Comprehensive geriatric assessment and its clinical impact in oncology. Eur J Cancer. 2007;43:2161-2169. [PMID: 17855074 DOI: 10.1016/j.ejca.2007.08.002]

Recent advances: adjuvant therapy for older women with breast cancer

The U.S. population is now healthier and more long-lived than ever, and the average life expectancy for a woman born today is about 80 years. An elderly woman's life expectancy, which is related to comorbidity and functional status, is particularly important when determining the appropriate choice of adjuvant chemotherapy and endocrine therapy. In addition, the disease stage and the tumor's biologic characteristics (grade and hormone/human epidermal growth factor [HER]-2 receptor status) must be considered when formulating a treatment plan for 3 clinically distinctive breast cancer subgroups: (1) hormone receptor negative (HR-) and HER-2 negative ("triple-negative" tumors, about 15% of older patients); (2) hormone receptor positive (HR+) and HER-2 negative (the largest group comprising about 70% of older patients); and (3) HER-2 positive irrespective of HR status (about 15% of older patients). The functional status of an older woman can be estimated by a Comprehensive Geriatric Assessment (CGA). A traditional CGA is time consuming, but testing of shorter, validated CGA instruments is ongoing. Monitoring toxicity in the elderly is especially important because even low-grade toxicity can have a significant effect on function. Eligible older women should be considered for state-of-the-art treatment, including clinical trials to determine the optimal adjuvant regimens for this patient population and how the therapies affect the woman's functioning and quality of life.

Comprehensive geriatric assessment in Korean elderly cancer patients receiving chemotherapy

BACKGROUND

Growing evidence suggests that a comprehensive geriatric assessment (CGA) in older patients with cancer can detect unsuspected health problems, predict survival, and predict tolerance to chemotherapy. However, studies regarding CGA in cancer patients are scarce in Asia.

METHODS

We prospectively enrolled 65 elderly cancer patients who were candidates of systemic chemotherapy between July 2006 and March 2008. Baseline CGA data including demographic information, comorbidity, functional status by means of Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL), cognition, psychological state, nutritional status, and medication were collected and analyzed. Quality of life (QoL) was assessed by the EORTC questionnaire QLQ-C30.

RESULTS

Of the 65 patients, the median age was 71 years (range, 65-80), 49 (75%) were males, and 58 (89%) had Eastern Cooperative Oncology Group performance status (ECOG PS) 0 or 1. All patients had solid tumor, 74% received palliative chemotherapy, and 18% received adjuvant chemotherapy. Twenty-five percent of patients had Charlson's comorbidity index score of 2 or more, 23% were ADL dependent, and 14% were IADL dependent. Using Mini-Mental Status Exam (MMSE), it was found that 51% of patients had mild cognitive impairment (MMSE score 17-24), and 5% had cognitive impairment (≤ 16). Forty percent of patients had depression by Short form Geriatric Depression Scale (SGDS), 19% had malnutrition by Mini-Nutritional Assessment (MNA), and 23% had body mass index (BMI) less than 19.4 kg/m(2) (lowest 10%). Global health status/quality of life (QoL) was less than 50% in 39% of patients. Frail patients according to the Balducci classification had significantly poor ECOG PS and worse global health status/QoL.

CONCLUSION

CGA was feasible and could detect multiple unsuspected health problems including functional impairment and malnutrition in Korean elderly cancer patients receiving chemotherapy.

Cancer in older people: a tale of two disciplines

Management of cancer in the elderly presents an unprecedented challenge in Australia with the proportion of the population aged over 65 years set to double over the next four decades. Despite the complex healthcare needs of the older patient with cancer, there is currently little communication or cooperation between the fields of oncology and geriatrics. Improved interdisciplinary communication would facilitate care that is framed within current oncology practice while taking account of physiological age, complex comorbidities, risk of adverse events and pharmacological interactions as well as the implications of cognitive impairment on suitability for treatment and consent. An important first step has been taken towards the development of a strategic, focused and collaborative approach to the management of cancer in older people through a national interdisciplinary workshop convened by the Clinical Oncological Society of Australia in April 2008. Engagement and commitment of both oncology and geriatric disciplines is now critical to ensure that momentum is not lost in progressing this important and growing area of healthcare.

