The role of food during oncology treatment: perspectives of cancer patients, caregivers and healthcare professionals

PURPOSE

Many cancer patients have problems eating which are usually connected to taste and smell alterations due to side effects of cancer treatment. These problems have consequences both in terms of malnutrition and reduced quality of life. In order to explore social and psychological consequences of eating problems in cancer patients, qualitative interviews were conducted with cancer patients, their caregivers and healthcare professionals.

METHODS

The study was conducted in three European countries (Poland, Spain and the UK) that differed in culture, oncology care approaches and availability of nutritional products targeted to cancer patients in the market.

RESULTS

Differences in the social role of eating between the three European countries were observed which subsequently influenced the impact of eating problems for cancer patients in these countries. Furthermore, the study found that problems with food affect not only the quality of life of cancer patients, but can also distress their caregivers, who are often unable to cope with such food-related problems. In addition, the study showed that commercially available nutritional products for cancer patients focus on nutritional value but tend to neglect an important aspect of eating, which is the enjoyment of food, both individually and socially.

Oral nutritional interventions in frail older people who are malnourished or at risk of malnutrition: a systematic review

BACKGROUND

Malnutrition worsens the health of frail older adults. Current treatments for malnutrition may include prescribed oral nutritional supplements, which are multinutrient products containing macronutrients and micronutrients.

OBJECTIVE

To assess the effectiveness and cost-effectiveness of oral nutritional supplements (with or without other dietary interventions) in frail older people who are malnourished or at risk of malnutrition.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Library, Scopus, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and grey literature were searched from inception to 13 September 2021.

REVIEW METHODS

A systematic review and meta-analysis was conducted to evaluate the effectiveness and cost-effectiveness of oral nutritional supplements in frail older people (aged ≥ 65 years) who are malnourished or at risk of malnutrition (defined as undernutrition as per National Institute for Health and Care Excellence guidelines). Meta-analysis and network meta-analysis were undertaken, where feasible, along with a narrative synthesis. A cost-effectiveness review was reported narratively. A de novo model was developed using effectiveness evidence identified in the systematic review to estimate the cost-effectiveness of oral nutritional supplements.

RESULTS

Eleven studies (n = 822 participants) were included in the effectiveness review, six of which were fully or partly funded by industry. Meta-analyses suggested positive effects of oral nutritional supplements compared with standard care for energy intake (kcal) (standardised mean difference 1.02, 95% confidence interval 0.15 to 1.88; very low quality evidence) and poor mobility (mean difference 0.03, p < 0.00001, 95% confidence interval 0.02 to 0.04; very low quality evidence) but no evidence of an effect for body weight (mean difference 1.31, 95% confidence interval -0.05 to 2.66; very low quality evidence) and body mass index (mean difference 0.54, 95% confidence interval -0.03 to 1.11; very low quality evidence). Pooled results for other outcomes were statistically non-significant. There was mixed narrative evidence regarding the effect of oral nutritional supplements on quality of life. Network meta-analysis could be conducted only for body weight and grip strength; there was evidence of an effect for oral nutritional supplements compared with standard care for body weight only. Study quality was mixed; the randomisation method was typically poorly reported. One economic evaluation, in a care home setting, was included. This was a well-conducted study showing that oral nutritional supplements could be cost-effective. Cost-effectiveness analysis suggested that oral nutritional supplements may only be cost-effective for people with lower body mass index (< 21 kg/m2) using cheaper oral nutritional supplements products that require minimal staff time to administer.

LIMITATIONS

The review scope was narrow in focus as few primary studies used frailty measures (or our proxy criteria). This resulted in only 11 included studies. The small evidence base and varied quality of evidence meant that it was not possible to determine accurate estimates of the effectiveness or cost-effectiveness of oral nutritional supplements. Furthermore, only English-language publications were considered.

CONCLUSIONS

Overall, the review found little evidence of oral nutritional supplements having significant effects on reducing malnutrition or its adverse outcomes in frail older adults.

FUTURE WORK

Future research should focus on independent, high-quality, adequately powered studies to investigate oral nutritional supplements alongside other nutritional interventions, with longer-term follow-up and detailed analysis of determinants, intervention components and cost-effectiveness.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42020170906.

FUNDING

This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 51. See the NIHR Journals Library website for further project information.

Improving outcomes for women aged 70 years or above with early breast cancer: research programme including a cluster RCT

Background

In breast cancer management, age-related practice variation is widespread, with older women having lower rates of surgery and chemotherapy than younger women, based on the premise of reduced treatment tolerance and benefit. This may contribute to inferior outcomes. There are currently no age- and fitness-stratified guidelines on which to base treatment recommendations.

Aim

We aimed to optimise treatment choice and outcomes for older women (aged ≥ 70 years) with operable breast cancer.

Objectives

Our objectives were to (1) determine the age, comorbidity, frailty, disease stage and biology thresholds for endocrine therapy alone versus surgery plus adjuvant endocrine therapy, or adjuvant chemotherapy versus no chemotherapy, for older women with breast cancer; (2) optimise survival outcomes for older women by improving the quality of treatment decision-making; (3) develop and evaluate a decision support intervention to enhance shared decision-making; and (4) determine the degree and causes of treatment variation between UK breast units.

Design

A prospective cohort study was used to determine age and fitness thresholds for treatment allocation. Mixed-methods research was used to determine the information needs of older women to develop a decision support intervention. A cluster-randomised trial was used to evaluate the impact of this decision support intervention on treatment choices and outcomes. Health economic analysis was used to evaluate the cost–benefit ratio of different treatment strategies according to age and fitness criteria. A mixed-methods study was used to determine the degree and causes of variation in treatment allocation.

Main outcome measures

The main outcome measures were enhanced age- and fitness-specific decision support leading to improved quality-of-life outcomes in older women (aged ≥ 70 years) with early breast cancer.

