The elderly patient with cancer: A holistic view

Preoperative frailty predicts postoperative falls in older patients with cancer

INTRODUCTION

Patient falls in the hospital lead to adverse outcomes and impaired quality of life. Older adults with cancer who are frail may be at heightened risk of falls in the postoperative period. We sought to evaluate the association between degree of preoperative frailty and risk of inpatient postoperative falls and other outcomes among older adults with cancer.

MATERIALS AND METHODS

We identified 7,661 patients aged 65 years or older who underwent elective cancer surgery from 2014 to 2020, had a hospital stay of ≥1 day, and had Memorial Sloan Kettering-Frailty Index (MSK-FI) data to allow assessment of frailty. Univariable logistic regression analysis was performed to evaluate the association between frailty and falls. Multivariable logistic regression analysis was performed to evaluate the composite outcome of 30-day readmission or 90-day death, with frailty, falls, and the interaction between frailty and falls as predictors; the analysis was adjusted for age, sex, race, and preoperative albumin level.

RESULTS

In total, 7,661 patients were included in the analysis. Seventy-one (0.9%) had a fall, of whom eight (11%) were readmitted to the hospital within 30 days and seven (10%) died within 90 days. Higher MSK-FI score was associated with higher risk of falls (odds ratio [OR], 1.40 [95% confidence interval [CI], 1.21-1.59]). The risk of falls for a patient with an MSK-FI score of 1 was 0.6%, compared with 1.7% for a patient with an MSK-FI score of 4. Poor outcome was associated with frailty (OR, 1.07 [95% CI, 1.02-1.13]) but not with falls (OR, 1.17 [95% CI, 0.57-2.22]).

DISCUSSION

Preoperative frailty is associated with risk of inpatient postoperative falls and with other adverse outcomes after surgery among older adults with cancer. Screening for frailty in the preoperative setting would enable healthcare institutions to implement interventions aimed at reducing the incidence of inpatient postoperative falls to reduce fall-related adverse events.

Dose-response relationship of resistance training for muscle morphology and strength in elderly cancer patients: A meta-analysis

Objective

To systematically evaluate the effects of resistance training (RT) on muscle strength and muscle hypertrophy in elderly cancer patients, and to provide dose-response relationships of RT variables that could improve muscle strength and morphology in elderly cancer patients.

Method

The Review Manager 5.3 was applied to analyze the 12 literatures (616 participants) through random or fixed effects model and global effect size to examine upper limb strength, lower extremity strength, and muscle hypertrophy. Sub-group analysis was made on five variables: the total number of repeated training times/week, load intensity, exercise frequency/week, exercise duration and gender. This study also examines the heterogeneity and publication bias.

Results

Twelve literatures (616 participants, 60-80 years) were included in meta-analysis. RT significantly increased the upper limb muscular strength (SMD = 0.51, 95% CI: 0.10-0.93; Z = 2.41; p = 0.02) and lower extremity strength (SMD = 0.48, 95% CI: 0.28-0.67; Z = 4.82; p < 0.00001), but had no significant effect on muscle morphology(SMD = 0.21, 95% CI: 0.01-0.42; Z = 1.88; p = 0.06). In subgroup analysis for lower extremity muscle strength in elderly male cancer patients, it was found that male intensity of 70-90%1RM, volume of 400-500 times per week, frequencies of 3 times per week, and session of 12-24 weeks, revealed the greatest effect. Funnel plot of the three studies shows that the results were reliable, and no publication bias was found.

Conclusion

RT had medium effects on improving muscle strength in elderly cancer patients, but it is not effective in improving muscle hypertrophy. In addition, when RT is performed, different training protocols can have an effect on the growth of muscle strength. Therefore, a lower extremity training protocol with a training intensity of 70-90% 1RM, a total of 400-500 repetitions per week, 3 times per week, and an exercise session of 12-24 weeks is most effective in improving lower extremity strength in elderly male cancer patients.

The effects of resistance training on muscular strength and hypertrophy in elderly cancer patients: A systematic review and meta-analysis

BACKGROUND

One of the most life-threatening comorbidities in elderly cancer patients is cancer cachexia, which is characterized by the ongoing loss of skeletal muscular strength and mass and is also associated with aging. There is a lack of recommendations for optimal resistance training (RT) for those patients. The purpose of this study was to systematically review and quantify the effects of RT on muscular strength and hypertrophy in elderly cancer patients.

METHODS

Five electronic databases were searched (until January 2020) for studies that met the following criteria: (i) cancer patients aged ≥60 years; (ii) structured and supervised RT intervention for ≥6 weeks; and (iii) measured muscular strength and/or hypertrophy.

RESULTS

Thirteen studies (717 participants, average age = 66 years) met the inclusion criteria. RT significantly increased muscular strength (mean effect size = 0.87, 95% confidence interval (95%CI): 0.43-1.32, p < 0.001) and did not significantly induce muscle hypertrophy (mean effect size = 0.09, 95%CI: -0.14 to 0.31, p = 0.45). In subgroup analyses for muscle strength, higher weekly frequency was significantly associated with larger effect size. Egger's test showed no significant publication bias for the 2 outcomes.

