Improving Care for Older Adults with Cancer in Canada: A Call to Action

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This article, entitled "Improving Care for Older Adults with Cancer in Canada: A Call to Action" addresses one of the great challenges of oncology today, the care of older cancer patient.

As the title itself indicates, the aim of the article is a call to action, which aims to highlight the existence of a reality that requires a health care plan to respond to it.

The structure of the article is that of an opinion article, where there is no specific methodology. It is not a systematic review of a pathology or a treatment, not even on geriatric assessment. Nor is it a structured consensus document.  

The document is well written, the content well structured and the information well referenced. 

In the first section, after the introduction, it raises the difficulties arising from the aging population: increase in the incidence of cancer in the older population, disparity in the management of the pathology in this population group and the difficulty for oncologists in dealing with geriatric concepts. The second section deals with the importance of geriatric assessment as a strategy to improve outcomes in this population group, and the third describes the current situation in Canada in terms of clinical care, research and teaching. And in the last one, he makes proposals for improvement.

In relation to the scientific information provided related to GA, I would like to comment:

- In general terms, I miss the inclusion of the concept of comprehensive geriatric assessment (CGA), carried out by geriatric specialists, and the added value of multidisciplinary teams that include the participation of geriatricians.

- Table 1 lacks important references on the impact of geriatric assessment and geriatric interventions on the health outcomes of these patients. Only studies without the participation of geriatricians are included.

-On page 4, the reference to the PGA tool should state that it is a consensus recommendation. As stated by the authors of the ASCO guidelines:

The Panel recommends the Practical Geriatric Assessment (PGA) as one option for this purpose. (Type: Informal consensus; Evidence quality: Moderate; Strength of recommendation: Weak)

Author Response

- In general terms, I miss the inclusion of the concept of comprehensive geriatric assessment (CGA), carried out by geriatric specialists, and the added value of multidisciplinary teams that include the participation of geriatricians.

This is an interesting comment by the reviewer. We do include a description of what a CGA is and the data surrounding this (Section 3). I suspect what the reviewer is referring to, as outlined by their subsequent comments, is the method in which CGA is administered (within the context of the oncology team, by a geriatrician, or by a multidisciplinary team). We address this in our response to the subsequent critique below.

- Table 1 lacks important references on the impact of geriatric assessment and geriatric interventions on the health outcomes of these patients. Only studies without the participation of geriatricians are included.

We acknowledge that the studies included in Table 1 are not comprehensive. The intent of this section was to provide the reader, who may have no knowledge about geriatric oncology, the key studies that support the use of GA in older adults receiving systemic therapy. Studies were chosen that were a) randomized and compared to usual oncology care, b) in older patients receiving systemic therapy and c) looked at, and for the most part showed improvements, in oncologic outcomes (of importance to oncologists). We did also include the RCT conducted in Canada although it is a negative study to highlight the Canadian contribution to the field.

We have added these caveats to section 3 (on The Role of Geriatric Assessment) – paragraph 2, sentences 5-8:

Several phase III randomized controlled trial (RCT) data comparing GA to usual oncology care have now been completed (Table 1). We present an overview of the most commonly cited and pivotal studies to provider readers an understanding of major findings supporting the use of GA in oncology in order to provide context for the paper and recommendations. It is not meant to be a comprehensive systematic review. The authors refer interested readers to the following reviews which include additional studies done in this area (50-52).

The GA in several of the studies in Table 1 (the Canadian 5C study and the INTEGERATE study) were in fact done with a geriatrician or geriatrician providing input on recommendations. It is an interesting comment as I have not seen many discussions specifically choosing or highlighting studies based on the method in which the GA was administered (with respect to discussions about its effect on oncologic outcomes). On reviewing the literature we did find one study which did subclassify studies based on this. To acknowledge differences in the ways that GA can be administered we have added a sentence about this, but as the ASCO guidelines do not distinguish between the methods of GA administration nor about differences in outcomes between these, we did not distinguish studies or provide any recommendations based on this distinction. Within Canada, it would be important for providers to have multiple options so they can adapt GA to their local context. We do however highlight to the readers that there are multiple ways GA was administered.

