Polypharmacy and potentially-inappropriate medications are prevalent in the elderly cancer patients receiving systemic cancer therapy and they co-relate with adverse outcomes

OBJECTIVES

Cancer is the disease of the ageing. Most of the elderly cancer patients have pre-existing illnesses requiring complexity of medical care. Excessive medications would lead not only futility, but also result in adverse outcomes especially if such over-prescription is not appropriate. This study was intended to determine the prevalence of polypharmacy (PP) and potentially-inappropriate medications (PIMs) among elderly cancer patients eligible for active cancer care and their associations with hospitalization and mortality.

MATERIALS AND METHODS

This was a prospective cohort study conducted among the elderly non-hematologic cancer patients (≥ 65 years old) whom a medical oncologist had decided suitable for systemic cancer therapy. Demographic data including age, sex, primary site of cancer, cancer stage at diagnosis, Charlson Comorbidity Index (CCI), numbers and kinds of medications used both prior to and during cancer treatment were recorded. Hospitalizations not related to systemic cancer therapy administration and mortality were prospectively monitored. All of the patients had to be followed at least one year after cancer diagnosis.

RESULTS

There were 180 eligible participants. Median age in years (IQR) was 68 (65-73). One hundred patients (55.56%) were male and 80 patients (44.44%) were female. Breast (35, 19.44%), lung (31, 17.22%) and colorectal (18, 10%) cancers were the most common diagnoses. Eighty-six patients (47.78%) had metastatic disease at cancer diagnosis. One hundred twenty-two patients (67.78%) had PP (5 or more medications a day) and thirty-six patients (20%) had hyper-PP (10 or more medications a day). One hundred twenty five of the whole cohort (69.4%) had PIMs. Patients with more serious CCI scores were associated with PP and hyper-PP. While patients with primary lung cancer was only the only factor associated with PIMs. When excluding opioids, laxatives and anti-emetics, the most frequently prescribed drugs during cancer treatment, the so-called corrected PP did not associate with worse 1-year survival. Factors correlated with 1-year mortality were more advanced age group (70 years old or more) (OR 2.24; 95% C.I., 1.14-4.41; p = 0.019), primary lung cancer (OR 2.89; 95% C.I., 1.45-5.78; p = 0.003), metastatic disease at cancer diagnosis (OR 4.57; 95% C.I., 1.90-10.97; p = 0.001), and unplanned hospitalizations (OR 3.09; 95% C.I.,1.60-5.99; p = 0.001). While male gender (OR 2.35; 95% C.I., 1.17-4.71; p = 0.016), metastatic stage at cancer diagnosis (OR 2.74; 95% C.I., 1.33-5.66; p = 0.006) and corrected PP (OR 1.90; 95% C.I. 1.01-3.56; p = 0.046) were the significant predictive factors of unplanned hospitalizations.

CONCLUSION

Among elderly cancer patients suitable for systemic cancer therapy, around two thirds of patients had PP and PIMs. Higher CCI score was the only significant predictor of PP and hyper-PP; while primary lung cancer was the sole independent factor predicting PIMs. PP was associated with unplanned hospitalizations, albeit not the survival.

Advances in rectal cancer: Real-world evidence suggests limited gains in prognosis for elderly patients

BACKGROUND

Rectal cancer treatment has improved considerably due to the introduction of total meso-rectal excision, radio-chemotherapy, and high-resolution imaging. The aim of this observational cohort study was to quantify the effectiveness of these advances using high-quality data from a representative cohort of patients.

METHODS

20 281 non-metastasized cases retrieved from the Munich Cancer Registry database were divided into three time periods corresponding to before (1988-1997), partial (1998-2007), and full implementation (2008-2019) of clinical advances. Early-onset (<50 yrs.), middle-aged, elderly patient subgroups (> 70 yrs.) were compared. The overall effectiveness of evidence-based guideline adherence was also examined.

