Assessing frailty in older Indian patients before cancer treatment: Comparative analysis of three scales and their implications for overall survival

INTRODUCTION

Frailty, characterized by ageing-related vulnerability, influences outcomes in older adults. Our study aimed to investigate the relationship between frailty and clinical outcomes in older Indian patients with cancer.

MATERIALS AND METHODS

Our observational single-centre study, conducted at Tata Memorial Hospital from February 2020 to July 2022, enrolled participants aged 60 years and above with cancer. Frailty was assessed using the Clinical Frailty Scale (CFS), G8, and Vulnerable Elders Survey (VES)-13. The primary objective was to explore the correlation between baseline frailty and overall survival. Statistical analyses include Kaplan-Meier, Cox proportional hazards, and Harrell's C test.

RESULTS

A total of 1,177 patients (median age 68, 76.9% male) were evaluated in the geriatric oncology clinic. Common malignancies included lung (40.0%), gastrointestinal (35.8%), urological (11.9%), and head and neck (9.0%), with 56.5% having metastatic disease. Using CFS, G8, and VES-13 scales, 28.5%, 86.4%, and 38.0% were identified as frail, respectively. Median follow-up was 11.6 months, with 43.3% deaths. Patients fit on CFS (CFS 1-2) had a median survival of 28.02 months, pre-frail (CFS 3-4) 13.24 months, and frail (CFS ≥5) 7.79 months (p < 0.001). Abnormal G8 (≤14) and VES-13 (≥3) were associated with significantly lower median survival (p < 0.001). Multivariate analysis confirmed CFS's predictive power for mortality (p < 0.001), with hazard ratios [HRs] for pre-frail at 1.61(95% confidence interval [CI] 1.25 to 2.06) and frail at 2.31 (95%CI 1.74 to 3.05). G8 ≤ 14 had HR 2.00 (95%CI 1.42 to 2.83), and abnormal VES-13 had HR 1.36 (95%CI 1.11-1.67). In the likelihood ratio test, CFS significantly improved the model fit (p < 0.001). Harrell's C index for survival prediction was 0.62 for CFS, 0.54 for G8, and 0.58 for VES-13.

DISCUSSION

In conclusion, our study highlights varying frailty prevalence and prognostic implications in older Indian patients with cancer, emphasizing the need for personalized care in oncology for this aging population. We would recommend using CFS as a tool to screen for frailty for older Indian patients with cancer.

Performance of potentially inappropriate medications assessment tools in older Indian patients with cancer

BACKGROUND

Polypharmacy and potentially inappropriate medication (PIM) use are common problems in older adults. Safe prescription practices are a necessity. The tools employed for the identification of PIM sometimes do not concur with each other.

METHODS

A retrospective analysis of patients ≥60 years who visited the Geriatric Oncology Clinic of the Tata Memorial Hospital, Mumbai, India from 2018 to 2021 was performed. Beer's-2015, STOPP/START criteria v2, PRISCUS-2010, Fit fOR The Aged (FORTA)-2018, and the EU(7)-PIM list-2015 were the tools used to assess PIM. Every patient was assigned a standardized PIM value (SPV) for each scale, which represented the ratio of the number of PIMs identified by a given scale to the total number of medications taken. The median SPV of all five tools was considered the reference standard for each patient. Bland-Altman plots were utilized to determine agreement between each scale and the reference. Association between baseline variables and PIM use was determined using multiple logistic regression analysis.

RESULTS

Of the 467 patients included in this analysis, there were 372 (79.66%) males and 95 (20.34%) females with an average age of 70 ± 5.91 years. The EU(7)-PIM list was found to have the highest level of agreement given by a bias estimate of 0.010, the lowest compared to any other scale. The 95% CI of the bias was in the narrow range of -0.001 to 0.022, demonstrating the precision of the estimate. In comparison, the bias (95%) CI of Beer's criteria, STOPP/START criteria, PRISCUS list, and FORTA list were -0.039 (-0.053 to -0.025), 0.076 (0.060 to 0.092), 0.035 (0.021 to 0.049), and -0.148 (-0.165 to -0.130), respectively. Patients on polypharmacy had significantly higher PIM use compared to those without (OR = 1.47 (1.33-1.63), p = <0.001).

CONCLUSIONS

The EU(7)-PIM list was found to have the least bias and hence can be considered the most reliable among all other tools studied.

Correlation of the Geriatric Assessment with Overall Survival in Older Patients with Cancer

AIMS

Global guidelines recommend that all older patients with cancer receiving chemotherapy should undergo a geriatric assessment. However, utilisation of the geriatric assessment is often constrained by its time-intensive nature, which limits its adoption in settings with limited resources and high demand. There is a lack of evidence correlating the results of the geriatric assessment with survival from the Indian subcontinent. Therefore, the aims of the present study were to assess the impact of the geriatric assessment on survival in older Indian patients with cancer and to identify the factors associated with survival in these older patients.

