Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

The effect of R-CHOP dose reduction on overall survival of elderly patients with DLBCL - comparative study

R-CHOP is the standard therapy for patients with diffuse large B-cell lymphoma (DLBCL). We evaluated the effect of reduced intensity R-CHOP on survival, and toxicity in patients 70 years or older with DLBCL. The retrospective analysis included 140 patients (median age 78 years). We showed that patients with a good performance status treated with reduced adriamycin dose had a statistically significant worse overall survival. In multivariable model, the HR with any 10% increase adriamycin-relative dose in the first cycle was, 0.81, 95% CI 0.70-0.94. Age, gender, albumin and IPI were also associated with overall survival. Hospitalizations of patients treated with reduced R-CHOP were longer; however, the rate of infection did not differ between the groups. Based on current data, the optimal treatment for elderly patients with DLBCL remains unclear, but it is apparent that the dose of chemotherapy should be tailored individually according to performance status.

Age-related Disparity: Breast Cancer in the Elderly

Aging poses an unique opportunity to study cancer biology and treatment in older adults. Breast cancer is often studied in young women; however, much investigation remains to be done on breast cancer in our expanding elderly population. Diagnostic and management strategies applicable to younger patients cannot be empirically used to manage older breast cancer patients. Lack of evidence-based data continues to be the major impediment toward delivery of personalized cancer care to elderly breast cancer patients. This article reviews the relevant literature on management of curable breast cancer in the elderly, the role of geriatric assessment, complex treatment decision making within the context of patient's expected life expectancy, comorbidities, physical function, socioeconomic status, barriers to health care delivery, goals of treatment, and therapy-related side effects. Continuing efforts for enrolling elderly breast cancer patients in contemporary clinical trials, and thus improving age-appropriate care, are emphasized.

Randomized study comparing full dose monotherapy (S-1 followed by irinotecan) and reduced dose combination therapy (S-1/oxaliplatin followed by S-1/irinotecan) as initial therapy for older patients with metastatic colorectal cancer: NORDIC 9

Background

Metastatic colorectal cancer (mCRC) is a disease of older age, but there is a relative lack of knowledge about effects of chemotherapy in older patients as they are under-represented in clinical trials. Little data can guide whether the strategy in older mCRC patients should be a sequential full-dose monotherapy chemotherapy approach or a dose-reduced combination chemotherapy approach. The oral 5FU prodrug S-1 seems to have less side effects than capecitabine and should be an optimal drug for older patients, but few data are available. Improved geriatric assessments are needed to select which older patients should receive therapy.

Methods

The NORDIC 9 trial is a Nordic multicenter randomized phase II study comparing full dose monotherapy (S-1 30 mg/m² twice daily days 1–14 every 3 weeks, followed by second line irinotecan 250–350 mg/m² iv day 1 every 3 weeks or 180–250 mg/m² iv day 1 every 2 weeks) with reduced dose combination therapy (S-1 20 mg/m² days 1–14 + oxaliplatin 100 mg/m² iv day 1 every 3 weeks, followed by second line S-1 20 mg/m² days 1–14 + irinotecan 180 mg/m² day 1 every 3 week) for older patients (≥70 years) with mCRC who are not candidates for full-dose standard combination therapy. Additional bevacizumab (7.5 mg/kg) is optional in first-line. Blood samples and tumor tissue will be collected to investigate predictive markers. Geriatric screening tools (G-8, VES-13, Timed-Up-and-Go and Handgrip strength), Charlson Comorbidty Index and quality of life (EORTC QLQ-C30) will be evaluated as predictors of efficacy and toxicity. The target sample size is 150 patients.

The primary endpoint is progression-free survival and secondary endpoints are time-to-failure of strategy, overall survival, response rate, toxicity, and correlations between biomarkers, pre-treatment characteristics and geriatric assessments.

Discussion

The study will add knowledge on how to treat older mCRC patients who are not candidates for standard combination therapy. Furthermore it may provide understanding of efficacy and tolerability of chemotherapy in older cancer patients and thus offer a better chance for tailored treatment strategies in these patients.

Trial registration

EU Clinical Trial Register, EudraCT no. 2014–000394-39. Registered 05 May 2014.

Comprehensive geriatric assessment in 326 older women with early breast cancer

Background:

One-third of new early breast cancer diagnoses occur in women over 70 years old. However, older women are less likely to receive radical curative treatments. This study prospectively evaluated a cohort of older women using a Comprehensive Geriatric Assessment (CGA) to determine whether fitness explained the apparent under-treatment in this patient group.

Methods:

In this multi-centre prospective study, patients aged ⩾70 years with Stages I–III breast cancer underwent a pretreatment baseline CGA consisting of eight assessment tools. Patients were defined as ‘fit’ if they had normal score in seven out of eight of the assessment tools. ‘High risk’ patients were defined as those with grade 3, ER negative, HER2 positive, or node positive breast cancer.

Results:

Data on 326 patients were available for full analysis. The median age was 77 years. In all, 182 (56%) of the total population were defined as high risk, with 49%, 61% and 53% of those in the 70–74, 75–84 and ⩾85 years age groups respectively having high risk tumours. A total of 301 patients had sufficient CGA records of whom 131 (44%) were reported as fit, with 34%, 54% and 12% of them in the 70–74, 75–84 and ⩾85 years age groups respectively. More fit than unfit patients underwent primary breast surgery (100% vs 91%, P=0.0002), axillary surgery (92% vs 84%, P=0.0340), and adjuvant chemotherapy for high-risk disease (51% vs 20%, P=0.0001). Rates of adjuvant radiotherapy after wide local excision were not significantly different (88% vs 90% respectively, P=0.8195).

Conclusions:

In this study, all women ⩾70 years deemed fit by CGA underwent primary surgery. Nearly 50% of fit women with high-risk disease did not receive adjuvant chemotherapy suggesting under treatment in this group.

Management and prognosis of hepatocellular carcinoma in the elderly: Results of an in-field multicenter cohort study

AIMS

This multicentre cohort study evaluated the role of ageing on clinical characteristics, treatment allocation and outcome of new hepatocellular carcinomas (HCCs), in clinical practice.

