Prediction of hospital admissions and grade 3-4 toxicities in cancer patients 70 years old and older receiving chemotherapy

Dietary restriction rescues 5-fluorouracil-induced lethal intestinal toxicity in old mice by blocking translocation of opportunistic pathogens

Chemotherapy remains a major treatment for malignant tumors, yet the application of standard dose intensity chemotherapy is limited due to the side effects of cytotoxic drugs, especially in old populations. The underlying mechanisms of cytotoxicity and strategies to increase the safety and tolerance of chemotherapy remain to be explored. Using 5-fluorouracil (5-FU), a cornerstone chemotherapeutic drug, we demonstrate that the main cause of death in ad libitum (AL) fed mice after 5-FU chemotherapy was infection caused by translocation of intestinal opportunistic pathogens. We show that these opportunistic pathogens greatly increase in the intestine after chemotherapy, which was closely related to loss of intestinal lysozyme. Of note, two weeks of dietary restriction (DR) prior to chemotherapy significantly protected the loss of lysozyme and increased the content of the beneficial Lactobacillus genera, resulting in a substantial inhibition of intestinal opportunistic pathogens and their translocation. The rescue effect of DR could be mimicked by Lysozyme or Lactobacillus gavage. Our study provides the first evidence that DR achieved a comprehensive protection of the intestinal physical, biological and chemical barriers, which significantly improved the overall survival of 5-FU-treated mice. Importantly, the above findings were more prominent in old mice. Furthermore, we show that patients over 65 years old have enriched opportunistic pathogens in their gut microbiota, especially after 5-FU based chemotherapy. Our study reveals important mechanisms for the poor chemotherapy tolerance of the elderly population, which can be significantly improved by short-term DR. This study generates new insights into methods for improving the chemotherapeutic prognosis by increasing the chemotherapy tolerance and safety of patients with malignant tumors.

Toxicities and Quality of Life during Cancer Treatment in Advanced Solid Tumors

The purpose of the study was to identify subgroups of advanced cancer patients who experienced grade 3-4 toxicities as reported by their oncologists as well as identify the demographic, clinical, and treatment symptom characteristics as well as QoL outcomes associated with distinct profiles of each patient. A prospective, multicenter, observational study was conducted with advanced cancer patients of 15 different hospitals across Spain. After three months of systemic cancer treatment, participants completed questionnaires that evaluated psychological distress (BSI-18), quality of life (EORTC QLQ-C30) and fatigue (FAS). The most common tumor sites for the 557 cancer patients with a mean age of 65 years were bronchopulmonary, digestive, and pancreas. Overall, 19% of patients experienced high-grade toxicities (grade 3-4) during treatment. Patients with recurrent advanced cancer, with non-adenocarcinoma cancer, undergoing chemotherapy, and a showing deteriorated baseline status (ECOG > 1) were more likely to experience higher toxicity. Patients who experienced grade 3-4 toxicities during cancer treatment had their treatment suspended in 59% of the cases. Additionally, 87% of the patients had a dose adjustment or a cycle delayed in their treatment due to a high risk of dying during treatment. Future research should focus on identifying interventions to reduce high-grade toxicities and improve quality of life in cancer patients.

Presentation, Molecular Characteristics, Treatment, and Outcomes of Colorectal Cancer in Patients Older than 80 Years Old

Background: An increasing proportion of the population of patients with cancer presents at an advanced age, increasing the challenges of successful and well-tolerated treatments. In the older spectrum of the geriatric cancer patients, those older than 80 years old, challenges are even higher because of increasing comorbidities and decreasing organ function reserves. Methods: Studies regarding colorectal cancer presentation, treatment, and prognosis in patients older than 80 years old available in the literature were evaluated and were compiled within a narrative review. Molecular attributes of colorectal cancer in the subset of patients older than 80 years old in published genomic cohorts were also reviewed and were compared with similar attributes in younger patients. Results: Characteristics of colorectal cancer in octogenarians are in many aspects similar to younger patients, but patients older than 80 years old present more often with right colon cancers. Surgical treatment of colorectal cancer in selected patients over 80 years old is feasible and should be pursued. Adjuvant chemotherapy is under-utilized in this population. Although combination chemotherapy is in most cases not advisable, monotherapy with fluoropyrimidine derivatives is feasible and efficacious. Conclusions: Outcomes of colorectal cancer patients over the age of 80 years old may be optimized with a combination of standard treatments adjusted to the individual patient's functional status and organ reserves. Increased support for the older age group during their colorectal cancer treatment modalities would improve oncologic outcomes with decreasing adverse outcomes of therapies.

