Comprehensive geriatric assessment for older patients with cancer

Perioperative Treatment in Resectable Gastric Cancer: Current Perspectives and Future Directions

Gastric cancer (GC) is the fifth-most common cancer worldwide and an important cause of cancer-related-death. The growing knowledge of its molecular pathogenesis has shown that GC is not a single entity, but a constellation of different diseases, each with its own molecular and clinical characteristics. Currently, surgery represents the only curative approach for localized GC, but only 20% of patients (pts) showed resectable disease at diagnosis and, even in case of curative resection, the prognosis remains poor due to the high rate of disease relapse. In this context, multimodal perioperative approaches were developed in western and eastern countries in order to decrease relapse rates and improve survival. However, there is little consensus about the optimal treatment for non-metastatic GC. In this review, we summarize the current status and future developments of perioperative chemotherapy in resectable GC, attempting to find clear answers to the real problems in clinical practice.

Determinants of functional decline in older adults experiencing cancer (the INCAPAC study)

BACKGROUND

Previous studies have reported on the higher risk of functional decline among older patients with cancer. However, few have focused on factors of functional decline in older persons with cancer and are mainly hospital-based and focus on consequences of cancer treatment. The aim of the study was to identify determinants of functional decline in older subjects with cancer in a population-based study.

METHODS

Using cancer registries, we identified older subjects (age ≥ 65 years) with cancer in three prospective cohort studies from Gironde, a French department. Functional status was measured using the Instrumental Activities of Daily Living (IADL) and the basic Activities of Daily Living (ADL) scales, and functional decline was measured between cancer pre- and post-diagnosis visits. Studied variables were demographic and socioeconomic (age at diagnosis, sex, living alone, education), cancer-related (stage at diagnosis, treatment received), smoking status, health-related (polypharmacy, depressive symptomatology), and geriatric-specific (cognitive impairment or dementia). Analyses were performed using logistic regression models.

RESULTS

Age (≥85 years), cognitive impairment or dementia, and advanced stage at diagnosis were associated with a higher risk of ADL limitations, whether considering death or not. Age (≥85 years), education and polypharmacy were associated with a higher risk of ADL and/or IADL limitations.

CONCLUSIONS

We identified factors that could impact on ADL and/or IADL limitations in older patients with cancer. The information on these determinants is useful in clinical settings to identify patients with cancer at high risk of functional decline.

Glioblastoma in Elderly Patients: Current Management and Future Perspectives

The incidence of glioblastoma (GBM) in the elderly population is slowly increasing in Western countries. Current management includes surgery, radiation therapy (RT) and chemotherapy; however, survival is significantly worse than that observed in younger patients and the optimal treatment in terms of efficacy and safety remains a matter of debate. Surgical resection is often employed as initial treatment for elderly patients with GBM, although the survival benefit is modest. Better survival has been reported in elderly patients treated with RT compared with those receiving supportive care alone, with similar survival outcome for patients undergoing standard RT (60 Gy over 6 weeks) and hypofractionated RT (25⁻40 Gy in 5⁻15 daily fractions). Temozolomide, an alkylating agent, may represent an effective and safe therapy in patients with promoter methylation of O⁶-methylguanine-DNA-methyltransferase (MGMT) gene which is predictor of responsiveness to alkylating agents. An abbreviated course of RT, 40 Gy in 15 daily fractions in combination with adjuvant and concomitant temozolomide has emerged as an effective treatment for patients aged 65 years old or over with GBM. Results of the National Cancer Institute of Canada Clinical Trials Group (NCIC CTG CE6) and European Organization for Research and Treatment of Cancer (EORTC 26062/22061) randomized study of short-course RT with or without concurrent and adjuvant temozolomide have demonstrated a significant improvement in progression-free survival and overall survival for patients receiving RT and temozolomide over RT alone, without impairing either quality of life or functional status. Although combined chemoradiation has become the recommended treatment in fit elderly patients with GBM, several questions remain unanswered, including the survival impact of chemoradiation in patients with impaired neurological status, advanced age (>75⁻80 years old), or for those with severe comorbidities. In addition, the efficacy and safety of alternative therapeutic approaches according to the methylation status of the O⁶-methylguanine-DNA methyl-transferase (MGMT) gene promoter need to be explored in future trials.

Comprehensive Geriatric Assessment in hospital and hospital-at-home settings: a mixed-methods study

Background

The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary process that determines a frail older person’s medical, functional, psychological and social capability to ensure that they have a co-ordinated plan for treatment and follow-up.

Objectives

To improve our understanding of the effectiveness, cost-effectiveness and implementation of the CGA across hospital and hospital-at-home settings.

Methods

We used a variety of methods. We updated a Cochrane review of randomised trials of the CGA in hospital for older people aged ≥ 65 years, conducted a national survey of community CGA, analysed data from three health boards using propensity score matching (PSM) and regression analysis, conducted a qualitative study and used a modified Delphi method.

Results

We included 29 trials recruiting 13,766 participants in the Cochrane review of the CGA. Older people admitted to hospital who receive the CGA are more likely to be living at home at 3–12 months’ follow-up [relative risk (RR) 1.06, 95% confidence interval (CI) 1.01 to 1.10] (high certainty). The probability that the CGA would be cost-effective at a £20,000 ceiling ratio for quality-adjusted life-years (QALYs), life-years (LYs) and LYs living at home was 0.50, 0.89, and 0.47, respectively (low-certainty evidence). After PSM and regression analysis comparing CGA hospital with CGA hospital at home, we found that the health-care cost (from admission to 6 months after discharge) in site 1 was lower in hospital at home (ratio of means 0.82, 95% CI 0.76 to 0.89), in site 2 there was little difference (ratio of means 1.00, 95% CI 0.92 to 1.09) and in site 3 it was higher (ratio of means 1.15, 95% CI 0.99 to 1.33). Six months after discharge (excluding the index admission), the ratio of means cost in site 1 was 1.27 (95% CI 1.14 to 1.41), in site 2 was 1.09 (95% CI 0.95 to 1.24) and in site 3 was 1.70 (95% CI 1.40 to 2.07). At 6 months’ follow-up (excluding the index admission), there may be an increased risk of mortality (adjusted) in the three hospital-at-home cohorts (site 1: RR 1.09, 95% CI 1.00 to 1.19; site 2: RR 1.29, 95% CI 1.15 to 1.44; site 3: RR 1.27, 95% CI 1.06 to 1.54). The qualitative research indicates the importance of relational aspects of health care, incorporating caregivers’ knowledge in care planning, and a lack of clarity about the end of an episode of health care. Core components that should be included in CGA focus on functional, physical and mental well-being, medication review and a caregiver’s ability to care.

