Journal of Geriatric Oncology

Editorial Board

2012-01-01

A comparison of two pre-operative frailty measures in older surgical cancer patients

2011-11-14

Abstract: Background: Measuring frailty in older adults with cancer may identify patients with an increased risk of treatment complications. As it remains controversial how to identify frailty, the aim of this study was to compare a pre-operative multi-domain frailty measure based on a comprehensive geriatric assessment (CGA) to a modified version of the physical phenotype of frailty (PF) in a cohort of older adults with colorectal cancer, and to analyze the ability of the two classifications to predict post-operative complications and survival.Methods: A prospective longitudinal study including 176 patients aged 70–94years electively operated for colorectal cancer in three Norwegian hospitals. A pre-operative CGA, self-reported quality of life, and measurements of grip strength and gait speed were performed. CGA-frailty was defined as fulfilling one or more of the following criteria: dependency in activities of daily living, severe comorbidity, cognitive dysfunction, depression, malnutrition, or >seven daily medications. PF was defined with three or more of the following criteria: unintentional weight loss, exhaustion, low physical activity, impaired grip strength, or slow gait speed. Outcome measures were post-operative complications and survival.Results: The agreement between the classifications was poor. CGA-frailty was identified in 75 (43%) patients, while PF was identified in 22 (13%) patients. Only CGA-frailty predicted post-operative complications [P=0.001]. Both measures predicted survival.Conclusions: A multi-domain frailty measure based on a CGA was more useful than frailty identified from a modified version of the PF criteria in predicting post-operative complications. For overall survival, both frailty measures were predictive.

Does life expectancy affect treatment of women aged 80 and older with early stage breast cancers?

2011-11-14

Abstract: Background: Data are needed on how life expectancy affects treatment decisions among women ≥80years with early stage breast cancer.Methods: We used the linked Surveillance Epidemiology and End Results-Medicare claims dataset from 1992 to 2005 to identify women aged ≥80 newly diagnosed with lymph node negative, estrogen receptor positive tumors, ≤5cm. To estimate life expectancy, we matched these women to women of similar age, region, and insurance, not diagnosed with breast cancer. We examined 5-year mortality of matched controls by illness burden (measured with the Charlson Comorbidity Index [CCI]) using Kaplan-Meier statistics. We examined treatments received by estimated life expectancy within CCI levels. We further examined factors associated with receipt of radiotherapy after breast conserving surgery (BCS).Results: Of 9,932 women, 39.6% underwent mastectomy, 30.4% received BCS plus radiotherapy, and 30.0% received BCS alone. Estimated 5-year mortality was 72% for women with CCIs of 3+, yet 38.0% of these women underwent mastectomy and 22.9% received radiotherapy after BCS. Conversely, estimated 5-year mortality was 36% for women with CCIs of 0 and 26.6% received BCS alone. Age 80–84, urban residence, higher grade, recent diagnosis, mammography use, and low comorbidity, were factors associated with receiving radiotherapy after BCS. Among women with CCIs of 3+ treated with BCS, 36.9% underwent radiotherapy.Conclusions: Many women aged ≥80 with limited life expectancies receive radiotherapy after BCS for treatment of early stage breast cancers while many in excellent health do not. More consideration needs to be given to patient life expectancy when considering breast cancer treatments.

Age, sex and gender impact multidimensional geriatric assessment in elderly cancer patients

C. Valentiny, G. Kemmler, R. Stauder — 2011-11-21

Abstract: Objectives: Multidimensional geriatric assessment (MGA) is essential in individualized treatment decisions in the elderly. The goal of this pilot study was to analyze the impact of age, sex and possibly gender on assessment status in senior cancer patients.Materials and methods: An MGA consisting of 12 scores was applied in 111 patients (range 60–99, median 75years; 51% female). The effect of sex on individual MGA test results was evaluated by analysis of covariance adjusting for the confounding effect of age. The effect of age was investigated by partial correlation analysis adjusting for sex.Results: Women were significantly older than men (men 76.6 vs. 72.2years, p=0.008), and advanced age was weakly associated with a reduced assessment status in most MGA dimensions. Age as a confounding factor was apparent in WHO performance status and in the “Timed Up and Go Test”; women's weaker performance status disappeared when adjusted for age. A significant effect of sex was observed in iADL (better functional activities in women), F-SozU (less perceived social support in women), BMI (lower BMI in women) and comorbidities (fewer comorbidities in women). The sex differences in iADL disappeared completely after omitting the gender-specific items in the iADL-5, thus implying a pronounced gender effect. Likewise, the significant difference in self-perceived emotional support (F-SozU 4.3 women vs. 4.6 men, p=0.005) suggests a gender effect in this dimension.Conclusion: Age, sex and gender need to be recognized and integrated as interplaying and confounding factors in the assessment of elderly cancer patients.

