Use Of Chemotherapy In Elderly Patients Research Articles

Patterns of Treatment and Survival in Elderly Patients with Primary CNS Lymphoma; An 11-Year Population-Based Analysis

Introduction Primary CNS lymphoma (PCNSL) is an aggressive form of lymphoid malignancy that occurs exclusively in the brain, meninges, spinal cord, and eyes. The incidence of PCNSL has been increasing, particularly in the elderly population, with a median age at diagnosis of 66 years (Olson J.E. et al., Cancer 2002). The primary modality of treatment for this deadly disease is systemic chemotherapy that includes high-dose methotrexate (HD-MTX), with or without whole-brain radiation. Due to the toxicity of HD-MTX, physicians tend to avoid using it in the elderly population. This was confirmed in previous reports from the 1990s (Panageas K.S. et al., Cancer 2007). In this comprehensive population-based analysis, we sought to examine the patterns of treatment and survival in elderly patients in the 2000s and sought to investigate clinical and socioeconomic predictors of treatment selection. Methods We conducted a retrospective cohort analysis using de-identified data accessed from the national cancer database (NCDB). The NCDB provided records of 2985 patients diagnosed with PCNSL between 2004 and 2015. We excluded patients who are younger than 65 years old, those who tested positive for HIV, and those who started treatment >120 days since diagnosis to account for immortal time bias. Patients were divided into four groups based on treatment received: combined modality treatment (CMT), chemotherapy alone, radiation alone, and no treatment. Exploratory analysis of the patient groups was performed. Summary statistics are presented as percentages for categorical data and median with interquartile range for quantitative data. Multivariate regression models were used to analyze predictors of the selection of any treatment versus no treatment and for selecting chemotherapy versus no chemotherapy. To account for variable baseline characteristics, we used propensity score weighting methodology to calculate estimates of interest. Survival estimates were performed using the Kaplan-Meier method, and survival differences were tested using the wilcoxon-rank test. Results We identified 1096 patients with PCNSL who fulfilled the inclusion criteria. The median age was 73 (IQR: 68-79). There were 52% males. The majority of the patients were whites (92%), lived in a metropolitan area (78%), treated at an academic/research center (57%). The most common treatment modality used was chemotherapy alone (48%), followed by CMT (22%), no treatment (16%), and radiation alone (13%). On multivariate analysis, age (OR: 0.94, 95% CI 0.92-0.96) and comorbidity score (OR: 0.63, 95% CI 0.52-0.76) significantly predicted receiving any type of treatment. Both age (OR: 0.91, 95% CI 0.89-0.94) and distance (OR: 1.006, 95% CI 1.001-1.01) were predictors of receiving chemotherapy. Median follow up was 12 months (IQR: 3-44). Median OS in months for the four groups was: 43.1 for CMT, 19.4 for chemotherapy alone, 17.2 for radiation alone, and 2.3 for no treatment. (wilcoxon-rank test p-value: <0.001). Median OS for the whole population was 17 months (IQR: 12-26). Patients >75 year old had lower median OS in general, but receiving CMT had a survival advantage as well. (Figures 1 and 2) Conclusions The majority of PCNSL patients in our analysis received treatment. Our results showed an increased trend of chemotherapy use in elderly patients compared with earlier reports, where radiation alone was the most common treatment modality. The median OS of patients was longer compared with the 1990s data (17 vs. 7 months). CMT was associated with better OS compared with no treatment and chemotherapy alone. Although this was numerically better compared with radiation alone, it was not statistically significant. Younger patients and patients with lower comorbidity scores were more likely to receive treatment. Younger patients and patients who live further from the treating facility were more likely to receive chemotherapy. Longer distance may have led to less radiation use due to the need for complex planning and frequent visits associated with radiation therapy. Our study is limited by its retrospective nature, which makes it at risk of selection bias. Using propensity score weighting methodology strengthens our results. Also, the NCDB lacks certain pertinent variables, such as details of chemotherapy regimens, and toxicity information especially for radiation in the CMT arm which will have practical implications. Disclosures Fazal: Glaxosmith Kline: Consultancy, Speakers Bureau; Incyte Corporation: Consultancy, Honoraria, Speakers Bureau; Karyopham: Speakers Bureau; Celgene: Speakers Bureau; BMS: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jansen: Speakers Bureau; Stemline: Consultancy, Speakers Bureau; Gilead/Kite: Consultancy, Speakers Bureau; Agios: Consultancy, Speakers Bureau; Amgen: Consultancy, Speakers Bureau; Takeda: Consultancy, Speakers Bureau; Novartis: Consultancy, Speakers Bureau; Jazz Pharma: Consultancy, Speakers Bureau. Kahn:Genetech: Honoraria; Takeda: Honoraria; Karyopharm: Honoraria; Seattle Genetics: Honoraria; Abbvie: Honoraria; Celgene: Honoraria; AstraZeneca: Honoraria; Beigene: Honoraria.