Results

(1) Cohort study: the study recruited 3416 UK women aged ≥ 70 years (median age 77 years). Follow-up was 52 months. (a) The surgery plus adjuvant endocrine therapy versus endocrine therapy alone comparison: 2854 out of 3416 (88%) women had oestrogen-receptor-positive breast cancer, 2354 of whom received surgery plus adjuvant endocrine therapy and 500 received endocrine therapy alone. Patients treated with endocrine therapy alone were older and frailer than patients treated with surgery plus adjuvant endocrine therapy. Unmatched overall survival and breast-cancer-specific survival were higher in the surgery plus adjuvant endocrine therapy group (overall survival: hazard ratio 0.27, 95% confidence interval 0.23 to 0.33; p < 0.001; breast-cancer-specific survival: hazard ratio 0.41, 95% confidence interval 0.29 to 0.58; p < 0.001) than in the endocrine therapy alone group. In matched analysis, surgery plus adjuvant endocrine therapy was still associated with better overall survival (hazard ratio 0.72, 95% confidence interval 0.53 to 0.98; p = 0.04) than endocrine therapy alone, but not with better breast-cancer-specific survival (hazard ratio 0.74, 95% confidence interval 0.40 to 1.37; p = 0.34) or progression-free-survival (hazard ratio 1.11, 95% confidence interval 0.55 to 2.26; p = 0.78). (b) The adjuvant chemotherapy versus no chemotherapy comparison: 2811 out of 3416 (82%) women received surgery plus adjuvant endocrine therapy, of whom 1520 (54%) had high-recurrence-risk breast cancer [grade 3, node positive, oestrogen receptor negative or human epidermal growth factor receptor-2 positive, or a high Oncotype DX® (Genomic Health, Inc., Redwood City, CA, USA) score of > 25]. In this high-risk population, there were no differences according to adjuvant chemotherapy use in overall survival or breast-cancer-specific survival after propensity matching. Adjuvant chemotherapy was associated with a lower risk of metastatic recurrence than no chemotherapy in the unmatched (adjusted hazard ratio 0.36, 95% confidence interval 0.19 to 0.68; p = 0.002) and propensity-matched patients (adjusted hazard ratio 0.43, 95% confidence interval 0.20 to 0.92; p = 0.03). Adjuvant chemotherapy improved the overall survival and breast-cancer-specific survival of patients with oestrogen-receptor-negative disease. (2) Mixed-methods research to develop a decision support intervention: an iterative process was used to develop two decision support interventions (each comprising a brief decision aid, a booklet and an online tool) specifically for older women facing treatment choices (endocrine therapy alone or surgery plus adjuvant endocrine therapy, and adjuvant chemotherapy or no chemotherapy) using several evidence sources (expert opinion, literature and patient interviews). The online tool was based on models developed using registry data from 23,842 patients and validated on an external data set of 14,526 patients. Mortality rates at 2 and 5 years differed by < 1% between predicted and observed values. (3) Cluster-randomised clinical trial of decision support tools: 46 UK breast units were randomised (intervention, n = 21; usual care, n = 25), recruiting 1339 women (intervention, n = 670; usual care, n = 669). There was no significant difference in global quality of life at 6 months post baseline (difference –0.20, 95% confidence interval –2.7 to 2.3; p = 0.90). In women offered a choice of endocrine therapy alone or surgery plus adjuvant endocrine therapy, knowledge about treatments was greater in the intervention arm than the usual care arm (94% vs. 74%; p = 0.003). Treatment choice was altered, with higher rates of endocrine therapy alone than of surgery in the intervention arm. Similarly, chemotherapy rates were lower in the intervention arm (endocrine therapy alone rate: intervention sites 21% vs. usual-care sites 15%, difference 5.5%, 95% confidence interval 1.1% to 10.0%; p = 0.02; adjuvant chemotherapy rate: intervention sites 10% vs. usual-care site 15%, difference 4.5%, 95% confidence interval 0.0% to 8.0%; p = 0.013). Survival was similar in both arms. (4) Health economic analysis: a probabilistic economic model was developed using registry and cohort study data. For most health and fitness strata, surgery plus adjuvant endocrine therapy had lower costs and returned more quality-adjusted life-years than endocrine therapy alone. However, for some women aged > 90 years, surgery plus adjuvant endocrine therapy was no longer cost-effective and generated fewer quality-adjusted life-years than endocrine therapy alone. The incremental benefit of surgery plus adjuvant endocrine therapy reduced with age and comorbidities. (5) Variation in practice: analysis of rates of surgery plus adjuvant endocrine therapy or endocrine therapy alone between the 56 breast units in the cohort study demonstrated significant variation in rates of endocrine therapy alone that persisted after adjustment for age, fitness and stage. Clinician preference was an important determinant of treatment choice.

Conclusions

This study demonstrates that, for older women with oestrogen-receptor-positive breast cancer, there is a cohort of women with a life expectancy of < 4 years for whom surgery plus adjuvant endocrine therapy may offer little benefit and simply have a negative impact on quality of life. The Age Gap decision tool may help make this shared decision. Similarly, although adjuvant chemotherapy offers little benefit and has a negative impact on quality of life for the majority of older women with oestrogen-receptor-positive breast cancer, for women with oestrogen-receptor-negative breast cancer, adjuvant chemotherapy is beneficial. The negative impacts of adjuvant chemotherapy on quality of life, although significant, are transient. This implies that, for the majority of fitter women aged ≥ 70 years, standard care should be offered.

Limitations

As with any observational study, despite detailed propensity score matching, residual bias cannot be excluded. Follow-up was at median 52 months for the cohort analysis. Longer-term follow-up will be required to validate these findings owing to the slow time course of oestrogen-receptor-positive breast cancer.

Future work

The online algorithm is now available (URL: https://agegap.shef.ac.uk/; accessed May 2022). There are plans to validate the tool and incorprate quality-of-life and 10-year survival outcomes.

Trial registration

This trial is registered as ISRCTN46099296.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 6. See the NIHR Journals Library website for further project information.

Bridging the age gap in breast cancer: impact of omission of breast cancer surgery in older women with oestrogen receptor-positive early breast cancer on quality-of-life outcomes

BACKGROUND

Primary endocrine therapy may be an alternative treatment for less fit women with oestrogen receptor (ER)-positive breast cancer. This study compared quality-of-life (QoL) outcomes in older women treated with surgery or primary endocrine therapy.

