Cancer in old age--is it inadequately investigated and treated?

Postoperative Course and Supportive Care in Very Elderly Cecum Cancer Patients

In developed countries like Japan, the size of the older population is rapidly increasing. Malignant neoplasms rank as the leading cause of death among the geriatric population of Japan, emphasizing the rising demand for cancer care in this demographic. Older patients, besides facing physical and cognitive challenges, are also affected by their social environment, necessitating tailored interventions. Few case reports have detailed the progress of cancer treatment in nonagenarian patients. This study presents the progress of two very old patients with cancer. The first case, a 95-year-old female with chronic constipation underwent emergency surgery for a cecal tumor. Despite initial improvements, her mobility declined after surgery, leading to institutionalization. Recurrent hospitalizations ensued with complications culminating in her death approximately 20 months after surgery. In the second case, a 94-year-old male, initially declining aggressive treatment for a suspected ileocecal malignancy, later opted for supportive care. Despite stable conditions, he eventually died at home after experiencing progressive weakness, which was approximately 20 months after the initial diagnosis. These cases shed light on the management of elderly patients with ileocecal cancer, illustrating the divergent trajectories between surgical intervention and supportive care. The tumor did not recur in the patient who underwent surgery; however, the independence in performing daily living activities declined significantly. In the case managed with the best-supportive care, progression was slow; however, severe anemia became a concern toward the end of life.

Lung cancer outcomes in the elderly: potential disparity in screening

OBJECTIVES

The aim of this study was to analyse outcomes of lung cancer in the elderly.

METHODS

A retrospective analysis was performed of patients in the National Cancer Database with NSCLC from 2004 to 2017 grouped into 2 categories: 70-79 years (A) and 80-90 years (B). Patients with multiple malignancies were excluded. Kaplan-Meier curves estimated the overall survival for each age group based on stage.

RESULTS

In total, 466 051 patients were included. Less-invasive techniques (imaging and cytology) diagnosed cancer as a function of age: 14.6% in A vs 21.3% in B [P < 0.001, standardized mean difference (SMD) 0.175]. Clinical stage IA was least common in B (15%) compared to 17.3% in A (P < 0.001, SMD 0.079). Approximately 83.0% in B did not receive surgery compared to 70.0% in A (P < 0.001, SMD 0.299). Of the 83.0%, 8.0% were considered poor surgical candidates because of age or comorbidities compared with 6.2% in A (P < 0.001, SMD 0.299) For 71.0% in B, surgery was not the first treatment plan compared to 62.0% in A (P < 0.001, SMD 0.299). Survival curves showed worse prognosis for each clinical and pathologic stage for B compared to A.

CONCLUSIONS

Patients older than 80 years present less frequently as clinical stage IA, are less commonly offered surgical intervention and are more frequently diagnosed using less accurate measures. They also have worse outcomes for each stage compared to younger patients.

Diagnostic Accuracy of Highest-Grade or Predominant Histological Differentiation of T1 Colorectal Cancer in Predicting Lymph Node Metastasis: A Systematic Review and Meta-Analysis

INTRODUCTION

Treatment guidelines for colorectal cancer (CRC) suggest 2 classifications for histological differentiation-highest grade and predominant. However, the optimal predictor of lymph node metastasis (LNM) in T1 CRC remains unknown. This systematic review aimed to evaluate the impact of the use of highest-grade or predominant differentiation on LNM determination in T1 CRC.

METHODS

The study protocol is registered in the International Prospective Register of Systematic Reviews (PROSPERO, registration number: CRD42023416971) and was published in OSF ( https://osf.io/TMAUN/ ) on April 13, 2023. We searched 5 electronic databases for studies assessing the diagnostic accuracy of highest-grade or predominant differentiation to determine LNM in T1 CRC. The outcomes were sensitivity and specificity. We simulated 100 cases with T1 CRC, with an LNM incidence of 11.2%, to calculate the differences in false positives and negatives between the highest-grade and predominant differentiations using a bootstrap method.

RESULTS

In 42 studies involving 41,290 patients, the differentiation classification had a pooled sensitivity of 0.18 (95% confidence interval [CI] 0.13-0.24) and 0.06 (95% CI 0.04-0.09) ( P < 0.0001) and specificity of 0.95 (95% CI 0.93-0.96) and 0.98 (95% CI 0.97-0.99) ( P < 0.0001) for the highest-grade and predominant differentiations, respectively. In the simulation, the differences in false positives and negatives between the highest-grade and predominant differentiations were 3.0% (range 1.6-4.4) and -1.3% (range -2.0 to -0.7), respectively.

DISCUSSION

Highest-grade differentiation may reduce the risk of misclassifying cases with LNM as negative, whereas predominant differentiation may prevent unnecessary surgeries. Further studies should examine differentiation classification using other predictive factors.

A scoping review of ageism towards older adults in cancer care

INTRODUCTION

Ageism towards older adults with cancer may impact treatment decisions, healthcare interactions, and shape health/psychosocial outcomes. The purpose of this review is twofold: (1) To synthesize the literature on ageism towards older adults with cancer in oncology and (2) To identify interventions that address ageism in the healthcare context applicable to oncology.

MATERIALS AND METHODS

We conducted a scoping review following Arksey and O'Malley and Levac methods and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We conducted an exhaustive multi-database search, screening 30,926 titles/abstracts. Following data abstraction, we conducted tabular, narrative, and textual synthesis.

RESULTS

We extracted data on 133 papers. Most (n = 44) were expert opinions, reviews, and letters to editors highlighting the negative impacts of ageism, expressing the need for approaches addressing heterogeneity of older adults, and calling for increased clinical trial inclusion for older adults. Qualitative studies (n = 3) described healthcare professionals' perceived influence of age on treatment recommendations, whereas quantitative studies (n = 32) were inconclusive as to whether age-related bias impacted treatment recommendations/outcomes or survival. Intervention studies (n = 54) targeted ageism in pre/post-licensure healthcare professionals and reported participants' improvement in knowledge and/or attitudes towards older adults. No interventions were found that had been implemented in oncology.

DISCUSSION

Concerns relating to ageism in cancer care are consistently described in the literature. Interventions exist to address ageism; however, none have been developed or tested in oncology settings. Addressing ageism in oncology will require integration of geriatric knowledge/interventions to address conscious and unconscious ageist attitudes impacting care and outcomes. Interventions hold promise if tailored for cancer care settings. 249/250.

Temporal trends in disease-specific causes of cardiovascular mortality amongst patients with cancer in the USA between 1999 and 2019

AIMS

We report disease-specific cardiovascular causes of mortality among cancer patients in the USA between 1999 and 2019, considering temporal trends by age, sex, and cancer site.

