Cancer Treatment In Older Adults Research Articles

Falls and hospitalization during chemotherapy in older women with early breast cancer.

12035 Background: Hospitalizations are frequent, burdensome, and potentially avoidable complications of cancer treatment in older adults. While geriatric assessments can identify older patients at risk for hospitalization, the use of these assessments in clinic is limited by time and resources. Screening for falls in the past 6 months is a quick and simple question that clinicians can ask in clinic and fall history has been linked to chemo-related toxicity. Here, we hypothesized that in older adults with cancer fall history prior to chemo is associated with an increased risk of hospitalization during chemo. Methods: In a prospective multicenter study of 497 women age ≥65 with stage I-III breast cancer treated with neo/adjuvant chemo, we assessed baseline self-reported fall history in the past 6 months as a dichotomous (yes/no) and continuous variable (no. of falls). Our primary endpoint was hospitalization during chemo (yes/no, yes defined as incident hospitalization assessed from start to end of chemo and attributed to toxicity from chemo). We used multivariable logistic regression to examine the association between fall history and hospitalization during chemo, adjusting for sociodemographic and clinical covariates. Results: The median age was 70 (65-86), 65% had stage II/III disease, 37% had anthracycline, and 72% received primary prophylaxis with G-CSF. Of the 497 participants, 60 (12%) reported falls (median 1.0 [1-6]) at baseline, and 114 (23%) were hospitalized during chemo (median 1.0 [1-4]). The most common toxicities that resulted in hospitalization were febrile neutropenia (25%), anemia (13%), dehydration (13%), and fatigue (13%). Women who fell in the 6 months prior to chemo had greater odds (adjusted OR = 2.69, 95% CI 1.42-5.11, p= 0.003) of being hospitalized during chemo compared to women who did not fall. Conclusions: In this cohort of older women with early breast cancer, fall history prior to chemo was associated with an increased risk of hospitalization during chemo, independent of sociodemographic and clinical factors. Oncologists do not routinely assess fall history when considering chemo in older adults. Screening for falls is a quick, simple, and important indicator of vulnerability that oncologists may use to identify patients at risk for hospitalization during chemo and inform personalized, patient-partnered treatment decisions. Clinical trial information: NCT01472094 . [Table: see text]

Tailoring adjuvant chemotherapy by circulating tumor DNA (ctDNA) in older patients with stage II-III colon cancer

In most western countries, the median age of patients with CRC is around 70years. Although the benefit of adjuvant chemotherapy has been established in stage III colon cancer, it remains controversial in patients with stage II disease. Colon cancer treatment in older adults follows the same basic concepts as in younger patients. However, for older patients, who may have age-related organ function decline and comorbid conditions that may limit life expectancy, special attention must be paid to the risks of chemotherapy, including treatment-related toxicities and quality of life issues. Long-term toxicities are particular concerns in older patients who received adjuvant chemotherapy. In the high-risk frail patient population, avoiding adjuvant therapies in patients with negative circulating tumor DNA (ctDNA) group, could prevent treatmentrelated toxicities while preserving the quality of life. In the treatment paradigm of earlystage colon cancer, the promise of ctDNA lies in its potential to detect minimal residual disease following resection of the primary tumor, allowing precise risk assessment and ctDNA-guided adjuvant therapy. Future studies will determine whether this technique may tailor treatment for patients in the adjuvant setting. Subgroup analyses by age may yield data on the use of ctDNA in older patients. Integration of the ctDNA approach to geriatric assessment may complete the missing piece of the puzzle when making adjuvant treatment decisions in older patients with colon cancer.

Economic Evaluation of a Geriatric Oncology Clinic.

Simple SummaryThere is increasing evidence supporting geriatric assessment (GA) prior to starting cancer treatment in older adults. However, GA is not widely available. One reason may be the lack of persuasive economic data demonstrating its value. We performed an economic evaluation of an academic geriatric oncology clinic and included 152 patients aged 65 years and older who underwent a GA in the pre-treatment setting. We carefully calculated the costs of the proposed treatment (prior to the GA), costs of the GA and associated recommendations, costs of the final treatment, and overall value. We found a GA saved CAD 7387 per patient seen. Extensive sensitivity analyses supported our finding that a GA is economically attractive and should be implemented more widely.Geriatric assessment (GA) is supported by recent trials and guidelines yet rarely implemented due to a lack of resources. We performed an economic evaluation of a geriatric oncology clinic. Pre-GA proposed treatments and post-GA actual treatments were obtained from a detailed chart review of patients seen at a single academic centre. GA-based costs for investigations and referrals were calculated. Unit costs were obtained for surgical, radiation, systemic therapy, laboratory, imaging, physician, nursing, and allied health care (all in 2019 Canadian dollars). A six-month time horizon and government payer perspective were used. Consecutive patients aged 65 years or older (n = 152, mean age 82 y) and referred in the pre-treatment setting between July 2016 and June 2018 were included. Treatment plans were modified for 51% of patients. Costs associated with planned treatment were CAD 3,655,015. Costs associated with GA and related interventions were CAD 95,798. Final treatment costs were CAD 2,436,379. Net savings associated with the clinic were CAD 1,122,837, or CAD 7387 per patient seen. Findings were robust in multiple sensitivity analyses. Combined with mounting trial data demonstrating the clinical benefits of GA, our data can inform a strong business case for geriatric oncology clinics in health care environments similar to ours, but additional studies in diverse health care settings are warranted.

