Cancer In Older Persons Research Articles

Skin cancers and their risk factors in older persons: a population-based study

BackgroundThe number of skin cancer is increasing rapidly. However, little is known about the risk factors of skin cancer in older persons. Our objectives were to determine the risk factors for skin cancer or its precursors in an older population. More specifically, to study the association of new skin cancers with previous skin cancer, sex, age, Fitzpatrick’s skin type, history of outdoor work and socioeconomic status (SES).MethodsIn this retrospective cross-sectional study of a large, well documented historical cohort data set a total body skin examination (TBSE) was performed for 552 participants aged between 70 and 93 years by dermatologists. The information gathered was augmented with health register data and self-reported data. The associations between skin cancer and its risk factors were studied by using the logistic regression analyses.ResultsAccording to the TBSE skin cancer/precursor was present in 25.5% of participants and was more common in males than in females (34.5% vs 20.2%, p < 0.001). Previous skin cancer increased the risk of subsequent skin cancer 2.6-fold (OR 2.56, 95% CI 1.43-4.55) and male sex nearly 2-fold (1.97, 95% CI 1.26-3.08). Specific risk factors for the first occurrence of skin cancer were male sex and outdoor work. There was also association between skin cancer and age and socioeconomic status.ConclusionsTBSE is recommend for physicians treating older persons to allow early recognition of skin cancers or their precursors. Older males need particularly close attention.

LEFT ATRIAL THROMBUS IN THE ABSENCE OF RISK FACTORS

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Left atrial thrombus is commonly seen in conditions such as atrial fibrillation, rheumatic mitral stenosis, and conditions of hypercoagulability. The cause of left atrial thrombus in the absence of these conditions is not clear. This is a case of a 59-year-old female who presented with emboli to her spleen, brain, and bilateral lower extremities. The patient was found to have a highly mobile thrombus attached to the posterior wall of the left atrium. She did not have atrial fibrillation, a history of clotting disorder, or significant mitral dysfunction and was up-to-date on all age appropriate cancer screenings. CASE PRESENTATION: A 59-year-old female presented with confusion and right arm weakness. Her past medical history is significant only for mitral valve repair which was done with minimally invasive annuloplasty 18 months prior. She was found to have an MCA stroke which was treated with emergent thrombectomy. Further workup revealed a 1.1 cm x 1.4 cm irregular, highly mobile mass attached to the posterior wall of the left atrium. One month prior the patient was found to have a splenic infarct and on re-inspection of the TTE done at that time, a much smaller thrombus was detected in the same location which was previously missed. Her TEE revealed mild mitral regurgitation and an EF of 20-25%-- down from 55-65% one month prior; this along with apical ballooning was suggestive of Takotsubo cardiomyopathy. Bilateral lower extremity Doppler found thrombi in both popliteal arteries. Her hypercoagulability work-up was completely negative and she was up-to-date on all age appropriate cancer screenings. The patient was discharged on apixaban for long-term anticoagulation after stabilization following her stroke with no residual deficits. DISCUSSION: The etiology of this patient’s left atrial thrombus remained unclear despite hypercoagulability testing, cancer screening, continuous telemetry, and a thirty-day event monitor. This presents a diagnostic and management challenge. Cardiac valve surgeries can be complicated by valvular thrombi. However, prosthetic annuloplasty rings, as seen in this patient, are less likely to cause thrombosis compared to prosthetic valves, especially so long after the procedure [1]. Moreover, the thrombus was not attached onto any part of the valve or prosthesis. Occult malignancy was also a concern, being a strong risk factor of arterial thromboembolism [2]. However, there was no objective evidence of malignancy and her screening was all up-to-date. Finally, given the unknown etiology of the thromboembolism there was very little guidance on the best anticoagulant to use. Apixaban was used eventually mostly due to patient preference and extrapolation from atrial fibrillation patients. CONCLUSIONS: Left atrial thrombus in the absence of several classic conditions presents a diagnostic and therapeutic challenge. Reference #1: 1. Nishimura R.A., Otto C.M., Bonow R.O., et al. 2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease: Executive Summary. Circulation: Journal of the American Heart Association, 129(1), 2440-2492. doi:10.1161 Reference #2: 2. Navi B.B., Reiner A.S., Kamel H., et al. (2019). Arterial thromboembolic events preceding the diagnosis of cancer in older persons. Blood, 133(8), 781. doi:10.1182 DISCLOSURES: No relevant relationships by Anat Bergner, source=Web Response No relevant relationships by Hadas Michaeli, source=Web Response No relevant relationships by Nino Nozadze, source=Web Response No relevant relationships by Curtis Xu, source=Web Response

Arterial thromboembolic events preceding the diagnosis of cancer in older persons

