Can Vulnerable Elders Survey-13 predict the impact of frailty on chemotherapy in elderly patients with gynaecological malignancies?

Assessing the ability of the Cancer and Aging Research Group tool to predict chemotherapy toxicity in older Japanese patients: A prospective observational study

INTRODUCTION

The Cancer and Aging Research Group (CARG) prediction tool was designed in the United States to predict grade ≥ 3 chemotherapy-related adverse events (CRAE) in older patients. However, its usefulness among Japanese people, who have different sensitivities to anticancer drugs and life expectancy, remains unknown. We aimed to prospectively evaluate the utility of the CARG tool for predicting severe CRAE in older Japanese patients with cancer.

MATERIAL AND METHODS

Patients with solid tumors aged 65 years and older who commenced anticancer drug regimens from April 2018 to October 2020 were divided into three groups (low, medium, and high-risk) based on their CARG risk scores. Toxicity was prospectively observed by a pharmacist. The primary objective was to evaluate the correlation between the incidence of grade ≥ 3 CRAE and the CARG risk score. The secondary objective was to evaluate hematological and non-hematological toxicities. CRAE incidence was compared among the three groups using a closed testing procedure: (1) Cochran-Armitage test for trend and (2) chi-square test for paired comparison.

RESULTS

The patients (N = 165) had a median age of 71 years (range: 65-89 years). CRAE in patients divided into low-, medium-, and high-risk groups, based on CARG risk scores, were 39%, 55%, and 82%, respectively (low vs high; p < 0.001, medium vs high; p < 0.01). The incidence of severe hematologic toxicity was 37%, 35%, and 50% in the low-, medium-, and high-risk groups, respectively; the incidence of severe non-hematologic toxicity was 15%, 36%, and 65%, respectively (low vs medium; p < 0.01, low vs high; p < 0.001, and medium vs high; p < 0.01).

DISCUSSION

To our knowledge, this is the first prospective observational study to validate the CARG prediction tool in older Japanese patients with cancer. The CARG risk score may be effective in predicting the development of non-hematologic toxicities. These results should be considered when administering chemotherapy to older Japanese patients with advanced solid tumors.

Cardiometabolic Disorders Are Important Correlates of Vulnerability in Hospitalized Older Adults

With an increasingly aging population worldwide, the concept of multimorbidity has attracted growing interest over recent years, especially in terms of frailty, which leads to progressive multisystem decline and increased adverse clinical outcomes. The relative contribution of multiple disorders to overall frailty index in older populations has not been established so far. This study aimed to assess the association between the vulnerable elders survey-13 (VES-13) score, which is acknowledged to be one of the most widely used measures of frailty, and the most common accompanying diseases amongst hospitalized adults aged 60 years old and more. A total of 2860 participants with an average age of 83 years were included in this study. Multiple logistic regression with adjustment for age and nutritional status was used to assess the independent impact of every particular disease on vulnerability. Diabetes mellitus type 2, coronary artery disease, atrial fibrillation, heart failure, chronic kidney disease, osteoarthritis, fractures, eyes disorders, depression, dementia, pressure ulcers, and urinary incontinence were associated with higher scores of VES-13. Hospital admission of older subjects with those conditions should primarily draw attention to the risk of functional decline, especially while qualifying older patients for further treatment in surgery and oncology. At the same time, lipid disorders, gastrointestinal diseases, higher body mass index, and albumins level were related to a lower risk of being vulnerable, which may be attributed to a younger age and better nutritional status of those patients.

Development and clinical application of a tool to identify frailty in elderly patients with gynecological cancers

OBJECTIVE

Frailty is more reliable than chronological age in predicting the effectiveness and tolerability of treatments in cancer patients. An increasing number of screening tools have been proposed, however none have received unanimous consent or been specifically designed for women with gynecological malignancies.This study's aim was to develop a clinical application of a screening tool to identify frail patients >70 years old diagnosed with either ovarian or endometrial cancers.

