Associated Factors to Efficacy and Tolerance of Immunotherapy in Older Patients with Cancer Aged 70 Years and Over: Impact of Coprescriptions

BACKGROUND

Immunotherapy with immune checkpoint blockers (ICB) significantly improves the prognosis for an increasing number of cancers. However, data on geriatric populations taking ICB are rare.

OBJECTIVE

This study aimed to identify factors associated with the efficacy and tolerance of ICB in an older population.

PATIENTS AND METHODS

This retrospective monocentric study included consecutive patients aged ≥ 70 years with solid cancer who received ICB between January 2018 and December 2019. Efficacy was assessed by progression-free survival (PFS) and tolerance was defined as cessation of immunotherapy due to the occurrence of any adverse event.

RESULTS

One hundred and five patients (65.7% men) were included, mainly at the metastatic stage (95.2%); 50.5% had lung cancer. Most (80%) patients were treated with anti-PD1 (nivolumab, pembrolizumab), 19.1% with anti-PD-L1 (atezolizumab, durvalumab, and avelumab) and 0.9% with anti-CTLA4 ICB (ipilimumab). Median PFS was 3.7 months [95% confidence interval (CI) (2.75-5.70)]. PFS was shorter in univariate analysis when ICB was taken concomitantly with an antiplatelet agent (AP) [hazard ratio (HR) = 1.93; 95% CI (1.22-3.04); p = 0.005]. Tolerance was lower in univariate analysis for lung cancer [odds ratio (OR) = 3.03; 95% CI (1.07-8.56), p < 0.05] and in patients taking proton pump inhibitors (PPI) [OR = 5.50; 95% CI (1.96-15.42), p < 0.001]. There was a trend toward poorer tolerance among patients living alone [OR = 2.26; 95% CI (0.76-6.72); p = 0.14].

CONCLUSIONS

In older patients taking ICB for solid cancers, concomitant AP may influence efficacy and concomitant PPI may influence tolerance. Further studies are needed to confirm these results.

Prevalence of Four Sarcopenia Criteria in Older Patients with Cancer, and Their Predictive Value for 6-Month Mortality: The NutriAgeCancer National Prospective Cohort Study

Older cancer patients have an elevated risk of sarcopenia. The aim was to estimate the prevalence of four criteria for sarcopenia case finding, assessment, diagnosis, and severity determination: abnormal strength, assistance with walking, rising from a chair, climbing stairs, and falls (SARC-F), low hand-grip strength (HGS), low arm circumference (AC, a muscle mass proxy), and low physical performance (PP). Sarcopenia (low HGS and AC) and severe sarcopenia (low HGS, AC, and PP) and their predictive values for 6-month mortality were estimated in the whole population and by metastatic status. We analyzed data from the NutriAgeCancer French nationwide study of cancer patients aged ≥70 referred for geriatric assessment before anti-cancer treatment. We performed Cox proportional hazards analysis for each criterion separately and all criteria combined. Overall, 781 patients from 41 geriatric oncology clinics were included (mean age: 83.1; females: 53%; main cancer types: digestive (29%) and breast (17%); metastases: 42%). The prevalence of abnormal SARC-F, low HGS, a low AC, low PP, sarcopenia, and severe sarcopenia were, respectively, 35.5%, 44.6%, 44.7%, 35.2%, 24.5%, and 11.7%. An abnormal SARC-F and/or low HGS, sarcopenia, and severe sarcopenia were associated with 6-month mortality in patients with metastases (adjusted hazard ratios [95% confidence interval]: 2.72 [1.34-5.49], 3.16 [1.48-6.75] and 6.41 [2.5-16.5], respectively). Sarcopenia was strongly predictive of 6-month mortality in patients with metastatic cancer.

Should we screen for colorectal cancer in people aged 75 and over? A systematic review - collaborative work of the French geriatric oncology society (SOFOG) and the French federation of digestive oncology (FFCD)

BACKGROUND

We have done a systematic literature review about CRC Screening over 75 years old in order to update knowledge and make recommendations.

METHODS

PUBMED database was searched in October 2021 for articles published on CRC screening in the elderly, and generated 249 articles. Further searches were made to find articles on the acceptability, efficacy, and harms of screening in this population, together with the state of international guidelines.

RESULTS

Most benefit-risk data on CRC screening in the over 75 s derived from simulation studies. Most guidelines recommend stopping cancer screening at the age of 75. In private health systems, extension of screening up to 80-85 years is, based on the life expectancy and the history of screening. Screening remains effective in populations without comorbidity given their better life-expectancy. Serious adverse events of colonoscopy increase with age and can outweigh the benefit of screening. The great majority of reviews concluded that screening between 75 and 85 years must be decided case by case.

CONCLUSION

The current literature does not allow Evidence-Based Medicine propositions for mass screening above 75 years old. As some subjects over 75 years may benefit from CRC screening, we discussed ways to introduce CRC screening in France in the 75-80 age group. IRB: An institutional review board composed of members of the 2 learned societies (SOFOG and FFCD) defined the issues of interest, followed the evolution of the work and reviewed and validated the report.

