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Lorentzen EH, Minami CA. Avoiding Locoregional Overtreatment in Older Adults With Early-Stage Breast Cancer. Clin Breast Cancer 2024; 24:319-327. [PMID: 38461117 DOI: 10.1016/j.clbc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/01/2024] [Accepted: 02/07/2024] [Indexed: 03/11/2024]
Abstract
Advances in the treatment of older women with early-stage breast cancer, particularly opportunities for de-escalation of therapy, have afforded patients and providers opportunity to individualize care. As the majority of women ≥65 have estrogen receptor-positive, HER2-negative disease, locoregional therapy (surgery and/or radiation) may be tailored based on a patient's physiologic age to avoid either over- or undertreatment. To determine who would derive benefit from more or less intensive therapy, an accurate assessment of an older patient's physiologic age and incorporation of patient-specific values are paramount. While there now exist well-validated geriatric assessment tools whose use is encouraged by the American Society of Clinical Oncology when considering systemic therapy, these instruments have not been widely integrated into the locoregional breast cancer care model. This review aims to highlight the importance of assessing frailty and the concepts of and over- and undertreatment, in the context of trial data supporting opportunities for safe deescalation of locoregional therapy, when treating older women with early-stage breast cancer.
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Affiliation(s)
- Eliza H Lorentzen
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA.
| | - Christina A Minami
- Department of Surgery, Brigham and Women's Hospital, Boston, MA; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA
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Soto-Perez-de-Celis E, Dale W, Katheria V, Kim H, Fakih M, Chung VM, Lim D, Mortimer J, Cabrera Chien L, Charles K, Roberts E, Vazquez J, Moreno J, Lee T, Fernandes Dos Santos Hughes S, Sedrak MS, Sun CL, Li D. Outcome prioritization and preferences among older adults with cancer starting chemotherapy in a randomized clinical trial. Cancer 2024. [PMID: 38630903 DOI: 10.1002/cncr.35333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Older adults with cancer facing competing treatments must prioritize between various outcomes. This study assessed health outcome prioritization among older adults with cancer starting chemotherapy. METHODS Secondary analysis of a randomized trial addressing vulnerabilities in older adults with cancer. Patients completed three validated outcome prioritization tools: 1) Health Outcomes Tool: prioritizes outcomes (survival, independence, symptoms) using a visual analog scale; 2) Now vs. Later Tool: rates the importance of quality of life at three times-today versus 1 or 5 years in the future; and 3) Attitude Scale: rates agreement with outcome-related statements. The authors measured the proportion of patients prioritizing various outcomes and evaluated their characteristics. RESULTS A total of 219 patients (median [range] age 71 [65-88], 68% with metastatic disease) were included. On the Health Outcomes Tool, 60.7% prioritized survival over other outcomes. Having localized disease was associated with choosing survival as top priority. On the Now vs. Later Tool, 50% gave equal importance to current versus future quality of life. On the Attitude Scale, 53.4% disagreed with the statement "the most important thing to me is living as long as I can, no matter what my quality of life is"; and 82.2% agreed with the statement "it is more important to me to maintain my thinking ability than to live as long as possible". CONCLUSION Although survival was the top priority for most participants, some older individuals with cancer prioritize other outcomes, such as cognition and function. Clinicians should elicit patient-defined priorities and include them in decision-making.
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Affiliation(s)
- Enrique Soto-Perez-de-Celis
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - William Dale
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Vani Katheria
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Heeyoung Kim
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Marwan Fakih
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Vincent M Chung
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Dean Lim
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Joanne Mortimer
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | | | | | - Elsa Roberts
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Jessica Vazquez
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Jeanine Moreno
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Ty Lee
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | | | - Mina S Sedrak
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Can-Lan Sun
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Daneng Li
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
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Stueger A, Joerger M, De Nys K. Geriatric evaluation methods in oncology and their use in clinical studies: A systematic literature review. J Geriatr Oncol 2024; 15:101684. [PMID: 38072709 DOI: 10.1016/j.jgo.2023.101684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/04/2023] [Accepted: 12/01/2023] [Indexed: 04/06/2024]
Abstract
INTRODUCTION Therapeutic options in oncology keep on expanding. Nonetheless, older adults are underrepresented in clinical trials and those enrolled often have a better health status than their average peers, resulting in a lack of representative evidence for this heterogenous population. The inclusion of older patients and a uniform categorization of "frailty" is becoming increasingly urgent. Standardized tools could contribute to the quality and comparability of clinical trials and facilitate clinical decisions. The aim of this literature review was to elaborate an overview of the use of geriatric evaluation (GE) methods in clinical cancer research. MATERIALS AND METHODS We performed a literature review of the PubMed database. Clinical pharmacotherapy studies that applied or evaluated a clearly defined system for the GE of oncological patients were included. Data retrieved encompassed the applied GE method(s), cancer type(s), and pharmacotherapy investigated, the number of included patients, study type, year of publication, as well as the primary purpose of the GE. The GEs used most frequently were depicted in more depth. RESULTS In this literature review, 103 publications were selected for inclusion. The biggest proportion of studies (36%, n = 34) used clearly defined, but not previously validated, GE methods (study-specific GE). Standardized GE methods encountered in at least five publications were the G8 screening test (applied in 18% of included studies, n = 17), the Balducci score (7%, n = 7), and a geriatric assessment based on Hurria (5%, n = 5). The primary purpose of GE was predominantly an appraisal of its potential role in pharmacotherapy optimization. The GE also served as baseline and outcome measure, inclusion/exclusion criterion, factor for stratified randomization, and to determine treatment allocation. DISCUSSION The wide range of GE methods used across studies make direct comparisons difficult, and many methods are poorly characterized and/or not previously validated. The further inclusion of representative older patients in clinical trials combined with the use of a standardized GE could help clinicians in the decision-making process.
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Affiliation(s)
- Amelie Stueger
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland.
| | - Markus Joerger
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland; Department of Oncology and Hematology, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9000 St. Gallen, Switzerland.
| | - Katelijne De Nys
- Palliativzentrum, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9000 St. Gallen, Switzerland; KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, ON2 Herestraat 49 - box 424, BE-3000 Leuven, Belgium.
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Jensen CE, Deal AM, Nyrop KA, Logan M, Mangieri NJ, Strayhorn MD, Miller J, Muss HB, Lichtman EI, Rubinstein SM, Tuchman SA. Geriatric assessment-guided interventions for older adults with multiple myeloma: A feasibility and acceptability study. J Geriatr Oncol 2024; 15:101680. [PMID: 38104482 PMCID: PMC10922464 DOI: 10.1016/j.jgo.2023.101680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/11/2023] [Accepted: 11/29/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Geriatric assessment (GA)-guided supportive care programs have been successful in improving treatment outcomes for older adults with solid-organ cancers. This study aimed to evaluate the feasibility of a GA-guided supportive care program among older adults treated for multiple myeloma (MM). MATERIALS AND METHODS The study utilized an existing registry of adults with plasma cell disorders at the University of North Carolina. Patients with MM, aged 60 or older, and having a GA-identified deficit in one or more problem area were offered referrals to supportive care resources during routine visits. Problem areas included physical function deficits, polypharmacy, and anxiety or depression. Patients with physical function deficits were offered referral to physical therapy (PT), those with polypharmacy to an Oncology Clinical Pharmacist Practitioner (CPP), and those with mental health symptoms to the Comprehensive Cancer Support Program (CCSP). RESULTS Of the 58 individuals identified as having at least one deficit on the GA, PT was the most commonly identified relevant resource (79%), followed by CPP visits (57%). Among individuals that were offered referral(s) to at least one new supportive care resource, the acceptance rate was 50%. Referral acceptance rates were highest among those recommended for a CPP visit (55% of those approached) and lowest for CCSP (0%). DISCUSSION The study examined the feasibility and acceptability of a referral program for supportive care resources among older adults with MM who have deficits on GA. The most commonly identified deficit was physical functioning, followed by polypharmacy and mental health. The study found that physical interventions and referrals to CPPs were the most accepted interventions. However, the low proportion of patients who accepted physical therapy referrals indicates the need for tailored and more personalized approaches. Further research is needed to explore the feasibility and impact of supportive care referral programs for older adults with MM.
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Affiliation(s)
- Christopher E Jensen
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Physicians Office Building, CB# 7305, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Kirsten A Nyrop
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA; Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Physicians Office Building, CB# 7305, Chapel Hill, NC 27599, USA.
| | - Maya Logan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Nicholas J Mangieri
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Martha D Strayhorn
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Jordan Miller
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Hyman B Muss
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA; Division of Oncology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Physicians Office Building, CB# 7305, Chapel Hill, NC 27599, USA.
| | - Eben I Lichtman
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Physicians Office Building, CB# 7305, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Samuel M Rubinstein
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Physicians Office Building, CB# 7305, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
| | - Sascha A Tuchman
- Division of Hematology, Department of Medicine, University of North Carolina at Chapel Hill, 170 Manning Drive, Physicians Office Building, CB# 7305, Chapel Hill, NC 27599, USA; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, 450 West Drive, Chapel Hill, NC 27599, USA.
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Friedberg JW, Bordoni R, Patel-Donnelly D, Larson T, Goldschmidt J, Boccia R, Cline VJM, Mamidipalli A, Liu J, Akyol A, Yasenchak CA. Brentuximab vedotin with dacarbazine or nivolumab as frontline cHL therapy for older patients ineligible for chemotherapy. Blood 2024; 143:786-795. [PMID: 37946283 DOI: 10.1182/blood.2022019536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 09/29/2023] [Accepted: 10/19/2023] [Indexed: 11/12/2023] Open
Abstract
ABSTRACT Older patients with advanced-stage classical Hodgkin lymphoma (cHL) have inferior outcomes compared with younger patients, potentially due to comorbidities and frailty. This noncomparative phase 2 study enrolled patients aged ≥60 years with cHL unfit for conventional chemotherapy to receive frontline brentuximab vedotin (BV; 1.8 mg/kg) with dacarbazine (DTIC; 375 mg/m2) (part B) or nivolumab (part D; 3 mg/kg). In parts B and D, 50% and 38% of patients, respectively, had ≥3 general comorbidities or ≥1 significant comorbidity. Of the 22 patients treated with BV-DTIC, 95% achieved objective response, and 64% achieved complete response (CR). With a median follow-up of 63.6 months, median duration of response (mDOR) was 46.0 months. Median progression-free survival (mPFS) was 47.2 months; median overall survival (mOS) was not reached. Of 21 patients treated with BV-nivolumab, 86% achieved objective response, and 67% achieved CR. With 51.6 months of median follow-up, mDOR, mPFS, and mOS were not reached. Ten patients (45%) with BV-DTIC and 16 patients (76%) with BV-nivolumab experienced grade ≥3 treatment-emergent adverse events; sensory peripheral neuropathy (PN; 27%) and neutropenia (9%) were most common with BV-DTIC, and increased lipase (24%), motor PN (19%), and sensory PN (19%) were most common with BV-nivolumab. Despite high median age, inclusion of patients aged ≤88 years, and frailty, these results demonstrate safety and promising durable efficacy of BV-DTIC and BV-nivolumab combinations as frontline treatment, suggesting potential alternatives for older patients with cHL unfit for initial conventional chemotherapy. This trial was registered at www.clinicaltrials.gov as #NCT01716806.
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Affiliation(s)
| | | | | | | | | | - Ralph Boccia
- Center for Cancer and Blood Disorders, Bethesda, MD
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Garg T, Frank K, Johns A, Rabinowitz K, Danella JF, Kirchner HL, Nielsen ME, McMullen CK, Murphy TE, Cohen HJ. Geriatric assessment-derived deficit accumulation and patient-reported treatment burden in older adults with bladder cancer. J Am Geriatr Soc 2024; 72:490-502. [PMID: 37974546 PMCID: PMC10922080 DOI: 10.1111/jgs.18676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 10/02/2023] [Accepted: 10/13/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND When a person's workload of healthcare exceeds their resources, they experience treatment burden. At the intersection of cancer and aging, little is known about treatment burden. We evaluated the association between a geriatric assessment-derived Deficit Accumulation Index (DAI) and patient-reported treatment burden in older adults with early-stage, non-muscle-invasive bladder cancer (NMIBC). METHODS We conducted a cross-sectional survey of older adults with NMIBC (≥65 years). We calculated DAI using the Cancer and Aging Research Group's geriatric assessment and measured urinary symptoms using the Urogenital Distress Inventory-6 (UDI-6). The primary outcome was Treatment Burden Questionnaire (TBQ) score. A negative binomial regression with LASSO penalty was used to model TBQ. We further conducted qualitative thematic content analysis of responses to an open-ended survey question ("What has been your Greatest Challenge in managing medical care for your bladder cancer") and created a joint display with illustrative quotes by DAI category. RESULTS Among 119 patients, mean age was 78.9 years (SD 7) of whom 56.3% were robust, 30.3% pre-frail, and 13.4% frail. In the multivariable model, DAI and UDI-6 were significantly associated with TBQ. Individuals with DAI above the median (>0.18) had TBQ scores 1.94 times greater than those below (adjusted IRR 1.94, 95% CI 1.33-2.82). Individuals with UDI-6 greater than the median (25) had TBQ scores 1.7 times greater than those below (adjusted IRR 1.70, 95% CI 1.16-2.49). The top 5 themes in the Greatest Challenge question responses were cancer treatments (22.2%), cancer worry (19.2%), urination bother (18.2%), self-management (18.2%), and appointment time (11.1%). CONCLUSIONS DAI and worsening urinary symptoms were associated with higher treatment burden in older adults with NMIBC. These data highlight the need for a holistic approach that reconciles the burden from aging-related conditions with that resulting from cancer treatment.
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Affiliation(s)
- Tullika Garg
- Department of Urology, Penn State Health Milton S. Hershey Medical Center, Hershey, PA
| | - Katie Frank
- Biostatistics Core, Geisinger, Danville, PA
- Department of Population Health Sciences, Geisinger, Danville, PA
| | - Alicia Johns
- Biostatistics Core, Geisinger, Danville, PA
- Department of Population Health Sciences, Geisinger, Danville, PA
| | | | | | | | - Matthew E. Nielsen
- Department of Urology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
- Departments of Epidemiology and Health Policy & Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC
| | | | - Terrence E. Murphy
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | - Harvey J. Cohen
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC
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Chamberlin M, Booth C, Brooks GA, Manirakiza A, Rubagumya F, Vanderpuye V. More Drugs Versus More Data: The Tug of War on Cancer in Low- and Middle-Income Countries. Hematol Oncol Clin North Am 2024; 38:229-238. [PMID: 37516631 DOI: 10.1016/j.hoc.2023.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2023]
Abstract
Although current value frameworks and economic models have allowed us to better quantify the net benefit associated with cancer therapy, holistic cancer care must consider patient time, family and social values, and overall life expectancy. Training programs must include training in health services research, difficult conversations, and shared decision-making strategies that are developed in social and cultural frameworks for their settings.
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Affiliation(s)
- Mary Chamberlin
- Dartmouth Cancer Center, 1 Medical Center Drive, Lebanon, NH 03765, USA
| | | | - Gabriel A Brooks
- Dartmouth Cancer Center, 1 Medical Center Drive, Lebanon, NH 03765, USA
| | | | - Fidel Rubagumya
- Department of Oncology, Rwanda Military Hospital, Kigali, Rwanda
| | - Verna Vanderpuye
- National Center for Radiotherapy, Oncology and Nuclear Medicine, Korlebu Teaching Hospital, PO Box KB 369, Accra.