MATERIALS AND METHODS

This was an observational study, conducted in the geriatric oncology clinic of the Tata Memorial Hospital (Mumbai, India). Patients aged 60 years and older with cancer who underwent a geriatric assessment were enrolled. We assessed the non-oncological geriatric domains of function and falls, nutrition, comorbidities, cognition, psychology, social support and medications. Patients exhibiting impairment in two or more domains were classified as frail.

RESULTS

Between June 2018 and January 2022, we enrolled 897 patients. The median age was 69 (interquartile range 65-73) years. The common malignancies were lung (40.5%), oesophagus (31.9%) and genitourinary (12.1%); 54.6% had metastatic disease. Based on the results of the geriatric assessment, 767 (85.4%) patients were frail. The estimated median overall survival in fit patients was 24.3 (95% confidence interval 18.2-not reached) months, compared with 11.2 (10.1-12.8) months in frail patients (hazard ratio 0.54; 95% confidence interval 0.41-0.72, P < 0.001). This difference in overall survival remained significant after adjusting for age, sex, primary tumour and metastatic status (hazard ratio 0.56; 95% confidence interval 0.41-0.74, P < 0.001). In the patients with a performance status of 0 or 1 (n = 454), 365 (80.4%) were frail; the median overall survival in the performance status 0-1 group was 33.0 months (95% confidence interval 24.31-not reached) in the fit group versus 14.4 months (95% confidence interval 12.25-18.73) in the frail patients (hazard ratio 0.50; 95% confidence interval 0.34-0.74, P = 0.001). In the multivariate analysis, the geriatric assessment domains that were predictive of survival were function (hazard ratio 0.68; 95% confidence interval 0.52-0.88; P = 0.003), nutrition (hazard ratio 0.64; 95% confidence interval 0.48-0.85, P = 0.002) and cognition (hazard ratio 0.67; 95% confidence interval 0.49-0.91, P = 0.011).

DISCUSSION

The geriatric assessment is a powerful prognostic tool for survival among older Indian patients with cancer. The geriatric assessment is prognostic even in the cohort of patients thought to be the fittest, i.e. performance status 0 and 1. Our study re-emphasises the critical importance of the geriatric assessment in all older patients planned for cancer-directed therapy.

Safety, immunogenecity and effectiveness of ChAdOx1 nCoV-19 vaccine during the second wave of pandemic in India: a real-world study

OBJECTIVES

This real-world study was conducted to assess the adverse effects following immunization (AEFI) and immunogenicity of ChAdO×1 nCoV-19 vaccine in terms of neutralising antibody titers and to study the effects of covariates such as age, sex, comorbidities and prior COVID status on these outcomes. Also, the effectiveness of the vaccine based on interval between the two doses was also investigated.

METHODS

A total of 512 participants (M/F=274/238) aged 35(18-87) years comprising a mixed population of healthcare workers, other frontline workers and general public were enrolled between March and May 2021. Records for adverse events if any were collected telephonically by following up with participants up to 6 months post first dose and graded as per Common Terminology Criteria for Adverse Events (CTCAE) version 5. Blood samples for measuring antibody titers against the receptor binding domain (RBD) were collected serially using a convenient sampling strategy up to 6 months after the first dose. Data on breakthrough COVID infection was collected telephonically till December 2021.

RESULTS

Incidence of local reactions was higher after first dose at 33.4 % (171/512) compared to those after second dose at 12.9 % (66/512). Commonest side effect observed was injection site pain after the first (87.1 %; 149/171) and second (87.9 %; 56/66) dose respectively. Among systemic reactions, fever was the most common manifestation followed by myalgia and headache. Female sex (p<0⸱001) and age less than 60 years (p<0⸱001) had significantly higher predilection for systemic toxicities. Age ≤60 years (p=0.024) and prior-COVID (p<0.001) were found to be significantly associated with higher antibody titers, however, no association was found between these variables and breakthrough COVID infection. Longer spacing between the doses (≥6 weeks) was found to offer better protection against breakthrough infection compared to a spacing of 4 weeks. All breakthroughs were mild-moderate in severity, not requiring hospitalization.

CONCLUSIONS

The ChAdOx1 nCov-19 vaccine is apparently safe and effective against SARS-CoV-2 virus infection. Prior COVID infection and younger age group achieve higher antibody titers, but no additional protection. Delaying the second dose up to at least 6 weeks is more effective compared to shorter spacing between doses.