METHODS

This was a multicentre, prospective, observational cohort study of surgery or primary endocrine therapy in women aged over 70 years with operable breast cancer. QoL was assessed using European Organisation for Research and Treatment of cancer QoL questionnaires QLQ-C30, -BR23, and -ELD14, and the EuroQol Five Dimensions 5L score at baseline, 6 weeks, and 6, 12, 18, and 24 months. Propensity score matching was used to adjust for baseline variation in health, fitness, and tumour stage.

RESULTS

The study recruited 3416 women (median age 77 (range 69-102) years) from 56 breast units. Of these, 2979 (87.2 per cent) had ER-positive breast cancer; 2354 women had surgery and 500 received primary endocrine therapy (125 were excluded from analysis due to inadequate data or non-standard therapy). Median follow-up was 52 months. The primary endocrine therapy group was older and less fit. Baseline QoL differed between the groups; the mean(s.d.) QLQ-C30 global health status score was 66.2(21.1) in patients who received primary endocrine therapy versus 77.1(17.8) among those who had surgery plus endocrine therapy. In the unmatched analysis, changes in QoL between 6 weeks and baseline were noted in several domains, but by 24 months most scores had returned to baseline levels. In the matched analysis, major surgery (mastectomy or axillary clearance) had a more pronounced adverse impact than primary endocrine therapy in several domains.

CONCLUSION

Adverse effects on QoL are seen in the first few months after surgery, but by 24 months these have largely resolved. Women considering surgery should be informed of these effects.

Bridging the age gap in breast cancer: cluster randomized trial of two decision support interventions for older women with operable breast cancer on quality of life, survival, decision quality, and treatment choices

BACKGROUND

Rates of surgery and adjuvant therapy for breast cancer vary widely between breast units. This may contribute to differences in survival. This cluster RCT evaluated the impact of decision support interventions (DESIs) for older women with breast cancer, to ascertain whether DESIs influenced quality of life, survival, decision quality, and treatment choice.

METHODS

A multicentre cluster RCT compared the use of two DESIs against usual care in treatment decision-making in older women (aged at least ≥70 years) with breast cancer. Each DESI comprised an online algorithm, booklet, and brief decision aid to inform choices between surgery plus adjuvant endocrine therapy versus primary endocrine therapy, and adjuvant chemotherapy versus no chemotherapy. The primary outcome was quality of life. Secondary outcomes included decision quality measures, survival, and treatment choice.

RESULTS

A total of 46 breast units were randomized (21 intervention, 25 usual care), recruiting 1339 women (670 intervention, 669 usual care). There was no significant difference in global quality of life at 6 months after the baseline assessment on intention-to-treat analysis (difference -0.20, 95 per cent confidence interval (C.I.) -2.69 to 2.29; P = 0.900). In women offered a choice of primary endocrine therapy versus surgery plus endocrine therapy, knowledge about treatments was greater in the intervention arm (94 versus 74 per cent; P = 0.003). Treatment choice was altered, with a primary endocrine therapy rate among women with oestrogen receptor-positive disease of 21.0 per cent in the intervention versus 15.4 per cent in usual-care sites (difference 5.5 (95 per cent C.I. 1.1 to 10.0) per cent; P = 0.029). The chemotherapy rate was 10.3 per cent at intervention versus 14.8 per cent at usual-care sites (difference -4.5 (C.I. -8.0 to 0) per cent; P = 0.013). Survival was similar in both arms.

CONCLUSION

The use of DESIs in older women increases knowledge of breast cancer treatment options, facilitates shared decision-making, and alters treatment selection. Trial registration numbers: EudraCT 2015-004220-61 (https://eudract.ema.europa.eu/), ISRCTN46099296 (http://www.controlled-trials.com).

Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life

Background

Age-related breast cancer treatment variance is widespread with many older women having primary endocrine therapy (PET), which may contribute to inferior survival and local control. This propensity-matched study determined if a subgroup of older women may safely be offered PET.

Methods

Multicentre, prospective, UK, observational cohort study with propensity-matched analysis to determine optimal allocation of surgery plus ET (S+ET) or PET in women aged ≥70 with breast cancer. Data on fitness, frailty, cancer stage, grade, biotype, treatment and quality of life were collected. Propensity-matching (based on age, health status and cancer stage) adjusted for allocation bias when comparing S+ET with PET.

Findings

A total of 3416 women (median age 77, range 69–102) were recruited from 56 breast units—2854 (88%) had ER+ breast cancer: 2354 had S+ET and 500 PET. Median follow-up was 52 months. Patients treated with PET were older and frailer than patients treated with S+ET. Unmatched overall survival was inferior in the PET group (hazard ratio, (HR) 0.27, 95% confidence interval (CI) 0.23–0.33, P < 0.001). Unmatched breast cancer–specific survival (BCSS) was also inferior in patients treated with PET (HR: 0.41, CI: 0.29–0.58, P < 0.001 for BCSS). In the matched analysis, PET was still associated with an inferior overall survival (HR = 0.72, 95% CI: 0.53–0.98, P = 0.04) but not BCSS (HR = 0.74, 95% CI: 0.40–1.37, P = 0.34) although at 4–5 years subtle divergence of the curves commenced in favor of surgery. Global health status diverged at certain time points between groups but over 24 months was similar when adjusted for baseline variance.

Interpretation

For the majority of older women with early ER+ breast cancer, surgery is oncologically superior to PET. In less fit, older women, with characteristics similar to the matched cohort of this study (median age 81 with higher comorbidity and functional impairment burdens, the BCSS survival differential disappears at least out to 4–5 year follow-up, suggesting that for those with less than 5-year predicted life-expectancy (>90 years or >85 with comorbidities or frailty) individualised decision making regarding PET versus S+ET may be appropriate and safe to offer. The Age Gap online decision tool may support this decision-making process (https://agegap.shef.ac.uk/).

Trial registration number

ISRCTN: 46099296.

