The added value of an assessment of the patient's hand grip strength to the comprehensive geriatric assessment in G8-abnormal older patients with cancer in routine practice

External validation of the first prognostic nomogram for older adults with cancer

Background

The geriatric oncology population tends to be complex because of multimorbidity, functional and cognitive decline, malnutrition and social frailty. Prognostic indices for predicting survival of elderly cancer patients to guide treatment remain scarce. A nomogram based on all domains of the geriatric assessment was previously developed at the National Cancer Centre Singapore (NCCS) to predict overall survival (OS) in elderly cancer patients. This nomogram comprised of six variables (age, eastern cooperative oncology group performance status, disease stage, geriatric depression scale (GDS), DETERMINE nutritional index and serum albumin).

Objectives

To externally validate the NCCS prognostic nomogram.

Design

This is a prospective cohort study.

Methods

The nomogram was developed based on a training cohort of 249 patients aged ⩾70 years who attended the NCCS outpatient geriatric oncology clinic between May 2007 and November 2010. External validation of the nomogram using the Royston and Altman approach was carried out on an independent testing cohort of 252 patients from the same clinic between July 2015 and June 2017. Model misspecification, discrimination and calibration were assessed.

Results

Median OS of the testing cohort was 3.1 years, which was significantly higher than the corresponding 1.0 year for the training cohort (log-rank p < 0.001). The nomogram achieved a high level of discrimination in the testing cohort (0.7112), comparable to the training cohort (0.7108). Predicted death probabilities were generally well calibrated with the observed death probabilities, as the joint test of calibration-in-the-large estimates at year 1, 2 and 3 from zeros and calibration slope from one was insignificant with p = 0.432. There were model misspecifications in GDS and serum albumin.

Conclusion

This study externally validated the prognostic nomogram in an independent cohort of geriatric oncology patients. This supports the use of this nomogram in clinical practice.

Practical Implementation of the Comprehensive Geriatric Assessment to Optimise Care for Older Adults with Cancer

Whilst cancer remains a very serious health problem at any stage, cancer combined with increasing age creates an even more challenging situation for health care providers [...].

Protocol for a randomised controlled trial on impact of comprehensive geriatric and supportive assessment versus standard care in older adults with cancer undergoing curative treatment: The Geriatric Oncology SuPportive clinic for ELderly (GOSPEL) study

Cancer affects older adults with varying levels of frailty, but cancer treatment is extrapolated from clinical trials involving predominantly young and robust subjects. Recent geriatric oncology randomised controlled trials (RCT) report that geriatric assessment leading to frailty-guided intervention reduces treatment-related toxicity whilst maintaining survival and improving quality of life (QoL). However, these positive results have not have been consistently reported in the literature. We postulate that the impact of geriatric interventions has been underestimated in these studies with the inclusion of subjects receiving palliative-intent chemotherapy in whom dose reduction is common. Integrating supportive care with current geriatric oncology models may improve the QoL of older adults undergoing treatment. However, no studies as yet have examined such integrated geriatric and supportive models of care. The Geriatric Oncology SuPportive clinic for Elderly (GOSPEL) study is a single-centre, open-label, analyst-blinded RCT evaluating the impact of comprehensive geriatric and supportive care on QoL of older adults with cancer undergoing curative treatment. Older adults aged above 65, with a Geriatric-8 score ≤ 14, with plans for high dose radiotherapy and/or curative chemotherapy will be recruited. The primary QoL outcome is measured using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-ELD14 mobility scale at 12 weeks. Secondary outcomes include overall and disease-free survival, treatment-related adverse events, and hospital admissions. We pre-powered this study to recruit 200 subjects based on the minimally clinically important difference for EORTC QLQ-ELD14 to achieve 80% statistical power (alpha 0.05), assuming 25% attrition. Outcomes will be analysed using intention-to-treat. Intervention consists of multi-domain comprehensive geriatric and supportive care assessments from a multidisciplinary team targeting unmet needs. These include functional decline, falls, incontinence, cognitive impairment, multi-morbidity, polypharmacy, and symptom relief, as well as social and psycho-spiritual concerns. Standard care entails routine oncological management with referral to geriatrics based on the discretion of the primary oncologist. Recruitment has been ongoing since August 2020. Results from the GOSPEL study will increase understanding of the impact of integrated geriatric and supportive care programs in older adults with cancer receiving curative treatment. Trial registration: This study is registered under ClinicalTrials.gov (ID NCT04513977).

Acetyl-L-carnitine Slows the Progression from Prefrailty to Frailty in Older Subjects: A Randomized Interventional Clinical Trial

BACKGROUND

Ageing is characterized by a gradual decline in body function, representing the clinical situation called "frailty". Prefrailty is the intermediate stage between frailty and robust condition. L-carnitine (LC) plays an important role in energy production from long-chain fatty acids in mitochondria, and its serum level is lower in prefrail and frail subjects.

