International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer

Tolerability and effectiveness of palbociclib in older women with metastatic breast cancer

PURPOSE

Palbociclib has become the standard of care for estrogen receptor-positive (ER+), human epidermal growth factor receptor 2 negative (HER2-) metastatic breast cancer, but real-world evidence in older women remains scarce. Therefore, we investigated tolerability of palbociclib in older women with metastatic breast cancer.

METHODS

Consecutive women aged ≥ 70 with ER+/HER2- metastatic breast cancer, treated with palbociclib in any treatment line in six hospitals, were included. Primary endpoint was grade ≥ 3 palbociclib-related toxicity. Predictors of toxicity were identified using logistic regression models. Progression-free survival (PFS) and overall survival (OS) were estimated using Kaplan Meier.

RESULTS

We included 144 women with a median age of 74 years. Grade 3-4 toxicity occurred in 54% of patients, of which neutropenia (37%) was most common. No neutropenic fever or grade 5 toxicity occurred. Dose reduction during treatment occurred in 50% of patients, 8% discontinued treatment due to toxicity and 3% were hospitalized due to toxicity. Polypharmacy (odds ratio (OR) 2.50; 95% confidence interval (CI) 1.12-5.58) and pretreatment low leukocytes (OR 4.81; 95% CI 1.27-18.21) were associated with grade 3-4 toxicity, while comorbidities were not. In first-line systemic therapy, median PFS was 12 months and median OS 32 months. In second-line, median PFS was 12 months and median OS 31 months.

CONCLUSION

Although grade 3-4 toxicity and dose reductions occurred frequently, most were expected and managed by dose reductions, showing that palbociclib is generally well tolerated and thus represents a valuable treatment option in the older population.

Randomized Phase 3 Trial of the Hypoxia Modifier Nimorazole Added to Radiation Therapy With Benefit Assessed in Hypoxic Head and Neck Cancers Determined Using a Gene Signature (NIMRAD)

PURPOSE

Tumor hypoxia is an adverse prognostic factor in head and neck squamous cell carcinoma (HNSCC). We assessed whether patients with hypoxic HNSCC benefited from the addition of nimorazole to definitive intensity modulated radiation therapy (IMRT).

METHODS AND MATERIALS

NIMRAD was a phase 3, multicenter, placebo-controlled, double-anonymized trial of patients with HNSCC unsuitable for concurrent platinum chemotherapy or cetuximab with definitive IMRT (NCT01950689). Patients were randomized 1:1 to receive IMRT (65 Gy in 30 fractions over 6 weeks) plus nimorazole (1.2 g/m2 daily, before IMRT) or placebo. The primary endpoint was freedom from locoregional progression (FFLRP) in patients with hypoxic tumors, defined as greater than or equal to the median tumor hypoxia score of the first 50 patients analyzed (≥0.079), using a validated 26-gene signature. The planned sample size was 340 patients, allowing for signature generation in 85% and an assumed hazard ratio (HR) of 0.50 for nimorazole effectiveness in the hypoxic group and requiring 66 locoregional failures to have 80% power in a 2-tail log-rank test at the 5% significance level.

RESULTS

Three hundred thirty-eight patients were randomized by 19 centers in the United Kingdom from May 2014 to May 2019, with a median follow-up of 3.1 years (95% CI, 2.9-3.4). Hypoxia scores were available for 286 (85%). The median patient age was 73 years (range, 44-88; IQR, 70-76). There were 36 (25.9%) locoregional failures in the hypoxic group, in which nimorazole + IMRT did not improve FFLRP (adjusted HR, 0.72; 95% CI, 0.36-1.44; P = .35) or overall survival (adjusted HR, 0.96; 95% CI, 0.53-1.72; P = .88) compared with placebo + IMRT. Similarly, nimorazole + IMRT did not improve FFLRP or overall survival in the whole population. In total (N = 338), 73% of patients allocated nimorazole adhered to the drug for ≥50% of IMRT fractions. Nimorazole + IMRT caused more acute nausea compared with placebo + IMRT (Common Terminology Criteria for Adverse Events version 4.0 G1+2: 56.6% vs 42.4%, G3: 10.1% vs 5.3%, respectively; P < .05).

CONCLUSIONS

Addition of the hypoxia modifier nimorazole to IMRT for locally advanced HNSCC in older and less fit patients did not improve locoregional control or survival.

Geriatric Assessment in the Era of Targeted and Immunotherapy

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.

Skeletal muscle density performance for screening frailty in older adults with cancer and the impact of diabetes: The CARE Registry

INTRODUCTION

Skeletal muscle density (SMD) measurements from imaging scans identify myosteatosis and could screen patients for geriatric assessment. We assessed SMD performance as a screening tool to identify older adults with cancer likely to be frail and who could benefit from in-depth assessment; we compared performance by sex and diabetes status.

MATERIALS AND METHODS

We analyzed patients in the Cancer & Aging Resilience Evaluation (CARE) Registry. Frailty and diabetes were captured using a patient-reported geriatric assessment (CARE tool). Frailty was defined using CARE frailty index (CARE-FI) based on principles of deficit accumulation. SMD was calculated from computed tomography scans (L3 vertebrae). Analyses were conducted by sex and diabetes status. Scatterplots and linear regression described crude associations between SMD and frailty score. Classification performance (frail vs. non-frail) was analyzed with (1) area under the receiver operating characteristic curves (AUC) and confidence intervals (CIs); and (2) sensitivity/specificity for sex-specific SMD quartile cut-offs (Q1, median, Q3). Performance was compared between patients with and without diabetes using differences and estimated CIs (2000 bootstrap replicates). We additionally calculated positive and negative likelihood ratios (LR+, LR-).

RESULTS

The analytic cohort included 872 patients (39% female, median age 68 years, 27% with diabetes) with predominately stage III/IV gastrointestinal cancer; >60% planning to initiate first-line chemotherapy. SMD was negatively associated with frailty score; models were best fit in male patients with diabetes. AUC estimates for female (range: 0.58-0.62) and male (0.58-0.68) patients were low. Q3 cut-offs had high sensitivity (range: 0.76-0.89), but poor specificity (0.25-0.34). Diabetes did not impact estimates for female patients. Male patients with diabetes had greater sensitivity estimates compared to those without (sensitivity differences: 0.23 [0.07, 0.38], 0.08 [-0.07, 0.24], and 0.11 [0.00, 0.22] for Q1, median, Q3, respectively). LR estimates were most notable for male patients with diabetes (LR+ = 2.92, Q1 cut-off; LR- = 0.46, Q3 cut-off).

DISCUSSION

Using SMD alone to screen older patients for geriatric assessment requires improvement. High-sensitivity cut-off points could miss 11-24% of patients with frailty, and many non-frail patients may be flagged. Screening with SMD is practical but work is needed to understand clinical andresource impacts of different cut-off points. Future research should evaluate performance with additional clinical data and in subgroups.

Comorbidity assessment methods and their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer - A scoping review

INTRODUCTION

The scoping review was performed to identify methods of comorbidity assessment and to evaluate their significance in predicting the results of treatment of older patients undergoing elective abdominal surgeries for cancer.

MATERIALS AND METHODS

Ovid MEDLINE, Embase, CENTRAL, Web of Science, ClinicalTrials.gov and European Trials Register were searched for eligible studies investigating the impact of comorbidity on various postoperative outcomes of patients aged ≥65. Findings were narratively reported.

RESULTS

The review identified 40 studies with a total population of 59,612 patients, using eight different methods of comorbidity assessment. The most used was Charlson Comorbidity Index (60 % of studies) and presence of specific comorbid conditions (38 %). No study provided rationale for the choice of specific comorbidity measure. Most of the included studies reported short-term results (75 %), such as postoperative complications (43 %) and mortality (18 %) as main clinical endpoint. The results were inconsistent across the studies.

DISCUSSION

There is still no consensus regarding the choice of comorbidity measures and their role in postoperative outcome prediction. Further efforts are needed to develop new, well-designed, more effective comorbidity assessments tools.

Geriatric assessment with management for older patients with cancer receiving radiotherapy: a cluster-randomised controlled pilot study

BACKGROUND

Geriatric assessment and management (GAM) improve outcomes in older patients with cancer treated with surgery or chemotherapy. It is unclear whether GAM may provide better function and quality of life (QoL), or be cost-effective, in a radiotherapy (RT) setting.