METHODS AND RESULTS

We used the Multiple Cause of Death database, accessed through the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research resource. We included 629 308 decedents with cardiovascular disease (CVD) recorded as the primary cause of death and active malignancy listed as a contributing cause of death. We created disease-specific CVD categories and grouped cancers by site. We calculated the proportion of CVD deaths attributed to each disease category stratified by sex, age, and cancer site. We also examined disease-specific temporal trends by cancer site. Ischaemic heart disease (IHD) was the most common cardiovascular cause of death across all cancer types (55.6%), being more common in men (59.8%), older ages, and in those with lung (67.8%) and prostate (58.3%) cancers. Cerebrovascular disease (12.9%) and hypertensive diseases (7.6%) were other common causes of death. The proportion of deaths due to heart failure was greatest in haematological (7.7%) and breast (6.3%) cancers. There was a decreasing temporal trend in the proportion of cardiovascular deaths attributed to IHD across all cancer types. The proportion of deaths due to hypertensive diseases showed the greatest percentage increase, with the largest change in breast cancer patients (+191.1%).

CONCLUSION

We demonstrate differential cardiovascular mortality risk by cancer site and demographics, providing insight into the evolving healthcare needs of this growing high-cardiovascular risk population.

Adjuvant Chemotherapy Benefit in Elderly Stage II/III Colon Cancer Patients

Background

Studies providing more evidence to guide adjuvant chemotherapy decisions in elderly colon cancer patients are expected.

Methods

We obtained data from the Surveillance, Epidemiology and End Results (SEER) database between 2004 and 2012. Kaplan-Meier survival curves were constructed to calculate the cancer-specific survival (CSS) rate, and comparisons of survival difference between different subgroups were performed using the log-rank test. Multivariate Cox proportional hazards regression models were carried out to estimate hazard ratio (HR) and 95% confidence intervals (CIs) of different clinicopathological characteristics.

Results

In stage II colon cancer patients aged 70 years or older, the Kaplan-Meier survival analysis showed that the 5-year CSS rates of no chemotherapy and chemotherapy groups were 82.0% and 72.4%, respectively (P &lt; 0.001). In stage III colon cancer patients aged 70 years or older, the Kaplan-Meier survival analysis showed that the 5-year CSS rates of no chemotherapy and chemotherapy groups were 50.7% and 61.3%, respectively (P &lt; 0.001). Patients with chemotherapy receipt were independently associated with a 35.8% lower cancer-specific mortality rate (HR = 0.642, 95% CI: 0.620-0.665, P &lt; 0.001) compared with those who did not receive chemotherapy.

Conclusions

Adjuvant chemotherapy should be considered during the treatment of stage III colon cancer patients aged 70 years or older, but the chemotherapy benefit in elderly stage II colon cancer is suboptimal.

Efficacy of FOLFIRI plus cetuximab vs FOLFIRI plus bevacizumab in 1st-line treatment of older patients with RAS wild-type metastatic colorectal cancer: an analysis of the randomised trial FIRE-3

Background

The evidence on the efficacy of anticancer therapy is limited in older patients with metastatic colorectal cancer (mCRC). This retrospective analysis of phase III FIRE-3 trial assesses the efficacy of FOLFIRI plus either cetuximab or bevacizumab according to the patients’ age and sidedness of primary tumour.

Methods

The study endpoints overall response rate (ORR), progression-free survival (PFS) and overall survival (OS) were compared between younger (<65 years) and older (≥65 years) patients, followed by stratification according to primary tumour sidedness. ORR was compared using Fisher´s exact test, OS and PFS were estimated by the Kaplan–Meier method and compared using the log-rank test. Univariate Cox regression analyses assessed hazard ratios and 95% confidence intervals for OS and PFS.

Results

Overall, older patients with RAS WT tumours had a significantly shorter OS when compared to younger patients (25.9 months vs 29.3 months, HR 1.29; P = 0.02). Also the proportion of right-sided tumours was significantly greater in older patients (27.1% vs 17.9%; P = 0.029). Secondary resection rates were numerically higher in younger patients (25.4% vs. 17.6%, P = 0.068) than in older patients. This was primarily seen in the Cetuximab arm, where older patients underwent less likely resection (13.1% vs. 26%; P = 0.02). Older patients with left-sided tumours showed only a trend towards greater efficacy of cetuximab (HR 0.86; P = 0.38). In patients with right-sided primary tumours, older patients did not appear to benefit from cetuximab in contrast to younger patients (≥65 years: 16.6 months vs 23.6 months, HR 1.1; P = 0.87; <65 years: 21.9 months vs 16.4 months HR 1.5; P = 0.31).

Conclusions

In FIRE-3, OS was generally shorter in older patients in comparison to younger patients. This could be explained by the overrepresentation of right-sided tumours and a lower secondary resection rate in older patients. The efficacy of targeted therapy was dependent on tumour sidedness in older patients with RAS WT mCRC.

Clinical trial

FIRE-3 (NCT00433927).

Real-world colorectal cancer diagnostic pathways in Ontario, Canada: A population-based study

OBJECTIVE

This study aimed to identify colorectal cancer (CRC) diagnostic pathways and describe patients in those pathway groups.

METHODS

This was a cross-sectional study of CRC patients in Ontario, Canada, diagnosed 2009-2012 that used linked administrative data at ICES. We used cluster analysis on 11 pathway variables characterising patient presentation, symptoms, procedures and referrals. We assessed associations between patient- and disease-related characteristics and diagnostic pathway group. We further characterised the pathways by diagnostic interval and number of related physician visits.

RESULTS

Six diagnostic pathways were identified, with three adhering to provincial diagnostic guidelines: screening (N = 4494), colonoscopy (N = 10,066) and imaging plus colonoscopy (N = 3427). Non-adherent pathways were imaging alone (N = 2238), imaging and emergency presentation (N = 2849) and no pre-diagnostic workup (N = 887). Patients in adherent pathways were younger, had fewer comorbidities, lived in less deprived areas and had earlier stage disease. The median diagnostic interval length varied across pathways from 12 to 126 days, correlating with the number of CRC-related visits.

CONCLUSIONS

This study demonstrated substantial variations in real-world CRC diagnostic pathways and 25% were diagnosed through non-adherent pathways. Those patients were older, had more comorbid disease and had higher stage cancer. Further research needs to identify and describe the reasons for divergent diagnostic processes.

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.

Determinants of delay from cancer diagnosis to treatment initiation in a cohort of brazilian women with breast cancer

This objective this study was to identify the time interval between breast cancer (BC) diagnosis and treatment initiation and delay-associated factors. This is a prospective cohort study that followed breast cancer patients, enrolled and treated at the cancer center in Rio de Janeiro (RJ) - Brazil, from October 02, 2014 to April 30, 2015. Participants were interviewed at the first consultation. Treatment-related information was collected six months after recruitment. The median and interquartile range (IQR) were calculated. The interval between breast cancer diagnosis and treatment initiation of more than 60 days was considered the delay, according to the maximum term determined by Brazilian law. The association between independent variables and the outcome was performed using the crude odds ratios (OR). Variables presenting p < .20 in the univariate analysis were included in the multiple logistic regression model by the stepwise forward method, and those with p < .05 were retained in the final model. A total of 470 patients were included in the study. The median time was of 127 days (IQR: 85- 174). Delay was observed in 89.1% of the cases. After adjustment, the variables associated with delay were age ≥ 60 years (OR: 2.48; 95% CI 1.22-5.06), initial clinical staging (<2B) (OR: 2.01; 95% CI 1.05-3.86) and residence outside the city of Rio de Janeiro (OR: 2.75; 95% CI 1.38-5.51). Delays in starting treatment were associated with sociodemographic and clinical factors. Improving patient quality of care and restructuring the health service can minimise delays.

