Geriatric assessment in the management of older patients with cancer – A systematic review (update)

Tumor Immunophenotypic Correlates in Patients Aged 80 Years or Older With Non-Small Cell Lung Cancer and Outcomes to First-Line Pembrolizumab in PD-L1 High (≥50%) Patients

BACKGROUND

Non-small cell lung cancer (NSCLC) patients aged ≥80 years [y] are underrepresented in clinical trials. We evaluated whether age correlates with a distinct immunophenotype or impacts outcomes to first-line pembrolizumab in patients with advanced NSCLC, PD-L1 Tumor Proportion Score (TPS) of ≥50%, and aged ≥80y.

METHODS

Three NSCLC cohorts were retrospectively analyzed to assess the impact of age (<80y versus ≥80y) on pembrolizumab efficacy and the tumor microenvironment (TME). Cohort A encompassed patients receiving first-line pembrolizumab for advanced NSCLC with PD-L1 ≥50%. Cohort B comprised patients with tumor profiling using multiplexed immunofluorescence (ImmunoPROFILE). Cohort C included The Cancer Genome Atlas (TCGA) and Stand Up to Cancer (SU2C) databases for gene expression analysis.

RESULTS

In Cohort A (N = 669), patients ≥80y (N = 111) showed no significant differences in objective response rate or median progression-free survival compared to younger patients (N = 558), but had shorter median overall survival and were less likely to receive second-line therapy after progression on pembrolizumab. In Cohort B (N = 567), tumors from patients ≥80y (N = 45) exhibited higher intratumoral FOXP3+ T cells and closer vicinity of PD-1+ immune cells to tumor cells compared to <80y (N = 522). Cohort C revealed a distinct immunophenotype in samples from patients ≥ 80y, with elevated specific immune cell subsets and up-regulated immune checkpoint proteins.

CONCLUSION

Patients ≥80y with PD-L1-high NSCLC displayed a distinct immunophenotype in the TME but achieved similar ORR and mPFS with first-line pembrolizumab compared to younger patients. OS was shorter in older patients, who were less likely to receive second-line therapy.

Immunosenescence and immunotherapy in elderly patients with hepatocellular carcinoma

Liver cancer, more specifically hepatocellular carcinoma (HCC), is a global health issue and one of the dominant causes of cancer death around the world. In the past few decades, remarkable advances have been achieved in the systemic therapy of HCC. Immune checkpoint inhibitors (ICIs) have become a therapy mainstay for advanced HCC and have shown promise in the neoadjuvant therapy before resection. Despite these significant advancements, the compositions and functions of the immune system occur various alterations with age, called "immunosenescence", which may affect the antitumor effects and safety of ICIs, thus raising concerns that immunosenescence may impair elderly patients' response to ICIs. Therefore, it is important to learn more about the immunosenescence characteristics of elderly patients. However, the real-world elderly HCC patients may be not accurately represented by the elderly patients included in the clinical trials, affecting the generalizability of the efficacy and safety profiles from the clinical trials to the real-world elderly patients. This review summarizes the characteristics of immunosenescence and its influence on HCC progression and immunotherapy efficacy as well as provides the latest progress in ICIs available for HCC and discusses their treatment efficacy and safety on elderly patients. In the future, more studies are needed to clarify the mechanisms of immunosenescence in HCC, and to find sensitive screening tools or biomarkers to identify the patients who may benefit from ICIs.

Are oldest old patients with diffuse large B-cell lymphoma different than their younger counterparts: Results from the REALYSA real-life cohort

INTRODUCTION

Over a half of diffuse large B-cell lymphoma (DLBCL) cases are diagnosed in adults aged 65 years and older. Older adults are a heterogeneous group, and few studies reported differences in care management and survival in the oldest old. We aimed to describe characteristics, care management, and survival of older adults aged 60 and over included in the REal-world dAta in LYmphoma and Survival in Adults (REALYSA) study.

MATERIALS

and methods: Patients newly diagnosed with DLBCL, aged over 60 years, included in REALYSA cohort between 2018/11 and 2021/12 and receiving therapy (RCHOP/miniRCHOP/Other) were included. Sociodemographic, living area and clinical characteristics, as well as the type of care center and pathway during the first year after diagnosis were described by age (60-69 y/70-79 y/≥80 y). Survival was described using Kaplan-Meier curves, the Cox model for adjusted survival, and net survival (Pohar-Perme estimator).

RESULTS

A total of 560 DLBCL patients with a median age at diagnosis of 72 years (IQR=67-77) were included. R-CHOP was the main curative treatment in patients aged 60-79, and R-miniCHOP in the oldest old. More than half of the patients were male, married or in a relationship, living in urban and low deprived area. With increasing age, the proportion of patients with performance status 0-1 or no Charlson comorbidity at diagnosis decreased. Two thirds of patients were diagnosed at advanced stage with comparable trends between age groups. However, the oldest patients were more likely to have high-risk disease and geriatric frailty at diagnosis. One-year net survival, in contrast to OS (91 %vs 95 % and 75 % for each age group), showed no significant reduction in survival for 80 + (93 %, 100 % and 87 % for each age group).

CONCLUSION

As the fastest-growing age group in developed countries, the oldest old require a special attention and further work on this population is needed.

Use of adjuvant capecitabine in older patients with early-stage triple-negative breast cancer

PURPOSE

Patients with triple-negative breast cancer (TNBC) who have residual disease after neoadjuvant chemotherapy (NACT) benefit from adjuvant capecitabine. Older patients are not always treated according to guidelines, likely due to concerns regarding tolerance. We examined the use of adjuvant capecitabine, its association with outcomes, and subsequent emergency room visits (ER) and hospitalizations (HSP) among older patients with early-stage TNBC.

METHODS

Retrospective, observational study using data in the SEER-Medicare database. Older patients (≥ 66 years) with early-stage TNBC, diagnosed in 2010-2019, who received NACT, underwent surgery, and were prescribed adjuvant capecitabine were included. We analyzed capecitabine use, its association with overall survival and breast-cancer specific survival, and time to first ER/HSP. Logistic regression, Kaplan-Meier estimates, and Cox regression models with propensity score adjustments were used.

RESULTS

239 of 1,799 older patients with TNBC received adjuvant capecitabine. Capecitabine use increased from 1.3% in 2010 to 29.6% in 2019. Older age, ≥ 71 years, (OR = 0.54, 95%CI 0.32-0.92) and ≥ 2 comorbidities (OR = 0.42, 95%CI 0.2-0.9) were associated with decreased odds of receiving ≥ 6 cycles of capecitabine. Increasing number of cycles of capecitabine was associated with decreased risks of death (HR = 0.74, 95%CI 0.66-0.83) and breast cancer-specific death (HR = 0.73, 95%CI 0.61-0.89). 55 patients (23%) treated with capecitabine experienced ER/HSP.

CONCLUSION

In recent years, adjuvant capecitabine is increasingly used for patients with early-stage TNBC. Patients with older age and more comorbidities received fewer cycles of capecitabine. While one-fourth of patients had ER/HSP, receipt of more cycles was associated with better survival.

What are the determinants of functional decline in older adults with cancer? Results from the INCAPAC study

INTRODUCTION

Older adults with cancer are exposed to greater difficulties in carrying out their daily activities due to cancer itself, its treatment, or both. The aim of this study was to describe functional decline after cancer diagnosis and to investigate the determinants of this decline among older individuals with cancer.

MATERIALS AND METHODS

Using the Gironde cancer registries, older subjects (≥65 years) with a diagnosis of cancer between 2005 and 2018 were identified in three prospective cohorts on aging. Functional decline was defined as an increase of 1 point for Activities of Daily Living (ADL), 2 points for Instrumental Activities of Daily Living (IADL), and 3 points for the overall score (ADL + IADL) between cancer pre- and post-diagnosis visits. Logistic regression models were used to identify determinants of functional decline among older subjects who underwent a post-diagnostic assessment. Additionally, multinomial logistic regression models were performed to account for individuals who had died prior to the post-diagnostic cancer visit.

RESULTS

A total of 306 individuals followed-up after the cancer diagnosis were included (median age at cancer diagnosis: 83; 44 % female). Older age at cancer, low educational level, impaired initial functional status, and poor five-year cancer-related prognosis were significantly associated with functional decline across all three scores. Multinomial logistic regression analyses (n = 489) yielded similar results, but only cancer-related factors, specifically unfavorable vital prognosis, were associated with higher risk of death.

DISCUSSION

Functional decline in older individuals with cancer is both multifactorial and multidimensional. Further studies are needed to disentangle the effects of cancer and aging.

Comprehensive geriatric assessment and early treatment failure in nonagenarian patients with cancer, a retrospective monocentric study

BACKGROUND

The incidence of cancer among patients aged over 90 is increasing, but this population is poorly described in literature. This underrepresentation complicates decision-making for cancer treatments, despite the contribution of comprehensive geriatric assessment (CGA). This study aimed to describe early failure of specific anti-cancer treatments in a population of nonagenarians treated in a Comprehensive Cancer Center after undergoing a CGA.