METHODS

In this Norwegian cluster-randomised controlled pilot study, we assessed the impact of a GAM intervention involving specialist and primary health services. It was initiated in-hospital at the start of RT by assessing somatic and mental health, function, and social situation, followed by individually adapted management plans and systematic follow-up in the municipalities until 8 weeks after the end of RT, managed by municipal nurses as patients' care coordinators. Thirty-two municipal/city districts were 1:1 randomised to intervention or conventional care. Patients with cancer ≥ 65 years, referred for RT, were enrolled irrespective of cancer type, treatment intent, and frailty status, and followed the allocation of their residential district. The primary outcome was physical function measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (QLQ-C30). Secondary outcomes were overall quality of life (QoL), physical performance, use and costs of health services. Analyses followed the intention-to-treat principle. Study registration at ClinicalTrials.gov ID NCT03881137.

RESULTS

We included 178 patients, 89 in each group with comparable age (mean 74.1), sex (female 38.2%), and Edmonton Frail Scale scores (mean 3.4 [scale 0-17], scores 0-3 [fit] in 57%). More intervention patients received curative RT (76.4 vs 61.8%), had higher irradiation doses (mean 54.1 vs 45.5 Gy), and longer lasting RT (mean 4.4 vs 3.6 weeks). The primary outcome was completed by 91% (intervention) vs 88% (control) of patients. No significant differences between groups on predefined outcomes were observed. GAM costs represented 3% of health service costs for the intervention group during the study period.

CONCLUSIONS

In this heterogeneous cohort of older patients receiving RT, the majority was fit. We found no impact of the intervention on patient-centred outcomes or the cost of health services. Targeting a more homogeneous group of only pre-frail and frail patients is strongly recommended in future studies needed to clarify the role and organisation of GAM in RT settings.

The association between social vulnerability and geriatric assessment impairments among older adults with gastrointestinal cancers-The CARE Registry

BACKGROUND

Older adults comprise the majority of patients with gastrointestinal (GI) cancer. Geriatric assessments (GAs) are recommended for older adults with cancer in part to detect aging-related impairments (e.g., frailty) associated with early mortality. Social factors like social vulnerability may also influence aging-related impairments. However, the association between social vulnerability and aging outcomes among older adults with cancer is understudied.

METHODS

The authors included 908 older adults aged 60 years and older who were recently diagnosed with GI cancer undergoing GA at their first prechemotherapy visit to the University of Alabama at Birmingham oncology clinic. The primary exposure of interest was the social vulnerability index (SVI). Outcomes were frailty (frail vs. robust/prefrail) and total number of GA impairments (range, 0-13). The authors examined the association between SVI and outcomes using Poisson regression with robust variance estimation and generalized estimating equations.

RESULTS

The median age at GA was 69 years (interquartile range, 64-75 years), 58.2% of patients were male, 22.6% were non-Hispanic Black, 29.1% had colorectal cancer, 28.2% had pancreatic cancer, and 70.3% had stage III/IV disease. Adjusting for age, sex, cancer type, and disease stage, each decile increase in the SVI was associated with an 8% higher prevalence of frailty (prevalence ratio, 1.08; 95% confidence interval, 1.05-1.11) and a 4% higher average count of total GA impairments (risk ratio, 1.04; 95% confidence interval, 1.02-1.06). The results were attenuated after further adjustment for race and education.

CONCLUSIONS

Greater social vulnerability was associated with a higher prevalence of frailty and an increasing average number of GA impairments among older adults with GI cancers before systemic treatment. Intervening on social vulnerability may be a target for improving the risk of frailty and GA impairments, but associations of race and education should be further evaluated.

Ageing-related considerations for medication used in supportive care in cancer

Both randomized controlled trials (RCTs) and retrospective studies have shown that a comprehensive geriatric assessment (CGA) prior to a patient commencing systemic anti-cancer therapy (SACT) results in improved quality of life outcomes and is associated with a decreased risk of grade 3-5 toxicity; however, data are lacking in relation to adverse drug events (ADE) associated with supportive care medications. Supportive care medications are prescribed as prophylactic agents in a SACT regimen, for management of treatment related toxicity and for symptoms caused by the disease itself. While necessary, the commencement of SACT and supportive medications may cause, or exacerbate, a significant drug burden in older patients, some of whom may have existing comorbidities. For many medications, older adults are underrepresented in pharmacokinetic and pharmacodynamic modelling studies. In this article we will review ageing-related changes in pharmacokinetics and pharmacodynamics, as well as how these changes may impact supportive care medications. Additional considerations for prescribing these medications in older adults with cancer, such as polypharmacy, potentially inappropriate medications, drug-drug interactions, and anticholinergic burden, as well as ageing-related considerations and recommendations for supportive care medications commonly used in older adults with cancer are also reviewed.

The significance of G8 and other geriatric assessments in urologic cancer management: A comprehensive review

In urologic oncology, which often involves older patients, it is important to consider how to manage their care appropriately. Geriatric assessment (GA) is a method that can address the specific needs of older cancer patients. The GA encompasses various assessment domains, but these domains exhibit variations across the literature. Some of the common items include functional ability, nutrition, comorbidities, cognitive ability, psychosocial disorders, polypharmacy, social and financial support, falls/imbalance, and vision/hearing. Despite the diversity of domains, there is limited consensus on reliable measurement methods. This review discusses the role of GA in managing urologic cancer in unique scenarios, such as those necessitating temporary or permanent urinary catheters or stomas due to urinary diversion. A comprehensive GA is time and human-resource-intensive in real-world clinical practice. Hence, simpler tools such as the Geriatric-8 (G8), capable of identifying high-risk patients requiring a detailed GA, are also under investigation in various contexts. Therefore, we conducted a systematic literature review on the G8. Our findings indicate that patients with low G8 scores encounter difficulties with stoma self-care after urinary diversion and have higher risks of urinary tract infections and ileus after radical cystectomy. The utilization of G8 as a screening tool for urologic cancer patients may facilitate the delivery of appropriate and personalized treatment and care.

A single-centre study evaluating a geriatric screening tool in oncology phase I trial patients

BACKGROUND

Though cancer is more prevalent in the older population, this patient group are underrepresented in phase I oncology trials.

AIMS

We evaluated the use of a geriatric screening tool (SAOP3) in patients of 70 years of age or older who attended a Phase I Clinical Trials Unit, with the aim of assessing the feasibility of the tool and identifying potential unmet needs in this patient group.

METHODS

Twenty-two patients over the age of 70 completed the SAOP3 questionnaire. Geriatric impairments and needs were analysed with descriptive statistics. Qualitative responses were grouped in themes using structured thematic analysis.

RESULTS

All of patients triggered at least 1 geriatric domain, most commonly mobility. Six core themes were identified as being important to the patient including family, friends and positivity. On cognition assessment over 20% of patients triggered as requiring further cognitive assessment. The group had a relatively high screen fail risk.

CONCLUSION

In conclusion, routine geriatric screening withSAOP3 was feasible and identified areas of patient need. Results highlight the prevalence of psychological distress and cognitive impairment. Geriatric screening offers an opportunity for prehabilitation prior to trial and support during trial participation to optimise safety and improve trial access.

Prognostic value of Geriatric-8 for adverse outcomes within 30 days of surgery in older adults with colorectal cancer: A retrospective cohort study

PURPOSE

It is unclear whether the Geriatric-8 (G8) has the accuracy to preselect patients for complete geriatric assessment, and has the ability to predict adverse outcomes in patients with colorectal cancer (CRC). We therefore aimed to determine whether the G8, or other variables present in the medical record, are applicable in predicting 30-day adverse outcomes in older patients undergoing surgery for CRC.

METHODS

We performed a retrospective cohort study involving patients ≥70 years who had surgery for CRC between 2018 and 2020 in a general hospital in the Netherlands. The primary outcome was adverse outcome(s), which is a composite of surgical and non-surgical complications, readmission and mortality, all within 30 days of surgery. The secondary endpoints were the individual components, such as delirium, infection and ileus. We explored potential prognostic factors using multivariable logistic regression analysis. Data were collected from the Dutch ColoRectal Audit (DRCA) and medical records.

RESULTS

The study included 200 patients (mean age 78.9 years: 50% female), with 36.5% having adverse outcomes in the first 30 days of surgery. In neither univariate nor multivariable analysis were G8 scores associated with adverse outcomes. Factors with higher odds of adverse outcomes were male gender, and having cognitive decline or previous delirium.

CONCLUSION

This study confirms that G8 scores have no prognostic value for adverse outcomes, complications and mortality within 30 days of surgery among older adults with CRC. Therefore, the G8 should not be the tool for short-term risk prediction of adverse outcomes in these patients.

An Annual Symposium on Disparities in Milwaukee, WI, with a 2023 Focus on Older Adults with Cancer

PURPOSE OF REVIEW

Cancer-related inequities are prevalent in Wisconsin, with lower survival rates for breast, colorectal, and lung cancer patients from marginalized communities. This manuscript describes the ongoing efforts at the Medical College of Wisconsin and potential pathways of community engagement to promote education and awareness in reducing inequities in cancer care.