The current status of geriatric oncology in India

Geriatric oncology in India is relatively new. The number of older persons with cancer is increasing exponentially; at our institution, 34% of patients registered are 60 years and over. Apart from the Tata Memorial Hospital in Mumbai, there are currently no other Indian centers that have a dedicated geriatric oncology unit. Geriatric assessments (GAs) are done sporadically, and older patients with cancer are usually assessed and treated based on clinical judgement. Challenges to increasing the uptake of GA include a lack of training/time/interest or knowledge of the importance of the GA. Other challenges include a lack of trained personnel with expertise in geriatric oncology, and a paucity of research studies that seek to advance the outcomes in older Indian patients with cancer. We anticipate that over the next 10 years, along with the inevitable increase in the number of older persons with cancer in India, there will be a commensurate increase in the number of skilled personnel to care for them. Key goals for the future include increased research output, increased number of dedicated geriatric oncology units across the country, India-specific geriatric oncology guidelines, geriatric oncology training programs, and a focus on collaborative work across India and with global partners. In this narrative review, we provide a broad overview of the status of geriatric oncology in India, along with a description of the work done at our center. We hope to spark interest and provide inspiration to readers to consider developing geriatric oncology services in other settings.

Validation of the Onco-MPI in predicting short-term mortality in older Indian patients with cancer

INTRODUCTION

The number of older patients with cancer is increasing exponentially worldwide, and a similar trend has also been noted in India. The Multidimensional Prognostic Index (MPI) strongly correlates the presence of individual comorbidities with mortality, and the Onco-MPI prognosticates patients accurately for overall mortality. However, limited studies have evaluated this index in patient populations beyond Italy. We evaluated the performance of the Onco-MPI index in predicting mortality in older Indian patients with cancer.

MATERIALS AND METHODS

This observational study was conducted between October 2019 and November 2021 in the Geriatric Oncology Clinic at Tata Memorial Hospital in Mumbai, India. The data of patients aged ≥60 years with solid tumors who underwent a comprehensive geriatric assessment was analysed. The study's primary aim was to calculate the Onco-MPI for patients in the study and correlate it with one-year mortality.

RESULTS

A total of 576 patients aged ≥60 years were included in the study. The median age (range) of the population was 68 (60-90) years, and 429 (74.5%) were male. After a median follow-up of 19.2 months, 366 (63.7%) patients had died. The proportion of patients classified as low risk (0-0.46), moderate risk (0.47-0.63) and high risk (0.64-1.0) were 38% (219 patients), 37% (211 patients) and 25% (145 patients), respectively. There was a significant difference in one-year mortality rates between the low-risk patients compared to medium and high-risk patients (40.6% vs 53.1% vs 71.7%; p < 0.001).

DISCUSSION

The current study validates the Onco-MPI as a predictive tool for estimating short-term mortality in older Indian patients with cancer. Further prospective studies need to build on this index to obtain a score with greater discrimination in the Indian population.

Analysis of inferior nasal turbinate volume in subjects with nasal septum deviation: a retrospective cone beam tomography study

Background

The association of the linear dimensions of the inferior turbinate hypertrophy with nasal septal deviation has been studied recently. However, the volumetric dimensions provide a more accurate status of the turbinate hypertrophy compared to linear measurements. The aim of this study was to analyze the association of inferior nasal turbinate volume with the degree of nasal septal deviation (NSD).

Methods

A retrospective evaluation of the cone beam computed tomography (CBCT) scans of 412 patients was carried out to obtain 150 scans which were included in the study. The scans were categorized into three groups. Group 1 comprised of 50 scans of patients with no inferior turbinate hypertrophy (ITH) and no nasal septal deviation. Group 2 comprised of 50 scans of patients with ITH and no NSD; whereas Group 3 included 50 scans of patients with ITH and NSD. The total turbinate volume of inferior turbinates (bilateral) were determined by using Vesalius 3D software (PS-Medtech, Amsterdam, Netherlands).

Results

The intraclass correlation coefficient (ICC) between the volumetric estimations performed by the two radiologists was 0.82. There were no significant age and gender related changes in the total turbinate volume. Patients in Group 3 had significantly higher (p = 0.001) total turbinate volume compared to Group 2 and Group 1. There was a positive and significant correlation (r = 0.52, p = 0.002) between the degree of septal deviation and total turbinate volume. When the total turbinate volume of the patients with different types of septal deviation was compared in Group 3, a statistically significant difference (p = 0.001) was observed. Regression analysis revealed that the septal deviation angle (SDA) (p = 0.001) had a relationship with total turbinate volume. From the results of the study we can conclude that the total turbinate volume is higher in patients with nasal septal deviation. It can also be concluded that the septal deviation angle has a positive correlation with total turbinate volume. The data obtained from the study can be useful in post-surgical follow up and evaluation of patients with nasal septal deviation and hypertrophied inferior nasal turbinate.

