Geriatric Assessment of Older Patients Receiving Trabectedin in First-Line Treatment for Advanced Soft Tissue Sarcomas: The E-TRAB Study from The German Interdisciplinary Sarcoma Group (GISG-13)

E-TRAB was a non-interventional, prospective trial investigating the feasibility and predictive value of geriatric assessments (GA) in older STS patients treated with trabectedin as first-line therapy. Primary endpoints were overall survival (OS), quality of life and individual clinical benefit assessed by the patient-reported outcome measures QLQ-C30 and PRO-CTCAE. Further, several GA tools were applied and correlated with clinical outcomes and treatment-related toxicities. The final analyses included 69 patients from 12 German-speaking sites. The median age of patients was 78 years (range: 55 to 88). Baseline data on PROs and GA identified a diverse population of older patients with respect to their global health status, although a large proportion of them suffered from limitations, required geriatric help and had a high risk of morbidity. The Cancer and Age Research Group (CARG) score classified 38%, 29% and 23% of the patients with low, intermediate and high risks for therapy-related side effects, respectively. Median OS was 11.2 months [95%CI: 5.6; 19.4]. The study confirmed that trabectedin as first-line treatment in older patients with STS has an acceptable and manageable safety profile. Potential prognostic factors for clinical outcome and therapy-related toxicity were identified among the GA tools. Long Timed Up and Go (TUG) showed a significant correlation to OS and early death, whereas a high CARG score (>9) was associated with an increase in unplanned hospitalizations and the incidence of toxicities grade ≥ 3.

Predicting Frailty and Geriatric Interventions in Older Cancer Patients: Performance of Two Screening Tools for Seven Frailty Definitions-ELCAPA Cohort

Screening tools have been developed to identify patients warranting a complete geriatric assessment (GA). However, GA lacks standardization and does not capture important aspects of geriatric oncology practice. We measured and compared the diagnostic performance of screening tools G8 and modified G8 according to multiple clinically relevant reference standards. We included 1136 cancer patients ≥ 70 years old referred for GA (ELCAPA cohort; median age, 80 years; males, 52%; main locations: digestive (36.3%), breast (16%), and urinary tract (14.8%); metastases, 43.5%). Area under the receiver operating characteristic curve (AUROC) estimates were compared between both tools against: (1) the detection of ≥1 or (2) ≥2 GA impairments, (3) the prescription of ≥1 geriatric intervention and the identification of an unfit profile according to (4) a latent class typology, expert-based classifications from (5) Balducci, (6) the International Society of Geriatric Oncology task force (SIOG), or using (7) a GA frailty index according to the Rockwood accumulation of deficits principle. AUROC values were ≥0.80 for both tools under all tested definitions. They were statistically significantly higher for the modified G8 for six reference standards: ≥1 GA impairment (0.93 vs. 0.89), ≥2 GA impairments (0.90 vs. 0.87), ≥1 geriatric intervention (0.85 vs. 0.81), unfit according to Balducci (0.86 vs. 0.80) and SIOG classifications (0.88 vs. 0.83), and according to the GA frailty index (0.86 vs. 0.84). Our findings demonstrate the robustness of both screening tools against different reference standards, with evidence of better diagnostic performance of the modified G8.

Reduced-dose of doublet chemotherapy combined with anti-EGFR antibodies in vulnerable older patients with metastatic colorectal cancer: Data from the REVOLT study

OBJECTIVES

To assess the toxicity patterns and effectiveness of doublet chemotherapy when administered at reduced doses of 20% (FOLFOX or FOLFIRI) in combination with anti-EGFR antibodies (cetuximab or panitumumab) in old, vulnerable patients with metastatic colorectal cancer (mCRC).

PATIENTS AND METHODS

We performed a retrospective observational study of RAS and BRAF wild-type, vulnerable patients aged ≥70 years with previously untreated mCRC. The primary endpoint was safety, and secondary endpoints were overall response rate (ORR), progression-free survival (PFS), and overall survival (OS).

RESULTS

One hundred and eighteen patients were collected from 14 selected Italian centres. The median age was 75 (range, 70-85). Geriatric screening by G8 tool gave a score ≤ 14 in all patients. In total, 75 and 43 patients received FOLFOX or FOLFIRI, respectively, in combination with panitumumab (53%) or cetuximab (47%). The overall incidence of grade (G) 3-4 neutropenia was 11.8%, and for skin rash 11%. The most frequent adverse events were G1-2 skin rash (49.1%), G1-2 diarrhea (21.1%) and G1-2 nausea (17.7%). The ORR was 57.3%. Stable disease was observed in 29.1% of patients, with a disease control rate of 86.4%. With a median follow-up of 18 months, the median PFS was 10.0 months (95% confidence interval [CI]: 8.5-11.4), while the median OS was 18.0 months (95% CI: 16.0-19.9). No statistically significant difference was observed between the regimens in terms of ORR, PFS (p = 0.908), and OS (p = 0.832).

