Integrated oncogeriatric approach: a systematic review of the literature using concept analysis

Supportive care needs among older Mexican adults with metastatic cancer

INTRODUCTION

Supportive care needs may vary according to age. The purpose of this research is to describe and compare supportive care needs between older adults with metastatic cancer (age ≥ 65 years) and their younger counterparts.

MATERIALS AND METHODS

We conducted a retrospective secondary analysis of a cohort of patients with newly diagnosed metastatic solid tumors. Supportive care needs were assessed at baseline and at a three-month follow-up. Patients were divided into two groups (aged ≥65/<65 years). Differences in clinical characteristics and supportive care needs were compared utilizing descriptive statistics. Multivariate logistic regression models were employed to identify patient characteristics associated with specific supportive care needs.

RESULTS

Between 2018 and 2022, 375 patients were enrolled. Median age was 66 years (interquartile range 19-94). At baseline, older adults had a higher number of supportive care needs (4.8 vs. 4.2, p = 0.01) and were at higher risk of malnutrition (75 vs. 65%, p = 0.05). Increasing age (odds ratio [OR] 1.02 (95% confidence interval [CI] 1.0-1.04, p = 0.03) and an estimated life expectancy <6 months (OR 3.0, 95%CI 1.5-6.1; p < 0.01) were associated with higher odds of malnutrition, while a higher educational level was associated with decreased odds (OR 0.68, 95%CI 0.5-0.8; p < 0.01). At three-month follow-up, older adults still had a higher number of supportive care needs (3.8 vs.2.6, p < 0.01) and were more likely to have fatigue (62 vs. 47%, p = 0.02). An estimated life expectancy of <6 months was associated with increased odds of fatigue (OR 3.0, 95%CI 1.5-6.3; p < 0.01).

DISCUSSION

Older adults reported significantly more supportive care needs, particularly risk of malnutrition and fatigue. This information can help in the creation of supportive care services tailored to the needs of older individuals.

Safety of curative-intent lung cancer surgery in older patients (octogenarians): A contemporary multicentre cohort study

INTRODUCTION

Despite octogenarians representing an ever-increasing proportion of patients with lung cancer, there is a paucity of evidence describing outcomes after lung resection for these patients. We aimed to evaluate short and mid-term outcomes for octogenarians after lung resection.

MATERIALS AND METHODS

A total of 5,470 consecutive patients undergoing lung resection for primary lung cancer from 2012-2019 in two UK centres were included. Primary outcomes were perioperative, 90-day, and one-year mortality in the octogenarian vs. non-octogenarian cohort. Appropriate statistical tests were used to compare outcomes between octogenarian and non-octogenarian patients. Secondary outcomes were post-operative complications and to validate the performance of the Thoracoscore model in the octogenarian cohort.

RESULTS

Overall, 9.4% (n=513) of patients were aged ≥80. The rates of 90-day mortality, one-year mortality, and post-operative atrial fibrillation were significantly higher for octogenarians. The one-year mortality rate for octogenarians fell significantly over time (2012-2015: 16.5% vs 2016-2019: 10.2%, p=0.034). Subgroup analysis (2016-2019 only) demonstrated no significant difference in peri-operative, 90-day, or one-year mortality between octogenarian and non-octogenarian patients. Validation of the Thoracoscore model demonstrated modest discrimination and acceptable calibration.

DISCUSSION

Mortality for octogenarians fell significantly over time in this study. Indeed, when confined to the most recent time period, comparable rates of both 90-day and one-year mortality for octogenarian and non-octogenarian patients were seen. Whilst preventative strategies to reduce the incidence of post-operative atrial fibrillation in octogenarians should be considered, these findings demonstrate that following appropriate patient selection, octogenarians can safely undergo lung resection for lung cancer.

Integrated Geriatric Assessment and Treatment Effectiveness (INTEGERATE) in older people with cancer starting systemic anticancer treatment in Australia: a multicentre, open-label, randomised controlled trial

BACKGROUND

The effectiveness of comprehensive geriatric assessment (CGA) in improving health outcomes in cancer settings is unclear. We evaluated whether CGA can improve health-related quality of life (HRQOL) in older people with cancer who are starting systemic anticancer treatment.

