Impact of an oncogeriatric consulting team on therapeutic decision-making

Perioperative disabilities in activities of daily living are associated with worse prognosis after hepatectomy for colorectal liver metastasis

BACKGROUND

The number of vulnerable patients with colorectal liver metastasis (CRLM) has increased. This study aimed to clarify the relationship between perioperative activities of daily living (ADL) and clinical outcomes after hepatectomy for CRLM.

METHODS

Consecutive patients undergoing resection of CRLM from 2004 to 2020 were included. Pre- or postoperative ADL was evaluated according to Barthel index (BI) scores, which range from 0 to 100. Higher scores represent greater level of independence in ADL. Pre- or postoperative BI scores of ≤85 were defined as perioperative disabilities in ADL. Multivariable Cox proportional hazard regression models were utilised to estimate adjusted hazard ratios (HRs) and confidence interval (CI).

RESULTS

A total of 218 patients were included, 16 (7.3%) revealed preoperative BI scores of ≤85, and 32 (15%) revealed postoperative BI scores of ≤85. In multivariate analyses, the perioperative disabilities in ADL were independently associated with shorter overall survival (HR, 1.96; 95% CI, 1.10-3.31; P = 0.023) and cancer-specific survival (HR, 2.31; 95% CI, 1.29-3.92; P = 0.006).

CONCLUSION

Perioperative disabilities in ADL were associated with poor prognosis following hepatectomy for CRLM. Improving preoperative vulnerability and preventing functional decline after surgery may provide a favourable prognosis for patients with CRLM.

Impairment of perioperative activities of daily living is associated with poor prognosis following hepatectomy for hepatocellular carcinoma

BACKGROUND

The number of cancer patients with impairment of activities of daily living (ADLs) has increased. This study aimed to examine associations of perioperative Barthel index score, a validated measure of ADLs, with survival outcomes following hepatectomy for hepatocellular carcinoma (HCC).

METHODS

We analyzed data of 492 consecutive patients who underwent hepatectomy for HCC between 2010 and 2018. Pre- and postoperative ADLs were assessed using the Barthel index (range, 0-100; higher scores indicate greater independence). Preoperative Barthel index score ≤85 or postoperative Barthel index score ≤85 was defined as impairment of perioperative ADLs. Cox proportional hazards regression was used to calculate hazard ratios (HRs) after adjusting for potential confounders.

RESULTS

Among the 492 patients, 26 (5.2%) had a preoperative Barthel index score ≤85 and 95 (19%) had a postoperative Barthel index score ≤85. Impairment of perioperative ADLs was independently associated with shorter overall survival (multivariable HR: 1.75, 95% confidence interval [CI]: 1.06-2.81, p = 0.028). The association of impairment of perioperative ADLs with recurrence-free survival was not statistically significant.

CONCLUSION

Impairment of perioperative ADLs is associated with poor prognosis following hepatectomy for HCC. Maintenance and improvement of perioperative ADLs would be important to provide favorable long-term outcomes in patients with HCC.

Impairment of Activities of Daily Living is an Independent Risk Factor for Recurrence and Mortality Following Curative Resection of Stage I-III Colorectal Cancer

BACKGROUND

With aging of the population, the number of colorectal cancer patients with impairment of activities of daily living (ADLs) has increased. The Barthel index is a validated tool for assessing functional levels of ADLs. In this retrospective study, we aimed to examine associations of Barthel index scores with recurrence and mortality after curative resection of colorectal cancer.

METHODS

We retrospectively analyzed data of 815 consecutive patients who had undergone curative resection of stage I-III colorectal adenocarcinoma between January 2009 and December 2017. Preoperative functional levels of ADLs were assessed prospectively using the Barthel index (range, 0 to 100; higher scores indicate greater independence). Recurrence-free survival (RFS) and overall survival (OS) were compared according to Barthel index scores. The Cox proportional hazards model was used to calculate hazard ratios (HRs), controlling for potential confounders.