Caregiver burden in older Indian patients with cancer- Experience from a tertiary care center

INTRODUCTION

Most of the long-term care for older adults with chronic or debilitating illnesses is provided by unpaid family members or informal caregivers. There is limited information on caregiver burden among caregivers of older patients with cancer in India. Hence, we assessed the prevalence and severity of caregiver burden among caregivers of older Indian patients with cancer.

METHODS

This was an observational study conducted at the geriatric oncology clinic at Tata Memorial Centre, Mumbai, India. Caregivers of patients aged 60 years and over with a diagnosis of cancer were assessed for caregiver burden using the Zarit Burden Interview. Descriptive statistics were used for demographic and clinical variables. Factors impacting caregiver burden were analyzed using multiple linear regression analysis.

RESULTS

Caregiver burden was assessed among 127 caregivers of older Indian patients with cancer. The median patient age was 69 years (range 60-90). Most patients were men (75.6%). There were 33 female caregivers (26%), and 94 male caregivers (74%). The median caregiver burden score was 12 (IQR 6-20). Caregiver burden was "little/none" in 97 (76.4%), "mild-moderate" in 25 (19.7%), "moderate-severe" in four (3.1%) and "severe" in one (0.8%) of the caregivers assessed. On multivariate analysis, factors that significantly impacted caregiver burden scores were the presence of psychological issues in the patient and the caregiver's educational level.

CONCLUSION

Caregiver burden was low among caregivers of older Indian patients with cancer seen at a single center. Caregivers of patients with psychological disorders, and those who had less schooling reported higher caregiver burden.

The prevalence of cognitive impairment in older Indian persons with cancer and brain metastases

Background

Older patients with cancer are more vulnerable to the effects of cognitive impairment affecting their functional status, quality of life, compliance to treatment and ultimately survival. Cancer-related cognitive impairment may be due to the cancer itself or due to the treatment of cancer. There are no data regarding the prevalence of cognitive impairment in older persons with cancer and brain metastasis.

Methods

This retrospective analysis was conducted on a prospectively collected data set of patients who attended the geriatric oncology clinic at a tertiary care comprehensive cancer centre in India from June 2018 to July 2021. Patients aged 60 years and above with malignancy were included. Cognition was assessed with the mini-mental status examination (MMSE); the Hindi MMSE was used for illiterate patients. A score of ≤23 on the MMSE was considered abnormal. Correlation between the presence of cognitive impairment and brain metastasis was tested using the chi-square test.

Results

A total of 597 patients were included, of which 462 (77.4%) were male. The median age was 69 years (range: 60–100 years). All patients had solid tumours; 244 (40.9%) had lung, 189 (31.7%) had gastrointestinal and 75 (12.6%) had head and neck malignancies. Forty-one (6.9%) patients had brain metastases, of which 10 (24.4%) had solitary, 30 (73.2%) had multiple lesions and 1 (2.4%) had leptomeningeal metastases. Cognitive impairment was noted in 11 (26.8%) of the 41 patients with brain metastases and 91 (16.4%) of the 556 patients without brain metastases. There was no significant correlation between the presence of brain metastases and cognitive impairment, p = 0.086.

Conclusion

Older persons with cancer and brain metastases were not found to have a higher occurrence of cognitive impairment than those without brain metastases in this study. The next step is to understand whether older persons with brain metastases are at a higher risk for cognitive decline as a result of therapeutic interventions such as cranial radiotherapy and chemotherapy.

Dose dependent slurred speech and laryngopharyngeal dysesthesia due to oxaliplatin

INTRODUCTION

Oxaliplatin is a platinum containing alkylating agent commonly used in the management of colorectal cancers. The most common dose-limiting toxicity of oxaliplatin is peripheral neuropathy, which can be severe enough to cause treatment discontinuation. We present a case of dysarthria and laryngopharyngeal dysesthesia (LPD) that developed during the first dose of oxaliplatin, which showed dose-dependent reduction in severity in subsequent cycles.

CASE REPORT

A 52-year-old female patient with adenocarcinoma of rectum (pT4N2M0) was prescribed oxaliplatin (130 mg/m²) and capecitabine(2000mg/m²). She developed heaviness in the tongue, slurred speech, jaw pain, perioral paresthesia within 30 min after the end of 3 h infusion of oxaliplatin in the first cycle. The symptoms subsided without any sequelae in two days. However, in the subsequent cycles as the dose of the oxaliplatin was reduced, similar symptoms reappeared but were of reduced in severity. No dysesthesia symptoms were observed in the 4th cycle when the oxaliplatin was administered at 85 mg/m².

MANAGEMENT AND OUTCOME

As and when the patient developed symptoms - slurred speech, jaw pain during the first three cycles, she was managed with inj. Hydrocortisone (100 mg i.v.) and one ampoule of pheniramine (45 mg i.v.).

