Management of metastatic prostate cancer: the crucial role of geriatric assessment

Clinical, Diagnostic and Therapeutic Framework of mHSPC and nmCRPC: A Multidisciplinary Consensus Project of the Italian Society for Uro-Oncology (SIUrO)

The recent evidences provided in metastatic hormone sensitive prostate cancer (nmHSPC) and in nonmetastatic castration resistant (nmCRPC) introduced the possibility to adopt Androgen Receptor Signaling inhibitor (ARSi) alone (both settings) or with chemotherapy (in mHSPC). In daily clinical practice there are some opening questions regarding the inclusion of next generation imaging, mainly PSMA-PET, how integrate local treatment as radiotherapy, how to select patients or drugs in a multiple-choice scenario, and how to manage patients with comorbidities and polypharmacy. These issues led the Italian Society for Uro-Oncology (SIUrO) to develop a consensus project involving all of the most important Italian scientific societies engaged in the multidisciplinary and multiprofessional management of the disease. This paper describes the items and statements approved, with the aim to support clinicians in managing metastatic hormone sensitive and nonmetastatic castration resistant prostate cancer patients.

Regulation and role of CAMKK2 in prostate cancer

In 2011, CAMKK2, the gene encoding calcium/calmodulin-dependent kinase kinase 2 (CAMKK2), was demonstrated to be a direct target of the androgen receptor and a driver of prostate cancer progression. Results from multiple independent studies have confirmed these findings and demonstrated the potential role of CAMKK2 as a clinical biomarker and therapeutic target in advanced prostate cancer using a variety of preclinical models. Drug development efforts targeting CAMKK2 have begun accordingly. CAMKK2 regulation can vary across disease stages, which might have important implications in the use of CAMKK2 as a biomarker. Moreover, new non-cell-autonomous roles for CAMKK2 that could affect tumorigenesis, metastasis and possible comorbidities linked to disease and treatment have emerged and could present novel treatment opportunities for prostate cancer.

Geriatric Nutritional Risk Index as a Prognostic Marker for Patients With Metastatic Castration-Resistant Prostate Cancer Receiving Docetaxel

Purpose: To investigate the prognostic efficacy of the Geriatric Nutritional Risk Index (GNRI) in patients with metastatic Castration–resistant Prostate Cancer (mCRPC) receiving docetaxel as the first line of treatment.

Methods: We retrospectively reviewed patients with mCRPC and receiving first line docetaxel in Taichung Veterans General Hospital from 2006 to 2012. The GNRI was calculated using serum albumin and body mass index, with a poor nutritional status defined as GNRI <92.0. Multivariate Cox-regression analysis was used to evaluate the risk of survival.

Results: One-hundred seventy patients with mCRPC were included. One-hundred twenty-five patients were of normal nutritional status (GNRI ≥92) and 45 patients were of poor nutritional status (GNRI <92). The cumulative docetaxel dosage was 600 (360–1,185) mg in the normal nutritional status group and 360 (127.5–660) mg in the poor nutritional status group (p < 0.001). The median overall survival from mCRPC was 30.39 months in the good nutritional status group and 11.07 months in the poor nutritional status group (p of log rank <0.001). In a multivariate model, poor nutritional status was an independent risk factor in overall survival (Hazard Ratio [HR] = 5.37, 95% Confidence Interval [CI] 3.27–8.83), together with a high metastatic volume (HR = 4.03, 95% CI 2.16–7.53) and docetaxel cumulative dosage (HR = 0.999, 95% CI 0.999–0.9998).

Conclusion: Poor nutritional status with a GNRI <92 is associated with shorter progression free survival and overall survival in mCRPC patients treated with docetaxel. Metastatic volume and cumulative docetaxel dosage are also independent prognostic factors in overall survival.

Risk Assessment and Considerations for Proper Management of Elderly Men with Advanced Prostate Cancer: A Systematic Review

CONTEXT

Treatment decisions for elderly men with prostate cancer are complicated by the intersection of competing risks of cancer, potential complications of treatment, and individual patients' comorbidities.

OBJECTIVE

To perform a systematic review of data guiding the assessment of elderly prostate cancer patients that addresses the risk from cancer and treatment, and to discuss a patient-centered approach to incorporating these factors into decision making.

EVIDENCE ACQUISITION

Evidence was gathered via a systematic review of the current literature. The search strategy used the terms prostate cancer, elderly, geriatric, >75 yr of age, risk assessment, and treatment in several combinations, and was limited to phase ≥ II clinical trials published between January 2008 and November 2018. Additional supporting literature for the discussion was pulled by hand search.