An evaluation of the Index4 tool for chemotherapy toxicity prediction in cancer patients older than 70 years old

Chemotherapy, although beneficial for improving outcomes in both localized and metastatic cancers, may be associated with significant adverse effects, especially for patients with decreased functional reserves. Prediction of patients who will not tolerate well chemotherapy treatment may help in modifying treatment plans and in reallocating resources to vulnerable patients. One hundred seventeen consecutive cancer patients over the age of 70 scheduled for chemotherapy treatment in a single cancer center were included in the study. Prediction of adverse chemotherapy outcomes were calculated using a prediction tool proposed and validated from the Cancer and Aging Research Group (CARG) and a prediction tool proposed by us, called Index4. The 2 tools were compared for their ability to predict grade 3 and 4 toxicities, Emergency Department (ED) and hospital admissions and chemotherapy discontinuation. The accuracy of both predictive tools was suboptimal. A high CARG score had a sensitivity of 46.3% and a specificity of 82% and an Index4 of 1 or above had a sensitivity of 53.7% and a specificity of 60% in predicting grade 3-4 adverse effects. The performance of the 2 tools in predicting ED and hospital admissions and chemotherapy discontinuation was comparable. An Index4 score of 0 was superior in predicting absence of grade 3-4 toxicities than a low CARG score (p = 0.002, McNemar's test). The CARG tool for chemotherapy adverse effect prediction in geriatric cancer patients and the Index4 were able to predict adverse outcomes with moderate accuracy. Given its ease of calculation Index4 may be an alternative to CARG tool, suitable for a busy oncology practice.

Prediction of Chemotoxicity, Unplanned Hospitalizations and Early Death in Older Patients with Colorectal Cancer Treated with Chemotherapy

Simple Summary

Chemotoxicity, unplanned hospitalizations (Uhs) and early death (ED) are common among older patients with cancer who receive chemotherapy. Our objective was to determine factors predicting these complications. A predictive score for these three complications based on geriatric, tumor and laboratory variables was developed in a series of 215 older patients with colorectal carcinoma receiving chemotherapy. The use of this score may reliably identify patients at risk to have excessive toxicity with chemotherapy, UH or ED, thus helping to plan treatment, implement adaptive measures, and intensify follow-up.

Abstract

Purpose: To identify risk factors for toxicity, unplanned hospitalization (UH) and early death (ED) in older patients with colorectal carcinoma (CRC) initiating chemotherapy. Methods: 215 patients over 70 years were prospectively included. Geriatric assessment was performed before treatment, and tumor and treatment variables were collected. The association between these factors and grade 3–5 toxicity, UH and ED (<6 months) was examined by using multivariable logistic regression. Score points were assigned to each risk factor. Results: During the first 6 months of treatment, 33% of patients developed grade 3–5 toxicity, 31% had UH and 23% died. Risk factors were, for toxicity, instrumental activities of daily living, creatinine clearance, weight loss and MAX2 index; for UH, Charlson Comorbidity Score, creatinine clearance, weight loss, serum albumin, and metastatic disease; and for ED, basic activities in daily living, weight loss, metastatic disease, and hemoglobin levels. Predictive scores were built with these variables. The areas under receiver operation characteristic (ROC) curves for toxicity, UH and ED were 0.70 (95% CI: 0.64–0.766), 0.726 (95% IC: 0.661–0.799) and 0.74 (95% IC: 0.678–0.809), respectively. Conclusion: Simple scores based on geriatric, tumor and laboratory characteristics predict severe toxicity, UH and ED, and may help in treatment planning.

