Geriatric oncology: challenges for the new century

Neoadjuvant Chemotherapy Is Associated With Reduced Amputation Risk in Synovial Sarcoma of the Lower Extremity

BACKGROUND AND OBJECTIVES

The combination of radiation and surgical resection represents the current standard of care for primary synovial sarcoma (SS). However, controversy remains regarding the role of chemotherapy. We sought to evaluate the impact of neoadjuvant chemotherapy on the likelihood of undergoing amputation for patients with lower extremity SS.

METHODS

We identified all adults (≥ 18 years) diagnosed with nonmetastatic SS of the lower extremity who underwent definitive resection within the 2004-2021 National Cancer Database. Multivariable models were developed to assess the independent association of neoadjuvant chemotherapy with likelihood of amputation versus limb salvage. We secondarily considered the independent association of neoadjuvant treatment or amputation with overall survival at 5 years.

RESULTS

Of 1207 patients, 376 (31%) received neoadjuvant chemotherapy. Patients who received neoadjuvant treatment were younger and more commonly presented with Stage III disease. Following comprehensive adjustment for patient, disease, and hospital factors, receipt of neoadjuvant chemotherapy was linked with significantly reduced likelihood of amputation (AOR 0.47, CI 0.27-0.84). Upon risk-adjusted survival analysis, receipt of neoadjuvant therapy was linked with similar outcomes, but amputation was associated with significantly greater mortality hazard over 5 years following resection (HR 1.75, CI 1.30-2.35).

CONCLUSIONS

In this national registry study, receipt of neoadjuvant chemotherapy was associated with significantly reduced odds of amputation. Amputation was linked with significantly greater mortality over 5 years while neoadjuvant chemotherapy did not improve 5-year overall survival.

Standard versus reduced-dose chemoradiotherapy in anal cancer (PLATO-ACT4): short-term results of a phase 2 randomised controlled trial

BACKGROUND

Localised squamous cell carcinoma of the anus is treated with radical chemoradiotherapy. Cure rates are high, but treatment can result in substantial acute and long-term morbidity. We aimed to assess whether lower dose chemoradiotherapy maintains high local control rates in patients with early-stage disease, with the secondary aim of reducing toxicity.

METHODS

ACT4 is a phase 2, prospective, multicentre, open-label, two-arm non-comparative, randomised, controlled trial, investigating reduced-dose intensity-modulated radiotherapy (rd-IMRT: 41·4 Gy in 23 fractions) in patients with early-stage anal cancer; T1-2 (≤4 cm) N0-NxM0. Eligible patients were at least 16 years of age, with an Eastern Cooperative Oncology Group performance status of 0-1. The primary outcome is 3-year loco-regional failure rates. Patients were randomly assigned 1:2 (with stratification by T stage, N stage, gender, HIV status, and randomising site) to standard-dose IMRT (sd-IMRT: 50·4 Gy in 28 fractions) or rd-IMRT with concurrent mitomycin and capecitabine chemotherapy. Here, we report the pre-planned, modified intention-to-treat analysis of secondary endpoints 6 months after treatment end-complete clinical response, compliance, patient-reported outcomes (EORTC QLQ-C30 and ANL27), and safety data. The trial is registered at the ISRCTN registry (ISRCTN88455282) and is ongoing but no longer recruiting.

FINDINGS

163 patients were recruited from 28 UK tertiary centres between April 24, 2017, and Dec 1, 2020. 160 patients were included in the primary analysis (sd-IMRT n=55; dr-IMRT n=105). Data on ethnicity were not collected. The median patient age was 66 years (IQR 58-72 years); 117 (73%) were female and 43 (27%) male; and 129 (94%) of 138 evaluable samples were p16 positive. Complete clinical responses at 6 months were 87% (46 of 53) for sd-IMRT and 92% (89 of 97) for rd-IMRT. Radiotherapy interruptions of 3 days or more occurred in 14 (26%) of 55 patients in sd-IMRT and 16 (15%) of 105 patients in rd-IMRT. Chemotherapy modifications occurred in 27 (49%) of 55 patients in sd-IMRT and 39 (37%) of 105 patients in rd-IMRT. Grade 3 or worse acute toxicity was reported in 25 (46%) of 55 patients in sd-IMRT and 37 (35%) of 105 patients in rd-IMRT. The most common grade 3 or worse adverse events were radiation dermatitis (seven [13%] of 55 in sd-IMRT and ten [10%] of 105 in rd-IMRT), and diarrhoea (four [7%] of 55 in sd-IMRT and nine [9%] of 105 in rd-IMRT). Serious adverse events occurred in eight (15%) of 55 patients in sd-IMRT and ten (10%) of 105 patients in rd-IMRT. Patient-reported outcomes for most issues deteriorated at the end of treatment and resolved to baseline by 6 weeks in both groups. Poorer sexual function for men and women was observed at 6 months following sd-IMRT.

INTERPRETATION

Good 6-month complete clinical responses rates were seen in both groups. Early results suggest rd-IMRT is well tolerated with oncological outcomes maintained. 3-year locoregional failure rates are awaited.

FUNDING

Cancer Research UK and Stand Up to Cancer.

A STROBE analysis of conservative laryngeal treatment in France for cT1-2N0M0 glottic squamous cell carcinoma in octogenarians

OBJECTIVES

To document conservative laryngeal treatment for cT12N0M0 glottic squamous cell carcinoma (SCC) in octogenarians in France in the 21st century.

MATERIAL AND METHODS

Retrospective observational study comparing a cohort of 38 octogenarians (Group A) to a control cohort of 107 septuagenarians (Group B), with isolated cT12N0M0 glottic SCC, consecutively managed between 2000 and 2018 at a single French university hospital center. The main endpoints were 5-year actuarial overall and disease-free survival and causes of death, compared between groups. Accessory endpoints were 5-year actuarial local control and laryngeal preservation. 93% of patients were followed until death or for a minimum 5years. The STROBE guideline was used. The significance threshold was set at P<0.005.

RESULTS

The only significant difference in demographic, oncologic and treatment variables between groups was a higher mean Charlson index in Group A (P=0.004). Five-year actuarial survival, at 79% overall, did not significantly differ between groups A and B (80% and 79%, respectively; P=0.30). Five-year actuarial disease-free survival, at 74% overall, did not significantly differ between groups (77% and 73%; P=0.42). Intercurrent disease accounted for 44% of causes of death, with cardiovascular etiology in 71% of cases. Five-year actuarial local control, at 76% overall, did not significantly differ between groups (80% and 75%; P=0.41). Salvage treatment for local recurrence yielded a 94% overall local control rate: 98% in Group A and 93% in Group B. Five-year actuarial laryngeal preservation rate, at 92%, did not significantly differ between groups (90% and 98%; P=0.20).

CONCLUSION

Conservative laryngeal treatment for cT12N0M0 SCC in octogenarians yielded the same results as in septuagenarians. Improvement in survival will depend on management and monitoring of comorbidity, and particularly cardiovascular comorbidity.

Uncovering the Daily Experiences of People Living With Advanced Cancer Using an Experience Sampling Method Questionnaire: Development, Content Validation, and Optimization Study

BACKGROUND

The experience sampling method (ESM), a self-report method that typically uses multiple assessments per day, can provide detailed knowledge of the daily experiences of people with cancer, potentially informing oncological care. The use of the ESM among people with advanced cancer is limited, and no validated ESM questionnaires have been developed specifically for oncology.

OBJECTIVE

This study aims to develop, content validate, and optimize the digital Experience Sampling Method for People Living With Advanced Cancer (ESM-AC) questionnaire, covering multidimensional domains and contextual factors.

METHODS

A 3-round mixed methods study was designed in accordance with the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) and the European Organization for Research and Treatment of Cancer guidelines. The study included semistructured interviews with 43 people with stage IV breast cancer or stage III to IV lung cancer and 8 health care professionals. Round 1 assessed the appropriateness, relative importance, relevance, and comprehensiveness of an initial set of ESM items that were developed based on the existing questionnaires. Round 2 tested the comprehensibility of ESM items. Round 3 tested the usability of the digital ESM-AC questionnaire using the m-Path app. Analyses included descriptive statistics and qualitative content analysis.