Quality of life and perceived burden of the primary caregiver of patients aged 70 and over with cancer 5 years after initial treatment

PURPOSE

Long-term effects of being the primary caregiver of an older patient with cancer are not known. This study aimed to assess health-related quality of life (HRQoL) in primary caregivers of patients aged 70 and older with cancer, 5 years after initial treatment. Secondly, to compare the HRQoL between former primary caregivers whose caregiving relationship had ceased (primary caregiver no longer directly assisting the patient because of patient death or removal to another city or admission to an institution) and current caregivers, and to determine the perceived burden of the primary caregivers.

METHODS

Prospective observational study including primary caregivers of patients aged 70 and older with cancer. HRQoL and perceived burden were assessed using the SF-12 and Zarit Burden Interview (ZBI) at baseline and 5 years after initial treatment.

RESULTS

Ninety-six caregivers were initially included; at 5 years, 46 caregivers completed the SF-12 and ZBI between June 15 and October 26, 2020. Primary caregiver's HRQoL scores had significantly decreased over time for physical functioning (mean difference = -10, p=0.04), vitality (MD= -10.5, p=0.02), and role emotional (MD= -8.1, p=0.01) dimensions. The comparison at 5 years according to caregiving status showed no difference for all HRQoL dimensions. There was no decrease in perceived burden at 5 years.

CONCLUSION

Some dimensions of HRQoL decreased at 5 years with a stable low perceived burden.

TRIAL REGISTRATION

NCT04478903.

Plasma MCP-1 and changes on cognitive function in community-dwelling older adults

Background

Monocyte Chemoattractant Protein-1 (MCP-1), a glial-derived chemokine, mediates neuroinflammation and may regulate memory outcomes among older adults. We aimed to explore the associations of plasma MCP-1 levels (alone and in combination with β-amyloid deposition—Aβ_42/40) with overall and domain-specific cognitive evolution among older adults.

Methods

Secondary analyses including 1097 subjects (mean age = 75.3 years ± 4.4; 63.8% women) from the Multidomain Alzheimer Preventive Trial (MAPT). MCP-1 (higher is worse) and Aβ_42/40 (lower is worse) were measured in plasma collected at year 1. MCP-1 in continuous and as a dichotomy (values in the highest quartile (MCP-1⁺)) were used, as well as a dichotomy of Aβ_42/40. Outcomes were measured annually over 4 years and included the following: cognitive composite z-score (CCS), the Mini-Mental State Examination (MMSE), and Clinical Dementia Rating (CDR) sum of boxes (overall cognitive function); composite executive function z-score, composite attention z-score, Free and Cued Selective Reminding Test (FCSRT - memory).

Results

Plasma MCP-1 as a continuous variable was associated with the worsening of episodic memory over 4 years of follow-up, specifically in measures of free and cued delayed recall. MCP-1⁺ was associated with worse evolution in the CCS (4-year between-group difference: β = −0.14, 95%CI = −0.26, −0.02) and the CDR sum of boxes (2-year: β = 0.19, 95%CI = 0.06, 0.32). In domain-specific analyses, MCP-1⁺ was associated with declines in the FCSRT delayed recall sub-domains. In the presence of low Aβ_42/40, MCP-1⁺ was not associated with greater declines in cognitive functions. The interaction with continuous biomarker values Aβ_42/40× MCP-1 × time was significant in models with CDR sum of boxes and FCSRT DTR as dependent variables.

Conclusions

Baseline plasma MCP-1 levels were associated with longitudinal declines in overall cognitive and episodic memory performance in older adults over a 4-year follow-up. How plasma MCP-1 interacts with Aβ_42/40 to determine cognitive decline at different stages of cognitive decline/dementia should be clarified by further research. The MCP-1 association on cognitive decline was strongest in those with amyloid plaques, as measured by blood plasma Aβ_42/40.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13195-021-00940-2.

Biomarkers of mitochondrial dysfunction and inflammaging in older adults and blood pressure variability

Most physiopathological mechanisms underlying blood pressure variability (BPV) are implicated in aging. Vascular aging is associated with chronic low-grade inflammation occurring in late life, known as "inflammaging" and the hallmark "mitochondrial dysfunction" due to age-related stress. We aimed to determine whether plasma levels of the pleiotropic stress-related mitokine growth/differentiation factor 15 (GDF-15) and two inflammatory biomarkers, interleukin 6 (IL-6) and tumor necrosis factor receptor 1 (TNFR-1), are associated with visit-to-visit BPV in a population of community-dwelling older adults. The study population consisted of 1096 community-dwelling participants [median age 75 (72-78) years; 699 females, 63.7%] aged ≥ 70 years from the MAPT study. Plasma blood sample was collected 12 months after enrolment and BP was assessed up to seven times over a 4-year period. Systolic (SBPV) and diastolic BPV (DBPV) were determined through several indicators taking into account BP change over time, the order of measurements and formulas independent of mean BP levels. Higher values of GDF-15 were significantly associated with increased SBPV (all indicators) after adjustment for relevant covariates [adjusted 1-SD increase in GDF-15: β (SE) = 0.07 (0.04), p < 0.044, for coefficient of variation%]. GDF-15 levels were not associated with DBPV. No significant associations were found between IL-6 and BPV, whereas TNFR1 was only partially related to DBPV. Unlike inflammation biomarkers, higher GDF-15 levels were associated with greater SBPV. Our findings support the age-related process of mitochondrial dysfunction underlying BP instability, suggesting that BPV might be a potential marker of aging.

