The effect of geriatric intervention in frail elderly patients receiving chemotherapy for colorectal cancer: a randomized trial (GERICO)

Effect of frailty on postoperative complications, mortality, and survival in older patients with non-metastatic colon cancer: A systematic review and meta-analysis

INTRODUCTION

New evidence has emerged on the impact of frailty on prognosis in colon cancer, but the findings are not always consistent and conclusive. The aim of this systematic review was to assess the effect of frailty on postoperative complications and mortality in patients with non-metastatic colon cancer (CC) aged 65 years and older.

MATERIALS AND METHODS

We systematically searched for original studies published in the PubMed and Web of Science databases up to June 2021. Two independent reviewers selected the studies and extracted predefined data. A meta-analysis was performed using the random effects model to assess the effect of frailty on 30-day, 3- to 6-month and 1-year mortality, survival, and postoperative complications.

RESULTS

The search yielded 313 articles, of which 14 were included in this systematic review. The meta-analysis showed an effect for frailty on 30-day, 3- to 6-month, and 1-year mortality with respective pooled odds ratios (ORs) of 3.67 (95% confidence interval [CI] 1.53-8.79, p = 0.004), 8.73 (95% CI 4.03-18.94, p < 0.0001), and 3.99 (95% CI 2.12-7.52, p < 0.0001). Frailty also had an effect on survival, with a pooled hazard ratio of 2.99 (95% CI 1.70-5.25. p < 0.0001), and on overall and severe postoperative complications with pooled ORs of 2.34 (95% CI 1.75-3.15; p < 0.0001) and 2.43 (95% CI 1.72-3.43; p < 0.0001), respectively.

DISCUSSION

Frailty in older patients with CC is a risk factor for postoperative complications and mortality in the short term (30 days), medium term (3-6 months), and long term (1 year).

Predictors and effects of toxicity experienced by older adults with cancer receiving systemic therapy in a randomized clinical trial of geriatric assessment

INTRODUCTION

Older adults represent a large segment of the oncology population, however, they remain underrepresented in clinical research. Treatment of older adults is often extrapolated using data from younger and fitter patients, which may not be appropriate. Furthermore the implications of toxicity from treatment can be greater for this population. Predicting toxicity from treatment and its effect on quality of life and functional status for older adults therefore is important.

MATERIALS AND METHODS

We analyzed data from a clinical trial of geriatric assessment and management for Canadian elders with cancer (5C study). We assessed whether the baseline Cancer and Aging Research Group (CARG) toxicity score, G8 score, and Eastern Cooperative Oncology Group (ECOG) performance predicted grade 3-5 toxicity using logistic regression and pattern mixture models. We also assessed the impact of toxicity on quality of life and functional decline. Patients were followed for six months.

RESULTS

Three hundred sixteen patients were included. Mean age was 76 years old and 40% of patients were female. One hundred nineteen patients (38%) experienced at least one grade 3-5 toxicity. Neither the CARG toxicity score, G8, or ECOG were predictive of grade 3-5 toxicity. Patients who experienced grade 3-5 toxicity were more likely to have functional impairments over time (odds ratio 3.71, p = 0.03). However, they maintained their quality of life.

DISCUSSION

In this secondary analysis of a randomized controlled trial of geriatric assessment and management we did not find any predictors of grade 3-5 toxicity. Patients who did experience toxicity were more likely to report functional decline over time. Older adults who do experience treatment related toxicity may benefit from increased supports.

CLINICAL TRIAL INFORMATION

NCT0315467.

Impact of patients' sex in assessments and treatment recommendations in an older adult cancer clinic

INTRODUCTION

In multiple settings, sex disparities have been seen in diagnosis, treatment, and outcomes. This study sought to determine whether there are sex differences in a geriatric oncology clinic concerning results of the comprehensive geriatric assessment (CGA) and treatment recommendations.

MATERIALS AND METHODS

This is a retrospective cohort study including patients ≥65 years old referred for consultation on cancer treatment decision-making who underwent a CGA between July 2015 and December 2020, in a single Canadian academic geriatric oncology (GO) clinic. We examined differences by sex, stratified by disease site, stage, treatment intent, CGA results by domain, final treatment plan, and referrals for abnormal CGA findings. Differences were assessed using chi-square, Fisher's exact, or t-test as appropriate. Multivariate logistic regression was performed to examine whether sex impacted recommendations to reduce treatment intensity.

