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Daviu Cobián C, Oreskov JO, Blaakaer J, Jespersen E, Jørgensen TL, Ryg J, Herrstedt J, Høgdall C, Lund CM, Seibæk L, Vinther A, Ekmann-Gade AW, Schnack TH. Impact of FRAilty screening and Geriatric assessment and INtervention in older patients with epithelial Ovarian Cancer: A multicenter randomized clinical trial protocol (FRAGINOC). J Geriatr Oncol 2024; 15:101713. [PMID: 38326125 DOI: 10.1016/j.jgo.2024.101713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/11/2024] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Radical surgery combined with chemotherapy is the only potential curative treatment of patients with advanced epithelial ovarian cancer (EOC). However, 43% of older Danish patients with EOC are not referred to surgery due to frailty, age, or fear of complications. Comprehensive geriatric assessment (CGA) has demonstrated ability to reduce frailty in older patients, but there is a knowledge gap regarding its effect before or during treatment in older adults with EOC. This protocol presents a randomized controlled trial (RCT), which evaluates the effect of CGA-based interventions including individualized physical exercise therapy in older adults with EOC during neoadjuvant chemotherapy (NACT). MATERIALS AND METHODS This RCT will include patients aged ≥70 years with primary EOC referred to NACT. Patients will be randomized 1:1 to intervention or standard of care, along with neoadjuvant antineoplastic treatment. Stratification for performance status and center of inclusion will be performed. In the intervention arm, a geriatrician will perform CGA and corresponding geriatric interventions and patients will undergo an individualized home-based exercise program managed by a physiotherapist. All patients will be evaluated with Geriatric-8, modified Geriatric-8, clinical frailty scale, and physical tests at randomization. Predictive values (positive/negative) will be evaluated for CGA detected impairments. The primary endpoint is the proportion of patients referred to interval debulking surgery (IDS). Secondary endpoints include the proportion who complete oncological treatment, improvements in physical tests, quality of life measured by European Organization for Research and Treatment of Cancer-Quality of Life questionnaires at inclusion, after three cycles of chemotherapy, and at end of chemotherapy treatment. Furthermore, the association between results of geriatric screening tests, CGA, and physical tests with complication rate and progression free survival will be examined. The primary outcome will be analyzed with logistic regression in the intention-to-treat population. Power calculations reveal the need to enroll 216 patients. DISCUSSION The present study examines whether CGA-based interventions including individualized physical exercise can increase the referral rate for potential curative IDS in older patients with EOC. If successful, this will result in more patients undergoing surgery and completing chemotherapy, preventing complications, and ultimately improving quality of life and survival. The study setup may establish the basis for direct clinical implementation if proven effective.
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Affiliation(s)
- Cristina Daviu Cobián
- Department of Gynecology and Obstetrics, Zealand University Hospital, Roskilde, Denmark; Department of Gynecology and Obstetrics, Odense University Hospital, Denmark.