Adherence to oral anti-cancer therapies in older patients is similar to that of younger patients

Introduction

The use of oral anti-cancer therapies is becoming increasingly common in the management of cancers, raising the question of adherence. The objective of this study was to assess adherence to oral anti-cancer therapies, as well as the impact of various factors that may influence it.

Methods

Patients starting oral chemotherapy (tyrosine kinase inhibitor or cytotoxic) were followed up for 3 months using a medication diary, which was given to the patient by the pharmacist during a multidisciplinary consultation. Adherence was assessed using the diary, as well as by counting the tablets they brought back.

Results

One hundred and fifty patients were included in the study. The main oral chemotherapy agents prescribed were palbociclib (23.3%), everolimus (18.7%), and capecitabine (13.3%). The adherence at the end of the 3 months, by means of dose intensity (i.e. percent of the dose prescribed that has been taken), was 95.5%. No significant difference in adherence was found based on age, sex, family circumstances, health status, co-medication, type of oral therapy, tumor location, number of previous treatment lines, or presence of toxicity. The main reasons for non-adherence were forgetting (50%) and toxicity (21%). Fifty-seven patients prematurely discontinued the study: 40.3% for toxicity and 36.8% for disease progression.

Conclusion

Adherence in this study is high in comparison to literature, which can be explained by close multidisciplinary follow-up. Moreover, no significant difference was observed between younger and older patients.

Surgical treatment of digestive cancer in a well-defined elderly population

INTRODUCTION

Digestive cancer is of concern because of its frequency and severity with an increasing older median age of onset. The purpose of this study was to describe in a well-defined population presenting with non-metastatic digestive cancer the frequency of surgical resection and outcomes according to age.

PATIENTS AND METHODS

We analyzed 7760 patients with a non-metastatic digestive cancer, recorded in the Burgundy population-based digestive cancer registry between 2009 and 2017. There were 3506 non-colorectal cancers and 4254 colorectal cancers with 3292 colon and 962 rectal cancers. The frequency of surgical resection was analyzed according to age (classified into four categories <70, [70-80[, [80-85[, and ≥85), sex, comorbidities and obesity. Postoperative mortality at 30 and 90 days was determined according to age, sex, comorbidity, obesity, location, surgery R0 or not. The 5-year survival study included 2952 patients with colorectal cancer, non-metastatic and who benefited from an R0 resection.

RESULTS

Overall, 64% of the patients with M0 digestive cancer underwent a surgical resection, varying from 31% for Non colorectal Digestive cancers to 94% for colon site. The percentage of patients operated on for a resectable disease decreases from 71% before age 70 to 43% from age 85. Age and comorbidities were the main criteria influencing the probability of resection. At 30 days, postoperative mortality was 3%, all localizations and ages combined. At 90 days, this rate was 5%. In patients over 85 years old it gradually increases from 7% at 30 days and to 10% at 90 days. A man under 70 years of age has a net survival of 0.88 at 5 years, and 0.91 for a woman. For a man between 70 and 80 years old, it decreases to 0.81 and to 0.66 from 80 years old. In women, net survival is 0.87 between 70 and 80 years of age at 5 years, then drops to 0.75 from age 80.

CONCLUSION

Our study shows a drop in access to surgery at different pivotal ages depending on the tumor location. This sudden drop in the resection rate is not justified by the increase in mortality with age, which is linear. In addition, the expected benefits of surgery are significant, with a net survival, mainly after the 1st year, of the same order as for younger patients. Age by itself should not be the only criterion in the medical decision. The challenge is to detect and treat the comorbidities that worsen the operative risk and the prognosis. There are few data on the management of digestive cancers specifically in the elderly. Our study shows that access to surgery is strongly linked to age and this in a non-linear way, whereas the expected benefits of surgery are significant, of the same order as for younger patients. Age itself should not be the only criterion in the medical decision.

Improvement of Treg immune response after treatment with tocilizumab in giant cell arteritis

Objectives

To study the percentage, suppressive function and plasticity of Treg in giant cell arteritis (GCA), and the effects of glucocorticoids and tocilizumab.

Methods

Blood samples were obtained from 40 controls and 43 GCA patients at baseline and after treatment with glucocorticoids + IV tocilizumab (n = 20) or glucocorticoids (n = 23). Treg percentage and phenotype were assessed by flow cytometry. Suppressive function of Treg was assessed by measuring their ability to inhibit effector T‐cell (Teff) proliferation and polarisation into Th1 and Th17 cells.

Results

Treg (CD4⁺CD25^highFoxP3⁺) frequency in total CD4⁺ T cells was decreased in active GCA patients when compared to controls (2.5% vs. 4.7%, P < 0.001) and increased after treatment with tocilizumab but worsened after treatment with glucocorticoids alone. Treg lacking exon 2 of FoxP3 were increased in GCA patients when compared to controls (23% vs. 10% of total Treg, P = 0.0096) and normalised after treatment with tocilizumab + glucocorticoids but not glucocorticoids alone. In GCA patients, Treg were unable to control Teff proliferation and induced ˜50% increase in the amount of IL‐17⁺ Teff, which was improved after in vitro blockade of the IL‐6 pathway by tocilizumab.

