International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer

PURPOSE

To update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on geriatric assessment (GA) in older patients with cancer.

METHODS

SIOG composed a panel with expertise in geriatric oncology to develop consensus statements after literature review of key evidence on the following topics: rationale for performing GA; findings from a GA performed in geriatric oncology patients; ability of GA to predict oncology treatment–related complications; association between GA findings and overall survival (OS); impact of GA findings on oncology treatment decisions; composition of a GA, including domains and tools; and methods for implementing GA in clinical care.

RESULTS

GA can be valuable in oncology practice for following reasons: detection of impairment not identified in routine history or physical examination, ability to predict severe treatment-related toxicity, ability to predict OS in a variety of tumors and treatment settings, and ability to influence treatment choice and intensity. The panel recommended that the following domains be evaluated in a GA: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and presence of geriatric syndromes. Although several combinations of tools and various models are available for implementation of GA in oncology practice, the expert panel could not endorse one over another.

CONCLUSION

There is mounting data regarding the utility of GA in oncology practice; however, additional research is needed to continue to strengthen the evidence base.

Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG)

BACKGROUND

As more and more cancers occur in elderly people, oncologists are increasingly confronted with the necessity of integrating geriatric parameters in the treatment of their patients.

METHODS

The International Society of Geriatric Oncology (SIOG) created a task force to review the evidence on the use of a comprehensive geriatric assessment (CGA) in cancer patients. A systematic review of the evidence was conducted.

RESULTS

Several biological and clinical correlates of aging have been identified. Their relative weight and clinical usefulness is still poorly defined. There is strong evidence that a CGA detects many problems missed by a regular assessment in general geriatric and in cancer patients. There is also strong evidence that a CGA improves function and reduces hospitalization in the elderly. There is heterogeneous evidence that it improves survival and that it is cost-effective. There is corroborative evidence from a few studies conducted in cancer patients. Screening tools exist and were successfully used in settings such as the emergency room, but globally were poorly tested. The article contains recommendations for the use of CGA in research and clinical care for older cancer patients.

CONCLUSIONS

A CGA, with or without screening, and with follow-up, should be used in older cancer patients, in order to detect unaddressed problems, improve their functional status, and possibly their survival. The task force cannot recommend any specific tool or approach above others at this point and general geriatric experience should be used.

Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score

BACKGROUND

Tools are lacking to assess the individual risk of severe toxicity from chemotherapy. Such tools would be especially useful for older patients, who vary considerably in terms of health status and functional reserve.

METHODS

The authors conducted a prospective, multicentric study of patients aged ≥70 years who were starting chemotherapy. Grade 4 hematologic (H) or grade 3/4 nonhematologic (NH) toxicity according to version 3.0 of the Common Terminology Criteria for Adverse Events was defined as severe. Twenty-four parameters were assessed. Toxicity of the regimen (Chemotox) was adjusted using an index to estimate the average per-patient risk of chemotherapy toxicity (the MAX2 index). In total, 562 patients were accrued, and 518 patients were evaluable and were split randomly (2:1 ratio) into a derivation cohort and a validation cohort.

RESULTS

Severe toxicity was observed in 64% of patients. The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score was constructed along 2 subscores: H toxicity and NH toxicity. Predictors of H toxicity were lymphocytes, aspartate aminotransferase level, Instrumental Activities of Daily Living score, lactate dehydrogenase level, diastolic blood pressure, and Chemotox. The best model included the 4 latter predictors (risk categories: low, 7%; medium-low, 23%; medium-high, 54%; and high, 100%, respectively; P(trend) < .001). Predictors of NH toxicity were hemoglobin, creatinine clearance, albumin, self-rated health, Eastern Cooperative Oncology Group performance, Mini-Mental Status score, Mini-Nutritional Assessment score, and Chemotox. The 4 latter predictors provided the best model (risk categories: 33%, 46%, 67%, and 93%, respectively; P(trend) < .001). The combined risk categories were 50%, 58%, 77%, and 79%, respectively; P(trend) < .001). Bootstrap internal validation and independent sample validation demonstrated stable risk categorization and P(trend) < .001.

CONCLUSIONS

The CRASH score distinguished several risk levels of severe toxicity. The split score discriminated better than the combined score. To the authors' knowledge, this is the first score systematically integrating both chemotherapy and patient risk for older patients and has a potential for future clinical application.

