Patients' selection and trial matching in early-phase oncology clinical trials

BACKGROUND

Early-phase clinical trials (EPCT) represent an important part of innovations in medical oncology and a valuable therapeutic option for patients with metastatic cancers, particularly in the era of precision medicine. Nevertheless, adult patients' participation in oncology clinical trials is low, ranging from 2% to 8% worldwide, with unequal access, and up to 40% risk of early discontinuation in EPCT, mostly due to cancer-related complications.

DESIGN

We review the tools and initiatives to increase patients' orientation and access to early phase cancer clinical trials, and to limit early discontinuation.

RESULTS

New approaches to optimize the early-phase clinical trial referring process in oncology include automatic trial matching, tools to facilitate the estimation of patients' prognostic and/or to better predict patients' eligibility to clinical trials. Classical and innovative approaches should be associated to double patient recruitment, improve clinical trial enrollment experience and reduce early discontinuation rates.

CONCLUSIONS

Whereas EPCT are essential for patients to access the latest medical innovations in oncology, offering the appropriate trial when it is relevant for patients should increase by organizational and technological innovations. The oncologic community will need to closely monitor their performance, portability and simplicity for implementation in daily clinical practice.

Advanced oesophago-gastric adenocarcinoma in older patients in the era of immunotherapy. A review of the literature

Gastric (G) and gastro-esophageal junction (GEJ) adenocarcinomas are of the most common and deadly cancers worldwide and affect mainly patients over 70 years at diagnosis. Older age has been associated in gastric cancers with distal tumour location, well-differentiated adenocarcinoma and microsatellite instability and is not identified itself as an independent prognostic factor. As immune checkpoint inhibitors recently changed the landmark of advanced G and GEJ adenocarcinomas treatment, we decided to perform a literature review to define the evidence-level of clinical data in older patients. This work underlined the lasting low -inclusion rate of older patients and -implementation rate of frailty screening tools in clinical trials in G/GEJ carcinomas. In the first-line metastatic setting, two prospective randomized phase III studies have specifically assessed the efficacy of chemotherapy in older patients with HER2-negative gastric cancers, demonstrating the feasibility of reduced dose oxaliplatin-based chemotherapy regimen in this population. Only few data are available in HER2-positive tumors, or in the second-line setting. Furthermore, no specific trial with immune checkpoint inhibitors was performed in older frail patients whereas their benefit/adverse events ratio make them attractive candidates in this patient's population. We conclude that older fit patients can be treated in the same way as younger ones and included in clinical trials. Improving the outcome of older frail patients should be the oncology community next focus by implementing targeted interventions before initiating cancer therapy and designing specific clinical trials. Frailty screening tools and geriatric data collection have to be implemented in routine-practice and clinical trials.

Immune checkpoint inhibitor treatment of a first cancer is associated with a decreased incidence of second primary cancer

Background

Second primary cancers (SPCs) are diagnosed in over 5% of patients after a first primary cancer (FPC). We explore here the impact of immune checkpoint inhibitors (ICIs) given for an FPC on the risk of SPC in different age groups, cancer types and treatments.

Patients and methods

The files of the 46 829 patients diagnosed with an FPC in the Centre Léon Bérard from 2013 to 2018 were analyzed. Structured data were extracted and electronic patient records were screened using a natural language processing tool, with validation using manual screening of 2818 files of patients. Univariate and multivariate analyses of the incidence of SPC according to patient characteristics and treatment were conducted.

Results

Among the 46 829 patients, 1830 (3.9%) had a diagnosis of SPC with a median interval of 11.1 months (range 0-78 months); 18 128 (38.7%) received cytotoxic chemotherapy (CC) and 1163 (2.5%) received ICIs for the treatment of the FPC in this period. SPCs were observed in 7/1163 (0.6%) patients who had received ICIs for their FPC versus 437/16 997 (2.6%) patients receiving CC and no ICIs for the FPC versus 1386/28 669 (4.8%) for patients receiving neither CC nor ICIs for the FPC. This reduction was observed at all ages and for all histotypes analyzed. Treatment with ICIs and/or CC for the FPC are associated with a reduced risk of SPC in multivariate analysis.

