Frailty status but not age predicts complications in elderly cancer patients: a follow-up study

Frailty and Cancer Prognosis

PURPOSE OF REVIEW

This review aims to summarize the current evidence regarding the prognostic role of frailty in older patients diagnosed with cancer and to explore the evidence regarding its prognostic implications in cancer survivors.

RECENT FINDINGS

Frailty has been consistently associated with mortality/overall survival, postoperative complications, short- and long-term postoperative mortality, length of stay, among other adverse health-related outcomes in several oncological contexts. The possible association between frailty and treatment toxicity has been less explored, however most studies suggest frailty is a predictor of treatment induced toxicity. In addition, in cancer survivors, frailty is a risk factor for cardiovascular disease, incident type 2 diabetes mellitus, mortality, altered cognitive performance and increased symptom severity. Due to its usefulness in establishing prognosis and informing treatment decision making, it is expected that frailty screening and assessment will continue to gain popularity as part of the pretreatment evaluation of older patients with cancer.

Patient and staff perspectives on the concept of frailty and its role in assessment and decision making in treatment for older people with lung cancer

PURPOSE

Frailty influences outcomes in patients with cancer and should be considered when making decisions about treatment but concerns have been raised about possible negative consequences of doing this. Many patients with lung cancer have attributes of frailty and this study explores patient and staff perspectives on its role in decision making in older people with lung cancer.

METHODS

The study adopted a two-phase qualitative approach using semi-structured telephone interviews and an in-person focus group. Data was analysed using framework techniques.

RESULTS

Three key themes were identified: describing frailty, assessing frailty and perceptions of frailty. Each presented opportunities and challenges for using frailty in the context of treatment decision making. Frailty was described in relation to diverse attributes which made it difficult to define and assess. It was also associated with negative connotations, particularly by patients.

CONCLUSION

Frailty has the potential to inform decision making that balances the wish to provide optimum treatment against risks to patients who may not be able to tolerate it. The challenge for healthcare staff is to incorporate frailty assessment into clinical practice in a way that is acceptable to patients and avoids potential unintended harms.

Development and feasibility of an exercise therapy intervention for older women with advanced epithelial ovarian cancer referred to neoadjuvant chemotherapy prior to possible interval debulking surgery

Objective

This study describes the development and examines the feasibility of an exercise therapy program for women aged 70 years or older with advanced EOC, receiving neoadjuvant chemotherapy (NACT) before possible major surgery.

Methods

In this feasibility study, patients participated in a mainly home-based exercise therapy program, including progressive resistance training, physical activity, and support from the supervising physiotherapist. The program included both supervised virtual and face-to-face sessions and self-administered daily exercise. Clinician-reported, patient-reported and physical performance measures were collected before and after NACT. Retention, adherence, and compliance to the program was monitored, and patient acceptability was explored in semi-structured interviews.

Results

Fifteen patients, median age of 77 years (range 70-85) completed the exercise therapy program concurrently to receiving NACT lasting a median of 12 weeks. Patients were physically frail at baseline but improved at follow-up on measures of performance status, level of frailty, patient-reported physical fitness, lower body strength, aerobic functional capacity, basic mobility, balance, and number of steps per day. High levels of participation were found to both supervised and self-administered exercise. Patient interviews highlighted the homebased setting, the individualised tailoring of exercises and the support from the physiotherapist as reasons to complete the exercise therapy program as prescribed.

Conclusions

The exercise therapy program was found to be feasible and acceptable in women aged 70 years or older with advanced EOC, receiving NACT before possible major surgery. The observed improvements and the positive experiences perceived by the patients support future application in research and clinical practice.

The Impact of Frailty on Chemotherapy Outcomes in Patients With Digestive System Tumors: A Systematic Review and Meta-analysis

BACKGROUND

The prevalence of patients with digestive system tumors has been high. In recent years, frailty has been considered to be associated with poor prognosis of digestive system tumors, but there are conflicting research results. A better understanding of the relationship between frailty and outcomes after chemotherapy can help advance the development of oncology care.

