Comprehensive geriatric assessment for older patients with cancer

Treatment reality in elderly patients with advanced ovarian cancer: a prospective analysis of the OVCAD consortium

Background

Approximately one third of women diagnosed with ovarian cancer is 70 years or older. Information on the treatment reality of these elderly patients is limited.

Methods

275 patients with primary epithelial ovarian cancer FIGO stage II-IV undergoing cytoreductive surgery and platinum-based chemotherapy were prospectively included in this European multicenter study. Patients <70 and ≥70 years were compared regarding clinicopathological variables and prognosis.

Results

Median age was 58 years (18–85); 47 patients (17.1%) were 70 years or older. The postoperative 60-day-mortality rate was 2.1% for elderly and 0.4% for younger patients (p < 0.001). Elderly patients were less likely to receive optimal therapy (no residual disease after surgery and platinum combination chemotherapy) compared to patients <70 years (40.4% vs. 70.1%, p < 0.001) and their outcome was less favorable regarding median PFS (12 vs. 20 months, p = 0.022) and OS (30 vs. 64 months, p < 0.001). However, in multivariate analysis age itself was not a prognostic factor for PFS while the ECOG performance status had prognostic significance in elderly patients.

Conclusions

Elderly patients with ovarian cancer are often treated less radically. Their outcome is impaired despite no consistent prognostic effect of age itself. Biological age and functional status should be considered before individualized treatment plans are defined.

Challenges in the treatment of older breast cancer patients

As the population ages, oncologists will be faced with managing an exploding number of older patients with breast cancer. The primary challenge of caring for older cancer patients is providing treatment options that maximize long-term survival while accounting for comorbidities, life expectancy, and effects of treatment. There is a paucity of data from trials on the risks and benefits of effective treatments in elderly breast cancer patients. This article discusses how to evaluate older breast cancer patients and provides guidelines for optimal therapies in the adjuvant and metastatic treatment settings.

Geriatric syndromes increased the nutritional risk in elderly cancer patients independently from tumour site and metastatic status. The ELCAPA-05 cohort study

BACKGROUND & AIMS

We assessed the prevalence and risk factors of malnutrition in elderly cancer patients.

METHODS

We studied a prospective cohort of solid cancer patients aged ≥70 years at referral to two geriatric oncology clinics between 2007 and 2010. Nutrition was evaluated using the Mini-Nutritional Assessment (MNA) using validated cut-offs (<17: malnutrition, 17-23.5: at-risk for malnutrition). Patients with non-digestive tumours (breast, prostate, urinary tract) and with digestive (colorectal, upper digestive tract and liver) were analysed separately using multinomial logistic regression.

RESULTS

Of 643 consecutive patients, 519 had available data (median age, 80; men, 48.2%; metastases, 46.3%; digestive cancer 47.8%). In non-digestive group, 13.3% had malnutrition versus 28.6% in digestive group. The link between metastasis and malnutrition was significantly higher in non-digestive group (adjusted odds ratio [ORa ], 25.25; 95%CI: 5.97-106.8) than in digestive group (ORa, 2.59; 1.08-6.24; p for heterogeneity = 0.04). Other factors independently associated with malnutrition were cognitive impairment (ORa MMMSE ≤ 24 versus > 24 in non-digestive group: 16.68; 4.89-56.90 and in digestive group: 3.93; 1.34-11.50), and depressed mood (ORa MiniGDS ≥1 versus <1 in non-digestive group: 11.11; 3.32-37.17 and in digestive group: 3.25; 1.29-8.15) and fall risk (ORa fall risk versus no fall risk in non-digestive group: 4.68; 1.77-12.37; in digestive group: 100% of malnourished patients were faller's).

CONCLUSION

We highlighted, in elderly cancer patients, the high prevalence of malnutrition and that geriatrics syndromes (i.e. cognitive impairment, depressed mood and fall risk) were independent risk factors for malnutrition. Moreover, metastatic status was significantly much more strongly associated with malnutrition in non-digestive than digestive tumours.

Geriatric assessment predicts survival for older adults receiving induction chemotherapy for acute myelogenous leukemia

We investigated the predictive value of geriatric assessment (GA) on overall survival (OS) for older adults with acute myelogenous leukemia (AML). Consecutive patients ≥ 60 years with newly diagnosed AML and planned intensive chemotherapy were enrolled at a single institution. Pretreatment GA included evaluation of cognition, depression, distress, physical function (PF) (self-reported and objectively measured), and comorbidity. Objective PF was assessed using the Short Physical Performance Battery (SPPB, timed 4-m walk, chair stands, standing balance) and grip strength. Cox proportional hazards models were fit for each GA measure as a predictor of OS. Among 74 patients, the mean age was 70 years, and 78.4% had an Eastern Cooperative Oncology Group (ECOG) score ≤ 1. OS was significantly shorter for participants who screened positive for impairment in cognition and objectively measured PF. Adjusting for age, gender, ECOG score, cytogenetic risk group, myelodysplastic syndrome, and hemoglobin, impaired cognition (Modified Mini-Mental State Exam < 77) and impaired objective PF (SPPB < 9) were associated with worse OS. GA methods, with a focus on cognitive and PF, improve risk stratification and may inform interventions to improve outcomes for older AML patients.

