Incorporating biomarkers of frailty and senescence in cancer therapeutic trials

Frailty affects prognosis in patients with colorectal cancer: A systematic review and meta-analysis

Background

The prevalence of colorectal cancer has remained high. Most patients have already developed into the middle and advanced stage when they are diagnosed with colorectal cancer, and a small number of them are accompanied by metastasis. In recent years, frailty has been recognized as an important factor affecting the prognosis of colorectal cancer. The aim of this study was to assess the value of frailty on prognosis in patients with colorectal cancer after treatment.

Method

We systematically searched PubMed, Embase, Web Of Science databases up until March2022. A total of 18 studies were retrieved that met the inclusion criteria, including 9 prospective studies and 9 retrospective studies. Frailty screening tools, proportion of frail patients, and outcomes of colorectal cancer patients after treatment were recorded.

Result

18 studies were included with a total of 352,535 participants. Regardless of differences in frailty screening and treatment approaches, outcomes for frailty patients were less favorable in all studies. Compared with the non-frail group, the frail group had higher mortality, more serious complications, more postoperative blood transfusions and delirium, and more support outside the home.

Conclusion

Although there is no uniform standard for frailty screening, assessing the frailty of colorectal cancer patients is of great significance for predicting prognosis of patients after treatment.

Incorporation of functional status, frailty, comorbidities, and co-medication in prediction models for colorectal cancer survival

Limitations in functional status, frailty, multiple comorbidities, and co-medications are common among older colorectal cancer (CRC) patients. We investigated whether adding these factors could improve the predictive value of a reference model containing age, sex, tumor stage and location for prediction of 5-year overall survival (OS), disease-free survival (DFS), disease-specific survival (DSS), recurrence-free survival (RFS), and non-disease-specific survival (nDSS) for all CRC patients as well as for younger (<65 years) and older patients (≥65 years). Overall, 3,410 CRC patients from the DACHS study were analyzed and area under receiver operating characteristic curves (AUC) and net reclassification improvements (NRI) were assessed. In prediction of OS, the reference model plus functional status was identified as the best model among all CRC patients (AUC: 0.762) and younger CRC patients (AUC: 0.820). In older CRC patients, comorbidity should additionally be added (AUC: 0.747). For nDSS, the reference model plus comorbidity and frailty had the best predictive performance in all CRC patients (AUC: 0.776). For the outcomes DFS (AUC: 0. 727), DSS (AUC: 0. 838), and RFS (AUC: 0. 784), the reference model was already the best model in all CRC patients because no significant NRIs were observed. The pattern "The less CRC-specific the survival outcome and the older the CRC patients, the more relevant the inclusion of functional status, comorbidity, and frailty in CRC prognostic scores is" was observed. Thus, different nomograms for younger and older CRC patients for 1-, 3-, and 5-year OS prognosis estimation are being suggested.

Perceptions of Older Adult Care Among Ambulatory Oncology Nurses

BACKGROUND

Most cancer treatment is provided in the ambulatory setting; thus, it is important to know what issues ambulatory oncology nurses identify in their practice with older cancer patients as well as resources that are helpful or are needed.

OBJECTIVE

The aim of this study was to capture ambulatory oncology nurses' perceptions of the unique aspects of caring for older patients and to present the development process, content validity testing, and psychometric evaluation of a survey designed to denote nurse perceptions of older adult care.

METHODS

An expert panel and 2 focus groups informed the development of a 34-item survey scored on a 5-point Likert-type agreement scale and 2 open-ended questions. Psychometric testing and descriptive statistics summarized the quantitative responses. Using thematic analysis, we identified the themes from the open-ended responses.

RESULTS

The survey demonstrated good psychometric qualities. A total of 401 participants, mostly staff from large, academic cancer centers, reported an average total score of 3.76, indicating generally positive perceptions of older adult care. The 269 (67%) open-ended responses were categorized into 4 main themes: concerns over medical issues, the need for specialized services, adequate support systems, and appropriate communication.