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Dotan E, Lynch SM, Ryan JC, Mitchell EP. Disparities in care of older adults of color with cancer: A narrative review. Cancer Med 2024; 13:e6790. [PMID: 38234214 PMCID: PMC10905558 DOI: 10.1002/cam4.6790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/06/2023] [Accepted: 11/23/2023] [Indexed: 01/19/2024] Open
Abstract
This review describes the barriers and challenges faced by older adults of color with cancer and highlights methods to improve their overall care. In the next decade, cancer incidence rates are expected to increase in the United States for people aged ≥65 years. A large proportion will be older adults of color who often have worse outcomes than older White patients. Many issues contribute to racial disparities in older adults, including biological factors and social determinants of health (SDOH) related to healthcare access, socioeconomic concerns, systemic racism, mistrust, and the neighborhood where a person lives. These disparities are exacerbated by age-related challenges often experienced by older adults, such as decreased functional status, impaired cognition, high rates of comorbidities and polypharmacy, poor nutrition, and limited social support. Additionally, underrepresentation of both patients of color and older adults in cancer clinical research results in a lack of adequate data to guide the management of these patients. Use of geriatric assessments (GA) can aid providers in uncovering age-related concerns and personalizing interventions for older patients. Research demonstrates the ability of GA-directed care to result in fewer treatment-related toxicities and improved quality of life, thus supporting the routine incorporation of validated GA into these patients' care. GA can be enhanced by including evaluation of SDOH, which can help healthcare providers understand and address the needs of older adults of color with cancer who face disparities related to their age and race.
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Affiliation(s)
- Efrat Dotan
- Department of Hematology/OncologyFox Chase Cancer CenterPhiladelphiaPennsylvaniaUSA
| | | | | | - Edith P. Mitchell
- Clinical Professor of Medicine and Medical OncologySidney Kimmel Cancer Center at JeffersonPhiladelphiaPennsylvaniaUSA
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Galvin A, Soubeyran P, Brain E, Cheung KL, Hamaker ME, Kanesvaran R, Mauer M, Mohile S, Montroni I, Puts M, Rostoft S, Wildiers H, Mathoulin-Pélissier S, Bellera C. Assessing patient-reported outcomes (PROs) and patient-related outcomes in randomized cancer clinical trials for older adults: Results of DATECAN-ELDERLY initiative. J Geriatr Oncol 2024; 15:101611. [PMID: 37679204 DOI: 10.1016/j.jgo.2023.101611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 08/01/2023] [Accepted: 08/23/2023] [Indexed: 09/09/2023]
Abstract
As older adults with cancer are underrepresented in randomized clinical trials (RCT), there is limited evidence on which to rely for treatment decisions for this population. Commonly used RCT endpoints for the assessment of treatment efficacy are more often tumor-centered (e.g., progression-free survival). These endpoints may not be as relevant for the older patients who present more often with comorbidities, non-cancer-related deaths, and treatment toxicity. Moreover, their expectation and preferences are likely to differ from younger adults. The DATECAN-ELDERLY initiative combines a broad expertise, in geriatric oncology and clinical research, with interest in cancer RCT that include older patients with cancer. In order to guide researchers and clinicians coordinating cancer RCT involving older patients with cancer, the experts reviewed the literature on relevant domains to assess using patient-reported outcomes (PRO) and patient-related outcomes, as well as available tools related to these domains. Domains considered relevant by the panel of experts when assessing treatment efficacy in RCT for older patients with cancer included functional autonomy, cognition, depression and nutrition. These were based on published guidelines from international societies and from regulatory authorities as well as minimum datasets recommended to collect in RCT including older adults with cancer. In addition, health-related quality of life, patients' symptoms, and satisfaction were also considered by the panel. With regards to tools for the assessment of these domains, we highlighted that each tool has its own strengths and limitations, and very few had been validated in older adults with cancer. Further studies are thus needed to validate these tools in this specific population and define the minimum clinically important difference to use when developing RCTs in this population. The selection of the most relevant tool should thus be guided by the RCT research question, together with the specific properties of the tool.
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Affiliation(s)
- Angéline Galvin
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene team, UMR 1219, Bordeaux, France
| | - Pierre Soubeyran
- Univ. Bordeaux, Inserm, UMR 1312, SIRIC BRIO, France; Department of medical oncology, Bergonie Institute, Comprehensive Cancer Center, Bordeaux, France
| | - Etienne Brain
- Department of Medical Oncology, Institut Curie/Saint-Cloud, Saint-Cloud, France
| | - Kwok-Leung Cheung
- School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis Utrecht/ Zeist/Doorn, Zeist, the Netherlands
| | | | - Murielle Mauer
- Statistics Department, European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Supriya Mohile
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Isacco Montroni
- Division of Colorectal Surgery, Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Hans Wildiers
- Department of General Medical Oncology and Multidisciplinary Breast Centre, University Hospitals Leuven, Leuven Cancer Institute, Belgium
| | - Simone Mathoulin-Pélissier
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene team, UMR 1219, Bordeaux, France; INSERM CIC1401, Clinical and Epidemiological Research Unit, Bergonie Institute, Comprehensive Cancer Center, F-33000 Bordeaux, France
| | - Carine Bellera
- Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, Epicene team, UMR 1219, Bordeaux, France; INSERM CIC1401, Clinical and Epidemiological Research Unit, Bergonie Institute, Comprehensive Cancer Center, F-33000 Bordeaux, France.
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Patel I, Winer A. Assessing Frailty in Gastrointestinal Cancer: Two Diseases in One? Curr Oncol Rep 2024; 26:90-102. [PMID: 38180691 DOI: 10.1007/s11912-023-01483-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Abstract
PURPOSEOF REVIEW This review examines the challenges of treating gastrointestinal cancer in the aging population, focusing on the importance of frailty assessment. Emphasized are the rise in gastrointestinal cancer incidence in older adults, advances in frailty assessments for patients with gastrointestinal cancer, the development of novel frailty markers, and a summary of recent trials. RECENT FINDINGS Increasing evidence suggests that the use of a Comprehensive Geriatric Assessment (CGA) to identify frail older adults and individualize cancer care leads to lower toxicity and improved quality of life outcomes. However, the adoption of a full CGA prior to chemotherapy initiation in older cancer patients remains low. Recently, new frailty screening tools have emerged, including assessments designed to specifically predict chemotherapy-related adverse events. Additionally, frailty biomarkers have been developed, such as blood tests like IL-6 and performance tracking through physical activity monitors. The relevance of nutrition and muscle mass is discussed. Highlights from recent trials suggest the feasibility of successfully identifying patients most at risk of serious adverse events. There have been promising developments in identifying novel frailty markers and methods to screen for frailty in the older adult population. Further prospective trials that focus on and address the needs of the geriatric population for early identification of frailty in cancer care, facilitating a more tailored treatment approach. Practicing oncologists should select a frailty assessment to implement into their routine practice and adjust treatment accordingly.
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Affiliation(s)
- Ishan Patel
- Inova Schar Cancer Institute, 8081 Innovation Park Drive, Falls Church, Falls Church, VA, 22031, USA.
| | - Arthur Winer
- Inova Schar Cancer Institute, 8081 Innovation Park Drive, Falls Church, Falls Church, VA, 22031, USA
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Woods JD, Klepin HD. Geriatric Assessment in Acute Myeloid Leukemia. Acta Haematol 2023; 147:219-228. [PMID: 38035561 PMCID: PMC10963150 DOI: 10.1159/000535500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) is a heterogenous disease that affects mostly older adults with varying baseline health and functional status. Treatment options have expanded for older adults, ranging from less intensive chronic therapies to intensive induction strategies with curative intent. Despite this, outcomes remain poor with advancing age due to underlying disease biology and variability in treatment tolerance. Reliance on chronological age alone, however, increases risks of both over- and under-treatment. Strategies to better characterize fitness in the context of therapy are needed to optimize decision-making and enhance clinical trial design. SUMMARY Geriatric assessment (GA) is a series of validated tools that evaluate multiple health and functional domains of an older adult including physical function, comorbidities, cognition, nutrition, psychological health, and social support. While studies of GA in AML remain limited, current evidence shows that it is feasible to perform GA among older adults starting therapy for AML. GA measures including those assessing physical function, cognition, and mood are associated with mortality and toxicity in both intensive and less intensive treatment settings. KEY MESSAGES In this review, we discuss the existing evidence to support use of GA in AML and highlight implications for clinical practice and future research.
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Affiliation(s)
- Justin D Woods
- Section on Hematology and Oncology, Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, North Carolina, USA
| | - Heidi D Klepin
- Section on Hematology and Oncology, Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston Salem, North Carolina, USA
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12
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Huang LW, Shi Y, Andreadis C, Logan AC, Mannis GN, Smith CC, Gaensler KML, Martin TG, Damon LE, Boscardin WJ, Steinman MA, Olin RL. Association of geriatric measures and global frailty with cognitive decline after allogeneic hematopoietic cell transplantation in older adults. J Geriatr Oncol 2023; 14:101623. [PMID: 37678052 PMCID: PMC11101048 DOI: 10.1016/j.jgo.2023.101623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 04/18/2023] [Accepted: 08/25/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION Allogeneic hematopoietic cell transplantation (alloHCT) is increasingly offered to older adults, and its potential impact on cognition in this population is understudied. This work aims to evaluate the ability of cancer-specific geriatric assessments (cGA) and a global frailty index based on accumulation of deficits identified in the cGA to predict the risk of cognitive decline after alloHCT in older adults. MATERIALS AND METHODS AlloHCT recipients aged 50 years or older completed a cGA, including a cognitive evaluation by the Blessed Orientation Memory Concentration (BOMC) test, at baseline prior to alloHCT and then at 3, 6, and 12 months after transplant. Baseline frailty was assessed using a deficit accumulation frailty index (DAFI) calculated from the cGA. A multinomial logit model was used to examine the association between predictors (individual cGA measures, DAFI) and the following three outcomes: alive with stable or improved cognition, alive with cognitive decline, and deceased. In post-hoc analyses, analysis of variance was used to compare BOMC scores at baseline, 3, 6, and 12 months across frailty categories. RESULTS In total, 148 participants were included, with a median age of 62 (range 50-76). At baseline, 12% had cognitive impairment; at one year, 29% of survivors had improved BOMC scores, 33% had stable BOMC, and 37% had worse BOMC. Prior to transplant, 25% were pre-frail and 11% were frail. Individual baseline cGA measures were not associated with cognitive change at one year as assessed by BOMC. Adjusting for age, sex, and education, those who were frail at baseline were 7.4 times as likely to develop cognitive decline at one year than those who were non-frail, although this finding did not reach statistical significance (95% confidence interval [CI] 0.74-73.8, p = 0.09). The probability of being alive with stable/improved cognition at 12 months for the non-frail, pre-frail, and frail groups was 43%, 34%, and 8%, respectively. DISCUSSION Baseline geriatric measures and frailty were not significantly associated with cognitive change as assessed by BOMC in adults aged 50 or older after alloHCT. However, the study was underpowered to detect clinically meaningful differences, and future work to elucidate potential associations between frailty and cognitive outcomes is warranted.
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Affiliation(s)
- Li-Wen Huang
- San Francisco VA Health Care System, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
| | - Ying Shi
- San Francisco VA Health Care System, San Francisco, CA, USA; Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Charalambos Andreadis
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Aaron C Logan
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Gabriel N Mannis
- Division of Hematology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Catherine C Smith
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Karin M L Gaensler
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Thomas G Martin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Lloyd E Damon
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - W John Boscardin
- San Francisco VA Health Care System, San Francisco, CA, USA; Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Michael A Steinman
- San Francisco VA Health Care System, San Francisco, CA, USA; Division of Geriatrics, University of California San Francisco, San Francisco, CA, USA
| | - Rebecca L Olin
- San Francisco VA Health Care System, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
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13
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Mady LJ, De Ravin E, Vohra V, Lu J, Newman JG, Hall DE, Dalton PH, Rowan NR. Exploring Olfactory Dysfunction as a Marker of Frailty and Postoperative Outcomes in Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2023; 149:828-836. [PMID: 37498617 PMCID: PMC10375382 DOI: 10.1001/jamaoto.2023.1935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 06/05/2023] [Indexed: 07/28/2023]
Abstract
Importance Olfactory dysfunction (OD) is increasingly recognized as a robust marker of frailty and mortality. Despite broad recognition of frailty as a critical component of head and neck cancer (HNC) care, there is no standardized frailty assessment. Objective To assess the prevalence of OD and its association with frailty and postoperative outcomes in HNC. Design, Setting, and Participants In this prospective cohort study with enrollment between February 17, 2021, to September 29, 2021, at a tertiary academic medical center, 85 eligible adult patients with primary, treatment-naive HNC of mucosal or cutaneous origin were included. Patients with a history of COVID-19, neurocognitive, or primary smell/taste disorders were excluded. Exposures Prospective olfactory assessments (self-reported, visual analog scale [VAS] and psychophysical, University of Pennsylvania Smell Identification Test [UPSIT]) with concurrent frailty assessment (Risk Analysis Index [RAI]) were used. Olfactory-specific quality of life (QOL) was examined with brief Questionnaire of Olfactory Disorders-Negative Statements (QOD-NS). Main Outcome(s) and Measure(s) The primary outcome was the prevalence of OD as assessed by VAS (0-10, no to normal smell) and UPSIT (0-40, higher scores reflect better olfaction) and its association with frailty (RAI, 0-81, higher scores indicate greater frailty). For surgical patients, secondary outcomes were associations between OD and postoperative length of stay (LOS), 30-day postoperative outcomes, and QOD-NS (0-21, higher scores indicate worse QOL). Results Among 51 patients with HNC (mean [SD] age, 63 [10] years; 39 [77%] male participants; 41 [80%] White participants), 24 (47%) were frail, and 4 (8%) were very frail. Despite median (IQR) self-reported olfaction by VAS of 9 (8-10), 30 (59%) patients demonstrated measured OD with psychophysical testing. No meaningful association was found between self-reported and psychophysical testing (Hodges-Lehmann, <0.001; 95% CI, -2 to 1); a total of 46 (90%) patients did not report decreased olfaction-specific QOL. Median UPSIT scores were lower in frail patients (Hodges-Lehmann, 6; 95% CI, 2-12). Multivariate modeling demonstrated severe microsmia/anosmia was associated with 1.75 (95% CI, 1.09-2.80) times odds of being frail/very frail and approximately 3 days increased LOS (β, 2.96; 95% CI, 0.29-5.62). Conclusions and Relevance Although patients with HNC are unaware of olfactory changes, OD is common and may serve as a bellwether of frailty. In this prospective cohort study, a dose-dependent association was demonstrated between increasing degrees of OD and frailty, and the potential utility of olfaction was highlighted as a touchstone in the assessment of HNC frailty.