OBJECTIVE

The aim of this study was to evaluate the effects of prechemotherapy frailty on chemotherapy toxicity, overall mortality, unplanned hospitalization, and overall survival in patients with digestive system tumors.

METHODS

Up to April 2023, observational studies assessing the impact of frailty on chemotherapy outcomes in patients with digestive system tumors were collected through searching 10 online research databases. Two evaluators independently extracted literature based on the inclusion and exclusion criteria and evaluated the quality of the studies using the Newcastle-Ottawa Scale.

RESULTS

Eventually, 11 cohort studies encompassing 2380 patients were included. The meta-analysis revealed that the frail group exhibited an increased risk of overall mortality, with poorer overall survival than the nonfrail group.

CONCLUSION

Frailty increases the risk of chemotherapy-induced toxic effects, unplanned hospitalization, and death in patients. However, because of this study's limited number of participants, large-sample, multicenter studies to verify these findings are required.

IMPLICATIONS FOR PRACTICE

This study provides theoretical support for incorporating frailty assessment into the nursing evaluation of patients with digestive system tumors before chemotherapy. This integration aids in predicting patients at a high risk of chemotherapy toxicity, mortality, and unplanned hospitalization, therefore providing corresponding interventions in advance to reduce adverse outcomes.

Effect of frailty on postoperative complications, mortality, and survival in older patients with non-metastatic colon cancer: A systematic review and meta-analysis

INTRODUCTION

New evidence has emerged on the impact of frailty on prognosis in colon cancer, but the findings are not always consistent and conclusive. The aim of this systematic review was to assess the effect of frailty on postoperative complications and mortality in patients with non-metastatic colon cancer (CC) aged 65 years and older.

MATERIALS AND METHODS

We systematically searched for original studies published in the PubMed and Web of Science databases up to June 2021. Two independent reviewers selected the studies and extracted predefined data. A meta-analysis was performed using the random effects model to assess the effect of frailty on 30-day, 3- to 6-month and 1-year mortality, survival, and postoperative complications.

RESULTS

The search yielded 313 articles, of which 14 were included in this systematic review. The meta-analysis showed an effect for frailty on 30-day, 3- to 6-month, and 1-year mortality with respective pooled odds ratios (ORs) of 3.67 (95% confidence interval [CI] 1.53-8.79, p = 0.004), 8.73 (95% CI 4.03-18.94, p < 0.0001), and 3.99 (95% CI 2.12-7.52, p < 0.0001). Frailty also had an effect on survival, with a pooled hazard ratio of 2.99 (95% CI 1.70-5.25. p < 0.0001), and on overall and severe postoperative complications with pooled ORs of 2.34 (95% CI 1.75-3.15; p < 0.0001) and 2.43 (95% CI 1.72-3.43; p < 0.0001), respectively.

DISCUSSION

Frailty in older patients with CC is a risk factor for postoperative complications and mortality in the short term (30 days), medium term (3-6 months), and long term (1 year).

Screening for Frailty Using the FRAIL Scale in Older Cancer Survivors: A Cross-sectional Comparison With the Fried Phenotype

OBJECTIVES

To examine the diagnostic performance of the FRAIL Scale for frailty screening with reference to the Fried phenotype and investigate its association with health outcomes in older cancer survivors.

DATA SOURCE

In this cross-sectional quantitative study, participants were post-treatment cancer survivors aged 65 or above. Measurements included the FRAIL Scale, Fried phenotype, Geriatric Depression Scale-15 item, Modified Barthel Inventory, and EORTC Core Quality of Life Questionnaire. Receiver operating characteristic curve analysis was performed to evaluate the diagnostic performance of the FRAIL Scale with reference to the Fried phenotype. Health outcomes associated with being frail as estimated by the FRAIL Scale and Fried phenotype were also examined using regressions.

