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Faour E, Guo S, Puts M. Geriatric Assessment in the Era of Targeted and Immunotherapy. Drugs Aging 2024; 41:577-582. [PMID: 38914823 DOI: 10.1007/s40266-024-01126-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2024] [Indexed: 06/26/2024]
Abstract
Cancer is a disease that mostly affects older adults and because of the aging of the population, the number of older adults diagnosed with cancer will increase significantly around the world. With increasing age, more older adults are living with frailty, and this may impact the tolerability of cancer treatments. International guidelines, such as the American Society for Clinical Oncology geriatric oncology guideline, recommend a geriatric assessment and management for all older adults with cancer to support the treatment decision-making process as well as develop a plan for supportive care interventions to support the older adults during cancer treatments. While there is clinical trial evidence to support a geriatric assessment and management for older adults receiving chemotherapy, there is less evidence to support a geriatric assessment for older adults starting immunotherapy. There are increasing numbers of new immunotherapies and targeted therapies available for older adults with cancer but often few older adults have been included in the clinical trials, leaving less evidence for clinicians to guide treatment decisions. In this current opinion, we review the current evidence on the use of a geriatric assessment and management in the context of immunotherapy and targeted therapy. We review how a geriatric assessment could support older adults making treatment decisions for immunotherapy, review how geriatric assessment parameters are linked with outcomes and provide guidance on how geriatric assessment can guide the supportive care plan during immunotherapy treatment.
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Guven DC, Martinez-Cannon BA, Testa GD, Martins JC, Velasco RN, Kalsi T, Gomes F. Immunotherapy use in older adults with cancer with frailty: A young SIOG review paper. J Geriatr Oncol 2024; 15:101742. [PMID: 38472009 DOI: 10.1016/j.jgo.2024.101742] [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: 09/30/2023] [Revised: 02/04/2024] [Accepted: 03/04/2024] [Indexed: 03/14/2024]
Abstract
Immune checkpoint inhibitors (ICIs) became a treatment option in most tumor types and improved survival in patients with cancer in the last decade. Older patients with cancer are underrepresented in the pivotal clinical trials with ICIs. Older patients with cancer often have significant comorbidities and geriatric syndromes like frailty, which can complicate cancer care and treatment decisions. Frailty is among the most prevalent geriatric syndromes in patients with cancer and could lead to inferior survival and a higher risk of complications in patients treated with chemotherapy. However, the effect of frailty on the efficacy and safety of ICIs is understudied. This review focuses on the available evidence regarding the association between frailty and ICI efficacy and safety. Although the survival benefits of ICIs have generally been shown to be independent of age, the available real-world data has generally suggested higher rates of immune-related adverse events (irAEs) and treatment discontinuation in older patients. While international organizations recommend conducting a comprehensive geriatric assessment CGA to assess and address frailty before the start of anti-cancer therapies, an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher is frequently used in clinical practice as synonymous with frailty, albeit with significant limitations. The available data has generally demonstrated diminished ICI efficacy in patients with an ECOG 2 or higher compared to patients with better performance status, while the incidence of high-grade irAEs were similar. Whilst evidence regarding outcomes with ICI in older patients and in those with sub-optimal performance status is growing, there is very limited data specifically evaluating the role of frailty with ICIs. These studies found a shortened overall survival, yet no evidence of a lower response rate to ICIs. These patients experienced more AEs, but they did not necessarily have a higher incidence of irAEs.
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Affiliation(s)
- Deniz Can Guven
- Medical Oncology Clinic, Health Sciences University, Elazig City Hospital, Elazig, Turkey.
| | | | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50139 Florence, Italy
| | | | - Rogelio N Velasco
- Clinical Trial and Research Division, Philippine Heart Center, Quezon City, Philippines
| | - Tania Kalsi
- Department of Ageing and Health, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Fabio Gomes
- Medical Oncology Department, The Christie NHS Foundation Trust, Manchester, UK
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3
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Young RB, Panchal H, Ma W, Chen S, Steele A, Iannucci A, Li T. Hospitalized cancer patients with comorbidities and low lymphocyte counts had poor clinical outcomes to immune checkpoint inhibitors. Front Oncol 2022; 12:980181. [PMID: 36185315 PMCID: PMC9515784 DOI: 10.3389/fonc.2022.980181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 08/22/2022] [Indexed: 01/26/2023] Open
Abstract
Background Immune checkpoint inhibitor (ICI) therapy has improved survivals with a favorable toxicity profile in a variety of cancer patients. We hypothesized that hospitalized cancer patients who have acute or chronic comorbidities may have suppressed immune systems and poor clinical outcomes to ICIs. The objective of this study was to explore clinical outcomes and predictive factors of hospitalized cancer patients who received ICI therapy at an NCI-designated Comprehensive Cancer Center. Methods A retrospective review of electronic medical records was conducted for adult cancer patients who received an FDA-approved ICI during admission from 08/2016 to 01/2022. For each patient we extracted demographics, cancer histology, comorbidities, reasons for hospitalization, ICI administered, time from treatment to discharge, time from treatment to progression or death, and complete blood counts. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method and compared using the log-rank test. The 95% confidence interval for survival was calculated using the exact binomial distribution. Statistical significance was defined as 2-sided p<0.05. Results Of 37 patients identified, 2 were excluded due to lack of complete blood counts on admission. Average hospital stay was 24.2 (95% CI 16.5, 31.9) days. Ten (27.0%) patients died during the same hospitalization as treatment. Of those who followed up, 22 (59.5%) died within 90 days of inpatient therapy. The median PFS was 0.86 (95% CI 0.43, 1.74) months and median OS was 1.55 (95% CI 0.76, 3.72) months. Patients with ≥3 comorbidities had poorer PFS (2.4 vs. 0.4 months; p=0.0029) and OS (5.5 vs. 0.6 months; p=0.0006). Pre-treatment absolute lymphocyte counts (ALC) <600 cells/µL were associated with poor PFS (0.33 vs. 1.35 months; p=0.0053) and poor OS (0.33 vs. 2.34 months; p=0.0236). Pre-treatment derived neutrophil to lymphocyte ratio (dNLR) <4 was associated with good median PFS (1.6 vs. 0.4 months; p=0.0157) and OS (2.8 vs. 0.9 months; p=0.0375). Conclusions Administration of ICI therapy was associated with poor clinical outcomes and high rates of both inpatient mortality and 90-day mortality after inpatient ICI therapy. The presence of ≥3 comorbidities, ALC <600/μL, or dNLR >4 in hospitalized patients was associated with poor survival outcomes.
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Affiliation(s)
- Richard Benjamin Young
- Division of Hematology/Oncology, Department of Internal Medicine, University of California Davis School of Medicine, University of California Davis Comprehensive Cancer Center, Sacramento, CA, United States
| | - Hemali Panchal
- Division of Hematology/Oncology, Department of Internal Medicine, University of California Davis School of Medicine, University of California Davis Comprehensive Cancer Center, Sacramento, CA, United States
| | - Weijie Ma
- Division of Hematology/Oncology, Department of Internal Medicine, University of California Davis School of Medicine, University of California Davis Comprehensive Cancer Center, Sacramento, CA, United States
| | - Shuai Chen
- Division of Biostatistics, Department of Public Health Sciences, University of California, Davis, Davis, CA, United States
| | - Aaron Steele
- Department of Pharmacy Services, University of California (UC) Davis Health, University of California (UC) Davis Comprehensive Cancer Center, Sacramento, CA, United States
| | - Andrea Iannucci
- Department of Pharmacy Services, University of California (UC) Davis Health, University of California (UC) Davis Comprehensive Cancer Center, Sacramento, CA, United States
| | - Tianhong Li
- Division of Hematology/Oncology, Department of Internal Medicine, University of California Davis School of Medicine, University of California Davis Comprehensive Cancer Center, Sacramento, CA, United States,*Correspondence: Tianhong Li,
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Bloom MD, Saker H, Glisch C, Ramnaraign B, George TJ, Markham MJ, Kelkar AH. Administration of Immune Checkpoint Inhibitors Near the End of Life. JCO Oncol Pract 2022; 18:e849-e856. [PMID: 35254868 DOI: 10.1200/op.21.00689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Recent literature suggests an increasing use of systemic treatment in patients with advanced cancer near the end of life (EOL), partially driven by the increasing adoption of immune checkpoint inhibitors (ICIs). While studies have identified this trend, additional variables associated with ICI use at EOL are limited. Our aim was to characterize a population of patients who received a dose of ICI in the last 30 days of life. METHODS We performed a manual retrospective chart review of patients ≥ 18 years who died within 30 days of receiving a dose of ICI. Metrics such as Eastern Cooperative Oncology Group performance status (ECOG PS), number of ICI doses, need for hospitalization, and numerous other variables were evaluated. RESULTS Over a 4-year time period, 97 patients received an ICI at EOL. For 40% of patients, the ICI given in the 30 days before death was their only dose. Over 50% of patients had an ECOG PS of ≥ 2, including 17% of patients with an ECOG PS of 3. Over 60% were hospitalized, 65% visited the emergency department, 20% required intensive care unit admission, and 25% died in the hospital. CONCLUSION Our study contributes to the ongoing literature regarding the risks and benefits of ICI use in patients with advanced cancer near the EOL. While accurate predictions regarding the EOL are challenging, oncologists may routinely use clinical factors such as ECOG PS along with patient preferences to guide recommendations and shared decision making. Ultimately, further follow-up studies to better characterize and prognosticate this population of patients are needed.