RESULTS

Of the 815 patients, Barthel index scores were 40 or lower in 129 (16%), 41-85 in 110 (13%), and 86 or more in 576 (71%). In multivariable analyses adjusting for potential confounders including age and disease stage, scores of 85 or lower on the Barthel index were independently associated with shorter RFS (multivariable HR: 1.74, 95% confidence interval: 1.28-2.37, P<0.001) and OS (multivariable HR: 2.10, 95% confidence interval: 1.45-3.04, P<0.001).

CONCLUSIONS

Lower scores on the Barthel index are associated with shorter RFS and OS following resection of nonmetastatic colorectal cancer. Further studies are needed to establish treatment strategies for colorectal cancer patients with poor functional capacity.

Frailty is associated with poor prognosis after resection for pancreatic cancer

BACKGROUND

With population aging, the number of frail patients with pancreatic cancer has increased. The Clinical Frailty Scale (CFS) is a simple and validated tool to assess frailty, and higher scores predict worse clinical outcomes after cardiovascular surgery. In this retrospective study, we aimed to examine the association of preoperative frailty with prognosis after resection for pancreatic cancer.

METHODS

We retrospectively analyzed data from 142 consecutive patients undergoing resection for pancreatic cancer between April 2010 and December 2018. We used the CFS: 1 (very fit) to 9 (terminally ill) to assess frailty and examined associations of the CFS scores with recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS). Multivariable Cox proportional hazards models were used to calculate hazard ratios (HRs), controlling for potential confounders.

RESULTS

Of the 142 patients, 113 (80%) had CFS scores of ≤ 3, 13 (9.2%) scores of 4, and 16 (11%) scores of ≥ 5. Scores of ≥ 5 on the CFS were associated with worse CSS (univariable HR: 2.62, 95% confidence interval [CI]: 1.19-5.18, P = 0.019; multivariable HR: 2.49, 95% CI 1.05-5.34, P = 0.039) and OS (univariable HR: 2.42, 95% CI 1.19-4.46, P = 0.016; multivariable HR: 2.25, 95% CI 1.05-4.43, P = 0.038). The association between CFS scores and RFS was not significant in multivariable analysis (univariable HR: 2.11, 95% CI 1.08-3.79, P = 0.030; multivariable HR: 1.47, 95% CI 0.71-2.83, P = 0.29).

CONCLUSION

Higher scores on the CFS are associated with worse CSS and OS after resection for pancreatic cancer. Preoperative measurement of frailty may improve risk assessment among patients with pancreatic cancer.

Impact of a comprehensive geriatric assessment on decision-making in older patients with hematological malignancies

OBJECTIVE

Hematological treatment decisions in older adults with hematological malignancies are complex. Our objective is to study the impact of a comprehensive geriatric assessment on hematological treatment decision in older patients and the factors associated with change in treatment plan.

METHODS

We conducted a cross-sectional analysis of patients aged 65 years and above with hematological malignancies, hospitalized between 2008 and 2019 at the University Cancer Institute of Toulouse. They were assessed by a geriatrician/nurse team using a comprehensive geriatric assessment (CGA). A penalized logistic regression model with elastic net regularization was used to identify factors associated with change in hematological treatment plan.

RESULTS

A total of 424 patients were included. Main hematological malignancies were lymphoma (36.1 %), acute myeloid leukemia (26.9 %) and myelodysplastic syndrome (19.8%). Change in hematological treatment plan was suggested after CGA for 92 patients (21.7%). Factors associated with change in treatment plan were functional impairment according to ADL and IADL scale, mobility impairment, the presence of comorbidity defined by the Charlson score >1 and increasing age.

CONCLUSION

A CGA has a significant impact on hematological treatment decision in older patients. Functional and mobility impairment, comorbidities and age are predictive factors of change in treatment plan.