Conclusion

Immunotherapy with ICIs alone and in combination with CC was found to be associated with a reduced incidence of SPC for all ages and cancer types.

•

From 2013 to 2018, 3.9% of the 46 829 patients diagnosed with a first cancer presented with an SPC.

•

Treatment of the first cancer with ICIs was associated with a major reduction of SPC.

•

CC given for an FPC was also associated with a lower magnitude of reduction of SPC.

•

There were no SPC in cancer patients treated with ICIs in the localized phase of their first cancer.

Abstract PD1-08: Phase 1/1b study of novel oral selective estrogen receptor degrader (SERD) LSZ102 for estrogen receptor-positive (ER+) advanced breast cancer (ABC) with progression on endocrine therapy (ET)

Background: LSZ102 is an orally bioavailable SERD that inhibits ER gene transcription, induces receptor degradation, and blocks ER-dependent cell growth in preclinical models. This study is evaluating LSZ102 as a single agent and in combination with the CDK 4/6 inhibitor ribociclib (LEE011) or the PI3K inhibitor alpelisib (BYL719) in patients (pts) with ER+ ABC. The LSZ102 single agent data are presented below; combination data are not discussed.

Methods: In the dose-escalation phase evaluating single-agent LSZ102 (Arm A), pts (age ≥18 years; ECOG PS 0-1) with histologically confirmed ER+ ABC and progression on endocrine therapy (ET) received LSZ102. The starting dose was 200 mg once daily. The primary objective of Arm A was to characterize the safety and tolerability of LSZ102 and identify a recommended dose for expansion (RDE). Secondary objectives included preliminary antitumor activity and pharmacokinetics (PK).

Results: As of January 22, 2018, 57 pts were enrolled to Arm A (LSZ102 200 mg, n=4; 400 mg, n=6; 450 mg fasted, n=15; 450 mg with food, n=6; 600 mg, n=20; 900 mg, n=6). Median age was 60 years, 75% (n=43) of pts had an ECOG PS of 0, 56% (n=32) had received prior fulvestrant, and 58% (n=33) had received prior CDK4/6 inhibitors; median number of prior lines of therapy (all settings) was 6. At data cut-off, 48 pts had discontinued treatment, most (n=45, 94%) due to disease progression. Dose-limiting toxicities across treatment groups included diarrhea (2 pts in the 900-mg group), vomiting (1 pt in the 600-mg group), and AST and ALT elevation (1 pt in the 450-mg with food group). The most common treatment-related adverse events (AEs) in the treatment period were diarrhea (60%), nausea (56%), and vomiting (30%). In the treatment period, treatment-related grade 3 AEs (12%) were infrequent, and there were no such grade 4 events. Six pts (11%) required dose reduction due to AEs (nausea, vomiting or diarrhea); 4/6 of the dose reductions occurred at 900 mg. Preliminary PK assessment showed rapid absorption and dose-proportional increases in LSZ102 exposure; trough concentrations were above the predicted tumorostatic concentrations at doses of ≥400 mg. Based on PK results for the 450-mg fasted and fed cohorts, LSZ102 exposure does not appear to be affected by dosing with a regular meal. Evidence of ER modulation by immunohistochemistry was observed in paired baseline and on-treatment biopsies. 18F-fluoroestradiol positron emission tomography (FES-PET) analysis (n=6) demonstrated abrogation of FES-PET signal for pts in the 450-mg and 600-mg dose groups. Seventeen pts (29.8%) had a best response of stable disease, and 1 pt, who happened to be in the 600-mg group, achieved a partial response.

Conclusion: In heavily pretreated pts, LSZ102 was well tolerated, demonstrated antitumor activity, and achieved effective exposure levels based on PK and pharmacodynamics. Food intake did not appear to significantly alter the PK profile of LSZ102. Dose escalation for LSZ102 in combination with ribociclib or alpelisib is ongoing and will be reported in a future analysis. An update on the recommended single agent dose and schedule will be presented.

