The relevance of a geriatric assessment for elderly patients with a haematological malignancy--a systematic review

A multicenter retrospective study to assess feasibility, safety and efficacy of first-line carboplatin-paclitaxel versus carboplatin monotherapy in a frail, elderly epithelial ovarian cancer population

OBJECTIVE

Underrepresentation of elderly ovarian cancer patients in clinical trials has led to lack of clarity regarding optimal first-line chemotherapy in this cohort. The Elderly Women with Ovarian Cancer (EWOC)-1 trial demonstrated that 3-weekly carboplatin (3wC) resulted in worse survival and feasibility compared with standard 3-weekly carboplatin-paclitaxel (3wCP) in frail, elderly ovarian cancer patients. Our retrospective study compares feasibility, safety, and efficacy of first-line 3wCP and 3wC in a frail ovarian cancer cohort.

METHODS

Clinical data were retrospectively analyzed for newly-diagnosed, International Federation of Gynecology and Obstetrics (FIGO) stage III/IV, ≥70-year-old epithelial ovarian cancer patients, treated by clinician choice with 3wC or 3wCP at two London cancer centers over a 2 year period. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status provided surrogate markers of frailty. Common Terminology Criteria for Adverse Events v5.0 graded toxicity.

RESULTS

A total of 107 patients were treated with 3wC (n=30) and 3wCP (n=77). Age, performance status, and CCI were significantly different between cohorts, with 3wC patients older (84 vs 75 years, p<0.001), with more comorbidities (median CCI 4 vs 3, p<0.001) and worse performance status (47% vs 17% PS ≥2, p=0.015). Surgical outcomes differed significantly between cohorts, with 20 (67%) 3wC patients not undergoing surgery, compared with 22 (29%) 3wCP patients (p<0.001). Median follow-up was 45.8 months (IQR 38.7-56.3 months). While we observed improved progression-free (HR 0.55, 95% CI 0.33 to 0.90, p=0.017) and overall survival (HR 0.44, 95% CI 0.27 to 0.73, p=0.001, log-rank test) in a univariate cox proportional hazards comparison between 3wCP and 3wC, this was not significant on multivariate analysis. Completion of six planned chemotherapy cycles was achieved by the majority, with similar discontinuation rates between groups (13% 3wC vs 8% 3wCP, p>0.05). Overall grade ≥3 hematological toxicity rates were similar between regimens (33% 3wC vs 44% 3wCP, p=0.37) with grade ≥3 neutropenia (p=0.019) and grade ≥3 thrombocytopenia (p=0.006) more common with 3wCP and 3wC, respectively. No treatment-related deaths occurred.

CONCLUSION

Our data demonstrates that standard 3wCP is a well-tolerated, feasible first-line treatment for frail, elderly ovarian cancer patients. Improved survival with 3wCP was not significant when corrected for established clinical prognostic factors.

Psychoneuroimmunology in multiple myeloma and autologous hematopoietic stem cell transplant: Opportunities for research among patients and caregivers

Multiple myeloma (MM) is an incurable cancer and is the leading indication for autologous hematopoietic stem cell transplantation (HSCT). To be eligible for HSCT, a patient must have a caregiver, as caregivers play a central role in HSCT preparation and recovery. MM patients remain on treatment indefinitely, and thus patients and their caregivers face long-term challenges including the intensity of HSCT and perpetual therapy after transplant. Importantly, both patients and their caregivers show heightened depressive and anxiety symptoms, with dyadic correspondence evidenced and caregivers' distress often exceeding that of patients. An extensive psychoneuroimmunology (PNI) literature links distress with health via immune and neuroendocrine dysregulation as well as biological aging. However, data on PNI in the context of multiple myeloma - in patients or caregivers - are remarkably limited. Distress in MM patients has been associated with poorer outcomes including higher inflammation, greater one year post-HSCT hospital readmissions, and worse overall survival. Further, anxiety and depression are linked to biological aging and may contribute to the poor long-term health of both patients and caregivers. Because MM generally affects older adults, individual differences in biological aging may represent an important modifier of MM biology and HSCT treatment outcomes. There are a number of clinical scenarios in which biologically younger people could be prescribed more intensive therapies, with potential for greater benefit, by using a personalized cancer therapy approach based on the quantification of physiologic reserve. Further, despite considerable psychological demands, the effects of distress on health among MM caregivers is largely unexamined. Within this context, the current critical review highlights gaps in knowledge at the intersection of HSCT, inflammation, and biological aging in the context of MM. Research in this area hold promise for opportunities for novel and impactful psychoneuroimmunology (PNI) research to enhance health outcomes, quality of life, and longevity among both MM patients and their caregivers.

Oncology care providers' perceptions and anticipated barriers regarding the use of geriatric assessment in routine clinic practice: A mixed-methods study

INTRODUCTION

Geriatric assessment (GA) is currently not a standard of cancer care across Canada. In the Canadian province of Saskatchewan, there are no known formal geriatric teams in outpatient oncology settings. Therefore, it is not known whether, how, and to what extent GA is performed in oncology clinics, or what supports are needed to carry out a GA. The objective of this study was to explore Saskatchewan oncology care providers' knowledge, perceptions, and practices regarding GA, and their perceived barriers to implementing formal GA.

MATERIALS AND METHODS

In this mixed-methods study, oncology physicians and nurses within the Saskatchewan Cancer Agency (SCA) were invited to participate in an anonymous survey and individual open-ended interview. Quantitative survey data were analyzed using descriptive statistics; free-text responses provided in the survey were summarized. Data from interviews were analyzed using thematic analysis.

RESULTS

A total of 19 physicians and 30 clinic nurses participated in the survey (response rate: 24% [physicians] and 38.0% [nurses]). In terms of cancer treatment and management, the majority (74% of physicians and 62% of nurses) stated considerations for older adults are different than younger patients. More than half (53% of physicians and 58% of nurses) reported making treatment and management decisions primarily based on judgement versus validated tools. For physicians whose practices involve prescribing chemotherapy (16/19), 75% rarely or never use validated tools (e.g., CARG, CRASH) to assess risk of chemotoxicity for older patients. Lack of time and supporting staff and feeling unsure as to where to refer older patients for help or follow-up were the most commonly voiced anticipated barriers to implementing GA. Two physicians and six nurses (n = 8) participated in the open-ended interviews. Main themes included: (1) tension between knowing the importance of GA versus capacity and (2) buy-in.

DISCUSSION

Our findings review barriers and opportunities for implementing GA in oncology care in Saskatchewan and provides foundational knowledge to inform efforts to promote personalized medicine and to optimize cancer care for older adults with cancer in this region.

Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG)

Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.

New treatment opportunities for older patients with acute myeloid leukemia and the increasing importance of frailty assessment - An oncogeriatric perspective

With the introduction of targeted chemotherapy drugs, a new age of treatment for acute myeloid leukemia (AML) has begun. The promotion of the azacitidine+venetoclax combination regimen to first line of treatment in patients deemed ineligible for intensive chemotherapy marks the first of many novel combination regimens becoming part of national treatment guidelines. We review recent phase II and III clinical trials and conclude that these novel regimens offer significant increases in response rates, remission rates, and overall survival. The incidence of adverse events, the accrued time toxicity, and the healthcare costs, however, are increasing as well. Compared with clinical trials, older patients in the real world frequently present with an inferior baseline health status, which is associated with an increased risk of experiencing side effects. The key to reaping the maximum benefit of the new agents and their combination regimens therefore lies in sufficient attention being given to a patients' preexisting comorbidities, potential frailty, and quality of life. A systematic collaboration between hemato-oncologists and geriatricians can be a potent first step towards addressing the increased treatment intensity patients with AML experience under the novel regimens. In this narrative review article we provide an overview of recent and ongoing clinical trials, highlight encountered adverse events, discuss frailty assessment options, and outline an oncogeriatic care path for older patients with AML.

