The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: scoring and interpretation

Relationship between quadriceps femoris echotexture biomarkers and muscle strength and physical function in older adults with heart failure with preserved ejection fraction

BACKGROUND

Muscle wasting is pronounced in patients with heart failure with preserved ejection fraction (HFpEF). The quadriceps femoris echotexture biomarkers assessed by ultrasound (US) have not been studied in these patients.

OBJECTIVE

To describe echotexture biomarkers assessed by the US and to assess their relationship with sex, age, body mass index (BMI), self-reported outcomes, muscle strength and physical function in older adults with HFpEF.

METHODS

A cross-sectional study was conducted. Patients 70 years and older with HFpEF were included. The sex, age, BMI, and self-reported outcomes were collected. The US assessed muscle and subcutaneous fat tissue contrast, correlation, energy, homogeneity, and entropy at rest and maximal voluntary isometrical contraction (MVIC). The six-minute walk test (6MWT), the short physical performance battery (SPPB), the timed up and go test (TUG), the usual pace gait speed test (UGS), and the fast pace gait speed test (FGS) were used to assess physical function. The five-repetitions sit-to-stand test (5-STS) was performed to assess muscle strength. Bivariant Pearson correlations and subsequent multivariate linear regression analyses were conducted.

RESULTS

Seventy-two older adults with HFpEF [81.06 years, 29.13 BMI, and 55.60% females] were recruited. In women, relaxed and MVIC muscle energy and entropy explained 35.40% of the TUG variance; relaxed muscle entropy and MVIC muscle energy shared 24.00% of the UGS variance; relaxed and MVIC muscle entropy, MVIC muscle contrast and MVIC muscle energy explained 32.60% of the FGS variance, adjusted all the models by age and BMI.

CONCLUSIONS

Echotexture biomarkers are related to women's muscle strength and physical function, especially muscle energy, contrast, and entropy. Echotexture biomarkers assessed by the US could facilitate the management of older adults with HFpEF, monitor its progression and assess the effectiveness of treatments on the musculoskeletal structure.

TRIAL REGISTRATION

NCT03909919. April 10, 2019. Retrospectively registered.

Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma in Older Patients: Are New Agents Bringing New Hope?

Head and neck cancer is a broad family of diseases, most of which are of squamous cell origin, affecting the epithelial mucosa lining the upper aerodigestive tract. They often recur or are progressive despite multimodality treatment approaches, resulting in a poor prognosis. Given the progressive aging of the global population, the probability to plan an active and eventually toxic treatment for an older patient, with either curative or palliative intent, can no longer be considered as an uncommon occurrence. A crucial point in offering a systemic treatment to older patients with head and neck squamous cell carcinoma is that they are underrepresented in randomised clinical trials, and evidence-based guidelines are lacking, while, from a clinical point of view, these patients may have varying grades of resilience to anticancer treatments due to differences in their health, social and/or economic status. Our aim is to draw attention to the older patient population suffering from recurrent and/or metastatic head and neck squamous cell carcinoma and to address some open questions, such as possible differences in epidemiology and biology compared with their younger counterparts; to highlight frailty and its components by discussing how to measure and use it to personalise treatment; to evaluate which outcomes should be best achieved in the older adult setting; finally, in the era of immunotherapy, to examine whether there are differences to be addressed when considering new treatments for older patients.

Relationship between quadriceps femoris muscle architecture and muscle strength and physical function in older adults with heart failure with preserved ejection fraction

Heart failure (HF)-related factors potentially lead to sarcopenia. Ultrasound (US) assessment has all the advantages of being used in clinical practice to assess muscle architecture. This study aimed to assess the relationship between the quadriceps femoris (QF) muscle architecture with the gender, age, body mass index (BMI), muscle strength and physical function in older adults with HF with preserved ejection fraction (HFpEF) as well as to assess the difference in these relationships between the two genders. Patients 70 years and older with HFpEF were included. The gender, age and BMI were collected. The QF muscle thickness, the QF muscle echo-intensity, the subcutaneous fat tissue thickness (FT) and the subcutaneous fat tissue echo-intensity were assessed by the US. The six-minute walk test, the short physical performance battery (SPPB), the timed up and go test (TUG), and the gait speed test (UGS) were used to assess physical function. The five-repetitions sit-to-stand test (5-STS) was performed to assess muscle strength. Bivariant Pearson correlations and subsequent multivariate linear regression analysis were conducted. Seventy older adults with HFpEF [81.00 (5.97) years] were recruited. The FT showed a correlation between poor and moderate muscle strength and physical function in women with HFpEF. The FT explained 24.5% of the 5-STS variance, 32.4% of the SPPB variance, 31.5% of the TUG variance, 28.6% of the UGS variance, and 21.4% of the FGS variance in women. The US assessment could allow clinicians to assess muscle architecture biomarkers related to muscle strength and physical function in older adults with HFpEF.Trial registration NCT03909919. April 10, 2019. Retrospectively registered.

Management of Advanced Urothelial Carcinoma in Older and Frail Patients: Have Novel Treatment Approaches Improved Their Care?