RESULTS

Following the first round, we developed an initial core set of 68 items (to be used with all patients) and a supplementary set (optional; patients select items), both covering physical, psychological, social, spiritual-existential, and global well-being domains and concurrent contexts in which experiences occur. We categorized items to be assessed multiple times per day as momentary items (eg, "At this moment, I feel tired"), once a day in the morning as morning items (eg, "Last night, I slept well"), or once a day in the evening as evening items (eg, "Today, I felt hopeful"). We used participants' evaluations to optimize the questionnaire items, the digital app, and its onboarding manual. This resulted in the ESM-AC questionnaire, which comprised a digital core questionnaire containing 31 momentary items, 2 morning items, and 7 evening items and a supplementary set containing 39 items. Participants largely rated the digital questionnaire as "easy to use," with an average score of 4.5 (SD 0.5) on a scale from 1 ("completely disagree") to 5 ("completely agree").

CONCLUSIONS

We developed the ESM-AC questionnaire, a content-validated digital questionnaire for people with advanced breast or lung cancer. It showed good usability when administered on smartphone devices. Future research should evaluate the potential of this ESM tool to uncover daily experiences of people with advanced breast or lung cancer, explore its clinical utility, and extend its validation to other populations with advanced diseases.

Outcomes of Multimodal Treatment in Elderly Patients with Localized Non-Small Lung Cancer from a Radiation Oncology Point of View: Special Focus on Low-Dose Cisplatin

Identification of the optimal treatment strategy is challenging in elderly with localized non-small cell lung cancer (NSCLC). Concurrent chemotherapy with low-dose cisplatin represents an option for elderly. Outcomes (1) in elderly (≥70 years, n = 158) vs. younger patients (n = 188) and (2), independently of age, in definitive radiochemotherapy, with low-dose cisplatin (n = 125) vs. cisplatin/vinorelbine (n = 76) were studied. Elderly included more males, had a lower Karnofsky index, more comorbidities, and lower stages. Low-dose cisplatin patients (vs. cisplatin/vinorelbine) had higher age, more comorbidities, and lower stages. We observed reduced dermatitis and dysphagia and increased anemia and thrombocytopenia in elderly vs. younger patients, without increased ≥grade 3 toxicities. Low-dose cisplatin was less toxic than cisplatin/vinorelbine. Survival outcomes were lower in elderly vs. younger and comparable between low-dose cisplatin and cisplatin/vinorelbine. In elderly, gender, Karnofsky index, stage, and multimodal treatment (including additional surgery/systemic therapy) were identified as prognostic factors. In conclusion, we found evidence for an acceptable toxicity profile and the need for improvement of outcomes in elderly with localized NSCLC. Multimodal strategies (including additional surgery/systemic treatment) showed favorable outcomes and should be reasonably considered in elderly who are deemed fit enough. Low-dose cisplatin should be discussed on an individual basis due to favorable toxicity and outcomes.

Checkpoint inhibitors in older patients with advanced non-small cell lung cancer

Immune checkpoint inhibitors (ICIs) have revolutionized lung cancer management improving overall survival and providing durable responses with a favorable toxicity profile. New questions have emerged regarding the efficacy and safety of immunotherapy among older adults, typically underrepresented in clinical trials. Several factors have to be taken into account in order to reduce the realistic risk of over or under-treatment of this growing subgroup of patients. In this perspective, geriatric assessment and screening tools should be implemented in clinical practice; moreover older patients' inclusion into adapted-designed clinical trials should be promoted. In this review, we discuss immunotherapy activity in advanced non-small cell lung cancer (NSCLC) older patients, the role of the comprehensive geriatric assessment, treatment toxicity and its management with a focus on future perspectives in this rapidly evolving scenario.

Are Extensive Open Lung Resections for Elderly Patients with Lung Cancer Justified?

BACKGROUND

Older patients with malignancies are more comorbid than younger ones and are usually undertreated only because of their age. The aim of this study is to investigate the safety of open anatomical lung resections for lung cancer in elderly patients.

METHODS

We retrospectively analyzed all patients who underwent lung resection for lung cancer in our institution and categorized them into two groups: the elderly group (≥70 years old) and the control (<70).

RESULTS

In total, 135 patients were included in the elderly group and 375 in the control. Elderly patients were more frequently diagnosed with squamous cell carcinoma (59.3% vs. 51.5%, p = 0.037), higher differentiated tumors (12.6% vs. 6.4%, p = 0.014), and at an earlier stage (stage I: 55.6% for elderly vs. 36.6%, p = 0.002). Elderly patients were more vulnerable to postoperative pneumonia (3.7% vs. 0.8%, p = 0.034), lung atelectasis (7.4% vs. 2.9%, p = 0.040), and pleural empyema (3.2% vs. 0%, p = 0.042), however, with no increased 30-day-mortality (5.2% for elderly vs. 2.7%, p = 0.168). Survival was comparable in both groups (43.4 vs. 45.3 months, p = 0.579).

CONCLUSIONS

Elderly patients should not be excluded from open major lung resections as the survival benefit is not reduced in selected patients.

Older patients with EGFR mutation-positive non-small cell lung cancer treated with afatinib in clinical practice: A subset analysis of the non-interventional GIDEON study

INTRODUCTION

Lung cancer is most common in older patients; despite this, older patients are historically under-represented in clinical studies. Here we present data from GIDEON, a study undertaken in Germany in patients with epidermal growth factor receptor mutation-positive (EGFRm+) non-small cell lung cancer (NSCLC) receiving first-line afatinib. GIDEON enrolled a high proportion of patients aged ≥70 years, providing an opportunity to study afatinib use in older patients.

MATERIALS AND METHODS

In GIDEON (NCT02047903), a prospective non-interventional study, patients with EGFRm+ NSCLC received first-line afatinib in routine clinical practice until disease progression, death or intolerable adverse events. Key objectives were twelve-month progression-free survival (PFS) rate and objective response rate (ORR). Overall survival (OS) and safety were also assessed. This post hoc analysis explores outcomes of patients grouped by age (≥70 and <70 years).

RESULTS

In the 152 patients enrolled in GIDEON (69.7% female, 64.5%/22.4%/13.2% with Del19/L858R/other exon 18-21 mutations, 33.6% with brain metastases), the median age was 67 years (range 38-89) and 43.4% were aged ≥70 years. In the ≥70 years age group and the <70 years age group, twelve-month PFS rate was 58.9% and 43.9%, median PFS was 17.2 months and 10.6 months, ORR was 72.0% and 76.5%, twelve-month OS rate was 79.1% and 79.2%, 24-month OS rate was 52.0% and 61.7%, and median OS was 30.4 months and 27.4 months, respectively. In the ≥70 years age group and the <70 years age group, grade ≥3 adverse drug reactions (ADRs) were observed in 34.8% and 40.7% of patients, respectively; the most common were diarrhea (13.6% and 14.0%), acneiform dermatitis (7.6% and 7.0%), stomatitis (1.5% and 4.7%) and maculopapular rash (1.5% and 4.7%).

DISCUSSION

Patients with EGFRm+ NSCLC aged ≥70 years showed clinical benefit from first-line afatinib with no unexpected safety signals, supporting the use of afatinib in this setting.

Impact of aging on the incidence and mortality of urological cancers: 20-year projection in Spain

INTRODUCTION

In 2020, 282,421 new cases of cancer were diagnosed in Spain, and urological neoplasms (UN) were among the most frequent ones. Cancer treatment in eldery people is challenging due to fragility and comorbidities of these patients. To meet the needs of treating UN in the eldery, it is necessary to optimize healthcare resources, for which a deep analysis of cancer registries becomes mandatory. The objective of this work was to provide a detailed analysis of the incidence and mortality of UN in Spanish people over 65 years old in the last year 2020, as well as the estimates for the year 2040.

MATERIAL AND METHODS

Incidence and mortality estimates were obtained from the GLOBOCAN database. The urological neoplasms that were included were: testicle, bladder, penis, kidney and prostate.

RESULTS

In 2020, 63,278 cases of UN were diagnosed in Spain. Most UN were much more frequent among patients >65 years old, except for testicular cancers. For the year 2040, an incidence increase of 41.5% is estimated, reaching 89,507 new cases of UN per year, with approximately 3 out of 4 patients being over 65 years old. Deaths in people over 65 will increase by 60.15% in 2040.

CONCLUSION

In the next two decades, it is expected that new cases UN in people over 65 years will increase above 50%. For Healthcare systems to face it, greater financial and human resources, as well as multidisciplinary teams with experience and geriatric training will be necessary.

Exploring Determinants of Interdisciplinary Collaboration within a Geriatric Oncology Setting: A Mixed-Method Study

Simple Summary

Collaboration between oncologists and geriatricians has been shown to improve the quality of elderly cancer patient care. However, previous research has revealed how interpersonal factors might hinder this interdisciplinary work. This study aims to assess sprocessual and contextual determinants of the collaboration between these two disciplines, including shared time and routines, medical decision criteria and perceptions of age and needs of elderly patients. These aspects are important to develop a more efficient patient-centered approach in oncogeriatric care and improve collaboration between the different disciplines involved.