MATERIAL & METHODS

From September 2008, 541 patients >70 years old (elderly group), and 527 ≤70 years old (non-elderly group) with newly diagnosed HCC were consecutively enrolled in 30 Italian centres. Differences in clinical characteristics and treatment allocation between groups were described by a multivariable logistic regression model measuring the inverse probability weight to meet the elderly group. Survival differences were measured by unadjusted and adjusted (by inverse probability weight) survival analysis.

RESULTS

Elderly patients were mainly females, hepatitis C virus infected and with better conserved liver function (P<.001). At presentation, HCC median size was similar in both groups while, in youngers, HCC was more frequently multinodular (P=.001), and associated with neoplastic thrombosis (P=.009). Adjusted survival analysis showed that age did not predict short-mid-term survival (within 24 months), while it was a significant independent predictor of long-term survival. Moreover, age had a significant long-term survival impact mainly on early HCC stages (Barcelona Clinic for Liver Cancer [BCLC] 0-A), its impact on BCLC B stage was lower, while it was negligible for advanced-terminal stages.

CONCLUSIONS

Age per se does not impact on short-mid-term prognosis (≤24 months) of HCC patients, and should not represent a limitation to its management.

Prognostic value of the G8 and modified-G8 screening tools for multidimensional health problems in older patients with cancer

BACKGROUND

The G8 screening tool has been developed to identify older cancer patients requiring a geriatric assessment for tailoring therapy. Little is known about its prognostic value, particularly by tumour site. An optimised version has been recently developed, but no prognostic information is available. We compared the prognostic value of both instruments overall and by tumour site.

METHODS

Data were from a prospective cohort of cancer patients ≥70 years old referred to 1 of 6 French geriatric oncology clinics between 2007 and 2014 (n = 1333). Endpoints were overall 1- and 3-year survival. Cox proportional-hazards models were built to assess the predictive value of abnormal G8 and modified-G8 scores, based on published cut-offs or by classes of increasing risk. Sensitivity analyses involved adjusting for age, gender, treatment, metastasis, and tumour site (digestive, breast, urinary tract, prostate, other solid cancers, and haematological malignancies) and stratifying by tumour site and metastatic status.

RESULTS

Abnormal scores were independently associated with overall 1-year survival: adjusted hazard ratio [aHR] = 4.3[G8]/4.9[modified-G8] and 3-year survival: aHR = 2.9/2.6; all p <0.0001. Associations persisted after stratifying by metastatic status and in most cancer sites (exceptions: colorectal (G8) and upper digestive cancer (both tools) [1-year analysis]; digestive cancers (both tools) [3-year analysis]). For both tools, classes of increasing risk showed a graded relationship with mortality (p < 0.0001).

CONCLUSIONS

Our results identified both abnormal G8 and modified-G8 scores as strong and consistent predictors of overall survival, regardless of metastatic status or tumour site. These findings strengthen the clinical utility of these instruments in the geriatric oncology setting.

Carboplatin plus weekly nanoparticle albumin-bound paclitaxel in elderly patients with previously untreated advanced squamous non-small-cell lung cancer selected based on Mini Nutritional Assessment short-form scores: a multicenter phase 2 study

PURPOSE

This multicenter, single-arm, open-label, phase 2 study assessed the efficacy and safety of carboplatin plus weekly nanoparticle albumin-bound paclitaxel in elderly patients with previously untreated advanced squamous non-small-cell lung cancer, selected based on the Mini Nutritional Assessment short-form scores (MNA-SF).

METHODS

Patients received carboplatin (area under the curve: 6) on Day 1, and nanoparticle albumin-bound paclitaxel (100 mg/m²) on Days 1, 8, and 15, every 28 days for ≤4 cycles. Eligibility criteria included an MNA-SF score of ≥8 points. The primary endpoint was the objective response rate.

RESULTS

Thirty patients with a median age of 76 (range 70-83) years were enrolled. The objective response rate was 50.0% (95% confidence interval: 31.3-68.7%), which met the primary objective of this study. The disease control rate was 73.3% (95% CI: 54.1-87.7%). At a median follow-up of 15.0 months, the median progression-free and overall survival was 7.1 and 19.1 months, respectively. The most common treatment-related adverse event of Grade ≥3 was neutropenia (66.7%). Non-hematological adverse events of Grade ≥3 were minor. Well-nourished patients, based on the MNA-SF, experienced fewer adverse events of Grade ≥3 compared to patients at risk of malnutrition. All treatment-related adverse events were tolerable and reversible. There were no treatment-related deaths.

CONCLUSIONS

Carboplatin plus weekly nanoparticle albumin-bound paclitaxel is effective and well tolerated as a first-line treatment for elderly patients with advanced squamous non-small-cell lung cancer. Eligibility based on MNA-SF screening may be useful in determining acceptable toxicity.

The footprint of the ageing stroma in older patients with breast cancer

Background

Tumours are not only composed of malignant cells but also consist of a stromal micro-environment, which has been shown to influence cancer cell behaviour. Because the ageing process induces accumulation of senescent cells in the body, this micro-environment is thought to be different in cancers occurring in old patients compared with younger patients. More specifically, senescence-related fibroblastic features, such as the senescence-associated secretory profile (SASP) and the induction of autophagy, are suspected to stimulate tumour growth and progression.

Methods

We compared gene expression profiles in stromal fields of breast carcinomas by performing laser capture microdissection of the cancer-associated stroma from eight old (aged ≥80 years at diagnosis) and nine young (aged <45 years at diagnosis) patients with triple-negative breast cancer. Gene expression data were obtained by microarray analysis (Affymetrix). Differential gene expression and gene set enrichment analysis (GSEA) were performed.

Results

Differential gene expression analysis showed changes reminiscent of increased growth, de-differentiation and migration in stromal samples of older versus younger patients. GSEA confirmed the presence of a SASP, as well as the presence of autophagy in the stroma of older patients.