Citation Format: Jhaveri K, Curigliano G, Yap Y-S, Cresta S, Duhoux FP, Terret C, Takahashi S, Ulaner GA, Kundamal N, Baldoni D, Liao S, Crystal A, Juric D. Phase 1/1b study of novel oral selective estrogen receptor degrader (SERD) LSZ102 for estrogen receptor-positive (ER+) advanced breast cancer (ABC) with progression on endocrine therapy (ET) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD1-08.

Abstract OT1-03-01: Phase 1/1b study of novel oral selective estrogen receptor degrader (SERD) LSZ102 in combination with alpelisib (BYL719) in estrogen receptor-positive (ER+), human epidermal growth factor receptor-2–negative (HER2–) advanced breast cancer (ABC) with progression on endocrine therapy (ET)

Background: Although ET remains the basis of therapy for ER+, HER2– ABC, treatment resistance frequently occurs. Novel strategies to target the receptor and/or alternative pathways to overcome therapeutic resistance are under investigation. LSZ102 is a novel, orally bioavailable, nonsteroidal SERD. Preclinically, LSZ102 inhibits ER gene transcription, induces receptor degradation, blocks ER-dependent cell growth, and has synergistic activity with the phosphoinositide 3-kinase (PI3K)-alpha inhibitor alpelisib (BYL719). The present study is evaluating the safety and tolerability of LSZ102 plus alpelisib in patients with ER+, HER2– ABC with progression on ET.

Trial Design: This phase 1/1b, open-label study is enrolling ˜18-30 patients (men and women of any menopausal status) in Arm C of the dose-escalation part of the study, which investigates the combination of LSZ102 and alpelisib; additional study arms will investigate LSZ102 as a single agent or in combination with ribociclib. Enrollment in Arm C started after identification of a safe and tolerable single-agent dose for LSZ102. Alpelisib dosing began at 200 mg/day and will not be escalated beyond the maximum tolerated dose (MTD) determined in the alpelisib single-agent arm of study CBYL719X2101 (400 mg/day). Dose escalation of alpelisib in combination with LSZ102 is guided by BLRM and integrates Cycle 1 DLT rates, lower grade and later cycle AE, PK, PD and preliminary activity to identify a recommended dose for expansion (RDE). Patients will receive treatment until disease progression, unacceptable toxicity, or withdrawal of consent. For inclusion in the study, patients must have histologically confirmed ER+, HER2– ABC and disease progression after ET for ABC or recurrence on/within 12 months of completion of adjuvant ET. In the escalation part of the study, patients are eligible regardless of PIK3CA status. Premenopausal women must receive concomitant treatment with a gonadotropin-releasing hormone agonist. Eligible patients must have adequate bone marrow and organ function, Eastern Cooperative Oncology Group performance status of 0 or 1, and have completed and recovered from acute toxicities of radiotherapy and/or prior anticancer therapy. Exclusion criteria include symptomatic central nervous system metastases, clinically significant cardiac disease or impaired cardiac function (including a QT interval corrected for heart rate using Fridericia's formula [QTcF] >460 ms in women or >450 ms in men), uncontrolled diabetes mellitus type II (or type I), and prior treatment with a PI3K inhibitor. The primary objectives are characterization of safety and tolerability for the combination and identification of a recommended dose. Secondary objectives include characterization of pharmacokinetic properties and pharmacodynamic effects. Recruitment for Arm C is ongoing. NCT02734615

Citation Format: Curigliano G, Cresta S, Yap Y-S, Juric D, Duhoux FP, Terret C, Takahashi S, Layman RM, Kundamal N, Baldoni D, Liao S, Crystal A, Jhaveri K. Phase 1/1b study of novel oral selective estrogen receptor degrader (SERD) LSZ102 in combination with alpelisib (BYL719) in estrogen receptor-positive (ER+), human epidermal growth factor receptor-2–negative (HER2–) advanced breast cancer (ABC) with progression on endocrine therapy (ET) [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr OT1-03-01.

Multidisciplinary development of the Geriatric Core Dataset for clinical research in older patients with cancer: A French initiative with international survey

BACKGROUND

To define a core set of geriatric data to be methodically collected in clinical cancer trials of older adults, enabling comparison across trials.