CONCLUSION

This study shows that with an appropriate design, including reduced doses, vulnerable older patients best tolerate chemotherapy when combined with anti-EGFR antibodies.

Scoping study of definitions and instruments measuring vulnerability in older adults

BACKGROUND

It is important to foster social participation and health equity, especially for older adults in situations of vulnerability. Despite growing interest in vulnerability, there is no consensus regarding how to define or measure this concept. This paper provides an inventory and synthesis of definitions of and instruments measuring vulnerability in older adults.

METHODS

Using a scoping study framework, eight databases (Abstracts in Social Gerontology, Academic Search Complete, AgeLine, CINAHL, MEDLINE, SocINDEX, PsycInfo, Scopus) were searched with relevant keywords [Vulnerab* AND (Concept*, Defin*, Meaning, Terminology, Measurement, Assessment*, Indicator*, Instrument*, Scale*, Questionnaire* OR Test*) AND (Aging, Aging, Elder*, Gerontolog*, Older OR Senior*)].

RESULTS

Thirty-one original definitions and five measuring instruments were identified, content-analyzed, and compared. Vulnerability definitions mostly focused on people under conditions that increased their risk of harm because of individual physical factors, the environment, and their interaction. Considering these definitions, experts in the field of aging, including two representing older adults, participated in a workshop, and a consensus was reached to define a situation of vulnerability as "a set of circumstances in which one or more individuals experience, at a specific moment in time, one or multiple physiological, psychological, socioeconomic or social difficulties that may interact to increase their risk of being harmed or having coping challenges that have a negative impact on their life." Although none of the measures fully targeted this definition, the Perceived Vulnerability Scale (PVS) is one of the most complete measures, with 22 items considering feelings of vulnerability toward personal and environmental factors, and good psychometric properties.

CONCLUSIONS

The proposed definition and the PVS help to provide a common language and measure in health and social sciences research, policy and practice identifying and reaching older adults in situations of vulnerability and intervening to foster social participation and health equity.

Frailty screening for predicting rapid functional decline, rapid progressive disease, and shorter overall survival in older patients with gastrointestinal cancer receiving palliative chemotherapy - a prospective, clinical study

OBJECTIVES

A growing number of older patients with cancer require well-founded clinical decision-making. Frailty screening is suggested as a service to improve outcomes in vulnerable older patients with cancer. This prospective study examined the value of frailty screening to predict rapid functional decline, rapid progressive disease (PD) and shorter overall survival (OS) in older patients with gastrointestinal cancer receiving palliative chemotherapy.

MATERIALS AND METHODS

Patients aged ≥70 years were screened for frailty in an oncologic department after clinical decision but before starting palliative chemotherapy. Screening was repeated at first response evaluation after approximately two months of chemotherapy. Frailty screening tools included performance status (PS), Charlson Comorbidity Index, G-8 using two different cut-offs (G8₁₄,G8₁₁), VES-13, Timed-Up-and-Go, Handgrip strength and falls.

RESULTS

A total of 170 patients were included, median age was 75.5 (70-88) years and 65.9% were male. The frequency of frailty varied from 14% to 74% according to the chosen frailty tool. In multivariate analysis G8₁₄ predicted OS (HR 1.5; 95%CI 1.0-2.4), whereas G8₁₁ predicted PD (OR 2.4; 1.1-5.6) and OS (HR 2.1; 1.4-2.9). VES-13 predicted functional decline (OR 3.5; 1.0-11.6), PD (OR 3.5; 1.5-8.4) and OS (HR 1.7; 1.2-2.4). Timed-Up-and-Go predicted OS (HR 1.8; 1.1-2.7). Handgrip strength and falls predicted functional decline (OR 4.5; 1.1-19 and OR 6.1; 1.4-25.8, respectively). PS predicted PD (OR 6.2; 2.6-14.7) and OS (HR 2.2; 1.5-3.2).

CONCLUSION

VES-13 was useful for predicting all three endpoints of interest. Frailty tools covering domains of functioning and nutrition are suggested for older patients with advanced gastrointestinal cancer.

Frailty screening in dermato-oncology practice: a modified Delphi study and a systematic review of the literature

Background

Appropriate management and prevention of both under‐ and overtreatment in older skin cancer patients can be challenging. It could be helpful to incorporate frailty screening in dermato‐oncology care, since frailty is associated with adverse health outcomes.

Objectives

This study aimed to identify and prioritize the requirements a frailty screening tool (FST) should fulfil in dermato‐oncology practice and to select the best existing FST(s) for this purpose.