RESULTS

Based on 293 older cancer survivors, the area under curve (AUC) of the FRAIL Scale was 0.79, and the optimal cut-off of 1 yielded a sensitivity of 92% and specificity of 41%. According to regression results, the FRAIL Scale was modified by adding an item on time since cancer treatment completion (AUC = 0.81), and using a cut-off of 2 for older cancer survivors, which yielded a sensitivity of 74% and specificity of 67%. The modified FRAIL Scale was associated with depressive symptoms, functional independence, fatigue, dyspnea, physical functioning, and role functioning.

CONCLUSIONS

The modified FRAIL Scale is proposed for use in older cancer survivors, and a cut-off of 2 should be used.

IMPLICATIONS FOR NURSING PRACTICE

The modified FRAIL Scale can serve as a brief screening tool for identifying frailty among older cancer survivors in practice.

Changes in the symptom clusters of elderly patients with lung cancer over the course of postoperative rehabilitation and their correlation with frailty and quality of life: A longitudinal study

OBJECTIVE

To explore changes in the symptom clusters of perioperatively elderly patients with lung cancer at different time points (i.e., the day of admission [T0]), 2-4 days after surgery [T1], 1 month after discharge [T2] and 3 months after discharge [T3]) and to analyze correlations between cluster severity, frailty and quality of life (QOL).

METHODS

A longitudinal study was conducted from August 2020 to June 2021 among elderly lung cancer patients undergoing surgery at hospitals in Jiangsu Province. Data were collected using the Chinese Tilburg Frailty Indicator, the MD Anderson Symptom Inventory and the Quality of Life-Core scale.

RESULTS

According to exploratory factor analysis, a total of 5 symptom clusters were found and three of them (the global mental function symptom cluster, the special mental function symptom cluster and the respiratory function symptom cluster) were persistent. The incidence of the top four symptoms varied at different time points. The severity of symptom clusters at different time points was positively correlated with frailty and negatively correlated with QOL.

CONCLUSIONS

The findings may serve as a reference for medical staff to implement symptom management in elderly lung cancer patients after surgery. Frailty may be an important variable affecting the severity of symptom clusters and the QOL of patients.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

Surgical treatment in older patients with endometrial cancer: A retrospective study

INTRODUCTION

Older patients (OP) diagnosed with endometrial cancer (EC) are less likely to receive an optimal surgical treatment compared with non-older patients (NOP). This undertreatment along with the presence of more aggressive tumours at diagnosis can explain the worse prognosis of EC in OP. There is limited evidence comparing perioperative outcomes between OP and NOP, and the benefit of applying complex procedures to OP is still controversial. The primary objective of the study was to compare intraoperative and postoperative complications between NOP and OP with EC that underwent primary surgery. Secondary objectives were to compare surgical management and survival rates.

METHODS

This is a retrospective single-centre observational study including women undergoing surgery for EC between 2010 and 2019. Patients were classified according to age as NOP (younger than 75 years) or OP (75 years or older). Basal characteristics and surgical outcomes of groups were compared using Chi-square, Fisher's exact tests, student T-tests or Mann Whitney tests. Kaplan Meier analysis was used to evaluate survival.

RESULTS

In total 281 patients underwent primary surgery for EC between 2010 and 2019 in our centre. At diagnosis, 184 patients were younger than 75 years while 97 were 75 and older. No differences were found in disease characteristics. Most of our patients (83,3%) underwent laparoscopic surgery. Pelvic (58,2% vs. 37,1%, p = 0,001) and para-aortic (46,7% vs. 23,7%, p < 0,001) lymphadenectomies were performed more frequently in NOP compared with OP. Rates of intra-operative (6,5% vs. 12,4%, p = 0,116) and post-operative (13,0% vs. 20,6%, p = 0,120) complications were not statistically different between NOP and OP, and neither was the rate of severe complications according to Clavien-Dindo classification (5,4% vs. 8,2% of complications grade III-V respectively, p = 0,387). The 5-year disease-specific survival (DSS) rate tended to be lower in the OP than in the NOP (74,8% vs. 82,5%, p = 0,071). Considering only patients in whom complete surgical staging was performed, OP presented similar DSS to NOP, with comparable complication rate.