RESULTS

Median survival improved by 1.5 yrs. from the first to the last time period. Relative survival increased from 74.9% (5-yr 95%CI[73.3 - 76.6]) to 79.2% (95%CI[77.8 - 80.5]). The incidence of locoregional recurrences was reduced dramatically by more than half (5-yr 17.7% (95%CI[16.5 - 18.8]); 6.7% (95%CI[6.1 - 7.3])). Gains in 5-yr relative survival were limited to early-onset and middle-aged patients with no significant improvement seen in elderly patients (Female 68.6% [63.9 - 73.3] to 67.6% [64.0 - 71.2]; Male 71.7% [65.9 - 77.4] to 74.0% [70.8 - 77.2]).

CONCLUSIONS

Real-world evidence suggests that recent treatment advances have lead to an increase in prognosis for rectal cancer patients. However, more effort should be made to improve the implementation of new developments in elderly patients. Especially considering, that these cases represent a growing majority of diagnosed patients.

Bioimpedentiometry parameters used as indicators of frailty and malnutrition: association between G8 score and Phase angle (PHA) in elderly cancer patients

BACKGROUND

Since the incidence of cancer increases with age, in older cancer patients important information may be missed without a Comprehensive Geriatric Assessment (CGA). On the other side, CGA is a time-consuming and complex instrument, so that Geriatric 8 (G8) has been proposed as a more feasible screening tool to identify patients who could benefit from a CGA evaluation. G8 consists of 8 questions (patient age + 7 items derived from the Mini Nutritional Assessment questionnaire). A G8 score ≤ 14 is considered associated with frailty and risk of malnutrition. Another screening test is Bioelectrical Impedance Analysis (Bioimpedentiometry, BIA), which enables to evaluate the nutritional status through a specific parameter known as Phase angle (PhA). This study is aimed at assessing the ability of G8 alone or in combination with PhA to detect elderly cancer patients at higher risk for malnutrition who cannot undergo immediate anticancer treatments.

METHODS

A total of 289 cancer patients (168 men and 121 women) aged ≥ 70 years old were enrolled and performed both G8 test, body mass index (BMI) and BIA assessments. A concurrent G8 score ≤ 14 and PhA < 5 defined subjects most exposed to the risk of malnutrition.

RESULTS

An association between BMI and G8 (p < 0.001, OR 1.54) and a clinically significant relationship between G8 and PhA (p = 0.013) were observed.

CONCLUSION

G8 can be used to identify patients at risk for malnutrition who would benefit from comprehensive CGA. The concurrent use of G8 and BIA presents a higher power in discriminating subjects at higher risk of malnutrition than a single test. This study suggests the need for routine assessment of nutritional status in cancer patients using combinations of methods, in order to implement strategies for individually-tailored care before starting any treatment.

Informational support for depression and quality of life improvements in older patients with cancer: a systematic review and meta-analysis

PURPOSE

To assess and summarize the effects of informational support on depression and quality of life of older patients with cancer.

METHODS

PubMed, MEDLINE, and Web of Science were searched to identify articles written in English and published until March 2021. Studies within 10 years period (2010-2021) were included. Randomized controlled trials were included if they evaluated the impact of informational support on depression and quality of life. All analyses were performed with Review Manager 5.3.

RESULTS

Twelve studies with a total of 2374 participants met the inclusion criteria. Our primary outcomes included depression and quality of life. (1) Depression: results indicated no statistically significant difference and low heterogeneity [SMD = 0.28, 95% CI (- 0.24,0.80), p = 0.45; I² = 0%], (2) Quality of life: in the subgroup analyses of EORTC QLQ-C30, results indicated a significant effect of informational support on quality of life [SMD = 2.84, 95% CI (0.63, 5.05), p = 0.03; I² = 79%]; in the subgroup analyses of FACT and SF-36, there were no significance.