EVIDENCE SYNTHESIS

The benefits of treatment identified for systemic therapies commonly used to treat men with prostate in general extend to elderly patients. Evidence supports a multifaceted assessment of the risks of cancer and aging, and an understanding of the side effects of treatment to optimally guide therapeutic decision making for elderly patients. There is little evidence defining a geriatric risk stratification system specific to prostate cancer, and recommendations are predominantly based on adapted geriatric oncology approaches and expert consensus.

CONCLUSIONS

The care of elderly men with prostate cancer should incorporate a review of cancer risk, an assessment of aging, and an understanding of the effects of treatment to provide the patient with thorough and personalized guidance for treatment decisions. Future studies of elderly men with prostate cancer can define and validate ideal risk stratification methods as well as management approaches that may be distinct from those for younger populations.

PATIENT SUMMARY

Treatment decisions for elderly men with prostate cancer require consideration of the risk posed by the cancer coupled with an understanding of the patient's general health status.

Targeting the androgenic pathway in elderly patients with castration-resistant prostate cancer: A meta-analysis of randomized trials

BACKGROUND

The novel hormonal drugs have recently entered in the armamentarium of therapies for treatment of metastatic castration-resistant prostate cancer (CRPC). First reports are available for their use in elderly men with CRPC.

METHOD

A meta-analysis of randomized controlled trials (RCTs) has been performed. PubMed, the Cochrane Library, and American Society of Clinical Oncology (ASCO) University Meeting were searched for data on the use of new hormonal treatment in elderly patients with CRPC.

RESULTS

Nine studies for a total of 3512 elderly patients were available for meta-analysis. Six studies reported outcomes of patients aged >75 years old while 2 studies reported on patients aged >70 years old. The pooled analysis of the androgen synthesis inhibitors revealed significantly increased overall survival (OS) due to antiandrogen agents compared with placebo or placebo and prednisone (hazard ratio (HR) for death: HR = 0.74, 95% CI: 0.67-0.82; P < 0.00001). Moreover, the new antiandrogenic therapy significantly improved the progression-free survival (HR = 0.45, 95% CI: 0.31-0.65; P < 0.0001). The incidence of any grade ≥3 adverse effect was only moderately higher during with the antiandrogenic therapy as compared to the control arms (response rate = 1.03, 95% CI: 0.88-1.20; P = 0.72).

CONCLUSION

This study confirmed that agents targeting the androgen axis (i.e., enzalutamide, abiraterone) significantly prolonged OS in elderly men with CRPC.

Graphene oxide-wrapped PEGylated liquid crystalline nanoparticles for effective chemo-photothermal therapy of metastatic prostate cancer cells

Here, we report the preparation of PEGylated liquid crystalline nanoparticles (LCN) loaded with docetaxel (DTX) and wrapped with graphene oxide (GO), called PEG-GO/LCN/DTX, for effective chemo-photothermal therapy of metastatic prostate cancer cells. The prepared formulation exhibited a small particle size (<250 nm), high drug loading capacity (∼15%), and efficient near infrared (NIR) light-induced thermal heat. Importantly, PEG-GO/LCN/DTX successfully accumulated in prostate cancer cells and exhibited potent apoptotic and antimigration effects, mediated by the combination of the anticancer effects of DTX and the thermal heat induced by exposure of GO to NIR light. Taken together, our findings support that PEG-GO/LCN/DTX may be an effective system for treatment of metastatic prostate cancer. Moreover, the results establish a proof-of-concept for the potential chemo-photothermal functionality of PEG-GO/LCN/DTX. This hybrid system of LCN and GO could provide controlled and targeted drug delivery with enhanced NIR-induced thermal effects for effective treatment of metastatic cancers.

Improved outcomes in elderly patients with metastatic castration-resistant prostate cancer treated with the androgen receptor inhibitor enzalutamide: results from the phase III AFFIRM trial

BACKGROUND

The randomized, double-blind phase III AFFIRM trial demonstrated that enzalutamide, an oral androgen receptor inhibitor, significantly prolonged overall survival (OS) [median 18.4 versus 13.6 months (hazard ratio, HR) 0.63 (95% confidence interval, CI, 0.53-0.75); P<0.001] compared with placebo in patients with metastatic castration-resistant prostate cancer who received prior docetaxel chemotherapy.