Frailty is an independent risk factor for recurrence and mortality following curative resection of stage I-III colorectal cancer

AIM

With population aging, the number of frail patients with colorectal cancer has increased. The Clinical Frailty Scale (CFS) is a validated tool for assessing frailty, and higher scores indicate worse clinical outcomes following cardiovascular procedures. This retrospective study aimed to examine preoperative frailty in relation to recurrence and mortality following curative resection of colorectal cancer.

METHODS

We retrospectively analyzed data for 729 consecutive patients undergoing curative resection of stage I-stage III colon and rectal adenocarcinoma between January 2009 and December 2016. Frailty was assessed using the CFS: 1 (very fit) to 9 (terminally ill), and frailty was defined as CFS ≥ 4. Recurrence-free survival (RFS) and overall survival (OS) were compared between frail and nonfrail patients. Cox proportional hazards model was used to calculate hazard ratios (HRs), controlling for potential confounders.

RESULTS

CFS score was negatively correlated with the Barthel index of activities of daily living (Spearman's ρ = -0.83). Of the 729 patients, 253 (35%) were frail. In multivariable analyses adjusting for potential confounders including age and disease stage, frailty was independently associated with shorter RFS (multivariable HR: 1.70, 95% confidence interval: 1.25-2.31, P < .001) and OS (multivariable HR: 2.04, 95% confidence interval: 1.40-2.99, P < .001). There were no significant interactions of frailty with age and disease stage regarding RFS and OS (P interaction > .72).

CONCLUSION

Preoperative frailty was independently associated with shorter RFS and OS following resection of nonmetastatic colorectal cancer, regardless of age and disease stage. Further trials are needed to establish treatment strategies for frail patients with colorectal cancer.

Interventions for older people having cancer treatment: A scoping review

OBJECTIVES

There is currently no overview of supportive interventions developed for older people having cancer treatment. The aims and objectives, methods, and outcomes of interest of existing supportive interventions have not been evaluated. To understand how health services might meet the needs of older people undergoing cancer treatment, a scoping review was undertaken to identify and characterise supportive interventions developed for this patient group.

MATERIALS AND METHODS

This scoping review examined supportive interventions (services, programs, tools or policies) applied during diagnosis or treatment that address physical, psychological, social or spiritual needs of older patients. A systematic search of the following electronic databases was undertaken August-October 2017 (updated March 2019): AMED; CINAHL; EMBASE; Medline; PsychINFO.

RESULTS

Sixty-two papers met the inclusion criteria. The review established that existing interventions to support older people having treatment for cancer are diverse in aim, and the evaluation methodology and outcome measure selection vary considerably. The interventions rarely target complex issues such as multimorbidity, frailty, or the impact of other geriatric syndromes in addition to cancer.

CONCLUSION

We suggest that future research should focus on patient populations with complex needs, including addressing comorbidity and age-associated conditions such as dementia.

Impact of the comprehensive geriatric assessment on treatment decision in geriatric oncology

Background

The comprehensive geriatric assessment (CGA) is the gold standard in geriatric oncology to identify patients at high risk of adverse outcomes and optimize cancer and overall management. Many studies have demonstrated that CGA could modify oncologic treatment decision. However, there is little knowledge on which domains of the CGA are associated with this change. Moreover, the impact of frailty and physical performance on change in cancer treatment plan has been rarely assessed.

Methods

This is a cross-sectional study of older patients with solid or hematologic cancer referred by oncologists for a geriatric evaluation before cancer treatment. A comprehensive geriatric assessment was performed by a multidisciplinary team to provide guidance for treatment decision. We performed a multivariate analysis to identify CGA domains associated with change in cancer treatment plan.

Results

Four hundred eighteen patients, mean age 82.8 ± 5.5, were included between October 2011 and January 2016, and 384 of them were referred with an initial cancer treatment plan. This initial cancer treatment plan was changed in 64 patients (16.7%). In multivariate analysis, CGA domains associated with change in cancer treatment plan were cognitive impairment according to the MMSE score (p = 0.020), malnutrition according to the MNA score (p = 0.023), and low physical performance according to the Short Physical Performance Battery (p = 0.010).

