Geriatric assessment and 1-year mortality in older patients with cancer in the head and neck region: A cohort study

Multidimensional Prognostic Index as a Predictor of Mortality in Head and Neck Cancer Patients: A Cohort Study

BACKGROUND

Head and neck cancer (HNC) significantly impacts older adults, with mortality influenced by multiple factors. The Multidimensional Prognostic Index (MPI), derived from comprehensive geriatric assessment (CGA), may improve risk stratification and clinical decision making.

METHODS

An observational cohort study was conducted at Erasmus Medical Center, Rotterdam, from December 2019 to June 2021. We included 423 HNC patients aged 70 years or older or younger patients with a G8 score of 14 or less. MPI stages were determined through CGA, categorized into stages 1, 2, and 3.

RESULTS

During a median follow-up of 595 days, 115 patients (29%) died. MPI stage 2 and stage 3 were associated with a higher mortality risk compared to MPI stage 1 (HR 2.18; 95% CI 1.46-3.26). In the surgical subgroup, similar mortality risks were observed, but MPI stages did not correlate with postoperative complications.

CONCLUSIONS

MPI stages derived from CGA effectively predict mortality risk in older HNC patients, though they do not predict postoperative complications.

Transoral Laser Microsurgery and Transoral Robotic Surgery in Aging Patients: A State-of-The-Art Review

Purpose

In the present study, the findings related to the epidemiology, clinical presentation, and therapeutic outcomes of elderly patients treated with transoral laser microsurgery (TOLM) and transoral robotic surgery (TORS) for supraglottic laryngeal squamous cell carcinoma (LSCC) have been reviewed.

Methods

A PubMed, Cochrane Library, and Scopus literature search was conducted according to the PRISMA statements. Critical literature analysis was carried out considering the last advancement in TOLS and TORS, and their related surgical, functional, and survival outcomes.

Findings

The mean age of patients with supraglottic LSCCs has progressively increased in the past decades. The data on postoperative complications in elderly patients with LSCC are heterogeneous and contradictory. The thought of the age-related high risk of complications was based on open supraglottic laryngectomy (SGL), but not on TOLM and TORS findings, which do not support an age-related increase of most postoperative complications. The only complication that could be associated with age is aspiration. The adequate selection of patients undergoing TOLM or TORS, and the pre- to postoperative evaluation of swallowing function can prevent this risk. The OS of elderly patients treated with TOLM or TORS SGL could be lower compared to younger patients. However, the disease-free survival was not influenced by age, highlighting the role of comorbidities and intercurrent diseases in the presumed lower survival. The survival analysis could definitively consider the physiological age rather than the chronological age to investigate the impact of age on survival outcomes.

Conclusion

The current literature supports an important place of TOLM and TORS in managing cT1-T3 supraglottic LSCC. The preoperative geriatric, nutritional, and swallowing evaluations are important for ensuring an adequate selection of patients treated with TORS or TOLM SGL.

Modified Textbook Outcome was a Predictor for Early Mortality After Oral Cancer Surgery

BACKGROUND

To explore prognostic factors for early mortality among patients undergoing surgery for oral cavity cancer (OCC) and identify valuable strategies to improve patient outcomes.

PATIENTS AND METHODS

A total of 397 patients treated by primary tumor resection and neck dissection between 2017 and 2021 were retrospectively analyzed. Univariate and multivariate Cox regression analysis were used to explore the relationships between the study factors and early death (within 12 months). Predictors were further incorporated into a nomogram for estimation of 1-year overall survival (OS).

RESULTS

The mean age was 57.2 (SD, 9.8) years and 92.9% patients were male. The early death rate was 12.6% overall, 35.6% in patients with pN2-3, 22.3% in patients with tumor size > 3 cm, and 36.2% in patients with lymphovascular invasion. A non-modified textbook outcome (mTO), pN2-3, tumor size > 3 cm, and lymphovascular permeation were independent prognosticators for early mortality. A nomogram with the above-mentioned four factors were created with good discrimination and calibration. Among the pN2-3 or tumor size > 3 cm subgroup, a non-mTO, cancer resource center (CRC) visits, perineural invasion, and lymphovascular permeation were independent prognostic factors for early death.