CONCLUSIONS

Although most perceived their geriatric practice environment favorably, nurses recognized the complexity of caring for older adults with cancer. They identified gaps in care, such as the need for geriatric specialists and better community resources, paid by insurance.

IMPLICATIONS FOR PRACTICE

Nurses need more time in the clinic to address complex advanced care planning, symptom burden and home services of older adults with cancer. Each institution should seek feedback from nurses to guide resource allocation.

Association of frailty with 90-day postoperative mortality & geriatric comanagement among older adults with cancer

INTRODUCTION

Geriatric medical comanagement of older surgical patients with cancer is associated with lower 90-day postoperative mortality. Here, we investigate the hypothesis that this association varies on the basis of the degree of a patient's frailty.

METHODS

Frailty was assessed using the Memorial Sloan Kettering Frailty Index. Our hypothesis was evaluated using two approaches, both adjusted for age, sex, American Society of Anesthesiologists Physical Status, preoperative albumin, operating room duration, and estimated blood loss. A logistic regression was performed with 90-day mortality as the outcome and geriatric comanagement, continuous Memorial Sloan Kettering Frailty Index, and an interaction term between these two variables as the primary predictors. We then categorized frailty into four levels and, within each level, performed logistic regression with geriatric comanagement as the primary predictor and 90-day mortality as the outcome. Finally, we extracted the effect size and used a meta-analytic approach to test for heterogeneity.

RESULTS

Of 1687 patients aged ≥75 years who underwent elective cancer surgery with a length of stay of ≥1 day, 931 (55%) received comanagement; 31 patients (3.3%) who received comanagement died within 90 days, compared with 72 (9.5%) who did not. Ninety-day mortality was not statistically significantly different by degree of frailty in either analysis (interaction P = 0.4; test of heterogeneity P = 0.8).

CONCLUSION

Geriatric comanagement is valuable for all older surgical patients, not just the frail, and should be provided to as large a portion of the older surgical population as possible. Further research should examine predictors of response to geriatric comanagement.

Frailty phenotype is associated with antiretroviral exposure among older persons living with HIV

PURPOSE OF REVIEW

This multicentre, cross-sectional study was carried out in the South of France to assess the association between frailty phenotype and antiretroviral therapy (ART) in older persons living with HIV (PLWHIV). Sociodemographic and HIV data, geriatric assessment, comorbidities, behavioral and age-related variables and the five frailty markers of Fried were recorded. Exposure to any pharmacological class of ART and all regimens were retrieved from medical records.

RECENT FINDINGS

The 509 PLWHIV analysed (72.7% male) received a mean of 6.01 ART regimens and 12.5 years exposure to ART. The prevalence of at least one frailty marker [frail and prefrail phenotype (FPFP)] was 66.4%. Duration of exposure to protease inhibitors and reverse transcriptase inhibitors, number of ART regimens and comorbidities, dyslipidaemia, cancer, depression, falls, disability and pain were significantly associated with FPFP by univariate analysis. In logistic regression multivariable analysis, independent predictors for FPFP were a large number of ART regimens, presence of cancer and pain. No significant association was found with HIV-related parameters neither with ART class and duration.

SUMMARY

A significant association was found between FPFP and a large number of different ART regimens among older PLWHIV. The burden of cancer and pain in these patients shows the importance of comprehensive care.

Comprehensive geriatric assessment is an independent prognostic factor in older patients with metastatic renal cell cancer treated with first-line Sunitinib or Pazopanib: a single center experience

BACKGROUND

There is poor data on the prognostic role of Comprehensive Geriatric Assessment (CGA) in older patients with metastatic renal cell carcinoma (mRCC) treated with first line Tyrosine Kinase Inhibitors (TKIs).

MATERIALS AND METHODS

We retrospectively reviewed the clinical charts of mRCC patients older than 70 years treated at our Institute with first-line Sunitinib or Pazopanib for at least 6 months. Every patient received a CGA at baseline and was identified as fit, vulnerable or frail according to Balducci's Criteria. We then assessed the impact of CGA category on survival, disease control and tolerability of TKIs.