Conclusion

Cognition, malnutrition and low physical performance are significantly associated with change in cancer treatment plan in older adults with cancer. More studies are needed to evaluate their association with survival, treatment toxicity and quality of life. The role of physical performance should be specifically explored.

Frailty status but not age predicts complications in elderly cancer patients: a follow-up study

OBJECTIVES

The purposes were to investigate the health status of elderly cancer patients by comprehensive geriatric assessment (CGA) and to compare the complications with respect to baseline CGA and to evaluate the need for geriatric interventions in an elderly cancer patients' population.

MATERIAL

Patients aged ≥70 years with lung cancer (LC), cancer of the head and neck (HNC), colorectal cancer (CRC), or upper gastro-intestinal cancer (UGIC) are referred to the Department of Oncology for cancer treatment.

METHODS

CGA was performed prior to cancer treatment and addressed the following domains: Activities of daily living (ADL), instrumental ADL (IADL), comorbidity, polypharmacy, nutrition, cognition, and depression. Complications, defined as dose reduction and discontinuation of treatment due to grade 3-4 toxicity, hospital admission, shift to palliative treatment, or death within 90 days, were identified from the medical files. Patients were classified as fit, vulnerable, or frail by CGA.

PRINCIPAL RESULTS

Patients (N = 217) with a median age of 75 years (range: 70-93 yeas) were included: 13% were fit, 35% vulnerable, and 52% frail. CGA significantly predicted admittance to hospital in frail and vulnerable patients compared to fit patients: risk ratio (RR) 2.12 (95% CI: 1.01; 4.46). Vulnerable and frail patients had higher absolute risk of death within 90 days compared to fit patients: 7% and 23% versus 0%. HR for death within 90 days in frail patients as compared to vulnerable patients was 3.50 (95% CI: 1.34; 9.15). More frail patients (88%) needed geriatric interventions than the vulnerable (46%) and fit patients (32%). Major conclusion: Few elderly cancer patients seem to be fit. CGA predicts admittance to hospital in a population of elderly patients with mixed cancer diseases. Frail and vulnerable patients have higher risk of death within 90 days as compared to fit patients.

What do we know about frailty in the acute care setting? A scoping review

BACKGROUND

The ability of acute care providers to cope with the influx of frail older patients is increasingly stressed, and changes need to be made to improve care provided to older adults. Our purpose was to conduct a scoping review to map and synthesize the literature addressing frailty in the acute care setting in order to understand how to tackle this challenge. We also aimed to highlight the current gaps in frailty research.

METHODS

This scoping review included original research articles with acutely-ill Emergency Medical Services (EMS) or hospitalized older patients who were identified as frail by the authors. We searched Medline, CINAHL, Embase, PsycINFO, Eric, and Cochrane from January 2000 to September 2015.

RESULTS

Our database search initially resulted in 8658 articles and 617 were eligible. In 67% of the articles the authors identified their participants as frail but did not report on how they measured frailty. Among the 204 articles that did measure frailty, the most common disciplines were geriatrics (14%), emergency department (14%), and general medicine (11%). In total, 89 measures were used. This included 13 established tools, used in 51% of the articles, and 35 non-frailty tools, used in 24% of the articles. The most commonly used tools were the Clinical Frailty Scale, the Frailty Index, and the Frailty Phenotype (12% each). Most often (44%) researchers used frailty tools to predict adverse health outcomes. In 74% of the cases frailty predicted the outcome examined, typically mortality and length of stay.

CONCLUSIONS

Most studies (83%) were conducted in non-geriatric disciplines and two thirds of the articles identified participants as frail without measuring frailty. There was great variability in tools used and more recently published studies were more likely to use established frailty tools. Overall, frailty appears to be a good predictor of adverse health outcomes. For frailty to be implemented in clinical practice frailty tools should help formulate the care plan and improve shared decision making. How this will happen has yet to be determined.