METHODS

This retrospective, monocentric cohort study included patients aged over 90 referred to an oncogeriatric team for CGA between 2019 and 2023, regardless of cancer type or planned treatment. The primary endpoint was the early treatment failure rate within 3 months of the initiation of treatment, defined as unplanned discontinuation, progression, or death.

RESULTS

119 patients were included, with a median age of 91 years (range: 90-99 years), 53 % were men. The most common cancers were skin (30 %), head and neck (24 %), genito-urinary (12 %), and breast cancers (11 %). Most patients were independent for activities of daily living with a median ADL score of 6/6 and IADL score of 3/4. They had an average of 1.3 severe comorbidities. Half of them suffered from undernutrition. The geriatric oncology team recommended 53.8 % treatment modifications (94.5 % de-escalation). The most common treatments received were radiotherapy (27 %), surgery (18 %), hormonal therapy (10 %) and chemotherapy (9 %). A quarter of the patients received exclusive supportive care. Among patients receiving specific treatment, early failure occurred in 22.7 % (20/88). The 6-month survival probability from initiation of treatment was 69.2 % (95 % CI: 60.3 %, 76.8 %), varying significantly by treatment intent: 93.9 % (95 % CI: 80.4 %, 98.3 %) for curative treatments, 77.4 % (95 % CI: 64.5 %, 86.6 %) for palliative treatments, and 26.8 % (95 % CI: 14.3 %, 44.6 %) for exclusive supportive care.

CONCLUSION

In this population of nonagenarians, who benefit from a CGA to identify and manage patient frailties, anti-cancer treatments were carried out with few early treatment failures.

Application of comprehensive geriatric assessment in oncology nursing: A literature review on optimizing treatment decisions and patient outcomes

With the global population aging, the care of elderly cancer patients has become increasingly complex and significant. Comprehensive geriatric assessment (CGA), a multidimensional evaluation tool, has been widely implemented in oncology nursing to enhance the precision of treatment decisions and improve patient outcomes. This review examines the application of CGA in oncology nursing, drawing on literature published between 2010 and 2024 in major databases using keywords such as "Comprehensive Geriatric Assessment" and "Oncology Nursing". It highlights how CGA contributes to optimizing treatment selection, monitoring the treatment process, and improving patients' quality of life and long-term outcomes. CGA provides a comprehensive evaluation of elderly cancer patients, including physical, psychological, and social aspects, enabling the identification of high-risk patients and reducing treatment-related side effects and complications. It also offers a critical foundation for developing personalized care plans. The article discusses various practical examples of CGA implementation across different countries and regions, including multidisciplinary collaborative models in France, the United States, and Australia, demonstrating CGA's flexible application in diverse healthcare settings. Although significant progress has been made in applying CGA in oncology nursing, numerous challenges remain in its implementation, such as resource limitations and insufficient personnel training. Future research will focus on integrating CGA with emerging technologies, such as artificial intelligence and precision medicine, to further improve the quality of care and treatment outcomes for elderly cancer patients. By summarizing the current status and challenges of CGA in oncology nursing, this review provides guidance for future research and clinical practice, emphasizing the importance of advancing CGA application to meet the growing demands of elderly oncology care.

Trends in cancer mortality in the elderly and oldest old in South America

BACKGROUND

Little is known about trends in cancer among the older segments of the population, even less for South America.

OBJECTIVE

To describe time trends in mortality of the most frequent causes of cancer death among the population aged 70 and over.

METHODS

Using the World Health Organization´s Cancer Mortality Database, we studied trends in mortality from lung, colorectal, stomach, liver, prostate, breast, and cervical cancer from 1985 onwards. Joinpoint analyses allow discerning changes in average annual percent change (i.e., slope AAPC) of these trends over time.

RESULTS

The region has a 2-3-fold variation in absolute age-specific cancer mortality rates, with the lowest rates in Argentina and Paraguay and the highest in Chile, Uruguay, and Venezuela. In most countries except for Brazil and Paraguay (both sexes), Peru (females and males 80 +), and Venezuela (males), overall cancer mortality rates were declining in the studied age range, with some fluctuations during the period. The most common causes by sex vary throughout the continent and by age group, but overall, increasing trends were observed for colorectal and breast cancer. In all countries, time trends show reductions in mortality from stomach cancer (AAPC up to -4.77 %) and in some countries (Argentina, Chile, Colombia, and Ecuador AAPC between -0.04 % and -4.37 %) for cervical cancer. In the other countries, cervical cancer mortality remained stable. Lung cancer declined in all countries in males (AAPC between -0.39 % and -2.24 %) except Brazil, Paraguay and the eldest males in Venezuela but among females, increases were observed in most countries (AAPC between +0.47 % and +4.05 %).

CONCLUSIONS

Cancer-specific mortality rates vary considerably between countries in South America and the high cancer mortality rates in the oldest segments of the population. Effective primary prevention strategies, vaccination implementation, early detection, effective treatment programs, and better access to healthcare overall can positively impact the trends.

Perspectives of healthcare professionals on frailty assessment among older patients with colorectal cancer: A qualitative study

PURPOSE

Exploring the perspectives of healthcare professionals (HCPs) working at the outpatient clinic on the value and practice of standardized frailty assessment in older adults with colorectal cancer (CRC). In current practice, frailty assessment comprises initial frailty screening using the G8 measurement, followed by a comprehensive geriatric assessment (CGA) to further evaluate frailty detected during screening.

METHODS

This is a qualitative study involving semi-structured interviews with 17 HCPs, conducted from February to July 2023. Physicians specializing in oncology, surgery, gastroenterology, and geriatrics were asked to participate as well as nurses and nurse practitioners at the outpatient clinic of a large teaching hospital involved in frailty assessment of patients with CRC.

RESULTS

Two main themes emerged: 1) the perceived value of the G8 measurement for frailty screening and 2) the perceived value of the CGA. The moment, content, and outcome of the G8 and CGA were discussed. Other issues discussed were the complexity of frailty appreciation and collaboration between HCPs. The integration of perspectives proved important to the overall added value of frailty assessment. The CGA is considered most beneficial in patients with suspected cognitive impairment or if there is uncertainty about the degree of frailty or about the optimal treatment.

CONCLUSION

We conclude that the G8 is not an appropriate screening instrument for this patient population. CGA adds value in a specific subset of patients if it is conducted before treatment decisions are made and integrated into an efficient, multidisciplinary pathway, focusing on collaborative decision-making, including with the patient.

[Implementation of geriatric oncology in a remote hospital in French Guiana]

INTRODUCTION

The aim was to analyze the implementation of the Onco-Geriatrics model in a remote ultramarine territory: West-French Guiana. The population is socially precarious in terms of income, social coverage and administrative status, and most often speaks a non-French language and has a non-Western culture.

METHODS

Narrative description of the implementation and retrospective study of anonymized data from the database of older patients managed for cancer between September 2014 and December 2020.

RESULTS

A total of 574 new patients were managed. Of these, 107 were aged 70 and over; 78 (73 %) had a G8 test. Forty-two patients had a multidimensional geriatric assessment (MGA). More than half the patients had dependency criteria, malnutrition and a high number of severe comorbidities. Difficulties encountered were language, level of education, clinical context (in 18 patients), but also insufficient involvement of health professional and the consequences of health organization and gradual implementation.

DISCUSSION

Implementation was impacted by the fact that quality criteria for implementation were not sufficient. Studies in high-middle-income countries in South America suggest that initial implementation of the MGA may be preferable, that frailty screening tests and the MGA procedure can be adapted to non-Western populations, and that the use of new technologies can improve the management of older patients in this context.

Describing the outcomes of frail patients undergoing treatment with systemic therapies for acute myeloid leukaemia: A systematic review

INTRODUCTION

Acute myeloid leukaemia (AML) is a disease of the older person. Due to the demands of intensive chemotherapy, there is a significant risk of over or undertreatment, leading to either iatrogenic harm or missed windows of opportunity for remission or cure. Better tools to aid clinical decision making and risk stratify patients are needed. We aimed to investigate the association between frailty and the treatment and disease-related outcomes of adults receiving systemic therapy for AML.

MATERIALS AND METHODS

A systematic search of PubMed, EMBASE, CINAHL, and Web of Science databases was undertaken for studies assessing frailty (defined as multi-dimensional assessment evaluating two or more geriatric relevant domains or usage of a validated geriatric assessment screening tool) in the setting of adults undergoing systemic therapy for AML.

RESULTS

We identified 6,644 publications, 16 of which met inclusion criteria for extraction. The most commonly described outcomes were overall survival (OS) (n = 12), mortality (n = 8), response rate (n = 6), and high grade toxicity (n = 5). Eleven studies correlated frailty with treatment outcomes: frailty was predictive of lower OS (n = 5), higher mortality (n = 3), and more high grade toxicity (n = 1). OS in particular retained this relationship when controlling for variables such as molecular markers and performance status. Significant heterogeneity in outcome reporting and frailty assessment precluded meta-analysis. Included studies were generally of moderate quality.