PATIENTS AND METHODS

A post hoc analysis was carried out to assess the efficacy and safety of enzalutamide on outcomes in younger (<75 years) and elderly (≥75 years) patients in the AFFIRM population. Statistics are presented by age group (<75 years, ≥75 years) for efficacy outcomes of OS, radiographic progression-free survival (rPFS), time to prostate-specific antigen (PSA) progression, PSA response, and safety.

RESULTS

OS was significantly improved with enzalutamide over placebo in patients<75 years [median not yet reached versus 13.6 months; HR 0.63 (95% CI 0.52-0.78), P<0.001] and in patients ≥75 years [median 18.2 versus 13.3 months; HR 0.61 (95% CI 0.43-0.86), P=0.004], respectively. rPFS was similarly improved in both the younger [HR 0.45 (95% CI 0.38-0.53), P<0.001] and elderly patient cohorts [HR 0.27 (95% CI 0.20-0.37), P<0.001] relative to placebo, as were time to PSA progression and PSA response. Adverse events (AEs) were similar between the two enzalutamide age groups, with the exception of an increase in patients≥75 years in the rates of all grade peripheral edema (22.1% versus 12.5%), fatigue (39.7% versus 31.6%), and diarrhea (26.6% versus 19.6%). The overall grade≥3 AE rates were low with no major difference in frequency or severity between age groups or treatment arms. Five patients were reported with seizure events; three patients<75 years and two patients ≥75 years.

CONCLUSIONS

Enzalutamide significantly improves outcomes in both younger (<75 years) and elderly patients (≥75 years), with comparable safety and tolerability.

Docetaxel based chemotherapy in the treatment of patients with castration resistant prostate cancer

INTRODUCTION

Docetaxel administered every 3- weeks is the standart treatment of castration resistant prostate cancer (CRPC) but it is associated with dose limiting toxicities. We analyzed the efficacy and tolerability of 3- weekly and weekly docetaxel in a Turkish cohort of CRPC patients with a special emphasis on the elderly patients.

MATERIALS AND METHODS

A retrospective analyses of 45 patients who received either 3- weekly or weekly docetaxel in a single urologic oncology clinic was performed. Response to therapy, toxicity and overall survival rates were evaluated.

RESULTS

The mean age of patients was 70.0 (±8.8) years. Complete or partial PSA response was obtained in 45% of patients. The median overall survival was 20,0 months (SE 6.46; 95% CI 7,3-32,6). Absence of metastasis, time to CRPC>10 months, DP 75mg/m2 once every three weeks and PSA<50% at the end of the third cycle were associated with better overall survival. There was no significant survival difference between the patients aged 75 or older versus younger ones. The most common hematological toxicity was leukopenia which was dose limiting in only one patient.

CONCLUSION

Administration of standart 3-weekly docetaxel is well tolerated in this relatively old cohort of Turkish CRPC patients and weekly administration can be a reasonable alternative in frail patients not only to prolong survival but also to palliate disease symptoms.

[Management of prostate cancer in the elderly]

The management of prostate cancer in elderly patients is a topic of controversial discussion. The current guidelines recommend diagnosis and treatment of prostate cancer only in patients with a life expectancy of more than 10 years. Especially in elderly patients pre-existing comorbidities play a crucial role in life expectancy. In clinical practice mostly patient age alone is considered for the treatment decision; however, a guideline-based therapy of prostate cancer should also be offered to elderly patients. The treatment decision should be based on patient general health status and the oncological risk. The patient individual health status can be determined on the basis of comorbidities present and patient nutritional and performance status. For an optimal therapy regime the oncological risk has to be considered in treatment decisions. The aim of this article is to give an overview of risk stratification and treatment options for localized and metastatic prostate cancer in elderly patients.

A comment on the International Society of Geriatric Oncology guidelines: evidence-based advice for the clinical setting

Largely a disease of older men, prostate cancer is likely to become a growing burden in the developed world as the population ages and overall life expectancy increases. Furthermore, prostate cancer management in older men is not optimal, reflecting the lack of training dedicated to senior adults in fellowship programs and the lack of specific guidelines to manage senior adults. The International Society of Geriatric Oncology (SIOG) convened a multidisciplinary Prostate Cancer Working Group to review the evidence base and provide advice on the management of the disease in senior age groups. The Working Group reported that advancing age, by itself, is not a reliable guide to treatment decision making for men with either localized or advanced prostate cancer. Instead, the SIOG guidelines advise health care teams to assess the patient's underlying health status, which is largely dictated by associated comorbid conditions, but also by dependency in activities of daily living and nutritional status, and to use the findings to categorize the individual into one of four groups: healthy, vulnerable, frail, or terminally ill. The guidelines recommend that a patient categorized as healthy or vulnerable (i.e., with reversible problems following geriatric intervention) should receive the same approach to treatment as a younger patient. Frail patients should be managed using adapted treatment strategies, and the terminally ill should receive symptomatic/palliative care only. The guidelines may have ongoing relevance as the treatment options for prostate cancer expand.