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Affiliation(s)
- Matthew D Bloom
- Division of Hematology & Oncology, College of Medicine, University of Florida, Gainesville, FL
| | - Haneen Saker
- Division of Hematology & Oncology, College of Medicine, University of Florida, Gainesville, FL
| | - Chad Glisch
- Division of Hematology & Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Brian Ramnaraign
- Division of Hematology & Oncology, College of Medicine, University of Florida, Gainesville, FL
| | - Thomas J George
- Division of Hematology & Oncology, College of Medicine, University of Florida, Gainesville, FL
| | - Merry J Markham
- Division of Hematology & Oncology, College of Medicine, University of Florida, Gainesville, FL
| | - Amar H Kelkar
- Division of Hematology & Oncology, College of Medicine, University of Florida, Gainesville, FL.,Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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An A, Hui D. Immunotherapy Versus Hospice: Treatment Decision-Making in the Modern Era of Novel Cancer Therapies. Curr Oncol Rep 2022; 24:285-294. [PMID: 35113356 DOI: 10.1007/s11912-022-01203-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Modern advances in cancer treatment with immunotherapy have created substantial hope for patients and oncologists alike due to a new possibility of durable response which can verge on "cure." This, in combination with a more favorable toxicity profile, has led many oncologists to consider immunotherapy for patients who might have previously been recommended for hospice. In this narrative review, we discuss (1) the risks and benefits of immunotherapy in patients with far advanced cancer in the last months of life, (2) the role of supportive and palliative care, and (3) how to navigate complex treatment decisions for these patients. RECENT FINDINGS Unfortunately, data on immunotherapy outcomes for patients with poor performance status and far advanced disease are quite limited. Where available, studies consistently report poorer survival outcomes compared to patients with preserved performance status. However, a minority of patients (15-30%) may achieve at least partial response with immunotherapy, which can be quite durable. Such prognostic uncertainty leads to additional challenges in treatment discussions and decision-making. Given such prognostic uncertainty, clinicians should individualize treatment with consideration for all the various factors that may inform each patient's expected outcome with immunotherapy. Early involvement of palliative care in the disease trajectory can help patients with advanced cancer to optimize their quality of life, improve illness understanding, navigate prognostic uncertainty, and facilitate complex decision-making regarding cancer treatments. With upfront, open discussions of immunotherapy expectations, oncologists can help ensure treatments are aligned with patient goals and optimize value outcomes.
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Affiliation(s)
- Amy An
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd. Unit 463, Houston, TX, 77030, USA.
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Gu YF, Lin FP, Epstein RJ. How aging of the global population is changing oncology. Ecancermedicalscience 2022; 15:ed119. [PMID: 35211208 PMCID: PMC8816510 DOI: 10.3332/ecancer.2021.ed119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
Population aging is causing a demographic redistribution with implications for the future of healthcare. How will this affect oncology? First, there will be an overall rise in cancer affecting older adults, even though age-specific cancer incidences continue to fall due to better prevention. Second, there will be a wider spectrum of health functionality in this expanding cohort of older adults, with differences between “physiologically older” and “physiologically younger” patients becoming more important for optimal treatment selection. Third, greater teamwork with supportive care, geriatric, mental health and rehabilitation experts will come to enrich oncologic decision-making by making it less formulaic than it is at present. Success in this transition to a more nuanced professional mindset will depend in part on the development of user-friendly computational tools that can integrate a complex mix of quantitative and qualitative inputs from evidence-based medicine, functional and cognitive assessments, and the personal priorities of older adults.
