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Enhancing collaboration to optimise medication therapy in older adults with cancer: a position paper from SOFOG-SFPO

The need for comprehensive management of older adults with cancer by the multidisciplinary team, particularly with support from pharmacy, is increasingly important. To this end, the Society of Geriatric Oncology and the French Society of Oncology Pharmacists have published a position paper to support this collaboration. Here, Chloé Herledan PharmD PhD, pharmacist, Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon and Université Claude Bernard Lyon 1, Lyon, France, shares an overview.

With an ageing population, providing optimal care for older patients with cancer is an increasingly important issue in modern oncology.

In this heterogeneous patient group, decisions on therapies and management must follow a multidimensional approach, integrating medical, socio-economic and psychological factors.

The benefits of incorporating a comprehensive geriatric assessment by a geriatrician or geriatric oncologist into the patient care pathway have been demonstrated in recent randomised clinical trials.1–3

Of the many collaborations essential to the care of older people with cancer, cooperation between pharmacists, oncologists and geriatricians is particularly important, as optimising drug therapy can be challenging in these patients.

They are particularly vulnerable to drug-related problems (DRPs), such as medication errors and inappropriate medication use, adverse drug effects, drug–drug interactions (DDIs), or difficulties with adherence.4,5

Polypharmacy – daily use of five or more drugs – is common in these patients and increases the risk of DRPs, which can result in adverse outcomes such as postoperative complications, chemotherapy toxicities and functional decline.4,6

Given these clinical consequences and associated healthcare expenditures, involving pharmacists in the multidisciplinary management of older patients with cancer seems essential.

Pharmaceutical care interventions, such as medication reconciliation and review, drug optimisation and deprescribing, or patient education, are effective in improving medication management and reducing DRPs and associated costs in this population.5,7,8

However, there is still a lack of guidance for structuring the collaboration of pharmacists with geriatricians and oncologists in the care pathway.

SoFOG and SFPO position paper

To support this development, geriatric oncologists from the French-speaking Society of Geriatric Oncology (SoFOG) and pharmacists from the French Society of Oncology Pharmacists (SFPO) recently produced a joint position paper.9

The article aims to emphasise the importance of collaboration between the geriatrician, oncologist and pharmacist, by demonstrating its relevance in several clinical situations and highlighting the pivotal aspects and challenges for its implementation in practice.

Clinical situations of special interest

All older patients with cancer are likely to benefit from collaborative practice involving pharmacists, geriatricians and oncologists, yet certain clinical situations are deemed high priorities.

  • Diabetes and cardiovascular comorbidities

Significant focus should be placed on optimising drug therapy in cases of cardiovascular comorbidities and/or diabetes. As these patients are often treated with multiple medications, the benefit–risk ratios should be regularly reassessed.

It is essential to meticulously consider therapeutic goals to limit side effects (hypoglycaemia, hypotension, bleeding, etc.) while avoiding undertreatment, as cardiovascular decompensation may be caused or aggravated by cancer and/or its treatment. Collaborative medication review is thus of particular importance in this context.

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  • Falls

Falls are a serious threat in geriatric oncology, with polypharmacy playing a major role in their occurrence.

Drug classes known to cause falls are commonly used in older patients, but cancer treatment can further increase this risk.10,11 This can be due to side effects of chemotherapy or the addition of certain supportive care medications.

Furthermore, falls can have severe consequences for older patients with cancer with osteoporosis or at risk of bleeding.12 Therefore, it is essential to conduct a therapeutic reassessment to reduce the risk of drug-induced falls in these patients.

  • Depression and anxiety

Depression is frequent in older adults with cancer but often undertreated.13 The optimisation of its treatment can improve patient outcomes (anxiety, sleep disorder, loss of appetite) and reduce the use of benzodiazepines.14

However selecting the appropriate antidepressant can be challenging, given their range of side effects and drug interactions with cancer treatments and routine medications.

The expertise of pharmacists can thus be valuable to geriatricians and oncologists when initiating or reassessing the treatment of depression. 

  • DDIs and adherence difficulties

DDIs are common among older patients with cancer, who often experience polypharmacy, with the addition of anticancer treatment and the possible use of complementary medicines.15,16

A comprehensive assessment of potential DDIs is strongly recommended, particularly at the start of anticancer treatment.

There are often difficulties with adherence from multiple causes including communication difficulties, dysphagia, polypharmacy and adverse drug events. In these situations, the involvement of pharmacists in multidisciplinary teams is essential to provide optimal patient-centred care.

Considerations and challenges for implementation

While collaboration between pharmacists, geriatricians and oncologists is particularly important at the start of anticancer treatment, it must continue throughout the patient’s care pathway. This pathway is particularly complex in geriatric oncology, with multiple providers and transitions between community and hospital settings increasing the risk of iatrogenic harm.