DISCUSSION

Frailty was predictive of poorer outcomes in patients with AML distinct from and complimentary to traditional disease prognostic schema. Routine implementation of frailty assessment could represent an important tool to risk stratify patients and improve clinical decision making.

Geriatric assessment domains as predictors for clinical endpoints in older adults with cancer: Protocol for an updated systematic review

Geriatric assessments (GA) are increasingly used to inform treatment decision making and tailoring supportive care for older adults with cancer. Identifying which domains predict clinically relevant outcomes might be particularly useful for risk stratification in settings where a GA is not available and/or feasible. The objective of this updated systematic review is to evaluate individual GA domains as predictors for mortality and treatment-related outcomes. Eligible studies will be identified using a predefined search strategy developed in collaboration with an expert librarian in electronic databases (Medline, Cochrane, Embase, CINAHL) and comprise peer-reviewed papers published in any language from July 2017 and reporting on the prospective association between individual GA domains and mortality as well as surgical- or systemic treatment-related outcomes in older adults with cancer. All title/abstract screening, full-text screening, and data extraction will be performed independently by at least 2 authors. Information on cut-offs of GA domains will also be extracted to assess for variability across studies. A decision on performing a meta-analysis versus a narrative summary will be made based on predetermined criteria, which will include heterogeneity among studies and variability in GA tools and cutoff used for each individual domain, as well as level of risk of bias. If a meta-analysis is indicated, a random effects meta-analysis will be conducted using the Comprehensive Meta-Analysis software. The review will be reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. This protocol has been registered with PROSPERO (ID: CRD42024580404). This review seeks to investigate individual GA domains as predictors for patient- and treatment-related outcomes. Findings may inform efforts on optimizing GA for this population.

Human rights and the comprehensive geriatric assessment: Is the standard of care compatible with a human rights approach?

The comprehensive geriatric assessment is a key tool of geriatricians. It encompasses a holistic approach to care and is now the standard of care for the provision of geriatric medical care for older, vulnerable people across multiple areas of practice. In this article, I argue that the CGA is a tool that allows respect for and support for a human rights' focused approach. This support for human rights has developed incidentally with the development of the CGA. As a result, there are risks to older people's human rights even with a well-applied CGA. The development of a specific human rights convention focused on older people would help focus attention on the rights of older people.

Trends in Incidence and Mortality of Head and Neck Cancer Subsites Among Elderly Patients: A Population-Based Analysis

The incidence of head and neck cancer (HNC) has significantly increased over the past two decades.

MATERIAL AND METHODS

This study analyzed trends in HNC incidence and mortality using data from the Polish Cancer Register (1999-2021) across three age cohorts (60-69, 70-79, and 80+) and projected trends through to 2035. Statistical analyses included regression, correlation, and parallelism tests, with significance levels of α = 0.05 and Bonferroni correction applied (αc ≈ 0.017).

RESULTS

In the 60-69 cohort, incidence rates increased faster than mortality rates (p < 0.001), especially for oral and oropharyngeal cancers in women (p < 0.001). For the 70-79 cohort, mortality rates rose slower than incidence (p < 0.05), most notably for salivary gland cancers across genders and oral cavity cancers in women. In the 80+ group, both incidence and mortality increased (p < 0.05), but mortality rates rose faster for laryngeal, hypopharyngeal, and oral cancers in men and the general population (p < 0.017). The largest increases were observed in oral cancer among women, with a marked rise across all age groups (p < 0.001). Gender-specific patterns highlighted stable or modestly rising trends in males but a notable increase in females, particularly in the 80+ group.

CONCLUSIONS

These findings underscore that older patients are not a homogeneous group in terms of HNC incidence and survival. This study emphasizes age- and gender-specific strategies for prevention and management. Expanding HPV vaccination and improving early detection are crucial, particularly for high-risk groups like older women and those with HPV-related cancers. Tailored approaches could mitigate rising trends and improve survival outcomes.

Could Sarcopenia Be Related to Chemotherapy in Gastrointestinal Cancer? A Cross-Sectional Study Including Comprehensive Geriatric Assessment

Background: Sarcopenia, which is characterized by the progressive loss of skeletal muscle mass, strength, and functionality, adversely affects cancer outcomes. This study aims to evaluate the development and progression of sarcopenia in patients with gastrointestinal cancer undergoing chemotherapy and its impact on comprehensive geriatric assessment outcomes in older participants. Methods: This cross-sectional study included 351 gastrointestinal cancer patients from October 2018 to December 2019. Pre- and post-chemotherapy measurements were taken for 243 participants. Sarcopenia was assessed using EWGSOP-2 criteria, including muscle mass, strength, and performance evaluations. A comprehensive geriatric assessment was conducted for patients aged 65 years and older. Results: The median age of participants was 57.84 years, with 31.7% being female and 29.2% being aged 65 years or older. A significant increase in the prevalence of sarcopenia post-chemotherapy was observed. The factors significantly associated with sarcopenia included low hand grip strength (-0.264; p < 0.001) and slow gait speed (0.222; p = 0.007). The muscle mass and albumin levels of older patients declined significantly post-treatment. Conclusions: This study highlights a strong association between chemotherapy and sarcopenia in gastrointestinal cancer patients, emphasizing the need for early detection and tailored interventions. Comprehensive geriatric assessments can provide critical insights that improve patient outcomes during chemotherapy.

Indications for chemoradiotherapy in older patients with locally advanced head and neck cancer in Japan: a questionnaire survey in the JCOG head and neck cancer study group

Introduction

Chemoradiation therapy (CRT) with concurrent high-dose cisplatin (CDDP) is one of the standard treatment options for locally advanced head and neck cancer. Since the indications specific to the older population have not been reported, we conducted a multicenter survey on the indications.

Methods

In April and May 2023, a questionnaire survey was emailed to all institutions belonging to the JCOG-HNCSG, consisting of 37 institutions.

Results

The major factors influencing the indications for high-dose CDDP were renal function and performance status (PS). The majority agreed that the treatment is administered to patients aged 65-74 years with PS 0-1 and 65-74 years with eGFR ≥60 (ml/ min/1.73m2), and not in patients aged ≥75 years with PS 2, ≥80 years with PS 1, and ≥65 years with eGFR <60. Regarding weekly CDDP, the majority agreed that the treatment is not conducted in patients aged ≥75 years with PS 2, ≥65 years with eGFR <40, and ≥70 years with eGFR <50.

Discussion

In Japan, where CRT is actively performed even among older people, a survey was conducted to determine its indications. Renal function and PS were considered important, and comorbidities, such as heart failure, were considered while determining the indication. These results will help define the eligibility criteria for prospective studies on CRT in older patients.

The value and effectiveness of geriatric assessments for older adults with cancer: an umbrella review

PURPOSE

This umbrella review aimed to summarise and synthesize the evidence on the outcomes reported and used to assess the value and or efficacy of geriatric assessments (GAs) for older adults with cancer.

METHODS

Six electronic databases, PsycINFO, MEDLINE, Embase, CINAHL, Cochrane Library and Web of Science databases, were searched to identify systematic reviews with or without meta-analyses that described the value or outcomes of GAs for older adults with cancer.

RESULTS

Twenty-six systematic reviews were included, of which six included a meta-analysis of the data. Thirteen associations and or outcomes were identified. Overall geriatric impairments predicted or were associated with majority of identified outcomes. However, the type of domains associated with outcomes differed within and across reviews. Only treatment toxicity was statistically significantly lower for patients allocated to the GA intervention group compared to standard care. Systematic reviews without meta-analyses demonstrated a positive impact of GA with management on treatment completion, communication and care planning and patient satisfaction with care.

CONCLUSION

There is evidence demonstrating the predictive value of GAs for older adults with cancer. GAs seems to be beneficial for older adults with cancer across some outcomes, with strong evidence demonstrating the impact of GA with management for treatment toxicity. However, there is mixed or limited evidence demonstrating the effect of GA in other treatment modalities, and on quality of life and economic outcomes.