CONCLUSIONS

In addition to traditional clinicopathological features, a non-mTO and CRC visits could serve as prognostic factors for early death in OCC. A novel nomogram had good discrimination and calibration. Quality improvements in terms of mTO and patients demanding resource support could improve survival outcomes in OCC.

Systematic nutritional screening and assessment in older patients: Rationale for its integration into oncology practice

As the global population ages, so does the number of older people being diagnosed, treated and surviving cancer. Challenges to providing appropriate healthcare management stem from the heterogeneity common in this population. Although malnutrition is highly prevalent in older people with cancer, ranging between 30 % and 80 % according to some analyses, is associated with frailty, and has been shown to be a major risk factor for poor treatment response and worse overall survival, addressing nutrition status is not always a priority among oncology healthcare providers. Evaluation of nutritional status is a two-step process: screening identifies risk factors for reduced nutritional intake and deficits that require more in-depth assessment. Screening activities can be as simple as taking weight and BMI measurements or using short nutritional questionnaires and asking the patient about unintentional weight loss to identify potential nutritional risk. Using geriatric assessment, deficits in the nutritional domain as well as in others reveal potentially reversible geriatric and medical problems to guide specific therapeutic interventions. The authors of this paper are experts in the fields of geriatric medicine, oncology, and nutrition science and believe that there is not only substantial evidence to support regularly performing screening and assessment of nutritional status in older patients with cancer, but that these measures lead to the planning and implementation of patient-centered approaches to nutrition management and thus enhanced geriatric-oncology care. This paper presents rationale for systematic nutrition screening and assessment in older adults with cancer.

Incorporation of stromal tumor-infiltrating lymphocytes into an early death prediction model significantly improves net reclassification for outcome estimation in advanced buccal cancer

We explored the impact of stromal tumor-infiltrating lymphocytes (sTILs) on the prognostic value of an early death model for advanced buccal cancer. We assessed 121 patients with advanced buccal cancer who underwent primary tumor resection at a medical center. Predictors of early death and 5-year overall survival (OS) were analyzed using Cox regression models. Performance of models was evaluated with the Harrell C and Akaike information criterion. The net reclassification improvement of the early death model was also calculated relative to the 5-year OS model for one-year all-cause mortality. A total of 121 patients with advanced buccal cancer were recruited. Mean age was 56.1 ± 9.8 years; 117 (96.7%) patients were male. sTILs ≤30%, clinical nodal disease, pathological nodal disease, poor differentiation, lymphovascular invasion, perineural invasion, WPOI 5, and no adjuvant radiotherapy were risk factors for early death in univariate analysis. In multivariate analysis, clinical TNM, sTILs, clinical nodal disease, poor differentiation, lymphovascular invasion, and no adjuvant RT were independent factors for early death. sTILs, pathological nodal disease, poor differentiation, lymphovascular invasion, and no adjuvant RT were independent factors for early death in the multivariate model with pathological TNM. The discriminatory ability was better for early death model for 1-year all-cause mortality. Finally, incorporation of sTILs into the early death model increased net reclassification by 21% for the clinical TNM model and 28% for the pathological TNM model. Addition of sTILs improved the early death model, which may help physicians to identify high-risk patients for more intensive treatment and follow-up.

Frailty in Non-geriatric Patients With Head and Neck cancer

OBJECTIVE

Patients with head and neck cancer (HNC) are characterized by a poor lifestyle and comorbidity. The Geriatric 8 (G8) is an established screening tool to identify frail older patients with cancer. However, studies evaluating frailty in younger HNC patients are lacking. The aim of this study is to evaluate if the G8 can identify frailty and if it is related to mortality in younger HNC patients.

STUDY DESIGN

Case-control study design.

SETTING

Tertiary cancer center.

METHODS

We studied patients <70 years with HNC. Patients with G8 ≤ 14 were considered frail. Patients were matched to nonfrail (G8 > 14) control patients. Patients were matched according to sex, age, smoking, tumor location, and period of first consultation. Baseline health characteristics were compared between frail patients and nonfrail controls. Second, the treatment plan and adverse outcomes were compared.

RESULTS

Forty-five patients with G8 ≤ 14 were included and matched to 90 nonfrail controls. The median follow-up time was 357 days. Frail patients had a significantly lower body mass index and level of education, a worse World Health Organization performance status, and reported lower experienced overall health. 28.9% of the frail patients died after 1 year versus 10% of the nonfrail control patients (hazard ratio: 3.87 [95% confidence interval: 1.32-11.36], p = 0.014).

