Treating cancer in older and oldest old patients

The so-called "silver tsunami" is a metaphor that the individuals 65 and older represent the most rapidly growing segment of the Western world population. Aging is an ongoing process that leads to the loss of functional reserve of multiple organ systems, increased susceptibility to stress, it is associated with increased prevalence of chronic disease, and functional dependence. Determined by a combination of genetic and environmental factors, this process is highly individualized and poorly reflected in chronologic age. The heterogeneity and the complexity of the older old population represent the main challenge to the treatment of cancer in those patients. We should discern "fit" elderly in whom standard cancer treatment appears to be comparable to a younger population and "unfit" or "frail" elderly, in which the risks of the treatment may overwhelm potential benefits. There are many aspects that have to be assessed before treating an elderly patient, or before to choose the treatment itself. In our review we will try to explain and describe the meaning and the most important aspects related to the oldest old complex patients, and how to manage those patients.

Recombinant Hemopoietic Growth Factors: Comparative Hemopoietic Response in Younger and Older Subjects

OBJECTIVE

To study the effectiveness of hemopoietic growth factors in older patients.

DESIGN

Literature review. All articles published in English language between 1987 and 1990 were reviewed. Those reporting studies without age limits as entry criteria and describing the effects of growth factors in individual patients were suitable for analysis. Bone marrow transplantation related articles were excluded.

MAIN OUTCOME MEASURES

The meanfold increase of granulocytes for Granulocyte-Colony Stimulating Factor, Granulocyte Macrophage-Colony Stimulating Factor, and Interleukin 3 and of hemoglobin for erythropoietin were compared in subjects younger and older than 65, by Mann-Whitney U test.

RESULTS

Of 68 studies, 23 were suitable for analysis. These included patients with myelodysplastic syndromes, aplastic anemia, chemotherapy-induced myelosuppression, chronic granulocytopenia, anemia, and myelosuppression of malignancies and of chronic disease. Of 204 patients, 67 were 65 years of age or older and 42 were over 70. No difference was seen in meanfold increase of granulocyte and hemoglobin in time of response to growth factors or in response in presence of an absolute neutrophil count lower than 1000/microliters between younger and older patients.

CONCLUSION

Early response to hemopoietic growth factors appears well maintained with advanced age. Prospective studies of the prolonged effects of these factors in older and younger patients are needed.

Prevalence of aging population in the Middle East and its implications on cancer incidence and care

The Middle Eastern population is aging rapidly, and as aging is the main risk factor for cancer, the incidence and prevalence of that disease are increasing among all the populations in the region. These developments represent huge challenges to national and community-based health services. At the current state of affairs, most Middle Eastern countries require the cooperation of international agencies in order to cope with such new challenges to their health systems. The focus and emphasis in facing these changing circumstances lie in the education and training of professionals, mainly physicians and nurses, at the primary, secondary and tertiary levels of health services. It is imperative that these training initiatives include clinical practice, with priority given to the creation of multidisciplinary teams both at the cancer centers and for home-based services.

Promoting new approaches for cancer care in the Middle East

Cancer is now the fastest growing killing disease in the Middle East. Accordingly, there is an urgent need to train local health professionals: oncologists, palliative care experts, oncology nurses, psychologists, along with social workers, physiotherapists and spiritual counselors on strategies for early detection, curative therapies and palliation. Professionals in the region, along with the public, need to convince medical administrators, regulators and policymakers about investing in education and training of YOUNG professionals, as well as those with already proven experience in cancer care. Training is the basis for any future cancer care program, which aims at the integration of palliative care practices into standard oncology care across the trajectory of the illness.

Improvement of a rapid screening test for chronic granulomatous disease

Diagnosis of CGD is made by demonstrating absent or markedly reduced oxidase activity in stimulated neutrophils. The screening test proposed is based upon the naked eye evaluation of the reduction of NBT on a solid surface. It seems to be a useful tool for rapid and inexpensive detection of CGD patients, especially for large-scale screening purposes. The test was carried out on forty-five subjects: two males affected by CGD, three female carriers and forty healthy donors. The test confirmed the results obtained with flow cytometric and NBT assays.