RESULTS

In the study period, 328 patients were assessed in the GO clinic (mean age 81 years). The most common cancer types were gastrointestinal (42.1%), hematologic (18.3%), and head and neck (17.3%). More males than females were assessed in the GO clinic (62.2% versus 37.8%, respectively). This proportion did not change over time (p = 0.58). The GO clinic recommended to reduce treatment intensity in 140 cases (42.7%), with no difference between sexes in adjusted models (43.6% of females and 42.2% of males, p = 0.80). There were no differences in any CGA domain by sex. There were also no differences in referrals made by the GO clinic to optimize abnormal CGA domains by sex.

DISCUSSION

Sex itself did not impact treatment decision-making, nor referrals to optimize abnormal CGA domains in our GO clinic using CGA-based care.

Protocol for a randomised controlled trial on impact of comprehensive geriatric and supportive assessment versus standard care in older adults with cancer undergoing curative treatment: The Geriatric Oncology SuPportive clinic for ELderly (GOSPEL) study

Cancer affects older adults with varying levels of frailty, but cancer treatment is extrapolated from clinical trials involving predominantly young and robust subjects. Recent geriatric oncology randomised controlled trials (RCT) report that geriatric assessment leading to frailty-guided intervention reduces treatment-related toxicity whilst maintaining survival and improving quality of life (QoL). However, these positive results have not have been consistently reported in the literature. We postulate that the impact of geriatric interventions has been underestimated in these studies with the inclusion of subjects receiving palliative-intent chemotherapy in whom dose reduction is common. Integrating supportive care with current geriatric oncology models may improve the QoL of older adults undergoing treatment. However, no studies as yet have examined such integrated geriatric and supportive models of care. The Geriatric Oncology SuPportive clinic for Elderly (GOSPEL) study is a single-centre, open-label, analyst-blinded RCT evaluating the impact of comprehensive geriatric and supportive care on QoL of older adults with cancer undergoing curative treatment. Older adults aged above 65, with a Geriatric-8 score ≤ 14, with plans for high dose radiotherapy and/or curative chemotherapy will be recruited. The primary QoL outcome is measured using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-ELD14 mobility scale at 12 weeks. Secondary outcomes include overall and disease-free survival, treatment-related adverse events, and hospital admissions. We pre-powered this study to recruit 200 subjects based on the minimally clinically important difference for EORTC QLQ-ELD14 to achieve 80% statistical power (alpha 0.05), assuming 25% attrition. Outcomes will be analysed using intention-to-treat. Intervention consists of multi-domain comprehensive geriatric and supportive care assessments from a multidisciplinary team targeting unmet needs. These include functional decline, falls, incontinence, cognitive impairment, multi-morbidity, polypharmacy, and symptom relief, as well as social and psycho-spiritual concerns. Standard care entails routine oncological management with referral to geriatrics based on the discretion of the primary oncologist. Recruitment has been ongoing since August 2020. Results from the GOSPEL study will increase understanding of the impact of integrated geriatric and supportive care programs in older adults with cancer receiving curative treatment. Trial registration: This study is registered under ClinicalTrials.gov (ID NCT04513977).

Surgery for T4 Colorectal Cancer in Older Patients: Determinants of Outcomes

Background: This study aimed to compare the outcomes of older and younger patients with T4 colorectal cancer (CRC) treated with surgery. Methods: Consecutive patients with T4 CRC treated surgically at Henri Mondor Hospital between 2008 and 2016 were retrospectively analyzed in age subgroups (1) 50−69 years and (2) ≥70 years for overall and relative survival. The multivariable analyses were adjusted for adjusted for age, margin status, lymph node involvement, CEA level, postoperative complications (POC), synchronous metastases, and type of surgery. Results: Of 106 patients with T4 CRC, 57 patients (53.8%) were 70 years or older. The baseline characteristics were generally balanced between the two age groups. Older patients underwent adjuvant therapy less commonly (42.9 vs. 57.1%; p = 0.006) and had a longer delay between surgery and chemotherapy (median 40 vs. 34 days; p < 0.001). A higher trend for POC was reported among the older patients but did not impact the survival outcomes. After adjusting for confounding factors, the overall survival was shorter among the older patients (HR = 3.322, 95% CI 1.49−7.39), but relative survival was not statistically correlated to the age group (HR = 0.873, 95% CI 0.383−1.992). Conclusions: Older patients with CRC were more prone to severe POC, but age did not impact the relative survival of patients with T4 colorectal cancer. Older patients should not be denied surgery based on age alone.