Protocol for a multi-centre observational and mixed methods pilot study to identify factors predictive of poor functional recovery after major gastrointestinal surgery and strategies to enhance uptake of perioperative optimization: Optimizing the care and treatment pathways for older patients facing major gastrointestinal surgery (OCTAGON)

INTRODUCTION

National datasets report large variations in outcomes from older people (≥65 years) between different UK surgical units. This implies that not all patients receive the same level of care or access to resources, such as rehabilitation or allied health professional input. This might impact functional decline.

AIMS

Our aim is to evaluate the baseline status of older patients facing major gastrointestinal surgery and the impact of variation in perioperative assessment and provision of perioperative support on functional outcomes. Patients' experiences and views of assessment and optimization will be explored via integrated qualitative semi-structured interviews.

METHODS AND ANALYSIS

This multi-centre, pilot cohort study will include patients ≥65 years presenting via both elective and emergency pathways at three to five South Yorkshire NHS hospitals (Clinical Trials registration NCT04545125). The primary outcome is functional recovery measured using the World Health Organization Disability Assessment Schedule 2.0 at 6 weeks post-operation. Secondary outcomes include feasibility, quality of life, length of stay and complication rate. An opportunistic sample size of 120 has been estimated and will inform the design of a future, adequately powered study. For the qualitative study, 20-30 semi-structured patient interviews will be undertaken with patients from the cohort study to explore experiences of assessment and optimization. Interviews will be digitally recorded, transcribed verbatim and analysed according to the framework approach.

ETHICS AND DISSEMINATION

This study has been approved by the National Health Service Research Ethics Committee and is registered centrally with Health Research Authority. It has been adopted by the National Institute for Health Research Portfolio scheme. Dissemination will be via international and national surgical and geriatric conferences.

Qualitative and Quantitative Analysis of Posttreatment Strategy After Endoscopic Resection for Patients with T1 Colorectal Cancer at High Risk of Lymph Node Metastasis

BACKGROUND

Although endoscopic resection is increasingly performed to treat submucosal invasive colorectal cancer (T1CRC), approximately 10% are at risk of lymph node metastasis. The Japanese Society for Cancer of the Colon and Rectum guideline indicates that the following risk factors should be considered when deciding whether to perform additional surgical resection with lymph node dissection: depth of T1 invasion, lymphovascular invasion, poor histological grade, and budding grade 2/3. However, there is little information about the prognosis of T1CRC patients, or factors to consider when deciding subsequent treatment of high-risk T1CRC.

METHODS

This retrospective mixed method study was conducted using electronic medical records at Kyoto University Hospital between February 2005 and February 2015. Participants were T1CRC patients at risk of lymph node metastasis with at least one of the above four risk factors. They were assigned either careful follow-up (FU) or additional surgery (AS) through shared decision-making. To identify factors affecting decision-making in the FU group, we performed qualitative content analysis of electronic medical records. The prognosis of the groups was compared using the Kaplan-Meier method and the log-rank test.

RESULTS

Of 161 T1CRC patients, 18 were included in the FU group and 19 in the AS group. The median follow-up time was 39.5 (range 23-126) months for the FU group and 62 (range 22-141) months for the AS group. Factors considered in selecting FU were advanced age, comorbidities, the sole presence of the "depth" risk factor, and lower rectal cancer. For AS, the risk factors cited in the guideline were considered. There was one recurrent case in each group during the research period. There were no significant differences in overall survival, cause-specific survival, or recurrence-free survival between the groups.

CONCLUSIONS

Age, comorbidities, and lower-rectal cancer location were considered in deciding posttreatment strategy among high-risk T1CRC patients, alongside with positive vertical margin, depth, lymphovascular invasion, poor histologic grade, and budding. During the research period, there was no prognostic difference between the FU and AS groups.

Associations between age discrimination and health and wellbeing: cross-sectional and prospective analysis of the English Longitudinal Study of Ageing

BACKGROUND

Age discrimination (or ageism) is pervasive in society. Other forms of discrimination (such as racism) have been linked with adverse health outcomes, but age discrimination has not been well studied in public health. We aimed to examine associations between perceived age discrimination and health and wellbeing in England.

METHODS

We did a longitudinal observational population study with data from the English Longitudinal Study of Ageing, a nationally representative sample of older men and women. Participants were aged 50 years or older and reported experiences of age discrimination via a face-to-face computer-assisted personal interview and a self-completed questionnaire between July, 2010, and June, 2011. Self-rated health, chronic health conditions, and depressive symptoms were assessed between July, 2010, and June, 2011, and between May, 2016, and June, 2017. We used logistic regression to test cross-sectional associations between perceived age discrimination and baseline health status and prospective associations between perceived age discrimination and incident ill health over 6 years. Analyses were adjusted for age, sex, and wealth.

FINDINGS

Our sample for cross-sectional analyses of 2010-11 data comprised 7731 people who took part in the face-to-face interview, returned the self-completion questionnaire, and had available data for age discrimination. Perceived age discrimination was reported by 1943 (25·1%) participants. Patients who perceived age discrimination were more likely to self-report fair or poor health (odds ratio [OR] 1·32 [95% CI 1·17-1·48]) and to have coronary heart disease (1·33 [1·14-1·54]), chronic lung disease (1·37 [1·11-1·69]), arthritis (1·27 [1·14-1·41]), limiting long-standing illness (1·35 [1·21-1·51]), and depressive symptoms (1·81 [1·57-2·08]) than those who did not perceive age discrimination. Follow-up data collected 6 years after the baseline assessment were available for 5595 participants. Longitudinally, perceived age discrimination was associated with the deterioration of self-rated health (OR 1·32 [95% CI 1·10-1·58]) and incident coronary heart disease (1·66 [1·18-2·35]), stroke (1·48 [1·08-2·10]), diabetes (1·33 [1·01-1·75]), chronic lung disease (1·50 [1·10-2·04]), limiting long-standing illness (1·32 [1·10-1·57]), and depressive symptoms (1·47 [1·16-1·86]) over 6 years.

INTERPRETATION

Among older adults living in England, perceived age discrimination was associated with increased odds of poor self-rated health and risk of incident serious health problems over a 6-year period. These findings underscore the need for effective interventions at the population level to combat age stigma and discrimination.

FUNDING

UK Economic and Social Research Council.

