Comprehensive geriatric assessment for older patients with cancer

[Management of advanced prostate cancer in elderly patients]

With the increase of the senior demographic, an increase in cancer including prostate cancer has been seen. The challenge is to offer personalized cancer care because of population specificity. The only way is to share two experiences: the oncologist's experience who knows prostate cancer, prognosis and adverses effects of treatments and geriatrician's experience who consider old patients in their entirety thanks to comprehensive geriatric assessment (CGA). This article provides data about treatments of prostate cancer and geriatric evaluation to demonstrate the importance to work together for a "tailored" care.

Predictors of early death risk in older patients treated with first-line chemotherapy for cancer

PURPOSE

Objective factors for making choices about the treatment of elderly patients with cancer are lacking. This investigation aimed to help physicians select appropriate treatments through the identification of factors that predict early death (< 6 months) after initiation of chemotherapy treatment.

PATIENTS AND METHODS

Previously untreated patients greater than 70 years of age who were scheduled for first-line chemotherapy for various types of cancer were included. Baseline abbreviated comprehensive geriatric assessment (aCGA), including the Mini-Mental State Exam, Timed Get Up and Go (GUG), Activities of Daily Living (ADL), Instrumental Activities in Daily Living (IADL), Mini Nutritional Assessment (MNA), Geriatric Depression Scale (GDS15), and comorbidities index (Cumulative Index Rating Scale-Geriatric), was carried out. Prognostic factors of early death were sought from aCGA results and traditional oncology measures.

RESULTS

A total of 348 patients were included across 12 centers in Southwest France (median age, 77.45 years; ratio of men to women, 1.47; advanced disease, 65%). Abnormal aCGA scores were observed for 18.1% of patients on the ADL, 73.0% of patients on the IADL, 24.1% of patients on the GUG, 19.0% of patients on the MMS, 44.0% of patients on the GDS15, and 64.9% of patients on the MNA. Advanced disease (odds ratio [OR], 3.9; 95% CI, [1.58 to 9.73]), a low MNA score (OR 2.77; 95% CI, [1.24 to 6.18]), male sex (OR, 2.40; 95% CI, [1.2 to 4.82]), and long GUG (OR, 2.55; 95% CI, [1.32 to 4.94] were associated with higher risk of early death.

CONCLUSION

In patients greater than 70 years of age with cancer, advanced disease, a low MNA score, and poor mobility predicted early death. We recommend that the MNA and GUG, performed by a trained nurse, be maintained as part of routine pretreatment workup in these patients to identify at-risk patients and to inform the decision-making process for chemotherapy.

Treatment and management of chronic lymphocytic leukemia in the elderly: what the pharmacist clinician should know

OBJECTIVE

To review the literature for current treatment options and supportive care management for elderly patients with chronic lymphocytic leukemia (CLL).

DATA SOURCES

PubMed searches using the terms chronic lymphocytic leukemia, elderly, practice guidelines, and controlled clinical trials were performed from 1949 through August 2011. Reference lists from relevant articles were examined for additional studies, review articles, and guidelines.

STUDY SELECTION AND DATA EXTRACTION

Eighty-three articles were generated and abstracted articles were chosen based on trial results that changed clinical practice, resulted in approval of new drugs for CLL by the Food and Drug Administration and/or had clinical relevance to the elderly population.

DATA SYNTHESIS

Fit elderly CLL patients have more treatment options than frail elderly. Most studies include patients younger than 65 years of age, and recent advances in treatment may not prove beneficial for all ages. Clinicians should use available evidence and clinical judgment when treating and monitoring elderly CLL patients.

CONCLUSION

Treatment armamentarium has improved over the last decade, yet clinical trials research should include more elderly cohorts as new agents are developed. Increased awareness of supportive care issues improves quality of life for a population with multiple disease complications.

Examining five- and ten-year survival in older women with breast cancer using cancer-specific geriatric assessment

PURPOSE

To examine five- and ten-year survival based on cancer-specific geriatric assessment (C-SGA) in older women with early stage breast cancer.

METHODS

We evaluated 660 women ≥65-years old diagnosed with stage I-IIIA primary breast cancer and attending physician permission to contact in four geographic regions in the United States of America (USA). Data were collected over ten-years of follow-up from consenting women's medical records, telephone interviews, National Death Index and Social Security Death Index. C-SGA was described by four domains using six measures: socio-demographic (financial resources); clinical (comorbidity, obesity); function (physical function limitations); and psychosocial (general mental health, social support). Survival from all-cause and breast-cancer-specific mortality and receipt of guideline-recommended therapy was assessed for different groups of subjects with C-SGA domain deficits (cut-off ≥3 deficits).