Future Perspectives on Prehabilitation Interventions in Cancer Surgery

OBJECTIVE

This article provides a map of key knowledge gaps regarding the evidence supporting prehabilitation and its integration with enhanced recovery after surgery (ERAS) programs. Filling this lack of knowledge with future research will further establish the effectiveness of prehabilitation.

DATA SOURCES

These are electronic databases including PubMed and CINAHL.

CONCLUSION

Future efforts must embrace the elderly frail or cognitively impaired patient with specific needs to further promote restoration of postoperative function throughout the surgical pathway. Prehabilitation should be coupled and integrated within the existent concept of the ERAS framework, to facilitate the continuous evolution of screening, assessment, and optimization of high-risk surgical patients who are at risk of not being restored to physical and psychological function after surgery, including independence.

IMPLICATIONS FOR NURSING PRACTICE

In the future, the ERAS nurse will be an essential figure of the prehabilitation program, proactively coordinating the assessment, optimization, and adjustment of perioperative comorbidity and guiding the rehabilitation process to improve patients' outcomes. These skills and characteristics will be required to provide optimal nursing care in the context of an integrated prehabilitation ERAS pathway.

Exclusion of Older Adults from Cancer Clinical Trials: Review of the Literature and Future Recommendations

In this review, we present the context of older adult (OA) cancer patients within the broader cancer population, including cancer burdens and trial representation. We first describe the proportion of older adults in clinical trials, with studies showing strong evidence that the proportion of OA in cancer trials is much less than the proportion of OA in the overall cancer population. We highlight the lack of generalizability that can lead to challenges in treatment decisions for OA as well as concerns regarding health inequity. We then discuss barriers to OA enrollment related to trial structure and design, physician perspective, and patient and/or caregiver perspective. We expand on this further by outlining these barriers throughout the process of trial design, patient enrollment/trial implementation, and data analysis in post-market settings. We summarize guidelines from national societies, regulatory agencies, and other institutional bodies, then present a compilation of on-the-ground actionable recommendations to address the challenges of clinical trial design, focusing on geriatric assessments and OA-specific trials. We conclude by providing an outline for future directions, noting specifically the potential impact that radiotherapy and radiation oncology may have on clinical trials related to OA patients.

Information provision to older patients receiving palliative chemotherapy: a quality study

OBJECTIVES

Cancer treatment has become increasingly successful. However, prolonging and preserving life has become an important goal of therapy since many patients generally receive palliative chemotherapy. The perception of life changes when patients are informed, that no curative treatment is possible. This raises new dilemmas for patients with incurable cancer, but only sparse information is available about the thoughts of these patients.The aim of this study was to explore how older patients experience the information on absence of curative treatment options.

METHODS

Qualitative interviews were performed in eleven older patients with incurable upper gastrointestinal cancer receiving first-line palliative chemotherapy. Median age was 74 (65-76) years. We used a qualitative approach to collect data through semistructured individual interviews conducted at the hospital or by telephone interviews by an experienced researcher. The thematic analysis was conveyed by Braun and Clarke.

RESULTS

The interview findings were grouped around three main themes: hope of being cured, hearing but not comprehending, and desired milestones to reach. Further, it was determined that patients hid their feelings and avoided talking about the disease with the health professionals due to fear of being told the truth.

CONCLUSIONS

Receiving information about their incurable cancer was an ongoing dilemma for the patients. Following the message, patients shared thoughts about reaching important milestones in life, spending time with their family or hope for a cure to be found.

Effect of the duration of the capecitabine regimen following colon cancer surgery in an elderly population: a retrospective cohort study

Background

Only 50–70% of elderly colon cancer patients could complete the recommended 6 months of postoperative chemotherapy. It is unknown whether a shorter duration of postoperative capecitabine-alone chemotherapy would compromise survival. We thus conducted this study to analyze the association between postoperative chemotherapy duration of a capecitabine-alone regimen and cancer-specific survival (CSS) and disease-free survival (DFS) of surgery-treated elderly colon cancer patients.

Methods

We performed a retrospective cohort study of surgically treated stage III and high-risk stage II colon cancer patients aged ≥ 70 treated at two medical centers. Cox proportional hazard regression models were utilized to calculate crude and adjusted hazard ratios (HRs). The nonlinear relationship between postoperative chemotherapy duration and survival was analyzed through restricted cubic spline regression analysis, and the threshold effect was calculated by the two-piecewise Cox proportional hazard model.

