Comprehensive geriatric assessment in Korean elderly cancer patients receiving chemotherapy

Associations of frailty with symptoms, and HRQOL in older cancer survivors after cancer treatments: a systematic review and meta-analyses

PURPOSE

Frailty in older adult cancer survivors after cancer treatments is associated with various health outcomes. However, there is less agreement on how frailty affects symptoms and health-related quality of life (HRQOL). This systematic review and meta-analysis aimed to evaluate the current literature on frailty, symptoms, and HRQOL, as well as the associations of frailty with these factors in older adult cancer survivors with chemotherapy.

METHODS

A review was conducted on peer-reviewed publications from 2008 to 2023, using seven electronic databases. Meta-analyses were performed using random effects models to determine pooled effect estimates for frailty prevalence, symptom severity, and HRQOL scores.

RESULTS

A total of 26 studies involving older cancer survivors were included in the analysis. Most of these studies were conducted in Western countries and focused on White survivors, particularly those with breast cancer. The mean pooled prevalence of frailty was 43.5%. Among frail survivors, the most common symptoms reported after cancer treatments were pain (36.4%), neuropathy (34.1%), and fatigue (21.3%). Frailty was associated with higher pooled mean symptom severity (B = 1.23, p = 0.046) and lower functional HRQOL (B = - 0.31, p = 0.051, with marginal significance) after cancer treatments.

CONCLUSION

Frail older cancer survivors are at high risk of adverse symptoms and poor HRQOL after cancer treatment. Further research on screening for frailty is needed to prevent older adults from developing worse symptoms burden and maintain HRQOL. It is also essential to understand the mechanisms of the associations between frailty, symptoms and HRQOL in this population.

Prevalence and co-incidence of geriatric syndromes according to the ECOG performance status in older cancer patients

Background

Geriatric syndromes may be more common in older cancer patients than in those without cancer. Geriatric syndromes can cause poor clinical outcomes. The Eastern Cooperative Oncology Group Performance Status (ECOG-PS) is often used as a clinically reported functional status score in oncology practice.

Methods

Our study was designed as a cross-sectional study and included 218 older cancer patients. This study aimed to determine the prevalence and relationship of geriatric syndromes according to the ECOG-PS in older cancer patients.

Results

The mean age of 218 participants was 73.0 ± 5.6 years, with 47.7% being women and 52.3% men in our study. ECOG-PS 0, 1, and 2 groups contained 51, 39, and 10% of the patients, respectively. The mean number of geriatric syndromes in the ECOG 0, 1, and 2 groups was 2.3 ± 2.2, 4.3 ± 2.4, and 5.7 ± 2.1, respectively (p < 0.001). After adjusting for age and sex, it was determined that dynapenia was 2.9 times, probable sarcopenia was 3.5 times, frailty was 4.2 times, depression was 2.6 times, malnutrition was 3.3 times, insomnia 2 was.2 times, falls was 2.5 times, and the risk of falling (TUG) was 2.4 times more likely in those with ECOG-PS 1 compared to those with ECOG-PS 0. In addition, it was found that dynapenia was 6 times, probable sarcopenia was 6.8 times, frailty was 10.8 times, depression was 3.3 times, malnutrition was 6.3 times, the risk of falling (Tinnetti Balance) was 28 times, and the risk of falling (TUG) was 13.6 times more likely in those with ECOG-PS 2 compared to those with ECOG-PS 0.

Conclusion

Our study found that the prevalence of geriatric syndromes increased as the ECOG-PS increased. Geriatric syndromes and their co-incidence were common in older cancer patients, even in normal performance status. Oncologists should incorporate geriatric syndromes into the decision-making process of cancer treatment to maximize the impact on clinical outcomes in older patients with cancer.

Functional impairment is associated with medical debt in male cancer survivors and credit card debt in female cancer survivors

PURPOSE

To examine the associations of functional limitations with medical and credit card debt among cancer survivor families and explore sex differences in these associations.

METHODS

This cross-sectional study used data from the 2019 wave of the Panel Study of Income Dynamics, a nationally representative, population-based survey of individuals and households in the US administered in both English and Spanish and includes all households where either the head of household or spouse/partner reported having been diagnosed with cancer. Participants reported on functional limitations in six instrumental activities of daily living (IADL) and seven activities of daily living (ADL). Functional impairment was categorized as 0, 1-2 and ≥ 3 limitations. Medical debt was defined as self-reported unpaid medical bills. Credit card debt was defined as revolving credit card debt. Multivariable logistic regression analyses were performed.

RESULTS

Credit card debt was more common than medical debt (39.8% vs. 7.6% of cancer survivor families). Families of male cancer survivors were 7.3 percentage points more likely to have medical debt and 16.0 percentage points less likely to have credit card debt compared to families of female cancer survivors. Whereas male cancer survivors with increasing levels of impairment were 24.7 percentage point (p-value = 0.006) more likely to have medical debt, female survivors with more functional impairment were 13.6 percentage points (p-value = 0.010) more likely to have credit card debt.

CONCLUSIONS

More research on medical and credit card debt burden among cancer survivors with functional limitations is needed.