Elderly Patients with Metastatic Neuroendocrine Tumors Are Undertreated and Have Shorter Survival: The LyREMeNET Study

INTRODUCTION

The incidence of neuroendocrine tumors (NETs) is rising, especially in elderly patients. The elderly cancer population presents considerable challenges, yet little is known about the characteristics, treatment patterns, and outcomes of metastatic NET (mNET) patients.

METHODS

The Lyon Real-life Evidence in Metastatic NeuroEndocrine Tumors study (LyREMeNET, NCT03863106) included consecutive mNET patients, diagnosed between January 1990 and December 2017. The exclusion criteria were nonmetastatic NET, poorly differentiated neuroendocrine carcinoma, and mixed neuroendocrine-nonneuroendocrine neoplasms. We aimed to compare patients ≥70 years old to patients <70 years old.

RESULTS

A total of 866 patients were included, 198 (23%) were ≥70 years old. There was no significant difference in characteristics except that elderly patients had synchronous metastasis more frequently. Elderly patients received significantly fewer treatments (median of 2.0 vs. 3.0 lines, respectively, p < 0.0001), were significantly less frequently treated by chemotherapy (32 vs. 54%), targeted therapy (16 vs. 30%), peptide receptor radionuclide therapy (5 vs. 16%), and they underwent significantly less frequently locoregional intervention. Median overall survival was significantly shorter in elderly patients (5.2 vs. 9.6 years). The most frequent cause of death was related to disease progression (71%). Multivariate analysis found that, after adjustment for tumor location, tumor grade, and number of metastatic sites, age remained significantly associated with overall survival (HR 1.66, 95% CI 1.26-2.18), indicating a poorer survival in patients ≥70 years old in comparison with younger patients (p = 0.0003).

CONCLUSION

Patients ≥70 years old have a worse survival, die frequently from their disease, and are undertreated compared to younger patients.

Ascertainment of cancer in longitudinal research: The concordance between the Rotterdam Study and the Netherlands Cancer Registry

Complete and accurate registration of cancer is needed to provide reliable data on cancer incidence and to investigate aetiology. Such data can be derived from national cancer registries, but also from large population‐based cohort studies. Yet, the concordance and discordance between these two data sources remain unknown. We evaluated completeness and accuracy of cancer registration by studying the concordance between the population‐based Rotterdam Study (RS) and the Netherlands Cancer Registry (NCR) between 1989 and 2012 using the independent case ascertainment method. We compared all incident cancers in participants of the RS (aged ≥45 years) to registered cancers in the NCR in the same persons based on the date of diagnosis and the International Classification of Diseases (ICD) code. In total, 2,977 unique incident cancers among 2,685 persons were registered. Two hundred eighty‐eight cancers (9.7%) were coded by the RS that were not present in the NCR. These were mostly nonpathology‐confirmed lung and haematological cancers. Furthermore, 116 cancers were coded by the NCR, but not by the RS (3.9%), of which 20.7% were breast cancers. Regarding pathology‐confirmed cancer diagnoses, completeness was >95% in both registries. Eighty per cent of the cancers registered in both registries were coded with the same date of diagnosis and ICD code. Of the remaining cancers, 344 (14.5%) were misclassified with regard to date of diagnosis and 72 (3.0%) with regard to ICD code. Our findings indicate that multiple sources on cancer are complementary and should be combined to ensure reliable data on cancer incidence.

What's new?

While national cancer registries and population‐based cohort studies are the primary sources of data on cancer risk and incidence, the degree to which these data sets are concordant remains unknown. In this investigation, the authors evaluated concordance between the population‐based Rotterdam Study and the Netherlands Cancer Registry. The two data sets were highly concordant for pathology‐confirmed cancers and cancer site. Non‐pathology‐confirmed cancers, however, were under‐registered in the Netherlands Cancer Registry, potentially resulting in underestimation of cancer incidence. The findings highlight the important role that different sources of cancer diagnosis registration serve in providing reliable estimates of cancer incidence.

Rectal cancer in old age -is it appropriately managed? Evidence from population-based analysis of routine data across the English national health service

BACKGROUND

There is significant debate as to where to draw the line between undertreating older rectal cancer patients and minimising treatment risks. This study sought to examine the use of radical rectal cancer treatments and associated outcomes in relation to age across the English NHS.

METHODS

Patient, tumour and treatment characteristics for all patients diagnosed with a first primary rectal cancer in England between 1st April 2009 and 31st December 2014 were obtained from the CORECT-R data repository. Descriptive analyses and adjusted logistic regression models were undertaken to examine any association between age and the use of major resection and post-surgical outcomes. Funnel plots were used to show variation in adjusted rates of major resection.

RESULTS

The proportion of patients who underwent a major surgical resection fell from 66.5% to 31.7%, amongst those aged <70 and aged ≥80 respectively. After adjustment, 30-day post-operative mortality, failure to rescue and prolonged length of stay were significantly higher among the oldest group when compared to the youngest. Patient reported outcomes were not significantly worse amongst older patients. Significant variation was observed in adjusted surgical resection rates in the oldest patients between NHS Trusts. The probability of death due to cancer was comparable across all age groups.

CONCLUSIONS

Older patients who are selected for surgery have good outcomes, often comparable to their younger counterparts. Significant variation in the treatment of older patients could not be explained by differences in measured characteristics and required further investigation.

Neurologic manifestations of elderly patients with cancer

BACKGROUND

The incidence of cancer is an age-related phenomenon; therefore, the interest on clinical manifestations, diagnostic approach and treatment strategies for older patients diagnosed with cancer has increased lately. Neurologic symptoms are one of the main reasons for consultation and a common cause of decreased quality of life among cancer patients.

AIMS

To identify the neurologic manifestations of patients ≥ 65 years of age diagnosed with cancer and compare them to those presented by a younger population.

METHODS

Cross-sectional study of cancer patients referred to neuro-oncologic consultation at a Cancer Center. Sociodemographic, health and oncologic characteristics were obtained through clinical interviews. Clinical symptoms and final diagnoses were also recorded. Bivariate logistic regression analyses were carried out.

RESULTS

More than 17,000 neuro-oncologic consultations in 3015 patients were given, 27% (n = 811) of them were ≥ 65 years of age. Most frequent primary neoplasms in elderly patients were: breast cancer, hematologic neoplasms, gynecological, urologic, skin and head and neck cancers. Elderly patients had an increased risk of having the following diagnoses: abnormal movements, stroke, peripheral vertigo, dementia, degenerative spine disorder, and delirium.

DISCUSSION

Elderly patients are considered a vulnerable population. The present study found that the main neoplasms associated with neurological manifestations are similar to the reported previously. We described the main symptoms that led to a neuro-oncological assessment. Moreover, we enlisted the final diagnoses made on elderly patients and compared them with others reports. To the best of our knowledge, this study provides valuable information, since there is scarce evidence in the literature about this topic.

CONCLUSION

Identifying the frequency and correlation of neurologic manifestations in older cancer patients will allow for the implementation of timely multidisciplinary care in an attempt to improve these patients' health-related quality of life.