Results

A total of 1217 surgery-treated colon cancer patients between August 1, 2013, and September 1, 2019, were reviewed, and 257 stage III and high-risk stage II patients aged ≥ 70 were enrolled. Postoperative chemotherapy with capecitabine was administered to 114 patients, and 143 patients only received surgery. As the duration of chemotherapy increased by 1 week, the risk of cancer-specific death was reduced by 11% (HR = 0.89, 95% confidence interval (CI) 0.82–0.96), and the risk of recurrence was reduced by 10% (HR = 0.90, 0.82–0.96). Nonlinearity exploration suggested a threshold effect of capecitabine duration on CSS in stage III disease. The HR for death was 0.79 (95% CI, 0.68–0.92) with duration ≤ 16 weeks and 1.34 (95% CI, 0.91–1.97) with duration > 16 weeks.

Conclusions

The postoperative capecitabine duration was significantly associated with a decrease in death risk and recurrence risk in elderly colon cancer patients. However, the threshold effect of capecitabine duration on survival suggests that short-term chemotherapy may improve survival in elderly stage III colon cancer patients.

Predictive value of geriatric oncology screening and geriatric assessment of older patients with cancer: A randomized clinical trial protocol (PROGNOSIS-RCT)

INTRODUCTION

Comprehensive geriatric assessment (CGA) has been shown to reduce frailty in older patients in general. In older patients with cancer, frailty affects quality of life (QoL), physical function, and survival. However, few studies have examined the effect of CGA as an additional intervention to antineoplastic treatment. This protocol presents a randomized controlled trial, which aims to evaluate the effects of CGA-based interventions in older patients with cancer and Geriatric 8 (G8) identified frailty.

MATERIALS AND METHODS

This randomized controlled trial will include patients, age 70+ years, with solid malignancies and G8 frailty (G8 ≤ 14). Patients will be separated into two groups, with different primary endpoints, depending on palliative or curative antineoplastic treatment initiation, and subsequently randomized 1:1 to either CGA with corresponding interventions or standard of care, along with standardized antineoplastic treatment. A geriatrician led CGA with corresponding interventions and clinical follow-up will be conducted within one month of antineoplastic treatment initiation. The interdisciplinary CGA will cover multiple geriatric domains and employ a standard set of validated assessment tools. Primary endpoints will be physical decline measured with the 30-s Chair-Stand-Test at three months (palliative setting) and unplanned hospital admissions at six months (curative setting). Additional outcomes include QoL, treatment toxicity and adherence, occurrence of polypharmacy, potential drug interactions, potential inappropriate medications, and survival. The primary outcomes will be analyzed using a mixed model regression analysis (30-s chair stand test) and linear regression models (unplanned hospitalizations), with an intention to treat approach. Power calculations reveal the need to enroll 134 (palliative) and 188 (curative) patients.

DISCUSSION

The present study will examine whether CGA, as an additional intervention to antineoplastic treatment, can improve endpoints valued by older patients with cancer. Inclusion began November 2020 and is ongoing, with 37 and 29 patients recruited April 15th, 2021. Registration:NCT04686851.

Multidisciplinary management of elderly patients with rectal cancer: recommendations from the SICG (Italian Society of Geriatric Surgery), SIFIPAC (Italian Society of Surgical Pathophysiology), SICE (Italian Society of Endoscopic Surgery and new technologies), and the WSES (World Society of Emergency Surgery) International Consensus Project

BACKGROUND AND AIMS

Although rectal cancer is predominantly a disease of older patients, current guidelines do not incorporate optimal treatment recommendations for the elderly and address only partially the associated specific challenges encountered in this population. This results in a wide variation and disparity in delivering a standard of care to this subset of patients. As the burden of rectal cancer in the elderly population continues to increase, it is crucial to assess whether current recommendations on treatment strategies for the general population can be adopted for the older adults, with the same beneficial oncological and functional outcomes. This multidisciplinary experts' consensus aims to refine current rectal cancer-specific guidelines for the elderly population in order to help to maximize rectal cancer therapeutic strategies while minimizing adverse impacts on functional outcomes and quality of life for these patients.