Limitations

The risk of residual confounding limits the certainty of the findings from the PSM analysis; a second major limitation is that the research plan did not include an investigation of social care or primary care.

Conclusions

The CGA is an effective way to organise health care for older people in hospital and may lead to a small increase in costs. There may be an increase in cost and the risk of mortality in the population who received the CGA hospital at home compared with those who received the CGA in hospital; randomised evidence is required to confirm or refute this. Caregiver involvement in the CGA process could be strengthened.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Novel Cancer Therapeutics in Geriatrics: What is Unique to the Aging Patient?

With the worldwide trend of aging populations, the number of older adults who develop and survive cancer is likely to increase. In the last decade, oncology drug development has shifted away from conventional chemotherapeutics towards agents that can 'target' a driver mutation of a specific cancer or 'unleash' the patient's native immune system to attack the cancer-so-called molecularly targeted therapies and immunotherapeutics. The basic algorithms of cancer treatment in elderly patients are essentially the same as in younger patients; however, one needs to pay exceptional attention to the effects of co-morbidities, interaction with other drugs, and the organ function reserve of an older individual before determining his/her 'eligibility' for a specific cancer treatment modality. Despite the growing evidence of safety and effectiveness of combination chemotherapy in fit elderly patients, the data are still lacking concerning the use of currently approved targeted agents and immunotherapies. The current evidence, though limited, suggests reasonable tolerability with comparable efficacy in patients > 65 years old treated with immune-based therapies to that in younger controls; however, it is unclear if this leads to significant patient-relevant gains such as improved survival with an acceptable quality of life. Nonetheless, these newer agents remain better tolerated than cytotoxic chemotherapy in clinical practice, particularly in older patients. Alternatively, a personalized approach for elderly patients with consideration of the incidence and management of adverse effects, as well as strategies for optimizing efficacy in the context of an aging immune system, would be of utmost value in our aging cancer population. Future trials should also explore immune markers to predict response to these therapeutics in elderly patients, taking into consideration the effects of immunosenescence and immune modulation in aging hosts.

Pan-Asian adapted Clinical Practice Guidelines for the management of patients with metastatic non-small-cell lung cancer: a CSCO-ESMO initiative endorsed by JSMO, KSMO, MOS, SSO and TOS

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of metastatic non-small-cell lung cancer (NSCLC) was published in 2016. At the ESMO Asia Meeting in November 2017 it was decided by both ESMO and the Chinese Society of Clinical Oncology (CSCO) to convene a special guidelines meeting immediately after the Chinese Thoracic Oncology Group Annual Meeting 2018, in Guangzhou, China. The aim was to adapt the ESMO 2016 guidelines to take into account the ethnic differences associated with the treatment of metastatic NSCLC cancer in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with metastatic NSCLC representing the oncological societies of China (CSCO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence, and was independent of both the current treatment practices and the drug availability and reimbursement situations in the six participating Asian countries. During the review process, the updated ESMO 2018 Clinical Practice Guidelines for metastatic NSCLC were released and were also considered, during the final stages of the development of the Pan-Asian adapted Clinical Practice Guidelines.

Sphincter-saving proctectomy for rectal cancer with NO COIL® transanal tube and without ostoma. Clinical outcomes, cost effectiveness and quality of life in the elderly

BACKGROUND

Colorectal cancer is one of the most common invasive cancers, and it is responsible for considerable physical and psychosocial morbidity specially in older patients. However, only few reports focused on quality of life, cost-effectiveness and clinical outcomes of rectal cancer patients undergone to surgery. This retrospective study compares short-term and long-term outcomes in rectal cancer patients with more and less than 75 years of age.

METHODS

Four hundred consecutive patients underwent radical surgery for rectal adenocarcinoma and they were collected in a prospective institutional database and divided into two groups: group 1 (≥75 years, N.=98); group 2 (<75 years, N.=302). Rectal anterior resection (RAR) with sphincter-saving restorative proctectomy and with application of silicone transanal tube NO COIL® 60-80 mm long, was the only procedure considered. Main clinical and pathological data were assessed and compared.

RESULTS

Statistically significant differences between the two groups were detected regard to comorbidities and the emergency presentation. Overall survival is lower in patients over 75 age, but cancer-related survival is not different between the two groups.

CONCLUSIONS

Although advanced age is associated with higher morbidity and mortality, in our experience, itself is not a contraindication for surgical sphincter-saving proctetomy in rectal cancer patients. The absence of a stoma also improved the cost effectiveness and patients' quality of life in both groups: psychological morbidity, sexuality, levels of anxiety and depression, body image.

Neurologic manifestations of elderly patients with cancer

BACKGROUND

The incidence of cancer is an age-related phenomenon; therefore, the interest on clinical manifestations, diagnostic approach and treatment strategies for older patients diagnosed with cancer has increased lately. Neurologic symptoms are one of the main reasons for consultation and a common cause of decreased quality of life among cancer patients.

AIMS

To identify the neurologic manifestations of patients ≥ 65 years of age diagnosed with cancer and compare them to those presented by a younger population.

METHODS

Cross-sectional study of cancer patients referred to neuro-oncologic consultation at a Cancer Center. Sociodemographic, health and oncologic characteristics were obtained through clinical interviews. Clinical symptoms and final diagnoses were also recorded. Bivariate logistic regression analyses were carried out.

RESULTS

More than 17,000 neuro-oncologic consultations in 3015 patients were given, 27% (n = 811) of them were ≥ 65 years of age. Most frequent primary neoplasms in elderly patients were: breast cancer, hematologic neoplasms, gynecological, urologic, skin and head and neck cancers. Elderly patients had an increased risk of having the following diagnoses: abnormal movements, stroke, peripheral vertigo, dementia, degenerative spine disorder, and delirium.