Comorbidity and functional status are independent in older cancer patients

PURPOSE

Comorbidity is a frequent and often therapeutically limiting problem in older cancer patients. However, to date, there is no standard measure of the comorbidity burden available for these patients. We tested the performance of two comorbidity scales and their relationship with functional status.

PATIENTS AND METHODS

The Cumulative Illness Rating Scale-Geriatric (CIRS-G) was compared with the Charlson scale in 203 patients who received a comprehensive geriatric assessment (CGA) in our Senior Adult Oncology Program (SAOP). Study end points were variability, reliability, correlation with Eastern Cooperative Oncology Group (ECOG) performance status (PS), Activities of Daily Living (ADL), and Instrumental Activities of Daily Living (IADL). The relative weight of comorbidity versus tumor stage in the correlations with functional status was assessed.

RESULTS

Median age was 75 years (range, 63 to 91). Sixty-four percent of patients scored 0 on the Charlson scale versus 6% on the CIRS-G. The correlation between the Charlson and CIRS-G was fair (p = 0.25 to 0.39). CIRS-G grade 3/4 had a fair correlation with ADL (p = 0.27). Otherwise, there was low or no correlation between comorbidity and functional status across the measures. Tumor stage was not correlated with functional status either. Correlation of ECOG PS with ADL (p = 0.51)c and IADL (p = 0.61) was moderate. Interrater and test-retest correlations were good or very good for both the Charlson and CIRS-G.

CONCLUSION

Comorbidity needs to be assessed independently from functional status. Both the Charlson and CIRS-G scales are reliable tools for use in trials of older cancer patients. Both can be tested in further studies as predictors of outcomes such as toxicity of treatment, changes in functional status, or survival.

Management of cancer in the older person: a practical approach

The management of cancer in the older aged person is an increasingly common problem. The questions arising from this problem are: Is the patient going to die with cancer or of cancer? Is the patient able to tolerate the stress of antineoplastic therapy? Is the treatment producing more benefits than harm? This article explores a practical, albeit evolving, approach to these questions including a multidimensional assessment of the older person and simple pharmacologic interventions that may ameliorate the toxicity of antineoplastic agents. Age may be construed as a progressive loss of stress tolerance, due to decline in functional reserve of multiple organ systems, high prevalence of comorbid conditions, limited socioeconomic support, reduced cognition, and higher prevalence of depression. Aging is highly individualized: chronologic age may not reflect the functional reserve and life expectancy of an individual. A comprehensive geriatric assessment (CGA) best accounts for the diversities in the geriatric population. The advantages of the CGA include:Recognition of potentially treatable conditions such as depression or malnutrition, that may lessen the tolerance of cancer treatment and be reversed with proper intervention; Assessment of individual functional reserve; Gross estimate of individual life expectancy; and Adoption of a common language to classify older cancer patients. The CGA allows the practitioner to recognize at least three stages of aging:People who are functionally independent and without comorbidity, who are candidates for any form of standard cancer treatment, with the possible exception of bone marrow transplant. People who are frail (dependence in one or more activities of daily living, three or more comorbid conditions, one or more geriatric syndromes), who are a candidate only for palliative treatment; and People in between, who may benefit from some special pharmacological approach, such as reduction in the initial dose of chemotherapy with subsequent does escalations. The pharmacological changes of age include decreased renal excretion of drugs and increased susceptibility to myelosuppression, mucositis, cardiotoxicity and neurotoxicity. Based on these findings, the proposal was made that all persons aged 70 and older, treated with cytotoxic chemotherapy of dose intensity comparable to CHOP, receive prophylactic growth factor treatment, and that the hemoglobin of these patients be maintained >/=12 gm/dl.

Comprehensive geriatric assessment for older patients with cancer

PURPOSE

During the last decade, oncologists and geriatricians have begun to work together to integrate the principles of geriatrics into oncology care. The increasing use of a comprehensive geriatric assessment (CGA) is one example of this effort. A CGA includes an evaluation of an older individual's functional status, comorbid medical conditions, cognition, nutritional status, psychological state, and social support; and a review of the patient's medications. This article discusses recent advances on the use of a CGA in older patients with cancer.

METHODS

In this article, we provide an update on the studies that address the domains of a geriatric assessment applied to the oncology patient, review the results of the first studies evaluating the use of a CGA in developing interventions to improve the care of older adults with cancer, and discuss future research directions.

