Comprehensive geriatric assessment in the older cancer patient: coming of age in clinical cancer care

Integrating Frailty Assessment to Enhance Care in Cancer Patients with Borderline Eastern Cooperative Oncology Group Performance Status

BACKGROUND

The (ECOG) performance status (PS) is commonly used to evaluate the functional ability of patients undergoing antitumor therapy. An ECOG PS of 2, indicating patients capable of self-care but restricted strenuous activity, can complicate treatment decisions owing to concerns regarding treatment-related toxicity. We investigated whether frailty assessment could help discriminate treatment tolerance and survival outcomes in patients with an ECOG PS of 2.

METHODS

We prospectively included 45 consecutive patients, aged ≥65 years, with an ECOG PS of 2, and newly diagnosed solid cancer scheduled for chemotherapy. Frailty was assessed using an eight-indicator geriatric assessment. The primary outcome was overall survival (OS) based on frailty status; secondary outcomes included treatment tolerance and toxicity.

RESULTS

The median patient age was 73 years (range 65-94), and 71% had stage IV disease. Predominant frailty-related deficits were functional decline (96%), malnutrition (78%), and polypharmacy (51%). The median OS was 12.6 months (95% confidence interval [CI]: 6.8-18.4). Patients with 4-6 deficits had significantly lower OS than those with 1-3 deficits (9.9 months vs. 20.0 months, adjusted hazard ratio 2.51, 95% CI: 1.16-5.44, P = .020). Frailty significantly correlated with reduced 12-week chemotherapy competence (52% vs. 85%, adjusted odds ratio [OR] .14, 95% CI: .03-.70, P = .016) and enhanced risk of unexpected hospitalization (60% vs. 20%, adjusted OR 6.80, 95% CI: 1.64-28.1, P = .008).

CONCLUSION

Our findings highlight the multifaceted nature of patients with an ECOG PS of 2 and emphasize the importance of frailty assessment for treatment outcomes.

A physiotherapists perspective of a geriatric clinic in a tertiary oncology centre

Aims and objectives

To analyse various domains amongst the geriatric population such as age, gender, body mass index (BMI), comorbidities, type of cancer and use of assistive devices, and find a correlation between the outcome measures such as short physical performance battery (SPPB) and performance-oriented mobility assessment (POMA).

Methodology

Patients above 60 years were screened and further referred to the physiotherapy department. A brief history was recorded to retrieve the demographic data such as name, age, gender, height, weight, BMI, hand dominance, diagnosis, previous investigations are done, comorbidities if any present, use of assistive devices if required and in case any previous oncological treatment has been delivered. Various outcome measures were administered such as POMA, SPPB, 6 minutes walk test (6 MWT) and numerical rating for fatigue. The interpretations were noted on a case report sheet and the appropriate interventions for the deficits were delivered to the patient. Also, the patients were asked to carry on the necessary investigation (if required) and get back to the physiotherapy OPD. No follow-up is required by the patients as this was a retrospective single-endpoint study.

Results and analysis

The descriptive analysis was done by using R software (version 4.2.3). The main objective was to analyse the variables descriptively using numbers and percentages. The correlation between 2 outcome measures: SPPB and POMA was assessed using Spearman's rank correlation.All the 100 patients had solid tumour malignancies, commonly GI (37%), thoracic (18%), breast (17%), H and N (13%), uro-oncology (11%) and gynecology (4%). The median age was 70 years (range, 60-88). The median BMI was 22.10 (IQR, 19.40-24.77). Among 100 patients, comorbidities were found in most of the patients, most commonly hypertension (35%), diabetes mellitus (20%), heart disease (9%) and other diseases (8%). Out of 100 patients, 15% of them used assistive devices but the remaining 85% of patients did not require any assistive devices. Different outcome measures were also assessed for understanding the patients' risk in different categories. On assessing POMA, most of the patients had a medium risk of fall (49%), followed by high risk (31%) and low risk (14%). On assessing SPPB, most of the patients had low risk (41%), followed by medium risk (31%) and high risk (28%). The aerobic capacity of patients was assessed using 6 MWT (walking capacity) which showed that most of them had a severe reduction in aerobic capacity (37%) followed by moderation reduction (28%), good aerobic capacity (25%) and mild reduction (10%). The treatment required by the patients involved most commonly LL strengthening (71; 30.6%) and aerobic conditioning (67; 28.9%) and the least was brisk walking (4; 1.72%) and UL strengthening (2; 0.86%).

Conclusion

Commonly deranged domains included fatigue (97%), risk of fall (80%), reduced aerobic capacity (75%) and comorbidities (73%). The correlation between SPPB and POMA was assessed using Spearman's rank correlation method which obtained a correlation coefficient of 0.79 which implies that there is a strong positive association between SPPB and POMA.