Using Biologic Age to Determine Cancer Treatment in Older Adults

Using Biologic Age to Determine Cancer Treatment in Older Adults

Older Adults With Lung Cancer: Assessment, Treatment Options, Survivorship Issues, and Palliative Care Strategies.

Treatment advances offer options for cancer treatment in older adults that are less invasive and have fewer side effects. Geriatric assessment is a key component of treatment planning to identify functional and physiologic status and is the basis of decision making. This article discusses the role of geriatric assessment, treatment options (e.g., surgical, chemotherapy, radiation therapy), survivorship issues, and palliative care strategies for older adults with cancer. Literature was reviewed to identify geriatric assessment implications, current treatment strategies, and survivorship and palliative care interventions for older adults with cancer based on a case study approach. Geriatric assessment is key to identifying deficits and disabilities in older adults with cancer and is a critical component in oncology treatment planning. Evidence-based, less invasive treatment options are available and offer older adults more tolerable oncologic therapies.

Financial Toxicity: Limitations and Challenges When Caring for Older Adult Patients With Cancer.

Financial toxicity refers to the unintended financial consequences and distress that patients and families can incur during treatment of cancer. Financial issues can add further stress to an already stressful situation. This article aims to increase awareness of the financial burden of cancer treatment in older adults with cancer and its effect on health-related quality of life for patients and their families and to increase knowledge of institutional and community resources to help patients manage financial concerns. A literature search was performed to investigate the burden of financial toxicity on older adults with cancer. High levels of financial burden have been linked to lower adherence to cancer treatments, shorter survival, poorer prognosis, and greater risk of recurrence. Older adults are particularly vulnerable and more likely to experience financial toxicity. Incorporating discussions about financial burden and exploring options to defray costs are key components of quality and patient-centered care.

Geriatric Assessment and Tools for Predicting Treatment Toxicity in Older Adults With Cancer.

Cancer is a disease of older adults, and the majority of new cancer cases and deaths occur in people 65 years or older. However, fewer data are available regarding the risks and benefits of cancer treatment in older adults, and commonly used assessments in oncology fail to adequately evaluate factors that affect treatment efficacy and outcomes in the older patients. The geriatric assessment is a multidisciplinary evaluation that provides detailed information about a patient's functional status, comorbidities, psychological state, social support, nutritional status, and cognitive function. Among older patients with cancer, geriatric assessment has been shown to identify patients at risk of poorer overall survival, and geriatric assessment-based tools are significantly more effective in predicting chemotherapy toxicity than other currently utilized measures. In this review, we summarize the components of the geriatric assessment and provide information about existing tools used to predict treatment toxicity in older patients with cancer.

390 Developing a decision tool for skin cancer treatment in older adults

Patient decision aids are designed to inform patients about the potential risks and benefits of available treatments. Decision tools can increase patient satisfaction and improve healthcare efficiency by better corresponding treatment received with patient treatment preferences. These are especially useful when several equivalent disease management options exist. This study aimed to develop a decision aid to assist older patients facing basal cell carcinoma (BCC) in their treatment decisions. We composed a brief, user-friendly, appealing, prototype decision aid suitable for use with older patients in accordance with the International Patient Decision Aid Standards. We modified it to ensure health literacy to 8th grade reading level. Based on successive input from patients, caregivers, and clinicians including dermatologists and dermatologic surgeons, the decision aid will be iteratively modified to incorporate feedback from all stakeholders. We will assess accessibility, bias, and usability through multiple rounds of focus groups and semi-structured interviews. Input from stakeholders will allow us to address all facets of the decision-making process, including: the emotional aspect of the fear associated with cancer, integrating the caregiver role, and the option to forego surgery in favor of less invasive options. The final product will then be subject to pilot testing in a clinical setting. The decision aid developed for this study is the first of its kind for BCCs in older adults. The decision aid appears feasible and comprehensible, and may serve as an effective means of encouraging active participation by patients in the clinical decision-making process.