CONCLUSIONS

OP do not present a significantly higher rate of perioperative complications compared to NOP. However, they underwent fewer lymphadenectomies and tended to present poorer DSS. Further studies are needed to standardize the surgical management of these patients.

Assessing how routes to diagnosis vary by the age of patients with cancer: a nationwide register-based cohort study in Denmark

BACKGROUND

Older patients with cancer have poorer prognosis compared to younger patients. Moreover, prognosis is related to how cancer is identified, and where in the healthcare system patients present, i.e. routes to diagnosis (RtD). We investigated whether RtD varied by patients' age.

METHODS

This population-based national cohort study used Danish registry data. Patients were categorized into age groups and eight mutually exclusive RtD. We employed multinomial logistic regressions adjusted for sex, region, diagnosis year, cohabitation, education, income, immigration status and comorbidities. Screened and non-screened patients were analysed separately.

RESULTS

The study included 137,876 patients. Both younger and older patients with cancer were less likely to get diagnosed after a cancer patient pathways referral from primary care physician compared to middle-aged patients. Older patients were more likely to get diagnosed via unplanned admission, death certificate only, and outpatient admission compared to younger patients. The patterns were similar across comorbidity levels.

CONCLUSIONS

RtD varied by age groups, and middle-aged patients were the most likely to get diagnosed after cancer patient pathways with referral from primary care. Emphasis should be put on raising clinicians' awareness of cancer being the underlying cause of symptoms in both younger patients and in older patients.

Frailty in Patients With Lung Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Previous studies regarding the prevalence of frailty in patients with lung cancer and mortality in frail patients with lung cancer are inconsistent and require clarification.

RESEARCH QUESTION

What is the prevalence and impact of frailty in patients with lung cancer?

STUDY DESIGN AND METHODS

This systematic review and meta-analysis used a combination of free-text terms and medical subject headings terms, according to the database requirements in MEDLINE/PubMed, Scopus, and Cochrane Library from inception until November 15, 2020.

RESULTS

A total of 2,571 articles were identified, and 16 articles involving 4,183 patients were included for study. The prevalence of frailty in lung cancer was 45% (95% CI, 28-61; I² = 99.5%; P < .0001). In patients with lung cancer, frailty was associated with an increased hazard ratio for mortality (hazard ratio, 3.01; 95% CI, 1.77-5.10; P < .001).

INTERPRETATION

The prevalence of frailty in lung cancer is 45%, which has a significant negative impact on survival of patients with lung cancer. These results highlight the importance of measuring frailty, which provides important prognostic information, and may provide opportunities for interventions to improve outcomes in patients with lung cancer.

The association of frailty and outcomes of geriatric assessment with acute radiation-induced toxicity in patients with head and neck cancer

BACKGROUND AND PURPOSE

Geriatric impairments and frailty are highly prevalent in patients with head and neck cancer (HNC). This study investigated the association of frailty and outcomes of geriatric assessment (GA) with radiation-induced toxicity (RIT) in patients undergoing (chemo)radiotherapy ((C)RT) for HNC.

MATERIALS AND METHODS

Between October 2014 and April 2016, patients with HNC were prospectively included in OncoLifeS, an institutional data-biobank. Before treatment initiation, patients underwent GA and frailty screening (Groningen Frailty Indicator and Geriatric 8). The main outcome of this study was RIT (weight loss, mucositis, salivary gland inflammation, oral pain, sore throat, hoarseness, dry mouth, dysgeusia, dysphagia and general pain) according to the common terminology criteria of adverse events (CTCAE) version 4.0. Linear mixed models were performed, to analyse factors associated with increasing mean RIT over time during the treatment period.