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Affiliation(s)
- Leila J. Mady
- Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emma De Ravin
- Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Varun Vohra
- Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Lu
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jason G. Newman
- MUSC Hollings Cancer Center, Charleston, South Carolina
- Department of Otolaryngology–Head and Neck Surgery, Medical University of South Carolina, Charleston
| | - Daniel E. Hall
- Wolff Center at UPMC, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Geriatric Research Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Nicholas R. Rowan
- Department of Otolaryngology–Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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14
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Isbell LK, Uibeleisen R, Friedl A, Burger E, Dopatka T, Scherer F, Orban A, Lauer E, Malenica N, Semenova I, Vreden A, Valk E, Wendler J, Neumaier S, Fricker H, El Rabih AAH, Gloggengießer C, Hilbig D, Bleul S, Weis J, Gmehlin D, Backenstrass M, Wirtz S, Ihorst G, Finke J, Illerhaus G, Schorb E. Age-adjusted high-dose chemotherapy followed by autologous stem cell transplantation or conventional chemotherapy with R-MP as first-line treatment in elderly primary CNS lymphoma patients - the randomized phase III PRIMA-CNS trial. BMC Cancer 2023; 23:767. [PMID: 37596517 PMCID: PMC10436648 DOI: 10.1186/s12885-023-11193-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/19/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Older primary central nervous system lymphoma (PCNSL) patients have an inferior prognosis compared to younger patients because available evidence on best treatment is scarce and treatment delivery is challenging due to comorbidities and reduced performance status. High-dose chemotherapy and autologous stem cell transplantation (HCT-ASCT) after high-dose methotrexate (MTX)-based immuno-chemotherapy has become an increasingly used treatment approach in eligible elderly PCNSL patients with promising feasibility and efficacy, but has not been compared with conventional chemotherapy approaches. In addition, eligibility for HCT-ASCT in elderly PCNSL is not well defined. Geriatric assessment (GA) may be helpful in selecting patients for the best individual treatment choice, but no standardized GA exists to date. A randomized controlled trial, incorporating a GA and comparing age-adapted HCT-ASCT treatment with conventional chemotherapy is needed. METHODS This open-label, multicenter, randomized phase III trial with two parallel arms will recruit 310 patients with newly diagnosed PCNSL > 65 years of age in 40 centers in Germany and Austria. The primary objective is to demonstrate that intensified chemotherapy followed by consolidating HCT-ASCT is superior to conventional chemotherapy with rituximab, MTX, procarbazine (R-MP) followed by maintenance with procarbazine in terms of progression free survival (PFS). Secondary endpoints include overall survival (OS), event free survival (EFS), (neuro-)toxicity and quality of life (QoL). GA will be conducted at specific time points during the course of the study. All patients will be treated with a pre-phase rituximab-MTX (R-MTX) cycle followed by re-assessment of transplant eligibility. Patients judged transplant eligible will be randomized (1:1). Patients in arm A will be treated with 3 cycles of R-MP followed by maintenance therapy with procarbazine for 6 months. Patients in arm B will be treated with 2 cycles of MARTA (R-MTX/AraC) followed by busulfan- and thiotepa-based HCT-ASCT. DISCUSSION The best treatment strategy for elderly PCNSL patients remains unknown. Treatments range from palliative to curative but more toxic therapies, and there is no standardized measure to select patients for the right treatment. This randomized controlled trial will create evidence for the best treatment strategy with the focus on developing a standardized GA to help define eligibility for an intensive treatment approach. TRIAL REGISTRATION German clinical trials registry DRKS00024085 registered March 29, 2023.
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Affiliation(s)
- Lisa K Isbell
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Roswitha Uibeleisen
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Alexander Friedl
- Department of Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Elvira Burger
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Tatja Dopatka
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Florian Scherer
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Andras Orban
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Eliza Lauer
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Natalie Malenica
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Inna Semenova
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Annika Vreden
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Elke Valk
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Julia Wendler
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Simone Neumaier
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Heidi Fricker
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Abed Al Hadi El Rabih
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Cora Gloggengießer
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Daniela Hilbig
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Sabine Bleul
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Joachim Weis
- Endowed Professorship Self-Help Research, Comprehensive Cancer Center, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Dennis Gmehlin
- Institute for Clinical Psychology, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Matthias Backenstrass
- Institute for Clinical Psychology, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Sebastian Wirtz
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Jürgen Finke
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Elisabeth Schorb
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany.
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15
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Johnson PC, Woyach JA, Ulrich A, Marcotte V, Nipp RD, Lage DE, Nelson AM, Newcomb RA, Rice J, Lavoie MW, Ritchie CS, Bartlett N, Stephens DM, Ding W, Owen C, Stone R, Ruppert AS, Mandrekar SJ, Byrd JC, El-Jawahri A, Le-Rademacher J, Rosko A. Geriatric assessment measures are predictive of outcomes in chronic lymphocytic leukemia. J Geriatr Oncol 2023; 14:101538. [PMID: 37329769 PMCID: PMC10599966 DOI: 10.1016/j.jgo.2023.101538] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 05/05/2023] [Accepted: 05/25/2023] [Indexed: 06/19/2023]
Abstract
INTRODUCTION Chronic lymphocytic leukemia (CLL) commonly affects older adults. However, few studies have examined the relationship between baseline geriatric domains and clinical outcomes in this population. Here, we aim to evaluate the use of a comprehensive geriatric assessment in older (>65 years) untreated patients with CLL to predict outcomes. MATERIALS AND METHODS We conducted a planned analysis of 369 patients with CLL age 65 or older treated in a phase 3 randomized trial of bendamustine plus rituximab versus ibrutinib plus rituximab versus ibrutinib alone (A041202). Patients underwent evaluations of geriatric domains including functional status, psychological status, social activity, cognition, social support, and nutritional status. We examined associations among baseline geriatric domains with grade 3+ adverse events using multivariable logistic regression and overall survival (OS) and progression-free survival (PFS) using multivariable Cox regression models. RESULTS In this study, the median age was 71 years (range: 65-87). In the combined multivariable model, the following geriatric domains were significantly associated with PFS: Medical Outcomes Study (MOS) - social activities survey score (hazard ratio [HR] [95% confidence interval (CI)] 0.974(0.961, 0.988), p = 0.0002) and nutritional status (≥5% weight loss in the preceding six months: (HR [95% CI] 2.717[1.696, 4.354], p < 0.001). MOS - social activities score [HR (95% CI) 0.978(0.958, 0.999), p = 0.038] was associated with OS. No geriatric domains were significantly associated with toxicity. There were no statistically significant interactions between geriatric domains and treatment. DISCUSSION Geriatric domains of social activity and nutritional status were associated with OS and/or PFS in older adults with CLL. These findings highlight the importance of assessing geriatric domains to identify high-risk patients with CLL who may benefit from additional support during treatment.
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Affiliation(s)
- P Connor Johnson
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Jennifer A Woyach
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA.
| | - Angela Ulrich
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Veronique Marcotte
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN, USA
| | - Ryan D Nipp
- University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Daniel E Lage
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ashley M Nelson
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Richard A Newcomb
- Dana-Farber/Partners CancerCare, Harvard Medical School, Boston, MA, USA
| | - Julia Rice
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Nancy Bartlett
- Washington University - Siteman Cancer Center, St. Louis, MO, USA
| | | | | | - Carolyn Owen
- Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta, Canada
| | - Richard Stone
- Dana-Farber/Partners CancerCare, Harvard Medical School, Boston, MA, USA
| | - Amy S Ruppert
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | | | - John C Byrd
- University of Cincinnati, Cincinnati, OH, USA
| | - Areej El-Jawahri
- Dana-Farber/Partners CancerCare, Harvard Medical School, Boston, MA, USA
| | | | - Ashley Rosko
- The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
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Raz DJ, Kim JY, Erhunwmunesee L, Hite S, Varatkar G, Sun V. The value of perioperative physical activity in older patients undergoing surgery for lung cancer. Expert Rev Respir Med 2023; 17:691-700. [PMID: 37668168 DOI: 10.1080/17476348.2023.2255133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/24/2023] [Accepted: 08/31/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION With a median age at diagnosis of 70, lung cancer represents an enormous public health problem among older Americans. An estimated 19,000 people age 65 and older undergo lung cancer surgery annually in the US. Older adults undergoing lung cancer surgery are often frail with limited physiologic reserves, multi-morbidities, and functional impairments. Physical function, dyspnea, and quality of life return to baseline slower in older adults compared with younger adults after lung surgery. AREAS COVERED In this review, we summarize available data about perioperative physical activity interventions that may improve outcomes for older adults undergoing lung cancer surgery. We also review the limitations of existing studies and discuss emerging data on the roles of telehealth and family caregiver inclusion in peri-operative physical activity interventions. EXPERT OPINION We propose that future perioperative physical activity interventions in older adults undergoing lung cancer surgery should include a comprehensive geriatric assessment to guide personalized interventions. Interventions should be conceptually based, with a focus on enhancing self-efficacy, motivation, and adherence through classic behavior change strategies that are proven to impact outcomes. Finally, interventions should be designed with attention to feasibility and scalability. Exercise programs delivered via telehealth (telephone or tele-video) may improve access and convenience for patients.
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Affiliation(s)
- Dan J Raz
- Department of Surgery, City of Hope, CA, USA
| | - Jae Y Kim
- Department of Surgery, City of Hope, CA, USA
| | - Loretta Erhunwmunesee
- Department of Surgery, City of Hope, CA, USA
- Department of Population Sciences, City of Hope, CA, USA
| | - Sherry Hite
- Department of Rehabilitation, City of Hope, CA, USA
| | | | - Virginia Sun
- Department of Surgery, City of Hope, CA, USA
- Department of Population Sciences, City of Hope, CA, USA
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17
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Ioffe D, Dotan E. Guidance for Treating the Older Adults with Colorectal Cancer. Curr Treat Options Oncol 2023; 24:644-666. [PMID: 37052812 DOI: 10.1007/s11864-023-01071-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 04/14/2023]
Abstract
OPINION STATEMENT The need for evidence-based data in the rapidly growing group of older patients is vast and more elderly-specific studies are desperately needed, for which there is clear demand from both patients and providers. Notably, many of the studies discussed in this review included unplanned subset analyses based on age and/or were not originally stratified by age; therefore, these data, particularly overall survival data, need to be interpreted with some caution as they may not be statistically valid based on the initial trial design and statistical plan. As we await data from ongoing elderly-specific trials, our recommendation for managing older patients with CRC should include geriatric screening tools (e.g., CSGA, VES-13, G8, CARG, CRASH) to help guide treatment adjustments for improved tolerability without sacrificing efficacy. For patients with a positive screen for significant geriatric concerns, a full geriatric assessment is recommended to guide treatment approach and supportive care. Prior data support the use of all approved medications for CRC in older adults who are fit; however, treatment breaks and dose attenuation with potential escalation are reasonable options for these patients. Ultimately, management decisions in the care of older adults with mCRC must be made through shared decision-making with the patient with consideration for the patient's functional status, comorbidities, goals of care, social support, as well as potential toxicities and possible effect on QoL.
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Affiliation(s)
- Dina Ioffe
- Department of Medical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA
| | - Efrat Dotan
- Department of Medical Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA.
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18
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Dotan E, Catalano P, Lenchik L, Boutin R, Yao X, Marques HS, Ioffe D, Zhen DB, Li D, Wagner LI, Simon MA, Wong TZ, O'Dwyer PJ. The GIANT trial (ECOG-ACRIN EA2186) methods paper: A randomized phase II study of gemcitabine and nab-paclitaxel compared with 5-fluorouracil, leucovorin, and liposomal irinotecan in older patients with treatment-naïve metastatic pancreatic cancer - defining a new treatment option for older vulnerable patients. J Geriatr Oncol 2023; 14:101474. [PMID: 36963200 PMCID: PMC10425127 DOI: 10.1016/j.jgo.2023.101474] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/06/2023] [Indexed: 03/26/2023]
Abstract
INTRODUCTION Pancreatic cancer is the fourth leading cause of cancer-related death in the US with an increasing incidence in older adults (OA) over age 70. There are currently no treatment guidelines for OA with metastatic pancreatic cancer (mPCA) and selecting a chemotherapy regimen for these patients is subjective, based largely on chronologic age and performance status (PS). Geriatric screening tools provide a more objective and accurate evaluation of a patient's overall health but have not yet been validated in patient selection for mPCA treatment. This study aims to elucidate the optimal chemotherapy treatment of vulnerable OA with mPCA and understand the geriatric factors that affect outcomes in this population. METHODS/DESIGN The GIANT (ECOG-ACRIN EA2186) study is multicenter, randomized phase II trial enrolling patients over age 70 with newly diagnosed mPCA. This study utilizes a screening geriatric assessment (GA) which characterizes patients as fit, vulnerable, or frail. Patients with mild abnormalities in functional status and/or cognition, moderate comorbidities, or over age 80 are considered vulnerable. Enrolled patients are randomized to one of two dose-reduced treatment regimens (gemcitabine/nab-paclitaxel every other week, or dose-reduced 5-fluoruracil (5FU)/ liposomal irinotecan (nal-IRI) every other week). GA and quality of life (QoL) evaluations are completed prior to treatment initiation and at each disease evaluation. Overall survival (OS) is the primary endpoint, with secondary endpoints including progression free survival (PFS) and objective response rate (ORR). Enrolled patients will be stratified by age (70-74 vs ≥75) and ECOG PS (0-1 vs 2). Additional endpoints of interest for OA include evaluation of risk factors identified through GA, QoL evaluation, and toxicities of interest for older adults. Correlative studies include assessment of pro-inflammatory biomarkers of aging in the blood (IL-6, CRP) and imaging evaluation of sarcopenia as predictors of treatment tolerance. DISCUSSION The GIANT study is the first randomized, prospective national trial evaluating vulnerable OA with mPCA aimed at developing a tailored treatment approach for this patient population. This trial has the potential to establish a new way of objectively selecting vulnerable OA with mPCA for modified treatment and to establish a new standard of care in this growing patient population. TRIAL REGISTRATION This trial is registered with ClinicalTrial.gov Identifier NCT04233866.
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Affiliation(s)
- Efrat Dotan
- Department of Hematology and Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA.
| | - Paul Catalano
- Dana Farber Cancer Institute - ECOG-ACRIN Biostatistics Center, Boston, MA, USA
| | - Leon Lenchik
- Department of Radiology, Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA
| | - Robert Boutin
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Xin Yao
- ThedaCare Regional Cancer Center-Appelton, WI, USA
| | - Helga S Marques
- Department of Biostatistics and Center for Statistical Sciences, Brown University, Providence, RI, USA
| | - Dina Ioffe
- Department of Hematology and Oncology, Fox Chase Cancer Center, Temple University Health System, Philadelphia, PA, USA
| | - David B Zhen
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA, USA; Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Daneng Li
- Department of Medical Oncology & Therapeutics Research, City of Hope National Medical Center, Duarte, CA, USA
| | - Lynne I Wagner
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Melissa A Simon
- Department of Obstetrics and Gynecology, Center for Health Equity Transformation, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Terence Z Wong
- Department of Radiology, Division of Nuclear Medicine and Radiotheranostics, Duke University Medical Center, Durham, NC, USA
| | - Peter J O'Dwyer
- University of Pennsylvania and Abramson Cancer Center, Philadelphia, PA, USA
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19
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Singhal S, Walter LC, Smith AK, Loh KP, Cohen HJ, Zeng S, Shi Y, Boscardin WJ, Presley CJ, Williams GR, Magnuson A, Mohile SG, Wong ML. Change in four measures of physical function among older adults during lung cancer treatment: A mixed methods cohort study. J Geriatr Oncol 2023; 14:101366. [PMID: 36058839 PMCID: PMC9974579 DOI: 10.1016/j.jgo.2022.08.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/18/2022] [Accepted: 08/22/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Functional outcomes during non-small cell lung cancer (NSCLC) treatment are critically important to older adults. Yet, data on physical function and which measures best capture functional change remain limited. MATERIALS AND METHODS This multisite, mixed methods cohort study recruited adults ≥65 years with advanced NSCLC starting systemic treatment (i.e., chemotherapy, immunotherapy, and/or targeted therapy) with non-curative intent. Participants underwent serial geriatric assessments prior to starting treatment and at one, two, four, and six months, which included the Karnofsky Performance Scale (KPS, range: 0-100%), instrumental activities of daily living (IADL, range: 0-14), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Physical Functioning subscale (EORTC QLQ-C30 PF, range: 0-100), and Life-Space Assessment (LSA, range: 0-120). For all measures, higher scores represent better functioning. In a qualitative substudy, 20 patients completed semi-structured interviews prior to starting treatment and at two and six months to explore how treatment affected their daily functioning. We created joint displays for each interview participant that integrated their longitudinal KPS, IADL, EORTC QLQ-C30 PF, and LSA scores with patient quotes describing their function. RESULTS Among 87 patients, median age was 73 years (range 65-96). Mean pretreatment KPS score was 79% (standard deviation [SD] 13), EORTC QLQ-C30 PF was 69 (SD 23), and LSA was 67 (SD 28); median IADL was 13 (interquartile range [IQR] 10-14). At two months after treatment initiation, 70% of patients experienced functional decline on at least one measure, with only 13% of these patients recovering at six months. At two and six months, decline in LSA was the most common (48% and 35%, respectively). Joint displays revealed heterogeneity in how well each quantitative measure of physical function captured the qualitative patient experience. DISCUSSION Functional decline during NSCLC treatment is common among older adults. LSA is a useful measure to detect subtle functional decline that may be missed by other measures. Given heterogeneity in how well each quantitative measure captures changes in physical function, there is value to including more than one functional measure in geriatric oncology research studies.