Integration of geriatric assessment into clinical oncology practice: A scoping review

Sixty percent of newly diagnosed cancers occur in older adults and more complex planning is required to sustain quality care for older populations. Individualized care incorporating geriatric assessment can predict early mortality and treatment toxicity for older cancer patients. We mapped and summarized the available evidence on the integration of geriatric assessment into clinical oncology practice, and ascertained which domains have been implemented. We systematically searched bibliographic databases and trial registries for reports of clinical studies, clinical practice guidelines, systematic and non-systematic reviews, and grey literature published in English. We gathered data on study characteristics, geriatric domains and strategies evaluated, and relevant study objectives and findings. From a total of 10,124 identified citations, 38 articles met our eligibility criteria, 3 of which were clinical practice guidelines. Nearly half of these articles came from the United States. Domains of the geriatric assessment implemented in studies ranged from 1 to 12, with varied combinations. We identified 27 studies on strategies for implementing geriatric assessment and 24 studies on feasibility of implementing geriatric assessment, into clinical oncology practice. We also identified 3 main geriatric assessment models: 2 from the United States and 1 from Australia. Furthermore, we identified 2 reviews that reported varied components of geriatric assessment models. There is increasingly robust evidence to implement formal geriatric assessment in oncology practice. There remains a great deal of variation in the tools recommended to address each of the domains in a geriatric assessment, with only 1 guideline (American Society of Clinical Oncology guideline) settling on a specific best practice. Protocol registration: Open Science Framework osf.io/mec93.

Predictive Value of Comprehensive Geriatric Assessment on Early Postoperative Complications Following Lumbar Spinal Stenosis Surgery: A Prospective Cohort Study

STUDY DESIGN

Prospective cohort study.

OBJECTIVE

The aim of this study was to evaluate the predictive value of comprehensive geriatric assessment (CGA) for early postoperative complications in elderly patients (aged 65 years or older) following lumbar spinal stenosis surgery.

SUMMARY OF BACKGROUND DATA

CGA is a multidisciplinary evaluation modality proven to be effective in various fields of geriatrics. However, limited evidence exists on the effectiveness of CGA in lumbar spinal stenosis patients in the literature.

METHODS

We prospectively enrolled consecutive patients who were at least 65 years' old and were scheduled to undergo elective surgery for lumbar spinal stenosis. One day before the operation, multidomain CGA was performed on the patient's functional status, comorbidities, nutrition, cognition, and psychological status. Patients with deficits in three or more CGA domains were defined as frail. The occurrence of postoperative complications (Clavien and Dindo grade 2 or higher) within 30 days after the surgery was assessed as the outcome. The predictive value of CGA was evaluated using crosstab and logistic regression analysis and compared to that of other risk stratification systems, including modified Frailty Index-5, -11, and American Society of Anesthesiologists Physical Classification System.

RESULTS

A total of 261 patients were included in the study, and 25 (9.6%) patients were assigned to the "frail" group. There were 27 (10.3%) patients with a postoperative complication (general: n = 20, 7.7%, surgical: n = 7, 2.7%) within postoperative 30 days. Patients with a complication showed significantly more deficits on preoperative CGA than those without complications (P = 0.004). On multivariate logistic regression analysis, frailty based on CGA (odds ratio = 3.51, P = 0.031) and the modified Frailty Index-11 (odds ratio = 3.13, P = 0.038) were associated with the occurrence of general complications.

CONCLUSION

Frailty based on CGA was significantly associated with early general complications following surgery for lumbar spinal stenosis in patients older than 65 years.

LEVEL OF EVIDENCE

2.

Polypharmacy, Inappropriate Medication Use, and Drug Interactions in Older Korean Patients with Cancer Receiving First-Line Palliative Chemotherapy

BACKGROUND

Polypharmacy is an important issue in the care of older patients with cancer, as it increases the risk of unfavorable outcomes. We estimated the prevalence of polypharmacy, potentially inappropriate medication (PIM) use, and drug-drug interactions (DDIs) in older patients with cancer in Korea and their associations with clinical outcomes.

SUBJECTS, MATERIALS, AND METHODS

This was a secondary analysis of a prospective observational study of geriatric patients with cancer undergoing first-line palliative chemotherapy. Eligible patients were older adults (≥70 years) with histologically diagnosed solid cancer who were candidates for first-line palliative chemotherapy. All patients enrolled in this study received a geriatric assessment (GA) at baseline. We reviewed the daily medications taken by patients at the time of GA before starting chemotherapy. PIMs were assessed according to the 2015 Beers criteria, and DDIs were assessed by a clinical pharmacist using Lexi-comp Drug Interactions. We evaluated the association between polypharmacy and clinical outcomes including treatment-related toxicity, and hospitalization using logistic regression and Cox regression analyses.

