Advances in the systemic treatment of cancers in the elderly

Feasibility of computer-based self-administered cancer-specific geriatric assessment in older patients with gastrointestinal malignancy

BACKGROUND

The Cancer-Specific Geriatric Assessment (CSGA) is a primarily self-administered paper survey of validated measures.

METHODS

We developed and tested the feasibility of a computer-based CSGA in patients ≥70 years of age who were receiving treatment for gastrointestinal malignancies at the Dana-Farber Cancer Institute. From December 2009 to June 2011, patients were invited to complete the CSGA at baseline (start of new treatment) and follow-up (at the first of 4 months later or within 4 weeks of completing treatment). Feasibility endpoints were proportion of eligible patients consented, proportion completing CSGA at baseline and follow-up, time to complete CSGA, and proportion of physicians reporting CSGA results that led to a change in clinical decision-making.

RESULTS

Of the 49 eligible patients, 38 consented (76% were treatment naive). Median age was 77 years (range: 70-89 years), and 48% were diagnosed with colorectal cancer. Mean physician-rated Karnofsky Performance Status was 87.5 at baseline (SD 8.4) and 83.5 at follow-up (SD 8). At baseline, 92% used a touchscreen computer; 97% completed the CSGA (51% independently). At follow-up, all patients used a touchscreen computer; 71% completed the CSGA (41% independently). Mean time to completion was 23 minutes at baseline (SD 8.4) and 20 minutes at follow-up (SD 5.1). The CSGA added information to clinical assessment for 75% at baseline (n = 27) and 65% at follow-up (n = 17), but it did not alter immediate clinical decision-making.

CONCLUSION

The computer-based CSGA feasibility endpoints were met, although approximately half of patients required assistance. The CSGA added information to clinical assessment but did not affect clinical decision-making, possibly due to limited alternate treatment options in this subset of patients.

Peculiaridades da radioterapia em idosos

É sabido que o envelhecimento da população do mundo durante o século XX e no início deste novo século constitui um desafio de primeira ordem para as nações, especialmente no campo socioeconômico. Um aspecto importante do envelhecimento populacional global é que, para grupos de idade mais avançada, a prevalência das doenças degenerativas também é maior, incluindo as doenças malignas. No universo de pacientes portadores de câncer, por outro lado, metade destes receberá radioterapia em algum momento de sua doença e suas características individuais podem influenciar, de alguma forma, o prognóstico, a indicação e as doses diárias de prescrição dos tratamentos. Neste contexto, a assistência à saúde do idoso portador de câncer deve ser vista como um importante desafio, principalmente devido a dois fatores: uma maior procura de tratamentos, em termos quantitativos, e características fisiológicas peculiares a esta população, que podem influenciar na tomada de decisões terapêuticas. Esta revisão propõe uma discussão sobre alguns aspectos relevantes tanto da fisiologia dos idosos, que pode influenciar o curso do tratamento irradiante, quanto de alguns avanços técnicos da radioterapia, que podem, por sua vez, beneficiar estes pacientes, oferecendo menor toxicidade e maior eficiência e rapidez, por exemplo.

Trends in population-based cancer survival in Germany: to what extent does progress reach older patients?

BACKGROUND

The ageing of populations makes outcome monitoring among elderly cancer patients particularly important.

PATIENTS AND METHODS

Using data from the population-based Cancer Registry of Saarland, we examined age-specific trends in 5-year relative survival from 1979 to 2003 for patients with 15 common cancers in Germany. Model-based period analysis was applied to estimate 5-year relative survival for four age groups (15-54, 55-64, 65-74, 75+) in the periods 1979-1983, 1984-1988, 1989-1993, 1994-1998, and 1999-2003.

RESULTS

Overall, 5-year relative survival improved steadily from 42.2% in 1979-1983 to 56.7% in 1999-2003. From the youngest to the oldest age group, 5-year relative survival increased by 14.5, 12.1, 12.5, and 8.4 percent units, respectively, after adjusting for changes in the spectrum of cancer sites, and survival significantly improved for 10, 12, 11, and 5 cancer sites, respectively. The age gradient particularly increased for cancer sites with major progress in chemotherapeutic treatment regimens, such as ovarian cancer, non-Hodgkin's lymphoma and leukemia.

CONCLUSIONS

Relative survival of cancer patients increased considerably for many forms of cancer in Germany from 1979 to 2003. Increases were much less pronounced among elderly patients, leading to an increasing age gradient in prognosis.

Factors associated with multiple transitions in care during the end of life following enrollment in a comprehensive palliative care program

Background

Patients often experience changes or transitions in where and by whom they are cared for at the end of life. These cause stress for both patients and families. Although not all transitions during the end of life can be avoided, advance identification of those who could potentially experience numerous transitions may allow providers and caregivers to anticipate the problem and consider strategies to minimize their occurrence. This study examines the relationship between patient characteristics and the total number of transitions experienced by the patient from the date of admission to a palliative care program (PCP) to death and during final weeks of life.

