Use of palliative chemotherapy in patients aged 80 years and over with incurable cancer: experience at three Sydney cancer centres

BACKGROUND

Octogenarians represent a growing population reviewed in medical oncology clinics, yet there is a paucity of data on how chemotherapy is tolerated in this age group.

AIM

To describe the use of palliative first-line chemotherapy in patients 80 years and over and factors associated with its use.

METHODS

We identified all new patients aged 80 years or older diagnosed with incurable advanced solid organ cancer and seen in one of three Sydney medical oncology outpatient clinics between January 2009 and December 2013. Patient, disease and treatment details were summarised and factors associated with chemotherapy use explored.

RESULTS

Of 420 eligible patients, 100 (24%) started first-line chemotherapy. Younger age at diagnosis was the only factor associated with receiving chemotherapy (median 82.9 vs 84.1 years, P = 0.002). A total of 78% of patients had single-agent chemotherapy, and 41% received a full dose for the first cycle. During treatment, 54% experienced toxicity, necessitating dose reduction, delay or omission, and 32% were hospitalised. These events were associated with receipt of combination chemotherapy (OR 5.1; P = 0.04) and full-dose chemotherapy for cycle 1 (OR 3.5; P = 0.02). Radiological disease control was achieved in 60%. Chemotherapy was stopped because of progressive disease (48%), toxicity (37%) or completion of planned course (17%).

CONCLUSION

A quarter of patients 80 years and older received first-line palliative chemotherapy. Despite most receiving a modified dose, one third were hospitalised during treatment. These findings highlight the need for careful clinical assessment and selection of older cancer patients for chemotherapy.

Social skills and associated psychopathology in children with chromosome 22q11.2 deletion syndrome: implications for interventions

BACKGROUND

Although distinctive neuropsychological impairments have been delineated in children with chromosome 22q11 deletion syndrome (22q11DS), social skills and social cognition remain less well-characterised.

OBJECTIVE

To examine social skills and social cognition and their relationship with neuropsychological function/behaviour and psychiatric diagnoses in children with 22q11DS.

METHODS

Sixty-six children with 22q11DS and 54 control participants underwent neuropsychological testing and were administered the Diagnostic Analysis of Non-Verbal Accuracy (DANVA) for face and auditory emotion recognition, a measure of social cognition: their parents/guardians were administered the Social Skills Rating System (SSRS) - parent version, Child Behavior Checklist (CBCL) - parent version and the Computerised Diagnostic Interview Schedule for Children (C-DISC).

RESULTS

The 22q11DS group exhibited significantly lower social skills total score and more problem social behaviours, lower neurocognitive functioning, higher rates of anxiety disorders and more internalising symptoms than the control group. Participants with 22q11DS also exhibited significant deficits in their ability to read facial expressions compared with the control group, but performed no differently than the control participants in the processing of emotions by tone of voice. Within the 22q11DS group, higher social competency was correlated with higher global assessment of functioning and parental socio-economic status. Social competency was worse in those with anxiety disorders, attention deficit hyperactivity disorder, more than two psychiatric diagnoses on the C-DISC and higher internalising symptoms. No significant correlations of SSRS scores were seen with IQ, executive functions, attention, or verbal learning and memory. No correlations were found between social cognition and social skill scores.

CONCLUSION

Our results indicate that social skills in children with 22q11DS are associated with behaviour/emotional functioning and not with neurocognition. Thus, treating the behaviour or emotional problems such as attention deficit hyperactivity disorder and anxiety disorders may provide a pathway for improving social skills in these children.

Treatment of minor depression in older adults: a pilot study comparing sertraline and exercise

The purpose of this study was to conduct a pilot clinical trial to test the feasibility and efficacy of an exercise program and anti-depressant treatment compared with usual care in improving the emotional and physical functioning of older adults with minor depression. Participants were 37 older adults with minor depression who were randomized to exercise, sertraline, or usual care; 32 participants completed the 16-week study. Outcomes included measures of both emotional (clinician and self-report) and physical (observed and self-report) functioning. There were trends for the superiority of the exercise and sertraline conditions over usual care in improving SF-36 mental health scores and clinician-rated depression scores. Individuals in the exercise condition showed greater improvements in physical functioning than individuals in the usual care condition. Both sertraline and exercise show promise as treatments for late-life minor depression. However, exercise has the added benefit of improving physical functioning as well.

