[Minimal geriatric assessment by an advanced practice nurse]

The prevalence of haematological malignancies increases in elderly patients. The complexity of therapeutic management makes it necessary to evaluate them using a global approach, namely bio-psycho-environmental. Identifying and assessing their weaknesses are part of the roles of advanced practice nurse (APN). Various tools are used to do this, including the G8 questionnaire, which directs patients towards a comprehensive geriatric assessment, or the Geriatric core dataset, designed to be used during clinical trials and which is more detailed and faster. Could an APN use the latter?

Pitfalls in Oncogeriatrics

An oncogeriatric interdisciplinary activity exists only in a minority of high-income countries, and it is almost absent in those with lower incomes. Considering topics, sessions, and tracks in the main meetings and conferences of the major Oncological Societies in Europe and worldwide, the USA excluded, little attention has thus far been paid to the problem of cancer in the elderly. Again, with the exception of the USA, the major cooperative groups, for example, the EORTC in Europe, have only dedicated marginal attention to the research of cancer in the elderly. Despite major shortcomings, professionals interested in geriatric oncology have taken a number of important initiatives to highlight the benefits of this particular activity, including the organization of an international society (Société Internationale de Oncogeriatrie, or SIOG). In spite of these efforts, the authors believe that the management of cancer in the older population is still encountering several important and generalized pitfalls. The main obstacle is the grossly inadequate number of geriatricians and clinical oncologists necessary to an integrated care of the ever-expanding aging population, but other hurdles have been reported. Additionally, the prejudice of ageism can lead to missing potential resources for the development of a generalized oncogeriatric approach.

[The place of support care]

Supportive care, in the context of breast cancer in the elderly, is part of standard oncogeriatric care. Nevertheless, the multidisciplinary reinforcement of the different transversal teams can support the global approach, that is essential to the quality of care and the life course. Evaluation is the basis of this management. As a result of this evaluation, the approach to sexual health is a novelty that is often insufficiently considered with elderly patients suffering from breast malignancy.

"Age is just a number"; frailty as a marker of peri-operative risk in head and neck surgery: Systematic review and meta-analysis

BACKGROUND

Frailty refers to a patient's reduced capacity to withstand stressors due to a reduction in physiologic reserves. We assessed the impact of frailty on outcomes following head and neck surgery.

METHODS

We performed a systematic review in accordance with the PRISMA guidelines. Meta-analysis was performed using the Mantel-Haenszel method.

RESULTS

Fourteen studies incorporating 182 059 patients were included in qualitative synthesis with 15 953 (8.8%) of patients deemed as frail. Meta-analysis incorporating nine studies demonstrated that frailty is associated with an increased 30 day postoperative morbidity (OR 2.74; 95% CI 1.98-3.80; p < 0.01) and meta-analysis with six studies suggested increased 30-day mortality (OR 2.94; 95% CI 2.62-3.31; p < 0.01). Preliminary meta-analyses between two and five studies suggested that frail patients had reduced overall survival and were more likely to be discharged to a nonhome location or readmitted within 30 days.

CONCLUSIONS

Frailty appears to be associated with poor short-term outcomes following head and neck surgery and may improve understanding of an individual patient's peri-operative risk.

Oncological Treatment-Related Fatigue in Oncogeriatrics: A Scoping Review

Simple Summary

Fatigue in older patients has multiple etiologies, as this symptom may be cancer-related, treatment-related, age-related, or part of frailty syndrome. Physicians need to identify this symptom and understand its risk factors but also evaluate the risk/benefit ratio of cancer treatments considering the risk of impairing the patient’s quality of life. This scoping review was aimed to present the level of information currently available on any-grade fatigue and grade 3 or more fatigue for each cancer treatment regimen, either in general or in older populations, for the most prevalent tumors.

Abstract

Fatigue is a highly prevalent symptom in both cancer patients and the older population, and it contributes to quality-of-life impairment. Cancer treatment-related fatigue should thus be included in the risk/benefit assessment when introducing any treatment, but tools are lacking to a priori estimate such risk. This scoping review was designed to report the current evidence regarding the frequency of fatigue for the different treatment regimens proposed for the main cancer indications, with a specific focus on age-specific data, for the following tumors: breast, ovary, prostate, urothelium, colon, lung and lymphoma. Fatigue was most frequently reported using the National Cancer Institute Common Terminology Criteria for Adverse Events (NCI CTCAE) versions 3 to 5. A total of 324 regimens were analyzed; data on fatigue were available for 217 (67%) of them, and data specific to older patients were available for 35 (11%) of them; recent pivotal trials have generally reported more fatigue grades than older studies, illustrating increasing concern over time. This scoping review presents an easy-to-understand summary that is expected to provide helpful information for shared decisions with patients regarding the anticipation and prevention of fatigue during each cancer treatment.