CONCLUSION

The G8 is a valid screening tool to identify frail patients in younger HNC patients.

Nutrition as prevention for improved cancer health outcomes: a systematic literature review

BACKGROUND

Among adults with cancer, malnutrition is associated with decreased treatment completion, more treatment harms and use of health care, and worse short-term survival. To inform the National Institutes of Health Pathways to Prevention workshop, "Nutrition as Prevention for Improved Cancer Health Outcomes," this systematic review examined the evidence for the effectiveness of providing nutrition interventions before or during cancer therapy to improve outcomes of cancer treatment.

METHODS

We identified randomized controlled trials enrolling at least 50 participants published from 2000 through July 2022. We provide a detailed evidence map for included studies and grouped studies by broad intervention and cancer types. We conducted risk of bias (RoB) and qualitative descriptions of outcomes for intervention and cancer types with a larger volume of literature.

RESULTS

From 9798 unique references, 206 randomized controlled trials from 219 publications met the inclusion criteria. Studies primarily focused on nonvitamin or mineral dietary supplements, nutrition support, and route or timing of inpatient nutrition interventions for gastrointestinal or head and neck cancers. Most studies evaluated changes in body weight or composition, adverse events from cancer treatment, length of hospital stay, or quality of life. Few studies were conducted within the United States. Among intervention and cancer types with a high volume of literature (n = 114), 49% (n = 56) were assessed as high RoB. Higher-quality studies (low or medium RoB) reported mixed results on the effect of nutrition interventions across cancer and treatment-related outcomes.

CONCLUSIONS

Methodological limitations of nutrition intervention studies surrounding cancer treatment impair translation of findings into clinical practice or guidelines.

Management of Older Patients with Head and Neck Cancer: A Comprehensive Review

The projected increase in life expectancy over the next few decades is expected to result in a rise in age-related diseases, including cancer. Head and neck cancer (HNC) is a worldwide health problem with high rates of morbidity and mortality. In this report, we have critically reviewed the literature reporting the management of older patients with HNC. Older adults are more prone to complications and toxicities secondary to HNC treatment, especially those patients who are frail or have comorbidities. Thus, this population should be screened prior to treatment for such predispositions to maximize medical management of comorbidities. Chronologic age itself is not a reason for choosing less intensive treatment for older HNC patients. Whenever possible, also older patients should be treated according to the best standard of care, as nonstandard approaches may result in increased treatment failure rates and mortality. The treatment plan is best established by a multidisciplinary tumor board with shared decision-making with patients and family. Treatment modifications should be considered for those patients who have severe comorbidities, evidence of frailty (low performance status), or low performance status or those who refuse the recommendations of the tumor board.

Malnutrition risk and frailty in head and neck cancer patients: coexistent but distinct conditions

PURPOSE

Both malnutrition and frailty are associated with adverse treatment outcomes. Malnutrition (risk) and frailty are each commonly present in patients with head and neck cancer (HNC). However, their coexistence and association is unknown. Main goal of this study is to determine the coexistence of, and the association between malnutrition risk and frailty in patients with HNC.

METHODS

In this retrospective analysis on prospectively collected data, newly diagnosed patients with HNC, enrolled in the OncoLifeS databiobank were included. The Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF) was used to assess malnutrition risk. The Groningen Frailty Indicator (GFI) was used to assess frailty status. Multivariate logistic regression analyses were performed, taking into account several patient- and tumor-related factors.

RESULTS

In total, 197 patients were included. Seventy-six patients (39%) had a medium or high malnutrition risk and 71 patients (36%) were frail. In 38 patients (19%), malnutrition risk coexisted with frailty. Patients with medium and high malnutrition risk were, respectively, 4.0 (95% CI 1.5-11.2) and 13.4 (95% CI 4.0-48.7) times more likely to be frail, compared to patients with low malnutrition risk. In turn, frail patients were 6.4 times (95% CI 2.6-14.9) more likely to have malnutrition risk compared to non-frail patients.

CONCLUSIONS

Malnutrition risk and frailty frequently coexist but not fully overlap in newly diagnosed patients with HNC. Therefore, screening for both conditions is recommended.