Monosegment ALPPS hepatectomy preserving segment 4 for colorectal liver metastases: literature review and our experience

Monosegment 4±1 Associating Liver Partition and Portal Vein ligation for Staged hepatectomy (ALPPS) for bilateral colorectal liver metastases decreases the risk of drop-out of two stage hepatectomy, triggering a rapid and significant increase in future liver remnant (FLR) with promising oncological outcomes. We report two cases of segment 4+1 monosegment ALPPS for multiple colorectal liver metastases performed at our institution. In the literature, seven similar cases have been reported. Short and long term outcomes of our two patients were reported along with a review of data from the literature. Our patients showed a FLR increase from 13% to 37% and from 14% to 41% of total liver volume, respectively. This was compared to a median growth from 19% at baseline to 34% before stage 2, in the literature. After 20 and 27 months since resection both patients are alive and disease-free. In the literature, median overall survival and disease free survival were 13 months (range, 5-24 months) and 5 months (range, 3-23 months), respectively. Segment 4±1 ALPPS is associated with promising oncological outcomes and a significant FLR growth. It may be safely performed in selected patients as a salvage procedure, reducing the risk of the dropout of two-stage hepatectomy.

A Scoping Review of Frailty and Acute Care in Middle-Aged and Older Individuals with Recommendations for Future Research

There is general agreement that frailty is a state of heightened vulnerability to stressors arising from impairments in multiple systems leading to declines in homeostatic reserve and resiliency, but unresolved issues persist about its detection, underlying pathophysiology, and relationship with aging, disability, and multimorbidity. A particularly challenging area is the relationship between frailty and hospitalization. Based on the deliberations of a 2014 Canadian expert consultation meeting and a scoping review of the relevant literature between 2005 and 2015, this discussion paper presents a review of the current state of knowledge on frailty in the acute care setting, including its prevalence and ability to both predict the occurrence and outcomes of hospitalization. The examination of the available evidence highlighted a number of specific clinical and research topics requiring additional study. We conclude with a series of consensus recommendations regarding future research priorities in this important area.

Colorectal cancer outcomes in patients aged over 85 years

INTRODUCTION

The prevalence of colorectal cancer is increasing in the elderly. We examined the treatment and outcomes in our institution of patients aged over 85 years with proven colorectal adenocarcinoma.

METHODS

One hundred and five patients were identified and stratified by treatment received: curative surgery (CS), other treatments (OT) or best supportive care (BSC). Data on demographics, staging, treatment and survival was collected and analysed.

RESULTS

Forty two patients received CS, 36 OT and 27 BSC. While the treated groups (CS and OT) were similar in terms of age (p=0.35) and staging (p=0.16), BSC patients were significantly older and had higher stage disease (p<0.01). Survival was significantly poorer among BSC patients, at a mean of 9.7 months (95% confidence interval [CI] 4.7-14.7) versus 41.6 months (95% CI 32.5-50.7) and OT 27.3 months (95% CI 20.4-34.1) for the CS and OT groups (p<0.001). There was no significant survival difference between CS and OT groups within 2 years of treatment (p=0.12). Thereafter, OT patients had a very similar 5-year survival to that of the BSC group, at 13% versus 43% in CS patients (p<0.001).

CONCLUSIONS

These data suggest that, up to 2 years following treatment, the risks of resectional surgery for colorectal cancer may neutralise any benefit. However, those that survive beyond this period show improvements. The challenge of improving patient selection is most acute in the growing ageing population, and highlights the current focus on presenting all treatment options to 'a reasonable patient'.

Estudo do tempo entre o diagnóstico e início do tratamento do câncer de mama em idosas de um hospital de referência em São Paulo, Brasil

Resumo Objetivou-se analisar o tempo entre o diagnóstico e o início do tratamento e conhecer o perfil sociodemográfico e clínico de mulheres com 60 ou mais anos de idade, diagnosticadas com câncer de mama entre os anos de 2001 a 2006, no Hospital Pérola Byington, São Paulo. Trata-se de um estudo descritivo, com dados secundários e amostra de 1299 casos. Coletou-se variáveis sociodemográficas, clínicas e temporais. Formou-se dois grupos de mulheres utilizando a variável tempo, sendo o tempo entre o diagnóstico e o início do tratamento: “até e maior que 60 dias”. A média do tempo entre o diagnóstico e o início do tratamento foi de 74,7 dias (DP = 212,6), e o tempo mediano de 45 dias. As idosas sem o diagnóstico e sem o tratamento anterior levaram menos tempo para dar início ao tratamento (p = 0,001), bem como as mulheres com estadiamento do tumor na fase inicial, in situ e I (p = 0,001). O tempo foi significante para os desfechos de recidiva (p = 0,004) e metástase (p = 0,038). O diagnóstico e o tratamento estabelecidos garantiu às idosas menor tempo para o início da assistência devida. Melhorar a estruturação e o funcionamento dos serviços de saúde constitui fator imprescindível para o atendimento dos casos da doença de forma eficiente, um importante desafio para o Sistema Único de Saúde.

The burden of disease in older people and implications for health policy and practice

23% of the total global burden of disease is attributable to disorders in people aged 60 years and older. Although the proportion of the burden arising from older people (≥60 years) is highest in high-income regions, disability-adjusted life years (DALYs) per head are 40% higher in low-income and middle-income regions, accounted for by the increased burden per head of population arising from cardiovascular diseases, and sensory, respiratory, and infectious disorders. The leading contributors to disease burden in older people are cardiovascular diseases (30·3% of the total burden in people aged 60 years and older), malignant neoplasms (15·1%), chronic respiratory diseases (9·5%), musculoskeletal diseases (7·5%), and neurological and mental disorders (6·6%). A substantial and increased proportion of morbidity and mortality due to chronic disease occurs in older people. Primary prevention in adults aged younger than 60 years will improve health in successive cohorts of older people, but much of the potential to reduce disease burden will come from more effective primary, secondary, and tertiary prevention targeting older people. Obstacles include misplaced global health priorities, ageism, the poor preparedness of health systems to deliver age-appropriate care for chronic diseases, and the complexity of integrating care for complex multimorbidities. Although population ageing is driving the worldwide epidemic of chronic diseases, substantial untapped potential exists to modify the relation between chronological age and health. This objective is especially important for the most age-dependent disorders (ie, dementia, stroke, chronic obstructive pulmonary disease, and vision impairment), for which the burden of disease arises more from disability than from mortality, and for which long-term care costs outweigh health expenditure. The societal cost of these disorders is enormous.

Is it helpful to give older people with cancer the same chance at rehabilitation as older general medical patients?

Although the complexity of age combined with a cancer diagnosis can result in unmet supportive care needs there are seldom resources to assess or address such needs for older people with cancer (OPWC). The purpose of this project was to trial a service to improve the care for OPWC through (1) an expanded supportive care screening process and (2) capacity building of subacute ambulatory care services (SACS) staff to increase referrals to community-based rehabilitation.