Methods

A modified two‐round Delphi procedure was performed among 50 Italian and Dutch specialists and patients to review and prioritize a list of potential FST requirements, using a 5‐point Likert scale. Consensus was defined as a mean score of ≥4.0. A systematic literature search was performed to identify existing multidomain FSTs, which were then assessed on the requirements resulting from the modified Delphi procedure.

Results

Consensus was achieved on evaluation of comorbidities (4.3 ± 0.7), polypharmacy (4.0 ± 0.9) and cognition (4.1 ± 0.8). The FST should have appropriate measurement properties (4.0 ± 1.0), be quickly executed (4.2 ± 0.7), clinically relevant (4.3 ± 0.7), and both easily understandable (4.1 ± 1.2) and interpretable (4.3 ± 0.7). Of the 26 identified FSTs, four evaluated the content‐related domains: the Geriatric‐8 (G8), the modified Geriatric‐8 (mG8), the Groningen Frailty Indicator (GFI) and the Senior Adult Oncology Program 2 (SAOP2) screening tool. Of these, the G8 was the most extensively studied FST, with the best psychometric properties and execution within 5 min.

Conclusions

The G8 appears the most suitable FST for assessing frailty in older adults with skin cancer, although clinical studies assessing its use in a dermato‐oncology population are needed to further assess whether or not frailty in this particular patient group is associated with relevant outcomes (e.g. complications and mortality), as seen in previous studies in other medical fields.

Managing older patients with cancer

With the growing population of adults over age 70 years, clinicians must know how to care appropriately for the increasing number of older patients with cancer. Although older adults have higher rates of surgical complications and chemotherapy-related toxicity, they should not be excluded from treatment opportunities based on age alone. Rather, patients should be assessed for fitness, or functional age, for a more accurate estimation of how they will tolerate treatment. This article discusses considerations clinicians should take into account when developing effective treatment plans that do not compromise quality of life for older patients with cancer.

Korean version of the G-8 geriatric screening tool: Translation and linguistic validation

OBJECTIVE

To develop a Korean version of the G-8 questionnaire validated with Korean patients over 70 years-of-age who were scheduled to undergo cancer surgery.

MATERIALS AND METHODS

We conducted a translation study over a nine-month period from February to November 2017. Permission was received to use the original version of the G-8 questionnaire for forward translation into Korean and reconciliation, for backward translation of the translated Korean version into English, for cognitive debriefing, and final proofreading. These steps were performed in the order of translation and then language validation. Forward translation was performed independently by two translators who were fluent in Korean and English. The cognitive debriefing was carried out through interviews with ten Korean nurses who cared for the patients surveyed.

RESULTS

In the forward translation, "mobility" was replaced by "degree of activity". During the reconciliation, the difference in meaning between the terms "loss of appetite" and "severe," as determined by the two translators, was adjusted. Moreover, to achieve more natural Korean expression, some revisions were made to the questions and answers. In the backward translation, most of the forward translations were accepted without any objection. During the final proofreading, no difficulties were found in understanding the questionnaire's content, and most terms were deemed easy to understand.

CONCLUSION

This Korean version of the G-8 questionnaire has been validated in accordance with appropriate procedures. Therefore, the questionnaire is appropriate for use as a geriatric screening tool for older patients with cancer in Korea.

Preoperative Assessment of Older Adults

Older patients undergoing surgery have reduced physiologic reserve caused by the combined impact of physiologic age-related changes and the increased burden of comorbid conditions. The preoperative assessment of older patients is directed at evaluating the patient's functional reserve and identifying opportunities to minimize any potential for complications. In addition to a standard preoperative evaluation that includes cardiac risk and a systematic review of systems, the evaluation should be supplemented with a review of geriatric syndromes. Age-based laboratory testing protocols can lead to unnecessary testing, and all testing should be requested if indicated by underlying disease and surgical risk.

Reduced-dose combination chemotherapy (S-1 plus oxaliplatin) versus full-dose monotherapy (S-1) in older vulnerable patients with metastatic colorectal cancer (NORDIC9): a randomised, open-label phase 2 trial

BACKGROUND

Older or vulnerable patients with metastatic colorectal cancer are seldom included in randomised trials. The multicentre NORDIC9 trial evaluated reduced-dose combination chemotherapy compared with full-dose monotherapy in older, vulnerable patients.

