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Sahakyan Y, Li Q, Alibhai SM, Puts M, Yeretzian ST, Anwar MR, Brennenstuhl S, McLean B, Strohschein F, Tomlinson G, Wills A, Abrahamyan L. Cost-Utility Analysis of Geriatric Assessment and Management in Older Adults With Cancer: Economic Evaluation Within 5C Trial. J Clin Oncol 2024; 42:59-69. [PMID: 37871266 PMCID: PMC10730076 DOI: 10.1200/jco.23.00930] [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: 05/02/2023] [Revised: 07/31/2023] [Accepted: 08/22/2023] [Indexed: 10/25/2023] Open
Abstract
PURPOSE Geriatric assessment (GA) is a guideline-recommended approach to optimize cancer management in older adults. We conducted a cost-utility analysis alongside the 5C randomized controlled trial to compare GA and management (GAM) plus usual care (UC) against UC alone in older adults with cancer. METHODS The economic evaluation, conducted from societal and health care payer perspectives, used a 12-month time horizon. The Canadian 5C study randomly assigned patients to receive GAM or UC. Quality-adjusted life-years (QALYs) were measured using the EuroQol five dimension-5L questionnaire and health care utilization using cost diaries and chart reviews. We evaluated the incremental net monetary benefit (INMB) for the full sample and preselected subgroups. RESULTS A total of 350 patients were included, of whom 173 received GAM and 177 UC. At 12 months, the average QALYs per patient were 0.728 and 0.751 for GAM and UC, respectively (ΔQALY, -0.023 [95% CI, -0.076 to 0.028]). Considering a societal perspective, the total average costs (in 2021 Canadian dollars) per patient were $46,739 and $45,177 for GAM and UC, respectively (ΔCost, $1,563 [95% CI, -$6,583 to $10,403]). At a cost-effectiveness threshold of $50,000/QALY, GAM was not cost-effective compared with UC (INMB, -$2,713 [95% CI, -$11,767 to $5,801]). The INMB was positive ($2,984 [95% CI, -$7,050 to $14,179]; probability of being cost-effective, 72%) for patients treated with curative intent, but remained negative for patients treated with palliative intent (INMB, -$9,909 [95% CI, -$24,436 to $4,153]). Findings were similar considering a health care payer perspective. CONCLUSION To our knowledge, this is the first cost-utility analysis of GAM in cancer. GAM was cost-effective for patients with cancer treated with curative but not with palliative intent. The study provides further considerations for future adoption of GAM in practice.
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Affiliation(s)
- Yeva Sahakyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Qixuan Li
- Biostatistics Department, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Shabbir M.H. Alibhai
- Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Martine Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Shant T. Yeretzian
- Turpanjian College of Health Sciences, American University of Armenia, Yerevan, Armenia
| | - Mohammed R. Anwar
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Sarah Brennenstuhl
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Bianca McLean
- Department of Medicine, Yale New Haven Hospital, New Haven, CT
| | - Fay Strohschein
- Faculty of Nursing, University of Calgary, Calgary, Alberta, Canada
- Cancer Strategic Clinical Network, Alberta Health Services, Edmonton, Alberta, Canada
| | - George Tomlinson
- Biostatistics Department, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Aria Wills
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Lusine Abrahamyan
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
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2
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Thoma LR, Wilson C. Principles of the Comprehensive Geriatric Assessment for Patients with Cancer. Home Healthc Now 2023; 41:283-284. [PMID: 37682744 DOI: 10.1097/nhh.0000000000001193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
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3
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Alexander K, Hamlin PA, Tew WP, Trevino K, Tin AL, Shahrokni A, Meditz E, Boparai M, Amirnia F, Sun SW, Korc-Grodzicki B. Development and implementation of an interdisciplinary telemedicine clinic for older patients with cancer-Preliminary data. J Am Geriatr Soc 2023; 71:1638-1649. [PMID: 36744590 PMCID: PMC10175129 DOI: 10.1111/jgs.18267] [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: 11/14/2022] [Revised: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND Frailty assessment is an important marker of the older adult's fitness for cancer treatment independent of age. Pretreatment geriatric assessment (GA) is associated with improved mortality and morbidity outcomes but must occur in a time sensitive manner to be useful for cancer treatment decision making. Unfortunately, time, resources and other constraints make GA difficult to perform in busy oncology clinics. We developed the Cancer and Aging Interdisciplinary Team (CAIT) clinic model to provide timely GA and treatment recommendations independent of patient's physical location. METHODS The interdisciplinary CAIT clinic model was developed utilizing the surge in telemedicine during the COVID-19 pandemic. The core team consists of the patient's oncologist, geriatrician, registered nurse, pharmacist, and registered dietitian. The clinic's format is flexible, and the various assessments can be asynchronous. Patients choose the service method-in person, remotely, or hybrid. Based on GA outcomes, the geriatrician provides recommendations and arrange interventions. An assessment summary including life expectancy estimates and chemotoxicity risk calculator scores is conveyed to and discussed with the treating oncologist. Physician and patient satisfaction were assessed. RESULTS Between May 2021 and June 2022, 50 patients from multiple physical locations were evaluated in the CAIT clinic. Sixty-eight percent was 80 years of age or older (range 67-99). All the evaluations were hybrid. The median days between receiving a referral and having the appointment was 8. GA detected multiple unidentified impairments. About half of the patients (52%) went on to receive chemotherapy (24% standard dose, 28% with dose modifications). The rest received radiation (20%), immune (12%) or hormonal (4%) therapies, 2% underwent surgery, 2% chose alternative medicine, 8% were placed under observation, and 6% enrolled in hospice care. Feedback was extremely positive. CONCLUSIONS The successful development of the CAIT clinic model provides strong support for the potential dissemination across services and institutions.