The efficacy and toxicity of chemotherapy in the elderly with advanced pancreatic cancer

ObjectivesFOLFIRINOX (FFX) or abraxane plus gemcitabine (AG)-based chemotherapy is used widely as firstline treatment for patients with pancreatic cancer. However, their use in the elderly is discouraged because of adverse events. More clinical data about the therapeutic response and tolerability to FFX or AG in elderly patents (over 70 years old) are required. MethodsPatients with advanced pancreatic cancer (n = 203; 131 metastatic pancreatic cancer patients (MPC) and 72 locally advanced pancreatic cancer patients (LAPC)) were treated using modified-FFX (mFFX) or AG and mFFX sequentially. The patients were grouped according to their age, patients below 70 years old and patients above 70 years old. The objective response rate (ORR), disease control rate (DCR), progression free survival (PFS), overall survival (OS) and adverse events were compared between the groups. ResultsThe ORRs in the elderly and in patients below 70 were similar (30.0% versus 32.3%). The median OS and PFS were also similar between the groups (mOS 13.3 m vs 12.7 m, p = 0.729, HR 0.874 (95% CI 0.5310 to 1.438); mPFS mPFS 10.6 m vs 10.3 m, p = 0.363, HR 0.800 (95% CI 0.4954 to 1.293)). However, the elderly patients suffered a higher incidence of severe adverse events (50% vs. 28.3%). ConclusionsThese data could provide guidance for chemotherapy use in elderly patients with advanced pancreatic cancer. Age did not affect treatment outcome; however, supportive treatment is very important for elderly patients receiving chemotherapy.

Chemotherapy in the elderly patients with advanced pancreatic cancer

Introduction: FOLFIRINOX or AG-based chemotherapy is widely accepted as the firstline treatment for patients with pancreatic cancer. Although these regimens present higher response rate and prolonged survival time, it was not well administered in elderly patients by clinicians due to adverse events. More clinical data about the therapeutic response and tolerability of elderly patents (over 70 years old) to FOLFIRINOX or AG are strongly required. Method: In our study, 197 patients with advanced pancreatic cancer (127 metastatic pancreatic cancer patients (MPC) and 70 locally advanced pancreatic cancer patients (LAPC)) were treated using modified-FOLFIRINOX (no Fluorouracil bolus, 85% Oxaliplatin and 75% Irinotecan) or AG between April 2014 and March 2019 in our department. 150 of them were restaged after chemotherapy. The objective response rate (ORR), disease control rate (DCR) and adverse events were measured. Patients were followed up every 3 months, progression free survival (PFS) and overall survival (OS) were calculated. Result: The ORR is 36.7% (11/30) in the elderly patients, which was similar to that in other patients (35.8% (43/120)). The median OS and PFS are 14.1 months and 10.8 months respectively in elderly patients while 12.7 months and 9.8 months in younger patients, no statistical significance was observed between these groups. However, older patients suffered a higher incidence of severe adverse events (50% vs. 26.7%). After given supportive treatments against adverse events, the tolerability of elderly patients were acceptable. Conclusion: These data might provide guidance for chemotherapy use in elderly patients with advanced pancreatic cancer. Age is not a key factor that affects the outcome of chemotherapy, but the supportive treatments are extremely important for elderly patients during the treatment.