RESULTS

The evidence from recent studies demonstrates that a CGA can predict morbidity and mortality in older patients with cancer. Accumulating data show the benefits of incorporating a CGA in the evaluation of older patients with cancer. Prospective trials evaluating the utility of a CGA to guide interventions to improve the quality of cancer care in older adults are justified.

CONCLUSION

Growing evidence demonstrates that the variables examined in a CGA can predict morbidity and mortality in older patients with cancer, and uncover problems relevant to cancer care that would otherwise go unrecognized.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Measuring comorbidity in older cancer patients

The aim of this article was to provide oncology researchers with adequate tools and practical advice to integrate comorbidity into clinical studies. Open research questions are also discussed. Commonly used comorbidity indexes were identified and a detailed literature search was done by MEDLINE and cross-referencing. Expert opinion was sought on each index. A common scheme exploring the description of the index, clinical experience, metrological performance, easiness of use, cross-compatibility and preservation of data was followed. The actual indexes are included in the Appendix. Four commonly used indexes were identified: the Charlson Comorbidity Index (Charlson), the Cumulative Illness Rating Scale (CIRS), the Index of Coexistent Disease (ICED), and the Kaplan-Feinstein index. The Charlson is the most commonly used whereas the performance of the first two indexes is best characterised. Most studies are retrospective and focus on mortality as an outcome and a base of grading. All indexes are easy to use and require a maximum of 10 min to be filled. Inter-rater and test-retest reliability is generally good. Little is known about other outcomes and the way various diseases cumulate in influencing prognosis. Thus, several reliable indexes are available to measure comorbidity in cancer patients. They show that globally comorbidity is a strong predictor of outcome. Since little is still known about the importance of individual comorbidities for various outcomes and the way comorbidity cumulates in influencing cancer treatment, a wide integration of comorbidity in prospective studies is essential.

Indoleamine 2,3-dioxygenase contributes to tumor cell evasion of T cell-mediated rejection

The priming of an appropriate anti-tumor T cell response rarely results in the rejection of established tumors. The characteristics of tumors that allow them to evade a T cell-mediated rejection are unknown for many tumors. We report on evidence that the expression of the immunosuppressive enzyme, indoleamine 2,3-dioxygenase (IDO) by mononuclear cells that invade tumors and tumor-draining lymph nodes, is 1 mechanism that may account for this observation. Lewis lung carcinoma (LLC) cells stimulated a more robust allogeneic T cell response in vitro in the presence of a competitive inhibitor of IDO, 1-methyl tryptophan. When administered in vivo this inhibitor also resulted in delayed LLC tumor growth in syngeneic mice. Our study provides evidence for a novel mechanism whereby tumors evade rejection by the immune system, and suggests the possibility that inhibiting IDO may be developed as an anti-cancer immunotherapeutic strategy.

Designing therapeutic clinical trials for older and frail adults with cancer: U13 conference recommendations

A majority of cancer diagnoses and deaths occur in patients age ≥ 65 years. With the aging of the US population, the number of older adults with cancer will grow. Although the coming wave of older patients with cancer was anticipated in the early 1980s, when the need for more research on the cancer-aging interface was recognized, many knowledge gaps remain when it comes to treating older and/or frailer patients with cancer. Relatively little is known about the best way to balance the risks and benefits of existing cancer therapies in older patients; however, these patients continue to be underrepresented in clinical trials. Furthermore, the available clinical trials often do not include end points pertinent to the older adult population, such as preservation of function, cognition, and independence. As part of its ongoing effort to advance research in the field of geriatric oncology, the Cancer and Aging Research Group held a conference in November 2012 in collaboration with the National Cancer Institute, the National Institute on Aging, and the Alliance for Clinical Trials in Oncology. The goal was to develop recommendations and establish research guidelines for the design and implementation of therapeutic clinical trials for older and/or frail adults. The conference sought to identify knowledge gaps in cancer clinical trials for older adults and propose clinical trial designs to fill these gaps. The ultimate goal of this conference series is to develop research that will lead to evidence-based care for older and/or frail adults with cancer.