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Affiliation(s)
- Koshy Alexander
- Memorial Sloan Kettering Cancer Center
- Weil Cornell Medical College
| | - Paul A Hamlin
- Memorial Sloan Kettering Cancer Center
- Weil Cornell Medical College
| | - William P Tew
- Memorial Sloan Kettering Cancer Center
- Weil Cornell Medical College
| | | | - Amy L Tin
- Memorial Sloan Kettering Cancer Center
| | - Armin Shahrokni
- Memorial Sloan Kettering Cancer Center
- Weil Cornell Medical College
| | | | | | - Farnia Amirnia
- Memorial Sloan Kettering Cancer Center
- Weil Cornell Medical College
| | - Sung Wu Sun
- Memorial Sloan Kettering Cancer Center
- Weil Cornell Medical College
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4
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Dickstein DR, Powers AE, Vujovic D, Roof S, Bakst RL. Clinical and Therapeutic Considerations for Older Adults with Head and Neck Cancer. Clin Interv Aging 2023; 18:409-422. [PMID: 36959837 PMCID: PMC10029371 DOI: 10.2147/cia.s366155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/04/2023] [Indexed: 03/18/2023] Open
Abstract
Approximately 30% of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age, and this percentage is expected to increase as the population increases and lives longer. Elderly patients are underrepresented in head and neck oncology clinical trials, and there is minimal evidence on the management of HNSCC for this population. Subsequently, despite their best intentions, physicians may unknowingly recommend an ill-suited course of therapy, which may result in suboptimal oncological or functional outcomes or adverse events. Surgical approaches have the potential to carry a higher risk of morbidity and mortality in older adults, especially in patients with multiple comorbidities. Definitive radiation therapy treatment in patients with HNSCC frequently involves 7 weeks of daily radiation, sometimes with concurrent chemotherapy, and this demanding treatment can be difficult for older adult patients, which may lead to treatment interruptions, potential removal of concurrent systemic therapy, compromised outcomes, and diminished quality of life. There are clinical trials currently underway investigating altered fractionation regimens and novel, less toxic systemic treatments in this population. This review provides an overview of how best to approach an older adult with HNSCC, from initial work-up to treatment selection.
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Affiliation(s)
- Daniel R Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ann E Powers
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Dragan Vujovic
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Scott Roof
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard L Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Correspondence: Richard L Bakst, Icahn School of Medicine at Mount Sinai, 1184 5th Avenue 1st Fl, Box 1236, New York, NY, 10029, USA, Tel/Fax +1 212 241 3545, Email
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5
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SUPeRO: A Multidimensional Approach to Prevent and Manage Oncological Frailty in a Radiation Oncology Unit. J Clin Med 2022; 11:jcm11226768. [PMID: 36431245 PMCID: PMC9699192 DOI: 10.3390/jcm11226768] [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: 10/01/2022] [Revised: 11/07/2022] [Accepted: 11/09/2022] [Indexed: 11/17/2022] Open
Abstract
Currently, the management of older cancer patients is directed by a personalized approach and, where possible, a tailor-made treatment. Based on our previous experiences and considering the opportunity of combining a geriatric department and a radiation-oncology department, we have developed a path that follows the patient from the beginning of the treatment, taking into account the complications/late toxicities and the survivors. This study aimed to evaluate the impact of remodeling and restructuring some oncology, radiotherapy, and geriatrics services based on the primary evidence for managing older cancer patients. In 2020, Gemelli ART underwent 60,319 radiation-oncology treatments, admitted 943 patients in the radiation-oncology and supportive care ward, and treated and followed 15,268 patients in clinics. The average length of stay of the admitted patients was reduced from 20.6 days to 13.2 days. In 2021, 1196 patients were assessed for frailty, 847 were admitted for toxicity, and 349 patients were evaluated within the geriatric oncology and supportive care outpatient clinic, and it was found that 59.2% were fit, 31.6% were vulnerable, and 9.2% were frail. This experience has shown a reduction in hospitalizations and the average hospital stay of patients in the case of side effects, a high toxicity to treatments, and the possibility of treating patients with a high level of complexity. This approach should represent the future target of geriatric oncology with the global management of older or complex patients with cancer.
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6
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Lee RXN, Cardoso MJ, Cheung KL, Parks RM. Immediate breast reconstruction uptake in older women with primary breast cancer: systematic review. Br J Surg 2022; 109:1063-1072. [PMID: 35909248 PMCID: PMC10364779 DOI: 10.1093/bjs/znac251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 06/22/2022] [Accepted: 07/04/2022] [Indexed: 08/02/2023]
Abstract
BACKGROUND Postmastectomy immediate breast reconstruction (PMIBR) may improve the quality of life of patients with breast cancer, of whom older women (aged 65 years or more) are a growing proportion. This study aimed to assess PMIBR in older women with regard to underlying impediments (if any). METHODS MEDLINE, Embase, and PubMed were searched by two independent researchers up to June 2022. Eligible studies compared PMIBR rates between younger and older women with invasive primary breast cancer. RESULTS A total of 10 studies (2012-2020) including 466 134 women were appraised, of whom two-thirds (313 298) were younger and one-third (152 836) older. Only 10.0 per cent of older women underwent PMIBR in contrast to 45.0 per cent of younger women. Two studies explored factors affecting uptake of PMIBR in older women; surgeon-associated (usual practice), patient-associated (socioeconomic status, ethnicity, and co-morbidities), and system-associated (insurance status and hospital location) factors were identified. CONCLUSION Uptake of PMIBR in older women is low with definable (and some correctable) barriers.
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Affiliation(s)
- Rachel Xue Ning Lee
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Queen’s Medical Centre Campus, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Maria Joao Cardoso
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- Breast Unit, Champalimaud Foundation and Nova Medical School Lisbon, Lisbon, Portugal
| | - Kwok Leung Cheung
- Nottingham Breast Cancer Research Centre, University of Nottingham, Nottingham, UK
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Ruth M Parks
- Correspondence to: Ruth M. Parks, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Uttoxeter Road, Derby DE22 3DT, UK (e-mail: )
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7
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Chemotherapy Toxicity in Older Adults Optimized by Geriatric Assessment and Intervention: A Non-Comparative Analysis. Curr Oncol 2022; 29:6167-6176. [PMID: 36135053 PMCID: PMC9498117 DOI: 10.3390/curroncol29090484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/17/2022] Open
Abstract
The Comprehensive Geriatric Assessment (CGA) is recommended to guide treatment choices in older patients with cancer. Patients ≥ 70 years referred to our oncology service with a new cancer diagnosis are screened using the G-8. Patients with a score of ≤14 are eligible to attend the Geriatric Oncology and Liaison (GOAL) Clinic in our institution, with referral based on physician discretion. Referred patients undergo multidimensional assessments at baseline. CGA domains assessed include mobility, nutritional, cognitive, and psychological status. Chemotherapy toxicity risk is estimated using the Cancer Aging and Research Group (CARG) calculator. We undertook a retrospective analysis of patients attending the GOAL clinic over a 30-month period to April 2021. The objective was to determine rates of treatment dose modifications, delays, discontinuation, and unscheduled hospitalizations as surrogates for cytotoxic therapy toxicity in these patients. These data were collected retrospectively. Ninety-four patients received chemotherapy; the median age was 76 (70–87) and 45 were female (48%). Seventy-five (80%) had an ECOG PS of 0–1. Seventy-two (77%) had gastrointestinal cancer, and most had stage III (47%) or IV (40%) disease. Chemotherapy with curative intent was received by 51% (n = 48) and 51% received monotherapy. From the CGA, the median Timed Up and Go was 11 s (7.79–31.6), and 90% reported no falls in the prior 6 months. The median BMI was 26.93 (15.43–39.25), with 70% at risk or frankly malnourished by the Mini Nutritional Assessment. Twenty-seven (29%) patients had impaired cognitive function. Forty-three (46%) had a high risk of toxicity based on the baseline CARG toxicity calculator. Twenty-six (28%) required dose reduction, 55% (n = 52) required a dose delay, and 36% (n = 34) had a hospitalization due to toxicity. Thirty-nine patients (42%) discontinued treatment due to toxicity. Despite intensive assessment, clinical optimization and personalized treatment decisions, older adults with cancer remain at high risk of chemotherapy toxicity.