METHODS

A 20 item questionnaire was developed and administered to the cohort before surgery or neoadjuvant chemotherapy. A cut-off for frailty definition was determined by analyzing the correlation of questionnaire scores with the completion of treatments. The association between frailty and treatment related complications was assessed using a Chi-squared test for categorical variables and a t-test for continuous variables.

RESULTS

Our study included 100 patients, 50% diagnosed with endometrial cancer and 50% with ovarian cancer. A questionnaire score of 4 was the best cut-off for frailty definition (sensitivity 77%, specificity 100%). Surgical grade III and grade IV complications were observed only in frail patients (p=0.01) and hospitalization was significantly longer in frail women affected by ovarian cancer (p=0.01). Frail patients were more exposed to chemotherapy administration delay (p=0.0005), treatment discontinuation (p=0.001) and hematological toxicities, especially anemia ≥grade 2 (p=0.009) and thrombocytopenia any grade (p=0.0001).

CONCLUSION

With a cut-off score of 4, our tool can identify frail patients with significantly higher incidence of grade III-IV postoperative complications, length of stay, medical treatment discontinuation rates and hematological toxicities.

The VES-13 and G-8 tools as predictors of toxicity associated with aromatase inhibitors in the adjuvant treatment of breast cancer in elderly patients: A single-center study

Background

Adjuvant hormone treatment of postmenopausal breast cancer is mainly based on aromatase inhibitors. Adverse events associated with such class of drugs are particularly severe in elderly patients. Therefore, we investigated the possibility of ab initio predict which elderly patients could encounter toxicity.

Methods

In light of national and international oncological guidelines recommending the use of screening tests for multidimensional geriatric assessment in elderly patients aged ≥70 years and eligible for active cancer treatment, we assessed whether the Vulnerable Elder Survey (VES)-13 and the Geriatric (G)-8 could be predictors of toxicity associated with aromatase inhibitors. Seventy-seven consecutive patients aged ≥70 diagnosed with non-metastatic hormone-responsive breast cancer and therefore eligible for adjuvant hormone therapy with aromatase inhibitors, were screened with the VES-13 and the G-8, and underwent a six-monthly clinical and instrumental follow-up in our medical oncology unit, from September 2016 to March 2019 (30 months). Said patients were identified as vulnerable (VES-13 score ≥3 or G-8 score ≤14) and fit (VES-13 score <3 or G-8 score >14). The likelihood of experiencing toxicity is greater among vulnerable patients.

Results

The correlation between the VES-13 or the G-8 tools and the presence of adverse events is equal to 85.7% (p = 0.03). The VES-13 demonstrated 76.9% sensitivity, 90.2% specificity, 80.0% positive predictive value, 88.5% negative predictive value. The G-8 demonstrated 79.2% sensitivity, 88.7% specificity, 76% positive predictive value, 90.4% negative predictive value.

Conclusion

The VES-13 and the G-8 tools could be valuable predictors of the onset of toxicity associated with aromatase inhibitors in the adjuvant treatment of breast cancer in elderly patients aged ≥70.

Clinical management of chemotherapy for elderly gynecological cancer patients

AIM

Since there are no established guidelines for the treatment of gynecological cancer in the elderly, medical treatment policy is currently decided by discussion with patients and their families based on doctors' experiences, referring to data from nonelderly patients and healthy elderly patients. The aim of this review was to clarify the current position of chemotherapy for elderly gynecological cancer patients and discuss the problems to be addressed in the future.

METHODS

Little evidence has been accumulated for anticancer drug treatment in elderly individuals with gynecological cancer. This review presents outlines and representative papers on general cancer chemotherapy for the elderly, and problems that need to be solved in gynecological cancer fields in the future are identified.

RESULTS

In 2018, the American Society of Clinical Oncology (ASCO) published guidelines for "Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology Summary". This guideline emphasizes that, when administering chemotherapy to patients over 65 years of age, vulnerabilities should be identified using geriatric assessment (GA). However, there have been no reports of clinical studies using GA in patients with cervical or uterine cancers, and only a few clinical studies using GA have been reported in patients with ovarian cancer.

CONCLUSIONS

Scoring systems suitable for elderly Japanese patients remain lacking. A Japanese gynecological GA needs to be developed in cooperation with other disciplines.