RESULTS

The proportion of women with ≥3 C-SGA deficits surviving ten-years was consistently statistically significantly lower (all-cause 26% versus 46% and breast-cancer-specific 76% versus 89%, p≤0.04). The proportion significantly decreased as number of C-SGA deficits increased (linear trend p<0.0001). Receipt of guideline-recommended therapy decreased with age but not consistently by number of C-SGA deficits. The all-cause and breast-cancer-specific death rate at five- and ten-years was consistently approximately two times higher in women with ≥3 C-SGA deficits even when fully adjusted for confounding factors (HR(5-yrAllCauseFullyAdjusted)=1.87 [1.36-2.57], HR(10-yrAllCauseFullyAdjusted)=1.74 [1.35-2.15], HR(5-yrBreastCancerFullyAdjusted)=1.95 [1.18-3.20], HR(10-yrBreastCancerFullyAdjusted)=1.99 [1.21-3.28]).

CONCLUSION

Regardless of age and stage of disease, C-SGA predicts five- and ten-year all-cause and breast-cancer-specific survival in older women. Hence, C-SGA may provide an effective strategy to guide treatment decision-making and to identify risk factors for intervention.

Biological, clinical, and psychosocial correlates at the interface of cancer and aging research

In September 2010, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging, conducted the first of three planned conferences to discuss research methodology to generate the highest quality research in older adults with cancer and then disseminate these findings among those working in the fields of cancer and aging. Conference speakers discussed the current level of research evidence in geriatric oncology, outlined the current knowledge gaps, and put forth principles for research designs and strategies that would address these gaps within the next 10 years. It was agreed that future oncology research trials that enroll older adults should include: (1) improved standardized geriatric assessment of older oncology patients, (2) substantially enhanced biological assessment of older oncology patients, (3) specific trials for the most vulnerable and/or those older than 75 years, and (4) research infrastructure that specifically targets older adults and substantially strengthened geriatrics and oncology research collaborations. This initial conference laid the foundation for the next two meetings, which will address the research designs and collaborations needed to enhance therapeutic and intervention trials in older adults with cancer.

[Myelodysplastic syndrome in the elderly: comprehensive geriatric assessment and therapeutic recommendations]

The onset of myelodysplastic syndromes (MDS) is usually around the age of 70. Despite this, most clinical trials are restricted to younger subjects. Thus, the management of elderly patients with MDS is not always optimal. Physiologically, elderly patients show characteristics that differ from those of younger patients and that condition their pharmacological treatment. In this regard, the comprehensive geriatric assessment (CGA) becomes particularly important. This document gathers conclusions from the 1(st) Meeting of Members of the Sociedad Española de Medicina Geriátrica and the Sociedad Española de Hematología y Hemoterapia, with the objective of proposing the establishment of CGA instruments to assist in the decision-making process of elderly patients with MDS. The results of this consensus document will focus on the diagnosis, prognosis, treatment and management of adverse events in this age group.

The use of radiation therapy in the geriatric population

The foregoing, it is hoped, has provided at least a taste of the past, present, and future in the use of RT for the elderly population. Based on many ongoing studies, it becomes clear that the radiation oncology world has come to recognize the geriatric population’s ability to tolerate, and perhaps even thrive from, a course of RT, when it is offered appropriately. In the final analysis, it has become clear that no simple age cutoff can substitute for clinical acumen and a thorough assessment of patients’ general health before the best treatment regimen can be chosen. One need only follow the trend both in American and in European trials (the RTOG and the EORTC) to appreciate the acceptance that has taken hold that there need not be an age cutoff so much as a set of clinical criteria, including performance status and other assessments of function and comorbidity, prior to patient enrollment in anational trial. With such an outlook, we eagerly anticipate the results from these trials and look forward to implementing them in our treatment of young and old patients alike.

Cancer surgery in the elderly

The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.

Polypharmacy and food-drug interactions among older persons: a review

Polypharmacy is generally defined as the use of 5 or more prescription medications on a regular basis. The average number of prescribed and over-the-counter medications used by community-dwelling older adults per day in the United States is 6 medications, and the number used by institutionalized older persons is 9 medications. Almost all medications affect nutriture, either directly or indirectly, and nutriture affects drug disposition and effect. This review will highlight the issues surrounding polypharmacy, food-drug interactions, and the consequences of these interactions for the older adult.

Does Life Expectancy Affect Treatment of Women Aged 80 and Older with Early Stage Breast Cancers?