Patients with urothelial carcinoma tend to be older and frailer with a large number of chronic medical conditions. This is particularly pronounced in those with unresectable locally advanced and metastatic urothelial carcinoma. Prior to 2016, treatment options in advanced urothelial carcinoma were limited to chemotherapy, and as a result, a large number of patients were not receiving disease-directed management. Over the last 6 years, multiple alternative modalities including immune checkpoint inhibitors and targeted therapies have been introduced. They are being utilized clinically in older and frail patients, but there are limited studies investigating outcomes in these specific populations. Based upon current evidence, age does not impact the efficacy and tolerance of immune checkpoint inhibitors if patients are fit enough to receive therapy. In frailer patients, immune checkpoint inhibitors appear to be safe, but outcomes from largely retrospective studies demonstrate mixed data regarding their efficacy. Although there are indications from clinical trials that enfortumab vedotin, sacituzumab govitecan, and erdafitinib are also efficacious irrespective of age, there is still not enough evidence to draw definitive conclusions about their use in older and frail patients. Regardless, in all older patients with advanced urothelial carcinoma, it is critical to evaluate for frailty through geriatric screening tools and comprehensive assessments. Combining these evaluations with consideration of an individual patient's goals should be the foundation upon which therapeutic decisions are made in this population of patients.

Adjuvant Treatment of Elderly Breast Cancer Patients: Offer the Best Chances of Cure

Background

Breast cancer remains the most common cancer in women and a leading cause of death. Elderly people have a higher incidence of breast cancer since it increases with age. Furthermore, the extended life expectancy and advances in imaging techniques have led to an increased number of cases. Guidelines concerning the management of this specific age group are rare, mainly due to underrepresentation of seniors in clinical trials. Moreover, increased frailty, comorbidities, and a poor performance status make it complex to determine the best therapeutic approach.

Summary

In this review, we attempt to summarize the current literature and aim to provide specific approaches and recommendations for prompt diagnosis, treatment, and management of breast cancer in the elderly.

Key Messages

The establishment of applicable protocols is imperative and efforts are being made in this direction. A careful geriatric assessment and adequate consultation should be the standard of care and patient's preferences should always be considered.

Clinical Significance of Frailty on Treatment Outcome in Nongeriatric Patients With Head and Neck Cancer and Esophageal Cancer Undergoing Curative-Intent Concurrent Chemoradiotherapy

BACKGROUND

Whether the prevalence of frailty and its clinical significance are relevant to treatment outcomes in younger (aged < 65 years) cancer patients remains uncertain. This study aimed to evaluate the impact of frailty on treatment outcomes in younger cancer patients with head and neck and esophageal malignancy.

MATERIAL AND METHODS

This multicenter prospective study recruited 502 patients with locally advanced head and neck and esophageal cancer during 2016-2017 in Taiwan, aged 20-64 years who received curative-intent concurrent chemoradiotherapy (CCRT) as first-line antitumor treatment. Baseline frailty assessment using geriatric assessment (GA) was performed for each patient within 7 days before CCRT initiation.

RESULTS

Frailty was observed in 169 (33.7%) of 502 middle-aged patients. Frail patients had significantly higher incidences of chemotherapy incompletion (16.6% versus 3.3%, P < .001) and radiotherapy incompletion (16.6% versus 3.6%, P < .001) than fit patients. During CCRT, frail patients had a significantly higher percentage of hospitalizations (42.0% versus 24.6%, P < .001) and a trend toward a higher percentage of emergency room visits (37.9% versus 30.0%, P = .08) than fit patients. Frail patients more likely had a significantly higher incidence of grade ≥ 3 adverse events than fit patients during CCRT. The 1-year survival rate was 68.7% and 85.2% (hazard ratio 2.56, 95% confidence interval 1.80-3.63, P < .001) for frail and fit patients, respectively.

CONCLUSIONS

This study demonstrated the significance of pretreatment frailty on treatment tolerance, treatment-related toxicity, and survival outcome in younger patients with head and neck and esophageal cancer undergoing CCRT. While GA is commonly targeted toward the older population, frailty assessment by GA may also be utilized in younger patients for decision-making guidance and prognosis prediction.

Performance of two frailty screening tools among patients with cancer in Taiwan

Background

Comprehensive Geriatric Assessment (CGA) is the gold standard for detecting frailty in elderly patients with cancer. Since CGA is time- and resource-consuming, many alternative frailty screening tools have been developed; however, it remains unknown whether these tools are suitable for older and adult patients with cancer. Therefore, we used the data collected for a large longitudinal study to compare the diagnostic performances of two frailty screening tools (Geriatric 8 [G8] and Flemish version of the Triage Risk Screening Tool [fTRST]) to identify frailty risk profile among patients with cancer.

Methods

Patients aged ≥20 years with newly diagnosed cancer were enrolled. Frailty screening with G8, fTRST, and CGA were performed before anti-cancer treatment. Diagnostic characteristics obtained using G8 and fTRST were analyzed by C-index, and the validity of G8 and fTRST was also determined.

Results

40.9% of the 755 patients with cancer displayed frailty on CGA. Both G8 and fTRST showed high sensitivity (80.6–88.4%) and negative predictive value (81.0–81.2%). The C-index of G8 was higher than that of fTRST (0.77 vs 0.71, p = .01). Moreover, the best G8 and fTRST cut-off points were ≤13 and ≥ 2, respectively. The validities of G8 and fTRST were also confirmed; however, frailty age differences were not observed in our study.

Conclusion

Frailty is a common problem for patients with cancer, and routine frailty screening is essential for both older and adult patients. G8 and fTRST are simple and useful frailty screening tools, while G8 is more suitable than fTRST for Taiwanese patients with cancer.

Factors associated with falls in older women with breast cancer: the use of a brief geriatric screening tool in clinic

PURPOSE

Unintentional falls and breast cancer are common among older women, but the associations between them are understudied. We aimed to identify factors associated with falls in older women with breast cancer.

METHODS

We retrospectively reviewed clinical records of older women with breast cancer at Duke Medical Center who had completed the Senior Adult Oncology Program geriatric assessment. Characteristics were compared between women had had at least one fall in the past year and those who did not. Pearson's Chi-square tests and t tests were used for comparison of groups' characteristics. Logistic regression determined factors associated with falling.