The performance of metabolomics-based prediction scores for mortality in older patients with solid tumors

Prognostic information is needed to balance benefits and risks of cancer treatment in older patients. Metabolomics-based scores were previously developed to predict 5- and 10-year mortality (MetaboHealth) and biological age (MetaboAge). This study aims to investigate the association of MetaboHealth and MetaboAge with 1-year mortality in older patients with solid tumors, and to study their predictive value for mortality in addition to established clinical predictors. This prospective cohort study included patients aged ≥ 70 years with a solid malignant tumor, who underwent blood sampling and a geriatric assessment before treatment initiation. The outcome was all-cause 1-year mortality. Of the 192 patients, the median age was 77 years. With each SD increase of MetaboHealth, patients had a 2.32 times increased risk of mortality (HR 2.32, 95% CI 1.59-3.39). With each year increase in MetaboAge, there was a 4% increased risk of mortality (HR 1.04, 1.01-1.07). MetaboHealth and MetaboAge showed an AUC of 0.66 (0.56-0.75) and 0.60 (0.51-0.68) for mortality prediction accuracy, respectively. The AUC of a predictive model containing age, primary tumor site, distant metastasis, comorbidity, and malnutrition was 0.76 (0.68-0.83). Addition of MetaboHealth increased AUC to 0.80 (0.74-0.87) (p = 0.09) and AUC did not change with MetaboAge (0.76 (0.69-0.83) (p = 0.89)). Higher MetaboHealth and MetaboAge scores were associated with 1-year mortality. The addition of MetaboHealth to established clinical predictors only marginally improved mortality prediction in this cohort with various types of tumors. MetaboHealth may potentially improve identification of older patients vulnerable for adverse events, but numbers were too small for definitive conclusions. The TENT study is retrospectively registered at the Netherlands Trial Register (NTR), trial number NL8107. Date of registration: 22-10-2019.

Optimizing Care Across the Continuum for Older Adults with Lung Cancer: A Review

Older adults with lung cancer experience inferior clinical outcomes compared to their younger counterparts. This review provides the scaffolding to address these disparities by delineating (1) the distinct and varied care needs of older adults with lung malignancies, (2) evidence-based measures for identifying subgroups within this population meriting tailored approaches to care, (3) age-specific considerations for the selection of cancer-directed therapy, and (4) opportunities for future work to enhance clinical outcomes and care delivery.

Association of Glasgow Prognostic Score with frailty, mortality and adverse health outcomes in older patients with cancer: A prospective cohort study

INTRODUCTION

To balance benefits and risks of cancer treatment in older patients, prognostic information is needed. The Glasgow Prognostic Score (GPS), composed of albumin and C-reactive protein (CRP), might provide such information. This study first aims to investigate the association between GPS and frailty, functional decline, and health-related quality of life (HRQoL) decline as indicators of health problems in older patients with cancer. The second aim is to study the predictive value of GPS for mortality, in addition to clinical predictors.

MATERIALS AND METHODS

This prospective cohort study included patients aged ≥70 years with a solid malignant tumor who underwent a geriatric assessment and blood sampling before treatment initiation. GPS was calculated using serum albumin and CRP measured in batch, categorized into normal (0) and abnormal GPS (1-2). Outcomes were all-cause mortality and a composite outcome of decline in daily functioning and/or HRQoL, or mortality at one year follow-up. Daily functioning was assessed by Activities of Daily Living and Instrumental Activities of Daily Living questionnaires and HRQoL by the EQ-5D-3L and EQ-VAS questionnaires.

RESULTS

In total, 192 patients with a median age of 77 years (interquartile range 72.3-81.0) were included. Patients with abnormal GPS were more often frail compared to those with normal GPS (79 % vs. 63 %, p = 0.03). Patients with abnormal GPS had higher mortality rates after one year compared to those with normal GPS (48 % vs. 23 %, p < 0.01) in unadjusted analysis. Abnormal GPS was associated with increased mortality risk (hazard ratio 2.8, 95 % CI 1.7-4.8). The area under the receiver operating characteristics curve of age, distant metastasis, tumor site, comorbidity, and malnutrition combined was 0.73 (0.68-0.83) for mortality prediction, and changed to 0.78 (0.73-0.86) with GPS (p = 0.10). The composite outcome occurred in 88 % of patients with abnormal GPS versus 83 % with normal GPS (p = 0.44).

DISCUSSION

Abnormal GPS was associated with frailty and mortality. The addition of GPS to clinical predictors showed a numerically superior mortality prediction in this cohort of older patients with cancer, although not statistically significant. While GPS may improve the stratification of future older patients with cancer, larger studies including older patients with similar tumor types are necessary to evaluate its clinical usefulness.

TRIAL REGISTRATION

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

The impact of multidisciplinary geriatric follow-up on quality of life in older, non-surgical prefrail and frail patients with cancer A randomized controlled trial

INTRODUCTION

Cancer management in older frail patients can be complex, given the high decline in functional status, comorbidity, and limited life expectancy affecting this group of patients. Therefore, this study aimed to investigate whether oncological treatment combined with comprehensive geriatric assessment (CGA) and tailored follow-up interventions improved or maintained quality of life (QoL) in older prefrail and frail patients with cancer.

MATERIALS AND METHODS

A single-center randomized controlled trial included participants aged 70 or older with head, neck, lung, upper gastrointestinal tract, colon, or rectum cancer referred to non-surgical treatment. All participants underwent CGA conducted by a multidisciplinary geriatric team in an outpatient oncological clinic. The team consisted of a geriatrician and a specialized nurse who provided tailored follow-up visits and phone calls within 90 days after randomization. Exclusion criteria were fit patients, referral for specialized palliative care, or participating in another geriatric research program. In patients with well-functioning cognition, QoL was assessed using the EORTC QLQ-C30 and QlQ-ELD-14 questionnaires before and after the intervention. In patients with cognitive impairment, the Overall QoL-Depression List was used. Changes in QoL were dichotomized into improved/unchanged or worsened and analyzed in a logistic regression model.

RESULTS

In total, 363 participants were included with a mean age of 76 years (SD 4.6) and 45 % were female. Sixty percent in the intervention group had improved or unchanged QoL compared to 66 % in the control group (odds ratio: 0.75 [95 % confidence interval(CI): 0.45-1.23]). Overall, clinically important changes were found in fatigue and reduced worries about the future. The intervention showed improvements in insomnia symptoms and reported decreased role functioning. Discrepancies were found in the burden of illness without a clinically important difference, where the intervention group experienced an increased burden while the control group had a decreased burden (coefficient: 9.02 [95 % CI, 0.49-17.5]).

DISCUSSION

Multidisciplinary geriatric follow-up did not universally improve QoL in older frail patients with cancer. However, positive changes in specific aspects of QoL revealed nuanced impacts, warranting further exploration and larger studies to validate these observations. Tailored interventions targeting fatigue, insomnia, and emotional well-being are crucial for improving QoL in this population.

TRIAL REGISTRATION

Registered in January 2016 at ClinicalTrials.gov (ID: NCT02837679).

Geriatric assessment for the practicing clinician: The why, what, and how

Older adults with cancer heterogeneously experience health care, treatment, and symptoms. Geriatric assessment (GA) offers a comprehensive evaluation of an older individual's health status and can predict cancer-related outcomes in individuals with solid tumors and those with hematologic malignancies. In the last decade, randomized controlled trials have demonstrated the benefits of GA and GA management (GAM), which uses GA information to provide tailored intervention strategies to address GA impairments (e.g., implementing physical therapy for impaired physical function). Multiple phase 3 clinical trials in older adults with solid tumors and hematologic malignancies have demonstrated that GAM improves treatment completion, quality of life, communication, and advance care planning while reducing treatment-related toxicity, falls, and polypharmacy. Nonetheless, implementation and uptake of GAM remain challenging. Various strategies have been proposed, including the use of GA screening tools, to identify patients most likely to benefit from GAM, the systematic engagement of the oncology workforce in the delivery of GAM, and the integration of technologies like telemedicine and mobile health to enhance the availability of GA and GAM interventions. Health inequities in minoritized groups persist, and systematic GA implementation has the potential to capture social determinants of health that are relevant to equitable care. Caregivers play an important role in cancer care and experience burden themselves. GA can guide dyadic supportive care interventions, ultimately helping both patients and caregivers achieve optimal health.

Toxicity of Cancer Immunotherapies in Older Patients: Does Age Make a Difference?

The use of immunotherapy agents especially immune checkpoint inhibitors is growing, and toxicities known as immune-related adverse events affecting any organ system may develop as a consequence of the treatment. With an ageing population, a considerable number of patients who will receive these therapies will be older adults. However, older patients who have highly heterogenous clinical characteristics, age-related changes in the immune system, a higher prevalence of comorbidities and frailty have been poorly represented in clinical trials, leaving gaps in understanding the safety of immune checkpoint inhibitor agents in this subgroup. Therefore, the safety of immune checkpoint inhibitors is a primary point of consideration when treating older patients with cancer. The available evidence is conflicting, but it generally suggests that the incidence of immune-related adverse events is not necessarily higher in older patients, but it may have a different profile. It is important to also note that the management of immune-related adverse events can be a challenge in these patients, owing to the risks associated with the use of corticosteroids and a reduced physiological reserve. A comprehensive characterisation of immune ageing, potential biomarkers to predict immune-related adverse events, the use of measures for frailty, enrolling older patients with cancer to clinical trials and analysis of real-world data are necessary to improve the evidence-based decision making for immune checkpoint inhibitor treatment in a geriatric oncology population.

Development and Implementation of a Geriatric Oncology Interdisciplinary Case-Based Educational Intervention for Cancer Care Providers

PURPOSE

To develop and implement a continuing professional development (CPD) activity focused on geriatric assessment (GA) in oncology for oncologists and geriatricians. We evaluated the impact of this activity on knowledge, skills, and performance regarding GA in oncology, as well as its feasibility and acceptability.