Conclusion

This study reports quantitative and functional disruptions in the regulatory immune response of GCA patients and demonstrates that, unlike glucocorticoids, tocilizumab improves Treg immune response.

Mucosal-associated invariant T cells in Giant Cell Arteritis

This study aimed to assess the implication of mucosal-associated invariant T (MAIT) cells in GCA. Blood samples were obtained from 34 GCA patients (before and after 3 months of treatment with glucocorticoids (GC) alone) and compared with 20 controls aged >50 years. MAIT cells, defined by a CD3⁺CD4^-TCRγδ^-TCRVα7.2⁺CD161⁺ phenotype, were analyzed by flow cytometry. After sorting, we assessed the ability of MAIT cells to proliferate and produce cytokines after stimulation with anti CD3/CD28 microbeads or IL-12 and IL-18. MAIT were stained in temporal artery biopsies (TAB) by confocal microscopy. MAIT cells were found in the arterial wall of positive TABs but was absent in negative TAB. MAIT frequency among total αβ-T cells was similar in the blood of patients and controls (0.52 vs. 0.57%; P = 0.43) and not modified after GC treatment (P = 0.82). Expression of IFN-γ was increased in MAIT cells from GCA patients compared to controls (44.49 vs. 32.9%; P = 0.029), and not modified after 3 months of GC therapy (P = 0.82). When they were stimulated with IL-12 and IL-18, MAIT from GCA patients produced very high levels of IFN-γ and displayed a stronger proliferation compared with MAIT from controls (proliferation index 3.39 vs. 1.4; P = 0.032). In GCA, the functional characteristics of MAIT cells are modified toward a pro-inflammatory phenotype and a stronger proliferation capability in response to IL-12 and IL-18, suggesting that MAIT might play a role in GCA pathogenesis. Our results support the use of treatments targeting IL-12/IL-18 to inhibit the IFN-γ pathway in GCA.

Not COVID-19, Don't Overlook Pneumocystis in Patients on Gefitinib!

Simple Summary

COVID-19 pneumonia can be confused with Pneumocystis jirovecii pneumonia (PJP) on computed tomography and is a source of misdiagnosis. This can lead to mistreatment and an increased risk of mortality. Gefitinib, a tyrosine kinase inhibitor anti-EGFR used in cancer therapy and corticosteroids, could increase the risk of PJP.

Abstract

An 82-year-old woman treated for advanced lung cancer with gefitinb was admitted to the emergency unit complaining of dyspnea. Chest computed tomography found abnormalities classified as possible diffuse COVID-19 pneumonia. RT-PCR for Sars-Cov-2 was twice negative. PCR for Pneumocystis jirovecii was positive on bronchoalveolar lavage. The final diagnosis was Pneumocystis jirovecii pneumonia. Therefore, physicians must be careful not to misdiagnose COVID-19, especially in cancer patients on small-molecule therapeutics like gefitinib and corticosteroids.

Long-term quality of life and sexual function of elderly people with endometrial or ovarian cancer

Background

With the growing number of older endometrial cancer (EC) and ovarian cancer (OC) survivors, data on long-term health-related quality of life (HRQoL) became an important issue in the management of older patients. So, the aim of this study was to describe and compare according to age long-term HRQoL, sexual function, and social deprivation of adults with either EC or OC.

Methods

A cross-sectional study was set up using data from the Côte d’Or gynecological cancer registry. A series of questionnaires assessing HRQoL (SF-12), sexual function (FSFI), anxiety/depression (HADS), social support (SSQ6) and deprivation (EPICES) were offered to women with EC or OC diagnosed between 2006 and 2013. HRQoL, sexual function, anxiety/depression, social support and deprivation scores were generated and compared according to age (< 70 years and ≥ 70 years).

Results

A total of 145 women with EC (N = 103) and OC (N = 42) participated in this study. Fifty-six percent and 38% of EC and OC survivors respectively were aged 70 and over. Treatment did not differ according to age either in OC or EC. The deprivation level did not differ between older and younger survivors with OC while older survivors with EC were more precarious. The physical HRQoL was more altered in older EC survivors. This deterioration concerned only physical functioning (MD = 24, p = 0.012) for OC survivors while it concerned physical functioning (MD = 30, p < 0.0001), role physical (MD = 22, p = 0.001) and bodily pain (MD = 21, p = 0.001) for EC survivors. Global health (MD = 11, p = 0.011) and role emotional (MD = 12, p = 0.018) were also deteriorated in elderly EC survivors. Sexual function was deteriorated regardless of age and cancer location with a more pronounced deterioration in elderly EC survivors for desire (p = 0.005), arousal (p = 0.015) and orgasm (p = 0.007). Social support, anxiety and depression were not affected by age regardless of location.

Conclusion

An average 6 years after diagnosis, the impact of cancer on HRQoL is greatest in elderly survivors with either EC or OC.