Conclusions

We provide the first evidence in humans that older age at diagnosis is associated with a different stromal micro-environment in breast cancers. The SASP and the presence of autophagy appear to be important age-induced stromal features.

Electronic supplementary material

The online version of this article (doi:10.1186/s13058-017-0871-0) contains supplementary material, which is available to authorized users.

The effect of geriatric intervention in frail elderly patients receiving chemotherapy for colorectal cancer: a randomized trial (GERICO)

Background

Better surgical techniques, chemotherapy and biological therapy have improved survival in patients with colorectal cancer (CRC), most markedly in younger patients. About half of patients over 70 years receive dose reductions or early treatment discontinuation of the planned adjuvant or first-line treatment due to side effects. The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary evaluation of an elderly individual’s health status. This assessment in older patients with cancer can predict survival, chemotherapy toxicity and morbidity.

Methods

This randomized phase II trial (GERICO) is designed to investigate whether comprehensive geriatric assessment and intervention before and during treatment with chemotherapy in frail elderly patients with stages II–IV CRC will increase the number of patients completing chemotherapy. All patients ≥70 years in whom chemotherapy for CRC is planned to start at Herlev and Gentofte Hospital are screened for frailty using the G8 questionnaire at the first visit to the outpatient clinic. The G8 questionnaire is a multi-domain screening tool to identify frail or vulnerable patients at risk of increased toxicity and morbidity. Frail patients are offered inclusion and are then randomized to two groups (the intervention group and the control group). Patients in the intervention group receive a full geriatric assessment of comorbidity, medication, psycho-cognitive function, physical, functional and nutrition status, and interventions are undertaken on identified health issues. Simultaneously, they are treated for their cancer according to international guidelines. Patients in the control group receive the same chemotherapy regimens and standard of care. Primary outcome is number of patients completing scheduled chemotherapy at starting dose. Secondary outcomes are dose reductions, treatment delays, toxicity, time to recurrence, survival, cancer-related mortality and quality of life.

Discussion

This ongoing trial is one of the first to evaluate the effect of geriatric intervention in frail elderly patients with CRC. The trial will provide new and valuable knowledge about whether it is beneficial for the elderly patient undergoing chemotherapy to be treated simultaneously by a geriatrician.

Trial registration

ClinicalTrials.gov ID: NCT02748811. The trial was registered retrospectively; registration date 04/28/2016.

The G8 screening tool enhances prognostic value to ECOG performance status in elderly cancer patients: A retrospective, single institutional study

Background

Some elderly cancer patients, even with good Eastern Cooperative Oncology Group performance status (ECOG-PS), have poor survival outcomes and cannot tolerate standard therapy. Few studies have detailed the associations between the G8 screening tool, ECOG-PS, and overall survival (OS) in such patients.

Methods

Cancer patients, aged 70 years or older, were assessed for G8 and classified into three groups according to their G8 score: <11 as the low score group, 11–14 as the intermediate score group, and >14 as the high score group. We retrospectively analyzed the association between G8 score and OS in all patients and for each ECOG-PS-categorized group.

Results

Out of 264 enrolled patients, most patients (87%) with solid tumor were categorized as TNM stage IV. ECOG-PS was 0 or 1 in 215 patients and ≥2 in 48; there was missing data for one patient. Among all patients, the low score group with a median OS of 7.7 months survived significantly less than both the high score group with a median OS of 25.6 months [Hazard ratio (HR) 3.48; 95% confidence interval (CI), 1.96–6.63; p < 0.0001] and the intermediate score group with a median of 15.6 months (HR 1.83; 95% CI, 1.28–2.65; p < 0.001). In the multivariate analysis, TNM stage and G8 score were independent prognostic factors for OS. When patients with an ECOG-PS of 0 or 1 were analyzed, patients with a lower G8 score showed significantly shorter OS than patients with a higher score when any two groups were compared.

Conclusion

This novel classification of the G8 score contributes to prompt identification of patients with poor prognosis and improved the prognostic value of ECOG-PS. Using G8 with ECOG-PS may be helpful in deciding treatment for elderly patients with advanced cancer.

Geriatric Assessment and Functional Decline in Older Patients with Lung Cancer

PURPOSE

Older patients with lung cancer are a heterogeneous population making treatment decisions complex. This study aims to evaluate the value of geriatric assessment (GA) as well as the evolution of functional status (FS) in older patients with lung cancer, and to identify predictors associated with functional decline and overall survival (OS).

METHODS

At baseline, GA was performed in patients ≥70 years with newly diagnosed lung cancer. FS measured by activities of daily living (ADL) and instrumental activities of daily living (IADL) was reassessed at follow-up to define functional decline and OS was collected. Predictors for functional decline and OS were determined.

RESULTS

Two hundred and forty-five patients were included in this study. At baseline, GA deficiencies were present in all domains and ADL and IADL were impaired in 51 and 63% of patients, respectively. At follow-up, functional decline in ADL was observed in 23% and in IADL in 45% of patients. In multivariable analysis, radiotherapy was predictive for ADL decline. No other predictors for ADL or IADL decline were identified. Stage and baseline performance status were predictive for OS.

CONCLUSIONS

Older patients with lung cancer present with multiple deficiencies covering all geriatric domains. During treatment, functional decline is observed in almost half of the patients. None of the specific domains of the GA were predictive for functional decline or survival, probably because of the high impact of the aggressiveness of this tumor type leading to a poor prognosis.

Update on the Management of Pancreatic Cancer in Older Adults

Pancreatic cancer is more common in older adults, who are underrepresented in clinical trials and frequently under treated. Chronological age alone should not deter clinicians from offering treatment to geriatric patients, as they are a heterogeneous population. Geriatric assessment, frailty assessment tools, and toxicity risk scores help clinicians select appropriate patients for therapy. For resectable disease, surgery can be safe but should be done at a high-volume center. Adjuvant therapy is important; though there remains controversy on the role of radiation, chemotherapy is well studied and efficacious. In locally advanced unresectable disease, chemoradiation or chemotherapy alone is an option. Neoadjuvant therapy improves the chances of resectability in borderline resectable disease. Chemotherapy extends survival in metastatic disease, but treatment goals and risk-benefit ratios have to be clarified. Adequate symptom management and supportive care are important. There are now many new treatment strategies and novel therapies for this disease.