Abstract

Therapeutic challenges regarding the population of elderly cancer patients and their heterogeneity lead to the need to implement person-centered approaches in order to optimize care strategies and adapt oncology treatments to each pattern of aging. The International Society of Geriatric Oncology recommends a multidisciplinary evaluation of these patients and the use of screening tools prior to the initiation of treatments. However, previous research shows a poor implementation of these recommendations in geriatric oncology. Although some studies have identified how different perceptions of geriatric oncology might hinder routine teamwork, little is known about the impact of other factors on promoting the collaboration between the two specialties. This mixed-method exploratory study used an online questionnaire to assess the perception of a group of 22 geriatricians and oncology physicians on different determinants of oncology care and teamwork. In this sample, older oncology patients benefited from geriatric care. However, there was a variability regarding age criteria and a limited use of screening tools. The multidimensional framework for interprofessional teamwork by Reeves has been used to analyze some of the determinants of the collaboration between oncology physicians and geriatricians. This study has identified systematic issues to consider when promoting communication and common values between the two disciplines, including available resources in terms of shared time, space and routine actions.

Frailty in Very Elderly Patients is Not Associated with Adverse Surgical or Oncological Outcomes in Extremity Surgery for Soft Tissue Sarcoma

Background

While surgery remains the mainstay of treatment for limb sarcoma, extreme old age is a relative contraindication to oncological surgery.

Methods

Patients >80 years referred with primary extremity soft-tissue sarcoma (ESTS) between 2007 and 2016 were retrospectively reviewed. Prognostic variables, including ASA status and Clinical Frailty Scores, were collected. Endpoints were perioperative morbidity, locoregional (LRR) and distant recurrence (DR), disease-specific survival (DSS) adjusted using competing risk modelling, and overall survival (OS).

Results

A total of 141 primary tumours were identified, with 116 undergoing resections. Main motives for nonoperative management were severe frailty or significant comorbidity (56.0%). The operative group had a median age of 84 (range 80-96) years and median follow-up of 16 months (range 0-95). 45.7% of patients received radiotherapy. Median hospital stay was 7 (range 0-40) days, with frailty (p = 0.25) and ASA (p = 0.28) not associated with prolonged admission. 12.9% developed significant complications, with one perioperative mortality.

24.1% had LRR, occurring at a median of 14.5 months. All patients with reported DR (28.4%), except one, died of their disease. Frailty did not confer a significant difference in adjusted LRFS (p = 0.95) and DMFS (p = 0.84). One- and 5-year adjusted DSS and OS was 87.0% versus 74.9% and 62.3% versus 27.4%, respectively. Frailty (CFS ≥4) was associated with worse OS (hazard ratio [HR] 2.49; 95% confidence interval [CI] 1.51-4.12; p < 0.001), however not with adjusted DSS (p = 0.16). Nonoperative management conferred a 1- and 5-year adjusted DSS was 58.3% and 44.4%, respectively.

Conclusions

Extremity surgery for sarcoma is well tolerated in the frail very elderly population with low morbidity and comparable oncological outcomes.

Multimodality treatment of undifferentiated pleomorphic soft tissue sarcoma of the extremity (eUPS) in the elderly

INTRODUCTION

This subgroup analysis of undifferentiated pleomorphic soft tissue sarcoma of the extremity (eUPS) from the PERSARC collaborative group aimed to achieve a more personalized multimodality treatment approach for primary eUPS in elderly patients.

MATERIAL AND METHODS

A multicenter retrospective study including primary high-grade eUPS surgically treated with curative intent between 2000 and 2016. Overall survival (OS), local recurrence (LR) and distant metastasis (DM) curves were calculated by Kaplan Meier analysis. Cox proportional hazard models were used to determine the effect of radiotherapy.

RESULTS

From a total of 2511 patients with extremity soft tissue sarcoma (eSTS) of the PERSARC study collaborative; 703 patients with eUPS were included in this study. In elderly patients with eUPS 5-year OS, LR and DM were 35.4 (95%CI 29.3-42.8), 17.7 (95%CI 12.7-22.6) and 24.6 (95%CI 19.1-30.1). eUPS was significantly less treated with radiotherapy compared with other eSTS, especially in elderly patients. Patients with R1-R2 margins treated with radiotherapy had about half the risk of developing LR compared with patients treated without radiotherapy (HR = 0.454, p = 0.033).

CONCLUSION

Elderly patients with eUPS were less often treated with radiotherapy and showed higher LR. Nowadays, given an increasing life expectancy in elderly patients, multimodality treatment should be considered.

Pneumonectomy for lung cancer in the elderly: lessons learned from a multicenter study

Background

60% of patients diagnosed with lung cancer are older than 65 years and are at risk for substandard treatment due to a reluctance to recommend surgery. Pneumonectomy remains a high risk procedure especially in elderly patients. Nevertheless, the impact of age and neoadjuvant treatment on outcomes after pneumonectomy is still not well described.

Methods

We performed a multicentric retrospective study, analyzing outcomes of patients older than 70 years who underwent pneumonectomy for central primary lung malignancy between January 2009 and June 2019 in 7 thoracic surgery departments: Lucerne and Bern (Switzerland), Hamilton (Canada), Alicante (Spain), Monza (Italy), London (UK), Leuven (Belgium). Survival was estimated with Kaplan-Meier, and differences in survival were determined by log-rank analysis. We investigated pre- and post-operative prognostic factors using Cox proportional hazards regression model; multivariable analysis was performed only with variables, which were statistically significant at the invariable analysis.

Results

A total of 136 patients were included in the study. Mean age was 73.8 years (SD 3.6). 24 patients (17.6%) had an induction treatment (chemotherapy alone in 15 patients and chemo-radiation in 9). Mean length of stay (LOS) was 12.6 days (SD 10.39) and 74 patients (54.4%) had experienced a post-operative complication: 29 (21.3%) had a pulmonary complication, 33 (24.3%) had a cardiac complication and in 12 cases (8.8%) patients experienced both cardiac and pulmonary complications. 16 patients were readmitted [median LOS 13.7 days (range, 2–39 days)] and of those 14 (10.3%) required redo surgery. Median overall survival (OS) of the entire cohort was 38 months (95% CI: 29.9–46.1 months); in-hospital mortality was 1.5%, 30-day mortality rate was 3.7%, while 90-day mortality was 8.8% accounting for 5 and 12 patients respectively. Patients receiving neo-adjuvant therapy did not experience a higher incidence of postoperative complications (P=0.633), did not have a longer postoperative course (P=0.588), nor did they have an increased mortality rate (P=0.863).

Conclusions

Age should not be considered an absolute contraindication for pneumonectomy in elderly patients even after neoadjuvant treatment. It has become apparent that especially in these patients, a patient-tailored approach with a careful selection should be used to define the risk-benefit balance.

Safety of Immune Checkpoint Inhibitors in Elderly Patients: An Observational Study

BACKGROUND

Immunotherapy has completely changed the treatment of solid tumors. Although immune checkpoint inhibitors (ICIs) seem to be an appealing alternative to chemotherapy, especially in elderly patients, due to a more tolerable toxicity profile, they can lead to a peculiar variety of immune-related adverse events (irAEs). However, data on tolerability and outcome of ICIs in the elderly are lacking due to poor accrual in clinical trials of these patients.

METHODS

We performed a retro-prospective analysis on patients treated with single agent anti-PD-L1/PD-1 at the Clinical Oncology Unit, Careggi University Hospital, from March 2016 to March 2020. Data on the treatment responses, type and severity of irAEs, as well as the corticosteroids (CCS) dosage used for irAEs and the discontinuation rate, were described per each patient, according to two different age-based cohorts of patients (< or ≥70 years).

RESULTS

We reported a lower incidence of all-grade toxicity in elderly compared to younger patients (64.9% vs. 44.9%, p = 0.018). The two age-cohorts showed a different profile of irAEs. Endocrine irAEs were significantly higher in younger patients (39.7% vs. 21.7%, p = 0.002), while dermatologic toxicities were more common in the older group (35.0% vs. 11.3%, p = 0.047). Use of CCS and treatment discontinuation rate do not differ significantly between the two age groups.

CONCLUSION

Our findings suggest that treatment with ICIs in elderly populations is safe and feasible. Patients over 70 years are more prone to develop skin irAEs, while younger patients are more subject to experience endocrine toxicities.