Association of Palliative Care Consultation With Reducing Inpatient Chemotherapy Use in Elderly Patients With Cancer in Japan: Analysis Using a Nationwide Administrative Database.

The administration of chemotherapy at the end of life is considered an aggressive life-prolonging treatment. The use of unnecessarily aggressive therapy in elderly patients at the end of life is an important health-care concern. To explore the impact of palliative care consultation (PCC) on chemotherapy use in geriatric oncology inpatients in Japan by analyzing data from a national database. We conducted a multicenter cohort study of patients aged ≥65 years, registered in the Japan National Administrative Healthcare Database, who died with advanced (stage ≥3) lung, stomach, colorectal, liver, or breast cancer while hospitalized between April 2010 and March 2013. The relationship between PCC and chemotherapy use in the last 2 weeks of life was analyzed using χ2 and logistic regression analyses. We included 26 012 patients in this analysis. The mean age was 75.74 ± 6.40 years, 68.1% were men, 81.8% had recurrent cancer, 29.5% had lung cancer, and 29.5% had stomach cancer. Of these, 3134 (12%) received PCC. Among individuals who received PCC, chemotherapy was administered to 46 patients (1.5%) and was not administered to 3088 patients (98.5%). Among those not receiving PCC, chemotherapy was administered to 909 patients (4%) and was not administered to the remaining 21 978 patients (96%; odds ratio [OR], 0.35; 95% confidence interval, 0.26-0.48). The OR of chemotherapy use was higher in men, young-old, and patients with primary cancer. Palliative care consultation was associated with less chemotherapy use in elderly Japanese patients with cancer who died in the hospital setting.

Chemotherapy in Elderly Patients with Acute Myeloid Leukemia (AML): Analysis of Socioeconomic Factors Using National Cancer Data Base (NCDB)

Acute myeloid leukemia (AML) is one of the most common types of leukemia in adults, accounting for approximately 35% of leukemia in United States (CA Cancer J Clin 2014;64(1):9-29). The use of chemotherapy is associated with significant survival benefit in AML, particularly young and fit individuals. Although survival rates have improved remarkably in the younger age group, the prognosis in older patients continues to be poor. The receipt of chemotherapy has a potential to alter the prognosis in elderly AML patients, however, many older patients may not be able to receive chemotherapy. We analyzed the trend in chemotherapy use in AML patients ³60 years using NCDB to understand the socioeconomic determinants of chemotherapy use.Methods: This is a retrospective study of AML patients (n= 99,664) diagnosed between 2000 and 2011 in the NCDB hospitals. NCDB contains approximately 70% of new cancer diagnosis in the United States and Puerto Rico. Chi-square test was used to determine any differences in characteristics of AML patients 60 years or above who did or did not receive systemic therapy.Results: Nearly 61% of AML patients were 60 years or above (n= 60,477), however, chemotherapy use was significantly lower in these patients than those below 60 years (57% vs 70%, p < .0001). In patients 60 years or above, males were more likely to receive chemotherapy than females (59% vs 55%; p < .0001) (Table 1). While their use was higher at academic vs. non-academic hospitals (67% vs 51%; p < .0001), presence or absence of other comorbidities in these patients also determined its use (55% vs 60%, p < .0001). However, race, education or household income did not significantly affect chemotherapy use in the elderly population.Conclusions: AML predominantly affects patients more than 60 years of age (Cancer. 2006;107(9):2099-107). The factors negatively influencing treatment outcomes, including poor performance status, the presence of comorbidities, adverse cytogenetics and antecedent hematologic disorders are more common in this subset of population (Blood research. 2014;49(2):95-9). The management of elderly AML patients is complex and requires good understanding of risks and benefits of chemotherapy in individual patient. Our study demonstrates that the chemotherapy use in elderly patients is lower than younger patients and differ by patients’ gender, type of hospital and the presesnce of comorbidties. Understanding the health care disparities can help individualize and optimize cancer treatment leading to better quality of care in patients expected to have poorer outcomes.Table 1Pattern of chemotherapy use in patients 60 years or above with AMLParameterPercent of cases receiving chemotherapyp-valueGender<.0001Male59Female55Race0.3677White57Black57Hispanics59Education (% with high school degree)0.8611³ 88%5770-88%57< 69%57Income0.0909< $28,00056$28,000 to $48,99957³ $49,00058Comorbidity<.0001None60³ 155Treatment Facility<.0001Academic Hospital67Other Hospitals51 DisclosuresNo relevant conflicts of interest to declare.