METHODS/DESIGN

Collaboration between allied health (AH) staff at an inner city general hospital with a large cancer service, a cancer specialist hospital, and a SACS service in Melbourne, Australia, developed an AH geriatric screening assessment (GSA) tool. Parallel to this process training was provided to SACS staff in relation to working with OPWC. Although close to one half (44%) of SACS staff who participated in this program (n = 22) had over 6 years' experience, 32% had not worked with OPWC. Prior to training, 81% did not feel confident in their knowledge about working with this cohort. After their training 72% were more confident about normal aging and implications for care of OPWC. Of the 491 patients screened, 80% were older than age 65, however, only 25 resided in the SACS catchment area. More than one third of these did not have clear rehabilitation needs, and the remainder were not referred due to ongoing medical issues. Less than one half of the patients in the catchment area were discussed in a Multi-disciplinary Meeting (MDM) but all were referred to allied health and assessed using the GSA. Although this project did not result in referrals of OPWC to SACS the training program for SACS staff was a success and allied health assessments were improved to include GSA factors. The complexity of care for OPWC was further highlighted through interviews with staff involved with the study.

Outcome of active anti-cancer treatment in elderly patients with advanced non-small cell lung cancer: A single center experience

BACKGROUND

This study aimed to evaluate the characteristics of active anti-cancer treatment (AAT) compared with best supportive care (BSC) in elderly patients with advanced non-small cell lung cancer (NSCLC).

METHODS

A retrospective analysis of 144 patients, aged 70 or older, with stage IIIb/IV NSCLC from 672 patients with confirmed lung cancer, was conducted.

RESULTS

Median age at diagnosis was 77 years and median survival time was five months. On multivariate analysis, AAT independently contributed to a decreased hazard ratio of death (P = 0.04), whereas male gender (P = 0.004), a body mass index of less than 18.5 (P = 0.004), and a poor performance score were associated with an increased risk of death (P < 0.001). The 52 subjects receiving AAT experienced longer survival than the 92 subjects receiving BSC (median seven months [AAT] versus three months [BSC]; P < 0.001). When sub-classified into five-year age intervals, AAT was a significant advantage in overall survival (OS) to patients aged 70-74, but not to those ≥75 years old.

CONCLUSIONS

AAT for patients ≥70 years old with advanced NSCLC extended OS. However, care should be taken in decisions on active anti-cancer treatments for patients over 75 years old. A prospective multicenter trial is required in the near future.

Assessment of cancer care in Indian elderly cancer patients: A single center study

Background and purpose:

This prospective study aimed to assess the profiles of elderly cancer patient to optimize cancer care in Indian setup. The profiles have been compared with that of younger patients in terms of epidemiological, clinical data, co-morbidity, treatment, toxicity, clinical outcome, and survival pattern.

Materials and Methods:

The study comprised cancer patients attending radiotherapy outdoor (November 2005 to June 2006). There were 104 patients of age ≥60 years (elderly group) and 121 patients of 45-59 years (younger group).

Results:

Elderly group had median age 65 years (60-88 years) with M:F = 1:1. The younger group had median age 50 years (45-59 years) with M:F = 1:2. Elderly had higher proportion of gastrointestinal and genito-urinary tract malignancies. Younger group had higher proportion of breast, lymphoma, and brain tumor. 13% had co-morbidity, 50% received treatment, 27% were treated with radiotherapy with or without surgery, and two-third of these cases belong to elderly group. Majority tolerated treatment well. 10% had significant grade of toxicity. 57% of elderly patients did not accept and one-fourth of all cases did not complete the prescribed treatment. 88% cases were responders of which 70% showed complete response. There were no differences between two groups. At 12 months 35% of treated patients came for follow-up. At first 12 months, 60-70% were alive without disease.

Conclusion:

There were differences between two groups in terms of performance status, treatment acceptance, and treatment modality prescribed. Elderly patients deserve same opportunity as younger patients for treatment and survival options from the oncologist.

A clinical risk model for the evaluation of bronchopleural fistula in non-small cell lung cancer after pneumonectomy

BACKGROUND

There are no reliable risk factors to predict bronchopleural fistula (BPF) formation in patients undergoing pneumonectomy for non-small cell lung cancer (NSCLC). This study aims to create a validated clinical model based on the risk factors for BPF after pneumonectomy. The model to estimate the risk of BPF may help select patients for intervention therapy to reduce the rate of BPF after pneumonectomy.

METHODS

This retrospective analysis included 684 patients with NSCLC who underwent pneumonectomy at our institution from 1995 to 2012. The rates of BPF were estimated by the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify the independent risk factors for the BPF and based on which a clinical model for the prediction of the incidence of BPF was formed.

RESULTS

The incidence of BPF was 4.4% (30 of 684 patients). Three factors were independently associated with BPF after pneumonectomy for NSCLC: neoadjuvant therapy (hazard ratio, 2.479), diabetes mellitus (hazard ratio, 1.061), and age 70 years or older (hazard ratio, 1.175). A scoring system for BPF was developed by assigning 2 points for a major risk factor (neoadjuvant therapy) and 1 point for each minor risk factor (diabetes mellitus and age ≥ 70 years). The 684 patients were divided into a low-risk group (score, 0 to 1), moderate-risk group (score, 2), and high-risk group (score, ≥ 3), with respective incidences of early BPF after pneumonectomy of 2.4%, 18.2%, and 58.3%

CONCLUSIONS

This model, based on readily available clinical characteristics, can estimate the risk of BPF after pneumonectomy in the NSCLC patients, independent of early BPF and late BPF classifications. This model could be used to select patients for intervention therapy (parenteral alimentation, control of blood glucose level, oxygen therapy, and strengthening the antibiotic treatment) if validated in independent data sets.

How I treat older patients with ALL

The treatment of older patients with acute lymphoblastic leukemia (ALL) is an unmet medical need. In Western countries, the population is aging, which means there will be an increasing number of older patients. However, in the past few decades, there has been little improvement in treating them, and few clinical trials specifically designed for older patients with ALL have been reported. Older patients with ALL have a significantly lower complete response rate, higher early mortality, higher relapse rate, and poorer survival compared with younger patients. This is partly explained by a higher incidence of poor prognostic factors. Most importantly, intensive chemotherapy with or without stem cell transplantation, both of which are successful in younger patients, is less well tolerated in older patients. For the future, the most promising approaches are optimized supportive care, targeted therapies, moderately intensified consolidation, and reduced-intensity stem cell transplantation. One of the most important challenges for physicians is to differentiate between fit and unfit older patients in order to offer both groups optimal treatment regarding toxicity and mortality risks, quality of life, and long-term outcome. Prospective trials for older patients with ALL are urgently needed.

Elderly patients with colon cancer have unique tumor characteristics and poor survival

BACKGROUND

The incidence of colon cancer increases with age, and colon cancer predominantly affects individuals >65 years old. However, there are limited data regarding clinical and pathologic factors, treatment characteristics, and survival of older patients with colon cancer. The objective of this study was to determine the effects of increasing age on colon cancer.