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Affiliation(s)
- Yan Fei Gu
- New Hope Cancer Center, United Family Hospitals, 9 Jiangtai W Rd, Chaoyang, Beijing 100015, China
| | - Frank P Lin
- Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, Sydney 2010, Australia.,NH&MRC Clinical Trials Centre, 92 Parramatta Rd, Camperdown, Sydney 2050, Australia
| | - Richard J Epstein
- New Hope Cancer Center, United Family Hospitals, 9 Jiangtai W Rd, Chaoyang, Beijing 100015, China.,Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, Sydney 2010, Australia.,UNSW Clinical School, St Vincent's Hospital, 390 Victoria St, Darlinghurst, Sydney 2010, Australia.,https://orcid.org/0000-0002-4640-0195
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Wasp GT, Knutzen KE, Murray GF, Brody-Bizar OC, Liu MA, Pollak KI, Tulsky JA, Schenker Y, Barnato AE. Systemic Therapy Decision Making in Advanced Cancer: A Qualitative Analysis of Patient-Oncologist Encounters. JCO Oncol Pract 2021; 18:e1357-e1366. [PMID: 34855459 PMCID: PMC9377707 DOI: 10.1200/op.21.00377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We sought to characterize patient-oncologist communication and decision making about continuing or limiting systemic therapy in encounters after an initial consultation, with a particular focus on whether and how oncologists foster shared decision making (SDM). METHODS We performed content analysis of outpatient oncology encounters at two US National Cancer Institute-designated cancer centers audio recorded between November 2010 and September 2014. A multidisciplinary team used a hybrid approach of inductive and deductive coding and theme development. We used a combination of random and purposive sampling. We restricted quantitative frequency counts to the coded random sample but included all sampled encounters in qualitative thematic analysis. RESULTS Among 31 randomly sampled dyads with three encounters each, systemic therapy decision making was discussed in 90% (84 of 93) encounters. Thirty-four (37%) broached limiting therapy, which 27 (79%) framed as temporary, nine (26%) as completion of a standard regimen, and five (15%) as permanent discontinuation. Thematic analysis of these 93 encounters, plus five encounters purposively sampled for permanent discontinuation, found that (1) patients and oncologists framed continuing therapy as the default, (2) deficiencies in the SDM process (facilitating choice awareness, discussing options, and incorporating patient preferences) contributed to this default, and (3) oncologists use persuasion rather than deliberation when broaching discontinuation. CONCLUSION In this study of outpatient encounters between patients with advanced cancer and their oncologists, when discussing systemic therapy, there exists a default to continue systemic therapy, and deficiencies in SDM contribute to this default.
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Affiliation(s)
- Garrett T Wasp
- Section of Oncology, Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, NH.,Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Kristin E Knutzen
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Genevra F Murray
- Department of General Internal Medicine, Boston Medical Center, Boston, MA
| | | | - Matthew A Liu
- University of California San Diego School of Medicine, La Jolla, CA
| | | | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Yael Schenker
- Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
| | - Amber E Barnato
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH.,The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH.,Section of Palliative Care, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
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Naltet C, Besse B. Immune checkpoint inhibitors in elderly patients treated for a lung cancer: a narrative review. Transl Lung Cancer Res 2021; 10:3014-3028. [PMID: 34295694 PMCID: PMC8264351 DOI: 10.21037/tlcr-20-1239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 06/08/2021] [Indexed: 12/26/2022]
Abstract
This article is a review of the literature concerning efficacy and safety of immune checkpoint inhibitors (ICIs) in the elderly population. In the past decade, immunotherapy deeply changed the treatment paradigm of lung cancer in particular in advanced non-small cell lung cancer (aNSCLC). Thus, ICIs have successively demonstrated a survival benefit as single agent in second line, and moved in first line as monotherapy for patients with high programmed death protein 1 (PD-L1) expression or in combination with chemotherapy regardless PD-L1 expression. If patients aged 70 years or older represent up to half of our patients in clinical routine, elderly population is significantly under-represented in clinical trials. This leads to a lack of knowledge concerning efficacy and safety of ICIs in a population of patients with frequent comorbidities, organs dysfunctions and a potential immune-senescence due to age. In this review, we described available data evaluating efficacy and safety of ICI either as monotherapy or in combination in elderly population treated for a lung cancer. These data derived from clinical trial evaluating ICIs in aNSCLC as single agent or in combination with chemotherapy or anti-cytotoxic T-lymphocyte antigen 4 (CTLA-4). As monotherapy, older patients seem to derive the same benefit from ICIs than younger patients with no excess of toxicities. In combination with chemotherapy, real impact of ICIs in elderly population is still unclear. Results of dedicated studies evaluating ICIs as single agent or in combination in elderly patients are needed.