Determination of an adequate screening tool for identification of vulnerable elderly head and neck cancer patients treated with radio(chemo)therapy

2011-12-30

Abstract: Objectives: We evaluated two proposed screening tools, the Vulnerable Elders Survey-13 (VES-13) and the G8, to identify patients who could benefit from a comprehensive geriatric assessment (CGA).Materials and Methods: All consecutive patients aged ≥65years with primary head and neck cancer were assessed with VES-13, G8 and CGA. Receiver operating characteristics (ROC)-analysis was used to determine diagnostic performance of both screening instruments.Results: Fifty-one patients were recruited, of which 39.2%, 66.7% and 68.6%, were defined vulnerable when evaluated with VES-13, G8 and CGA, respectively. The area under the ROC-curves (AUC±SE) of VES-13 (0.889±0.045) and G8 (0.909±0.040) did not significantly differ (P=0.7083). A sensitivity and specificity of respectively 57.1% and 100% for VES-13 (cut-off ≥3) and 85.7% and 75.0% for G8 (cut-off ≤14) was obtained. The combined score “VES-13+(maximum-G8)” (AUC=0.971±0.019) showed a superior AUC to G8 (P=0.0242) and VES-13 (P=0.0237). The most optimal cut-off score of 5 for the combined test resulted in a sensitivity of 91.4% and a specificity of 93.8%. Positive and negative predictive values were 100% and 51.6%, 88.2% and 70.6%, and 97.0% and 83.3% for the VES-13, G8 and combined test respectively.Conclusion: Both tools were found to have good diagnostic performance. However, at the proposed cut-off scores, our data suggest the G8 as the most optimal screening tool. Moreover, the combined tool could represent an interesting alternative.

Polypharmacy and drug use in elderly Danish cancer patients during 1996 to 2006

T.L. Jorgensen, J. Herrstedt, S. Friis, J. Hallas — 2011-10-24

Abstract: Background: Elderly people are frequently exposed to polypharmacy defined as the simultaneous use of multiple drugs. However, data on drug use among elderly cancer patients are limited. The aims of this study were to describe drug use and polypharmacy in cancer patients aged≥70years and to describe their drug usage pattern prior to and following the cancer diagnosis.Methods: Population-based case-control study of all incident cancer cases in the Danish province of Funen (population 480,000) from 1996 to 2006. Data were collected from the Danish Cancer Registry and the Odense Pharmacoepidemiologic Database. Conditional logistic regression was used to compare drug use in cases and controls.Results: We identified 24,808 cancer cases and 99,299 controls. Of these, 47% were aged≥70years. At diagnosis, 35% of elderly cases used ≥5 drugs daily compared with 27% of controls, OR 1.76 (95% CI 1.66–1.86), and drug use was significantly higher as early as 18months prior to the cancer diagnosis. In particular, use of analgesics, acid-suppressing drugs, and antibiotics increased markedly six months preceding cancer diagnosis. Mean daily drug use at diagnosis increased during the study period.Conclusion: Newly diagnosed elderly cancer patients use more drugs than the background population. Drug use increased markedly the last six months prior to the cancer diagnosis. This could suggest an increased symptom burden in patients prior to diagnosis and might serve as a warning signal for general practitioners.

Influence of age on the pharmacokinetics of i.v. vinflunine: Results of a phase I trial in elderly cancer patients

2012-01-06

Abstract: Objective: Vinflunine (VFL) is a novel microtubule inhibitor indicated in the treatment of advanced or metastatic urothelial transitional cell cancer after failure of a prior platinum-containing regimen at the recommended dose of 320mg/m² q3 weeks. This trial was designed to assess the pharmacokinetic (PK) behavior and tolerance of VFL in elderly patients (pts), and to propose dose-adjustments if necessary.Material and methods: Three groups of cancer pts over 70years old (y) were open to recruitment: 70–75y, 75–80y and ≥80y. Each group of pts received intravenous VFL, respectively at 320, 280 and 250mg/m² on cycle 1. Pharmacokinetics and safety data were collected at cycle 1 and were compared to reference values from younger pts <70y.Results: 46 pts were treated. For pts 70–75y and 75–80y, there was no statistically age-related change for VFL PK. For pts ≥80y, VFL blood total clearance (Cltot) was significantly decreased by 18%. The most common adverse events observed in this elderly population were not different from those seen in younger pts. No toxic death was recorded. Main toxicities were neutropenia (Grade 3/4: 73% of pts), constipation (all grade: 63%) and asthenia (all grade: 56%), without any relationship between the observed incidence and the ageing of pts.Conclusion: Based on PK and safety data, a dose reduction at 280mg/m² and 250mg/m² is recommended in pts 75–80y and ≥80y respectively.