RESULTS

In total, 301 patients (median age 75 years; range, 70-93) were enrolled; the most common cancer types were colorectal cancer (28.9%) and lung cancer (24.6%). Mean number of daily medications was 4.7 (±3.1; range, 0-14). The prevalence of polypharmacy (≥5 medications) was 45.2% and that of excessive polypharmacy (≥10 medications) was 8.6%. PIM use was detected in 137 (45.5%) patients. Clinically significant DDIs were detected in 92 (30.6%) patients. Polypharmacy was significantly associated with hospitalization or emergency room (ER) visits (odds ratio: 1.73 [1.18-2.55], p < .01). Neither polypharmacy nor PIM use showed association with treatment-related toxicity.

CONCLUSION

Polypharmacy, PIM use, and potential major DDIs were prevalent in Korean geriatric patients with cancer. Polypharmacy was associated with a higher risk of hospitalization or ER visits during the chemotherapy period.

IMPLICATIONS FOR PRACTICE

This study, which included 301 older Korean patients with cancer, highlights the increased prevalence of polypharmacy in this population planning to receive palliative chemotherapy. The prevalence of polypharmacy and excessive polypharmacy was 45.2% and 8.6%, respectively. The prescription of potentially inappropriate medications (PIMs) was detected in 45.5% and clinically significant drug-drug interaction in 30.6% of patients. Given the association of polypharmacy with increased hospitalization or emergency room visits, this study points to the need for increased awareness and intervention to minimize polypharmacy in the geriatric cancer population undergoing chemotherapy. Moreover, specific criteria for establishing PIMs should be adopted for the treatment of older adults with cancer.

Frailty identified by geriatric assessment is associated with poor functioning, high symptom burden and increased risk of physical decline in older cancer patients: Prospective observational study

BACKGROUND:

Maintaining quality of life including physical functioning is highly prioritized among older cancer patients. Geriatric assessment is a recommended approach to identify patients with increased vulnerability to stressors (frailty). How frailty affects quality of life and physical functioning in older cancer patients has scarcely been investigated.

AIM:

Focusing on physical functioning and global quality of life, we investigated whether frailty identified by a geriatric assessment was associated with higher risk of quality-of-life deterioration during cancer treatment and follow-up.

DESIGN:

Prospective, observational study. Patients were classified as frail or non-frail by a modified geriatric assessment. Quality of life was measured using the European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire at inclusion, 2, 4, 6 and 12 months.

SETTING:

Eight Norwegian outpatient cancer clinics.

PARTICIPANTS:

Patients ⩾70 years with solid tumours referred for palliative or curative systemic medical cancer treatment.

RESULTS:

Among 288 patients included, 140 (49%) were frail and 148 (51%) non-frail. Frail patients consistently reported poorer scores on all functioning and symptom scales. Independent of age, gender and major cancer-related factors, frail patients had significantly poorer physical functioning and global quality of life during follow-up, and opposed to non-frail patients they had both a clinically and statistically significant decline in physical functioning from baseline until 12 months.

CONCLUSIONS:

Geriatric assessment identifies frail patients with increased risk of physical decline, poor functioning and high symptom burden during and following cancer treatment. Frail patients should therefore receive early supportive or palliative care.

Prospective Validation of The Korean Cancer Study Group Geriatric Score (KG)-7, a Novel Geriatric Screening Tool, in Older Patients with Advanced Cancer Undergoing First-line Palliative Chemotherapy

Purpose

The purpose of this study was to prospectively validate the Korean Cancer Study Group Geriatric Score (KG)-7, a novel geriatric screening tool, in older patients with advanced cancer planned to undergo first-line palliative chemotherapy.

Materials and Methods

Participants answered the KG-7 questionnaire before undergoing geriatric assessment (GA) and first-line palliative chemotherapy. The performance of KG-7 was evaluated by calculating the sensitivity (SE), specificity (SP), positive and negative predictive value (PPV and NPV), balanced accuracy (BA), and area under the curve (AUC).

Results

The baseline GA and KG-7 results were collected from 301 patients. The median age was 75 years (range, 70 to 93 years). Abnormal GA was documented in 222 patients (73.8%). Based on the ≤ 5 cut-off value of KG-7 for abnormal GA, abnormal KG-7 score was shown in 200 patients (66.4%). KG-7 showed SE, SP, PPV, NPV, and BA of 75.7%, 59.7%, 84.4%, 46.0%, and 67.7%, respectively; AUC was 0.745 (95% confidence interval, 0.687 to 0.803). Furthermore, patients with higher KG-7 scores showed significantly longer survival (p=0.006).

Conclusion

KG-7 appears to be adequate in identifying patients with abnormal GA prospectively. Hence, KG-7 can be a useful screening tool for Asian countries with limited resources and high patient volume.

[What is the role of the comprehensive geriatric assessment in Geriatric Oncology?]

The growing increase in world population and generalised aging have been accompanied by an increase in the prevalence of cancer in the elderly. Aging is associated with certain physiological changes, some of which are enhanced by the neoplasm itself. Along with this, the elderly oncology patient usually has more problems than the rest of the elderly, and has a multitude of deficits. These characteristics require a special handling of the older patient with cancer, by using the main tool used in Geriatrics, the comprehensive geriatric assessment. This article analyses the importance of the comprehensive geriatric assessment in this population group, paying special attention to its ability to predict the toxicity of chemotherapy and the survival of the elderly oncology, as well as its ability to classify these patients into groups that help in the decision making process.