RESULTS

We identified 425 women, age 76.2 years (range 65-89 years), at the time of the assessment. 118 (27.8%) women reported a fall in the prior year. Age, race, ethnicity, and time since diagnosis (all p > 0.05) were similar between groups. In univariate analyses, metastatic disease (p = 0.023) and history of endocrine therapy (p = 0.042) were more common among women who fell. Women who fell had lower systolic (p = 0.001), diastolic (p < 0.001) blood pressures, and SpO₂ (p = 0.018). Women who had fallen had a higher Charlson Comorbidity Index (CCI: p = 0.033), and were more likely to report using a walking aide (p < 0.001), nutritional issues (p = 0.006), and depression symptoms (p = 0.038). In multivariate analysis, falling was associated with low DBP (OR 0.93; p = 0.0017), low SpO₂ (OR 0.79; p = 0.0169), a higher CCI (OR 1.23; p = 0.0076), and depression symptoms (OR 1.61; p = 0.039).

CONCLUSIONS

Among older women with breast cancer, depressive symptoms, higher comorbidity level, and vital sign measurements were associated with having fallen.

Usefulness of eight screening tools for predicting frailty and postoperative short- and long-term outcomes among older patients with cancer who qualify for abdominal surgery

INTRODUCTION

The aim of this study was to compare the ability of eight frailty screening scores to predict short- (30-day major morbidity and mortality), long-term outcomes (12-month mortality) and to compare their accuracy for predicting frailty among older patients with cancer undergoing elective abdominal surgery with curative intent.

MATERIALS AND METHODS

Consecutive patients aged ≥70 years were enrolled prospectively. The diagnostic performance of eight screening tests were evaluated: The Vulnerable Elderly Survey (VES-13), Triage Risk Screening Tool (TRST), Geriatric 8 (G8), Groningen Frailty Index (GFI), abbreviated Comprehensive Geriatric Assessment (aCGA), Rockwood, Balducci and Fried score. Frailty was defined based on the Geriatric Assessment (GA) with two (2ID) or three impaired domains (3ID).

RESULTS

The study included 269 consecutive patients; median age 78 (range 70-94) years. The prevalence of frailty based on the reference GA was: 40.9% (2ID), 34.2% (3ID) and using screening tools 40-75.5%. The area under the curve (AUC) for predicting the postoperative outcome was: 0.58-0.75 (30-day morbidity), 0.54-0.71 (30-day mortality) and 0.59-0.74 (12-month mortality), respectively, being the highest for the G8. The AUC for the frailty screening tests was: 0.67-0.85 (at the 2ID) and 0.63-0.83 (at the 3ID), being the highest for the aCGA.

CONCLUSION

The G8 was the best predictor of 30-day major morbidity, 30-day and 12-month mortality. It also had the highest sensitivity and negative predictive value in frailty screening, in case of both frailty definitions. In turn, the aCGA had the highest discriminatory ability in terms of frailty screening.

Application of comprehensive geriatric assessment in predicting early mortality among elder patients with B-cell lymphoma receiving immunochemotherapy

OBJECTIVES

Early mortality, defined as death within 120 days after initiated antitumor therapy, is an important issue especially for elder patients with B-cell lymphoma. This study aimed to evaluate the clinical value of comprehensive geriatric assessment (CGA) in early mortality prediction in elderly patients with B-cell lymphoma receiving immunochemotherapy.

METHODS

Seventy-six consecutive patients with newly diagnosed B-cell lymphoma receiving immunochemotherapy from a medical center in Taiwan were prospectively enrolled. Patients were divided into fit (n = 49) and frail (n = 27) groups per pretreatment CGA for early mortality comparison.

RESULTS

The early mortality rate in our patient cohort was 16% (n = 12): from 6% in patients with no CGA domain impairment to 43% in patients with ≥4 CGA domain impairment. The early mortality rate was 6% and 33% in fit and frail patients (odds ratio, 7.67; 95% CI, 1.86-31.6; P = .005), respectively. Frailty was the significant predictor for early mortality in univariate and multivariate analysis.

CONCLUSION

In this study, the number of geriatric domain impairment is positively associated with the early mortality risk in elderly patients with B-cell lymphoma. Therefore, CGA can help clinicians to identify the risk of early mortality in elderly patients and provide alternative treatment.

The impact of early comprehensive geriatric screening on the readmission rate in an acute geriatric ward: a quasi-experimental study

Background

Unplanned readmission is an important healthcare quality issue. We studied the effect of a comprehensive geriatric screen (CGS) in the early admission course followed by a comprehensive geriatric assessment on readmission rates in elderly patients.

Methods

This quasi-experimental study with a historical comparison group was conducted in the geriatric ward of a referral centre in northern Taiwan. Older adults (aged > = 65 y/o) admitted from June 2013 to December 2013 were recruited for the geriatric screen group (N = 377). Patients admitted to the same ward from July 2011 to June 2012 were selected for the historical group (N = 380). The CGS was administered within the first 48 h after admission and was followed by a comprehensive geriatric assessment (CGA). Confounding risk factors included age, gender, Charlson comorbidity index, Barthel index score and medical utilization (length of stay and number of admissions), which were controlled using logistic regression models. We also developed a scoring system to identify the group that would potentially benefit the most from the early CGS.