Plasma Aromatase Activity Index, Gonadotropins and Estrone Are Associated with Frailty Syndrome in Post-Menopausal Women with Breast Cancer

Frailty syndrome is associated with poor outcomes, morbidity and premature mortality. We performed a cross-sectional study to evaluate the presence of frailty syndrome based on Fried’s frailty phenotype in post-menopausal women with breast cancer. We further analyzed the association between frailty syndrome with geriatric assessments and the association with the concentration of gonadotropins LH and FSH, estrogens, androgens and the aromatase activity index in the blood. We enrolled 47 post-menopausal women with localized breast cancer (mean age 66.8 ± 1.3 years (range 52−83)) prior to the starting of adjuvant endocrine therapy. Patients were identified as “non-frail” (robust) or “prefrail/frail” if they fulfilled at least one frailty criteria. In order to determine associations among variables and to control for other variables potentially affecting frailty syndrome (age, comorbidity index and previous chemotherapy treatment), we performed a logistic regression analysis. The receiver operating characteristic curve was performed to assess the sensitivity and specificity of the hormonal concentration to discriminate prefrail/frail versus non-frail individuals. Significant positive associations were observed between the severity of frailty syndrome and estrone, FSH and LH concentrations and the aromatase activity index in the blood (p < 0.05). Further research into the role of hormonal biomarkers should be evaluated in follow-up studies in order to recommend their use as suitable biomarkers of frailty syndrome in breast cancer patients.

Multi-Disciplinary Care Planning of Ovarian Cancer in Older Patients: General Statement-A Position Paper from SOFOG-GINECO-FRANCOGYN-SFPO

Simple Summary

This position paper aims to provide practitioners a proposal for multidisciplinary care planning for older patients with ovarian cancer from the time of suspected diagnosis. The first-line treatment of advanced ovarian cancer involves several interdependent sequences: cytoreductive surgery, (neo)adjuvant chemotherapy and maintenance targeted treatments. In older patients, care planning must be adapted to their geriatric parameters and consider the geriatric impact of each treatment sequence to allow treatment completion. Care planning should be centered on patient motivation and imply multidisciplinarity. Each step of treatment plan should be reconsidered in light of a geriatric assessment and follow-up. Studies are needed to prospectively evaluate the impact of geriatric vulnerability parameters at each step of the treatment agenda and the impact of geriatric interventions on patient outcomes.

Abstract

In this position paper the Société Francophone d’OncoGériatrie (SOFOG; French-speaking oncogeriatric society), the Société Française de Pharmacie Oncologique (SFPO, French society for oncology pharmacy), the Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO, National Investigators’ Group for Studies in Ovarian and Breast Cancer) and the Groupe Français de chirurgie Oncologique et Gynécologique (FRANCOGYN) propose a multi-disciplinary care planning of ovarian cancer in older patients. The treatment pathway is based on four successive decisional nodes (diagnosis, resectability assessment, operability assessment, adjuvant, and maintenance treatment decision) implying multidisciplinarity and adaptation of the treatment plan according to the patient’s geriatric covariates and her motivation towards treatment. Specific attention must be paid to geriatric intervention, supportive care and pharmaceutical conciliation. Studies are needed to prospectively evaluate the impact of geriatric vulnerability parameters at each step of the treatment agenda and the impact of geriatric interventions on patient outcomes.