Management of breast cancer in elderly individuals: recommendations of the International Society of Geriatric Oncology

Breast cancer is the most commonly diagnosed cancer and the leading cause of cancer mortality in women worldwide. Elderly individuals make up a large part of the breast cancer population, and there are important specific considerations for this population. The International Society of Geriatric Oncology created a task force to assess the available evidence on breast cancer in elderly individuals, and to provide evidence-based recommendations for the diagnosis and treatment of breast cancer in such individuals. A review of the published work was done with the results of a search on Medline for English-language articles published between 1990 and 2007 and of abstracts from key international conferences. Recommendations are given on the topics of screening, surgery, radiotherapy, (neo)adjuvant hormone treatment and chemotherapy, and metastatic disease. Since large randomised trials in elderly patients with breast cancer are scarce, there is little level I evidence for the treatment of such patients. The available evidence was reviewed and synthesised to provide consensus recommendations regarding the care of breast cancer in older adults.

End Points and Trial Design in Geriatric Oncology Research: A Joint European Organisation for Research and Treatment of Cancer–Alliance for Clinical Trials in Oncology–International Society of Geriatric Oncology Position Article

Selecting the most appropriate end points for clinical trials is important to assess the value of new treatment strategies. Well-established end points for clinical research exist in oncology but may not be as relevant to the older cancer population because of competing risks of death and potentially increased impact of therapy on global functioning and quality of life. This article discusses specific clinical end points and their advantages and disadvantages for older individuals.

Randomized or single-arm phase II trials can provide insight into the range of efficacy and toxicity in older populations but ideally need to be confirmed in phase III trials, which are unfortunately often hindered by the severe heterogeneity of the older cancer population, difficulties with selection bias depending on inclusion criteria, physician perception, and barriers in willingness to participate. All clinical trials in oncology should be without an upper age limit to allow entry of eligible older adults. In settings where so-called standard therapy is not feasible, specific trials for older patients with cancer might be required, integrating meaningful measures of outcome. Not all questions can be answered in randomized clinical trials, and large observational cohort studies or registries within the community setting should be established (preferably in parallel to randomized trials) so that treatment patterns across different settings can be compared with impact on outcome. Obligatory integration of a comparable form of geriatric assessment is recommended in future studies, and regulatory organizations such as the European Medicines Agency and US Food and Drug Administration should require adequate collection of data on efficacy and toxicity of new drugs in fit and frail elderly subpopulations.

Comorbidity in older adults with cancer

Comorbidity is an issue of growing importance due to changing demographics and the increasing number of adults over the age of 65 with cancer. The best approach to the clinical management and decision-making in older adults with comorbid conditions remains unclear. In May 2015, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging, met to discuss the design and implementation of intervention studies in older adults with cancer. A presentation and discussion on comorbidity measurement, interventions, and future research was included. In this article, we discuss the relevance of comorbidities in cancer, examine the commonly used tools to measure comorbidity, and discuss the future direction of comorbidity research. Incorporating standardized comorbidity measurement, relaxing clinical trial eligibility criteria, and utilizing novel trial designs are critical to developing a larger and more generalizable evidence base to guide the management of these patients. Creating or adapting comorbidity management strategies for use in older adults with cancer is necessary to define optimal care for this growing population.

Measurement and impact of comorbidity in older cancer patients

As the world population ages, oncologists are increasingly confronted with the problem of comorbidity in cancer patients. This has stemmed an increasing interest into approaching comorbidity in a systematic way, in order to integrate it in treatment decisions. So far, data on the subject have been widely scattered through the medical literature. This article is aimed at reviewing the available data on the interaction of comorbidity and prognosis. This overview should provide an accessible source of references for oncological investigators developing research in the field. Various methods have been used to sum comorbidity. However, a major effort remains to be done to analyze how various diseases combine in influencing prognosis. The main end-point explored so far is mortality, with which comorbidity globally is reliably correlated. A largely open challenge remains to correlate comorbidity with treatment tolerance, and functional and quality of life outcomes, as well as to integrate it in clinical decision-making.

