Geriatric assessment of patients treated for cutaneous head and neck malignancies in a tertiary referral center: Predictors of postoperative complications

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.

Geriatric dermatologic surgery part I: Frailty assessment and palliative treatments in the geriatric dermatology population

Longer life expectancy and increasing keratinocyte carcinoma incidence contribute to an increase in geriatric patients presenting for dermatologic surgery. Unique considerations accompany geriatric patients including goals of care, physiologic changes in medication metabolism, cognitive decline, and frailty. Limited geriatric training in dermatology residency has created a knowledge gap and dermatologic surgeons should be familiar with challenges facing older patients to provide interventions more congruent with goals and avoid overtreatment. Frailty assessments including the Geriatric 8 and Karnofsky Performance Scale are efficient tools to identify patients who are at risk for poor outcomes and complications. When frail patients are identified, goals of care discussions can be aided using structured palliative care frameworks including the 4Ms (what matters, medications, mentation, and mobility), REMAP (reframing, expecting emotion, mapping patient goals, aligning patient goals, and proposing a plan), and Serious Illness Conversation Guide. Most geriatric patients will tolerate standard of care treatments including invasive modalities like Mohs surgery and excision. However, for frail patients, nonstandard treatments including topicals, energy-based devices, and intralesional chemotherapy may be appropriate options to limit patient morbidity while offering reasonable disease control.

Predicting short-term treatment toxicity in head and neck cancer through a systematic review and meta-analysis

INTRODUCTION

Frailty is a recognized condition associated with poorer outcomes in patients with head and neck cancer (HNC). The objective of this study was to ascertain the prognostic significance of various frailty metrics on short-term treatment toxicity in patients with HNC undergoing curative-intent therapy.

MATERIALS AND METHODS

A systematic review was performed searching multiple databases. An inverse-variation, random-effects model was used to perform the meta-analysis to evaluate the prognostic significance of various frailty metrics on short-term treatment-related toxicity in this population.

RESULTS

A total of 292,560 patients with HNC originating from 36 observational studies were analyzed. The most frequently reported frailty metrics were the modified frailty index (mFI), Geriatric 8 questionnaire (G8), Adjusted Clinical Groups (ACG), Groningen Frailty Indicator (GFI), and comprehensive geriatric assessment (CGA). The overall prevalence of frailty using any metric in all included studies was 7.5 %. The combined odds ratio (OR) for short-term treatment toxicity using the mFI was 2.60 (95 % CI of 1.81-3.72), G8 2.69 (95 % CI 1.37-5.28), ACG 3.43 (95 %CI 2.52-4.67), GFI 2.71 (95 % CI 1.11-6.62), and CGA 3.36 (95 % CI 1.18-9.53). The association of frailty with short-term treatment toxicity using various frailty metrics was more pronounced in patients with upfront surgery (OR 3.00, 95 %CI of 2.35-3.81) compared to definitive (chemo)radiotherapy 2.64 (95 % CI 1.04-6.68).

DISCUSSION

Various frailty metrics exists in the HNC literature, with the most common being the mFI, G8, ACG, GFI, and CGA. Patients with HNC and frailty are more than twice as likely to suffer a short-term treatment-related toxicity when undergoing curative-intent HNC treatment than patients without frailty. This effect is more pronounced in patients undergoing upfront surgery.