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Affiliation(s)
- Surbhi Singhal
- Division of Medical Oncology, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Louise C Walter
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Alexander K Smith
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging & Human Development and Duke Cancer Institute, Duke University, Durham, NC, USA
| | - Sandra Zeng
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - W John Boscardin
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Carolyn J Presley
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Grant R Williams
- Divisions of Hematology/Oncology and Gerontology, Geriatrics, and Palliative Care, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Allison Magnuson
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Melisa L Wong
- Division of Geriatrics, University of California, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA; Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.
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20
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Cencini E, Tucci A, Puccini B, Cavallo F, Luminari S, Usai SV, Fabbri A, Pennese E, Marino D, Zilioli VR, Balzarotti M, Petrucci L, Tafuri A, Arcari A, Botto B, Zanni M, Hohaus S, Sartori R, Merli M, Gini G, Al Essa W, Musurca G, Tani M, Nassi L, Daffini R, Mammi C, Marcheselli L, Bocchia M, Spina M, Merli F. The elderly prognostic index predicts early mortality in older patients with diffuse large B-cell lymphoma. An ad hoc analysis of the elderly project by the Fondazione Italiana Linfomi. Hematol Oncol 2023; 41:78-87. [PMID: 36177902 DOI: 10.1002/hon.3081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/09/2022] [Accepted: 09/17/2022] [Indexed: 02/03/2023]
Abstract
The Elderly Prognostic Index (EPI) is based on the integration of a simplified geriatric assessment, hemoglobin levels and International Prognostic Index and has been validated to predict overall survival in older patients with diffuse large B-cell lymphoma (DLBCL). In this study, we evaluated the ability of EPI to predict the risk of early mortality. This study included all patients registered in the Elderly Project for whom treatment details and a minimum follow-up of 3 months were available. Three main treatment groups were identified based on the anthracycline amount administered: cases receiving >70% of the theoretical anthracyclines dose (Full Dose [FD] group), ≤70% (Reduced Dose [RD]) and palliative therapy (PT; no anthracyclines). The primary endpoint was early mortality rate, defined as death for any cause occurring within 90 days from diagnosis. We identified 1150 patients with a median age of 76 years (range 65-94). Overall, 69 early deaths were observed, accounting for 19% of all reported deaths. The cumulative rate of early mortality at 90 days was 6.0%. Comparing early with delayed deaths, we observed a lower frequency of deaths due to lymphoma progression (42% vs. 75%; p < 0.001) and a higher frequency due to toxicity and infections (22% vs. 4%, p < 0.001, and 22% vs. 3%, p < 0.001, respectively) for early events. A multivariable logistic analysis on 931 patients (excluding PT) confirmed an independent association of high-risk EPI (odds ratio [OR] 3.60; 95% confidence interval [CI] 1.15-11.2) and bulky disease (OR 2.08; 95% CI 1.09-3.97) with the risk of early mortality. The cumulative incidence of early mortality for older patients with DLBCL is not negligible and is mainly associated with non-lymphoma related events. For patients receiving anthracyclines, high-risk EPI and bulky disease are associated with a higher probability of early mortality.
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Affiliation(s)
- Emanuele Cencini
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Alessandra Tucci
- Hematology Division, ASST Spedali Civili Brescia, Brescia, Italy
| | - Benedetta Puccini
- Hematology Department, Careggi Hospital and University of Florence, Firenze, Italy
| | - Federica Cavallo
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino/AOU "Città della Salute e della Scienza di Torino", Torino, Italy
| | - Stefano Luminari
- Hematology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.,Department CHIMOMO, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Sara Veronica Usai
- Division of Hematology, Ospedale Oncologico Armando Businco, Cagliari, Italy
| | - Alberto Fabbri
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Elsa Pennese
- Lymphoma Unit, Department of Hematology, Ospedale Spirito Santo, Pescara, Italy
| | - Dario Marino
- Oncology 1 Unit, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | | | - Monica Balzarotti
- Department of Medical Oncology and Hematology, IRCCS Humanitas Research Hospital, Milano, Italy
| | - Luigi Petrucci
- Insitute of Hematology, Department of Tanslational and Precision Medicine "La Sapienza", University of Roma, Roma, Italy
| | - Agostino Tafuri
- Hematology, University Hospital S.Andrea-Sapienza, Roma, Italy
| | - Annalisa Arcari
- Hematology Unit, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Barbara Botto
- Division of Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Manuela Zanni
- Hematology Unit, Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Stefan Hohaus
- University Policlinico Gemelli Foundation-IRCCS, Catholic University of Sacred Heart, Roma, Italy
| | - Roberto Sartori
- Oncohematology Unit, Veneto Institute of Oncology, IOV-IRCCS, Padova, Italy
| | - Michele Merli
- Division of Hematology, Ospedale di Circolo e Fondazione Macchi - ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Guido Gini
- Clinic of Hematology AOU Ospedali Riuniti Ancona, Università Politecnica delle Marche, Ancona, Italy
| | - Wael Al Essa
- Division of Hematology, Department of Translational Medicine, Amedeo Avogadro University of Eastern Piedmont, and Azienda Ospedaliero-Universitaria Maggiore della Carità Novara, Novara, Italy
| | - Gerardo Musurca
- Hematology Unit, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) "Dino Amadori", Meldola, Italy
| | - Monica Tani
- Hematology Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Luca Nassi
- Hematology Department, Careggi Hospital and University of Florence, Firenze, Italy
| | - Rosa Daffini
- Hematology Division, ASST Spedali Civili Brescia, Brescia, Italy
| | - Caterina Mammi
- Gruppo Amici dell'Ematologia GRADE-Onlus Foundation, Reggio Emilia, Italy
| | | | - Monica Bocchia
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Michele Spina
- Division of Medical Oncology and Immunerelated Tumors, Centro di Riferimento Oncologico di Aviano (CRO), IRCCS, Aviano, Italy
| | - Francesco Merli
- Hematology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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21
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Platt JR, Todd OM, Hall P, Craig Z, Quyn A, Seymour M, Braun M, Roodhart J, Punt C, Christou N, Taieb J, Karoui M, Brown J, Cairns DA, Morton D, Gilbert A, Seligmann JF. FOxTROT2: innovative trial design to evaluate the role of neoadjuvant chemotherapy for treating locally advanced colon cancer in older adults or those with frailty. ESMO Open 2023; 8:100642. [PMID: 36549127 PMCID: PMC9800329 DOI: 10.1016/j.esmoop.2022.100642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/19/2022] [Accepted: 10/21/2022] [Indexed: 12/24/2022] Open
Abstract
Treating older adults with cancer is increasingly important in modern oncology practice. However, we currently lack the high-quality evidence needed to guide optimal management of this heterogeneous group. Principally, historic under-recruitment of older adults to clinical trials limits our understanding of how existing evidence can be applied to this group. Such uncertainty is particularly prevalent in the management of colon cancer (CC). With CC being most common in older adults, many patients also suffer from frailty, which is recognised as being strongly associated with poor clinical outcomes. Conducting clinical trials in older adults presents several major challenges, many of which impact the clinical relevance of results to a real-world population. When considering this heterogeneous group, it may be difficult to define the target population, recruit participants effectively, choose an appropriate trial design, and ensure participants remain engaged with the trial during follow-up. Furthermore, after overcoming these challenges, clinical trials tend to enrol highly selected patient cohorts that comprise only the fittest older patients, which are not representative of the wider population. FOxTROT1 was the first phase III randomised controlled trial to illustrate the benefit of neoadjuvant chemotherapy (NAC) in the treatment of CC. Patients receiving NAC had greater 2-year disease-free survival compared to those proceeding straight to surgery. Outcomes for older adults in FOxTROT1 were similarly impressive when compared to their younger counterparts. Yet, this group inevitably represents a fitter subgroup of the older patient population. FOxTROT2 has been designed to investigate NAC in a full range of older adults with CC, including those with frailty. In this review, we describe the key challenges to conducting a robust clinical trial in this heterogeneous patient group, highlight our strategies for overcoming these challenges in FOxTROT2, and explain how we hope to provide clarity on the optimal treatment of CC in older adults.
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Affiliation(s)
- J R Platt
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds. https://twitter.com/Jplatt_19
| | - O M Todd
- Academic Unit for Ageing and Stroke Research, University of Leeds, Leeds. https://twitter.com/ToddOly
| | - P Hall
- University of Edinburgh Cancer Research Centre, Edinburgh
| | - Z Craig
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - A Quyn
- The John Goligher Colorectal Surgery Unit, St James's University Hospital, The Leeds Teaching Hospitals NHS Trust, Leeds
| | - M Seymour
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds
| | - M Braun
- Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester; School of Medical Sciences, University of Manchester, Manchester, UK
| | - J Roodhart
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht
| | - C Punt
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - N Christou
- Department of Digestive Surgery, University Hospital of Limoges, Limoges. https://twitter.com/CNikinc
| | - J Taieb
- Department of Gastroenterology and Digestive Oncology, Georges Pompidou European Hospital, Assistance publique-Hôpitaux de Paris, Sorbonne Paris Cité, University Paris-Cité (Paris Descartes), Paris
| | - M Karoui
- Department of Digestive and Oncological Surgery, Georges Pompidou European Hospital, Assistance publique-Hôpitaux de Paris, Paris Cité University, Paris, France
| | - J Brown
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - D A Cairns
- Leeds Cancer Research UK Clinical Trials Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds. https://twitter.com/kennycairns
| | - D Morton
- Institute of Cancer and Genomic Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - A Gilbert
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds
| | - J F Seligmann
- Department of Oncology, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds.
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22
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Garner WB, Smith BD, Ludmir EB, Wakefield DV, Shabason J, Williams GR, Martin MY, Wang Y, Ballo MT, VanderWalde NA. Predicting future cancer incidence by age, race, ethnicity, and sex. J Geriatr Oncol 2023; 14:101393. [PMID: 36692964 DOI: 10.1016/j.jgo.2022.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 10/04/2022] [Accepted: 10/12/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Cancer remains a substantial burden on society. Our objective was to update projections on the number of new cancer diagnoses in the United States by age, race, ethnicity, and sex through 2040. MATERIALS AND METHODS Population-based cancer incidence data were obtained using Surveillance, Epidemiology, and End Results (SEER) data. Population estimates were made using the 2010 US Census data population projections to calculate future cancer incidence. Trends in age-adjusted incidence rates for 23 cancer types along with total cancers were calculated and incorporated into a second projection model. RESULTS If cancer incidence remains stable, annual cancer diagnoses are projected to increase by 29.5% from 1.86 million to 2.4 million between 2020 and 2040. This increase outpaces the projected US population growth of 12.3% over the same period. The population of older adults is projected to represent an increasing proportion of total cancer diagnoses with patients ≥65 years old comprising 69% of all new cancer diagnoses and patients ≥85 years old representing 13% of new diagnoses by 2040. Cancer diagnoses are projected to increase in racial minority groups, with a projected 44% increase in Black Americans (from 222,000 to 320,000 annually), and 86% in Hispanic Americans (from 175,000 to 326,000 annually). DISCUSSION The landscape of cancer care will continue to change over the next several decades. The burden of disease will remain substantial, and the growing proportion of older and minority patients with cancer remains of particular interest. These projections should help guide future health policy and research priorities.
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Affiliation(s)
- Wesley B Garner
- Department of Radiation Oncology, West Cancer Center, Memphis, TN, United States of America; Department of Radiation Oncology, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | - Benjamin D Smith
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Ethan B Ludmir
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Daniel V Wakefield
- Department of Radiation Oncology, West Cancer Center, Memphis, TN, United States of America; Department of Radiation Oncology, University of Tennessee Health Science Center, Memphis, TN, United States of America; Harvard T.H. Chan School of Public Health, Boston, MA, United States of America
| | - Jacob Shabason
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Grant R Williams
- Division of Hematology/Oncology, University of Alabama Birmingham, Birmingham, AL, United States of America
| | - Michelle Y Martin
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States of America
| | - Yuefeng Wang
- Department of Radiation Oncology, West Cancer Center, Memphis, TN, United States of America
| | - Matthew T Ballo
- Department of Radiation Oncology, West Cancer Center, Memphis, TN, United States of America
| | - Noam A VanderWalde
- Department of Radiation Oncology, West Cancer Center, Memphis, TN, United States of America; Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN, United States of America.
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23
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Freedman RA, Li T, Sedrak MS, Hopkins JO, Tayob N, Faggen MG, Sinclair NF, Chen WY, Parsons HA, Mayer EL, Lange PB, Basta AS, Perilla-Glen A, Lederman RI, Wong A, Tiwari A, McAllister SS, Mittendorf EA, Miller PG, Gibson CJ, Burstein HJ. 'ADVANCE' (a pilot trial) ADjuVANt chemotherapy in the elderly: Developing and evaluating lower-toxicity chemotherapy options for older patients with breast cancer. J Geriatr Oncol 2023; 14:101377. [PMID: 36163163 PMCID: PMC10080267 DOI: 10.1016/j.jgo.2022.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/08/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Older adults with breast cancer receiving neo/adjuvant chemotherapy are at high risk for poor outcomes and are underrepresented in clinical trials. The ADVANCE (ADjuVANt Chemotherapy in the Elderly) trial evaluated the feasibility of two neo/adjuvant chemotherapy regimens in parallel-enrolling cohorts of older patients with human epidermal growth factor receptor 2-negative breast cancer: cohort 1-triple-negative; cohort 2-hormone receptor-positive. MATERIALS AND METHODS Adults age ≥ 70 years with stage I-III breast cancer warranting neo/adjuvant chemotherapy were enrolled. Cohort 1 received weekly carboplatin (area under the curve 2) and weekly paclitaxel 80 mg/m2 for twelve weeks; cohort 2 received weekly paclitaxel 80 mg/m2 plus every-three-weekly cyclophosphamide 600 mg/m2 over twelve weeks. The primary study endpoint was feasibility, defined as ≥80% of patients receiving ≥80% of intended weeks/doses of therapy. All dose modifications were applied per clinician discretion. RESULTS Forty women (n = 20 per cohort) were enrolled from March 25, 2019 through August 3, 2020 from three centers; 45% and 35% of patients in cohorts 1 and 2 were age > 75, respectively. Neither cohort achieved targeted thresholds for feasibility. In cohort 1, eight (40.0%) met feasibility (95% confidence interval [CI] = 19.1-63.9%), while ten (50.0%) met feasibility in cohort 2 (95% CI = 27.2-72.8). Neutropenia was the most common grade 3-4 toxicity (cohort 1-65%, cohort 2-55%). In cohort 1, 80% and 85% required ≥1 dose holds of carboplatin and/or paclitaxel, respectively. In cohort 2, 10% required dose hold(s) for cyclophosphamide and/or 65% for paclitaxel. DISCUSSION In this pragmatic pilot examining chemotherapy regimens in older adults with breast cancer, neither regimen met target goals for feasibility. Developing efficacious and tolerable regimens for older patients with breast cancer who need chemotherapy remains an important goal. CLINICALTRIALS gov Identifier: NCT03858322.