Anemia, fatigue and aging

Aging is associated with increased incidence and prevalence of both cancer and anemia. Cancer and aging may conspire in making anemia more frequent and more severe. This article reviews the causes and the consequences of anemia in the older individual. The most common causes include chronic inflammation that is a typical manifestation of aging, iron deficiency that may be due to chronic hemorrhage, malabsorption and Helicobacter pylori infection, cobalamin deficiency from malabsorption and renal insufficiency. Other causes of anemia whose prevalence is not well established include myelodysplasia, copper deficiency, hypothyroidism, and sarcopenia. Anemia is associated with increased risk of mortality, functional dependence, dementia, falls, and chemotherapy-related toxicity. When correcting the anemia of older cancer patients one should remember that the erythropoietic stimulating agents (ESA) may stimulate cancer growth and cause thrombosis. These products may be safe when given exclusively to patients receiving chemotherapy and when the hemoglobin levels are maintained below 12 g/dL.

Impact of VEGF and CgA as new predictive tools in management of elderly hormone-refractory prostate cancer (HRPC) patients

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Background: Prostate cancer is one of the most frequent malignancy in men of the Western countries. The identification of new predictive factors of drug activity is crucial for elderly cancer patients, who need a particular selection according to prediction of efficacy and safety by pre-treatment parameters. Several prostate cancers show focal neuroendocrine (NE) spots and CgA seems to be associated to NE phenotype both in tissue and in circulation. VEGF expression in NE cells is corelated with clinical characteristics and disease-specific survival. Somatostatin analogues induce a decrease in plasma CgA and could have also anti-angiogenic activity by inhibition of VEGF, bFGF and GH/IGF-I axis. Methods: elderly patients, median age 75 (range: 65–83), were selected for hormone-refractory disease, previously treated with CAB. Serum PSA and plasmatic CgA and VEGF were evaluated in all pts at baseline (T0) and at 4 months (T4) and 8 months (T8) after therapy. Pts were treated with docetaxel 75 mg/m2 every 3 weeks for 6 cycles and octreotide acetate 20 mg administered intramuscularly every 4 weeks until progression. Clinical and biochemical response, progression- free survival and toxicity were also evaluated. A correlation of basal CgA and VEGF with biochemical response, clinical response and clinical benefit was also investigated. Results: Median duration of follow-up was 18 months (range: 8–32). Patients evaluable for response were 22. PSA response rate (RR) was observed in 10/22 (45%); clinical objective RR was 33% (7/22). Clinical benefit was observed in 19/22 pts (86%). Only mild toxicities was observed in both groups. CgA and VEGF were both strongly reduced after therapy. Lower CgA values correlated with clinical benefit, lower VEGF values also correlated with biochemical and clinical response. Conclusions: This combination treatment showed a good toxicity profile. The most relevant data in this study refer to the role of serum CgA and VEGF levels, for prediction of tumour response. If these findings were confirmed, it could be sufficient to measure these markers levels for identification of those HRPC patients who have more probability of obtaining clinical benefit from a docetaxel-based treatment in combination with a somatostatin analogue.

No significant financial relationships to disclose.

A dose-escalating phase I study of biweekly docetaxel in older men with hormone refractory prostate cancer (HRPC)

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Background: Docetaxel has been shown to be effective and is used in the treatment of HRPC. This phase I study is designed to investigate the maximum tolerated dose, tolerability and activity of docetaxel administered on a biweekly schedule in older patients with HRPC. This study will also explore the feasibility of a self-report geriatric assessment tool in this population. Methods: HRPC patients with progression of metastatic disease during hormonal therapy received docetaxel q 2 wks at dose levels of 40 (level 0), 45 (level 1), 50 (level 2), or 55 mg/m2 (level 3). The trial is a conventional phase I 3+3 dose-escalation design. Treatment was continued until progression, refused further treatment, or unacceptable toxicity. Patients were given the Vulnerable Elders Survey (VES-13) for completion every 4 weeks. Results: 16 patients were enrolled in the study. All are evaluable for toxicity, 10 for response. Pts had a median (range) age 76 (72–87). Median doses administered was 6 (range 3–19). The maximum tolerated dose (MTD) was not reached in the study. No dose limiting side effects were reported for any of the dosing levels in the 8 week assessment period. Five patients had a ≥50% decline in serum PSA on two consecutive measurements taken at least 2 weeks apart. Of the 10 patients with measureable disease, 2 patients (one at dose level 0 and one at dose level 3) achieved a complete response, 2 patients (one at dose level 1 and one at dose 2) achieved a partial response, and 3 patients had stable disease (one each at dose levels 1, 2, and 3). At the time of entry onto the study, 4 patients required narcotic analgesics for bone pain; after treatment, 1 (25%) discontinued their pain medications. The completion rate of the Vulnerable Elders Survey (VES-13) was 94.6%. Conclusions: Biweekly docetaxel can be safely administered in older metastatic HRPC patients and showed activity. For phase II evaluation, a bi-weekly dose of 55 mg/m2 appears to be suitable. The administration of the VES-13 was feasible in this population.