Implementation of a nurse-led, multidisciplinary model of care for older adults with cancer: a process evaluation protocol

INTRODUCTION

Cancer is predominantly a disease of older adults, with an increasing number of cancer diagnoses in individuals aged 65 or older. Multiple geriatric factors have been shown to impact patient outcomes in cancer treatment. However, oncology specialists are not well adapted to incorporate geriatric assessment into practice due to a lack of resources and knowledge of the specialty.The primary aim of this study is to implement and evaluate a nurse-led, multidisciplinary model of care for older adults with cancer at two public tertiary hospitals in Melbourne, Australia.

METHODS AND ANALYSIS

This study will aim to assess 200 patients across 2 sites. Both sites will assess individuals with lung cancer; the second site will also include individuals with genitourinary, upper gastrointestinal and colorectal cancers.This process evaluation will use quantitative and qualitative methods to explore the reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) of the nurse-led, multidisciplinary model of care.

ETHICS AND DISSEMINATION

Ethical approval and local governance approvals have been obtained by Austin Health and Monash Health Human Research Ethics committees. Dissemination will occur via publications, conferences, social medical and local engagement with clinicians, consumers and managers.

Frailty assessment to individualize treatment in older patients with lymphoma

PURPOSE

A study analyzing the application of a protocol of comprehensive geriatric assessment (CGA) in older patients with lymphoma was carried out to allow frailty-based patient classification and individualized treatment.

METHODS

Lymphoma patients older than 70 years referred to the Geriatric Clinic at a tertiary hospital between May 2016 and March 2021 were included. The assessment protocol included comorbidity, polypharmacy, nutritional, functional, and mental status, geriatric syndromes, and life expectancy. CGA enabled patient classification into four groups (Type I to Type IV) based on frailty assessment instrument scoring and clinical, functional, and mental status. Variables were compared using parametric and non-parametric statistical tests and Kaplan-Meier survival curves.

RESULTS

Ninety-three patients (55.9% women) were included. Median age was 81.1 years (± 5.7). 23 patients (24.7%) were classified as robust (type I), 30 (32.3%) as pre-frail (type II) with potentially reversable deficits, 38 (40.9%) as frail (type III), and 2 (2.2%) as requiring palliative care (type IV). Patients received oncospecific treatment with modifications carried out in 64.5% of cases based on CGA results. Differences in overall survival (p = 0.002), response to treatment (p < 0.001) and likelihood of increased frailty (p = 0.024) were observed, with type III-IV patients showing significantly worse outcomes.

CONCLUSION

Performance of standardized, systematic CGA by geriatricians permits older lymphoma patients to be classified according to frailty, with significant differences in terms of clinical outcomes across groups. We propose incorporating CGA performed by geriatricians as part of the multidisciplinary care team to optimize therapeutic strategy for these patients.

Determination and Management of Risks for Practices and Procedures in the Elderly (DRIPP): the impact of a comprehensive geriatric evaluation in elderly with diffuse large B-cell lymphoma

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) treatment in older patients is challenging. The Determination and Management of Risks for Practices and Procedures in the Elderly (DRIPP) is a multidimensional evaluation program that involves patients undergoing oncological treatments.

OBJECTIVE

We aimed to evaluate the overall survival and progression-free survival (PFS) of patients evaluated and those not evaluated by the DRIPP.

MATERIALS AND METHODS

Retrospective cohort study, patients > 65 years with DLBCL were included. They were divided into 3 groups: patients with a diagnosis prior to the DRIPP implementation (pre-DRIPP), patients with the DRIPP (DRIPP) and patients with a diagnosis after the DRIPP implementation, but who did not undergo the evaluation (non-DRIPP).

RESULTS

A total of 125 patients were analyzed. Fourteen (11%) patients in the pre-DRIPP group, 74 (59%) in the DRIPP group, and 37 (30%) in the non-DRIPP group. In 43 (58%) patients of the DRIPP group, some drug dose adjustments were made vs. 19 (15%) in the non-DRIPP (p = 0.03). There were no significant differences in terms of discontinuation of treatment or hematological toxicity between groups. The OS and PFS in one year was 64% (95%CI 34-83) and 50% (95%CI 23-72) for the pre-DRIPP group, 82% (95%CI 71-89) and 72% (95%CI 60-81) for the DRIPP group, 58% (95% CI 41-72) and 56% (95% CI 38-70) for the non-DRIPP group, (p = 0.08). The analysis was adjusted for probable confounders and no differences were found.

CONCLUSIONS

This is the first study to evaluate the DRIPP as a decision-making tool in patients with lymphoma and showed a trend towards improvement in the OS in evaluated patients.

Supportive Care in Older Lymphoma Patients to Reduce Toxicity and Preserve Quality of Life

The treatment paradigm in older patients with malignant hemopathies is the choice between an effective conservative treatment that preserves quality of life and an intensive, potentially curative treatment with more toxicities. For each patient, it is important to determine the risk/benefit ratio. The patient should be involved in the discussion, sufficiently informed and able to express himself and his expectations in terms of quality of life. However, this informed consent is conditioned by the ability of the patient to understand the risks and benefits of the treatment. Decline in quality of life is an important parameter for older patients with cancer and many prospective trials have now confirmed the impact of different side effects of treatment, such as recurrent hospitalization, loss of autonomy in daily activities, loss of contact with grandchildren and loss of cognitive functions. Interventions oriented to vulnerabilities detected in the older patients (by comprehensive geriatric assessment) and an optimal approach, including preventive measures to reduce treatment-related toxicity and mortality, are directly correlated to improvement in quality of life.

Prognosis of older adults with chronic lymphocytic leukemia: A Surveillance, Epidemiology, and End Results-Medicare cohort study

INTRODUCTION

While prognosis for patients with chronic lymphocytic leukemia (CLL) has improved over time in younger adults, only modest improvements have occurred in older adults. We conducted a descriptive study of prognosis in older adults with CLL.

MATERIALS AND METHODS

We used data from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database from 2003 to 2016. We identified older adults (≥66 years) diagnosed with primary CLL between 2004 and 2015 (Overall Cohort). A subset who initiated CLL-directed therapy during the year following diagnosis was also identified (Treated Cohort). Both cohorts were matched to Medicare beneficiaries without cancer based on age, sex, and region. For each year from 2004 to 2013, three-year survival for patients with CLL and non-cancer comparators was described using Kaplan-Meier analysis. Inverse probability weighted Cox regression models were used to compare survival in the CLL and non-cancer comparator cohorts, accounting for demographic information and comorbidity and frailty indices. Among older adults with CLL, ten-year cause-specific cumulative mortality was estimated using Aalen-Johansen estimators that accounted for competing risks. Predictors of cause-specific mortality, including comorbidity and frailty burden, were assessed using sub-distribution hazards models.

RESULTS

In the Overall Cohort, three-year survival increased non-monotonically from 71.4% in 2004 to 73.4% in 2013, with a peak of 74.4% in 2011, and was lower than survival in non-cancer comparators (78.3% in 2004 to 83.2% in 2013). In the Treated Cohort, three-year survival was 56.3% in 2004 and 56.5% in 2013, with a peak of 64.2% in 2011. Cox models suggested that survival in the Treated Cohort was approaching survival in non-cancer comparators after 2011 (hazard ratio = 1.04, 95% confidence interval, 0.93-1.17). Ten-year cumulative mortality was 68.6% in the Overall Cohort and 81.7% in the Treated Cohort, with most deaths attributed to non-CLL causes. In the sub-distribution hazards models, age, year of diagnosis, frailty, and comorbidities were all associated with prognosis.

DISCUSSION

Prognosis in older adults has been stable over time and most patients with CLL die from non-CLL causes. CLL-directed treatment decision-making in older adults should consider age-related factors, such as comorbidity and frailty.