Use of geriatric assessment and screening tools of frailty in elderly patients with prostate cancer. Review

The management of prostate cancer in the elderly is a major public health concern in most countries. Currently, most prostate cancers are diagnosed in elderly males. The elderly population is very heterogeneous. Thus, the current challenge is to identify better those individuals for whom specific screening tools and a Comprehensive Geriatric Assessment (CGA) would be beneficial. On the basis of the recommendations of the Prostate Cancer Working Group in the International Society of Geriatric Oncology, older patients with prostate cancer should be managed according to their individual health status and not by their age. CGA is the best tool for determining the health status of an older patient. In this article, we sought to assemble all available evidence on the models of CGA and the prevalence of geriatric conditions in older patients with prostate cancer. We also discuss the feasibility of the most used screening tools in elderly patients, that is, the Vulnerable Elders Survey-13 (VES-13) and G-8 as screening tools in this group of patients.

Curative Treatment for Muscle Invasive Bladder Cancer in Elderly Patients: A Systematic Review

CONTEXT

The incidence of muscle invasive bladder cancer (MIBC) increases with age. With increased life expectancy the number of elderly MIBC patients is expected to increase. Existing guidelines on management of MIBC do not preclude curative treatments for elderly patients. However, it is necessary to assess the risks and benefits of a treatment to avoid overtreatment that results in decreased health-related quality of life without prolonging survival.

OBJECTIVE

To report on overall survival (OS), cancer specific survival (CSS), and morbidity after curative treatment in elderly patients, defined as age >70 yr, with nonmetastatic MIBC and to compare this with the outcome of younger MIBC patients.

EVIDENCE ACQUISITION

A systematic review was performed using Medline, PubMed, and Embase databases. Articles were included if they addressed one of the three research questions: Only articles including >100 patients and with a clear age-stratification were included.

EVIDENCE SYNTHESIS

Forty-two articles were retrieved for review. No article directly addressed the use of geriatric assessment. OS and CSS worsen significantly with age both after radical cystectomy and radiotherapy regimens. While POM significantly increases with age, morbidity seems comparable between younger and older patients.

CONCLUSIONS

Although a proportion of elderly patients with MIBC will benefit from curative treatment, we observed worse OS, CSS, and POM with age. The impact of age on late morbidity is less clear. Prospective studies evaluating geriatric assessments are critically needed to optimize MIBC management in the elderly.

PATIENT SUMMARY

We performed a systematic review to evaluate the outcome and complication rate in elderly patients with muscle invasive bladder cancer. We observed that overall survival and cancer specific survival significantly decrease and perioperative mortality significantly increases with age. The impact of age on late morbidity is less clear. There is a need for geriatric assessments to select those patients that will benefit from curative treatment.

4th symposium on primary breast cancer in older women. Theme: putting personalized care into practice (Held: 3 March 2017)

Following the inception in 2010, the University of Nottingham hosted the 4th Symposium on Primary Breast Cancer in Older Women, under the auspices of the International Society of Geriatric Oncology, in March 2017, at East Midlands Conference Centre.  This is the only meeting of its kind in the UK, now held biennially, aiming at a multidisciplinary audience, including patients, their carers and advocates.  With a theme on ‘Putting personalising care into practice’, this Symposium included sessions on ‘local and systemic therapies’, ‘new ideas’, ‘patients and carers’, and ‘challenging areas’, covered by an international and local faculty, interviewing patients and carers, and abstract presentations.  Topics covered were practical and wide-ranging, including selectng for chemotherapy, radiotherapy and breast reconstruction, treating HER2-positive disease, and the roles of the geriatrician and geriatric oncology nurse.

Diagnostic performance of gait speed, G8 and G8 modified indices to screen for vulnerability in older cancer patients: the prospective PF-EC cohort study

Background

The diagnostic performance of tools used to screen vulnerability in older cancer patients varies widely. We assessed the diagnostic performance of gait speed (GS) for assessing vulnerability in such patients.

Methods

All consecutive outpatients 65 years and older were referred for geriatric oncology assessment (GA) before a therapeutic decision between November 2013 and April 2016 in a bicentric observational and prospective cohort study. Vulnerability was defined as impaired score on at least one of the 6 domains of the GA. GS and the G8 index and G8 modified index were assessed at the first geriatric oncology visit during the GA. Sensitivity, specificity, positive and negative predictive value and positive and negative likelihood ratio were estimated. The accuracy of the three tools was analysed by the area under the receiver operating characteristic curve (AUC).

Results

Among 269 included patients (mean [SD] age, 81.3 years [5.9]; 55% women, 94.4% solid tumors; 39.4% with metastasis), 252 (93.7%) had impaired GA. With the GS threshold of 1 m/s, sensitivity was 79.4% (95% CI, 73.8-84.2), specificity 64.7% (38.3-85.8), and AUC 82.0 (74.0-90.0). The corresponding values for the G8 index were 90.1% (85.7-93.5), 35.3% (14.2-61.7), and 79.0 (70.0-88.0) and G8 modified index were 89.3% (84.8-92.8), 64.7% (38.3-85.8), and 84.0 (74.0-92.0).

Conclusions

GS < 1 m/s with a single measure could be used as a new screening tool for detecting vulnerability in older cancer outpatients. This first external validation of the G8 modified index was very good.

Management of metastatic colorectal cancer patients: guidelines of the Italian Medical Oncology Association (AIOM)

In the past 15 years, the outcome for patients with metastatic colorectal cancer has substantially improved owing to the availability of new cytotoxic and biological agents along with many significant advances in molecular selection, the use of personalised therapy and locoregional treatment, a more widespread sharing of specific professional experiences (multidisciplinary teams with oncologists, surgeons, radiotherapists, radiologists, biologists and pathologists), and the adoption of patient-centred healthcare strategies. The Italian Medical Oncology Association (AIOM) has developed evidence-based recommendations to help oncologists and all professionals involved in the management of patients with metastatic colorectal cancer in their daily clinical practice.