AbstractCancer patients face an increased risk of arterial thromboembolism; however, it is uncertain when this excess risk begins. This study evaluated the risk of arterial thromboembolism before cancer diagnosis. Using the population-based Surveillance Epidemiology and End Results-Medicare linked dataset, we identified 374 331 patients ≥67 years of age with a new primary diagnosis of breast, lung, prostate, colorectal, bladder, uterine, pancreatic, gastric cancer, or non-Hodgkin lymphoma from 2005 through 2013. Cancer patients were individually matched by demographics and comorbidities to Medicare beneficiaries without cancer, who served as controls. Validated diagnosis codes were used to identify arterial thromboembolic events, defined as a composite of myocardial infarction or ischemic stroke. The Mantel-Haenszel estimator was used to compare risks of arterial thromboembolic events between cancer and noncancer groups during 30-day periods in the 360 days before date of cancer diagnosis. From 360 to 151 days before cancer diagnosis, the 30-day interval risks of arterial thromboembolic events were similar between cancer patients and matched controls. From 150 to 1 day before cancer diagnosis, the interval 30-day risks of arterial thromboembolic events were higher in cancer patients vs matched controls, progressively increasing as the cancer diagnosis date approached and peaking during the 30 days immediately before cancer diagnosis, when 2313 (0.62%) cancer patients were diagnosed with an arterial thromboembolic event vs 413 (0.11%) controls (odds ratio, 5.63; 95% confidence interval, 5.07-6.25). In conclusion, the risk of arterial thromboembolic events begins to increase 150 days before the date of cancer diagnosis in older persons and peaks in the 30 days before.

When My Mother Wanted to Die

When My Mother Wanted to Die

Promoting access to innovation for frail old persons. IAGG (International Association of Gerontology and Geriatrics), WHO (World Health Organization) and SFGG (Société Française de Gériatrie et de Gérontologie) Workshop--Athens January 20-21, 2012.

Frailty tends to be considered as a major risk for adverse outcomes in older persons, but some important aspects remain matter of debate. The purpose of this paper is to present expert's positions on the main aspects of the frailty syndrome in the older persons. Workshop organized by International Association of Gerontology and Geriatrics (IAGG), World Health Organization (WHO) and Société Française de Gériatrie et de Gérontologie (SFGG). Frailty is widely recognized as an important risk factor for adverse health outcomes in older persons. This can be of particular value in evaluating non-disabled older persons with chronic diseases but today no operational definition has been established. Nutritional status, mobility, activity, strength, endurance, cognition, and mood have been proposed as markers of frailty. Another approach calculates a multidimensional score ranging from "very fit" to "severely frail", but it is difficult to apply into the medical practice. Frailty appears to be secondary to multiple conditions using multiple pathways leading to a vulnerability to a stressor. Biological (inflammation, loss of hormones), clinical (sarcopenia, osteoporosis etc.), as well as social factors (isolation, financial situation) are involved in the vulnerability process. In clinical practice, detection of frailty is of major interest in oncology because of the high prevalence of cancer in older persons and the bad tolerance of the drug therapies. Presence of frailty should also be taken into account in the definition of the cardiovascular risks in the older population. The experts of the workshop have listed the points reached an agreement and those must to be a priority for improving understanding and use of frailty syndrome in practice. Frailty in older adults is a syndrome corresponding to a vulnerability to a stressor. Diagnostic tools have been developed but none can integrate at the same time the large spectrum of factors and the simplicity asked by the clinical practice. An agreement with an international common definition is necessary to develop screening and to reduce the morbidity in older persons.

Cdc42 is involved in basal cell carcinoma carcinogenesis

Basal cell carcinoma (BCC) is the most common type of skin cancer in older persons and is a rapidly rising incidence. E-cadherin-mediated cell-cell adhesion activates Cdc42, a Rho GTPase essential for cell polarity in numerous settings. No study has yet addressed a biological significance of Cdc42 alterations in BCC pathogenesis. Our aim was to investigate E-cadherin-dependent cell-cell contacts and Cdc42 activity in BCC formation. We evaluated E-cadherin and Cdc42 expression by immunohistochemistry and Western blot analysis in samples of 15 normal skin (NS) and 30 BCC (10 superficial, 9 nodular and 11 infiltrative subtypes). Low E-cadherin and high Cdc42 immunohistochemical expression were found in BCC samples compared with NS. E-cadherin staining was significantly reduced in infiltrative BCC compared with superficial and nodular. A significantly greater Cdc42 expression was observed in BCC compared with NS; moreover, superficial BCC had a significantly lower Cdc42 expression in respect to the other subtypes. Western blot analysis confirmed the significantly decreased E-cadherin expression in infiltrative BCC as well as Cdc42 reduction in superficial BCC in respect to the other subtypes. In BCC the increased Cdc42 in association with reduced E-cadherin might contribute to the disruption of adhesion mechanisms and to the loss of cell polarity, thus explaining a mechanism by which cancer cells can escape from the control of adjacent normal keratinocytes. Our study also showed that Cdc42 and E-cadherin expression differed according to aggressive behaviour of BCC subtypes and suggested important functions of these molecules in regulating tumour demarcation and progression.