Abstract P1-05-20: Comparing the frequency and types of genetic aberrations between older and younger women with metastatic breast cancer at the University of North Carolina at Chapel Hill

Abstract Background: Targeted therapies have the potential to revolutionize cancer treatment in older adults as they are often oral, convenient, may be better tolerated than cytotoxic chemotherapy, and can be tailored to an individual's biomarker profile. We explore the frequency and distribution of potentially actionable genomic alterations among older (≥65) and younger (<65) patients (pts) with metastatic breast cancer (MBC). Method: Next generation genetic sequencing (UNCseq™) of a dynamic panel of target genes was prospectively offered to pts with MBC treated at the University of North Carolina at Chapel Hill (UNC). DNA libraries were prepared separately from a retrieved archival FFPE tumor sample and a matched normal sample from each pt. Relevant targets were enriched by custom Agilent SureSelect hybrid capture baits using standard protocols. Samples were sequenced on Illumina HiSeq 2000/2500 platforms. Mutational findings were reviewed by a molecular tumor board; variants identified to be potentially actionable underwent confirmatory testing in a CLIA approved laboratory. Confirmed findings were inserted into the pt's EMR accessible by both the pt and the treating oncologist. Two-sided Fisher's exact test was used to compare percentages between age-specific groups. Results: As of 3/31/16, results were available for 140 pts. 19% were 65 years or older. Breast cancer clinical subtypes were: HR+/HER2- 49%, HER2+ (HR any) 17%, TN 34% and metastatic location was: bone only 5%, visceral only 44%, bone & visceral 51%; no significant differences were observed between older and younger age groups. Older pts were more likely to be Caucasian compared to younger patients (92% v 75%, p=0.06). Overall, older patients had a higher total number of mutations compared to younger patients (see Table) (p=0.04). Mutation types were similar between age groups, although a trend for more PIK3CA mutations among older patients was seen (37% v 20%, p=0.07). Observed Mutations by Age. ≥ 65 years (%) N=27< 65 years (%) N=113pNumber of Mutations 01127.0414849.0423320.04374.04Type of mutation PIK3CA3720.07CCND179.99NF-1115.37FGFR144.99PTEN49.69EGFR04.99 Conclusion: Genomic alterations may allow therapeutic tailoring in both older and younger patients with breast cancer. In this cohort with metastatic disease, older patients had significantly more mutations, but no clear difference in mutational types was seen by age. The relative small number of older pts in this cohort limits generalization, but supports the need for more extensive characterization of molecular aberrations among older pts with metastatic breast cancer in the new era of targeted therapy. Research support by the University Cancer Research Fund, NCI Breast Cancer SPORE grant (CA58223), John A. Hartford Foundation and Susan G. Komen Foundation. Citation Format: Jolly TA, Grilley-Olson JE, Deal AM, Ivanova A, Hayward MC, Benbow JM, Parker JS, Patel NM, Eberhard DA, Weck KE, Mieczkowski P, Dees EC, Muss HD, Reeder-Hayes KE, Earp HS, Sharpless NE, Carey LA, Hayes DN, Anders CK. Comparing the frequency and types of genetic aberrations between older and younger women with metastatic breast cancer at the University of North Carolina at Chapel Hill [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P1-05-20.

Feasibility of geriatric assessment in community oncology clinics

Emerging results support the value of geriatric assessment (GA) in determining the risk and benefits of cancer treatment in older adults. A brief GA tool consisting of valid and reliable measures has been developed; however, little data exist on the ability to perform the GA in community oncology clinics. The objective of this study was to determine the feasibility of performing the GA in the community. Patients aged ≥65 were eligible. The GA included a health care provider assessment of performance status, cognitive function, a Timed Up and Go test, and a self-administered patient questionnaire that evaluated measures of functional status, comorbidity, psychological state, social support, and nutritional status. From 2009 to 2013, 1088 patients were assessed including 339 (31%) from seven community clinics across North Carolina. The median amount of time to complete the patient-report portion of the GA was 19min in the academic center versus 22min in the community. The median amount of time to complete the entire GA was 23min in the academic center and 30min in community settings. Significantly more patients in the community required assistance completing the questionnaire (24% vs. 14%); however, most patients required no assistance (76%). A brief GA can be performed in community oncology clinics. The time to complete the professional assessments and patient self-assessments were similar in both settings. Future studies are planned to determine if such assessments can improve cancer care for older patients.

Factors influencing adherence to cancer treatment in older adults with cancer: a systematic review.

Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer. Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011. Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies. Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.