Patients and family caregivers report high treatment expectations during palliative chemotherapy: a longitudinal prospective study

Background

When discussing treatment options and future care, it is important to understand the expectations of patients and family caregivers related to palliative chemotherapy and to identify patterns in patients’ quality of life. The study aims were to evaluate differences in treatment expectations and quality of life between patients with thoracic cancer (non-small-cell lung cancer, small-cell lung cancer and mesothelioma) who were < 70 and ≥ 70 years of age and receiving palliative chemotherapy and to assess family caregivers’ treatment expectations.

Methods

A prospective longitudinal study included patients with thoracic cancer receiving outpatient palliative chemotherapy at a university hospital in Denmark and their family caregivers. Patients’ treatment expectations and quality of life were assessed three times during treatment with a survey of treatment expectations and the Functional Assessment of Cancer Therapy – General questionnaire. Family caregivers’ treatment expectations were assessed once.

Results

A total of 48 patients and 36 family caregivers participated between 2018 and 2019. No statistically significant age-related differences in treatment expectations and quality of life were identified. 28% of patients aged < 70 years and 7% of those aged ≥70 years expected a cure. Among family caregivers, 36% expected a cure. Across both age groups, mean total quality of life scores significantly decreased from 73.2 at first palliative chemotherapy cycle to 70.5 at third cycle (p = 0.02). No meaningful changes were found in quality of life within either age group. A subgroup analysis found no significant between-group differences in quality of life. Mean physical well-being score for all patients decreased from 20.3 at first cycle to 18.4 at third cycle (p = 0.03) and mean emotional well-being score decreased from 15.4 at first cycle to 14.6 at third cycle (p = 0.04).

Conclusion

This study emphasizes the importance of initiating conversations about treatment expectations and paying attention to expectations that may differ by the age of the patient and between patients and family caregivers. Addressing treatment expectations among patients and family caregivers and monitoring quality of life among patients is important in clinical practice.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00731-4.

Impact of patient age on outcome after resection for hepatocellular carcinoma

There is little information on the impact of aging on liver resection of hepatocellular carcinoma (HCC). The aim of study was to evaluate the prognostic impact of the patient's age on the long-term survival after resection of HCC. The postoperative outcomes of the 291 elderly (≥ 70 years) and 340 younger (< 70 years) patients underwent curative liver resection for HCC were analyzed using multivariate and propensity-score matching. Risk score were calculated from the results of Cox regression analysis. The overall survival rate was significantly lower in the elderly group than that in the younger group (p = 0.01). Factors related to overall survival were vascular invasion (absent vs. present, HR 2.25; 95% CI 1.52-3.33, p = 0.0001), albumin level (< 3.0 vs. ≥ 3.0 g/dl, HR 2.23; 95% CI 1.31-3.79, p = 0.003), and number of tumors (solitary vs. multiple, HR 1.68; 95% CI 1.24-2.27, p = 0.001). The results of risk-score analysis with a Cox proportional-hazards model indicated that the proportion of poor-risk patients was significantly higher in the elderly than in the younger group. Propensity-score matching analysis yielded 234 pairs of patients. There were no significant differences in baseline profiles or risk scores between the two groups (p = 0.43). There were also no significant differences in the overall survival between the two groups (p = 0.23). Advanced age does not have a significant impact on the outcomes of patients after resection of HCC.

Quality of life for older patients with cancer: a review of the evidence supporting melatonin use

Purpose

The proportion of older populations living with cancer is on the increase. Maintaining or improving their quality of life (QoL) has become an important goal in the treatment of cancer and has become an endpoint in clinical trials. Melatonin regulates a wide variety of physiological functions and is involved in the initiation of sleep and the improvement of QoL. With age, the secretion of melatonin decreases and could lead to a deterioration in QoL.

Methods

Literature searches were conducted using the PubMed database. The search terms and derivatives of “metastatic cancer”, “older patients”, “quality of life” and “melatonin” were used. Titles and abstracts were screened to identify whether studies were relevant for full-text screening.

Results

There is major concern about the symptoms older cancer patients encounter during treatment because they can impact their QoL. Melatonin supplementation presents several benefits for older patients: improvement in survival, decrease in symptoms induced by cancer and cancer treatment, and also improvements in quality of life.

Conclusion

It therefore seems appropriate to study the impact of melatonin supplementation during cytotoxic therapy on QoL among elderly patients with metastatic cancer. The use of melatonin as a therapeutic strategy seems particularly suitable for elderly patients, a population known to secrete significantly less melatonin. However, to date, no studies have been conducted in this population.

Cancer and older adult patient care

Cancer occurs most frequently in patients aged 65 and older. With the increasing age of the world's population, there will be a significant increase in cancer diagnoses in older adults. Aging imposes a wide variety of physiological responses, comorbidities, and ailments, but older patients are less represented in clinical studies. Specific needs of older patients with cancer often go under-recognized and consequently unmet. In this review, common diagnoses that can affect the outcomes of this population, including frailty, malnutrition, and delirium, are discussed. Areas that need further research to improve the care of geriatric cancer patients, particularly in the hospital settings, are also identified.

Retrospective analysis of the 13-year trend in acute and elective surgery for patients aged 60 years and over at Auckland City Hospital, New Zealand

BACKGROUND

As the worldwide population has aged, the number of surgical procedures performed on older patients has increased. It is not known whether this increase has been proportional to growth in the elderly population. The aim of this study was to assess the population-adjusted incidence of acute and elective general and orthopaedic surgery in older patients at a tertiary hospital in New Zealand.

METHODS

This was a retrospective study using routinely collected electronic data from Auckland District Health Board (DHB) and New Zealand Ministry of Health databases. Population estimates and numbers of general surgical and orthopaedic procedures from 2004 to 2016 were obtained. Annual age-specific incidence rates of surgical procedures were calculated and trends analysed using negative binomial regression.

RESULTS

The incidence of elective surgery increased by 5.35% annually from 2004 to 2016. The rate of increase is lower in the Māori population (2.14%) compared with other ethnic groups (4.22%-5.62%). The incidence of acute surgery in those aged 70 years and above decreased from 2004 to 2016. The European and other ethnic group had the highest rate of acute surgery, and higher rates of elective surgery than Pacific and Asian peoples.

CONCLUSION

The increasing number of elective general surgical and orthopaedic procedures performed on older patients in Auckland DHB is beyond what is expected for population growth alone. This has significant implication for clinicians, healthcare providers and governmental institutions. Ethnic differences are evident and warrants further attention as these may reflect disparities in access to surgery.

Comparative Study of the Safety and Efficacy of First-Line Cisplatin and Carboplatin Chemotherapy in Elderly Patients with Metastatic Urothelial Carcinoma

OBJECTIVES

Platinum-based chemotherapy is the standard treatment for metastatic urothelial carcinoma (mUC). However, considering elderly patients often experience comorbidities and frailty, the utility of cisplatin-based chemotherapy for elderly patients is still debatable. We conducted this study to compare the safety and efficacy of carboplatin and cisplatin in elderly patients with mUC.

METHODS

This retrospective study enrolled elderly patients with mUC (defined as aged ≥70 years) who underwent first-line platinum-based chemotherapy between September 2001 and October 2018. The primary endpoints were chemotherapy-related adverse events (AEs), including treatment-related hospitalization or death. The secondary outcomes were overall survival (OS) and progression-free survival calculated by Kaplan-Meier analysis.

RESULTS

In total, 108 elderly patients with mUC were enrolled and allocated into the cisplatin or carboplatin group. Patients treated with carboplatin-based chemotherapy had a significantly higher incidence of all grade ≥3 AEs (78.8 vs. 50.0%, p = 0.008) than those on cisplatin. AE-related hospitalization (47.5 vs. 19.1%, p = 0.002) and treatment-related death (17.5 vs. 4.4%, p = 0.02) were significantly increased in the carboplatin group. In the univariate analysis, the median OS in the cisplatin group was significantly increased compared with the carboplatin group (13.6 vs. 7.2 months, p = 0.045). The Cox multivariate regression model indicated that leukocytosis (HR 3.17, 95% CI 1.84-5.46, p < 0.001) and anemia (HR 2.02, 95% CI 1.11-3.65, p = 0.02) were independent prognostic factors.

CONCLUSION

Elderly patients with mUC treated with cisplatin-based chemotherapy had better survival and safety profiles than those treated with carboplatin. Age itself was not a crucial factor in determining cisplatin eligibility.

