Meeting the Needs of the Aging Population: The Canadian Network on Aging and Cancer—Report on the First Network Meeting, 27 April 2016

The aging of the Canadian population represents the major risk factor for a projected increase in cancer incidence in the coming decades. However, the evidence base to guide management of older adults with cancer remains extremely limited. It is thus imperative that we develop a national research agenda and establish a national collaborative network to devise joint studies that will help to accelerate the development of high-quality research, education, and clinical care and thus better address the needs of older Canadians with cancer. To begin this process, the inaugural meeting of the Canadian Network on Aging and Cancer was held in Toronto, 27 April 2016. The meeting was attended by 51 invited researchers and clinicians from across Canada, as well as by international leaders in geriatric oncology from the United States and France. The objectives of the meeting were to (1) review the present landscape of education, clinical care, and research in the area of cancer and aging in Canada; (2) identify issues of high research priority in Canada within the field of cancer and aging; (3) identify current barriers to geriatric oncology research in Canada and develop potential solutions; (4) develop a Canadian collaborative multidisciplinary research network between investigators to improve health outcomes for older adults with cancer; (5) learn from successful international efforts to stimulate the geriatric oncology research agenda in Canada. In the present report, we describe the education, clinical care, and research priorities that were identified at the meeting.

Models of Care in Geriatric Oncology

Cancer is common in older adults and the approach to cancer treatment and supportive measures in this age group is continuously evolving. Incorporating geriatric assessment (GA) into the care of the older patient with cancer has been shown to be feasible and predictive of outcomes, and there are unique aspects of the traditional geriatric domains that can be considered in this population. Geriatric assessment-guided interventions can also be developed to support patients during their treatment course. There are several existing models of incorporating geriatrics into oncology care, including a consultative geriatric assessment, geriatrician "embedded" within an oncology clinic and primary management by a dual-trained geriatric oncologist. Although a geriatrician or geriatric oncologist leads the geriatric assessment, is it truly a multidisciplinary assessment, and often includes evaluation by a physical therapist, occupational therapist, pharmacist, social worker and nutritionist.

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.

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.

The impact of cancer on geriatric syndromes in older Medicare beneficiaries

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Background: Geriatric syndromes are highly prevalent in the elderly population and are associated with increased morbidity and mortality. The impact of a history of cancer on the presence of geriatric syndromes has not been well described. Methods: Using the 2003 Medicare Current Beneficiary Survey (MCBS), we analyzed a national sample of 12,480 community-based elders. Differences in prevalence of geriatric syndromes between those with and without cancer were estimated. Multivariate logistic regressions were used to identify independent predictors of geriatric syndromes, including the specific type of cancer. Results: 2349 (18%) reported current or history of cancer. Among cancer subjects, 63% had a prevalence ≥ 1 geriatric syndrome as compared to 57% of the non-cancer subjects (p<0.0001). Cancer subjects overall had a significantly higher prevalence of hearing trouble, incontinence, falls, depression, and osteoporosis than those without cancer (all p values <0.001). Adjusting for possible confounders including age and comorbidity, subjects with any diagnosis of cancer were more likely to have hearing trouble (OR 1.31, 95% CI: 1.10–1.56), incontinence (OR 1.35, 95% CI: 1.16–1.57), falls (OR 1.18, 95% CI: 1.05–1.31), depression (OR 1.19, 95% CI: 1.03–1.39), and osteoporosis (OR 1.20, 95% CI: 1.06–1.35). A cancer history was not significantly associated with dementia and poor eyesight. Analysis of specific cancer subtypes showed the following: lung cancer predicted vision and hearing trouble and depression; prostate cancer predicted incontinence and falls; and cervical/uterine cancer predicted incontinence, falls, and osteoporosis. Conclusions: Elderly cancer patients have a higher prevalence of geriatric syndromes than those without cancer. We advocate the use of geriatric assessment tools to detect geriatric syndromes in older cancer survivors as these may greatly reduce quality of life. More research is needed to evaluate whether cancer and/or its treatment leads to higher prevalences of geriatric syndromes in older cancer survivors and whether in older cancer survivors, geriatric syndromes are linked to higher morbidity or mortality.

No significant financial relationships to disclose.

Neuroprotective effect of SSRI among 781 cancer patients receiving chemotherapy: A URCC CCOP Study