METHODS

The discussion among the steering group of clinical experts and methodologists from the societies' expert panel involved clinicians practicing in general surgery, colorectal surgery, surgical oncology, geriatric oncology, geriatrics, gastroenterologists, radiologists, oncologists, radiation oncologists, and endoscopists. Research topics and questions were formulated, revised, and unanimously approved by all experts in two subsequent modified Delphi rounds in December 2020-January 2021. The steering committee was divided into nine teams following the main research field of members. Each conducted their literature search and drafted statements and recommendations on their research question. Literature search has been updated up to 2020 and statements and recommendations have been developed according to the GRADE methodology. A modified Delphi methodology was implemented to reach agreement among the experts on all statements and recommendations.

CONCLUSIONS

The 2021 SICG-SIFIPAC-SICE-WSES consensus for the multidisciplinary management of elderly patients with rectal cancer aims to provide updated evidence-based statements and recommendations on each of the following topics: epidemiology, pre-intervention strategies, diagnosis and staging, neoadjuvant chemoradiation, surgery, watch and wait strategy, adjuvant chemotherapy, synchronous liver metastases, and emergency presentation of rectal cancer.

Clinical Effectiveness of Oncological Treatment in Metastatic Colorectal Cancer Is Independent of Comorbidities and Age

Simple Summary

Colorectal cancer (CRC) is the third most common cancer worldwide. As with many other cancers, the risk for CRC increases with age. This is also true for comorbidities, which may hamper sufficient treatment of the cancer. Due to restrictive inclusion criteria, older patients and patients with comorbidities are underrepresented in clinical trials. Comprehensive knowledge about modern effectiveness of oncological treatments in older and/or comorbid patients is sparse. Due to the lack of clinical trials, this issue is investigated in real-life settings predominantly. In our retrospective study we show that patients benefit from oncological treatments irrespective of comorbidities, measured by the age-adjusted Charlson Comorbity (aaCCI) index, and age. Differences found in treatment outcomes are marginal and are likely due to less intense treatment of comorbid or elderly patients. Balancing risk and benefit for treatment decisions should take potential under-treatment of comorbid and older patients into account.

Abstract

We aimed to investigate the effectiveness of oncological treatments in metastatic CRC related to comorbidities and age. This retrospective study included 1105 patients from three oncological centers. aaCCI and CCI was available from 577 patients. An aaCCI > 3 was of the highest predictive value compared to other aaCCI-levels, CCI or age (p < 0.001 for all). Treatment (best supportive care (BSC), systemic treatment only (STO) and resection of metastases (ROM)) significantly prolonged survival in patients with aaCCI > 3 (STO: HR 0.39, CI 0.29–0.51; ROM: HR 0.16, CI 0.10–0.24) and patients older than 70 years (STO: HR 0.56, CI 0.47–0.66; ROM: HR 0.23, 0.18–0.30). Median overall survival was shorter in patients with aaCCI or age > 70 years and interaction for treatment type not significant for aaCCI, but significant for age older or younger than 70 years (STO: p = 0.01; ROM p = 0.02). BSC is more often considered as optimal care for patients with an aaCCI > 3 (37.6% vs. 12.4%; p < 0.001) or age > 70 years (35.7% vs. 11.2%; p < 0.001). Older patients or patients with comorbidities benefit from cancer-specific therapy independently of their age and comorbidities.

The effect of geriatric intervention in frail older patients receiving chemotherapy for colorectal cancer: a randomised trial (GERICO)

BACKGROUND

Older patients with colorectal cancer (CRC) experience chemotherapy dose reductions or discontinuation. Comprehensive geriatric assessment (CGA) predicts survival and chemotherapy completion in patients with cancer, but the benefit of geriatric interventions remains unexplored.

METHODS

The GERICO study is a randomised Phase 3 trial including patients ≥70 years receiving adjuvant or first-line palliative chemotherapy for CRC. Vulnerable patients (G8 questionnaire ≤14 points) were randomised 1:1 to CGA-based interventions or standard care, along with guideline-based chemotherapy. The primary outcome was chemotherapy completion without dose reductions or delays. Secondary outcomes were toxicity, survival and quality of life (QoL).

RESULTS

Of 142 patients, 58% received adjuvant and 42% received first-line palliative chemotherapy. Interventions included medication changes (62%), nutritional therapy (51%) and physiotherapy (39%). More interventional patients completed scheduled chemotherapy compared with controls (45% vs. 28%, P = 0.0366). Severe toxicity occurred in 39% of controls and 28% of interventional patients (P = 0.156). QoL improved in interventional patients compared with controls with the decreased burden of illness (P = 0.048) and improved mobility (P = 0.008).

