Comprehensive geriatric assessment for older patients with cancer

Phase I/II study of vinorelbine and exisulind as first-line treatment of advanced non-small cell lung cancer in patients at least 70 years old: a wisconsin oncology network study

INTRODUCTION

Exisulind is an apoptotic agent with preclinical activity in non-small cell lung cancer (NSCLC). Vinorelbine is safe and effective in older patients with advanced NSCLC. We assessed these agents together as palliative treatment for older patients with advanced NSCLC.

METHODS

Chemotherapy-naive patients >/=70-years-old with stage IIIB-IV NSCLC and a performance status (PS)

RESULTS

Fourteen phase I patients (median PS 1; median age 78 years) were enrolled. Dose-limiting toxicities included grade 3 constipation (one patient), grade 3 febrile neutropenia (one patient) and grade 3 diarrhea (one patient). The maximum tolerated dose of oral exisulind with 25 mg/m/wk of intravenous vinorelbine was 125 mg twice daily. Thirty phase II patients (median PS 1; median age 78 years) were enrolled. Grade >/=3 neutropenia occurred in 14/30 patients. Two patients experienced neutropenic fever. There were no complete responses, one partial response and 12 patients with stable disease as their best response. The objective response rate was 4.0% (95% CI: 0.1-20.4%). Phase II median time-to-progression was 4.7 months (95% CI: 3.1-9.3 months) and median OS was 9.6 months (95% CI: 6.6-19.1 months).

CONCLUSIONS

This combination is safe, seems to have activity in the elderly with advanced NSCLC and a PS Collapse

Key Words

• elderly
• exisulind
• sulindac sulfone
• non-small cell lung cancer
• vinorelbine
• phase i
• phase ii

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MESH Headings

• Aged
• Aged, 80 and over
• Antineoplastic Combined Chemotherapy Protocols/therapeutic use
• Carcinoma, Non-Small-Cell Lung/drug therapy
• Carcinoma, Non-Small-Cell Lung/pathology
• Female
• Humans
• Lung Neoplasms/drug therapy
• Lung Neoplasms/pathology
• Male
• Maximum Tolerated Dose
• Neoplasm Staging
• Prognosis
• Sulindac/administration & dosage
• Sulindac/analogs & derivatives
• Survival Rate
• Vinblastine/administration & dosage
• Vinblastine/analogs & derivatives
• Vinorelbine

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Grants

• P30 CA014520 NCI NIH HHS
• P30 CA14520 NCI NIH HHS
• T32 CA009614 NCI NIH HHS
• U01 CA062491 NCI NIH HHS
• K12 CA087718 NCI NIH HHS

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Affiliation(s)

Steven Attia University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI
Anne M. Traynor University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI
KyungMann Kim University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI
Joseph J. Merchant McFarland Clinic PC, Ames, IA
Tien Hoang University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI
Harish G. Ahuja Aspirus Wausau Hospital, Wausau, WI
Peter A. Beatty Dean Cancer Clinic, Madison, WI
Richard M. Hansen Waukesha Regional Cancer Center, Waukesha, WI
Gregory A. Masters Medical Oncology-Hematology Consultants PA, Newark, DE
Kurt R. Oettel Gunderson Lutheran Hospital and Clinics, LaCrosse, WI
Gary R. Shapiro Johns Hopkins Kimmel Comprehensive Cancer Center, Baltimore, MD
Martha M. Larson University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI
Marilyn L. Larson University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Madison, WI
Joan H. Schiller University of Texas-Southwestern Medical Center, Dallas, TX

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Collaborators Collapse

Colon cancer: update on adjuvant therapy

Colon cancer is a public health problem worldwide. Although potentially curable at early stages, a substantial number of patients will inevitably present with or eventually develop metastatic disease, which is often incurable. Despite the progress achieved with the introduction of new cytotoxic agents, recurrence rates for patients with resected stage II/III disease remain > 20%. Therefore, a great deal of effort and resources have been put into improving early diagnosis and prevention tools as well as the efficacy of adjuvant treatment. Oxaliplatin-based chemotherapy is now considered the standard of care in node-positive colon cancer, but there remains controversy with regard to the indication and type of adjuvant treatment in patients with nodenegative disease. Oral fluoropyrimidines play a growing role in the management of colorectal cancer and can be currently considered an alternative to 5-fluorouracil. Numerous reports have suggested that elderly patients benefit equally from chemotherapy, but the growing numbers of octogenarian and nonagenarian patients in our clinics, many of whom occasionally struggle through treatment, are a reminder of the challenges ahead. Finally, as we might have reached a plateau in terms of cytotoxic chemotherapy, numerous clinical trials are now focusing on the role of biologic agents in the adjuvant setting.

Docetaxel-based chemotherapy in elderly patients (age 75 and older) with castration-resistant prostate cancer

BACKGROUND

There are no data on the patterns of care and outcome of very elderly patients with castration-resistant prostate cancer (CRPC) treated with docetaxel.