Chemotherapy in older adult gynecologic oncology patients: Can a phenotypic frailty score predict tolerance?

OBJECTIVE

Evaluate the ability of an office-administered phenotypic frailty assessment to predict chemotherapy tolerance in older adult gynecologic oncology patients, and describe practice patterns for chemotherapy administration in this population.

METHODS

Prospective, single-institution cohort study of gynecologic oncology patients 65 or older initiating chemotherapy. Phenotypic frailty testing at an office visit encompassed components of two validated frailty assessments: Fried Score (physical testing and patient response) and FRAIL Scale (patient response only). Patients were followed through three cycles of neoadjuvant chemotherapy or six cycles of adjuvant chemotherapy. Standard statistics examined the relationship of frailty to chemotherapy regimen, ability to complete chemotherapy, and complications.

RESULTS

Eighty patients were included, 65% with ovarian and 34% with endometrial cancer. On average 57% of patients were fit, 32% intermediately frail, and 11% frail. 68% received adjuvant chemotherapy versus 32% neoadjuvant. The majority (81%) received IV chemotherapy on a 21-day cycle and 81% initially received a regimen consistent with standard-of-care chemotherapy (SOCC). Age was not associated with receiving SOCC, or tolerance or completion of chemotherapy. Frailty was associated with non-initiation of SOCC in all patients and inability to complete SOCC in adjuvant patients. Complications and regimen alterations were common but were not associated with frailty.

CONCLUSIONS

There is a need to develop tools to help physicians predict chemotherapy tolerance among older adult gynecologic oncology patients in order to prevent both under- and over-treatment while minimizing morbidity. However, in this study phenotypic frailty assessment had limited predictive utility. Among adjuvant chemotherapy patients, frailty was associated with inability to complete SOCC and thus may be helpful in selecting patients appropriate for less aggressive chemotherapy regimens.

Quality of life of older adults with cancer in Korea

This study examines the quality of life (QoL) of older adults with cancer (N = 176), by comparing them with age- and gender-matched groups without cancer (N = 176), and investigates factors associated with their QoL. The results of Medical Outcome Study Short Form-36 (MOS SF-36) showed that the study group had significantly lower scores than the noncancer group on all eight scales and on the Physical Component Summary and the Mental Component Summary. Comparison with gender and age groups revealed some differences. Optimism and social support were positively related to QoL while comorbidity, cancer-related concerns, and financial worries were inversely related.

Charlson Comorbidity Index Is Related to Organ Damage in Systemic Lupus Erythematosus: Data from KORean lupus Network (KORNET) Registry

OBJECTIVE

The aim of this study was to identify whether comorbidity status is associated with organ damage in patients with systemic lupus erythematosus (SLE).

METHODS

A total of 502 patients with SLE enrolled in the KORean lupus Network were consecutively recruited. Data included demographics, age-adjusted Charlson Comorbidity Index (CCIa), disease activity indexes, the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI), the Medical Outcomes Study Short Form-36 health survey (SF-36) score, and the Beck Depression Inventory (BDI) score.

RESULTS

Of the total patients, 21.1% (n = 106) experienced organ damage (SDI ≥ 1). Univariate correlation analysis revealed that SDI was not statistically correlated with any clinical variables (correlation coefficient r < 0.3 of all). There were significant differences in the BDI, mental component score of the SF-36, Systemic Lupus Erythematosus Disease Activity Index (SLEDAI), CCIa, C-reactive protein, and mean dose of corticosteroid between non-damage (SDI = 0) and damage (SDI ≥ 1) groups. The presence of damage to at least 1 organ in patients with SLE was found to be closely related with higher CCIa, higher SLEDAI, and mean dose of corticosteroid (OR 1.884, 95% CI 1.372-2.586, p < 0.001; OR 1.114, 95% CI 1.041-1.192, p = 0.002; OR 1.036, 95% CI 1.004-1.068, p = 0.026; respectively) in binary logistic regression analysis.

CONCLUSION

This study suggests that organ damage as assessed by the SDI in Korean patients with SLE is related to comorbidities together with disease activity and corticosteroid exposure.

Predicting cumulative incidence of adverse events in older patients with cancer undergoing first-line palliative chemotherapy: Korean Cancer Study Group (KCSG) multicentre prospective study

Background

Older patients have increased risk of toxicity from chemotherapy. Current prediction tools do not provide information on cumulative risk.

Methods

Patients aged ≥ 70 years with solid cancer were prospectively enrolled. A prediction model was developed for adverse events (AEs) ≥ Grade 3 (G3), based on geriatric assessment (GA), laboratory, and clinical variables.

Results

301 patients were enrolled (median age, 75 years). Median number of chemotherapy cycles was 4. During first-line chemotherapy, 53.8% of patients experienced AEs ≥ G3. Serum protein < 6.7 g/dL, initial full-dose chemotherapy, psychological stress or acute disease in the past 3 months, water consumption < 3 cups/day, unable to obey a simple command, and self-perception of poor health were significantly related with AEs ≥ G3. A predicting model with these six variables ranging 0–8 points was selected with the highest discriminatory ability (c-statistic= 0.646), which could classify patients into four risk groups. Predicted cumulative incidence of AEs ≥ G3 was discriminated according to risk groups.