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Affiliation(s)
- Charles Naltet
- Cancer Medicine Department, Gustave Roussy, Villejuif, France.,Department of Pulmonology and Thoracic Oncology, Hôpital Saint Joseph, Paris, France
| | - Benjamin Besse
- Cancer Medicine Department, Gustave Roussy, Villejuif, France.,Paris-Sacaly University, Orsay, France
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Almutairi AR, Slack M, Erstad BL, McBride A, Abraham I. Association of immune-checkpoint inhibitors and the risk of immune-related colitis among elderly patients with advanced melanoma: real-world evidence from the SEER-Medicare database. Ther Adv Drug Saf 2021; 12:2042098621991279. [PMID: 33796257 PMCID: PMC7970695 DOI: 10.1177/2042098621991279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 01/08/2021] [Indexed: 12/13/2022] Open
Abstract
Background: The use of anti-cytotoxic T-lymphocyte antigen 4 (anti-CTLA4) therapy (ipilimumab) and anti-programmed cell-death 1 (anti-PD1) agents (nivolumab and pembrolizumab) in advanced melanoma have been associated with immune-related adverse events (irAEs) including colitis. We aimed to estimate the incidence and the risk of colitis in elderly patients with advanced melanoma treated with anti-CTLA4 and anti-PD1 in the real-world setting. Methods: Elderly patients (age ⩾ 65 years) diagnosed with advanced melanoma between 2011 and 2015 and treated with anti-CTLA4 or anti-PD1 agents were identified from the Surveillance, Epidemiology, and End Results (SEER)–Medicare data. We estimated the risk of colitis from start of treatment up to 90 days from the last dose of therapy. We used the log-rank test and logistic regression with adjustment for potential confounders using the inverse probability of treatment weighting method. We conducted several sensitivity analyses. Results: A total of 274 elderly patients with advanced melanoma were included in our cohort. The risk of colitis was similar between anti-PD1 users and anti-CTLA4 users based on log-rank test (p = 0.17) and logistic regression [odds ratio (OR) = 0.35, 95% confidence interval (95%CI) 0.04–2.79]. Sensitivity analyses for patients with all-stage melanoma showed a significantly lower risk of colitis in anti-PD1 compared with anti-CTLA4 treated patients based on log-rank test (p = 0.017) and logistic regression (OR = 0.21, 95%CI 0.09–0.53). Conclusion: Elderly with advanced melanoma treated with anti-CTLA4 or anti-PD1 had a similar risk of developing colitis. However, there was a statistically significant difference in the risk of colitis between anti-CTLA4 or anti-PD1 users among all-stage-melanoma patients. Plain Language Summary Risk of colitis (inflammation of the large intestine) in elderly patients with melanoma treated with immune-checkpoint inhibitors (a group of medications that uses the patient’s immune system to fight cancer) While the anti-cancer agents known as immune-checkpoint inhibitors have had a great impact on the treatment of melanoma, they may also have side effects. This study estimated the risk of colitis, a chronic inflammation of the colon, in elderly patients with melanoma treated with anti-cytotoxic T-lymphocyte antigen 4 (anti-CTLA4) or anti-programmed cell-death 1 (anti-PD1) agents, using data from the Surveillance, Epidemiology, and End Results (SEER)–Medicare linked database. Overall, we found that the risk of colitis was not different between anti-PD1 users and anti-CTLA4 users with advanced-stage melanoma. However, after including patients across all stages of melanoma, we found a significantly lower risk of colitis with anti-PD1 compared with anti-CTLA4.