DISCUSSION

Occurrence of laryngopharyngeal dysesthesia due to oxaliplatin does not warrant drug withdrawal, dose titration can be helpful, thereby preventing the drug withdrawal for the patient management.

Impact of the geriatric assessment on clinical treatment decision in older Indian persons with cancer

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Background: The geriatric assessment (GA) is a multidimensional evaluation of an older person. Identification of the non-oncologic vulnerabilities, estimation of life expectancy and chemotherapy risk prediction aid the clinicians in the therapeutic risk-benefit ratio analysis. Globally, GA leads to changes in oncologic decisions in 28% of patients. Methods: An observational study with a retrospective and prospective cohort of patients who underwent a GA in the geriatric oncology clinic at the Tata Memorial Hospital in Mumbai, India. The study was approved by the institutional ethics committee (IEC) and registered with Clinical Trials Registry of India-CTRI/2020/04/024675. Written informed consent was obtained from the patients enrolled in the prospective part of the study; the IEC granted a consent waiver for the retrospective portion of the study. Patients aged 60 years and older with a diagnosis of malignancy were evaluated in the geriatric oncology clinic. The results of the GA were entered in the electronic medical records (EMR). The systemic therapy plan prior to the GA and the actual therapy plan made were retrospectively captured from the EMR. The primary objective was to determine the proportion of patients in whom the systemic therapy plan was changed following the GA. Results: Between June 2018 and Feb 2021, 340 patients were evaluated in the geriatric oncology clinic for whom the pre-GA and post-GA systemic therapy plans were available. The median age was 70 years (range, 60-100); 264 (78%) were men. The common malignancies were lung cancer in 134 (39.4%) and gastrointestinal in 119 (35%). The intent of therapy was palliative in 190 (56%) patients. Following the GA, the systemic therapy plan was changed in 125 (36.8%) patients. The most common change was deintensification of therapy in 106 patients (31.2%), including dose reduction in 41 (12%), decrease in the number of chemotherapy medicines in 8 (2.4%), substitution of chemotherapy by targeted therapy (4, 1.2%)/oral hormonal therapy (4, 1.2%)/oral TKI (11, 3.2%)/immunotherapy (2, 0.6%) and withholding systemic therapy in 36 (10.6%) patients. Withholding systemic therapy consisted of a change from chemoradiotherapy to radical radiation alone in 17 (5%), withholding neoadjuvant or adjuvant chemotherapy in 5 (1.5%) and a change to best supportive care in 14 (4.1%). Conclusions: The results of the GA led to a change in the management plan in over one-third of older Indian patients with cancer. GA is an important tool in the oncologic decision-making process for older persons with cancer. Clinical trial information: CTRI/2020/04/024675.

The prevalence of cognitive impairment in older Indian persons with cancer and brain metastases

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Background: Normal aging is associated with a decline in neurocognitive abilities. Regardless of age, 42% to 91% of persons with cancer and brain metastases are reported to have neurocognitive impairment. There are no data regarding the prevalence of cognitive impairment in older persons with cancer and brain metastasis. Methods: This retrospective analysis was performed on a prospectively collected dataset of patients who attended the geriatric oncology clinic at the Tata Memorial Hospital, a tertiary-care comprehensive cancer center in India from June 2018 to February 2021. Patient aged 60 years and over with malignancy were included. Cognition was assessed with the mini-mental status examination (MMSE); the Hindi MMSE was used for illiterate patients. A score of < 23 on the MMSE was considered abnormal. Correlation between the presence of cognitive impairment and brain metastases was tested using the chi-square test. Results: A total of 401 patients were included, of which 318 (79.3%) were males. The median age was 70 years (range: 60-100 years). All patients had solid tumors; 162 (40.4%) had lung, 139 (34.7%) had gastrointestinal and 48 (12%) had head and neck malignancies. Twenty-five (6.2%) patients had brain metastases, of which 5 (20%) had solitary, 19 (76%) had multiple lesions, and 1 (4%) had leptomeningeal metastases. Cognitive impairment was noted in 4 (16%) of the 25 patients with brain metastases and 61 (16.2%) out of 376 patients without brain metastases. There was no significant correlation between the presence of brain metastases and cognitive impairment, p = 0.57. Conclusions: Older persons with cancer and brain metastases do not have a higher incidence of cognitive impairment than those without brain metastases. The next step is to understand whether older persons with brain metastases are more at risk for cognitive decline as a result of therapeutic interventions such as cranial radiotherapy and chemotherapy.