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Aristei C, Bölükbaşı Y, Kaidar-Person O, Pfeffer R, Arenas M, Boersma LJ, Ciabattoni A, Coles CE, Franco P, Krengli M, Leonardi MC, Marazzi F, Masiello V, Meattini I, Montero A, Offersen B, Trigo ML, Bourgier C, Genovesi D, Kouloulias V, Morganti AG, Meduri B, Pasinetti N, Pedretti S, Perrucci E, Rivera S, Tombolini V, Vidali C, Valentini V, Poortmans P. Ways to improve breast cancer patients' management and clinical outcome: The 2020 Assisi Think Tank Meeting. Crit Rev Oncol Hematol 2022; 177:103774. [PMID: 35917884 DOI: 10.1016/j.critrevonc.2022.103774] [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: 06/08/2021] [Revised: 07/19/2022] [Accepted: 07/29/2022] [Indexed: 10/16/2022] Open
Abstract
We report on the third Assisi Think Tank Meeting (ATTM) on breast cancer, a brainstorming project which involved European radiation and clinical oncologists who were dedicated to breast cancer research and treatment. Held on February 2020, the ATTM aimed at identifying key clinical questions in current clinical practice and "grey" areas requiring research to improve management and outcomes. Before the meeting, three key topics were selected: 1) managing patients with frailty due to either age and/or multi-morbidity; 2) stereotactic radiation therapy and systemic therapy in the management of oligometastatic disease; 3) contralateral breast tumour prevention in BCRA-mutated patients. Clinical practice in these areas was investigated by means of an online questionnaire. In the lapse period between the survey and the meeting, the working groups reviewed data, on-going studies and the clinical challenges which were then discussed in-depth and subjected to intense brainstorming during the meeting; research protocols were also proposed. Methodology, outcome of discussions, conclusions and study proposals are summarized in the present paper. In conclusion, this report presents an in-depth analysis of the state of the art, grey areas and controversies in breast cancer radiation therapy and discusses how to confront them in the absence of evidence-based data to guide clinical decision-making.
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Affiliation(s)
- Cynthia Aristei
- Radiation Oncology Section, Department of Medicine and Surgery, University of Perugia and Perugia General Hospital, Perugia, Italy.
| | - Yasemin Bölükbaşı
- Radiation Oncology Acıbadem Mehmet Ali Aydınlar University School of Medicine, Istanbul, Turkey
| | - Orit Kaidar-Person
- Breast Radiation Unit, Radiation Oncology, Sheba Medical Center, Ramat Gan, Israel
| | - Raphael Pfeffer
- Oncology Institute, Assuta Medical Center, Tel Aviv and Ben Gurion University Medical School, Israel
| | - Meritxell Arenas
- Universitat Rovira I Virgili, Radiation Oncology Department, Hospital Universitari Sant Hoan de Reus, IISPV, Spain
| | - Liesbeth J Boersma
- Radiation Oncology (Maastro), GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Antonella Ciabattoni
- Department of Radiation Oncology, San Filippo Neri Hospital, ASL Rome 1, Rome, Italy
| | | | - Pierfrancesco Franco
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | - Marco Krengli
- Depatment of Translational Medicine, University of Eastern Piedmont and Department of Radiation Oncology, 'Maggiore della Carità' University Hospital, Novara, Italy
| | | | - Fabio Marazzi
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Valeria Masiello
- Unità Operativa di Radioterapia Oncologica, Dipartimento di Diagnostica per Immagine, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Gemelli IRCSS Roma, Italy
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Angel Montero
- Department of Radiation Oncology, University Hospital HM Sanchinarro, HM Hospitales, Madrid, Spain
| | - Birgitte Offersen
- Department of Experimental Clinical Oncology, Department of Oncology, Danish Centre for Particle Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Maria Lurdes Trigo
- Service of Brachytherapy, Department of Image and Radioncology, Instituto Português Oncologia Porto Francisco Gentil E.P.E., Portugal
| | - Céline Bourgier
- Radiation Oncology, ICM-Val d'Aurelle, Univ Montpellier, Montpellier, France
| | - Domenico Genovesi
- Radiation Oncology, Ospedale Clinicizzato Chieti and University "G. d'Annunzio", Chieti, Italy
| | - Vassilis Kouloulias
- 2(nd) Department of Radiology, Radiotherapy Unit, Medical School, National and Kapodistrian University of Athens, Greece
| | - Alessio G Morganti
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna; DIMES, Alma Mater Studiorum Bologna University; Bologna, Italy
| | - Bruno Meduri
- Radiation Oncology Unit, University Hospital of Modena, Modena, Italy
| | - Nadia Pasinetti
- Radiation Oncology Service, ASST Valcamonica Esine and Brescia University, Brescia, Italy
| | - Sara Pedretti
- Istituto del Radio "O.Alberti" - Spedali Civili Hospital and Brescia University, Brescia
| | | | - Sofia Rivera
- Radiation Oncology, Institut Gustave Roussy, Villejuif, France
| | - Vincenzo Tombolini
- Radiation Oncology, Department of Radiological, Oncological and Pathological Science, University "La Sapienza", Roma, Italy
| | - Cristiana Vidali
- former Senior Assistant Department of Radiation Oncology, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Vincenzo Valentini
- Division of Radiation Oncology, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Philip Poortmans
- Department of Radiation Oncology, Iridium Kankernetwerk, Antwerp, Belgium; University of Antwerp, Faculty of Medicine and Health Sciences, Antwerp, Belgium
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9
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Dickstein DR, Lehrer EJ, Hsieh K, Hotca A, Jones BM, Powers A, Sharma S, Liu J, Gupta V, Mell L, Husain Z, Kirke D, Misiukiewicz K, Posner M, Genden E, Bakst RL. Management of Older Adults with Locally Advanced Head and Neck Cancer. Cancers (Basel) 2022; 14:cancers14112809. [PMID: 35681789 PMCID: PMC9179912 DOI: 10.3390/cancers14112809] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Approximately one third of patients with head and neck cancer are older adults. The number of older adults with head and neck cancer continues to rise especially as life expectancy increases. However, this population remains significantly underrepresented in clinical trials. Due to this, there is no clear consensus regarding the optimal treatment for older adults with head and neck cancer. In general, older adults are a complex cohort due to variations in functional and performance status, medical comorbidities, and medication management. Treatment for head and neck cancer involves surgery, radiation therapy, systemic therapy, or a combination. These treatments are highly demanding. Additionally, they are associated with toxicity which can be especially difficult for older adults to tolerate. This may lead to treatment interruptions and compromised