Pharmacology of anticancer drugs in the elderly: tools for dose-adjustment

Life expectancy increasing and cancer incidence rising with age, geriatric and cancer care will become a significant medical, public health, challenge. It is possible that the lack of efficacy of cancer therapies in the elderly may simply be due to the fact that physicians reduce anticancer drug doses empirically, in order to avoid "putative" toxicities that might arise as a result of alterations of physiological functions or as a result of co-morbidities generally present within this population. However, many authors have demonstrated that some patients over 70 years old could tolerate and obtain same benefit from therapies as younger adults, when some who are frail need less aggressive therapies. It is imperative that decisions regarding the management of cancer in older persons should be based upon the individual needs and fitness of the patient, and not based on chronological age. The main difficulty is the lack of scientific references on optimal treatment-dosing in the elderly, and we cannot extrapolate, as it stands, the information from younger patient. Indeed, aging is associated with multidimensional changes, including alteration of physiological status, comorbidities and polymedications. These changes may lead to pharmacokinetic (PK) modifications, namely in absorption, distribution, metabolism and elimination of drugs as well as pharmacodynamic (PD) modifications. Prospective studies need to be implemented in the elderly in order to study in depth the PK and PD properties of the drugs used for these patients, and establish PK-PD relationships in this specific population. Such studies have been successfully conducted in the elderly, some of them leading to dose recommendations. This paper detail the different sources of PK-PD variability in the elderly, some practical considerations regarding the design of studies using the population approach, as well as some examples of studies performed in the elderly. We conclude with some recommendations in this population at risk.

Melanoma in the Older Patient: Measuring Frailty as an Index of Survival

The population continues to age, and with that aging will come increasing numbers of cancer cases diagnosed at older ages, including cutaneous melanoma. The number of people in the United States aged 65 and above is expected to increase from 35 million in 2000 to 86.7 million by 2050. 1 Age-adjusted mortality rates for all cancers in the United States are higher for patients age 65 and above than for patients younger than 65. For melanoma, both the incidence and mortality rates are higher among older patients. 2 The explanation for the difference in melanoma outcomes in older patients is likely to be multifactorial; it could be related to differences in biology of cancer itself in older patients; differences in patient physiology, with older patients more likely to have immune system dysfunction or multiple comorbidities; or differences in access to and application of health care resources. 3 Care of the older melanoma patient presents many challenges, related both to different biology of cancer in older persons and to the different biology of older persons themselves. The risk of being diagnosed with melanoma increases with age. 2 In the United States, men between the ages of 40 and 59 years have a 1 in 157 probability of being diagnosed with melanoma, compared to a probability of 1 in 54 at age 70 and older. For women, the probability of being diagnosed with melanoma is 1 in 181 between 40 and 59 years, and increases to 1 in 123 at 70 years and older. 4 Moreover, older melanoma patients on average possess poorer prognostic factors at diagnosis. Older patients are more likely to have primary melanomas that are thicker, nodular, ulcerated, and located on the head and neck. More new melanoma cases are now diagnosed in people over age 60 and with the aging of the population, this trend is expected to continue, with even greater numbers of melanoma cases being diagnosed in older persons in the coming decades. Improvement in the evaluation and treatment of melanoma in the older person will assume increasing importance. Older patients are not only more likely to be diagnosed with melanoma, but are also more likely to die from this malignancy. In a multivariable analysis of over 17,600 patients, age was an independent poor prognostic factor in patients with stage I–III melanoma. 5 Age is a persistently significant poor prognostic factor among node-positive melanoma patients. In a recent multivariable analysis of 2313 node-positive melanoma patients from the American Joint Commission on Cancer (AJCC) database, patients age C70 years had significantly poorer survival than did younger patients. 6 The reason for poorer outcomes in older

Chemotherapy in the elderly: how and for whom?

Management of cancer in the older-aged patient is an increasingly common problem in our occidental societies. Cancer is a disease primarily of older persons: over 60% of all cases of cancer are diagnosed after age 65 - an age group that constitutes less than 20% of the western population and the risk of persons over 65 years of age developing cancer is at least 10 times that of those under 65. Cancer in older persons may be considered a different disease from cancer in the younger in that way that biology of the host could influence the growth of cancer, that the management of the disease deserved an individualized approach. Indeed, the normal process of aging is associated with a progressive age-related reduction in function of many organs, including losses such as renal, pulmonary, cardiac, immune, hepatic, haematological, muscles, osseous, sight, hearing and brain functions. The consequences of these changes with age, added to comorbid diseases, have major implications on toxicities of anti-cancer therapies, surgery, radiotherapy as well as chemotherapy. However chronologic age should not be used as a guide to cancer therapy. Performance status and physiologic performance of the older patient are of prime importance to decide and conduct chemotherapy.