TCD-Guided management in carotid endarterectomy: a retrospective study

BACKGROUNDː: Stroke, primarily resulting from ischemic conditions, is the foremost cause of mortality and long-term impairment and is frequently associated with narrowing of the carotid arteries. Although carotid endarterectomy (CEA) is the treatment of choice, it carries the risk of cerebral ischemia and reduced blood flow. Transcranial Doppler (TCD) ultrasound offers a nonintrusive method to assess cerebral blood circulation during CEA, potentially enhancing surgical outcomes. The objective of this study was to assess the clinical utility and safety of TCD monitoring during CEA and to identify factors influencing postoperative complications. METHODS: This retrospective analysis included 158 CEA patients (from January 2021-August 2023) who underwent TCD monitoring and whose data were compared to historical standard care data. The primary outcomes were operation duration and artery occlusion time. Secondary outcomes included carotid shunt usage, seven-day postoperative complications, and six-month carotid artery patency. Logistic regression identified factors linked to adverse reactions, and a predictive model was evaluated with a receiver operating characteristic (ROC) curve. RESULTSː: Comparative analysis indicated significant reductions in both the duration of surgery (113.26 ± 7.29 min) and artery occlusion time (21.85 ± 2.92 min) for patients monitored with TCD (P < 0.001) and an increase in carotid shunt implementation (25% as opposed to traditional care). The observed postoperative complications were minor, with a nonsignificant trend that favored the use of TCD-monitored procedures (1% vs. historical rates). Factors such as patient age and plaque echogenicity were found to be predictive of postoperative issues, with plaque echogenicity emerging as a significant predictive factor (OR = 10.70, 95% CI: 2.14-202, P = 0.02) upon multivariate analysis. The predictive model exhibited high precision (AUC = 0.93). CONCLUSION: This retrospective evaluation suggested that TCD monitoring in the CEA may reduce procedural time and potentially decrease postoperative complications, supporting its use for personalized surgical planning.

Evaluation of a new two-step frailty assessment of head and neck patients in a prospective cohort

PURPOSE

Assessing frailty, in head and neck cancer (HNC) patients is key when choosing appropriate treatment. Optimal screening is challenging, as it should be feasible and should avoid over-referral for comprehensive geriatric assessment (CGA) This study aims to evaluate the association between geriatric assessment using a new two-step care pathway, referral to geriatrician and adverse outcomes.

METHODS

This institutional retrospective analysis on a prospective cohort analysed the multimodal geriatric assessment (GA) of newly diagnosed HNC patients. Uni- and multivariable logistic regression was performed to study the association between the screening tests, and referral to the geriatrician for complete geriatric screening, and adverse outcomes.

RESULTS

This study included 539 patients, of whom 276 were screened. Patients who underwent the GA, were significantly older and more often had advanced tumour stages compared to non-screened patients. Referral to the geriatrician was done for 30.8% of patients. Of the 130 patients who underwent surgery, 26/130 (20%) experienced clinically relevant postoperative complications. Of the 184 patients who underwent (radio)chemotherapy, 50/184 (27.2%) had clinically relevant treatment-related toxicity. Age, treatment intensity, polypharmacy and cognitive deficits, were independently associated with referral to geriatrician. A medium to high risk of malnutrition was independently associated with acute radiation induced toxicity and adverse outcomes in general.

CONCLUSION

The current study showed a 30.8% referral rate for CGA by a geriatrician. Age, treatment intensity, cognitive deficits and polypharmacy were associated with higher rates of referral. Furthermore, nutritional status was found to be an important negative factor for adverse treatment outcomes, that requires attention.

Tumeszenz-Lokalanästhesie bei geriatrischen Patienten mit Hauttumoren im Kopf-Hals-Bereich - Eine retrospektive Studie an 782 Patienten: Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients

Hintergrund und Zielsetzung

Aufgrund ihrer Morbidität werden dermatochirurgische Eingriffe bei älteren Patienten vorzugsweise in Tumeszenz‐Lokalanästhesie durchgeführt. Allerdings ist die Datenlage hierzu begrenzt. Ziel der Arbeit war es, die Tumeszenz‐Lokalanästhesie für Hautkrebsoperationen bei älteren Patienten mit dem Fokus auf klinische Vorteile (Behandlungsprozesse, Schmerzmanagement) und dem lokalen postoperativen Komplikationsrisiko zu evaluieren.

Patienten und Methodik

Untersuchung von Patienten ≥75 Jahren mit stationär durchgeführten Hautkrebsoperationen im Kopf‐Hals‐Bereich unter Tumeszenz‐Lokalanästhesie.