| | - Jakob O Oreskov
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jan Blaakaer
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark
| | - Eva Jespersen
- Department of Clinical Research, University of Southern Denmark, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Trine L Jørgensen
- Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark; Department of Oncology, Odense University Hospital, Denmark
| | - Jesper Ryg
- Department of Clinical Research, University of Southern Denmark, Denmark; Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, Denmark; Department of Geriatric Medicine, Odense University Hospital, Denmark
| | - Jørn Herrstedt
- Department of Clinical Oncology and Palliative Care, Zealand University Hospital, Roskilde, Denmark
| | - Claus Høgdall
- Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Cecilia M Lund
- Department of Medicine, Herlev and Gentofte hospital, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, Copenhagen University, Denmark
| | - Lene Seibæk
- Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Vinther
- Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark; Hospital Secretariat and Communications, Research, Copenhagen University Hospital, Herlev and Gentofte Hospital, Herlev, Denmark
| | - Anne Weng Ekmann-Gade
- Department of Obstetrics and Gynecology, Herlev University Hospital, Herlev, Denmark
| | - Tine H Schnack
- Department of Gynecology and Obstetrics, Odense University Hospital, Denmark; Department of Clinical Research, University of Southern Denmark, Denmark
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Tortorella L, Cappuccio S, Giannarelli D, Nero C, Marchetti C, Gallotta V, Costantini B, Pasciuto T, Minucci A, Fagotti A, Scambia G. Distribution and prognostic role of BRCA status in elderly ovarian cancer patients. Gynecol Oncol 2024; 182:57-62. [PMID: 38262239 DOI: 10.1016/j.ygyno.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/25/2024]
Abstract
OBJECTIVE In the era of target therapy and personalized medicine, BRCA mutational status has a major influence on survival in ovarian cancer patients. Our aim is to verify if the poorer prognosis of elderly ovarian cancer patients can be related to the biology of the tumor beyond their own morbidities and/or suboptimal treatments. METHODS This is a retrospective single-institution study evaluating prognosis of patients with a diagnosis of ovarian cancer and known BRCA status. We collected clinical and surgical characteristics and the distribution of BRCA mutational status according to age groups. RESULTS 1840 patients were included in the analysis. The rate of BRCA mutated decreased over age-range from 49.7% in patients aged <50 years to 18.8% in ≥80 years old women. The prognostic role of BRCA status on survival is maintained when focusing on the elderly population, with improved Disease Free Survival (27.2 months vs 16.5 months for BRCA mutated and wild type respectively, p = 0.001) and Cancer Specific Survival (117.6 months vs 43.1 months for BRCA mutated and wild type respectively, p = 0.001) for BRCAmut compared to BRCAwt patients. In the multivariable analysis, among elderly women, upfront surgery and BRCA mutation are independent factors affecting survival. CONCLUSIONS Elderly patients experiment a poorer prognosis due to multiple factors that include both their medical condition and comorbidities, under-treatment and most importantly disease characteristics. We found that beyond disparities, BRCA mutation is still the strongest independent prognostic factor affecting both the risk of recurrence and death due to disease.
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Affiliation(s)
- Lucia Tortorella
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Serena Cappuccio
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Diana Giannarelli
- Epidemiology and Biostatistics Facility G-STeP Generator Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Camilla Nero
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Claudia Marchetti
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Valerio Gallotta
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Barbara Costantini
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Unicamillus, International Medical University, Via di Sant'Alessandro 8, 00131 Rome, Italy
| | - Tina Pasciuto
- Epidemiology and Biostatistics Facility G-STeP Generator Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Angelo Minucci
- Genomics Core Facility, Gemelli Science and Technology Park (G-STeP), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go A. Gemelli, 00167 Roma, Italy
| | - Anna Fagotti
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00167 Rome, Italy.
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00167 Rome, Italy
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Carmona-Gonzalez CA, Cunha MT, Menjak IB. Bridging research gaps in geriatric oncology: unraveling the potential of pragmatic clinical trials. Curr Opin Support Palliat Care 2024; 18:3-8. [PMID: 38170199 DOI: 10.1097/spc.0000000000000688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW This review examines the role of pragmatic clinical trials (PCTs) in addressing the underrepresentation of older adults with cancer (OAC) in clinical trials. Focusing on real-world evidence (RWE), it aims to provide a comprehensive overview of PCT utilization, emphasizing their potential to enhance treatment decisions and patient outcomes. Existing knowledge gaps in PCT implementation are also discussed. RECENT FINDINGS PCTs are identified as effective tools to include OACs with comorbidities and complex conditions in research, bridging the representation gap. Despite their proven value in healthcare provision, their application in OAC contexts remains limited, hindering comprehensive understanding and inclusivity in clinical trials. SUMMARY While randomized controlled trials (RCTs) are considered the gold standard in oncology research, OACs have historically been excluded, perpetuating underrepresentation. Furthermore, even in current oncology clinical development trials, this demographic continues to be underrepresented. PCTs offer a valuable avenue for the identification and evaluation of therapies within authentic RW contexts, encompassing various healthcare settings, such as hospitals, clinics, and physician practices. RCTs and PCTs complement one another, and the utilization of PCTs has the potential to inform clinical decision-making across the OACs entire treatment trajectory.