Caregiver burden in older Indian patients with cancer: Experience from a tertiary care center

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Background: Most of the care for adults with chronic/debilitating illnesses is provided by unpaid family members. There is little information on caregiver burden in older patients with cancer in India. Methods: This was an observational study conducted in the geriatric oncology clinic at the Tata Memorial Centre, a tertiary care oncology center in Mumbai, India. The Fronto Temporal Lobe Disorders (FTLDA) caregiver burden scale was administered to the caregiver who accompanied the patient to the geriatric clinic. The scale has 22 questions, each scored from 0 to 4. The points were added to give the total caregiver burden score. The severity of the caregiver burden was scored based on the standard key: 0-20 little or no burden, 21-40 mild to moderate burden, 41-60 moderate to severe burden, 61-88 severe burden. Descriptive statistics were used for demographic & clinical variables. The factors impacting the caregiver burden were analyzed using multiple linear regression analysis. The caregiver burden score was the dependent variable in this analysis. The independent variables evaluated were patient-related factors (sex, education, primary tumor type), vulnerabilities noted on the geriatric assessment (function & falls, psychological status -depression & anxiety, cognition, nutrition, comorbidity) and caregiver-related, i.e., the relationship of the caregiver with the patient. Results: The caregiver burden scores were obtained from the caregivers of 127 older Indian patients with cancer between June 2020 & January 2021. The median age of patients in this study was 69 years (range, 60-90). There were 96 (75.6%) males; the two commonest malignancies were lung carcinoma (47 patients, 37%) & gastrointestinal cancers (46 patients, 36.2%). The relationship of the caregiver to the patient was child (94, 74%), in-law (12, 9.4%), spouse (7, 5.5%), grandchild (6, 4.7%) and other relative (8, 6.3%). The median caregiver burden score was 12 (IQR, 6-20). The caregiver burden was -little/no in 97 (76.4%), mild-moderate in 25 (19.7%), moderate-severe in 4 (3.1%) & severe in 1 (0.8%) of the caregivers assessed. On multivariate analysis, the factors that significantly impacted the caregiver burden score included the sex of the patient ( P= .0445) & the presence of psychological problems ( P= .0164). In the univariate analysis, the caregiver burden was higher in caregivers of female patients (median score, 16 [IQR 9-25] versus 10 [IQR 5-19], P= .02036). Caregivers of patients with psychological issues also had higher caregiver burden (median score, 19 [IQR 10-28] versus 10 [IQR 5.25-17], P= .00224). Conclusions: The caregiver burden was low in older Indian patients with cancer. Higher caregiver burden was experienced by the caregivers of female patients & patients with psychological disorders. Clinical trial information: CTRI/2020/04/024675.

Accuracy of the CARG chemotherapy toxicity risk prediction tool in older Indian patients with cancer

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Background: Clinical judgement alone is inadequate in accurately predicting chemotherapy toxicity in older adult cancer patients. Hurria and colleagues developed and validated, the CARG score (range, 0–17) as a convenient and reliable tool for predicting chemotherapy toxicity in older cancer patients in America, however, its applicability in Indian patients is unknown. Methods: An observational retrospective and prospective study between 2018 and 2020 was conducted in the Department of Medical Oncology at Tata Memorial Hospital, Mumbai, India. The study was approved by the institutional ethics committee (IEC-III; Project No. 900596) and registered in the Clinical Trials Registry of India (CTRI/2020/04/024675). Written informed consent was obtained in the prospective part of the study. Patients aged ≥ 60 years and planned for systemic therapy were evaluated in the geriatric oncology clinic and their CARG score was calculated. Patients were stratified into low (0-4), intermediate (5-9) and high risk (10-17) based on the CARG scores. The CARG score was provided to the treating physicians, along with the results of the geriatric assessment. Chemotherapy-related toxicities were captured from the electronic medical record and graded as per the NCI CTCAE, version 4.0. Results: We assessed 130 patients, with a median age 69 years (IQR, 60 to 84); 72% patients were males. The common malignancies included gastrointestinal (52%) and lung (30%). Approximately 78% patients received polychemotherapy and 53% received full dose chemotherapy. Based on the CARG score, 28 (22%) patients belonged to low risk, 80 (61%) to intermediate risk and 22 (17%) to the high risk category. The AU-ROC of the CARG score in predicting grade 3-5 toxicities was 0.61 (95% CI, 0.51-0.71). The sensitivity and specificity of the CARG score in predicting grade 3-5 toxicities were 60.8% and 78.6%. Grade 3-5 toxicities occurred in 6/28 patients (21%) in the low risk group, compared to 62/102 patients (61%) in the intermediate /high risk group, p = 0.0002. There was also a significant difference in the time to development of grade 3-5 toxicities, which occurred at a median of 2.5 cycles (IQR, 1-3.8) in the intermediate /high risk group and at a median of 6 cycles (IQR, 3.5-8) in the low risk group, p = 0.0011. Conclusions: In older Indian patients with cancer, the CARG score reliably stratifies patients into low risk and intermediate/high risk categories, predicting both the occurrence and the time to occurrence of grade 3-5 toxicities from chemotherapy. The CARG score may aid the oncologist in estimating the risk-benefit ratio of chemotherapy. An important limitation was that we provided the CARG score to the treating oncologists prior to the start of chemotherapy, which may have resulted in alterations in the chemotherapy regimen and dose and may have impacted the CARG risk prediction model. Clinical trial information: CTRI/2020/04/024675.