How I treat older patients with ALL

The treatment of older patients with acute lymphoblastic leukemia (ALL) is an unmet medical need. In Western countries, the population is aging, which means there will be an increasing number of older patients. However, in the past few decades, there has been little improvement in treating them, and few clinical trials specifically designed for older patients with ALL have been reported. Older patients with ALL have a significantly lower complete response rate, higher early mortality, higher relapse rate, and poorer survival compared with younger patients. This is partly explained by a higher incidence of poor prognostic factors. Most importantly, intensive chemotherapy with or without stem cell transplantation, both of which are successful in younger patients, is less well tolerated in older patients. For the future, the most promising approaches are optimized supportive care, targeted therapies, moderately intensified consolidation, and reduced-intensity stem cell transplantation. One of the most important challenges for physicians is to differentiate between fit and unfit older patients in order to offer both groups optimal treatment regarding toxicity and mortality risks, quality of life, and long-term outcome. Prospective trials for older patients with ALL are urgently needed.

A retrospective study on 73 elderly patients (≥75years) with aggressive B-cell non Hodgkin lymphoma: clinical significance of treatment intensity and comprehensive geriatric assessment

OBJECTIVE

The clinical outcome of elderly (≥75years) patients with aggressive B-cell non-Hodgkin lymphoma (B-NHL) is not firmly established because few studies have specifically addressed this issue. In addition, the usefulness of a comprehensive geriatric assessment (CGA) in B-NHL still needs to be deeply explored.

MATERIALS AND METHODS

We evaluated the prognostic factors of 73 patients aged ≥75years (median age: 78) with B-NHL treated by clinical judgment with curative anthracycline-based approaches (n=36) or with conservative treatments without anthracyclines (n=37). Analysis of clinical outcomes also included baseline CGA stratification.

RESULTS

The curative approaches resulted in a better clinical outcome than conservative approaches [overall response rate: 91.2% vs. 69.7%, P=0.003; 2-year progression-free survival: 47.2% vs. 21.6%, P=0.006; and 2-year overall survival (OS): 58.3% vs 24.3%, P=0.003] with similar safety profiles. Independent of treatment type, patients classified as "fit" and "intermediate" by CGA presented with better OS compared to patients classified as "frail" (P<0.001). Patients classified as "fit" and "intermediate" who were receiving curative treatments presented with a significantly better OS when compared with those treated conservatively on the basis of clinical judgment. A curative anthracycline-based therapy (P=0.048), the response to treatment (P=0.017) and a "frail" condition (P=0.031) were the only factors affecting OS in multivariate analysis.

CONCLUSIONS

Present data indicates that even in elderly patients with B-NHL curative anthracycline-based therapies are more effective than conservative approaches. However, choice of treatment should rely more on objective than on subjective parameters. Therefore, further prospective trials are warranted to better define the CGA role in hematopoietic malignancies.

Outcome of frail elderly patients with diffuse large B-cell lymphoma prospectively identified by Comprehensive Geriatric Assessment: results from a study of the Fondazione Italiana Linfomi

In 2003 the Fondazione Italiana Linfomi (FIL) started a clinical research program for investigating initial treatment of frail elderly patients with diffuse large B-cell lymphoma (DLBCL) identified by Comprehensive Geriatric Assessment (CGA). From 2003 to 2006, 334 elderly patients underwent CGA assessment, and 99 patients were classified as frail. Frail patients had a median age of 78 years, stage III-IV disease in 62% and age-adjusted International Prognostic Index (aaIPI) of 2-3 in 53%. Treatment consisted of several different regimens according to physician discretion. After a median follow-up of 36 months, 5-year overall survival (OS) was 28%. In multivariate analysis, aaIPI 2-3 (p = 0.005) and the presence of respiratory comorbidity (p = 0.044) were the only factors that showed independent correlation with OS. Frail patients had a poorer outcome compared with fit patients also if they were treated with rituximab-containing combination chemotherapy (hazard ratio 2.37, 95% confidence interval 1.48-3.78; p < 0.001). CGA is a valid tool to prospectively identify frail subjects among elderly patients with DLBCL.

[Prostate cancer in elderly subjects: how diagnosis should be made, why and how geriatric assessment should be implemented]

Managing an elderly subject with prostate cancer brings into play the notion of likelihood of survival before any diagnostic or therapeutic decision can be made. The diagnostic strategy must be specified for each patient in accordance with the clinical presentation so as to determine whether prostate biopsies are indicated in this elderly population. To estimate the likelihood of survival, one must make use of geriatric assessment techniques comprising medical strategies ranging from screening for frailty to detailed geriatric evaluation for the most complex patients. The many tools available for estimating the likelihood of survival requires a critical review of their advantages and disadvantages in daily clinical practice.

Tolerability and outcomes of radiotherapy or chemoradiotherapy for rectal cancer in elderly patients aged 70 years and older

PURPOSE

To assess the safety and outcomes of radiotherapy (RT) or chemoradiotherapy (CRT) in elderly patients (≥70) with rectal cancer.

METHODS

Elderly patients aged 70 and older with rectal cancer, who were treated with RT or CRT at a single institution, were retrospectively analyzed. Performance status (KPS and ECOG score) and comorbidity (Charlson comorbidity index) were calculated, and their correlation with treatment toxicity and overall survival were studied. Risk factors for overall survival were investigated using univariate and multivariate survival analysis.