METHODS

INTEGERATE is a multicentre, open-label, pragmatic, parallel-group, randomised controlled trial that was done at three hospitals in Australia. Participants aged 70 years and older with solid cancer or diffuse large B-cell lymphoma planned for chemotherapy, targeted therapy, or immunotherapy, were randomly assigned (1:1; using a central computer-generated minimisation algorithm with a random element, balancing treatment intent, cancer type, age, sex, and performance status) to receive CGA integrated into oncology care (integrated oncogeriatric care) or usual care only. Group assignment was not concealed from the participants and clinicians. The primary outcome was HRQOL over 24 weeks, assessed at baseline, week 12, week 18, and week 24, using the Elderly Functional Index (ELFI; score range 0-100). Analyses were by intention to treat. The trial is registered with ANZCTR.org.au, ACTRN12614000399695, and is completed.

FINDINGS

Between Aug 18, 2014, and Sept 5, 2018, 154 participants were randomly assigned to integrated oncogeriatric care (n=76) or usual care (n=78). 13 participants died by week 12 and 130 (92%) of the remaining 141 participants completed two or more ELFI assessments. Participants assigned to integrated oncogeriatric care reported better adjusted ELFI change scores over 24 weeks compared with those in the usual care group (overall main effect of group: t=2·1, df=213, p=0·039; effect size=0·38), with maximal between-group differences at week 18 (mean difference in change 9·8 [95% CI 2·4-17·2]; p=0·010, corrected p=0·030, effect size=0·48). The integrated oncogeriatric care group also had significantly fewer unplanned hospital admissions at 24 weeks (multivariable-adjusted incidence rate ratio 0·60 [95% CI 0·42-0·87]; p=0·0066). No statistically significant between-group difference was observed in overall survival.

INTERPRETATION

CGA led to better quality of life and health-care delivery in older people receiving systemic anticancer treatment. Routine CGA-based interventions should be considered in at-risk older people starting systemic anticancer treatment.

FUNDING

National Health and Medical Research Council (Australia), Monash University, and Eastern Health.

Exploring Determinants of Interdisciplinary Collaboration within a Geriatric Oncology Setting: A Mixed-Method Study

Simple Summary

Collaboration between oncologists and geriatricians has been shown to improve the quality of elderly cancer patient care. However, previous research has revealed how interpersonal factors might hinder this interdisciplinary work. This study aims to assess sprocessual and contextual determinants of the collaboration between these two disciplines, including shared time and routines, medical decision criteria and perceptions of age and needs of elderly patients. These aspects are important to develop a more efficient patient-centered approach in oncogeriatric care and improve collaboration between the different disciplines involved.

Abstract

Therapeutic challenges regarding the population of elderly cancer patients and their heterogeneity lead to the need to implement person-centered approaches in order to optimize care strategies and adapt oncology treatments to each pattern of aging. The International Society of Geriatric Oncology recommends a multidisciplinary evaluation of these patients and the use of screening tools prior to the initiation of treatments. However, previous research shows a poor implementation of these recommendations in geriatric oncology. Although some studies have identified how different perceptions of geriatric oncology might hinder routine teamwork, little is known about the impact of other factors on promoting the collaboration between the two specialties. This mixed-method exploratory study used an online questionnaire to assess the perception of a group of 22 geriatricians and oncology physicians on different determinants of oncology care and teamwork. In this sample, older oncology patients benefited from geriatric care. However, there was a variability regarding age criteria and a limited use of screening tools. The multidimensional framework for interprofessional teamwork by Reeves has been used to analyze some of the determinants of the collaboration between oncology physicians and geriatricians. This study has identified systematic issues to consider when promoting communication and common values between the two disciplines, including available resources in terms of shared time, space and routine actions.