Clinical implications of aging with HIV infection: perspectives and the future medical care agenda

: The increasing number of aging HIV-infected (HIV+) persons comprises a unique population at risk for illnesses and syndromes traditionally associated with the elderly. As a result, similar to the current need for primary care providers to manage chronic noninfectious comorbidities among aging persons with well controlled HIV infection, HIV clinical care will need to routinely involve geriatric medicine in a new HIV-geriatric discipline. The objective of this article is to provide a conceptual framework in which HIV and geriatric management considerations for healthcare professionals caring for HIV+ persons are integrated. The provision of contemporary HIV clinical care extends well beyond the achievement of HIV virologic suppression and antiretroviral therapy management and includes a need for careful characterization of geriatric syndromes based upon functional capacity and extent of disability. Screening for geriatric syndromes is both a multidisciplinary and multidimensional process, designed to evaluate an older person's functional ability, physical health, cognition, overall mental health, and socio-environmental circumstances. Although routine incorporation of geriatric assessment into clinical trials involving HIV+ persons is feasible, a current challenge is the availability of a consensus clinical definition of frailty or vulnerability. To maximize the efficiency, value, and convenience of outpatient care visits for older HIV+ persons, these visits should include encounters with multiple providers, including primary care clinicians, social workers, and geriatricians. Challenges may exist in the routine provision of these assessments to older HIV+ persons, but clearly such cross-disciplinary collaboration will not only markedly enhance the care of aging HIV+ persons but may also constitute a model of successful healthcare management that can be applied to all aging persons with changing healthcare needs.

Frailty Markers and Treatment Decisions in Patients Seen in Oncogeriatric Clinics: Results from the ASRO Pilot Study

Background

Comprehensive Geriatric Assessment (CGA) is the gold standard to help oncologists select the best cancer treatment for their older patients. Some authors have suggested that the concept of frailty could be a more useful approach in this population. We investigated whether frailty markers are associated with treatment recommendations in an oncogeriatric clinic.

Methods

This prospective study included 70 years and older patients with solid tumors and referred for an oncogeriatric assessment. The CGA included nine domains: autonomy, comorbidities, medication, cognition, nutrition, mood, neurosensory deficits, falls, and social status. Five frailty markers were assessed (nutrition, physical activity, energy, mobility, and strength). Patients were categorized as Frail (three or more frailty markers), pre-frail (one or two frailty markers), or not-frail (no frailty marker). Treatment recommendations were classified into two categories: standard treatment with and without any changes and supportive/palliative care. Multiple logistic regression models were used to analyze factors associated with treatment recommendations.

Results

217 patients, mean age 83 years (± Standard deviation (SD) 5.3), were included. In the univariate analysis, number of frailty markers, grip strength, physical activity, mobility, nutrition, energy, autonomy, depression, Eastern Cooperative Oncology Group Scale of Performance Status (ECOG-PS), and falls were significantly associated with final treatment recommendations. In the multivariate analysis, the number of frailty markers and basic Activities of Daily Living (ADL) were significantly associated with final treatment recommendations (p<0.001 and p = 0.010, respectively).

Conclusion

Frailty markers are associated with final treatment recommendations in older cancer patients. Longitudinal studies are warranted to better determine their use in a geriatric oncology setting.

Treating older adults with cancer: geriatric perspectives

The proportion of older adults (age 65 and older) in oncology practices continues to increase. Older adults present with unique issues that complicate management decisions and evidence from randomized clinical trials to inform management of these patients is lacking. Despite this, principles of geriatric medicine need to be incorporated into oncology practice to provide optimal individualized care to patients. There is increasing evidence from observational studies that geriatric assessment (GA) strategies can be applied in oncology, can help predict treatment outcomes, and can inform supportive care management for older adults. In this review, we discuss the principles of GA and their use in older adults with cancer. In addition, considerations on when to refer to a geriatrician and issues related to management of vulnerable older adults will be addressed.