Conclusions

This prediction tool could identify the risk of AEs ≥ G3 after chemotherapy and provide information on the cumulative incidence of AEs in each cycle.

Clinical Trial Id

WHO ICTRP number, KCT0001071

Is Frailty a Modifiable Risk Factor of Future Adverse Outcomes in Elderly Patients with Incident End-Stage Renal Disease?

Little is known about the clinical significance of frailty and changes of frailty after dialysis initiation in elderly patients with end-stage renal disease (ESRD). We prospectively enrolled 46 elderly patients with incident ESRD at a dialysis center of a tertiary hospital between May 2013 and March 2015. Frailty was assessed by using a comprehensive geriatric assessment protocol and defined as a multidimensional frailty score of ≥ 10. The main outcome was the composite of all-cause death or cardiovascular hospitalization, as determined in June 2016. The median age of the 46 participants was 71.5 years, and 63.0% of them were men. During the median 17.7 months follow-up, the rate of composite outcome was 17.4%. In multivariate logistic regression analysis, after adjusting for age, sex, diabetes, body mass index (BMI), and time of predialytic nephrologic care, female sex, and increased BMI were associated with increased and decreased odds of frailty, respectively. In multivariate Cox proportional hazards analysis, after adjusting for age, sex, diabetes, BMI, and time of predialytic nephrologic care, frailty was significantly associated with the composite adverse outcome. In repeated frailty assessments, the multidimensional frailty score significantly improved 12 months after the initiation of dialysis, which largely relied on improved nutrition. Therefore, frailty needs to be assessed for risk stratification in elderly patients with incident ESRD.

Use of the frailty index in evaluating the prognosis of older people in Beijing: A cohort study with an 8-year follow-up

OBJECTIVE

Frailty is a significant healthcare challenge in China. However, the relationship between frailty and the prognosis of older people in China remains unclear. The present study aimed to evaluate the prevalence of frailty and determine if the frailty index, a comprehensive geriatric assessment, was associated with the prognosis of older people in a Chinese population.

METHODS

Data were drawn from the Beijing Longitudinal Study of Aging, a representative cohort study with an 8-year follow-up. Evaluations based on the use of the frailty index were performed in a cohort of 1808 people aged 60 years and over residing in Beijing urban and rural areas. The initial survey was conducted in 2004, with follow-up surveys at 3, 5, and 8 years. Mortality data for all individuals were collected and analyzed.

RESULTS

The frailty index and the age of individuals showed the same trend, with a higher frailty index expected as age increased. Respondents with the same frailty index level differed across factors such as sex and location. Male individuals, rural dwellers, and older individuals showed higher frailty rates than female individuals, urban dwellers, and younger individuals.

CONCLUSIONS

Frailty is a condition associated with problems across multiple physiological systems. The frailty index increases with age, and may be a significant tool for evaluation of the prognosis of older people in China.

A Novel Geriatric Screening Tool in Older Patients with Cancer: The Korean Cancer Study Group Geriatric Score (KG)-7

Geriatric assessment (GA) is resource-consuming, necessitating screening tools to select appropriate patients who need full GA. The objective of this study is to design a novel geriatric screening tool with easy-to-answer questions and high performance objectively selected from a large dataset to represent each domain of GA. A development cohort was constructed from 1284 patients who received GA from May 2004 to April 2007. Items representing each domain of functional status, cognitive function, nutritional status, and psychological status in GA were selected according to sensitivity (SE) and specificity (SP). Of the selected items, the final questions were chosen by a panel of oncologists and geriatricians to encompass most domains evenly and also by feasibility and use with cancer patients. The selected screening questions were validated in a separate cohort of 98 cancer patients. The novel screening tool, the Korean Cancer Study Group Geriatric Score (KG)-7, consisted of 7 items representing each domain of GA. KG-7 had a maximal area under the curve (AUC) of 0.93 (95% confidence interval (CI) 0.92−0.95) in the prediction of abnormal GA, which was higher than that of G-8 (0.87, 95% CI 0.85–0.89) within the development cohort. The cut-off value was decided at ≤ 5 points, with a SE of 95.0%, SP of 59.2%, positive predictive value (PPV) of 85.3%, and negative predictive value (NPV) of 82.6%. In the validation cohort, the AUC was 0.82 (95% CI 0.73−0.90), and the SE, SP, PPV, and NPV were 89.5%, 48.6%, 77.3%, and 75.0%, respectively. Furthermore, patients with higher KG-7 scores showed significantly longer overall survival (OS) in the development and validation cohorts. In conclusions, the KG-7 showed high SE and NPV to predict abnormal GA. The KG-7 also predicted OS. Given the results of our studies, the KG-7 could be used effectively in countries with high patient burden and low resources to select patients in need of full GA and intervention.

Treating gynecologic malignancies in elderly patients

AIM

To determine the relative benefits of full and partial treatment for gynecologic malignancies in elderly patients.