METHODS

We included teams composed of an oncologist and a geriatrician working in Mexico. Curriculum content was selected from geriatric oncology guidelines. We used Project Extension for Community Healthcare Outcome (ECHO)'s model to create a 12-week online course. A one-group pretest post-test quasi-experimental design was used to evaluate the intervention's effectiveness. At baseline, participants answered a multiple-choice knowledge assessment, a survey on self-perceived competence in GA, and an adaptation of the Association for Community Cancer Centers Geriatric Oncology Gap Assessment Tool, evaluating self-perceived performance in conducting geriatric interventions. These assessments and a satisfaction questionnaire were also completed postintervention. Baseline and postintervention scores were compared using paired t-tests.

RESULTS

We included 40 participants (20 oncologists and 20 geriatricians). Median attendance was 10 sessions (range 2-12). Thirty-eight participants completed the satisfaction questionnaire, with a median score of 10/10 (range 8-10). The mean baseline and postintervention knowledge scores were 59.5 ± 12.8 and 74.4 ± 9.7, respectively (P < .001, effect size 1.14). The mean baseline and postintervention competence scores were 6.42 ± 2.5 and 9.02 ± 0.8, respectively (P < .001, effect size 1.03). The mean baseline and postintervention performance scores were 2.58 ± 0.65 and 3.29 ± 0.5, respectively (P < .001, effect size 1.64).

CONCLUSION

A CPD activity for oncologists and geriatricians on the basis of the Project ECHO model was feasible and acceptable, leading to increased knowledge, competence, and performance in geriatric oncology. This could represent a novel method for increasing the geriatric competence of the cancer care workforce in Latin America and globally.

A multicenter retrospective study to assess feasibility, safety and efficacy of first-line carboplatin-paclitaxel versus carboplatin monotherapy in a frail, elderly epithelial ovarian cancer population

OBJECTIVE

Underrepresentation of elderly ovarian cancer patients in clinical trials has led to lack of clarity regarding optimal first-line chemotherapy in this cohort. The Elderly Women with Ovarian Cancer (EWOC)-1 trial demonstrated that 3-weekly carboplatin (3wC) resulted in worse survival and feasibility compared with standard 3-weekly carboplatin-paclitaxel (3wCP) in frail, elderly ovarian cancer patients. Our retrospective study compares feasibility, safety, and efficacy of first-line 3wCP and 3wC in a frail ovarian cancer cohort.

METHODS

Clinical data were retrospectively analyzed for newly-diagnosed, International Federation of Gynecology and Obstetrics (FIGO) stage III/IV, ≥70-year-old epithelial ovarian cancer patients, treated by clinician choice with 3wC or 3wCP at two London cancer centers over a 2 year period. Charlson Comorbidity Index (CCI) and Eastern Cooperative Oncology Group (ECOG) performance status provided surrogate markers of frailty. Common Terminology Criteria for Adverse Events v5.0 graded toxicity.

RESULTS

A total of 107 patients were treated with 3wC (n=30) and 3wCP (n=77). Age, performance status, and CCI were significantly different between cohorts, with 3wC patients older (84 vs 75 years, p<0.001), with more comorbidities (median CCI 4 vs 3, p<0.001) and worse performance status (47% vs 17% PS ≥2, p=0.015). Surgical outcomes differed significantly between cohorts, with 20 (67%) 3wC patients not undergoing surgery, compared with 22 (29%) 3wCP patients (p<0.001). Median follow-up was 45.8 months (IQR 38.7-56.3 months). While we observed improved progression-free (HR 0.55, 95% CI 0.33 to 0.90, p=0.017) and overall survival (HR 0.44, 95% CI 0.27 to 0.73, p=0.001, log-rank test) in a univariate cox proportional hazards comparison between 3wCP and 3wC, this was not significant on multivariate analysis. Completion of six planned chemotherapy cycles was achieved by the majority, with similar discontinuation rates between groups (13% 3wC vs 8% 3wCP, p>0.05). Overall grade ≥3 hematological toxicity rates were similar between regimens (33% 3wC vs 44% 3wCP, p=0.37) with grade ≥3 neutropenia (p=0.019) and grade ≥3 thrombocytopenia (p=0.006) more common with 3wCP and 3wC, respectively. No treatment-related deaths occurred.

CONCLUSION

Our data demonstrates that standard 3wCP is a well-tolerated, feasible first-line treatment for frail, elderly ovarian cancer patients. Improved survival with 3wCP was not significant when corrected for established clinical prognostic factors.

Physical decline, falls, and hospitalization among vulnerable older patients in the trajectory of colorectal cancer treatment

INTRODUCTION

Resilience to anticancer treatment for colorectal cancer (CRC) among older patients varies. Many experience weight loss, physical decline, falls, and hospitalization during treatment, often leading to early discontinuation of otherwise effective chemotherapy. Screening for vulnerability might help to identify patients at risk of these adverse outcomes in older adults.

MATERIALS AND METHODS

This is a secondary analysis from the GERICO trial. Patients aged ≥70 years assessed for chemotherapy for CRC were screened for eligibility for the GERICO trial with the geriatric-8 (G8) frailty screening tool. The present study population comprised patients who were (1) screened with G8 but for reasons not included in the GERICO study and (2) patients who were randomized to the GERICO control group. We evaluated whether patients identified as vulnerable with G8 (≤14/17) or retrospectively constructed mG8 (≥6/35) had higher risk of experiencing decline in performance status (PS), falls, and unplanned hospitalization during treatment. The association between frailty status and the adverse outcomes was analyzed with univariate and multivariate logistic regression. The discriminative ability of G8/mG8 to predict outcomes was analyzed using the area under the curve for receiver operating characteristics curves.

RESULTS

In total, 238 patients (median age 74 years [range 70-91]) were included in this analysis. More vulnerable than fit patients experienced decline in PS (G8: 41% vs. 14%, p = 0.006 and mG8: 28% vs. 17%, p = 0.04) during treatment. Furthermore, more vulnerable than fit patients experienced falls (G8 14% vs. 6% p = 0.04) and unplanned hospitalization (G8: 31% vs. 14%, p = 0.009 and mG8: 34% vs. 13%, p < 0.001). Multivariate analyses showed an association between G8 vulnerability and decline in PS, falls, and hospitalization.

DISCUSSION

Patients with G8 or mG8 vulnerability were more likely to experience decline in PS and unplanned hospitalization during chemotherapy for CRC than fit patients. More G8 vulnerable patients experienced falls compared with fit patients. Appropriate interventions should be offered to older patients with CRC assessed as vulnerable with G8 or mG8 to maintain PS during chemotherapy.

Implementation status of comprehensive geriatric assessment among older inpatients: A nationwide retrospective study

AIM

The importance of comprehensive geriatric assessment (CGA) is increasing in aging societies worldwide. However, there are few comprehensive studies on CGA, resulting in a limited understanding of its implementation rate, temporal changes and factors associated with its implementation. We aimed to investigate the implementation status of CGA and its regional variance in Japan.

METHODS

Using the Diagnosis Procedure Combination database, we investigated CGA trends, and identified the patient, hospital and regional factors associated with its implementation. We identified patients aged ≥65 years who were admitted for the first time between 2016 and 2020 with a diagnosis of stroke, heart failure, pneumonia, bone fracture or colorectal cancer. We examined the CGA implementation rate according to patient and hospital characteristics. We also investigated temporal changes and tendencies to carry out CGA in different prefectures.

RESULTS

A total of 1 974 817 patients were analyzed, of whom 570 696 (28.9%) underwent CGA. The implementation trend increased steadily from 25.3% in fiscal year 2016 to 33.4% in fiscal year 2019. The implementation rate also increased with patient age (30.3% in patients aged ≥95 years). Regional variations in its implementation status were observed, with a higher tendency to be implemented in areas near major metropolitan regions. A trend toward carrying out CGA for colorectal cancer, but not for other diseases, has been observed in eastern Japan.

CONCLUSION

Although CGA is increasingly carried out, considerable regional differences remain in its implementation status. Initiatives to reduce variations are necessary. Geriatr Gerontol Int 2024; 24: 904-911.

Effect of comprehensive geriatric assessment on hospitalizations in older adults with frailty initiating curatively intended oncologic treatment: The PROGNOSIS-RCT study

INTRODUCTION

Frailty constitutes a risk for unplanned hospitalizations in older adults with cancer. This study examines whether comprehensive geriatric assessment (CGA) as an add-on to standard oncologic care can prevent unplanned hospitalizations in older adults with frailty and cancer who initiate curative oncological treatment.