Lung Cancer: New Directions in Senior Patients Assessment

Age is but one significant prognostic factor in lung cancer, influencing survival, treatment response, and outcomes. This narrative review synthesizes findings from searches of 11 leading databases of research studies, systematic reviews, book chapters, and clinical trial reports on lung cancer in senior patients, with a focus on geriatric assessment as well as biomarkers. Key prognostic factors for lung cancer in seniors include biological age, functional capability, physical and psychological comorbidities, frailty, nutrition, status, and biomarkers like DNA methylation age. We identified the most valuable assessments that balance efficacy with quality of life. Optimizing care and improving outcomes with senior lung cancer patients benefits from a tailored therapeutic approach incorporating a complex geriatric assessment. A multidisciplinary collaboration between geriatricians, oncologists, and pulmonologists is crucial.

Evaluating the Effectiveness of Geriatric-Specific Cancer Rehabilitation Programs on Patient Health Outcomes

OBJECTIVE

This study evaluated a specialized rehabilitation program's impact on senior cancer patients' quality of life.

METHODS

one hundred and thirty patients aged ≥65 years with various cancer types undergoing/recovering from treatment were enrolled in oncology clinics in Al-Ahsa, Saudi Arabia. The intervention arm (n=65) participated in a tailored geriatric cancer rehabilitation program. The control group (n=65) received standard oncology care. The Functional Assessment of Cancer Therapy-General (FACT-G) tool assessed the quality of life across physical, social, emotional, and functional domains. T-tests and multivariate regression analyses compared outcomes.

RESULT

Total FACT-G scores showed a significantly higher quality of life for the geriatric cancer rehabilitation group versus standard care. Rehabilitation patients also demonstrated meaningful improvements across physical, social, and functional subscales. Rehabilitation involvement was the most predictive factor for optimized outcomes.

CONCLUSION

Specialized geriatric cancer rehabilitation meaningfully improved several quality of life domains in older patients over standard care. Despite persistent barriers, rehabilitation programming optimized older cancer patients' physical and psychosocial health. Oncology and geriatrics must collaborate to ensure evidence-based rehabilitation access meets older cohorts' unique needs.

Educational interventions to reduce depression and anxiety in older adults with cancer in the community: a systematic review, meta-analysis and meta-regression of randomised controlled trials

BACKGROUND

Older adults make up half of those with cancer and are prone to mood disorders, such as depression and severe anxiety, resulting in negative repercussions on their health-related quality-of-life (HRQOL). Educational interventions have been shown to reduce adverse psychological outcomes. We examined the effect of educational interventions on the severity of psychological outcomes in older adults with cancer (OAC) in the community.

METHOD

This PRISMA-adherent systematic review involved a search of PubMed, MedLine, Embase and PsycINFO for randomised controlled trials (RCTs) that evaluated educational interventions impacting the severity of depression, anxiety and HRQOL in OAC. Random effects meta-analyses and meta-regressions were used for the primary analysis.

RESULTS

Fifteen RCTs were included. Meta-analyses showed a statistically insignificant decrease in the severity of depression (SMD = -0.30, 95%CI: -0.69; 0.09), anxiety (SMD = -0.30, 95%CI: -0.73; 0.13) and improvement in overall HRQOL scores (SMD = 0.44, 95%CI: -0.16; 1.04). However, subgroup analyses revealed that these interventions were particularly effective in reducing the severity of depression and anxiety in specific groups, such as OAC aged 60-65, those with early-stage cancer, those with lung cancer and those treated with chemotherapy. A systematic review found that having attained a higher education and income level increased the efficacy of interventions in decreasing the severity of adverse psychological outcomes.

CONCLUSION

Although overall meta-analyses were statistically insignificant, subgroup meta-analyses highlighted a few specific subgroups that the educational interventions were effective for. Future interventions can be implemented to target these vulnerable groups.

Chemotherapy Primary Dose Reduction in Older Cancer Patients: A Retrospective Cohort

Primary dose reduction (PDR) in the first course of chemotherapy is an empirical practice, commonly used in older population. Patients over 70 years old receiving a first course of chemotherapy for a solid tumor were enrolled. A total of 179 patients were included. Standard dose was used in 69.8% of patients, while 30.2% received PDR of chemotherapy. Only 29.6% received a standardized geriatric assessment. Patients receiving standard doses presented 83.2% of toxicities, while 68% of toxicities were reported in patients receiving PDR. The toxicity rate was significantly decreased in patients treated with reduced first-cycle dose of chemotherapy.

Frailty and long-term survival among patients in Australian intensive care units with metastatic cancer (FRAIL-CANCER study): a retrospective registry-based cohort study

BACKGROUND

Recent advances in cancer therapeutics have improved outcomes, resulting in increasing candidacy of patients with metastatic cancer being admitted to intensive care units (ICUs). A large proportion of patients also have frailty, predisposing them to poor outcomes, yet the literature reporting on this is scarce. We aimed to assess the impact of frailty on survival in patients with metastatic cancer admitted to the ICU.