DISCUSSION

Elderly patients are considered a vulnerable population. The present study found that the main neoplasms associated with neurological manifestations are similar to the reported previously. We described the main symptoms that led to a neuro-oncological assessment. Moreover, we enlisted the final diagnoses made on elderly patients and compared them with others reports. To the best of our knowledge, this study provides valuable information, since there is scarce evidence in the literature about this topic.

CONCLUSION

Identifying the frequency and correlation of neurologic manifestations in older cancer patients will allow for the implementation of timely multidisciplinary care in an attempt to improve these patients' health-related quality of life.

Prospective Validation of The Korean Cancer Study Group Geriatric Score (KG)-7, a Novel Geriatric Screening Tool, in Older Patients with Advanced Cancer Undergoing First-line Palliative Chemotherapy

Purpose

The purpose of this study was to prospectively validate the Korean Cancer Study Group Geriatric Score (KG)-7, a novel geriatric screening tool, in older patients with advanced cancer planned to undergo first-line palliative chemotherapy.

Materials and Methods

Participants answered the KG-7 questionnaire before undergoing geriatric assessment (GA) and first-line palliative chemotherapy. The performance of KG-7 was evaluated by calculating the sensitivity (SE), specificity (SP), positive and negative predictive value (PPV and NPV), balanced accuracy (BA), and area under the curve (AUC).

Results

The baseline GA and KG-7 results were collected from 301 patients. The median age was 75 years (range, 70 to 93 years). Abnormal GA was documented in 222 patients (73.8%). Based on the ≤ 5 cut-off value of KG-7 for abnormal GA, abnormal KG-7 score was shown in 200 patients (66.4%). KG-7 showed SE, SP, PPV, NPV, and BA of 75.7%, 59.7%, 84.4%, 46.0%, and 67.7%, respectively; AUC was 0.745 (95% confidence interval, 0.687 to 0.803). Furthermore, patients with higher KG-7 scores showed significantly longer survival (p=0.006).

Conclusion

KG-7 appears to be adequate in identifying patients with abnormal GA prospectively. Hence, KG-7 can be a useful screening tool for Asian countries with limited resources and high patient volume.

Oligometastatic cancer in elderly patients: the "blitzkrieg" radiotherapy approach : SBRT in oligometastatic elderly patients

AIMS

To retrospectively evaluate the outcome of stereotactic body radiation therapy (SBRT) in the treatment of elderly patients affected by isolated body metastasis from different primitive tumors.

METHODS

70 patients with isolated body metastasis were treated. Median age at diagnosis was 75 years (IQR 69-80). The most common SBRT fractionation scheme was 5 × 7 Gy (total dose 35 Gy). The primary endpoints were Local Control (LC) and Toxicity. Secondary endpoints were Overall Survival (OS) and Disease-Specific Survival (DSS). Response to radiotherapy was assessed according to RECIST criteria v1.1. Toxicity was registered according to Common Terminology Criteria for Adverse Events (CTCAE) v 4.0. We performed survival analysis with the Kaplan-Meier method. The correlation between time actuarial incidence and clinical parameters was studied.

RESULTS

Median follow-up was 26.5 months. 44 patients (62.8%) were alive at the time of analysis, while 22 (31.4%) died because of the disease. Local control at 2 and 3 years was 87%. The 2-year OS and DSS were 84 and 71%, respectively, while the 3-year values were 57 and 62%. PFS at 2 and 3 years was 41 and 25%, respectively. On univariate analysis, KPS ≥ 90 is statistically correlated with improved OS and DSS (p < 0.05). Acute toxicity of grade ≥ 2 occurred in 4 (5.7%) patients, while late toxicity ≥ 2 was recorded in 6 (8.6%) patients.

CONCLUSIONS

Ablative Radiotherapy represents a safe, effective, and minimally invasive treatment modality for elderly oligometastatic patients who are judged unfit for systemic therapy.

Questionnaire survey on adjuvant chemotherapy for elderly patients after gastrectomy indicates their vulnelabilities

BACKGROUND

In Japan, S-1 adjuvant chemotherapy for 1 year is the standard of care for the treatment of stage II and III patients under 80 years old with gastric cancer after curative operation. However, the feasibility of S-1 chemotherapy in patients over 80 years old has not yet been elucidated.

METHODS

To clarify the current treatment situation and feasibility of S-1 treatment in patients over 80 years old, a questionnaire survey of the patients treated from January 2011 to December 2012 was conducted at 58 member institutions of the Stomach Cancer Study Group of the JCOG (Japan Clinical Oncology Group).

RESULTS

Gastrectomy was performed in 15,573 patients of all ages, and 1,660 (10.7%) patients were over 80 years of age. Of these elderly patients, 661 (4.2%) were diagnosed as stage II and III. While S-1 adjuvant chemotherapy was recommended to 248 (37.5%) of the stageII/III patients, only 99 (15.0%) of them actually received S-1. Interestingly, the creatinine clearance rate was between 30 and 80 mL/min in 87 (87.9%) of the patients suggesting that S-1 dose modification should be considered. Moreover, S-1 compliance was poor in patients with more than 15% body weight loss.

CONCLUSION

In general practice, surgery alone can be regarded as the standard of care for stage II and III gastric cancer patients over 80 years old. The feasibility and efficacy of S-1 adjuvant chemotherapy should be elucidated in a randomized control trial considering the vulnerabilities of the elderly.

How I treat elderly patients with plasma cell dyscrasias

Plasma cell dyscrasias are a rare heterogeneous group of hematological disorders which are more prevalent in the older part of the population. The introduction of novel agents, improved understanding of disease biology and better supportive management have improved outcomes considerably and in the era of the aging population the question of how to best manage older patients with plasma cell dyscrasias has never been more relevant. Data on how to treat these patients comes mostly from subgroup analysis as they are underrepresented in clinical trials. This review will cover issues, available evidence and recommendations relevant to diagnosis and management of the older patients with Multiple Myeloma (MM), Waldenstrom Macroglobulinemia (WM) and systemic AL Amyloidosis. What will become increasingly evident is the need to develop and establish the use of disease-specific geriatric assessment (GA) tools. Frailty status assessment using GA tools and moving away from making decisions based merely on chronological age will allow setting clear treatment goals and consequently achieving an optimum balance between effectiveness and toxicity for this complex and heterogeneous group of patients.