BACKGROUND: Data are needed on how life expectancy affects treatment decisions among women ≥80 years with early stage breast cancer. METHODS: We used the linked Surveillance Epidemiology and End Results-Medicare claims dataset from 1992-2005 to identify women aged ≥80 newly diagnosed with lymph node negative, estrogen receptor positive tumors, ≤5 centimeters. To estimate life expectancy, we matched these women to women of similar age, region, and insurance, not diagnosed with breast cancer. We examined 5-year mortality of matched controls by illness burden (measured with the Charlson Comorbidity Index [CCI]) using Kaplan-Meier statistics. We examined treatments received by estimated life expectancy within CCI levels. We further examined factors associated with receipt of radiotherapy after breast conserving surgery (BCS). RESULTS: Of 9,932 women, 39.6% underwent mastectomy, 30.4% received BCS plus radiotherapy, and 30.0% received BCS alone. Estimated 5-year mortality was 72% for women with CCIs of 3+, yet 38.0% of these women underwent mastectomy and 22.9% received radiotherapy after BCS. Conversely, estimated 5-year mortality was 36% for women with CCIs of 0 and 26.6% received BCS alone. Age 80-84, urban residence, higher grade, recent diagnosis, mammography use, and low comorbidity, were factors associated with receiving radiotherapy after BCS. Among women with CCIs of 3+ treated with BCS, 36.9% underwent radiotherapy. CONCLUSIONS: Many women aged ≥80 with limited life expectancies receive radiotherapy after BCS for treatment of early stage breast cancers while many in excellent health do not. More consideration needs to be given to patient life expectancy when considering breast cancer treatments. KEY WORDS: Breast cancer, older women, treatment, life expectancy, radiation.

Management of the Elderly Patient With Gynecologic Cancer: Report of the 2011 Workshop in Geriatric Gynecologic Oncology

Abstract

Reflecting the worldwide aging trend and close association of aging with cancer, geriatric oncology is now growing beyond its pioneer years. Nevertheless, geriatric oncology in the gynecologic field is in the beginning stage; indeed, there is no geriatric specialist who is trained in this particular field of gynecologic oncology. Therefore, we held the first workshop in geriatric gynecologic oncology. In this review, we summarize what we discussed at the workshop and provide evidence-based recommendations for the diagnosis and treatment of gynecologic cancer in elderly individuals.

Management of cancer in the older adult

Cancer incidence and mortality rise exponentially in the elderly. With the aging of the population there is an urgent need to address this issue with evidence-based guidelines. Delayed diagnosis and incomplete workup and treatment are well documented in this population. Incorporation of a geriatric evaluation in oncology practice should be routinely implemented to prevent adverse outcomes. Treatment decisions in the elderly should not be based solely on survival gains but should also take quality of life into consideration. Cancer treatment is safe and effective in the elderly population. Social issues and other comorbidities should be addressed to improve compliance and outcome. Many unanswered questions regarding the optimal management of elderly cancer patients can be addressed only with the new clinical trials. Eliminating age bias among health care providers by providing education will help achieve optimal care for the elderly with cancer.

Adjuvant chemotherapy for breast cancer in older women: emerging evidence to aid in decision making

To prevent breast cancer-related recurrence and death, adjuvant therapy, including chemotherapy, is given. The decision to deliver chemotherapy requires careful weighing of the risk of toxicity versus the estimated benefit. The risk and benefit are based on information from clinical trials, statistical models, and past clinical experience . Compared to younger patients, it is perceived that older patients have cancers that are lower risk, gain less benefit from chemotherapy, and are at higher risk of toxicity. There is now strong evidence that healthy older women tolerate treatment and stand to gain the same benefits from treatment as do younger women. Numeric age alone, therefore, does not justify withholding adjuvant chemotherapy. New tools to aid in the decision are needed. Fortunately, the expected great increase in the size of the geriatric population spawned the field of geriatric oncology and the development of brief, practical versions of the Comprehensive Geriatric Assessment (CGA) for use in busy oncology clinics are in sight. It is time for us to incorporate elements of the CGA into practice, to systematically identify older patients at substantial risk of toxicity. For frail older women with breast cancer, no therapy or less toxic therapies can be considered, some of which are suggested herein. In addition, as always in oncology, physicians and patients should look for and participate in clinical trials that will define how to treat cancer, especially in older patients, in the future.

Mini Nutritional Assessment (MNA) and biochemical markers of cachexia in metastatic lung cancer patients: interrelations and associations with prognosis

PURPOSE

Lung cancer patients frequently present with weight loss in the context of the cachexia syndrome. Despite its high clinical significance, definite diagnostic criteria of cachexia are lacking. Nutritional screening questionnaires, like the Mini Nutritional Assessment (MNA), have been proposed for the timely diagnosis of the syndrome. The aim of this study was to evaluate the correlation of MNA with laboratory markers of inflammation/cachexia in patients with metastatic lung cancer. The prognostic value of the measured parameters was also examined.