METHODS

In this retrospective registry-based cohort study, we used data from the Australia and New Zealand Intensive Care Society Adult Patient (age ≥16 years) database to identify patients with advanced (solid and haematological cancer) and a documented Clinical Frailty scale (CFS) admitted to 166 Australian ICUs. Patients without metastatic cancer were excluded. We analysed the effect of frailty (CFS 5-8) on long-term survival, and how this effect changed in specific subgroups (cancer subtypes, age [<65 years or ≥65 years], and those who survived hospitalisation). Because estimates tend to cluster within centres and vary between them, we used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty on survival time up to 4 years after ICU admission between groups.

FINDINGS

Between Jan 1, 2018, and March 31, 2022, 30 026 patients were eligible, and after exclusions 21 174 patients were included in the analysis; of these, 6806 (32·1%) had frailty, and 11 662 (55·1%) were male, 9489 (44·8%) were female, and 23 (0·1%) were intersex or self-reported indeterminate sex. The overall survival was lower for patients with frailty at 4 years compared with patients without frailty (29·5% vs 10·9%; p<0·0001). Frailty was associated with shorter 4-year survival times (adjusted hazard ratio 1·52 [95% CI 1·43-1·60]), and this effect was seen across all cancer subtypes. Frailty was associated with shorter survival times in patients younger than 65 years (1·66 [1·51-1·83]) and aged 65 years or older (1·40 [1·38-1·56]), but its effects were larger in patients younger than 65 years (pinteraction<0·0001). Frailty was also associated with shorter survival times in patients who survived hospitalisation (1·49 [1·40-1·59]).

INTERPRETATION

In patients with metastatic cancer admitted to the ICU, frailty was associated with poorer long-term survival. Patients with frailty might benefit from a goal-concordant time-limited trial in the ICU and will need suitable post-intensive care supportive management.

FUNDING

None.

Checkpoint inhibitors in older patients with advanced non-small cell lung cancer

Immune checkpoint inhibitors (ICIs) have revolutionized lung cancer management improving overall survival and providing durable responses with a favorable toxicity profile. New questions have emerged regarding the efficacy and safety of immunotherapy among older adults, typically underrepresented in clinical trials. Several factors have to be taken into account in order to reduce the realistic risk of over or under-treatment of this growing subgroup of patients. In this perspective, geriatric assessment and screening tools should be implemented in clinical practice; moreover older patients' inclusion into adapted-designed clinical trials should be promoted. In this review, we discuss immunotherapy activity in advanced non-small cell lung cancer (NSCLC) older patients, the role of the comprehensive geriatric assessment, treatment toxicity and its management with a focus on future perspectives in this rapidly evolving scenario.

Are we overtreating stage I triple-negative breast cancer in Ontario? A population-based retrospective epidemiological analysis using the ICES database

Triple-negative breast cancer (TNBC) is associated with inferior outcomes. The use of adjuvant chemotherapy is the mainstay of treatment, and its efficacy was demonstrated to be correlated with tumor size. Different guidelines exist regarding chemotherapy in early-stage TNBC. This study uses ICES database to examine the outcomes of the use of adjuvant chemotherapy in stage I TNBC in Ontario stratified by tumor size. Records of TNBC patients diagnosed in 2012 to 2014 were collected from ICES database. Stage I patients were analyzed by tumor size: T1a (≤ 0.5 cm), T1b (> 0.5 cm and ≤ 1.0 cm), and T1c (> 1.0 cm and ≤ 2.0 cm). Kaplan-Meier curves, log-rank test statistic, and Cox's proportional hazard regression were used to compare differences in overall survival (OS) between chemotherapy and no-chemotherapy groups. Of 610 patients, 183 had tumor sizes ≤ 1 cm, representing stages T1aN0M0 and T1bN0M0, and 427 had tumors > 1 cm to 2 cm, representing stage T1cN0M0. Patients with tumors ≤ 1 cm who received chemotherapy did not have a significant difference in OS compared to the no-chemotherapy group (p = 0.41, hazard ratio (HR) 0.40, 95% confidence interval (CI) 0.021-2.5). However, patients with tumor sizes > 1 cm to 2 cm who received chemotherapy demonstrated significantly better OS compared to those without (p = 0.023, HR = 0.40, 95% CI 0.16-0.86). Patients with TNBC stage T1cN0M0 should receive adjuvant chemotherapy. For TNBC tumors ≤ 1 cm, avoidance of chemotherapy can be considered. Prospective research should further investigate the efficacy of chemotherapy in TNBC stages T1a-bN0M0.Trial Registration University of Windsor REB#16-119.

Management of Advanced Urothelial Carcinoma in Older and Frail Patients: Have Novel Treatment Approaches Improved Their Care?