The Prognostic Impact of Dose-attenuated R-CHOP Therapy for Elderly Patients with Diffuse Large B-cell Lymphoma

Objective Although R-CHOP (rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone) is a standard therapy for diffuse large B-cell lymphoma (DLBCL), the optimal dose for elderly patients remains unclear. Methods and Patients We retrospectively verified our R-CHOP dose-attenuation system implemented from 2005 for DLBCL patients. Among the 115 DLBCL patients treated during 2001-2010, 33 patients treated during 2001-2005 received R-CHOP doses adjusted according to physicians' decisions (PHY group). Eighty-two patients treated after 2005 received adjusted R-CHOP doses according to a unified dose-attenuation system (UNI group). Patients aged <60, 60-69, 70-79, and ≥80 years received the standard R-CHOP, 100% R-CHO+P (50 mg/m²), 100% R+75% CHO+P (40 mg/m²), and 100% R+50% CHO+P (30 mg/m²), respectively. We compared the responses, survival, and treatment cessation between the PHY and UNI groups. Results The patients' characteristics between both groups were closely comparable. All PHY patients received randomly adjusted R-CHOP doses; 94% of UNI patients received scheduled doses. The complete response rates differed significantly between the UNI (77%) and PHY patients (50%) (p=0.011). The two-year event-free survival rates were 50% and 32% in the UNI and PHY groups, respectively (p=0.0083). The two-year OS rates were 77% and 72% in the UNI and PHY group (p=0.16). Among the patients aged >70 years (n=59) overall survival was shorter in the PHY group (62%) than in the UNI group (72%; p=0.02). The UNI group received higher anti-tumor agent doses than the PHY group. The therapy discontinuation rates were 5% in the UNI group and 24% in the PHY group. Conclusion Carrying out unified dose reduction may improve the efficacy and prognosis among elderly DLBCL patients.

Immunotherapy in Older Adults With Advanced Cancers: Implications for Clinical Decision-Making and Future Research

Immunotherapy has expanded the therapeutic landscape for advanced cancers, including solid tumors and lymphomas. For many patients with cancer, these agents have been shown to have substantial efficacy and favorable toxicity compared with cytotoxic agents, particularly in the second-line setting. With the advent of anti-PD-1 and anti-PD-L1 checkpoint inhibitors, combination immunotherapy- and chemoimmunotherapy-based strategies have emerged as promising novel regimens to improve cancer-related outcomes. Older adults age 65 or older represent the growing majority of patients diagnosed with cancer. However, older adults are under-represented in clinical trials in general, as well as in the landmark studies that led to approval of these immunotherapy agents. Because of increasing age and attendant multimorbidity and impaired functional status, many of these patients seen in the community-based oncology practices would not have been considered eligible for such studies. Thus, the results of these studies are difficult to generalize to a broader patient population with these competing risks. Furthermore, robust evaluation of toxicities, effect on quality of life and functional status, and aging-related (i.e., immunosenescence) and immunotherapy-related changes affecting the immune system remain underexplored research areas for older adults. This review examines the role of immunotherapy and its unique issues, specifically in older adults with lung cancer, bladder cancer, and lymphomas.

Compliance and Outcome of Elderly Patients Treated in the Concurrent Once-Daily Versus Twice-Daily Radiotherapy (CONVERT) Trial

Introduction

There is a lack of data on the efficacy and safety of concurrent chemoradiotherapy in elderly, limited-stage, patients with SCLC.

Methods

We compared outcomes of patients 70 years of age or older versus younger patients within the Concurrent Once-daily Versus twice-daily RadioTherapy (CONVERT) trial. Patients were randomized to receive 45 Gy/30 twice-daily fractions/19 days or 66 Gy/33 once-daily fractions/45 days concurrently with platinum-based chemotherapy. Overall survival and progression-free survival were evaluated using Kaplan-Meier methodology and Cox proportional hazards regression.

Results

Of 547 patients randomized between April 2008 and November 2013, 57 did not receive protocol treatment and were excluded. Of the 490 patients included, 67 (14%) were 70 years of age or older (median age: 73 years; range: 70–82). Fewer older patients received the optimal number of radiotherapy fractions (73% versus 85%; p = 0.03); however, chemotherapy compliance was similar in both groups (p = 0.24). Neutropenia grade 3/4 occurred more frequently in the elderly (84% versus 70%; p = 0.02) but rates of neutropenic sepsis (4% versus 7%; p = 0.07) and death (3% versus 1.4%; p = 0.67) were similar in both groups. With a median follow-up of 46 months; median survival in the elderly versus younger groups was 29 (95% confidence interval [CI]: 21–39) versus 30 months (95% CI: 26–35), respectively; (hazard ratio: 1.15, 95% CI: 0.84–1.59; p = 0.38). Median time to progression in the elderly versus younger groups was 18 months (95% CI: 13–31) versus 16 months (95% CI: 14–19), respectively (hazard ratio: 1.04, 95% CI: 0.76–1.41; p = 0.81).

Conclusions

Concurrent chemoradiotherapy with modern radiotherapy techniques should be a treatment option for fit, older patients.

Pilot Randomized Trial of a Pharmacy Intervention for Older Adults with Cancer

BACKGROUND

Oncology clinicians often struggle with managing medications and vaccinations in older adults with cancer. We sought to demonstrate the feasibility and preliminary efficacy of integrating pharmacists into the care of older adults with cancer to enhance medication management and vaccination administration.

METHODS

We randomly assigned patients aged ≥65 years with breast, gastrointestinal, or lung cancer receiving first-line chemotherapy to the pharmacy intervention or usual care. Patients assigned to the intervention met with a pharmacist once during their second or third chemotherapy infusion. We obtained information about patients' medications and vaccinations via patient report and from the electronic health record (EHR) at baseline and week 4. We determined the number of discrepant (difference between patient report and EHR) and potentially inappropriate (Beers Criteria assessed by nonintervention pharmacists blinded to group assignment) medications. We defined the intervention as feasible if >75% of patients enrolled in the study and received the pharmacist visit.

RESULTS

From January 17, 2017, to October 27, 2017, we enrolled and randomized 60 patients (80.1% of patients approached). Among those assigned to the intervention, 96.6% received the pharmacist visit. At week 4, intervention patients had higher rates of acquiring vaccinations for pneumonia (27.6% vs. 0.0%, p = .002) and influenza (27.6% vs. 0.0%, p = .002) compared with usual care. Intervention patients had fewer discrepant (5.82 vs. 8.07, p = .094) and potentially inappropriate (3.46 vs. 4.80, p = .069) medications at week 4, although differences were not significant.

