduction it went from 71%
9:27
experiencing severe toxicity in the
9:28
standard care group down to 51% in the
9:31
intervention group wow a 20% absolute
9:34
reduction in severe potentially
9:36
dangerous side effects just from doing
9:39
the assessment and tailoring the
9:40
supportive care that's huge it is huge
9:43
it represents real patients experiencing
9:44
less severe suffering fewer
9:46
hospitalizations potentially and they
9:49
also found other benefits in the game
9:50
trial the intervention group experienced
9:52
fewer falls and they were more likely to
9:54
have their chemotherapy doses adjusted
9:56
appropriately based on evidence which is
9:58
crucial for safety and tolerability
10:00
that's incredibly powerful evidence were
10:02
there other trials showing similar
10:04
things yes thankfully other trials
10:07
helped corroborate this uh the integrate
10:09
trial which was done in Australia showed
10:11
improvements not just in reducing
10:12
toxicity but also in patients reported
10:14
quality of life and interestingly fewer
10:17
unplanned hospital admissions in the
10:19
group that got GAG guided management
10:21
better quality of life and staying out
10:22
of the hospital more often those are
10:24
outcomes patients really care about
10:26
absolutely and studies coming out of
10:27
Europe around the same time like those
10:29
led by Dr cindy Kenis and her group
10:31
confirm these kinds of benefits and
10:33
fewer serious toxicities better
10:35
preservation of physical function during
10:37
treatment and higher rates of actually
10:39
completing the planned chemotherapy
10:41
course okay so this wave of high quality
10:43
RCT evidence all pointing in the same
10:46
direction it seems like it would be
10:48
impossible for the oncology community to
10:50
ignore it really was and it led to what
10:54
many consider a major tipping point the
10:56
publication of the American Society of
10:58
Clinical Oncology ASCO guidelines in
11:00
2018 asco guidelines okay what did they
11:03
say based squarely on this strong body
11:04
of evidence from the RCTs ASCO
11:07
recommended that all adults aged 65 and
11:09
older who are being considered for
11:11
chemotherapy should undergo a geriatric
11:13
assessment all of them all of them the
11:16
purpose being explicitly to identify
11:18
potential vulnerabilities and they use
11:20
that information to guide their care to
11:22
guide interventions so that
11:23
recommendation essentially cemented GA
11:25
as a standard of care didn't it it
11:27
absolutely did it moved it from
11:28
something researchers were exploring to
11:30
something that should be happening in
11:32
routine practice so the significance of
11:35
the 2010s is really that definitive
11:37
proof ga isn't just a predictive tool
11:39
anymore it's a therapeutic strategy in
11:41
itself acting on it directly improves
11:44
outcomes making cancer treatment safer
11:46
more tolerable and truly more patient
11:48
centered for older adults okay so with
11:51
the why GA is important firmly
11:53
established by all that evidence where
11:55
does that leave us now we're in the
11:56
2020s looking ahead your sources
11:59
describe this current period as the era
12:00
of implementation expansion and
12:02
refinement sounds practical exactly the
12:05
focus has really shifted now from
12:07
proving that GA works the evidence for
12:10
that is clear to figuring out how to
12:11
make it work seamlessly and widely in
12:13
the real world how do we actually
12:15
integrate this into busy oncology
12:17
clinics how do we apply its principles
12:19
beyond just chemotherapy which was the
12:21
initial focus and how do we make the
12:23
interventions themselves the things we
12:24
do based on the GA even better even more
12:27
targeted implementation does sound like
12:29
a big practical challenge I mean a full
12:31
geriatric assessment takes time and
12:33
expertise right that's not always easy
12:35
to find in a busy cancer center it can
12:37
yes a full comprehensive GA can take
12:40
maybe 45 minutes to an hour sometimes
12:43
more depending on the patient so a key
12:46
solution that's being validated and
12:47
widely adopted now is using short
12:50
screening tools first screening tools
12:52
like a quick first pass precisely there
12:55
are validated tools like the G8 or the
12:57
VES13 these are quick questionnaires
12:59
often just a handful of questions that
13:01
can be completed in just a few minutes
13:03
sometimes even by the patient themselves