Therapeutic drug monitoring as a tool to optimize 5-FU-based chemotherapy in gastrointestinal cancer patients older than 75 years

AIMS

Most clinical trials exclude elderly people, leading to a limited understanding of the benefit-to-risk ratio in this population. Despite existing data regarding the oncological management of elderly receiving fluorouracil (5-FU)-based regimen, our objective was to investigate 5-FU exposure/toxicity relationship in patients ≥75 years and compare the effectiveness of 5-FU therapeutic drug monitoring between elderly and younger patients.

METHODS

Hundred fifty-four patients (31 of whom are older than 75 years) with gastrointestinal cancers, who were to receive 5-FU-based regimens, were included in our study. At cycle 1 (C1), the 5-FU dose was calculated using patient's body surface area, then a blood sample was drawn to measure 5-FU concentration and 5-FU dose was adjusted at the subsequent cycles based on C1 concentration. Assessments of toxicity were performed at the beginning of every cycle.

RESULTS

Seventy-one percent of elderly patients required dose adjustments after C1, compared with 50% for younger patients. Percentages of patients within 5-FU area under the curve range at cycle 2 were 64% and 68%, respectively, for elderly and younger patients. The proportion of elderly patients experiencing severe toxicities fell from 15% at C1 to only 5% at cycle 3.

CONCLUSION

Pharmacokinetic-guided 5-FU-dosing algorithm, leading to an improved tolerability while remaining within therapeutic concentration range, is even more valuable for patients older than 75 years than in younger patients.

Identification of resources and skills developed by partners of patients with advanced colon cancer: a qualitative study

PURPOSE

Family caregivers play an important role in caring for patients with advanced cancer. To become competent, individuals must draw on and mobilise an adequate combination of resources. Our goal was to identify the skills developed by caregivers of patients with advanced cancer and the associated resources mobilised. We chose to do it with partners of patients with colon cancer.

METHODS

The study used a cross-sectional qualitative design based on 20 individual interviews and a focus group. Partners were recruited from patients treated in three hospitals of France. Semi-structured interviews were conducted until data saturation was achieved. Each interview was transcribed verbatim, and thematic analyses were performed to extract significant themes and subthemes.

RESULTS

Results from the individual and focus group interviews showed that the skills implemented by the partners (in domains of social relationships and health, domestic, organisational, emotional and well-being dimensions) were singular constructs, dependant on if resources (personal, external and schemes) may have been missing and insufficient. In addition, partners may have had these resources but not mobilised them.

CONCLUSION

The identification of the skills and associated resources could allow healthcare professionals better identifying and understanding of the difficulties met by partners in taking care of patients. This could enable them to offer appropriate support to help the caregivers in their accompaniment.

Management of elderly patients suffering from cancer: Assessment of perceived burden and of quality of life of primary caregivers

OBJECTIVE

To evaluate the perceived burden and the quality of life (QoL) at 3 and 6months of the primary caregiver (PC) of patients aged 70 and over suffering from cancer and the predictors of QoL in this population.

METHODS

In this prospective observational study, 98 patients aged 70 and older with cancer and 96 PCs were included between 01/06/2014 and 18/03/2015. The Medical Outcomes Study 12-item Short Form Health Survey (SF-12) was used to assess the QoL of PCs and the Zarit Burden Interview (ZBI) was used to measure the perceived burden at 3 and 6months. The major determinants of QoL were identified using mixed linear models for the dimensions of the SF-12 that showed an average difference of at least 5 points between baseline and follow-up at 6months.

RESULTS

The QoL scores of PCs showed a decrease in the dimensions "role emotional" and "bodily pain" over 6months. In multivariate analysis, the main determinants of QoL for "role emotional" were the PC's age (p=0.005), a low perceived burden (p<0.0001) and a functionally independent patient (p=0.01), and for "bodily pain" was a low perceived burden (p<0.0001) and the non-use of hormone therapy during the treatment (p<0.0001).

CONCLUSION

The main determinants of the QoL of PCs concerned factors inherent to the PC (age and perceived burden) and patient (functional independence).

Involvement and prognosis value of CD8(+) T cells in giant cell arteritis

CD8(+) T cells participate in the pathogenesis of some vasculitides. However, little is known about their role in Giant Cell Arteritis (GCA). This study was conducted to investigate CD8(+) T cell involvement in the pathogenesis of GCA. Analyses were performed at diagnosis and after 3 months of glucocorticoid treatment in 34 GCA patients and 26 age-matched healthy volunteers. Percentages of CD8(+) T-cell subsets, spectratype analysis of the TCR Vβ families of CD8(+) T cells, levels of cytokines and chemokines and immunohistochemistry of temporal artery biopsies (TAB) were assessed. Among total CD8(+) T cells, percentages of circulating cytotoxic CD8 T lymphocytes (CTL, CD3(+)CD8(+)perforin(+)granzymeB(+)), Tc17 (CD3(+)CD8(+)IL-17(+)), CD63(+)CD8(+) T cells and levels of soluble granzymes A and B were higher in patients than in controls, whereas the percentage of Tc1 cells (CD3(+)CD8(+)IFN-γ(+)) was similar. Moreover, CD8(+) T cells displayed a restricted TCR repertoire in GCA patients. Percentages of circulating CTL, Tc17 and soluble levels of granzymes A and B decreased after treatment. CXCR3 expression on CD8(+) T cells and its serum ligands (CXCL9, -10, -11) were higher in patients. Analyses of TAB revealed high expression of CXCL9 and -10 associated with infiltration by CXCR3(+)CD8(+) T cells expressing granzyme B and TiA1. The intensity of the CD8 T-cell infiltrate in TAB was predictive of the severity of the disease. This study demonstrates the implication and the prognostic value of CD8(+) T-cells in GCA and suggests that CD8(+) T-cells are recruited within the vascular wall through an interaction between CXCR3 and its ligands.