A retrospective study of the impact of age on patterns of care for elderly patients with metastatic breast cancer

This study aims at evaluating the impact of age on patterns of care in elderly patients with metastatic breast cancer (MBC) and their outcome. We identified 177 patients aged ≥ 65 treated for MBC at the National Cancer Center Hospital in Japan from 1999 to 2007. We evaluated the impact of age on the selection of best supportive care (BSC) only, chemotherapy as first-line treatment, and chemotherapy after first-line endocrine therapy. Fisher's exact test and a multivariate logistic regression analysis with variables of age, performance status (PS), hormone receptor (HR) status, human epidermal growth factor-2 (HER2), and life-threatening disease (LTD) were used. The median age of patients was 72, and 60 patients (33.9%) were aged ≥ 75. HR-negative patients and those whose PS was ≥ 2, regardless of age, were more likely to choose BSC without chemotherapy. Multivariate analysis revealed age ≥ 75 (P = 0.018), positive-HR status (P < 0.001), and absence of LTD (P < 0.001) were significantly correlated to choose endocrine therapy rather than chemotherapy. In patients who had previous endocrine therapy, age (P = 0.008) and absence of HER2 (P = 0.018) were related not to choose chemotherapy. Not age but HR-negative status or PS ≥ 2 were related to the selection of BSC. In selecting endocrine therapy rather than chemotherapy, age (≥ 75), HR-positive, and absence of LTD were significant factors. In patients failed to endocrine therapy, age and HER2 status were correlated to decision-making to choose chemotherapy.

EORTC elderly task force position paper: approach to the older cancer patient

As a result of an increasing life expectancy, the incidence of cancer cases diagnosed in the older population is rising. Indeed, cancer incidence is 11-fold higher in persons over the age of 65 than in younger ones. Despite this high incidence of cancer in older patients, solid data regarding the most appropriate approach and best treatment for older cancer patients are still lacking, mostly due to under-representation of these patients in prospective clinical trials. The clinical behaviour of common malignant diseases, e.g. breast, ovarian and lung cancers, lymphomas and acute leukaemias, may be different in older patients because of intrinsic variation of the neoplastic cells and the ability of the tumour host to support neoplastic growth. The decision to treat or not these patients should be based on patients' functional age rather than the chronological age. Assessment of patients' functional age includes the evaluation of health, functional status, nutrition, cognition and the psychosocial and economic context. The purpose of this paper is to focus on the influence of age on cancer presentation and cancer management in older cancer patients and to provide suggestions on clinical trial development and methodology in this population.

Experience with sorafenib and the elderly patient

Renal cell carcinoma primarily affects older individuals. Approximately half of all new renal cell carcinoma diagnoses are made in persons 65 years of age or older. Devising a treatment plan for the elderly patient population requires special consideration. Age-related physiological, cognitive, and social characteristics of elderly patients may influence each stage of patient care. Until recently, treatment options were limited for elderly patients with renal cell carcinoma. Sorafenib is the first multikinase inhibitor approved for use in renal cell carcinoma in the United States and Europe. In the phase III Treatment Approaches in Renal Cell Cancer Global Evaluation Trial, sorafenib significantly extended progression-free survival in patients with advanced renal cell carcinoma, regardless of age. Incidence rates of adverse events were not significantly higher in elderly patients receiving sorafenib than in younger patients. Thus, sorafenib represents an important treatment option for elderly patients with renal cell carcinoma. This report describes particular considerations for physicians to be aware of when choosing a treatment regimen for their elderly patients with renal cell carcinoma and offers recommendations on how to integrate specific management strategies into clinical practice that will optimize the use of sorafenib in the elderly. The strategies focus on patient selection, assessment of quality of life, management of adverse events, and appropriate dose modifications. The goal of these recommendations is to maximize the clinical benefit of sorafenib in the elderly patient population through appropriate use.

Assessment of pain, fatigue, sleep and quality of life (QoL) in elderly hospitalized cancer patients

As the proportion of older adults in the population continues to grow, the number of patients with cancer is expected to increase proportionally. In the previously conducted studies, data on elderly cancer patients were generally compared with the QoL scores of elderly patient group and with the data of non-cancer individuals. The purpose of this study was to examine differences in reported pain, fatigue, sleep problems and QoL between middle-aged and elderly hospitalized patients with cancer. We included 53 middle-aged (between 18 and 50 years) hospitalized cancer patients and 47 elderly (>60 years) hospitalized cancer patients in this study. Pain (visual analog scale=VAS, verbal pain rating), fatigue (brief fatigue inventory=BFI), sleep problems, QoL (Short Form 36=SF36), and European Organization for Research and Treatment of Cancer (EORTC)-QoL-C30 data were gathered using standardized measures. In the elderly group, no significant difference was detected in terms of VAS, verbal pain rating, fatigue, fatigue type, sleep problems and QoL scores (p>0.05). When the two age groups were compared, BFI scores were found to be significantly high among the elderly patients (p<0.05). A significant relationship was observed in both age groups between the scores of pain, fatigue and sleep problems, and QoL (p<0.05). Elderly hospitalized cancer patients did not demonstrate a distinctive difference in terms of pain, sleep and QoL compared to the younger group. The relationship between pain, fatigue, sleep and QoL should be definitely kept in mind in clinical practice.

Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up

PURPOSE

To evaluate geriatric assessment (GA) domains in relation to clinically important outcomes in older breast cancer survivors.

METHODS

Six hundred sixty women diagnosed with primary breast cancer in four US geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island) were selected with disease stage I to IIIA, age >or= 65 years at date of diagnosis, and permission from attending physician to contact. Data were collected over 7 years of follow-up from consenting patients' medical records, telephone interviews, physician questionnaires, and the National Death Index. Outcomes included self-reported treatment tolerance and all-cause mortality. Four GA domains were described by six individual measures, as follows: sociodemographic by adequate finances; clinical by Charlson comorbidity index (CCI) and body mass index; function by number of physical function limitations; and psychosocial by the five-item Mental Health Index (MHI5) and Medical Outcomes Study Social Support Survey (MOS-SSS). Associations were evaluated using t tests, chi(2) tests, and regression analyses.

RESULTS

In multivariable regression including age and stage, three measures from two domains (clinical and psychosocial) were associated with poor treatment tolerance; these were CCI >or= 1 (odds ratio [OR] = 2.49; 95% CI, 1.18 to 5.25), MHI5 score less than 80 (OR = 2.36; 95% CI, 1.15 to 4.86), and MOS-SSS score less than 80 (OR = 3.32; 95% CI, 1.44 to 7.66). Four measures representing all four GA domains predicted mortality; these were inadequate finances (hazard ratio [HR] = 1.89; 95% CI, 1.24 to 2.88; CCI >or= 1 (HR = 1.38; 95% CI, 1.01 to 1.88), functional limitation (HR = 1.40; 95% CI, 1.01 to 1.93), and MHI5 score less than 80 (HR = 1.34; 95% CI, 1.01 to 1.85). In addition, the proportion of women with these outcomes incrementally increased as the number of GA deficits increased.

CONCLUSION

This study provides longitudinal evidence that GA domains are associated with poor treatment tolerance and predict mortality at 7 years of follow-up, independent of age and stage of disease.

EORTC Elderly Task Force and Lung Cancer Group and International Society for Geriatric Oncology (SIOG) experts' opinion for the treatment of non-small-cell lung cancer in an elderly population

Non-small-cell lung cancer (NSCLC) represents a common health issue in the elderly population. Nevertheless, the paucity of large, well-conducted prospective trials makes it difficult to provide evidence-based clinical recommendations for these patients. The present paper reviews the currently available evidence regarding treatment of all stages of NSCLC in elderly patients. Surgery remains the standard for early-stage disease, though pneumonectomy is associated with higher incidence of postoperative mortality in elderly patients. Given the lack of demonstrated benefit for the use of adjuvant radiotherapy, it is also not recommended in elderly patients. Elderly patients seem to derive the same benefit from adjuvant chemotherapy as younger patients do, with no significant increase in toxicity. For locally advanced NSCLC, concurrent chemoradiotherapy may be offered to selected elderly patients as there is a higher risk for toxicity reported in the elderly population. Third-generation single-agent treatment is considered the standard of care for patients with advanced/metastatic disease. Platinum-based combination chemotherapy needs to be evaluated in prospective trials. Unfortunately, with the exception of advanced/metastatic NSCLC, prospective elderly-specific NSCLC trials are lacking and the majority of recommendations made are based on retrospective data, which might suffer from selection bias. Prospective elderly-specific trials are needed.

Surgical risk and post-operative complications in older unfit cancer patients

Surgeons have always dealt with elderly cancer patients, but understanding frailty and tailoring treatment is a new achievement endeavour. Mounting evidence is resulting in the introduction of geriatric assessment into clinical practice. Particularly, undernourishment should be assessed and corrected in order to avoid emergency situations whenever possible.