Patients with urothelial carcinoma tend to be older and frailer with a large number of chronic medical conditions. This is particularly pronounced in those with unresectable locally advanced and metastatic urothelial carcinoma. Prior to 2016, treatment options in advanced urothelial carcinoma were limited to chemotherapy, and as a result, a large number of patients were not receiving disease-directed management. Over the last 6 years, multiple alternative modalities including immune checkpoint inhibitors and targeted therapies have been introduced. They are being utilized clinically in older and frail patients, but there are limited studies investigating outcomes in these specific populations. Based upon current evidence, age does not impact the efficacy and tolerance of immune checkpoint inhibitors if patients are fit enough to receive therapy. In frailer patients, immune checkpoint inhibitors appear to be safe, but outcomes from largely retrospective studies demonstrate mixed data regarding their efficacy. Although there are indications from clinical trials that enfortumab vedotin, sacituzumab govitecan, and erdafitinib are also efficacious irrespective of age, there is still not enough evidence to draw definitive conclusions about their use in older and frail patients. Regardless, in all older patients with advanced urothelial carcinoma, it is critical to evaluate for frailty through geriatric screening tools and comprehensive assessments. Combining these evaluations with consideration of an individual patient's goals should be the foundation upon which therapeutic decisions are made in this population of patients.

T cell immune awakening in response to immunotherapy is age-dependent

BACKGROUND

Precision immuno-oncology approaches are needed to improve cancer care. We recently demonstrated that in patients with metastatic melanoma, an increase of clonality or diversity of the T cell receptor (TCR) repertoire of peripheral T cells following one cycle of immunotherapy is coincident with response to immune-checkpoint blockade (ICB). We also identified a subset of peripheral CD8+ immune-effector memory T cells (TIE cells) whose expansion was associated with response to ICB and increased overall survival. To improve our understanding of peripheral T cell dynamics, we examined the clinical correlates associated with these immune signatures.

METHODS

Fifty patients with metastatic melanoma treated with first-line anti-PD-1 ICB were included. We analysed TCR repertoire and peripheral TIE cell dynamics by age before treatment (T0) and after the first cycle of treatment at week 3 (W3).

RESULTS

We observed a correlation between TIE abundance and age at T0 (r = 0.40), which reduced following treatment at W3 (r = 0.07). However, at W3, we observed two significantly opposing patterns (p = 0.03) of TCR repertoire rearrangement in patients who responded to treatment, with patients ≥70 years of age showing an increase in TCR clonality and patients <70 years of age showing an increase in TCR diversity.

CONCLUSIONS

We demonstrate that immunotherapy-induced immune-awakening patterns in patients with melanoma are age-related and may impact patient response to ICB, and thus have implications for biomarker development and planning of personalised therapeutic strategies.

Clinical Significance of Frailty on Treatment Outcome in Nongeriatric Patients With Head and Neck Cancer and Esophageal Cancer Undergoing Curative-Intent Concurrent Chemoradiotherapy

BACKGROUND

Whether the prevalence of frailty and its clinical significance are relevant to treatment outcomes in younger (aged < 65 years) cancer patients remains uncertain. This study aimed to evaluate the impact of frailty on treatment outcomes in younger cancer patients with head and neck and esophageal malignancy.

MATERIAL AND METHODS

This multicenter prospective study recruited 502 patients with locally advanced head and neck and esophageal cancer during 2016-2017 in Taiwan, aged 20-64 years who received curative-intent concurrent chemoradiotherapy (CCRT) as first-line antitumor treatment. Baseline frailty assessment using geriatric assessment (GA) was performed for each patient within 7 days before CCRT initiation.

RESULTS

Frailty was observed in 169 (33.7%) of 502 middle-aged patients. Frail patients had significantly higher incidences of chemotherapy incompletion (16.6% versus 3.3%, P < .001) and radiotherapy incompletion (16.6% versus 3.6%, P < .001) than fit patients. During CCRT, frail patients had a significantly higher percentage of hospitalizations (42.0% versus 24.6%, P < .001) and a trend toward a higher percentage of emergency room visits (37.9% versus 30.0%, P = .08) than fit patients. Frail patients more likely had a significantly higher incidence of grade ≥ 3 adverse events than fit patients during CCRT. The 1-year survival rate was 68.7% and 85.2% (hazard ratio 2.56, 95% confidence interval 1.80-3.63, P < .001) for frail and fit patients, respectively.

CONCLUSIONS

This study demonstrated the significance of pretreatment frailty on treatment tolerance, treatment-related toxicity, and survival outcome in younger patients with head and neck and esophageal cancer undergoing CCRT. While GA is commonly targeted toward the older population, frailty assessment by GA may also be utilized in younger patients for decision-making guidance and prognosis prediction.