CONCLUSIONS

Informational support could reduce depression and did improve the quality of life in older cancer patients with statistical significance. The findings suggested that informational support was an effective approach to improve depression and quality of life in older patients with cancer.

Research on the quality hospice care of elderly cancer patients in China under social work intervention

BACKGROUND

Few studies have specifically addressed quality of life issues for elderly hospice patients. The purpose of this study is to explore various factors and service patterns of the quality of life of end-of-life care for the elderly.

METHODS

We collect the data and make small-scale exploratory study via semi-structured individual interviews. Data were collected from the family of 2 elderly cancer patients receiving hospice services, and the data were analyzed qualitatively.

RESULTS

After investigation, we found that elderly people in hospice care, regardless of age, are suffering from physical and psychological pain and do not want to spend the rest of their lives in the hospital, but want to die in their own homes.

CONCLUSIONS

Both hospitalization and in-home care can improve resource utilization, and the key is to find various factors affecting the quality of life. Improving the quality of life is what patients and their families need most.

Clinical factors associated with the therapeutic outcome of chemotherapy in very elderly cancer patients

Background

The purpose of this study was to detect background factors that might be associated with the therapeutic and curative outcome of chemotherapy in elderly cancer patients aged over 75 years.

Methods

A retrospective study was conducted for elderly cancer patients aged over 75 years who had received more than 2 courses of chemotherapy at our hospital. We analyzed the relationships between RECIST outcome and background factors, such as age, sex, clinical TNM stage, pre-treatment history, ECOG performance status, serum albumin, and Charlson comorbidity index using logistic regression analysis.

Results

A total of 103 cancer patients aged over 75 years were analyzed in this study, including 28 with hematological neoplasia, 36 with gastrointestinal tract cancers, 25 with breast cancers, and 14 with other malignancies originating in various tissues. Seventy-one patients (69.1%) had a positive clinical outcome including RECIST CR (complete response), PR (partial response) and SD (stable disease). Multivariate analysis showed that a high serum albumin level of more than 3.5 g/dl and a Charlson comorbidity index score of less than 2 points were positively correlated with a favorable therapeutic outcome.

Conclusions

The results of the current study suggested that serum albumin level and comorbidity index are the principal clinical factors affecting therapeutic outcomes in elderly cancer patients receiving chemotherapy. In the future, these factors may make chemotherapy adaptations, continuity, and effectiveness easier to predict than GA screening.

Nutritional interventions in elderly gastrointestinal cancer patients: the evidence from randomized controlled trials

Literature concerning nutritional interventions in elderly patients with gastrointestinal cancer, with special reference to randomized clinical trials, has been critically reviewed. This segment of oncologic population was found to be penalized by a high prevalence of malnutrition and sarcopenia which translated in an increased rate of toxicity from chemotherapy, poor compliance with oncologic treatments, and, finally, with a poor prognosis. Attempts to reverse this condition included a potentiation of nutrients intake which should sequentially proceed through the use of dietary counseling and administration of standard or ω-3 fatty acid-enriched oral supplements to finally come to enteral or parenteral nutrition. Randomized clinical trials investigating the effects of simple dietary advice and use of standard oral supplements were disappointing as regards long-term compliance and results. Nutritional and clinical benefits were reported with the use of ω-3 fatty acid-enriched oral supplements and especially with long-term supplemental parenteral nutrition. Despite the general recommendation of the scientific community that emphasizes the use of the enteral route, whenever possible, for delivering the nutritional support, it appears from the literature that more consistent benefits can be achieved, especially in the long-term nutritional support, when an insufficient oral nutrition is partnered with intravenous nutrition.