CONCLUSION

The results suggest that RT improves muscular strength but does not significantly induce muscle hypertrophy in elderly cancer patients.

Physical and Mental Health Factors Associated with Poor Nutrition in Elderly Cancer Survivors: Insights from a Nationwide Survey

Elderly cancer survivors (patients with any stage of cancer or a history of cancer) are precious members of our society and they can be easily found in various types of surveys. As is well known, good nutrition is important in elderly people suffering from cancer. Proper nutritional evaluation and intervention not only improves their quality of life but also helps them to receive adequate treatment, thereby prolonging individual survival and reducing social healthcare costs. In this study, we retrieved elderly cancer survivors from national survey data and assessed their nutritional status as good or bad. Then, we described the individual, physical, and mental health factors between people with good and bad nutrition. Physical and psychological variables associated with poor nutritional status were evaluated through regression analysis. We investigated data from the 2017 National Survey of Older Persons, and cancer patients aged 65 years or over were eligible. A total of 360 adults were enrolled and more than half (57.2%, n = 206) were in a poor nutritional status. We applied individual variable-adjusted statistical models and discovered that limited instrumental activities of daily living (IADL) (OR 2.15, 95% CI 1.08–4.28) and poor subjective health status (OR 1.74, 95% CI 1.00–3.02) were significantly associated with poor nutrition on logistic regression. Our research findings suggested that IADL and self-rated health status needed to be addressed in old cancer survivors at nutritional risk. The early recognition and management of nutrition in these populations might help them to live longer and have a better quality of life, eventually reducing socioeconomic burdens.

MRI-Determined Psoas Muscle Fat Infiltration Correlates with Severity of Weight Loss during Cancer Cachexia

PURPOSE

To evaluate the suitability of psoas and erector spinae muscle proton density fat fraction (PDFF) and fat volume as biomarkers for monitoring cachexia severity in an oncological cohort, and to evaluate regional variances in muscle parameters over time.

METHODS

In this prospective study, 58 oncological patients were examined by a 3 T MRI receiving between one and five scans. Muscle volume and PDFF were measured, segmentation masks were divided into proximal, middle and distal muscle section.

RESULTS

A regional variation of fat distribution in erector spinae muscle at baseline was found (p < 0.01). During follow-ups significant relative change of muscle parameters was observed. Relative maximum change of erector spinae muscle showed a significant regional variation. Correlation testing with age as a covariate revealed significant correlations for baseline psoas fat volume (r = -0.55, p < 0.01) and baseline psoas PDFF (r = -0.52, p = 0.02) with maximum BMI change during the course of the disease.

CONCLUSION

In erector spinae muscles, a regional variation of fat distribution at baseline and relative maximum change of muscle parameters was observed. Our results indicate that psoas muscle PDFF and fat volume could serve as MRI-determined biomarkers for early risk stratification and disease monitoring regarding progression and severity of weight loss in cancer cachexia.

Developing Machine Learning Algorithms for the Prediction of Early Death in Elderly Cancer Patients: Usability Study

BACKGROUND

The importance of classifying cancer patients into high- or low-risk groups has led many research teams, from the biomedical and bioinformatics fields, to study the application of machine learning (ML) algorithms. The International Society of Geriatric Oncology recommends the use of the comprehensive geriatric assessment (CGA), a multidisciplinary tool to evaluate health domains, for the follow-up of elderly cancer patients. However, no applications of ML have been proposed using CGA to classify elderly cancer patients.

OBJECTIVE

The aim of this study was to propose and develop predictive models, using ML and CGA, to estimate the risk of early death in elderly cancer patients.

METHODS

The ability of ML algorithms to predict early mortality in a cohort involving 608 elderly cancer patients was evaluated. The CGA was conducted during admission by a multidisciplinary team and included the following questionnaires: mini-mental state examination (MMSE), geriatric depression scale-short form, international physical activity questionnaire-short form, timed up and go, Katz index of independence in activities of daily living, Charlson comorbidity index, Karnofsky performance scale (KPS), polypharmacy, and mini nutritional assessment-short form (MNA-SF). The 10-fold cross-validation algorithm was used to evaluate all possible combinations of these questionnaires to estimate the risk of early death, considered when occurring within 6 months of diagnosis, in a variety of ML classifiers, including Naive Bayes (NB), decision tree algorithm J48 (J48), and multilayer perceptron (MLP). On each fold of evaluation, tiebreaking is handled by choosing the smallest set of questionnaires.

RESULTS

It was possible to select CGA questionnaire subsets with high predictive capacity for early death, which were either statistically similar (NB) or higher (J48 and MLP) when compared with the use of all questionnaires investigated. These results show that CGA questionnaire selection can improve accuracy rates and decrease the time spent to evaluate elderly cancer patients.

CONCLUSIONS

A simplified predictive model aiming to estimate the risk of early death in elderly cancer patients is proposed herein, minimally composed by the MNA-SF and KPS. We strongly recommend that these questionnaires be incorporated into regular geriatric assessment of older patients with cancer.

