Best of Heme 2025: Hematology and Aging – Tailoring Treatment for Older Adults
Presented by:
William Dale, MD, PhD, FASCO
Conference:
Best of Heme 2025
Introduction
As the population ages, hematologic malignancies are increasingly diagnosed in older adults. Most clinical trial data, however, is derived from younger patients, leaving significant gaps in evidence-based care for older individuals. At the 2025 Best of Hematology conference, Dr William Dale, a geriatric oncologist at City of Hope, discussed geriatric assessment (GA)-driven strategies to optimize treatment decisions, reduce toxicity, and improve outcomes for older adult patients with blood cancers.
Key Learning Objectives
Dr Dale’s presentation was focused on recognizing the unique challenges of treating older adults with hematologic malignancies and making better use of geriatric assessments (GA) to guide therapy. In addition, Dr Dale outlined some risk prediction models, including the CARG toxicity tool and CHARM (Composite Health Assessment Risk Model), which can be used to assess chemotherapy and transplant-related toxicity, respectively. He further noted the importance of multidisciplinary strategies to optimize care for older patients.
The Aging Population in Hematologic Oncology
Dr Dale emphasized that while aging is a major risk factor for hematologic malignancies, the older adults most encountered in clinic often differ from those who have been studied in clinical trials. Indeed, older adults represent most hematology patients, but historically they have been dramatically underrepresented in clinical studies. An important concept for clinicians to understand, Dr Dale noted, is that chronological age does not necessarily equal biologic age, in that many older adults are in fact fit enough for treatment, while others have vulnerabilities that may require more tailored approaches. In this regard, he noted that comprehensive geriatric assessment (GA) is a tool that can be used to identify frailty, functional impairments, as well as social determinants of health (SDOH), all of which can impact treatment outcomes.
Why Do We Need Geriatric Assessments (GA)?
A comprehensive GA evaluates several critical factors, beyond performance status (PS) alone, and as such, provides a more accurate picture of an older patient’s fitness for treatment. Dr Dale noted the GA is composed of 7 key domains, including Physical function (for which between 7 and 89% of older patients may have deficits), Comorbid conditions (seen in between 19 and 58% of older patients), Mental health conditions(e.g., depression, anxiety, seen in between 10 and 56% of patients), Medication burden, or polypharmacy(present in between 28 and 58% or older patients), Cognitive impairment (seen in 1 to 24% of older patients), Nutritional deficits (seen in about 28 to 45% of patients) and Social support (which can be inadequate for about 54% of patients). One of the key statistics that Dr Dale noted is that 25% or more of older hematology patients have cognitive impairment that goes undiagnosed.
Predicting Chemotherapy Toxicity in Older Adults
Dr Dale highlighted a freely available tool that clinicians can use to help predict toxicity of chemotherapy. The CARG (Cancer and Aging Research Group) toxicity tool was developed specifically to predict chemotherapy-related toxicity risk in older adults. Notably, the CARG toxicity tool effectively outperforms the Karnofsky Performance Status (KPS) in identifying patients at risk of toxicity. This 11-factor risk model predicts grade 3-5 toxicity risk, from 25% to nearly 90%, and is available online for free at www.mycarg.org. Using the CARG tool can help clinicians determine whether to use full-dose chemotherapy, dose reductions, or less toxic alternative regimens.
Geriatric Assessment-Guided Interventions: Clinical Trials Supporting GA
Dr Dale noted results from two landmark randomized trials which support the use of GA in oncology. The GAIN Trial (City of Hope, published in JAMA Oncology 2021) showed that GA with targeted supportive care led to reduced chemotherapy toxicity and increased completion of advance directives for older patients with cancer. The GAP Trial (published in Lancet 2021) showed that GA-directed interventions led to a 20% reduction in the occurrence of grade 3-5 toxicity. In addition, polypharmacy was reduced leading to fewer adverse drug interactions. Importantly, survival was unchanged for patients, despite dose reductions, showing that less aggressive therapy did not compromise efficacy. Overall, Dr Dale noted that available data to date show that GA-directed interventions can effectively reduce toxicity without compromising survival.