PATIENTS AND METHODS

Patients with metastatic lung cancer referred for systemic therapy were eligible. Baseline clinical characteristics were recorded and nutritional status was assessed using MNA. Blood samples were also collected and the following parameters were measured: hemoglobin (Hb), albumin (Alb), C-reactive protein (CRP), ghrelin, adiponectin, leptin and insulin growth factor I (IGF-I).

RESULTS

Totally, 115 patients (101 males) [median age 66 years (range 32-86)] were evaluated. According to MNA score, 27 (23.5%) patients were well nourished, 59 (51.3%) were at nutritional risk and 29 (25.2%) were already malnourished at diagnosis. MNA correlated with the following parameters: Hb (p=0.001), albumin (p<0.001), CRP (p=0.002), adiponectin (p=0.037) and leptin (p=0.008). After a median follow up of 38.2 months, multivariate analysis revealed that age (p=0.008), number of metastatic sites (p<0.001), MNA (p=0.044) and leptin (p=0.004) independently correlated with overall survival.

CONCLUSIONS

Based on the MNA, the majority of patients were either malnourished or at nutritional risk. MNA correlated with laboratory parameters related to inflammation/cachexia and was independently associated with survival.

Analysis of very elderly (≥80 years) non-hodgkin lymphoma: impact of functional status and co-morbidities on outcome

Data on outcome, prognostic factors, and treatment for very elderly non-Hodgkin lymphomas (NHL) is sparse. We conducted a multicentre retrospective analysis of NHL patients ≥80 years (at diagnosis) treated between 1999 and 2009. Detailed characteristics were obtained including geriatric syndromes, activities of daily living (ADLs), and co-morbidities using the Cumulative Illness Rating Scale-Geriatrics (CIRS-G). We identified 303 patients: 170 aggressive NHL (84% B cell/16% T cell) and 133 indolent NHL (82% B cell/18% T cell). Median age was 84 years (80-95). A geriatric syndrome was present in 26% of patients, 18% had ≥1 grade 4 CIRS-G, and 14% had loss of ADLs. At 49-month median follow-up, 4-year progression-free (PFS) and overall survival (OS) for aggressive NHLs were 31% and 44% respectively (stage I/II: PFS 53% and OS 66%; stage III/IV: PFS 20% and OS 32%; P < 0·0001 and 0·0002, respectively). Four-year PFS and OS for indolent NHL were 44% and 66% respectively, regardless of stage. Multivariate regression analysis identified two key factors that predicted inferior PFS and OS for both NHL groups: lack of CR and loss of ADLs. Prospective studies for very elderly NHL that incorporate geriatric tools, especially ADLs, are warranted.

Study protocol of KLIMOP: a cohort study on the wellbeing of older cancer patients in Belgium and the Netherlands

Background

Cancer is mainly a disease of older patients. In older cancer patients, additional endpoints such as quality of survival and daily functioning might be considered equally relevant as overall or disease free survival. However, these factors have been understudied using prospective designs focussing on older cancer patients. Therefore, this study will focus on the impact of cancer, ageing, and their interaction on the long-term wellbeing of older cancer patients.

Methods/Design

This study is an observational cohort study. We aim to recruit 720 cancer patients above 70 years with a new diagnosis of breast, prostate, lung or gastrointestinal cancer and two control groups: one control group of 720 patients above 70 years without a previous diagnosis of cancer and one control group of 720 cancer patients between 50 - 69 years newly diagnosed with breast, prostate, lung or gastrointestinal cancer. Data collection will take place at inclusion, after six months, after one year and every subsequent year until death or end of the study. Data will be collected through personal interviews (consisting of socio-demographic information, general health information, a comprehensive geriatric assessment, quality of life, health locus of control and a loneliness scale), a handgrip test, assessment of medical records, two buccal swabs and a blood sample from cancer patients (at baseline). As an annex study, caregivers of the participants will be recruited as well. Data collection for caregivers will consist of a self-administered questionnaire examining depression, coping, and burden.

Discussion

This extensive data collection will increase insight on how wellbeing of older cancer patients is affected by cancer (diagnosis and treatment), ageing, and their interaction. Results may provide new insights, which might contribute to the improvement of care for older cancer patients.

Comparison of safety and efficacy of S-1 monotherapy and S-1 plus cisplatin therapy in elderly patients with advanced gastric cancer

BACKGROUND

Although S-1 plus cisplatin (SP) therapy is recognized as the standard treatment for advanced gastric cancer (AGC) in Japan, its safety and efficacy in elderly patients have not been investigated sufficiently.

METHODS

We retrospectively reviewed the data of 58 patients with AGC selected from 82 consecutive patients who were ≥70 years old and were treated with SP or S-1 monotherapy as the first-line therapy. In SP, S-1 (40 mg/m(2), bid) was administered for 3 weeks and cisplatin (60 mg/m(2)) on day 8, every 5 weeks. In S-1 monotherapy, S-1 (40 mg/m(2), bid) was administered for 4 weeks, every 6 weeks.