PREDOMOS study, impact of a social intervention program for socially isolated elderly cancer patients: study protocol for a randomized controlled trial

Background

Cancer incidence and social isolation increase along with advanced age, and social isolation potentiates the relative risk of death by cancer. Once spotted, social isolation can be averted with the intervention of a multidisciplinary team. Techniques of automation and remote assistance have already demonstrated their positive impact on falls prevention and quality of life (QoL), though little is known about their impact on socially isolated elderly patients supported for cancer.

The primary objective of the PREDOMOS study is to evaluate the impact of establishing a Program of Social intervention associated with techniques of Domotic and Remote assistance (PS-DR) on the improvement of QoL of elderly isolated patients, treated for locally advanced or metastatic cancer. The secondary objectives include treatment failure, tolerance, survival, and autonomy.

Methods/design

This trial is a multicenter, prospective, randomized, placebo-controlled, open-label, two-parallel group study. The setting is 10 French oncogeriatric centers. Inclusion criteria are patients aged at least 70 years with a social isolation risk and a histological diagnosis of cancer, locally advanced or metastatic disease. The groups are (1) the control group, receiving usual care; (2) the experimental group, receiving usual care associating with monthly social assistance, domotic, and remote assistance. Participants are randomized in a 1:1 allocation ratio. Evaluation times involve inclusion (randomization) and follow-up (12 months). The primary endpoint is QoL at 3 months (via European Organization for Research and Treatment of Cancer (EORTC) QLQ C30); secondary endpoints are social isolation, time to treatment failure, toxicity, dose response-intensity, survival, autonomy, and QoL at 6 months. For the sample size, 320 individuals are required to obtain 90% power to detect a 10-point difference (standard deviation 25) in QoL score between the two groups (20% loss to follow-up patients expected).

Discussion

The randomized controlled design is the most appropriate design to demonstrate the efficacy of a new experimental strategy (Evidence-Based Medicine Working Group classification). National and international recommendations could be updated based on the findings of this study.

Trial registration

ClinicalTrials.gov, NCT02829762. Registered on 29 June 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1894-7) contains supplementary material, which is available to authorized users.

Prognostic Value of Geriatric 8 and Identification of Seniors at Risk for Hospitalized Patients Screening Tools for Patients With Lung Cancer

BACKGROUND

Because of the time-consuming aspect of geriatric assessments, cancer specialists are seeking shorter screening tools to distinguish fit and frail patients. We analyzed the predictive value of the Geriatric 8 (G8) and Identification of Seniors at Risk for Hospitalized Patients (ISAR-HP) in elderly patients with lung cancer.

PATIENTS AND METHODS

From January 2014 to April 2016, the data from patients with lung cancer aged > 70 years at 2 teaching hospitals in the Netherlands were included in a database. The patients were classified as potentially frail if they had a G8 of ≤ 14 or ISAR-HP of ≥ 2.

RESULTS

Of the 142 included patients (median age, 77 years; interquartile range, 73-82 years), 108 (76%) were potentially frail. After correction for possible confounders, the potentially frail patients had a significantly greater risk of 1-year mortality (hazard ratio [HR], 4.08; 95% confidence interval [CI] 1.67-9.99; P = .02). Higher disease stage (HR, 1.72; 95% CI, 1.40-2.12; P < .001) was also a significant predictor of mortality; however, initial treatment (standard or otherwise) and age were not. When using both screening instruments separately, an impaired score on the G8 and higher disease stage were the variables remaining in the regression analyses (HR for impaired G8, 3.01; 95% CI, 1.35-6.72; P < .001). Patients with impaired scores on the ISAR-HP and G8 had more geriatric impairments than did patients with only an impaired G8 score.

CONCLUSION

G8 screening is useful for the prognostication of elderly patients with lung cancer and could be used in combination with ISAR-HP to increase specificity at the cost of sensitivity. Using the ISAR-HP as the only screening tool would be insufficient.

[Colorectal cancer in the elderly. Surgical treatment, chemotherapy, and contribution from geriatrics]

Age is the biggest risk factor for colorectal cancer, with 70% of the cases in patients over 70 years old. For this reason, a review is presented on the surgical treatment and chemotherapy of cancer of colon and rectum in the elderly. A search was performed in PubMed, including words such as elderly, surgery, colorectal cancer, chemotherapy, radiotherapy, and oncogeriatrics, and review articles and originals on treatment of colorectal cancer in the elderly were selected. A narrative form was developed from the latest evidence with the results obtained on the treatment of this pathology. Although the treatment of colorectal cancer is standardised, a prior comprehensive geriatric assessment is required in the case of the elderly, before deciding the type of treatment in order to offer these robust elderly-standardised guidelines for the robust elderly and adapt them for use in fragile patients.

Cancer Treatment as an Accelerated Aging Process: Assessment, Biomarkers, and Interventions

An accumulating body of evidence supports the hypothesis that cancer and/or cancer treatment is associated with accelerated aging. The majority of these data come from the pediatric literature; however, a smaller yet growing body of literature points toward similar findings in the geriatric population. This is a key survivorship issue the growing number of older adults with cancer face, along with the short- and long-term impact of cancer therapy on the aging process. This article will review clinical and biologic markers of aging in older adults with cancer, use cardiovascular disease as a model of accelerated aging, and discuss potential interventions to decrease the risk.

Management of Prostate Cancer in Elderly Patients: Recommendations of a Task Force of the International Society of Geriatric Oncology

CONTEXT

Prostate cancer is the most frequent male cancer. Since the median age of diagnosis is 66 yr, many patients require both geriatric and urologic evaluation if treatment is to be tailored to individual circumstances including comorbidities and frailty.