Comparison of validated screening tools for the assessment of potentially inappropriate medications in older Indian patients with cancer

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Background: The use of potentially inappropriate medication (PIM) and polypharmacy are highly prevalent in older cancer patients and are recognized as potential risk factors for adverse outcomes during cancer treatment. With geriatric cases increasing steadily in India, there is a need for comprehensive studies to identify a reliable screening tool for the assessment of PIMs. Methods: Retrospective analysis of patients ≥ 60 years who visited the Geriatric Oncology Clinic of the Tata Memorial Hospital, Mumbai, India between 2018-2021. Five tools (Beers-2015, STOPP and START-2014, PRISCUS-2010, FORTA-2018, and the EU (7)-PIM list-2015) were used to assess PIM. A standardized PIM value (SPV) was assigned for each patient for each scale which represented the ratio of the number of PIMs identified by a given scale to the total number of medications taken. The median SPV of all 5 scales for each patient was considered the reference standard. Agreement between each scale and the reference was carried out using Bland-Altman plots. The agreement was determined based on bias and the width of the limit of agreement. Association between categorical variables such as sex, comorbidities, and number of medications (above and below the median) and PIM use was determined using the chi-squared test. Results: 352 patients were included; median age - 70(range: 60-100) years, 287 (81.6%) were males. The bias and limit of agreement given by the Bland-Altman plot for each scale is shown in Table 1. The EU(7)-PIM list was found to have the least bias of 0.7% and the narrowest limits of agreement of 0.43 (-0.21 to 0.22). PIM use was observed to be significantly higher in patients with diabetes than without (83/281 versus 13/82, respectively, p = 0.013) and, patients prescribed with > 7 medications compared with ≤7 (137/281 versus 06/70, respectively, p < 0.001). Conclusions: The EU(7)-PIM list was found to have the least bias and thus considered the most reliable among all other scales in our study population. A high degree of discordance was observed between the tools, thus, we emphasize the need for future studies to identify the most reliable tool for the prediction of PIMs to aid clinical decision-making in geriatric practice.[Table: see text]

Parry Romberg syndrome with en coup de sabre: A report of a rare case

The basis of the problem: Parry Romberg syndrome (PRS) is a rare developmental disorder manifesting as a slow and progressive atrophy of the face which is often unilateral, hence also termed as rpogressivehemifacial atrophy. The extent of the atrophy may vary, involving the superficial skin extending upto the underlying bone. The clinical features of PRS include craniofacial, neurologic, ophthalmic and dermatological manifestations, which result in various functional and psychological problems. PRS and linear scleroderma belong to the same disease spectrum. There can be demarcating line between the normal and abnormal skin seen in PRS, termed as "en coup de sabre". PRS is most commonly seen in females and involves the left side of the face. Method: We hereby report a case of PRS in a young girl presenting with en coup de sabre appearance on the right side of face. Results: Microsurgical facial reconstruction of the affected side is known to be the gold standard method for correction of the facial symmetry. In our case, the patient is currently kept under long term follow up and cosmetic surgical treatment will be planned once the atrophy attains stability. Conclusion: The association of PRS with linear scleroderma may present difficulty in its diagnosis. Hence, careful recording of the history and clinical examination with appropriate investigations can aid in establishing the correct diagnosis.

Lipid peroxidation marker in saliva of Type 2 Diabetes Mellitus with oral manifestations – A Clinical and biochemical study