OBJECTIVE

To assess the routine use of first-line docetaxel-based chemotherapy in CRPC patients aged >75 yr.

DESIGN, SETTING, AND PARTICIPANTS

We reviewed the clinical files of 175 patients aged > or =75 yr with CRPC treated with first-line docetaxel in nine French tertiary care cancer centres from 2000 to 2007.

MEASUREMENTS

Response rate, survival, and adverse events (AE).

RESULTS AND LIMITATIONS

Median age was 78 yr. Ninety-five patients (54%) received a standard 3-wk regimen (SR), and 80 patients (46%) received an adapted regimen (AR) delivered on a weekly schedule with various times for rest periods. Patients treated with an AR were older (>80 yr) and had poorer performance status (PS; > or =2) than patients treated with the SR. The prostate-specific antigen (PSA) response rates were not significantly different between the standard and adapted treatment groups (71% vs 68%, p=0.79). The median progression-free survival (PFS) was 7.4 mo. The median overall survival (OS) was 15 mo. The incidence of grade 3 or 4 AEs was 46% and was correlated with poor PS and the presence of visceral disease but not with the regimen. Early discontinuation of treatment because of toxicity occurred more frequently in the AR group than in the SR group (30% vs 8.4%, p=0.0005). In multivariate analysis, only PS and the presence of visceral disease were predictors of OS.

CONCLUSIONS

Docetaxel is active and feasible in elderly patients with good PS. The optimal treatment of frail patients with CRPC remains to be established. Geriatric tools should be used to more accurately detect elderly CRPC patients who are unfit for chemotherapy. Age by itself should not be used as a criterion to deny patients with CRPC a potentially effective chemotherapy.

Implications of aging and self-tolerance on the generation of immune and antitumor immune responses

Cancer statistics show a disproportionately higher burden of tumors in the old. Most of the studies evaluating vaccination strategies have not taken into consideration the effect that aging has on the immune system. For the first time, we describe an animal tumor model in which self-tolerance and aging are present at the same time. FVB-Her-2/neu mice which are tolerant to neu antigens crossed with HLA-A2/Kb mice (A2xneu) develop spontaneous tumors when they are more than 22 months old. Analysis of CD8(+) T-cell-specific responses in A2xneu mice indicated that the priming activity of old A2xneu mice to induce an immune response was diminished compared with young animals. Following intratumoral injections of CpG-ODN, approximately 30% of young A2xneu mice rejected the tumor; however, no antitumor effect was observed in old A2xneu mice. Analysis of T regulatory cells (Treg) indicated that there are significantly more Tregs in old animals. After CpG-ODN vaccination plus Treg depletion, 70% of young A2xneu mice rejected the tumor. The same treatment prolonged survival in old A2xneu mice, but none of the animals rejected the tumor. Even though CpG-ODN injections plus Treg depletion could rescue the antitumor responses against self-tumor antigens in young tolerant mice, the same therapy is not as effective in old tolerant hosts. Relevant tumor models such as the A2xneu mice in which self-tolerance and aging are present at the same time are critical to allow the optimization of vaccination strategies to effectively stimulate immune responses against self-tumor antigens in the young and the old.

Pemetrexed plus carboplatin in elderly patients with malignant pleural mesothelioma: combined analysis of two phase II trials

The incidence of malignant pleural mesothelioma (MPM) in elderly patients is increasing. In this study, pooled data from two phase II trials of pemetrexed and carboplatin (PC) as first-line therapy were retrospectively analysed for comparisons between age groups. Patients received pemetrexed 500 mg m(-2) and carboplatin AUC 5 mg ml(-1) min(-1) intravenously every 21 days with standard vitamin supplementation. Elderly patients were defined as those >or=70 years old. A total of 178 patients with an ECOG performance status of or=70 years (27%). Grade 3-4 haematological toxicity was slightly worse in >or=70 vs <70-year-old patients, with neutropenia observed in 25.0 vs 13.8% (P=0.11), anaemia in 20.8 vs 6.9% (P=0.01) and thrombocytopenia in 14.6 vs 8.5% (P=0.26). Non-haematological toxicity was mild and similar in the two groups. No significant difference was observed in terms of overall disease control (60.4 vs 66.9%, P=0.47), time to progression (7.2 vs 7.5 months, P=0.42) and survival (10.7 vs 13.9 months, P=0.12). Apart from slightly worse haematological toxicity, there was no significant difference in outcome or toxicity between age groups. The PC regimen is effective and well tolerated in selected elderly patients with MPM.

Epidemiology of aging

Over the past century, truly remarkable changes have been observed in the health of older persons throughout the world, and these changes have strongly impacted society. The growth of the older population has resulted mostly from a general increase in the overall population size but is also strongly influenced by major declines in leading causes of mortality. These demographic transformations reverberate in society, increasing medical care and social needs, which are expected to increase steeply in the years to come. Based on demographic and epidemiologic perspectives, these changes were already detectable decades before and should have prompted radical changes in the structure and function of our system of health and social protection at that time. We come to this enormous challenge unprepared.