[Table: see text]

Treating elderly patients with hormone sensitive breast cancer: what do the data show?

Elderly patients with breast cancer frequently present with one or more comorbid conditions in addition to their cancer, and this can complicate clinicians' treatment decisions. Declining estrogen levels increase the risk for conditions such as cardiovascular disease and osteoporosis in the elderly. Evidence from clinical trials suggests that the elderly are frequently underrepresented; this may be due to an inherent reluctance among physicians to prescribe the latest, most effective therapies and/or recommend elderly patients for participation in clinical trials. Nonetheless, there is evidence that breast cancer in the elderly is generally more indolent than in younger patients, with a low proliferative and invasive capacity and a high degree of hormone responsiveness, making elderly patients ideal candidates for adjuvant endocrine therapies. The aromatase inhibitors, including anastrozole, letrozole, and exemestane, have proven to be well tolerated and superior alternatives to tamoxifen for post-menopausal women with hormone-sensitive breast cancer, whether used upfront or sequentially with adjuvant tamoxifen. Although the elderly have also been underrepresented in clinical trials of the aromatase inhibitors, evidence from the major trials has not shown any decrement in efficacy or major safety concerns when these drugs are used in older populations. While recently published data from MA.17 and the Breast International Group 1-98 showed letrozole to be effective irrespective of age, clinicians should carefully consider underlying comorbidities when prescribing adjuvant endocrine treatments to elderly patients with breast cancer.

Comparison between gemcitabine-based combination (G) and single-agent chemotherapy (S) for elderly patients (EP) with advanced non-small cell lung cancer (NSCLC): A literature-based meta-analysis

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Background: It was estimated that a quarter of all patients who have a diagnosis of NSCLC worldwide are more than 70 years old. This meta-analysis tries to shed light on the controversial results of phase III trials evaluating in NSCLC EP doublets against third generation S. Methods: We performed a literature search using MEDLINE and Cochrane Library. We selected only clinical trials responding to the question of our meta-analysis. Outcomes recorded were 1-year survival rate (1-y SR), overall response rate (ORR) and haematological toxicity (HT). Fixed-effects and random-effects models were used to calculate pooled odds ratios (OR). An OR greater than 1 indicates that doublet is more effective for 1-y SR and ORR and more toxic for HT. Results: Three published randomized controlled phase III trials (SICOG 9909; MILES; AISCAP-SICOG) were selected yielding a total of 1082 patients (G: 426; S: 655) clustered in seven comparisons. Drugs delivered to randomized patients included gemcitabine, vinorelbine and paclitaxel. EP treated with doublets showed respect to control patients a pooled estimate for 1-y SR advantage of 36%, not statistically significant (OR=1.356; 95% CI=0.925–1.990; p>0.05). The pooled estimate for ORR advantage was 57% and statistically significant (OR=1.559; 95% CI=1.220–2.015; p<0.05). However G showed not significant difference for HT (OR=1.168; 95% CI=0.685–1.992; p>0.05). Conclusions: These data confirm in EP superior efficacy and equal tolerability of G in comparison with S previously demonstrated for adult patients. Anyway G seems to not change prognosis of NSCLC EP. It is worthy to note that all the trials analysed showed some biases: early closure of the study, second-line therapy or crossover, lower dosage of drugs in combination regimen, inclusion of unfit or strongly comorbid patients. This meta-analysis doesn’t solve troubles in decision-making of treatment for EP, but suggest to design a better phase III trial including more patients and improving accrual criteria for reducing biases. An indication of a potentially active combination regimen (gemcitabine + paclitaxel) is suggested in SICOG 9909 trial.

No significant financial relationships to disclose.