OBJECTIVE

To update the 2014 International Society of Geriatric Oncology (SIOG) guidelines on prostate cancer in men aged >70 yr. The update includes new material on health status evaluation and the treatment of localised, advanced, and castrate-resistant disease.

DATA ACQUISITION

A multidisciplinary SIOG task force reviewed pertinent articles published during 2013-2016 using search terms relevant to prostate cancer, the elderly, geriatric evaluation, local treatments, and castration-refractory/resistant disease. Each member of the group proposed modifications to the previous guidelines. These were collated and circulated. The final manuscript reflects the expert consensus.

DATA SYNTHESIS

Elderly patients should be managed according to their individual health status and not according to age. Fit elderly patients should receive the same treatment as younger patients on the basis of international recommendations. At the initial evaluation, screening for cognitive impairment is mandatory to establish patient competence in making decisions. Initial evaluation of health status should use the validated G8 screening tool. Abnormal scores on the G8 should lead to a simplified geriatric assessment that evaluates comorbid conditions (using the Cumulative Illness Score Rating-Geriatrics scale), dependence (Activities of Daily Living) and nutritional status (via estimation of weight loss). When patients are frail or disabled or have severe comorbidities, a comprehensive geriatric assessment is needed. This may suggest additional geriatric interventions.

CONCLUSIONS

Advances in geriatric evaluation and treatments for localised and advanced disease are contributing to more appropriate management of elderly patients with prostate cancer. A better understanding of the role of active surveillance for less aggressive disease is also contributing to the individualisation of care.

PATIENT SUMMARY

Many men with prostate cancer are elderly. In the physically fit, treatment should be the same as in younger patients. However, some elderly prostate cancer patients are frail and have other medical problems. Treatment in the individual patient should be based on health status and patient preference.

A Risk-benefit Assessment Approach to Selection of Adjuvant Chemotherapy in Elderly Patients with Early Breast Cancer: A Mini Review

Decision-making regarding the use and selection of adjuvant chemotherapy for breast cancer in elderly patients is challenging due to the presence of age-related comorbidities, frailty, and competing causes of mortality. One area, relatively neglected in most guidelines, is the effect of competing causes of mortality on presumed benefit of adjuvant chemotherapy for breast cancer in these patients. This article utilizes a clinical case to illustrate the principles of risk-benefit assessment of adjuvant chemotherapy in elderly patients. We suggest an approach that incorporates validated tools for estimating survival benefits of adjuvant chemotherapy, geriatric assessment, predicting toxicity, and estimating remaining life expectancy without cancer. Integration of all these variables provides a better picture of the possible benefits and harms of adjuvant chemotherapy in this population compared to conventional approaches that incorporate tumor-related variables and nonstandard measures of geriatric assessment.

Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma: age is not a problem

OBJECTIVE

Sorafenib is the standard of care for patients with advanced hepatocellular carcinoma (HCC), but data on its use in the elderly are inconclusive.

METHODS

All consecutive HCC patients who were treated in our institution with sorafenib since its licensing were included in the analysis. Patients were divided into two groups: (A) up to 75 and (B) older than 75 years old. Our endpoints were overall survival (OS) and time to treatment failure (TTF) because of disease progression or toxicity. Safety parameters and the prognostic effect of HCC characteristics were also investigated.

RESULTS

Data from 190 patients (157 men), median age 66 (26-87) years, were studied (A=151 and B=39). No significant difference in OS and TTF was detected between the two groups [7.1 (5.5-8.7) vs. 10.4 (6.5-14.3) months, P=0.360 and 4.2 (2.3-6.2) vs. 5.6 (3.1-8.1) months, P=0.369, respectively]. Incidence of toxicities at all grades and dose reductions were comparable between groups A and B. In a multivariate setting, patients with Child-Pugh B score at baseline were associated with a higher risk of death (adjusted hazard ratio=2.17, 95% confidence interval:1.24-3.79, P=0.007) and treatment failure (adjusted hazard ratio=4.64, 95% confidence interval: 2.55-8.42, P=0.001) and had shorter OS and TTF compared with patients with a Child-Pugh A (P=0.004 and P<0.001, respectively).

CONCLUSION

Elderly patients with advanced HCC, when treated with sorafenib, have an equivalent clinical outcome with similar toxicity rates as their younger counterparts. Age alone should not be a discriminating factor for the management of advanced HCC with sorafenib.

Chronic lymphocytic leukemia and small lymphocytic lymphoma: two faces of the same disease

INTRODUCTION

Chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL) are considered indolent lymphocytic malignancies, more often requiring active surveillance rather than intervention. Despite the indolent nature of CLL/SLL, treatment is likely indicated in a patients' lifetime. Recent changes in the therapeutic landscape have created more options to the clinician. Areas covered: The authors provide a broad assessment of the current state of disease, including the work-up, prognostic features, and mutational aspects of the disease that should be acknowledged when developing a rational treatment plan. Key studies, guideline recommendations, and expert analysis are used to create this update on CLL/SLL. Expert commentary: The recent pace of treatment additions in CLL/SLL is a welcome addition. Moving forward, it is anticipated that treatment modalities will continue to evolve, leading to additional management options that truly would define CLL/SLL as a chronic disease.

Medical Treatment in Elderly Patients with Non-Small Cell Lung Cancer

OPINION STATEMENT

Lung cancer is the leading cause of cancer-related deaths worldwide. In the USA, ≈60 % of lung cancer cases are diagnosed in elderly patients (≥65 years of age). However, elderly patients are underrepresented in clinical studies, leading to a paucity of evidence to guide treatment decisions. Several treatment barriers exist in elderly patients, including comorbidities and poor performance status. In addition, lack of reliable geriatric assessment tools and physician reluctance to treat may contribute to undertreatment in this population. For decades, systemic chemotherapy for elderly patients with advanced non-small cell lung cancer (NSCLC) was either omitted or given as monotherapy, frequently with significant dose reductions, potentially compromising the efficacy of these therapies. Recent analyses of elderly subgroups from multiple clinical trials provide evidence for improved outcomes associated with platinum-based doublet chemotherapies vs monotherapy. Moreover, in the new era of precision medicine, molecularly targeted therapies and more recently immune-targeting therapies (anti-PD-1 and anti-PD-L1 agents) exhibit relatively milder toxicities but superior clinical outcomes in subgroups of patients compared with conventional cytotoxic chemotherapies. Further clinical trials will be needed to confirm similar safety and efficacy profiles of these therapeutic approaches in the elderly compared with their younger counterparts. In this article, we review available evidence from clinical studies and also present expert consensus on the management of NSCLC in the elderly, including treatment in the adjuvant setting and treatment of advanced disease. Screening tools, such as the Comprehensive Geriatric Assessment, that help to identify the right population of elderly patients suitable for systemic treatment are also discussed.