Inclusion of older patients with cancer in randomised controlled trials with patient-reported outcomes: a systematic review

OBJECTIVES

Inclusion of patient-reported outcomes (PROs) in cancer randomised controlled trials (RCTs) may be particularly important for older patients. The objectives of this systematic review were to quantify the frequency with which older patients are included in RCTs with PROs and to evaluate the quality of PRO reporting in those trials.

METHODS

All RCTs with PRO endpoints, published between January 2004 and February 2019, which included a patient sample with a mean/median age ≥70 years, were considered for this systematic review. The following cancer malignancies were considered: breast, colorectal, lung, prostate, gynaecological and bladder cancer.Quality of PRO reporting was evaluated using the International Society for Quality of Life Research-PRO standards. Studies meeting at least two-thirds of these criteria were considered to have high-quality PRO reporting.

RESULTS

Of 649 RCTs identified with a PRO endpoint, only 72 (11.1%) included older patients. Of these, 35 trials (48.6%) were conducted in patients with metastatic/advanced disease. PROs were primary endpoints in 20 RCTs (27.8%). Overall survival was the most frequently reported clinical outcome in studies of patients with metastatic/advanced cancer (n=28, 80%). One-third of the RCTs (n=24, 33.3%) were considered to have high-quality PRO reporting. Overall, the largest prevalence of RCTs with high-quality PRO reporting was observed in prostate and colorectal cancers.

CONCLUSIONS

Our review indicates not only that PRO-RCT-based studies in oncology rarely include older patients but also that completeness of PRO reporting of many of them is often suboptimal.

Approved and emerging treatments of malignant pleural mesothelioma in elderly patients

Introduction: Malignant pleural mesothelioma (MPM) is a rare neoplasm with asbestos exposure as the dominant etiologic agent. Owing to the long latent period following exposure, MPM is often diagnosed late in life. Despite this, elderly patients are under-represented in clinical trials. To date, data regarding the tolerability and efficacy of anticancer treatments for elderly patients affected by MPM are still lacking.Areas covered: The current state-of-the-art of approved treatments employed in the treatment of MPM elderly patients is reviewed and discussed, with a look to emerging therapies. A structured search of bibliographic databases for peer-reviewed research literature and of main meeting abstracts using a focused review question was undertaken.Expert opinion: Even though the median age of MPM patients enrolled in the most recent experimental trials is increasing, no specific analysis has been reported so far in the elderly. Moreover, no data are available for the 'oldest of the elderly' (>75 years). Treatment of elderly patients with MPM is one of the major challenges to the clinician. There is a clear need of large, well-conducted retrospective studies and above all of prospective investigations in this patient population, both in the first-and in the second-line setting.

Nivolumab versus investigator's choice in patients with recurrent or metastatic squamous cell carcinoma of the head and neck: Efficacy and safety in CheckMate 141 by age

OBJECTIVES

Many patients with squamous cell carcinoma of the head and neck (SCCHN) are ≥65 years old; comorbidities and other age-related factors may affect their ability to tolerate traditional chemotherapy. Nivolumab is the only immunotherapy to significantly improve overall survival (OS) versus investigator's choice (IC) of single-agent chemotherapy at primary analysis in a phase 3 trial (CheckMate 141) in patients with recurrent/metastatic SCCHN post-platinum therapy. In this post hoc analysis, we report efficacy and safety by age.

PATIENTS AND METHODS

Eligible patients were randomized 2:1 to nivolumab 3 mg/kg every 2 weeks (n = 240) or IC (methotrexate, docetaxel, or cetuximab n = 121). The primary endpoint of the trial was OS. For this analysis, outcomes were analyzed by age < 65 and ≥65 years. The data cut-off date was September 2017 (minimum follow-up 24.2 months).

RESULTS

At baseline, 68 patients (28.3%) receiving nivolumab and 45 patients (37.2%) receiving IC were ≥65 years. Baseline characteristics were generally similar across age groups. OS and tumor response benefits with nivolumab versus IC were maintained regardless of age. The 30-month OS rates of 11.2% (<65 years) and 13.0% (≥65 years) with nivolumab were more than tripled versus corresponding IC rates of 1.4% and 3.3%, respectively. The nivolumab arm had a lower rate of treatment-related adverse events versus IC regardless of age, consistent with the overall patient population.

CONCLUSION

In CheckMate 141, nivolumab resulted in a higher survival versus IC in patients <65 and ≥65 years, with a manageable safety profile in both age groups. ClinicalTrials.gov: NCT02105636.

Prognostic Factors in Elderly Patients with Diffuse Large B-Cell Lymphoma and Their Treatment Results

Objective:

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL). The treatment of older NHL patients has always been a struggle; however, treatment statistics have begun showing favorable results similar to those of younger DLBCL patients thanks to newer treatment protocols. Here, we analyze the progress of our own elderly DLBCL patients who were followed between 2000 and 2016 in our center.

Materials and Methods:

Eighty-seven DLBCL patients, who were diagnosed and treated in the Dokuz Eylül University Department of Hematology between 2000 and 2016, were included in this study. Median age was 72 (65-89) years and 13 (14.9%) patients were older than 80 years.

Results:

Median follow-up time was 19 months and 45 patients (51.7%) died during the follow-up period. Median overall survival (OS) was 55 months and median progression-free survival was calculated as 27 months. Sixty-three patients (72.4%) received standard R-CHOP therapy. Complete response was seen in 46 (52.9%) patients. The median survival time for patients who had complete response was 136 months (p<0.001); however, OS was not statistically different between older (>80 years) and younger patients (p=0.236).

Conclusion:

According to our findings, we think that being able to complete standard R-CHOP therapy is vital for the survival rate of elderly DLBCL patients.

Patterns of Symptom Distress in Adults Receiving Treatment for Lung Cancer

Knowledge of the patterns of symptom distress in adults receiving treatment for lung cancer is an important first step in developing interventions that can potentially lessen symptom distress. The purposes of this secondary analysis were to describe the changes in patterns of symptom distress over time in adults receiving treatment for lung cancer, and to examine the relationship of selected demographic and clinical characteristics to symptom distress. Complete data were available for 117 patients. The patterns of symptom distress in adults receiving treatment for lung cancer varied between treatment groups and over time. Symptom distress scores were moderate to high on entry into the study, indicating that symptom management in newly diagnosed lung cancer patients is essential and should begin early in the course of illness. Moreover, clinical interventions should be tailored to the type of treatment. Various demographic and clinical variables were weak and inconsistent predictors of symptom distress, underscoring the importance of examining the role of psychosocial factors in mediating symptom distress.

Changes in the Use of Comprehensive Geriatric Assessment in Clinical Trials for Older Patients with Cancer over Time

BACKGROUND

The objective of this study was to describe the implementation of comprehensive geriatric assessment (CGA) in clinical trials dedicated to older patients before and after the creation of the International Society of Geriatric Oncology in the early 2000s.

SUBJECTS, MATERIALS, AND METHODS

All phase I, II, and III trials dedicated to the treatment of cancer among older patients published between 2001 and 2004 and between 2011 and 2014 were reviewed. We considered that a CGA was performed when the authors indicated an intention to do so in the Methods section of the article. We collected each geriatric domain assessed using a validated tool even in the absence of a clear CGA, including nutritional, functional, cognitive, and psychological status, comorbidity, comedication, overmedication, social status and support, and geriatric syndromes.

RESULTS

A total of 260 clinical trials dedicated to older patients were identified over the two time periods: 27 phase I, 193 phase II, and 40 phase III trials. CGA was used in 9% and 8% of phase II and III trials, respectively; it was never used in phase I trials. Performance status was reported in 67%, 79%, and 75% of phase I, II, and III trials, respectively. Functional assessment was reported in 4%, 11%, and 13% of phase I, II, and III trials, respectively. Between the two time periods, use of CGA increased from 1% to 11% (p = .0051) and assessment of functional status increased from 3% to 14% (p = .0094).

CONCLUSION

The use of CGA in trials dedicated to older patients increased significantly but remained insufficient.

IMPLICATIONS FOR PRACTICE

This article identifies the areas in which research efforts should be focused in order to offer physicians well-addressed clinical trials with results that can be extrapolated to daily practice.

Frailty Prevalence and Characteristics in Older Adults with Hematologic Cancer: a Descriptive Study

Objective:

This study investigated the prevalence of frailty in older patients with hematologic cancer and assessed the association between older patients’ characteristics and frailty.