Symptom clusters in irradiated brain tumor survivors

8581

Background: Symptom clusters, whereby ≥2 symptoms coexist within patients, occur with cancer and its treatment. Identification and treatment of symptom clusters may improve functional status and health-related quality of life (HRQL). We report the characterization of symptom clusters occurring in irradiated brain tumor survivors. Materials/Methods: 34 adult survivors of primary or metastatic brain tumors following partial or whole brain irradiation ≥6 months prior were enrolled in an open-label Phase II study of donepezil, an acetylcholinesterase inhibitor (Rapp et al and Shaw et al, Neuro-Oncology 6:357 and 358, 2004). Eligibility criteria included life expectancy ≥30 weeks, no imaging evidence of progressive brain disease ≥3 months, stable/decreasing steroid dose, Karnofsky Performance Status (KPS) ≥70, and no brain tumor therapy during the study period. Patients received donepezil 5mg/day for 6 weeks, then 10mg/day for 18 weeks, followed by 6 weeks observation off drug. Symptoms were assessed at baseline, 6, 12, 24, and 30 weeks with the Functional Assessment of Cancer Therapy - Brain (FACT-Br) and Profile of Mood States (POMS). Factor analysis, multidimensional scaling and multivariate cluster analysis were used to characterize symptom clustering. Results: Of 34 patients enrolled, 24 remained on study for 24 weeks and 21 remained for the entire 30 weeks. Utilizing the HRQL data, all three methods of analysis demonstrated 3 distinct symptom clusters: mood, cognition and energy. The factor analysis table below illustrates such findings. Conclusions: Three symptom clusters with symptoms related to mood, cognitive function and energy were identified in this group of irradiated brain tumor survivors. Further research should focus on therapeutic interventions for symptom clusters rather than the traditional emphasis on single-symptom therapy. This study was supported by NCI grant 1 U10 CA81851.

[Table: see text]

No significant financial relationships to disclose.

Symptom clusters in newly-diagnosed brain tumor patients

8587

Background: A symptom cluster is 2 or more co-occurring symptoms. Patients with brain tumors experience disease and treatment-related symptoms that impact their health-related quality of life (QOL). Identifying symptom clusters will facilitate treatment and improve QOL outcomes. Methods: 66 patients were enrolled in a phase III, placebo-controlled, double-blind, prospective randomized clinical trial assessing the effect of prophylactic d-methylphenidate (d-MPH) on QOL in newly diagnosed brain tumor patients receiving brain radiation therapy (RT). Inclusion criteria were: age ≥ 13 years, primary or metastatic brain tumor, partial or whole brain RT with a total dose of ≥ 2,500 cGy in ≥ 10 fractions, KPS ≥ 70, and life expectancy ≥ 3 months. Patients received d-MPH 5–15 mg BID (or placebo) starting week 1 of RT and continuing for 8 weeks post-RT. QOL data were collected at baseline, the end of RT, and 4, 8, and 12 weeks following RT using the Functional Assessment of Cancer Therapy-Brain (FACT-Br) and the Center for Epidemiologic Studies Depression Scale (CES-D). Symptom data were analyzed using exploratory factor analysis, multi-dimensional scaling (MDS), and cluster analysis. Results: The study failed to show a treatment effect for d-MPH (Butler J et al, Int J Radiat Oncol Biol Physics 63 [Supp1]:80, 2005).Thus, both d-MPH and placebo patients were analyzed together. 58 and 48 patients were analyzed at baseline and the end of RT, respectively. Two symptom clusters were identified using exploratory factor analysis and supported by MDS and cluster analysis: an expressive language cluster including difficulty reading, writing, and finding the right words, and a mood cluster including feeling sad, anxious, and having depressed mood. Conclusions: Two symptom clusters were identified in patients undergoing brain RT: an expressive language cluster and a mood cluster. This suggests that interventions that target both cognitive function and mood should be utilized. Further research on symptom clusters in cancer patients is needed. This study was supported by NCI grant 1 U10 CA81851.

No significant financial relationships to disclose.