Benefits, Challenges, and Opportunities of Integrating Patient-Reported Outcome Measures in Geriatric Oncology to Advance Patient Screening for Functional Fitness for Treatment

OBJECTIVES

To discuss potential benefits, challenges, and opportunities of integrating patient-reported outcome measures in geriatric oncology, with the goal being to advance patient screening for 'functional fitness for treatment.'

DATA SOURCES

This is narrative review of the relevant literature using PubMed.

CONCLUSION

Patient screening in geriatric cancer care can be driven by patient self-reports. Most of the research on patient-reported outcome measures in cancer care to date has involved, in different proportions and to different extents, older patients with cancer (≥70 years of age). However, reports specifically targeting implementation of patient-reported outcome measures in geriatric cancer care are surprisingly fewer. The International Society of Geriatric Oncology Priorities Initiative calls for more research into the use of patient-reported outcome measures for older adults with cancer. More feasibility studies will be required to evaluate patient-reported outcome measures as fit-for-purpose, reporting frequency, patient burden, integration and display of patient-reported information, and workflow impact. Developing, adapting, and validating patient-reported outcome measures for use in geriatric oncology will be key to ensure adequacy of measurement. Groundwork involving consultation of all potential end users of patient-reported information is paramount because there is no one size fits all. When the ground is ready for implementation adequate preparation, training, resources, and ongoing support will be needed.

IMPLICATIONS FOR NURSING PRACTICE

Working within the multidisciplinary team, nurses can promote patient screening that is led by the patient. Nursing roles can be developed, supported, expanded, or repurposed to involve greater use of patient-reported outcome measures for several key patient outcomes in geriatric cancer care.

The impacts of collaboration between local health care and non-health care organizations and factors shaping how they work: a systematic review of reviews

BACKGROUND

Policymakers in many countries promote collaboration between health care organizations and other sectors as a route to improving population health. Local collaborations have been developed for decades. Yet little is known about the impact of cross-sector collaboration on health and health equity.

METHODS

We carried out a systematic review of reviews to synthesize evidence on the health impacts of collaboration between local health care and non-health care organizations, and to understand the factors affecting how these partnerships functioned. We searched four databases and included 36 studies (reviews) in our review. We extracted data from these studies and used Nvivo 12 to help categorize the data. We assessed risk of bias in the studies using standardized tools. We used a narrative approach to synthesizing and reporting the data.

RESULTS

The 36 studies we reviewed included evidence on varying forms of collaboration in diverse contexts. Some studies included data on collaborations with broad population health goals, such as preventing disease and reducing health inequalities. Others focused on collaborations with a narrower focus, such as better integration between health care and social services. Overall, there is little convincing evidence to suggest that collaboration between local health care and non-health care organizations improves health outcomes. Evidence of impact on health services is mixed. And evidence of impact on resource use and spending are limited and mixed. Despite this, many studies report on factors associated with better or worse collaboration. We grouped these into five domains: motivation and purpose, relationships and cultures, resources and capabilities, governance and leadership, and external factors. But data linking factors in these domains to collaboration outcomes is sparse.

CONCLUSIONS

In theory, collaboration between local health care and non-health care organizations might contribute to better population health. But we know little about which kinds of collaborations work, for whom, and in what contexts. The benefits of collaboration may be hard to deliver, hard to measure, and overestimated by policymakers. Ultimately, local collaborations should be understood within their macro-level political and economic context, and as one component within a wider system of factors and interventions interacting to shape population health.

Screening Tools for Identifying Older Adults With Cancer Who May Benefit From a Geriatric Assessment: A Systematic Review

Importance

Older adults with cancer are at risk of overtreatment or undertreatment when decision-making is based solely on chronological age. Although a geriatric assessment is recommended to inform care, the time and expertise required limit its feasibility for all patients. Screening tools offer the potential to identify those who will benefit most from a geriatric assessment. Consensus about the optimal tool to use is lacking.

Objective

To appraise the evidence on screening tools used for older adults with cancer and identify an optimal screening tool for older adults with cancer who may benefit from geriatric assessment.

