From suboptimal to optimal treatment in older patients with cancer

Impact of geriatric assessment for the therapeutic decision-making of breast cancer: results of a French survey. AFSOS and SOFOG collaborative work

BACKGROUND

Cancer management in the elderly is often considered as suboptimal, highly variable, and rarely evidence-based. Data are needed to understand decision-making processes in this population.

MATERIALS AND METHODS

A survey was performed in France to describe decision-making in gynaecologic patients over 70. It followed a three-step method: (1) 101 representative physicians questioned about treatment decision criteria; (2) simplified individual data were collected; (3) as well as detailed data patients receiving chemotherapy. This analysis refers to breast cancer subgroup of patients.

RESULTS

Main decision criteria were performance status, comorbidities, and renal function. In adjuvant setting, the main concern was life expectancy, whereas it was quality of life in metastatic setting. Of the 631 patients entered in the simplified analysis, 41% had been evaluated by a geriatrician, 67% received chemotherapy. In the detailed analysis, patients older than 75 were more likely to receive a monochemotherapy and to be treated with weekly/divided dose. In adjuvant setting, respectively, 19, 55, and 26% of the patients were treated with regimen validated in the elderly, validated in a younger population, and not validated. A G-CSF was prescribed in 48% of the patients, as primary prophylaxis in 78 and in 41% of patients with a risk of febrile neutropenia < 10%.

CONCLUSION

Geriatric covariates become an increasing concern in the decision-making process. This survey also suggests an insufficient use of validated chemotherapy regimens. To date, age remains a risk factor for heterogeneity in oncologic practice justifying a persistent effort for elaborating and disclosing specific recommendations.

Treatment of the elderly patient with mantle cell lymphoma

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