Methods

Subjects included all adults registered with the PCP in Halifax, Nova Scotia, Canada between 1998 and 2002 and who had died during that period. Data was extracted from the regional PCP database and linked to census information. Transitions were defined as either: 1) a change in location of where the patient was cared for; or 2) a change in which service (specialist groupings, primary care, etc) provided care. Descriptive statistics were calculated plus rate ratios for the association between patient characteristics and total number of transitions.

Results

In total, 3972 patients made 5903 transitions during the study period. Although 28% experienced no transitions, over 40% experienced one and 6.3% five or more. At least one transition was made by 47% during the last four weeks of life. Adjusted results suggest women, the elderly and more recent death are associated with experiencing fewer transitions. Multiple transitions were associated with a hospital death and a cancer diagnosis. During the last month of life, age was no longer associated with the total number of transitions, cancer patients were found to experience a similar number or fewer transitions than patients with a non-cancer diagnosis and pain and symptom control become a significant factor associated with a greater number of transitions.

Conclusion

Our data suggest there is some variation in the number of transitions associated with the demographics and diagnoses of patients. Associations with gender and age require further exploration as does the contribution of caregiver supports and symptom issues.

Characterization of neutropenic fever in patients receiving first-line adjuvant chemotherapy for epithelial ovarian cancer

OBJECTIVES

Limited information is available on the incidence and characteristics of neutropenic fever (NF) in patients receiving contemporary regimens for epithelial ovarian cancer (EOC). We examined this issue in patients receiving first-line adjuvant chemotherapy with platinum- and paclitaxel-based regimens at a major cancer institute.

METHODS

Charts of patients with EOC at a single institute from 1998 through 2002 were reviewed. Data were collected on the incidence and duration of NF, duration of hospitalization and fever, cultures, antibiotic and chemotherapy regimen, and type of debulking procedure.

RESULTS

140 patients were treated for EOC. 125 patients received first line chemotherapy. 15 episodes of NF were observed. Mean duration of neutropenia and fever was 2.33 and 3.07 days respectively. 9 of 15 (60%) NF episodes occurred after cycle 1. Cultures were positive in 7 of 15 patients (47%). Organisms most frequently recovered were bowel-derived. 8 patients (53%) had bowel resections, and 15 patients (100%) had radical or supraradical procedures. There was a correlation between incidence of NF and type of procedure (P = 0.01) and stage of EOC (P = 0.04). There was no correlation between NF and elderly age, medical comorbidities, and postoperative complications.

CONCLUSIONS

The rate of NF was higher than previously reported. NF occurred most frequently after cycle 1. NF patients were of advanced stage that had undergone more aggressive surgery and had bowel resections. Our data suggest that patients with advanced EOC who undergo more radical procedures should be identified as high risk for developing NF in early cycles.

Criteria for the design and biological characterization of radiolabeled peptide-based pharmaceuticals

Radiolabeled peptide-based formulations are being evaluated for their application in oncological imaging and therapy using nuclear medicine techniques. A major breakthrough in the field was the discovery and identification of the G-protein coupled receptor superfamily that are overexpressed in a variety of human cancers. These receptors act as targets for endogenous compounds, often of peptidic nature, which can be radiolabeled and, therefore, could potentially be utilized as radiopharmaceuticals. This general strategy has proven successful for application in humans in only a few cases thus far. However, the use of more sophisticated structural methodology to enhance our understanding of the interactions between the receptor and the endogenous peptide or its analogs, and a more efficient preclinical evaluation process, may help to single out the most promising compounds for further development and eventual use in the clinical application of radiopharmaceuticals. This review analyzes current methods of approaching these key points. The rational process for developing peptide-based radiopharmaceuticals is presented, from the structural analysis of the peptide-receptor interaction for the identification and modeling of the peptide analogs to the synthesis, with an appropriate metal carrier, of compounds that mimic endogenous peptides. Finally, the in vitro and in vivo biological testing and evaluation in preclinical animal models is described. To render the entire process successful, expertise in different areas of drug development is indispensable.

Comparison of pharmacokinetics and pharmacodynamics of docetaxel and Cisplatin in elderly and non-elderly patients: why is toxicity increased in elderly patients?

PURPOSE

Following phase I studies of docetaxel and cisplatin in patients with non-small-cell lung cancer, the recommended doses of docetaxel were different for elderly (> or = 75 years) and non-elderly (< 75 years) patients. To elucidate the mechanism of the difference, the pharmacokinetics of docetaxel and cisplatin were investigated in two phase II studies separately conducted in elderly and non-elderly patients.