RESULTS

A total of 126 patients with locally advanced disease, local recurrence or synchronous metastasis were included, with a 3-year OS rate of 48.1%. Scheduled dosage of radiation was delivered to 69% of patients. Grade 3 toxicities occurred more often in patients treated with CRT versus RT. The occurrence of grade 3 toxicities was not related to KPS score, ECOG score, number of comorbidities, and Charlson score. Multivariate analysis found that only age and Charlson score were independent prognostic factors for predicting patients' 3-year OS. The 3-year OS rate was significantly higher in patients with Charlson score <4 vs Charlson score ≥4 (71.1% vs. 26.4%, P=0.0003).

CONCLUSIONS

Although toxicities may be significant, elderly patients with rectal cancer of varied stages can be safely treated with RT or CRT with careful monitoring and frequent modification of treatment. Except for patients' age, Charlson comorbidity index may be helpful in assessing patients' outcomes in elderly patients with rectal cancer.

Safety and effectiveness of oxaliplatin-based chemotherapy regimens in adults 75 years and older with colorectal cancer

Although the safety and efficacy of oxaliplatin-based chemotherapy regimens for colorectal cancer (CRC) have been demonstrated in adults > 75 years of age enrolled in clinical trials, safety and effectiveness outside the trial setting are less established. In this comparative effectiveness study, we note that older adults with stage III and metastatic CRC treated outside of a clinical trial experienced safety and effectiveness of oxaliplatin-based chemotherapy regimens comparable to that of younger adults.

BACKGROUND

Although the safety and efficacy of oxaliplatin-based chemotherapy regimens for colorectal cancer (CRC) have been demonstrated in adults ≥ 75 years of age who are enrolled in clinical trials, safety and effectiveness outside the trial setting are less established.

METHODS

We retrospectively collected cases of patients ≥ 75 years of age who were diagnosed with stage III and metastatic CRC and initiated treatment between January 2000 and January 2007 at 2 academic hospitals in Boston, MA. Cases were matched in a 1:2 ratio to controls who were < 75 years of age by hospital site, stage of disease (stage III vs. metastatic) and line of therapy (first- or second-line or beyond). The primary study endpoints were grade ≥ 3 treatment-associated toxicities and intolerance (number of dose delays/reductions and hospital/facility admissions during treatment). The secondary endpoint was overall survival.

RESULTS

We identified 84 patients ≥ 75 years of age (25% ≥ 80 years) and 168 controls. In the cohort, 77% had colon cancer, 75% had metastatic disease, and 60% were receiving oxaliplatin as first-line therapy. There was no significant difference in grade ≥ 3 treatment-associated toxicities between the patients and the controls (71.4% vs. 68.5%, respectively; P = .63). Further there was no statistically significant difference between patients and controls for combined endpoints of any grade ≥ 3 toxicity or hospital/facility admission (P = .92). With a median follow-up of 52 months, 2-year overall survival was similar between patients and controls (43% vs. 52%, respectively; P = .87).

CONCLUSION

Older adults with stage III and metastatic CRC treated outside of a clinical trial experienced safety and effectiveness of oxaliplatin-based chemotherapy regimens that was comparable to that of younger adults.

Prognostic value of geriatric assessment in older patients with advanced breast cancer receiving chemotherapy

INTRODUCTION

The prognostic value of geriatric assessment in older patients with breast cancer treated with chemotherapy is largely unknown.

METHODS

Fifty-five patients with advanced breast cancer aged 70 years or older were assessed by Mini Nutritional Assessment (MNA), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Groningen Frailty Indicator (GFI) and Mini Mental State Examination (MMSE). Levels of albumin, hemoglobin, creatinine and lactate dehydrogenase were measured. Patients completing at least four cycles of chemotherapy were reassessed by GFI and MMSE and mortality was evaluated using Cox regression analysis.

RESULTS

The mean age was 76 year (SD 4.8). Inferior MNA and GFI scores were associated with increased hazard ratios for mortality: 3.05 (95% confidence interval [CI]: 1.44-6.45; p = 0.004) and 3.40 (95% CI: 1.62-7.10; p = 0.001), respectively. Physical aspects of frailty worsened during the course of chemotherapy. Laboratory values were not associated with assessment scores nor were they predictive for mortality.

CONCLUSIONS

Malnutrition and frailty, rather than cognitive impairment and laboratory values, were associated with an increased mortality risk in these elderly breast cancer patients with advanced breast cancer.

Evaluation of the cardiovascular health study (CHS) instrument and the Vulnerable Elders Survey-13 (VES-13) in elderly cancer patients. Are we still missing the right screening tool?

BACKGROUND

A geriatric screening tool would be valuable to identify elderly cancer patients who might benefit from a comprehensive geriatric assessment (CGA). This study evaluated the accuracy of the cardiovascular health study (CHS) instrument in predicting abnormality in CGA. The vulnerable elders' survey-13 (VES-13) was also evaluated.

PATIENTS AND METHODS

Patients aged ≥ 70 years with solid tumors underwent a CGA after being screened with the CHS and VES-13. Analyses were conducted for the overall population and according to the disease status (early or advanced) and type of early cancer (breast or gastrointestinal, GI).

RESULTS

Of 259 patients, 75% were impaired according to the CHS and 47% according to the VES-13. CGA impairment was reported in 171 patients (66%). In the overall population, overall accuracy, sensitivity and specificity of CHS in identifying CGA impairments were 74%, 87% and 49%, respectively. The corresponding figures for the VES-13 were 68%, 62% and 81%. Sensitivity and specificity of CHS in predicting CGA impairments in subgroups were early 81% and 55%, advanced 98% and 29%; early breast 78% and 69%, early GI 87.5% and 19%.