Epidemiological Trends of Haematological Malignancies in Belgium 2004-2018: Older Patients Show the Greatest Improvement in Survival

(1) Background: Haematological malignancies (HMs) represent a heterogeneous group of mostly rare cancers that differ in pathophysiology, incidence, and outcome. (2) Methods: Our study aims to understand the epidemiological situation and trends of 24 main types of HMs in Belgium over a 15-year period, with a focus on the impact of age. Age-standardised incidence, average annual percentage change (AAPC), 5- and 10-year relative survival (RS) and RS trends were estimated for all HMs (N = 94,415) diagnosed between 2004 and 2018. (3) Results: Incidence rates of HM increased, mainly in the 70+ age group (AAPC: 3%). RS varied by age and HM type. For each HM type, outcome decreased with age. The greatest decrease with age in 5-year RS is observed for aggressive HM, acute myeloid leukaemia (AML), acute lymphoblastic leukaemia, and Burkitt lymphoma, from 67%, 90%, and 97% below 20 years, to 2%, 12%, and 16% above 80 years of age, respectively. The moderate improvement in 5-year RS over the 2004-2018 period for all HMs, of +5 percentage point (pp), masks highly heterogenous outcomes by HM type and age group. The most impressive improvements are observed in the 80+ group: +45, +33, +28, and +16 pp for Hodgkin lymphoma, immunoproliferative disorders, follicular lymphoma, and chronic myeloid leukaemia, respectively. (4) Conclusions: The increasing incidence and survival over the 2004-2018 period are likely explained by diagnostic and therapeutic innovations, which have spread to populations not targeted by clinical trials, especially older adults. This real-world population-based study highlights entities that need significant improvement, such as AML.

Improving care for older adults with hematological malignancies in India: Conquering the challenge

In India, the number of older adults is steadily increasing and expected to reach around 200 million by 2030. Along with demographic change, India is experiencing a shift in family structure from multi-generational to nuclear families, affecting the social and psychological support available to older adults. The majority of hematological malignancies are diagnosed after the age of 60 years. Multiple issues associated with ageing, denoted as geriatric impairments, adversely affect the care of patients with cancer. Geriatric assessment and management is conspicuously underutilized and missing from the medical education curriculum in developing countries including India. Geriatric assessments may provide valuable information for the care of older adults with hematological malignancies, but incorporating geriatrics into the care of older patients with cancer in India will require knowledge of different approaches and consideration of the local healthcare context. In this article we will discuss the distinctive considerations in caring for older adults with hematological malignancies in India and to examine the unmet needs, challenges, and opportunities in improving the care of this population in the Indian context.

Multidrug chemotherapy, whole-brain radiation and cytarabine therapy for primary central nervous system lymphoma in elderly patients with dose modification based on geriatric assessment: study protocol for a phase II, multicentre, non-randomised study

INTRODUCTION

Multidrug chemoimmunotherapy with rituximab, high-dose methotrexate, procarbazine and vincristine (R-MPV) is a standard therapy for younger patients with primary central nervous system lymphoma (PCNSL); however, prospective data regarding its use in elderly patients are lacking. This multi-institutional, non-randomised, phase II trial will assess the efficacy and safety of R-MPV and high-dose cytarabine (HD-AraC) for geriatric patients with newly diagnosed PCNSL.

METHODS AND ANALYSIS

Forty-five elderly patients will be included. If R-MPV does not achieve complete response, the patients will undergo reduced-dose, whole-brain radiotherapy comprising 23.4 Gy/13 fractions, followed by local boost radiotherapy comprising 21.6 Gy/12 fractions. After achieving complete response using R-MPV with or without radiotherapy, the patients will undergo two courses of HD-AraC. All patients will undergo baseline geriatric 8 (G8) assessment before HD-AraC and after three, five and seven R-MPV courses. Patients with screening scores of ≥14 points that decrease to <14 points during subsequent treatment, or those with screening scores <14 points that decrease from the baseline during subsequent treatment are considered unfit for R-MPV/HD-AraC. The primary endpoint is overall survival, and the secondary endpoints are progression-free survival, treatment failure-free survival and frequency of adverse events. The results will guide a later phase III trial and provide information about the utility of a geriatric assessment for defining chemotherapy ineligibility.

ETHICS AND DISSEMINATION

This study complies with the latest Declaration of Helsinki. Written informed consent will be obtained. All participants can quit the study without penalty or impact on treatment. The protocol for the study, statistical analysis plan and informed consent form have been approved by the Certified Review Board at Hiroshima University (CRB6180006) (approval number: CRB2018-0011). The study is ongoing within nine tertiary and two secondary hospitals in Japan. The findings of this trial will be disseminated through national and international presentations and peer-reviewed publications.

TRIAL REGISTRATION

jRCTs061180093.

[Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies]

Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies Abstract: Older patients face an increased risk of complications and adverse outcomes during and after operations, interventions, and intense oncological therapies. At the same time, this patient group should not be excluded per se from potentially beneficial medical procedures based on chronological age alone. The timely identification of geriatric syndromes and increased vulnerability by means of comprehensive geriatric assessment is becoming increasingly important and is already recommended in the guidelines of professional societies of several medical disciplines. Nonetheless, the geriatric assessment should ideally be followed by proactive co-management in the sense of integrated care. The establishment of interdisciplinary and integrated care pathways for older hospital patients can contribute to significantly improved treatment outcomes. In addition to better patient-related outcomes and rising quality indicators, this approach may also offer positive health economic effects.

Provision and delivery of survivorship care for adult patients with haematological malignancies: A scoping review protocol

INTRODUCTION

Haematological malignancies are a heterogenous group of blood and lymphatic cancers. Survivorship care is a similarly diverse term concerning patients' health and wellbeing from diagnosis to end of life. Survivorship care for patients with haematological malignancies has traditionally been consultant-led and secondary care-based, although shifts away from this model have been occurring, largely via nurse-led clinics and interventions with some remote monitoring. However, there remains a lack of evidence regarding which model is most appropriate. Although previous reviews exist, patient populations, methodologies, and conclusions are varied, and further high-quality research and evaluation has been recommended.

AIMS

The aim of the scoping review this protocol describes is to summarise current evidence on the provision and delivery of survivorship care for adult patients diagnosed with a haematological malignancy, and to identify existing gaps to inform future research.

METHODOLOGY

A scoping review will be carried out utilising Arksey and O'Malley's guidelines as its methodological framework. Studies published in the English language from December 2007 to the present will be searched on bibliographic databases, including Medline, CINAHL, PsycInfo, Web of Science, and Scopus. Papers' titles, abstracts, and full text will predominantly be screened by one reviewer with a second reviewer blind screening a proportion. Data will be extracted using a customised table developed in collaboration with the review team, and presented in tabular and narrative format, arranged thematically. Studies included will contain data regarding adult (25+) patients diagnosed with any haematological malignancy in combination with aspects related to survivorship care. The survivorship care elements could be delivered by any provider within any setting, but should be delivered pre- or post-treatment, or to patients on a watchful waiting pathway.

REGISTRATION

The scoping review protocol has been registered on the Open Science Framework (OSF) repository Registries (https://osf.io/rtfvq; DOI: 10.17605/OSF.IO/RTFVQ).

Non-intensive acute myeloid leukemia therapies for older patients

INTRODUCTION

Acute myeloid leukemia (AML) is an aggressive disease predominantly affecting the elderly population. The elderly population represents a challenging group to treat and the prognosis is generally poor with significantly worse treatment outcomes compared to the younger population. While the goal of treatment for younger fit patients is cure and includes intensive chemotherapy and stem cell transplantation, these strategies are not always feasible for elderly unfit patients due to increased frailty, co-morbidities, and, subsequently, an increased risk of treatment-related toxicity and mortality.

AREAS COVERED

This review will discuss both patient- and disease-related factors, outline prognostication models and summarize current treatment options, including intensive and less intensive treatment strategies and novel agents.

EXPERT OPINION

Although recent years have seen major advances in the development of low-intensity therapies, there is still a lack of consensus on the optimal treatment for this patient group. Because of the heterogeneity of the disease, personalizing the treatment strategy is important and curative-oriented approaches should be selected wisely, rather than following a rigid hierarchical algorithm.

Frailty and Cancer: Current Perspectives on Assessment and Monitoring

Frailty, an age-related condition of increased vulnerability to acute endogenous or exogenous stressors, is a key barrier to successful treatment of cancer in older people. In this group of patients, assessment of frailty is required before starting a new treatment. According to guidelines, the gold standard to assess frailty in older adults with cancer is geriatric screening followed by geriatric assessment (GA) across essential GA-domains (social status, physical function, nutrition, cognition, emotion, co-morbidity, polypharmacy). GA enables tailoring of both oncological therapy and non-oncological interventions to the patient's vulnerabilities. Large clinical trials recently have demonstrated that the feasibility and tolerability of systemic cancer treatment in older patients are significantly improved by such GA-guided management. Indications and optimal tools for frailty monitoring during the course of cancer treatment have not yet been defined in greater detail. New technologies such as wearable sensors or apps offer promising new opportunities to further develop frailty monitoring. This review describes the current standards and perspectives for the assessment and monitoring of frailty in elderly patients with cancer.