Ethical considerations in conducting clinical trials for elderly cancer patients

Under-representation of the elderly in clinical trials leads to inadequate information on the effect of age with regard to new anticancer treatments. The exclusion of elderly patients from cancer experimentation, often due to limiting medical or psychosocial factors, appears to also stem from misconceptions about aging and frailty. Limited data on elderly cancer patients enrolled in clinical trials suggest that age itself, in the absence of severe concomitant illnesses or psychological, cognitive or functional impairment, is not an independent risk factor for either increased toxicity or lack of treatment efficacy. Prospective benefits of inclusion of the elderly in clinical trials must be weighed against exposing individual patients to potential risks. The medical, ethical and methodological implications of experimentation in the elderly need to be studied in depth. This article reviews ethical issues in cancer clinical trials, focusing on aspects that may deserve special attention when elderly patients are enrolled.

Biweekly carboplatin/gemcitabine in patients with advanced urothelial cancer who are unfit for cisplatin-based chemotherapy: report of efficacy, quality of life and geriatric assessment

OBJECTIVE

We evaluated safety and efficacy of first-line gemcitabine/carboplatin in unfit-for-cisplatin patients with advanced urothelial carcinoma and the effect on the quality of life and functional status of elderly patients (aged >70).

METHODS

Unfit patients had ECOG performance status (PS) > or =2, creatinine clearance <50 ml/min or comorbidities precluding cisplatin administration. Carboplatin at area under the curve of 2.5 and gemcitabine 1,250 mg/m(2) were administered biweekly. Elderly patients were stratified into group 1 (no activities of daily living (ADL) or instrumental ADL dependency and no comorbidities), group 2 (instrumental ADL dependency or 1-2 comorbidities) and group 3 (ADL dependency or > or =2 comorbidities).

RESULTS

Thirty-four patients were enrolled: 68% had PS 2-3, 69% a creatinine clearance <50 ml/min and 65% had 1 or more comorbidities. There were 3 cases of grade 3 toxicity (9%). Response rate was 24% [95% confidence interval (CI) 11-41]. Median follow-up was 8 months, median progression-free survival 4.4 months (95% CI 1.03-7.75) and median overall survival 9.8 months (95% CI 4.7-14.9). Patients in geriatric assessment groups 1 and 2 had a significantly longer median progression-free survival compared to group 3 [6.9 months (95% CI 1.3-12.4) vs. 1.9 months (95% CI 0.5-3.2); p = 0.005].

CONCLUSION

First-line gemcitabine/carboplatin combination is active in unfit-for-cisplatin patients with advanced urothelial carcinoma. Pretreatment quality of life and geriatric assessment may be useful in selecting patients likely to benefit from this treatment.

Mammography Screening and Treatment of Breast Cancer in the Elderly

Breast cancer patients of an advanced age will suffer from ailments related to both senescence and cancer. Some will have been denied access to screening programmes and will present with an advanced disease. Many will need the expertise of the geriatrician and the oncologist who will participate in specific case discussions to look at social and medical issues that will affect the treatment plan (with questions regarding surgery, radiation, drug therapy, rehabilitation, supportive care, and palliative care often intertwined). This paper reviews recommendations by the International Society of Geriatric Oncology (SIOG) task force which recently assessed the available evidence on breast cancer in elderly individuals, and provided evidence-based recommendations for the diagnosis and treatment of breast cancer in such individuals. Recommendations on the topics of screening, surgery, radiotherapy, (neo)adjuvant hormone treatment, and chemotherapy, and on metastatic disease have been given. Oncologists are now learning to take into account the physiological age of their patient, which is the reflection of a normal and sometimes abnormally accelerated loss of body reserves which is certainly related to chronological age but not precisely dictated by it. Understanding the biology of breast cancer will allow to optimally adapt the treatment of the elderly patient.

Step by step development of clinical care pathways for older cancer patients: necessary or desirable?

Medical and nursing staff in oncology for older cancer patients are confronted with a range of problems including co-morbidity, poly-pharmacy, cognitive impairments, emotional problems, functional limitations, sensory impairment and a lack of social support. Comprehensive geriatric assessment identifies many of the existing problems and can be used to estimate life expectancy and tolerance of treatment. However, health care providers have to interpret and apply the medical and nursing information and must deal with specific problems and care needs throughout the continuum of cancer care. Imperfect interdisciplinary communication, cooperation and patient-provider communication may further complicate the care actually delivered. A clinical care pathway aims to improve continuity, increase multidisciplinary tuning and deliver appropriate patient education, treatment and care for vulnerable older cancer patients. This paper gives an overview of common problems in older cancer patients and addresses communication barriers through the development of clinical care pathways in geriatric oncology.