Evidence Review

Systematic review of 4 databases (MEDLINE, Embase, CINAHL [Cumulative Index to Nursing and Allied Health Literature], and PubMed) with narrative synthesis from January 1, 2000, to March 14, 2019. Studies reporting on the diagnostic accuracy and use of validated screening tools to identify older adults with cancer who need a geriatric assessment were eligible for inclusion. Data were analyzed from March 14, 2019, to March 23, 2020.

Findings

Seventeen unique studies were included, reporting on the use of 12 screening tools. Most studies were prospective cohort studies (n = 11) with only 1 randomized clinical trial. Not all studies reported time taken to administer the screening tools. The Geriatric-8 (G8) (n = 12) and the Vulnerable Elders Survey-13 (VES-13) (n = 9) were the most frequently evaluated screening tools. The G8 scored better in sensitivity and the VES-13 in specificity. Other screening tools evaluated include the Groningen Frailty Index, abbreviated comprehensive geriatric assessment, and Physical Performance Test in 2 studies each. All other screening tools were evaluated in 1 study each.

Conclusions and Relevance

To date, the G8 and VES-13 have the most evidence to recommend their use to inform the need for geriatric assessment. When choosing a screening tool, clinicians will need to weigh the tradeoffs between sensitivity and specificity. Future research needs to further validate or improve current screening tools and explore other factors that can influence their use, such as ease of use and resourcing.

Caring for older cancer patients: A scoping review

There is a growing recognition among oncologists that older patients differ from other cancer patients. Older patients present age-specific issues affecting the prevention and management of their cancer. Over the years, this has led to the development of the discipline of geriatric oncology, which is the set of practices elaborated to evaluate, treat, follow-up and rehabilitate the population of older cancer patients. Geriatric oncology is still struggling to establish itself in healthcare settings managing older cancer patients. Efforts are currently being made to make it a recognized medical specialty. Health policy makers have to have a grasp of the evolution of this discipline because it concerns a fast growing segment of the cancer patient population. To shed light on the literature about this field, we undertook a scoping review in which we identified relevant studies; charted the data from the selected studies, collated, summarized and reported the results. From 2043 references initially identified, we included 92 articles in our scoping review and extracted data from 88 articles. The included articles were classified into three major categories, namely Advancing the discipline, Organization of care and Nursing and support services for patient and their caregivers. This review affords researchers and policy makers a foundation to help conduct many other conversations on each theme and sub-theme.

Assessment methods and services for older people with cancer in the United Kingdom

BACKGROUND

National cancer strategy calls for comprehensive assessments for older people but current practice across the United Kingdom is not well described.

AIM

To identify current assessment methods and access to relevant supporting services for older people with cancer.

METHODS

A web-based survey (SurveyMonkey) targeting health professionals (oncologists, cancer surgeons, geriatricians, nurses and allied health professionals) was distributed January-April 2016 via United Kingdom nationally recognised professional societies. Responses were analysed in frequencies and percentages. Chi Square was used to compare differences in responses between different groups.

RESULTS

640 health care professionals responded. Only 14.1% often/always involved geriatricians and 52.0% often/always involved general practitioners in assessments. When wider assessments were used, they always/often influenced decision-making (40.5%) or at least sometimes (34.1%). But 30.5%-44.3% did not use structured assessment methods. Most clinicians favoured clinical history taking. Few used scoring tools and few wished to use them in the future. Most had urgent access to palliative care but only a minority had urgent access to other key supporting professionals (e.g. geriatricians, social workers, psychiatry). 69.6% were interested in developing Geriatric Oncology services with geriatricians.

CONCLUSION

There is variability in assessment methods for older people with cancer across the United Kingdom and variation in perceived access to supporting services. Clinical history taking was preferred to scoring systems. Fostering closer links with geriatricians appears supported.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study

Background

The aim of this study was to provide high-quality evidence on delivering hospital-wide Comprehensive Geriatric Assessment (CGA).