RESULTS

SP and S-1 was administered in 21 and 37 patients, respectively. There were some differences in patient characteristics between the treatment groups, such as histological type (P = 0.16); the presence of liver metastasis (P = 0.07); and the presence of peritoneal metastasis (P = 0.02). The incidences of grade 3/4 hematological toxicities were 57% (12/21) in the SP and 35% (13/37) in the S-1 group (P = 0.17). Those of non-hematological toxicities were 14% (3/21) and 14% (5/37) for anorexia, 10% (2/21) and 14% (5/37) for fatigue, and 5% (1/21) and 5% (2/37) for nausea in the SP and S-1 groups, respectively. Median progression-free survival and median overall survival in the SP and S-1 groups were 5.0 and 5.2 months, and 14.4 and 10.9 months, respectively.

CONCLUSION

SP and S-1 therapy were both feasible in elderly patients, though there is the risk of a high incidence of hematological toxicities.

Pretransplantation assessments and symptom profiles: predicting transplantation-related toxicity and improving patient-centered outcomes

With the advent of reduced-intensity conditioning regimens and improvements in supportive care, hematopoietic cell transplantation (HCT) has become increasingly available to older adults and medically vulnerable populations with hematologic diseases. However, adverse outcomes including long-term treatment-related distress, disability (frailty), and death remain important concerns in this population. In other areas of oncology, comprehensive geriatric assessments have been used to stratify patients for treatment-related risk, and patient-reported outcomes (PROs) have helped in understanding treatment-related toxicity from a patient perspective. However, these powerful tools have not yet become widely used in HCT. Here, we review the theories and available data that support the development of pretreatment functional assessments and longitudinal PRO sampling in HCT. We discuss the potential for these techniques to improve transplantation outcomes through risk stratification, interventional studies, and predictive models that incorporate genetic and biomarker data. Predicting and understanding long-term transplantation-related toxicity through functional assessments and PROs will be critical to calculating the risk/benefit ratio of aggressive therapies in older patient populations, and we contend that functional assessments and PRO sampling should become standard parts of the routine evaluation of HCT patients.

Completion of Adjuvant Chemotherapy and Use of Health Services for Older Women With Epithelial Ovarian Cancer

Purpose

This analysis identifies factors associated with completion of adjuvant chemotherapy for patients with ovarian cancer and subsequent use of health services.

Patients and Methods

We used the Surveillance, Epidemiology, and End Results (SEER) –Medicare database to identify 4,617 women age 65 years or older with ovarian cancer diagnosed from 2001 to 2005. By using multivariable analyses with completion of chemotherapy as the outcome of interest, we describe factors associated with completion of treatment, including age, race, marital status, comorbidities, and sociodemographic factors. Use of health services was captured from Medicare claims.

Results

Among 4,617 patients with untreated ovarian cancer, 1,329 (28.8%) received no chemotherapy, 1,139 (24.7%) received a partial course of chemotherapy, and 2,149 (46.5%) completed chemotherapy. Women age 75 years or older were at greater risk of incomplete chemotherapy versus women age 65 to 74 years (odds ratio [OR], 1.64; 95% CI, 1.33 to 2.04). Having two or more comorbidities was also significantly associated with incomplete chemotherapy (OR, 1.83; 95% CI, 1.34 to 2.50). Among women who received either a partial or complete course of chemotherapy, we did not find an increase in use of health services (hospitalizations, emergency department visits, or physician visits) for the oldest women (age 80 years or older) compared with younger women.

Conclusion

There is considerable room for improvement in helping older patients with ovarian cancer initiate and complete chemotherapy. The oldest women who completed chemotherapy in this study did not use health services more than younger women did. Treatment teams for older patients with ovarian cancer should include expertise in geriatric assessment, should carefully identify medical and psychosocial barriers to completing treatment, and should support patients throughout treatment.

The association between chronic disease burden and quality of life among breast cancer survivors in Missouri