METHODS

A retrospective cohort study of all consecutive patients (n=169) aged 79 and older (median age 82 y; range, 79 to 94 y), diagnosed between 1971 and 2007 with various types of gynecologic malignancies (endometrial, 52%; ovarian, 26%; vulvar, 11%; cervical, 5%; other, 6%) was conducted. Stages were I to II (47%), III to IV (35.5%), and unknown (17.5%). Major comorbidities were hypertension (51%), diabetes (17%), cardiac diseases (34%), and other malignancy (12%). Regardless of age or chronic illnesses, patients were grouped on the basis of having been treated optimally (100 patients; 59.2%), defined as the accepted standard for each diagnosis and stage including surgery and adjuvant radiation or chemotherapy as indicated; or suboptimally (69 patients; 40.8%), that is, no or only partial treatment. Kaplan-Meier survival analysis and Cox proportional hazard models, univariate and multivariable were conducted.

RESULTS

For all patients with suboptimal treatment, the age-and-stage-adjusted hazard ratio for death was 1.76 (95% CI, 1.203-2.570; P=0.004) compared with optimal treatment. Age-adjusted hazard ratio was 2.15 (95% CI, 1.127-4.114; P=0.02) and 2.3 (95% CI, 1.415-3.779; P=0.001) for ovarian and endometrial cancer patients, respectively. Age-adjusted and stage-adjusted hazard ratio was 2.8 (95% CI, 1.099-5.157; P=0.028) and 1.53 (95% CI, 0.867-2.702; P=0.1420) for ovarian and endometrial cancer patients, respectively.

CONCLUSIONS

Optimal treatment in patients with gynecologic malignancies evidently improves survival in elderly patients at any age, and in patients with ovarian cancer at any stage. Regardless of chronological age, the aim should be to deliver optimal treatment.

Characteristics and treatment options of elderly Chinese patients with cancer as determined by Comprehensive Geriatric Assessment (CGA)

OBJECTIVE

China is experiencing a rapid increase in cancer incidence in elderly patients. In order to better understand this group, a large study of patients from multiple tertiary centers in the Beijing area was designed. This study was designed to provide insight into their unique treatment preferences, including the use of traditional Chinese medicine (TCM).

MATERIALS AND METHODS

803 patients from nine hospitals in the Beijing area were enrolled into this study. The inclusion criteria were patients who were 65 years or older and had a diagnosis of cancer at any stage. The CGA questionnaire used with these patients included the Chinese translation of the Gero-Oncology Health and Quality of Life Assessment tool. The questionnaire was provided to patients by a research nurse and was administered in Mandarin.

RESULTS

The mean age of the patients was 72 years (range 65-94). The patients were mainly male (59.8%) and of Han ethnicity (95.4%). About 45% of these patients also had concurrent TCM in addition to their other cancer treatments. About 70% were able to manage their activities of daily living without assistance. Patients on TCM were more likely to have higher number of co-morbidities compared to their counterparts.

CONCLUSION

This is the largest prospective study of CGA assessments done on elderly patients with cancer in Asia. The study demonstrates that CGA provides insights into understanding the needs of elderly Chinese patients with cancer. TCM is used frequently in China, and its impact on quality of life needs further investigation.

The early discontinuation of palliative chemotherapy in older patients with cancer

PURPOSE

Older patients with cancer may have an increased risk of early discontinuation of active treatment (ED), which results in poor outcome in curative or adjuvant settings. We aimed to determine the association between survival and ED and to identify predictors of ED in palliative setting.

METHODS

Ninety-eight patients older than 65 years of age who received a comprehensive geriatric assessment (CGA) before palliative first-line chemotherapy were analyzed. Clinical information and CGA results were retrieved from electronic medical record. CGA included Charlson's co-morbidity index, activities of daily living (ADL), instrumental ADL (IADL), Mini-Mental Status Examination, short-form of the geriatric depression scale, timed-get-up-and-go test (TGUG), and mini-nutritional assessment (MNA). ED was defined as no active cancer treatment (radiotherapy and/or chemotherapy) beyond palliative first-line chemotherapy. Predictors of ED were identified using clinical parameters and CGA.

RESULTS

Active treatment was discontinued after first-line chemotherapy in 30 patients during median follow-up period of 15.1 months. ED after first-line chemotherapy was associated with shorter overall survival (OS; median OS = 3.1 vs. 14.7 months in patients with ED compared with patients without ED, p < 0.001). Eastern Cooperative Oncology Group performance status, living alone, ADL, IADL, MNA, and TGUG were associated with ED (p = 0.001, p = 0.048, p = 0.001, p < 0.001, p < 0.001, p = 0.002, respectively). In multivariable analysis, malnutrition and dependent IADL were the independent predictive factors for ED (odds ratio = 5.03; 95 % confidence interval = 1.50-16.87: odds ratio = 3.06; confidence interval = 1.03-9.12, respectively).

CONCLUSIONS

ED was associated with shorter OS in older patients with cancer. Malnutrition and dependent IADL were identified as independent predictive factors for ED.