CONCLUSIONS

The CHS compared favourably with VES-13 for sensitivity. However, the great variability in specificity observed with the CHS within subgroups limits its applicability in the global population.

Merckel cell carcinoma: the impact of multidisciplinary management

Merkel cell carcinoma (MMC) is a rare primary neuroendocrine skin tumor associated with a poor prognosis. MMC is histologically similar to small cell lung carcinoma. The incidence of MCC is increasing with a median age of discovery of approximately 70 years old. Treatment of MCC, which usually occurs in sun-exposed skin, includes surgery with reconstruction associated with radiotherapy and/or chemotherapy for advanced stages including widespread metastases. We report two cases of Merkel cell carcinoma in 76 and 84 year old patients and describe the natural history of this cancer and management in geriatric patients. Merkel cell carcinoma (MCC) is a rare cancer with high malignant potential that mainly affects people over the age of 65. It must be diagnosed early to improve the prognosis. The survival rate at 5 years for local or regional invasion is 65%. The median survival for metastasized stages is 10 months. The therapeutic regimen recommended for the treatment of MCC is influenced by the geriatric status of patients, and a multidisciplinary oncogeriatric approach could be of interest.

Feasibility of computer-based self-administered cancer-specific geriatric assessment in older patients with gastrointestinal malignancy

BACKGROUND

The Cancer-Specific Geriatric Assessment (CSGA) is a primarily self-administered paper survey of validated measures.

METHODS

We developed and tested the feasibility of a computer-based CSGA in patients ≥70 years of age who were receiving treatment for gastrointestinal malignancies at the Dana-Farber Cancer Institute. From December 2009 to June 2011, patients were invited to complete the CSGA at baseline (start of new treatment) and follow-up (at the first of 4 months later or within 4 weeks of completing treatment). Feasibility endpoints were proportion of eligible patients consented, proportion completing CSGA at baseline and follow-up, time to complete CSGA, and proportion of physicians reporting CSGA results that led to a change in clinical decision-making.

RESULTS

Of the 49 eligible patients, 38 consented (76% were treatment naive). Median age was 77 years (range: 70-89 years), and 48% were diagnosed with colorectal cancer. Mean physician-rated Karnofsky Performance Status was 87.5 at baseline (SD 8.4) and 83.5 at follow-up (SD 8). At baseline, 92% used a touchscreen computer; 97% completed the CSGA (51% independently). At follow-up, all patients used a touchscreen computer; 71% completed the CSGA (41% independently). Mean time to completion was 23 minutes at baseline (SD 8.4) and 20 minutes at follow-up (SD 5.1). The CSGA added information to clinical assessment for 75% at baseline (n = 27) and 65% at follow-up (n = 17), but it did not alter immediate clinical decision-making.

CONCLUSION

The computer-based CSGA feasibility endpoints were met, although approximately half of patients required assistance. The CSGA added information to clinical assessment but did not affect clinical decision-making, possibly due to limited alternate treatment options in this subset of patients.

Breast cancer in women 80 years of age and older: a comprehensive analysis of an underreported entity

BACKGROUND

Approximately 10% of breast cancer (BC) patients are over the age of 80. We present the first comprehensive review on this particular group of patients.

PATIENTS AND METHODS

The treatments and disease courses of an unselected cohort of patients, whose age at first diagnosis was ≥ 80 years (n = 151), were compared to those of a group of women, who were aged 56-66 years (n = 372).

RESULTS

The group of elderly patients had larger tumors at first diagnosis (25 mm vs. 18 mm, p < 0.001) and higher disease stages (I: 31.1% vs. 44.1%, IV: 11.9% vs. 5.4%; each p < 0.001). There were no significant differences between both groups in terms of histologic subtype, grading, hormonal receptor status and HER2 status. The tumors of older patients were more often detected by clinical examination (38.9% vs. 17.0%, p < 0.001) and less often by mammography/sonography (10.4% vs. 29.9%, p < 0.001). The rate of patients who died of BC were similar in both groups (21.2% vs. 21.5%, p = 1.00). In the patients who had no evidence of metastases and who opted for primary non-surgical management (n = 21), the tumor could be stabilized without considerable morbidity in only 42.9%. Persistence to adjuvant endocrine therapy was comparable (83.0% vs. 88.3%, p = 0.357). In the adjuvant as well as in the palliative settings, elderly patients received less chemotherapy than younger ones (adjuvant: 1.6% vs. 23.3%; palliative: 32.3% vs. 68.4%; each p < 0.001). For palliative treatments only, elderly patients received fewer treatment regimens (≥ 3 therapy lines: 16.0% vs. 54.9%, p < 0.001). In those patients who died of BC, elderly women had inferior overall (25 vs. 54.5 months, p < 0.001) as well as metastatic-disease survival (11.5 vs. 19 months, p = 0.062).

CONCLUSION

It must be ensured that appropriate standard therapies should not be routinely withheld in older patients based on erroneous perceptions regarding the biological nature of BC in the elderly and lack of knowledge about available therapy regimens. Physicians should consider that preservation of current life circumstances and maintenance of quality of life are frequently more important than "classical" hard medical facts such as survival times.

The impact of medication therapy management in older oncology patients

PURPOSE

This project aimed to identify common drug-related problems (DRP) among elderly cancer patients, to determine the effectiveness of medication therapy management (MTM) service in resolving DRP, to determine the clinical significance of pharmacist interventions, and to determine patients' satisfaction level of MTM service.