Greater chronic disease burden may decrease quality of life (QOL) of breast cancer survivors. Our objective was to investigate the association between chronic disease burden and QOL in breast cancer survivors at 1 year post-diagnosis. We analyzed cross-sectional data collected 1 year post-diagnosis from a sample of female breast cancer survivors identified from the Missouri cancer registry. We used eight RAND-36 subscales to assess physical, emotional, and social functioning QOL domains. Using Katz's measure of comorbidity, we computed chronic disease burden (0, 1, and 2+). Multivariable general linear models for each QOL subscale were used to examine associations between chronic disease burden and QOL after controlling for potential covariates: socio-demographic, clinical, psychosocial, behavioral risk factors, and access to medical care. Participants (n = 1089) were 58-year old on average (range 27-96) and mostly White (92%), married (68%), had at least a high school education (95%), and had health insurance (97%). Sixty-six percent of survivors had a chronic disease burden score of 0, 17% had 1, and 17% had 2+. Chronic disease burden was significantly associated with each QOL subscale in crude models (P < 0.001). In fully adjusted models, chronic disease burden was still significantly correlated with six subscales, but not with the emotional well-being and role limitations due to emotional problems subscales. One year post-diagnosis, breast cancer survivors with higher chronic disease burden had lower physical and social functioning than survivors without additional health conditions. These differences were not fully explained by relevant covariates. Identifying modifiable targets for intervention will be critical for improving QOL outcomes among survivors who have other chronic health conditions.

The feasibility of inpatient geriatric assessment for older adults receiving induction chemotherapy for acute myelogenous leukemia

OBJECTIVES

To test the feasibility and utility of a bedside geriatric assessment (GA) to detect impairment in multiple geriatric domains in older adults initiating chemotherapy for acute myelogenous leukemia (AML).

DESIGN

Prospective observational cohort study.

SETTING

Single academic institution.

PARTICIPANTS

Individuals aged 60 and older with newly diagnosed AML and planned chemotherapy.

MEASUREMENTS

Bedside GA was performed during inpatient exmination for AML. GA measures included the modified Mini-Mental State Examination; Center for Epidemiologic Studies Depression Scale; Distress Thermometer, Pepper Assessment Tool for Disability (includes self- reported activities of daily living (ADLs), instrumental ADLs, and mobility questions); Short Physical Performance Battery (includes timed 4-m walk, chair stands, standing balance); grip strength, and Hematopoietic Cell Transplantation Comorbidity Index.

RESULTS

Of 54 participants (mean age 70.8 ± 6.4) eligible for this analysis, 92.6% completed the entire GA battery (mean time 44.0 ± 14 minutes). The following impairments were detected: cognitive impairment, 31.5%; depression, 38.9%; distress, 53.7%; impairment in ADLs, 48.2%; impaired physical performance, 53.7%; and comorbidity, 46.3%. Most were impaired in one (92.6%) or more (63%) functional domains. For the 38 participants rated as having good performance status according to standard oncologic assessment (Eastern Cooperative Oncology Performance Scale score ≤1), impairments in individual GA measures ranged from 23.7% to 50%. Significant variability in cognitive, emotional, and physical status was detected even after stratification according to tumor biology (cytogenetic risk group classification).

CONCLUSION

Inpatient GA was feasible and added new information to standard oncology assessment, which may be important for stratifying therapeutic risk in older adults with AML.

Analysis of prognostic factors of comprehensive geriatric assessment and development of a clinical scoring system in elderly Asian patients with cancer

PURPOSE

To determine the impact of each comprehensive geriatric assessment (CGA) domain on overall survival (OS) and develop a prognostic scoring system for elderly patients with cancer.

PATIENTS AND METHODS

A retrospective analysis of CGA data collected from 249 consecutive patients with cancer who attended the outpatient geriatric oncology clinic at the National Cancer Center Singapore age 70 years or older was performed. Univariate and multivariate analyses were performed using Cox proportional hazards method to identify significant prognostic factors within the CGA. A simple nomogram to predict OS was developed using regression coefficients from the multivariate model. Concordance between predicted and observed response of the individual patient score was evaluated by means of Harrell's c-index. Calibration was performed using simulated data via bootstrap.

RESULTS

Median age of the patients was 77 years (range, 70 to 94 years). In our model, age (hazard ratio [HR], 1.04; 95% CI, 1.01 to 1.07), abnormal albumin level (HR, 1.97; 95% CI, 1.23 to 3.15), poor Eastern Cooperative Oncology Group performance status (≥ 2 v < 2: HR, 1.77; 95% CI, 1.15 to 2.72), abnormal geriatric depression scale status (HR, 1.81; 95% CI, 1.29 to 2.56), high malnutrition risk (high v low risk: HR, 1.84; 95% CI, 1.17 to 2.87), and advanced disease stage (late v early: HR, 1.71; 95% CI, 0.98 to 2.95) were independent predictors of survival.

CONCLUSION

Results confirm the importance of the CGA in assessment of elderly patients with cancer. The development of this nomogram incorporating these prognostic factors helps predict OS of patients, for further intervention.

Adherence and oral agents with older patients

OBJECTIVE

Oral antineoplastic agents offer multiple advantages in cancer therapies. Thus, understanding issues of adherence to these agents for older adults becomes critical to successful comprehensive care of the older cancer patient.

DATA SOURCES

This analysis of adherence to oral agents among older cancer patients draws on interdisciplinary geriatric and oncologic research reports and clinical reviews.