9512

Background: Cancer and its treatment impact important areas of cognitive function such as attention and memory, which are essential to patients effective psychosocial functioning and quality of life. Previous studies reported that 17% to 75% of cancer patients reported cognitive dysfunction during and after treatment. Few studies, however, have examined the effectiveness of pharmacological interventions to control cancer-related cognitive dysfunction (CRCD). The present study examines the effect of paroxetine hydrochloride (Paxil, P) on CRCD. Methods: The sample included 574 female and 207 male cancer patients between 22 and 87 years. Memory Problems was assessed using a Self-Reported Memory Problem (SRMP) measures derived from the Fatigue Symptom Checklist that relate to memory dysfunction. Cronbach coefficient alpha (α) and a principal components analysis (PCA) were conducted to determine reliability and appropriateness of the SRMP for this sample. A repeated measure ANOVA (r-ANOVA) and t-tests were used to assess changes in mean scores on the SRMP and the effect of P versus placebo. Depression was assessed using the CESD. Results: Scale reliability assessment showed α = .90, supporting the reliability of the SRMP. The PCA revealed a one-component structure that explained 72% of the variance. The r-ANOVA showed a significant difference between scores on the SRMP at baseline (after first chemotherapy cycle, and before P) and follow-up (after four cycles of chemotherapy, after P) (Wilks' Lambda = .99, F (1, 583) = 5.52, p = 0.02). The t-tests also showed a significant effect of P on CRMP (p < 0.05). P had a significant effect after controlling for depression (p < 0.001) Conclusions: CRCD is a serious problem for patients that can be alleviated by P. Future studies should examine the usefulness of other psychotropic agents and combined behavioral and pharmacologic interventions to control CRCD. Supported by NCI Grants U10CA37420, R25CA102618, and 3U01CA116924–04S1.

No significant financial relationships to disclose.

Abnormal physical performance and frailty in older men with biochemical recurrence of prostate cancer (PCa) on androgen deprivation therapy (ADT)

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Background: ADT has recognized toxicities including osteoporosis, muscle weakness and wasting, anemia, and fatigue. ADT is increasingly being used in men with biochemical recurrence (BCR) despite the fact that earlier initiation has not been shown to improve overall survival in this setting. Little is known about the impact of ADT on physical performance or the development of frailty in older patients. Methods: A case-control study (n=119) of men age 65+ with BCR on ADT ≥ 6 months with stable PSA (n=56) compared to controls with history of PCa status post radiation or surgery with no evidence of recurrence (n=63) was conducted. Frailty prevalence per Fried's criteria (validated measures of weight loss, exhaustion, grip strength, walking speed, and physical activity), Short Physical Performance Battery scores (SPPB: validated measure of balance, walking speed and timed chair stands) and falls were compared between groups. Exploratory analyses of proposed biomarkers of frailty (CRP, ESR, hemoglobin, albumin, and total cholesterol) were conducted. Results: Age, ethnicity and socioeconomic status were not different between groups. Total score on the SPPB was significantly lower in the ADT group (9.1 vs. 10.2, p = .01), indicating higher risk of incident morbidity and mortality. 7.2% of men in ADT group met Fried's criteria for frailty compared to 3.2% in control group and 58.9% met criteria for “prefrail” in ADT group compared to 41.9% controls (p=0.03 for trend). Quadriceps strength, as measured by chair stands in SPPB, was significantly worse for ADT group (p<.01). Incident falls were higher in ADT group (14.3% vs. 3.2%, p=.05). With the exception of hemoglobin (12.7 vs 14.4 g/dl, p< .01), putative frailty biomarkers were not significantly different between groups. Conclusions: Men with BCR of PCa on ADT have worse physical performance, are more frail, and have a higher incidence of falls than controls, but biomarkers suggest that mechanism of frailty is different than in the geriatric syndrome. A prospective trial is needed to establish a temporal link between initiation of ADT and frailty.

No significant financial relationships to disclose.

Geriatric assessment of older adults with cancer: Baseline data from a 500 patient multicenter study

9546

Background: As the cancer population ages, a brief, comprehensive measure is needed to characterize the “functional age” of a patient, in order to optimize treatment decisions and evaluate outcomes based on factors other than chronological age. A geriatric assessment (GA) evaluates factors other than age that predict morbidity and mortality in older adults. The goals of this study are to describe the results of a GA performed in 500 older adults with cancer from 7 participating institutions and to evaluate the feasibility of completing this assessment in oncology practice. Methods: The GA is comprised of validated measures of functional status, comorbidity, cognition, psychological status, social functioning and support, and nutritional status (Hurria et al, Cancer 2005). The GA was completed prior to the start of a new chemotherapy regimen in patients age ≥ 65 with a solid tumor or lymphoma. Results: 500 patients (mean age 73; range 65–91) completed the GA. The most common tumor types were lung (29%), GI (29%) and breast/gyn (22%) cancer; 57% had stage IV disease. The GA revealed that 41% of patients needed assistance with instrumental activities of daily living despite a mean physician-reported KPS of 85 (range 50–100), 92% had ≥1 comorbid medical conditions (mean 2.5; range 0–9), 95% took ≥ 1 medications (mean 5; range 0–23), 16% had ≥ 1 falls in the past 6 months, 6% had gross cognitive impairment on the Blessed Orientation-Memory-Concentration Test, and 39% had > 5% weight loss in the past 6 months. The mean time to complete the GA was 27 minutes (range 10–80); 94% were satisfied with the GA length and 70% were able to complete the GA without assistance. Multivariate logistic regression identified the following sociodemiographic and disease variables predict the need for assistance with completion of the GA: age ≥ 80 (p=0.02), high school education or less (p<0.01), non-white race (p<0.01), and the presence of metastatic disease (p=0.01). Conclusions: This brief GA is largely self-administered, can be completed by the majority of older patients without assistance, and identifies important deficits and problems that may impact morbidity and mortality. Prospective data are being acquired to identify factors in the GA that predict chemotherapy toxicity in older adults with cancer.

No significant financial relationships to disclose.