Protocol for a randomised controlled trial on impact of comprehensive geriatric and supportive assessment versus standard care in older adults with cancer undergoing curative treatment: The Geriatric Oncology SuPportive clinic for ELderly (GOSPEL) study

Cancer affects older adults with varying levels of frailty, but cancer treatment is extrapolated from clinical trials involving predominantly young and robust subjects. Recent geriatric oncology randomised controlled trials (RCT) report that geriatric assessment leading to frailty-guided intervention reduces treatment-related toxicity whilst maintaining survival and improving quality of life (QoL). However, these positive results have not have been consistently reported in the literature. We postulate that the impact of geriatric interventions has been underestimated in these studies with the inclusion of subjects receiving palliative-intent chemotherapy in whom dose reduction is common. Integrating supportive care with current geriatric oncology models may improve the QoL of older adults undergoing treatment. However, no studies as yet have examined such integrated geriatric and supportive models of care. The Geriatric Oncology SuPportive clinic for Elderly (GOSPEL) study is a single-centre, open-label, analyst-blinded RCT evaluating the impact of comprehensive geriatric and supportive care on QoL of older adults with cancer undergoing curative treatment. Older adults aged above 65, with a Geriatric-8 score ≤ 14, with plans for high dose radiotherapy and/or curative chemotherapy will be recruited. The primary QoL outcome is measured using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-ELD14 mobility scale at 12 weeks. Secondary outcomes include overall and disease-free survival, treatment-related adverse events, and hospital admissions. We pre-powered this study to recruit 200 subjects based on the minimally clinically important difference for EORTC QLQ-ELD14 to achieve 80% statistical power (alpha 0.05), assuming 25% attrition. Outcomes will be analysed using intention-to-treat. Intervention consists of multi-domain comprehensive geriatric and supportive care assessments from a multidisciplinary team targeting unmet needs. These include functional decline, falls, incontinence, cognitive impairment, multi-morbidity, polypharmacy, and symptom relief, as well as social and psycho-spiritual concerns. Standard care entails routine oncological management with referral to geriatrics based on the discretion of the primary oncologist. Recruitment has been ongoing since August 2020. Results from the GOSPEL study will increase understanding of the impact of integrated geriatric and supportive care programs in older adults with cancer receiving curative treatment. Trial registration: This study is registered under ClinicalTrials.gov (ID NCT04513977).

Outcomes of comprehensive geriatric assessment and surgical management in head and neck cancers of the elderly: an observational study

AIM

The aims of this study were to assess the survival benefit of optimal vs suboptimal management in elderly patients presenting with upper aerodigestive tract (UADT) cancer for which surgery was the standard of care, and determine if comprehensive geriatric assessment (CGA) was a prognostic factor for survival.

MATERIALS AND METHODS

This single-center retrospective cohort study was conducted from January 2014 to December 2018. Included patients were aged 70 or older at the time of diagnosis, and presented with UADT cancer with a theoretical indication for curative-intent surgery according to international guidelines.

RESULTS

A total of 188 patients were included, with a median age of 78 years. Treatment included surgery in 67.6% of cases and was considered optimal in 60.6% of patients. The overall 3-year survival was 55.2%, and was significantly better in case of optimal vs suboptimal treatment (74.5% vs 25.8%, p < 0.001). In univariate analysis, factors associated with a significantly improved 3-year survival included surgery (p < 0.001), age < 80 years, performance status < 2 and G8 score > 14. In multivariate analysis, CGA was associated with a better survival.

CONCLUSIONS

In patients aged over 70 presenting with UADT cancer for which the standard of care is surgery, an optimal management is associated with better overall survival. Receiving a CGA seems to provide a survival benefit in patients with a G8 score ≤ 14, through an optimization of the care pathway before and after the cancer treatment.

Disadvantaged Subgroups Within the Global Head and Neck Cancer Population: How Can We Optimize Care?