Methods:

This descriptive study enrolled 90 older patients undergoing treatment for hematological malignancies at an oncology hospital. Frailty was assessed with the Edmonton Frailty Scale as not frail (0–4), apparently vulnerable (5–6), mildly frail (7–8), moderately frail (9–10), and severely frail (11–17). The association of frailty and older patient characteristics and diagnosis was assessed by logistic regression.

Results:

The prevalence of frailty (mild, moderately, and severely) was 42.2%, and “apparently vulnerable” frailty was 60%. The mean scale score was 5.59 ± 3.13. Frailty was more prevalent in patients who were ≥75 years of age, had ≥4 children, were diagnosed with leukemia, and were diagnosed for ≥2 years. Gender, diagnosis, and employment were factors associated with the presence of frailty. Female gender and lack of employment were factors associated with a high risk of frailty. A diagnosis of multiple myeloma was associated with a low risk of frailty.

Conclusions:

The prevalence of frailty was high in older patients. Female and unemployed patients were at high risk for frailty. Frailty characteristics of older patients with hematologic cancer highlighted the need for comprehensive geriatric assessment and frailty screening, provided prevalence and characteristics of frailty in this group of patients during treatment, and highlighted the need for holistic care approach.

Free flap head and neck reconstruction: Feasibility in older patients

OBJECTIVES

The main purpose of this study was to evaluate the perioperative morbidity of free flap head and neck reconstructive surgery in patients aged 70 years and over (Group A) by comparison with a cohort of younger patients (Group B). Secondary objectives included assessment of survival rates and functional outcomes in these older patients, likewise by comparison with a cohort of younger patients.

METHODS

A retrospective study was conducted on all patients aged 70 years and over who underwent free flap reconstruction between 2012 and 2017. They were compared to a control group of younger patients to investigate hospital length of stay, postoperative complications and survival rates, and functional outcomes.

RESULTS

No significant difference was observed between the two groups in terms of variables such as hospital length of stay and medical/surgical complications. In multivariate analysis, comorbidity was the only predictive factor for postoperative medical complications, and pharyngolaryngeal location the only significant predictive factor for surgical complications. Factors significantly associated with hospital length of stay were older age, active smoking, pharyngolaryngeal location and the Charlson Comorbidity Index (CCI). Overall survival was the only factor that was substantially lower in the over 70 group, while disease-specific and relapse-free survival were comparable in both groups.

CONCLUSION

Old age per se should not be considered a contraindication to major surgery combined with free flap reconstruction in older patients.

Local ablation or radioembolization of colorectal cancer metastases: comorbidities or older age do not affect overall survival

Background

Local ablative techniques are emerging in patients with oligometastatic disease from colorectal carcinoma, commonly described as less invasive than surgical methods. This single arm cohort seeks to determine whether such methods are suitable in patients with comorbidities or higher age.

Methods

Two hundred sixty-six patients received radiofrequency ablation (RFA), CT-guided high-dose rate brachytherapy (HDR-BT) or Y90-radioembolization (Y90-RE) during treatment of metastatic colorectal cancer (mCRC). This cohort comprised of patients with heterogenous disease stages from single liver lesions to multiple organ systems involvement commonly following multiple chemotherapy lines. Data was reviewed retrospectively for patient demographics, previous therapies, initial or disease stages at first intervention, comorbidities and mortality. Comorbidity was measured using the Charlson Comorbidity Index (CCI) and age-adjusted Charlson Index (CACI) excluding mCRC as the index disease. Kaplan-Meier survival analysis and Cox regression were used for statistical analysis.

Results

Overall median survival of 266 patients was 14 months. Age ≥ 70 years did not influence survival after local therapies. Similarly, CCI or CACI did not affect the patients prognoses in multivariate analyses. Moderate or severe renal insufficiency (n = 12; p = 0.005) was the only single comorbidity identified to negatively affect the outcome after local therapy.

Conclusion

Interventional procedures for mCRC may be performed safely even in elderly and comorbid patients. In severe renal insufficiency, the use of invasive techniques should be limited to selected cases.

[Proposed development of a geriatric oncology unit. Times of change: Our reality]

Age is one of the main risk factors for the development of cancer. It is expected that the progressive aging of the population will have an unprecedented impact on the incidence of various tumours. In fact, the management of elderly cancer patients is already a major public health problem in developed countries. However, elderly patients have systematically been excluded from cancer drug studies or protocol development. This has left health professionals in uncharted territory, without proper tools to address the multiple difficulties that arise in the treatment of these patients. A comprehensive geriatric assessment may serve as an ideal tool for the correct detection of hidden problems, facilitating treatment decisions in these complex patients, and integrating the care of patients with comorbidities.

Safety and Efficacy of Extended Bevacizumab Therapy in Elderly (≥70 Years) Versus Younger Patients Treated for Newly Diagnosed Ovarian Cancer in the International ROSiA Study

OBJECTIVE

The single-arm ROSiA study explored an extended duration of frontline bevacizumab-containing therapy for ovarian cancer. Post hoc analyses explored safety and efficacy according to age.

PATIENTS AND METHODS

After primary debulking surgery, patients with stage IIB-IV or grade 3 stage I-IIA ovarian cancer received 4-8 cycles of paclitaxel [weekly or every 3 weeks (q3w)], carboplatin AUC 5-6 q3w, and bevacizumab 15 (or 7.5) mg/kg q3w, followed by single-agent bevacizumab until progression or for up to 24 months. The primary end point was safety; progression-free survival (PFS) was a secondary end point.

RESULTS

Of 1021 patients treated, 121 (12%) were aged 70 years or older and 44 (4%) were 75 years or older. Compared with younger patients, more patients aged 70 years or older had hypertension at baseline, stage IV disease, and Eastern Cooperative Oncology Group performance status 1 or above. Bevacizumab was continued for more than 15 months in 49% of older versus 53% of younger patients. Older patients experienced higher incidences of all-grade anemia (44% vs 32%), diarrhea (35% vs 25%), and asthenia (22% vs 12%), and grade ≥3 hypertension (41% vs 22%) and thromboembolic events (7% vs 2%) compared with younger patients. Fatal bevacizumab-related adverse events occurred in 1 (0.8%) older versus 5 (0.6%) younger patients. Median PFS was 23.7 (95% confidence interval, 18.6-27.9) versus 25.6 (95% confidence interval, 23.7-28.4) months in patients aged 70 or older versus those younger than 70 years, respectively.

CONCLUSION

Bevacizumab-treated patients aged 70 years or older had higher incidences of anemia, low-grade diarrhea, and asthenia, and grade ≥3 hypertension and thromboembolic events than those younger than 70 years, but no other relevant increase in toxicity. Median PFS of approximately 2 years is similar to that in younger patients despite the worse prognosis. Older age should not preclude bevacizumab therapy for ovarian cancer in carefully selected patients aged 70 years or older. Given the higher background hypertension prevalence, elderly patients should be monitored more closely while receiving bevacizumab.

Systematic review of care needs for older patients treated with anticancer drugs

OBJECTIVE

When treated with anticancer therapies, a number of issues are raised for older patients such as physical needs (coping with symptoms and side-effects) or psychological needs. Geriatric tailored interventions addressing these needs may be effective in terms of improving quality of life of our patients.

METHODS

A systematic review was performed in September 2017 in MEDLINE. All reports assessing older patients with cancer care needs in the context of anticancer systemic therapy were reviewed.

RESULTS

A total of 357 articles were analyzed. From these, 35 studies were included in the analysis. Compared to younger patients, the elderly had less supportive care needs. While older patients asked for less information than their younger counterparts, they still requested information on diagnosis, seriousness of the disease, chances of cure, spread of the disease, recovery, courses of illness, possible consequences, treatment procedures, treatment options, possible side effects and how to deal with them, and what they could do in daily life. When taking into consideration the various needs as assessed by the "Supportive Care Needs Survey", physical and daily living were the most frequently reported needs with emphasis on nutrition, coping with physical symptoms, dealing with side effects of treatment, and performing usual physical tasks and activities.

CONCLUSION

Information demand seemed moderate but a great deal of attention was paid to nutrition and well-being.

Postoperative chemoradiotherapy in patients with head and neck cancer aged 70 or older with positive margins or extranodal extension and the influence of nodal classification

BACKGROUND

Postoperative concomitant chemoradiotherapy (CRT) improves outcomes for younger adults with head and neck squamous cell carcinoma (HNSCC) and positive margins or extranodal extension (ENE), but its benefit for older adults is not well established.

METHODS

Patients from the National Cancer Data Base (NCDB) with HNSCC undergoing curative-intent resection, neck dissection, and postoperative radiation with positive margins or ENE were identified.