Cancer physicians' attitude towards treatment of the elderly cancer patient in a developed Asian country

Background

With an aging population and an increasing number of elderly patients with cancer, it is essential for us to understand how cancer physicians approach the management and treatment of elderly cancer patients as well as their methods of cancer diagnosis disclosure to older versus younger patients in Singapore, where routine geriatric oncology service is not available.

Methods

57 cancer physicians who are currently practicing in Singapore participated in a written questionnaire survey on attitudes towards management of the elderly cancer patient, which included 2 hypothetical clinical scenarios on treatment choices for a fit elderly patient versus that for a younger patient.

Results

The participants comprised of 68% medical oncologists, 18% radiation oncologists, and 14% haematologists. Most physicians (53%) listed performance status (PS) as the top single factor affecting their treatment decision, followed by cancer type (23%) and patient’s decision (11%). The top 5 factors were PS (95%), co-morbidities (75%), cancer stage (75%), cancer type (75%), patient’s decision (53%), and age (51%). 72% of physicians were less likely to treat a fit but older patient aggressively; 53% and 79% opted for less intensive treatments for older patients in two clinical scenarios of lymphoma and early breast cancer, respectively. 37% of physicians acknowledged that elderly cancer patients were generally under-treated.

Only 9% of physicians chose to disclose cancer diagnosis directly to the older patient compared to 61% of physicians to a younger patient, citing family preference as the main reason. Most participants (61%) have never engaged a geriatrician’s help in treatment decisions, although the majority (90%) would welcome the introduction of a geriatric oncology programme.

Conclusions

Advanced patient age has a significant impact on the cancer physician’s treatment decision-making process in Singapore. Many physicians still accede to family members’ request and practice non-disclosure of cancer diagnosis to geriatric patients, which may pose as a hurdle to making an informed decision regarding management for the geriatric cancer patients. Having a formal geriatric oncology programme in Singapore could potentially help to optimize the management of geriatric oncology patients.

Comprehensive geriatric assessment can predict postoperative morbidity and mortality in elderly patients undergoing elective surgery

The proportion of elderly patients who undergo surgery has rapidly increased; however, clinical indicators predicting outcomes are limited. Our aim was to evaluate the significance of comprehensive geriatric assessment (CGA) in elderly patients undergoing elective surgery. We studied 141 consecutive elderly patients (age: 78.0±6.5 years old, male: 41.1%) who were referred to our geriatric department for surgical risk evaluation. CGA was performed to evaluate physical health, functional status, psychological health, and social support. The primary composite outcome of this study was in-hospital death or post-discharge institutionalization. In-hospital adverse events, such as delirium, pressure ulcers, pneumonia, and urinary tract infections, were also evaluated. The associations between CGA and in-hospital adverse events, in-hospital death, and post-discharge institutionalization were investigated. There were 32 adverse outcomes (6 in-hospital deaths and 26 post-discharge institutionalizations). Compared with the patients who were discharged to their homes, patients with adverse outcomes were characterized by poor nutritional status and prior strokes. However, there was no significant difference in surgical risk or anesthesia type. The CGA results showed that patients with adverse outcomes were associated with functional dependency and poor nutrition. The cumulative number of impairments in the CGA domain was significantly associated with adverse outcomes, in-hospital events, and prolonged hospital stays. In multiple logistic regression analysis, cumulative impairment in CGA was independently associated with surgical outcomes in elderly patients undergoing elective surgery. Preoperative CGA can identify elderly patients at greater risk for mortality, post-discharge institutionalization, adverse in-hospital events, and prolonged length of hospital stay.

Use of geriatric assessment for older adults in the oncology setting: a systematic review

BACKGROUND

Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult's medical, psychological, social, and functional capacity. No systematic review of the use of geriatric assessment in oncology has been conducted. The goals of this systematic review were: 1) to provide an overview of all geriatric assessment instruments used in the oncology setting; 2) to examine the feasibility and psychometric properties of those instruments; and 3) to systematically evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes (including the impact on treatment decision making, toxicity of treatment, and mortality).

METHODS

We searched Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library for articles published in English, French, Dutch, or German between January 1, 1996, and November 16, 2010, reporting on cross-sectional, longitudinal, interventional, or observational studies that assessed the feasibility or effectiveness of geriatric assessment instruments. The quality of articles was evaluated using relevant quality assessment frameworks.

RESULTS

We identified 83 articles that reported on 73 studies. The quality of most studies was poor to moderate. Eleven studies examined psychometric properties or diagnostic accuracy of the geriatric assessment instruments used. The assessment generally took 10-45 min. Geriatric assessment was most often completed to describe a patient's health and functional status. Specific domains of geriatric assessment were associated with treatment toxicity in 6 of 9 studies and with mortality in 8 of 16 studies. Of the four studies that examined the impact of geriatric assessment on the cancer treatment decision, two found that geriatric assessment impacted 40%-50% of treatment decisions.

CONCLUSION

Geriatric assessment in the oncology setting is feasible, and some domains are associated with adverse outcomes. However, there is limited evidence that geriatric assessment impacted treatment decision making. Further research examining the effectiveness of geriatric assessment on treatment decisions and outcomes is needed.