RECENT FINDINGS

While some cancer inequities are related to aggressive disease biology, health-related social risks may be addressed through community-academic partnerships via an open dialogue between the community members and academic faculty. To develop potential pathways of community-academic partnerships, an annual Cancer Disparities Symposium concept evolved as a pragmatic and sustainable model in an interactive learning environment. In this manuscript, we describe the programmatic development and execution of the annual Cancer Disparities Symposium, followed by highlights from this year's meeting focused on geriatric oncology as discussed by the speakers.

Intramuscular adipose tissue, muscle area, and power as predictors of performance in breast cancer survivors

PURPOSE

The decline in physical performance, assessed by physical tests such as the timed up and go (TUG) test, is a consequence of reduced physiological reserves at higher levels of a hierarchical process. This occurs due to changes in muscle architecture, including atrophy and fat infiltration into the muscles, which in turn lead to changes in muscle function, resulting in reduced muscle strength and power and, consequently, affecting physical performance. This study investigated predictive factors for physical performance in breast cancer survivor (BCS), focusing on intramuscular adipose tissue (IMAT), quadríceps muscle area (QMA), and muscular power.

METHODS

This observational, analytical, and cross-sectional study included 23 women without a history of cancer (age, 58.5 ± 8.3 years; BMI, 27.2 ± 5.1 kg/m2) and 56 BCS (age, 58.5 ± 8.3 years; BMI, 27.2 ± 5.1 kg/m2). QMA and IMAT were assessed using computed tomography images. Muscular power and physical performance were measured using the 5-repetition sit-to-stand and TUG tests, respectively.

RESULTS

IMAT (r = 0.4, P < 0.01) and muscular power (r =  - 0.4, P < 0.01) were associated with TUG performance in BCS, whereas QMA (r =  - 0.22, P = 0.10) showed no significant association. QMA (r = 0.55, P < 0.01) was associated with muscular power, while no significant association was found between IMAT and muscular power (r =  - 0.05, P = 0.73). Age explained 19% (P < 0.01) of TUG performance variability. Adding muscular power increased explanatory power by 12% (P < 0.01), and including IMAT further increased it by 7% (P = 0.02) for TUG performance. Collectively, age, muscular power, and IMAT accounted for 38% of the performance variance in the TUG test (age, B = 0.06, P = 0.043; muscular power, B =  - 0.01, P = 0.002; IMAT, B =  - 0.05, P = 0.020).

CONCLUSIONS

Our findings suggest that IMAT and muscular power predict the physical performance of BCS, while QMA does not have the same predictive capability.

Oncology care providers' perceptions and anticipated barriers regarding the use of geriatric assessment in routine clinic practice: A mixed-methods study

INTRODUCTION

Geriatric assessment (GA) is currently not a standard of cancer care across Canada. In the Canadian province of Saskatchewan, there are no known formal geriatric teams in outpatient oncology settings. Therefore, it is not known whether, how, and to what extent GA is performed in oncology clinics, or what supports are needed to carry out a GA. The objective of this study was to explore Saskatchewan oncology care providers' knowledge, perceptions, and practices regarding GA, and their perceived barriers to implementing formal GA.

MATERIALS AND METHODS

In this mixed-methods study, oncology physicians and nurses within the Saskatchewan Cancer Agency (SCA) were invited to participate in an anonymous survey and individual open-ended interview. Quantitative survey data were analyzed using descriptive statistics; free-text responses provided in the survey were summarized. Data from interviews were analyzed using thematic analysis.

RESULTS

A total of 19 physicians and 30 clinic nurses participated in the survey (response rate: 24% [physicians] and 38.0% [nurses]). In terms of cancer treatment and management, the majority (74% of physicians and 62% of nurses) stated considerations for older adults are different than younger patients. More than half (53% of physicians and 58% of nurses) reported making treatment and management decisions primarily based on judgement versus validated tools. For physicians whose practices involve prescribing chemotherapy (16/19), 75% rarely or never use validated tools (e.g., CARG, CRASH) to assess risk of chemotoxicity for older patients. Lack of time and supporting staff and feeling unsure as to where to refer older patients for help or follow-up were the most commonly voiced anticipated barriers to implementing GA. Two physicians and six nurses (n = 8) participated in the open-ended interviews. Main themes included: (1) tension between knowing the importance of GA versus capacity and (2) buy-in.

DISCUSSION

Our findings review barriers and opportunities for implementing GA in oncology care in Saskatchewan and provides foundational knowledge to inform efforts to promote personalized medicine and to optimize cancer care for older adults with cancer in this region.

Association between dietary supplement use and mortality in cancer survivors with different body mass index and frailty status: a cohort study

Background

The association between Body Mass Index (BMI), frailty index (FI), and dietary supplement in cancer survivors has been a subject of growing interest. This study investigates the relationship of BMI and FI with mortality in American cancer survivors and explores the impact of dietary supplement usage on different BMI and FI groups.

Methods

Three thousand nine hundred and thirty-two cancer patients from the National Health and Nutrition Examination Survey (NHANES) database were included in the analyses. BMI, FI, and supplement usage were obtained through the NHANES structured survey and the 49-item FI tool. Weighted logistic and Cox proportional hazards models, Kaplan-Meier survival analyses, and propensity score matching (PSM) were used to elucidate the relationships between BMI, FI, dietary supplement, and mortality outcomes.

Results

The study found significant associations between higher BMI and increased frailty (Odds ratio [OR] = 1.04, 95% confidence interval [95% CI], 1.02-1.06). BMI < 25 kg/m2 and FI > 0.2 are associated with an increased mortality rate. Dietary supplement use can reduce all-cause and cancer mortality in cancer patients with BMI < 25 kg/m2 (Hazard ratio [HR] = 0.63, 95% CI, 0.47-0.84; HR = 0.48, 95% CI, 0.29-0.80) or FI ≤ 0.2 (HR = 0.77, 95% CI, 0.60-0.99; HR = 0.59, 95% CI, 0.39-0.89). In cancer patients with BMI < 25 kg/m2 and FI ≤ 0.2, dietary supplement users had lower all-cause and cancer mortality (HR = 0.49, 95% CI, 0.30-0.79; HR = 0.25, 95% CI, 0.10-0.60).

Conclusion

The study revealed a negative correlation between BMI and the FI among the cancer patient cohort as well as their complex impact on mortality and highlighted the role of dietary supplement in cancer prognosis, indicating benefits for non-frail patients with BMI < 25 kg/m2.

Prognostic impact of neurocognitive disorders in older patients with cancer: the ELCAPA prospective cohort study

OBJECTIVE

To assess the prognostic value of neurocognitive disorder (NCD) for 12 month-overall mortality in patients aged 70 or more with a solid cancer.

DESIGN

prospective, observational, multicenter cohort.

SETTING AND PARTICIPANTS

We analyzed data from the ELCAPA longitudinal multicenter observational cohort of patients aged 70 or over, referred for a geriatric assessment (GA) before a new cancer treatment modality between January 31st, 2007, and December 29th, 2017. We defined the baseline NCD in four classes: no NCD, mild NCD, moderate NCD, and major NCD, based on the Mini-Mental State Examination (MMSE) score, memory complaint, and the Instrumental Activities of Daily Living (IADL) score.

STATISTICAL METHODS

We compared the baseline characteristics of patients according to NCD classes, globally and by pairs (with Bonferroni' correction). Prognosis value of NCD classes were analysed by using univariable and then multivariable 12 month survival analysis with age as time-variable and with and without adjustement for the treatment strategy (curative, palliative or exclusive supportive care).

RESULTS

2784 patients with solid-cancer were included, with a median [interquartile range] age of 82 [78;86]. 36% of the patients were free of NCD, 34% had a mild NCD, 17% had a moderate NCD, and 13% had a major NCD. We identified the following independent prognostic factors for 12 month-overall mortality: NCD (adjusted hazard ratio (aHR) [95% confidence interval (CI)] for a major NCD = 1.54 [1.19-1.98] (p < 0.001), type of cancer, metastatic status, inpatient consultation, poor general health (assessed as the level of fatigue and Eastern Cooperative Oncology Group performance status [ECOG-PS]), greater weight loss, palliative treatment, and exclusive supportive care. Additional adjustment for the treatment strategy did not greatly change the strength of the association of a major NCD with 12 month-overall mortality (HR [95%CI] = 1.78 [1.39-2.29] (p < 0.001).

CONCLUSION

Our results suggest that the presence of a major NCD has direct prognostic value (independently of other geriatric factors, the type of cancer and the treatment strategy) in older patients with a solid cancer.