RESULTS

160 patients were included. 114 (71.3%) were male and the mean age was 66.1 years. Age ≥ 65 (β = 0.03(95 %CI = 0.01;0.05), p = 0.01), regional RT (β = 0.05(95 %CI = 0.02;0.09), p = 0.004), and concurrent chemotherapy (β = 0.04(95 %CI = 0.02;0.07), p = 0.001), were independent factors associated with increasing toxicity during the 7-week treatment period, adjusted for relevant covariates. None of the single items of GA, as well as the frailty screening instruments, were associated with increasing RIT.

CONCLUSION

In this study, frailty and GA were not associated with additional RIT during treatment. These results suggest that (C)RT is equally tolerated in frail and non-frail patients, with respect to acute RIT. RT could be a suitable alternative to surgery in selected frail patients.

Health-Related Quality of Life, Psychosocial Distress and Unmet Needs in Older Patients With Head and Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) is the most common cancer involving the mucosal surfaces of the head and neck and is associated with a number of etiological factors, including cigarette smoking, alcohol and betel nut consumption and exposure to high-risk human papillomavirus. The risk of HNSCC increases with age, peaking in the seventh and eighth decade, but this varies by anatomical and histological subtype. While several advancements have been made in the treatment of head and neck cancer (HNC) in recent decades, undertaking curative treatment still subjects the majority of HNSCC patients to substantial treatment-related toxicity requiring patients to tolerate a gamut of physical, psychological, and emotional demands on their reserves. In conjunction with other patient-related factors, clinicians involved in treating patients with HNSCC may incorporate advancing chronological age into their decision-making process when determining treatment recommendations. While advancing chronological age may be associated with increased concerns regarding physical treatment tolerability, clinicians may also be concerned about heightened vulnerability in various health and wellbeing outcomes. The available literature, however, does not provide evidence of this vulnerability in patients with advancing age, and, in many instances, older patients self-report greater resilience compared to their younger counterparts. While this data is reassuring it is limited by selection bias and heterogeneity in trial and study design and the absence of a consistent definition of the elderly patient with HNSCC. This narrative review article also includes a review of the measures used to assess HRQL, psychosocial outcomes and unmet needs in elderly or older patients with HNSCC.

Management of Advanced Basal Cell Carcinoma of the Head and Neck

Basal cell carcinoma is the most common human malignancy, with an incidence exceeding all other cancers combined. Advanced basal cell cancer requires a multidisciplinary approach to management. The mainstay of treatment remains surgical excision with appropriate reconstruction. Some advanced tumors may require radical resections; however, extensive, high-risk surgery may be justified by the indolent biology of the disease and the likelihood of cure. Other options, such as radiation or systemic targeted therapy, may be considered in selected patients who either refuse or are not candidates for surgery. The focus of this article is primarily on management of these high-risk cases.

Current Treatment Approaches and Outcomes in the Management of Rectal Cancer Above the Age of 80

Background: The number of cases of rectal cancer in our older cohort is expected to rise with our ageing population. In this study, we analysed patterns in treatment and the long-term outcomes of patients older than 80 years with rectal cancer across a health district. Methods: All cases of rectal cancer managed at the Illawarra Cancer Care Centre, Australia between 2006 and 2018 were analysed from a prospectively maintained database. Patients were stratified into three age groups: ≤65 years, 66–79 years and ≥80 years of age. The clinicopathological characteristics, operative and non-operative treatment approach and survival outcomes of the three groups were compared. Results: Six hundred and ninety-nine patients with rectal cancer were managed, of which 118 (17%) were aged 80 and above. Patients above 80 were less likely to undergo surgery (71% vs. 90%, p < 0.001) or receive adjuvant/neoadjuvant chemoradiotherapy (p < 0.05). Of those that underwent surgical resection, their tumours were on average larger (36.5 vs. 31.5 mm, p = 0.019) and 18 mm closer the anal verge (p = 0.001). On Kaplan–Meier analysis, those above 80 had poorer cancer-specific survival when compared to their younger counterparts (p = 0.032), but this difference was no longer apparent after the first year (p = 0.381). Conclusion: Patients above the age of 80 with rectal cancer exhibit poorer cancer-specific survival, which is accounted for in the first year after diagnosis. Priority should be made to optimise care during this period. There is a need for further research to establish the role of chemoradiotherapy in this population, which appears to be underutilised.