Never Too Old? Age Should Not Be a Barrier to Enrollment in Cancer Clinical Trials

Throughout Europe and the U.S., over 60% of the total incidence of cancer occurs in the elderly (> or =65 years) population, a patient group that requires particular consideration when making treatment decisions due to a number of factors. Despite this, elderly patients are generally under-represented in clinical trials such that study data should be interpreted with caution because results in younger cancer patients may not always extrapolate to the typical elderly cancer patient. Reports suggest that elderly cancer patients represent around 22% of patients enrolled in phase II clinical studies. Barriers to the accrual of elderly patients to clinical trials include lack of appropriate trials, high burden of comorbidity, study-imposed restrictions, and attitudes of physicians. There is a belief that elderly patients may be unable to tolerate various cancer therapies, which may result in this patient population being excluded from prospective trials. However, clinical data demonstrate that age alone is not a sufficient reason to withhold treatment. Lack of clinical trial data and the associated lack of evidence-based guidelines for elderly patients mean physicians have little to guide them, with the result that patients may not receive the optimal therapy. As clinical trials are the primary method of evaluating the efficacy and safety of adjuvant and palliative cancer therapies, trials that specifically target the elderly cancer patient are required to adequately assess the risks and benefits of treatment in this vulnerable population. This review aims to assess the clinical reality and clinical trial age mismatch to evaluate implications for elderly cancer patients and to identify how this situation may be addressed. Possible reasons for the disparity, and the resulting clinical consequences, are also considered.

A comprehensive geriatric intervention detects multiple problems in older breast cancer patients

Studies of comprehensive geriatric assessment (CGA) have shown the importance of follow-up for effectiveness, but this has not been tested in an oncology clinic. In this pilot study, we enrolled 15 early breast cancer patients, aged 70 and older. They received a multidisciplinary CGA every 3 months and structured follow-up from the SAOP nurse practitioner, dietitian, social worker, and pharmacist according to risk. Total follow-up was 6 months. Median age of evaluable patients was 79 years (range 72-87). Median number of comorbidities by Cumulative Index Rating Scale-Geriatric (CIRS-G) was 5 (3-9) at baseline. Ten patients were at pharmacological risk, five at psychosocial risk, and eight at nutritional risk. Patients presented on average six problems initially, and three new problems during follow-up. The intervention directly influenced oncological treatment in four cases. It ensured continuity/coordination of care in seven cases. Success rate in addressing problems was 87%. Mean Functional Assessment of Cancer Treatment-Breast (FACT-B) scores improved from 110.5 (S.D. 16.7) to 116.3 (S.D. 16.5) (t=0.025). Function and independence were maintained.

CONCLUSIONS

Older patients with early breast cancer have a high prevalence of comorbidity. A CGA with follow-up has potential for improving the treatment and prognosis of these patients and is feasible in an academic oncology setting.

What threshold for adjuvant therapy in older breast cancer patients?

PURPOSE

To consider the question of when to prescribe adjuvant treatment for elderly breast cancer patients, particularly when comorbidities are present. Knowledge of the threshold relapse risks above which adjuvant treatment is worth prescribing would enhance decision making.

PATIENTS AND METHODS

A Markov analysis of data from the medical literature was conducted. Patients aged 65 to 85 years were considered, along with three levels of comorbidity. The threshold risk of relapse at 10 years (RR10), at which time treatment provides absolute reduction or reduction of an absolute 1% in relapse or mortality, was evaluated.

RESULTS

The threshold RR10 for an absolute reduction in mortality risk by adjuvant treatment was low through the age of 85 years. However, for an absolute 1% reduction, the effect of treatment on relapse and the effect of treatment on mortality increasingly diverged. The threshold RR10 for an absolute 1% reduction in relapse risk remained fairly low (5% to 6% for tamoxifen, 12% to 19% for chemotherapy). The threshold RR10 for an absolute 1% reduction in mortality risk, although starting close to the RR10 for an absolute 1% reduction in relapse risk, rose sharply. For tamoxifen, the difference between the two was 4% for an average 65-year-old, 6% at the age of 75 years, and 15% at the age of 85 years. For chemotherapy, the differences were 6%, 12%, and 30%, respectively. Similarly, thresholds increased with increasing comorbidity. In older and sicker patients, the maximum benefit was reached after 5 years rather than 10 years.

CONCLUSION

Older breast cancer patients can expect a reduction in relapse that is fairly similar to that of younger patients. However, the effect on mortality diverges markedly, and attention should be paid to this difference in clinical decision making. Comorbidity should be considered in recommendations for adjuvant treatment, including clinical practice guidelines.

Are older French patients as willing as older American patients to undertake chemotherapy?

PURPOSE

A view often held in Europe is that older Europeans are less willing than older Americans to undertake chemotherapy. This study assesses whether this view is valid.