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Affiliation(s)
- Rachel A Freedman
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| | - Tianyu Li
- Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Judith O Hopkins
- Novant Health Cancer Institute / SCOR NCORP, Winston Salem, NC, USA
| | - Nabihah Tayob
- Harvard Medical School, Boston, MA, USA; Department of Data Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Meredith G Faggen
- Dana-Farber Brigham Cancer Center at South Shore Hospital, South Weymouth, MA, USA
| | - Natalie F Sinclair
- Dana-Farber Brigham Cancer Center at Milford Regional Medical Center, Milford, MA, USA
| | - Wendy Y Chen
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Heather A Parsons
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Erica L Mayer
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Paulina B Lange
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ameer S Basta
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Ruth I Lederman
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Andrew Wong
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Abhay Tiwari
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Sandra S McAllister
- Harvard Medical School, Boston, MA, USA; Hematology Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Stem Cell Institute, Cambridge, MA, USA; Broad Institute of the Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA
| | - Elizabeth A Mittendorf
- Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter G Miller
- Harvard Medical School, Boston, MA, USA; Broad Institute of the Massachusetts Institute of Technology and Harvard University, Cambridge, MA, USA; Center for Cancer Research, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher J Gibson
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Harold J Burstein
- Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA; Breast Oncology Program, Dana-Farber Brigham Cancer Center, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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Kimmick G, Sedrak MS, Williams G, McCleary NJ, Rosko AE, Berenberg JL, Freedman RA, Smith ML, Ahmed A, Muss HB, Chow S, Dale W. Infrastructure to Support Accrual of Older Adults to National Cancer Institute Clinical Trials. J Natl Cancer Inst Monogr 2022; 2022:151-158. [PMID: 36519814 PMCID: PMC9753220 DOI: 10.1093/jncimonographs/lgac025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/30/2022] [Accepted: 10/27/2022] [Indexed: 12/23/2022] Open
Abstract
As part of ongoing efforts to meaningfully improve recruitment, enrollment, and accrual of older adults into cancer clinical trials, the National Cancer Institute (NCI) sponsored a workshop with experts across the country entitled Engaging Older Adults in the NCI Clinical Trials Network: Challenges and Opportunities. Three working groups, including Study Design, Infrastructure, and Stakeholders, were formed, who worked together to offer synergistic improvements in the system. Here, we summarize the workshop discussions of the Infrastructure Working Group, whose goal was to address infrastructural challenges, identify underlying resources, and offer solutions to facilitate accrual of older adults into cancer clinical trials. Based on preconference work and workshop discussions, four key recommendations to strengthen NCI infrastructure were proposed: 1) further centralize resources and expertise; 2) provide training for clinical research staff; (3) develop common data elements; and 4) evaluate what works and does not work. These recommendations provide a strategy to improve the infrastructure to enroll more older adults in cancer clinical trials.
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Affiliation(s)
- Gretchen Kimmick
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center/Duke Cancer Institute, Durham, NC, USA
| | - Mina S Sedrak
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Grant Williams
- Institute for Cancer Outcomes & Survivorship and Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nadine J McCleary
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ashley E Rosko
- Department of Internal Medicine, Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Jeffrey L Berenberg
- Department of Medicine, Division of Medical Oncology, Hawaii Minority Underserved National Cancer Institute Community Oncology Research Program, Honolulu, HI, USA
| | - Rachel A Freedman
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Amina Ahmed
- Department of Obstetrics and Gynecology, Division of Gyn Oncology, Rush University Medical Center, Chicago, IL, USA
| | - Hyman B Muss
- Lineberger Comprehensive Cancer Center, Division of Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Selina Chow
- Department of Medicine, Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA
| | - William Dale
- Department of Supportive Care Medicine, City of Hope, Duarte, CA, USA
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25
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Magnuson A, Van der Walde N, McKoy JM, Wildes TM, Wong ML, Le-Rademacher J, Little RF, Klepin HD. Integrating Geriatric Assessment Measures into National Cancer Institute Clinical Trials. J Natl Cancer Inst Monogr 2022; 2022:142-150. [PMID: 36519816 PMCID: PMC9949568 DOI: 10.1093/jncimonographs/lgac021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 12/23/2022] Open
Abstract
To improve the care of older adults with cancer, the traditional approach to clinical trial design needs to be reconsidered. Older adults are underrepresented in clinical trials with limited or no information on geriatric-specific factors, such as cognition or comorbidities. To address this knowledge gap and increase relevance of therapeutic clinical trial results to the real-life population, integration of aspects relevant to older adults is needed in oncology clinical trials. Geriatric assessment (GA) is a multidimensional tool comprising validated measures assessing specific health domains that are more frequently affected in older adults, including aspects related to physical function, comorbidity, medication use (polypharmacy), cognitive and psychological status, social support, and nutritional status. There are several mechanisms for incorporating either the full GA or specific GA measures into oncology therapeutic clinical trials to contribute to the overarching goal of the trial. Mechanisms include utilizing GA measures to better characterize the trial population, define trial eligibility, allocate treatment receipt within the context of the trial, develop predictive models for treatment outcomes, guide supportive care strategies, personalize care delivery, and assess longitudinal changes in GA domains. The objective of this manuscript is to review how GA measures can contribute to the overall goal of a clinical trial, to provide a framework to guide the selection and integration of GA measures into clinical trial design, and ultimately enable accrual of older adults to clinical trials by facilitating the design of trials tailored to older adults treated in clinical practice.
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Affiliation(s)
- Allison Magnuson
- Department of Medicine, University of Rochester Medical Center, Wilmot Cancer Institute, Rochester, NY, USA
| | - Noam Van der Walde
- Department of Radiation Oncology, West Cancer Center and Research Institute, University of Tennessee Health Science Center, Germantown, TN, USA
| | - June M McKoy
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Tanya M Wildes
- Division of Hematology and Oncology, Department of Internal Medicine, University of Nebraska Medical Center, Nebraska Medicine, Omaha, NE, USA
| | - Melisa L Wong
- Divisions of Hematology and Oncology and Geriatrics, Department of Internal Medicine, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, USA
| | | | - Richard F Little
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Heidi D Klepin
- Correspondence to: Heidi D. Klepin, MD, MS, Section on Hematology and Oncology, Department of Internal Medicine, Wake Forest School of Medicine, Medical Center Blvd, Winston Salem, NC 27157, USA (e-mail: )
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Clinical Dilemmas in the Treatment of Elderly Patients Suffering from Hodgkin Lymphoma: A Review. Biomedicines 2022; 10:biomedicines10112917. [PMID: 36428485 PMCID: PMC9687245 DOI: 10.3390/biomedicines10112917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/02/2022] [Accepted: 11/03/2022] [Indexed: 11/16/2022] Open
Abstract
Elderly patients make up a significant number of cases of newly diagnosed Hodgkin lymphoma. However, unlike in young patients, the outcomes of elderly patients are poor, and they are under-represented in phase III trials. Prior to treatment initiation, geriatric assessment should ideally be performed to address the patient's fitness and decide whether to pursue a curative or palliative approach. The ABVD regimen is poorly tolerated in unfit patients, with high treatment-related mortality. Alternative chemotherapy approaches have been explored, with mixed results obtained concerning their feasibility and toxicity in phase II trials. The introduction of brentuximab vedotin-based regimens led to a paradigm shift in first- and further-line treatment of elderly Hodgkin lymphoma patients, providing adequate disease control within a broader patient population. As far as checkpoint inhibitors are concerned, we are only just beginning to understand the role in the treatment of this population. In relapsed/refractory settings there are few options, ranging from autologous stem cell transplantation in selected patients to pembrolizumab, but unfortunately, palliative care is the most common modality. Importantly, published studies are frequently burdened with numerous biases (such as low numbers of patients, selection bias and lack of geriatric assessment), leading to low level of evidence. Furthermore, there are few ongoing studies on this topic. Thus, elderly Hodgkin lymphoma patients are hard to treat and represent an unmet need in hematologic oncology. In conclusion, treatment needs to be personalized and tailored on a case-by-case basis. In this article, we outline treatment options for elderly Hodgkin lymphoma patients.
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Zurlo IV, Pozzo C, Strippoli A, Mignogna S, Basso M, Vivolo R, Trovato G, Ciaburri M, Morelli F, Bria E, Leo S, Tortora G. Safety and Efficacy of a First-Line Chemotherapy Tailored by G8 Score in Elderly Metastatic or Locally Advanced Gastric and Gastro-Esophageal Cancer Patients: A Real-World Analysis. Geriatrics (Basel) 2022; 7:geriatrics7050107. [PMID: 36286210 PMCID: PMC9601931 DOI: 10.3390/geriatrics7050107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/12/2022] [Accepted: 09/23/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: Gastric (GC) and gastro-esophageal cancer (GEC) are common neoplasms in the elderly. However, in clinical practice, the correct strategy for elderly patients who might benefit from chemotherapy (CT) is unknown. Prospective data are still poor. In this context, we performed a retrospective analysis of GC patients aged ≥75 years and treated at our institutions. Material and Methods: We retrospectively analyzed 90 patients with confirmed metastatic GC or GEC, treated with an upfront CT. Inclusion criteria were patients aged ≥75 years, PS 0−2, normal bone marrow/liver/renal function and no major comorbidities. All patients received a G8 score, and some patients with G8 ≤14 received a comprehensive geriatric assessment (CGA). The primary goal was to perform a safety evaluation based on the incidence of adverse events (AE), and the secondary goal was to determine the efficacy (PFS and OS). The chi-square test and the Kaplan−Meier method were used to estimate the outcomes. The statistical significance level was set at p < 0.05. Results: Toxicity rates were quite low: G1/G2 (51.1%) and G3/G4 (25.5%). No toxic deaths were reported. The median PFS was 6.21 months and the median OS 11 months. The G8 score and PS ECOG significantly influenced both PFS and OS. A statistically significant correlation among G8, weight loss, hypoalbuminemia and risk of G3/G4 adverse events was also found. Conclusion: Our research on selected elderly patients did not detect broad differences of efficacy and tolerability compared to a young population. Our study, although retrospective and small-sized, showed that G8 score might be an accurate tool to identify elderly GC/GEC patients who could be safely treated with CT, further recognizing patients who could receive a doublet CT and who may require a single agent chemotherapy or a baseline dose reduction.
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Affiliation(s)
- Ina Valeria Zurlo
- Medical Oncology Unit, “Vito Fazzi” Hospital, 73100 Lecce, Italy
- Correspondence:
| | - Carmelo Pozzo
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Antonia Strippoli
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | | | - Michele Basso
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Raffaella Vivolo
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Giovanni Trovato
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Michele Ciaburri
- Geriatric Unit, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Franco Morelli
- Medical Oncology Unit, Gemelli Molise, 86100 Campobasso, Italy
| | - Emilio Bria
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
| | - Silvana Leo
- Medical Oncology Unit, “Vito Fazzi” Hospital, 73100 Lecce, Italy
| | - Giampaolo Tortora
- Medical Oncology Unit, Comprehensive Cancer Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, 00168 Rome, Italy
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Williams GR, Dai C, Giri S, Al-Obaidi M, Harmon C, Kenzik KM, McDonald A, Gbolahan O, Outlaw D, Khushman M, Richman J, Bhatia S. Geriatric Assessment Predictors of 1-Year Mortality in Older Adults With GI Malignancies: A Survival Tree Analysis. JCO Clin Cancer Inform 2022; 6:e2200065. [PMID: 36070529 PMCID: PMC9470132 DOI: 10.1200/cci.22.00065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 06/13/2022] [Accepted: 07/25/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Identifying older patients with GI malignancies who are at increased risk of mortality remains challenging. The goal of our study was to examine geriatric assessment (GA) predictors of 1-year mortality and explore the use of a survival tree analysis in a prospective cohort of older adults (≥ 60 years) with newly diagnosed GI malignancies. METHODS Survival tree analysis was performed to understand variable interactions and identify predictors of overall survival, computed from time of GA to death or last follow-up. Cox regression was used to estimate associations of 1-year mortality, first using a base model (age, race, cancer stage, cancer risk group, and planned chemotherapy), then using all significant predictors from the univariable analyses, and finally only those identified in survival tree analysis. RESULTS A total of 478 participants met eligibility, with a mean age of 70 years. The survival tree analysis identified nutrition, cancer stage, physical and emotional health, age, and functional status as predictors of mortality. Older patients without malnutrition or depression had the best 1-year survival, whereas those with malnutrition, stage IV disease, and functional limitations had the worst 1-year survival. Our base model demonstrated good discrimination (area under curve [AUC] 0.76) but was improved with the addition of GA variables (AUC 0.82) or from survival tree analysis (AUC 0.82). CONCLUSION Measures of function, nutrition, and mental health are important predictors of mortality in older adults with GI cancers. Using GA as part of clinical management can aid in the prediction of survival and help inform treatment decision making.
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Affiliation(s)
- Grant R. Williams
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Chen Dai
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Smith Giri
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Mustafa Al-Obaidi
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Christian Harmon
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Kelly M. Kenzik
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Andrew McDonald
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Olumide Gbolahan
- Division of Hematology/Oncology, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Darryl Outlaw
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Moh'd Khushman
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Joshua Richman
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
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29
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Rier HN, Meinardi MC, van Rosmalen J, Westerweel PE, de Jongh E, Kitzen JJEM, van den Bosch J, Trajkovic M, Levin MD. Association Between Geriatric Assessment and Post-Chemotherapy Functional Status in Older Patients with Cancer. Oncologist 2022; 27:e878-e888. [PMID: 35861263 PMCID: PMC9632320 DOI: 10.1093/oncolo/oyac131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 06/15/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Maintaining functional status is among the most important patient-centered outcomes for older adults with cancer. This study investigated the association between comprehensive geriatric assessment (CGA) and progressive disease or decline of IADL-independence 1 year after chemotherapy, overall survival (OS), and premature termination of chemotherapy. CGA-based functional status and quality of life (QOL) 1 year after chemotherapy are also described. METHODS This prospective cohort study involved patients aged ≥65 years treated with chemotherapy for any cancer type. CGA and the G8-screening tool were performed before and after the completion of chemotherapy. Analyses were adjusted for tumor type and treatment intent: (a) indolent hematological malignancies, (b) aggressive hematological malignancies, c) solid malignancies treated with curative intent, and (d) solid malignancies treated with palliative intent. RESULTS All 291 included patients lived in The Netherlands; 193 (67.4%) lived fully independent prior to chemotherapy. The median age was 72 years; 164 (56.4%) were male. IADL independence, CGA-based functional status, and QOL were maintained in half of the patients 1 year after chemotherapy. An abnormal G8-score before chemotherapy was a higher risk for progressive disease or a decline of IADL-independence (OR 3.60, 95% CI, 1.98-6.54, P < .0001), prematurely terminated chemotherapy (OR 2.12, 95% CI, 1.24-3.65, P = .006), and shorter median OS (HR 1.71, 95% CI, 1.16-2.52, P = .007). The impact of an abnormal G8-score differed across tumor type (oncological or hematological) and treatment indication (adjuvant or palliative). CONCLUSION An abnormal G8 score before chemotherapy is associated with progressive disease and functional decline after chemotherapy and shorter median OS, especially in patients with solid malignancies.