Ergebnisse

2940 Eingriffe bei 782 Patienten (Durchschnittsalter 83,3 Jahre) mit dem Ziel einer vollständigen Tumorresektion während des stationären Aufenthaltes wurden durchgeführt. 3,8 (Bereich: 1–20) Eingriffe erfolgten über einen Zeitraum von durchschnittlich 4,9 Tagen (Bereich: 1–28). 43,2% benötigten keine postoperative Analgesie. 53,5% erhielten NSAID, 3,3% Opioide. Wundinfektionen (13,6%) waren die häufigste lokale postoperative Komplikation. Chirurgische Interventionen aufgrund von Nachblutungen waren in 2,8% der Fälle erforderlich. Keine der Blutungen waren hämoglobinrelevant oder lebensbedrohlich. Nahtdehiszenzen und Nekrosen waren selten (0,6%).

Schlussfolgerungen

Die Tumeszenz‐Lokalanästhesie ist für Hautkrebsoperationen bei älteren Menschen eine effektive Anästhesiemethode. Durch den Verzicht auf eine Vollnarkose können die Behandlungsabläufe optimiert und anästhesiologische Risiken minimiert werden. Lokale postoperative Komplikationen treten eher selten auf und sind gut behandelbar. Die langanhaltende Analgesie führt zu einem geringeren Analgetikabedarf und selteneren Medikamenteninteraktionen.

Tumescent local anesthesia in geriatric patients with head and neck skin cancer - a retrospective study of 782 patients

BACKGROUND AND OBJECTIVES

Due to frailty, dermatosurgery in the elderly is preferably performed under tumescent local anesthesia, but data is limited. The aim was to evaluate tumescent local anesthesia for skin cancer surgery in the elderly with focus on clinical benefits (treatment processes, pain management) and local postoperative complication risk.

PATIENTS AND METHODS

Investigation of patients ≥ 75 years with inpatient head and neck skin cancer surgery under tumescent local anesthesia.

RESULTS

2,940 procedures in 782 patients (mean age 83.3 years) were performed with the aim of complete tumor resection during the inpatient stay. 3.8 (range: 1-20) interventions were done over an average of 4.9 days (range: 1-28). 43.2% did not require any postoperative analgesia. 53.5% received NSAIDs, 3.3% opioids. Infection (13.6%) was the most common local postoperative complication. Surgical intervention due to bleeding was required in 2.8%. None was hemoglobin relevant or life-threatening. Suture dehiscence and necrosis were rare (0.6%).

CONCLUSIONS

Tumescent local anesthesia is an effective method for skin cancer surgery in the elderly. By avoiding general anesthesia, treatment processes can be optimized and anesthesiologic risks minimized. Local postoperative complications are still low and well treatable. The long-lasting analgesia results in a reduced need for analgesics and drug interactions.

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.

Incidence of preoperative instrumental activities of daily living (IADL) dependence and adverse outcomes in older surgical patients: A systematic review and meta-analysis

STUDY OBJECTIVE

Instrumental activities of daily living (IADLs) are essential to patient function and quality of life after surgery. In older surgical patients, the incidence of preoperative IADL dependence has not been well characterized in the literature. This systematic review and meta-analysis aimed to determine the pooled incidence of preoperative IADL dependence and the associated adverse outcomes in the older surgical population.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) were searched for relevant articles from 1969 to April 2022.

PATIENTS

Patients aged ≥60 years old undergoing surgery with preoperative IADL assessed by the Lawton IADL Scale.

INTERVENTIONS

Preoperative assessment.

MEASUREMENT

The primary outcome was the pooled incidence of preoperative IADL dependency. Additional outcomes included post-operative mortality, postoperative delirium [POD], functional status improvement, and discharge disposition.

MAIN RESULTS

Twenty-one studies (n = 5690) were included. In non-cardiac surgeries, the pooled incidence of preoperative IADL dependence was 37% (95% CI: 26.0%, 48.0%) among 2909 patients. Within cardiac surgeries, the pooled incidence of preoperative IADL dependence was 53% (95% CI: 24.0%, 82.0%) among 1074 patients. Preoperative IADL dependence was associated with an increased risk of postoperative delirium than those without IADL dependence (44.9% vs 24.4, OR 2.26; 95% CI: 1.42, 3.59; I2: 0%; P = 0.0005).