OBJECTIVE

This study aims to evaluate the effect of Acetyl-L-carnitine (ALCAR) in pre-frail older patients.

METHODS

We scheduled 3 months of treatment and then 3 months of follow-up. A total of 92 subjects were selected from May, 2009 to July, 2017, in a randomized, observational, double-blind, placebo-controlled study. We scheduled 3 months of treatment and then 3 months of follow-up. ALCAR (oral 1.5 g/bis in die - BID) or placebo groups were used.

RESULTS

After the treatment, only the treated group displayed a decrease in C reactive protein (CRP) p < 0.001 and an increase in serum-free carnitine and acetylcarnitine (p < 0.05) in Mini-Mental state (MMSE) p < 0.0001 and 6-walking distance (p < 0.0001); ALCAR group vs. placebo group showed a decrease in HDL cholesterol and CRP (p < 0.01), an increase in MMSE score (p < 0.001) and in the 6-walking distance (p < 0.001).

CONCLUSIONS

ALCAR treatment delays the incidence and severity of onset of degenerative disorders of the elderly in prefrail subjects with improvement in memory and cognitive processes.

Hand grip strength in patients with LVADs: A scoping review

BACKGROUND AND PURPOSE

Hand grip strength (HGS) is a simple test to evaluate the upper limb strength function in patients with different diseases. The purpose of this review was to investigate HGS in patients who have been implanted with left ventricular assist devices (LVADs) or waiting for implantation. The objectives were: (1) defining if HGS can predict rehabilitative outcomes such as the walked distance at the 6-minute walking test, and (2) identifying specific HGS cut-off values.

METHODS

We searched eight primary databases for English-language studies published from their inception until April 2021. We excluded editorials, letters to the editor, and studies that did not describe HGS assessment procedures.

RESULTS

A total of 30 articles were identified. We ultimately included 5 publications, and 217 patients constituted the cohort of the present study. In three studies, HGS was evaluated before implantation. Two studies were conducted during the postoperative course, and HGS measurements were taken before and after rehabilitation. In two studies, HGS has correlated with a significant increase of the 6-MWT passing from 300.1 to 404.8 m and 56.6 to 83.8 m, respectively. HGS in patients with LVADs ranges between (1) ca.18 and ca.33 Kg at the preoperative stage, (2) ca.24 and >40 Kg postoperatively, and (3) ca.33 and >36 Kg after having attended a postoperative rehabilitation program.

CONCLUSION

HGS appears to be a simple and reliable measure to correlate rehabilitative outcomes, such as the 6-MWT, in patients receiving or awaiting LVADs.

Combination of the G-8 Screening Tool and Hand-Grip Strength to Predict Long-Term Overall Survival in Non-Small Cell Lung Cancer Patients Undergoing Stereotactic Body Radiotherapy

The Geriatric 8 (G-8) is a known predictor of overall survival (OS) in older cancer patients, but is mainly based on nutritional aspects. This study aimed to assess if the G-8 combined with a hand-grip strength test (HGST) in patients with NSCLC treated with stereotactic body radiotherapy can predict long-term OS better than the G-8 alone. A total of 46 SBRT-treated patients with NSCLC of stage T1-T2N0M0 were included. Patients were divided into three groups: fit (normal G-8 and HGST), vulnerable (abnormal G-8 or HGST), or frail (abnormal G-8 and HGST). Statistically significant differences were found in 4-year OS between the fit, vulnerable, and frail groups (70% vs. 46% vs. 25%, p = 0.04), as well as between the normal and abnormal G-8 groups (69% vs. 39%, p = 0.02). In a multivariable analysis of OS, being vulnerable with a hazard ratio (HR) of 2.03 or frail with an HR of 3.80 indicated poorer OS, but this did not reach statistical significance. This study suggests that there might be a benefit of adding a physical test to the G-8 for more precisely predicting overall survival in SBRT-treated patients with localized NSCLC. However, this should be confirmed in a larger study population.

Perspectives on functional status in older adults with cancer: An interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG

Most adults with cancer are over 65 years of age, and this cohort is expected to grow exponentially. Older adults have an increased burden of comorbidities and risk of experiencing adverse events on anticancer treatments, including functional decline. Functional impairment is a predictor of increased risk of chemotherapy toxicity and shorter survival in this population. Healthcare professionals caring for older adults with cancer should be familiar with the concept of functional status and its implications because of the significant interplay between function, cancer, anticancer treatments, and patient-reported outcomes. In this narrative review, we provide an overview of functional status among older patients with cancer including predictors, screening, and assessment tools. We also discuss the impact of functional impairment on patient outcomes, and describe the role of individual members of an interprofessional team in addressing functional impairment in this population, including the use of a collaborative approach aiming to preserve function.