MATERIALS AND METHODS

This randomized controlled trial included older adults aged ≥70 with frailty (Geriatric 8 [G8] ≤14), and solid cancers who initiated curative oncological treatment. Participants were randomized 1:1 to either standard oncologic care (control) or standard oncologic care supplemented with CGA-guided interventions (intervention). Baseline characteristics were retrieved prior to randomization. The primary endpoint, the between-group rate ratio of unplanned hospitalizations within six months of treatment initiation, was analyzed using negative binominal regression. Analyses were performed using an intention-to-treat approach, followed by per-protocol analysis, including participants receiving CGA within 30 days of randomization, and preplanned subgroup analyses based on treatment modality and Geriatric 8 screening. Secondary endpoints included acute hospital contacts, treatment adherence, and toxicity.

RESULTS

From November 1, 2020 to May 31, 2023, 173 participants were enrolled. Median age was 75 (interquartile range 72-79), 51.5% were female, 58% had a G8 score > 12, and 84% had Eastern Cooperative Oncology Group performance status 0-1. The most common cancer sites were lung (23%), upper gastrointestinal (15%), and breast (13%). The rate (per person-years) of unplanned hospitalization was 1.32 in the intervention group and 1.81 in the control group, with a between-group rate ratio of 0.74 (95% confidence interval [CI] 0.45-1.23, P = 0.25) favoring the intervention. The between-group rate ratio increased in the per-protocol analysis (0.64 [95% CI 0.37-1.10, P = 0.10]). Similarly, no significant between group differences were found in treatment adherence, rate of acute hospital contacts, or toxicity.

DISCUSSION

In this study, CGA did not significantly reduce the rate of unplanned hospitalizations. Furthermore, no between-group differences were found in treatment adherence, toxicity lead hospitalizations, or treatment completion in older adults with cancer and frailty. However, per-protocol analysis suggests that increasing adherence to CGA may improve the outcome. Larger studies ensuring higher CGA adherence are warranted to confirm our findings.

Predicting future medical needs and mortality risk in geriatric long-term care patients : Development and validation of the Nascher score and revised Nascher score

BACKGROUND

Choosing the right intensity of medical care is a huge challenge particularly in long-term geriatric care. The Nascher score was developed to assess future medical care needs. The aim of this study was to determine whether the Nascher score and a revised version can predict future medical needs.

METHODS

In this retrospective cohort study, 396 residents in long-term care hospitals, who were admitted over a period of two years and followed up to two and a half yeare, were analysed. Outcome parameters were: (1) number of medication changes, (2) number of ward doctor documentations and (3) number of acute illnesses treated with antibiotics, and mortality risk. Based on the first results, an alternative scoring of the Nascher score with 12 instead of 26 items was developed, called the revised Nascher score.

RESULTS

The Nascher score significantly correlated with the number of medication changes, the number of ward doctor documentations, and the number of acute ilnesses treated with antibiotics with Spearman correlation coefficients of 0.30, 0.26, and 0.15, respectively. The revised Nascher score showed a higher correlation with correlation coefficients of 0.36, 0.26, and 0.21, respectively. Residents with a Nascher score in the highest quartile had a significantly higher mortality risk than residents in the lowest quartile (hazard ratio, HR 2.97, 95% confidence interval, CI 1.80-4.34). The corresponding values for the revised Nascher score were HR 3.03, 95% CI 2.03-4.54 in the highest and HR 1.80, 95% CI 1.24-2.60 in the middle quartiles.

CONCLUSION

The Nascher score and even more so the revised Nascher score are well suited to predicting the various parameters of future medical needs and mortality risk.

How to incorporate chronic health conditions in oncologic decision-making and care for older patients with cancer? A survey among healthcare professionals

PURPOSE

A substantial proportion of patients with cancer are older and experience multimorbidity. As the population is ageing, the management of older patients with multimorbidity including cancer will represent a significant challenge to current clinical practice.

METHODS

This study aimed to (1) identify which chronic health conditions may cause change in oncologic decision-making and care in older patients and (2) provide guidance on how to incorporate these in decision-making and care provision of older patients with cancer. Based on a scoping literature review, an initial list of prevalent morbidities was developed. A subsequent survey among healthcare providers involved in the care for older patients with cancer assessed which chronic health conditions were relevant and why.

RESULTS

A list of 53 chronic health conditions was developed, of which 34 were considered likely or very likely to influence decision-making or care according to the 39 healthcare professionals who responded. These conditions were further categorized into five patient profiles. From these conditions, five patient profiles were developed, namely, (1) a somatic profile consisting of cardiovascular, metabolic, and pulmonary disease, (2) a functional profile, including conditions that cause disability, dependency or a high caregiver burden, (3) a psychosocial profile, including cognitive impairment, (4) a nutritional profile also including digestive system diseases, and finally, (5) a concurrent cancer profile. All profiles were considered likely to impact decision-making with differences between treatment modalities. The impact on the care trajectory was generally considered less significant, except for patients with care dependency and psychosocial health problems.

CONCLUSIONS

Chronic health conditions have various ways of influencing oncologic decision-making and the care trajectory in older adults with cancer. Understanding why specific chronic health conditions may impact the oncologic care trajectory can aid clinicians in the management of older patients with multimorbidity, including cancer.

Geriatric Assessment in the Era of Targeted and Immunotherapy

Cancer is a disease that mostly affects older adults and because of the aging of the population, the number of older adults diagnosed with cancer will increase significantly around the world. With increasing age, more older adults are living with frailty, and this may impact the tolerability of cancer treatments. International guidelines, such as the American Society for Clinical Oncology geriatric oncology guideline, recommend a geriatric assessment and management for all older adults with cancer to support the treatment decision-making process as well as develop a plan for supportive care interventions to support the older adults during cancer treatments. While there is clinical trial evidence to support a geriatric assessment and management for older adults receiving chemotherapy, there is less evidence to support a geriatric assessment for older adults starting immunotherapy. There are increasing numbers of new immunotherapies and targeted therapies available for older adults with cancer but often few older adults have been included in the clinical trials, leaving less evidence for clinicians to guide treatment decisions. In this current opinion, we review the current evidence on the use of a geriatric assessment and management in the context of immunotherapy and targeted therapy. We review how a geriatric assessment could support older adults making treatment decisions for immunotherapy, review how geriatric assessment parameters are linked with outcomes and provide guidance on how geriatric assessment can guide the supportive care plan during immunotherapy treatment.

The 7th Symposium on primary breast cancer in older women. Theme: involving the caregivers (Held: 1 March 2024)

The 7th Symposium on Primary Breast Cancer in Older Women, hosted by the University of Nottingham in association with the International Society of Geriatric Oncology (SIOG), was held in the Jubilee Conference Centre in Nottingham on 1 March 2024. With the theme of 'involving the caregivers', topics included: barriers to clinical trial participation among older women, the use of geriatric assessment tools to tailor treatments to individual patient's level of frailty and interventions such as medication review and de-prescription to reduce toxicity and increase compliance with treatment.The symposium began with an upbeat introduction from the symposium chair, Kwok-Leung Cheung (Professor of Breast Surgery and Medical Education, University of Nottingham, Consultant Breast Surgeon, Royal Derby Hospital; UK National Representative, SIOG). Cheung welcomed attendees and contributors from a wide range of disciplines including surgeons, geriatricians, clinical nurse specialists, pharmacists and patient representatives.Cheung outlined how this biennial symposium, the only one of its kind to focus on primary breast cancer in older women, had grown in both size and ambition since its inception in 2010. For the first time, this year's proceedings included a dedicated multidisciplinary team discussion of geriatric breast cancer cases submitted by delegates.The main theme of the day's proceedings "involving the caregivers" was also emphasized in the introductory comments.

Geriatric assessment with management for older patients with cancer receiving radiotherapy: a cluster-randomised controlled pilot study

BACKGROUND

Geriatric assessment and management (GAM) improve outcomes in older patients with cancer treated with surgery or chemotherapy. It is unclear whether GAM may provide better function and quality of life (QoL), or be cost-effective, in a radiotherapy (RT) setting.

METHODS

In this Norwegian cluster-randomised controlled pilot study, we assessed the impact of a GAM intervention involving specialist and primary health services. It was initiated in-hospital at the start of RT by assessing somatic and mental health, function, and social situation, followed by individually adapted management plans and systematic follow-up in the municipalities until 8 weeks after the end of RT, managed by municipal nurses as patients' care coordinators. Thirty-two municipal/city districts were 1:1 randomised to intervention or conventional care. Patients with cancer ≥ 65 years, referred for RT, were enrolled irrespective of cancer type, treatment intent, and frailty status, and followed the allocation of their residential district. The primary outcome was physical function measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-C30 (QLQ-C30). Secondary outcomes were overall quality of life (QoL), physical performance, use and costs of health services. Analyses followed the intention-to-treat principle. Study registration at ClinicalTrials.gov ID NCT03881137.

RESULTS

We included 178 patients, 89 in each group with comparable age (mean 74.1), sex (female 38.2%), and Edmonton Frail Scale scores (mean 3.4 [scale 0-17], scores 0-3 [fit] in 57%). More intervention patients received curative RT (76.4 vs 61.8%), had higher irradiation doses (mean 54.1 vs 45.5 Gy), and longer lasting RT (mean 4.4 vs 3.6 weeks). The primary outcome was completed by 91% (intervention) vs 88% (control) of patients. No significant differences between groups on predefined outcomes were observed. GAM costs represented 3% of health service costs for the intervention group during the study period.