PATIENTS AND METHODS

Following a consensus approach, a panel of 14 geriatricians from oncology clinics identified seven domains of importance in geriatric assessment. Based on the international recommendations, geriatricians selected the mostly commonly used tools/items for geriatric assessment by domain (January-October 2015). The Geriatric Core Dataset (G-CODE) was progressively developed according to RAND appropriateness ratings and feedback during three successive Delphi rounds (July-September 2016). The face validity of the G-CODE was assessed with two large panels of health professionals (55 national and 42 international experts) involved both in clinical practice and cancer trials (March-September 2017).

RESULTS AND DISCUSSION

After the last Delphi round, the tools/items proposed for the G-CODE were the following: (1) social assessment: living alone or support requested to stay at home; (2) functional autonomy: Activities of Daily Living (ADL) questionnaire and short instrumental ADL questionnaire; (3) mobility: Timed Up and Go test; (4) nutrition: weight loss during the past 6 months and body mass index; (5) cognition: Mini-Cog test; (6) mood: mini-Geriatric Depression Scale and (7) comorbidity: updated Charlson Comorbidity Index. More than 70% of national experts (42 from 20 cities) and international experts (31 from 13 countries) participated. National and international surveys showed good acceptability of the G-CODE. Specific points discussed included age-year cut-off, threshold of each tool/item and information about social support, but no additional item was proposed.

CONCLUSION

We achieved formal consensus on a set of geriatric data to be collected in cancer trials of older patients. The dissemination and prospective use of the G-CODE is needed to assess its utility.

Abstract P5-21-04: Phase I/Ib study of the SERD LSZ102 alone or in combination with ribociclib in ER+ breast cancer

Background: LSZ102 is an orally bioavailable selective estrogen receptor degrader (SERD) that inhibits estrogen receptor (ER) gene transcription, induces receptor degradation, and blocks ER-dependent cell growth in preclinical models. This Phase I/Ib, open-label study is evaluating LSZ102 as a single agent and in combination with the CDK4/6 inhibitor ribociclib (LEE011) or the PI3K inhibitor alpelisib (BYL719) in patients (pts) with locally advanced/metastatic ER-positive (ER+) breast cancer (BC).

Methods: The primary objective is to characterize the safety and tolerability, and identify a recommended dose and regimen of LSZ102 alone (Arm A) or in combination with ribociclib (Arm B) or alpelisib (Arm C). Secondary objectives include evaluation of preliminary antitumor activity and pharmacokinetics (PK). Eligible pts (aged ≥18 yrs; ECOG PS 0-1) have histologically confirmed ER+ BC that has progressed after endocrine therapy.

Results: As of March 14, 2017, dose escalation evaluating 16 pts in Arm A (LSZ102 200 mg [n=4], 400 mg [n=6], and 600 mg [n=6]) had completed (median age 57.5 yrs; 81% ECOG PS 0; 63% received prior fulvestrant). Five pts (median age 59.0 yrs; 80% ECOG PS 0; 60% received prior fulvestrant) had enrolled in the first cohort of Arm B (LSZ102 200 mg QD + ribociclib 300 mg 3 weeks on/1 week off) with evaluation ongoing. Arm C (LSZ102 + alpelisib) had yet to open. As of March 14, 2017, 9/16 (56%) pts in Arm A had discontinued treatment, all due to progressive disease (PD); in Arm B all pts were still receiving treatment. There were no dose-limiting toxicities in either arm at the dose levels evaluated; dose escalation is ongoing. The most common drug-related adverse events (AEs) were diarrhea (Grade [Gr] 1: 7/16; Gr 2: 2/16 pts), nausea (Gr 1: 6/16; Gr 2: 2/16 pts), and vomiting (Gr 1: 3/16 pts) in Arm A, and hot flush, nausea, vaginal discharge (all Gr 1: 2/5 pts), thrombocytopenia (Gr 1: 1/5; Gr 2: 1/5 pts), and neutropenia (Gr 2: 1/5, Gr 3: 1/5 pts) in Arm B. There were no drug-related Gr 3/4 AEs reported in Arm A; in Arm B, Gr 3 neutropenia, leukopenia, and lymphopenia each occurred in 1/5 pts. Preliminary PK assessment showed single-agent LSZ102 exposure increased dose-proportionally from 200 to 600 mg QD. In combination with ribociclib, exposures were consistent with those of the single agent at the same dose. In Arm A, preliminary evidence of antitumor activity was observed. Efficacy data for Arms B and C were not available as of March 14, 2017. One pt, whose tumor harbored an ESR1 D538G mutation, had been treated with multiple prior therapies in the metastatic setting, including letrozole, exemestane, tamoxifen, exemestane + everolimus, and anastrozole, as well as fulvestrant for 120 days prior to PD, and letrozole + palbociclib for 94 days prior to PD. As of March 14, 2017, this pt had been on LSZ102 treatment (400 mg QD) for 167 days, with a best response of stable disease (14% reduction in sum of diameter of target lesions).