Chemotherapy for colorectal cancer in the elderly: Whom to treat and what to use

The median age at diagnosis of colorectal cancer is during the seventh decade, and the incidence of the disease increases continuously with age. However, as the age increases, the possibilities of receiving adequate cancer treatment diminish and the mortality rises. So, there is a huge need for defined treatment strategies in elderly patients with colorectal carcinoma. The geriatric population is a very heterogeneous group where patients with an excellent health status coexist with the patients with both co-morbidities and functional dependency. Therefore, it is necessary to personalize each treatment according to the degree of vulnerability of the elderly patients. It is essential to set up a multidimensional geriatric assessment in order to consider not only the stage of the disease, but also all the factors that may influence the survival and interfere with the treatment. The aim of this review is to discuss the potential benefits and issues of chemotherapy in the elderly patients affected with colorectal cancer.

Frail old patients as a target population for cancer trials

The recent distinction between co-morbidity and multi-morbidity well stresses the difficulty of managing old patients with cancer whose complexity is not captured by a list of diagnoses or biological burden alone. The most adequate answer found by oncologists and geriatricians was to work together for better evaluating the physiological age and body reserve of the patient. The gold standard tool to assess old patient with cancer is named Comprehensive Geriatric Assessment. Its systematic application needs geriatric competences and time. In this context, a great number of cancer patients are considered as "frail" because they have reduced available physiological reserves. They might not withstand stress when challenged. Oncologists and geriatricians have imagined an innovative process to change the screening procedure of these patients, determine the prognosis, adapt the treatment strategy, to increase the patient's survival and his/her quality of life. The internet website "www.clinicaltrials.com" only lists 8 studies focused on frail elders with cancer. Six of them are focused on specific cancers or specific treatments, one was applied to all kind of cancers and the last was an opinion overview from oncologists and geriatricians. The selection criteria of frail patients are very diverse and probably include cancer patients who are not comparable. It is now time to try to identify new practical, reliable and accurate tools to facilitate the inclusion of the same kind of patients suffering from the same kind of cancer to be able to give more appropriate care and at the same time to constitute a valuable data base. Existing tools are reviewed and analyzed.

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.

Controversies of total mesorectal excision for rectal cancer in elderly patients

The cornerstone of treatment for rectal cancer is resectional treatment according to the principles of total mesorectal excision (TME). However, population-based registries show that improvements in outcome after resectional treatment occur mainly in younger patients. Furthermore, 6-month postoperative mortality is significantly increased in elderly patients (> or = 75 years of age) compared with younger patients (< 75 years of age). Several confounding factors, such as treatment-related complications and comorbidity, are thought to be responsible for these disappointing findings. Thus, major resectional treatment is not advantageous for all older patients with rectal cancer. However, the Dutch TME trial showed a good response to a short course of neoadjuvant radiotherapy in elderly patients. Biological responses to cancer treatment seem to change with age, and, therefore, individualised cancer treatments should be used that take into account the heterogeneity of ageing. For elderly patients who retain a good physical and mental condition, treatment that is given to younger patients is deemed appropriate, whereas for those with diminished physiological reserves and comorbid conditions, alternative treatments that keep surgical trauma to a minimum and optimise the use of radiotherapy might be more suitable.

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.

Contribution of the geriatrician to the management of cancer in older patients

With an increasingly aged population, many patients will present with cancer in their 80s and 90s. Although some may be very fit, frail individuals will require the input of geriatricians to aid in the assessment of co-existing morbidity, in an attempt to assess those most likely to benefit from active treatment of their cancer, and those in whom the 'giants of geriatric medicine' require special consideration before undergoing definitive cancer therapy. The role of the geriatrician in assessment and management of such patients, together with communication and end of life care, may be more important in ensuring a good quality of life, than the cancer therapy itself. Whilst numbers of geriatricians will not be adequate to care for all elderly patients with cancer, a variety of assessment scales will help target financial and manpower resources to those most at risk.

Ageing or cancer: a review on the role of caretakers and gatekeepers

Ageing is due to the accumulation of damage, which arises because of evolved limitations in mechanisms for maintenance and repair. Accumulated damage may cause genomic instability, which in organisms with renewable tissues may result in cancer. To keep cancer at bay, two different tumour suppression mechanisms evolved: caretakers and gatekeepers. Caretakers protect the genome against mutations, while gatekeepers induce cell death or cell cycle arrest of potentially tumourigenic cells. It has been hypothesised that decreased activity of a caretaker may reduce life span, by increasing cancer risk, while the effects of increased activity of a gatekeeper on cancer risk and life span may be antagonistically pleiotropic. Apoptosis and senescence will promote early-life survival by curtailing the development of cancer, but may eventually limit longevity. This article reviews the evidence for this hypothesis. We conclude that several different findings indeed hint at an important role for gatekeeper mediated processes in ageing and its related pathologies. The relative contribution of apoptosis and senescence in specific age-related pathologies remains to be established.