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Affiliation(s)
- Hánah N Rier
- Corresponding author: Hánah N. Rier, MD, PhD, Department of Internal Medicine, Albert Schweitzer Hospital, Albert Schweitzerplaats 25, 3314 AT Dordrecht, The Netherlands. Tel: +31 621645973;
| | - Marieke C Meinardi
- Department of Geriatric Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands,Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Peter E Westerweel
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Eva de Jongh
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Jos J E M Kitzen
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Joan van den Bosch
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Marija Trajkovic
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Mark-David Levin
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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30
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Alfano CM, Oeffinger K, Sanft T, Tortorella B. Engaging TEAM Medicine in Patient Care: Redefining Cancer Survivorship From Diagnosis. Am Soc Clin Oncol Educ Book 2022; 42:1-11. [PMID: 35649204 DOI: 10.1200/edbk_349391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
New approaches to cancer survivorship care must address the rising number of survivors who need complex care; the need to personalize care to improve health equity; workforce shortages and clinician knowledge deficits about the long-term and late effects of cancer; the need to engage and coordinate oncology, primary care, and a large multidisciplinary team of subspecialists and programs to meet survivors' needs; and the need to control costs and deliver better value. This review proposes eight core tenets of an evolved standard of care to meet these needs by starting at diagnosis and continuing throughout oncology and into follow-up to: (1) facilitate team medicine by connecting oncology, primary care, subspecialists and programs, researchers, and patients and caregivers; (2) educate patients and support them in self-management; (3) mitigate toxicities; (4) manage comorbidities; (5) promote healthy behaviors and wellness; (6) improve health equity; (7) provide clear personalized follow-up; and (8) provide ongoing opportunities for participation in research as the standard of care. Strategies to successfully implement this care are discussed from the perspectives of oncology, primary care, and health care administration.
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Affiliation(s)
- Catherine M Alfano
- Northwell Health Cancer Institute, New York, NY.,Institute of Health System Science, Feinstein Institutes for Medical Research, New York, NY
| | - Kevin Oeffinger
- Duke University, Durham, NC.,Duke Cancer Institute, Durham, NC
| | - Tara Sanft
- Smilow Cancer Hospital at Yale New Haven, Yale Cancer Center, New Haven, CT
| | - Brooke Tortorella
- Northwell Health Cancer Institute, New York, NY.,Institute of Health System Science, Feinstein Institutes for Medical Research, New York, NY
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31
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Rosati G. Learning to Care for the Older People: An Urgent Need in the Daily Practice of Oncologists. J Clin Med 2022; 11:jcm11113149. [PMID: 35683536 PMCID: PMC9181090 DOI: 10.3390/jcm11113149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 05/30/2022] [Indexed: 12/21/2022] Open
Affiliation(s)
- Gerardo Rosati
- Medical Oncology Unit, "San Carlo" Hospital, 85100 Potenza, Italy
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32
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Cole A, Richardson DR, Adapa K, Khasawneh A, Crossnohere N, Bridges JFP, Mazur L. Development of a patient-centered preference tool for patients with hematologic malignancies: protocol for a mixed methods study (Preprint). JMIR Res Protoc 2022; 11:e39586. [PMID: 35767340 PMCID: PMC9280452 DOI: 10.2196/39586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 05/25/2022] [Accepted: 05/26/2022] [Indexed: 11/18/2022] Open
Abstract
Background The approval of novel therapies for patients diagnosed with hematologic malignancies have improved survival outcomes but increased the challenge of aligning chemotherapy choices with patient preferences. We previously developed paper versions of a discrete choice experiment (DCE) and a best-worst scaling (BWS) instrument to quantify the treatment outcome preferences of patients with hematologic malignancies to inform shared decision making. Objective We aim to develop an electronic health care tool (EHT) to guide clinical decision making that uses either a BWS or DCE instrument to capture patient preferences. The primary objective of this study is to use both qualitative and quantitative methods to evaluate the perceived usability, cognitive workload (CWL), and performance of electronic prototypes that include the DCE and BWS instrument. Methods This mixed methods study includes iterative co-design methods that will involve healthy volunteers, patient-caregiver pairs, and health care workers to evaluate the perceived usability, CWL, and performance of tasks within distinct prototypes. Think-aloud sessions and semistructured interviews will be conducted to collect qualitative data to develop an affinity diagram for thematic analysis. Validated assessments (Post-Study System Usability Questionnaire [PSSUQ] and the National Aeronautical and Space Administration’s Task Load Index [NASA-TLX]) will be used to evaluate the usability and CWL required to complete tasks within the prototypes. Performance assessments of the DCE and BWS will include the evaluation of tasks using the Single Easy Questionnaire (SEQ), time to complete using the prototype, and the number of errors. Additional qualitative assessments will be conducted to gather participants’ feedback on visualizations used in the Personalized Treatment Preferences Dashboard that provides a representation of user results after completing the choice tasks within the prototype. Results Ethical approval was obtained in June 2021 from the Institutional Review Board of the University of North Carolina at Chapel Hill. The DCE and BWS instruments were developed and incorporated into the PRIME (Preference Reporting to Improve Management and Experience) prototype in early 2021 and prototypes were completed by June 2021. Heuristic evaluations were conducted in phase 1 and completed by July 2021. Recruitment of healthy volunteers began in August 2021 and concluded in September 2021. In December 2021, our findings from phase 2 were accepted for publication. Phase 3 recruitment began in January 2022 and is expected to conclude in September 2022. The data analysis from phase 3 is expected to be completed by November 2022. Conclusions Our findings will help differentiate the usability, CWL, and performance of the DCE and BWS within the prototypes. These findings will contribute to the optimization of the prototypes, leading to the development of an EHT that helps facilitate shared decision making. This evaluation will inform the development of EHTs to be used clinically with patients and health care workers. International Registered Report Identifier (IRRID) DERR1-10.2196/39586
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Affiliation(s)
- Amy Cole
- Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Daniel R Richardson
- University of North Carolina Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Karthik Adapa
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Amro Khasawneh
- Industrial Engineering Department, School of Engineering, Mercer University, Macon, GA, United States
| | - Norah Crossnohere
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Lukasz Mazur
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Webb T, Verduzco-Aguirre HC, Rao AR, Ramaswamy A, Noronha V. Addressing the Needs of Older Adults With Cancer in Low- and Middle-Income Settings. Am Soc Clin Oncol Educ Book 2022; 42:1-10. [PMID: 35427187 DOI: 10.1200/edbk_349829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The number of older adults in the world is projected to increase steeply over the next 30 years; most older adults will live in low- and middle-income countries. This will have a direct impact on the global cancer burden, as cancer is largely a disease of aging. A revolution in the way we care for older adults in low- and middle-income settings is needed to meet rapidly rising demands. Regardless of a nation's relative wealth or resources, implementing the geriatric assessment in cancer care has presented a challenge because of omission of the principles of geriatric oncology from formal training and continuing education, lack of time, and a shortage of qualified personnel. To meet the challenge of caring for older adults globally, we must: (1) re-imagine aging-focused training for providers and nurses, (2) create and strengthen collaborations/partnerships between geriatric oncology teams and aging-service organizations, and (3) increase advocacy for age-friendly health care policy. By harnessing technology, the reach of specialized oncology education and care can be extended even-or especially-to low- and middle-income settings.
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Affiliation(s)
- Tracy Webb
- Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC
| | | | - Abhijith Rajaram Rao
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Anant Ramaswamy
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Vanita Noronha
- Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Geriatric assessment for older adults receiving less intensive therapy for acute myeloid leukemia: Report of CALGB 361101. Blood Adv 2022; 6:3812-3820. [PMID: 35420672 PMCID: PMC9631575 DOI: 10.1182/bloodadvances.2021006872] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/29/2022] [Indexed: 11/20/2022] Open
Abstract
Baseline geriatric assessment measures are associated with survival among older AML patients treated with nonintensive chemotherapy. Baseline global quality of life is associated with survival among older AML patients treated with nonintensive chemotherapy.
Geriatric assessment (GA) predicts survival among older adults with acute myeloid leukemia (AML) treated intensively. We evaluated the predictive utility of GA among older adults treated with low-intensity therapy on a multisite trial. We conducted a companion study (CALGB 361101) to a randomized phase 2 trial (CALGB 11002) of adults ≥60 years and considered “unfit” for intensive therapy, testing the efficacy of adding bortezomib to decitabine therapy. On 361101, GA and quality of life (QOL) assessment was administered prior to treatment and every other subsequent cycle. Relationships between baseline GA and QOL measures with survival were evaluated using Kaplan-Meier estimation and Cox proportional hazards models. One-hundred sixty-five patients enrolled in CALGB 11002, and 96 (52%) of them also enrolled in 361101 (median age, 73.9 years). Among participants, 85.4% completed ≥1 baseline assessment. In multivariate analyses, greater comorbidity (hematopoietic cell transplantation-specific comorbidity index >3), worse cognition (Blessed Orientation-Memory-Concentration score >4), and lower European Organization for Research and Treatment of Cancer global QOL scores at baseline were significantly associated with shorter overall survival (P < .05 each) after adjustment for Karnofsky Performance Status, age, and treatment arm. Dependence in instrumental activities of daily living and cognitive impairment were associated with 6-month mortality (hazard ratio [HR], 3.5; confidence interval [CI], 1.2-10.4; and HR, 3.1; CI, 1.1-8.6, respectively). GA measures evaluating comorbidity, cognition, and self-reported function were associated with survival and represent candidate measures for screening older adults planned to receive lower-intensity AML therapies. This trial was registered at www.clinicaltrials.gov as #NCT01420926 (CALGB 11002).
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Williams GR, Al-Obaidi M, Harmon C, Dai C, Outlaw D, Gbolahan O, Khushman M, Nyrop KA, Gilmore N, Bhatia S, Giri S. Racial disparities in frailty and geriatric assessment impairments in older adults with cancer in the Deep South: Results from the CARE Registry. Cancer 2022; 128:2313-2319. [PMID: 35403211 PMCID: PMC9437907 DOI: 10.1002/cncr.34178] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/19/2021] [Accepted: 12/10/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Despite recent advances in cancer, racial disparities in treatment outcomes persist, and their mechanisms are still not fully understood. The objective of this study was to examine racial differences in frailty and geriatric assessment impairments in an unselected cohort of older adults with newly diagnosed gastrointestinal (GI) malignancies. METHODS This study used data from the Cancer and Aging Resilience Evaluation Registry, a prospective cohort study that enrolled older adults (≥60 years) with GI malignancies who were presenting for their initial consultation. Participants who had a geriatric assessment completed before chemotherapy initiation and self-reported as either White or Black were included. Frailty was defined with a frailty index based on the deficit accumulation method. The differences in the prevalence and adjusted odds ratios for frailty and geriatric assessment impairments between Black and White participants were examined. RESULTS Of the 710 eligible patients who were seen, 553 consented with sufficient data for analyses. The mean age at enrollment was 70 ± 7.1 years, 58% were male, and 23% were Black. Primary cancer diagnoses included colorectal cancer (32%), pancreatic cancer (27%), and hepatobiliary cancer (18%). Black participants were more likely to be frail (50.0% vs 32.7%; P < .001) and report limitations in activities of daily living (27.3% vs 14.1%; P = .001), instrumental activities of daily living (64.8% vs 47.3%; P = .002), and walking 1 block (62.5% vs 48.2%; P = .004). These associations persisted even after adjustments for age, sex, education, cancer type, cancer stage, and comorbidity. CONCLUSIONS Black participants were frailer and reported more limitations in function in comparison with White participants. These findings may partially explain disparities in cancer outcomes and warrant further examination.
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Affiliation(s)
- Grant R Williams
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mustafa Al-Obaidi
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Christian Harmon
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Chen Dai
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Darryl Outlaw
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama
| | - Olumide Gbolahan
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Moh'd Khushman
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kirsten A Nyrop
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Smita Bhatia
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Smith Giri
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama.,O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
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Weiss MC. Systemic Treatment of Soft Tissue Sarcomas in the Geriatric Population. Curr Treat Options Oncol 2022; 23:855-863. [PMID: 35389146 DOI: 10.1007/s11864-022-00972-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 11/24/2022]
Abstract
OPINION STATEMENT As the population ages, there will be an increase in the incidence and prevalence of soft tissue sarcoma (STS) within the geriatric population. As this disease disproportionately affects older adults, the percentage of adults >65 years old is expected to increase in the coming years. Geriatric patients are often more vulnerable to disease-related symptoms and have more difficulty tolerating treatment-related side effects. While there are no formal existing guidelines to direct the care of this geriatric patient population, it is of utmost importance to consider each patients' fitness and co-morbidities when selecting treatment plans. This review focuses on the current state of research of older adults with advanced or metastatic soft tissue sarcoma, highlighting the lack of representation of this patient population in clinical trials. Given that chronological age does not necessarily equate to physiologic age, integration of comprehensive geriatric and quality of life assessments is needed in the care of geriatric patients to help guide therapeutic decisions.
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Affiliation(s)
- Mia C Weiss
- Division of Medical Oncology, Washington University in St. Louis, St. Louis, MO, 63110, USA. .,Siteman Cancer Center, St. Louis, MO, 63110, USA.
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Skelly A, O'Donovan A. Recognizing Frailty in Radiation Oncology Clinical Practice: Current Evidence and Future Directions. Semin Radiat Oncol 2022; 32:115-124. [DOI: 10.1016/j.semradonc.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Kronfli D, Savla B, Lievers A, Baker K, Eggleston C, Miller R, Bentzen SM, Mohindra P, Vyfhuis MA. Identifying Psychosocial Needs of Cancer Patients Undergoing Curative Radiation Therapy in an Inner-City Academic Center to Address Racial Disparities. Int J Radiat Oncol Biol Phys 2022; 114:185-194. [DOI: 10.1016/j.ijrobp.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/17/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022]
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Bumanlag IM, Jaoude JA, Rooney MK, Taniguchi CM, Ludmir EB. Exclusion of Older Adults from Cancer Clinical Trials: Review of the Literature and Future Recommendations. Semin Radiat Oncol 2022; 32:125-134. [PMID: 35307114 PMCID: PMC8944215 DOI: 10.1016/j.semradonc.2021.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Isabela M Bumanlag
- The University of Texas, Anderson Cancer Center, Houston, TX.; The University of Texas Health Science Center, McGovern Medical School, Houston, TX
| | | | | | | | - Ethan B Ludmir
- The University of Texas, Anderson Cancer Center, Houston, TX..