outcomes. In order to understand the optimal treatment for older adults with head and neck cancer, novel predictive scores are being developed. Additionally, ongoing clinical trials are investigating less intensive treatments for older adults. This review provides an overview of current clinical data, treatment considerations, and future areas of investigation for older adults with head and neck cancer. Abstract Thirty percent of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age. This number continues to rise as life expectancy continues to increase. Still, older adults with HNSCC remain underrepresented in clinical trials, resulting in ambiguity on optimal management. Older adults are a complex patient population, often requiring increased support due to issues relating to functional and performance status, medical comorbidities, and medication management. Furthermore, in older adults with HNSCC, many of these conditions are independently associated with increased toxicity and worse outcomes. Toxicity in the older adult remains difficult to predict and to understand, and as treatment decisions are based on treatment tolerability, it is essential to understand the toxicities and how to minimize them. Novel predictive scores are being developed specifically for older adults with HNSCC to understand toxicity and to assist in personalized treatment decisions. There are clinical trials presently underway that are investigating shortened radiation courses and novel, less toxic systemic treatments in this population. In the forthcoming sections, we provide a detailed overview of the clinical data, treatment paradigms, and considerations in this population. This review provides a comprehensive overview of existing clinical data and clinical considerations in the older adult head and neck cancer population. Additionally, we provide a detailed overview of pertinent current and ongoing clinical trials, as well as future areas for investigation.
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Affiliation(s)
- Daniel R. Dickstein
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Eric J. Lehrer
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Kristin Hsieh
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Alexandra Hotca
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Brianna M. Jones
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Ann Powers
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Sonam Sharma
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Jerry Liu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Vishal Gupta
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
| | - Loren Mell
- Department of Radiation Oncology, University of San Diego, La Jolla, CA 92110, USA;
| | - Zain Husain
- Department of Radiation Oncology, University of Toronto, Toronto, ON M5S 1A1, Canada;
| | - Diana Kirke
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Krzysztof Misiukiewicz
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.M.); (M.P.)
| | - Marshall Posner
- Department of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (K.M.); (M.P.)
| | - Eric Genden
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.P.); (D.K.); (E.G.)
| | - Richard L. Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (D.R.D.); (E.J.L.); (K.H.); (A.H.); (B.M.J.); (S.S.); (J.L.); (V.G.)
- Correspondence:
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10
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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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11
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Fitch MI, Nicoll I, Newton L, Strohschein FJ. Challenges of Survivorship for Older Adults Diagnosed with Cancer. Curr Oncol Rep 2022; 24:763-773. [PMID: 35286555 PMCID: PMC8918886 DOI: 10.1007/s11912-022-01255-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review The purpose of this brief review is to highlight significant recent developments in survivorship research and care of older adults following cancer treatment. The aim is to provide insight into care and support needs of older adults during cancer survivorship as well as directions for future research. Recent Findings The numbers of older adult cancer survivors are increasing globally. Increased attention to the interaction between age-related and cancer-related concerns before, during, and after cancer treatment is needed to optimize outcomes and quality of life among older adult survivors. Issues of concern to older survivors, and ones associated with quality of life, include physical and cognitive functioning and emotional well-being. Maintaining activities of daily living, given limitations imposed by cancer treatment and other comorbidities, is of primary importance to older survivors. Evidence concerning the influence of income and rurality, experiences in care coordination and accessing services, and effectiveness of interventions remains scant for older adults during survivorship. Summary There is a clear need for further research relating to tailored intervention and health care provider knowledge and education. Emerging issues, such as the use of medical assistance in dying, must be considered in this population.
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Affiliation(s)
- Margaret I. Fitch
- Bloomberg Faculty of Nursing, University of Toronto, 207 Chisholm Ave, Toronto, ON M4C 4V9 Canada
| | | | - Lorelei Newton
- School of Nursing, STN CSC, University of Victoria, PO Box 1700, Victoria, BC V8W 2Y2 Canada
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12
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Gu YF, Lin FP, Epstein RJ. How aging of the global population is changing oncology. Ecancermedicalscience 2022; 15:ed119. [PMID: 35211208 PMCID: PMC8816510 DOI: 10.3332/ecancer.2021.ed119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
Population aging is causing a demographic redistribution with implications for the future of healthcare. How will this affect oncology? First, there will be an overall rise in cancer affecting older adults, even though age-specific cancer incidences continue to fall due to better prevention. Second, there will be a wider spectrum of health functionality in this expanding cohort of older adults, with differences between “physiologically older” and “physiologically younger” patients becoming more important for optimal treatment selection. Third, greater teamwork with supportive care, geriatric, mental health and rehabilitation experts will come to enrich oncologic decision-making by making it less formulaic than it is at present. Success in this transition to a more nuanced professional mindset will depend in part on the development of user-friendly computational tools that can integrate a complex mix of quantitative and qualitative inputs from evidence-based medicine, functional and cognitive assessments, and the personal priorities of older adults.