Within the global head and neck cancer population, there are subgroups of patients with poorer cancer outcomes independent from tumor characteristics. In this article, we review three such groups. The first group comprises patients with nasopharyngeal cancer in low- and middle-income countries where access to high-volume, well-resourced radiotherapy centers is limited. We discuss a recent study that is aiming to improve outcomes through the instigation of a comprehensive radiotherapy quality assurance program. The second group comprises patients with low socioeconomic status in a high-income country who experience substantial financial toxicity, defined as financial hardship for patients due to health care costs. We review causes and consequences of financial toxicity and discuss how it can be mitigated. The third group comprises older patients who may poorly tolerate and not benefit from intensive standard-of-care treatment. We discuss the role of geriatric assessment, particularly in relation to the use of chemotherapy. Through better recognition and understanding of disadvantaged groups within the global head and neck cancer population, we will be better placed to instigate the necessary changes to improve outcomes and quality of life for patients with head and neck cancer.

Developing a Stacked Ensemble-Based Classification Scheme to Predict Second Primary Cancers in Head and Neck Cancer Survivors

Despite a considerable expansion in the present therapeutic repertoire for other malignancy managements, mortality from head and neck cancer (HNC) has not significantly improved in recent decades. Moreover, the second primary cancer (SPC) diagnoses increased in patients with HNC, but studies providing evidence to support SPCs prediction in HNC are lacking. Several base classifiers are integrated forming an ensemble meta-classifier using a stacked ensemble method to predict SPCs and find out relevant risk features in patients with HNC. The balanced accuracy and area under the curve (AUC) are over 0.761 and 0.847, with an approximately 2% and 3% increase, respectively, compared to the best individual base classifier. Our study found the top six ensemble risk features, such as body mass index, primary site of HNC, clinical nodal (N) status, primary site surgical margins, sex, and pathologic nodal (N) status. This will help clinicians screen HNC survivors before SPCs occur.

The Multidimensional Prognostic Index as a Measure of Frailty in Elderly Patients with Head and Neck Cancer

Purpose

The multidimensional prognostic index (MPI) is a prognostic model derived from the comprehensive geriatric assessment (CGA) which can predict 1-year mortality risk in elderly individuals. We hypothesized that the MPI also reflects the degree of frailty and thus will correlate with established measures of frailty. Therefore, the aim of this study is to explore whether the MPI-score is a measure of frailty in older head and neck cancer patients and is associated with several physical functioning measurements.

Patients and Methods

From November 2019 to July 2020, a prospective cohort study enrolled patients with head and neck cancer aged ≥70 years, and patients <70 years with an abnormal G8 score. The MPI-score ranged from 0 to 1 and was categorized in MPI-stage 1 (≤0.33, non-frail); MPI-stage 2 (0.34-0.66, mildly frail), and MPI-stage 3 (≥0.67, severe frail). Pearson's correlation coefficient and multivariable linear regression were used to study the association between MPI-score and the physical functioning measurements handgrip strength, gait speed, and the timed up and go test (TUGT).

Results

A total of 163 patients were included. One hundred four (63.8%) patients were categorized as non-frail according MPI-stage 1, and 59 (36.2%) patients as mildly or severe frail (n=55 MPI-stage 2; n=4 MPI-stage 3, respectively). A higher MPI-score was significantly associated with lower hand grip strength (B -0.49 [95% CI -0.71; -0.28] p<0.001), lower gait speed (B -0.41 [95% CI -0.55; -0.25] p<0.001), and a slower TUGT (B 0.53 [95% CI 0.66; 0.85] p<0.001).

Conclusion

Almost one-third of the included patients with head and neck cancer was mild or severe frail. A higher MPI-score, indicating higher degree of frailty, was associated with worse physical performance by lower handgrip strength, gait speed, and a slower TUGT. Thus, the MPI reflects the degree of frailty.

Digestion-Specific Acupuncture Effect on Feeding Intolerance in Critically Ill Post-Operative Oral and Hypopharyngeal Cancer Patients: A Single-Blind Randomized Control Trial