Geographic access and age-related variation in chemotherapy use in elderly with metastatic breast cancer.

Significant age-related variation in chemotherapy use has been observed among elderly patients with metastatic breast cancer (MBC), which may be partly attributable to geographic access factors such as local area physician practice culture and local health care system capacity. The purpose of the paper was to examine how age may modify the effect of geographic access on chemotherapy use in elderly patients with MBC. This was a retrospective cohort study based on the surveillance, epidemiology, and end results-Medicare-linked database of 1992-2002. Chemotherapy use was defined as at least one chemotherapy-related claim within 6-month post-diagnosis. Geographic access to cancer care was measured by four variables: patient travel time to the nearest oncologist practice, local area per capita number of oncologists, local area per capita number of hospices, and local area chemotherapy rate. Using multivariate logistic regression model, both aggregate models with interaction terms and subgroup analyses were conducted. Among 4,533 elderly with MBC, 30.16 % used chemotherapy. Chemotherapy use decreased with age. Both the aggregate model with interaction terms and the subgroup analysis showed that local area chemotherapy rate was positively associated with chemotherapy use (P = .0004 in the whole group; in the subgroup analyses, P < .0001, P = .0006, P = .0006, P = .18, P = .026, respectively). In addition, subgroup analysis showed that, among patients aged 85+ years old, local area oncologist supply was negatively associated with chemotherapy use (P = .028). The impact of geographic access to cancer care is the greatest among the oldest group, for whom the clinical evidence is the least certain.

Chemotherapy Use in Elderly Patients with Soft Tissue Sarcoma: A Population-based Study

Adjuvant chemotherapy for soft tissue sarcoma (STS) remains controversial while improvement in survival has never been conclusively demonstrated for metastatic STS. We identified individuals in SEER–Medicare with resected or metastatic STS, 1991–2007. Of 2,382 patients with resected STS, 106 (4.5%) received chemotherapy. High tumor grade, larger tumor size, and malignant fibrous histiocytoma subtype were associated with chemotherapy receipt. Of 365 patients with metastatic STS, 118 (32.4%) received chemotherapy. Younger age, fewer comorbidities, and being married were associated with chemotherapy receipt. Consistent with clinical trials, we found minimal use of chemotherapy. Clinical factors were associated with chemotherapy receipt in nonmetastatic STS.

Rates and predictors of chemotherapy use for stage III colon cancer

Despite consensus regarding the benefits of chemotherapy for stage III colon cancer, multiple reports have found significant variations in rates of use. In the current study, the authors attempted to systematically review reports of the community rates at which chemotherapy is administered for stage III colon cancer in the US, and in so doing plan strategies for improving rates of use. A systematic search strategy was undertaken using MEDLINE, Web of Science, and bibliographies to find reports of the rates at which patients with stage III colon cancer receive chemotherapy. A total of 22 studies published since 1990 were identified, with rates of chemotherapy use ranging from 39% to 71%. Age and comorbidity were found to be the most significant patient factors, but studies also found racial/ethnic and socioeconomic disparities in the rates of chemotherapy. Patients treated at teaching hospitals did not clearly receive chemotherapy more often. Oncologists and surgeons who treat a higher volume of colorectal cancer patients were more likely to have chemotherapy initiated in their patients. The authors developed a conceptual model of the process pathway experienced by patients with stage III colon cancer to demonstrate areas of potential underuse of chemotherapy. Nearly half of patients with stage III chemotherapy in the US do not receive chemotherapy. Although many patients are too old or frail to benefit appropriately, for many patients chemotherapy is simply not initiated. Attention needs to be focused on systematic approaches to prevent systems failures that result in underuse. Guidelines regarding chemotherapy use in elderly patients are especially important.

