Frailty screening in dermato-oncology practice: a modified Delphi study and a systematic review of the literature

Exploration of the causality of frailty index on psoriasis: A Mendelian randomization study

BACKGROUND

Frailty is associated with a variety of diseases, but the relationship between frailty and psoriasis remains unclear.

METHODS

First, we conducted a two-sample Mendelian randomization based on genome-wide association studies (GWAS) to investigate genetic causality between frailty index and common diseases in dermatology. Inverse variance weighted was used to estimate causality. Second, expression quantitative trait locus (eQTLs) analysis was conducted to identify the genes affected by Single nucleotide polymorphisms (SNPs). Third, we performed function and pathway enrichment, transcriptome-wide association studies (TWAS) analysis based on eQTLs.

RESULTS

It was shown that the rise of frailty index could increase the risk of psoriasis (IVW, beta = 0.916, OR = 2.500, 95%CI:1.418-4.408, p = 0.002) through Mendelian randomization (MR), and there was no heterogeneity and pleiotropy. There was no causality between the frailty index and other common diseases in dermatology. We found 31 eQTLs based on strongly correlated SNPs in the causality. TWAS analysis found that the expressions of four genes were closely related to psoriasis, including HLA-DQA1, HLA-DQA2, HLA-DRB1 and HLA-DQB1.

CONCLUSION

It suggested that the frailty index had a significant positive causality on the risk of psoriasis, which was well documented by combined genomic, transcriptome, and proteome analyses.

Complex Management of Basal Cell Carcinoma in a Frail Patient

Basal cell carcinoma (BCC) is one of the most common cancers diagnosed in older patients and has low mortality. Surgical versus medical management is considered in patients with multiple comorbidities and limited life expectancy (LLE), where the risk-to-benefit ratio must be carefully assessed. Watchful waiting (WW) is a viable option for some patients with severe LLE when follow-up care can be provided vigilantly and frequently. Special consideration should be given to morbidity factors such as tumor growth, bleeding, pain, and social withdrawal that negatively affect the quality of life. We present the case of a 75-year-old male with a past medical history of multiple system atrophy, who presented with a BCC on the ear and face. We discuss the management of this patient and factors that may have led to the inappropriate use of WW.

Identifying and prioritizing sustainability indicators for China's assessing demolition waste management using modified Delphi-analytic hierarchy process method

Addressing the sustainability issues arising from construction and demolition waste management (DWM) has gained little traction due to the lack of incentives, stringent regulations, and systematic guidance. This study aims to empower systematic decision-making concerning DWM alternative selection by developing a sustainability assessment framework by coupling a modified Delphi method with the multicriteria decision analysis technique. First, the study identifies a comprehensive inventory of indicators across three dimensions of sustainability in the context of DWM. Next, the study combines a modified Delphi method with the analytic hierarchy process to validate and prioritize the selected sustainability indicators. For the first time, insights regarding the DWM sustainability indicators from China's construction industry practitioners' perspectives are elicited using a mixed method comprising online semistructured interviews and two rounds of questionnaire surveys. Experts participating in the research are mostly based in Guangzhou and Shenzhen, where local governments exhaust all efforts in promoting carbon-neutral and sustainable development. The findings reveal that eight sustainability indicators were regarded as the determinants for the sustainability performance of DWM, with the global warming potential (32%), energy efficiency (16.1%) and land use (13.5%) receiving the highest preference scores (weights) based on the experts' judgment. Notably, the economic factors like the total cost (6.54%) appeared not highly prioritized by the local experts as typically did in the previous studies from developing countries.

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

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

Multidimensional Oncological Frailty Scale (MOFS): A New Quick-To-Use Tool for Detecting Frailty and Stratifying Risk in Older Patients with Cancer-Development and Validation Pilot Study

BACKGROUND

Frailty detection with comprehensive geriatric assessment (CGA) is of pivotal importance in older patients with cancer to avoid over- or under-treatment and to detect those at increased risk for poor outcomes. Several tools have been developed to capture the complexity of frailty, but only a few were explicitly conceived for older adults with cancer. The study aimed at developing and validating a multidimensional, easy-to-use diagnostic tool for early-risk stratification in patients with cancer, called the Multidimensional Oncological Frailty Scale (MOFS).