Prevalence and Risk of Polypharmacy Among Elderly Cancer Patients Receiving Chemotherapy in Ambulatory Oncology Setting

PURPOSE OF REVIEW

This was a single center, retrospective cross-sectional study looking into the incidence and types of drug-related problems (DRPs) detected among elderly cancer patients receiving at least three long-term medications concurrent with IV chemotherapy, and the types of intervention taken to address these DRPs. This paper serves to elucidate the prevalence and risk of polypharmacy in our geriatric oncology population in an ambulatory care setting, to raise awareness on this growing issue and to encourage more resource allocation to address this healthcare phenomenon.

RECENT FINDINGS

DRP was detected in 77.6% of elderly cancer patients receiving at least three long-term medications concurrent with IV chemotherapy, with an average incidence of three DRPs per patient. Approximately half of DRPs were related to long-term medications. Forty percent of DRPs required interventions at the prescriber level. The use of five or more medications was shown to almost double the risk of DRP occurrence (OR 1.862, P = 0.039). Out of the eight predefined categories of DRPs, underprescribing was the most common (26.7%), followed by adverse drug reaction (25.0%) and drug non-adherence (16.2%). Polypharmacy leading to DRPs is a common occurrence in elderly cancer patients receiving outpatient IV chemotherapy. There should be systematic measures in place to identify patients who are at greater risk of inappropriate polypharmacy and DRPs, and hence more frequent drug therapy optimization and monitoring. The identification of DRPs is an important step to circumvent serious drug-related harm. Future healthcare interventions directed at reducing DRPs should aim to assess the clinical and economic impact of such interventions.

An overview of the toxicities of checkpoint inhibitors in older patients with cancer

Checkpoint inhibitors offer an exciting new option for treatment of a wide variety of cancers. By binding to surface receptors or their associated ligands on T cells, this class of drugs enhances immune activation and response to cancer cells. In available studies, the drugs are well tolerated, although toxicity involving skin, gastrointestinal tract, liver, lungs, and endocrine organs has been observed. Unfortunately, few studies to date have included patients older than 70 years of age. Since aging has been linked to changes in immune function, there are theoretical concerns that this patient population might experience a different profile of adverse events. This article reviews the tolerability of checkpoint inhibitors in older patients with cancer in clinical practice.

Preoperative Nutritional Assessment in Elderly Cancer Patients Undergoing Elective Surgery: MNA or PG-SGA?

This study aims to evaluate and compare the use of patient-generated subjective global assessment (PG-SGA) and mini nutritional assessment (MNA) as a preoperative nutritional assessment tool in elderly cancer patients. This was a prospective study carried out on 47 patients, 45 years and above suffering from cancer and admitted to Padmashree Dr. D.Y. Patil Medical College and Hospital, Pune. The patients were evaluated with PG-SGA and MNA tools at the time of admission and baseline data were collected. All patients had undergone surgeries as per indications. Postoperatively, the surgical outcomes and adverse events were noted and statistically evaluated. The average age of the study sample was 61.46 years and 29 patients were females. The patients classified by PG-SGA were ten in group A and 37 in group B and C. The patients classified by MNA were five in no risk group and 42 in group with patients at risk and malnourished. When evaluated with PG-SGA in group B and C, wound infections and requirement of change of antibiotic were seen in 86.4 % patients and their average day of onset of infection was 5.6 days. Antibiotics were administered to these patients for an average of 14.2 days and their average duration of stay was 29 days. On the other hand, the evaluation of patients with MNA, at risk and malnourished patients, wound infections, and requirement of change of antibiotic were seen in 81 % of patients and their average day of onset of infection was 5.6 days. Antibiotics were administered to these patients for an average of 13.8 days and their average duration of stay was 27 days. The results were statistically significant. The mini nutritional assessment is more exhaustive in identifying patients at risk and is useful in screening populations to identify frail elderly persons allowing us to intervene earlier, thereby improving the patient prognosis. The patient-generated subjective global assessment is a more comprehensive tool for elderly cancer patients, which identifies a more extensive range of nutrition impact symptoms and predicts the postoperative outcomes more accurately. Authors recommend its usage in evaluating the aforementioned subset of patients.