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Propensity matched study of women >70 with breast cancer comparing surgery or PET

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Unmatched analysis found surgery improves overall & disease-specific survival.

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Matched analysis (stage, age, health, frailty) found similar disease-specific survival

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Surgery led to adverse events in 19% & negative impacts on QoL and physical function

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Less fit women >85 may be offered PET to reduce morbidity, without survival detriment

Patient Food Preferences can Help Plan Hospital Menus for Older Patients

Aims: Malnutrition causes a huge burden on health and social services; wastage of hospital food is high and intake poor, particularly in older patients.  This study looks at the lunch choices of older patients and considers how hospital meals could be altered to improve consumption. Study Design: Over a four week period, the food choices of patients on elderly care wards were studied. The amount of food consumed and choice was evaluated in the context of food availability. Place and Duration of Study: The project was undertaken in Elderly Care Medicine wards in a District General Hospital in the South East of England. Participants were older patients with a variety of medical conditions who had the capacity to consent to a discussion about their food choices, consumption of food and preference for different food items. Methods: Of the 402 patients studied, 23% were given food they did not like and that they would not usually chose.  Results: Popular menu choices included “unusual soups” and “baked or roasted meat”.  Unpopular menu choices included sandwiches and desserts with no fruit.  The items that were most consumed were desserts containing fruit and vegetarian main courses.  Vegetarian pastry dishes and sandwiches were poorly consumed.  Conclusion: Many older patients who are able to choose from a hospital menu failed to see foods that they would normally consume.  Certain foods are preferentially chosen and when delivered were consumed well.  Older patients in this geographical area chose traditional foods and foods that are more difficult or more costly to prepare at home e.g. roast joints of meat and fruit containing desserts.

The influence of nutritional supplement drinks on providing adequate calorie and protein intake in older adults with dementia

OBJECTIVES

Investigate the impact of the provision of ONS on protein and energy intake from food and ability to meet protein and calorie requirements in people with dementia.

DESIGN

After consent by proxy was obtained, participants took part in a cross over study comparing oral intake on an intervention day to an adjacent control day.

SETTING

The study occurred in Nursing homes and hospitalised settings.

PARTICIPANTS

Older adults with dementia over the age of 65 were recruited. 26 participants (aged 83.9+/-8.4years, MMSE 13.08+/-8.13) took part. Intervention (if any): On the intervention day nutritional supplement drinks were provided three times. Each drink provided 283.3+/-41.8 Kcal of energy and 13.8+/-4.7g of protein. Supplements were removed approximately 1 hour before meals were served and weighed waste (g) was obtained.

MEASUREMENTS

Intake of food consumed was determined on intervention and control days using the quartile method (none, quarter, half, three quarters, all) for each meal component.

RESULTS

More people achieved their energy and protein requirements with the supplement drink intervention with no sufficient impact on habitual food consumption.

CONCLUSION

Findings from these 26 participants with dementia indicate that supplement drinks may be beneficial in reducing the prevalence of malnutrition within the group as more people meet their nutritional requirements. As the provision of supplement drinks is also demonstrated to have an additive effect to consumption of habitual foods these can be used alongside other measures to also improve oral intake.

A review of vertebroplasty for osteoporotic and malignant vertebral compression fractures

Vertebral compression fractures are a common clinical problem and the incidence of them will increase with the ageing population. Traditionally management has been conservative; however, there has been a growing trend towards vertebroplasty as an alternative therapy in patients with persisting severe pain. NICE produced guidance in 2003 recommending the procedure after 4 weeks of conservative management. Recent high-quality studies have been contradictory and there is currently a debate surrounding the role of the procedure with no agreement in the literature. We examine the evidence in both osteoporotic and malignant vertebral compression fractures; we also describe the benefits and side effects, alternative treatment options and the cost of the procedure. Finally, we recommend when vertebroplasty is most appropriately used based on the best available evidence.

Management of elderly patients with breast cancer: updated recommendations of the International Society of Geriatric Oncology (SIOG) and European Society of Breast Cancer Specialists (EUSOMA)

As the mean age of the global population increases, breast cancer in older individuals will be increasingly encountered in clinical practice. Management decisions should not be based on age alone. Establishing recommendations for management of older individuals with breast cancer is challenging because of very limited level 1 evidence in this heterogeneous population. In 2007, the International Society of Geriatric Oncology (SIOG) created a task force to provide evidence-based recommendations for the management of breast cancer in elderly individuals. In 2010, a multidisciplinary SIOG and European Society of Breast Cancer Specialists (EUSOMA) task force gathered to expand and update the 2007 recommendations. The recommendations were expanded to include geriatric assessment, competing causes of mortality, ductal carcinoma in situ, drug safety and compliance, patient preferences, barriers to treatment, and male breast cancer. Recommendations were updated for screening, primary endocrine therapy, surgery, radiotherapy, neoadjuvant and adjuvant systemic therapy, and metastatic breast cancer.

Investigating age-related changes in taste and affects on sensory perceptions of oral nutritional supplements

BACKGROUND

sip feeds are oral nutritional supplements (ONSs) that are commonly prescribed to malnourished patients to improve their nutritional and clinical status. However, ONSs are poorly consumed and frequently wasted, with sweetness being identified as one of the factors leading to patients' dislike of ONSs.

OBJECTIVES

to investigate if age affects sweetness thresholds and if this impacts upon perceived sweetness intensity, hedonic (sweetness and overall) and ranked preference of ONS products.

DESIGN

prospective, observational.

SUBJECTS

thirty-six young adults (18-33 years) and 48 healthy older adults (63-85 years).

SETTING

Department of Food and Nutritional Sciences and the Clinical Health Sciences at the University of Reading.

METHODS

detection and recognition threshold levels, basic taste identification and 'just about right' level of sweetness were examined. Three ONSs (chocolate, vanilla, strawberry) and sucrose solutions were evaluated for hedonic sweetness, overall hedonic liking, sweetness intensity and rank preference.