Omission of adjuvant radiotherapy for older adults with early-stage breast cancer particularly in the COVID era: A literature review (on the behalf of Italian Association of Radiotherapy and Clinical Oncology)

This review is aimed at evaluating whether radiation therapy (RT) can be omitted in older adult early-stage low-risk breast cancer (BC) patients. The published data are particularly relevant at present, during the COVID-19 pandemic emergency, to define a treatment strategy and to prioritize essential therapy. Cochrane Database of Systematic Reviews and PubMED were systematically researched from outset through April 2020 using Mesh terms. Only randomized controlled trials (RCT), with one arm without adjuvant whole-breast irradiation (WBI), were included in the analysis. Recent literature regarding the COVID pandemic and BC RT was assessed. The reported RCTs identified a group of BC patients (pT1-2N0M0 R0, grade 1-2, estrogen receptor (ER) positive, human epidermal growth factor receptor 2 (HER2) negative tumours) in which the absolute risk of local recurrence (LR) was considered low enough to omit RT. The most common risk factors were tumor diameter, nodal and receptor status. Adjuvant RT had a significant impact on LR but not on distant metastasis (DM) or death. During the COVID 19 pandemic, results from RTCs were re-considered to define treatment recommendations for BC patients. International scientific societies and radiation oncology experts suggested RT omission, whenever possible, in older adult early-stage BC patients. Adjuvant RT might be omitted in a highly selected group of older adult early-stage BC patients with favourable prognostic factors. Hypofractionated regimens should be the standard. RT omission, partial breast irradiation (PBI), and ultra- hypofractionated regimens could be considered in selected cases due to the pandemic.

Use of Comprehensive Geriatric Assessment in Oncology Patients to Guide Treatment Decisions and Predict Chemotherapy Toxicity

Purpose

Our objective was to review the utility of pretreatment comprehensive geriatric assessment (CGA) and its impact on decision making regarding choice and intensity of oncologic therapeutic regimens for older, frail, or poor-functional-status patients, as well as using this prospective assessment to predict chemotherapy-related toxicities. Database searches were conducted in Medline, PubMed, and Ovid for clinical studies, review articles, and journal publications. Search terms included geriatric assessment, medical oncology, chemotherapy, frailty, toxicity, and functional status. Thirty-seven pertinent articles were retrieved and serve as the basis for this clinical review.

Observations

CGA is an important tool for examining aspects of frailty and functional status that are not captured by traditional performance status measures. These findings may then be used in selection of appropriate therapeutic regimens for a given patient that are efficacious and tolerable. Such pretreatment assessments also have been used in predicting therapy-related toxicities.

Conclusions

Frail and older patients are common in oncology practices and are at high risk for therapy-related toxicities because of comorbidities and physiologic changes, presenting a considerable clinical challenge. CGA establishes evidence-based strategies to better assess the functional status of such patients and is predictive for chemotherapy-related toxicities in this vulnerable group. Despite publications on these measures in the oncology literature, there is limited evidence-based research to demonstrate the utility of CGA by practicing oncology providers and how to implement it into practice.

Performance of two frailty screening tools among patients with cancer in Taiwan

Background

Comprehensive Geriatric Assessment (CGA) is the gold standard for detecting frailty in elderly patients with cancer. Since CGA is time- and resource-consuming, many alternative frailty screening tools have been developed; however, it remains unknown whether these tools are suitable for older and adult patients with cancer. Therefore, we used the data collected for a large longitudinal study to compare the diagnostic performances of two frailty screening tools (Geriatric 8 [G8] and Flemish version of the Triage Risk Screening Tool [fTRST]) to identify frailty risk profile among patients with cancer.

Methods

Patients aged ≥20 years with newly diagnosed cancer were enrolled. Frailty screening with G8, fTRST, and CGA were performed before anti-cancer treatment. Diagnostic characteristics obtained using G8 and fTRST were analyzed by C-index, and the validity of G8 and fTRST was also determined.

Results

40.9% of the 755 patients with cancer displayed frailty on CGA. Both G8 and fTRST showed high sensitivity (80.6–88.4%) and negative predictive value (81.0–81.2%). The C-index of G8 was higher than that of fTRST (0.77 vs 0.71, p = .01). Moreover, the best G8 and fTRST cut-off points were ≤13 and ≥ 2, respectively. The validities of G8 and fTRST were also confirmed; however, frailty age differences were not observed in our study.

Conclusion

Frailty is a common problem for patients with cancer, and routine frailty screening is essential for both older and adult patients. G8 and fTRST are simple and useful frailty screening tools, while G8 is more suitable than fTRST for Taiwanese patients with cancer.

Usability of a self-administered geriatric assessment mHealth: Cross-sectional study in a geriatric clinic

AIM

mHealth can facilitate comprehensive geriatric assessment (CGA) in countries with limited geriatric healthcare facilities. It can compensate for the lack of trained geriatricians and integrate CGA in different healthcare disciplines leading to better clinical outcomes. This study assessed the usability of a self-administered geriatric assessment smartphone application.