Malnourishment is prevalent in patients suffering from head and neck cancer. The postoperative period is crucial in terms of nutritional support, especially after composite resection and reconstruction surgery. These patients present with a number of risk factors that aggravate feeding intolerance, including postoperative status, prolonged immobility, decreased head elevation, mechanical ventilation, and applied sedative agents. Routine management protocols for feeding intolerance include prokinetic drug use and post-pyloric tube insertion, which could be both limited and accompanied by detrimental adverse events. This single-blind clinical trial aimed to investigate the effects of acupuncture in postoperative feeding intolerance in critically ill oral and hypopharyngeal cancer patients. Twenty-eight patients were randomized into two groups: Intervention group and Control group. Interventions were administered daily over three consecutive postoperative days. The primary outcome revealed that the intervention group reached 70% and 80% of target energy expenditure (EE) significantly earlier than the control group (4.00 ± 1.22 versus 6.69 ± 3.50 days, p = 0.012), accompanied by higher total calorie intake within the first postoperative week (10263.62 ± 1086.11 kcals versus 8384.69 ± 2120.05 kcals, p = 0.004). Furthermore, the intervention group also needed less of the prokinetic drug (Metoclopramide, 20.77 ± 48.73 mg versus 68.46 ± 66.56 mg, p = 0.010). In conclusion, digestion-specific acupuncture facilitated reduced postoperative feeding intolerance in oral and hypopharyngeal cancer patients.

Use of the Geriatric-8 screening tool to predict prognosis and complications in older adults with head and neck cancer: A prospective, observational study

OBJECTIVES

To clarify the usefulness of geriatric assessment screening tools for predicting prognosis and complications in older adults with head and neck cancer (HNC).

MATERIAL AND METHODS

The geriatric-8 (G8) screening tool was administered to 78 older adults with HNC at their first visit to the hospital before any treatments. The ability of the G8 to predict survival was evaluated by receiver operating characteristic (ROC) curve analysis and determining the cut-off value using Youden's Index. The G8 and other factors related to prognosis (age, performance status (PS), Charlson comorbidity index, number of oral medicines (polypharmacy), the controlling nutritional status (CONUT) score for biological nutrition status, and treatment intent (curative or palliative)) were validated by Cox proportional hazards regression analysis. The survival analysis was validated in a propensity score-weighting cohort to correct for confounding factors. Correlations between these factors and complications were examined using Fishers exact test.

RESULTS

The G8 cut-off value for overall survival was 10.5 (area under the curve (AUC) 0.69; 95% confidence interval (CI) 0.56-0.82). In the propensity score-weighted cohort, on Cox proportional hazards regression analysis, the hazard ratio of an abnormal G8 (<11) was 3.70 [1.59-8.61 (p = 0.002)], and the hazard ratio of PS-abnormal (≥2) was 0.85 [0.09-7.60 (p = 0.88)]. Thirty-day mortality and all-complication rates were significantly higher in the G8-abnormal group. Neither major complications nor transfer to other institutions was correlated with an abnormal G8.

CONCLUSION

The G8 was a strong prognostic factor and a possible predictor of complications in older adults with HNC.

Prognostic Factors Predict Oncological Outcome in Older Patients With Head and Neck Cancer Undergoing Chemoradiation Treatment

Purpose

Older patients with head and neck cancer (HNC) represent a challenging group, as frailty and comorbidities need to be considered. This study aimed to evaluate the efficacy and side effects of curative and palliative (chemo) radiation ([C]RT) with regard to basic geriatric screening in older patients.

Methods

This study included HNC patients aged ≥70 years who were treated with curative or palliative (C)RT. Clinicopathological data including Charlson Comorbidity Index (CCI), Karnofsky performance status (KPS), and treatment data were analyzed as predictors of overall survival (OS).

Results

A total of 271 patients (median age, 74 years) were enrolled. The majority had UICC stage III/IV (90%) and underwent curative treatment (85.2%). A total of 144 (53.1%) patients received definitive and 87 (32.1%) had adjuvant (C)RT. Overall, 40 patients (14.8%) received palliative (C)RT. Median follow-up duration (curative setting) was 87 months, and the 2- and 5-year OS rates were 57.8 and 35.9%, respectively. Median OS was significantly different for age ≤75 vs. >75 years, CCI <6 vs. ≥6, KPS ≥70 vs. <70%, Tx/T1/T2 vs. T3/T4, and adjuvant vs. definitive (C)RT, respectively. Age 70–75 years (p = 0.004), fewer comorbidities when CCI < 6 (p = 0.014), good KPS ≥ 70% (p = 0.001), and adjuvant (C)RT (p = 0.008) independently predicted longer survival. Palliative RT resulted in a median OS of 4 months.