RESULTS

We identified 86 eligible patients. Median age: 74.5 years, 56% males; 45.4% were fit, 37.2% vulnerable and 17.4% frail at CGA. There were no significant differences in the rate of Grade (G)1-2 and G3-4 toxicities, dose reduction rates, PFS and OS between Sunitinib and Pazopanib. Fit, vulnerable and frail patients achieved significantly different median PFS (18.9 vs 11.2 vs 5.1 months; p < 0.001) and OS (35.5 vs 14.6 vs 10.9 months; p < 0.001). Patients categorized as fit had higher chance of receiving a second-line treatment (66.6% vs 28.9% in vulnerable/frail; p = 0.002). The incidence of G3/4 events was significantly lower in the fit subgroup (19% vs 45% in vulnerable/frail; p = 0.0025).

CONCLUSIONS

In our retrospective single-center experience, CGA could accurately discriminate patients with higher risk of experiencing G3/4 toxicities, shorter PFS, and lower chance of receiving a second line treatment. CGA strongly impacted on OS, independently from International mRCC Database Consortium (IMDC) classification.

Measuring Aging and Identifying Aging Phenotypes in Cancer Survivors

Observational data have shown that some cancer survivors develop chronic conditions like frailty, sarcopenia, cardiac dysfunction, and mild cognitive impairment earlier and/or at a greater burden than similarly aged individuals never diagnosed with cancer or exposed to systemic or targeted cancer therapies. In aggregate, cancer- and treatment-related physical, cognitive, and psychosocial late- and long-term morbidities experienced by cancer survivors are hypothesized to represent accelerated or accentuated aging trajectories. However, conceptual, measurement, and methodological challenges have constrained efforts to identify, predict, and mitigate aging-related consequences of cancer and cancer treatment. In July 2018, the National Cancer Institute convened basic, clinical, and translational science experts for a think tank titled "Measuring Aging and Identifying Aging Phenotypes in Cancer Survivors." Through the resulting deliberations, several research and resource needs were identified, including longitudinal studies to examine aging trajectories that include detailed data from before, during, and after cancer treatment; mechanistic studies to elucidate the pathways that lead to the emergence of aging phenotypes in cancer survivors; long-term clinical surveillance to monitor survivors for late-emerging effects; and tools to integrate multiple data sources to inform understanding of how cancer and its therapies contribute to the aging process. Addressing these needs will help expand the evidence base and inform strategies to optimize healthy aging of cancer survivors.

Rerouting Geriatric Medicine by Complementing Static Frailty Measures With Dynamic Resilience Indicators of Recovery Potential

Medicine is still very inadequate in forecasting recovery of tipping points in health and disease, especially in older adults. However, increasingly, diseases and invasive treatments unexpectedly push older patients with low resilience over their tipping points (TPs). These TPs are the points in human physiology that separate more healthy conditions from disease conditions or malfunctioning of the older human’s subsystems or organs, such as delirium, syncope and falls in old age, which threaten the functioning of the older person as a whole. Either the person may recover from the perturbation induced by such a subsystem TP and the balance of the whole system is restored, or the TP may set in motion a cascade of events driving the system down to a state of more decline, ultimately leading to death. A main unanswered question here is how to predict whether these older persons will recover or not. To improve this TP-recovery-forecasting, intriguing findings on measures of resilience found in other complex biological systems may be translated to humans. New dynamic resilience biomarkers for resilience can enrich clinical prediction for pathophysiological recovery and could test interventions for their effectiveness in improving resilience. Therefore, we hypothesize that dynamic, stimulus-response measures of recovery rate over time, observed after having received a minor stressor in a healthy condition, can be used to quantify recovery potential following subsystem TPs in disease and following invasive treatments in humans and thus the person’s resilience. Current static frailty prognostics can predict risks for death, institutionalization, delirium, falls, and other TP transitions, but it has not been proven that they can predict recovery. Our hypothesis on dynamic indicators of recovery is logical and timely, as it can now be studied with sensor technology to create a fundamentally different approach of variables that may be validated to forecast recovery potential. By generating dynamic measures of systemic resilience over various organ systems, we may subsequently model resilience generically across many chronic diseases, affecting different organ systems. Next, quantifying systemic resilience may reroute scientific and clinical pathways by predicting and preventing irreversible tipping points and by improving recovery by older adults.