Prognostic Factors Predict Oncological Outcome in Older Patients With Head and Neck Cancer Undergoing Chemoradiation Treatment

Purpose

Older patients with head and neck cancer (HNC) represent a challenging group, as frailty and comorbidities need to be considered. This study aimed to evaluate the efficacy and side effects of curative and palliative (chemo) radiation ([C]RT) with regard to basic geriatric screening in older patients.

Methods

This study included HNC patients aged ≥70 years who were treated with curative or palliative (C)RT. Clinicopathological data including Charlson Comorbidity Index (CCI), Karnofsky performance status (KPS), and treatment data were analyzed as predictors of overall survival (OS).

Results

A total of 271 patients (median age, 74 years) were enrolled. The majority had UICC stage III/IV (90%) and underwent curative treatment (85.2%). A total of 144 (53.1%) patients received definitive and 87 (32.1%) had adjuvant (C)RT. Overall, 40 patients (14.8%) received palliative (C)RT. Median follow-up duration (curative setting) was 87 months, and the 2- and 5-year OS rates were 57.8 and 35.9%, respectively. Median OS was significantly different for age ≤75 vs. >75 years, CCI <6 vs. ≥6, KPS ≥70 vs. <70%, Tx/T1/T2 vs. T3/T4, and adjuvant vs. definitive (C)RT, respectively. Age 70–75 years (p = 0.004), fewer comorbidities when CCI < 6 (p = 0.014), good KPS ≥ 70% (p = 0.001), and adjuvant (C)RT (p = 0.008) independently predicted longer survival. Palliative RT resulted in a median OS of 4 months.

Conclusion

Older age, lower KPS, higher CCI, and definitive (C)RT are indicators of worse survival in older patients with HNC treated curatively. Without a comprehensive geriatric assessment in patients aged >75 years, the KPS and CCI can be useful tools to account for “fitness, vulnerability or frailty” to help in treatment decision-making.

The effect of treatment modifications by an onco-geriatric MDT on one-year mortality, days spent at home and postoperative complications

OBJECTIVES

Decision-making in older patients with cancer can be complex, as benefits of treatment should be weighed against possible side-effects and life-expectancy. A novel care pathway was set up incorporating geriatric assessment into treatment decision-making for older cancer patients. Treatment decisions could be modified following discussion in an onco-geriatric multidisciplinary team (MDT). We assessed the effect of treatment modifications on outcomes.

MATERIALS AND METHODS

This retrospective study was performed in the surgical department of a University Hospital. Patients of 70 years and older with a solid malignancy were included. All patients underwent a nurse-led geriatric assessment (GA) and were discussed in an onco-geriatric MDT. This could result in a modified or an unchanged treatment advice compared to the regular tumor board. Primary outcome was one-year mortality. Secondary outcomes were post-operative complications and days spent in hospital in the first year after inclusion.

RESULTS

For the 184 patients in the analyses, the median age was 77.5 years and 41.8% were female. For 46 patients (25%), the treatment advice was modified by the onco-geriatric MDT. There was no significant difference in one-year mortality between the unchanged and modified group (29.7% versus 26.1%, p = 0.7). There were, however, significantly fewer days spent in hospital (median 5 vs 8.5 days p = 0.02) and fewer grade II or higher postoperative complications (13.3% versus 35.5% p = 0.005) in the modified group.

CONCLUSION

Incorporating geriatric assessment in decision-making did not lead to excess one-year mortality, but did result in fewer complications and days spent in hospital.