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Presley CJ, Mohamed MR, Culakova E, Flannery M, Vibhakar PH, Hoyd R, Amini A, VanderWalde N, Wong ML, Tsubata Y, Spakowicz DJ, Mohile SG. A Geriatric Assessment Intervention to Reduce Treatment Toxicity Among Older Adults With Advanced Lung Cancer: A Subgroup Analysis From a Cluster Randomized Controlled Trial. Front Oncol 2022; 12:835582. [PMID: 35433441 PMCID: PMC9008713 DOI: 10.3389/fonc.2022.835582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 03/04/2022] [Indexed: 01/05/2023] Open
Abstract
Introduction More older adults die from lung cancer worldwide than breast, prostate, and colorectal cancers combined. Current lung cancer treatments may prolong life, but can also cause considerable treatment-related toxicity. Objective This study is a secondary analysis of a cluster-randomized clinical trial which evaluated whether providing a geriatric assessment (GA) summary and GA-guided management recommendations can improve grade 3-5 toxicity among older adults with advanced lung cancer. Methods We analyzed participants aged ≥70 years(y) with stage III & IV (advanced) lung cancer and ≥1 GA domain impairment starting a new cancer treatment with high-risk of toxicity within the National Cancer Institute's Community Oncology Research Program. Community practices were randomized to the intervention arm (oncologists received GA summary & recommendations) versus usual care (UC: no summary or recommendations given). The primary outcome was grade 3-5 toxicity through 3 months post-treatment initiation. Secondary outcomes included 6-month (mo) and 1-year overall survival (OS), treatment modifications, and unplanned hospitalizations. Outcomes were analyzed using generalized linear mixed and Cox proportional hazards models with practice site as a random effect. Trial Registration: NCT02054741. Results & Conclusion Among 180 participants with advanced lung cancer, the mean age was 76.3y (SD 5.1), 39.4% were female and 82.2% had stage IV disease. The proportion of patients who experienced grade 3-5 toxicity was significantly lower in the intervention arm vs UC (53.1% vs 71.6%, P=0.01). More participants in the intervention arm received lower intensity treatment at cycle 1 (56.3% vs 35.3%; P<0.01). Even with a cycle 1 dose reduction, OS at 6mo and 1 year was not significantly different (adjusted hazard ratio [HR] intervention vs. UC: 6mo HR=0.90, 95% CI: 0.52-1.57, P=0.72; 1 year HR=0.89, 95% CI: 0.58-1.36, P=0.57). Frequent toxicity checks, providing education and counseling materials, and initiating direct communication with the patient's primary care physician were among the most common GA-guided management recommendations. Providing a GA summary and management recommendations can significantly improve tolerability of cancer treatment among older adults with advanced lung cancer.
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Affiliation(s)
- Carolyn J. Presley
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Mostafa R. Mohamed
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
| | - Eva Culakova
- Department of Surgery, University of Rochester Cancer Center National Cancer Institute (NCI) Community Oncology Research Program (NCORP) Research Base, Rochester, NY, United States
| | - Marie Flannery
- Department of Radiation Oncology, School of Nursing, University of Rochester, Rochester, NY, United States
| | - Pooja H. Vibhakar
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Rebecca Hoyd
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Arya Amini
- Department of Radiation Oncology, City of Hope Comprehensive Cancer Center, Duarte, CA, United States
| | - Noam VanderWalde
- West Cancer Center & Research Institute, Memphis, TN, United States
| | - Melisa L. Wong
- Divisions of Hematology/Oncology and Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Yukari Tsubata
- Division of Medical Oncology and Respiratory Medicine, Department of Internal Medicine, Shimane University Faculty of Medicine, Izumo, Japan
| | - Daniel J. Spakowicz
- Division of Medical Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, United States
| | - Supriya G. Mohile
- Department of Medicine, University of Rochester Medical Center, Rochester, NY, United States
- Department of Surgery, University of Rochester Cancer Center National Cancer Institute (NCI) Community Oncology Research Program (NCORP) Research Base, Rochester, NY, United States
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Treatment of Metastatic Melanoma in the Elderly. Curr Oncol Rep 2022; 24:825-833. [PMID: 35316844 DOI: 10.1007/s11912-022-01257-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW This study aims to review the clinical experience of melanoma treatments in patients with advanced age. RECENT FINDINGS During the last decade, the treatment paradigm for melanoma has changed dramatically with the use of checkpoint inhibitors, oncolytic viruses, and targeted therapies. We reviewed both the clinical trial and real-world experience of these therapies in patients of advanced age, and discuss how a personalized approach should be taken for these patients with consideration of incidence and management of side effects. Although special consideration should be taken, immunotherapy, oncolytic viruses, and targeted therapy have shown efficacy and tolerability in older patients with melanoma.
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McCleary NJ, Harmsen WS, Haakenstad E, Cleary JM, Meyerhardt JA, Zalcberg J, Adams R, Grothey A, Sobrero AF, Van Cutsem E, Goldberg RM, Peeters M, Tabernero J, Seymour M, Saltz LB, Giantonio BJ, Arnold D, Rothenberg ML, Koopman M, Schmoll HJ, Pitot HC, Hoff PM, Tebbutt N, Masi G, Souglakos J, Bokemeyer C, Heinemann V, Yoshino T, Chibaudel B, deGramont A, Shi Q, Lichtman SM. Metastatic Colorectal Cancer Outcomes by Age Among ARCAD First- and Second-Line Clinical Trials. JNCI Cancer Spectr 2022; 6:pkac014. [PMID: 35603849 PMCID: PMC8935011 DOI: 10.1093/jncics/pkac014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/09/2021] [Accepted: 11/04/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND We evaluated the time to progression (TTP) and survival outcomes of second-line therapy for metastatic colorectal cancer among adults aged 70 years and older compared with younger adults following progression on first-line clinical trials. METHODS Associations between clinical and disease characteristics, time to initial progression, and rate of receipt of second-line therapy were evaluated. TTP and overall survival (OS) were compared between older and younger adults in first- and second-line trials by Cox regression, adjusting for age, sex, Eastern Cooperative Oncology Group Performance Status, number of metastatic sites and presence of metastasis in the lung, liver, or peritoneum. All statistical tests were 2-sided. RESULTS Older adults comprised 16.4% of patients on first-line trials (870 total older adults aged >70 years; 4419 total younger adults aged ≤70 years, on first-line trials). Older adults and those with Eastern Cooperative Oncology Group Performance Status >0 were less likely to receive second-line therapy than younger adults. Odds of receiving second-line therapy decreased by 11% for each additional decade of life in multivariable analysis (odds ratio = 1.11, 95% confidence interval = 1.02 to 1.21, P = .01). Older and younger adults enrolled in second-line trials experienced similar median TTP and median OS (median TTP = 5.1 vs 5.2 months, respectively; median OS = 11.6 vs 12.4 months, respectively). CONCLUSIONS Older adults were less likely to receive second-line therapy for metastatic colorectal cancer, though we did not observe a statistical difference in survival outcomes vs younger adults following second-line therapy. Further study should examine factors affecting decisions to treat older adults with second-line therapy. Inclusion of geriatric assessment may provide better criteria regarding the risks and benefits of second-line therapy.
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Affiliation(s)
- Nadine J McCleary
- Gastrointestinal Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - William S Harmsen
- Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
| | - Ellana Haakenstad
- Gastrointestinal Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - James M Cleary
- Gastrointestinal Cancer Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | | | - Richard Adams
- Cardiff University and Velindre Cancer Centre, Cardiff, UK
| | - Axel Grothey
- West Cancer Center and Research Institute, OneOncology, Germantown, TN, USA
| | | | | | - Richard M Goldberg
- West Virginia University Cancer Institute and the Mary Babb Randolph Cancer Center, Morgantown, WV, USA
| | - Marc Peeters
- Department of Oncology, Antwerp University Hospital, Antwerp, Belgium
| | - Josep Tabernero
- Vall d’Hebron University Hospital and Institute of Oncology (VHIO), Institute of Oncology Barcelona-Quiron, UVic-UCC, Barcelona, Spain
| | - Matt Seymour
- NIHR Clinical Research Network, Leeds, UK
- St. James’s Hospital and University of Leeds, Leeds, UK
| | | | - Bruce J Giantonio
- Perelman School of Medicine Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Dirk Arnold
- Instituto CUF de Oncologia, Lisbon, Portugal
- Asklepios Tumorzentrum Hamburg, Asklepios Klinik Altona, Hamburg, Germany
| | | | - Miriam Koopman
- Department of Medical Oncology, University Medical Center Utrecht, University of Urtrecht, Utrecht, Netherlands
| | - Hans-Joachim Schmoll
- Klinik fur Innere Med IV, University Clinic Halle (Saale), Halle, Germany
- Martin Luther University, Halle, Germany
| | - Henry C Pitot
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Paulo M Hoff
- Centro de Oncologia de Brasilia do Sirio Libanes-Unidade Lago Sul, Siro Libanes, Brazil
- Universidade de São Paulo Instituto do Cancer do Estado de São Paulo, São Paulo, Brazil
| | - Niall Tebbutt
- University of Sydney Medical School, Sydney, Australia
- Austin Health, Heidelberg, Victoria, Australia
| | - Gianluca Masi
- Department of Oncology, University of Pisa, Pisa, Italy
| | - John Souglakos
- Department of Medical Oncology, University General Hospital of Heraklion, Heraklion, Greece
| | | | - Volker Heinemann
- Department of Hematology/Oncology, Comprehensive Cancer Center Munich, University Hospital, LMU Munich, Germany
| | | | - Benoist Chibaudel
- Department of Medical Oncology, Institut Franco-Britannique, Levallois-Perret, France
| | - Aimery deGramont
- Department of Medical Oncology, Institut Franco-Britannique, Levallois-Perret, France
| | - Qian Shi
- Department of Health Science Research, Mayo Clinic, Rochester, MN, USA
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Lund JL, Duberstein PR, Loh KP, Gilmore N, Plumb S, Lei L, Keil AP, Islam JY, Hanson LC, Giguere JK, Vogel VG, Burnette BL, Mohile SG. Life expectancy in older adults with advanced cancer: Evaluation of a geriatric assessment-based prognostic model. J Geriatr Oncol 2022; 13:176-181. [PMID: 34483079 PMCID: PMC8882125 DOI: 10.1016/j.jgo.2021.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 08/06/2021] [Accepted: 08/25/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Oncologists estimate patients' prognosis to guide care. Evidence suggests oncologists tend to overestimate life expectancy, which can lead to care with questionable benefits. Information obtained from geriatric assessment may improve prognostication for older adults. In this study, we created a geriatric assessment-based prognostic model for older adults with advanced cancer and compared its performance to alternative models. MATERIALS AND METHODS We conducted a secondary analysis of a trial (URCC 13070; PI: Mohile) capturing geriatric assessment and vital status up to one year for adults age ≥ 70 years with advanced cancer. Oncologists estimated life expectancy as 0-6 months, 7-12 months, and > 1 year. Three statistical models were developed: (1) a model including age, sex, cancer type, and stage (basic model), (2) basic model + Karnofsky Performance Status (≤50, 60-70, and 80+) (KPS model), and (3) basic model +16 binary indicators of geriatric assessment impairments (GA model). Cox regression was used to model one-year survival; c-indices and time-dependent c-statistics assessed model discrimination and stratified survival curves assessed model calibration. RESULTS We included 484 participants; mean age was 75; 48% had gastrointestinal or lung cancer. Overall, 43% of patients died within one year. Oncologists classified prognosis accurately for 55% of patients, overestimated for 35%, and underestimated for 10%. C-indices were 0.61 (basic model), 0.62 (KPS model), and 0.63 (GA model). The GA model was well-calibrated. CONCLUSIONS The GA model showed moderate discrimination for survival, similar to alternative models, but calibration was improved. Further research is needed to optimize geriatric assessment-based prognostic models for use in older adults with advanced cancer.
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Affiliation(s)
- Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Paul R Duberstein
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ, USA
| | - Kah Poh Loh
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Nikesha Gilmore
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Sandy Plumb
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
| | - Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Alexander P Keil
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jessica Y Islam
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jeffrey K Giguere
- NCORP of the Carolinas (Greenville Health System NCORP), Greenville, SC, USA
| | | | - Brian L Burnette
- Cancer Research of Wisconsin and Northern Michigan (CROWN) NCORP, Grand Rapids, MI, USA
| | - Supriya G Mohile
- James P. Wilmot Cancer Institute, Division of Hematology/Oncology, Department of Medicine, University of Rochester, Rochester, NY, USA
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Geriatric-assessment-identified functional deficits among adults with multiple myeloma with normal performance status. J Geriatr Oncol 2022; 13:182-189. [PMID: 34389255 PMCID: PMC8828804 DOI: 10.1016/j.jgo.2021.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/12/2021] [Accepted: 08/04/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Findings from a brief geriatric assessment (GA) in a cohort of adults with multiple myeloma (MM) are presented, with particular attention to the utility of the GA in identifying important deficits in adults judged to have a normal Karnofsky Performance Status (KPS ≥ 80). MATERIALS AND METHODS Adults age 18 and older with MM were recruited into an observational study from 2018 to 2020. A modified Cancer and Aging Research Group (CARG) GA was administered at enrollment. Enrollees also completed the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life of Cancer Patients Core 30 questionnaire (QLQ-C30), with subscales of physical, social, role, and cognitive functioning (range 0-100; higher values indicate better function). Data were analyzed using descriptive statistics for the full cohort and stratified by concurrent KPS (score < 80 vs ≥ 80). RESULTS Among 89 adults, the mean age was 69.1 years, 68% were aged ≥65 years, and 70% were white. In this cohort, 78% had KPS ≥ 80. Among those with KPS ≥ 80, functional impairments (Timed Up and Go ≥14 s and dependence in ≥1 instrumental activity of daily living) were seen in 30% and 21%, respectively, with 11% reporting ≥1 fall in the prior 6 months. At least two GA-identified deficits were detected in 50% of the overall cohort and in 41% of those with KPS ≥ 80. Among those with KPS ≥ 80, self-reported physical impairment on EORTC QLQ-C30 was noted by 34%. CONCLUSION Using a modified CARG GA and EORTC questionnaire, functional impairments were identified among adults considered to have a good performance status based on a KPS (≥ 80). Future studies should focus on using GA measures for therapy assignment and identifying opportunities for intervening upon GA-identified deficits.