CONCLUSIONS

In this heterogeneous cohort of older patients receiving RT, the majority was fit. We found no impact of the intervention on patient-centred outcomes or the cost of health services. Targeting a more homogeneous group of only pre-frail and frail patients is strongly recommended in future studies needed to clarify the role and organisation of GAM in RT settings.

Updates on the Management of Colorectal Cancer in Older Adults

Colorectal cancer (CRC) poses a significant global health challenge. Notably, the risk of CRC escalates with age, with the majority of cases occurring in those over the age of 65. Despite recent progress in tailoring treatments for early and advanced CRC, there is a lack of prospective data to guide the management of older patients, who are frequently underrepresented in clinical trials. This article reviews the contemporary landscape of managing older individuals with CRC, highlighting recent advancements and persisting challenges. The role of comprehensive geriatric assessment is explored. Opportunities for treatment escalation/de-escalation, with consideration of the older adult's fitness level. are reviewed in the neoadjuvant, surgical, adjuvant, and metastatic settings of colon and rectal cancers. Immunotherapy is shown to be an effective treatment option in older adults who have CRC with microsatellite instability. Promising new technologies such as circulating tumor DNA and recent phase III trials adding later-line systemic therapy options are discussed. Clinical recommendations based on the data available are summarized. We conclude that deliberate efforts to include older individuals in future colorectal cancer trials are essential to better guide the management of these patients in this rapidly evolving field.

Immunotherapy use in older adults with cancer with frailty: A young SIOG review paper

Immune checkpoint inhibitors (ICIs) became a treatment option in most tumor types and improved survival in patients with cancer in the last decade. Older patients with cancer are underrepresented in the pivotal clinical trials with ICIs. Older patients with cancer often have significant comorbidities and geriatric syndromes like frailty, which can complicate cancer care and treatment decisions. Frailty is among the most prevalent geriatric syndromes in patients with cancer and could lead to inferior survival and a higher risk of complications in patients treated with chemotherapy. However, the effect of frailty on the efficacy and safety of ICIs is understudied. This review focuses on the available evidence regarding the association between frailty and ICI efficacy and safety. Although the survival benefits of ICIs have generally been shown to be independent of age, the available real-world data has generally suggested higher rates of immune-related adverse events (irAEs) and treatment discontinuation in older patients. While international organizations recommend conducting a comprehensive geriatric assessment CGA to assess and address frailty before the start of anti-cancer therapies, an Eastern Cooperative Oncology Group (ECOG) performance status of 2 or higher is frequently used in clinical practice as synonymous with frailty, albeit with significant limitations. The available data has generally demonstrated diminished ICI efficacy in patients with an ECOG 2 or higher compared to patients with better performance status, while the incidence of high-grade irAEs were similar. Whilst evidence regarding outcomes with ICI in older patients and in those with sub-optimal performance status is growing, there is very limited data specifically evaluating the role of frailty with ICIs. These studies found a shortened overall survival, yet no evidence of a lower response rate to ICIs. These patients experienced more AEs, but they did not necessarily have a higher incidence of irAEs.

Geriatric Assessment in CKD Care: An Implementation Study

Rationale & Objective

Older people with progressive chronic kidney disease (CKD) have complex health care needs. Geriatric evaluation preceding decision making for kidney replacement is recommended in guidelines, but implementation is lacking in routine care. We aimed to evaluate implementation of geriatric assessment in CKD care.

Study Design

Mixed methods implementation study.

Setting & Participants

Dutch nephrology centers were approached for implementation of geriatric assessment in patients aged ≥70 years and with an estimated glomerular filtration rate of ≤20 mL/min/1.73 m2.

Quality Improvement Activities/Exposure

We implemented a consensus-based nephrology-tailored geriatric assessment: a patient questionnaire and professionally administered test set comprising 16 instruments covering functional, cognitive, psychosocial, and somatic domains and patient-reported outcome measures.

Outcomes

We aimed for implementation in 10 centers and 200 patients. Implementation was evaluated by (i) perceived enablers and barriers of implementation, including integration in work routines (Normalization Measure Development Tool) and (ii) relevance of the instruments to routine care for the target population.

Analytical Approach

Variations in implementation practices were described based on field notes. The postimplementation survey among health care professionals was analyzed descriptively, using an explanatory qualitative approach for open-ended questions.

Results

Geriatric assessment was implemented in 10 centers among 191 patients. Survey respondents (n = 71, 88% response rate) identified determinants that facilitated implementation, ie, multidisciplinary collaboration (with geriatricians) -meetings and reports and execution of assessments by nurses. Barriers to implementation were patient illiteracy or language barrier, time constraints, and patient burden. Professionals considered geriatric assessment sufficiently integrated into work routines (mean, 6.7/10 ± 2.0 [SD]) but also subject to improvement. Likewise, the relevance of geriatric assessment for routine care was scored as 7.8/10 ± 1.2. The Clinical Frailty Score and Montreal Cognitive Assessment were perceived as the most relevant instruments.

Limitations

Selection bias of interventions' early adopters may limit generalizability.

Conclusions

Geriatric assessment could successfully be integrated in CKD care and was perceived relevant to health care professionals.

State of the scientific evidence and recommendations for the management of older patients with gastric cancer

Gastric cancer is one of the most frequent and deadly tumours worldwide. However, the evidence that currently exists for the treatment of older adults is limited and is derived mainly from clinical trials in which older patients are poorly represented. In this article, a group of experts selected from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Group for the Treatment of Digestive Tumours (TTD), and the Spanish Multidisciplinary Group on Digestive Cancer (GEMCAD) reviews the existing scientific evidence for older patients (≥65 years old) with gastric cancer and establishes a series of recommendations that allow optimization of management during all phases of the disease. Geriatric assessment (GA) and a multidisciplinary approach should be fundamental parts of the process. In early stages, endoscopic submucosal resection or laparoscopic gastrectomy is recommended depending on the stage. In locally advanced stage, the tolerability of triplet regimens has been established; however, as in the metastatic stage, platinum- and fluoropyrimidine-based regimens with the possibility of lower dose intensity are recommended resulting in similar efficacy. Likewise, the administration of trastuzumab, ramucirumab and immunotherapy for unresectable metastatic or locally advanced disease is safe. Supportive treatment acquires special importance in a population with different life expectancies than at a younger age. It is essential to consider the general state of the patient and the psychosocial dimension.

Prevalence of frailty and pain in hospitalised cancer patients: implications for older adult care

A hospital-wide point prevalence study investigated frailty and pain in patients with a cancer-related admission. Modifiable factors associated with frailty in people with cancer were determined through logistic regression. Forty-eight patients (19%) with cancer-related admissions were 2.65 times more likely to be frail and 2.12 more likely to have moderate pain. Frailty and pain were highly prevalent among cancer-related admissions, reinforcing the need for frailty screening and importance of pain assessment for patients with cancer.

Do older patients with colorectal cancer experience more deterioration in health-related quality of life than younger patients during the first year of palliative chemotherapy? A prospective real-world observational study

INTRODUCTION

The primary aim was to evaluate changes in health-related quality of life (HRQoL) in a real-life population among younger (< 70 years) and older patients with metastatic colorectal cancer (mCRC) during the first year of palliative chemotherapy. The secondary aims were to assess the impact of chemo-break on HRQoL and to report overall survival (OS).

MATERIALS AND METHODS

Patients with newly diagnosed mCRC, ≥ 18 years, and scheduled for first line palliative chemotherapy were included in this multicentre longitudinal observational study. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (0-100) was filled in at baseline and every second month. Changes or differences in QoL scores of >20, 10-20, and 5-10 points were considered to be of large, moderate, and small clinical magnitude, respectively. Comparing means of different QoL scores between groups or over time, a threshold of 5-10 was considered the minimally important difference (MID). Treatments, patient characteristics, and tumour characteristics were prospectively registered.

RESULTS

A total of 214 patients were included, and 146 were alive after one year. Four months after start of treatment, large deteriorations in fatigue and physical functioning were reported by 40% and 25% of the patients, respectively. Changes in global QoL, physical functioning, role functioning, fatigue, pain, and nausea/vomiting were not significantly different between the age groups and reached baseline levels after one year. Patients on chemo-break reported significant improvements in several HRQoL domains. Median OS was 17.5 months [95% confidence interval 14.4-20.5] with no difference between younger and older patients.

DISCUSSION

Older patients did not experience more deterioration in HRQoL than younger patients during the first year of palliative chemotherapy. Measures to mitigate the deteriorations in fatigue and physical functioning observed during the first months of palliative treatment are warranted.

TRIAL REGISTRATION

NCT02395224, March 23, 2015, retrospectively registered.