CONCLUSION

Integrating pharmacists into the care of older adults with cancer is feasible with encouraging preliminary efficacy for enhancing medication management and improving vaccination rates.

IMPLICATIONS FOR PRACTICE

Results of this study showed the feasibility, acceptability, and preliminary efficacy of an intervention integrating pharmacists into the care of older adults with cancer. Notably, patients assigned to the intervention had fewer discrepant medications and were more likely to acquire vaccinations for pneumonia and influenza. Importantly, this work represents the first randomized controlled trial involving the integration of pharmacists into the outpatient oncologic care of older adults with cancer. In the future, a larger randomized trial is needed to demonstrate the efficacy of this care model to enhance medication management and improve vaccination outcomes for older patients with cancer.

The role of Geriatric screening tool (G8) in predicting side effect in older patients during therapy with aromatase inhibitor

BACKGROUND

Endocrine therapy is the main treatment in hormonosensitive breast cancer; the most frequent side effects are arthralgia, osteoporosis, depression, dyslipidemia and hypertension. G8 is a simple test developed to identify older patients who could benefit from a comprehensive geriatric assessment (CGA). The aim of this study is to evaluate the possible role of G8 in predicting side effects from treatment with aromatase inhibitor in women ≥65 years old.

MATHERIAL AND METHOD

Women ≥65 years old affected by breast cancer about to start a therapy with an aromatase inhibitor, in the adjuvant setting, were evaluated with the G8 tool. Patients were classified as "fit" with G8 score > 14 or "vulnerable" with G8 score ≤ 14; they then started treatment and clinical-instrumentalfollow-up.

RESULTS

From April 2016 to February 2018, 50 consecutive patients were screened. Median age was 75.1 (range 65-86). G8 identified 30 patients (60%) as "fit" (score > 14) and 20 (40%) as "vulnerable" (score ≤ 14). The grade of concordance between G8 score and the appearance/absence of adverse events were statistically significant (41/50 patients, 82%, p = 0.0002); sensitivity resulted in 78% and specificity was 81%; positive predictive value was 70% and negative predictive value was 87%. The most frequent adverse event was arthromyalgia.

CONCLUSION

The G8 screening tool has a potential role in predicting side effects during a treatment with aromatase inhibitor. G8 could be very useful in everyday clinical practice for this population.

Regeneration of older patients after oncologic surgery. A temporal trajectory of geriatric assessment and quality of life parameters

AIMS

The effectiveness of surgery depends on it being carried out safely, which allows patients to return to independent lives. Because gastrointestinal cancers are a major cause of morbidity and mortality in older people, we examined the dynamics of recuperation after elective, curative surgery. As disease parameters alone may not suffice to address geriatric patients' issues after onco-surgical interventions, Comprehensive Geriatric and QOL Assessments (CGA/QOL) were performed at four time points to gain information on clinical, functional, and cognitive aspects.

METHODS

CGA/QOL including standard geriatric instruments, socio-demographic, clinical data, and the EORTCQLQ-C30 questionnaire were applied pre-operatively (T1), at discharge (T2), after three (T3), and after six months (T4).

RESULTS

200 patients gave their informed consent, 70 patients declined. At T1 n = 195, at T2 n = 155, at T3 n = 130, and at T4 n = 124 patients were actually assessed. Patients experienced a significant decline in most functional capabilities and increased symptoms at T2. While most parameters re-approached baseline results by T4, sophisticated abilities (instrumental ADL, IADL) remained impaired. Fatigue was the most prominent symptom that persisted in many at T4. Risk for malnutrition as well as BMI significantly decreased during regeneration. Global QOL correlated with parameters of independence (ADL, IADL) and low symptom burden. Role and social functions' correlation with global QOL increased from T1 to T4.

CONCLUSIONS

Longitudinal assessments before and after oncologic surgery highlight changes even after six months in QOL and independence that may be ameliorated by focused supportive care. Trial registry number: DRKS: 00000425.

Treating Diffuse Large B Cell Lymphoma in the Very Old or Frail Patients

OPINION STATEMENT

R-CHOP has been the standard of care for diffuse large B cell lymphoma (DLBCL), curing approximately 60% of patients for more than 2 decades. However, the optimal treatment of patients who are too frail to tolerate this regimen and/or are not candidates for anthracycline therapy continues to be debated. MInT and GELA trials established addition of rituximab to CHOP in DLBCL but excluded patients older than 80 years. Multiple regimens have been tried with varying success in the very elderly, including R-mini-CHOP, R-mini CEOP, R-split CHOP, pre-phase strategies, and R-GCVP. However, there has not been a randomized trial among these strategies. Although addition of novel agents including ibrutinib, brentuximab vedotin, lenalidomide, and many others on the horizon holds promise in this population, none have been tested in a randomized setting or have results awaited. There is also a lack of a validated and easy to use clinical tool in this population to predict patients who will not tolerate R-CHOP. Identifying patients who will not tolerate R-CHOP early with the help of tools like CGA, along with integrating biology-based treatment (ibrutinib, lenalidomide in activated B cell type DLBCL) is being investigated in this population.

Patients electing to have PET rather than surgery for operable breast cancer are a high risk of treatment failure

BACKGROUND

Primary endocrine therapy (PET) is a treatment option for elderly patients with ER-positive breast cancer enabling frail patients to avoid surgery. As a long-term treatment option, it has been shown to be inferior to surgery in controlling local disease. Decision-making in these patients is crucial in avoiding treatment failure. We examined the influence of decision-making on outcomes of PET failure as a secondary analysis as part of a large observational study.

METHODS

Consecutive patients treated with PET between 2005 and 2015 for operable breast cancers were included in a retrospective observational study in 3 breast centres in the North-East. Treatment decision processes were examined by case note review and outcomes of treatment success or failure recorded.