CONCLUSION

Geriatric interventions compared with standard care increased the number of older, vulnerable patients with CRC completing adjuvant chemotherapy, and may improve the burden of illness and mobility.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02748811.

Bacteria-derived ferrichrome inhibits tumor progression in sporadic colorectal neoplasms and colitis-associated cancer

BACKGROUND

Colorectal cancers develop through several pathways, including the adenoma-carcinoma sequence and colitis-associated carcinogenesis. An altered intestinal microflora has been reported to be associated with the development and progression of colorectal cancer via these pathways. We identified Lactobacillus casei-derived ferrichrome as a mediator of the bacterial anti-tumor effect of colorectal cancer cells through the upregulation of DDIT3. In this study, we investigated the anti-tumor effects of ferrichrome on precancerous conditions and cancer cells associated with sporadic as well as colitis-associated colorectal cancer.

METHODS

SRB and MTT assays were performed to assess growth inhibition in vitro. Eighteen organoids were prepared from biopsy specimens obtained by colonoscopy. An AOM-DSS carcinogenesis model and xenograft model of colorectal cancer cells were generated for the assessment of the tumor suppressive effect of ferrichrome in vivo.

RESULTS

Ferrichrome inhibited the cell growth of colorectal cancer cells in vitro and in in vivo xenograft models. Ferrichrome exerted a strong tumor-suppressive effect that was superior to that of currently available anti-tumor agents, including 5-FU and cisplatin, both in vitro and in vivo. The tumor-suppressive effect of the combination of ferrichrome and 5-FU was superior to that of single treatment with either drug. The tumor suppressive effects of ferrichrome were confirmed through the upregulation of DDIT3 in patient-derived organoids of adenoma and carcinoma. Ferrichrome inhibited the tumor progression in the AOM-DSS model while exhibiting no anti-inflammatory effect in the DSS-colitis model, suggesting that ferrichrome inhibited cancer cells, but not a precancerous condition, via the colitis-associated pathway.

CONCLUSIONS

Ferrichrome exerts a tumor suppressive effect on precancerous conditions and cancer cells associated with sporadic as well as colitis-associated colorectal cancer. The anti-tumor effect of ferrichrome was mediated by the upregulation of DDIT3, and was superior to that of 5-FU or cisplatin. These results suggest that Lactobacillus brevis-derived ferrichrome may be a candidate anti-tumor drug for the treatment of colorectal neoplasms.

Real-world implementation of a geriatric-specific ERAS protocol in patients undergoing colonic cancer surgery

BACKGROUND

The aim of this single-center observational study was to evaluate the impact of implementing Enhanced Recovery After Surgery (ERAS) protocols, combined with systematic geriatric assessment and support, on surgical and oncological outcomes in patients aged 70 or older undergoing colonic cancer surgery.

METHODS

Two groups were formed from an actively maintained database from all patients undergoing laparoscopic colonic surgery for neoplasms during a defined period before (standard group) or after (ERAS group) the introduction of an ERAS program associated with systematic geriatric assessment. The primary outcome was postoperative 90-day morbidity. Secondary outcomes were total length of hospital stay, initiated and completed adjuvant chemotherapy (AC) rate, and 1-year mortality rate.

RESULTS

A total of 266 patients (135 standard and 131 ERAS) were included in the study. Overall 90-day morbidity and mean hospital stay were significantly lower in the ERAS group than in the standard group (22.1% vs. 35.6%, p = 0.02; and 6.2 vs. 9.3 days, p < 0.01, respectively). There were no differences in readmission rates and anastomotic complications. AC was recommended in 114 patients. The rate of initiated treatment was comparable between the groups (66.6% vs. 77.7%, p = 0.69). The rate of completed AC was significantly higher in the ERAS group (50% vs. 20%, p < 0.01) with a lower toxicity rate (57.1% vs. 87.5%, p = 0.002). The 1-year mortality rate was higher in the standard group (7.4% vs. 0.8%, p < 0.01).

CONCLUSIONS

The combination of ERAS protocols and geriatric assessment and support reduces the overall morbidity rate and improves 12-month oncologic outcomes.