METHODS

In this single-center prospective study, we consecutively enrolled 163 older women (age ≥ 75 years) with breast cancer, screened with a G8 score ≤ 14 during the outpatient preoperative evaluation at our breast centre, as the development cohort. Seventy patients with different types of cancer admitted to our OncoGeriatric Clinic served as the validation cohort. Using stepwise linear regression analysis, we evaluated the relationship between Multidimensional Prognostic Index (MPI) and CGA items, and, finally, realized a screening tool based on the combination of the significant variables.

RESULTS

The mean age of the study population was 80.4 ± 5.8 years, while the mean age of the validation cohort was 78.6 ± 6.6 years [42 women (60%)]. A composite model of the Clinical Frailty Scale, G8, and hand grip strength test showed a strong correlation with MPI (R= -0.712, p < 0.001). The MOFS accuracy in the prediction of mortality was optimal in both the development and the validation cohorts (AUC 0.82 and 0.87; p < 0.001 and 0.003, respectively).

CONCLUSION

MOFS represents a new, accurate, quick-to-use frailty screening tool for stratifying the risk of mortality in geriatric cancer patients.

A prospective, multicentre study to assess frailty in elderly patients with leg ulcers (GERAS study)

BACKGROUND

Although leg ulcers are a burdensome disease most common in those aged 65 years and older, frailty in this population has not yet been well established.

OBJECTIVES

The aim of this study was to prospectively explore and compare the presence of frailty in elderly patients with chronic leg or foot ulcers by applying different validated frailty screening methods in three healthcare settings and to assess the feasibility of frailty screening.

METHODS

We compared frailty of leg ulcer patients referred to an academic hospital with a non-academic hospital, leg ulcer patients receiving (primary) homecare, and a dermato-oncology patient population (control group). Frailty and quality of life were assessed using four validated questionnaires: the Groninger Frailty Indicator, Geriatric-8, Mini-Cog and Wound Quality of Life. To analyse data multiple (non)-parametric tests were performed.

RESULTS

Fifty of 60 included leg ulcer patients (83%) scored "frail" on at least one frailty questionnaire (GFI, G8 or Mini-Cog). The number of patients scoring "frail" on two or three out of three applied frailty questionnaires were significantly higher in the academic and homecare ulcer population compared with the non-academic ulcer population and control group (p = 0.002). In the academic ulcer population mean Wound Quality of Life scores were 30.2 (SD 17.6), compared with 17.7 (SD 13.1) in the non-academic and 15.0 (SD 10.4) in the homecare ulcer population (p = 0.002).

CONCLUSION

The majority of patients suffering from leg ulcers in this study was frail. The highest frailty prevalence was observed in the academic and homecare ulcer populations. The largest impaired quality of life was reported in the academic ulcer population. In dermatology practice, implementing frailty screening and initiating appropriate (paramedical) supportive care should be considered to improve patient outcomes.

Age-based treatment differences in and reluctance to treating older adults with systemic antipsoriatic therapy - a mixed-method pilot study

BACKGROUND

Evidence-based guidance in older adults (≥65 years) with psoriasis is sparse and undertreatment might be present.

OBJECTIVES

To assess prescribing patterns, comfort levels, barriers and needs of dermatologists when treating older adults with systemic antipsoriatic therapy.

METHODS

A mixed-methods design was used including a survey among all Dutch dermatologists and residents, followed by semi-structured interviews.

RESULTS

Most of the survey respondents applied systemic treatment to the same extent in older versus younger patients (n = 49; 67.1%) and weren't reluctant prescribing systemic therapy (n = 50; 68.5%) in older adults. However, 26% (n = 19) of the respondents treated older adults less often with systemic therapy compared to younger patients and 68.1% (n = 49) performed additional actions in older adults, e.g. intensified monitoring or dose reduction. Based on the survey and interviews (n = 10), the main reasons for these age-based treatment differences were comorbidity, comedication, and fear of adverse events. More evidence-based guidance, education, and time to assess older adults were identified as most important needs, especially regarding frailty screening.