Results

The 30-day readmission rate was significantly lower in the early CGS group than in the historical comparison group (11.4% vs 16.9%, p = 0.03). After adjusting for confounding variables, the hazard ratio of the early CGS group was 0.64 (95% CI 0.43–0.95). After scoring the potential benefit to the patients in the early CGS group, the log rank test showed a significant difference (p = 0.001 in the high-potential group and p = 0.98 in the low-potential group).

Conclusion

An early CGS followed by a CGA may significantly reduce the 30-day readmission rate of elderly patients.

Utility of a chemotherapy toxicity prediction tool for older patients in a community setting

Background

Expert groups have recommended incorporation of a geriatric assessment into clinical practice for older patients starting oncologic therapy. However, that practice is not standard primarily because of resource limitations. In the present study, we evaluated the effect on treatment decisions by oncologists in the community oncology setting of a brief geriatric assessment tool that estimates risk of toxicity.

Methods

This prospective longitudinal study in 5 community oncology practices in British Columbia involved patients 70 years of age and older starting a new cytotoxic chemotherapy regimen. Clinical personnel completed a brief validated geriatric assessment tool-the Cancer and Aging Research Group chemotherapy toxicity tool (carg-tt)-that estimates the risk of grade 3 or greater toxicity in older patients. Physicians were asked if the carg-tt changed their treatment plan or prompted extra supports. Patients were followed to assess the incidence of toxicity during treatment.

Results

The study enrolled 199 patients between July 2016 and February 2018. Mean age was 77 years. Treatment was palliative in 61.4% of the group. Compared with physician judgment, the carg-tt predicted higher rates of toxicity. In 5 patients, treatment was changed based on the carg-tt. In 38.5% of the patients, data from the tool prompted extra supports. Within the first 3 cycles of treatment, 21.3% of patients had experienced grade 3 or greater toxicity.

Conclusions

This study demonstrates that use of a brief geriatric assessment tool is possible in a broad community oncology practice. The tool modified the oncologist's supportive care plan for a significant number of older patients undertaking cytotoxic chemotherapy.

Glioblastoma in Elderly Patients: Current Management and Future Perspectives

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

Using a geriatric oncology assessment to link with services (GOAL)

OBJECTIVE

Geriatric screening tools assess functional limitations and inform clinical decision-making for older adults with cancer. Our objective was to evaluate the feasibility and effectiveness of a screener in community-based oncology clinics.

MATERIALS AND METHODS

Eligible patients were from two rural, underserved community-based cancer clinics; within 12 months of a cancer diagnosis (breast, lung, colorectal, pancreas, esophageal); aged ≥60 years; and not exclusively pursuing palliative care. We used a previously validated tool that was embedded in the electronic health record (EHR). Patient-reported responses identified memory impairment, depressive symptoms, deficits in activities of daily living, poor nutrition, and polypharmacy. At the discretion of the oncologist, responses prompted service referrals. From the EHR, we extracted information about referrals and completion of planned therapy. We present descriptive statistics.

RESULTS

Enrolled patients (n = 44) had a mean age of 71.5 years (SD = 6.9). Most were non-white (61%), women (66%), with government-sponsored health insurance (80%). The most commonly identified geriatric syndromes: polypharmacy (89%), reduced quality of life (39%), and poor nutrition (39%). The screener triggered a referral in 98% of patients. Generated referrals were for depressive symptoms (52% needed, 39% received), nutrition (43% needed, 37% received), and polypharmacy (89% needed, 26% received). Patients were referred to social work (56%), nutrition (44%), and pharmacy (25%). Many patients completed planned radiation therapy (100%), surgery (70%), and chemotherapy (60%).

CONCLUSIONS

Use of an EHR-embedded brief geriatric oncology assessment in rural oncology clinics identified geriatric syndromes that would benefit from provision of services in nearly all enrolled patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02906592.

Adjusted Chemotherapy According to Frailty Status in Elderly Patients With Diffuse Large B-Cell Lymphoma: Experience From a Single Referral Center in Mexico City

BACKGROUND

Chemotherapy is associated with significant toxicity in elderly patients treated for hematological malignancies. Adequate tools to identify the best tailored treatment are essential.

PATIENTS AND METHODS

Medical charts of patients treated with adjusted chemotherapy for diffuse large B-cell lymphoma according to frailty status between August 1, 2013 and June 30, 2016 were included. Three groups were identified: fit, unfit, and frail patients.

RESULTS

Fifty-six patients with a median age of 70.5 years were analyzed. Adverse prognostic characteristics were more frequent than expected in the frail group, contributing to a worse outcome. The complete response (CR) rate for all patients was 61.2% (66.6%, 78.3%, and 40.0% for fit, unfit, and frail patients, respectively; P = .121). The 2-year overall survival (OS) for all patients was 78% (87%, 82%, and 59% for fit, unfit, and frail patients, respectively; P = .159) and the mean 2-year disease-free survival was 96% (87% for frail patients and 100% for unfit and fit patients; P = .287). Grade 3/4 hematologic toxicity was present in 83.3%, 65.2%, and 45% of fit, unfit, and frail patients, respectively. CR after therapy had a positive effect on OS, whereas ≥ 2 extranodal sites and febrile neutropenia had a negative effect.

CONCLUSION

Frailty status assessment resulted in the identification of a group of unfit patients who had adequate tolerance to adjusted chemotherapy (R-choP; rituximab with cyclophosphamide, doxorubicin, and vincristine adjusted to 80% of the corresponding total doses in R-CHOP [rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone]) with good results.

Frailty in geriatric head and neck cancer: A contemporary review

OBJECTIVE

To provide a summary of the current frailty literature relating to head and neck cancer.

DATA SOURCES

Ovid MEDLINE, PubMed, Google Scholar.