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Affiliation(s)
- Yan Fei Gu
- New Hope Cancer Center, United Family Hospitals, 9 Jiangtai W Rd, Chaoyang, Beijing 100015, China
| | - Frank P Lin
- Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, Sydney 2010, Australia.,NH&MRC Clinical Trials Centre, 92 Parramatta Rd, Camperdown, Sydney 2050, Australia
| | - Richard J Epstein
- New Hope Cancer Center, United Family Hospitals, 9 Jiangtai W Rd, Chaoyang, Beijing 100015, China.,Garvan Institute of Medical Research, 384 Victoria St, Darlinghurst, Sydney 2010, Australia.,UNSW Clinical School, St Vincent's Hospital, 390 Victoria St, Darlinghurst, Sydney 2010, Australia.,https://orcid.org/0000-0002-4640-0195
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13
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Ng ZX, Zheng H, Chen MZ, Soon YY, Ho F. Comprehensive Geriatric Assessment guided treatment versus usual care for older adults aged 60 years and above with cancer. Hippokratia 2021. [DOI: 10.1002/14651858.cd014875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zhi Xuan Ng
- National University Hospital Singapore; Singapore Singapore
| | - Huili Zheng
- National Registry of Diseases Office; Health Promotion Board; Singapore Singapore
| | | | - Yu Yang Soon
- Department of Radiation Oncology; National University Cancer Institute; Singapore Singapore
| | - Francis Ho
- Department of Radiation Oncology; National University Cancer Institute; Singapore Singapore
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14
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Fallah J, Zhang L, Amatya A, Gong Y, King-Kallimanis B, Bhatnagar V, Weinstock C, Suzman DL, Agrawal S, Chang E, Anscher MS, Chi DC, Xu JX, Brewer JR, Brave MH, Hadadi M, Theoret MR, Kluetz PG, Goldberg KB, Ibrahim A, Tang S, Pazdur R, Beaver JA, Amiri-Kordestani L, Singh H. Survival outcomes in older men with non-metastatic castration-resistant prostate cancer treated with androgen receptor inhibitors: a US Food and Drug Administration pooled analysis of patient-level data from three randomised trials. Lancet Oncol 2021; 22:1230-1239. [PMID: 34310904 DOI: 10.1016/s1470-2045(21)00334-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 05/21/2021] [Accepted: 05/28/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Little is known about the benefit-risk profile of second-generation androgen receptor inhibitors in older men with non-metastatic castration-resistant prostate cancer. We aimed to examine the efficacy and safety of second-generation androgen receptor inhibitors in men aged 80 years or older with non-metastatic castration-resistant prostate cancer. METHODS We searched for all randomised controlled clinical trials evaluating second-generation androgen receptor inhibitors in patients with non-metastatic castration-resistant prostate cancer submitted to the US Food and Drug Administration before Aug 15, 2020, and pooled data from three trials that met the selection criteria. All three trials enrolled patients who were aged 18 years or older with an Eastern Cooperative Oncology Group performance status of 0-1, castration-resistant prostate cancer, prostate-specific antigen (PSA) 2·0 μg/L or greater, PSA doubling time of 10 months or less, and no evidence of distant metastatic disease on conventional imaging per the investigator's assessment at the time of screening. All patients had histologically or cytologically confirmed adenocarcinoma of the prostate without neuroendocrine differentiation or small-cell features. All patients who were randomly assigned to androgen receptor inhibitor or placebo groups in these trials were considered assessable and were included in this pooled analysis. We evaluated the effect of age on metastasis-free survival and overall survival across age groups (<80 years vs ≥80 years) in the intention-to-treat population. Safety analyses were done in patients who received at least one dose of study treatment. FINDINGS Between Oct 14, 2013, and March 9, 2018, 4117 patients were assigned to androgen receptor inhibitor (apalutamide, enzalutamide, or daralutamide; n=2694) or placebo (n=1423) across three randomised trials. The median follow-up duration for metastasis-free survival was 18 months (IQR 11-26) and for overall survival was 44 months (32-55). In patients aged 80 years or older (n=1023), the estimated median metastasis-free survival was 40 months (95% CI 36-41) in the androgen receptor inhibitor groups and 22 months (18-29) in the placebo groups (adjusted hazard ratio [HR] 0·37 [95% CI 0·28-0·47]), and the median overall survival was 54 months (50-61) versus 49 months (43-58), respectively (adjusted HR 0·79 [0·64-0·98]). In patients younger than 80 years of age (n=3094), the estimated median metastasis-free survival was 41 months (95% CI 36-not estimable [NE]) in the androgen receptor inhibitor groups and 16 months (15-18) in the placebo groups (adjusted HR 0·31 [95% CI 0·27-0·35]), and the median overall survival was 74 months (74-NE) versus 61 months (56-NE), respectively (adjusted HR 0·69 [0·60-0·80]). In patients aged 80 years or older, grade 3 or worse adverse events were reported in 371 (55%) of 672 patients in the androgen receptor inhibitor groups and 140 (41%) of 344 patients in the placebo groups, compared with 878 (44%) of 2015 patients in the androgen receptor inhibitor groups and 321 (30%) of 1073 patients in the placebo groups among patients younger than 80 years. The most common grade 3-4 adverse events were hypertension (168 [8%] of 2015 patients aged <80 years and 51 [8%] of 672 patients aged ≥80 years in the androgen receptor inhibitor groups vs 53 [5%] of 1073 patients aged <80 years and 22 [6%] of 344 patients aged ≥80 years in the placebo groups) and fracture (61 [3%] and 36 [5%] in the androgen receptor inhibitor groups vs 15 [1%] and 11 [3%] in the placebo groups). INTERPRETATION The findings of this pooled analysis support the use of androgen receptor inhibitors in older men with non-metastatic castration-resistant prostate cancer. Incorporating geriatric assessment tools in the care of older adults with non-metastatic castration-resistant prostate cancer might help clinicians to offer individualised treatment to each patient. FUNDING None.