Impact of FRAilty screening and Geriatric assessment and INtervention in older patients with epithelial Ovarian Cancer: A multicenter randomized clinical trial protocol (FRAGINOC)

INTRODUCTION

Radical surgery combined with chemotherapy is the only potential curative treatment of patients with advanced epithelial ovarian cancer (EOC). However, 43% of older Danish patients with EOC are not referred to surgery due to frailty, age, or fear of complications. Comprehensive geriatric assessment (CGA) has demonstrated ability to reduce frailty in older patients, but there is a knowledge gap regarding its effect before or during treatment in older adults with EOC. This protocol presents a randomized controlled trial (RCT), which evaluates the effect of CGA-based interventions including individualized physical exercise therapy in older adults with EOC during neoadjuvant chemotherapy (NACT).

MATERIALS AND METHODS

This RCT will include patients aged ≥70 years with primary EOC referred to NACT. Patients will be randomized 1:1 to intervention or standard of care, along with neoadjuvant antineoplastic treatment. Stratification for performance status and center of inclusion will be performed. In the intervention arm, a geriatrician will perform CGA and corresponding geriatric interventions and patients will undergo an individualized home-based exercise program managed by a physiotherapist. All patients will be evaluated with Geriatric-8, modified Geriatric-8, clinical frailty scale, and physical tests at randomization. Predictive values (positive/negative) will be evaluated for CGA detected impairments. The primary endpoint is the proportion of patients referred to interval debulking surgery (IDS). Secondary endpoints include the proportion who complete oncological treatment, improvements in physical tests, quality of life measured by European Organization for Research and Treatment of Cancer-Quality of Life questionnaires at inclusion, after three cycles of chemotherapy, and at end of chemotherapy treatment. Furthermore, the association between results of geriatric screening tests, CGA, and physical tests with complication rate and progression free survival will be examined. The primary outcome will be analyzed with logistic regression in the intention-to-treat population. Power calculations reveal the need to enroll 216 patients.

DISCUSSION

The present study examines whether CGA-based interventions including individualized physical exercise can increase the referral rate for potential curative IDS in older patients with EOC. If successful, this will result in more patients undergoing surgery and completing chemotherapy, preventing complications, and ultimately improving quality of life and survival. The study setup may establish the basis for direct clinical implementation if proven effective.

Cardiovascular Concerns, Cancer Treatment, and Biological and Chronological Aging in Cancer: JACC Family Series

Cardiovascular disease (CVD) and cancer are leading causes of death globally, particularly among the rapidly growing population of older adults (OAs). CVD is a leading cause of mortality among cancer survivors, often accelerated by cancer treatments associated with short- or long-term cardiotoxicity. Moreover, there is a dynamic relationship among CVD, cancer, and aging, characterized by shared risk factors and biological hallmarks, that plays an important role in caring for OAs, optimizing treatment approaches, and developing preventive strategies. Assessment of geriatric domains (eg, functional status, comorbidities, cognition, polypharmacy, nutritional status, social support, psychological well-being) is critical to individualizing treatment of OAs with cancer. The authors discuss considerations in caring for an aging population with cancer, including methods for the assessment of OAs with CVD and/or cardiovascular risk factors planned for cancer therapy. Multidisciplinary care is critical in optimizing patient outcomes and maintaining quality of life in this growing vulnerable population.

A Retrospective Age Analysis of the Ambulatory Oncology Patient Satisfaction Survey: Differences in Satisfaction across Dimensions of Person-Centred Care and Unmet Needs among Older Adults Receiving Cancer Treatment

Over half of all new cancer cases in Alberta are diagnosed among people aged 65+ years, a group that encompasses vast variation. Patient-reported experience measures are routinely collected within Cancer Care Alberta; however, the specific consideration of the needs and concerns of older Albertans with cancer is lacking. In 2021, 2204 adults who had received treatment at a cancer centre in Alberta completed the Ambulatory Oncology Patient Satisfaction Survey (AOPSS). In this study, we explored the age differences in satisfaction across six dimensions of person-centred care and in the proportions of unmet needs across eight types of issues, with specific attention to older adults. Using three age groups (18-39, 40-64, 65+), only the physical comfort dimension showed significantly lower satisfaction among those aged 65+ years. Using five age groups (18-39, 40-64, 65-74, 75-84, 85+), significantly lower levels of satisfaction were found related to 'physical comfort' for those aged 65-74 and 75-84, 'coordination and continuity of care' for those aged 75-84 and 85+, and 'information, communication, and education' for those aged 85+. Therefore, grouping together all older adults aged 65+ years obscured lower levels of satisfaction with some dimensions of person-centred care among those aged 75-84 and 85+ years. Unmet needs generally increased with age for all types of issues, with significant differences across age groups for emotional, financial, social/family, and sexual health issues. The lower levels of satisfaction and higher proportions of unmet needs call for tailored interventions to promote optimal care experiences and outcomes among older adults receiving cancer care in Alberta and their families.

Leave no one behind: A global survey of the current state of geriatric oncology practice by SIOG national representatives

INTRODUCTION

The Sustainable Development Goals of the United Nations include a commitment to "leave no one behind" as a universal goal. To achieve this in geriatric oncology (GO) worldwide, it is important to understand the current state of GO at an international level. The International Society of Geriatric Oncology (SIOG) has several National Representatives (NRs) who act as SIOG's delegates in their respective countries. The NRs took part in this international survey exploring the state of GO practice, identifying barriers and solutions.

MATERIALS AND METHODS

The NRs answered open-ended questions by email from February 2020 to October 2022. The questionnaire domains included the demographic information of older adults for their countries, and the NRs' opinions on whether GO is developing, what the barriers are to developing GO, and proposed actions to remove these barriers. The demographic data of each country reported in the survey was adjusted using literature and database searches.

RESULTS

Twenty-one of thirty countries with NRs (70%) participated in this questionnaire study: 12 European, four Asian, two North American, two South American, and one Oceanian. The proportion of the population aged ≥75 years varied from 2.2% to 15.8%, and the average life expectancy also varied from 70 years to 86 years. All NRs reported that GO was developing in their country; four NRs (18%) reported that GO was well developed. Although all NRs agreed that geriatric assessment was useful, only three reported that it was used day-to-day in their countries' clinical practice (14%). The major barriers identified were the lack of (i) evidence to support GO use, (ii) awareness and interest in GO, and (iii) resources (time, manpower, and funding). The major proposed actions were to (i) provide new evidence through clinical trials specific for GO patients, (ii) stimulate awareness through networking, and (iii) deliver educational materials and information to healthcare providers and medical students.

DISCUSSION

This current survey has identified the barriers to GO and proposed actions that could remove them. Broader awareness seems to be essential to implementing GO. Additional actions are needed to develop GO within countries and can be supported through international partnerships.

Real world efficacy and toxicity of consolidation durvalumab following chemoradiotherapy in older Australian patients with unresectable stage III non-small cell lung cancer

INTRODUCTION

Consolidation durvalumab following platinum-based chemoradiotherapy (CRT) significantly improved overall survival for patients with unresectable stage III non-small cell lung cancer (NSCLC) in the PACIFIC trial. However, older patients were underrepresented in PACIFIC, and subsequent analyses suggested trends toward poorer survival and increased toxicity in patients aged ≥70 years old. We assessed the effectiveness and safety of consolidation durvalumab following CRT in older Australian patients with unresectable stage III NSCLC.

MATERIALS AND METHODS

This retrospective observational study was conducted across seven sites in Sydney, Australia between January 2018 and September 2021. All adult patients with unresectable stage III NSCLC who received platinum-based chemoradiotherapy followed by at least one cycle of consolidation durvalumab were included. Older patients were defined as being ≥70 years old.

RESULTS

Of 152 patients included in the analysis, 42.8% (n = 67) patients were 70 years or older. Median follow-up was 26.1 months. The two-year overall survival and median PFS was similar between older and younger patients. At two years, 74.8% (95% confidence interval [CI]: 65.4-84.2%) of patients <70 years old and 65.2% (95% CI: 53.4-77.0%) of older patients were alive (p = 0.07; hazard ratio [HR] 1.64, 95% CI: 0.95-2.81). Median progression-free survival (PFS) in patients <70 years was 30.3 months (95% CI: 22.2-38.4 months) compared with 26.7 months (95% CI: 12.8-40.6 months) in older patients (p = 0.22; HR 1.46, 95% CI: 0.80-2.65). Toxicity was also similar, with 11.5% of patients <70 years old and 18.5% of older patients experiencing grade 3-4 adverse events (AEs; p = 0.23); 16.1% and 24.6% of the patients, respectively, discontinued treatment due to toxicity (p = 0.19). Grade 3-4 AEs and treatment discontinuation were associated with Charlson Comorbidity Index >5 (p = 0.011) and chronic obstructive pulmonary disease diagnosis at presentation (p = 0.002), respectively.

DISCUSSION

Older Australian patients receiving consolidation durvalumab following CRT experienced comparable outcomes to their younger peers. Comorbidity burden may be more important determinants of treatment tolerance than chronological age.