Curative intent therapy for DLBCL in the elderly

Older patients with aggressive lymphoma are extremely heterogeneous due to the high frequency of functional limitations and comorbidities and to the different biological profiles and clinical behavior of the disease. The stratification in three geriatric categories (fit-unfit-frail) based on multidimensional geriatric assessment (GA) helps physicians tailor a potentially curative treatment.While an intensive approach with the standard R-CHOP regimen is feasible in fit patients, leading to similar long-term response and survival rates compared to younger ones, in unfit patients a balance between treatment toxicity and curative intent can be obtained through the reduction of dose intensity. Frail patients, treated with best supportive care so far, could benefit from a chemo-free approach with new target drugs. These novel agents, either alone or in combination with chemo-immunotherapy, are changing the therapeutic landscape of older patients with aggressive lymphoma, both in first-line therapy and in the setting of the relapsed/refractory disease.

Management of glioblastoma in elderly patients: A review of the literature

High grade gliomas are the most common primary aggressive brain tumours with a very poor prognosis and a median survival of less than 2 years. The standard management protocol of newly diagnosed glioblastoma patients involves surgery followed by radiotherapy, chemotherapy in the form of temozolomide and further adjuvant temozolomide. The recent advances in molecular profiling of high-grade gliomas have further enhanced our understanding of the disease. Although the management of glioblastoma is standardised in newly diagnosed adult patients there is a lot of debate regarding the best treatment approach for the newly diagnosed elderly glioblastoma patients. In this review article we attempt to summarise the findings regarding surgery, radiotherapy, chemotherapy, and their combination in order to offer the best possible management modality for this group of patients. Elderly patients 65-70 with an excellent functional level could be considered as candidates for the standards treatment consisting of surgery, standard radiotherapy with concomitant and adjuvant temozolomide. Similarly, elderly patients above 70 with good functional status could receive the above with the exception of receiving a shorter course of radiotherapy instead of standard. In elderly GBM patients with poorer functional status and MGMT promoter methylation temozolomide chemotherapy can be considered. For elderly patients who cannot tolerate chemotherapy, hypofractionated radiotherapy is an option. In contrast to the younger adult patients, it seems that a careful individualised approach is a key element in deciding the best treatment options for this group of patients.

Hospitalisation and adverse drug events in a geriatric oncology setting: A systematic review of the literature

BACKGROUND

Geriatric Oncology is a specialty where a multidisciplinary approach can address the unmet needs of older adults with cancer. Older adults are at increased risk of adverse drug events (ADE) due to age-related changes in pharmacokinetics and pharmacodynamics, increasing treatment complexity, and medication burden.

OBJECTIVES

To review the literature to determine the incidence of unplanned hospitalisation due to ADE for all medications, both systemic anticancer therapy (SACT) and non-SACT medications.

METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. The search included the following databases: PubMed, CINAHL, and Embase. A manual search of Scopus was then performed. Study quality was assessed using the Cochrane Handbook for Systematic Reviews of Interventions, Mixed Methods Appraisal Tool (MMAT) and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework.

RESULTS

Overall, three studies were included. One observational study reported 19 % of unplanned hospital admissions due to ADE in patients aged ≥70 years with cancer. The first retrospective study reported 24 % of unplanned hospital admissions are due to ADE in patients aged ≥70 years with cancer, and the second retrospective study reported 26 % of patients with metastatic melanoma treated with immune checkpoint inhibitors had an unplanned hospital admission due to an ADE.

CONCLUSION

There is a paucity of studies assessing unplanned hospitalisation due to ADE in older adults with cancer. Future studies are needed and should account for the reporting of potential ADE relative to supportive care, ancillary medications, and indeed chronic medications used to treat long-standing comorbidities.

Treatment with (chemo)-radiation in old patients (≥76 years of age) with newly diagnosed non-metastatic squamous cell cancer of the head and neck region: real-world data from a tertiary referral center

Purpose

Treatment of patients with cancer of the head and neck region is in focus in a multitude of studies. Of these patients, one patient group, those aged 76 and more, is mostly underrepresented despite requiring thorough and well-reasoned treatment decisions to offer curative treatment. This study investigates real-world data on curative treatment of old (≥76 years) patients with newly diagnosed squamous cell carcinoma of the head and neck region (HNSCC).

Patients and methods

Between January 2010 and December 2021, we identified 71 patients older than 76 years with newly diagnosed HNSCC and cM0 at the Department of Radiation Oncology of the University Hospital of Erlangen-Nuremberg. Using electronic medical records, we analyzed treatment patterns and outcomes in terms of overall survival (OS), progression-free survival (PFS), and locoregional control (LRC) rate. Additionally, we performed univariate risk analysis and Cox regression in order to identify predictive factors associated with the abovementioned treatment outcomes.

Results

The median follow-up was 18 months. OS was 83%, 79%, and 72% after 1 year, 2 years, and 3 years, respectively. PFS was 69%, 54%, and 46% after 1 year, 2 years, and 3 years, respectively. A total of 34 (48%) patients were treated with standard therapy according to current guidelines. The reasons for deviation from standard therapy before or during treatment were as follows: unfitness for cisplatin-based chemotherapy (n = 37), reduction of chemotherapy (n = 3), and dose reduction/interruption of radiotherapy (n = 8). Carboplatin-based systemic therapy showed improved PFS compared to cisplatin or cetuximab (60 vs. 28 vs. 15 months, p = 0.037) but without impact on OS (83 vs. 52 vs. 38 months, p = 0.807). Oropharyngeal tumor localization (p = 0.026) and combined treatment (surgery and postoperative treatment) (p = 0.008) were significant predictors for a better OS. In multivariate analysis, oropharyngeal tumor localization (p = 0.011) and combined treatment (p = 0.041) showed significantly increased PFS. After 1 year, 2 years, and 3 years, the cumulative incidence of locoregional recurrences (LRRs) was 13%, 24%, and 27%, respectively, and was significantly decreased in patients with oropharyngeal tumor localization (p = 0.037).

Conclusions

Adherence to treatment protocols for radiotherapy alone in old patients with HNSCC is good, whereas the application of concurrent chemotherapy often deviates from guidelines in terms of de-escalation. An important risk factor for decreased OS, PFS, and a higher rate of LRR appears to be non-oropharyngeal tumor location in old patients.

Evaluation of a new two-step frailty assessment of head and neck patients in a prospective cohort

PURPOSE

Assessing frailty, in head and neck cancer (HNC) patients is key when choosing appropriate treatment. Optimal screening is challenging, as it should be feasible and should avoid over-referral for comprehensive geriatric assessment (CGA) This study aims to evaluate the association between geriatric assessment using a new two-step care pathway, referral to geriatrician and adverse outcomes.

METHODS

This institutional retrospective analysis on a prospective cohort analysed the multimodal geriatric assessment (GA) of newly diagnosed HNC patients. Uni- and multivariable logistic regression was performed to study the association between the screening tests, and referral to the geriatrician for complete geriatric screening, and adverse outcomes.

RESULTS

This study included 539 patients, of whom 276 were screened. Patients who underwent the GA, were significantly older and more often had advanced tumour stages compared to non-screened patients. Referral to the geriatrician was done for 30.8% of patients. Of the 130 patients who underwent surgery, 26/130 (20%) experienced clinically relevant postoperative complications. Of the 184 patients who underwent (radio)chemotherapy, 50/184 (27.2%) had clinically relevant treatment-related toxicity. Age, treatment intensity, polypharmacy and cognitive deficits, were independently associated with referral to geriatrician. A medium to high risk of malnutrition was independently associated with acute radiation induced toxicity and adverse outcomes in general.

CONCLUSION

The current study showed a 30.8% referral rate for CGA by a geriatrician. Age, treatment intensity, cognitive deficits and polypharmacy were associated with higher rates of referral. Furthermore, nutritional status was found to be an important negative factor for adverse treatment outcomes, that requires attention.

Outcome prioritization and preferences among older adults with cancer starting chemotherapy in a randomized clinical trial

INTRODUCTION

Older adults with cancer facing competing treatments must prioritize between various outcomes. This study assessed health outcome prioritization among older adults with cancer starting chemotherapy.

METHODS

Secondary analysis of a randomized trial addressing vulnerabilities in older adults with cancer. Patients completed three validated outcome prioritization tools: 1) Health Outcomes Tool: prioritizes outcomes (survival, independence, symptoms) using a visual analog scale; 2) Now vs. Later Tool: rates the importance of quality of life at three times-today versus 1 or 5 years in the future; and 3) Attitude Scale: rates agreement with outcome-related statements. The authors measured the proportion of patients prioritizing various outcomes and evaluated their characteristics.