CONCLUSIONS

There is a high incidence of IADL dependence in older surgical patients undergoing non-cardiac and cardiac surgery. Preoperative IADL dependence was associated with a two-fold risk of postoperative delirium. Further work is needed to determine the feasibility of using the IADL scale preoperatively as a predictive tool for postoperative adverse outcomes.

Radiologically Defined Sarcopenia as a Biomarker for Frailty and Malnutrition in Head and Neck Skin Cancer Patients

The aim of this study was to evaluate whether radiologically defined sarcopenia, or a low skeletal muscle index (SMI), could be used as a practical biomarker for frailty and postoperative complications (POC) in patients with head and neck skin cancer (HNSC). This was a retrospective study on prospectively collected data. The L3 SMI (cm²/m²) was calculated with use of baseline CT or MRI neck scans and low SMIs were defined using sex-specific cut-off values. A geriatric assessment with a broad range of validated tools was performed at baseline. POC was graded with the Clavien-Dindo Classification (with a grade of > II as the cut-off). Univariate and multivariable regression analyses were performed with low SMIs and POC as the endpoints. The patients' (n = 57) mean age was 77.0 ± 9 years, 68.4% were male, and 50.9% had stage III-IV cancer. Frailty was determined according to Geriatric 8 (G8) score (OR 7.68, 95% CI 1.19-49.66, p = 0.032) and the risk of malnutrition was determined according to the Malnutrition Universal Screening Tool (OR 9.55, 95% CI 1.19-76.94, p = 0.034), and these were independently related to low SMIs. Frailty based on G8 score (OR 5.42, 95% CI 1.25-23.49, p = 0.024) was the only variable related to POC. However, POC was more prevalent in patients with low SMIs (∆ 19%, OR 1.8, 95% CI 0.5-6.0, p = 0.356).To conclude, a low SMI is a practical biomarker for frailty and malnutrition in HNSC. Future research should be focused on interventions based on low SMI scores and assess the effect of the intervention on SMI, frailty, malnutrition, and POC.

Risk analysis of systemic side effects of tumescent local anaesthesia in the surgical treatment of geriatric and multimorbid patients with skin cancer

BACKGROUND

Due to demographic change and increased UV exposure, the number of dermatosurgical procedures in the elderly is increasing. Data on the occurrence of systemic side effects during and after treatment with tumescent local anaesthesia are limited and do not refer to details such as volume and composition of local anaesthetics or epinephrine additive.

OBJECTIVES

The aim of this study was to investigate the risk of systemic side effects in elderly patients undergoing skin tumour surgery with tumescent local anaesthesia.

METHODS

Investigation of systemic complications in patients (≥75 years) who underwent head and neck skin tumour surgery under tumescent local anaesthesia at the Department of Dermatology, University Medical Centre Tübingen, between October 2018 and March 2020.

RESULTS

In total 782 patients (479 males, 303 females) with a mean age of 83.3 years (range: 75.1-102.2 years) could be included. A total of 2940 procedures were performed. Patients were assigned to two groups. The old-old group (≥75-84 years) included 491 patients and the oldest-old group (≥85 years) included 291 patients. The total inpatient stay and thus mean follow-up period was 4.9 days (range 1-28 days). 92.0% (719/782) suffered from pre-existing comorbidities. Systemic complications occurred in 10.2% (80/782; old-olds: 8.6%, oldest-olds: 13.1%). Hypertensive crisis (>180/120 mmHg) requiring intervention (6.7%) that occurred intraoperatively or during the inpatient stay was the most frequent systemic complication. Cardiac arrhythmias occurred postoperatively in 0.8% of cases. No life-threatening complications directly related to tumescent local anaesthesia were found.

CONCLUSIONS

Skin tumour surgery in tumescent local anaesthesia for the elderly is safe, and complications caused by general anaesthesia can be avoided. Systemic complications can occur, but are usually mild, are caused by pre-existing diseases and perioperative excitement, and can be rapidly detected and well treated by monitoring. There is no direct correlation of complications to high-tumescent concentrations or volume quantities.