Objective(s)

(1) To define CGA, its processes, outcomes and costs in the published literature, (2) to identify the processes, outcomes and costs of CGA in existing hospital settings in the UK, (3) to identify the characteristics of the recipients and beneficiaries of CGA in existing hospital settings in the UK and (4) to develop tools that will assist in the implementation of hospital-wide CGA.

Design

Mixed-methods study combining a mapping review, national survey, large data analysis and qualitative methods.

Participants

People aged ≥ 65 years in acute hospital settings.

Data sources

Literature review – Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, MEDLINE and EMBASE. Survey – acute hospital trusts. Large data analyses – (1) people aged ≥ 75 years in 2008 living in Leicester, Nottingham or Southampton (development cohort,n = 22,139); (2) older people admitted for short stay (Nottingham/Leicester,n = 825) to a geriatric ward (Southampton,n = 246) or based in the community (Newcastle,n = 754); (3) people aged ≥ 75 years admitted to acute hospitals in England in 2014–15 (validation study,n = 1,013,590). Toolkit development – multidisciplinary national stakeholder group (co-production); field-testing with cancer/surgical teams in Newcastle/Leicester.

Results

Literature search – common outcomes included clinical, operational and destinational, but not patient-reported, outcome measures. Survey – highly variable provision of multidisciplinary assessment and care across hospitals. Quantitative analyses – in the development cohort, older people with frailty diagnoses formed a distinct group and had higher non-elective hospital use than older people without a frailty diagnosis. Patients with the highest 20% of hospital frailty risk scores had increased odds of 30-day mortality [odds ratio (OR) 1.7], long length of stay (OR 6.0) and 30-day re-admission (OR 1.5). The score had moderate agreement with the Fried and Rockwood scales. Pilot toolkit evaluation – participants across sites were still at the beginning of their work to identify patients and plan change. In particular, competing definitions of the role of geriatricians were evident.

Limitations

The survey was limited by an incomplete response rate but it still provides the largest description of acute hospital care for older people to date. The risk stratification tool is not contemporaneous, although it remains a powerful predictor of patient harms. The toolkit evaluation is still rather nascent and could have meaningfully continued for another year or more.

Conclusions

CGA remains the gold standard approach to improving a range of outcomes for older people in acute hospitals. Older people at risk can be identified using routine hospital data. Toolkits aimed at enhancing the delivery of CGA by non-specialists can be useful but require prolonged geriatrician support and implementation phases. Future work could involve comparing the hospital-based frailty index with the electronic Frailty Index and further testing of the clinical toolkits in specialist services.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Health status, emergency department visits, and oncologists' feedback: An analysis of secondary endpoints from a randomized phase II geriatric assessment trial

PURPOSE

Geriatric Assessment (GA) can help uncover previously unknown health issues and recommend tailored interventions to optimize outcomes; however, no completed randomized trial has examined the impact of GA on utility-based health status, healthcare use, and oncologists' opinions about GA. We examined these secondary outcomes of a randomized phase II trial.

METHODS

A planned analysis of secondary outcomes of a two-group parallel single-blind randomized phase II trial of GA (ClinicalTrials.gov Identifier:NCT02222259) recruited patients ≥ age 70, diagnosed with stage II-IV breast/gastrointestinal/genitourinary cancer within six weeks of beginning chemotherapy at the Princess Margaret Cancer Centre, Toronto, Canada. Descriptive analyses using intent-to-treat were conducted for health status (EuroQol EQ-5D-3L) and healthcare utilization (patient self-report). Oncologist opinions were captured via open-ended interviews and summarized.

RESULTS

A total of 95 patients who met the inclusion criteria were approached; 61 of them consented (64%). For health status, at all time-points, there were no significant differences between the two groups. The number of emergency department and family physician visits was low overall; there were no statistically significant differences between the two groups at any time point. All interviewed oncologists (eight of fourteen invited) were satisfied with the intervention, but wanted more straightforward recommendations and earlier GA results.