METHODS

A comprehensive review of the literature was performed from 2000 to 2017 using key words frailty, elderly, geriatric, surgery, otolaryngology, head and neck cancer.

RESULTS

The aging population has led to an increased diagnosis of head and neck cancer in elderly patients. The prevalence of comorbidities, disabilities, geriatric syndromes and social issues can make treatment planning and management in this population challenging. Chronological age alone may not be the optimal approach to guiding treatment decisions, as there is marked heterogeneity amongst this age group. Individualization of treatment can be achieved by assessing for the presence of frailty, which has growing evidence as an important marker of health status in geriatric oncology. Frailty is a complex geriatric syndrome characterized by a state of increased vulnerability to stressors and is associated with morbidity, mortality, and treatment toxicity. Screening for frailty may provide an efficient method to identify those who would benefit from further assessment or pretreatment optimization, and to provide prognostic information to assist clinicians and patients in formulating the most ideal treatment plan for the elderly individual with head and neck cancer.

CONCLUSIONS

Frailty has emerged as an important concept in geriatric oncology, with wide significance in head and neck cancer. Incorporating frailty assessments into clinical practice may provide otolaryngologists pertinent information regarding health status and outcomes leading to optimal care of the elderly cancer patient. Laryngoscope, 128:E416-E424, 2018.

Validation of a frailty index in older cancer patients with solid tumours

Background

Frailty is an indicator of physiological reserve in older people. In non-cancer settings, frailty indices are reliable predictors of adverse health outcomes. The aims of this study were to 1) derive and validate a frailty index (FI) from comprehensive geriatric assessment (CGA) data obtained in the solid tumour chemotherapy setting, and 2) to explore whether the FI-CGA could predict chemotherapy decisions and survival in older cancer patients with solid tumours.

Methods

Prospective cohort study of a consecutive series sample of 175 cancer patients aged 65 and older with solid tumours. A frailty index was calculated using an accumulated deficits model, coding items from the comprehensive geriatric assessment tool administered prior to chemotherapy decision-making. The domains of physical and cognitive functioning, nutrition, mood, basic and instrumental activities of daily living, and comorbidities were incorporated as deficits into the model.

Results

The FI-CGA had a right-skewed distribution, with median (interquartile range) of 0.27 (0.21–0.39). The 99% limit to deficit accumulation was below the theoretical maximum of 1.0, at 0.75. The FI-CGA was significantly related (p < 0.001) to vulnerability as assessed by the Vulnerable Elders Survey-13 and to medical oncologists’ assessments of fitness or vulnerability to treatment. Baseline frailty as determined by the FI-CGA was also associated with treatment decisions (Treatment Terminated, Treatment Completed, No Planned Treatment) (p < 0.001), with the No Planned Treatment group significantly frailer than the other two groups.

Conclusion

The FI-CGA is a potentially useful adjunct to cancer clinical decision-making that could predict chemotherapy outcomes in older patients with solid tumours.

Multidisciplinary development of the Geriatric Core Dataset for clinical research in older patients with cancer: A French initiative with international survey

BACKGROUND

To define a core set of geriatric data to be methodically collected in clinical cancer trials of older adults, enabling comparison across trials.

PATIENTS AND METHODS

Following a consensus approach, a panel of 14 geriatricians from oncology clinics identified seven domains of importance in geriatric assessment. Based on the international recommendations, geriatricians selected the mostly commonly used tools/items for geriatric assessment by domain (January-October 2015). The Geriatric Core Dataset (G-CODE) was progressively developed according to RAND appropriateness ratings and feedback during three successive Delphi rounds (July-September 2016). The face validity of the G-CODE was assessed with two large panels of health professionals (55 national and 42 international experts) involved both in clinical practice and cancer trials (March-September 2017).

RESULTS AND DISCUSSION

After the last Delphi round, the tools/items proposed for the G-CODE were the following: (1) social assessment: living alone or support requested to stay at home; (2) functional autonomy: Activities of Daily Living (ADL) questionnaire and short instrumental ADL questionnaire; (3) mobility: Timed Up and Go test; (4) nutrition: weight loss during the past 6 months and body mass index; (5) cognition: Mini-Cog test; (6) mood: mini-Geriatric Depression Scale and (7) comorbidity: updated Charlson Comorbidity Index. More than 70% of national experts (42 from 20 cities) and international experts (31 from 13 countries) participated. National and international surveys showed good acceptability of the G-CODE. Specific points discussed included age-year cut-off, threshold of each tool/item and information about social support, but no additional item was proposed.

CONCLUSION

We achieved formal consensus on a set of geriatric data to be collected in cancer trials of older patients. The dissemination and prospective use of the G-CODE is needed to assess its utility.

Head and Neck Cancer in the Elderly: Frailty, Shared Decisions, and Avoidance of Low Value Care

Head and neck cancer (HNC) is a disease of older adults. Recurrent and metastatic head and neck squamous cell carcinoma portends a poor prognosis, with median overall survival of less than 12 months. Within this vulnerable population, significant treatment-related toxicities and physical and psychosocial sequelae can be devastating to quality of life at the end of life. Shared decision making and early comprehensive palliative and support services are at the crux of the approach to older adults with HNC. In doing so, low-value care that fails to meet the goals of patients and their caregivers at the end-of-life may be avoided.