Role of the vulnerable elders survey-13 screening tool in predicting treatment plan modification for older adults with cancer

BACKGROUND

The Vulnerable Elders Survey (VES-13) is commonly used to identify older patients who may benefit from Comprehensive Geriatric Assessment (CGA) prior to cancer treatment. The optimal cut point of the VES-13 to identify those whose final oncologic treatment plan would change after CGA is unclear. We hypothesized that patients with high positive VES-13 scores (7-10)have a higher likelihood of a change in treatment compared to low positive scores (3-6).

METHODS

Retrospective review of a customized database of all patients seen for pre-treatment assessment in an academic geriatric oncology clinic from June 2015 to June 2019. Various VES-13 cut points were analyzed to identify those individuals whose treatment was modified after CGA. Area under the curve (AUC) was calculated and subgroups of patients treated locally or systemically were also examined to determine if performance varied by treatment modality.

RESULTS

We included 386 patients with mean age 81, 58% males. Gastrointestinal cancer was the most common site (31%) and 60% were planned to receive curative treatment. The final treatment plan was modified in 59% overall, with 52.7% modified with VES-13 scores 7-10, 50.8% with scores 3-6 and 28.1% with scores <3 (P = 0.002). VES-13 performance in predicting treatment modification was similar for cut points 3 (AUC 0.58), 4 (0.59), 5 (0.59), and 6 (0.59) and in those considering local treatment vs. chemotherapy.

CONCLUSIONS

A positive VES-13 score was associated with final oncologic treatment plan modification. A high positive score was not superior to the conventional cut point of ≥3.

Low surgical Apgar score in older patients with gynecological cancer is a risk factor for postoperative complications and 1-year mortality: A multicenter retrospective cohort study

Little is known about preoperative and intraoperative risk factors for postoperative complications in older patients with gynecological cancer. The present retrospective multi-institutional study included 173 older patients with primary gynecological cancer between January 2015 and December 2015 at four institutions. The cancer stage, medical history, Charlson comorbidity score, body mass index (BMI), subjective global assessment, fall risk assessment, American Society of Anesthesiologists physical status classification, surgical Apgar score (SAS), type of surgery and 1-year postoperative mortality were investigated. Multivariate analysis revealed that BMI and mental illness were risk factors for postoperative complications, and low SAS increased the risk for both postoperative complications and mortality within 1 year. Receiver operating characteristic curve analysis of postoperative complications in terms of SAS revealed that low SAS predicted high risk with a sensitivity of 85.7% and a specificity of 46.5%, and high SAS predicted low risk with a sensitivity of 21.4% and a specificity of 95%. The present results suggest that SAS, which is an intraoperative assessment, may be useful for assessing the risks of postoperative complications and mortality within 1 year. It is important to develop a preoperative assessment tool that can predict a low SAS score and reflect the postoperative prognosis of older patients with gynecological cancer.

Definition and assessment of frailty in older patients: the surgical, anaesthesiological and oncological perspective

The number of oncology, surgery and anaesthesia procedures in older patients has greatly increased in recent years due to ageing populations. Older patients are typically characterised by physical changes such as comorbidities, decline in physiological activities and cognitive impairment. All these factors, together with polypharmacological therapies, may substantially impact perioperative outcome, quality of recovery and, more in general, quality of life. A comprehensive multidisciplinary approach to perioperative care is thus needed. The assessment of frailty has a central role in the pre-operative evaluation of older patients and, with a multidisciplinary approach. The best surgical procedures and oncologic therapies can be accurately discussed in the pre- and post-operative periods. All clinicians involved in this scenario should be proactive in multidisciplinary care to achieve better outcomes.