RESULTS

significant differences were found in both sweetness detection and recognition thresholds (P = 0.0001) between young and older adults, with older adults more likely to incorrectly identify the taste (P = 0.0001). Despite the deterioration in sweetness sensitivity among the older adults, there were no significant differences found in sweetness intensity perceived for the ONS products presented (P > 0.05) when compared with the young adults. However, across both groups sweetness intensity was found to be correlated with overall product dislike across all flavour variants tested (R = 0.398, P = 0.0001).

CONCLUSIONS

sweetness appears to be one of many factors contributing to the dislike of ONSs. Manufacturers are encouraged to reconsider the formulations of these products so that beneficial effects of ONSs can be delivered in a more palatable and acceptable form and wastage reduced.

Review of the evidence for a colorectal cancer screening programme in elderly people

Colorectal cancer is a major public health issue, contributing to 16,000 UK deaths per year, most of these in the elderly population. A new NHS screening programme for colorectal cancer in people over 60 is being introduced across the country throughout 2009. The aim of this research was to review the current literature on colorectal cancer screening and determine how much of the evidence for screening is applicable to elderly people. MEDLINE database was searched for articles published between 1990 and 2007, using search terms of colorectal neoplasms, mass-screening, faecal occult blood, colonoscopy and sigmoidoscopy. Articles for inclusion were limited to those in English and those including older adults. The results showed that evidence for colorectal cancer screening in general has been well researched. However, little was found specifically on screening for elderly people, or looking at the different benefits and limitations in older people compared to younger people. Very few health agencies suggested an upper age limit for screening. In conclusion, there is very little research on screening for colorectal cancer specifically in elderly people, although many health authorities advise such screening. The health needs of an older population are different to those of middle-aged people and at present the screening programmes do not appear to reflect this.

Treatment of the elderly colorectal cancer patient: SIOG expert recommendations

Colorectal cancer (CRC) is one of the commonest malignancies of Western countries, with approximately half the incidence occurring in patients >70 years of age. Elderly CRC patients, however, are understaged, undertreated and underrepresented in clinical trials. The International Society of Geriatric Oncology created a task force with a view to assessing the potential for developing guidelines for the treatment of elderly (geriatric) CRC patients. A review of the evidence presented by the task force members confirmed the paucity of clinical trial data in elderly people and the lack of evidence-based guidelines. However, recommendations have been proposed on the basis of the available data and on the emerging evidence that treatment outcomes for fit, elderly CRC patients can be similar to those of younger patients. It is hoped that these will pave the way for formal treatment guidelines based upon solid scientific evidence in the future.

Tracheal pH monitoring and aspiration in acute stroke

BACKGROUND

aspiration can lead to chest infections, increased morbidity and mortality in stroke sufferers. It is important clinically and for research purposes to identify all patients who aspirate. At present, videofluoroscopy is the gold standard for detecting aspiration. The aim of this study was to investigate aspiration in acute stroke patients, who are safe for oral intake as assessed by bedside swallow test and videofluoroscopy, using tracheal pH monitoring.

METHODS

thirty-four stroke patients admitted to the Acute Stroke Unit gave informed consent and underwent tracheal pH monitoring 4-19 days post-stroke. A standardised acid meal was served.

RESULTS

two traces were discarded. Nine of the 32 remaining studies showed a drop in tracheal pH <5.5 following ingestion of an acidic meal. Two patterns of lowered tracheal pH were observed: three cases showed a prolonged fall in pH to <5.5, which took over 15 minutes to return to baseline and six had acute falls in pH to <5.5, which rapidly recovered in under 4 minutes. In six the drop occurred immediately after the meal, and in three a delay was observed prior to the drop.

CONCLUSION

tracheal acidification, which could represent aspiration, has been observed in 9 of 32 stroke patients assessed as safe to take diet and fluids orally by bedside assessment and videofluoroscopy. This is a preliminary investigation that provides information about tracheal pH monitoring in acute stroke patients.

The role of selective decontamination of the digestive tract in acute stroke

BACKGROUND

following a stroke, morbidity and mortality is high, with aspiration pneumonia being a common complication.

OBJECTIVES

to determine the levels of colonisation by and isolation of aerobic Gram-negative bacteria (AGNB) in acute stroke patients and determine the effect of selective decontamination of the digestive tract (SDD) on oral flora and whether it reduces both morbidity and mortality after an acute stroke.

DESIGN

a prospective, randomised, placebo-controlled double blind trial.

SETTING

acute stroke assessment units of three hospitals in the northwest of England.

SUBJECTS

203 patients admitted to hospital following a first acute stroke.

METHODS

participants were randomised to SDD oral gel or placebo. Swallow was assessed on admission to hospital, and oral swabs were obtained thrice weekly. Demographic and clinical data were recorded.

RESULTS

203 patients (106 males and 97 females) participated, of whom 20 died during their hospitalisation, 19 withdrew and full follow-up was obtained for the remaining 164. A total of 122 AGNB were isolated in 105 samples from 48 patients. Abnormal swallow on admission was found in 58 patients (29%). A total of 34 patients carried a single gram-negative micro-organism that was present on one or more occasions. More than one AGNB was carried in 14 patients, and organisms were significantly more likely to be isolated from the placebo group than the active group during weeks 2 and 3 of treatment (P = 0.034, chi-squared). Seven patients in the placebo group and one in the treatment group developed pneumonia (P = 0.029, Fisher's exact test).

CONCLUSIONS

high carriage of and colonisation by AGNB was found within this study, which was reduced by the addition of SDD. Although SDD reduced the presence of both organisms and documented episodes of pneumonia, mortality remained unchanged.