Section 3 (The Role of Geriatric Assessment), paragraph 3, sentence 2:

Considering this data, several international organizations, including the International Society of Geriatric Oncology (SIOG) and the American Society of Clinical Oncology (ASCO) recommend a GA in patients aged ≥65 contemplating systemic therapy (52,53). While the GA is very adaptable and can be administered in a variety of ways (e.g. self-administered, electronically, in clinic) and within different healthcare contexts (e.g. through a geriatrician, multidisciplinary team, or within the oncology clinic), uptake of GA has been poor.

In addition, in reviewing the studies we included in Table 1 in light of the reviewer’s comment, cross referencing 3 systematic reviews on the topic, we have added in Dumontier’s study as it was included in all 3 reviews and is a geriatrician based GA intervention. This is in addition to the two geriatrician based GA studies (5C and INTEGERATE) that were already included. Hopefully this addresses some of the reviewer’s concerns.

-On page 4, the reference to the PGA tool should state that it is a consensus recommendation. As stated by the authors of the ASCO guidelines: 

The Panel recommends the Practical Geriatric Assessment (PGA) as one option for this purpose. (Type: Informal consensus; Evidence quality: Moderate; Strength of recommendation: Weak)

This has been added to the end of the last paragraph of Section 3 (The Role of Geriatric Assessment):

The use of PGA was a consensus recommendation by the ASCO panel (Type: Informal consensus; Evidence quality: Moderate; Strength of recommendation: Weak).

Reviewer 2 Report

Comments and Suggestions for Authors

this is a interesting research but have been improved, follow PRISMA checklist to perform a systematic review and add data from canada goverment to study the situation in canada

Author Response

This is a interesting research but have been improved, follow PRISMA checklist to perform a systematic review and add data from canada government to study the situation in Canada

Thank you for the feedback. This is a paper looking at both characterizing the current state of geriatric oncology in Canada and with this background to then offer strategies to build on this to improve care in older adults with cancer. Given the broad topic (spanning the domains of clinical care, education and research), we did not do a systematic review. In the former two domains, the actual breadth of existing initiatives is greater than that which is published. We have clarified the intent of the paper and how the information was gathered in the introduction of the paper. If you wish, we can further add that we did not conduct a formal systematic review and the reasons for this, but it seemed to disrupt the flow of the introduction.

Introduction, sentence 11-13:

Here we present a synthesis of the state of geriatric oncology in Canada. This is compiled using the authors’ knowledge of published and unpublished initiatives as leaders in the field within Canada. The intent of this paper is to identify gaps and challenges in the Canadian landscape and propose a dedicated strategy to accelerate developments in clinical care, research, and education for older adults with cancer is imperative to improve care for this large segment of the cancer population.

We recognize the importance of engaging the Canadian government in any initiatives to systemically improve outcomes in older patients with cancer. We call on the government to develop strategies that help disseminate interventions that positively improve outcomes in older patients with cancer. We have added, at the reviewer’s suggestion, about having the government formally study the current state of geriatric oncology and care in Canada.

Section 5, paragraph 8:

In addition to increased funding, the authors call for a purposeful and coordinated plan to engage cancer care organizations and politicians involved in healthcare administration. This is important in advancing the care of older adults with cancer in Canada. As an initial step, a study of the current state of affairs in geriatric oncology in Canada would be helpful including available including formal characterization of available clinical programs and current outcomes in older adults with cancer. Subsequently sharing evidence of improvements from interventions on outcomes that positively impact patients but also society at large would be beneficial.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this paper. This is an appropriate call to action paper, supported by a narrative review and highlighting the issues pertinent to Canada-wide.

Just one suggest to provide the main key points after the sentence "This paper describes the .... current gaps in care......". The abstract needs to attract the readers and it doesn't have enough to entice people to read further.

Author Response

Just one suggest to provide the main key points after the sentence "This paper describes the .... current gaps in care......". The abstract needs to attract the readers and it doesn't have enough to entice people to read further.

Thank you for the feedback. We have amended the abstract to include more information which hopefully makes it more interesting.