RESULTS

This analysis included 1199 patients aged ≥ 70 years with median follow-up of 42.6 months. Postoperative concurrent CRT was associated with improved overall survival (OS; hazard ratio [HR] 0.752; 95% confidence interval [CI] 0.638-0.886) compared to radiation alone in multivariable analysis. Three-year OS was 52.4% with CRT versus 43.4% with radiation (P = .012) in propensity-score matched cohorts. The survival impact of CRT varied by N classification (P = .002 for interaction), with benefit seen only in those with N2 to N3 disease.

CONCLUSION

Postoperative concurrent CRT may benefit older patients with HNSCC with positive margins or ENE, particularly those with higher nodal burden.

Update in geriatrics: What geriatric oncology can learn from general geriatric research

Life expectancy has been steadily increasing for decades and this trend is likely to continue in coming years. In fact, there is more than a 50% probability that by 2030 female life expectancy could break the 90 year barrier, with more than half of the expected gains due to enhanced longevity above the age of 65 years. The resultant aging of societies means that health care will be faced with a rising number of increasingly older patients, who are also likely to have higher levels of multimorbidity. Most issues regarding assessment, prognostication and, management of older patients are not unique to geriatric oncology and thus there is opportunity to learn from progress in other fields. The purpose of this paper is to provide an update on research, reviews, and debate in general geriatrics that may be relevant to clinicians and researchers active in geriatric oncology. The selection of topics was based on a general search of the table of contents of widely read geriatrics and internal medicine journals, and includes geriatric co-management, improving research for older patients, caregiver issues, eliciting patient preferences, and shared-decision making.

Gemcitabine and Carboplatin Treatment in Advanced NSCLC: A Retrospective Evaluation Including Elderly Patients

Background

Carboplatin-containing regimens are sometimes preferred for patients with advanced non-small cell lung cancer.

Methods

Eighty-three patients with stage III-IV non-small cell lung cancer received 3 to 4 cycles of carboplatin AUC 5 on day 2 and gemcitabine 1250 mg/m2 on days 1 and 8 every 21 days.

Results

The overall response rate was 43.4%. Results obtained from elderly and non-elderly groups were compared using the logrank method. Median overall survival and progression-free survival were 11 and 7 months, respectively (12 and 7 months, non-elderly group; 6.5 and 5 months, elderly group, P = 0.28 and 0.25 respectively). Grade 3–4 toxicity included neutropenia, thrombocytopenia, anemia, nausea/vomiting, and diarrhea. Incidences of grade 3–4 toxicity were similar for elderly and non-elderly patients.

Conclusions

Data confirm that carboplatin-gemcitabine is an active and well-tolerated regimen in advanced non-small cell lung cancer and could be investigated in elderly patients.

Elderly cancer patients’ preferences regarding the disclosure of cancer diagnosis. Experience of a single institution in Italy

The disclosure of a diagnosis of cancer is complex, particularly in older patients for reasons related to the wishes of the family, fear of discouraging the patient, or the patient's inability to understand the information. So our insight into older people's perspectives regarding the disclosure of their cancer diagnosis is fragmentary and inadequate. To examine the views of older adults regarding this issue, we performed a prospective observational study in an inpatient oncology clinic. From January 2006 to June 2006, a sample of 132 consecutive cancer patients aged over 70 years with a variety of solid tumors, recently diagnosed and mainly at an advanced stage, agreed to take part in a survey about the disclosure of the diagnosis of their disease. Of the 132 patients who verbally agreed to participate and were given questionnaires, 106 returned data. The majority of patients (64.1%) in this study wanted to be informed about the diagnosis of their disease also if it was cancer, and 58.5% were in fact informed about the exact nature of their disease. Male patients were more keen to know the diagnosis than female patients (P = 0.002) and they were in fact more informed about their diagnosis than female patients (P = 0.005). Patients with more formal education were more informed than patients with less formal education (P = 0.035). This study demonstrates that the preferences of older patients regarding cancer diagnosis disclosure are highly similar to those of younger people. Male patients and patients with more formal education were more informed than female patients and patients with less formal education.

Elderly patients with gastrointestinal stromal tumour (GIST) receive less treatment irrespective of performance score or comorbidity - A retrospective multicentre study in a large cohort of GIST patients

OBJECTIVE

Although gastrointestinal stromal tumours (GIST) predominantly occur in older patients, data on treatment patterns in elderly GIST patients are scarce.

METHODS

Patients registered in the Dutch GIST Registry (DGR) from January 2009 until December 2016 were included. Differences in treatment patterns between elderly (≥75 years) and younger patients were compared. Multivariate analyses were conducted using logistic regression.

RESULTS

Data of 145 elderly and 665 non-elderly patients were registered (median age 78 and 60 years respectively). In elderly patients, performance score (WHO-PS) and age-adjusted Charlson comorbidity index (ACCI) were significantly higher (p < 0.05; p < 0.001), and albumin level significantly lower (p = 0.04). Hundred-and-nine (75.2%) elderly and 503 (75.6%) non-elderly patients had only localised disease. Surgery was performed in 57% of elderly versus 84% of non-elderly patients (p = 0.003, OR: 0.26, 95% CI: 0.11-0.63). No differences in surgery outcome or complications were found. Thirty-eight percent of elderly with an indication for adjuvant treatment did receive imatinib versus 68% of non-elderly (p = 0.04, OR: 0.47, 95% CI: 0.23-0.95). Thirty-six elderly and 162 non-elderly patients had metastatic disease. Palliative imatinib was equally given (mean dose 400 mg) and adverse events were mostly minor (p = 0.71). In elderly, drug-related toxicity was in 32.7% reason to discontinue imatinib versus 5.1% in non-elderly (p = 0.001, OR 13.5, 95% CI: 2.8-65.0). Median progression-free survival (PFS) was 24 months in elderly and 33 months in non-elderly (p = 0.10). Median overall survival (OS) was 34 months and 59 months respectively (p = 0.01).

CONCLUSIONS

Elderly GIST patients with localised disease receive less surgery and adjuvant treatment, irrespective of comorbidity and performance score. Drug-related toxicity results more often in treatment discontinuation. This possibly results in poor outcome.

Identification of polymorphisms in cancer patients that differentially affect survival with age

The World Health Organization predicts that the proportion of the world's population over 60 will almost double from 12% to 22% between 2015 and 2050. Ageing is the biggest risk factor for cancer, which is a leading cause of deaths worldwide. Unfortunately, research describing how genetic variants affect cancer progression commonly neglects to account for the ageing process. Herein is the first systematic analysis that combines a large longitudinal data set with a targeted candidate gene approach to examine the effect of genetic variation on survival as a function of age in cancer patients. Survival was significantly decreased in individuals with heterozygote or rare homozygote (i.e. variant) genotypes compared to those with a common homozygote genotype (i.e. wild type) for two single nucleotide polymorphisms (rs11574358 and rs4147918), one gene (SIRT3) and one pathway (FoxO signalling) in an age-dependent manner. All identified genes and pathways have previously been associated with ageing and cancer. These observations demonstrate that there are ageing-related genetic elements that differentially affect mortality in cancer patients in an age-dependent manner. Understanding the genetic determinants affecting prognosis differently with age will be invaluable to develop age-specific prognostic biomarkers and personalized therapies that may improve clinical outcomes for older individuals.

Breast cancer in elderly women and altered clinico-pathological characteristics: a systematic review

PURPOSE

Breast cancer is the most common malignancy in women in terms of incidence and mortality. Age is undoubtedly the biggest breast cancer risk factor. In this study we examined clinical, histological, and biological characteristics and mortality of breast cancer in elderly women along with their changes with advancing age.

METHODS

We reviewed 63 original articles published between 2006 and 2016 concerning women over 70 years with breast cancer.

RESULTS

Compared to patients 70-79 years, patients aged 80 and over had larger tumor size with fewer T1 (42.9% vs 57.7%, p < 0.01) and more T2 lesions (43.5% vs 33.0%, p < 0.01). Lymph nodes and distant metastases were more frequent, with more N + (49.5% vs 44.0%, p < 0.01) and more M1 (8.0% vs 5.9%, p < 0.01). Infiltrating mucinous carcinomas were more frequent (4.3% vs 3.7%, p < 0.01). Tumors had lower grades, with more grade 1 (23.2% vs 19.8%, p = 0.01) and fewer grade 3 (21.5% vs 25.5%, p < 0.01), and were more hormone-sensitive: PR was more often expressed (72.6% vs 67.3%, p < 0.01). Lympho-vascular invasion was less frequent in the 80 years and over (22.9% vs 29.7%, p = 0.01). Breast cancer-specific mortality was higher both at 5 years (25.8% vs 17.2%, p < 0.01) and 10 years (32.7% vs 26.6%, p < 0.01).