METHOD

Elderly cancer patients (age ≥65) who were at least on one chronic medication would be eligible for the MTM service. Any DRP that was detected would be recorded and steps to resolve it were taken. Pre- and post-service patient satisfaction surveys (PSS) were conducted before and after MTM. All interventions performed by MTM pharmacists were subjected to independent evaluation by a panel of three judges.

RESULTS

One hundred eighteen patients received at least one session of MTM. We identified and attempted to resolve 361 DRPs, and the most common DRPs were drug interactions (117 cases, 32.4 %), adverse effects (114 cases, 31.6 %), and non-adherence (48 cases, 13.3 %). Forty-four interventions were performed by pharmacists and forty cases (91 %) were accepted by physicians. Almost two third of these interventions were deemed significant (or higher) by the judges. Seventy-two patients completed PSS. There was statistically significant improvement in patients' satisfaction level after the service was provided.

CONCLUSION

MTM is an important platform in identifying and managing DRPs. Patients are generally satisfied with MTM services.

[1st National Meeting of Multidisciplinary Work in Oncogeriatrics: expert consensus document]

On 2nd of June 2011 the Institut Català d' Oncologia l'Hospitalet--Hospital Duran i Reynals hosted the first Meeting of Multidisciplinary Work in Oncogeriatrics. The reason for the meeting, which follows on from an initiative of the Medical Societies of Radiotherapy, Oncology, Geriatrics and Gerontology and Palliative Care and Medical Oncology, was to initiate a joint line of work among the different specialties that generally take part in the handling of the elderly patient suffering from oncologic pathologies. This document summarises the different subjects covered during the Meeting.

Impact and feasibility of a comprehensive geriatric assessment in the oncology setting: a pilot study

OBJECTIVES

A comprehensive geriatric assessment (CGA) is an objective means of assessing the global health of older patients. While evidence suggesting its promise in improving outcome prediction in the oncology setting is growing, its benefit in guiding treatment decisions remains uncertain. We sought to determine the feasibility and impact of CGA, from a consultative geriatric-oncology service, on treatment decisions in older cancer patients.

METHODS

A pilot clinic, where patients underwent CGA with a medical oncologist and geriatrician, was established. Patients ≥70 years, with gastrointestinal or lung cancer were eligible. Following standard assessment by the primary oncologist, a treatment decision was recorded. Patients subsequently underwent a CGA. The final treatment plan was made by the primary oncologist after receipt of findings and recommendations from the CGA. Changes in treatment decisions were recorded.

RESULTS

The study enrolled from January to October 2009. Of 168 eligible patients, 120 (71%) were not referred for assessment. Thirty of 48 patients approached underwent CGA. In six patients the treatment plan was undecided at time of referral. In five of these, CGA impacted the ultimate decision (83%). Where the management plan was decided at time of referral (n=24), CGA impacted the final decision in only 1 patient (4%). Previously unidentified medical problems were identified in 70% of patients.

CONCLUSIONS

Several factors limited the feasibility of a consultation-type geriatric-oncology service to assess older cancer patients. The impact of CGA in informing treatment decisions was modest but may be of value when the initial treatment decision is uncertain.

Clinical usefulness of the Frontal Assessment Battery at bedside (FAB) for elderly cancer patients

BACKGROUND

The number of elderly cancer patients has been rising in recent years, and decreases in cognitive function are reportedly seen in 25-50% of these patients. However, no validated and practical tests are available for the assessment of cognitive function in cancer patients. Age and the effects of cancer treatment have been pointed out as possible causes of these decreases in cognitive function; in both instances, a strong possibility of a decrease in frontal lobe function exists.

METHODS

We administered the Frontal Assessment Battery at bedside (FAB), the Mini-Mental State Examination (MMSE), the Barthel Index, and the Instrumental Activities of Daily Living (IADL) to 54 cancer patients who were 65 years of age or older and assessed the clinical usefulness of the FAB.

RESULTS

The results showed that the FAB scores were significantly correlated with the MMSE and IADL scores and were unaffected by the number of years of education. Moreover, when the subjects were divided into two groups according to whether their total FAB score was less than 16 points or 16 points or more, significant differences in the total MMSE scores and the total IADL scores were observed.

CONCLUSIONS

Based on these findings and because the FAB sensitively detected decreases in cognitive function, accurately reflected the status of everyday life, and could be performed conveniently and in a short time, we concluded that the FAB may be very useful clinically as a means of evaluating the cognitive function of elderly cancer patients.

Multiple myeloma in octogenarians: clinical features and outcome in the novel agent era

BACKGROUND

Multiple myeloma (MM) affects mainly elderly persons and because the population of octogenarians increases, it is common to treat patients ≥ 80 years of age. These patients are often not included in clinical trials; thus, there is limited data on their characteristics and treatment outcome.

PATIENTS AND METHODS

We retrospectively analyzed 682 consecutive, unselected patients with newly diagnosed symptomatic myeloma who started treatment between January 1, 2003 and December 31, 2010.

RESULTS

We identified 155 (23%) patients ≥ 80 years of age. Compared to patients <80 years, octogenarians had poorer performance status (P < 0.001), anemia (P = 0.006), low serum albumin (P = 0.001), and advanced ISS (P < 0.001). The median survival of patients ≥ 80 years was 22 months, and 14% died within 2 months from therapy initiation. The median survival of patients ≥ 80 years who received upfront novel agents was 26 vs. 17 months for those who did not. ECOG performance status ≤ 1 and frontline use of novel agents were independently associated with better survival. Response to first-line therapy was associated with improved survival (29 vs. 16 months, P = 0.017).