What Every Oncologist Should Know About Geriatric Assessment for Older Patients With Cancer: Young International Society of Geriatric Oncology Position Paper

Aging is a heterogeneous process. Most newly diagnosed cancers occur in older adults, and it is important to understand a patient's underlying health status when making treatment decisions. A geriatric assessment provides a detailed evaluation of medical, psychosocial, and functional problems in older patients with cancer. Specifically, it can identify areas of vulnerability, predict survival and toxicity, assist in clinical treatment decisions, and guide interventions in routine oncology practice; however, the uptake is hampered by limitations in both time and resources, as well as by a lack of expert interpretation. In this review, we describe the utility of geriatric assessment by using an illustrative case and provide a practical approach to geriatric assessment in oncology.

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.

Radiation therapy for older patients with brain tumors

The incidence of brain tumors in the elderly population has increased over the last few decades. Current treatment includes surgery, radiotherapy and chemotherapy, but the optimal management of older patients with brain tumors remains a matter of debate, since aggressive radiation treatments in this population may be associated with high risks of neurological toxicity and deterioration of quality of life. For such patients, a careful clinical status assessment is mandatory both for clinical decision making and for designing randomized trials to adequately evaluate the optimal combination of radiotherapy and chemotherapy.

Several randomized studies have demonstrated the efficacy and safety of chemotherapy for patients with glioblastoma or lymphoma; however, the use of radiotherapy given in association with chemotherapy or as salvage therapy remains an effective treatment option associated with survival benefit. Stereotactic techniques are increasingly used for the treatment of patients with brain metastases and benign tumors, including pituitary adenomas, meningiomas and acoustic neuromas. Although no randomized trials have proven the superiority of SRS over other radiation techniques in older patients with brain metastases or benign brain tumors, data extracted from recent randomized studies and large retrospective series suggest that SRS is an effective approach in such patients associated with survival advantages and toxicity profile similar to those observed in young adults. Future trials need to investigate the optimal radiation techniques and dose/fractionation schedules in older patients with brain tumors with regard to clinical outcomes, neurocognitive function, and quality of life.

[Comprehensive geriatric assessment (CGA) in elderly with cancer: For whom?]

Scientific societies recommend the implementation of a comprehensive geriatric assessment (CGA) in cancer patients aged 70 and older. The EGA is an interdisciplinary multidimensional diagnostic process seeking to assess the frail older person in order to develop a coordinated plan of treatment and long-term follow-up. Identification of comorbidities and age-induced physiological changes that may increase the risk of anticancer treatment toxicities is essential to better assess the risk-benefit ratio in elderly cancer patients. The systematic implementation of a CGA for each patient is difficult to perform in daily practice. Therefore, it is recommended to screen vulnerable patients who will benefit from a complete CGA. Our work presents the vulnerability screening tools validated by at least two independent studies in a cancer elderly population setting. Among seven screening tools, the G8 and the VES13 are the most effective, and have been validated specifically in older population with cancer. The G8 is recommended by scientific societies and the French National Cancer Institute (INCa) because of its easy implementation in daily clinical practice, its high sensitivity and fair specificity. Although studies are underway to improve its performance, the G8 is currently the simplest tool to routinely identify older cancer patients who should have a complete assessment in geriatric oncology.

Geriatric assessment for oncologists

The world is experiencing aging of its population. Age-specific incidence rates of cancer are higher and cancer is now recognized as a part of aging. Treating older patients can be challenging. The clinical behavior of some tumors changes with age and the aging process itself brings physiological changes leading to decline in the function of organs. It is essential to identify those patients with longer life expectancy, potentially more likely to benefit from aggressive treatment vs. those that are more vulnerable to adverse outcomes. A primary determination when considering therapy for an older cancer patient is a patient's physiologic, rather than chronologic age. In order to differentiate amongst patients of the same age, it is useful to determine if a patient is fit or frail. Frail older adults have multiple chronic conditions and difficulties maintaining independence. They may be more vulnerable to therapy toxicities, and may not have substantial lasting benefits from therapy. Geriatric assessment (GA) may be used as a tool to determine reversible deficits and devise treatment strategies to mitigate such deficits. GA is also used in treatment decision making by clinicians, helping to risk stratify patients prior to potentially high-risk therapy. An important practical aspect of GA is the feasibility of incorporating it into a busy oncology practice. Key considerations in performing the GA include: available resources, patient population, GA tools to use, and who will be responsible for using the GA results and develop care plans. Challenges in implementing GA in clinical practice will be discussed.

Treating gynecologic malignancies in elderly patients

AIM

To determine the relative benefits of full and partial treatment for gynecologic malignancies in elderly patients.

METHODS

A retrospective cohort study of all consecutive patients (n=169) aged 79 and older (median age 82 y; range, 79 to 94 y), diagnosed between 1971 and 2007 with various types of gynecologic malignancies (endometrial, 52%; ovarian, 26%; vulvar, 11%; cervical, 5%; other, 6%) was conducted. Stages were I to II (47%), III to IV (35.5%), and unknown (17.5%). Major comorbidities were hypertension (51%), diabetes (17%), cardiac diseases (34%), and other malignancy (12%). Regardless of age or chronic illnesses, patients were grouped on the basis of having been treated optimally (100 patients; 59.2%), defined as the accepted standard for each diagnosis and stage including surgery and adjuvant radiation or chemotherapy as indicated; or suboptimally (69 patients; 40.8%), that is, no or only partial treatment. Kaplan-Meier survival analysis and Cox proportional hazard models, univariate and multivariable were conducted.

RESULTS

For all patients with suboptimal treatment, the age-and-stage-adjusted hazard ratio for death was 1.76 (95% CI, 1.203-2.570; P=0.004) compared with optimal treatment. Age-adjusted hazard ratio was 2.15 (95% CI, 1.127-4.114; P=0.02) and 2.3 (95% CI, 1.415-3.779; P=0.001) for ovarian and endometrial cancer patients, respectively. Age-adjusted and stage-adjusted hazard ratio was 2.8 (95% CI, 1.099-5.157; P=0.028) and 1.53 (95% CI, 0.867-2.702; P=0.1420) for ovarian and endometrial cancer patients, respectively.