Temporal trends and predictors of perioperative chemotherapy use in elderly patients with resected nonsmall cell lung cancer

The authors assessed patterns of perioperative chemotherapy use in elderly patients with resected stage I, II, or IIIA nonsmall cell lung cancer (NSCLC) from 1992 to 2002. By using data from the Surveillance, Epidemiology, and End Results Program, 11,807 patients were identified who had resected stage I, II, or IIIA NSCLC between 1992 and 2002 and survived >or=120 days beyond diagnosis. The rate of perioperative chemotherapy use was measured by calendar year, and the association between clinical/demographic characteristics and the receipt of chemotherapy was examined by using logistic regression. In total, 957 patients with stage I, II, or IIIA NSCLC (8.1% of the study population) received perioperative chemotherapy. The proportion of patients receiving chemotherapy for stage I NSCLC changed little during the study period. Of 3230 patients with stage II and IIIA NSCLC, 609 patients (18.9%) received chemotherapy, 423 patients (13%) received chemotherapy combined with radiation. 452 patients (15.6%) received adjuvant chemotherapy, and 66 patients (2.3%) received neoadjuvant chemotherapy. The use of chemotherapy increased significantly among patients who were diagnosed after 1994 relative to patients who were diagnosed in 1992 after controlling for sociodemographic and treatment characteristics (P< .001). There was significantly increased use of new-generation chemotherapy agents, such as carboplatin and taxanes (P< .001). The proportion of patients receiving combined-modality therapy also increased significant (P< .001). Younger age, being married, having advanced-stage tumor or adenocarcinoma, having a later diagnosis year, receiving radiation, and seeing an oncologist were predictors for the receipt of chemotherapy (P< .001). A substantial proportion of Medicare beneficiaries with NSCLC received perioperative chemotherapy. Specifically designed prospective trials that focus on older patients are needed.

Who Gets Chemotherapy for Metastatic Lung Cancer?

To determine the prevalence and factors associated with chemotherapy use in elderly patients presenting with advanced lung cancer. A retrospective cohort study using administrative data. We analyzed the medical bills for the 6,308 Medicare patients > 65 years old with diagnosed stage IV non-small cell lung cancer (NSCLC) in the 11 SEER (survival, epidemiology, and end results) regions between 1991 and 1993. The main outcome measure, chemotherapy administration, was identified by the relevant medical billing codes. Patient sociodemographic and disease characteristics were obtained from the SEER database and census data. Almost 22% of patients received chemotherapy at some time for their metastatic NSCLC. As expected, younger patients and those with fewer comorbid conditions were more likely to receive chemotherapy. However, several nonmedical factors, such as nonblack race, higher socioeconomic status, treatment in a teaching hospital, and living in the Seattle/Puget Sound or Los Angeles SEER regions, also significantly increased a patient's likelihood of receiving chemotherapy. Compared to previous reports, the prevalence of chemotherapy use for advanced NSCLC appears to be increasing. However, despite uniform health insurance coverage, there is wide variation in the utilization of palliative chemotherapy among Medicare patients, and nonmedical factors are strong predictors of whether a patient receives chemotherapy. While it is impossible to know the appropriate rate of usage, nonmedical factors should only influence a patient's likelihood of receiving treatment if they reflect patient treatment preference. Research to further clarify the costs, benefits, and patient preferences for chemotherapy in this patient population is warranted in order to minimize the effect of nonmedical biases on management decisions.