13:04
in the waiting room and what do these
13:06
screeners do they help quickly flag
13:08
patients who are likely to be frail or
13:10
have significant vulnerabilities they
13:12
basically sort patients if you score
13:14
well on the screener you might be
13:16
considered robust and maybe don't need
13:18
the full timeintensive GA right away but
13:21
if the screener raises concerns Yeah and
13:23
you get the deeper dive the full GA
13:25
Exactly it creates a practical tiered
13:27
approach screen everyone quickly then do
13:30
the full assessment on those who really
13:31
need it it makes implementation much
13:33
more feasible in busy settings that
13:35
makes a lot of sense are there other
13:37
ways they're trying to make
13:38
implementation easier yeah
13:40
implementation science is exploring lots
13:42
of models for instance letting patients
13:45
complete parts of the GA electronically
13:47
before their appointment using what are
13:50
called EPRO's
13:52
electronic patient reported outcomes ah
13:54
using technology right also setting up
13:57
dedicated geriatric oncology clinics or
14:00
consultation services within cancer
14:02
centers and of course leveraging
14:04
teleaalth which became much more common
14:06
recently to conduct parts of the
14:08
assessment or deliver interventions
14:10
remotely okay so lots of work on the
14:12
how-to what about the expansion part you
14:14
mentioned applying GA beyond just
14:16
chemotherapy yes this is a major area of
14:19
growth right now the understanding is
14:21
dawning that the underlying
14:22
vulnerabilities GA identifies things
14:24
like functional decline cognitive issues
14:27
poor nutrition they're relevant no
14:29
matter what kind of cancer treatment
14:31
someone is getting so for surgery for
14:32
example absolutely for older adults
14:35
undergoing major cancer surgery GA can
14:38
help predict who's at higher risk for
14:39
complications like delirium longer
14:41
hospital stays or needing to go to rehab
14:44
afterwards and importantly it can guide
14:46
prehabilitation rehabilitation like
14:48
rehab before the surgery kind of yeah
14:51
using the time before surgery to
14:53
implement interventions maybe exercise
14:55
programs nutritional support medication
14:58
review aimed at getting the patient
15:00
fitter and more resilient before the
15:02
stress of the operation ga helps target
15:04
who needs prehab and what kind
15:06
interesting what about radiation therapy
15:08
similar principles apply ga can help
15:10
predict who might have trouble adhering
15:12
to the daily radiation treatment
15:13
schedule perhaps due to transportation
15:15
issues or cognitive problems identified
15:17
in the GA it can also predict who might
15:20
be more likely to suffer severe side
15:21
effects from radiation and what about
15:23
the newer types of cancer therapies
15:25
immunotherapies targeted drugs that's a
15:28
really hot area right now there's a
15:30
rapidly growing evidence base looking at
15:32
applying GA principles there too early
15:34
findings are starting to link frailty
15:36
and other geriatric vulnerabilities
15:38
identified by GA to a higher risk of
15:41
experiencing those severe immunereated
15:43
adverse events the can happen with
15:46
checkpoint inhibitors wow so GA could
15:48
even help predict serious side effects
15:50
from amunotherapy that's the hope and
15:52
the early data looks promising it's
15:55
critical information that could help
15:56
tailor treatment decisions and
15:58
monitoring strategies even for these
16:00
cutting edge therapies it sounds like
16:01
the goals of using GA are also
16:03
broadening out maybe moving beyond just
16:05
focusing on preventing toxicity or
16:08
predicting survival definitely there's a
16:10
strong and I think really positive
16:13
movement towards focusing more on
16:15
patient- centered outcomes ga is the
16:17
fantastic tool for facilitating crucial
16:19
conversations between the doctor the
16:21
patient and their family it helps with
16:23
shared decision-making it's because it
16:24
provides a clearer picture of the
16:26
patients overall health their reserves
16:28
their potential vulnerabilities and it
16:30
often includes questions about their
16:32
values and priorities it helps ensure
16:34
the treatment plan aligns with what
16:36
matters most to you the patient is the
16:38
top priority extending life at all costs
16:41
or is it maintaining independence
16:43