CONCLUSIONS

Optimal treatment in patients with gynecologic malignancies evidently improves survival in elderly patients at any age, and in patients with ovarian cancer at any stage. Regardless of chronological age, the aim should be to deliver optimal treatment.

Geriatric screening tools are of limited value to predict decline in functional status and quality of life: results of a cohort study

BACKGROUND

Geriatric screening tools are increasingly implemented in daily practice, especially in the oncology setting, but also in primary care in some countries such as the Netherlands. Nonetheless, validation of these tools regarding their ability to predict relevant outcomes is lacking. In this study we evaluate if geriatric screening tools predict decline in functional status and quality of life after one year, in a population of older cancer patients and an older primary care population without cancer with a life expectancy of at least six months.

METHODS

Older cancer patients and a general older primary care population without a history of cancer (≥ 70 years) were included in an on-going prospective cohort study. Data were collected at baseline and after one-year follow-up. Functional decline was based on the Katz Index and Lawton IADL-scale and was defined as deterioration on one or more domains. Decline in quality of life was measured using the global health related subscale of the EORTC QLQ-C30, and was defined as a decline ≥ 10 points. The selected geriatric screening tools were the abbreviated Comprehensive Geriatric Assessment, Groningen Frailty Indicator, Vulnerable Elders Survey-13, and G8. We calculated sensitivity, specificity, predictive values, and odds ratios to assess if normal versus abnormal scores predict functional decline and decline in quality of life.

RESULTS

One-year follow-up data were available for 134 older cancer patients and 220 persons without cancer. Abnormal scores of all screening tools were significantly associated with functional decline. However, this was only true for older persons without cancer, and only in univariate analyses. For functional decline, sensitivity ranged from 54% to 71% and specificity from 33% to 66%. For decline in quality of life, sensitivity ranged from 40% to 67% and specificity from 37% to 54%.

CONCLUSION

In older persons with a relatively good prognosis, geriatric screening tools are of limited use in identifying persons at risk for decline in functional status or quality of life after one year. Hence, a geriatric screening tool cannot be relied on in isolation, but they do provide very valuable information and may prompt physicians to also consider different aspects of functioning.

Optimal management of breast cancer in the elderly patient: current perspectives

Breast cancer (BC) is the most common female malignancy in the world and almost one third of cases occur after 70 years of age. Optimal management of BC in the elderly is a real challenge and requires a multidisciplinary approach, mainly because the elderly population is heterogeneous. In this review, we describe the various possibilities of treatment for localized or metastatic BC in an aging population. We provide an overview of the comprehensive geriatric assessment, surgery, radiotherapy, and adjuvant therapy for early localized BC and of chemotherapy and targeted therapies for metastatic BC. Finally, we attempt to put into perspective the necessary balance between the expected benefits and risks, especially in the adjuvant setting.

Screening for vulnerability in older cancer patients: the ONCODAGE Prospective Multicenter Cohort Study

Background

Geriatric Assessment is an appropriate method for identifying older cancer patients at risk of life-threatening events during therapy. Yet, it is underused in practice, mainly because it is time- and resource-consuming. This study aims to identify the best screening tool to identify older cancer patients requiring geriatric assessment by comparing the performance of two short assessment tools the G8 and the Vulnerable Elders Survey (VES-13).

Patients and Methods

The diagnostic accuracy of the G8 and the (VES-13) were evaluated in a prospective cohort study of 1674 cancer patients accrued before treatment in 23 health care facilities. 1435 were eligible and evaluable. Outcome measures were multidimensional geriatric assessment (MGA), sensitivity (primary), specificity, negative and positive predictive values and likelihood ratios of the G8 and VES-13, and predictive factors of 1-year survival rate.

Results

Patient median age was 78.2 years (70-98) with a majority of females (69.8%), various types of cancer including 53.9% breast, and 75.8% Performance Status 0-1. Impaired MGA, G8, and VES-13 were 80.2%, 68.4%, and 60.2%, respectively. Mean time to complete G8 or VES-13 was about five minutes. Reproducibility of the two questionnaires was good. G8 appeared more sensitive (76.5% versus 68.7%, P =  0.0046) whereas VES-13 was more specific (74.3% versus 64.4%, P<0.0001). Abnormal G8 score (HR = 2.72), advanced stage (HR = 3.30), male sex (HR = 2.69) and poor Performance Status (HR = 3.28) were independent prognostic factors of 1-year survival.

Conclusion

With good sensitivity and independent prognostic value on 1-year survival, the G8 questionnaire is currently one of the best screening tools available to identify older cancer patients requiring geriatric assessment, and we believe it should be implemented broadly in daily practice. Continuous research efforts should be pursued to refine the selection process of older cancer patients before potentially life-threatening therapy.

How to implement a geriatric assessment in your clinical practice

Cancer is a disease that mostly affects older adults. Other health conditions, changes in functional status, and use of multiple medications change the risks and benefits of cancer treatment for older adults. Several international organizations, such as the International Society of Geriatric Oncology, the European Organization for Research and Treatment of Cancer, recommend the conduct of a geriatric assessment (GA) for older adults with cancer to help select the most appropriate treatment and identify any underlying undetected medical, functional, and psychosocial issues that can interfere with treatment. The aim of this review is to describe what a GA is and how to implement it in daily clinical practice for older adults with cancer in the oncology setting. We provide an overview of commonly used tools. Key considerations in performing the GA include the resources available (staff, space, and time), patient population (who will be assessed), what GA tools to use, and clinical follow-up (who will be responsible for using the GA results for developing care plans and who will provide follow-up care). Important challenges in implementing GA in clinical practice include not having easy and timely access to geriatric expertise, patient burden of the additional hospital visits, and establishing collaboration between the GA team and oncologists regarding expectations of the population referred for GA and expected outcomes of the GA. Finally, we provide some possible interventions for problems identified during the GA.