Docetaxel in combination with estramustine and prednisolone for castration-resistant prostate cancer

BACKGROUND

The aim of this study was to investigate the efficacy and toxicity of docetaxel-based chemotherapy, and to investigate pretreatment factors that can predict overall survival (OS) in patients with castration-resistant prostate cancer (CRPC).

METHODS

From June 2005 to July 2010, 70 patients with CRPC underwent docetaxel-based chemotherapy at Wakayama Medical University and related hospitals. Docetaxel was given at a dose of 70 mg/m(2) once every 3 weeks or 35 mg/m(2) twice every 3 weeks. Oral estramustine 560 mg was given concurrently for five consecutive days during weeks 1 and 2 of each cycle, and prednisolone 10 mg was given every day. Dexamethasone 8 mg was premedicated intravenously before docetaxel administration.

RESULT

The patients received a median of four cycles of treatment (range 1-31). In the serum prostate-specific antigen response, 13 (18.6%) patients achieved a complete response and 29 (41.4%) achieved a partial response. Median OS and time to progression were 14 months and 6 months, respectively. Median follow-up period was 9.5 months. Two independent pretreatment risk factors that predicted OS were visceral metastasis including lymph node metastasis and anemia. Grade 3/4 neutropenia and anemia occurred in 25.7 and 8.6% of the patients, respectively. Four treatment-related deaths were seen during the observation period.

CONCLUSION

The combination of docetaxel, estramustine and prednisolone was effective in Japanese patients with CRPC; however, this combination therapy should be carefully indicated to elderly and/or poor performance status patients due to its toxicity. Visceral metastasis and anemia were identified as independent risk factors which could predict OS.

Nanosponge-encapsulated camptothecin exerts anti-tumor activity in human prostate cancer cells

Camptothecin (CPT) is a potent DNA Topoisomerase I inhibitor with anti-tumor activity in hematological and solid tumors. However, it did not reach clinical use because of its poor solubility and high degrability. β-Cyclodextrin nanosponge (CN) have been demonstrated to be able to increase the solubility of lipophilic compounds and to protect them from degradation. In the present study, we evaluated whether β-Cyclodextrin nanosponge carriers can overcome CPT chemical disadvantages and improve the in vitro anti-tumor efficacy in the androgen refractory models of prostate cancer DU145 and PC-3 and the androgen sensitive model LNCaP. Camptothecin-loaded β-Cyclodextrin nanosponge (CN-CPT) showed sizes of about 400 nm, spherical shape and a drug loading of 38%. HPLC analysis, performed on the cell pellet after treatment with CN-CPT revealed that CPT concentration increased over time indicating a prolonged release of the drug. Moreover, CN-CPT inhibited Topoisomerase I activity, and induced DNA damage, and cell cycle arrest more effectively than CPT, indicating that the CN-CPT formulation does not affect activity of the drug. Moreover, Annexin V/Propidium Iodide staining showed an induction of cell death at low concentrations that were not effective for CTP. LNCaP cells were less sensitive to CPT than PC-3 and DU145 cells, but CN-CPT still exerted higher anti-proliferative activity and DNA damage ability than CPT. The experiments performed in LNCaP cells demonstrated that CN-CPT treatment inhibited expression of the androgen receptor at doses where CPT was ineffective. Our results demonstrated the higher anti-tumor effectiveness of CN-CPT compare to CPT in prostate cancer cells, supporting the relevance of future studies for the use of the β-Cyclodextrin nanosponge to deliver anticancer drugs in vivo.