METHODS

Patients diagnosed with colon cancer between 1988 and 2006 were identified through the Los Angeles County Cancer Surveillance Program, in Southern California. Patients were stratified into 4 age groups: 18-49, 50-64, 65-79, and ≥80 years. Clinical and pathologic characteristics and disease-specific and overall survival were compared between patients from different age groups.

RESULTS

A total of 32,819 patients were assessed. Patients aged 18 to 49 and 65 to 79 years represented the smallest and largest groups, respectively. A near equal number of males and females were diagnosed with colon cancer in the 3 youngest age groups, whereas patients who were ≥80 years old were more commonly white and female. Tumor location was different between groups, and the frequency of larger tumors (>5 cm) was greatest in youngest patients (18-49 years). The oldest patients (≥80 years) were administered chemotherapy at the lowest frequency, and disease-specific and overall survival rates decreased with increasing age.

CONCLUSIONS

This investigation demonstrates that older age is associated with alterations in clinical and pathologic characteristics and decreased survival. This suggests that the phenotype of colon cancer and the efficacy of colon cancer therapies may be dependent on the age of patients.

Adjuvant chemotherapy in older women (ACTION) study - what did we learn from the pilot phase?

Background:

The ACTION trial was initiated to provide evidence from a randomised trial on the effects of chemotherapy in women aged over 70 years where evidence for risk and benefit are lacking.

Methods:

This was a randomised, phase III clinical trial for high risk, oestrogen receptor (ER) negative/ER weakly positive early breast cancer. The trial planned to recruit 1000 women aged 70 years and older, randomised to receive 4 cycles of anthracycline chemotherapy or observation. The primary endpoint was relapse-free interval. The trial included a pilot phase to assess the acceptability and feasibility of recruitment.

Results:

The trial opened at 43 UK centres. Information on number of patients approached was available from 38 centres. Of the 43 eligible patients that were approached, 39 were not randomised due to patients declining entry. After 10 months only 4 patients had been randomised and after discussion with the research funder, the trial was closed and funding terminated.

Conclusion:

Despite widespread support at several public meetings, input from patient groups including representation on the Trial Management Group, the trial failed to recruit due to the inability to convince patients to accept randomisation. It would therefore seem that randomising the patients to receive chemotherapy vs observation is not a viable design in the current era for this patient population.

Comprehensive Geriatric Assessment in the Decision-Making Process in Elderly Patients With Cancer: ELCAPA Study

Purpose

To identify Comprehensive Geriatric Assessment (CGA) components independently associated with changes in planned cancer treatment.

Patients and Methods

We prospectively included 375 consecutive elderly patients with cancer (ELCAPA01 study) assessed by geriatricians using the CGA. Multivariate analysis was used to identify factors associated with changes in the cancer treatment (intensification, decrease, or delayed > 2 weeks). Change was defined as a difference between the initial treatment proposal and the final treatment selected in a multidisciplinary meeting.

Results

Mean age was 79.6 years (standard deviation [SD], 5.6 years), and 197 (52.5%) were women. The most common tumor location was the digestive system (58.7%). The mean number of comorbidities was 4.2 (SD, 2.7) per patient, and the mean Cumulative Illness Rating Scale for Geriatrics score was 11.8 (SD, 5.3). After the CGA, the initial cancer treatment plan was modified for 78 (20.8%) of 375 patients (95% CI, 16.8 to 25.3), usually to decrease treatment intensity (63 [80.8%] of 78 patients). By univariate analysis, cancer treatment changes were associated with Eastern Cooperative Oncology Group performance status ≥ 2 (73.3% in the group with changes v 41.1% in the in the group without changes; P < .001), dependency for one or more activities of daily living (ADL; 59.0% v 24.2%; P < .001), malnutrition (81.8% v 51.2%; P < .001), cognitive impairment (38.5% v 24.9%; P = .023), depression (52.6% v 21.7%; P < .001), and greater number of comorbidities (mean, 4.8 [SD, 2.9] v 4.0 [SD, 2.6]; P = .02). By multivariate analysis, factors independently associated with cancer treatment changes were a lower ADL score (odds ratio [OR], 1.25 per 0.5-point decrease; CI, 1.04 to 1.49; P = .016) and malnutrition (OR, 2.99; CI, 1.36 to 6.58; P = .007).

Conclusion

Functional status assessed by the ADL score and malnutrition were independently associated with changes in cancer treatment.

Longevity in the 21st Century

The main objective of this paper is to offer a detailed analysis of mortality change in the United Kingdom at the beginning the 21st century. Starting from an exploration of 20th century mortality trends, focusing in particular on the 1990s, underlying forces driving trends in longevity are discussed. These include the ‘cohort effect’ and the ‘ageing of mortality improvement’. International mortality statistics and trends are also analysed. The pace of medical advances is discussed, with specific focus on research into the ageing process and a potential treatment for cardiovascular disease. The paper also discusses the potential threat from infectious diseases.

The analysis of underlying trends suggests that life expectancy in retirement in the U.K. is likely to increase rapidly in the early part of the 21st century. Some scientists are also claiming that we will be seeing the fruits of anti-ageing research within just a few decades.

A core theme of the paper is that future projections should be grounded in as good an understanding of the past as possible. Different methods for projecting future rates of mortality are discussed, and it is noted that emphasis should be placed on the uncertainty surrounding projections.

The financial impact of using different assumptions for future mortality is explored. Significant differences in the cost of an annuity or pension arise from the use of the various projection bases.

Life assurance companies have already declared significant losses as a result of strengthening reserves on annuity portfolios. Taken together, future increases in life expectancy, increasing awareness of the risk of providing longevity insurance, changes in legislation and shortages in market capacity and capital, may well lead to worsening annuity rates.

It is difficult to assess the precise impact of future changes in life expectancy on final salary pension schemes. There is a lack of readily available information on the mortality assumptions being used in practice. It is therefore suggested that more disclosure in this area would be helpful. Employers sponsoring final salary schemes are making promises to their employees that extend up to 70 or 80 years into the future. Actuaries should be clear in spelling out to employers and trustees the nature of the risks behind the promises they are making. Future scheme design should reflect the possibility of substantial increases in life expectancy.

An over-riding implication of the anticipated increases in life expectancy is that people will remain in work for longer in the future. The age at which people retire will inevitably have to increase, and this trend will necessarily drive changes in all aspects of our society. As actuaries we have a vital role in helping to inform the wider debate.

Under-representation of the elderly in cancer clinical trials

Cancer predominantly affects the elderly, but those over 65 years of age are significantly and consistently under-represented in clinical trials of potential new treatments. How important is this to cancer care in the elderly, are there identifiable reasons for the disparity and can anything be done to redress the imbalance?

What the specific tools of geriatrics and oncology can tell us about the role and status of geriatricians in a pilot geriatric oncology program

BACKGROUND

Pilot Oncogeriatric Coordination Units (UPCOGs) were created by the French National Cancer Institute (INCA) in order to implement routine geriatric assessment of all cancer patients over 75 years of age. This article examines the role of geriatric and oncologic tools in the organization of medical oncogeriatric activities, focusing on the role and place of geriatricians.