METHODS

This randomised, open-label phase 2 trial was done in 23 Nordic oncology clinics and included patients aged 70 years or older with previously untreated metastatic colorectal cancer who were not candidates for full-dose combination chemotherapy. Patients were block randomised (1:1) using a web-based tool to full-dose S-1 (30 mg/m² orally twice daily on days 1-14 every 3 weeks) followed by second-line treatment at progression with irinotecan (250 mg/m² intravenously on day 1 every 3 weeks or 180 mg/m² intravenously on day 1 every 2 weeks) or reduced-dose combination chemotherapy with S-1 (20 mg/m² orally twice daily on days 1-14) and oxaliplatin (100 mg/m² intravenously on day 1 every 3 weeks) followed by second-line treatment at progression with S-1 (20 mg/m² orally twice daily on days 1-14) and irinotecan (180 mg/m² intravenously on day 1 every 3 weeks). Use of bevacizumab (7·5 mg/kg intravenously on day 1 of each cycle) was optional. Treatment allocation was not masked and randomisation was stratified for institution and bevacizumab. The primary outcome was progression-free survival. Survival analyses were by intention to treat and safety analyses were done on the treated population. This trial is registered with EudraCT, number 2014-000394-39, and is closed to new participants.

FINDINGS

From March 9, 2015, to Oct 11, 2017, 160 patients with a median age of 78 years (IQR 76-81) were randomly assigned to full-dose monotherapy (n=83) or reduced-dose combination chemotherapy (n=77). At data cutoff (Sept 1, 2018; median follow-up 23·8 months [IQR 18·8-30·9]), 81 (98%) patients in the full-dose monotherapy group and 71 (92%) patients in the reduced-dose combination group had progressed or died. Median progression-free survival was significantly longer with reduced-dose combination chemotherapy (6·2 months [95% CI 5·3-8·3]) than with full-dose monotherapy (5·3 months [4·1-6·8]; hazard ratio [HR] 0·72 [95% CI 0·52-0·99]; p=0·047). Toxicity was evaluated in 157 patients who received treatment. Significantly more patients in the full-dose monotherapy group (51 [62%] of 82 patients) experienced at least one grade 3-4 adverse event than in the reduced-dose combination group (32 [43%] of 75 patients; p=0·014). Grade 3-4 diarrhoea (12 [15%] vs two [3%]; p=0·018), fatigue (ten [12%] vs three [4%]; p=0·083), and dehydration (five [6%] vs none; p=0·060) were more frequent in the full-dose monotherapy group than in the reduced-dose combination group. Treatment-related deaths occurred in three patients during first-line treatment and three patients during second-line treatment (two in the full-dose monotherapy group vs one in the reduced-dose combination group in both cases).

INTERPRETATION

Reduced-dose combination chemotherapy with S-1 and oxaliplatin for older, vulnerable patients with metastatic colorectal cancer was more effective and resulted in less toxicity than full-dose monotherapy with S-1. Reduced-dose combination chemotherapy could be a preferred treatment for this population.

FUNDING

Taiho Pharmaceuticals, Nordic Group, the Danish Cancer Society, the Swedish Cancer Society, Academy of Geriatric Research (AgeCare), and Region of Southern Denmark.

Frailty status but not age predicts complications in elderly cancer patients: a follow-up study

OBJECTIVES

The purposes were to investigate the health status of elderly cancer patients by comprehensive geriatric assessment (CGA) and to compare the complications with respect to baseline CGA and to evaluate the need for geriatric interventions in an elderly cancer patients' population.

MATERIAL

Patients aged ≥70 years with lung cancer (LC), cancer of the head and neck (HNC), colorectal cancer (CRC), or upper gastro-intestinal cancer (UGIC) are referred to the Department of Oncology for cancer treatment.

METHODS

CGA was performed prior to cancer treatment and addressed the following domains: Activities of daily living (ADL), instrumental ADL (IADL), comorbidity, polypharmacy, nutrition, cognition, and depression. Complications, defined as dose reduction and discontinuation of treatment due to grade 3-4 toxicity, hospital admission, shift to palliative treatment, or death within 90 days, were identified from the medical files. Patients were classified as fit, vulnerable, or frail by CGA.

PRINCIPAL RESULTS

Patients (N = 217) with a median age of 75 years (range: 70-93 yeas) were included: 13% were fit, 35% vulnerable, and 52% frail. CGA significantly predicted admittance to hospital in frail and vulnerable patients compared to fit patients: risk ratio (RR) 2.12 (95% CI: 1.01; 4.46). Vulnerable and frail patients had higher absolute risk of death within 90 days compared to fit patients: 7% and 23% versus 0%. HR for death within 90 days in frail patients as compared to vulnerable patients was 3.50 (95% CI: 1.34; 9.15). More frail patients (88%) needed geriatric interventions than the vulnerable (46%) and fit patients (32%). Major conclusion: Few elderly cancer patients seem to be fit. CGA predicts admittance to hospital in a population of elderly patients with mixed cancer diseases. Frail and vulnerable patients have higher risk of death within 90 days as compared to fit patients.