Enhanced Recovery Stem-Cell Transplantation: Multidisciplinary Efforts to Improve Outcomes in Older Adults Undergoing Hematopoietic Stem-Cell Transplant

PURPOSE

Older adults have unique risk factors for poor outcomes after hematopoietic stem-cell transplant (HSCT). We sought to determine the impact of our multidisciplinary supportive care program, Enhanced Recovery after stem-cell transplant (ER-SCT), on survival outcomes in patients age 65 years and older who underwent HSCT.

PATIENTS AND METHODS

In this retrospective study, clinicodemographic data, nonrelapse mortality (NRM), overall survival (OS), and relapse were compared between 64 patients age 65 years and older who underwent allogeneic stem-cell transplant during ER-SCT program's first year, October 2017 through September 2018, and 140 historical controls age 65 years and older who underwent allogeneic HSCT, January 2015 through September 2017.

RESULTS

In the ER-SCT cohort, 41% (26 of 64) of patients were women, and the median (range) age was 68 (65-74) years; in the control cohort, 38% (53 of 140) of patients were women, and the median (range) age was 67 (65-79) years. Hematopoietic cell transplant comorbidity index and donor type/cell source were similar between cohorts. The ER-SCT cohort had a lower 1-year NRM rate (13% v 26%, P = .03) and higher 1-year OS rate (74% v 53%, P = .007). Relapse rate did not differ significantly between cohorts. In multivariate analyses, ER-SCT was associated with improved 1-year NRM (hazard ratio, 0.4; 95% CI, 0.2 to 0.9; P = .02) and improved 1-year OS (hazard ratio, 0.5; 95% CI, 0.3 to 0.9; P = .03).

CONCLUSION

A multidisciplinary supportive care program may improve NRM and OS in older patients undergoing allogeneic HSCT. Randomized studies are warranted to confirm this benefit and explore which program components most contribute to the improved outcomes.

Multidimensional Oncological Frailty Scale (MOFS): A New Quick-To-Use Tool for Detecting Frailty and Stratifying Risk in Older Patients with Cancer-Development and Validation Pilot Study

BACKGROUND

Frailty detection with comprehensive geriatric assessment (CGA) is of pivotal importance in older patients with cancer to avoid over- or under-treatment and to detect those at increased risk for poor outcomes. Several tools have been developed to capture the complexity of frailty, but only a few were explicitly conceived for older adults with cancer. The study aimed at developing and validating a multidimensional, easy-to-use diagnostic tool for early-risk stratification in patients with cancer, called the Multidimensional Oncological Frailty Scale (MOFS).

METHODS

In this single-center prospective study, we consecutively enrolled 163 older women (age ≥ 75 years) with breast cancer, screened with a G8 score ≤ 14 during the outpatient preoperative evaluation at our breast centre, as the development cohort. Seventy patients with different types of cancer admitted to our OncoGeriatric Clinic served as the validation cohort. Using stepwise linear regression analysis, we evaluated the relationship between Multidimensional Prognostic Index (MPI) and CGA items, and, finally, realized a screening tool based on the combination of the significant variables.

RESULTS

The mean age of the study population was 80.4 ± 5.8 years, while the mean age of the validation cohort was 78.6 ± 6.6 years [42 women (60%)]. A composite model of the Clinical Frailty Scale, G8, and hand grip strength test showed a strong correlation with MPI (R= -0.712, p < 0.001). The MOFS accuracy in the prediction of mortality was optimal in both the development and the validation cohorts (AUC 0.82 and 0.87; p < 0.001 and 0.003, respectively).

CONCLUSION

MOFS represents a new, accurate, quick-to-use frailty screening tool for stratifying the risk of mortality in geriatric cancer patients.

Survival in Elderly Patients Diagnosed With Acute Myeloid Leukemia: A Hospital-Based Study

Background

Acute myeloid leukemia (AML) is a hematological neoplasm that is more frequent in elderly patients. The objective of this study was to evaluate elderly patients' survival with de novo AML and acute myeloid leukemia myelodysplasia-related (AML-MR), treated with intensive and less-intensive chemotherapy and supportive care.

Methods

A retrospective cohort study was conducted in Fundacion Valle del Lili (Cali, Colombia), between 2013 and 2019. We included patients ≥ 60 years old diagnosed with AML. The statistical analysis considered the leukemia type (de novo vs. myelodysplasia-related) and treatment (intensive chemotherapy regimen, less-intensive chemotherapy regimen, and without chemotherapy). Survival analysis was performed using Kaplan-Meier method and Cox regression models.

Results

A total of 53 patients were included (31 de novo and 22 AML-MR). Intensive chemotherapy regimens were more frequent in patients with de novo leukemia (54.8%), and 77.3% of patients with AML-MR received less-intensive regimens. Survival was higher in the chemotherapy group (P = 0.006), but with no difference between chemotherapy modalities. Additionally, patients without chemotherapy were 10 times more likely to die than those who received any regimen, independent of age, sex, Eastern Cooperative Oncology performance status, and Charlson comorbidity index (adjusted hazard ratio (HR) = 11.6, 95% confidence interval (CI) 3.47 - 38.8).

Conclusions

Elderly patients with AML had longer survival time when receiving chemotherapy, regardless of the type of regimen.

Integrating Geriatric Assessment Measures into National Cancer Institute Clinical Trials

To improve the care of older adults with cancer, the traditional approach to clinical trial design needs to be reconsidered. Older adults are underrepresented in clinical trials with limited or no information on geriatric-specific factors, such as cognition or comorbidities. To address this knowledge gap and increase relevance of therapeutic clinical trial results to the real-life population, integration of aspects relevant to older adults is needed in oncology clinical trials. Geriatric assessment (GA) is a multidimensional tool comprising validated measures assessing specific health domains that are more frequently affected in older adults, including aspects related to physical function, comorbidity, medication use (polypharmacy), cognitive and psychological status, social support, and nutritional status. There are several mechanisms for incorporating either the full GA or specific GA measures into oncology therapeutic clinical trials to contribute to the overarching goal of the trial. Mechanisms include utilizing GA measures to better characterize the trial population, define trial eligibility, allocate treatment receipt within the context of the trial, develop predictive models for treatment outcomes, guide supportive care strategies, personalize care delivery, and assess longitudinal changes in GA domains. The objective of this manuscript is to review how GA measures can contribute to the overall goal of a clinical trial, to provide a framework to guide the selection and integration of GA measures into clinical trial design, and ultimately enable accrual of older adults to clinical trials by facilitating the design of trials tailored to older adults treated in clinical practice.

How Have Targeted Agents Changed the Treatment Landscape for Elderly Patients with CLL?

PURPOSE OF REVIEW

Chronic lymphocytic leukemia (CLL) is a common hematologic malignancy in elderly patients. At the time of diagnosis, most patients have comorbid medical conditions. Although patients have other competing medical issues, the majority of patients will die from CLL or CLL-related complications. This review will discuss treatment in elderly patients with CLL.

RECENT FINDINGS

Recent work has focused on understanding the role comorbid medical conditions play in the management of CLL in elderly patients, including the use of geriatric assessment, Charlson comorbidity index, cumulative illness rating scale, and most recently, the CLL-comorbidity index. The treatment landscape for CLL has shifted from chemoimmunotherapy to the use of targeted agents. Several clinical trials in elderly patients have demonstrated improvement in progression-free survival (PFS) with ibrutinib + / - obinutuzumab, acalabrutinib + / - obinutuzumab, zanubrutinib, venetoclax-obinutuzumab, idelalisib, and duvelisib. The adverse event profile and potential for drug-drug interactions in the treatment of CLL in elderly patients have not been described, and further studies are needed to determine optimal treatment. Treatment of elderly patients with CLL should be made on a case-by-case basis based on a patient's fitness, comorbid medical conditions, and concomitant medications. The use of targeted agents has improved outcomes in this patient population, but further studies are needed to determine the best practice.