Comorbidity and geriatric assessment for older patients with hematologic malignancies: A review of the evidence

M. Extermann, U. Wedding — 2011-12-06

Abstract: The majority of hematologic malignancies occur in patients aged more than 65years. Such patients have very variable health status, comorbidity levels, and geriatric syndrome prevalence. It is important to identify who would be a candidate for standard treatment schemes, and who would be a candidate for modified therapeutic approaches. Accurate assessment of patient fitness and comorbidities is key when planning therapy for this group as such factors will affect prognosis. In this paper, we review the published literature on a comprehensive geriatric assessment and comorbidity measurements in patients with hematologic malignancies and their correlation with outcomes. Our review identified the Charlson score and the Cumulative Illness Rating Scale-Geriatric as the most frequently used comorbidity instruments in the general setting, and the Hematopoietic Cell Transplantation-Comorbidity Index in the transplant setting. For the geriatric assessments, the most commonly used scheme combines age, comorbidity, Activities of Daily Living, and the presence of geriatric syndromes. Correlations with overall survival and treatment tolerance are fairly consistently demonstrated. Some tentative thresholds are apparent but remain to be firmly confirmed. Future trials should integrate these assessments as correlates or stratification tools in order to build on the early results already available.

Understanding the link between cancer and neurodegeneration

Jane A. Driver — 2011-12-19

Abstract: There is growing evidence that cancer shares a number of biological pathways with common neurodegenerative diseases of aging. In epidemiologic studies, Parkinson's and Alzheimer's disease seem to be associated with a decreased cancer risk. Genes associated with neurodegeneration have important functions in protein folding and processing, but often play a role in the cell cycle. Activation and deregulation of the cell cycle is a core feature of both diseases; in the neuron, the end result is apoptosis, while in the malignant cell, it is uncontrolled proliferation. Successful aging requires a careful balance between the forces that promote tissue renewal and those that suppress the cell cycle. Proteins such as p53 and Pin1 might explain why some individuals are relatively protected from cancer but at increased risk of neurodegeneration. This article reviews the available epidemiologic evidence linking neurodegenerative disease and cancer, discusses the cellular pathways and genes which might account for this unexpected relationship, and explores the potential therapeutic implications of this area of research.

First Asian Congress on Cancer in Older Patients Kuching, Malaysia 22–23rd January 2011

Rajiv C. Apsani, Shamir Chandran, Swee Tang Tieng, Beena C.R. Devi — 2012-01-04

Abstract: SIOG 2011-First Asian Congress on Cancer in Older Patients organized by Sarawak Hospice Society, was held in Kuching, Sarawak, Malaysia from 22 to 23rd January 2011 under the chair of Riccardo A. Audisio and Matti A. Aapro. The meeting was accredited by ACOE and ESMO and endorsed by UICC and ESSO and first to be held in Asia.The congress was well attended with 500 participants from 16 countries. The participants included doctors, nurses, pharmacists and X-ray technologists. The topics included the global and South East Asian perspective on older patients, under treatment, clinical assessment tools, surgical treatment of breast, lung and esophageal cancers, supportive care for breast cancer, cultural barriers in Malaysia, newer radiotherapy techniques that can be used in older patients, targeted treatment of lung, colorectal cancers and hematology. Preliminary findings of using the Groningen Frailty Index in an Asian oncology patient population were presented. An interesting topic on the cultural barriers to cancer care in the elderly from the three ethnic groups in Sarawak was presented. The findings revealed the challenges faced by the public as well as the healthcare professionals. The topics discussed were relevant to the local needs of the participants so that they could apply the knowledge when they returned home.The Meeting Highlights collect the views of the panelists: to update on the cutting edge of present knowledge, in order to improve our understanding of the malignant disease affecting the senior patients and its implication in the Asian setting and to optimize the management.

The wand chooses the wizard: What I learned on my way to geriatric oncology

Miriam B. Rodin — 2011-12-05

Abstract: Geriatric oncology just makes sense. Cancers are age-associated diseases and one cannot treat one without attending to the other. We are in the phase of professional evolution now where we need to develop, test and report on models of care that fuse knowledge and tools of both fields.