Conclusion

Older age, lower KPS, higher CCI, and definitive (C)RT are indicators of worse survival in older patients with HNC treated curatively. Without a comprehensive geriatric assessment in patients aged >75 years, the KPS and CCI can be useful tools to account for “fitness, vulnerability or frailty” to help in treatment decision-making.

Design and rationale of a routine clinical care pathway and prospective cohort study in older patients needing intensive treatment

BACKGROUND

Treatment decisions concerning older patients can be very challenging and individualised treatment plans are often required in this very heterogeneous group. In 2015 we have implemented a routine clinical care pathway for older patients in need of intensive treatment, including a comprehensive geriatric assessment (CGA) that was used to support clinical decision making. An ongoing prospective cohort study, the Triaging Elderly Needing Treatment (TENT) study, has also been initiated in 2016 for participants in this clinical care pathway, to study associations between geriatric characteristics and outcomes of treatment that are relevant to older patients. The aim of this paper is to describe the implementation and rationale of the routine clinical care pathway and design of the TENT study.

METHODS

A routine clinical care pathway has been designed and implemented in multiple hospitals in the Netherlands. Patients aged ≥70 years who are candidates for intensive treatments, such as chemotherapy, (chemo-)radiation therapy or major surgery, undergo frailty screening based on the Geriatric 8 (G-8) questionnaire and the Six-Item Cognitive Impairment Test (6CIT). If screening reveals potential frailty, a CGA is performed. All patients are invited to participate in the TENT study. Clinical data and blood samples for biomarker studies are collected at baseline. During follow-up, information about treatment complications, hospitalisations, functional decline, quality of life and mortality is collected. The primary outcome is the composite endpoint of functional decline or mortality at 1 year.

DISCUSSION

Implementation of a routine clinical care pathway for older patients in need of intensive treatment provides the opportunity to study associations between determinants of frailty and outcomes of treatment. Results of the TENT study will support individualised treatment for future patients.

TRIAL REGISTRATION

The study is retrospectively registered at the Netherlands Trial Register (NTR), trial number NL8107 . Date of registration: 22-10-2019.

Nutritional status and interventions for patients with cancer - A systematic review

BACKGROUND

Malnourishment is commonly seen in ageing, cancer and many chronic conditions, and is associated with poorer prognosis.

AIM

We set out to collect all currently available evidence on the association between nutritional status assessed with a validated screening tool and prognosis or course of treatment in older patients with cancer, and on the benefit of nutritional interventions in improving these outcomes.

METHODS

A systematic search in MEDLINE and EMBASE.

RESULTS

We included 71 studies on the association between nutritional status and outcome in (older) patients with cancer and 17 studies on the benefit of nutritional interventions in improving outcomes in this patient population. There is a significant association between nutritional status and increased intermediate- and long-term mortality (hazard ratio 1.87 (95% confidence interval 1.62-2.17). Those with poorer nutritional status were less likely to complete oncologic treatment according to plan and had higher health care consumption. Benefit of dietary interventions was limited although dietary counselling may lead to improved quality of life while nutritional support may lead to a decrease in post-operative complication rates.

CONCLUSION

Nutritional status is associated with poorer survival, decreased treatment completion and higher health care consumption and nutritional interventions are only able to negate these negatives outcome to a very limited degree.

Nutritional status according to the mini nutritional assessment (MNA)® as potential prognostic factor for health and treatment outcomes in patients with cancer - a systematic review

Background

Patients with cancer have an increased risk of malnutrition which is associated with poor outcome. The Mini Nutritional Assessment (MNA®) is often used in older patients with cancer but its relation to outcome is not known.

Methods

Four databases were systematically searched for studies relating MNA-results with any reported outcome. Two reviewers screened titles/abstracts and full-texts, extracted data and rated the risk of bias (RoB) independently.

Results

We included 56 studies which varied widely in patient and study characteristics. In multivariable analyses, (risk of) malnutrition assessed by MNA significantly predicts a higher chance for mortality/poor overall survival (22/27 studies), shorter progression-free survival/time to progression (3/5 studies), treatment maintenance (5/8 studies) and (health-related) quality of life (2/2 studies), but not treatment toxicity/complications (1/7 studies) or functional status/decline in (1/3 studies). For other outcomes – length of hospital stay (2 studies), falls, fatigue and unplanned (hospital) admissions (1 study each) – no adjusted results were reported. RoB was rated as moderate to high.