Cancer progression and successive treatment regimens are significant contributors to the decompensation in geriatric syndromes.17

Metastatic and palliative situations may lead to changes in therapeutic goals for the management of comorbidities. Regular and comprehensive reassessment of drug therapy is therefore necessary to evaluate the relevance, tolerability and potential for DDIs of each medication.

Conclusion

Given the many aspects for which collaborative practice with pharmacists could be valuable in geriatric oncology, their integration into multidisciplinary teams seems necessary to ensure optimal drug therapy management; however, it is often limited by funding constraints.18

Robust economic evaluations of pharmaceutical care are still lacking in geriatric oncology, although required to support the establishment of pricing models for the integration of pharmacists into multidisciplinary practice.

Nevertheless, given the medical evidence of its benefits, it seems crucial that funding considerations do not delay the development of collaborative practice and its incorporation into the recommendations of international scientific societies.

Author

Chloé Herledan PharmD PhD, pharmacist, Clinical Oncology Pharmacy Unit, Hospices Civils de Lyon and Université Claude Bernard Lyon 1, Lyon, France

References

  1. Li D et al. Geriatric Assessment–Driven Intervention (GAIN) on Chemotherapy-Related Toxic Effects in Older Adults With Cancer: A Randomized Clinical Trial. JAMA Oncol 2021;7:e214158
  2. Mohile SG et al. Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study. Lancet 2021;398:1894–904
  3. Soo WK et al. Integrated Geriatric Assessment and Treatment Effectiveness (INTEGERATE) in older people with cancer starting systemic anticancer treatment in Australia: a multicentre, open-label, randomised controlled trial. Lancet Healthy Longev 2022;3:e617–e627
  4. Mohamed MR et al. Associations of Polypharmacy and Inappropriate Medications with Adverse Outcomes in Older Adults with Cancer: A Systematic Review and Meta-Analysis. Oncologist 2020;25:e94–e108
  5. Herledan C et al. Impact of pharmaceutical care interventions on multidisciplinary care of older patients with cancer: A systematic review. J Geriatric Oncol 2023;101450
  6. Mohamed MR et al. Association of polypharmacy and potential drug-drug interactions with adverse treatment outcomes in older adults with advanced cancer. Cancer 2023;129:1096–104
  7. Herledan C et al. Clinical impact and cost-saving analysis of a comprehensive pharmaceutical care intervention in older patients with cancer. J Am Geriatr Soc 2023;Oct 11: doi:10.1111/jgs.18585
  8. Kantilal K et al. How-to guide for medication reviews in older adults with cancer: A Young International Society of Geriatric Oncology and Nursing & Allied Health Interest Group initiative. J Geriatr Oncol 2022;13:1283–6
  9. Herledan C et al. Enhancing collaboration between geriatricians, oncologists, and pharmacists to optimize medication therapy in older adults with cancer: A position paper from SOFOG-SFPO. Crit Rev Oncol Hematol 2023;190:104117
  10. de Jong MR, Van der Elst M, Hartholt KA. Drug-related falls in older patients: implicated drugs, consequences, and possible prevention strategies. Ther Adv Drug Saf 2013;4:147–54
  11. Kotwal A et al. Immune checkpoint inhibitors: an emerging cause of insulin-dependent diabetes. BMJ Open Diab Res Care 2019;7:e000591
  12. Myint ZW et al. Evaluation of Fall and Fracture Risk Among Men With Prostate Cancer Treated With Androgen Receptor Inhibitors: A Systematic Review and Meta-analysis. JAMA Netw Open 2020;3:e2025826
  13. Kok RM, Reynolds CF III. Management of Depression in Older Adults: A Review. JAMA 2017;317:2114–22
  14. Trevino KM, Saracino RM, Roth AJ. Symptomatology, assessment, and treatment of anxiety in older adults with cancer. J Geriatr Oncol 2012;12:316–19
  15. Ramsdale E et al. Polypharmacy, Potentially Inappropriate Medications, and Drug-Drug Interactions in Vulnerable Older Adults With Advanced Cancer Initiating Cancer Treatment. Oncologist 2022;27:e580–e588
  16. Clairet A-L et al. Interaction between phytotherapy and oral anticancer agents: prospective study and literature review. Med Oncol 2019;36:45
  17. Caillet P et al. Comprehensive geriatric assessment in the decision-making process in elderly patients with cancer: ELCAPA study. J Clin Oncol 2011;29:3636–42
  18. Walsh DJ et al. Medication assessment in older adults with cancer – Current practices in clinical pharmacy. J Geriatr Oncol 2023;14:101531.






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