CONCLUSIONS

Patients ≥ 80 years of age present with features of advanced myeloma and impaired performance status. The addition of novel agents may improve their outcome, but careful assessment and prospective clinical trials targeting the population of elderly patients are needed.

Depression Treatment Patterns among Elderly with Cancer

Little is known about cancer treatment patterns among the elderly as depression and cancer in this older population have not been well explored. This study seeks to fill a gap in the literature by using data from the Medicare Current Beneficiary Survey from years 2000-2005 to examine depression treatment patterns among elderly diagnosed with both cancer and depression. Depression treatments examined include antidepressants with and without psychotherapy. We found that of those with both cancer and depression, 57.7% reported antidepressant use only, 19.7% received psychotherapy with or without antidepressants, and 22.6% had no depression treatment. We found those with greater comorbidity, of a minority race, with lower levels of education, and living in rural areas were less likely to receive treatment for depression. These findings highlight the need to address disparities in the treatment of depression in the elderly population with cancer.

Doublet chemotherapy in the elderly patient with ovarian cancer

The aging of the population has focused on the need to evaluate older patients with cancer. Approximately 50% of patients with ovarian cancer will be older than age 65 years. Increasing age has been associated with decreased survival. It is uncertain whether this relates to biologic factors, treatment factors, or both. There is concern that undertreatment may be associated with decreased survival. Older patients with ovarian cancer have been underrepresented in clinical trials. Therefore, the evidence base on which make decisions is lacking. Clinicians need to be aware of the currently available data to aid in treatment decisions. Doublet therapy is the most common standard treatment in epithelial ovarian cancer. It usually consists of a taxane and a platinum compound. A series of cooperative group studies in both the United States and Europe established intravenous paclitaxel and carboplatin as the most common standard in optimally debulked patients. The recent introduction of intraperitoneal therapy has complicated decision making in terms of which older patients would benefit from this more toxic therapy. In relapsed patients, the issue of platinum sensitivity is critical in deciding whether to reutilize platinum compounds. It is unclear whether single agents or combinations are superior, particularly in older patients. Geriatric assessment is an important component of decision making. Prospective studies are needed to develop strategies to determine the optimal treatment for older patients with ovarian cancer.

Assessment of health status in elderly patients with cancer

BACKGROUND

Health status assessment of senior adults is one of the most important aspects of a treatment decision making process. A group of elderly cancer patients is very heterogeneous according to the health status - some of them are fit enough for aggressive treatment, but others are frail and vulnerable. Treatment for the latter group has to be adapted and carefully monitored.

AIM

To review and analyze relevant literature on the usage and optimization of Comprehensive Geriatric Assessment (CGA).

MATERIALS AND METHODS

Medline search of studies published between 2000 and 2011, containing key words: Comprehensive Geriatric Assessment, aging, cancer in senior adults, frailty.

RESULTS

To recognize and address individual needs of senior adults, a special holistic approach has been developed - comprehensive geriatric assessment (CGA). This tool is a gold standard in gerontooncology, recommended by International Society of Geriatric Oncology. CGA evaluates all important health domains, from physiology to social and economical problems, using sets of different tests. Assessment has to be performed by a trained team, including a physician, nurse and social worker. CGA has been clinically validated in many studies, but it is still not clear whether CGA improves the outcome of treatment of the elderly with cancer.

CONCLUSIONS

Complexity and multidimensionality of CGA pose a logistic challenge for everyday clinical practice. Special senior programs, which could be developed inside comprehensive cancer center, focusing attention on seniors' problems and needs seem to be a way forward for geriatric oncology.

Screening older cancer patients: first evaluation of the G-8 geriatric screening tool

BACKGROUND

Development of a geriatric screening tool is necessary to identify elderly cancer patients who would benefit from comprehensive geriatric assessment (CGA). We develop and evaluate the G-8 screening tool against various reference tests.

PATIENTS AND METHODS

Analyses were based on 364 cancer patients aged>70 years scheduled to receive first-line chemotherapy included in a multicenter prospective study. The G-8 consists of seven items from the Mini Nutritional Assessment (MNA) questionnaire and age. Our primary reference test is based on a set of seven CGA scales: Activities Daily Living (ADL), Instrumental ADL, MNA, Mini-Mental State Exam, Geriatric Depression Scale, Cumulative Illness Rating Scale-Geriatrics, and Timed Get Up and Go. We considered the presence of at least one questionnaire with an impaired score as an abnormal reference exam. Additional reference exams are also discussed.

RESULTS

The prevalence of being at risk varied from 60% to 94% according to the various definitions of the reference test. When considering the primary reference test, a cut-off value of 14 for the G-8 tool provided a good sensitivity estimate (85%) without deteriorating the specificity excessively (65%).

CONCLUSION

The G-8 shows good screening properties for identifying elderly cancer patients who could benefit from CGA.

Age and treatment choices in advanced colorectal cancer

SUMMARY Colorectal cancer is primarily a disease of the elderly. During the past 15 years, the median survival for metastatic colorectal cancer has increased significantly. Older patients are a heterogeneous population, and chronological age is not a reliable predictor of tolerance of treatment. There is now a significant body of evidence that demonstrates equal efficacy and tolerability of treatment between older and younger patients. Despite this, chemotherapy use declines with advancing age. Further research is needed to enable optimal management of this significant group of patients.