Decision-Making in Older Adults: Balancing Risk vs. Benefit
Dr Dale outlined a framework for decision-making in older adults with hematologic malignancies to balance risk and benefit of therapies. He noted three key components in this process: 1) Assess vulnerability - Using a GA to identify risks such as frailty, polypharmacy and cognitive deficits, 2) Predict Treatment-Related Risks - Using tools such as the CARG Score (for chemotherapy toxicity) or other tools such as CHARM (see below) to assess transplant-related toxicity, and 3) Personalize Therapy Based on Goals of Care – Balance overall treatment intensity versus quality of life by engaging patients in shared decision making.
Transplant and CAR-T Therapy in Older Adults
Dr Dale noted that, historically, older adults have been largely excluded from hematopoietic stem cell transplant (HCT) and CAR-T cells trials based on chronological age alone. He highlighted CHARM (Composite Health Assessment Risk Model) which was developed to predict 1-year non-relapse mortality (NRM) following allogeneic HCT in adults ≥60 years. The clinical factors considered in the model include serum albumin, creatinine clearance, and CRP, cognition (MOCA), and the Hematopoietic Cell Transplantation-Comorbidity Index (HCT-CI). Using these variables, CHARM stratifies patients into risk tertiles and helps to determine their eligibility for transplant. Dr Dale noted the model will soon be available online for clinicians.
Expanding Transplant Access for Older Adults
Dr Dale described their current process at City of Hope, to evaluate older patients for transplant using GA, with three possible decisions: 1) Proceed with the transplant (for fit patients), 2) Defer and optimize to address reversible deficits, such as nutrition and/or mobility problems, or 3) Discuss alternative treatment options for higher risk patients. One of the key points to emphasize, he noted, is that chronological age alone should not be a barrier to interventions such as transplant or CAR-T therapy.
Barriers to Geriatric Assessment (GA) in Oncology
In the final portion of his presentation, Dr Dale noted that despite the proven benefits of GA, it has been largely underutilized in hematology clinics. He noted results from a recent survey of over 1,200 oncologists to identify the top 3 barriers for using GA routinely. These included uncertainty about which tools to use (76%), a lack of training in GA (72%), and a lack of clinical support staff (68%) to implement the tool. Some of the possible solutions to these barriers Dr Dale suggested, are the use of available online GA tools (e.g., MyCARG.org, CHARM calculator), the integration of GA into routine oncology visits (e.g., pre-clinic screening by nurses or medical assistants), and reimbursement reforms to support GA implementation. Overall, Dr Dale thought that GA should become standard of care in hematologic oncology.
Conclusion
Dr Dale’s presentation highlights the importance of geriatric assessment in hematologic oncology. By implementing GA-driven interventions, risk prediction tools, and shared decision-making, it is possible to tailor treatments to improve both quality and quantity of life in older adults with hematologic cancers.
Quick Summary
While older adults make up a majority of hematology patients, they remain significantly underrepresented in clinical trials.
Geriatric assessment (GA) can improve clinical decision-making, reduce treatment-related toxicities, and help to maintain survival.
Validated risk models (e.g., CARG toxicity tool, CHARM) can help guide chemotherapy and transplant decisions in patients with hematologic malignancies.
Chronological age alone should not be a basis for excluding patients from more intensive therapies.
Expanding and implementing the use of GA requires training, clinic workflow adaptation, and policy changes.
Speaker Disclosure Information: Dr Dale reports no relevant financial relationships for this presentation, and that the presentation and/or comments provide a balanced, non-promotional, and evidence-based approach to all diagnostic, therapeutic and/or research related content.
You can see the full presentation by Dr Dale at the 2025 Best of Hematology conference, beginning at the 58:00 mark, here.