CONCLUSION

Clinico-pathological characteristics, increased incidence, and mortality associated with aging can be explained on one hand by biological changes of the breast such as increased estrogen sensitivity, epithelial cell alterations, immune senescence, and tumor microenvironment modifications. However, sociologic factors such as increased life expectancy, under-treatment, late diagnosis, and insufficient individual screening, are also involved.

Lung Cancer in the Oldest Old: A Nation-Wide Study in The Netherlands

INTRODUCTION

An important step in improving research and care for the oldest patients with lung cancer is analyzing current data regarding diagnostic work-up, treatment choices, and survival.

METHODS

We analyzed data on lung cancer from the Netherlands Cancer Registry (NCR-IKNL) regarding diagnostic work-up, treatment, and survival in different age categories; the oldest old (≥85 years of age) versus those aged 71-84 (elderly) and those aged ≤70 years (younger patients).

RESULTS

47,951 patients were included in the 2010-2014 NCR database. 2196 (5%) patients were aged ≥85 years. Histological diagnosis was obtained significantly less often in the oldest old (38%, p < 0.001), and less standard treatment regimen was given (8%, p < 0.001) compared to elderly and younger patients. 67% of the oldest old received best supportive care only versus 38% of the elderly and 20% of the younger patients (p < 0.001). For the oldest old receiving standard treatment, survival rates were similar in comparison with the elderly patients. In the oldest old, no survival differences were found when comparing standard or adjusted regimens for stage I and IV NSCLC; for stage III, oldest old receiving standard treatment had longer survival. No oldest old patients with stage II received standard treatment.

CONCLUSION

Clinicians make limited use of diagnostics and invasive treatment in the oldest old; however, selected oldest old patients experienced similar survival rates as the elderly when receiving some form of anticancer therapy (standard or adjusted). More research is needed to further develop individualized treatment algorithms.

Trends in treatment and relative survival among Non-Small Cell Lung Cancer patients in the Netherlands (1990-2014): Disparities between younger and older patients

BACKGROUND

This study aimed to describe trends over time regarding disparities in treatment and relative survival (RS) between younger and older patients with non-small cell lung cancer (NSCLC).

METHODS

All patients diagnosed with pathologically verified NSCLC in 1990-2014 were included from the Netherlands Cancer Registry (n=187,315). Treatment and RS (adjusted for sex, histology and treatment) were analyzed according to age group (<70 years versus ≥70 years), stage and five-year period of diagnosis.

RESULTS

Between 1990 and 2014, five-year RS increased from 17 to 22% among younger patients and from 12 to 16% among elderly. The application of surgery increased over time for elderly with stage I NSCLC, decreased for elderly with stage II, and was stable but higher for younger patients. Disparities in RS between age groups with stage I became smaller since 2000-2004, but did not change over time for stage II. For stage III and IV, both age groups showed strong increases over time in chemoradiotherapy and chemotherapy from 2000 onwards, although considerably less among elderly. One-, three- and five-year RS increased more strongly over time for the younger group leading to larger disparities between age groups with stage III or IV NSCLC.

CONCLUSION

More curative-intent treatment and improved RS for NSCLC were seen over time, but were less profound among elderly. Disparities herein between age groups seemed to become smaller over time for stage I NSCLC, did not change for stage II, and were widening for stage III and IV at the expense of elderly. Future prospective studies should focus on optimizing treatment selection and outcomes for elderly.

The Effect of A Geriatric Assessment on Treatment Decisions for Patients with Lung Cancer

Background

Decision-making for older patients with lung cancer can be complex and challenging. A geriatric assessment (GA) may be helpful and is increasingly being used since 2005 when SIOG advised to incorporate this in standard work-up for the elderly with cancer. Our aim was to evaluate the value of a geriatric assessment in decision-making for patients with lung cancer.

Methods

Between January 2014 and April 2016, data on patients with lung cancer from two teaching hospitals in the Netherlands were entered in a prospective database. Outcome of geriatric assessment, non-oncologic interventions, and suggested adaptations of oncologic treatment proposals were evaluated.

Results

83 patients (median age 79 years) were analyzed with a geriatric assessment, of which 59% were treated with a curative intent. Half of the patients were classified as ECOG PS 0 or 1. The majority of the patients (78%) suffered from geriatric impairments and 43% (n = 35) of the patients suffered from three or more geriatric impairments (out of eight analyzed domains). Nutritional status was most frequently impaired (52%). Previously undiagnosed impairments were identified in 58% of the patients, and non-oncologic interventions were advised for 43%. For 33% of patients, adaptations of the oncologic treatment were proposed. Patients with higher number of geriatric impairments more often were advised a reduced or less intensive treatment (p < 0.001).

Conclusion

A geriatric assessment uncovers previously unknown health impairments and provides important guidance for tailored treatment decisions in patients with lung cancer. More research on GA-stratified treatment decisions is needed.

External-beam radiation therapy combined with limb-sparing surgery in elderly patients (>70 years) with primary soft tissue sarcomas of the extremities : A retrospective analysis

PURPOSE

To report our experience with EBRT combined with limb-sparing surgery in elderly patients (>70 years) with primary extremity soft tissue sarcomas (STS).

METHODS

Retrospectively analyzed were 35 patients (m:f 18:17, median 78 years) who all presented in primary situation without nodal/distant metastases (Charlson score 0/1 in 18 patients; ≥2 in 17 patients). Median tumor size was 10 cm, mainly located in lower limb (83%). Stage at presentation (UICC7th) was Ib:3%, 2a:20%, 2b:20%, and 3:57%. Most lesions were high grade (97%), predominantly leiomyosarcoma (26%) and undifferentiated pleomorphic/malignant fibrous histiocytoma (23%). Limb-sparing surgery was preceded (median 50 Gy) or followed (median 66 Gy) by EBRT.

RESULTS

Median follow-up was 37 months (range 1-128 months). Margins were free in 26 patients (74%) and microscopically positive in 9 (26%). Actuarial 3‑ and 5‑year local control rates were 88 and 81% (4 local recurrences). Corresponding rates for distant control, disease-specific survival, and overall survival were 57/52%, 76/60%, and 72/41%. The 30-day mortality was 0%. Severe postoperative complications were scored in 8 patients (23%). Severe acute radiation-related toxicity was observed in 2 patients (6%). Patients with Charlson score ≥2 had a significantly increased risk for severe postoperative complications and acute radiation-related side effects. Severe late toxicities were found in 7 patients (20%), including fractures in 3 (8.6%). Final limb preservation rate was 97%.

CONCLUSION

Combination of EBRT and limb-sparing surgery is feasible in elderly patients with acceptable toxicities and encouraging but slightly inferior outcome compared to younger patients. Comorbidity correlated with postoperative complications and acute toxicities. Late fracture risk seems slightly increased.

Prophylactic cranial irradiation after definitive chemoradiotherapy for limited-stage small cell lung cancer: Do all patients benefit?

PURPOSE

Prophylactic cranial irradiation (PCI) can improve overall survival (OS) and suppress brain metastases (BM) in patients with limited-stage small cell lung cancer (LS-SCLC) after complete response to primary therapy. However, PCI can be toxic. We sought to identify characteristics of patients who may not benefit from PCI.

METHODS

We identified 658 patients who received chemoradiotherapy at MD Anderson in 1986-2012; 364 received PCI and 294 did not. Median follow-up time was 21.2months (range 1.2-240.8months). Cox proportional hazards regression, competing-risk regression, and Kaplan-Meier analyses were used to identify factors influencing OS and BM.

RESULTS

PCI reduced risks of death [HR 0.73, 95% CI 0.61-0.88, P=0.001] and BM [HR 0.54, 95% CI 0.39-0.76, P<0.001]. Having tumors ⩾5cm increased the risk of BM [HR 1.77, 95% CI 1.22-2.55, P=0.002] but not death [HR 1.16, 95% CI 0.96-1.40, P=0.114]. Among patients ⩾70years with ⩾5-cm tumors, PCI did not improve OS [2-year rates 39.4% vs 40.9%, P=0.739].

CONCLUSIONS

PCI remains standard therapy after complete response to chemoradiotherapy for LS-SCLC. However, older patients may be at risk from comorbidity or extracranial disease. Further work is warranted to identify patients who may not benefit from PCI.