Muscle weakness is a significant problem in older patients receiving chemotherapy

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Background: Accurate prediction of toxicities from chemotherapy in the elderly could lead to improved decision making and supportive care. Methods: A large prospective multicentric cohort study of older cancer patients undergoing chemotherapy is underway to document the occurrence of chemotherapy toxicity and to develop a predictive score: the CRASH score (Chemotherapy Risk Assessment Score for High Age patients). Toxicity, including muscle weakness, is assessed using the Common Toxicity Criteria v.3.0. Results: An analysis of the first 200 patients entered in the study revealed an infrequently highlighted side effect: muscle weakness. Twenty patients were not evaluable for this analysis. Muscle weakness was reported by 22 patients. This represented 12.2% of the patients, of whom 13 (7.2%) had grade 3 muscle weakness. There was no grade 4 muscle weakness. This side effect appears to be independent from fatigue: only 4/22 patients reported concomitant severe (grade 3–4) fatigue, and among the 24 patients with severe fatigue, only 4 reported any muscle weakness. Muscle weakness occurred fairly early during the treatment: median 30 days (range 6–126 days). The muscle weakness was predominantly of two types: a generalized muscle weakness, or a weakness affecting the lower extremities. It was accompanied by falls in two patients. That weakness was present across tumor types, chemotherapy types, individual physicians, and oncology centers. Like the rest of the study population, the majority of these patients had advanced disease. Other frequent severe side effects were: grade 4 neutropenia 31.7%; grade 3–4: hypokalemia 8.8%, hyperglycemia 8.3%, hyponatremia 7.2%, febrile neutropenia 7.2%, diarrhea 7.2%, infection with neutropenia 6.7%. Conclusion: Muscle weakness is a frequent and clinically significant side effect of chemotherapy in the elderly, distinguishable from fatigue. This could be targeted by a preventive physical therapy intervention to prevent muscle deconditioning.

[Table: see text]

Treatment efficacy and tolerance in geriatric oncology

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Background: Elderly patients share the majority of the disease burden in cancer. Although 61% of new cancer cases occur among elderly, yet elderly comprise only 25% of the patients enrolled in clinical trials. A systematic review to assess the accurate participation of elderly in randomized clinical trials (RCT) has not been done. Methods: We reviewed all consecutively completed phase III RCTs conducted by 5 National Cancer Institute sponsored cooperative groups. Published papers and study protocols were used to ensure the accuracy of the data extraction. We used a cut-off of age ≥65 to define elderly patients. For trials that did not have an exclusive ≥65 age criteria for enrollment, data were extracted on number of participants ≥65. Outcome between the innovative and the standard treatment was compared. Data were extracted as per the methods recommended by the Cochrane Collaboration. Results: Out of 413 studies, only two trials exclusively enrolled elderly patients (0.5%). 57% (n=235) of the trials did not have any stratification by age. Only 10% of the studies had a stratification age at ≥65 (n=42). Contrary to the general notion that elderly may not respond well to newer chemotherapy combination treatments, overall survival in these two trials exclusively enrolling elderly favored the newer treatments [Hazard ratio (HR) 0.62(95%CI 0.44, 0.87)]. In addition, trials enrolling >40% of elderly had favorable outcomes involving innovative treatments for survival and event-free survival [HR survival 0.85(95%CI 0.77, 0.94), HR event-free survival was 0.76(95%CI 0.64, 0.92)]. Treatment related mortality was similar in the innovative and the standard arms [HR 0.87(95%CI 0.39, 1.96)]. Conclusions: Our data indicate that enrollment of elderly in experimental RCTs is not associated with increased harms to this patient population. Increased participation of elderly may help in finding new treatments that are clinically applicable specifically to this cohort of patients.

No significant financial relationships to disclose.