Integration of a Geriatric Assessment With Intervention in the Care of Older Adults With Hematologic Malignancies

The incidence of hematologic malignancies (HMs) is highest in the seventh decade of life and coincides with increasing occult, age-related vulnerabilities. Identification of frailty is useful in prognostication and treatment decision-making for older adults with HMs. This real-world analysis describes 311 older adults with HMs evaluated in a multidisciplinary oncogeriatric clinic. The accumulation of geriatric conditions [1-unit increase, hazards ratio (HR) = 1.13, 95% CI 1.00-1.27, p = 0.04] and frailty assessed by the Rockwood Clinical Frailty Scale (CFS, mild/moderate/severe frailty vs. very fit/well, HR = 2.59, 95% CI 1.41-4.78, p = 0.002) were predictive of worse overall survival. In multivariate analysis, HM type [acute leukemia, HR = 3.84, 95% CI 1.60-9.22, p = 0.003; myelodysplastic syndrome (MDS)/myeloproliferative neoplasm (MPN)/bone marrow failure, HR = 2.65, 95% CI 1.10-6.35, p = 0.03], age (per 5-year increase, HR = 1.46, 95% CI 1.21-1.76, p < 0.001), hemoglobin (per 1 g/dl decrease, HR = 1.21, 95% CI 1.05-1.40, p = 0.009), deficit in activities of daily living (HR = 2.20, 95% CI 1.11-4.34, p = 0.02), and Mini Nutrition Assessment score (at-risk of malnutrition vs. normal, HR = 2.00, 95% CI 1.07-3.73, p = 0.03) were independently associated with risk of death. The most commonly prescribed geriatric interventions were in the domains of audiology (56%) and pharmacy (54%). The Rockwood CFS correlated with prescribed interventions in nutrition (p = 0.01) and physical function (p < 0.001) domains. Geriatric assessment with geriatric intervention can be practically integrated into the routine care of older adults with HMs.

[Needs and feelings of caregivers in oncogeriatrics, usefulness of a serious game]

Faced with an ageing population, carers are real allies and partners who are essential to the smooth running of the care of elderly patients. The objective of this study was to analyse their needs in oncogeriatrics, in order to verify the relevance of developing a serious game to support them. Although the need for better support for carers in oncogeriatrics was recognized, they especially value the need for human exchanges.

Evaluating the Clinical Utility of Routine Sentinel Lymph Node Biopsy and the Value of Adjuvant Chemotherapy in Elderly Patients Diagnosed With Oestrogen Receptor Positive, Clinically Node Negative Breast Cancer

Background

Sentinel lymph node biopsy (SLNB) provides staging information and guides adjuvant therapy in early breast cancer (EBC). Routine SLNB in oncogeriatricians with low-risk EBC remains controversial.

Aims

To evaluate axillary management in elderly patients diagnosed with oestrogen receptor positive (ER+), clinically lymph node negative (cLN-) EBC, and to assess whether SLNB affects further axillary management or adjuvant chemotherapy (ACTX) decision making.

Methods

Female patients aged > 65 years, diagnosed with ER+, human epidermal growth factor receptor-2 negative (HER2-), and cLN- breast cancer (BC), who underwent surgery and SLNB were included. Clinicopathological predictors of ACTX and completion axillary lymph node dissection (CALND) were determined. Kaplan-Meier analyses assessed survival outcomes.

Results

A total of 253 patients were included (median age: 72 years, range: 66-90), all underwent SLNB; 50 (19.8%) had lymphatic metastasis on SLNB (SLNB+). Of these, 19 proceeded to CALND (38.0%), 10 (52.6%) of whom had further axillary disease (ALND+). 20 of the 50 SLNB+ patients received ACTX (40.0%) as did 31 of the 203 SLNB- patients (15.2%) (P < .001). Oncotype DX (ODX) testing was utilized in 82 cases (32.8%). Younger age (P < .001), SLNB+ (P < .001) and ODX score (P = .003) were all associated with ACTX prescription. ODX > 25 (OR: 4.37, 95% CI: 1.38-13.80, P = .012) independently predicted receiving ACTX. Receiving ACTX and proceeding to CALND did not improve disease-free (P = .485 and P = .345) or overall survival (P = .981 and P = .646).

Conclusions

Routine SNLB may not be necessary in elderly patients diagnosed with ER+, cLN- EBC. Future oncogeriatric practice is likely to see genomic testing guiding ACTX prescription in this group.

Overcoming the Chasm Between Evidence and Routine Practice for Bladder Cancer; Just a Quixotic Notion?

There has been a failure to improve outcomes in bladder cancer over the last 30 years. This is despite clinical trial evidence showing a benefit of interventions such as neoadjuvant chemotherapy or concurrent radiosensitisation for non-metastatic muscle-invasive bladder cancer. The bladder cancer population is characteristically elderly, who typically suffer from multiple comorbidities. Historically, radical cystectomy has been heralded as the treatment of choice, with radiotherapy being reserved for those with inoperable tumours or those unfit for major pelvic surgery, despite a lack of robust comparative or quality of life data to support one treatment recommendation over the other. Although patients with non-metastatic muscle-invasive bladder cancer have potentially curable disease, a growing body of population-based analyses persistently highlights that most patients do not undergo curative-intent treatments - a trend that remains static. The causes for the disparity between evidence and routine practice is not clearly understood. Here, the facets of patient-centred evidence-based care, with respect to bladder conservation therapy, are examined, with proposals to reverse this unacceptable status quo.