Mini nutritional assessment

PURPOSE OF REVIEW

To summarize recent evidences and advances on the implementation and the use of the Mini Nutritional Assessment (MNA).

RECENT FINDINGS

Despite being introduced and validated for clinical use about 20 years ago, the MNA has recently received new attention in order to more widely disseminate among healthcare professionals the practice of a systematic nutritional screening and assessment of the old patient. Particularly, the structure has been implemented to face the difficulties in having the patients contributing to the assessment and to reduce further the time required to complete the evaluation. Recent data also confirm that in older populations prevalence of malnutrition by this tool is associated with the level of dependence. The rationale of nutritional assessment is to identify patients candidate to nutritional support. However, the sensitivity of the MNA is still debated because it has been associated with a high-risk 'overdiagnosis' and the advantages of a positive screening need to be assessed both in terms of outcome and money saving.

SUMMARY

The MNA is a simple and highly sensitive tool for nutritional screening and assessment. The large mass of data collected and the diffusion among healthcare professionals clearly support its use. However, the cost-effectiveness of interventions based on its scoring deserves investigation.

Comprehensive geriatric assessment and its clinical impact in oncology

The sum of these intervention studies suggests that a CGA can be performed in a variety of settings (inpatient, outpatient, or home), is a multidisciplinary effort, and can lead to interventions that may decrease the risk of morbidity and mortality in older patients with cancer. Further studies are needed using a CGA to (1) guide and test interventions to improve the care of older adults with cancer and (2) evaluate the impact of cancer therapy on geriatric assessment domains.

Comparison of safety and efficacy of S-1 monotherapy and S-1 plus cisplatin therapy in elderly patients with advanced gastric cancer

BACKGROUND

Although S-1 plus cisplatin (SP) therapy is recognized as the standard treatment for advanced gastric cancer (AGC) in Japan, its safety and efficacy in elderly patients have not been investigated sufficiently.

METHODS

We retrospectively reviewed the data of 58 patients with AGC selected from 82 consecutive patients who were ≥70 years old and were treated with SP or S-1 monotherapy as the first-line therapy. In SP, S-1 (40 mg/m(2), bid) was administered for 3 weeks and cisplatin (60 mg/m(2)) on day 8, every 5 weeks. In S-1 monotherapy, S-1 (40 mg/m(2), bid) was administered for 4 weeks, every 6 weeks.

RESULTS

SP and S-1 was administered in 21 and 37 patients, respectively. There were some differences in patient characteristics between the treatment groups, such as histological type (P = 0.16); the presence of liver metastasis (P = 0.07); and the presence of peritoneal metastasis (P = 0.02). The incidences of grade 3/4 hematological toxicities were 57% (12/21) in the SP and 35% (13/37) in the S-1 group (P = 0.17). Those of non-hematological toxicities were 14% (3/21) and 14% (5/37) for anorexia, 10% (2/21) and 14% (5/37) for fatigue, and 5% (1/21) and 5% (2/37) for nausea in the SP and S-1 groups, respectively. Median progression-free survival and median overall survival in the SP and S-1 groups were 5.0 and 5.2 months, and 14.4 and 10.9 months, respectively.

CONCLUSION

SP and S-1 therapy were both feasible in elderly patients, though there is the risk of a high incidence of hematological toxicities.

Charlson Comorbidity Index is an independent prognostic factor among elderly patients with diffuse large B-cell lymphoma

PURPOSE

The clinical outcome for elderly patients with diffuse large B-cell lymphoma (DLBCL) has improved. However, the management of elderly patients with cancer is frequently complicated by their coexisting disorders. The aim of this study was to evaluate the correlation between comorbid medical status and clinical outcome among elderly patients with DLBCL.

METHODS

We retrospectively analyzed all patients over 65 years old with newly diagnosed DLBCL from 2001 to 2008 in our institution. To assess their comorbid medical status, we calculated Charlson Comorbidity Index (CCI) of each patient without considering primary disease and then divided them into low CCI (0 or 1) or high CCI group (2 or more).

RESULTS

A total of 80 patients from age of 66-90 years (median 73 years) were analyzed. Seventy-two patients (90%) were treated with cyclophosphamide-, doxorubicin-, vincristine-, and prednisone (CHOP)-based chemotherapy, and 14 patients (18%) were assigned to high CCI. The overall survival (OS) rate at 3 years for all patients was 70%, with significant difference between good and poor risk patients in revised International Prognostic Index (IPI) (90 vs. 45%, P < 0.0001). Multivariate analysis revealed high CCI was associated with worse OS, while independent of other prognostic factors consisting IPI (hazard ratio 4.44, 95% confidence interval [1.63-11.3], P = 0.0045). In addition, high CCI group was significantly inferior to low CCI group for overall response rate (93 vs. 64% P = 0.0158) and 3-year OS (85 vs. 55% P = 0.0026), respectively.

CONCLUSIONS

Among elderly DLBCL, high CCI was independently associated with worse outcome. Novel discrete strategies for these deteriorated patients are therefore warranted.