CONCLUSION

Older adults are at increased risk for poor adherence to oral agents. Barriers to adherence are diverse. Problems emerge from age-related physical changes, comorbid conditions, polypharmacy, and drug interactions. Psychosocial barriers include limited insurance coverage and transportation problems to social isolation and inadequate social support.

IMPLICATION FOR NURSING PRACTICE

Nurses should lead interdisciplinary, individualized plans of care to mitigate barriers and support adherence to cancer therapy.

Clinical pharmacology of chemotherapy agents in older people with cancer

Populations around the world are aging, and the associated increase in cancer incidence has led to the recognition of the importance of geriatric oncology. Chronological age is a poor determinant of pharmacological response to cancer chemotherapy agents. Age-associated changes in physiology and organ function have a significant impact on the clinical pharmacology of cancer chemotherapy agents used in cancer treatment. Altered response to medicines in older people is a consequence of changes in body composition, organ function, concomitant pathophysiology, multiple medications, genetic determinants of drug response, and patient's clinical status. These issues highlight the need to individualize the management of cancer in the older people with consideration of age-related changes in the clinical pharmacology of cancer drugs, analgesics, and adjunctive therapies.

Systemic therapies for metastatic renal cell carcinoma in older adults

The introduction of targeted therapies has radically changed the treatment paradigm for metastatic renal cell carcinoma (mRCC). However, multiple clinical dilemmas have emerged. For instance, limited data are available to juxtapose the safety and efficacy profile of targeted therapies between older and younger adults. Herein, pivotal trials of vascular endothelial growth factor (VEGF)- and mammalian target of rapamycin (mTOR)-directed therapies are assessed in the context of their implications in treating older adults with mRCC. In general, subset analyses from these pivotal studies suggest similar efficacy of targeted therapies amongst older adults. Aging is accompanied by a multitude of physiological changes, as well as an increased prevalence of co-morbidities. The age-related toxicity profiles of targeted agents for mRCC are detailed to provide a framework for the risks and benefits of these therapies in older adults. Ultimately, tools such as the Comprehensive Geriatric Assessment (CGA) that account for physiological (as opposed to chronological) age may prove useful in the evaluation and treatment of older adults with mRCC.

Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study

PURPOSE

Older adults are vulnerable to chemotherapy toxicity; however, there are limited data to identify those at risk. The goals of this study are to identify risk factors for chemotherapy toxicity in older adults and develop a risk stratification schema for chemotherapy toxicity.

PATIENTS AND METHODS

Patients age ≥ 65 years with cancer from seven institutions completed a prechemotherapy assessment that captured sociodemographics, tumor/treatment variables, laboratory test results, and geriatric assessment variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status). Patients were followed through the chemotherapy course to capture grade 3 (severe), grade 4 (life-threatening or disabling), and grade 5 (death) as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events.

RESULTS

In total, 500 patients with a mean age of 73 years (range, 65 to 91 years) with stage I to IV lung (29%), GI (27%), gynecologic (17%), breast (11%), genitourinary (10%), or other (6%) cancer joined this prospective study. Grade 3 to 5 toxicity occurred in 53% of the patients (39% grade 3, 12% grade 4, 2% grade 5). A predictive model for grade 3 to 5 toxicity was developed that consisted of geriatric assessment variables, laboratory test values, and patient, tumor, and treatment characteristics. A scoring system in which the median risk score was 7 (range, 0 to 19) and risk stratification schema (risk score: percent incidence of grade 3 to 5 toxicity) identified older adults at low (0 to 5 points; 30%), intermediate (6 to 9 points; 52%), or high risk (10 to 19 points; 83%) of chemotherapy toxicity (P < .001).

CONCLUSION

A risk stratification schema can establish the risk of chemotherapy toxicity in older adults. Geriatric assessment variables independently predicted the risk of toxicity.

Metastatic spine disease in the elderly: diagnostic and management considerations

Metastatic spine disease is becoming a more frequent problem in cancer patients as advancements in treatment for primary tumors prolong patient survival. Elderly patients over 60 years of age make up the majority of these cases, with the incidence of metastatic disease several folds higher in the elderly than in any other age group. These patients are also the most challenging group to treat, given higher rates of comorbidities and decreased tolerance to medical, surgical and radiation therapies. Advancements in therapeutic strategies, including minimally invasive surgeries and stereotactic radiosurgery, have provided increasingly attractive treatment options for elderly patients owing to their decreased procedure-associated morbidity. This article will discuss efficacy and limitations of conventional, as well as more recent, treatment modalities with an emphasis on their role in the management of elderly patients.