Geriatric oncology research to improve clinical care

Cancer incidence increases with advanced age. The Cancer and Aging Research Group, in partnership with the National Institute on Aging and NCI, have summarized the gaps in knowledge in geriatric oncology and made recommendations to close these gaps. One recommendation was that the comprehensive geriatric assessment (CGA) should be incorporated within geriatric oncology research. Information from the CGA can be used to stratify patients into risk categories to better predict their tolerance of cancer treatment, and to follow functional consequences from treatment. Other recommendations were to design trials for older adults with study end points that address the needs of the older and/or vulnerable adult with cancer and to build a better infrastructure to accommodate the needs of older adults to improve their representation in trials. We use a case-based approach to highlight gaps in knowledge regarding the care of older adults with cancer, discuss our current state of knowledge of best practice patterns, and identify opportunities for research in geriatric oncology. More evidence regarding the treatment of older patients with cancer is urgently needed.

The effect of aging and cancer on the symptom experience and physical function of elderly breast cancer survivors

BACKGROUND

The majority of cancer survivors are aged ≥ 65 years, yet, historically, cancer research has focused infrequently on older patients. The objective of this study was to examine predictors of physical function within a framework that integrates the gerontologic and oncologic needs of older cancer survivors.

METHODS

Path analysis tested 759 women who were breast cancer survivors aged ≥ 70 years from the American Cancer Society Study of Cancer Survivors II to examine the cancer, aging, and personal characteristics that had an impact on symptoms and physical functioning.

RESULTS

High levels of symptom bother (β = -.42) and comorbidities (β = -.21) were strongly associated with lower physical function. Comorbidity and social support (β = .21) indirectly influenced symptom bother through emotional status (β = -.35). The model demonstrated good fit with the data (chi-square statistic, 50.6; adjusted chi-square statistic, 2.8; P < .001; goodness-of-fit index, .98; root mean square error of approximation, .049 [confidence interval, .03-.05]).

CONCLUSIONS

The current findings supported prior research indicating that the majority of older survivors of breast cancer are doing well, but there is a subset of survivors that requires ongoing attention to symptoms, comorbidities, emotional health, and social support to thrive after cancer treatment.

Comprehensive geriatric assessment for older women with early breast cancer - a systematic review of literature

BACKGROUND

The Comprehensive Geriatric Assessment (CGA) is an analytical tool increasingly implemented in clinical practice. Breast cancer is primarily a disease of older people; however, most evidence-based research is aimed at younger patients.

METHODS

A systematic review of literature was carried out to assess the use of CGA in older breast cancer patients for clinical decision making. The PubMed, Embase and Cochrane databases were searched.

RESULTS

A total of nine useful full text article results were found. Only five of these were exclusively concerned with early breast cancer; thus, studies involving a variety of cancer types, stages and treatments were accepted, as long as they included early breast cancer.The results comprised a series of low sources of evidence. However, all results shared a common theme: the CGA has a use in determining patient suitability for different types of cancer treatment and subsequently maximizing the patient's quality of life.

CONCLUSIONS

There is not yet sufficient high level evidence to instate CGA guidelines as a mandatory practice in the management of breast cancer, due to the heterogeneity of available studies. More studies need to be conducted to cement current work on the benefits of the CGA. An area of particular interest is with regard to treatment options, especially surgery and chemotherapy, and identifying patients who may be suitable for these treatments.

Optimal pharmacotherapeutic strategies for elderly patients with advanced non-small cell lung cancer

Increases in both life expectancy and cancer incidence with age result in a significant rise in lung cancer rates among elderly patients, with a median age at diagnosis of between 63 and 70 years. However, elderly patients are under-represented in clinical trials and generally receive suboptimal treatment, mainly because of fears about increased toxicity of chemotherapy. Indeed, physiological modification of renal and haematopoietic functions with age together with co-morbidity and associated polypharmacy may alter the metabolism of chemotherapy drugs, resulting in greater toxicity. Moreover, performance status (PS), the main prognostic factor in younger patients, does not correlate well with geriatric indexes such as activities of daily living, cognition and physical performance, and comprehensive geriatric assessment is important in elderly patients. Until 2010, based on the small number of clinical trials designed for elderly patients, monotherapy was the recommended treatment for those with advanced non-small cell lung cancer (NSCLC), whereas for fit younger patients, a platinum-based doublet was and continues to be the recommended first-line therapy. However, at the plenary session of the 2010 Annual Meeting of the American Society of Clinical Oncology, results were presented from a randomized controlled trial conducted by the French Intergroup of Thoracic Oncology that demonstrated that in PS 0-2 patients aged≥70 years with advanced NSCLC, monthly carboplatin with weekly paclitaxel resulted in significantly longer survival than single-agent therapy (vinorelbine or gemcitabine). It should be noted that even in a priori unfavourable prognostic subgroups (patients with a PS score of 2, those aged>80 years or those with an activities of daily living scale score of <6), doublet therapy was associated with a survival advantage over monotherapy. Thus, the new paradigm of treatment of elderly patients with advanced NSCLC and a PS score of 0-2 should now be monthly carboplatin with weekly paclitaxel. While there have been no trials of second-line therapy for NSCLC specifically in elderly patients, exploratory subgroup analyses indicate that docetaxel, pemetrexed and erlotinib may provide outcomes in elderly patients similar to those reported in younger patients. However, specific second-line therapy trials in elderly patients are required as the elderly patients in trials conducted to date were probably highly selected to fit the inclusion criteria. There is no more room for nihilism in the treatment of elderly patients with advanced NSCLC. Such patients should be evaluated carefully by geriatric indexes and, if they have a PS score of 0-2, may be treated with platinum-based (mostly carboplatin) doublet therapy in the same manner as their younger counterparts. The optimal second line treatment remains to be determined.

