Under-representation of the elderly in cancer clinical trials

Screening for Atrial Fibrillation by Digital Health Technology in Older People in Homecare Settings: A Feasibility Trial

Aims

Users of homecare services are often excluded from clinical trials due to advanced age, multimorbidity, and frailty. Atrial fibrillation (AF) is a common and frequently undiagnosed arrhythmia in the elderly and is associated with severe mortality, morbidity, and healthcare costs. Timely identification prevents associated complications through evidence-based treatment. This study is aimed at assessing the feasibility of AF screening using new digital health technology in older people in a homecare setting.

Methods

Users of homecare services ≥ 65 years old with at least one additional risk factor for stroke in two Norwegian municipalities were assessed for study participation by nurses. Participants performed a continuous prolonged ECG recording using a patch ECG device (ECG247 Smart Heart Sensor).

Results

A total of 144 individuals were assessed for study participation, but only 18 (13%) were included. The main reasons for noninclusion were known AF and/or anticoagulation therapy (25%), severe cognitive impairment (26%), and lack of willingness to participate (36%). The mean age of participants performing the ECG test was 81 (SD ± 7) years, and 9 (50%) were women. All ECG tests were interpretable; the mean ECG monitoring time was 104 hours (IQR 34-338 hours). AF was detected in one individual (6%).

Conclusion

This feasibility study highlights the challenges of enrolling older people receiving homecare services in clinical trials. However, all included participants performed an interpretable and prolonged continuous ECG recording with a digital ECG patch device. This trial is registered with NCT04700865.

Clinical trials in older people

Randomised controlled trials (RCTs) usually provide the best evidence for treatments and management. Historically, older people have often been excluded from clinical medication trials due to age, multimorbidity and disabilities. The situation is improving, but still the external validity of many trials may be questioned. Individuals participating in trials are generally less complex than many patients seen in geriatric clinics.

Recruitment and retention of older participants are particular challenges in clinical trials. Multiple channels are needed for successful recruitment, and especially individuals experiencing frailty, multimorbidity and disabilities require support to participate. Cognitive decline is common, and often proxies are needed to sign informed consent forms. Older people may fall ill or become tired during the trial, and therefore, special support and empathic study personnel are necessary for the successful retention of participants.

Besides the risk of participants dropping out, several other pitfalls may result in underestimating or overestimating the intervention effects. In nonpharmacological trials, imperfect blinding is often unavoidable. Interventions must be designed intensively and be long enough to reveal differences between the intervention and control groups, as control participants must still receive the best normal care available. Outcome measures should be relevant to older people, sensitive to change and targeted to the specific population in the trial. Missing values in measurements are common and should be accounted for when designing the trial.

Despite the obstacles, RCTs in geriatrics must be promoted. Reliable evidence is needed for the successful treatment, management and care of older people.

Effects of Radiation Therapy and Comorbidity on Health-Related Quality of Life and Mortality Among Older Women With Low-Risk Breast Cancer: Protocol for a Retrospective Cohort Study

Background

The National Comprehensive Cancer Network Breast Cancer Guidelines Committee suggests that the omission of adjuvant radiation therapy (RT) after breast-conserving surgery can be a reasonable option among older women with low-risk breast cancer (early-stage, estrogen receptor-positive, and node-negative) if they are treated with endocrine therapy. However, RT usage in this group of women still exceeds 50%. Conversely, older women tend to forego RT (even when necessary) due to cost, inconvenience, and potential adverse responses associated with RT. Understanding health-related quality of life (HRQOL) change with receipt of RT among older women in the modern era is limited due to the under-representation of this population in clinical trials.

Objective

The proposed study aims to examine the associations of RT with HRQOL trajectories as well as survival outcomes among older women with 5-10 years of follow-up. We will also assess whether prediagnosis comorbidity burden influences receipt of RT and whether the associations between RT and HRQOL trajectory and survival outcomes are modified by the comorbidity burden.

Methods

We will use a retrospective cohort study design with the population-based Surveillance, Epidemiology, and End-Results database linked to the Medicare Health Outcomes Survey (SEER-MHOS). Older women (≥65 years) who were diagnosed with low-risk breast cancer in 1998-2014, received breast-conserving surgery, and participated in MHOS 1998-2016 are eligible for this analysis. The latent class analysis clustering method will be used to identify each patient’s prediagnosis comorbidity burden, and HRQOL will be evaluated using the Short Form 36/Veterans RAND 12-Item Health Survey scales. The inverse-weighted estimates of the probability of treatment will be included to control for treatment selection bias and confounding effects in subsequent analysis. The association of RT with HRQOL trajectory will be evaluated using inverse-weighted multilevel growth mixture models. The inverse-weighted Cox regression model will be used to obtain hazard ratios with 95% CIs for the association of RT with survival outcomes. Differential effects of RT on both outcomes according to comorbidity burden class will also be evaluated.