Adjuvant Chemotherapy in Elderly Colorectal Cancer Patients

The value of adjuvant chemotherapy in elderly patients has been the subject of many overviews, with opinions varying from “not effective”, since randomized trials have not been performed, to “as effective as in young individuals”, based upon many retrospective analyses of randomized trials that have included patients of all ages. In the absence of randomized trials performed specifically with elderly patients, retrospective analyses demonstrate that the influence on the time to tumour recurrence (TTR) may be the same as in young individuals, but that endpoints that include death for any reason, such as recurrence-free survival (RFS), disease-free survival (DFS), and overall survival (OS), are poorer in the elderly. This is particularly true if oxaliplatin has been part of the treatment. The need for adjuvant chemotherapy after colorectal cancer surgery in elderly patients is basically the same as that in younger patients. The reduction in recurrence risks may be similar, provided the chosen treatment is tolerated but survival gains are less. Adding oxaliplatin to a fluoropyrimidine is probably not beneficial in individuals above a biological age of approximately 70 years. If an oxaliplatin combination is administered to elderly patients, three months of therapy is in all probability the most realistic goal.

The impact of a tailored follow-up intervention on comprehensive geriatric assessment in older patients with cancer - a randomised controlled trial

PURPOSE

Comprehensive Geriatric Assessment (CGA) can identify health problems in older persons. In addition, CGA includes intervention towards the identified problems. With follow up, more problems may be identified and the interventions can be adjusted. We wanted to compare CGA with or without tailored follow-up in a randomised design.

PATIENTS AND METHODS

Patients 70+ years referred for oncology treatment with four primary tumour sites. Participants were randomised 1:1 to either control group with no follow-up or intervention group with a tailored follow-up by a multidisciplinary team. Primary outcome was adherence to cancer treatment. Secondary outcomes were daily life activities, physical performance and hospitalisation.

RESULTS

In total, 363 participants were randomised. After randomisation only 301 were planned to receive specific cancer treatment. Median age was 75 years. Among the 301 participants, 52% of control group vs. 61% of intervention group completed treatment. Risk Rate (RR): 1.16 (95% Confidence Interval (CI): 0.95-1.42), p = .14. The impact varied between the included tumour-sites, p < .01. We found no difference in 90 days physical performance or daily life activities between groups. During the study period, 55% of controls vs. 47% in the intervention group were admitted to hospital, RR: 0.86 (95%CI: 0.69-1.07), p = .19.

CONCLUSION

In frail and vulnerable patients with cancer, a tailored follow-up on CGA showed no differences in ability to complete initially planned cancer treatment. The impact varied between the included tumour sites. We did not find any impact of tailored follow-up on daily life activities, physical performance or hospitalisation.

Risk factors of short-term survival in the aged in elective colon cancer surgery: a population-based study

PURPOSE

Patients aged > 80 years represent an increasing proportion of colon cancer diagnoses. Selecting patients for elective surgery is challenging because of possibly compromised health status and functional decline. The aim of this retrospective, population-based study was to identify risk factors and health measures that predict short-term mortality after elective colon cancer surgery in the aged.

METHODS

All patients > 80 years operated electively for stages I-III colon cancer from 2005 to 2016 in four Finnish hospitals were included. The prospectively collected data included comorbidities, functional status, postoperative surgical and medical outcomes as well as mortality data.

RESULTS

A total of 386 patients (mean 84.0 years, range 80-96, 56% female) were included. Male gender (46% vs 35%, p = 0.03), higher BMI (51% vs 37%, p = 0.02), diabetes mellitus (51% vs 37%, p = 0.02), coronary artery disease (52% vs 36%, p = 0.003) and rheumatic diseases (67% vs 39%, p = 0.03) were related to higher risk of complications. The severe complications were more common in patients with increased preoperative hospitalizations (31% vs 15%, p = 0.05) and who lived in nursing homes (30% vs 17%, p = 0.05). The 30-day and 1-year mortality rates were 6.0% and 15% for all the patients compared with 30% and 45% in patients with severe postoperative complications (p < 0.001). Severe postoperative complications were the only significant patient-related variable affecting 1-year mortality (OR 9.60, 95% CI 2.33-39.55, p = 0.002).