Conclusions

MNA®-result predicts mortality/survival, cancer progression, treatment maintenance and (health-related) quality of life and did not predict adverse treatment outcomes and functional status/ decline in patients with cancer. For other outcomes results are less clear. The moderate to high RoB calls for studies with better control of potential confounders.

[Head and neck cancer in the elderly-current aspects]

BACKGROUND

The treatment of head and neck cancer is dominated by surgery and radiochemotherapy, which is in part associated with high morbidity. In elderly patients, however, the otorhinolaryngologist often has to question the rationality of invasive treatment. Although the proportion of geriatric patients with head and neck tumors is increasing, the paucity of data means that there are few consistent standards and recommendations in the literature and guidelines.

OBJECTIVE

The aim of this paper is to provide concrete clinical recommendations for geriatric patients with head and neck tumors based on a systematic literature search.

MATERIALS AND METHODS

A keyword-based literature search was performed to present the current level of evidence and provide a clinical algorithm.

RESULTS

In addition to age, the pretreatment dispositional evaluation of geriatric patients should include psychosocial, functional, and medical (patient history) comorbidities. For pretreatment risk stratification, an algorithm was created on the basis of these data for individual evaluation of the patient's pretreatment risk.

CONCLUSION

Pretreatment risk stratification of geriatric patients with head and neck malignancies is of high relevance for the individual decision for or against invasive treatment, but the currently available evidence is limited. This paper is based on a systematic literature review and provides a clinical algorithm for otorhinolaryngologists and head and neck surgeons.

Early mortality after diagnosis of cancer of the head and neck - A population-based nationwide study

Background

Cancers of the head and neck have a high mortality rate, and roughly 10% of the patients die within six months of diagnosis. To our knowledge little has been written about this group.

We wished to identify risk factors for early death, to predict and monitor patients at risk better and, if possible, avoid unjustified major treatment.

Methods and findings

This population-based nationwide study from the Swedish Head and Neck Cancer Register (SweHNCR) included data from 2008–2015 and 9733 patients at potential risk of early death.

A total of 925 (9.5%) patients died within six months. For every year older the patients became, the risk of early death increased by 2.3% (p<0.001). The relative risk of death was 3.37 times higher (237%) for patients with WHO score 1 compared with WHO score 0. A primary tumour in the hypopharynx correlated with a 24% increased risk over the oral cavity (p<0.024). Patients with stage IV disease had a 3.7 times greater risk of early death than those with stage I (p<0.001). As expected, a 12 times increased risk of early death was noted in the palliative treatment group, compared to the curative group.

Limitations to this study were that the actual cause of death was not recorded in the SweHNCR, and that socioeconomic factors, alcohol consumption, smoking habits, and HPV status, were not reported in SweHNCR until 2015. However, the fact that this is a population-based nationwide study including 9733 patients compensates for some of these limitations.

Conclusions

Identification of patients at increased risk of early death shows that older patients with advanced disease, increased WHO score, primary tumour in the hypopharynx, and those given palliative treatment, are more likely than the others to die from head and neck cancer within six months of diagnosis.

Geriatric assessment and 1-year mortality in older patients with cancer in the head and neck region: A cohort study

Background

The aim is to describe the association of functional capacity and cognitive functioning with 1‐year mortality in older patients with cancer in the head and neck region.

Methods

We performed a cohort study in which all patients aged 70 years and older received a geriatric screening before treatment. Main outcome was 1‐year mortality.

Results

A total of 102 patients were included. Median age was 78.7 years (interquartile range [IQR], 72.3‐84.5), 25% were cognitive impaired, 40% were malnourished, and 28.4% used a walking device. Overall, 1‐year mortality was 42.3%. Male sex (hazard ratio [HR], 4.30; 95% confidence interval [CI], 1.35‐13.67), malnutrition (HR, 2.55; 95% CI, 1.19‐5.16), and using a walking device (HR, 2.80; 95% CI 1.13‐6.93) were associated with higher mortality risk, independent of stage and comorbidities.

Conclusion

In older patients with head and neck cancer, the mortality rates are high. Nutritional status and mobility are determinants of 1‐year mortality, independent of tumor stage, age, and comorbidity.