METHODS

A cross-sectional study included participants from the geriatric clinic at Ain Shams University Hospital, Cairo, Egypt. This study was performed in three phases: development and validation of an abbreviated geriatric assessment tool, and validation of the application prototype. Twenty subjects were recruited for pretesting the abbreviated assessment tool, then another 50 patients to validate this tool in a face-to-face interview. Afterwards, another 12 patients completed the prototype followed by a standardized office visit interview. Each assessment domain was evaluated in agreement with a valid reference test during the clinical interview.

RESULTS

The application was simple and user friendly. The scores of each domain correlated to the reference test scores (rho = 0.59-0.93). Most of the domains exhibited good agreement with the reference tests (kappa = 0.68-1.00) (except for frailty and nutritional assessment).

CONCLUSIONS

The mHealth geriatric assessment is possible and highly desirable during physical distancing and beyond. Obviously, this approach cannot substitute for clinical examination and multidisciplinary standard CGA. However, it may overcome some barriers facing the geriatrization of medicine. It would help general practitioners to provide pre-CGA evaluation, particularly in areas with limited access to formal geriatric healthcare services. Geriatr Gerontol Int 2021; 21: 222-228.

Application of comprehensive geriatric assessment in predicting early mortality among elder patients with B-cell lymphoma receiving immunochemotherapy

OBJECTIVES

Early mortality, defined as death within 120 days after initiated antitumor therapy, is an important issue especially for elder patients with B-cell lymphoma. This study aimed to evaluate the clinical value of comprehensive geriatric assessment (CGA) in early mortality prediction in elderly patients with B-cell lymphoma receiving immunochemotherapy.

METHODS

Seventy-six consecutive patients with newly diagnosed B-cell lymphoma receiving immunochemotherapy from a medical center in Taiwan were prospectively enrolled. Patients were divided into fit (n = 49) and frail (n = 27) groups per pretreatment CGA for early mortality comparison.

RESULTS

The early mortality rate in our patient cohort was 16% (n = 12): from 6% in patients with no CGA domain impairment to 43% in patients with ≥4 CGA domain impairment. The early mortality rate was 6% and 33% in fit and frail patients (odds ratio, 7.67; 95% CI, 1.86-31.6; P = .005), respectively. Frailty was the significant predictor for early mortality in univariate and multivariate analysis.

CONCLUSION

In this study, the number of geriatric domain impairment is positively associated with the early mortality risk in elderly patients with B-cell lymphoma. Therefore, CGA can help clinicians to identify the risk of early mortality in elderly patients and provide alternative treatment.

The added value of geriatric assessment in evaluating a patient's Health-Related Quality-of-Life: A study in ≥70-year-old early-stage invasive breast cancer patients

OBJECTIVE

The objective of this study was to assess the relationship between geriatric assessment (GA) and health-related Quality-of-Life (HRQOL) in older patients with breast cancer.

METHODS

Patients were assigned either to adjuvant chemotherapy (CTG) or to a control group (CG). Spearman rank coefficients (ρ) calculated correlations between HRQOL and GA at baseline, 3 months and 1 year. Multivariate regressions modelled the prognostic value of GA in evaluating of a patient's HRQOL and the accuracy of baseline GA in predicting HRQOL decline (change of ≥10 points).

RESULTS

The analysis included 57 patients in the CTG and 52 in the CG. Strong correlations (ρ ≥ 0.5) were reported between the EORTC QLQ-C30 Physical Functioning Scale and Activities of Daily Living (ADL), Instrumental ADL (iADL) and Leuven Oncogeriatric Frailty Score Scale (LOFS). Multivariate models demonstrated that poor iADL, ADL and LOFS (CG) and ADL and iADL (CTG) contributed to a statistically (all p < .05) worse HRQOL. The relative gain in predicting 3-month and 1-year HRQOL decline was 24.1% and 4.7% (CG) and 6.1% and 18.3% (CTG).

CONCLUSION

Our results show that the functional measures in the GA are strongly correlated with patient self-reported functioning. Poor baseline GA has a modest probability of predicting HRQOL deterioration.

Measuring Aging and Identifying Aging Phenotypes in Cancer Survivors

Observational data have shown that some cancer survivors develop chronic conditions like frailty, sarcopenia, cardiac dysfunction, and mild cognitive impairment earlier and/or at a greater burden than similarly aged individuals never diagnosed with cancer or exposed to systemic or targeted cancer therapies. In aggregate, cancer- and treatment-related physical, cognitive, and psychosocial late- and long-term morbidities experienced by cancer survivors are hypothesized to represent accelerated or accentuated aging trajectories. However, conceptual, measurement, and methodological challenges have constrained efforts to identify, predict, and mitigate aging-related consequences of cancer and cancer treatment. In July 2018, the National Cancer Institute convened basic, clinical, and translational science experts for a think tank titled "Measuring Aging and Identifying Aging Phenotypes in Cancer Survivors." Through the resulting deliberations, several research and resource needs were identified, including longitudinal studies to examine aging trajectories that include detailed data from before, during, and after cancer treatment; mechanistic studies to elucidate the pathways that lead to the emergence of aging phenotypes in cancer survivors; long-term clinical surveillance to monitor survivors for late-emerging effects; and tools to integrate multiple data sources to inform understanding of how cancer and its therapies contribute to the aging process. Addressing these needs will help expand the evidence base and inform strategies to optimize healthy aging of cancer survivors.