Effect of Burden of Comorbidity on Optimal Breast Cancer Treatment in Older Adults

Effect of Burden of Comorbidity on Optimal Breast Cancer Treatment in Older Adults

A call for observational cohort studies in geriatric oncology

Abstract In November of 2011, an international group of leaders met to discuss how to improve evidence in geriatric oncology at the meeting of the International Society of Geriatric Oncology (SIOG) held in Paris, France. A recommendation from the conference participants was to develop and implement observational cohort studies to increase evidence on the efficacy and safety of cancer treatment in older adults. An observational cohort study is a study that prospectively follows a group of individuals who have specific features in common over a defined period of time. Rigorous observational cohort studies can complement randomized controlled trial (RCT) data with information on efficacy, safety, and patient compliance with cancer treatment in a population of “real-world” patients. Well-designed observational cohort studies could be extremely valuable for gathering evidence on the efficacy and safety of cancer treatments, including those that are already available, in older adults in a more cost-effective and timely way than RCTs. Funding mechanisms through the National Institutes on Health, foundations, and European funding agencies devoted specifically to developing high impact observational cohort studies in geriatric oncology would help to provide evidence for a significant proportion of older patients over a short period of time.

Cancer Treatment in Older Adults: Implications for Psychosocial Research

The purpose of this article is to describe areas in need of psychosocial research for older adults who are currently receiving cancer treatment. Areas in which there are gaps in knowledge related to psychosocial research are outlined. Topics discussed for future research include comorbidity, physical function, cognitive status, frailty, and geriatric syndromes. In addition, the need for intervention to support patients and family caregivers is outlined. There are numerous areas of concern to older patients with cancer receiving treatment that warrant further study. Research is needed to identify ways to support patients and families at the time of cancer treatment so that they can make informed decisions and actively participate in cancer treatment.

Role of Age and Health in Treatment Recommendations for Older Adults With Breast Cancer: The Perspective of Oncologists and Primary Care Providers

To determine the impact of age and health status on adjuvant treatment recommendations for older patients with breast cancer from the perspective of medical oncologists and primary care physicians with geriatric expertise. One hundred fifty-one oncologists and 158 primary care physicians with geriatric expertise participated in an online survey. The survey described hypothetical patients of varying ages (70, 75, 80, and 85 years) and health status (good, average, and poor) who had node-positive, hormone receptor-positive, human epidermal growth factor receptor 2 (HER-2)/neu-negative; and hormone receptor-negative, HER-2/neu-positive breast cancers. The effects of patient age and health status on the survey participants' adjuvant treatment recommendations were examined using generalized estimation equation methods. The majority of both oncologists and primary care physicians recommended some form of adjuvant therapy for patients of all ages (70, 75, 80, and 85 years) and health status. Both oncologists and primary care providers were less likely to recommend adjuvant treatment as a patient's age increased or health status declined (P < .0001). There were no significant differences in treatment recommendations among primary care physicians and oncologists for patients with hormone receptor-negative, HER-2/neu-positive tumors (P = .54). However, primary care providers were more likely than oncologists to recommend no adjuvant treatment for patients age 75 years or older with hormone receptor-positive, HER-2/neu-negative tumors (P < .01). Age and health status influence oncologists' and primary care providers' adjuvant treatment recommendations. Evidence-based guidelines for breast cancer treatment in older adults taking into account age and health status are needed.

Cancer chemotherapy in older adults. A tolerability perspective.

The incidence of cancer increases with age. Since the geriatric population is growing, we will be confronted with an increasing number of patients with cancer who are > 65 years of age. The purpose of this review is to address the use of cancer chemotherapy in older persons with respect to its tolerability. We performed a review of the literature using 'Medline' and the bibliographies of pertinent publications. Information about cancer treatment in older adults was extracted with particular attention to chemotherapy-related toxicity in patients aged > 65 years. Comorbid disease, polypharmacy/drug interactions, psychosocial issues and age-related physiological changes are major issues in caring for older patients with cancer. Since older individuals may have a greater number of comorbid illnesses, treatment should be initiated on the basis of physiological rather than chronological age. Comparative studies show that chemotherapy-related toxicity is similar in older and younger patients, with the exception of haematological toxicity, which may be more severe in older patients, and cardiotoxicity, which is more frequent in the elderly. Other evidence suggests that gastrointestinal and neurotoxicities may also be more severe in older individuals. The dosages of chemotherapeutic agents that are primarily renally excreted may require adjustment in older patients. Haematological reserve is decrease in older individuals, and drugs that cause myelosuppression must be used with care. The use of haemopoietic growth factors in geriatric patients is currently being investigated.