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Affiliation(s)
- Jaleh Fallah
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA.
| | - Lijun Zhang
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Anup Amatya
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Yutao Gong
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Bellinda King-Kallimanis
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Vishal Bhatnagar
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Chana Weinstock
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Daniel L Suzman
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Sundeep Agrawal
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Elaine Chang
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Mitchell S Anscher
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Dow-Chung Chi
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - James X Xu
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Jamie R Brewer
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Michael H Brave
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Mehrnoosh Hadadi
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Marc R Theoret
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA; Oncology Center of Excellence, Food and Drug Administration, Silver Spring, MD, USA
| | - Paul G Kluetz
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA; Oncology Center of Excellence, Food and Drug Administration, Silver Spring, MD, USA
| | - Kirsten B Goldberg
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA; Oncology Center of Excellence, Food and Drug Administration, Silver Spring, MD, USA
| | - Amna Ibrahim
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Shenghui Tang
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Richard Pazdur
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA; Oncology Center of Excellence, Food and Drug Administration, Silver Spring, MD, USA
| | - Julia A Beaver
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA; Oncology Center of Excellence, Food and Drug Administration, Silver Spring, MD, USA
| | - Laleh Amiri-Kordestani
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA
| | - Harpreet Singh
- Center for Drug Evaluation and Research, Office of New Drugs, Office of Oncologic Diseases, Food and Drug Administration, Silver Spring, MD, USA; Oncology Center of Excellence, Food and Drug Administration, Silver Spring, MD, USA
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15
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Scheubeck S, Ihorst G, Schoeller K, Holler M, Möller MD, Reinhardt H, Wäsch R, Engelhardt M. Comparison of the prognostic significance of 5 comorbidity scores and 12 functional tests in a prospective multiple myeloma patient cohort. Cancer 2021; 127:3422-3436. [PMID: 34061991 DOI: 10.1002/cncr.33658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Because of the various therapeutic options available for multiple myeloma (MM), remarkable interest exists today in individualized therapeutic concepts based on patients' fitness. The main objectives of this study were to compare different comorbidity scores and functional tests with respect to their impact on survival (overall survival [OS] and progression-free survival [PFS]); develop a time-efficient, MM-specific functional assessment (FA); and evaluate changes in patients' FA during treatment. METHODS The authors performed a prospective FA in 266 consecutive patients with MM at their initial diagnosis. This included 5 comorbidity scores and 12 commonly used geriatric functional tests. To evaluate changes in the course of treatment, the authors reassessed these 17 tests after ≥6 months. The entire analysis included 7327 FA tests. RESULTS On the basis of univariate and multivariate Cox regression analyses, the authors identified 4 of the 17 evaluated scores and functional tests as most relevant: the Revised Myeloma Comorbidity Index (R-MCI), Activity of Daily Living (ADL), the Mini-Mental State Examination (MMSE), and the quality-of-life 12-Item Short Form Health Survey Physical Composite Scale (SF-12 PCS). These showed precise group differences for fit, (intermediate-fit), and frail patients in OS and PFS: the 3-year OS rates were 90%, 74%, and 43% via the R-MCI for fit, intermediate-fit, and frail patients, respectively (P = .0006); 80% and 66% via the ADL for fit and frail patients, respectively (P = .0159); 78% and 48% via the MMSE for fit and frail patients, respectively (P = .0001); and 86% and 66% via the SF-12 PCS for fit and frail patients, respectively (P = .0091). In follow-up analyses, 16 of 17 FA tests improved, mostly in younger patients (<70 years old) and responding patients (partial remission or better). CONCLUSIONS Patients may recover from functional and physical limitations under applied MM therapy. The newly established MM-specific FA (via the R-MCI, ADL, MMSE, and SF-12 PCS) allows a precise evaluation of the prognosis and risk status in MM. Its use may improve treatment tolerability and should be validated to individualize MM treatment decisions in the future. LAY SUMMARY The authors performed a prospective functional assessment (FA) in 266 consecutive patients with multiple myeloma at their initial diagnosis. On the basis of univariate and multivariate Cox regression analyses, the authors identified 4 of 17 initially evaluated scores and functional tests as most relevant: the Revised Myeloma Comorbidity Index, Activity of Daily Living, the Mini-Mental State Examination, and the quality-of-life 12-Item Short Form Health Survey Physical Composite Scale. The authors checked the stability of the final model by applying forward and stepwise selection. To evaluate changes in the course of treatment, they reassessed these 17 tests in 165 patients after ≥6 months: 16 of the 17 FA tests improved, mostly in younger patients (<70 years old) and responding patients (partial remission or better).
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Affiliation(s)
- Sophia Scheubeck
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katja Schoeller
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Holler
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mandy-Deborah Möller
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heike Reinhardt
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Achieving 'Marginal Gains' to Optimise Outcomes in Resectable Pancreatic Cancer. Cancers (Basel) 2021; 13:cancers13071669. [PMID: 33916294 PMCID: PMC8037133 DOI: 10.3390/cancers13071669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/19/2021] [Accepted: 03/24/2021] [Indexed: 12/21/2022] Open
Abstract
Simple Summary Improving outcomes in pancreatic cancer is achievable through the accumulation of marginal gains. There exists evidence of variation and undertreatment in many areas of the care pathway. By fully realising the existing opportunities, there is the potential for immediate improvements in outcomes and quality of life. Abstract Improving outcomes among patients with resectable pancreatic cancer is one of the greatest challenges of modern medicine. Major improvements in survival will result from the development of novel therapies. However, optimising existing pathways, so that patients realise benefits of already proven treatments, presents a clear opportunity to improve outcomes in the short term. This narrative review will focus on treatments and interventions where there is a clear evidence base to improve outcomes in pancreatic cancer, and where there is also evidence of variation and under-treatment. Avoidance of preoperative biliary drainage, treatment of pancreatic exocrine insufficiency, prehabiliation and enhanced recovery after surgery, reducing perioperative complications, optimising opportunities for elderly patients to receive therapy, optimising adjuvant chemotherapy and regular surveillance after surgery are some of the strategies discussed. Each treatment or pathway change represents an opportunity for marginal gain. Accumulation of marginal gains can result in considerable benefit to patients. Given that these interventions already have evidence base, they can be realised quickly and economically.
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Fitch MI, Strohschein FJ, Nyrop K. Measuring quality of life in older people with cancer. Curr Opin Support Palliat Care 2021; 15:39-47. [PMID: 33507038 DOI: 10.1097/spc.0000000000000535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW The number of individuals aged 65+ with cancer will double in the next decade. Attention to quality of life (QOL) is imperative to identify relevant endpoints/outcomes in research and provide care that matches individual needs. This review summarizes recent publications regarding QOL measurement in older adults with cancer, considering implications for research and practice. RECENT FINDINGS QOL is a complex concept and its measurement can be challenging. A variety of measurement tools exist, but only one specific to older adults with cancer. QOL is frequently measured as functional health, adverse symptoms, and global QOL, thus only capturing a portion of this concept. Yet successful QOL intervention for older adults requires drawing from behavioral and social dimensions.Growing interest in comprehensive geriatric assessment (CGA) and patient-reported outcomes (PROs) provides important opportunities for measuring QOL. Recommendations for use of CGAs and PROs in clinical practice have been made but widespread uptake has not occurred. SUMMARY QOL is important to older adults and must be central in planning and discussing their care. It is modifiable but presents measurement challenges in this population. Various domains are associated with decline, survival, satisfaction with life, coping, and different interventions. Measurement approaches must fit with intention and capacity to act within given contexts.