Sarcomas in patients over 90: Natural history and treatment-A nationwide study over 6 years

Soft tissue sarcomas (STS) are rare tumors accounting for less than 1% of human cancers. While the highest incidence of sarcomas is observed in elderly, this population is often excluded or poorly represented in clinical trials. The present study reports on clinicopathological presentation, and outcome of sarcoma patients over 90 recorded in the Netsarc.org French national database. NETSARC (netsarc.org) is a network of 26 reference sarcoma centers with specialized multidisciplinary tumor board (MDTB), funded by the French National Cancer Institute to improve the outcome of sarcoma patients. Since 2010, presentation to an MDTB, second pathological review, and collection of sarcoma patient characteristics and follow‐up are collected in a database Information of patients registered from January 1, 2010, to December 31, 2016, in NETSARC were collected, analyzed and compared to the younger population. Patients with sarcomas aged >90 have almost exclusively sarcomas with complex genomics (92.0% vs. 66.3%), are less frequently metastatic (5.3% vs. 14·7%) at diagnosis, have more often superficial tumors (39.8% vs. 14.7%), as well as limbs and head and neck sites (75.2% vs. 38.7%) (all p < 0.001). Optimal diagnostic procedures and surgery were less frequently performed in patients over 90 (p < 0.001). These patients were less frequently operated in NETSARC centers, as compared to those of younger age groups including aged 80–90. However, local relapse‐free survival, metastatic relapse‐free survival and relapse‐free survival were not significantly different from those of younger patients, in the whole cohort, as well as in the subgroup of operated patients. As expected overall survival was worse in patients over 90 (p < 0.001). Patients over 90 who were not operated had worse overall survival than younger patients (9.9 vs. 27.3 months, p < 0.001). Patients with STS diagnosed after 90 have distinct clinicopathological features, but comparable relapse‐free survival, unless clinical practice guidelines recommendations are not applied. Standard management should be proposed to these patients if oncogeriatric status allows.

What's new?

While the highest incidence of soft‐tissue sarcoma (STS) is observed in the elderly, this population is often excluded or poorly represented in clinical trials. Therefore, little is known about the characteristics, treatment, and outcomes of STS in these patients. In this study, the authors analyzed numerous clinical characteristics of patients with sarcoma diagnosed at age 91 or older. They conclude that standard STS management and clinical practice guidelines should be followed for these patients if possible.

Outcomes by treatment modality in elderly patients with localized gastric and esophageal cancer

Background

We aimed to assess current treatment patterns and outcomes in elderly patients with localized gastric and esophageal (ge) cancers.

Methods

This retrospective analysis considered patients 75 years of age or older with ge cancers treated during 2012-2014. Patient demographics and tumour characteristics were collected. Overall survival (os) and disease-free survival were assessed by univariable and multivariable Cox proportional hazards regression, adjusting for demographics. Logistic regression analyses were used to examine factors affecting treatment choices.

Results

The 110 patients in the study cohort had a median age of 81 years (range: 75-99 years). Primary disease sites were esophageal (55%) and gastric (45%). Treatment received included radiation therapy alone (29%), surgery alone (26%), surgery plus perioperative therapy (14%), chemoradiation alone (10%), and supportive care alone (14%). In multivariable analyses, surgery (hazard ratio: 0.48; 95% confidence interval: 0.26 to 0.90; p = 0.02) was the only independent predictor for improved os. Patients with a good Eastern Cooperative Oncology Group performance status (p = 0.008), gastric disease site (p = 0.02), and adenocarcinoma histology (p = 0.01) were more likely to undergo surgery.

Conclusions

At our institution, few patients 75 years of age and older received multimodality therapy for localized ge cancers. Outcomes were better for patients who underwent surgery than for those who did not. To ensure optimal treatment selection, comprehensive geriatric assessment should be considered for patients 75 years of age and older with localized ge cancers.

Sphincter-saving proctectomy for rectal cancer with NO COIL® transanal tube and without ostoma. Clinical outcomes, cost effectiveness and quality of life in the elderly

BACKGROUND

Colorectal cancer is one of the most common invasive cancers, and it is responsible for considerable physical and psychosocial morbidity specially in older patients. However, only few reports focused on quality of life, cost-effectiveness and clinical outcomes of rectal cancer patients undergone to surgery. This retrospective study compares short-term and long-term outcomes in rectal cancer patients with more and less than 75 years of age.