Implementation of a systematic comprehensive geriatric assessment for elderly patients suspected of pulmonary hypertension

BACKGROUND

The phenotype of patients seen for a suspicion of pulmonary hypertension has changed, with an increasing age and frequency of comorbidities. Selection of elderly patients, in whom a classical work-up is mandatory, is challenging. Comprehensive geriatric assessment (CGA) has modified the management of elderly patients with cancer. Pulmonary hypertension (PH) shares with cancer a functional impact and may evolve rapidly, depending on the group of PH. We assessed the impact of a systematic CGA in patients over 70 years old referred for a suspicion of PH.

METHODS

A standardised CGA was performed on every patient older than 70 years old, referred for a PH suspicion, before considering invasive tests for diagnosis and treatment, between July 2014 and May 2019. Our primary aim was to describe the impact of CGA on the decision to stop or pursue the recommended diagnostic work-up for PH.

RESULTS

Among the thirty-one patients evaluated [mean age 81,5 (72-91) years], a negative CGA leads to stop the diagnostic work-up in eleven patients. Among the nineteen remaining patients, sixteen had confirmed PH, with half being chronic thromboembolic pulmonary hypertension.

CONCLUSIONS

Our study indicates that comprehensive geriatric assessment could be an excellent first screen for elderly patients referred for a PH suspicion. Involving a geriatric physician stopped the investigations in one third of patients. In patients with a favourable CGA, PH was confirmed in most of the cases, with chronic thromboembolic pulmonary hypertension being the first cause of PH.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Post-Acute Care among Older Adults with Stage I to III Colorectal Cancer

BACKGROUND

Little information is available on the long-term use of post-acute care among older patients with colorectal cancer (CRC), relative to individuals without cancer. This study examines the use of post-acute care among older cancer survivors (>65 y) with CRC and compares it with noncancer patients up to 5 years from surgery.

DESIGN

Retrospective cohort.

SETTING

SEER-Medicare.

PARTICIPANTS

Patients treated for stage I to III CRC between January 1, 2000, and December 31, 2011 (n = 40 812) and noncancer Medicare beneficiaries hospitalized for noncancer treatment matching on age, sex, race, comorbidity, and Medicaid dual eligibility.

MEASUREMENTS

Incident post-acute care claims (skilled nursing, long-term care facility, and home health) from 0 to 100 days, 101 to 365 days, and 1 to 5 years from hospitalization.

RESULTS

The median age was 77 years. All patients had surgery, 34% received chemotherapy, and 27% received surgery and adjuvant therapy. The cumulative incidence of any post-acute care within 100 days of hospitalization was 45.7% for stage III, 37.9% for stage I/II, and 39% for controls (p < .001). Within the CRC cohort only, the cumulative incidence of post-acute care was 2.9% (stage I/II) and 4.2% (stage III, p < .001) from 101 to 365 days and 15.8% (stage I/II) and 16.9% (stage III, p < .001) from 1 to 5 years. Increasing age, ostomies, and neoadjuvant or adjuvant therapy were associated with increased hazard of all post-acute patients within 100 days from hospitalization. From 1 to 5 years from diagnosis, adjuvant therapy was associated with greater exclusive home health care use.

CONCLUSIONS

Survivorship planning among older CRC patients should include discussions of post-acute care following cancer therapy, even several years after treatment. J Am Geriatr Soc 67:937-944, 2019.

Experience with age discrimination and attitudes toward ageism in older patients with cancer and their caregivers: A nationwide Korean survey

OBJECTIVE

It is not clear whether age-related differences in treatment and treatment decision-making are the result of age discrimination or just a reflection of older patients' elevated risk and their own preferences. Therefore, it is critical to understand older patients' own views toward their care in regard to its relationship to age.

MATERIAL AND METHODS

439 older patients with cancer (age ≥ 60) and 358 family members from eleven cancer centers participated in this cross-sectional survey.

RESULTS

Almost all patients (91.2%) and caregivers (92.7%) thought that older patients should be treated equal to younger patients, across all questionnaire items. The proportions of patients who reported having experienced age discrimination according to each item were: disease information (12.3%), treatment information (11.0%), participation in treatment decision (10.7%), attention from healthcare professionals (6.2%), supportive care (5.2%), and treatment (3.2%). Increasing age was the only demographic characteristic that was associated with greater ageism experience (p < .001). Patients' ageism attitudes, as well as caregivers' ageism attitudes, were negatively associated with ageism experience. Ageism experience was associated with a higher depression score, as well as a lower quality of life.