The challenge of individualised risk assessment and therapy planning in elderly high-risk myelodysplastic syndromes (MDS) patients

Myelodysplastic syndromes (MDS) represent one of the most frequent and serious haematologic diseases of the elderly. Effective therapies exist ranging from best supportive care to haematologic stem cell transplantation (HSCT). Decision making, however, is rather complex in this group of patients because ageing is a multidimensional process involving not only physiological changes but also changes in functional, social, emotional and cognitive capacities. All these factors can have a significant impact on the efficacy and tolerability of a potential therapy and therefore have to be thoroughly assessed before deciding on individual treatment regimens. Risk assessment tools are available both to classify the stage and prognosis of MDS and to meet the needs of elderly patients. A tool explicitly focussing on elderly MDS patients, however, is still missing. The current report approached this issue by combining the well established MDS-risk score 'International Prognostic Scoring System' (IPSS) with the 'Multidimensional Geriatric Assessment' (MGA). As decision making is most complex in high-risk MDS patients, the new algorithm is presented exemplarily for this group of patients. In a first step, MDS-related risk is identified using IPSS, in a second step, patients are assigned to one of three risk categories of the MGA (go-go/fit, slow-go/vulnerable, no-go/frail). While go-go patients might be subjected to therapies comparable to those given to younger patients, in no-go patients, a palliative therapy combined with best supportive care will probably be most appropriate. In slow-go patients, age-related life expectancy taken from public age statistics should be compared to the MDS-related life expectancy. Based on this combined assessment procedure and also on treatment tolerance in terms of the expectations/wishes of the patient and his/her family, an individualised therapeutic approach should be developed. Specific treatment recommendations for these three groups of patients are given, including HSCT, azanucleosides and best supportive care. To illustrate its practicability, i.e. the implementation of the novel algorithm in clinical practice, the case of an elderly high-risk MDS patient is presented and discussed in detail. This new algorithm will facilitate the identification of the very particular needs and conditions of elderly MDS patients in clinical practice. Based on this, individually tailored therapeutic approaches can be developed--the prerequisite for the best possible clinical outcome.

Tailored therapy in an unselected population of 91 elderly patients with DLBCL prospectively evaluated using a simplified CGA

BACKGROUND

Elderly patients with diffuse large B-cell lymphoma (DLBCL) are a heterogeneous population; clinical trials have evaluated a minority of these patients.

PATIENTS AND METHODS

Ninety-one elderly patients with DLBCL received tailored treatment based on a comprehensive geriatric assessment (CGA). Three groups were identified: I, fit patients; II, patients with comorbidities; III, frail patients. Group I received 21-day cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP-21), group II received R-CHOP-21 with liposomal doxorubicin, and group III received 21-day cycles of reduced-dose CHOP. Fifty-four patients (59%) were allocated to group I, 22 (25%) were allocated to group II, and 15 (16%) were allocated to group III.

RESULTS

The complete response (CR) rates were 81.5% in group I, 64% in group II, and 60% in group III. With a median follow-up of 57 months, 42 patients are alive, with 41 in continuous CR: 31 patients (57%) in group I, seven patients (32%) in group II, and four patients (20%) in group III. The 5-year overall survival, event-free survival, and disease-free survival rates in all patients were 46%, 31%, and 41%, respectively. Multivariate analysis selected group I assignment as the main significant prognostic factor for outcome.

CONCLUSIONS

This approach in an unselected population of elderly DLBCL patients shows that treatment tailored according to a CGA allows the evaluation of elderly patients who are currently excluded from clinical trials.

Referral of elderly cancer patients to specialists: action proposals for general practitioners

BACKGROUND

Many studies have identified advanced age as a barrier to accessing specialized oncological care.

OBJECTIVES

To identify elements from the literature influencing general practitioners (GPs) in their decisions to refer elderly patients with cancer to oncology teams, and propose focused actions to improve referral processes.

METHODS

Eligible articles published up to July 2010 identifying factors associated with referral decisions for elderly cancer patients were selected. A quality assessment of each article was performed. All factors identified were considered for possible interventions classified by the Effective Practice and Organisation of Care (EPOC) taxonomy and development of recommendations for referral of elderly patients.

RESULTS

Thirty eligible articles were found with only 18 articles specifically exploring factors influencing physicians in the referral of their patients with cancer. Twelve focused on delay to treatment and only two uniquely on elderly patients. Patient age was the main factor associated with referral decisions, but this factor can influence GP's differently depending on the type of cancer. The small size of these studies, heterogeneity of study populations, and diversity of outcome measures used meant that compilation of guidelines based on high-quality evidence was not possible. However, organizational factors hindering decisions to refer are identified and highlighted as crucial for inclusion in intervention programs, specifically to reach GPs in smaller locations or with less experience in collaborating with specialists. For patient-related factors, professional and organizational interventions are necessary, aimed at both GPs and patients to update knowledge of the non-linear relationship between chronological age and a patient's ability to tolerate treatment.

CONCLUSIONS

First and foremost, this article highlights the scarcity of literature specific to elderly patients with cancer. It also identifies the public health need for better knowledge of the factors for referral of elderly patients. Focussed action proposals are presented to improve knowledge and consequently, optimize the referral process.