Background: Type 2 Diabetes progresses gradually and in a stepwise order. It commences with insulin resistance and progresses slowly with time until the body fails to maintain glucose homeostasis. These alterations are accompanied with changes in lipid peroxidation. The determination of the oxidative stress requires sometimes invasive techniques. Exploring saliva for oxidative stress has great clinical interestObjective: The present study was undertaken to estimate, compare and correlate the levels of malondialdehyde (MDA) in the serum and saliva of patients with type 2 diabetes mellitus with oral manifestations and healthy controls.Materials and Methods: Serum and salivary Malondialdehyde levels were estimated in 45 healthy subjects (Group I) and 45 patients with Type 2 Diabetes with oral manifestations (Group II). Estimation of Random blood sugar levels were done by GOD-PAP methodology. The data obtained from the present study was analyzed using SPSS software. Independent T test was used to compare the levels in the study and control group. Pearson’s correlation coefficient was used to correlate the changes in serum and saliva. P< 0.05 was considered significant.Results:The mean serum Malondialdehyde levels in Group I was 0.958 μM/l, while the mean serum Malondialdehyde levels of Group II was 2.828 μM/l. The mean salivary Malondialdehyde levels in Group I was 0.217 μM/l, while the mean salivary Malondialdehyde levels of Group II was 0.688μM/l. The mean serum and salivary Malondialdehyde levels were significantly increased in subjects with Type 2 Diabetes with oral manifestations in comparison to the healthy subjects. Fair positive correlation was observed between serum and salivary Malondialdehyde levels in Group I (r = 0.341) and very good positive correlation was observed between serum and salivary Malondialdehyde levels in Group II (r = 0.613).Conclusion: Serum and salivary Malondialdehyde was significantly higher in subjects with Type 2 Diabetes Mellitus with oral manifestations when compared to healthy controls. The increase in serum and salivary levels of MDA, shows that free radicals are formed disproportionately in diabetes mellitus by glucose degradation, non-enzymatic glycation of proteins, and the subsequent oxidative degradation, which may play an important role in the development of complications in diabetic patients. Fair positive correlation was found between serum and salivary Malondialdehyde in healthy subjects and very good positive correlation was observed between serum and salivary Malondialdehyde in subjects with Type 2 Diabetes Mellitus with oral manifestations. This study highlights that type 2 diabetic patients undergo abnormally high levels of oxidative stress. Hence exploring saliva for oxidative stress is of great importance. Thus saliva could be used as a reliable, non-invasive tool in the assessment of oxidative status.Bangladesh Journal of Medical Science Vol.17(4) 2018 p.644-651

Interdependence of antioxidants and micronutrients in oral cancer and potentially malignant oral disorders: a serum and saliva study

OBJECTIVE

In our previous studies we have evaluated the role of antioxidants and trace elements in potentially malignant disorders and cancers of the oral cavity, taking into consideration the importance of antioxidants as biomarkers in cancer detection. We felt that other than evaluation, the correlation and interdependence that existed among antioxidants and trace elements require further evaluation in order to develop a better understanding.

MATERIALS AND METHODS

Serum and salivary zinc, glutathione, and superoxide dismutase levels were evaluated in 65 healthy controls, 115 subjects with potentially malignant oral disorders, and 50 subjects with oral squamous cell carcinoma, using the atom absorption photometry, [5, 5-Dithiobis (2 nitrobenzoic acid)], and nitroblue tetrazolium methods, respectively.

RESULTS

Serum zinc and serum glutathione showed significant positive correlation (r=0.76, P=0.01). Similarly, salivary glutathione and salivary zinc levels had a positive correlation (r=0.68, P=0.01). Serum superoxide dismutase showed a strong positive correlation with serum zinc (r=0.64, P=0.01). Similarly, there was a moderate positive correlation between salivary superoxide dismutase and salivary zinc (r=0.67, P=0.01).

CONCLUSION

Our findings showed that trace elements and antioxidants exhibited interdependence in serum, as well as in saliva, in both physiologic and pathologic states such as oral cancer.

Status of salivary lipid peroxidation in oral cancer and precancer

Introduction:

Lipid oxidation gives rise to number of secondary by-products. Malondialdehyde (MDA) is the principal and most widely studied product of polyunsaturated fatty acid peroxidation. This aldehyde is a highly toxic molecule and should be considered as more than just a marker of lipid peroxidation in oral carcinogenesis.

Materials and Methods:

Salivary malondiadldehyde was evaluated in 65 healthy controls (HC), 115 subjects with oral, potentially malignant disorders (PMD) and 50 subjects with oral squamous cell carcinoma (OSCC) using the Thiobarbituric-Trichloroacetitic acid (TBA-TCA) method.

Results:

A consistent elevation in the levels of salivary MDA was observed in HC with tobacco related habits, subjects with PMD and subjects with OSCC. The elevation in the salivary MDA was significant (P = 0.001) in the groups PMD and OSCC and group OSCC when compared to HC.

Conclusion:

The significant and encouraging findings of this study thus validate and reinforce that salivary malodialdehyde analysis can be used as an efficient, noninvasive tool for the early diagnosis of PMD and OSCC for planning comprehensive treatment protocol.

Drug induced xerostomia in elderly individuals: An institutional study

Introduction:

With better health care facilities and nutritional levels the average life expectancy of Indian population has been on the rise over the years. Most of the geriatric population is under long-term medication.

Aim:

The aim of this study was to evaluate the synergistic effect of multiple xerostomia drugs.

Materials and Methods:

Unstimulated saliva was measured in 60 geriatric patients, and xerostomia questionnaire and quality-of-life scale were also administered.

Results:

There was a very highly significant reduction in the salivary flow rates of patients under multiple xerostomia-inducing drugs.

Conclusion:

The synergistic effect of the xerostomia inducing medication could be the possible factor responsible for reduced salivary flow in elderly individuals using such drugs