Acute Sarcopenia Secondary to Hospitalisation - An Emerging Condition Affecting Older Adults

There has been increasing interest and research into sarcopenia in community-dwelling older adults since the European Working Group on Sarcopenia in Older People (EWGSOP) agreed a consensus definition in 2010. Sarcopenia has been defined as loss of muscle mass with loss of muscle function (strength or physical performance), with measurements two Standard Deviations (SDs) below the mean of a young reference population. This definition does not necessitate longitudinal measurements, or the absence of acute illness and diagnosis can be made from single measurements. We hypothesise that hospitalisation, due to a combination of acute inflammatory burden and muscle disuse, leads to an acute decline in muscle mass and function and may lead to some individuals meeting criteria for sarcopenia, acutely, based on the EWGSOP definition. This may be partially recoverable or may lead to increased risk of developing sarcopenia long-term. We have denoted the term “acute sarcopenia” to refer to acute loss of muscle mass and function associated with hospitalisation. This review discusses some of the current available research in this context and also identifies some of the knowledge gaps and potential areas for future research.

How should older adults with cancer be evaluated for frailty?

Traditionally used as a descriptive term, frailty is now a recognized medical syndrome identifying individuals with decreased physiologic reserve. Frailty is characterized by diminished strength, endurance, and reduced physiologic function. Several valid frailty screening tools exist in the literature, and these measures have been used to relate frailty to outcomes important to the older patient with cancer. Frail adults are at increased risk of adverse surgical outcomes and early findings suggest that frailty predicts poor chemotherapy tolerance. While much research is needed to explore the biologic relationships between frailty and cancer, there is an urgent need to implement frailty screening and management into the care of the older patient with cancer in order to improve outcomes in this vulnerable subset. The purpose of this paper is to provide an introduction of frailty to oncologists including a review of the definition, frailty screening tools, its clinical relevance to older patients with cancer, and a brief guide to frailty management.

Mortality in Relation to Frailty in Patients Admitted to a Specialized Geriatric Intensive Care Unit

Background.

In older adults admitted to intensive care units (ICUs), frailty influences prognosis. We examined the relationship between the frailty index (FI) based on deficit accumulation and early and late survival.

Methods.

Older patients (≥65 years) admitted to a specialized geriatric ICU at the Liuhuaqiao Hospital, Guangzhou, China between July–December 2011 (n = 155; age 82.7±7.1 y; 87.1% men) were followed for 300 days. The FI was calculated as the proportion present of 52 health deficits. FI performance was compared with that of several prognostic scores.

Results.

The 90-day death rate was 38.7% (n = 60; 27 died within 30 days). The FI score was correlated with the Glasgow Coma Scale, Karnofsky Scale, Palliative Performance Scale, Acute Physiology Score—APACHE II and APACHE IV (r² = 0.52 to 0.72, p < 0.001). Patients who died within 30 days had higher mean FI scores (0.41±0.11) than those who survived to 300 days (0.22±0.11; F = 38.91, p < 0.001). Each 1% increase in the FI from the previous level was associated with an 11% increase in the 30-day mortality risk (95% CI: 7%–15%) adjusting for age, sex, and the prognostic scores. The FI discriminated patients who died in 30 days from those who survived with moderately high accuracy (AUC = 0.89±0.03). No one with an FI score >0.46 survived past 90 days.

Conclusion.

ICU survival was strongly associated with the level of frailty at admission. An FI based on health deficit accumulation may help improve critical care outcome prediction in older adults.