Evaluation of Agreement Among Frailty Assessment Tools in Head and Neck Surgery

OBJECTIVE

To evaluate intertest agreement among hand grip strength (HGS), the modified Frailty Index (mFI), and the Edmonton Frail Scale (EFS) in patients presenting for presurgical assessment in a head and neck surgery clinic.

STUDY DESIGN

Prospective observational study.

SETTING

Academic tertiary medical center.

METHODS

Prospective data relating to 3 frailty measurements were collected for 96 consecutive adults presenting for presurgical counseling at a single high-volume head and neck surgical oncology clinic. Frailty was determined with previously validated thresholds for the mFI (≥3) and EFS (>7). The highest of 2 HGS measurements performed for the dominant hand was used to determine frail status based on previously validated sex- and body mass index-specific thresholds. Baseline characteristics were identified to determine the association of such variables to each tool. Agreement among frailty assessment tools was examined.

RESULTS

The frequency of frailty in the cohort varied among tools, ranging from 29.2% (28/96) for HGS to 12.5% (12/96) for the mFI and 4.2% (4/96) for the EFS. The overall agreement among the 3 frailty tools via the Fleiss index was poor (kappa, 0.088; 95% CI, -0.028 to 0.203).

CONCLUSION

Assessment of frailty is complex, and established frailty assessment tools may not agree on which patients are frail. When assessing a patient as frail, clinicians must be vigilant to the influence of frailty assessment tools on such determinations, which may contribute critical input during shared decision making for patients considering head and neck surgery or nonsurgical alternatives.

The Effect of Tumor Characteristics and Location on the Extent of Lymph Node Metastases of Head and Neck Cutaneous Squamous Cell Carcinoma

Background

The extent of a neck dissection for patients with metastasis of cutaneous squamous cell carcinoma of the head and neck (HNcSCC) is still subject to debate and clear guidelines are lacking. Tumor characteristics like size, differentiation and tumor location are known risk factors for lymph node metastasis (LNM). There is some evidence that, depending on tumor location, LNM follows a specific pattern. This study aims to identify which tumor characteristics can predict the pattern and extent of LNM.

Method

In this cohort study 80 patients were included, who underwent a primary neck dissection for LNM of HNcSCC between 2003 and 2018 at the University Medical Center Groningen, the Netherlands. Retrospective data was collected for primary tumor characteristics and LNM and included surgical and follow-up data. Influence of tumor characteristics on the extent of LNM was analyzed using non-parametric tests. Logistic regression analysis were used to identify a metastasis pattern based on the primary tumor location.

Results

Only primary tumor location was associated with the pattern of LNM. HNcSCC of the ear metastasized to level II (OR = 2.6) and the parotid gland (OR = 3.6). Cutaneous lip carcinoma metastasized to ipsilateral and contralateral level I (OR = 5.3). Posterior scalp tumors showed a metastasis pattern to level II (OR = 5.6); level III (OR = 11.2), level IV (OR = 4.7) and the parotid gland (OR = 10.8). Ear canal tumors showed a low risk of LNM for all levels. The extent of LNM was not related to age or any tumor characteristics i.e. tumor diameter, infiltration depth, differentiation grade, perineural growth and vascular invasion.

Conclusion

Primary tumor location determines the LNM pattern. Whereas known unfavorable tumor characteristics did not relate to the extent of LNM. Location guided limited neck dissection combined with parotidectomy will treat most patients adequately.

Evaluation of the Comprehensive Geriatric Assessment (CGA) tool as a predictor of postoperative complications following major oncological abdominal surgery in geriatric patients

Introduction

The concept of frailty extends beyond chronological age. Identifying frailty using a two-step approach, starting with the use of a screening tool (G8) followed by comprehensive geriatric assessment (CGA), may be useful in guiding treatment decisions and follow-up. This study evaluated the association between G8 and CGA, and the risk of 90-day postoperative complications risk, in oncogeriatric patients.

Methods

Data on geriatric patients with major oncological abdominal surgery was retrospectively collected from our hospital records between 2016 and 2019. Patients with an impaired G8 screening score, who subsequently underwent CGA geriatric screening, were included. Postoperative complications were classified using the Clavien-Dindo classification (CD), and the Comprehensive Complication Index (CCI). The association between the individual components of the geriatric assessment tools and the 90-day postoperative complications risk was analyzed.