Health-related quality of life is a prognostic factor for survival in older patients after colorectal cancer diagnosis: A population-based study

BACKGROUND

Studies carried out in the context of clinical trials have shown a relationship between survival and health-related quality of life in colorectal cancer patients.

AIMS

We assessed the prognostic value of health-related quality of life at diagnosis and of its longitudinal evolution on survival in older colorectal cancer patients.

METHODS

All patients aged ≥65 years, diagnosed with new colorectal cancer between 2003 and 2005 and registered in the Digestive Cancer Registry of Burgundy were eligible. Patients were asked to complete the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 at inclusion, three, six and twelve months after. Multivariate regression models were used to evaluate the prognostic value of health-related quality of life scores at diagnosis and their deterioration on relative survival.

RESULTS

In multivariate analysis, a role functioning dimension lower than median was predictive of lower survival (hazard ratio=3.1, p=0.015). After three and six months of follow-up, patients with greater appetite loss were more likely to die, with hazard ratios of 4.7 (p=0.013) and 3.7 (p=0.002), respectively.

CONCLUSIONS

Health-related quality of life assessments at diagnosis are independently associated with older colorectal cancer patients' survival. Its preservation should be a major management goal for older cancer patients.

Assessment of the interest of the geriatric oncology consultation among French general practitioners

OBJECTIVE

We assessed the interest of the geriatric oncology (GO) consultation (GOC) among general practitioners (GPs).

MATERIALS AND METHODS

We conducted a survey among GPs whose patients had had a GOC in 2012. A questionnaire was sent to GPs. The 1st part collected GPs' characteristics including medical education in geriatrics and GO, and knowledge of GOC. The following parts concerned the GOC and included the cancer type, GOC report and care plan.

RESULTS

One-hundred twenty-six questionnaires corresponding to 94 GPs were collected. Concerning the GPs' characteristics, age range 50-59 (44.7%), men (62.8%) and urban practice (79.8%) were the most represented, 80.8% had no expertise in geriatrics, 60.6% knew of the existence of GOCs, and 14.9% had received medical education in GO. The most frequent cancer location was gynecological (40.7%) (82.6% were breast cancers). Of the GPs, 69.8% had received a GOC report and 92% were (very) satisfied with the delivery time. A care plan was proposed after the GOC in 83% of cases. It was satisfactory in 96.4% of cases, and applied by 74.7% of GPs. Sixteen percent of GPs were called by the GO team. The less the GP was satisfied with the GOC, the more he or she wanted phone contact (p=0.02); 94% of GPs considered the GOC (very) satisfactory. Sixty-seven percent of GPs wanted to be trained in GO.

CONCLUSION

Very few GPs had been trained in geriatrics and/or GO. They were mostly satisfied with GOC and expressed a wish to be trained in GO.

Age-related socio-economic and geographic disparities in breast cancer stage at diagnosis: a population-based study

BACKGROUND

This study aimed to determine the impact of socio-economic and geographic disparities on disease stage at diagnosis according to age in breast cancer (BC) patients. Secondary purpose was to describe survival

METHODS

All women with primary invasive BC, diagnosed from 1998 to 2009 in the department of Côte d'Or were retrospectively selected using data from the Côte d'Or BC registry. European transnational ecological deprivation index (French European Deprivation Index) was used to measure the socio-economic environment. Relationships between socio-geographic deprivation and disease stage at diagnosis according to age were assessed by a multilevel ordered logistic regression model. Relative survival rates (RSRs) were given at 5 years according to tumour and patients characteristics.

RESULTS

In total, 4364 women were included. In multivariable analysis, socio-economic deprivation was associated with disease stage at diagnosis. Women aged between 50 and 74 years and living in deprived areas were more often diagnosed with advanced tumour stages (stages II/III vs. I or stages IV vs. II/III) with odds ratio = 1.27 (1.01-1.60). RSRs were lowest in women living in the most deprived area compared with those living in most affluent area with RSR = 88.4% (85.9-90.4) and 92.6% (90.5-94.2), respectively.

CONCLUSIONS

Socio-economic factors affected tumour stage at diagnosis and survival. Living in a deprived area was linked to advanced-stage BC at diagnosis only in women aged 50-74 years. This is probably due to the socio-economic disparities in participation in organized BC screening programmes. Furthermore, living in deprived area was associated with a poor survival rate.