Care of the elderly patient with prostate cancer: what's new and what's the same

As the number of men in the United States 65 years of age or older increases--from 12% in 2000 to 20% in 2030--the burden of prostate cancer also is increasing. Standard therapy is appropriate for healthy men with a life expectancy of more than 10 years; however, clinicians may fear either overtreating frail patients or undertreating patients who are physically fit. Evidence suggests the best approach is to conduct a comprehensive geriatric assessment using available measures and published guidelines to individualize treatment plans. Recent Food and Drug Administration approval of cabazitaxel, sipuleucel-T, and denosumab has expanded available treatment options. Managing symptoms related to disease complications and side effects of treatment is increasingly more complicated with the addition of these new regimens and extended life expectancy. Pharmacists' participation in patient assessment and supportive care are necessary components of comprehensive care for cancer patients.

Management of prostate cancer in older men: recommendations of a working group of the International Society of Geriatric Oncology

Prostate cancer is the most prevalent cancer in men and predominantly affects older men (aged >or=70 years). The median age at diagnosis is 68 years; overall, two-thirds of prostate cancer-related deaths occur in men aged >or=75 years. With the exponential ageing of the population and the increasing life-expectancy in developed countries, the burden of prostate cancer is expected to increase dramatically in the future. To date, no specific guidelines on the management of prostate cancer in older men have been published. The International Society of Geriatric Oncology (SIOG) conducted a systematic bibliographic search based on screening, diagnostic procedures and treatment options for localized and advanced prostate cancer, to develop a proposal for recommendations that should provide the highest standard of care for older men with prostate cancer. The consensus of the SIOG Prostate Cancer Task Force is that older men with prostate cancer should be managed according to their individual health status, which is mainly driven by the severity of associated comorbid conditions, and not according to chronological age. Existing international recommendations (European Association of Urology, National Comprehensive Cancer Network, and American Urological Association) are the backbone for localized and advanced prostate cancer treatment, but need to be adapted to patient health status. Based on a rapid and simple evaluation, patients can be classified into four different groups: 1, 'Healthy' patients (controlled comorbidity, fully independent in daily living activities, no malnutrition) should receive the same treatment as younger patients; 2, 'Vulnerable' patients (reversible impairment) should receive standard treatment after medical intervention; 3, 'Frail' patients (irreversible impairment) should receive adapted treatment; 4, Patients who are 'too sick' with 'terminal illness' should receive only symptomatic palliative treatment.

Patient-reported outcomes after cytotoxic chemotherapy in metastatic castration-resistant prostate cancer: a systematic review

BACKGROUND

In the clinical setting of metastatic castration-resistant prostate cancer the aim of treatment is palliation. Palliation can refer to symptom management or non-curative treatments. Patient-reported outcome is any outcome based on data provided by patients. The aim of this paper is to perform a systematic review of clinical trials including a patient-reported outcome assessment in patients treated with cytotoxic chemotherapy, and to compare their results by traditional medical and patient-reported outcomes assessment.

METHODS

In November 2009 a literature search for published studies was undertaken. Selected phase-3 studies were primarily evaluated on the quality of patient-reported outcomes reporting and assessment methodology.

FINDINGS

Health-related quality of life assessment was the most common endpoint, pain control the second one. Results of patient-reported and traditional endpoints analysis are resumed, as well as methodology assessment and quality of patient-reported outcomes reporting. Frequently, methodologic limitations affect patient-reported outcomes assessment in clinical trials, either data analysis, particularly not reporting individual scores of health-related quality of life questionnaires, statistical corrections, limited efforts to avoid missing data, or lacking report of duration of palliative response.

CONCLUSIONS

Results of trials can differ if different outcomes, medical or patient-reported, are considered in the analysis. Cytotoxic chemotherapy of metastatic castration-resistant prostate cancer is a challenging issue. A survival benefit is reported only for docetaxel, but this treatment is not always feasible. In all patients, initiation of chemotherapy should be based on patient's preferences within discussion of individual risk and benefit, particularly in patients with extensive asymptomatic and symptomatic metastases.

Background for the proposal of SIOG guidelines for the management of prostate cancer in senior adults

BACKGROUND

The incidence of prostate cancer increases with age, with a median age at diagnosis of 68 years. Owing to increased life expectancy, the management of prostate cancer in senior adult men (i.e., aged 70 years or older) represents an important public health concern and a major challenge for the future. No specific guidelines have previously been published on the management of prostate cancer in older men. The SIOG has developed a proposal of recommendations in this setting.

METHODS

A systematic bibliographical search focused on screening, diagnostic procedures, treatment options for localised, locally advanced and metastatic prostate cancer in senior adults was performed. Specific aspects of the geriatric approach were emphasised, including evaluation of health status (nutritional, cognitive, thymic, physical and psycho-social) and screening for vulnerability and frailty. Attention was drawn to the consequences of androgen deprivation and complications of local treatment, mainly incontinence. The collected material has been reviewed and discussed by a scientific panel including urologists, radiation oncologists, medical oncologists and geriatricians from both Europe and North America.