CONCLUSION

Discrimination in treatment and the treatment decision process based on age was not justified. Interventions that address ageist attitudes in older patients, family caregivers, and healthcare professionals are needed to reduce age discrimination, and thereby improve the quality of life of older patients with cancer.

Age-dependent differences in first-line chemotherapy in patients with metastatic colorectal cancer: the DISCO study

OBJECTIVES

First-line chemotherapy for metastatic colorectal cancer (mCRC) is effective and feasible in selected older patients. We investigated age-dependent differences in treatment and outcomes in patients with mCRC in clinical practice.

MATERIAL AND METHODS

A retrospective study of 654 patients with mCRC referred to first-line chemotherapy in 2008-2014. Patients were divided into two age groups: 50-69 and ≥70 (older patients). Binary outcomes were analyzed by logistic regression. Progression-free survival (PFS) and overall survival (OS) were analyzed by Cox proportional hazards regression, CRC-specific and other-cause mortality with Fine and Gray proportional hazard model for the sub-distribution of a competing risk.

RESULTS

After adjusting for performance status (PS) and comorbidity, older patients were more likely to receive monotherapy (adjusted odds ratio (aOR) = 9.00, 95% confidence interval (CI) 4.52-17.91), lower doses, and no additional targeted therapy (aOR = 1.89, 95% CI 1.28-2.78) than younger patients. Yet, older patients experienced more toxicity and hospitalizations (aOR = 1.53, 95% CI 1.08-2.17). Among those treated, older patients had shorter PFS (hazard ratio (HR) = 1.32, 95% CI 1.11-1.57), but after adjusting for PS and comorbidity, PFS was similar. No significant difference was found in CRC mortality (HR = 1.15, 95% CI 0.95-1.40) between age groups. Poor PS was associated with shorter OS and PFS and higher CRC mortality.

CONCLUSIONS

In the DISCO study, older patients with mCRC received less aggressive first-line chemotherapy. Yet, they experienced more toxicity. Younger and older patients had similar CRC mortality. Shorter PFS and higher CRC mortality were observed in patients with poor PS.

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.

Characteristics of older people in an inpatient haematology unit: A descriptive study

OBJECTIVE

To characterise older inpatients in a haematology unit.

METHODS

Hospital case-mix data of haematology separations of all ages (n = 7419) and more extensive data restricted to older patients (age ≥75 years, n = 1025) were evaluated.

RESULTS

From 2000 to 2014, there was a 200% increase in those aged ≥85 years who were more likely to have a geriatric syndrome as the principal diagnosis (P < 0.05), have delirium (P < 0.05), receive less intensive treatment (P < 0.001) and be discharged to a nursing home (P < 0.001). Compared to younger inpatients, those aged ≥75 years were more likely to be emergency admissions (48% vs 37%, P < 0.001) and die during the admission (8% vs 4%, P < 0.001).

CONCLUSION

Haematologists care for older inpatients who are complex with multidisciplinary health service needs. There may be value in conducting comprehensive geriatric assessments in this setting.

Sociodemographic variation in the use of chemotherapy and radiotherapy in patients with stage IV lung, oesophageal, stomach and pancreatic cancer: evidence from population-based data in England during 2013-2014

BACKGROUND

Sociodemographic inequalities in cancer treatment have been generally described, but there is little evidence regarding patients with advanced cancer. Understanding variation in the management of these patients may provide insights into likely mechanisms leading to inequalities in survival.

METHODS

We identified 50,232 patients with stage IV lung, oesophageal, pancreatic and stomach cancer from the English national cancer registry. A generalised linear model with a Poisson error structure was used to explore variation in radiotherapy and chemotherapy within 6 months from diagnosis by age, sex, deprivation, ethnicity, cancer site, comorbidity and, additionally, performance status.

RESULTS

There was substantial variation by cancer site, large gradients by age, and non-trivial associations with comorbidity and deprivation. After full adjustment, more deprived patients were consistently least likely to be treated with chemotherapy alone or chemotherapy and radiotherapy combined compared with less deprived patients with equally advanced disease stage (treatment rate ratio: 0.82 95% CI (0.78, 0.87) for CT, 0.78 95% CI (0.71, 0.85) for CTRT p < 0.0001).

CONCLUSIONS

There was marked variation in the management of patients with stage IV cancer. Routinely collected data could be used for surveillance across all cancers to help reduce treatment variation and optimise outcomes among patients with advanced cancer.