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Affiliation(s)
- Margaret I Fitch
- Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Fay J Strohschein
- Oncology and Aging Program, Jewish General Hospital, Montreal, Canada, Nursing Research Consultant, Wainwright, Alberta
| | - Kirsten Nyrop
- Division of Oncology, School of Medicine, Lineberger Comprehensive Cancer Center, Deputy Director/Research - Geriatric Oncology Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Perspectives and experiences of patients and healthcare professionals with geriatric assessment in chronic kidney disease: a qualitative study. BMC Nephrol 2021; 22:9. [PMID: 33407240 PMCID: PMC7789317 DOI: 10.1186/s12882-020-02206-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 12/10/2020] [Indexed: 12/24/2022] Open
Abstract
Background Older patients with end-stage kidney disease (ESKD) often live with unidentified frailty and multimorbidity. Despite guideline recommendations, geriatric assessment is not part of standard clinical care, resulting in a missed opportunity to enhance (clinical) outcomes including quality of life in these patients. To develop routine geriatric assessment programs for patients approaching ESKD, it is crucial to understand patients’ and professionals’ experiences with and perspectives about the benefits, facilitators and barriers for geriatric assessment. Methods In this qualitative study, semi-structured focus group discussions were conducted with ESKD patients, caregivers and professionals. Participants were purposively sampled from three Dutch hospital-based study- and routine care initiatives involving geriatric assessment for (pre-)ESKD care. Transcripts were analysed inductively using thematic analysis. Results In six focus-groups, participants (n = 47) demonstrated four major themes: (1) Perceived characteristics of the older (pre)ESKD patient group. Patients and professionals recognized increased vulnerability and (cognitive) comorbidity, which is often unrelated to calendar age. Both believed that often patients are in need of additional support in various geriatric domains. (2) Experiences with geriatric assessment. Patients regarded the content and the time spent on the geriatric assessment predominantly positive. Professionals emphasized that assessment creates awareness among the whole treatment team for cognitive and social problems, shifting the focus from mainly somatic to multidimensional problems. Outcomes of geriatric assessment were observed to enhance a dialogue on suitability of treatment options, (re)adjust treatment and provide/seek additional (social) support. (3) Barriers and facilitators for implementation of geriatric assessment in routine care. Discussed barriers included lack of communication about goals and interpretation of geriatric assessment, burden for patients, illiteracy, and organizational aspects. Major facilitators are good multidisciplinary cooperation, involvement of geriatrics and multidisciplinary team meetings. (4) Desired characteristics of a suitable geriatric assessment concerned the scope and use of tests and timing of assessment. Conclusions Patients and professionals were positive about using geriatric assessment in routine nephrology care. Implementation seems achievable, once barriers are overcome and facilitators are endorsed. Geriatric assessment in routine care appears promising to improve (clinical) outcomes in patients approaching ESKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02206-9.
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Abstract
PURPOSE OF REVIEW To provide an overview of the recent advancements in predicting toxicity associated with cancer treatment in older patients. RECENT FINDINGS Various screening tools and validated risk calculators have been shown to help predict toxicity from surgery and chemotherapy. Radiation therapy has been more challenging to select the appropriate tool to reliably predict patients at risk for toxicity and noncompliance. Ongoing work on electronic geriatric assessment tools is showing promise in making comprehensive assessment more feasible. SUMMARY Selecting appropriate cancer therapy is particularly important in older patients, and validated tools have been developed to guide clinicians for surgery and chemotherapy; however, radiotherapy toxicity remains an area for further development, as does the uptake of existing tools into routine oncology practice.
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Wieland GD. New Variations on the Theme of Multidimensional Geriatric Assessment. Geriatrics (Basel) 2020; 5:geriatrics5040104. [PMID: 33348535 PMCID: PMC7768399 DOI: 10.3390/geriatrics5040104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/16/2022] Open
Abstract
Geriatric assessment—broadly defined—has become foundational to systems of care for frail elderly people at risk for functional decline, death, intensification of services, and long-term institutionalization [...]
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Affiliation(s)
- G Darryl Wieland
- Duke University Center for the Study of Aging and Human Development, Durham, NC 27708, USA
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21
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O'Donovan A, Leech M. Personalised treatment for older adults with cancer: The role of frailty assessment. Tech Innov Patient Support Radiat Oncol 2020; 16:30-38. [PMID: 33102819 PMCID: PMC7568178 DOI: 10.1016/j.tipsro.2020.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 12/13/2022] Open
Abstract
It is widely accepted in clinical practice that chronological age is a poor predictor of treatment tolerance and outcomes in older adults with cancer. Intrinsic vulnerability is more a function of underlying frailty, rather than chronological age. Frailty is a state of increased vulnerability to stressors, such as cancer and its treatment, which can lead to adverse health outcomes for patients. Capturing this heterogeneity in reserve capacity is the cornerstone of management in geriatricmedicine, but remains poorly understood or adopted in radiation oncology. A two-step approach, using a shorter screening tool, followed by full assessment for those who need it, is the mostresourceful way of implementing frailty assessment in radiotherapy departments. It is important for radiation oncology professionals to identify frailty and to use this information in multidisciplinary decision making in order to develop a personalised radiotherapy approach for the older person. There are many ways we can effectively use this information, such as considering treatment fractionation schedules that would limit the burden of travel for those with social frailty, or reviewing the range of modalities at our disposal, which might limit toxicity in the older person at high risk of deterioration during treatment. Frailty assessment is not carried out in many radiotherapy departments presently, but there are many international models to use as exemplars as to how it may be implemented in clinical practice. There are many opportunities for further research and role development in this field at the current time.
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Guarnieri C, Von Hoff DD. Phase 1 Clinical Trials in the Elderly: Enrollment Challenges. J Adv Pract Oncol 2020; 11:494-501. [PMID: 32974073 PMCID: PMC7508253 DOI: 10.6004/jadpro.2020.11.5.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Cancer mostly affects older adults. Despite the increased incidence of cancer among older adults, they are underrepresented in oncology clinical trials. Such trials can provide patients with early access to promising interventions. Clinical trials are changing the future of cancer treatments. This article provides advanced practitioners in oncology an understanding of potential barriers to enrollment of older adults in oncology clinical trials. This article also summarizes the literature comparing tolerance, toxicity, and clinical benefit in the elderly compared with the nonelderly. Enrollment of elderly patients is essential. It is therefore important to create strategies to increase their enrollment. Advanced practitioners, along with other members of the health-care team, play an important role to advocate for elderly patients in phase I clinical trials.