CONCLUSIONS

No difference was found in terms of relationships between GA and utility-based health status or GA and healthcare use. Underreporting of healthcare use was possible. Oncologists welcome GA feedback and prefer to receive it in pre-treatment decision context. Larger trials with earlier GA are warranted.

Tumour boards in geriatric oncology

Multidisciplinary tumour board is an integral part of cancer treatment planning. Although no definite survival benefits have yet been shown by mostly observational studies, other benefits of multidisciplinary tumour board have been identified. Traditionally the multidisciplinary tumour board involves participation of treating clinicians-medical, radiation and surgical oncologists. They tend to focus on the cancer alone. There is an increasing awareness that the treatment goal for cancer in older adults is not primarily on prolonging survival, with functional preservation and quality of life being particularly important for this population. The use of Comprehensive Geriatric Assessment and the input of the geriatrician in informing the oncologists regarding treatment decision have increasingly been shown to be beneficial. The integration of the geriatrician into the multidisciplinary tumour board should be urgently explored.

What is Comprehensive Geriatric Assessment (CGA)? An umbrella review

Background

Comprehensive Geriatric Assessment (CGA) is now the accepted gold standard for caring for frail older people in hospital. However, there is uncertainty about identifying and targeting suitable recipients and which patients benefit the most.

Objectives

our objectives were to describe the key elements, principal measures of outcome and the characteristics of the main beneficiaries of inpatient CGA.

Methods

we used the Joanna Briggs Institute umbrella review method. We searched for systematic reviews and meta-analyses describing CGA services for hospital inpatients in the Cochrane Database of Systematic Reviews, Database of Reviews of Effectiveness (DARE), MEDLINE and EMBASE and a range of other sources.

Results

we screened 1,010 titles and evaluated 419 abstracts for eligibility, 143 full articles for relevance and included 24 in a final quality and relevance check. Thirteen reviews, reported in 15 papers, were selected for review. The most widely used definition of CGA was: 'a multidimensional, multidisciplinary process which identifies medical, social and functional needs, and the development of an integrated/co-ordinated care plan to meet those needs'. Key clinical outcomes included mortality, activities of daily living and dependency. The main beneficiaries were people ≥55 years in receipt of acute care. Frailty in CGA recipients and patient related outcomes were not usually reported.

Conclusions

we confirm a widely used definition of CGA. Key outcomes are death, disability and institutionalisation. The main beneficiaries in hospital are older people with acute illness. The presence of frailty has not been widely examined as a determinant of CGA outcome.

[Colorectal cancer in the elderly. Surgical treatment, chemotherapy, and contribution from geriatrics]

Age is the biggest risk factor for colorectal cancer, with 70% of the cases in patients over 70 years old. For this reason, a review is presented on the surgical treatment and chemotherapy of cancer of colon and rectum in the elderly. A search was performed in PubMed, including words such as elderly, surgery, colorectal cancer, chemotherapy, radiotherapy, and oncogeriatrics, and review articles and originals on treatment of colorectal cancer in the elderly were selected. A narrative form was developed from the latest evidence with the results obtained on the treatment of this pathology. Although the treatment of colorectal cancer is standardised, a prior comprehensive geriatric assessment is required in the case of the elderly, before deciding the type of treatment in order to offer these robust elderly-standardised guidelines for the robust elderly and adapt them for use in fragile patients.

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.

The expanding role of primary care in cancer control

The nature of cancer control is changing, with an increasing emphasis, fuelled by public and political demand, on prevention, early diagnosis, and patient experience during and after treatment. At the same time, primary care is increasingly promoted, by governments and health funders worldwide, as the preferred setting for most health care for reasons of increasing need, to stabilise health-care costs, and to accommodate patient preference for care close to home. It is timely, then, to consider how this expanding role for primary care can work for cancer control, which has long been dominated by highly technical interventions centred on treatment, and in which the contribution of primary care has been largely perceived as marginal. In this Commission, expert opinion from primary care and public health professionals with academic and clinical cancer expertise—from epidemiologists, psychologists, policy makers, and cancer specialists—has contributed to a detailed consideration of the evidence for cancer control provided in primary care and community care settings. Ranging from primary prevention to end-of-life care, the scope for new models of care is explored, and the actions needed to effect change are outlined. The strengths of primary care—its continuous, coordinated, and comprehensive care for individuals and families—are particularly evident in prevention and diagnosis, in shared follow-up and survivorship care, and in end-of-life care. A strong theme of integration of care runs throughout, and its elements (clinical, vertical, and functional) and the tools needed for integrated working are described in detail. All of this change, as it evolves, will need to be underpinned by new research and by continuing and shared multiprofessional development.