Cancer in older persons: an international issue in an aging world

Persons age 65 years and older bear the greater burden of cancer in the United States and other industrial nations. A cross-national perspective using data from several population-based resources (eg, the NCI Surveillance, Epidemiology, and End Results Program; US Bureau of Census; World Health Organization; and International Association for Research on Cancer) illustrates current and future demographic transitions in America in comparison with six industrial nations, and profiles cancer mortality in older persons across the selected nations-Denmark, France, Italy, Japan, Sweden, and United Kingdom. Mortality rates, age-standardized to the world population, are presented for major tumors. US aging and cancer profiles are highlighted. Demographic projections portend a substantial increase in numbers of older persons, and thus, imply resultant increases in cancer incidence and mortality in the elderly. By 2030, there will be larger proportions of persons in the age group most vulnerable to cancer. Information is needed on how age-related health problems affect cancer prevention, detection, prognosis, and treatment. A knowledge base as guidance in management of cancer in the elderly is lacking. Planning for effective prevention measures and improvement of treatment for the elderly is imperative to meet current and future quality cancer care needs.

Aging and cancer.

The world's population is aging. Older age is associated with an increase in the incidence of cancer, especially cancer of the breast, lung, prostate, and colon. The management of older patients with cancer is biased by the simple fact of their chronologic age. Underscreening, understaging, less aggressive therapy, lack of participation in clinical trials, or no treatment at all reflect this bias. Although an age-related reduction in the physiologic function of many organs occurs with age, these are not contraindications to treatment with surgery, radiation therapy, or chemotherapy. Chronologic age alone should not be used as a guide for cancer management. Rather, physiologic function or existence of comorbid conditions should be major factors in determining treatment. As a result of the impending need for improved cancer management in older persons, a new subspecialty is evolving: geriatric oncology. This field stresses an important interaction between geriatricians and oncologists, development of research directed at the problems of cancer in older persons, and education at all levels with respect to cancer prevention, cancer detection, and cancer therapy. Physicians and oncologists need to be prepared for the projected increase of cancer in older persons.

CLINICAL RESEARCH IN THE OLDER CANCER PATIENT

The opportunities for conducting focused research in older patients with cancer continue to increase and reflect the increasing awareness of the incidence of cancer in older persons. As the population ages, cancer will become more and more a problem of the elderly. Despite the magnitude of this problem, exploration of the unique problems associated with cancer in the aging has only begun. Economic issues, access to care, and the frequency of other serious illness in older patients often make screening and treatment of malignancy in older patients a great challenge. Oncologists and geriatricians must work together to guarantee that appropriate funding is made available for cancer research in the elderly population.

Concerns of special populations: cancer and the aging population--a meeting of the President's Cancer Panel, July 31, 1997.

Concerns of special populations: cancer and the aging population--a meeting of the President's Cancer Panel, July 31, 1997.

Prevalence of Cancer in Older Persons Living at Home and in Institutions

Even though the elderly have the greatest risk of developing and dying of cancer, screening for cancer occurs less often in older persons. Cancer screening is appropriate for nursing home residents with the cognitive ability to understand the screening method and its implications, who do not have comorbid illnesses that would preclude treatment, and who have at least a five-year life expectancy. Screening recommendations are provided for cancers of the breast, cervix, prostate, colon, skin, and mouth.

Cancer in older persons. Magnitude of the problem--how do we apply what we know?

The elderly experience the major impact of cancer. The incidence rate for those aged 65 and older is 2085.3 per 100,000 as compared with 193.9 per 100,000 for those younger than 65. Overall, 58% of all cancer incidence is in the older segment of the population. Cancer mortality in the elderly now accounts for 67% of all cancer deaths. Data from the National Cancer Institute Surveillance, Epidemiology, and End Results program for 1985-1989 reveal many salient facts. Older persons have a risk of developing cancer 10 times greater than that for individuals younger than 65. This paper outlines the magnitude of the major cancers that affect the elderly. Incidence and mortality data are presented according to individual tumors (colon, rectum, lung/bronchus, pancreas, stomach, urinary bladder, breast, ovary, and prostate). Demographic data from the U.S. Bureau of the Census focus on the expanding elderly population in the United States and projections for the future. Needs for cancer care and treatment for the elderly, already great, are likely to increase. It is imperative that older persons receive special attention for cancer prevention, early diagnosis, and treatment efforts, especially because there is almost always an overlay of other chronic diseases and age-associated declines concurrent with the diagnosis of cancer in the elderly. This paper highlights issues unique to older persons as individuals at high risk for cancer and suggests research strategies that should be made in anticipation of the even greater cancer burden for the elderly as this subset of the population expands.