Influence of nutritional support on tolerability and results of treatment in patients with newly diagnosed hemoblastoses received program chemotherapy

Background. Nutritional deficiency in malignant hematological diseases is a common condition that contributes to a decrease in functionality, tolerability of anticancer treatment and patient quality of life, and an increase in mortality rates. Often, malnutrition develops even before the start of anticancer treatment or during therapy and often remains unrecognized up to pronounced stages. despite the obvious importance of assessing and correcting the nutritional status in patients with hematological malignancies, this problem remains poorly understood.Aim. To evaluate the effect of nutritional support on the tolerability and results of treatment in patients with hemoblastoses.Materials and methods. The study included 40 patients with newly diagnosed hemoblastoses with nutritional deficiency or at risk of its development, who received program chemotherapy. patients were randomized into 2 comparable groups: in the main group (n = 20) patients received 2–3 bottles of Nutridrink compact protein mixture per day for 30 days, in the control group (n = 20) they ate at their own discretion without the use of additional enteral nutrition.Results. Comparative results of laboratory monitoring showed a significant increase in albumin levels in the main group compared with the control group (p <0.01). In the main group, less severe gastrointestinal toxicity of systemic anticancer therapy was observed: a tendency to a lower incidence of diarrhea and mucositis, a statistically significant reduction in the frequency of constipation, and a significant 2.8-fold decrease in the frequency of taste changes (25 % versus 70 %). Assessment of hematological toxicity showed that pancytopenia persisted in the control group (decrease in leukocytes, erythrocytes, hemoglobin, hematocrit and platelets levels), which was absent in the main group; leukocytes, hemoglobin, hematocrit, platelets and eosinophils were statistically significantly lower compared to the main group.Conclusion. The use of the Nutridrink compact protein mixture within 30 days from the start of treatment in patients with newly diagnosed hemablastoses contributed to an increase in albumin level, and reduced the incidence of gastrointestinal and hematological toxicity during systemic antitumor therapy.

The Therapeutic Potential of the Endocannabinoid System in Age-Related Diseases

The endocannabinoid system (ECS) dynamically regulates many aspects of mammalian physiology. ECS has gained substantial interest since growing evidence suggests that it also plays a major role in several pathophysiological conditions due to its ability to modulate various underlying mechanisms. Furthermore, cannabinoids, as components of the cannabinoid system (CS), have proven beneficial effects such as anti-inflammatory, immunomodulatory, neuromodulatory, antioxidative, and cardioprotective effects. In this comprehensive review, we aimed to describe the complex interaction between CS and most common age-related diseases such as neuro-degenerative, oncological, skeletal, and cardiovascular disorders, together with the potential of various cannabinoids to ameliorate the progression of these disorders. Since chronic inflammation is postulated as the pillar of all the above-mentioned medical conditions, we also discuss in this paper the potential of CS to ameliorate aging-associated immune system dysregulation.

Peripheral blood CD3+ T-cell gene expression biomarkers correlate with clinical frailty in patients with haematological malignancies

Older patients with cancer often receive treatment regimens based on their age without considering other objective factors that may influence outcomes. Assessment of frailty can identify older patients who are robust and therefore more likely to benefit from intensive treatment, or conversely, frail and might instead be offered alternative approaches. However, such assessment requires specialised training and dedicated clinical resources. Alternative quantitative biomarkers associated with frailty are lacking. Here, we asked if expression signatures of 74 immune cell, ageing, and senescence-related messenger RNAs in purified peripheral blood T cells could identify associations with clinical frailty in patients with haematological malignancies. We studied 69 patients between the ages of 36 and 92 years (median 76 years) with leukaemia, lymphoma, or multiple myeloma, across two institutions. Expression of four genes (aryl hydrocarbon receptor [AHR], CD27, CD28, and interleukin-2 receptor subunit alpha [IL2RA; CD25]) in T cells was associated with frailty, independent of age. An expression-based regression model had 76% sensitivity and 90% specificity to assign a patient as robust. These data identify measurable peripheral blood correlates of clinical frailty and suggest biomarkers for future prospective assessment.

Transplant-ineligible but chimeric antigen receptor T-cells eligible: a real and relevant population

Autologous stem cell transplantation (ASCT) and chimeric antigen receptor (CAR) T-cells are two therapeutic options for relapsed/refractory diffuse large B-cell lymphoma. Both are intensive and potentially curative therapies but differ in their efficacy and toxicity. ASCT may be offered to 'fit' patients (i.e. usually young with limited comorbidities) with chemosensitive disease. On the other hand, real world studies have shown that CAR T-cells may be safely administered to less fit and older patients. Thus, there is a potentially significant population of patients who may be offered CAR T-cell therapy despite not being eligible for ASCT. As the relative role of ASCT and CAR T-cells evolves, recognising and defining this population may be increasingly relevant. Here, we review criteria which may help identify this 'ASCT-ineligible but CAR T-cells eligible' population of patients.

Association of Polypharmacy and Potentially Inappropriate Medications With Frailty Among Older Adults With Blood Cancers

BACKGROUND

Polypharmacy and potentially inappropriate medications (PIMs) are common among older adults with blood cancers, but their association with frailty and how to manage them optimally remain unclear.

PATIENTS AND METHODS

From 2015 to 2019, patients aged ≥75 years presenting for initial oncology consult underwent screening geriatric assessment. Patients were determined to be robust, prefrail, or frail via deficit accumulation and phenotypic approaches. We quantified each patient's total number of medications and PIMs using the Anticholinergic Risk Scale (ARS) and a scale we generated using the NCCN Medications of Concern called the Geriatric Oncology Potentially Inappropriate Medications (GO-PIM) scale. We assessed cross-sectional associations of PIMs with frailty in multivariable regression models adjusting for age, gender, and comorbidity.

RESULTS

Of 785 patients assessed, 603 (77%) were taking ≥5 medications and 421 (54%) were taking ≥8 medications; 201 (25%) were taking at least 1 PIM based on the ARS and 343 (44%) at least 1 PIM based on the GO-PIM scale. Among the 468 (60%) patients on active cancer treatment, taking ≥8 medications was associated with frailty (adjusted odds ratio [aOR], 2.82; 95% CI, 1.92-4.17). With each additional medication, the odds of being prefrail or frail increased 8% (aOR, 1.08; 95% CI, 1.04-1.12). With each 1-point increase on the ARS, the odds of being prefrail or frail increased 19% (aOR, 1.19; 95% CI, 1.03-1.39); with each additional PIM based on the GO-PIM scale, the odds increased 65% (aOR, 1.65; 95% CI, 1.34-2.04).

CONCLUSIONS

Polypharmacy and PIMs are prevalent among older patients with blood cancers; taking ≥8 medications is strongly associated with frailty. These data suggest careful medication reconciliation for this population may be helpful, and deprescribing when possible is high-yield, especially for PIMs on the GO-PIM scale.

Association Between Geriatric Assessment and Post-Chemotherapy Functional Status in Older Patients with Cancer

BACKGROUND

Maintaining functional status is among the most important patient-centered outcomes for older adults with cancer. This study investigated the association between comprehensive geriatric assessment (CGA) and progressive disease or decline of IADL-independence 1 year after chemotherapy, overall survival (OS), and premature termination of chemotherapy. CGA-based functional status and quality of life (QOL) 1 year after chemotherapy are also described.

METHODS

This prospective cohort study involved patients aged ≥65 years treated with chemotherapy for any cancer type. CGA and the G8-screening tool were performed before and after the completion of chemotherapy. Analyses were adjusted for tumor type and treatment intent: (a) indolent hematological malignancies, (b) aggressive hematological malignancies, c) solid malignancies treated with curative intent, and (d) solid malignancies treated with palliative intent.