Female cancer survivors are more likely to be at high risk of malnutrition and meet the threshold for clinical importance for a number of quality of life subscales

BACKGROUND

The present study aimed to explore malnutrition risk, handgrip strength and quality of life (QOL) in cancer survivors.

METHODS

In total, 232 individuals completed a demographic questionnaire, Patient-Generated Subjective Global Assessment Short Form and the European Organization for Research and Treatment of Cancer QOL Questionnaire (EORTC QLQ-C30). Handgrip strength was determined using a spring-loaded handgrip dynamometer and anthropometric measurements were taken by an oncology nurse. Frequencies and distribution data, analysis of variance and chi-squared tests were then conducted.

RESULTS

The majority of the cohort were female (n = 141; 60.8%) had breast cancer (n = 62; 26.7%) and the mean ± SD body mass index (BMI) was 26.6 ± 6.2 kg m^-2 . Less than a one-third reported seeing a dietitian (n = 68; 29.3%). Over one-third reported recent weight loss (n = 88; 37.3%). Some 40.9% (n = 95) were at moderate to high risk of malnutrition, with women more likely than men to be classified as high risk (p < 0.05). Mean ± SD handgrip strength was 25 ± 15 kg and this differed significantly by gender (p = 0.00), cancer type (p = 0.01) and BMI classification (p = 0.01). One-fifth of individuals were classified as having dynapenia (n = 48; 21.1%). Median (interquartile range) QOL score was 66.7 (33.3). The proportion of individuals meeting the threshold for clinical importance for QOL subscales ranged from 12.5% (constipation) to 42.7% (physical functioning). Females were more likely than males to meet the threshold for physical functioning (p = 0.00), fatigue (p = 0.02) and pain (p = 0.01).

CONCLUSIONS

Females are more likely than males to be at high risk of malnutrition and meet the threshold for clinical significance for several QOL subscales.

Nutritional status according to the mini nutritional assessment (MNA)® as potential prognostic factor for health and treatment outcomes in patients with cancer - a systematic review

Background

Patients with cancer have an increased risk of malnutrition which is associated with poor outcome. The Mini Nutritional Assessment (MNA®) is often used in older patients with cancer but its relation to outcome is not known.

Methods

Four databases were systematically searched for studies relating MNA-results with any reported outcome. Two reviewers screened titles/abstracts and full-texts, extracted data and rated the risk of bias (RoB) independently.

Results

We included 56 studies which varied widely in patient and study characteristics. In multivariable analyses, (risk of) malnutrition assessed by MNA significantly predicts a higher chance for mortality/poor overall survival (22/27 studies), shorter progression-free survival/time to progression (3/5 studies), treatment maintenance (5/8 studies) and (health-related) quality of life (2/2 studies), but not treatment toxicity/complications (1/7 studies) or functional status/decline in (1/3 studies). For other outcomes – length of hospital stay (2 studies), falls, fatigue and unplanned (hospital) admissions (1 study each) – no adjusted results were reported. RoB was rated as moderate to high.

Conclusions

MNA®-result predicts mortality/survival, cancer progression, treatment maintenance and (health-related) quality of life and did not predict adverse treatment outcomes and functional status/ decline in patients with cancer. For other outcomes results are less clear. The moderate to high RoB calls for studies with better control of potential confounders.

How best to palliate and treat emergency conditions in geriatric patients with colorectal cancer

Almost one third of colorectal cancer (CRC) cases are diagnosed in an emergency setting, mostly among geriatric patients. Clinical scenarios are often complex and decision making delicate. Besides the obvious need to consider the patient's and/or family and care givers' desires, the surgeon should be able to make the best educated guess on future outcomes in three areas: oncological prognosis, morbidity and mortality risk, and long-term functional loss. Using simple and brief tools for frailty screening reasonable treatment goals with curative or palliative intent can be planned. The most frequent clinical scenarios of CRC in emergency are bowel obstruction and perforation. We propose treatment algorithms based on assessment of the patient's overall reserve and discuss the indications, techniques and impact of a stoma in the geriatric patient. Bridge to surgery strategies may be best adapted to help the frail geriatric patient overcome the acute disease and maybe return to previous state of function. Post-operative morbidity and mortality rates are high in emergency surgery for CRC, but if the geriatric patient survives the post-operative period, oncological prognosis seems to be similar to younger patients. Because the occurrence of complications is the strongest predictor of functional decline and death, post-operative care plays a major role to optimize outcomes. Future studies should further investigate emergency surgery of CRC in the older adults focusing in particular on functional outcomes in order to help physicians counsel patients and families for a tailored treatment.