Conclusions: Oral single-agent LSZ102 appears well-tolerated, with a manageable safety profile. Preliminary data also suggest tolerability when combined with ribociclib. Preliminary evidence of single-agent antitumor activity was seen in heavily pretreated pts with ER+ BC in a post-fulvestrant setting.

Citation Format: Juric D, Curigliano G, Cresta S, Yap Y-S, Terret C, Duhoux FP, Takahashi S, Kundamal N, Bhansali S, Liao S, Crystal A, Jhaveri K. Phase I/Ib study of the SERD LSZ102 alone or in combination with ribociclib in ER+ breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-21-04.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†

BACKGROUND

Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.

MATERIALS AND METHODS

SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.

RESULTS

Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.

CONCLUSIONS

Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

Abstract OT3-1-10: ASTER 70s (UNICANCER phase III trial): Is personalized adjuvant treatment for women over 70 with luminal breast cancer the way to go?

Background

The question of the additional benefit of adjuvant chemotherapy (CT) compared to hormonal therapy alone (HT) for women >70 with ER+ / HER2- breast cancer (BC) and aggressive characteristics is still unsolved. This trial compares the impact of both strategies on overall survival (OS).

Trial design

Following surgery, ∼2,000 patients will have a Genomic Grade (GG) centrally performed on FFPE specimens. Those with a high or equivocal GG will be randomized HT alone vs HT+CT. Patients with low GG will be followed as an observational cohort. The study, on-going in France since April 2012, has been recently activated in Belgium.

Eligibility criteria

Any ER+ HER2- BC after complete surgery, M0, any pT or pN. Normal organ functions. No specific BC treatment before surgery. Contralateral BC, invasive BC after ductal carcinoma in situ and isolated local invasive relapse when adjuvant systemic treatment is considered are all eligible. Multifocal or bilateral are eligible according to focus with worst GG. The G8 screening tool is used as stratification criteria for randomization.

Specific aims

OS (all deaths) is the primary endpoint. Secondary objectives include competing events, cost-effectiveness and Q-TWiST analysis, geriatric dimension, acceptability/willingness and health-related quality of life including specific ELD15. The Lee's 4-year mortality score is calculated. Translational research will focus on prognostic biomarkers and pharmacogenetic, investigating also the impact of treatments on putative ageing biomarkers as CRAMP, stathmin, EF-1α and chitinase and telomeres length.

Statistical methods

Sample size based on 4-year OS (87.5 vs 80%), bilateral test, α = 0.05, β = 0.20 and HR = 0.60.

In total, 129 events are expected, requiring 340 patients/arm. Considering those lost to follow-up, ∼700 patients in total should be included (5 extra patients/year).

Present accrual and target accrual

As of May 2013, 43 centres have included 406 Patients aged 70-88.

Only 14 GG evaluations were not performed for the following reasons: Patients consent withdrawal (n = 3), tumour block not available for the GG test (n = 5), CT not a treatment option anymore (patients or investigator's decision) (n = 2) or tumour status (ER+/HER2-) not confirmed by central review (n = 4). 8 GG evaluations are on-going.

Of 384 cases with GG report, 160 (42%), 151 (39%) and 65 (17%) were respectively GG-1 (low risk), GG-3 (high risk) and GG-EQ (equivocal); 8 (2%) tests failed for technical reasons. The proportion of high GG in the study (53%) is similar to those observed in previous studies in general BC populations (40% to 60%).