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Affiliation(s)
- Carlos A Carmona-Gonzalez
- Division of Medical Oncology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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Impact of surgery and chemotherapy timing on outcomes in older versus younger epithelial ovarian cancer patients: A nationwide Danish cohort study. J Geriatr Oncol 2023; 14:101359. [PMID: 35989185 DOI: 10.1016/j.jgo.2022.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/30/2022] [Accepted: 08/12/2022] [Indexed: 11/21/2022]
Abstract
INTRODUCTION To explore differences in surgical complexity, chemotherapy administration, and treatment delays between younger and older Danish patients with epithelial ovarian cancer (EOC). MATERIALS AND METHODS We included a nationwide cohort diagnosed with EOC from 2013 to 2018. We described surgical complexity and outcomes, the extent of chemotherapy and treatment delays stratified by age (<70 and ≥ 70 years), and surgical modality (primary, interval, or no debulking surgery). RESULTS In total, we included 2946 patients. For patients with advanced-stage disease, 52% of the older patients versus 25% of the younger patients did not undergo primary debulking surgery (PDS) or interval debulking surgery (IDS). For patients undergoing PDS or IDS, older patients underwent less extensive surgery and more often had residual disease after surgery >0 cm compared to younger patients. Furthermore, older patients were less often treated with chemotherapy. Older patients had PDS later than younger. We did not find any differences between age groups concerning treatment delays. Two-year cancer-specific survival differed significantly between age groups regardless of curatively intended treatment. DISCUSSION This study demonstrates that older patients are treated less actively concerning surgical and oncological treatment than younger patients, leading to worse cancer-specific survival. Older patients do not experience more treatment delays than younger ones.
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Ekmann-Gade AW, Høgdall CK, Seibæk L, Noer MC, Fagö-Olsen CL, Schnack TH. Incidence, treatment, and survival trends in older versus younger women with epithelial ovarian cancer from 2005 to 2018: A nationwide Danish study. Gynecol Oncol 2022; 164:120-128. [PMID: 34716025 DOI: 10.1016/j.ygyno.2021.10.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/12/2021] [Accepted: 10/15/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To examine clinical trends in Denmark for younger and older epithelial ovarian cancer (EOC) patients, focusing on incidence, treatment, and survival changes. METHODS We included a nationwide cohort diagnosed with EOC from 2005 to 2018. We described age-standardized incidence, surgical patterns, residual disease trends, and cancer-specific survival stratified by age (<70 and ≥ 70 years), stage, and period (2005-09, 2010-13, 2014-18). RESULTS We included 7522 patients. The incidence decreased from 16.3 (2005) to 11.4 (2018) per 100,000 woman-years, driven by the younger cohort. While the proportion of patients with stage IIIC-IV disease undergoing primary debulking surgery (PDS) decreased, the proportion of patients having interval debulking surgery (IDS) and no debulking surgery increased significantly. In 2014-18, 36% and 24% had PDS for younger and older patients, respectively, compared to 72% and 62% in 2005-09. In both age cohorts, the proportion of patients debulked to no residual disease increased significantly among patients with stage IIIC-IV and in the total cohort. Two-year cancer-specific survival increased from 75% (2005-09) to 84% (2014-18) for younger patients and from 53% to 66% for older patients. After adjusting for potential confounders, age ≥ 70 was associated with a 1.4-fold increased risk of cancer-specific death (95% confidence interval: 1.2,1.5). CONCLUSIONS The proportion of patients with advanced EOC not undergoing PDS or IDS increased significantly. During the same period, patients debulked to no residual disease, and cancer-specific survival increased. However, a survival gap in favor of the younger patients remains after adjusting for potential confounders.
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Affiliation(s)
| | | | - Lene Seibæk
- Department of Gynecology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Calundann Noer
- Department of Gynecology and Obstetrics, Nordsjællands Hospital, Hillerød, Denmark
| | | | - Tine Henrichsen Schnack
- Department of Gynecology, Rigshospitalet, Copenhagen, Denmark; Department of Gynecology, Odense University Hospital, Odense, Denmark
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