RESULTS

All 291 included patients lived in The Netherlands; 193 (67.4%) lived fully independent prior to chemotherapy. The median age was 72 years; 164 (56.4%) were male. IADL independence, CGA-based functional status, and QOL were maintained in half of the patients 1 year after chemotherapy. An abnormal G8-score before chemotherapy was a higher risk for progressive disease or a decline of IADL-independence (OR 3.60, 95% CI, 1.98-6.54, P < .0001), prematurely terminated chemotherapy (OR 2.12, 95% CI, 1.24-3.65, P = .006), and shorter median OS (HR 1.71, 95% CI, 1.16-2.52, P = .007). The impact of an abnormal G8-score differed across tumor type (oncological or hematological) and treatment indication (adjuvant or palliative).

CONCLUSION

An abnormal G8 score before chemotherapy is associated with progressive disease and functional decline after chemotherapy and shorter median OS, especially in patients with solid malignancies.

A Multicenter Study of 239 Patients Aged Over 70 Years With Diffuse Large B-Cell Lymphoma in China

Background: Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive lymphoma subtype worldwide and occurs frequently in the elderly population. However, there are limited data on the clinical profiles of patients with DLBCL over 70 years of age. Our objective was to summarize the clinical characteristics, treatment strategies and survival outcomes of this population in China.

Methods: This multicenter retrospective study was conducted in China from January 2012 to July 2020 to investigate the clinical characteristics and survival outcomes. A total of 239 patients with DLBCL aged over 70 years underwent pretreatment evaluations, treatment, and follow-up at local hospitals. The primary endpoints were the progression-free survival (PFS) and the overall survival (OS) rates at 2 years. Secondary endpoints included median PFS and OS, the estimated PFS and OS rates at 5 years, and adverse events during treatment.

Results: With a median follow-up of 50 months (range, 1–102 months), the 2-year PFS and OS rates were 53.0% and 65.5%, respectively. The median PFS and OS were 42.1 and 96.4 months, respectively; and the estimated 5-year PFS and OS rates were 44.7% and 56.1%, respectively. Hematological toxicities were the most common adverse effects in this study, accounting for 90.4%; and leukopenia was the most frequently observed ≥ grade 3 event. Furthermore, we found that regimens without rituximab and chemotherapy cycles < 6 were significantly associated with worse survival. Additionally, in the 70–80-year group, reduction in chemotherapy dose was associated with a significantly shorter OS, with a 2-year OS rate of 74.4% in the full dose group, compared to 67.1% for the decreased-dose group (p = 0.044).

Conclusion: Our study presents the clinical profiles and survival outcomes of elderly patients with DLBCL in China. Treatment of these patients requires careful evaluation of toxicities and benefits. To this end, a prognosis model, such as comprehensive geriatric assessment, is required in clinical practice to optimally manage elderly patients with DLBCL.

SOHO State of the Art Updates and Next Questions: Treatment of Older, Vulnerable Adults with Multiple Myeloma

Multiple myeloma is primarily a disease of the elderly, and optimal treatments must weigh the risks of toxicity with the benefits of therapy.  Frailty scales have been developed to aid treatment-decision making for older adults with MM.   This review provides a framework for incorporating frailty scales into clinical care and highlights how patient-aligned priorities for care can influence the management of older or more vulnerable adults with newly diagnosed multiple myeloma newly diagnosed multiple myeloma. We review the currently available systemic therapies for managing older or more vulnerable adults with newly diagnosed multiple myeloma otherwise considered ineligible for autologous stem cell transplantation.

Assessing frailty using comprehensive geriatric assessment in older patients with hematologic malignancy

The incidence of hematologic malignancy increases with age; thus, the number of older patients who require intensive chemotherapy is expected to increase with the aging population. In Korea, 61.8%, 59.3%, 47.0%, and 46.7% of newly diagnosed cases of multiple myeloma, myelodysplastic syndrome, myeloproliferative disorder, and non-Hodgkin lymphoma, respectively, occurred in patients aged >65 years in 2018. Health status among older patients, defined by frailty, age-related syndrome of physiological decline and increased vulnerability, is associated with adverse health outcomes. Health status is highly heterogeneous among older patients, and treatment outcomes vary according to frailty and physiologic age rather than chronologic age. Comprehensive geriatric assessment (CGA) is a multidimensional and multidisciplinary diagnostic and treatment process that identifies multiple domains, including functional status, cognition, comorbidities, medications, socioeconomic status, and nutritional status, to develop a coordinated plan to improve treatment-related outcomes and quality of life. Frailty can be assessed with CGA findings, and CGA is considered the "gold standard of care" for frail, older patients. Through CGA, unidentified problems can be assessed, and pre-emptive and non-oncologic interventions can be delivered. CGA is an objective and reliable tool for predicting further treatment-related complications and identifying patients for whom intensive chemotherapy with curative intent is appropriate. CGA should be considered a routine practice before starting treatment planning in older patients diagnosed with hematologic malignancies who require intensive chemotherapy. Further study is needed to allocate individualized treatment plans or multidisciplinary geriatric interventions according to CGA results.

Geriatric assessment for older adults receiving less intensive therapy for acute myeloid leukemia: Report of CALGB 361101

Baseline geriatric assessment measures are associated with survival among older AML patients treated with nonintensive chemotherapy.

Baseline global quality of life is associated with survival among older AML patients treated with nonintensive chemotherapy.

Geriatric assessment (GA) predicts survival among older adults with acute myeloid leukemia (AML) treated intensively. We evaluated the predictive utility of GA among older adults treated with low-intensity therapy on a multisite trial. We conducted a companion study (CALGB 361101) to a randomized phase 2 trial (CALGB 11002) of adults ≥60 years and considered “unfit” for intensive therapy, testing the efficacy of adding bortezomib to decitabine therapy. On 361101, GA and quality of life (QOL) assessment was administered prior to treatment and every other subsequent cycle. Relationships between baseline GA and QOL measures with survival were evaluated using Kaplan-Meier estimation and Cox proportional hazards models. One-hundred sixty-five patients enrolled in CALGB 11002, and 96 (52%) of them also enrolled in 361101 (median age, 73.9 years). Among participants, 85.4% completed ≥1 baseline assessment. In multivariate analyses, greater comorbidity (hematopoietic cell transplantation-specific comorbidity index >3), worse cognition (Blessed Orientation-Memory-Concentration score >4), and lower European Organization for Research and Treatment of Cancer global QOL scores at baseline were significantly associated with shorter overall survival (P < .05 each) after adjustment for Karnofsky Performance Status, age, and treatment arm. Dependence in instrumental activities of daily living and cognitive impairment were associated with 6-month mortality (hazard ratio [HR], 3.5; confidence interval [CI], 1.2-10.4; and HR, 3.1; CI, 1.1-8.6, respectively). GA measures evaluating comorbidity, cognition, and self-reported function were associated with survival and represent candidate measures for screening older adults planned to receive lower-intensity AML therapies. This trial was registered at www.clinicaltrials.gov as #NCT01420926 (CALGB 11002).

Geriatric assessment predicts non-fatal toxicities and survival for intensively treated older adults with AML

Given a few prospective studies with conflicting results, we investigated the prognostic value of multi-parameter geriatric assessment (GA) domains on tolerance and outcomes after intensive chemotherapy in older adults with acute myeloid leukemia (AML). Newly diagnosed AML aged over 60 years who received intensive chemotherapy consisting of cytarabine and idarubicin (n=105) were enrolled prospectively. Pretreatment GA included evaluations for social and nutritional support, cognition, depression, distress, and physical function. The median age was 64 years (range, 60-75), and 93% had an Eastern Cooperative Oncology Group score <2. Between 32.4% and 69.5% of patients met the criteria for impairment for each domain of GA. Physical impairment by the Short Physical Performance Battery (SPPB) and cognitive dysfunction by the Mini-Mental State Examination in the Korean version of the CERAD Assessment Packet (MMSE-KC) were significantly associated with non-fatal toxicities, including grade III-IV infections (SPPB, P=0.024; MMSE-KC, P=0.044), acute renal failure (SPPB, P=0.013), and/or prolonged hospitalization (³40 days) during induction chemotherapy (MMSE-KC, P=0.005). Reduced physical function by SPPB and depressive symptoms by the Korean version of the short form of geriatric depression scales (SGDS-K) were significantly associated with inferior survival (SPPB, P=0.027; SGDS-K, P=0.048). Gait speed or sit-and-stand speed was the single powerful tool to predict survival outcomes. Notably, the addition of SPPB and SGDS-K, gait speed and SGDS-K, or sit-and-stand speed and SGDS-K significantly improved the power of existing survival prediction models. In conclusion, GA improved risk stratification for treatment decisions and may inform interventions to improve outcomes for older adults with AML. This study was registered at the Clinical Research Information Service (KCT0002172).