Oral metronomic cyclophosphamide in advanced ovarian cancer: long-lasting clinical response in an elderly frailty patient

Elderly patients with ovarian cancer are an increasing population and many of them are frailty with an increased risk of postoperative complications, chemotherapy intolerance and mortality. Metronomic chemotherapy is the chronic administration of low, equally spaced, doses of antineoplastic drugs with therapeutic efficacy and low toxicity. Oral metronomic cyclophosphamide has gained increasing interest in recent years in the treatment of patients with recurrent ovarian cancer. We report the case of a 87-year-old and -frailty woman with advanced ovarian cancer, not eligible for surgery or standard first-line intravenous chemotherapy. The patient has received oral metronomic cyclophosphamide with a long-lasting clinical response and improved performance status. Oral metronomic cyclophosphamide is a promising treatment for elderly and frailty advanced ovarian cancer patients and should be further investigated.

Frailty is a determinant of suboptimal chemotherapy in women with advanced ovarian cancer

OBJECTIVE

To evaluate the relationship between frailty and chemotherapy delivery among women with epithelial ovarian cancer (EOC).

METHODS

We included women who underwent primary debulking surgery (PDS) for stage IIIC/IV EOC between 1/2/2003 and 12/30/2011, received adjuvant chemotherapy at our institution, and had data available to calculate a frailty deficit index. Frailty was defined as a frailty deficit index ≥0.15. Relative dose intensity (RDI) of chemotherapy was calculated as the percentage of the standard dose that was administered, and compared between frail and non-frail using the Wilcoxon rank-sum test.

RESULTS

Failure to receive chemotherapy following PDS was twice as common among frail vs. non-frail women (26.7% vs 14.2%, p = 0.001). Of the 169 women who received chemotherapy at our institution, 17.2% (29/169) were frail. Frail women were older (mean, 67.9 vs 62.3 years, p = 0.01), had higher BMI (mean, 29.6 vs 25.7 kg/m², p = 0.003), and were less likely to complete 6 cycles of chemotherapy (75.9 vs. 93.6%, p = 0.008). Using an RDI cutoff of 85%, frail women were less likely to have adequate doses of carboplatin (15.8 vs. 66.2%, p < 0.001) and paclitaxel (57.9 vs. 80.5%, p = 0.07) despite no differences in dose delays (34.5 vs. 42.1%), dose reductions (65.5 vs. 68.6%), and severe neutropenia (44.8 vs. 39.3%). After adjusting for age, frailty was associated with shorter progression-free (HR 1.58, 95% CI: 0.99-2.50) and overall survival (HR 2.14, 95% CI: 1.35-3.41).

CONCLUSION

Frail women with EOC were less likely to receive chemotherapy or the optimal dose of chemotherapy after PDS despite no evidence of treatment-related toxicity. Frail EOC patients demonstrated shorter progression-free and overall survival. Further studies are needed to explore the association between frailty, chemotherapy, and survival.

Validation of the French version of the Vulnerable Elders Survey-13 (VES-13)

Background

Identifying and assessing degree and type of frailty among older persons is a major challenge when targeting high risk populations to identify preventive interventions. The Vulnerable Elders Survey-(VES-13) is a simple instrument to identify frailty defined as risk for death, functional decline or institutionalization.

Objective

Translate VES-13 into French and validate it.

Methods

The French version of VES-13 was developed by forward-backward translation of the VES-13 survey instrument. The authors assessed its feasibility, construct validity, and ability to predict the combined outcomes of admission to institution or death at 18 months, in 135 persons over 70 years of age living in the community. Subjects were recruited from three settings: Group 1 – a health prevention center (n = 45); Group 2 – an ambulatory care geriatric clinic (n = 40); and Group 3 – an intermediate care hospital unit (n = 50). The combined outcomes data were recorded by telephone interview with participants or a proxy.

Results

Feasibility of the French version, named Echelle de Vulnérabilité des Ainés-13 or EVA-13, was excellent. The scale classified 5 (11%) persons as vulnerable (score of 3 or more) in Group 1, 23 (58%) in Group 2 and 45 (90%) in Group 3 (p < 0.001) with scores of 0.91 +/− 1.16, 4.27 +/− 3.17 and 6.90 +/− 3.17, respectively (p < 0.001). At follow-up, among the 60 non-vulnerable subjects, 58 (96%) were alive and living at home, whereas 46 (65%) of the 70 vulnerable subjects were alive and living at home (p < 0.001).

Conclusions

EVA-13 was determined to be valid and reliable.