Optimising the management of primary breast cancer in older women - a report of a multi-disciplinary study day

PURPOSE

The objectives of the study day were to (i) develop an in-depth understanding around the biology and treatment options; (ii) explore the specific physical and psychosocial needs and consideration including patients perspective; and (iii) gain insight into the development of a dedicated, holistic and multi-disciplinary clinic service and the importance of supporting research, for older women with primary breast cancer.

DESIGN

The format included presentations (with lectures from external and local faculty, and short research papers from Nottingham) with a number of interactive discussions, and sharing of patients' experience.

RESULTS

Four sessions were held covering (i) pathological features, (ii) role of radiotherapy and adjuvant chemotherapy, (iii) role of surgery, geriatric assessment and quality of life issues, and (iv) challenges in running research trials.

CONCLUSIONS

A dedicated and joint team approach is required to improve clinical service and support research, in order to optimise the management of primary breast cancer in older women.

The treatment of early breast cancer in women over the age of 70

One third of all breast cancers are diagnosed in women aged 70 or over. Older women are a heterogeneous population who are under-represented in clinical trials, and as a result uncertainty can exist as to what represents optimal treatment. This minireview, from an international authorship, summarises the existing evidence surrounding the management of early breast cancer in women aged 70 and over. The use of primary surgery and endocrine therapy, and adjuvant chemotherapy, radiotherapy, endocrine therapy and trastuzumab are discussed. Reference is made to ongoing clinical trials in this area and areas of controversy are highlighted.

Polypharmacy in elderly patients with cancer: clinical implications and management

More and more elderly people with cancer are treated in oncology clinics worldwide every year, many of whom have comorbid disorders treated with one or more drugs. Moreover, these patients might also take self-prescribed over-the-counter drugs or complementary and alternative medicines, which they might not tell their doctor about. Initiation of chemotherapy with one or more cytotoxic or targeted agents and drugs for treatment of cancer symptoms or toxic effects related to treatment can result in polypharmacy. We examine the clinical implications of polypharmacy. Challenges for the medical teams who treat elderly patients with cancer include identification of what drugs are actually being taken by the patient, avoidance or management of any adverse effects or drug interactions, and reassessing the patient's overall treatment. We address these issues and propose practical recommendations for management of treatment for elderly patients with cancer.

Weekly regimen of paclitaxel and carboplatin as first-line chemotherapy in elderly patients with stage IIIB-IV non small cell lung cancer (NSCLC): results of a phase II study

Single-agent chemotherapy is the preferred treatment option in chemonaive elderly patients with advanced nonsmall-cell lung cancer (NSCLC). The role of combination chemotherapy in this setting is uncertain although several studies report satisfactory efficacy and safety using weekly paclitaxel and carboplatin (AUC=6) as first-line chemotherapy in elderly patients. It is still unclear which schedule of this regimen which could offer the best therapeutic index. The aim of this study was to evaluate the activity and tolerability of concomitant weekly administration of paclitaxel and carboplatin in untreated elderly patients with advanced NSCLC. From february 2005 to April 2008 36 consecutive elderly patients with advanced NSCLC were enrolled. Median age was 74 years (range, 70-83 years) and median ECOG PS was 1 (range, 0-1). patients received carboplatin (AUC=2) and paclitaxel 80 mg/m² on days 1,8 and 15 every 28 days. All patients were evaluable for efficacy and toxicity; a median of 4 cycles was administered. Twelve patients had partial response (33%; 95% C.I. 15,8-52,3%), 10 patients (28%) showed stable disease. The median time to progression (TTP) was 5.7 months (95% C.I. 3.1-8.6 months) with a median overall survival (MOS) of 9 months (95% C.I. 4.4-13.9 months). Toxicity was mild with no cases of febrile neutropenia; 5 patients (14%) developed grade 2 neuropathy. Our study confirms the substantial activity of weekly regimen of paclitaxel and carboplatin. Due to its favorable profile of toxicity this schedule could represent an interesting therapeutic option in selected chemonaive elderly patients with advanced NSCLC.

Care of the elderly patient with prostate cancer: what's new and what's the same

As the number of men in the United States 65 years of age or older increases--from 12% in 2000 to 20% in 2030--the burden of prostate cancer also is increasing. Standard therapy is appropriate for healthy men with a life expectancy of more than 10 years; however, clinicians may fear either overtreating frail patients or undertreating patients who are physically fit. Evidence suggests the best approach is to conduct a comprehensive geriatric assessment using available measures and published guidelines to individualize treatment plans. Recent Food and Drug Administration approval of cabazitaxel, sipuleucel-T, and denosumab has expanded available treatment options. Managing symptoms related to disease complications and side effects of treatment is increasingly more complicated with the addition of these new regimens and extended life expectancy. Pharmacists' participation in patient assessment and supportive care are necessary components of comprehensive care for cancer patients.