RESULTS

488 patients were included with mean follow-up of 31 months. Overall 63 (12%) experienced treatment failure. 227 (46.6%) were given a choice between surgery and PET at diagnosis. Logistic regression identified older age [OR 0.94 (0.91-0.96) p < 0.001] and reduced mobility [OR 0.6 (0.37-0.97) p 0.036] to be less likely offered surgery. Those offered surgery were more likely to experience treatment failure with PET [SHR 1.78 (1.05-3.02) p 0.033].

CONCLUSIONS

Despite a low failure rate in our series (literature failure rates vary between 12 and 85%), these results suggest that those actively offered a choice between surgery and PET are at greater risk of failure when choosing PET.

Treatment of advanced non-small cell lung cancer in the elderly

INTRODUCTION

Lung cancer is predominantly a disease that affects the elderly; about 30-40% of lung cancers are diagnosed in patients aged 70 or more. The increasing number of elderly patients over the next decades is generating a new social and health problem; despite that, these patients are underrepresented in clinical trials and undertreated in clinical practice. Areas covered: The main difficulty in treating elderly patients is to maximize the therapy benefits while minimizing the treatment risk. Elderly patients show a vulnerable clinical profile due to the higher prevalence of comorbid disease, higher polypharmacy interactions and aged organ dysfunction that increase the risk of mortality and toxicity with cancer treatments compared to younger patients. Expert commentary: The choice to treat or not to treat elderly patients cannot be taken only on the basis of the chronological age. Thus, the clinical approach should be to select patients who are effectively suitable for treatment having a better individual functional reserve and a better life expectancy. Elderly patients are a heterogeneous population and those who are fit to receive cancer treatment can be treated similarly to younger patients.

Age-related differences in prognosis and prognostic factors among patients with epithelial ovarian cancer

Approximately 40% of all patients with ovarian cancer in Japan are aged ≥65 years. The aim of the present study was to evaluate the differences in prognosis and prognostic factors between elderly and younger patients with epithelial ovarian cancer. A total of 114 patients with International Federation of Gynecology and Obstetrics (FIGO) stage I-IV ovarian cancer who were initiated on primary treatment at the Osaka City University Hospital (Osaka, Japan) were included in this study. Patient characteristics, treatment outcome and prognosis were compared between elderly (aged ≥65 years) and younger patients, and the prognostic factors associated with overall survival were evaluated by univariate and multivariate analyses. The most common histological type in younger patients was clear cell carcinoma (33.8%) vs. serous carcinoma in elderly patients (44.1%), with a significant difference in the distribution of histological type (P=0.006). Complete resection was achieved in 56.2% of younger patients compared with 32.4% of elderly patients (P=0.03). The rates of standard primary treatment were comparable (56.7% of younger vs. 50.0% of elderly patients). Overall and disease-free survival did not differ significantly between the two groups. Multivariate analyses identified FIGO stage and standard primary therapy as prognostic factors in younger patients and performance status in elderly patients. Age was not an independent significant prognostic factor among patients with ovarian cancer. Therefore, performance status, rather than age, should be considered when selecting the optimal treatment for elderly patients based on objective assessment.

Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology

Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .

A new prognostic model identifies patients aged 80 years and older with diffuse large B-cell lymphoma who may benefit from curative treatment: A multicenter, retrospective analysis by the Spanish GELTAMO group

The means of optimally managing very elderly patients with diffuse large B-cell lymphoma (DLBCL) has not been established. We retrospectively analyzed 252 patients aged 80-100 years, diagnosed with DLBCL or grade 3B follicular lymphoma, treated in 19 hospitals from the GELTAMO group. Primary objective was to analyze the influence of the type of treatment and comorbidity scales on progression-free survival (PFS) and overall survival (OS). One hundred sixty-three patients (63%) were treated with chemotherapy that included anthracyclines and/or rituximab, whereas 15% received no chemotherapeutic treatment. With a median follow-up of 44 months, median PFS and OS were 9.5 and 12.5 months, respectively. In an analysis restricted to the 205 patients treated with any kind of chemotherapy, comorbidity scales did not influence the choice of treatment type significantly. Independent factors associated with better PFS and OS were: age < 86 years, cumulative illness rating scale (CIRS) score < 6, intermediate risk (1-2) R-IPI, and treatment with R-CHOP at full or reduced doses. We developed a prognostic model based on the multivariate analysis of the 108 patients treated with R-CHOP-like: median OS was 45 vs. 12 months (P = .001), respectively, for patients with 0-1 vs. 2-3 risk factors (age > 85 years, R-IPI 3-5 or CIRS > 5). In conclusion, treatment with R-CHOP-like is associated with good survival in a significant proportion of patients. We have developed a simple prognostic model that may aid the selection patients who could benefit from a curative treatment, although it needs to be validated in larger series.

Communication about geriatric assessment domains in advanced cancer settings: "Missed opportunities"

OBJECTIVES

Older patients with advanced cancer often have age-related health issues (e.g., memory impairment) that influence their cancer treatment decisions. Communication about these age-related concerns can potentially lead to further assessment and subsequent clinical interventions to improve treatment decision-making and patients' quality of life. Yet, little is known about the communication of age-related concerns between oncologists, patients, and caregivers.

MATERIALS AND METHODS

This study is a secondary analysis of data from the Values and Options in Cancer Care (VOICE) study. Audio-recorded and transcribed outpatient clinical oncology encounters with 37 patients with advanced cancer ≥60 years of age were content-analyzed. Two trained coders used a structured coding scheme based on pre-specified geriatric assessment (GA) domains to examine the transcripts for the frequency and quality of communication about age-related concerns. Atlas.ti version 6 was used for all analyses.

RESULTS

The median age of the patients was 66 years (range = 60-90 years); patients were mostly female (26/37), married (22/37), and White (36/37). Out of 37 audio-recorded visits, 31 had at least one mention of an age-related concern with a total of 70 mentions. Oncologists initiated communication about age-related concerns half of the time (53%). When age-related concerns were mentioned, half of the time (50%) the oncologist did not implement further evidence-based interventions to address the age-related concern (e.g., conduct a cognitive screen for a memory concern).

CONCLUSION

Interventions are needed to improve the frequency and quality of the communication about age-related concerns to improve the care of older adults with cancer.

Validation and Refinement of the Age, Comorbidities, and Albumin Index in Elderly Patients with Diffuse Large B-Cell Lymphoma: An Effective Tool for Comprehensive Geriatric Assessment

BACKGROUND

We aimed to validate and refine the Age, Comorbidities, and Albumin (ACA) index in elderly Chinese patients with diffuse large B-cell lymphoma (DLBCL) and propose a more effective method for comprehensive geriatric assessment (CGA).