Most patients diagnosed with and dying from cancer in Canada are older adults with aging contributing to the large projected growth in cancer incidence. Older adults with cancer have unique needs, and on a global scale increasing efforts have been made to address recognized gaps in their cancer care. However, in Canada, geriatric oncology remains a new and developing field. There is increasing recognition about the value of geriatric oncology and there are a growing number of healthcare providers interested in developing the field. While there are increasing number of dedicated programs in geriatric oncology, they remain limited overall. Developing novel methods to delivery geriatric care in the oncology setting and improving visibility is important. Formal incorporation of geriatric oncology curriculum into training is critical to improve both knowledge and demonstrate value to healthcare providers. Although a robust group of dedicated researchers exist, increased collaboration is needed to capitalize on existing expertise. Dedicated funding is critical to promoting clinical programs, research, and training new clinicians and leaders in the field. By addressing challenges and capitalizing on opportunities for improvement, Canada can better meet the unique needs of its aging population with cancer and ultimately improve their outcomes.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear author,

I appreciate the responses to my comments and the changes made.

However, I feel that the most important point of the article's approach remains unresolved.

An article entitled "Improving Care for Older Adults with Cancer in Canada: A Call to Action" should cover the full range of geriatric assessment possibilities: from the standard goal of a CGA performed by a geriatric expert to more basic tools (GA) that allow for more widespread use but provide less value. The article only discusses the latter possibility. To understand what a GA consists of, the concept of CGA must first be described. It is important to convey that the GA, in any of its formats, is a resource for simplifying the CGA to facilitate the implementation of geriatric assessment.

Author Response

We’d like to thank the reviewer for their ongoing diligence about the distinction between CGA and GA. Certainly one of our authors has been vocal about the distinction between the two.

We have added in clarification of the difference between a GA and GA and management or CGA. (Section 3, paragraph 2):

GA is a multidimensional process that seeks to evaluate a patient’s health in multiple domains, including medical, psychosocial and functional, to identify vulnerabilities not otherwise captured through traditional oncologic assessment. While assessment is important, it is often the intervention and management that is important to capitalize on outcomes. This process of addressing identified impairments is often referred to as GA and management (GAM) or comprehensive geriatric assessment (CGA).

In addition we have updated the section to highlight when studies did GA vs. GA and management (GAM). We elected to use the term GAM which is more consistent with the wordage used by the ASCO guidelines. We highlighted that the Practical Geriatric Assesment tool is a form of GA and that we highlighted that GA without management may not result in improved patient outcomes. (Section 3, paragraph 4, sentences 1, 4 and 6):

Considering this data, several international organizations, including the International Society of Geriatric Oncology (SIOG) and the American Society of Clinical Oncology (ASCO) recommend a GAM in patients aged ≥65 contemplating systemic therapy (54,55)…ASCO therefore updated their guidelines in 2023 to try and address these barriers unveiling the Practical Geriatric Assessment (PGA) tool, a structured GA, which prioritizes evaluation of key geriatric domains associated with cancer care outcomes, namely physical/cognitive/emotional health, comorbidities, polypharmacy, nutrition, and social support…For each domain in the PGA, ASCO advise assessment measures that can be efficiently completed in clinic and provides suggestions about how to utilize findings and address vulnerabilities identified (management), an important part of improving patient outcomes and actualizing the benefits of GAM reported in randomized studies (51).

We hope this addresses the reviewer’s concerns. We note that in Table 1, all studies included are CGA/GAM.

Reviewer 2 Report

Comments and Suggestions for Authors

now paper is better, I recommend to perform a systematic research of studies to include in table 1, explain the target goal and inclusion-exclusion criteria, this is important to avoid the risk of not include important studies

Author Response

Thank you for the suggestion. As you know, systematic reviews are rigorous with set methodology and criteria to conduct (including a PRISMA checklist as you suggested previously). This was not the intent of the paper and would be challenging to do in the time requested for a response. For this reason we did refer to other systematic reviews in case the reader is interested in learning more.

I am thus wondering if the reviewer is asking for some information about how the studies we put into Table 1 were chosen? Essentially we reviewed the ASCO guidelines and the systematic reviews and correlated them. We also only included randomized studies compared to usual oncologic care with outcomes of interest (related to oncologic outcomes).

Is this what the reviewer is looking for? The reviewer has been very thoughtful and we wish to address this the best we can but doing a systematic review within a call to action paper is not possible and beyond the purview of the paper (which is really more focused on the Canadian landscape of geriatric oncology, rather than geriatric assessment itself).

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

well paper is now better, I suggest add a table to evaluatre the quality o your selected papers

Author Response

Please see revision with addition of Table 2, as per line 148 and lines 185-189.