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Baltatzis M, Rodriquenz MG, Siriwardena AK, De Liguori Carino N. Contemporary management of pancreas cancer in older people. Eur J Surg Oncol 2020; 47:560-568. [PMID: 32950314 DOI: 10.1016/j.ejso.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/20/2022] Open
Abstract
As the population of western countries is aging, the number of patients diagnosed with cancer is growing. Therefore older people, more susceptible to develop pancreatic malignancy, will likely represent the prototype of a pancreatic cancer patient in the near future. Diagnostic modalities utilised for younger patients are also applicable for older individuals. There is accumulative evidence that biological age is not an independent factor predicting poor outcome in elderly patients with resectable disease undergoing surgery, however increased postoperative morbidity and mortality within the elderly group has also been reported. Adjuvant chemotherapy should be offered in all patients with good performance status regardless of their age. Palliative measures for unresectable tumours including relief from biliary and duodenal obstruction as well as chemotherapy should be considered in non-frail patients with reasonable life expectancy. Palliative chemotherapy options are FOLFIRINOX or gemcitabine/nab-paclitaxel for patients with good performance status (0-1) and gemcitabine alone for patients with performance status 2-3. The cornerstone for improving the outcomes of the elderly age group is careful patient selection and perioperative optimization of those who have indication for surgery. Patients and their carers should be involved in the decision making process with emphasis on the expected functional recovery after the proposed treatment modality. The presence of geriatricians in the multidisciplinary team meetings is crucial in order to identify the optimal treatment pathway for elderly patients. Geriatric input regarding peri-habilitation pathways to improve surgical outcomes, to decrease mortality and to expedite patients' functional recovery is highly recommended.
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Affiliation(s)
- Minas Baltatzis
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Maria Grazia Rodriquenz
- Oncology Unit, Foundation IRCCS, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Ajith K Siriwardena
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicola De Liguori Carino
- Regional Hepato-Pancreatico-Biliary Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
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George M, Smith A. Use of an Abbreviated Geriatric Screening Tool in the Assessment of Older Cancer Patients' Functional Status, Dependency, and Comorbidities: Cross-Sectional Audit and Observations From a Regional Cancer Center in Australia. JMIR Cancer 2020; 6:e16408. [PMID: 32255433 PMCID: PMC7175185 DOI: 10.2196/16408] [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: 09/26/2019] [Revised: 01/21/2020] [Accepted: 02/20/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Malignancies are the leading cause of disease burden in Australia, comprising 19% of total diseases. Approximately 1 in 4 men and 1 in 6 women die from malignancies by 85 years of age, with patients aged 65 years and older contributing to 58% of diagnoses and 76% of cancer mortality. In the context of malignancy-related disease and age-related degeneration, there is a need for comprehensive assessment of older patients to plan for appropriate management and predict prognosis. The utility of available comprehensive geriatric assessment tools has been limited in routine practice because of their time-consuming nature, despite their informing clearer understanding of patients' functional status, better clinical decision making, prevention of unpredictable admissions and emergency department overload, and support services planning. Though there are several promising tools available, there is a lack of literature on tools that can comprehensively assess functional status in an expedited fashion. OBJECTIVE This study aimed to document functional status and comorbidities among a geriatric oncology patient cohort attending a regionally located, dedicated cancer care facility, using the completed Adelaide tool assessments. This study documents cohort characteristics, including sociodemographics, malignancy type, and comorbidities. Secondarily, we observed the utility of an abridged functional assessment in the multidisciplinary team (MDT) management of older cancer patients. METHODS The study comprised a facility-based cross-sectional audit of results obtained from a screening tool administered to patients aged 65 years and older and attending an outpatient medical oncology clinic for management of cancer from late 2015 to 2017. Data relating to five domains were collected, including instrumental activities of daily living, activities of daily living, performance status, unintended weight loss, and exhaustion. Sociodemographic and disease-related factors were summarized as frequencies with percentages or mean with SD. Distribution of functional status based on sociodemographic characteristics, living status, disease-related factors, and comorbidities was analyzed using a chi-square test. Cumulative dependencies in the five domains were identified, and patients were classified as fit, vulnerable, or frail. Supplementary review of presentation notes for cases discussed at MDT meetings was undertaken to identify discrepancies. RESULTS A majority of the study population showed poor functional status, with 88.7% (243/274) categorized as vulnerable and 8.4% (23/274) as frail. Exhaustion and unintended weight loss were identified as the most common contributors to dependency. Polypharmacy was strongly associated with decreased functional status. CONCLUSIONS The outcomes of this study are congruent with the existence of dependency in various domains, and with similar research in geriatric oncology. The Adelaide tool provided a useful basis for MDT discussion and management, where cases were referred to the MDT. We recommend further examination of the tool's utility and impact in clinical decision making, and the distribution of dependencies in a rural cohort compared with metropolitan patients.
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Affiliation(s)
- Mathew George
- North West Cancer Centre, Tamworth Hospital, Hunter New England Local Health District, Tamworth, Australia
- School of Rural Medicine, University of New England, Armidale, Australia
| | - Alexandra Smith
- North West Cancer Centre, Tamworth Hospital, Hunter New England Local Health District, Tamworth, Australia
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Loh KP, Kaushik R, Mohile SG, Ogie S, Kadambi S, Zittel J, Yousefi-Nooraie R, Moorthi K, Patil A, Sanapala C, Yang S, Ramsdale E. Speeding the dissemination and implementation of geriatric assessment: What we can learn from the business world. J Geriatr Oncol 2020; 11:1170-1174. [PMID: 32220588 DOI: 10.1016/j.jgo.2020.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/08/2020] [Accepted: 03/10/2020] [Indexed: 01/14/2023]
Affiliation(s)
- Kah Poh Loh
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Ramya Kaushik
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Supriya G Mohile
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Samuel Ogie
- School of Business, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Sindhuja Kadambi
- School of Business, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Jason Zittel
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Reza Yousefi-Nooraie
- Department of Public Health, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA.
| | | | - Amita Patil
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Chandrika Sanapala
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Shuhan Yang
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
| | - Erika Ramsdale
- James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA.
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