RESULTS

A total of 219 patients (median [range] age 71 [65-88], 68% with metastatic disease) were included. On the Health Outcomes Tool, 60.7% prioritized survival over other outcomes. Having localized disease was associated with choosing survival as top priority. On the Now vs. Later Tool, 50% gave equal importance to current versus future quality of life. On the Attitude Scale, 53.4% disagreed with the statement "the most important thing to me is living as long as I can, no matter what my quality of life is"; and 82.2% agreed with the statement "it is more important to me to maintain my thinking ability than to live as long as possible".

CONCLUSION

Although survival was the top priority for most participants, some older individuals with cancer prioritize other outcomes, such as cognition and function. Clinicians should elicit patient-defined priorities and include them in decision-making.

Prevalence of geriatric impairments and frailty categorization among real-world patients with multiple myeloma: a prospective cohort study (MFRAIL)

There is limited knowledge regarding the prevalence of geriatric impairments and frailty among patients with multiple myeloma (MM) in a real-world setting. This study evaluated the distribution of frailty profiles among 116 patients with newly diagnosed or relapsed MM, using four common frailty scales. The proportion of patients classified as frail varied significantly, ranging from 15.5% to 56.9%, due to differences in how frailty was operationalized between each frailty measure. Functional, cognitive, and mobility impairments were common overall and irrespective of performance status. Analyses between frailty and treatment selection (dose reduction and doublet vs. triplet therapy) demonstrated significant differences in non-steroid MM drug dose reductions between frail vs. non-frail patients, as scored by the International Myeloma Working Group (IMWG) Frailty Index and Simplified Frailty Score (p < .05). A standardized approach to frailty assessment that is practical in application, and beneficial in guiding treatment selection and minimizing treatment related toxicity is necessary to provide optimal tailored care.

Physical health-related quality of life trajectories over two years following breast cancer diagnosis in older women: a secondary analysis

PURPOSE

To identify distinct trajectories of physical health-related quality of life (HRQoL) in older women over the first two years following breast cancer diagnosis, and to examine characteristics associated with trajectory group membership.

METHODS

A secondary analysis of a longitudinal study of women diagnosed with stage I-III breast cancer who completed surveys within eight months of diagnosis and six, twelve, and eighteen months later that focuses on a subset of women aged ≥ 65 years (N = 145).Physical HRQoL was assessed using the Physical Component Score (PCS) of the SF-36 Health Survey. Finite mixture modeling identified distinct PCS trajectories. Multivariable logistic regression identified variables predictive of low PCS group membership.

RESULTS

Two distinct patterns of PCS trajectories were identified. The majority (58%) of women had PCS above the age-based SF-36 population norms and improved slightly over time. However, 42% of women had low PCS that remained low over time. In multivariable analyses, older age, difficulty paying for basics, greater number of medical comorbidities, and higher body mass index were associated with low PCS group membership. Cancer treatment and psychosocial variables were not significantly associated.

CONCLUSION

A large subgroup of older women reported very low PCS that did not improve over time. Older age, obesity, multiple comorbidities, and lower socioeconomic status may be risk factors for poorer PCS in women with breast cancer. Incorporating routine comprehensive geriatric assessments that screen for these factors may help providers identify older women at risk for poorer physical HRQoL post breast cancer treatment.

Comparing Preoperative Screening Tools for Elective Urologic Cancer Surgery: Insights from a Cluster Analysis

INTRODUCTION

The aim of this study was to evaluate the features and benefits of different geriatric screening tools for enhancing the perioperative care of patients who undergo elective cancer surgery using cluster analysis.

METHODS

This study was a retrospective, observational analysis of 1,019 consecutive patients who had elective major cancer surgery in the urology department of our hospital from October 2019 to January 2023. Before the surgery, a trained nurse screened the patients using six tools: Eastern Clinical Oncology Group performance status (ECOG-PS), flemish version of the triage risk screening tool (fTRST), geriatric-8 (G8), instrumental activities of daily living, patient health questionnaire-2 (PHQ-2), and simple questionnaire to rapidly diagnose sarcopenia (SARC-F). The study grouped the patients into four clusters based on their scores on these tools and compared their outcomes after the surgery. The outcomes included overall survival, ambulation failure, delirium, and severe complications. The study also examined how each screening tool was associated with the outcomes.

RESULTS

Based on their clinical data and screening results, we classified the patients into four groups: Healthy (73%), Depressive (11%), Intermediate (11%), and Unhealthy (5%). The Unhealthy group had the worst outcomes in overall survival (OS), ambulation failure, and delirium, followed by the Intermediate group. In addition, fTRST and SARC-F emerged as significant predictors of OS; ECOG-PS, fTRST, G8, and SARC-F of ambulation failure; ECOG-PS, fTRST, and G8 of delirium; and G8 of severe complications.

CONCLUSION

Various geriatric screening tools were found to have the potential to forecast diverse postoperative outcomes.

Older patients' experiences with and attitudes towards an oncogeriatric pathway: A qualitative study

INTRODUCTION

To tailor treatment for older patients with cancer, an oncogeriatric care pathway has been developed in the Leiden University Medical Center. In this care pathway a geriatric assessment is performed and preferences concerning cancer treatment options are discussed. This study aimed to explore patient experiences with and attitudes towards this pathway.

MATERIALS AND METHODS

A qualitative study was performed using an exploratory descriptive approach. Individual face-to-face semi-structured interviews were conducted with older patients (≥70 years) who had followed the oncogeriatric care pathway in the six months prior to the interview. The interviews were audio-recorded and transcribed verbatim. The transcripts were analyzed inductively using thematic analysis.

RESULTS

After interviews with 14 patients with a median age of 80 years, three main themes were identified. (1) Patients' positive experiences with the oncogeriatric pathway: Patients appreciated the attitudes of the healthcare professionals and felt heard and understood. (2) Unmet information needs about the oncogeriatric care pathway: Patients experienced a lack of information about the aim and process. (3) Incomplete information for decision-making: Most patients were satisfied with decision-making process. However, treatment decisions had often been made before oncogeriatric consultation. No explicit naming and explaining of different available treatment options had been provided, nor had risk of physical or cognitive decline during and after treatment been addressed.

DISCUSSION

Older patients had predominately positive attitudes towards the oncogeriatric care pathway. Most patients were satisfied with the treatment decision. Providing information on the aim and process of the care pathway, available treatment options, and treatment-related risks of cognitive and physical decline may further improve the oncogeriatric care pathway and the decision-making process.

The antioxidant and anti-inflammatory activities of avasopasem manganese in age-associated, cisplatin-induced renal injury

PURPOSE

Cisplatin contributes to acute kidney injury (AKI) and chronic kidney disease (CKD) that occurs with greater frequency and severity in older patients. Age-associated cisplatin sensitivity in human fibroblasts involves increased mitochondrial superoxide produced by older donor cells.

EXPERIMENTAL DESIGN

Young and old C57BL/6 J murine models of cisplatin-induced AKI and CKD were treated with the SOD mimetic avasopasem manganese to investigate the potential antioxidant and anti-inflammatory effects. Adverse event reporting from a phase 2 and a phase 3 randomized clinical trial (NCT02508389 and NCT03689712) conducted in patients treated with cisplatin and AVA was determined to have established the incidence and severity of AKI.

RESULTS

Cisplatin-induced AKI and CKD occurred in all mice, however, was more pronounced in older mice. AVA reduced cisplatin-induced mortality, AKI, and CKD, in older animals. AVA also alleviated cisplatin-induced alterations in mitochondrial electron transport chain (ETC) complex activities and NADPH Oxidase 4 (NOX4) and inhibited the increased levels of the inflammation markers, TNFα, IL1, ICAM-1, and VCAM-1. Analysis of age-stratified subjects treated with cisplatin from clinical trials (NCT02508389, NCT03689712) also supported that the incidence of AKI increased with age and AVA reduced age-associated therapy-induced adverse events (AE), including hypomagnesemia, increased creatinine, and AKI.

CONCLUSIONS

Older mice and humans are more susceptible to cisplatin-induced kidney injury, and treatment with AVA mitigates age-associated damage. Mitochondrial ETC and NOX4 activities represent sources of superoxide production contributing to cisplatin-induced kidney injury, and pro-inflammatory cytokine production and endothelial dysfunction may also be increased by superoxide formation.