Is influenza vaccination cost effective for healthy people between ages 65 and 74 years? A randomised controlled trial

The aim of this study was to determine the cost effectiveness of influenza vaccination for healthy people aged 65-74 years living in the UK. People without risk factors for influenza (chronic heart, lung or renal disease, diabetic, immunosuppressed or those living in an institution) were identified from 20 general practitioner (GP) practices in Liverpool in September 1999. 729/5875 (12.4%) eligible individuals were recruited and randomised to receive either influenza vaccine or placebo (ratio 3:1), with all participants receiving 23-valent-pneumococcal polysaccharide vaccine unless already administered. The primary analysis was the frequency of influenza as recorded by a GP diagnosis of pneumonia or influenza like illness. In 2000, the UK vaccination policy was changed with influenza vaccine becoming available for all people aged 65 years and over irrespective of risk. As a consequence of this policy change, the study had to be fundamentally restructured and only results obtained over a one rather than the originally planned two-year randomised controlled trial framework were used. Results from 1999/2000 demonstrated no significant difference between groups for the primary outcome (relative risk 0.8, 95% CI 0.16-4.1). In addition, there were no deaths or hospitalisations for influenza associated respiratory illness in either group. The subsequent analysis, using both national and local sources of evidence, estimated the following cost effectiveness indicators: (1) incremental NHS cost per GP consultation avoided = 2000 pound sterling; (2) incremental NHS cost per hospital admission avoided = 61,000 pound sterling; (3) incremental NHS cost per death avoided = 1,900,000 pound sterling and (4) incremental NHS cost per QALY gained = 304,000 pound sterling. The analysis suggested that influenza vaccination in this population would not be cost effective.

Pressure-relieving equipment: promoting its correct use amongst nurses via differing modes of educational delivery

AIMS AND OBJECTIVES

To examine the impact of written and verbal education on bed-making practices, in an attempt to reduce the prevalence of pressure ulcers.

BACKGROUND

The Department of Health has set targets for a 5% reduction per annum in the incidence of pressure ulcers. Electric profiling beds with a visco-elastic polymer mattress are a new innovation in pressure ulcer prevention; however, mattress efficacy is reduced by tightly tucking sheets around the mattress.

DESIGN

A prospective randomized pre/post-test experimental design.

METHODS

Ward managers at a teaching hospital were approached to participate in the study. Two researchers independently examined the tightness of the sheets around the mattresses. Wards were randomized to one of two groups. Groups A and B received written education. In addition, group B received verbal education on alternate days for one week. Beds were re-examined one month later. One researcher was blinded to the educational delivery received by the wards.

RESULTS

Twelve wards agreed to participate in the study and 245 beds were examined. Before education, 113 beds (46%) had sheets tucked correctly around the mattresses. Following education, this increased to 215 beds (87.8%) (chi2 = 68.03, P < 0.001). There was no significant difference in the number of correctly made beds between the two different education groups: 100 (87.72%) beds correctly made in group A vs. 115 (87.79%) beds in group B (chi2 = 0, P = 0.987).

CONCLUSIONS

Clear, concise written instruction improved practice but verbal education was not additionally beneficial.

RELEVANCE TO CLINICAL PRACTICE

Nurses are receptive to clear, concise written evidence regarding pressure ulcer prevention and incorporate this into clinical practice.

Under-investigation of older people with abnormal chest radiographs

BACKGROUND

Whilst many authors have previously suggested that older people are under-represented in the investigation and management of lung cancer, few data are available as to the effect of age on the subsequent investigation and management of a patient with an abnormal chest radiograph.

METHODS

During a 3-month period in a university teaching hospital, all abnormal chest radiographs suggestive of a possible diagnosis of lung cancer were identified, and patients subsequently followed to determine investigation, management and date of death over a 5-year period.

RESULTS

Thirty-seven younger (</=69 years, median age 62 years) and 43 older patients (>/=70 years, median age 80 years) were identified. Of the 80 patients with a possible bronchial carcinoma only 59% had a further chest radiograph performed. Bronchoscopy was performed in 34% of patients, but a biopsy of the lesion was undertaken in only 24% of patients. Sixteen of the 80 patients, irrespective of what investigations had been undertaken, were referred for an oncological or surgical opinion. During the study period (3 months), 24% of the patients died. At 6, 24 and 60 months, respectively, the total deaths were 40, 78 and 88%.

CONCLUSION

Older patients compared with those aged less than 70 years were less likely to be investigated, further, were more likely to be managed differently (i.e., less aggressively) and more likely to die within each time interval. In more of the older group a presumed death certificate diagnosis of pneumonia was made. When an abnormal chest radiograph raises the possibility of an underlying bronchial carcinoma, the finding of this study suggests that an ageist attitude influences the subsequent management of some patients.

The incidence of oral Gram-negative bacteria in patients with Parkinson's disease

Background: Parkinson's disease is a common neurodegenerative disorder that affects an increasing number of older people every year. Dysphagia is not only a common feature, but one that results in poor nutrition and an increased risk of bronchopneumonia. Previous work has suggested that the oral flora is altered in patients with oral pathology. Methods: Fifty patients were assessed to quantify the incidence of oral Gram-negative bacteria. Results: Sixteen of the patients with Parkinson's disease were found to have six different Gram-negative bacilli in their oral cavities. The 20 different Gram-negative bacteria present were Escherichia coli (n=7), Klebsiella spp. (n=3), Kluyvera spp. (n=3), Serratia spp. (n=3), Proteus spp. (n=2) and Enterobacter spp. (n=2). We found that the oral cavity of 16 (32%) of the patients with Parkinson's disease was abnormally colonised with Gram-negative bacteria and that Gram-negative bacteria were more likely to occur in those patients in whom oromuscular dysfunction was present (88% vs. 21%; p<0.05). Conclusion: Further work is required to determine the association between oral flora and the pathogenic organisms found in aspiration pneumonia as well as work on innovative treatments to reduce oral Gram-negative bacteria in those patients at particular risk of aspiration pneumonia.

Cost-benefit evaluation of routine influenza immunisation in people 65-74 years of age

OBJECTIVES

To determine the cost-effectiveness of influenza vaccination in people aged 65-74 years in the absence of co-morbidity.

DESIGN

Primary research: randomised controlled trial.

SETTING

Primary care.

PARTICIPANTS

People without risk factors for influenza or contraindications to vaccination were identified from 20 general practitioner (GP) practices in Liverpool in September 1999 and invited to participate in the study. There were 5875/9727 (60.4%) people aged 65-74 years identified as potentially eligible and, of these, 729 (12%) were randomised.