MATERIALS AND METHODS

Patients ≥65 years of age who had been diagnosed with de novo DLBCL in the Institute of Hematology, Beijing Hospital, were screened for eligibility (n = 99).

RESULTS

Based on the ACA index, 39, 31, 26, and 3 patients were categorized into the "excellent," "good," "moderate," and "poor" groups, respectively. The 2-year treatment-related mortality rate was significantly higher and the survival rates poorer in the ACA "moderate to poor" group compared with those of the ACA "good" and "excellent" groups. Multivariable model analysis identified two independent predictors of overall survival: the instrumental activities of daily living (IADL) scale and the ACA index. IADL scores of 6 to 7 and the ACA "good" group were assigned 1 point; IADL scores ≤5 and the ACA "moderate to poor" group were assigned 2 points. Based on these data, we created a three-category system (IADL ACA index [IACA index]): low risk, score 0; intermediate risk, score 1 to 2; and high risk, score 3 to 4. The IACA index could effectively discriminate the response rates, overall survival, and progression-free survival rates in elderly patients with DLBCL.

CONCLUSION

We observed that the ACA index could partially predict the clinical outcomes of elderly DLBCL patients in China. Based on this index, we proposed the IACA index as an effective tool for CGA in DLBCL.

IMPLICATIONS FOR PRACTICE

Diffuse large B-cell lymphoma (DLBCL) is one of the most frequent types of malignant lymphoma in elderly people, and identifying patients suitable for curative therapy is critical in the improvement of clinical outcomes. Recently, some authors proposed the Age, Comorbidities, and Albumin (ACA) index. Combining the use of the instrumental activities of daily living (IADL) scale and the ACA index, this article describes the IADL ACA index (IACA index), which is an effective tool for comprehensive geriatric assessment in DLBCL.

Oncologic outcomes after radical surgery for periampullary cancer in octogenarians

Backgrounds/Aims

Interest in treatments for elderly patients has increased with life expectancy, and various studies have reported on the safety and feasibility of radical surgery in elderly patients with cancer. Here, we investigated oncologic outcomes of periampullary cancer in octogenarians.

Methods

We retrospectively reviewed medical records of 68 patients over 80 years of age who were diagnosed with periampullary cancer and were eligible for surgery; we analyzed overall survival (OS) and immediate postoperative complications and mortality.

Results

There were no significant differences in mean age, disease type, oncologic features, comorbidities, or nutritional status between the patients who had surgery and those who did not. Five patients (20.0%) had major postoperative complications, but there was no immediate postoperative mortality. Patients who had surgery (n=25) had better OS (29.3 months; 95% confidence interval [CI]: 5.6–53.0) than did those who did not (n=43, OS: 7.6 months; 95% CI: 3.2–12.0 months; p<0.001). Similarly, patients with distal common bile duct cancer who underwent surgery had better OS than those who did not (surgery group: n=13, OS: 29.3 months, 95% CI: 8.9–49.7; non-surgery group: n=15, OS: 5.7 months, 95% CI: 4.2–7.2 months; p=0.002).

Conclusions

Radical surgery for octogenarian patients with periampullary cancer is safe, feasible, and expected to result in better survival outcomes, especially for patients with common bile duct cancer.

Preventing Treatment-Related Functional Decline: Strategies to Maximize Resilience

The majority of patients with cancer are older adults. A comprehensive geriatric assessment (CGA) will help the clinical team identify underlying medical and functional status issues that can affect cancer treatment delivery, cancer prognosis, and treatment tolerability. The CGA, as well as more abbreviated assessments and geriatric screening tools, can aid in the treatment decision-making process through improved individualized prediction of mortality, toxicity of cancer therapy, and postoperative complications and can also help clinicians develop an integrated care plan for the older adult with cancer. In this article, we will review the latest evidence with regard to the use of CGA in oncology. In addition, we will describe the benefits of conducting a CGA and the types of interventions that can be taken by the interprofessional team to improve the treatment outcomes and well-being of older adults.

Management of older adults with acute lymphoblastic leukemia: challenges & current approaches

The management of acute lymphoblastic leukemia (ALL) in older patients is challenging. Older patients often have multiple comorbidities and poor performance status, and disease factors associated with poor prognosis are more common in this age group. Patient and disease-related factors should be taken into account to determine whether intensive therapy is appropriate. The use of comorbidity indices and comprehensive geriatric assessment tools can be valuable in this setting. Fit patients should be considered for aggressive therapies including allogeneic hematopoietic stem cell transplantation, whereas low intensity options may be more suitable for the frail. The Philadelphia (Ph) chromosome is present in up to half of the cases of ALL in older patients. The incorporation of TK inhibitors into the treatment plans of older patients with Ph-positive ALL has improved the outcomes significantly. For less fit patients with Ph-positive ALL, the use of TK inhibitors with reduced-intensity chemotherapy or steroids alone results in high rates of remission, but, without further consolidation, relapses are inevitable. Many novel targeted and immunotherapeutic agents are being developed, offering more effective and tolerable treatment options.

General recommendations paper on the management of older patients with cancer: the SEOM geriatric oncology task force's position statement

Population aging is associated with greater numbers of older people with cancer. Thanks to treatment advances, not only are more seniors diagnosed with cancer, but there are also more and more older cancer survivors. This upward trend will continue. Given the heterogeneity of aging, managing older patients with cancer poses a significant challenge for Medical Oncology. In Spain, a Geriatric Oncology Task Force has been set up within the framework of the Spanish Society for Medical Oncology (SEOM). With the aim of generating evidence and raising awareness, as well as helping medical oncologists in their training with respect to seniors with cancer, we have put together a series of basic management recommendations for this population. Many of the patients who are assessed in routine clinical practice in Oncology are older. CGA is the basic tool by means of which to evaluate older people with cancer and to understand their needs. Training and the correct use of recommendations regarding treatment for comorbidities and geriatric syndromes, support care, and drug–drug interactions and toxicities, including those of antineoplastic agents, as detailed in this article, will ensure that this population is properly managed.