PATIENTS AND METHODS

Twenty-seven elderly and 25 non-elderly patients were treated with three weekly administrations of docetaxel and cisplatin every 4 weeks. Doses of docetaxel were 20 and 35 mg/m(2) for elderly and non-elderly patients, respectively. All patients received 25 mg/m(2) of cisplatin. The pharmacokinetics and pharmacodynamics of docetaxel and cisplatin were compared in elderly and non-elderly patients.

RESULTS

There were no differences in pharmacokinetics of docetaxel or cisplatin between elderly versus non-elderly patients with regard to clearance and volume of distribution. In the pharmacodynamic analysis, neutropenia was positively correlated with the area under the concentration-time curve for docetaxel but not for cisplatin. In evaluating the relationship between neutropenia and the area under the concentration-time curve of docetaxel, elderly patients experienced greater neutropenia than those predicted by a pharmacodynamic model developed in non-elderly patients; the residual for prediction of the percent change in neutrophil count was -11.2% (95% CI, -21.8 to -0.5%).

CONCLUSION

The pharmacokinetics of docetaxel and unchanged cisplatin were not different between elderly and non-elderly patients. The elderly patients were more sensitive to docetaxel exposure than the non-elderly patients, resulting in the different recommended doses for the phase II studies.

Patterns of chemotherapy use for women with ovarian cancer: a population-based study

PURPOSE

To evaluate adherence to published recommendations for chemotherapy for ovarian cancer patients in the general community and to identify factors associated with its use.

PATIENTS AND METHODS

The study population consisted of 2,150 women residing in Northern California with a first diagnosis of primary epithelial ovarian cancer between January 1994 and December 1996. Patients were identified through the California Cancer Registry and their physicians were surveyed to supplement registry treatment information.

RESULTS

Almost 89% of women younger than 75 years with International Federation of Gynecology and Obstetrics stage III or IV tumors received chemotherapy, with levels of treatment highest for women diagnosed at stage III. Patients 75 years of age and older were significantly less likely than younger women to receive chemotherapy (58.2% v 86.1%; P =.001) regardless of stage at diagnosis. Approximately 20% of patients younger than 55 years with early-stage (stage IC and II) cancer received no chemotherapy. Treatment in an American College of Surgeons hospital and treatment by a gynecologic oncologist increased the likelihood of receiving chemotherapy. Hospitalization for comorbid illness, race/ethnicity, census-based measures of socioeconomic status, and size or teaching status of hospital were all unrelated to probability of treatment after adjustment for other factors. Reasons reported most frequently by physicians for no treatment were lack of clinical indication and patient refusal.

CONCLUSION

The results of this study suggest that, despite scientific evidence and published guidelines that advocate chemotherapy for most women with ovarian cancer, some groups of women did not receive optimum treatment.

Alterations of the lymphocytic set-up in elderly patients with cancer

It is assumed that the increased incidence of neoplastic pathologies with advancing age is correlated with the immunosenescence and with the altered immune-surveillance. The present study was aimed at evaluating the role of the immunocompetent system and immunosenescence in carcinogenesis. A pool of 99 subjects (38 females, 61 males) has been analyzed in three groups as follows. Group A: 51 elderly subjects with cancer (16 females and 35 males, average age 73.7 +/- 7.5 years). Group B: 24 young subjects with cancer (12 females, 12 males, average age 49.5 +/- 10.3 years). Group C: 24 elderly subjects without any clinical evidence of cancer (10 females, 14 males, average age 74.6 +/- 6.3 years). Hemo-chromocytometric analysis and cytofluorimetric typifying have been performed in all subjects. A decrease of T (CD3+)-lymphocytes has been observed in group A, if compared to group B (P < 0.007), and to group C (P < 0.01), The T (CD4+)-lymphocytes were fewer in group A, than in group C (P < 0.004), and also the NK cells showed the same trend (P < 0.002). The numbers of leukocytes and monocytes increased in group A compared to group C (P < 0.01 and P < 0.004, respectively). Red cell numbers, hemoglobin and hematocrit values were lower in group A than in group B (P < 0.03, P < 0.03, P < 0.01, respectively), and also than in group C (P < 0.007, P < 0.001, P < 0.01, respectively), The results demonstrate that the alterations of the immunocompetent cells, particularly of the T-cell pool, may play an important role in the carcinogenesis of the elderly.

Immunosenescence and cancer: a review

The human neoplastic pathologies are age-dependent. The increased occurrence of tumors observed with advancing age may be determined by the accumulation of certain phenomena promoting different phases of neoplastic processes. In these events, important roles can be attributed to mutations of the genome that accumulate during aging and to the immunosenescence. It may be hypothesized that certain tumors controlled by the immune system may become more frequent in the elderly as a consequence of the decreased functionality of this important defense system of the organism. Nevertheless, the problems of the interrelationships between the immunosenescence and tumors are seriously contradictory. Therefore, on the one hand, one has to establish how much the immunodeficit of the elderly patient may be responsible for the neoplastic pathology, while on the other hand, one cannot neglect important environmental and pathophysiological factors in these cases.