[New therapies in oncogeriatrics]

Cancer management is changing rapidly. Changes in practices are not all transferable to the elderly population, which is heterogeneous. The description of the intrinsic toxicity of anti-cancer treatments is insufficient in the elderly. Recent studies dedicated to the elderly incorporate composite evaluation criteria combining efficacy and toxicity with a broad definition including, among other things, loss of functional autonomy. These new data acquired, as well as new organisations integrating the new profession of advanced practice nurse in oncogeriatrics will enable us to better respond to the challenge of caring for elderly patients in the future.

[Healthcare research, a reflexive approach in oncogeriatric]

Healthcare research is developing. The oncogeriatrics team of the Toulouse University Hospital started from an innovative practice to think about a research protocol. It is an evolving, reflexive and complex approach for the caregivers with the hazards of responding to calls for research projects.

Are Older Patients with Cervical Cancer Managed Differently to Younger Patients? An International Survey

Although a quarter of cervical cancers occur after the age of 65 years, there is no treatment consensus for these patients. The aim of this work was to survey how physicians treat patients with advanced cervical cancer, focusing on treatment adjustments according to age and frailty status. Specialists were invited to an online survey. Data collected included information on respondent and treatment strategy in four cases (FIGO IIb, FIGO IVa, FIGO IVb, metastatic recurrence) with three age scenarios (45-year-old, 75-year-old and fit, 75-year-old and unfit). We received 237 responses of which 117 were fully completed. Thirty-four percent of respondents reported they had available access to a geriatric team and 25% used a frailty screening tool in routine. Therapeutic strategies did not differ between young and old fit patients. However, treatment modalities and intensity were different for old and unfit patients. Physicians answered that they would treat old fit patients as their younger counterparts but would reduce treatment intensity for old unfit patients. However, even if they were willing to adapt their treatment strategy based on frailty status, most of them do not use the tools that would allow distinguishing "fit" and "unfit" older patients, leaving room for improving accurate geriatric evaluation.

Delivering comprehensive geriatric assessment in new settings: advice for frontline clinicians

Over the decades, as the principles of comprehensive geriatric assessment have been established, there have been attempts to apply its principles to settings other than acute hospital medical wards or the general communitydwelling older population, for example, to other settings where older people with infirmity are found. The purpose of this paper is to describe and reflect upon the application of and evidence for comprehensive geriatric assessment in these new settings and give some advice to clinicians about how to optimise their contributions to these processes. I will state my advice having first discussed intermediate care, emergency surgery (hip fracture), elective surgery, dementia and delirium care, emergency care, cancer care, and the care of residents of care homes (mindful of the irony of calling the latter a new setting, given that geriatric medicine originated in long term care).

[Assessment of screening in women cancers and in 75 years older in Loire department]

In France, there is an important interregional disparity concerning participation to cancer screening programs. The aim of this study was to assess oncologic screening practices in Loire, a French rural department, in women and in the elderly (over age 74 years). For this, two surveys were conducted. The first one was regarding screening for breast, cervical and colorectal cancer in women over age 18 years living in Loire. The second survey was regarding onco-geriatric screening through two questionnaires : one for the elderly and the other for general practitioner (GP) of the department, evaluating screening for breast, colorectal, prostate, cervical and lung cancer. One hundred sixty six women were included in the first investigation mean age of 47.6 years. Ninety three point six per cent were screening for breast cancer, 19% received Human Papilloma virus vaccine, 83.1% were screening by Papanicolau smear for cervical cancer and finally, 51.7% were screening for colorectal cancer, among the one entering screening program criteria. In the second survey, 44 patients and 28 GP were included. Thirty-eight point six per cent of patients over 74 years continue screening. Only 11.4% were reluctant to screening and in 80% because of anxiety du to the results. Among GP, 50 % continued screening on two major criteria : life expectancy and performans status. The present study shows heterogeneity of screening in this department both rural and working class and gives us a societo-medical photography.