PATIENTS AND METHODS

Three-hundred twenty outpatients aged 70 years and older were interviewed via anonymous questionnaires: French patients with and without cancer and American patients with and without cancer. The response rate was 61% (195 of 320 questionnaires). Ages ranged from 70 to 95 years (29% aged 80 years and older). Two scenarios were presented: a strong chemotherapy (platinum/taxane combination-like) and a milder chemotherapy (weekly vinorelbine-like). The options were to refuse chemotherapy or to accept for a threshold chance of cure, of life prolongation, or of symptom relief. Functional status, education, self-rated health, and depression were controlled for.

RESULTS

French noncancer patients (34%) were less willing to accept the strong chemotherapy than French cancer patients (77.8%), American noncancer patients (73.8%), and American cancer patients (70.5%) (P <.001 for each pair). This was also true for the moderate chemotherapy (67.9% v 100%, 95.2%, and 88.5%, respectively; P <.001). Age and sex did not correlate with response, but self-rated health, cancer status, and nationality did. Thresholds varied from patient to patient.

CONCLUSION

Whereas older French people without cancer are more reluctant than older Americans to envision chemotherapy, older cancer patients in both countries have the same amenability to treatment. Chemotherapy options should be fully discussed with older cancer patients, given that most are willing to consider them.

Interaction between Comorbidity and Cancer

Background

Older patients have an average of three comorbidities in addition to their cancer. Oncologic studies have usually ignored this aspect when adjusting for confounders. There is mounting evidence that comorbidity interacts with risk, survival, disease progression, and treatment of elderly patients with cancer. The strength of many of these interactions increases with age.

Methods

A review of the literature was undertaken regarding two of these interactions: cancer risk and prognosis.

Results

In older patients, the risk and behavior of cancer can be strongly affected by comorbidities and their related treatment. Rather than a blanket effect, this effect might be attached to groups of syndromes with common pathophysiologic mechanisms. This is notably true for metabolic disorders and inflammatory diseases.

Conclusions

In addition to focusing on the influence of cancer treatment on comorbidity or on the effect of comorbidity in delivering cancer treatment, future endeavors will need to consider the direct impact of comorbidity on the risk and the behavior of the cancer in elderly patients.

Can older cancer patients tolerate chemotherapy? A prospective pilot study

BACKGROUND

To the authors' knowledge, few data currently are available regarding the tolerance to chemotherapy in older cancer patients. This prospective pilot study evaluated the changes in functional, mental, nutritional, and comorbid status, as well as the quality of life (QOL), in geriatric oncology patients receiving chemotherapy.

METHODS

Sixty patients age > or = 70 years who were undergoing cancer chemotherapy were recruited in a university-based comprehensive cancer center. Changes in physical function were measured by the Eastern Cooperative Oncology Group performance status (ECOG PS) and Instrumental Activities of Daily Living (IADLs), mental health changes were measured by the Mini-Mental State Examination and the Geriatric Depression Scale (GDS), comorbidity was measured by Charlson's index and the Cumulative Illness Rating Scale-Geriatric, nutrition was measured by the Mini-Nutritional Assessment, and QOL was measured by the Functional Assessment of Cancer Therapy-General (FACT-G). Changes were assessed at baseline and at the end of treatment (EOT). Grade 4 hematologic and Grade 3-4 nonhematologic toxicities were recorded.

RESULTS

Thirty-seven patients (63%) completed both assessments. Older cancer patients demonstrated a significant decline in measurements of physical function after receiving chemotherapy, as indicated by changes in scores on the IADL (P = 0.04) and on the physical (P = 0.01) and functional (P = 0.03) subscales of the FACT-G. They also displayed worse scores on the GDS administered postchemotherapy (P < 0.01). Patients who experienced severe chemotoxicity had more significant declines in ECOG PS (P = 0.03), IADL (P = 0.03), and GDS (P = 0.04), and more gain in the social well-being subscale (P = 0.02) of the FACT-G, than those who did not experience severe chemotoxicity. However, changes in most scores were small in magnitude clinically. No significant change was found between baseline and EOT in nutrition, comorbidity, and other aspects of the FACT-G.

CONCLUSIONS

Older cancer patients undergoing chemotherapy may experience toxicity but generally can tolerate it with limited impact on independence, comorbidity, and QOL levels. It is important to recognize and monitor these changes during geriatric oncology treatment.