Preconditioning Frailty Phenotype Influences Survival and Relapse for Older Allogeneic Transplantation Recipients

Hematologic malignancies disproportionately affect older adults. Hematopoietic cell transplantation (HCT) is potentially curative, but poor overall survival (OS) has limited its use in older adults. Fried's frailty phenotype (FFP) is a geriatric assessment tool that combines objective and subjective performance measures: gait speed, grip strength, activity level, exhaustion, and weight loss. People meeting ≥3 criteria are classified as frail; 1 or 2 criteria, as pre-frail; and 0 criteria, as fit. To evaluate the association of pre-HCT FFP with post-HCT outcomes, we assessed FFP prior to conditioning for 280 HCT recipients age ≥60 years with acute leukemia or a myeloid neoplasm at 3 institutions. When analyzing survival by age group, patients age ≥70 years had inferior OS compared to patients age 60 to 69 years (P = .002), with corresponding OS estimates of 38.9% (95% confidence interval [CI], 27.8% to 49.9%) and 59.3% (95% CI, 51.9% to 65.9%). Nonrelapse mortality (NRM) also was significantly higher in the older patients (P = .0005); the 2-year cumulative incidences of NRM were 38.5% (95% CI, 27.5% to 49.2%) and 17.2% (95% CI, 12.3% to 22.8%), for older and younger recipients, respectively. The cumulative incidences of relapse did not differ by age group (P = .3435). Roughly one-third (35.5%) of the patients were fit, 57.5% were pre-frail, and 7.5% were frail, with corresponding 2-year OS estimates of 68.4% (95% CI, 57.9% to 76.8%), 45.5% (95% CI, 37.4% to 53.2%), and 45.8% (95% CI, 23.4% to 65.8%) (P = .013). FFP was not significantly associated with NRM, but being frail or pre-frail was associated with a higher rate of disease-related deaths (33.3% and 27.3%, respectively, compared with 17.4% for fit patients; P = .043). In univariate modeling of restricted mean survival time with a 3-year horizon (RMST_3y), the factors that were significantly associated were FFP, age, Karnofsky Performance Status (KPS), Disease Risk Index (DRI), and HCT-specific Comorbidity Index (HCT-CI). Of those factors, only FFP (P = .006), age (P = .006), KPS (P = .004), and DRI (P = .005) were significantly associated in multivariate modeling of RMST_3y. Estimates of RMST_3y were computed and 5 risk-groups were created with survival ranging from 31.4 months for those who were age 60 to 69 years, fit, had KPS 90 to 100, and low/intermediate-risk DRI compared to 10.5 months for those who had high-risk features for all the evaluated factors. In univariate and multivariate analyses for restricted mean time to relapse with a 3-year horizon (RMRT_3y), FFP (pre-frail versus fit, P = .007; frail versus fit, P = .061) and DRI (P = .001) were the only significant factors. Predicted RMRT_3y was longest (30.6 months) for those who were fit and had low/intermediate-risk DRI scores and shortest (19.1 months) for those who were frail and had high-risk or very high-risk DRI scores. Both age and FFP impact survival after HCT. Incorporation of FFP into pre-HCT evaluations may improve decision-making and counseling regarding HCT risk for older adults. Our findings support future trials designed to reverse frailty, such as pre-HCT supervised exercise programs, and correlative analyses to unravel the connection of frailty and relapse to generate future targets for intervention. Finally, exploration of novel HCT platforms to reduce relapse in pre-frail and frail patients, as well as reduce NRM in adults age >70 years, are warranted.

Resistance Training-Induced Gains in Muscle Strength and Power Mediate the Improvement in Walking Speed in Middle-Aged Women Who Are Breast Cancer Survivors

ABSTRACT

Santagnello, SB, Martins, FM, de Oliveira Junior, GN, de Sousa, JdeFR, Nomelini, RS, Murta, EFC, and Orsatti, FL. Resistance training-induced gains in muscle strength and power mediate the improvement in walking speed in middle-aged women who are breast cancer survivors. J Strength Cond Res 38(4): 773-782, 2024-(a) Ascertain whether lower muscle mass, strength (1 repetition maximum [1RM]), and power (Pmax) in middle-aged women who are breast cancer survivors (BCS), when compared with women of a similar age never diagnosed with cancer (WNC), are related with lower walking speed (WS). (b) Ascertain whether changes in WS are associated with changes in muscle mass, 1RM, and (or) Pmax after resistance training (RT) in middle-aged BCS. A cross-section study was performed. Twenty WNC and 21 BCS were evaluated for lean mass of legs (LLM), 1RM (knee extension), muscle quality index (MQI = 1RM/LLM), Pmax (maximum muscle power-knee extension), and fast WS (10 and 400-meters). Randomized clinical trial was performed. The BCS were randomly divided into the control group ( n = 9) and the RT group ( n = 11). Breast cancer survivors exhibited lower 1RM (24.2%, p ˂ 0.001), Pmax (30.6%, p ˂ 0.001), MQI (22.2%, p = 0.001), and WS (10-m = 17.0%, p ˂ 0.001 and 400-m = 10.5%, p = 0.002) than WNC. Resistance training increased 1RM (31.6%, p = 0.001), MP (29.0%, p = 0.012), MQI (28.5%, p = 0.008), and WS (10-m = 9.4%, p = 0.009 and 400-m = 6.2%, p = 0.006) in BCS. The changes in WS were positively associated with 1RM (10-m = 68%, p = 0.001 and 400-m = 37%, p = 0.036) and Pmax (10-m = 56%, p = 0.005 and 400-m = 40%, p = 0.027) and MQI (10-m = 63%, p = 0.043 and 400-m = 37%, p = 0.035). Resistance training-induced gains in muscle strength and power mediate the improvement in WS in middle-aged BCS. Resistance training is an effective strategy to improve WS in middle-aged BCS.

Geriatric evaluation methods in oncology and their use in clinical studies: A systematic literature review

INTRODUCTION

Therapeutic options in oncology keep on expanding. Nonetheless, older adults are underrepresented in clinical trials and those enrolled often have a better health status than their average peers, resulting in a lack of representative evidence for this heterogenous population. The inclusion of older patients and a uniform categorization of "frailty" is becoming increasingly urgent. Standardized tools could contribute to the quality and comparability of clinical trials and facilitate clinical decisions. The aim of this literature review was to elaborate an overview of the use of geriatric evaluation (GE) methods in clinical cancer research.

MATERIALS AND METHODS

We performed a literature review of the PubMed database. Clinical pharmacotherapy studies that applied or evaluated a clearly defined system for the GE of oncological patients were included. Data retrieved encompassed the applied GE method(s), cancer type(s), and pharmacotherapy investigated, the number of included patients, study type, year of publication, as well as the primary purpose of the GE. The GEs used most frequently were depicted in more depth.

RESULTS

In this literature review, 103 publications were selected for inclusion. The biggest proportion of studies (36%, n = 34) used clearly defined, but not previously validated, GE methods (study-specific GE). Standardized GE methods encountered in at least five publications were the G8 screening test (applied in 18% of included studies, n = 17), the Balducci score (7%, n = 7), and a geriatric assessment based on Hurria (5%, n = 5). The primary purpose of GE was predominantly an appraisal of its potential role in pharmacotherapy optimization. The GE also served as baseline and outcome measure, inclusion/exclusion criterion, factor for stratified randomization, and to determine treatment allocation.

DISCUSSION

The wide range of GE methods used across studies make direct comparisons difficult, and many methods are poorly characterized and/or not previously validated. The further inclusion of representative older patients in clinical trials combined with the use of a standardized GE could help clinicians in the decision-making process.

Comparison of the prognostic value of eight nutrition-related tools in older patients with cancer: A prospective study

OBJECTIVES

The primary objective of the present study was to evaluate and compare the ability of eight nutrition-related tools to predict 1-year mortality in older patients with cancer.

DESIGN, SETTING AND PARTICIPANTS

We studied older patients with cancer from the ELCAPA cohort and who had been referred for a geriatric assessment at one of 14 participating geriatric oncology clinics in the greater Paris area of France between 2007 and 2018.

MEASUREMENTS

The studied nutrition-related tools/markers were the body mass index (BMI), weight loss (WL) in the previous 6 months, the Mini Nutritional Assessment, the Geriatric Nutritional Risk Index (GNRI), the Prognostic Nutritional Index, the Glasgow Prognostic Score (GPS), the modified GPS, and the C-reactive protein/albumin ratio.

RESULTS

A total of 1361 patients (median age: 81; males: 51%; metastatic cancer: 49%) were included in the analysis. Most of the tools showed a progressively increase in the mortality risk as the nutrition-related risk category worsened (overall p-values <0.02 for all) after adjustment for age, outpatient status, functional status, severe comorbidities, cognition, mood, cancer treatment strategy, tumour site, and tumour metastasis. All the models were discriminant, with a C-index ranging from 0.748 (for the BMI) to 0.762 (for the GPS). The concordance probability estimate ranged from 0.764 (WL) to 0.773 (GNRI and GPS)).

CONCLUSION

After adjustment for relevant prognostic factors, all eight nutrition-related tools/markers were independently associated with 1-year mortality in older patients with cancer. Depending on the time or context of the GA, physicians do not always have the time or means to perform and assess all the tools/markers compared here. However, even when some information is missing, each nutritional tool/marker has prognostic value and can be used in the evaluation.