Treatment of older adult or frail patients with multiple myeloma

Older adults with multiple myeloma (MM) are a growing population, and personalizing treatment based on disease and health status is imperative. Similar to MM staging systems that provide disease-related prognostic information, myeloma-specific frailty tools can better identify subgroups at greatest risk for treatment-related toxicity and early treatment discontinuation, as well as predict overall survival. Several myeloma-specific validated tools are well studied. Although these fitness/frailty scores have shaped our understanding of the heterogeneity among older adults with myeloma, the application of such scores in treatment decision making (ie, transplant considerations, relapse) is an unmet need. Here we outline how to incorporate frailty assessments in the evaluation of older adults with MM in the clinical setting with consideration of other factors such as patient preferences, treatment risks/benefits, life expectancy, and disease biology.

A simplified frailty score predicts survival and can aid treatment-intensity decisions in older patients with DLBCL

A simplified frailty score predicts survival and toxicity in older patients with DLBCL and can inform treatment-intensity decisions.

Full-dose R-CHOP is not superior to R-miniCHOP in older unfit DLBCL patients, whereas older fit patients likely benefit from full-dose R-CHOP.

Patients with diffuse large B-cell lymphoma (DLBCL) have a median age of 70 years. Yet, empirical knowledge about the treatment of older patients is limited because they are frequently excluded from clinical trials. We aimed to construct a simplified frailty score and examine survival and treatment-related mortality (TRM) according to frailty status and treatment intensity in an older real-world population with DLBCL. All patients aged ≥70 years diagnosed with DLBCL between 2006 and 2016 in southeastern Norway (N = 784) were included retrospectively and divided into training (n = 522) and validation (n = 262) cohorts. We constructed and validated a frailty score based on geriatric assessment variables and examined survival and TRM according to frailty status and treatment. The frailty score identified 3 frailty groups with distinct survival and TRM, independent of established prognostic factors (2-year overall survival [OS]: fit, 82%; unfit, 47%; frail, 14%; P < .001). For fit patients, full-dose R-CHOP (initial dosage >80%) was associated with better survival than attenuated R-CHOP ([R-miniCHOP]; 2-year OS: 86% vs 70%; P = .012), also in adjusted analyses. For unfit and frail patients, full-dose R-CHOP was not superior to R-miniCHOP, whereas an anthracycline-free regimen was associated with poorer survival in adjusted analyses. A simplified frailty score identified unfit and frail patients with a higher risk for death and TRM, which can aid treatment-intensity decisions in older patients with DLBCL. In this study, fit patients benefited from full-dose R-CHOP, whereas unfit and frail patients had no benefit from full-dose R-CHOP over R-miniCHOP. An online calculator for assessment of the frailty score is available at https://wide.shinyapps.io/app-frailty/.

A Wearable Walking Gait Speed-Sensing Device using Frequency Bifurcations of Multi-Resonator Inductive Link

This paper describes a wearable inductive sensing system to monitor (i.e., sense and estimate) walking gait speed. This proposed design relies on the multi-resonance inductive link to quantify the angle of the human legs for calculating the speed of walking. The walking gait speed can be used to estimate the frailty in elderly patients with cancer. We have designed, optimized, and implemented a multi-resonator sensor unit to precisely measure the angle between human legs during walking. The couplings between resonators change by lateral displacements due to walking, and a reading coil senses the frequency bifurcations, corresponding to the changes in angle between legs. The proposed design is optimized using ANSYS HFSS and implemented using copper foil. The Specific Absorption Rate, SAR, in the human body is calculated 0.035 W/kg using the developed HFSS model. The operating frequency range of the proposed sensor is from 25 MHz to 46 MHz, and it can measure angles up to 90° (-45° to +45°). The measured resolution for estimating the angle shows the capability of the sensor for calculating the walking speed with a resolution of less than 0.1 m/s.

The beginning of a new therapeutic era in acute myeloid leukemia

In the field of AML, the early 2000s were shaped by the advent of novel molecular biology technologies including high-throughput sequencing that improved prognostic classification, response evaluation through the quantification of minimal residual disease, and the launch of research on targeted therapies. Our knowledge of leukemogenesis, AML genetic diversity, gene-gene interactions, clonal evolution, and treatment response assessment has also greatly improved. New classifications based on chromosomal abnormalities and gene mutations are now integrated on a routine basis. These considerable efforts contributed to the discovery and development of promising drugs which specifically target gene mutations, apoptotic pathways and cell surface antigens as well as reformulate classical cytotoxic agents. In less than 2 years, nine novels drugs have been approved for the treatment of AML patients, and many others are being intensively investigated, in particular immune therapies. There are now numerous clinical research opportunities offered to clinicians, thanks to these new treatment options. We are only at the start of a new era which should see major disruptions in the way we understand, treat, and monitor patients with AML.

Multicenter analysis of geriatric fitness and real-world outcomes in older patients with classical Hodgkin lymphoma

We performed a multicenter retrospective analysis across 10 US academic medical centers to evaluate treatment patterns and outcomes in patients age ≥60 years with classic Hodgkin lymphoma (cHL) from 2010-2018. Among 244 eligible patients, median age was 68, 63% had advanced stage (III/IV), 96% had Eastern Cooperative Oncology Group performance status (PS) 0-2, and 12% had documented loss of ≥1 activity of daily living (ADL). Medical comorbidities were assessed by the Cumulative Illness Rating Scale-Geriatric (CIRS-G), where n = 44 (18%) had total scores ≥10. Using multivariable Cox models, only ADL loss predicted shorter progression-free (PFS; hazard ratio [HR] 2.13, P = .007) and overall survival (OS; HR 2.52, P = .02). Most patients (n = 203, 83%) received conventional chemotherapy regimens, including doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD; 56%), AVD (14%), and AVD with brentuximab vedotin (BV; 9%). Compared to alternative therapies, conventional regimens significantly improved PFS (HR 0.46, P = .0007) and OS (HR 0.31, P = .0003). Survival was similar following conventional chemotherapy in those ages 60-69 vs ≥70: PFS HR 0.88, P = .63; OS HR 0.73, P = .55. Early treatment discontinuation due to toxicity was more common with CIRS-G ≥10 (28% vs 12%, P = .016) or documented geriatric syndrome (28% vs 13%, P = .02). A competing risk analysis demonstrated improved disease-related survival with conventional therapy (HR 0.29, P = .02) and higher mortality from causes other than disease or treatment with high CIRS-G or geriatric syndromes. This study suggests conventional chemotherapy regimens remain a standard of care in fit older patients with cHL, and highlights the importance of geriatric assessments in defining fitness for cHL therapy going forward.

Advances in treatment of elderly primary central nervous system lymphoma

The management of older individuals (≥60 years) with primary central nervous system lymphoma remains a clinical challenge. Identification of optimal therapy and delivering adequate dose intensity are two of the major issues in treating elderly patients. Premorbid performance status and comorbidities influence individualised treatment approaches and geriatric assessment tools are increasingly utilised. Optimal induction treatment remains high-dose methotrexate-based immunochemotherapy, delivery is feasible in the majority of patients and the goal of treatment remains achieving complete remission. Consolidation strategies are also relevant in the elderly, aiming to maximise duration of response and quality of life (QoL). Potential options include high-dose therapy with haematopoietic stem cell consolidation, non-myeloablative chemotherapy and whole-brain radiotherapy. Efficacy of novel agents, such as Bruton tyrosine kinase inhibitors and lenalidomide, have been reported; these represent an alternative for elderly patients unfit for chemotherapy. Prognosis remains poor, improvement of outcomes in this age group is urgently needed.