RESULTS

The consensus is to use either European Association of Urology or National Comprehensive Cancer Network clinical recommendations for prostate cancer treatment and to adapt them to health status based on instrumental activities of daily living (IADL) and activities daily living (ADL), comorbidity evaluation by Cumulative Illness Scoring Rating-Geriatrics and screening for malnutrition. Patients in Group 1 (no abnormality) are 'fit' and should receive the same treatment as younger patients; patients in Group 2 (one impairment in IADL or one uncontrolled comorbidity or at risk of malnutrition) are 'vulnerable' and should receive standard treatment after medical intervention; patients in Group 3 (one impairment in ADL or more than one uncontrolled comorbidity or severe malnutrition) are 'frail' and should receive adapted treatment; patients in Group 4 (dependent) should receive only symptomatic palliative treatment.

CONCLUSIONS

Treatment of prostate cancer in senior adults should be adapted to health status. Specific prospective studies in this setting are warranted.

Experience with sorafenib and the elderly patient

Renal cell carcinoma primarily affects older individuals. Approximately half of all new renal cell carcinoma diagnoses are made in persons 65 years of age or older. Devising a treatment plan for the elderly patient population requires special consideration. Age-related physiological, cognitive, and social characteristics of elderly patients may influence each stage of patient care. Until recently, treatment options were limited for elderly patients with renal cell carcinoma. Sorafenib is the first multikinase inhibitor approved for use in renal cell carcinoma in the United States and Europe. In the phase III Treatment Approaches in Renal Cell Cancer Global Evaluation Trial, sorafenib significantly extended progression-free survival in patients with advanced renal cell carcinoma, regardless of age. Incidence rates of adverse events were not significantly higher in elderly patients receiving sorafenib than in younger patients. Thus, sorafenib represents an important treatment option for elderly patients with renal cell carcinoma. This report describes particular considerations for physicians to be aware of when choosing a treatment regimen for their elderly patients with renal cell carcinoma and offers recommendations on how to integrate specific management strategies into clinical practice that will optimize the use of sorafenib in the elderly. The strategies focus on patient selection, assessment of quality of life, management of adverse events, and appropriate dose modifications. The goal of these recommendations is to maximize the clinical benefit of sorafenib in the elderly patient population through appropriate use.

Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up

PURPOSE

To evaluate geriatric assessment (GA) domains in relation to clinically important outcomes in older breast cancer survivors.

METHODS

Six hundred sixty women diagnosed with primary breast cancer in four US geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island) were selected with disease stage I to IIIA, age >or= 65 years at date of diagnosis, and permission from attending physician to contact. Data were collected over 7 years of follow-up from consenting patients' medical records, telephone interviews, physician questionnaires, and the National Death Index. Outcomes included self-reported treatment tolerance and all-cause mortality. Four GA domains were described by six individual measures, as follows: sociodemographic by adequate finances; clinical by Charlson comorbidity index (CCI) and body mass index; function by number of physical function limitations; and psychosocial by the five-item Mental Health Index (MHI5) and Medical Outcomes Study Social Support Survey (MOS-SSS). Associations were evaluated using t tests, chi(2) tests, and regression analyses.

RESULTS

In multivariable regression including age and stage, three measures from two domains (clinical and psychosocial) were associated with poor treatment tolerance; these were CCI >or= 1 (odds ratio [OR] = 2.49; 95% CI, 1.18 to 5.25), MHI5 score less than 80 (OR = 2.36; 95% CI, 1.15 to 4.86), and MOS-SSS score less than 80 (OR = 3.32; 95% CI, 1.44 to 7.66). Four measures representing all four GA domains predicted mortality; these were inadequate finances (hazard ratio [HR] = 1.89; 95% CI, 1.24 to 2.88; CCI >or= 1 (HR = 1.38; 95% CI, 1.01 to 1.88), functional limitation (HR = 1.40; 95% CI, 1.01 to 1.93), and MHI5 score less than 80 (HR = 1.34; 95% CI, 1.01 to 1.85). In addition, the proportion of women with these outcomes incrementally increased as the number of GA deficits increased.

CONCLUSION

This study provides longitudinal evidence that GA domains are associated with poor treatment tolerance and predict mortality at 7 years of follow-up, independent of age and stage of disease.