The association between food access and frailty among older adults with gastrointestinal malignancies-The CARE Registry

BACKGROUND

Food access is associated with higher gastrointestinal (GI) cancer mortality; however, its association with frailty, which is a predictor of premature mortality among older adults with cancer, is less understood.

METHODS

The authors included 880 adults aged 60 years and older who were recently diagnosed with GI cancers and were undergoing self-reported geriatric assessment at their first prechemotherapy visit to the University of Alabama at Birmingham oncology clinic. Food access was measured using the 2019 US Department of Agriculture Economic Research Service designation low-income, low-access (LILA), classifying census tracts based on income and/or access to food stores at various distances. The primary outcome was frailty on the CARE (Cancer and Aging Resilience Evaluation) Frailty Index, a composite of the proportion of impaired geriatric assessment measures. The authors examined the LILA-frailty association with modified Poisson regression accounting for census-tract clustering.

RESULTS

The median patient age was 69 years, 58.1% were men, 22.5% were non-Hispanic Black, 29.2% had colorectal cancer, 28.0% had pancreatic cancer, 70.1% presented with stage III/IV disease, and 34.9% were frail. A higher proportion in LILA areas were non-Hispanic Black (44.1% vs. 10.8%; p < .001) and had less education (high school or less: 48.1% vs. 37.9%; p = .020). Adjusting for age, race and ethnicity, sex, cancer type and stage, and education, an LILA designation was associated with 58% greater odds of worsening frailty status (95% confidence interval, 1.18-2.12). An analysis of LILA subcategories revealed that associations were maintained across all LILA measures.

CONCLUSIONS

Poor food access was associated with a greater risk of frailty among newly diagnosed older adults with GI cancers before they received systemic treatment. Intervening on local food access, particularly in LILA areas, may be a target for improving rates of frailty and promoting health equity in this population.

Longitudinal changes in patient-reported cognitive complaints among older adults with gastrointestinal malignancies - results from the Cancer and Aging Resilience Evaluation (CARE) Registry

PURPOSE

Longitudinal change in patient-reported cognitive complaints (CC) in older adults with cancer is poorly understood. The purpose of this study was to evaluate early longitudinal CC and predictors among older adults with cancer.

METHODS

We examined early CC change on the PROMIS® Short Form4a Cognitive Function among adults ≥ 60 years with GI cancer enrolled in the Cancer and Aging Resilience Evaluation (CARE) undergoing geriatric assessment (GA) at baseline and one 3-6-month follow-up. Multivariable linear regression examined associations of demographics, socioeconomics, GA domains, baseline cognitive score, and treatment toxicities on follow-up cognitive score. Bayesian analysis of covariance (ANCOVA) determined best fitting model.

RESULTS

A total of 218 participants were included. The median follow-up was 3.7 months, the mean age was 69.2 ± 7.1, and 57.3% were male. The most common cancer was colorectal (30.7%) with most stage III/IV (73.7%). About half (51.8%) had stable cognition baseline to follow-up (follow-up t-score ± 5 points of baseline), 20.6% improved (≥ 5 increase), and 27.5% declined (≥ 5 decrease). After adjustment, there were no significant baseline predictors of follow-up cognitive t-score. Baseline t-score was the best-fitting predictor of follow-up t-score.

CONCLUSIONS

In this first study, examining early change in CC among older adults with cancer, ~ 28% exhibited cognitive decline. Baseline cognition is the most important early predictor of follow-up cognition. Longer follow-up is needed to identify long-term predictors of CC change in cancer survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Cognitive decline, even early, may occur in many older adults with cancer. Baseline and regular follow-up assessments of cognitive symptoms are an important component of survivorship care.

Prognostic factors for overall survival in clinical node-positive patients with upper tract urothelial carcinoma

BACKGROUND

There is sparse evidence regarding optimal management and prognosticators for oncologic outcomes in patients with clinical node-positive (cN+) upper tract urothelial carcinoma (UTUC).

METHODS

We retrospectively analyzed the data from 105 UTUC patients with cN1-2M0 between June 2010 and June 2022 at multiple institutions affiliated with our university. At the time of diagnosis, all patients received standard-of-care treatment including radical nephroureterectomy (RNU), chemotherapy, and/or palliative care. We employed a Cox regression model to analyze the prognostic importance of various factors on overall survival (OS).

RESULTS

Of 105 patients, 54 (51%) underwent RNU, while 51 (49%) did not. RNU was likely to be selected in patients with younger and higher G8 score, resulting in better median OS in patients who underwent RNU than in those who did not (42 months vs. 15 months, p < 0.001). Multivariable analysis among the entire cohort revealed that low G8 score (≤14) (hazard ratio [HR]: 2.07, 95% confidence interval [CI]: 1.08-3.99), elevated pretreatment C-reactive protein (CRP) (HR: 3.35, 95%CI: 1.63-6.90), and failure to perform RNU (HR: 2.16, 95%CI: 1.06-4.42) were independent prognostic factors for worse OS. In the subgroup analyses of cohorts who did not undergo RNU, elevated pretreatment CRP was the only independent prognostic factor for worse OS in cN+ UTUC patients.

CONCLUSIONS

RNU seems to be a reasonable treatment option in cN+ UTUC patients where applicable. Elevated pretreatment CRP appears to be a reliable prognosticator of worse OS and may be helpful in optimizing candidate selection for intensified treatment in this setting.

Transplantation and Cellular Therapy for Older Adults-The MSK Approach

PURPOSE OF REVIEW

Hematologic malignances more commonly affect older individuals and often present with advanced, higher risk disease than younger patients. Allogeneic and autologous hematopoietic cell transplantation is well-established treatment modalities with curative potential following either frontline treatments for these diseases or salvage therapy in the relapsed or refractory setting. More recently, novel cellular immunotherapy such as chimeric antigen receptor T-cell therapy has been shown to lead to high response rate and durable remission in many patients with advanced blood cancers.

RECENT FINDINGS

Given unique characteristics of older patients, how best to deliver these higher-intensity and time sensitive treatment modalities for them remains challenging. Moreover, their short-term and potential long-term impact on their functional status, cognitive status, and quality of life may be significant considerations for many older patients. All these issues contributed to the lack of access and significant underutilization of these potential curative treatment strategies. In this review, we present up to date evidence to support potential benefits of transplantation and cellular therapy for older adults, their steady improving outcomes, and most importantly, highlight the use of geriatric assessment to help select appropriate older patients and optimize them prior to and following transplantation and cellular therapy. We specifically describe our approach at Memorial Sloan Kettering Cancer Center and encouraging early results from its implementation.

Predictive value of the G8 screening tool for postoperative complications in older adults undergoing cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Older adults with cancer who are being considered for cancer surgery are heterogenous, with variation in their physical, mental, and social baselines and risk of postoperative complications. Due in part to the complex nature of this population, the optimal preoperative evaluation method is not clearly defined. In this study we investigated whether geriatric-8 (G8), a screening tool for older patients with cancer that determines the need for a full geriatric assessment, is suitable for assessing the risk of postoperative complications in this population being considered for surgery.

MATERIALS AND METHODS

Studies that enrolled older patients undergoing cancer surgery and compared prevalence of postoperative complications in G8 "high" (≥15) patients and G8 "low" (<15) patients were identified using PubMed and EMBASE. A meta-analysis was conducted to calculate the risk ratio of postoperative complication rate. Postoperative mortality was systematically reviewed.

RESULTS

Eleven studies published between 2017 and 2022 were included in our analysis with a total of 2,691 older patients who underwent various types of cancer surgery and were characterized by their G8 scores: 1,255 G8 high (≥15) patients and 1,436 G8 low (<15) patients. G8 low patients had a significantly higher prevalence of postoperative complications than G8 high patients (risk ratio [95% confidence interval]: 1.56 [1.18-2.07], p = 0.002, I2 = 79%).

DISCUSSION

G8 can be an effective and efficient preoperative tool to assess risk of postoperative complications in older adults undergoing cancer surgery and identify potential need for further evaluation of an individual's risk with a comprehensive geriatric assessment.

Adjuvant chemotherapy and survival outcomes in older women with HR+/HER2- breast cancer: a propensity score-matched retrospective cohort study using the SEER database

OBJECTIVES

This study aimed to investigate the impact of adjuvant chemotherapy (ACT) on survival outcomes in older women with hormone receptor-positive and human epidermal growth factor receptor 2-negative (HR+/HER2-) breast cancer (BC).

DESIGN

A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results database, which contains publicly available information from US cancer registries.

SETTING AND PARTICIPANTS

The study included 45 762 older patients with BC aged over 65 years diagnosed between 2010 and 2015.