Factors Influencing Global Health Related Quality of Life in Elderly Cancer Patients: Results of a Secondary Data Analysis

Cancer treatment for elderly patients is often complicated by poor physical condition, impaired functioning and comorbidities. Patient reported health related quality of life (HRQOL) can contribute to decisions about treatment goals and supportive therapy. Knowledge about factors influencing HRQOL is therefore needed for the development of supportive measures and care pathways. An exploratory secondary data analysis on 518 assessments of the European Organisation for Research and Treatment of Cancer (EORTC) core questionnaire (EORTC QLQ-C30) and the elderly module (EORTC QLQ-ELD14) was performed to identify factors predictive for global HRQOL. Preliminary simple and multivariable regression analyses were conducted resulting in a final model comprising sociodemographic and disease specific variables and scales of the QLQ-C30 and QLQ-ELD14. Age, sex and disease related variables explained only part of the variance of global HRQOL (adjusted R2 = 0.203). In the final model (adjusted R2 = 0.504) fatigue, social function, burden of illness and joint stiffness showed possible influence on global HRQOL. Fatigue, social function and burden of illness seem to have the largest impact on global HRQOL of elderly cancer patients. Further prospective studies should examine these domains. Actionable symptoms should be given special attention to initiate targeted supportive measures aiming to maximize HRQOL of older cancer patients.

An analysis of the types of recently published research in the field of cachexia

Introduction Cachexia is a common complication of many and varied chronic disease processes, yet it has received very little attention as an area of clinical research effort until recently. We sought to survey the contemporary literature on published research into cachexia to define where it is being published and the proportion of output classified into the main types of research output. Methods I searched the PubMed listings under the topic research term "cachexia" and related terms for articles published in the calendar years of 2015 and 2016, regardless of language. Searches were conducted and relevant papers extracted by two observers, and disagreements were resolved by consensus. Results There were 954 publications, 370 of which were review articles or commentaries, 254 clinical observations or non-randomised trials, 246 original basic science reports and only 26 were randomised controlled trials. These articles were published in 478 separate journals but with 36% of them being published in a core set of 23 journals. The H-index of these papers was 25 and there were 147 papers with 10 or more citations. Of the top 100 cited papers, 25% were published in five journals. Of the top cited papers, 48% were review articles, 18% were original basic science, and 7% were randomised clinical trials. Discussion This analysis shows a steady but modest increase in publications concerning cachexia with a strong pipeline of basic science research but still a relative lack of randomised clinical trials, with none exceeding 1000 patients. Research in cachexia is still in its infancy, but the solid basic science effort offers hope that translation into randomised controlled clinical trials may eventually lead to effective therapies for this troubling and complex clinical disease process.

Prognostic value of the G8 and modified-G8 screening tools for multidimensional health problems in older patients with cancer

BACKGROUND

The G8 screening tool has been developed to identify older cancer patients requiring a geriatric assessment for tailoring therapy. Little is known about its prognostic value, particularly by tumour site. An optimised version has been recently developed, but no prognostic information is available. We compared the prognostic value of both instruments overall and by tumour site.

METHODS

Data were from a prospective cohort of cancer patients ≥70 years old referred to 1 of 6 French geriatric oncology clinics between 2007 and 2014 (n = 1333). Endpoints were overall 1- and 3-year survival. Cox proportional-hazards models were built to assess the predictive value of abnormal G8 and modified-G8 scores, based on published cut-offs or by classes of increasing risk. Sensitivity analyses involved adjusting for age, gender, treatment, metastasis, and tumour site (digestive, breast, urinary tract, prostate, other solid cancers, and haematological malignancies) and stratifying by tumour site and metastatic status.

RESULTS

Abnormal scores were independently associated with overall 1-year survival: adjusted hazard ratio [aHR] = 4.3[G8]/4.9[modified-G8] and 3-year survival: aHR = 2.9/2.6; all p <0.0001. Associations persisted after stratifying by metastatic status and in most cancer sites (exceptions: colorectal (G8) and upper digestive cancer (both tools) [1-year analysis]; digestive cancers (both tools) [3-year analysis]). For both tools, classes of increasing risk showed a graded relationship with mortality (p < 0.0001).

CONCLUSIONS

Our results identified both abnormal G8 and modified-G8 scores as strong and consistent predictors of overall survival, regardless of metastatic status or tumour site. These findings strengthen the clinical utility of these instruments in the geriatric oncology setting.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Adjuvant chemotherapy in elderly patients with breast cancer: key challenges

Elderly women with early breast cancer (BC) form a heterogeneous and large subgroup (41.8% of women with BC are over 65). Decision making in this subgroup is made more difficult by lack of familiarity with their physical, cognitive and social issues. Adequate management depends on biological factors and accurate clinical evaluation through comprehensive geriatric assessment (CGA). CGA can help to better select and determine potential risks factors for patients who are candidates for adjuvant chemotherapy. It is still recently introduced in geriatric oncology and there is a lack of awareness of its importance. Available data on adjuvant chemotherapy for BC is limited but suggests it can be of benefit for well selected patients, though the risk of short and long-term toxicity is significant. Here we provide a discussion of the key practical issues in decision making in the setting of adjuvant chemotherapy for elderly BC patients.