Influence of the geriatric oncology consultation on the final therapeutic decision in elderly subjects with cancer: analysis of 191 patients

OBJECTIVES

Evaluate the impact of the Geriatric Oncology Consultation on the final therapeutic management of cancer in elderly patients aged 70 and older.

DESIGN

Retrospective study.

SETTING

The Pilot Coordination Unit in Geriatric Oncology of Côte d'Or, Burgundy, France.

PARTICIPANTS

From January 2010 to December 2010, 191 patients with cancer aged 70 and older.

MEASUREMENTS

The concordance between the treatments proposed following the Tumor Board, those proposed following the Geriatric Evaluation (GE) and those actually given to the patients was evaluated using the Kappa agreement test.

RESULTS

One hundred and ninety-one patients were included. Mean age was 81.5. The most frequent cancer locations were breast (31.9%), colon-rectum (14.1%) and lung (10.5%). Concordance between the cancer treatments proposed by the Tumor Board and those suggested after the GE was excellent except for chemotherapy and targeted therapy, which were recommended less frequently by the geriatrician (Kappa = 0.67), and support care, which was more often proposed after the GE (Kappa = 0.61). However, concordance between treatments proposed by the geriatrician and treatment actually given was not so good for chemotherapy (Kappa = 0.58), and surgery (Kappa = 0.61), since both were often replaced by a less aggressive treatment.

CONCLUSION

Concordance between the therapies proposed during the Tumor Board or after the Geriatric Oncology Consultation and the treatment actually given was satisfactory. However, the role of the oncologist remains determinant in the final choice, especially for chemotherapy.

Population-based study of breast cancer in older women: prognostic factors of relative survival and predictors of treatment

Background

A large proportion of women with breast cancer (BC) are elderly. However, there is a lack of information regarding BC prognostic factors and care in this population. The aims of this study were to assess the prognostic factors of relative survival (RS) among women with BC aged ≥ 75 years old and to identify the predictive factors of treatments administered to this population.

Methods

A population-based study was performed using data from the Cote d’Or breast and gynaecological cancer registry. Women aged 75 years and older with primary invasive BC and resident in Cote d’Or at the time of diagnosis made between January 1998 and December 2008 were retrospectively selected. Prognostic factors of RS were estimated in a generalized linear model with a Poisson error structure. RS rate for the whole population was given at 5 years. Logistic regression models were used to identify the predictors of the treatments administered.

Results

Six hundred and eighty-one women were included. Median age at diagnosis was 80. Comorbidities (p=0.02), pT stage (p=0.04), metastases (p=<0.001), having a family doctor (p=0.03) and hormone-receptor status (p=0.006) were independent prognostic factors of RS. The RS rate at 5 years for the whole population was 78.2%, 95%CI = [72.2-83.0]. Age, pT stage, metastases, histoprognostic SBR grade, hormone receptor status and comorbidities were frequently found to be predictors of treatment with surgery alone, hormone therapy alone, breast conserving surgery plus adjuvant therapy and mastectomy plus adjuvant therapy.

Conclusions

Comorbid conditions adversely affect survival in older women with breast cancer. Moreover the results of this study showed that there are numerous predictors of the type of treatment administered, and that the most important were age and comorbidities.

[Type 2 diabetes in the elderly, which specific features?]

Type 2 diabetes, whose prevalence has increased among elderly aged over 75 years, has a number of specific features which differ from that in young people: heterogeneous population, association with other cardiovascular risk factors and several comorbidities, different therapeutic constraints and risks, and lower life expectancy. By using a standardized geriatric assessment it is possible to determine therapeutic and glycemic goals for each patient. In the elderly, main complications of diabetes are hypoglycemia and foot lesions. In order to avoid malnutrition, lifestyle and dietary rules should not be too strict. Recommendations for the prescription of oral antidiabetic agents are the same for both elderly and young subjects, but with increased monitoring in the elderly because of the high risk of complications including iatrogenic hypoglycemia. Insulin therapy should be preferred.

Comorbidities alone do not explain the undertreatment of colorectal cancer in older adults: a French population-based study

OBJECTIVES

To investigate the influence of comorbidities on treatment modalities of colorectal cancer according to the age of patients and French recommendations.

DESIGN

Population-based study

SETTING

French Digestive Cancer Registry, Burgundy.

PARTICIPANTS

Two thousand nine hundred twenty-one incident colorectal cancers diagnosed between 2004 and 2007.

MEASUREMENTS

The independent influence of comorbidities (recorded according to the Charlson index) on treatment was analyzed using multivariate logistic regressions controlling for age, sex, and their interaction.

RESULTS

The association between comorbidities and resection for cure was significant only in patients younger than 75 (P interaction=.008). For Stage III colon cancer, 40.4% of the patients aged 75 and older had adjuvant chemotherapy, versus 90.5% of those younger than 75 (P<.001). The association between comorbidities and adjuvant chemotherapy for Stage III colon cancer was significant only in patients younger than 75 (P interaction=.004). Patients aged 75 and older were less likely to receive chemotherapy, even when they had few or no comorbidities. Overall, 29.3% of patients aged 75 and older with advanced colorectal cancer had palliative chemotherapy, versus 77.1% of those younger than 75 (P<.001). Whatever the age, palliative chemotherapy was less frequent for a Charlson comorbidity index of 2 or greater (P interaction=.16). Radiotherapy was administered in 59.0% of patients aged 75 and older with rectal cancer, versus 85.3% of those younger than 75 (P<.001). Whatever the age, patients with a Charlson score of 2 or greater were less likely to receive radiotherapy for rectal cancer than were patients without comorbidities (P interaction=.86).