METHODS

Patients were divided into two groups based on age: 65-79 years and ≥80 years. Propensity score matching (PSM) was employed to balance clinicopathological characteristics between patients who received ACT and those who did not. Data analysis used the χ2 test and Kaplan-Meier method, with a subgroup analysis conducted to identify potential beneficiaries of ACT.

OUTCOME MEASURES

Overall survival (OS) and cancer-specific survival (CSS).

RESULTS

Due to clinicopathological characteristic imbalances between patients with BC aged 65-79 years and those aged ≥80 years, PSM was used to categorise the population into two groups for analysis: the 65-79 years age group (n=38 128) and the ≥80 years age group (n=7634). Among patients aged 65-79 years, Kaplan-Meier analysis post-PSM indicated that ACT was effective in improving OS (p<0.05, HR=0.80, 95% CI 0.73 to 0.88), particularly in those with advanced disease stages, but did not show a significant benefit in CSS (p=0.09, HR=1.13, 95% CI 0.98 to 1.31). Conversely, for patients aged ≥80 years, ACT did not demonstrate any improvement in OS (p=0.79, HR=1.04, 95% CI 0.79 to 1.36) or CSS (p=0.09, HR=1.46, 95% CI 0.69 to 2.26) after matching. Subgroup analysis also revealed no positive impact on OS and CSS.

CONCLUSIONS

Patients with HR+/HER2- BC ≥80 years of age may be considered exempt from ACT because no benefits were found in terms of OS and CSS.

Accelerated Aging in Cancer Survivors: Cellular Senescence, Frailty, and Possible Opportunities for Interventions

The population of cancer survivors has markedly increased due to the rapid improvements in cancer treatment. However, cancer survivors experience accelerated aging, which leads to chronic diseases and other age-related conditions, such as frailty. Those conditions may persist years after cancer diagnosis and treatment. Cellular senescence, a hallmark of aging, is one of the mechanisms that contribute to accelerated aging in cancer survivors. Several aging measures, including measures based on clinical markers and biomarkers, have been proposed to estimate the aging process, and some of them have shown associations with mortality and frailty in cancer survivors. Several anti-aging interventions, including lifestyle changes and anti-aging drugs, have been proposed. Future research, particularly in large-scale studies, is needed to determine the efficiency of these aging measures and anti-aging interventions before considering their application in clinics. This review focuses on the mechanisms of cellular senescence and accelerated aging in cancer survivors, assessment of the aging process using clinical markers and biomarkers, and the high prevalence of frailty in that population, as well as possible opportunities for anti-aging interventions. A deeper understanding of aging measures and anti-aging interventions in cancer survivors will contribute to the development of effective strategies to mitigate accelerated aging in cancer survivors and improve their quality of life.

Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG)

Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.

ESGO-ESMO-ESP consensus conference recommendations on ovarian cancer: pathology and molecular biology and early, advanced and recurrent disease

The European Society of Gynaecological Oncology, the European Society for Medical Oncology (ESMO) and the European Society of Pathology held a consensus conference (CC) on ovarian cancer on 15-16 June 2022 in Valencia, Spain. The CC panel included 44 experts in the management of ovarian cancer and pathology, an ESMO scientific advisor and a methodologist. The aim was to discuss new or contentious topics and develop recommendations to improve and harmonise the management of patients with ovarian cancer. Eighteen questions were identified for discussion under four main topics: (i) pathology and molecular biology, (ii) early-stage disease and pelvic mass in pregnancy, (iii) advanced stage (including older/frail patients) and (iv) recurrent disease. The panel was divided into four working groups (WGs) to each address questions relating to one of the four topics outlined above, based on their expertise. Relevant scientific literature was reviewed in advance. Recommendations were developed by the WGs and then presented to the entire panel for further discussion and amendment before voting. This manuscript focuses on the recommendation statements that reached a consensus, their voting results and a summary of evidence supporting each recommendation.

Preoperative frailty screening in elderly patients with non-small cell lung cancer surgery: an essential step for a good surgical outcome

INTRODUCTION

Non-small cell lung cancer (NSCLC) is a disease commonly diagnosed in the elderly, often in advanced stages. However, elderly patients with lung cancer can benefit from surgery, provided that postoperative risks are assessed appropriately before surgery. Frailty is a measure of age-related impaired functional status and a predictor of mortality and morbidity. However, its importance as a preoperative marker is not well defined.

AREAS COVERED

This systematic review discusses the importance of preoperative frailty screening in elderly patients with NSCLC. A literature search was performed on the MEDLINE database in June 2023, and relevant studies on frailty or preoperative assessment of NSCLC which were published between 2000 and 2023 were retained and discussed in this review.

EXPERT OPINION

Among the types of existing methods used to assess frailty those on the geriatric assessment seem to be the most appropriate; however, they are unable to fully capture the 'surgical' frailty; thus, other instruments should be developed and validated in NSCLC.

Implementation of a geriatric oncology service at the Royal Marsden Hospital

INTRODUCTION

Despite significant evidence supporting the benefits of comprehensive oncogeriatric assessment in the management of older patients with cancer, the adoption of specialised geriatric oncology programs in the United Kingdom remains limited. Descriptions of clinic structure and models, patient demographics and baseline characteristics, resource utilisation, and predictors of resource utilisation are lacking in this population, which may complicate or impede the planning, resourcing, and development of further services in this subspecialty on a national and regional basis.

MATERIALS AND METHODS

Between November 2021 and April 2023, 244 patients commencing systemic anticancer treatment at the Royal Marsden Hospital, London underwent geriatric screening using the Senior Adult Oncology Programme-3 (SAOP3) screening tool. Baseline clinical factors (sex, age, Charlson Comorbidity Index score, Cumulative Illness Rating Scale-Geriatric [CIRS-G] score, Katz Index score, Barthel Index score, treatment intent, and Eastern Cooperative Oncology Group Performance Status [ECOG-PS]) were assessed as predictors of geriatric impairments and need for multidisciplinary referral and intervention using a negative binomial regression analysis. Referral rates to multidisciplinary teams were assessed against ECOG-PS score using point-biserial correlation, as well as against a historical control using descriptive statistics.

RESULTS

The median age of participants was 77; 75.8% were female. Breast cancer was the most prevalent diagnosis (61.9%). Most patients (67.6%) were undergoing treatment in the palliative setting. Two hundred eleven (86.5%) patients were identified as having at least one geriatric impairment. Six hundred forty-nine multidisciplinary referrals were made, of which 583 (86.7%) were accepted by the referred patient. Higher ECOG PS was positively associated with geriatric impairments in physiotherapy, occupational therapy, dietetics, pharmacy, and welfare rights domains, as well as with the overall number of geriatric impairments.

DISCUSSION

The Royal Marsden Senior Adult Oncology Programme represents the first geriatric oncology service in a tertiary cancer centre in the United Kingdom. Following implementation of SAOP3 screening, we observed a substantial increase in referrals to all multidisciplinary teams, suggestive of previously underrecognized needs among this population. The need for multidisciplinary intervention was strongly correlated with baseline ECOG-PS score, but not with other measured clinical variables, including comorbidity or functional indices.

Geriatric assessment-guided interventions for older adults with multiple myeloma: A feasibility and acceptability study

INTRODUCTION

Geriatric assessment (GA)-guided supportive care programs have been successful in improving treatment outcomes for older adults with solid-organ cancers. This study aimed to evaluate the feasibility of a GA-guided supportive care program among older adults treated for multiple myeloma (MM).

MATERIALS AND METHODS

The study utilized an existing registry of adults with plasma cell disorders at the University of North Carolina. Patients with MM, aged 60 or older, and having a GA-identified deficit in one or more problem area were offered referrals to supportive care resources during routine visits. Problem areas included physical function deficits, polypharmacy, and anxiety or depression. Patients with physical function deficits were offered referral to physical therapy (PT), those with polypharmacy to an Oncology Clinical Pharmacist Practitioner (CPP), and those with mental health symptoms to the Comprehensive Cancer Support Program (CCSP).

RESULTS

Of the 58 individuals identified as having at least one deficit on the GA, PT was the most commonly identified relevant resource (79%), followed by CPP visits (57%). Among individuals that were offered referral(s) to at least one new supportive care resource, the acceptance rate was 50%. Referral acceptance rates were highest among those recommended for a CPP visit (55% of those approached) and lowest for CCSP (0%).

DISCUSSION

The study examined the feasibility and acceptability of a referral program for supportive care resources among older adults with MM who have deficits on GA. The most commonly identified deficit was physical functioning, followed by polypharmacy and mental health. The study found that physical interventions and referrals to CPPs were the most accepted interventions. However, the low proportion of patients who accepted physical therapy referrals indicates the need for tailored and more personalized approaches. Further research is needed to explore the feasibility and impact of supportive care referral programs for older adults with MM.