INTERVENTION

Participants were randomised to receive either influenza vaccine or placebo (ratio 3:1), with all individuals receiving pneumococcal vaccine unless administered in the previous 10 years. Of the 729 people randomised, 552 received vaccine and 177 received placebo; 726 individuals were administered pneumococcal vaccine. MAIN OUTCOME MEASURES AND METHODOLOGY OF ECONOMIC EVALUATION: GP attendance with influenza-like illness (ILI) or pneumonia (primary outcome measure); or any respiratory symptoms; hospitalisation with a respiratory illness; death; participant self-reported ILI; quality of life (QoL) measures at 2, 4 and 6 months post-study vaccination; adverse reactions 3 days after vaccination. A cost-effectiveness analysis was undertaken to identify the incremental cost associated with the avoidance of episodes of influenza in the vaccination population and an impact model was used to extrapolate the cost-effectiveness results obtained from the trial to assess their generalisability throughout the NHS.

RESULTS

In England and Wales, weekly consultations for influenza and ILI remained at baseline levels (less than 50 per 100,000 population) until week 50/1999 and then increased rapidly, peaking during week 2/2000 with a rate of 231/100,000. This rate fell within the range of 'higher than expected seasonal activity' of 200-400/100,000. Rates then quickly declined, returning to baseline levels by week 5/2000. The predominant circulating strain during this period was influenza A (H3N2). Five (0.9%) people in the vaccine group were diagnosed by their GP with an ILI compared to two (1.1%) in the placebo group [relative risk (RR), 0.8; 95% confidence interval (CI) = 0.16 to 4.1]. No participants were diagnosed with pneumonia by their GP and there were no hospitalisations for respiratory illness in either group. Significantly fewer vaccinated individuals self-reported a single ILI (4.6% vs 8.9%, RR, 0.51; 95% CI for RR, 0.28 to 0.96). There was no significant difference in any of the QoL measurements over time between the two groups. Reported systemic side-effects showed no significant differences between groups. Local side-effects occurred with a significantly increased incidence in the vaccine group (11.3% vs 5.1%, p = 0.02). Each GP consultation avoided by vaccination was estimated from trial data to generate a net NHS cost of 174 pounds.

CONCLUSIONS

No difference was seen between groups for the primary outcome measure, although the trial was underpowered to demonstrate a true difference. Vaccination had no significant effect on any of the QoL measures used, although vaccinated individuals were less likely to self-report ILI. The analysis did not suggest that influenza vaccination in healthy people aged 65-74 years would lead to lower NHS costs. Future research should look at ways to maximise vaccine uptake in people at greatest risk from influenza and also the level of vaccine protection afforded to people from different age and socio-economic populations.

Are we wasting our money on food supplements in elder care wards?

BACKGROUND

It is reported that undernutrition in older hospitalized patients is commonly found, but estimates of its prevalence vary. It is also not clear which treatment approaches are best because poor methodology prevents comparison of outcomes between different studies.

RATIONALE

The rationale of this observational study was to look at typical elder care wards in order to determine what food supplements were being prescribed. We wished to determine whether serum albumin and/or body mass index (BMI) were appropriately related to the prescription of sip feeds and also to determine the palatability of supplements provided.

METHOD

We monitored the wastage of sip feeds over a 24-hour period and extrapolated an estimated cost. Ninety-six patients were studied, including 23 patients with a BMI of less than 20, of whom 30% were on supplementary feeds.

RESULTS

Seventy percentage of prescribed sip feeds were being given to people with a BMI of 20 or more. The mean wastage in this 24-hour period was 63% ( pound 79.56) in four wards containing 96 older patients.

CONCLUSION

We concluded that there was no relationship between the numbers of patients with a low albumin and BMI and the prescription of sip feeds. We found compliance to be low (37%) because of poor palatability, with a large number of patients who appeared to require sip feeds not being prescribed them and those who received them wasting more than they drank.

Acute stroke predisposes to oral gram-negative bacilli -- a cause of aspiration pneumonia?

OBJECTIVES

To assess any change in the oral flora in the mouths of stroke patients during the acute and rehabilitation phases and to determine whether this is related to episodes of aspiration pneumonia and clinical outcome.

MATERIALS AND METHODS

This observational study was carried out in hospital wards in a University teaching hospital. The subjects were patients immediately post-stroke and during the rehabilitation period, acute admissions and a group of healthy volunteers. An assessment of dentition and swallow in the presence or absence of oral aerobic gram-negative bacilli (AGNB) was correlated.

RESULTS

Of the acute stroke patients 52% had an unsafe swallow. AGNB carriage was documented in 34% of the acute stroke group. Of the 11 patients who died 55% had AGNB, 73% had an unsafe swallow and 36% had a combination of both.

CONCLUSION

AGNB is a common finding in acute stroke patients. It is not a consequence of age or acute hospitalisation and is associated with an unsafe swallow and a higher mortality.

Side effects of influenza vaccination in healthy older people: a randomised single-blind placebo-controlled trial

OBJECTIVES

To investigate the frequency of side effects following influenza vaccination in healthy participants aged 65-74 years.

MATERIALS AND METHODS

A single-blind randomised placebo-controlled trial was performed in general practices in central Liverpool on 729 healthy individuals (341 females and 388 males) aged 65-74 (median age 68.9) years, of whom 552 received influenza vaccine and 177 received placebo. The main outcome measures were analysed from adverse reactions reported by the subjects on a postal questionnaire 3 days after vaccination.

RESULTS

724 (99.3%) questionnaires were returned. 62 (11.3%) participants who received influenza vaccination complained of local symptoms compared with 9 (5.1%) participants who received placebo (difference 6.2%; 95% CI 1.3 to 10.0%; p = 0.02). 192 (35.1%) individuals who received influenza vaccine complained of one or more systemic side effects compared with 75 (42.4%) who received placebo (difference -7.3%; 95% CI -15.6 to 0.9%; p = 0.10).

CONCLUSION

Healthy people belonging to this age group can be reassured that, when compared with placebo, influenza vaccination causes few, if any, systemic side effects and only a low incidence of local side effects.