CONCLUSION

Further studies are warranted to identify more precisely the reasons for lower treatment rates for colorectal cancer in the older population.

Calcium, phosphorus, vitamin D, dairy products and colorectal carcinogenesis: a French case--control study

A protective effect of calcium against colorectal cancer has been described in Anglo-Saxon but not in Latin communities, and no such effect has been observed regarding adenomas. We investigated the relationship between calcium, dairy products and the adenoma-carcinoma sequence in a French region by comparing small adenoma ( < 10 mm, n = 154), large adenoma (n = 208) and polyp-free (n = 426) subjects, and cancer cases (n = 171) with population controls (n = 309). There was no protective effect of calcium against colorectal tumours except for low fat calcium and large adenomas in men (OR for highest quintile = 0.3, P for trend = 0.06). There was even a trend towards an increased risk of cancer with dairy calcium in men and non-dairy calcium in women. Vitamin D was inversely related to the risk of small adenomas in women (OR for highest quintile = 0.4, P for trend = 0.04). Regarding dairy products, only consumption of yoghurt displayed an inverse relationship with risk of large adenomas, in both men and women. These data failed to demonstrate a protective effect of calcium against colorectal carcinogenesis. They suggest that the type of dairy product might be the important factor with regard to prevention of colorectal tumours.

[MRI in the early diagnosis of spinal metastases of bronchial cancer]

MRI of the whole spine and radionuclide bone scan were performed prospectively on 50 consecutive patients with newly diagnosed non small-cell lung carcinoma. The final diagnosis of vertebral metastasis was made by means of follow-up studies. The prevalence of vertebral metastasis was 24% (12/50 patients). The sensitivity of MR imaging (92%) was superior to that of radionuclide bone scan (67%) in the detection of vertebral involvement, the specificity was the same (94%). MRI of the spine was not useful as a screening procedure before treatment, but offered advantages over radionuclide bone scan in patients with symptoms and when bone scintigraphy detected abnormal foci, including identification of additional vertebral metastatic foci and better analysis of the extent of metastatic involvement within vertebrae.

Family history of colorectal tumours and implications for the adenoma-carcinoma sequence: a case control study

Family history of colorectal cancer is a risk factor for sporadic colorectal cancer, but it is not known which step of the adenoma-carcinoma pathway it influences. This case control study investigated the relation between family history of cancer and colorectal adenomas and cancers. Family history of colorectal cancer (FHCRC) was as frequent in small (< 10 mm) adenoma patients (11.7%, n = 154) as in polyp free patients (10.6%, n = 426), whereas it was more frequent in patients with large adenoma(s) (18.8%, n = 208; p < 0.01). Odds ratios for FHCRC were 1.2 (p > 0.10) for small adenomas and 2.1 (p < 0.01) for large adenomas. Family history of other (non-colorectal) cancers (FHOC) was similar in the three groups. Patients with a colorectal cancer (n = 171) had more frequently a family history of cancer, both colorectal (15.8%; p < 0.01) and other cancers (35.7%; p < 0.001) than general population controls (n = 309; FHCRC: 8.1%; FHOC: 21.7%). In a logistic model, both factors were independently related to colorectal cancers (odds ratios: 1.9 (p < 0.05) for FHCRC and 2.1 (p < 0.001) for FHOC). These data suggest that family history of colorectal cancer influences only the growth of adenomas or their malignant transformation. The finding of a further predisposition to any type of cancer needs to be confirmed.

Tobacco, alcohol, and colorectal tumors: a multistep process

A case-control study in the Côte d'Or area of France used the multistep concept of colorectal carcinogenesis to compare lifetime tobacco consumption and present alcohol consumption in patients with small adenomas (less than 1 cm, n = 154) or large adenomas (n = 208) and in polyp-free controls (n = 427). Cancer patients (n = 171) were compared with population controls (n = 309). In men, smoking was associated with the risk of adenomas (odds ratio = 3.6 over 20 pack-years vs. nonsmokers, p < 0.001). Alcohol was a risk factor for large adenomas only, with relative risks of 4.2 (p < 0.01), 3.0 (p < 0.05), and 4.4 (p < 0.01) for consumptions of 20-39, 40-59, and 60 g/day compared with less than 10 g/day. When patients with large adenomas were compared with polyp-free controls, both alcohol and tobacco were independently related to the risk of tumor. There was no association between tobacco or alcohol intakes and cancer risk. In women, consumption was much lower in all groups, and no significant association with either risk factor was observed. These data suggest for the first time that there is an independent effect of alcohol and tobacco in men at different early steps of the adenoma-carcinoma sequence. They demonstrate the usefulness of such a model for etiologic studies on cancer.