Determining chemotherapy tolerance in older patients with cancer

Older adults with cancer constitute a heterogeneous group of patients who pose unique challenges for oncology care. One major concern is how to identify patients who are at a higher risk for chemotherapy intolerance, because a standard oncology workup may not always be able to distinguish an older individual's level of risk for treatment-related complications. Geriatric oncologists incorporate tools used in the field of geriatrics, and have developed the Comprehensive Geriatric Assessment to enhance the standard oncology workup. This assessment pinpoints problems with daily activities, comorbidities, medications, nutritional status, cognitive function, psychological state, and social support systems, all of which are risk factors for treatment vulnerability in older adults with cancer. Additional tools that also serve to predict chemotherapy toxicity in older patients with cancer are now available to identify patients at higher risk for morbidity and mortality. Together, these instruments complement the standard oncology workup by providing a global assessment, thereby guiding therapeutic interventions that may improve a patient's quality of life and clinical outcomes.

A review of the management of elderly patients with non-small-cell lung cancer

Most patients with non-small-cell lung cancer (NSCLC) are elderly but evidence to guide appropriate treatment decisions for this age group is generally scant. Careful evaluation of the elderly should be undertaken to ensure that treatment appropriate for the stage of the tumour is guided by patient characteristics and not by age. The Comprehensive Geriatric Assessment (CGA) remains the preferred option, but briefer tools may be appropriate to select patients for further evaluation. The predicted outcome should be used to guide management decisions together with a reappraisal of polypharmacy. Patient expectations should also be taken into account. Management recommendations are generally similar to those of general guidelines for the NSCLC population, although the risks of surgery and toxicity of chemotherapy and radiotherapy are often increased in the elderly compared with younger patients; therefore, patients should be closely scrutinised and subjected to a CGA to ensure suitability of the planned treatment. If surgery is indicated, then lobectomy is generally the preferred option, although limited resection may be more feasible for some. Radiotherapy with curative intent is an alternative, with stereotactic body radiotherapy the most likely preferred modality. Adjuvant chemotherapy is also an appropriate approach, whereas adjuvant radiotherapy is generally not recommended. Concurrent chemoradiotherapy should be considered for elderly patients with inoperable locally advanced disease and chemotherapy for advanced/metastatic disease. Efforts should also be made to increase participation of elderly patients with NSCLC in clinical trials, thereby enhancing evidence-based treatment decisions for this majority group. This will require overcoming barriers relating to trial design and to physician and patient awareness and attitudes.

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

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Treatment of elderly patients with chronic lymphocytic leukemia: an unmet cinical need

In chronic lymphocytic leukemia (CLL), the most prevalent lymphoid malignancy in western countries, patients have a median age at diagnosis of 72 years. In the last few years, there has been remarkable progress in understanding the biology of CLL, the detection of molecular prognostic factors and the development of more effective therapies. However, many of the milestone studies were conducted in populations that were considerably younger than the average age of the CLL population. Today, the challenge is to improve management of elderly patients. In this population, outcome of treatment with newer highly effective therapies is often compromised by comorbidities and poor performance status. Decision on how elderly patients should be treated is thus a complex issue. The management of these patients should rely on the development of risk-stratified treatment strategies based on the assessment of individual functional status and the biologic characteristics of CLL. New single agents with reduced toxic effects (i.e., inhibitors of BCR signalling) that have achieved promising results in Phase I/II studies when available should modify the paradigm of the treatment of elderly patients with CLL.

Toxicity of initial chemotherapy in older patients with lung cancers

OBJECTIVES

Despite the growing number of elderly patientswith lung cancers,we lack adequate information about how best to treat them. A phase III trial demonstrated a survival benefit of doublet chemotherapy in elderly patients with lung cancers compared to single agents at the cost of increased toxicity. We undertook this study to identify and describe chemotherapyassociated toxicity patterns among elderly patients treated for lung cancers.

MATERIALS AND METHODS

We reviewed records of patients age 70 or older with metastatic lung cancers who received initial chemotherapy at the Memorial Sloan-Kettering Cancer Center during 2008 and 2009.

RESULTS

We identified 70 patients: 28 (40%) completed at least 4 cycles of chemotherapy without dose reduction but 31 (44%) required hospitalization for toxicity. Baseline albumin <3.5 g/dL and anemiawere associatedwith grade 3–5 chemotherapy-associated toxicity. Also, an increase in platelets from cycle 1 to cycle 2 was associated with chemotherapy-associated toxicity. No other statistically significant associations between chemotherapy-associated toxicity and putative biologic and functional risk factors, including age and performance status, were identified.

CONCLUSION

Patients deemed eligible for chemotherapy by their physicianswere just as likely to have severe chemotherapy-associated toxicity requiring hospitalization as to finish an initial course of therapy without any serious problems. An increase in platelet count from cycle 1 to cycle 2 was associated with increased toxicity. Additional research, such as exploration of inflammatory cytokines (PDGF, IL6, and IGF-1) to identify the mechanisms of chemotherapy tolerance and prospective evaluation and validation of existing metrics, is needed so that all patients can be appropriately risk stratified.

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.