Smoking cessation

Smoking cessation has been shown to be cost effective, even in older individuals. It is therefore important that this health promotion is not missed in this vulnerable group.

Factors affecting influenza vaccination rates in older people admitted to hospital with acute medical problems

Influenza is a major problem both in the community and hospital and elderly people who are at particular risk should be included in vaccination programmes. In August 1998 the Chief Medical Officer for England extended the current influenza immunization policy to include all those aged 75 years or over. However, prior to this date only those patients with co-existing cardiac or respiratory diseases at increased risk of influenza were vaccinated routinely. In order to determine whether such patients had been immunized, we approached all patients admitted to Care of the Elderly wards during an 8-week period in January and February. The study additionally identified factors that may have influenced patients' participation in this immunization programme. Six hundred and forty-nine patients on Care of the Elderly wards with acute medical illness were questioned with regard to vaccination against influenza during the previous year. Of the 649 patients 279 were suitable for entry into the study. Of these 39% had been vaccinated against influenza. When considering the 171 who were not vaccinated, 25% (44 patients) had actually been offered and declined vaccination, in 46% of these cases due to previous side-effects, or fear of anticipated side-effects. In those unvaccinated three-quarters considered that the influenza vaccine was not efficacious. Unfortunately, patients with co-existing cardiac, respiratory or endocrine diseases were no more likely to have been vaccinated than were those without these diseases. Many older patients admitted with acute medical problems had not been vaccinated against influenza and the reasons for this included not being offered vaccination, a belief that influenza vaccination was not efficacious and concerns about possible side-effects. The role of community doctors and nurses in facilitating the vaccination of such an at-risk group is evident and should be incorporated into resource planning.

Surgery for colorectal cancer in elderly patients: a systematic review. Colorectal Cancer Collaborative Group

BACKGROUND

The effectiveness of surgery for colorectal cancer depends on it being carried out safely, which allows most patients to return to productive lives, with an improved postoperative life expectancy, or at least one that is not diminished by the surgery. Because colorectal cancer is a major cause of morbidity and mortality in elderly people, we have examined how the outcomes of surgery in elderly patients differ from those in younger patients.

METHODS

We did a systematic review of published and aggregate data provided by investigators. Studies were identified by computerised and manual searches of published and unpublished reports, scanning references, and contacting investigators. Within each study, outcomes for patients aged 65-74 years, 75-84 years, and 85+ years were expressed in relation to those aged less than 65 years.

FINDINGS

From 28 independent studies, and a total of 34,194 patients, we found that elderly patients had an increased frequency of comorbid conditions, were more likely to present with later-stage disease and undergo emergency surgery, and less likely to have curative surgery than younger patients. The incidence of postoperative morbidity and mortality increased progressively with advancing age. Overall survival was reduced in elderly patients, but for cancer specific survival age-related differences were much less striking.

INTERPRETATION

The relation between age and outcomes from colorectal cancer surgery is complex and may be confounded by differences in stage at presentation, tumour site, pre-existing comorbidities, and type of treatment received. However, selected elderly patients benefit from surgery since a large proportion survive for 2 or more years, irrespective of their age.

Palliative chemotherapy for advanced or metastatic colorectal cancer. Colorectal Meta-analysis Collaboration

BACKGROUND

Despite the increasing use of palliative chemotherapy for advanced colorectal cancer, there remains uncertainty as to the true effectiveness of this intervention. This review was therefore undertaken to assess the available evidence for the benefit of palliative chemotherapy in this disease.

OBJECTIVES

To determine the benefits and harms of palliative chemotherapy in patients with locally advanced or metastatic colorectal cancer. A secondary objective was to investigate outcomes for younger and elderly patients.

SEARCH STRATEGY

Trials were identified by computerised and hand searches of the literature, scanning references and contacting investigators.

SELECTION CRITERIA

All randomised controlled trials of palliative chemotherapy compared with supportive care alone in patients with advanced or metastatic colorectal cancer. Both randomised and non-randomised studies were considered when searching for data on quality of life, resource use and cost effectiveness of palliative chemotherapy.

DATA COLLECTION AND ANALYSIS

Investigators from all eligible studies were asked to supply individual patient data. Meta-analysis was performed using both published data and individual patient data. Studies were grouped according to whether chemotherapy was administered regionally or systemically.

MAIN RESULTS

13 randomised controlled trials representing a total of 1365 randomised patients met the inclusion criteria. Meta-analysis of a subset of trials that provided individual patient data demonstrated that palliative chemotherapy was associated with a 35% (95% CI 24% to 44%) reduction in the risk of death. This translates into an absolute improvement in survival of 16% at both 6 months and 12 months and an improvement in median survival of 3.7 months. The overall quality of evidence relating to treatment toxicity, symptom control and quality of life was poor.

REVIEWER'S CONCLUSIONS

Chemotherapy is effective in prolonging time to disease progression and survival in patients with advanced colorectal cancer. The survival benefit may be underestimated by this meta-analysis, as a proportion of patients in the control arms of some trials received chemotherapy. No age related differences were found in the effectiveness of chemotherapy, but elderly patients were under represented in trials. Treatment toxicity and impact upon quality of life and symptom control have been inadequately assessed in the majority of trials and further research is needed to clarify the palliative benefit of chemotherapy.

Nurses response to terminal care in the geriatric unit

The elderly patient poses a major challenge in the future organisation of nursing services. Over half of all cancers occur in the elderly and account for a considerable proportion of diagnoses for patients in geriatric units. The aim of this exploratory study was to investigate the attitudes of nurses towards terminal care of patients on their wards. The questionnaire sought the opinions of nurses on acute and rehabilitation wards with regard to various aspects of terminal care. The study identified several areas where nurses on both acute and rehabilitation wards felt uncomfortable with their role in the care of such patients and areas where they felt to be lacking in certain skills. The study highlighted that although nurses considered care in these wards to be good, the provision of specialised training, and support of these nurses, would perhaps enable more satisfaction for the nurses and improve care of elderly patients during their terminal illness.