CONCLUSIONS

The ability to identify preoperatively patients at high risk of decreased survival and thus prevent severe postoperative complications could improve overall outcome of aged colon cancer patients.

Impact of age on toxicity and efficacy of 5-FU-based combination chemotherapy among patients with metastatic colorectal cancer; a pooled analysis of five randomized trials

OBJECTIVE

To assess the impact of age on toxicity and efficacy outcomes of metastatic colorectal cancer treated with 5FU-based combination chemotherapy.

METHODS

Project Data Sphere (PDS) platform has been accessed and de-identified datasets of the following clinical trials were downloaded (NCT00272051; NCT00305188; NCT00115765; NCT00364013; and NCT00384176). Multivariable logistic regression analysis was used to assess the impact of age (< 70 years versus ≥ 70 years) on the probability of different toxicities. Multivariable Cox regression analysis was additionally used to evaluate the impact of age (< 70 years versus ≥ 70 years) on overall and progression-free survival.

RESULTS

Among a total of 3223 patients included in the current analysis, 2488 patients were < 70 years; while 735 patients were ≥ 75 years at randomization. Older age was associated with a higher probability of serious adverse events (OR (odds ratio) 0.649; 95% CI 0.545-0.772; P < 0.001), fatal adverse events (OR 0.416; 95% CI 0.299-0.579; P < 0.001), all-grade diarrhea (OR 0.834; 95% CI 0.699-0.994, P = 0.043), high-grade diarrhea (OR 0.734; 95% CI 0.577-0.933, P = 0.012), high-grade stomatitis (OR 0.500, 95% CI 0.290-0.861, P = 0.012), high-grade thrombocytopenia (OR 0.578; 95% CI 0.359-0.930, P = 0.024), all-grade neutropenia (OR 0.690; 95% CI 0.578-0.824, P < 0.001), and high-grade neutropenia (OR 0.661; 95% CI 0.549-0.796, P < 0.001). In a multivariable Cox regression analysis for factors affecting overall survival, older age was associated with worse overall survival (hazard ratio for younger age versus older age 0.848; 95% CI 0.754-0.954, P = 0.006). On the hand, older age was not associated with worse progression-free survival (hazard ratio for younger age versus older age 0.933; 95% CI 0.843-1.032, P = 0.179).

CONCLUSION

Metastatic colorectal cancer patients ≥ 70 years of age who are treated with 5FU-based combination chemotherapy are more likely to have serious adverse events, fatal adverse events as well as worse overall survival compared to younger patients.

Enhanced recovery after surgery (ERAS) programs for esophagectomy

A perioperative treatment protocol, enhanced recovery after surgery (ERAS) focuses on accelerating patient recovery. Previous studies confirmed that ERAS decreases surgical trauma and the stress response, which improved outcomes including reduced length of hospital stay (LOS) and decreased postoperative morbidity. While ERAS protocols have been successfully implemented in a variety of surgical disciplines (colorectal, bariatric, orthopedic, and gynecologic surgery), its use in esophageal surgery is still limited. This paper analyzes the feasibility and value of the ERAS protocol for esophageal surgery. Reviewing the literature found that implementation of ERAS resulted in decreased costs, length of stay and pulmonary specific complication reduction, but not overall morbidity. The evidence lacks randomized control trials. Further, the ERAS Society published recommendations for esophageal resection. This opportunity for unification of the protocol would make the studies more comparable and leads to stronger conclusions. Surgery specific items also require further confirmation. Nonetheless, the successful introduction of the ERAS protocol into a wide variety of surgical disciplines provides optimism for ERAS's effectiveness in esophageal surgery.