METHODS

We conducted a qualitative sociological survey in the West Paris Oncogeriatric Program (POGOP), one of the Pilot Oncogeriatric Coordination Units (UPCOGs) recently created in France. Various qualitative methods were used including a review of the literature, participative observational surveys, and semidirective interviews with medical staff managing elderly cancer patients.

RESULTS

The results show that the way in which geriatric assessment procedures are implemented confirms the role of the geriatrician in the diagnosis and prevention of vulnerabilities and fragility at the time of initial diagnosis and medical decision making. Nevertheless, the articulation of these different working methods gives rise to various organizational configurations.

CONCLUSIONS

The POGOP has largely contributed to clarifying medical activity in oncogeriatrics: identification of physicians, definition of shared goals, initiation, and structuring of new partnerships. Nevertheless, the geriatrician's tools, expertise, and know-how are often perceived ambiguously.

Changes in the risk of death from cancer up to five years after diagnosis in elderly patients: a study of five common cancers

Cancer mortality in elderly people is described to highlight the mechanisms that could potentially explain observed differences with other age groups. Data from 15 French cancer registries were considered in the search for the 5-year outcome of patients diagnosed during the period 1989-1997. Relative survival, excess mortality hazard, and hazard ratio of mortality were estimated to describe patient outcome according to age. Five cancer sites were selected: colon/rectum, prostate, breast, head/neck, and lung. An excess mortality rate was found in patients aged over 75 at the time of diagnosis. This excess mortality rate was mainly seen during the first months after diagnosis, then it decreased gradually with time. An initial phenomenon of patient selection, a greater disease severity at the time of diagnosis, and less-effective treatments given to elderly patients are the most plausible explanations for the increased risk of cancer-related death in the eldest patients.

Effect of patient age on management decisions in breast cancer: consensus from a national consultation

This qualitative study investigated the attitudes, perceptions, and practices of breast cancer specialists with reference to the effect of patient age on management decisions in breast cancer, and attempted to identify national consensus on this issue. One hundred thirty-three relevant specialists, including 75 surgeons and 43 oncologists, participated in a virtual consultation using e-mailed questionnaires and open-ended discussion documents, culminating in the development of proposed consensus statements sent to participants for validation. A strong consensus was seen in favor of incorporating minimum standards of diagnostic services, treatment, and care for older patients with breast cancer into relevant national guidance, endorsed by professional bodies. Similarly, an overwhelming majority of participants agreed that simple, evidence-based protocols or guidelines on standardizing assessment of biological and chronological age should be produced by the National Institute for Health and Clinical Excellence and the Scottish Medicines Consortium, developed in collaboration with specialist oncogeriatricians, and endorsed by professional bodies. A further recommendation that all breast cancer patient treatment and diagnostic procedures be undertaken in light of up-to-date, relevant scientific data met with majority support. This study was successful in gauging national specialist opinion regarding the effect of patient age on management decisions in breast cancer in the U.K.

Continuous intra-arterial infusion chemotherapy as a palliative treatment for oral squamous cell carcinoma in octogenarian or older patients

We intend to determine the potential benefits and analyze the outcomes of regional intra-arterial infusion chemotherapy (IAIC) for the octogenarian and older patients with oral cancer. Eighteen patients with oral squamous cell carcinoma were included. They were 12 males and six females with ages ranging from 80 to 96 years. An implantable port-catheter system was used for catheterization. Using a portable pump, methotrexate was given continuously through the external carotid artery for a mean period of 5.5 days (range, 4-7 days) followed by weekly bolus of low dose (25mg) of methotrexate until the clinical condition was stabilized. During the first week of IAIC, all tumors began to reduce in size. Of them 11 (61%) had a complete clinical response and 7 (39%) achieved a partial clinical response, after a mean follow-up period of 26 months (range, 8-72 months). The one- and three-year survival rates were 87% and 56%, respectively. There were no catheter-related complications. The side effects were mild and tolerable. IAIC might be specially indicated for oral cancer elderly with co-morbidity since a radical surgery or extensive radiotherapy can be avoided, and offers an acceptable palliative treatment in such patients.

Are GPs under-investigating older patients presenting with symptoms of ovarian cancer? Observational study using General Practice Research Database

BACKGROUND

Recent studies suggest that older patients in the United Kingdom are not benefiting as much from improvements in cancer treatments as their younger counterparts. We investigate whether this might be partly due to differential referral rates using ovarian cancer as an example.

METHODS

From the General Practice Research Database (GPRD), we identified all women aged 40-80 years on 1 June 2002 with a Read code for ovarian cancer between 1 June 2002 and 31 May 2007. Using these records, we compared the GPRD incidence of ovarian cancer with rates compiled from the UK cancer registries and investigated the relationship between age and coded investigations for suspected ovarian cancer.

RESULTS

The GPRD rates peaked earlier, at 70-74, and were lower than registry rates for nearly all ages particularly for patients over 59. The proportion investigated or referred by the GP decreased significantly with age and delays between first coded symptom and investigation showed a U-shaped distribution by age.

CONCLUSIONS

GPs appear to be less likely to recognise and to refer patients presenting with ovarian cancer as they get older. If our findings extend to other cancers, lack of or delays in referral to secondary care may partly explain poor UK cancer mortality rates of older people.

Management of operable invasive breast cancer in women over the age of 70: long-term results of a large-scale single-institution experience

BACKGROUND

The treatment of choice for elderly women with breast cancer remains controversial. This retrospective analysis of a cohort from a single institution was designed to evaluate whether such patients are really undertreated because of their age and to reappraise their usual management.

METHODS

The characteristics of 538 patients aged > or = 70 years with operable breast cancer, treated between 1995 and 1999, were retrospectively analyzed comparing patients aged 70 to 75 years (group I, n = 288), 75 to 80 years (group II, n = 156), and > or = 80 years (group III, n = 94). Cause-specific survival, distant recurrence-free interval, and local control were estimated by the Kaplan-Meier method and compared by log rank test. Multivariate analysis used Cox regression.

RESULTS

In group III, tumors were more frequently T2 than T1 (P < 0.0001) and estrogen receptor negative (P = 0.045) than in groups I and II. Surgery was performed in 94.6% of patients, breast-conserving in 72.1% (62% in group III; P = 0.0015) with axillary dissection in 89.2% (77% in group III; P = 0.0015); 100% received radiotherapy after lumpectomy (hypofractionated in 63% of group III; P < 0.0001). Adjuvant hormone therapy and chemotherapy were administered to 57 and 3.7% of patients, respectively. At 7 years, no difference in the three groups was observed for cause-specific survival (91% for group I, 89% for group II, 86% for group III) distant recurrence-free interval, and local control (>90%).

CONCLUSIONS

Elderly patients with operable breast cancer who are completely and correctly treated with realistic treatment options that are based on surgery and adjuvant radiotherapy have a similar chance of being cured as younger patients.