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Affiliation(s)
- Abdulaali R. Almutairi
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA; Drug Sector, Saudi Food and Drug Authority, Riyadh, Saudi Arabia
| | - Marion Slack
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Brian L. Erstad
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
- University of Arizona Cancer Center, Tucson, AZ, USA
| | - Ali McBride
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
- University of Arizona Cancer Center, Tucson, AZ, USA
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Patell R, Einstein D, Miller E, Dodge L, Halleck J, Buss M. Patient Perceptions of Treatment Benefit and Toxicity in Advanced Cancer: A Prospective Cross-Sectional Study. JCO Oncol Pract 2021; 17:e119-e129. [PMID: 33444075 DOI: 10.1200/op.20.00517] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Prior studies show that many patients receiving palliative cancer therapies misperceive likelihood of cure. Patients' understanding of treatment benefits and risks beyond cure is unknown. We explore patient perceptions of palliative treatment in the novel therapeutic era. METHODS We surveyed patients with advanced solid cancers and their oncologists regarding benefits and risks of palliative therapies. We assessed perceived likelihood of tumor response, survival benefit, symptom palliation, and side effects. We used generalized estimating equations to calculate least squares means of misperception (patient-assessed minus physician-assessed likelihood of benefit), accounting for clustering by physician, and compared the degree of misperception by participant characteristics. RESULTS Of the 119 patients enrolled, median age was 65 years (range, 59-73 years), 55% were male, and 56% had prior treatment. Treatments included chemotherapy (60%), immunotherapy (24%), and targeted therapy (15%). Compared with their oncologists, patients overestimate curability (median misperception, 20%; interquartile range [IQR], 0 to 60), chances of tumor response (median, 20%; IQR, 0 to 40), symptom palliation (median, 10%; IQR, -10 to 30), and survival benefit (median, 20%; IQR, 0 to 40). Toxicity was relatively accurately estimated (median, 0.5%; IQR, -20 to 20). Immunotherapy was associated with higher risk of misperception of tumor response and toxicity. Misperceptions of tumor response and curability did not correlate (r = 0.13, P = .15). CONCLUSION Compared with their oncologists, patients overestimated chances of tumor response, symptom palliation, and survival benefit, but accurately perceived likelihood of toxicity. There was no strong correlation between perception of curability and other goals of therapy. Communication focused on treatment goals alongside risks may reduce misperceptions and facilitate informed choices by patients.
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Affiliation(s)
- Rushad Patell
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - David Einstein
- Division of Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eric Miller
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Laura Dodge
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jennifer Halleck
- Division of Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mary Buss
- Section of Palliative Care, Division of General Medicine and Primary Care, Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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11
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Patel MN, Nicolla JM, Friedman FAP, Ritz MR, Kamal AH. Hospice Use Among Patients With Cancer: Trends, Barriers, and Future Directions. JCO Oncol Pract 2020; 16:803-809. [PMID: 33186083 DOI: 10.1200/op.20.00309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Patients with advanced cancer and their families frequently encounter clinical and logistical challenges related to end-of-life care. Hospice provides interdisciplinary and holistic care to meet patients' biomedical, psychosocial, and spiritual needs in the last phases of life. Despite increasing general acceptance and use among patients with cancer, hospice remains underused. Underuse stems from ongoing misconceptions regarding hospice and its purpose, coupled with the rapid development of novel anticancer treatments, such as immunotherapies and targeted therapies, that have changed the landscape of possibilities. Furthermore, rapid evolutions in how end-of-life care is structured and reimbursed for will affect how oncology patients will intersect with hospice care. In this review, we explore the current and future challenges to greater integration of hospice care in the care of patients with advanced cancer and propose five recommendations as part of the path forward.
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Affiliation(s)
- Mihir N Patel
- Trinity College of Arts and Sciences, Duke University, Durham, NC
| | | | | | - Michala R Ritz
- Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Center, Durham, NC.,Duke Fuqua School of Business, Durham, NC
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