Of 216 GG-3/-EQ cases, 4 were not randomized because of distant metastases detected during extensive work-up (n = 3) and Patient refusal of CT treatment before randomization (n = 1). Five randomizations are on-going.

GG determination was obtained in 384 leading to randomization in 207, totalizing so far 30% of the projected recruitment for the primary objective. This confirms the feasibility of such multicentre strategic program with an innovative prognostic signature in the elderly BC population.

Contact information

c-orsini@unicancer.fr.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT3-1-10.

Health status in senior adult prostate cancer patients: Limits for active treatment and clinical trials inclusion

15550

Background: Two-third of patients (pts) with prostate cancer are older than 70 years. Patients are likely to receive active treatments in the curative and palliative settings if they have good health status, moreover they are likely to be offered to participate to clinical trials. Health status evaluation is performed by Comprehensive Geriatric Assessement (CGA). Methods: We have prospectively performed a mini- CGA (Terret C, Expert Rev Anticancer Ther. 2004; 4 : 469–75.) in 69 patients with prostate cancer : 33% pts had localized disease, median age was 78.7 years (68–92). Mini-CGA was based on a careful clinical examination with analysis of physical function, nutritional status (MNA), functional domain (ADL, IADL), cognitive and emotional domains (MMSE, GDS), identification and grading of comorbid conditions (CIRS-G), and a medication review. Social and familial evaluations complete the procedure. Results: Dependancy: only 12% pts are fully independant for ADL and 11% for IADL; 20% pts experienced falls and 32% were at risk of fall. Cognitive functions and depression: 60% pts had normal cognitive funtions, 46% and 4% were moderately and deeply depressed respectively. Nutrition: 22% pts had severe weight loss, 23% were mal nourished and 41% at risk of denutrition. Comorbidities: median CISR-G score was 8 (3–12), 80% and 21% pts had at least one grade 3 and one grade 4 comorbidity respectively. The most frequent comorbidities were by decreasing order of incidence : psychologic, hematologic, endocrine and osteo-articular pathologies. Polymedication: median number of drugs taken by pts was 5 (0–14) and iatrogenicity was observed in 30% pts. A caregiver was identified in 83% pts and 16% pts were living alone. None of the pts were fully independant with no major comorbidity. Conclusions: Health status of prostate cancer patients older than 70 years must be evaluated with the objective to either tailor specific clinical trials or apply adapted standard treatments. Task forces of the International Society of Geriatric Oncology (SIOG) are on the process to establish specific guidelines for prostate cancer treatment in the senior adults and for selection of manageable CGA procedures.

[Table: see text]

The illness trajectory of elderly cancer patients across cultures: SIOG position paper

BACKGROUND

Due to the aging of the population, cancer has become a health priority worldwide. While the number of elderly cancer patients is rapidly increasing, many barriers still exist to their effective management. Compared with their younger counterparts, the elderly are less likely to receive optimal medical, psychological and spiritual treatment provided in a culturally competent manner.

DESIGN

The scanty literature on cultural competence in elderly cancer patients has been reviewed. Additional material has been selected based on the authors' clinical research in medical oncology and psycho-oncology, and on their scholarly work in anthropology and bioethics.

RESULTS

The aging process is a synergistic product of biological, behavioral and social issues within a cultural context. Knowledge about how older people understand, perceive and experience their illness trajectory and make choices is essential to the planning and delivering of effective cancer care.

CONCLUSION

This position paper of the SIOG Task Force on Cultural Competence in the Elderly creates awareness of the influence of culture in geriatric oncology. Negotiating cross-cultural issues in geriatric oncology helps managing possible conflicts between patients, families and physicians over differing health care values, beliefs, or practices. Possible areas of future scholarly investigation and clinical research are identified.