Walking a tightrope: clinical use of ibrutinib in mantle cell lymphoma in the elderly

Representative clinical case. A 74-year-old male patient was diagnosed with stage 3 mantle cell lymphoma in 2012. Because he was ineligible for intensive treatment (age, previous myocardial infarction [MI]), he received rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemoimmunotherapy for 6 cycles (reaching complete response) and then rituximab maintenance (RM) for 2 years. One year after the end of RM, he relapsed with disseminated disease. He was started on ibrutinib 560 mg/day. Two weeks after the start of ibrutinib, he developed grade 3 diarrhea that required interruption of ibrutinib. Two weeks after the regular dose was restarted (month 3), the patient had repeated bleeding (patient was receiving aspirin for previous MI) and had to stop ibrutinib again. Because the patient was in partial response (PR) with lack of disease-associated symptoms, he was restarted on ibrutinib 280 mg/day with no further adverse events, and he had maintained PR at last follow-up (month 9 on ibrutinib).

Treatment of the elderly patient with mantle cell lymphoma

Treatment options for mantle cell lymphomas have expanded considerably over recent years, offering hematologists solutions for older patients with an appropriate risk-to-benefit ratio. Indeed, unfit older patients are exposed to a higher risk of toxicity with a standard treatment. Although new treatments have generally good safety profiles, they may lead to unexpected consequences in unfit older patients. Involving geriatricians and a comprehensive geriatric assessment in patient care could help hematologists address these vulnerabilities. The geriatric evaluation process is time-consuming but can be simplified, and its potential to help hematologists foresee unexpected consequences of treatment has now been demonstrated.

Decision-making in geriatric oncology: systemic treatment considerations for older adults with colon cancer

Colon cancer is common and can be considered a disease of older adults with more than half of cases diagnosed in patients aged over 70 years. Decision-making about treatment with chemotherapy for older adults may be complicated by age-related physiological changes, impaired functional status, limited social supports, concerns regarding the occurrence of and ability to tolerate treatment toxicity, and the presence of comorbidities. This is compounded by a lack of high quality evidence guiding cancer treatment decisions for older adults. Areas covered: This narrative review evaluates the evidence for adjuvant and palliative systemic therapy in older adults with colon cancer. The value of an adequate assessment prior to making a treatment decision is addressed, with emphasis on the geriatric assessment. Guidance in making a treatment decision is provided. Expert commentary: Treatment decisions should consider goals of care, a patient's treatment preferences, and weigh up relative benefits and harms.

Improving outcomes for older women with gynaecological malignancies

The incidence of most gynaecological malignancies rises significantly with increasing age. With an ageing population, the proportion of women over the age of 65 with cancer is expected to rise substantially over the next decade. Unfortunately, survival outcomes are much poorer in older patients and evidence suggests that older women with gynaecological cancers are less likely to receive current standard of care treatment options. Despite this, older women are under-represented in practice changing clinical studies. The evidence for efficacy and tolerability is therefore extrapolated from a younger; often more fit population and applied to in every day clinical practice to older patients with co-morbidities. There has been significant progress in the development of geriatric assessment in oncology to predict treatment outcomes and tolerability however there is still no clear evidence that undertaking a geriatric assessment improves patient outcomes. Clinical trials focusing on treating older patients are urgently required. In this review, we discuss the evidence for treatment of gynaecological cancers as well as methods of assessing older patients for therapy. Potential biomarkers of ageing are also summarised.

Use of palliative chemotherapy in patients aged 80 years and over with incurable cancer: experience at three Sydney cancer centres

BACKGROUND

Octogenarians represent a growing population reviewed in medical oncology clinics, yet there is a paucity of data on how chemotherapy is tolerated in this age group.

AIM

To describe the use of palliative first-line chemotherapy in patients 80 years and over and factors associated with its use.

METHODS

We identified all new patients aged 80 years or older diagnosed with incurable advanced solid organ cancer and seen in one of three Sydney medical oncology outpatient clinics between January 2009 and December 2013. Patient, disease and treatment details were summarised and factors associated with chemotherapy use explored.

RESULTS

Of 420 eligible patients, 100 (24%) started first-line chemotherapy. Younger age at diagnosis was the only factor associated with receiving chemotherapy (median 82.9 vs 84.1 years, P = 0.002). A total of 78% of patients had single-agent chemotherapy, and 41% received a full dose for the first cycle. During treatment, 54% experienced toxicity, necessitating dose reduction, delay or omission, and 32% were hospitalised. These events were associated with receipt of combination chemotherapy (OR 5.1; P = 0.04) and full-dose chemotherapy for cycle 1 (OR 3.5; P = 0.02). Radiological disease control was achieved in 60%. Chemotherapy was stopped because of progressive disease (48%), toxicity (37%) or completion of planned course (17%).

CONCLUSION

A quarter of patients 80 years and older received first-line palliative chemotherapy. Despite most receiving a modified dose, one third were hospitalised during treatment. These findings highlight the need for careful clinical assessment and selection of older cancer patients for chemotherapy.