Results

One hundred and twelve patients, aged ≥ 70 years, operated for an intra-abdominal tumor with curative intent, were included. Seventy-six patients (67.9%) presented with an impaired G8, out of whom sixty-six (58.9%) had a CGA performed. On univariate analysis, altered nutritional status assessed by the Mini-Nutritional Assessment-Short Form was the only variable associated with higher postoperative total complication rate (p = 0.01). Patients with an impaired G8 had significantly more postoperative complications and higher 1-year mortality rates than patients with normal G8. Fifteen patients (13.4%) had grade III-IVb complications. A CCI > 50 was recorded in 16 patients (14.3%). All-cause 90-day postoperative mortality was 10.7%.

Conclusion

Identifying an altered preoperative nutritional status, as part of the CGA, in patients screening positive for frailty, is a potentially modifiable risk factor that can enhance preoperative management and optimize treatment decision making. G8 may be a predictive factor for postoperative complications in oncogeriatric patients.

Age-related Differences in Tumour Characteristics and Prognostic Factors for Disease Progression in Cutaneous Squamous Cell Carcinoma of the Head and Neck

Guidelines for cutaneous squamous cell carcinoma of the head and neck do not take the age of the patient into account, but instead assume equal tumour characteristics and prognostic factors for poor outcome in younger and elderly patients. The aim of this study was to compare tumour characteristics of younger (< 75 years) and elderly (≥ 75 years) patients and identify age-specific risk factors for progression of disease, comprising local recurrence, nodal metastasis and distant metastasis. Patient and tumour characteristics were compared using χ2 or Fisher's exact tests. Multivariable competing risk analyses were performed to compare risk factors for progression of disease, incorporating the risk of dying before developing progression of disease. A total of 672 patients with primary cutaneous squamous cell carcinoma of the head and neck were retrospectively included. Larger tumour diameter, worse differentiation grade and deeper invasion were observed in older patients. In elderly patients, but not in younger patients, tumour diameter ≥ 40 mm, moderate differentiation grade and an invasion depth ≥ 2 mm were independent risk factors for progression of disease.

Management of elderly patients with advanced cutaneous squamous cell carcinoma

The incidence of cutaneous squamous cell carcinoma has been increasing rapidly in recent years, especially among the elderly. The purpose of this review article is to summarize the findings of studies on systemic therapy for advanced cutaneous squamous cell carcinoma, to review geriatric screening tools, which can assess frailty and predict treatment outcomes, and discuss the indications of their use in advanced cases. A literature review revealed that studies on systemic therapy for advanced cutaneous squamous cell carcinoma often included relatively older patients. However, there has been little research on the safety and efficacy of systemic therapy for advanced disease that takes older age and frailty into account. Notably, studies on geriatric screening for skin cancer have been conducted in recent years, mainly to detect early-stage resectable cases. The Geriatric 8 screening tool is considered the most useful for predicting post-operative complications in patients with early-stage cancer, as it can evaluate comorbidities, polypharmacy and cognition, has appropriate measurement properties, can be quickly executed and is clinically relevant, easily understandable and interpretable. This geriatric screening tool may also be applicable in advanced-stage cancer. In conclusion, despite the fact that advanced cutaneous squamous cell carcinoma occurs mainly in the elderly, the importance of geriatric screening has not yet been fully appreciated by dermato-oncologists. In the future, geriatric screening tools should be actively used in clinical trials for the appropriate assessment of drug efficacy and toxicity in elderly patients with advanced cutaneous squamous cell carcinoma.

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.

Validation of the G8 screening tool in older patients with cancer considered for surgical treatment

BACKGROUND

The Geriatric 8 (G8) has proven to be one of the most sensitive frailty-screening tools for older patients with cancer undergoing systemic treatment. In this study we validated whether the G8 is also suitable for identifying impairments in their comprehensive geriatric assessment (CGA) in older patients with cancer undergoing surgery. Thereby, we investigated the differences in postoperative outcomes between the fit and frail patients classified by the G8.