Efficacy of PD-1 & PD-L1 inhibitors in older adults: a meta-analysis

Background

Immune checkpoint inhibitors targeting PD-1/PD-L1 pathway demonstrated promising activities in variety of malignancies, however little is known regarding their efficacy in adults aged ≥65 years.

Methods

We conducted a systematic review and a study-level meta-analysis to explore efficacy of ICIs based on age, younger vs older than 65 years. We included in this analysis randomized controlled phase II or III studies in patients with metastatic solid tumors that compared efficacy of PD-1 or PD-L1 inhibitors to a non-PD-1/PD-L1 inhibitor. Aggregated estimates of overall survival (OS) and progression-free survival (PFS) are based on random/mixed effects (RE) models to allow for heterogeneity between the studies.

Results

Initial search identified 53 articles, 17 were randomized controlled trials that compared nivolumab, pembrolizumab or atezolizumab to chemotherapy or targeted therapy. Only 9 trials reported hazard ratiios (HR) for OS based on age and were included in this meta-analysis. Out of those studies seven reported HR for PFS but only 4 studies included subgroup-analysis based on age for PFS. The overall estimated random-effects HR for death was 0.64 with 95% CI of 0.54–0.76 in patients ≥65 years vs. 0.68 with 95% CI of 0.61–0.75 in patients < 65 years. The overall estimated random-effects for HR for progression was 0.74 with 95% CI of 0.60–0.92 in patients ≥65 years vs. 0.73 with 95% CI of 0.61–0.88 in patients < 65 years.

Conclusions

PD-1 (nivolumab and pembrolizumab) and PD-L1 (atezolizumab) inhibitors had comparable efficacy in adults younger vs ≥ 65 years.

Geriatric assessment-driven polypharmacy discussions between oncologists, older patients, and their caregivers

OBJECTIVES

Polypharmacy (PP) and potentially inappropriate medications (PIM) are common in older adults with cancer, increasing the risk of adverse outcomes. Approaches to identifying and addressing PP/PIM are needed.

MATERIALS AND METHODS

Patients ≥70 years with advanced cancer were enrolled in this cluster-randomized study. All underwent geriatric assessment (GA), and oncologists randomized to the intervention arm received GA-driven recommendations; no information was provided to oncologists at usual care sites. For patients with PP (≥5 medications or ≥1 high-risk medication), clinic visits with treating oncologists were audiorecorded and transcribed, and discussions regarding PP/PIM identified. Quality of provider response was coded as dismissed, mentioned, acknowledged, or addressed.

RESULTS

Forty patient transcripts were analyzed (20 per arm). More discussions occurred in the intervention group (n = 81) versus the usual care group (n = 51). More concerns per patient were brought up in the intervention group (4.1 vs. 2.6, p = 0.07). Physician-initiated discussions were higher in the intervention group (73% vs. 49%, p = 0.006). More PP concerns were "addressed" in the intervention group (59% vs. 45%, p = 0.1). Oncology supportive care medication concerns were more often addressed in the usual care group (58% vs. 18%, p = 0.008), but medication management concerns were addressed more commonly in the intervention group (38% vs. 79%, p = 0.003).

CONCLUSION

In this secondary analysis, a GA-driven intervention increased PP discussions, particularly about total number of medications and medication management. PP/PIM concerns were more commonly addressed in the intervention group, except for the subset of conversations about supportive care medications.

Modeling individual and relative accuracy of screening tools in geriatric oncology

Background

Classification probabilities reflect to what degree a screening test represents the true disease state and include true positive (TPF) and false positive fractions (FPF). With two tests, one can compare TPF and FPF using relative probabilities which offer advantages in terms of interpretation and statistical modeling. Our objective was to highlight how individual and relative TPF and FPF can be easily estimated and compared within a regression modeling framework. This allows the modeling of tests' accuracy while adjusting for multiple covariates, and thus provides valuable information in addition to the crude TPF and FPF. We illustrate our purpose with the G8 and VES-13 screening tests aimed at identifying elderly cancer patients in need for a comprehensive geriatric assessment (CGA).

Methods

Prospective cohort with a paired design. TPF and FPF of each test, as well as relative TPF and FPF were modeled using log-linear models.

Results

G8 detected patients in need for CGA better than VES-13 at the expense of misclassifying a large number of normal patients. Both tests had better TPF with older age and poorer performance status (PS), and for all cancer subtypes compared with prostate cancer. Effect of age and PS on TPF was more pronounced with VES-13. Age affected FPF, but not differentially.

Conclusions

Regression modeling helps provide a thorough assessment of the accuracy of diagnostic tests and should be used more frequently. In the context of screening, we encourage the use of G8 as failing to identify patients in need of a CGA might be more problematic than over-detection. Moreover, although we identified variables associated with the sensitivity of these tests, this association was less pronounced for the G8.

Geriatric assessment may help decision-making in elderly patients with inoperable, locally advanced non-small-cell lung cancer

Background:

Although concurrent chemoradiotherapy (cCRT) increases survival in patients with inoperable, locally advanced non-small-cell lung cancer (NSCLC), there is no consensus on the treatment of elderly patients. The aim of this study was to determine the prognostic value of the comprehensive geriatric assessment (CGA) and its ability to predict toxicity in this setting.

Methods:

We enrolled 85 consecutive elderly (⩾75 years) participants, who underwent CGA and the Vulnerable Elders Survey (VES-13). Those classified as fit and medium-fit by CGA were deemed candidates for cCRT (platinum-based chemotherapy concurrent with thoracic radiation therapy), while unfit patients received best supportive care.

Results:

Fit (37%) and medium-fit (48%) patients had significantly longer median overall survival (mOS) (23.9 and 16.9 months, respectively) than unfit patients (15%) (9.3 months, log-rank P=0.01). In multivariate analysis, CGA groups and VES-13 were independent prognostic factors. Fit and medium-fit patients receiving cCRT (n=54) had mOS of 21.1 months (95% confidence interval: 16.2, 26.0). In those patients, higher VES-13 (⩾3) was associated with shorter mOS (16.33 vs 24.3 months, P=0.027) and higher risk of G3-4 toxicity (65 vs 32%, P=0.028).

Conclusions:

Comprehensive geriatric assessment and VES-13 showed independent prognostic value. Comprehensive geriatric assessment may help to identify elderly patients fit enough to be treated with cCRT.