preserving cognitive function maximizing
16:46
quality of life even if it means less
16:48
aggressive treatment ga helps bring
16:50
those crucial goals into the discussion
16:52
making the treatment fit the person not
16:53
just the disease exactly and the final
16:56
part you mentioned was refinement
16:57
refining the interventions themselves
16:59
yes we know from the 2010s trials that
17:01
GA guided care overall improves outcomes
17:05
but the next level question is what are
17:07
the absolute best most effective
17:09
interventions for specific
17:10
vulnerabilities found on the GA research
17:13
is now moving towards more precision can
17:15
you give an example sure instead of just
17:17
generally recommending exercise for
17:19
someone identified as frail before
17:20
surgery research is now testing say the
17:23
specific type of exercise strength
17:25
training versus aerobic versus balance
17:27
or the optimal dose how many times per
17:29
week for how long that is most effective
17:31
in a prehabilitation program to improve
17:33
surgical outcomes we're moving beyond
17:36
general recommendations towards creating
17:37
precise evidence-based prescriptions
17:40
tailored to the individual specific GA
17:42
findings so pulling it all together the
17:44
2020s and beyond seem to be all about
17:47
making geriatric assessment a truly
17:49
practical sophisticated and ideally
17:52
universal part of highquality cancer
17:54
care for every older adult that's
17:56
absolutely the driving force now yeah
17:58
making it standard making it smart and
18:00
making it reach everyone who could
18:01
benefit okay let's quickly recap this
18:03
remarkable journey we've traced through
18:04
your source material it's quite a story
18:06
of medical progress it really is it
18:08
began back in the 1990s with that
18:10
critical realization that awakening that
18:12
older adults are complex age isn't
18:14
nearly enough to go on and the old
18:16
system was just missing too much crucial
18:18
information right identifying the
18:20
problem then the 2000s brought more
18:22
rigorous studies the predictive era
18:24
proving that GA could actually forecast
18:27
risk identifying specific
18:29
vulnerabilities strongly linked to
18:31
severe treatment outcomes establishing
18:32
the science the 2010s deliver that
18:35
definitive proof the intervention era
18:37
with the big RCTs showing that using GA
18:40
to actively guide management
18:41
dramatically improves outcomes less
18:44
toxicity better quality of life improve
18:46
safety that led to the ESCO guideline
18:48
the proof it works and now the 2020s is
18:52
this era of practical implementation
18:54
figuring out the how-to expanding GA's
18:57
reach beyond chemo to surgery radiation
18:59
even newer therapies and constantly
19:02
refining the interventions based on its
19:03
findings to make them even more
19:05
effective and what's truly fascinating
19:07
here I think is how this isn't just some
19:09
academic exercise or a change buried in
19:11
research papers for you the listener
19:13
this whole story is profoundly important
19:16
it's about ensuring that if you or
19:18
perhaps someone you care about is an
19:20
older adult facing a cancer diagnosis
19:23
their care isn't based on just a simple
19:25
number like age but on a deep holistic
19:29
understanding of their unique biological
19:31
reserve their individual vulnerabilities
19:33
and crucially what truly matters most to
19:35
them as a person it's ultimately about
19:37
getting safer more effective and much
19:40
more aligned care it really is a
19:42
powerful evolution towards truly
19:44
personalized medicine especially in this
19:47
often vulnerable population a much
19:49
needed one and that really leaves us
19:50
with something to ponder doesn't it if
19:52
understanding an individual's full
19:54
multi-dommain complexity their true
19:56
biological reality that goes way beyond
19:58
simple demographics if that can have
20:00
such a profound positive impact on
20:02
outcomes in something as complex and
20:04
high stakes as cancer treatment for
20:06
older adults well what other areas of
20:09
health or maybe even other aspects of
20:11
society might we significantly improve
20:13
by moving beyond those broad simple
20:15
labels and making the effort to truly
20:17
understand the unique complex individual
20:20
that's a great question to end on
20:21
something to think about until our next
20:22
deep dive
20:39
[Music]
#Aging & Geriatrics
#Cancer