CONCLUSIONS

Age-based treatment differences in and reluctance to treating older adults with systemic antipsoriatic therapy were common. There is a need for more evidence-based guidance, education, and consultation time, to improve treatment in this growing population.

Characteristics and management of skin cancers in very elderly patients: A real-world challenge for clinicians

The increase life expectancy led to an expected increase in skin cancer incidence in older patients. Their treatment can require a complex decision-making process. Limited data are available on characteristics, management and outcome of skin tumours in nonagenarian and centenarian patients. The aim of our study was to describe epidemiology, clinical-pathological features and treatment strategies of skin cancers in a cohort of patients aged ≧95 years. A total of 116 patients ≧95 years of age presented for the evaluation of 225 skin lesions (mean of 1.94 lesions per patient). The mean age was 97.4 years, 57.8% were women. Most patients had an ECOG score of 3 (49.3%) or 4 (32%). Lesions were mainly located on the head and neck area (74.2%), upper (7.1%) and lower (6,2%) limbs. The majority of patients presented with non-melanoma skin cancers (183/225; 81.3%), 25/225 (11.1%) had actinic keratosis, 5 (2.2%) melanoma and 2 (0.9%) atypical fibroxanthoma. Forty-eight lesions (21.3%) were treated with surgery, 58 (25.8%) with radiotherapy. The management of 73 lesion (32.4%) was discussed at the multidisciplinary tumour board meeting. One patient died for the progression of a squamous cell carcinoma; 74 patients died for causes unrelated to skin tumours, 36 are still alive after a mean follow-up of 27.27 months. This cohort study confirms that age is not per se a contraindication for treatment of skin cancers in elderly patients. Our results support the importance of a patient-centred care approach that should take into consideration patient's preferences, comorbidities, compliance and possible adverse events.

Management of elderly patients with advanced cutaneous squamous cell carcinoma

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

Optimizing shared decision-making in older adults with basal cell carcinoma: experiences from a specialized outpatient clinic

Balancing the risk for under- and overtreatment in older adults with basal cell carcinoma (BCC) frequently proves challenging.^1,2 As BCCs are slowly growing tumors and initially asymptomatic, patients with limited life expectancy (LLE) might frequently be overtreated,² leading to unnecessary and avoidable treatment burden, while little or no improvement in quality of life might be achieved. To improve patient-centered care for older BCC patients, it was hypothesized that a more holistic approach, with specific attention for patient-related factors and treatment goals, leads to different BCC management choices, better aligning with patient preferences, and resulting in less overtreatment.

Predictors of surgical treatment burden, outcomes, and overall survival in older adults with basal cell carcinoma: Results from the prospective, multicenter BATOA cohort

BACKGROUND

Incorporating patient-related factors associated with treatment outcomes could improve personalized care in older patients with basal cell carcinoma (BCC).

OBJECTIVE

To evaluate and identify predictors of treatment burden, treatment outcomes, and overall survival in patients aged ≥70 years, surgically treated for BCC in the head and neck area.

METHODS

The data from the prospective, multicenter Basal Cell Carcinoma Treatment in Older Adults (BATOA) cohort study were extracted to evaluate the experienced treatment burden (visual analog scale, 0-10 cm; lower scores indicating higher treatment burden), treatment outcomes, and mortality.

RESULTS

A total of 539 patients were included (median age, 78 years). The patients experienced a low overall treatment burden (median, 8.6) and good cosmetic results. The predictors of higher treatment burden were instrumental activities of daily living (iADL) dependency, female sex, complications, larger tumor diameter, and polypharmacy. Thirty-five patients (6.5%) died (none of the deaths were due to BCC) within the follow-up period; the predictors of mortality were increasing comorbidity index and iADL dependency. No difference in these outcomes was seen between Mohs micrographic surgery and conventional excision after correction for covariates. Age was not significantly associated with any outcome.

LIMITATIONS

A selection bias may exist owing to the observational design.

CONCLUSION

BCC management decisions based on chronological age alone should be avoided, whereas more attention is recommended for patient-related factors. Based on these data, early BCC intervention is beneficial for robust and fit patients or those experiencing symptoms.