Results

As of October 2020, the study was approved by the institutional review board, and SEER-MHOS data were obtained from the National Cancer Institute. Women with low-risk breast cancer who met inclusion and exclusion criteria have been identified, and prediagnosis comorbidity burden class has been characterized using latent class analysis. Further data analysis will begin in November 2020, and the first manuscript will be submitted in a peer-reviewed journal in February 2021.

Conclusions

This research can potentially improve clinical outcomes of older women with low-risk breast cancer by providing them additional information on the HRQOL trajectories when they make RT treatment decisions. It will facilitate informed, shared treatment decision making and cancer care planning to ultimately improve the HRQOL of older women with breast cancer.

International Registered Report Identifier (IRRID)

DERR1-10.2196/18056

The safety of a "fast-track" program after laparoscopic colorectal surgery is comparable in older patients as in younger patients

INTRODUCTION

Fast-track protocols, introduced in the late 1990 s, have been applied in several surgical fields, particularly for colorectal surgery. However, currently many surgical patients are elderly, and discussion about the application of such programs for elderly patients is lacking. The present study was designed to assess the safety of application of a fast-track program after laparoscopic colorectal surgery in elderly patients.

METHODS

From August 2009 to January 2011, we prospectively collected data from patients who underwent laparoscopic colorectal surgery with a perioperative fast-track program. The data of patients older and younger than 70 years were compared.

RESULTS

Of a total of 337 patients, the group of patients older than 70 years (OG) totaled 87 (25.8 %) and the younger group (YG) totaled 250 (74.2 %). Ten patients (11.5 %) were excluded in the OG and 24 (9.6 %) in the YG. There were no differences in gender, history of previous surgeries, body mass index, type of operation, operative time, or blood loss between groups. Age (74.8 vs. 56.7 years, p < 0.001), presence of comorbidities (70.1 vs. 44.7 %, p < 0.001), and ASA score (I:II:III, 33.8:57.1:9.1 vs. 60.6:33.2:6.2 %, p < 0.001) were significantly different between the two groups. Postoperative course did not show differences, including return of flatus, stool passage, advancement of diet, removal of urinary catheter, length of usage of IV antibiotics, complications, and length of postoperative stay. Emergency department visits or readmission within a month after discharge were more frequent in the OG (11.7 %) than the YG (4 %; p = 0.013).

CONCLUSIONS

Fast-track after laparoscopic colorectal surgery can be safely applied in carefully selected elderly patients older than age 70 years. Physicians should keep in mind complications that may present after discharge and should actively educate patients about them.

Cancer surgery in the elderly

The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.

Multiple diseases and polypharmacy in the elderly: challenges for the internist of the third millennium

The pattern of patients admitted to internal medicine wards has dramatically changed in the last 20-30 years. Elderly people are now the most rapidly growing proportion of the patient population in the majority of Western countries, and aging seldom comes alone, often being accompanied by chronic diseases, comorbidity, disability, frailty, and social isolation. Multiple diseases and multimorbidity inevitably lead to the use of multiple drugs, a condition known as polypharmacy. Over the last 20-30 years, problems related to aging, multimorbidity, and polypharmacy have become a prominent issue in global healthcare. This review discusses how internists might tackle these new challenges of the aging population. They are called to play a primary role in promoting a new, integrated, and comprehensive approach to the care of elderly people, which should incorporate age-related issues into routine clinical practice and decisions. The development of new approaches in the frame of undergraduate and postgraduate training and of clinical research is essential to improve and implement suitable strategies meant to evaluate and manage frail elderly patients with chronic diseases, comorbidity, and polypharmacy. Journal of Comorbidity 2011;1:28-44.

Management of cancer in the older adult

Cancer incidence and mortality rise exponentially in the elderly. With the aging of the population there is an urgent need to address this issue with evidence-based guidelines. Delayed diagnosis and incomplete workup and treatment are well documented in this population. Incorporation of a geriatric evaluation in oncology practice should be routinely implemented to prevent adverse outcomes. Treatment decisions in the elderly should not be based solely on survival gains but should also take quality of life into consideration. Cancer treatment is safe and effective in the elderly population. Social issues and other comorbidities should be addressed to improve compliance and outcome. Many unanswered questions regarding the optimal management of elderly cancer patients can be addressed only with the new clinical trials. Eliminating age bias among health care providers by providing education will help achieve optimal care for the elderly with cancer.