Systematic Review and Meta-Analysis on the Associations of Polypharmacy and Potentially Inappropriate Medication With Adverse Outcomes in Older Cancer Patients

BACKGROUND

Both polypharmacy and potentially inappropriate medication (PIM) intake are highly prevailing in older cancer patients. However, only studies on the association of polypharmacy and postoperative complications have been meta-analyzed previously.

METHODS

A systematic review and a meta-analysis of prospective/retrospective observational studies reporting associations of polypharmacy or PIM with at least one out of five predefined adverse health outcomes in a population of older cancer patients (≥60 years) were carried out. PubMed and Web of Science were used to search for relevant studies published between January 1991 and March 2020. Data were pooled by adopting a random-effects model.

RESULTS

Overall, 42 publications were included in the systematic review. Meta-analyses could be performed on 39 studies about polypharmacy and 13 studies about PIM. Polypharmacy was found to be statistically significantly associated with all-cause mortality (risk ratio [95% confidence interval]: 1.37 [1.25-1.50]), hospitalization (1.53 [1.37-1.71]), treatment-related toxicity (1.22 [1.01-1.47]), and postoperative complications (1.73 [1.36-2.20]). The association of polypharmacy with prolongation of hospitalization was not statistically significant at the p < .05 significance level (1.62 [0.98-2.66]). With respect to PIM, a statistically significant association with all-cause mortality (1.43 [1.08-1.88]) was observed but not with other adverse outcomes.

CONCLUSIONS

Polypharmacy was found to be associated with several adverse outcomes and PIM use with all-cause mortality in older cancer patients. However, these results should be interpreted with caution because about three-quarters of the studies identified did not adjust for comorbidity and are prone to confounding by indication.

Unplanned emergency department visits and hospital admissions of older adults under treatment for cancer in the ambulatory/community setting

PURPOSE

This study aims to identify the incidence and risk/protective factors for (1) unplanned emergency department (ED) visits and hospital admissions (HA) and (2) nausea/vomiting/dehydration (NVD) at time of treatment in older adults under treatment for cancer.

MATERIALS AND METHODS

This is a exploratory retrospective cohort study of adults (60 and older) with cancer. Adults were included if they had a new cancer diagnosis and were being treated with chemotherapy. Study outcomes included the number of ED visits and HA (cycles 1-4) and NVD at the time of receiving chemotherapy (cycles 2-4). Repeated measures, Poisson regression was used to obtain risk ratios with 95% confidence intervals for independent predictors of outcomes.

RESULTS

Of 402 study participants, 20% experienced an ED visit, and 18% experienced a HA. Common reasons for ED visits were pain (23.5%) and NVD (20.4%). Common reasons for HA were infection (34.4%) and NVD (22.2%). Multivariate analysis showed risk factors for ED visits included chemotherapy cycle 1, having esophageal cancer, being treated with ≥ 3 chemotherapy agents, and increasing levels of functional impairment. Risk factors for HA included chemotherapy cycle 1, increasing levels of functional impairment, intravenous fluids between treatment, and being prescribed antiemetics for home use. Predictors of NVD at time of chemotherapy treatment included Hispanic ethnicity, insurance status, cancer type, chemotherapy emetic potent, treatment frequency, intravenous fluids between cycles, and number of home antiemetics.

CONCLUSION

Unplanned ED visits and HA occur in older adults under treatment for cancer due to numerous treatment-related side effects. Helping older adults identify and manage side effects early may reduce the number of unplanned admissions.

Predictors of Unplanned Hospitalizations Among Older Adults Receiving Cancer Chemotherapy

PURPOSE

Hospitalizations during cancer treatment are costly, can impair quality of life, and negatively affect therapy completion. Our objective was to identify risk factors for unplanned hospitalization among older adults receiving chemotherapy.