The Care of the Leukemic Patients in Times of SARS-CoV-2

PURPOSE OF REVIEW

The spread of the novel coronavirus SARS-CoV-2 and its associated disease, coronavirus disease of 2019 (COVID-19), has significantly derailed cancer care. Patients with leukemia are more likely to have severe infection and increased rates of mortality. There is paucity of information on how to modify care of leukemia patients in view of the COVID-19 risks and imposed restrictions. We review the available literature on the impact of COVID-19 on different types of leukemia patients and suggest general as well as disease-specific recommendations on care based on available evidence.

RECENT FINDINGS

The COVID-19 infection impacts leukemia subtypes in variable ways and the standard treatments for leukemia have similarly, varying effects on the course of COVID-19 infection. Useful treatment strategies include deferring treatment when possible, use of less intensive regimens, outpatient targeted oral agents requiring minimal monitoring, and prioritization of curative or life-prolonging strategies. Reducing health care encounters, rational transfusion standards, just resource allocation, and pre-emptive advance care planning will serve the interests of leukemia patients. Ad hoc modifications based on expert opinions and extrapolations of previous well-designed studies are the way forward to navigate the crisis. This should be supplanted with more rigorous prospective evidence.

Outcomes of Second Allogeneic Hematopoietic Cell Transplantation for Patients With Acute Myeloid Leukemia

Relapse after allogeneic hematopoietic cell transplantation (HCT) leads to poor survival in patients with acute myeloid leukemia (AML). A second HCT (HCT2) may achieve durable remission. To determine the outcomes of patients who received an HCT2 for relapsed AML and to evaluate the predictors of overall survival (OS) and progression-free survival (PFS). We retrospectively reviewed medical records of adult patients who underwent an HCT2 for relapsed AML at our institution during 2000 to 2019. Ninety-one patients were identified with a median age of 44 years (range 18-73) at HCT2. Donor types were HLA-identical sibling (n = 37 [41%]), HLA-matched-unrelated (n = 34 [37%]), haploidentical (n = 19 [21%]), and cord blood (n=1 [1%]). Donors were different at HCT2 in 53% of patients. The majority of patients received reduced intensity conditioning (n = 71 [78%]) and were in remission (n = 56 [61%]) at HCT2. The median remission duration after HCT1 was 8.4 months (range 1-70) and the median time between transplants was 14 months (range 3-73). The median follow-up of surviving patients after HCT2 was 66 months (range 2-171), with 32% alive at time of analysis. The most common cause of death was disease recurrence (n = 45 [73%]). At 2 years, the rates of OS, PFS, progression, and nonrelapse mortality were 36%, 27%, 42%, and 18%, respectively. The development of chronic graft-versus-host disease (GVHD) after first HCT and HCT comorbidity index (HCT-CI) ≥2 at HCT2 were associated with inferior PFS and OS after HCT2. A second HCT is feasible in selected patients with AML who have relapsed after HCT1. Long-term survival benefit is possible in patients without chronic GVHD after HCT1 and HCT-CI <2 at HCT2.

Prognostic value of disease risk score versus gait speed in older adults with lymphoma

Measures of physical function predict survival in older patients with lymphoma but their prognostic ability has not been compared to disease-specific risk scores. We prospectively recruited patients ≥75 years with lymphoma. Patients underwent a frailty screen including 4-m gait speed. Disease-specific risk scores were obtained retrospectively. Among 168 patients, there was no association between disease-specific risk score and survival. Conversely, faster gait speed was significantly associated with survival in the entire cohort (HR = 0.16; 95%CI, 0.06-0.42; p = 0.0003) indicating a HR of 0.63 for an increase in gait speed of 0.25 m/s. When gait speed was added to the DLBCL IPI and FLIPI separately, it was significantly associated with OS (p = 0.004 for DLBCL, p = 0.03 for FLIPI) which increased its predictive power. Our study of older lymphoma patients demonstrates gait speed may improve outcome prediction beyond standard prognostic scores.

Impact of age, functional status, and comorbidities on quality of life and outcomes in elderly patients with AML: review

The incidence of acute myeloid leukemia increases with age, and more than half of AML patients are over 60 years old. Treating elderly AML patients presents several challenges and uncertainties, linked partly to disease characteristics and partly to the difficulty of establishing which patients could benefit from the best treatment. Although some elderly fit patients can receive intensive therapy, many of them are not treated and not enrolled in clinical trials. Yet supportive care is associated with significantly lower survival rates compared to intensive therapy or lower intensive therapy. A poorer prognosis in elderly patients is related to age, functional status, and comorbidities, combined with leukemia characteristics. Chronological age is not the best surrogate factor for selecting patients eligible for intensive chemotherapy. Scoring systems-including patient characteristics (ECOG, comorbidities) and disease characteristics (cytogenetics and molecular parameters)-designed to evaluate probabilities of response to treatment, morbidity, and survival may be used to balance the risk-benefit ratio for intensive therapy. A geriatric assessment (GA) to evaluate physical function, comorbidities, nutritional status, cognitive function, and social support could help identify the most vulnerable patients so that they can receive intensive therapy. A GA would also help take the necessary steps to improve tolerance to treatment. Evaluating markers of fitness and quality of life as part of clinical trials should be favored.

Conventional chemotherapy for acute myeloid leukemia in older adults: Impact on nutritional, cognitive, and functional status

OBJECTIVES

The impact of conventional treatment for acute myeloid leukemia (AML) on the nutritional, cognitive, and functional status of elderly patients is seldom studied. This assessment was performed in the context of the LAMSA 2007 trial.

METHODS

The trial enrolled 424 patients with de novo AML. Among them, 316 benefited from geriatric assessment (GA) including nutritional, cognitive, and functional status and were scored according to Eastern Cooperative Oncology Group (ECOG) and sorror for the prediction of treatment toxicity, morbidity, and mortality. Patients were investigated at diagnosis for three times during follow-up.

RESULTS

This study showed that AML and its treatment have no impact on cognitive (P = .554) nor functional status (P = .842 for Activity of Daily Living and P = .087 for Instrumental Activities of Daily Living). The nutritional status improved over time (P = .041). None of these three parameters at baseline, associated or not with ECOG and sorror scores, impacted survivals or toxicities.

CONCLUSIONS

The cognitive, functional, and nutritional status had no impact in this cohort of fit elderly AML patients without unfavorable cytogenetics. The GA tools used provided no additional information compared with ECOG and sorror scores, to predict toxicity, morbidity, or mortality due to intensive chemotherapy.

Identifying frailty in clinically fit patients diagnosed with hematological malignancies using a simple clinico-biological screening tool: The HEMA-4 study

INTRODUCTION

This study aims to develop and validate a simple score to estimate survival in the older population suffering from malignant hemopathies.

METHODS

We prospectively recruited 285 patients, aged ≥65 years, admitted to receive chemotherapy. At inclusion, a geriatric assessment was performed. Cox proportional hazards models were performed to assess correlations between vulnerabilities and one-year survival. We developed a frailty score, HEMA-4, based on the most powerful prognostic factors. It was externally confirmed with an independent cohort.

RESULTS

In the development cohort, 206 patients were evaluable. Mean age was 76 years (range 65-90). The HEMA-4 score was created based on four independent predictive factors for survival: cognitive impairment (MMSE<27), comorbidities (≥2 on Charlson comorbidity index), CRP (≥10 mg/L) and low albumin level (<35 g/L). The population was stratified into three groups: good prognosis (score = 0-1, n = 141), intermediate prognosis (score = 2, n = 37) and poor prognosis (score = 3-4, n = 28). Their respective one-year survival was 74%, 51% (HR = 2.30; 95% CI =1.31-4.05; p < 0.01) and 36% (HR = 3.95; 95% CI =2.23-6.98; p < 0.01). In the validation cohort (n = 25), the one-year survival was 78% in the good prognosis group (n = 9) and 50% in the intermediate prognosis group (n = 6). The poor prognosis group had a median survival of four months in the development cohort and six months in the validation cohort (n = 10).

CONCLUSION

The HEMA-4 score is a simple score that combines cognitive impairment, comorbidities, inflammation and low albumin level. Our data suggest that it predicts survival among older patients suffering from malignant hemopathies referred to receive chemotherapy regardless of their chronological age.