Comparison of toxicity experienced by older versus younger patients enrolled in breast cancer clinical trials

BACKGROUND

Elderly patients form a large proportion of patients with breast cancer but are underrepresented in clinical trials. We examined whether elderly patients experience more toxicity than younger patients within breast cancer clinical trials.

MATERIALS AND METHODS

All breast cancer trials open from 1999 to 2012 at BCCA, Vancouver Center, were reviewed. The primary endpoint was meaningful toxicity (MTOX), defined as any grade 3 or 4 adverse event (AE), any AE leading to dose delay or reduction, or premature discontinuation of therapy.

RESULTS

In the 46 trials enrolling 799 patients, the therapy given was chemotherapy to 18% of the patients, hormonal therapy to 40%, skeletal therapy to 14%, and targeted therapy and a combination of chemotherapy and targeted therapy to 14%. Elderly patients were more likely to enroll in hormonal and skeletal therapy trials, and younger patients were evenly distributed among the therapy types. Toxicity data were available for 778 patients (97%). Elderly patients and younger patients experienced a similar number and frequency of MTOX. The therapy type was the strongest predictor of toxicity on multivariate analysis. In non-chemotherapy-containing trials, elderly and younger patients had a similar frequency and number of toxicities. Few elderly patients were enrolled in cytotoxic chemotherapy trials, but they experienced no more toxicity than did the younger patients.

CONCLUSION

The appropriate selection of elderly patients using eligibility criteria, self selection, and/or clinician assessment will allow safe participation of elderly patients in breast cancer trials.

Management of operable primary breast cancer in older women

A considerable number of breast cancer diagnoses are made in older women. Differing physiological needs of older patients and biology of tumors compared with younger patients may alter treatment options between surgery and nonsurgical primary approaches. Adjuvant therapies may benefit these patients; however, concerns about toxicity and physical demands of treatment may affect patient choice regarding treatment. Furthermore, quality of life may be more important to the older individual than curative treatment alone. Growing evidence is emerging for employing Comprehensive Geriatric Assessment to determine other factors that may contribute to treatment decision-making in the older population. The way geriatric oncology is delivered varies, bringing the importance of the multidisciplinary team to the forefront of care delivery in this age group. Future research in this area should include combined consideration of tumor biology and geriatric needs.

Personalized surgical management of colorectal cancer in elderly population

Colorectal cancer (CRC) in the elderly is extremely common but only a few clinicians are familiar with the complexity of issues which present in the geriatric population. In this phase of the life cycle, treatment is frequently suboptimal. Despite the fact that, nowadays, older people tend to be healthier than in previous generations, surgical undertreatment is frequently encountered. On the other hand, surgical overtreatment in the vulnerable or frail patient can lead to unacceptable postoperative outcomes with high mortality or persistent disability. Unfortunately, due to the geriatric patient being traditionally excluded from randomized controlled trials for a variety of factors (heterogeneity, frailty, etc.), there is a dearth of evidence-based clinical guidelines for the management of these patients. The objective of this review was to summarize the most relevant clinical studies available in order to assist clinicians in the management of CRC in the elderly. More than in any other patient group, both surgical and non-surgical management strategies should be carefully individualized in the elderly population affected by CRC. Although cure and sphincter preservation are the primary goals, many other variables need to be taken into account, such as maintenance of cognitive status, independence, life expectancy and quality of life.