Retrospective study of locally advanced bladder cancer in elderly patients

18523

Background: Bladder cancer is one of the most frequent tumors in elderly patients (pts). However, guidelines have not been established yet in this age group. Methods: We analyzed retrospectively pts aged 75 years or more, with muscle invasive or metastatic bladder cancer treated between January 2000 and June 2005, in three institutions in Lyon-France: Léon Bérard Center, Saint Luc Saint Joseph Hospital and Protestant Infirmary. Results: Data from 126 pts (81% male) were available: median age was 80 years (75–94). 99 pts had disease confined to the bladder, 19 confirmed metastatic cancer and 8 at least T2aM0 disease. 42% of pts had a history of superficial bladder cancer; 96% an urothelial carcinoma, 19% an associated in situ carcinoma. Of note, 33% of male pts had a concomitant prostate cancer. Median Performance Status, American Society of Anesthesia score and Charlson Comorbidity index were 1, 2 and 2.14 respectively. Cardiovascular comorbidities were the most common (42.8%). 87% of pts were taking medications; median number of drug intake was 4. We focused on pts with muscle invasive, non metastatic bladder cancer: 55 of 99 pts underwent surgery; 48 of them had external urinary diversion. Postoperative complications occurred in 34% of pts: evisceration (15%), sepsis, hemorrhage, acute cardiac failure, acute renal failure, pulmonary embolism (3.7% each), bowel obstruction and acute arterial thrombosis of lower limbs (1.8% each), and 2 immediate postoperative deaths. 16 pts received radiotherapy with a curative intent, 6 of them had chemoradiation. Mean irradiation dose and duration were respectively 56.4 Gy and 6.5 weeks. Toxicity occurred in 5 pts: 2 discontinuations for intolerance, 1 acute cardiac failure, 1 grade 3 thrombopenia, and 1 toxic death (intestinal perforation). The last 28 pts received palliative care. After a median follow up of 14 months, 33 operated pts and 3 pts treated by radiotherapy were still alive in complete remission. Disease free survival and median survival were 11.5 and 42 months in the surgical group respectively and 12 and 12 months in the radiotherapy group respectively. Conclusions: Treatment of locally advanced bladder cancer in the elderly carries significant morbidity and mortality. Oncogeriatric assessment benefit for individual management must be studied.

No significant financial relationships to disclose.

Nutritional status in elderly cancer patients: Why is it so important?

8532

Background: To assess the prevalence of malnutrition in elderly patients (pts) with cancer and to determine the effect of malnutrition on Overall Survival (OS). Methods: Cancer pts aged 65 and older underwent a multidimensional geriatric assessment at our institution. Data were collected for calorie and protein intakes, Mini Nutritional assessment (MNA Nestlé), functional status (ADL score), and comorbidity (CIRS-G). Survival time was defined as the time from geriatric assessment to date of death or last follow-up. A Cox regression model was used to estimate the hazards ratio (HR) and 95 percent confidence intervals (95%CI) of risk factors for death. Results: 133 consecutive pts (68% male, 50% hospitalized) were evaluated from 05/1999 to 08/2002. Median age was 78 years (range: 66–92). Main tumour sites were prostate (36%), breast (15%), bladder (12%) and Head and Neck (10%). Forty eight pts (36%) had metastatic disease. Only 55 pts (43%) were fully independent in ADLs (score = 6), and 15 pts were completely independent in IADLs (score = 14). Fifty one pts (43%) had mild to severe disability/morbidity status (CIRS-G severity index ≥2). Regarding nutritional status, only 34% were estimated well nourished with MNA >23.5, 54% had calorie intake ≤1500 kcal/day and 38% had body weight loss > 5% in the last 3 months. Survival analysis was performed with a 16-month median follow up. Median survival time was 7 months (95%CI 6–9 months). In the univariate analysis, male gender, metastatic stage, MNA, ADL score and CIRS-G severity index were significantly correlated with OS. In the multivariate analysis, male gender (HR=2.3, 95% CI: 1.3–4.1), metastasis (HR=1.6, 95% CI: 1.0–2.6), MNA<23.5 (HR=3.3, 95% CI: 1.8–6.0), CIRS-G severity index ≥2 (HR=2.8, 95%CI: 1.7–4.7) and ADL score <6 (HR=1.9, 95%CI: 1.1–3.3), were found to be independent prognostic factors for shorter OS. Conclusions: These data show that malnutrition has a major impact on survival independently of cancer severity. Thus, nutritional status must be systematically assessed before treatment decision-making. Benefits of nutritional interventions need to be studied in future trials.

No significant financial relationships to disclose.