METHODS

Four hundred consecutive patients underwent radical surgery for rectal adenocarcinoma and they were collected in a prospective institutional database and divided into two groups: group 1 (≥75 years, N.=98); group 2 (<75 years, N.=302). Rectal anterior resection (RAR) with sphincter-saving restorative proctectomy and with application of silicone transanal tube NO COIL® 60-80 mm long, was the only procedure considered. Main clinical and pathological data were assessed and compared.

RESULTS

Statistically significant differences between the two groups were detected regard to comorbidities and the emergency presentation. Overall survival is lower in patients over 75 age, but cancer-related survival is not different between the two groups.

CONCLUSIONS

Although advanced age is associated with higher morbidity and mortality, in our experience, itself is not a contraindication for surgical sphincter-saving proctetomy in rectal cancer patients. The absence of a stoma also improved the cost effectiveness and patients' quality of life in both groups: psychological morbidity, sexuality, levels of anxiety and depression, body image.

Ribociclib with letrozole vs letrozole alone in elderly patients with hormone receptor-positive, HER2-negative breast cancer in the randomized MONALEESA-2 trial

Purpose

Determine the efficacy and safety of first-line ribociclib plus letrozole in elderly patients with HR+, HER2− advanced breast cancer.

Methods

668 postmenopausal women with HR+, HER2− advanced breast cancer and no prior systemic therapy for advanced disease were enrolled in the Phase III MONALEESA-2 trial (NCT01958021); 295 patients were aged ≥ 65 years. Patients were randomized to ribociclib (600 mg/day; 3-weeks-on/1-week-off) plus letrozole (2.5 mg/day) or placebo plus letrozole until disease progression, unacceptable toxicity, death, or treatment discontinuation. The primary endpoint was PFS, which was evaluated in elderly (≥ 65 years) and younger (< 65 years) patients. Secondary endpoints included response rates and safety.

Results

Ribociclib plus letrozole significantly improved PFS vs placebo plus letrozole in elderly (hazard ratio: 0.608; 95% CI 0.394–0.937) and younger patients (hazard ratio: 0.523; 95% CI 0.378–0.723). Overall response rates were numerically higher in the ribociclib vs placebo arm, regardless of age. Ribociclib plus letrozole was well tolerated in elderly patients, with the safety profile similar to the overall study population. Nausea, vomiting, alopecia, and diarrhea were > 10% more frequent in the ribociclib plus letrozole vs placebo plus letrozole arm in both subgroups; most events were grade 1/2. In elderly patients, grade 1/2 anemia and fatigue were > 10% more frequent in the ribociclib plus letrozole vs placebo plus letrozole arm and discontinuation rates were similar in both arms.

Conclusions

Addition of ribociclib to letrozole is a valid therapeutic option for elderly patients with HR+, HER2− advanced breast cancer in the first-line setting.

Identifying critical steps towards improved access to innovation in cancer care: a European CanCer Organisation position paper

In recent decades cancer care has seen improvements in the speed and accuracy of diagnostic procedures; the effectiveness of surgery, radiation therapy and medical treatments; the power of information technology; and the development of multidisciplinary, specialist-led approaches to care. Such innovations are essential if we are to continue improving the lives of cancer patients across Europe despite financial pressures on our healthcare systems. Investment in innovation must be balanced with the need to ensure the sustainability of healthcare budgets, and all health professionals have a responsibility to help achieve this balance. It requires scrutiny of the way care is delivered; we must be ready to discontinue practices or interventions that are inefficient, and prioritise innovations that may deliver the best outcomes possible for patients within the limits of available resources. Decisions on innovations should take into account their long-term impact on patient outcomes and costs, not just their immediate costs. Adopting a culture of innovation requires a multidisciplinary team approach, with the patient at the centre and an integral part of the team. It must take a whole-system and whole-patient perspective on cancer care and be guided by high-quality real-world data, including outcomes relevant to the patient and actual costs of care; this accurately reflects the impact of any innovation in clinical practice. The European CanCer Organisation is committed to working with its member societies, patient organisations and the cancer community at large to find sustainable ways to identify and integrate the most meaningful innovations into all aspects of cancer care.

Cancer and inflammatory bowel disease in the elderly

Cancer may be a complication of inflammatory bowel disease (IBD) or its treatments. In older Crohn's disease and ulcerative colitis patients, the risk of malignancy is of particular concern. IBD diagnosis at an advanced age is associated with earlier development of colitis-associated colorectal cancer. Thiopurine use in older IBD patients is tied to an increased risk of non-Hodgkin's lymphoma, nonmelanoma skin cancer, and urinary tract cancers. Additionally, older age is accompanied by multimorbidity, an increased risk of malnutrition, and decreased life expectancy, factors that complicate the management of cancer in the elderly. The optimal approach to the increased risk of malignancy in older age IBD is appropriate cancer screening and medical treatment. This may include age-specific colorectal cancer screening and limiting UV radiation exposure. With a growing number of older IBD patients, further studies are necessary to delineate the risk of cancer in this population.