Fatigue is a cause of functional dependence in older cancer survivors

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Background: The incidence and prevalence of cancer increase with age, but the impact of cancer and its treatment on the function of older cancer survivors is unknown. The aim of the study was to establish the prevalence of fatigue in older cancer patients off chemotherapy and the correlation of fatigue with Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL). Methods: We reviewed the cases of 214 individuals aged 70–90 with different cancers, subsequently processed through the Senior Adult Oncology Program (SAOP) over 4 months. All patients of the SAOP are evaluated for function, depression, comorbidity and fatigue, and all of them have a complete blood count. Depression is assessed with the geriatric depression scale (GDS); comorbidity with the cumulative illness rating scale for geriatrics (CIRS-G), and fatigue with the Fatigue symptom inventory (FSI). Results: We found that 82% of the patients reported some degree of fatigue and in 74% of cases fatigue interfered with their daily activities. The average fatigue severity was 5.38 ± 2.59; the FSI interference score 19.1 ± 16.1, the average number of days fatigued in a week 4.07 ± 2.6. Fatigue severity was positively correlated with CIRS_G score (p = 0.04), creatinine clearance (p = 0.02) performance status (PS) (p < 0.0001), GDS (p = 0.04); ADL (0.02); Minimental status (MMS) (p = 0.05); fatigue interference with Cr Clp = ).005); PD (p = 0.001) ADL (p = 0.02); GDS (p = 0.01), and fatigue frequency with CIRS-G (p = 0.04); Cr CL (p = 0.01), PS (p = 0.0001), ADL (p = 0.03); IADL (p = 0.03), and GDS(0.09). ADL dependence was related to intensity (0.02), interference (0.0001) and days of fatigue; IADL dependence to interference score (p = 0.0001) and days of fatigue (p = 0.017) and GDS to intensity (p = 0.004); interference score (p = 0. 006) and frequency of fatigue. Conclusions: Fatigue is common in long term older cancer survivors, and is associated with functional dependence and depression. Control of fatigue may improve the function of older cancer survivors

No significant financial relationships to disclose.

Anemia in the elderly—Clinical findings and impact on health

Anemia is common in older people and it becomes more so with advancing decades. Because the older population is increasing, the prevalence of anemia and consequently its impact on health and healthcare expenditure is expected to rise. Although the causes and consequences of anemia have not been fully elucidated and its etiology is occasionally elusive, clinical evidence has indicated that anemia itself is a cause of morbidity and it can complicate other health conditions. The clinical approach to anemia is evolving. In the past, anemia was mainly seen as a sign of underlying disease; today, anemia is considered to be a cause of severe deterioration of quality of life, morbidity, and decline in physical function, and a risk factor for death. A better understanding of anemia in the elderly will lead to improved treatment strategies, including the more judicious use of transfusion and appropriate use of erythropoietic agents.

Predictors of tolerance to chemotherapy in older cancer patients: a prospective pilot study

Few data are available to help predict which older cancer patient is at risk of developing chemotherapy-related toxicity. This study was a pilot for a project designing a predictive risk score. Chemotherapy patients aged 70 years and older were prospectively enrolled. Chemotherapies were adjusted for their published toxicity. 60 patients were enrolled, 59 were evaluable. Mean dose-intensity was 90.3%, range 33.3-129.0%. 47% of the patients experienced grade 4 haematological and/or grade 3-4 non-haematological toxicity. Published toxicity (MAX2), diastolic blood pressure, marrow invasion and lactate dehydrogenase (LDH) were all associated with toxicity (P<0.1); Body Mass Index, previous chemotherapy, red blood cells, platelets, polymedication with dose-intensity; and polymedication with FACT-G change. After adjustment for the published toxicity, the variables retained their significance, except for LDH and polymedication (for dose-intensity). Although the size of this pilot study imposes a cautious interpretation, patient-related and chemotherapy-related variables correlated independently with toxicity. Designing a composite predictive score to use in assessing the toxicity of multiple chemotherapy regimens therefore appears to be a valid undertaking.

Validity and reliability of the FACT-G scale for use in the older person with cancer

This project was designed to evaluate the Functional Assessment of Cancer Therapy General Scale (FACT-G) for use in the older patient with cancer. Subjects were administered the MOS Short Form Health Survey (SF-36) and the FACT-G scale. Subscale and total scores were compared using the Pearson product correlation test. FACT-G total and subscores were compared with the mixed aged cancer patient normative group of Cella et al. (1993). Good correlations were found between total and subscores of the SF-36 and the FACT-G in all areas except vitality. The mean total FACT-G score was 82.2 +/- 16.2 SD for the patients with cancer, and 92.3 +/- 11.8 SD for community-dwelling elderly (CDE). The FACT-G was able to discriminate between patients that received cancer care and CDE (p < 0.002). Subjects who scored higher on the FACT-G were found to have higher Eastern Cooperative Oncology Group Performance Status (PS). Subjects with a PS of 0 had a mean total FACT-G score of 87.9 +/- 14.4 SD. Subjects with a PS of 3 had a mean score of 59.0 +/- 23.2 SD. The FACT-G is a valid and reliable instrument for use in the older patient with cancer. The FACT-G is not an age-biased instrument.