Treatment of Elderly Patients with Squamous Cell Carcinoma of the Head and Neck

The demographics of squamous cell carcinoma of the head and neck (SCCHN) is marked by a growing number of patients aged 65 and over, which is in line with global projections for other cancer types. In developed countries, more than half of new SCCHN cases are diagnosed in older people, and in 15 years from now, the proportion is expected to rise by more than 10%. Still, a high-level evidence-based consensus to guide the clinical decision process is strikingly lacking. The available data from retrospective studies and subset analyses of prospective trials suffer from a considerable underrepresentation of senior participants. The situation is even more challenging in the recurrent and/or metastatic setting, where usually only palliative measures are employed. Nevertheless, it is becoming clear that, if treated irrespective of chronological age, fit elderly patients in a good general condition and with a low burden of comorbidities may derive a similar survival advantage as their younger counterparts. Despite that, undertreatment represents a widespread phenomenon and, together with competing non-cancer mortality, is suggested to be an important cause of the worse treatment outcomes observed in this population. Due to physiological changes in drug metabolism occurring with advancing age, the major concerns relate to chemotherapy administration. In locally advanced SCCHN, concurrent chemoradiotherapy in patients over 70 years remains a point of controversy owing to its possibly higher toxicity and questionable benefit. However, accumulating evidence suggests that it should, indeed, be considered in selected cases when biological age is taken into account. Results from a randomized trial conducted in lung cancer showed that treatment selection based on a comprehensive geriatric assessment (CGA) significantly reduced toxicity. However, a CGA is time-consuming and not necessary for all patients. To overcome this hurdle, geriatric screening tools have been introduced to decide who needs such a full evaluation. Among the various screening instruments, G8 and Flemish version of the Triage Risk Screening Tool were prospectively verified and found to have prognostic value. We, therefore, conclude that also in SCCHN, the application of elderly specific prospective trials and integration of clinical practice-oriented assessment tools and predictive models should be promoted.

An update on adjuvant systemic therapy for elderly patients with early breast cancer

INTRODUCTION

Elderly women with early breast cancer require an individualized approach to risk assessment and treatment. Unfortunately, there are limited data to inform optimal adjuvant therapy decisions in this population. Cytotoxic chemotherapy, biologic treatments and endocrine agents, while important in reducing breast cancer recurrence and mortality, are associated with the potential for adverse effects that may be of particular significance to elderly patients.

AREAS COVERED

In this review, we summarize the evidence for geriatric assessment in elderly patients with early breast cancer, outline special considerations for the use of chemotherapy and trastuzumab in older adults, and describe the age-specific risks of endocrine therapy in the adjuvant breast cancer setting.

EXPERT OPINION

The treatment of elderly women with early breast cancer should take into account cancer risk, life expectancy, comorbidities, functional status, physiologic changes, and patient values. Formal geriatric assessment may better inform treatment recommendations for individual patients. In general, there is no strong evidence to suggest that older women benefit less from standard adjuvant therapies than do their younger counterparts. When choosing between endocrine therapies, the differential risks associated with each agent should be considered and particular attention to the fracture risk on aromatase inhibitors (AIs) is warranted. Enrolment of women over 70 years of age into breast cancer clinical trials should be encouraged to better inform treatment guidelines.

Hand grip strength as a screening tool for frailty in older patients with haematological malignancies

OBJECTIVES

Frailty is a geriatric syndrome characterized by decreased physiological reserves and an age-related vulnerability to stressors with higher risk of adverse health outcomes. Comprehensive geriatric assessment (CGA) might detect frailty but is time-consuming, implying the need for initial frailty screening. Most frailty screening tools do not include functional measures. Hand grip strength (HGS) is a reliable surrogate for overall muscle strength and predicts functional decline, morbidity and mortality. No studies are available in cancer patients on HGS as screening tool for frailty. We aimed to assess whether HGS can be used as a screening tool to predict an abnormal CGA and therefore frailty.

METHODS

Single centre cohort study in 59 patients aged 70 years or more with a haematological malignancy. HGS was measured using a vigorimeter. A patient was considered frail if any of the CGA elements were impaired.

RESULTS

Mean HGS before start of therapy in women was 37.0 ± 14.3 kPa and in men 66.1 ± 13.1 kPa. An abnormal CGA was present in 52 subjects (88%). HGS was associated with concurrent abnormal CGA (p = 0.058 in women, p = 0.009 in men). AUC was 0.800 (SE = 0.130) in women and 0.847 (SE = 0.118) in men. Optimal HGS cut-off points for likelihood of abnormal CGA were ≤52 kPa in women and ≤80 kPa in men.

DISCUSSION

In older patients with haematological malignancies, impairment in muscle function is present at diagnosis. HGS seems a promising screening tool to identify patients with abnormal CGA.

Comprehensive geriatric assessment and comorbidities predict survival in geriatric oncology

OBJECTIVES

The comprehensive geriatric assessment (CGA) can detect geriatric problems and potentially improve survival, physical, and cognitive state of patients, as well as increase an older person's chances of staying at home longer. In older people, the number and severity of comorbidity increase with age and are an important determinant of survival. The aim of the study was to assess to which extent CGA and comorbidities could be seen as determinants of survival.

MATERIALS AND METHODS

This study analyzed data from two hospitals that included geriatric assessments of patients aged 70 years and more with cancer linked to mortality. Logistic regression was used to model survival predictors.

RESULTS

Two hundred and five various cancer patients (47% females) with a median age of 79 were included. They presented with a lot of undiagnosed geriatric problems. Screening scales (G8, SEGA), cognitive, and psychological disorders, and low albumin levels appeared to be independent survival factors. A frailty profile classification was associated with higher mortality. The average comorbidity was graded 2 according to the Charlson scale. By the geriatric cumulative illness rating scale (CIRS-G), the arithmetic average number of affected organ systems was 5 (range 0-10) in all patients. Cardiovascular disorders were the most common comorbidity. Renal insufficiency and anaemia were negatively associated with survival.

CONCLUSION

Old cancer patients present a lot of comorbidities and newly diagnosed geriatric problems. Several tools provide determinants of survival in old cancer patients. Prospective trials evaluating the utility of a CGA to guide interventions to improve quality of cancer care in older adults are justified.