Cancer and aging. An evolving panorama

This article illustrates how the nosology of cancer evolves with the patient's age. If the current trends are maintained, 70% of all neoplasms will occur in persons aged 65 years and over by the year 2020, leading to increased cancer-related morbidity among older persons. Cancer control in the older person involves chemoprevention, early diagnosis, and timely and effective treatment that entails both antineoplastic therapy and symptom management. These interventions must be individualized based on a multidimensional assessment that can predict life expectancy and treatment complications and that may evaluate the quality of life of the older person. This article suggests a number of interventions that may improve cancer control in the aged. Public education is needed to illustrate the benefits of health maintenance and early detection of cancer even among older individuals, to create realistic expectations, and to heighten awareness of early symptoms and signs of cancer. Professional education is needed to train students and practitioners in the evaluation and management of the older person. Of special interest is the current initiative of the Hartford Foundation offering combined fellowships in oncology and geriatrics and incorporating principles of geriatric medicine in medical specialty training. Prudent pharmacologic principles must be followed in managing older persons with cytotoxic chemotherapy. These principles include adjusting the dose according to the patient's renal function, using epoietin to maintain hemoglobin levels of 12 g/dL or more, and using hemopoietic growth factors in persons aged 70 years and older receiving cytotoxic chemotherapy of moderate toxicity (e.g., CHOP). To assure uniformity of data, a cooperative oncology group should formulate a geriatric package outlining a common plan for evaluating function and comorbidity. This article also suggests several important areas of research items: Molecular interactions of age and cancer Host-tumor interactions in the older tumor host Chemoprevention of cancer and aging Laboratory evaluation of aging Development of shorter forms of geriatric assessment Management of the frail cancer patients Clinical trials of tumor-specific issues.

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.

Cancer-Related Cognitive Outcomes Among Older Breast Cancer Survivors in the Thinking and Living With Cancer Study

PURPOSE

To determine treatment and aging-related effects on longitudinal cognitive function in older breast cancer survivors.

METHODS

Newly diagnosed nonmetastatic breast cancer survivors (n = 344) and matched controls without cancer (n = 347) 60 years of age and older without dementia or neurologic disease were recruited between August 2010 and December 2015. Data collection occurred during presystemic treatment/control enrollment and at 12 and 24 months through biospecimens; surveys; self-reported Functional Assessment of Cancer Therapy-Cognitive Function; and neuropsychological tests that measured attention, processing speed, and executive function (APE) and learning and memory (LM). Linear mixed-effects models tested two-way interactions of treatment group (control, chemotherapy with or without hormonal therapy, and hormonal therapy) and time and explored three-way interactions of ApoE (ε4+ v not) by group by time; covariates included baseline age, frailty, race, and cognitive reserve.

RESULTS

Survivors and controls were 60 to 98 years of age, were well educated, and had similar baseline cognitive scores. Treatment was related to longitudinal cognition scores, with survivors who received chemotherapy having increasingly worse APE scores ( P = .05) and those initiating hormonal therapy having lower LM scores at 12 months ( P = .03) than other groups. These group-by-time differences varied by ApoE genotype, where only ε4+ survivors receiving hormone therapy had short-term decreases in adjusted LM scores (three-way interaction P = .03). For APE, the three-way interaction was not significant ( P = .14), but scores were significantly lower for ε4+ survivors exposed to chemotherapy (-0.40; 95% CI, -0.79 to -0.01) at 24 months than ε4+ controls (0.01; 95% CI, 0.16 to 0.18; P < .05). Increasing age was associated with lower baseline scores on all cognitive measures ( P < .001); frailty was associated with baseline APE and self-reported decline ( P < .001).

CONCLUSION

Breast cancer systemic treatment and aging-related phenotypes and genotypes are associated with longitudinal decreases in cognitive function scores in older survivors. These data could inform treatment decision making and survivorship care planning.

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.

NCCN Guidelines® Insights: Older Adult Oncology, Version 1.2021

The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults, including screening and comprehensive geriatric assessment (CGA), assessing the risks and benefits of treatment, preventing or decreasing complications from therapy, and managing patients deemed to be at high risk for treatment-related toxicity. CGA is a multidisciplinary, in-depth evaluation that assesses the objective health of the older adult while evaluating multiple domains, which may affect cancer prognosis and treatment choices. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines providing specific practical framework for the use of CGA when evaluating older adults with cancer.