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Brem EA, Li H, Beaven AW, Caimi PF, Cerchietti L, Alizadeh A, Olin R, Henry NL, Dillon H, Little RF, Laubach C, LeBlanc M, Friedberg JW, Smith SM. SWOG 1918: A phase II/III randomized study of R-miniCHOP with or without oral azacitidine (CC-486) in participants age 75 years or older with newly diagnosed aggressive non-Hodgkin lymphomas - Aiming to improve therapy, outcomes, and validate a prospective frailty tool. J Geriatr Oncol 2022; 13:258-264. [PMID: 34686472 PMCID: PMC9879719 DOI: 10.1016/j.jgo.2021.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/08/2021] [Indexed: 01/28/2023]
Abstract
Diffuse large B cell lymphoma (DLBCL) is an aggressive but potentially curable malignancy; however, cure is highly dependent on the ability to deliver intensive, anthracycline-based chemoimmunotherapy. Nearly one third of cases of DLBCL occur in patients over age 75 years, and advanced age is an important adverse feature in prognostic models. Despite this incidence in older patients, there is no clear accepted standard of care due to under-representation of this group in large randomized clinical trials. Furthermore, insufficient assessments of baseline frailty and prediction of toxicity hamper clinical decision-making. Here, we present an ongoing randomized study of R-miniCHOP chemoimmunotherapy with or without oral azacitidine (CC-486, Onureg) for patients age 75 and older with newly diagnosed DLBCL and associated aggressive lymphomas. The incorporation of an oral hypomethylating agent is based on increased tumor methylation as a biologic feature of older patients with DLBCL and a desire to minimize the injection burden for this population. This is the first randomized study in this population conducted in North America by the National Clinical Trials Network (NCTN) and will enroll up to 422 patients including 40 patients in a safety run-in phase. This study incorporates an objective assessment of baseline frailty (the FIL Tool) and a serial comprehensive geriatric assessment (CGA). Key correlative tests will include circulating tumor DNA (ctDNA) assays at pre-specified timepoints to explore if ctDNA quantity and methylation patterns correlate with response. S1918 has the potential to impact future trial design and to change the standard of care for patients 75 years and older with aggressive lymphoma given its randomized design, prospective incorporation of geriatric assessments, and exploration of ctDNA correlatives. Trial registration: The trial is registered with ClinicalTrial.gov Identifier NCT04799275.
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Affiliation(s)
| | - Hongli Li
- SWOG Statistics and Data Management Center, Seattle, WA,Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Anne W. Beaven
- Lineberger Comprehensive Cancer Center University of North Carolina, Chapel Hill, NC
| | - Paolo F. Caimi
- Case Western Reserve University School of Medicine, Case Comprehensive Cancer Center, Cleveland, OH
| | | | - Ash Alizadeh
- Stanford University Medical Center, Stanford, CA
| | - Rebecca Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | | | | | - Richard F. Little
- National Cancer Institute, Cancer Therapy Evaluation Program (CTEP), Bethesda, MD
| | | | - Michael LeBlanc
- SWOG Statistics and Data Management Center, Seattle, WA,Fred Hutchinson Cancer Research Center, Seattle, WA
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Akhtar OS, Huang LW, Tsang M, Torka P, Loh KP, Morrison VA, Cordoba R. Geriatric assessment in older adults with Non-Hodgkin lymphoma: A Young International Society of Geriatric Oncology (YSIOG) review paper. J Geriatr Oncol 2022; 13:572-581. [PMID: 35216939 DOI: 10.1016/j.jgo.2022.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/08/2022] [Indexed: 12/13/2022]
Abstract
Non-Hodgkin lymphoma (NHL) is a disease of older adults, with a median age at diagnosis of 67 years. Treatment in older adults with NHL is challenging. The aging process is associated with a decline in functional reserve that varies among individuals, and results in an increasing risk of treatment-related toxicity and mortality. Chronological age and performance status fail to capture the multidimensional and heterogeneous nature of the aging process. A geriatric assessment (GA) screens multiple geriatric domains and provides a more accurate assessment of functional reserve. Several abbreviated GA tools have been developed for use in oncology clinics and help identify patients at high risk for chemotherapy-related toxicity and mortality. In this review, we explore GA tools validated for use in patients with NHL. We discuss the evidence behind GA-guided treatment in NHL and present a suggested approach to assessing frailty in this patient population.
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Affiliation(s)
| | - Li-Wen Huang
- San Francisco VA Medical Center, San Francisco, CA, USA; Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Mazie Tsang
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
| | - Pallawi Torka
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Kah Poh Loh
- University of Rochester Medical Center, James P. Wilmot Cancer Institute, Rochester, NY, USA
| | - Vicki A Morrison
- Hennepin Healthcare/University of Minnesota, Minneapolis, MN, USA
| | - Raul Cordoba
- Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
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Flannery MA, Mohile S, Culakova E, Norton S, Kamen C, Dionne-Odom JN, DiGiovanni G, Griggs L, Bradley T, Hopkins JO, Liu JJ, Loh KP. Completion of Patient-Reported Outcome Questionnaires Among Older Adults with Advanced Cancer. J Pain Symptom Manage 2022; 63:301-310. [PMID: 34371137 PMCID: PMC8816807 DOI: 10.1016/j.jpainsymman.2021.07.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/22/2021] [Accepted: 07/28/2021] [Indexed: 02/03/2023]
Abstract
CONTEXT Systematic collection of patient-reported outcomes (PROs) reduces symptom burden and improves quality of life. The ability of older adults to complete PROs, however, has not been thoroughly studied. OBJECTIVES To determine whether older adults with advanced cancer received assistance completing PROs, the nature of the assistance, the factors associated with receiving assistance, and how the prevalence of assistance changed over time. METHODS Data were obtained from a multisite cluster randomized controlled study of geriatric assessment (Clinicaltrials.gov: NCT02107443). Adults ≥70 years with advanced cancer completed multiple PROs at 4 time points (enrollment, 6 weeks, 3 months, 6 months). Factors associated with receipt of assistance were assessed with bivariate and multivariate analyses. RESULTS The study included 541 adults (range 70-96 years, 49% female, mixed incurable cancer diagnoses). Twenty-eight percent (153/541) received assistance completing PROs. Of these, 42% received assistance from caregivers, 37% from research staff, and 15% from both. Factors associated with receiving assistance included older age [Adjusted Odds Ratio (AOR) 3.71, 95% Confidence Interval (CI) 1.03-13.38], lower education level (3.92, 2.11-7.29), impaired cognition (1.90, 1.23-2.93), impaired functional status (2.16, 1.33-3.52), and impaired hearing (1.38, 1.05-1.80). Eighty percent of individuals who received assistance were identified at study initiation. Receiving assistance decreased over time from 28% to 18%, partially due to drop-outs. CONCLUSION Over a quarter of older adults with advanced cancer in this study received assistance completing PROs. Completing PROs is a key aspect of many clinical programs and cancer trials; assistance in completing PROs should be offered and provided.
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Affiliation(s)
- Marie A Flannery
- School of Nursing (M.A.F., S.N.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA.
| | - Supriya Mohile
- University of Rochester School of Medicine and Dentistry (S.M., E.C., C.K., G.D., K.P.L.), Rochester, New York, USA
| | - Eva Culakova
- University of Rochester School of Medicine and Dentistry (S.M., E.C., C.K., G.D., K.P.L.), Rochester, New York, USA
| | - Sally Norton
- School of Nursing (M.A.F., S.N.), University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Charles Kamen
- University of Rochester School of Medicine and Dentistry (S.M., E.C., C.K., G.D., K.P.L.), Rochester, New York, USA
| | - J Nicholas Dionne-Odom
- University of Alabama (J.N.D.-O.), Birmingham, School of Nursing, Birmingham, Alabama, USA
| | - Grace DiGiovanni
- University of Rochester School of Medicine and Dentistry (S.M., E.C., C.K., G.D., K.P.L.), Rochester, New York, USA
| | - Lorraine Griggs
- University of Rochester Medical Center (L.G.), SCOREBOARD, Patient Advisory Board, Rochester, New York, USA
| | | | - Judith O Hopkins
- Southeast Clinical Oncology Research Consortium NCORP (J.O.H.), Winston Salem, North Carolina, USA
| | - Jane Jijun Liu
- Illinois Cancer Care and Heartland NCORP (J.J.L.), Illnois, USA
| | - Kah Poh Loh
- University of Rochester School of Medicine and Dentistry (S.M., E.C., C.K., G.D., K.P.L.), Rochester, New York, USA
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Li D, Sun CL, Allen R, Crook CJ, Levi A, Ballena R, Klepin HD, Elias R, Mohile SG, Tew WP, Owusu C, Muss HB, Lichtman SM, Gross CP, Chapman AE, Gajra A, Cohen HJ, Katheria V, Hurria A, Dale W. Risk Factors for Hospitalizations Among Older Adults with Gastrointestinal Cancers. Oncologist 2022; 27:e37-e44. [PMID: 35305099 PMCID: PMC8842372 DOI: 10.1093/oncolo/oyab016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/18/2021] [Indexed: 11/29/2022] Open
Abstract
Background Older adults (≥65 years) with gastrointestinal (GI) cancers who receive chemotherapy are at increased risk of hospitalization caused by treatment-related toxicity. Geriatric assessment (GA) has been previously shown to predict risk of toxicity in older adults undergoing chemotherapy. However, studies incorporating the GA specifically in older adults with GI cancers have been limited. This study sought to identify GA-based risk factors for chemotherapy toxicity–related hospitalization among older adults with GI cancers. Patients and Methods We performed a secondary post hoc subgroup analysis of two prospective studies used to develop and validate a GA-based chemotherapy toxicity score. The incidence of unplanned hospitalizations during the course of chemotherapy treatment was determined. Results This analysis included 199 patients aged ≥65 years with a diagnosis of GI cancer (85 colorectal, 51 gastric/esophageal, and 63 pancreatic/hepatobiliary). Sixty-five (32.7%) patients had ≥1 hospitalization. Univariate analysis identified sex (female), cardiac comorbidity, stage IV disease, low serum albumin, cancer type (gastric/esophageal), hearing deficits, and polypharmacy as risk factors for hospitalization. Multivariable analyses found that patients who had cardiac comorbidity (OR 2.48, 95% CI 1.13-5.42) were significantly more likely to be hospitalized. Conclusion Cardiac comorbidity may be a risk factor for hospitalization in older adults with GI cancers receiving chemotherapy. Further studies with larger sample sizes are warranted to examine the relationship between GA measures and hospitalization in this vulnerable population.
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Affiliation(s)
- Daneng Li
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Can-Lan Sun
- Patient and Family Resource Center, City of Hope, Duarte, CA, USA
| | - Rebecca Allen
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Christiana J Crook
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Abrahm Levi
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Richard Ballena
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
| | - Heidi D Klepin
- Department of Internal Medicine, Section on Hematology and Oncology, Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Rawad Elias
- Department of Medical Oncology, Hartford Healthcare Cancer Institute, Hartford, CT, USA
| | - Supriya G Mohile
- Department of Medicine, Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA
| | - William P Tew
- Department of Gynecologic Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cynthia Owusu
- Department of Medicine, School of Medicine, Case Western University School of Medicine, Cleveland, OH, USA
| | - Hyman B Muss
- Geriatric Oncology Program, Division of Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stuart M Lichtman
- Department of Gynecologic Medical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cary P Gross
- Cancer Outcomes Public Policy and Effectiveness Research (COPPER) Center, Yale School of Medicine, New Haven, CT, USA
| | - Andrew E Chapman
- Department of Medical Oncology, Sidney Kimmel Cancer Center/Jefferson Health, Philadelphia, PA, USA
| | - Ajeet Gajra
- Cardinal Health, Dublin, OH, USA
- SUNY Upstate Medical University, Syracuse, NY, USA
| | - Harvey J Cohen
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - Vani Katheria
- Center for Cancer and Aging, City of Hope, Duarte, CA, USA
| | - Arti Hurria
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, CA, USA
- Department of Population Sciences, City of Hope, Duarte, CA, USA
| | - William Dale
- Department of Supportive Care, City of Hope, Duarte, CA, USA
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Vergote I, Van Nieuwenhuysen E, De Waele S, Vulsteke C, Lamot C, Van den Bulck H, Claes N, Graas MP, Debrock G, Spoormans I, Vuylsteke P, Honhon B, Verhoeven D, De Maeseneer D, Dirix L, Mebis J, Vroman P, Denys H, Martinez Mena C, Pelgrims G, Van Steenberghe M, van Gorp T, Gennigens C. Prospective non-interventional BELOVA/BGOG-ov16 study on safety of frontline bevacizumab in elderly patients with FIGO stage IV ovarian cancer: a study of the Belgian and Luxembourg Gynaecological Oncology Group. Int J Gynecol Cancer 2022; 32:753-760. [DOI: 10.1136/ijgc-2021-003190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
ObjectiveBecause elderly patients with ovarian cancer are underrepresented in randomized studies, this study aimed to expand our knowledge on the safety and effectiveness of frontline treatment with bevacizumab in combination with standard carboplatin and paclitaxel chemotherapy in patients aged 70 years and older with a diagnosis of Federation of Gynecology and Obstetrics (FIGO) stage IV ovarian cancer in routine clinical practice in Belgium.MethodsPatients aged 70 years and older with FIGO stage IV ovarian cancer were included in a multicenter, non-interventional prospective studyto evaluate the safety and effectiveness of treatment with bevacizumab in combination with frontline carboplatin and paclitaxel chemotherapy. Comprehensive geriatric assessments were performed at baseline and during treatment.ResultsThe most frequently reported adverse events for bevacizumab were hypertension (55%), epistaxis (32%) and proteinuria (21%). The Kaplan-Meier estimate of progression-free survival was 14.5 months. The results of the comprehensive geriatric assessments during treatment indicated a slight improvement in the geriatric eight health status screening tool score for general health status and the mini-nutritional assessment score for nutritional status. The median change from baseline score was close to zero for the instruments measuring independency, activity of daily living and instrumental activities of daily living, and for the mobility-tiredness test measuring self-perceived fatigue.ConclusionsNo new safety signals were registered in this study in patients aged 70 years and older treated with bevacizumab and frontline carboplatin and paclitaxel for FIGO stage IV ovarian cancer. Elderly patients should not be excluded from treatment for advanced ovarian cancer based on age alone.EU PAS registerENCEPP/SDPP/13849.ClinicalTrials.gov identifierNCT02393898.
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50
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The association of polypharmacy with functional status impairments, frailty, and health-related quality of life in older adults with gastrointestinal malignancy - Results from the Cancer and Aging Resilience Evaluation (CARE) registry. J Geriatr Oncol 2022; 13:624-628. [PMID: 34998720 DOI: 10.1016/j.jgo.2021.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 10/23/2021] [Accepted: 12/10/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Polypharmacy is a common problem among older adults that can complicate cancer care and outcomes. Our objective was to examine the prevalence of polypharmacy and its potential association with functional status impairments, frailty, and health-related quality of life (HRQoL) in older adults with gastrointestinal (GI) malignancy. METHODS The Cancer and Aging Resilience Evaluation (CARE) registry is an ongoing prospective cohort study that uses a patient-reported geriatric assessment (GA) in older adults with cancer. For this cross-sectional analysis, we focused on older adults with GI malignancy that completed the GA prior to starting systemic cancer therapy. Polypharmacy was defined as patients reporting the use of ≥9 daily medications at their first visit to the medical oncology clinic. Using multivariable analyses, we examined the association of polypharmacy with functional status limitations, frailty, and HRQoL. RESULTS 357 patients were included in our analysis, with a mean age of 70.1 years. 24.1% of patients reported taking ≥9 medications. In multivariable analyses adjusted for age, sex, race, cancer type, cancer stage, and medical comorbid conditions, patients taking ≥9 medications were more likely to report limitations in activities of daily living (adjusted odds ratio [aOR] 3.29, 95% confidence interval [CI] 1.72-6.29) and instrumental activities of daily living (aOR 2.86, 95% CI 1.59-5.14), have a higher prevalence of frailty (aOR 3.06, 95% CI 1.73-5.41), and report lower physical HRQoL (aOR 2.82, 95% CI 1.70-4.69) and mental HRQoL (aOR 1.73, 95% CI 1.03-2.91). CONCLUSIONS Older adults with GI malignancy taking ≥9 medications prior to cancer therapy were more likely to report functional status limitations, frailty, and reduced HRQoL, independent of the presence of medical comorbid conditions.
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