METHODS

This is a secondary analysis of a multisite cohort study (N = 750) of patients ≥ 65 years of age evaluated with a geriatric assessment (GA) to predict chemotherapy toxicity. The primary outcome of this analysis was unplanned hospitalizations during treatment; the secondary outcome was length of stay (LOS) of the first hospitalization. Independent variables included pretreatment GA measures, laboratory values, cancer type and stage, and treatment intensity characteristics. We used logistic regression to estimate the odds of hospitalization and generalized linear models for LOS in multivariable analyses.

RESULTS

The sample median age was 72 years (range, 65-94 years); 59% had stage IV disease. At least one unplanned hospitalization occurred in 193 patients (25.7%) during receipt of chemotherapy. In multivariable analyses controlling for cancer type, the following baseline characteristics were significantly associated with increased odds of hospitalization: needing help bathing or dressing (odds ratio [OR], 1.8; 95% CI, 1.0 to 3.1), polypharmacy (≥ 5 meds) (OR, 1.6; 95% CI, 1.1 to 2.4), more comorbid conditions (OR, 1.1; 95% CI, 1.0 to 1.3), availability of someone to take them to the doctor (OR, 2.0; 95% CI, 1.0 to 4.1), CrCl < 60 mL/min (OR, 1.7; 95% CI, 1.1 to 2.4), and albumin < 3.5 g/dL (OR, 1.8; 95% CI, 1.2 to 2.8). In multivariable analyses, older age, self-reported presence of liver or kidney disease, living alone and depressive symptoms were associated with longer LOS.

CONCLUSION

Readily available GA variables and laboratory data, but not age, were associated with unplanned hospitalizations among older adults receiving chemotherapy. If validated, these data can inform prediction models and the design of interventions to decrease unplanned hospitalizations.

Prediction of Unplanned Hospitalizations in Older Patients Treated with Chemotherapy

PURPOSE

To determine the incidence of unplanned hospitalization (UH) and to identify risk factors for UH in elderly patients with cancer who start chemotherapy.

METHODS

In all, 493 patients over 70 years starting new chemotherapy regimens were prospectively included. A pre-chemotherapy geriatric assessment was performed, and tumor and treatment variables were collected. The association between these factors and UH was examined by using multivariable logistic regression. Score points were assigned to each risk factor.

RESULTS

During the first 6 months of treatment, 37% of patients had at least one episode of UH. Risk factors were the use of combination chemotherapy at standard doses, a MAX2 index ≥1, a Charlson comorbidity score ≥2, albumin level <3.5 g/dL, falls in the past 6 months ≥1, and weight loss >5%. Three risk groups for UH were established according to the score in all patients: 0-1: 17.5%; 2: 34%; and 3-7: 57% (p < 0.001). The area under receiver operation characteristic (ROC) curve was 0.72 (95% CI: 0.67-0.77).

CONCLUSION

This simple tool can help to reduce the incidence of UH in elderly patients with cancer who are scheduled to initiate chemotherapy treatment.

Breast Cancer in Patients 80 Years-Old and Older

Objective

Breast cancer is the most common cancer in women and one in ten patients affected are over age 80. However, this age group is mostly excluded from clinical trials and data to inform their care is sparse.

Materials and Methods

Medical records of all patients aged 80 years-old and older diagnosed and treated for breast cancer in a single center over a six-year period were retrospectively reviewed. A cohort of patients aged 65 to 75 treated for breast cancer at the same center during the same period was also reviewed for comparison.

Results

Patients in the 80 and over age group were commonly diagnosed with stage II or III disease (39.2%) compared to younger patients who were diagnosed more commonly (61.6%) with stage I disease. Sub-types of breast cancer had a similar representation in the two groups. Hormonal therapy was used equally in the two groups, but significantly fewer patients in the 80 and over age group had radiation therapy and chemotherapy as part of their treatment. Despite these differences, recurrence rates were not significantly different between the two groups.

Conclusion

Individualized treatments taking into consideration the patient's general status, comorbidities and life expectancy are feasible in the older breast cancer population and result in outcomes similar to those of younger patients in the short and intermediate terms.