METHODS

Patients ≥70 years with a surgery indication because of a (suspected) malignant disease were prospectively enrolled. In all patients, a CGA was performed. The G8 results were assessed in parallel. The diagnostic value of the G8 was determined by comparing the result with the CGA as a reference test. Deficits in CGA was defined as ≥ two impairments of the CGA. Postoperative complications were retrospectively obtained from the medical record and compared between the fit and frail patients.

RESULTS

In total, 143 patients were enrolled. The sensitivity, specificity, and negative predictive value of the G8 were 82% (95% CI 70-91), 63% (95% CI 52-73), and 85% (95% CI 75-91). In the patients with an impaired G8, a significantly prolonged hospital stay, higher rate of delirium, and higher 1-year mortality rate were seen.

CONCLUSION

The G8 is a simple and useful screening tool for identifying deficits in CGA in older patients with cancer requiring surgery. Second, we concluded that patients with an impaired G8 are more at risk for a complicated recovery from surgery.

Treatment of keratinocyte carcinoma in elderly patients - a review of the current literature

A large percentage of the patients with keratinocyte carcinoma (KC, formerly known as non‐melanoma skin cancer) is of advanced age and often too frail for standard therapies. However, no specific treatment recommendations are given for this population. This review aimed to give an overview of the current literature on the best practice for the treatment of elderly patients with KC. A literature search was performed in MEDLINE, using ‘keratinocyte carcinoma’, ‘elderly’, ‘treatment’ and various synonyms. Case reports, reviews, comments, non‐English literature and studies with a sample size <15 were excluded. After selection, a total of 47 studies were reviewed. Two types of studies were identified, focusing on (I) the effect of age on treatment outcomes and (II) alternative treatment schedules for elderly patients. Studies on surgery, the gold standard, describe larger lesions and defect size in the elderly population. Recurrence rate, complication rate and disease‐specific survival were not affected by age. Depending on the expected morbidity of a suggested (re‐)excision and patient preferences, a conservative watchful waiting policy can be agreed upon as a shared decision. Other common treatment modalities, such as adjuvant radiotherapy, photodynamic therapy and systemic therapy for basal cell carcinoma (BCC), show comparable results in the elderly and younger population. Alternative treatment schedules for elderly patients include primary hypofractionated radiotherapy, which seems effective and well‐tolerated, although research is limited to case series. Additionally, localized and topical treatments seem safe and effective especially for low‐risk tumours. Data are lacking on the efficacy of systemic therapies of metastatic KC in elderly patients. Efficacy of most treatments (with the exception of photodynamic therapy) is not dependent on age. There is need for more research on the efficacy of adjusted treatment modalities, such as hypofractionated radiotherapy and palliative or curative systemic treatment.

The OncoLifeS data-biobank for oncology: a comprehensive repository of clinical data, biological samples, and the patient's perspective

Background

Understanding cancer heterogeneity, its temporal evolution over time, and the outcomes of guided treatment depend on accurate data collection in a context of routine clinical care. We have developed a hospital-based data-biobank for oncology, entitled OncoLifeS (Oncological Life Study: Living well as a cancer survivor), that links routine clinical data with preserved biological specimens and quality of life assessments. The aim of this study is to describe the organization and development of a data-biobank for cancer research.

Results

We have enrolled 3704 patients aged ≥ 18 years diagnosed with cancer, of which 45 with hereditary breast-ovarian cancer (70% participation rate) as of October 24th, 2019. The average age is 63.6 ± 14.2 years and 1892 (51.1%) are female. The following data are collected: clinical and treatment details, comorbidities, lifestyle, radiological and pathological findings, and long-term outcomes. We also collect and store various biomaterials of patients as well as information from quality of life assessments.

Conclusion

Embedding a data-biobank in clinical care can ensure the collection of high-quality data. Moreover, the inclusion of longitudinal quality of life data allows us to incorporate patients’ perspectives and inclusion of imaging data provides an opportunity for analyzing raw imaging data using artificial intelligence (AI) methods, thus adding new dimensions to the collected data.