Elderly Oncology Patients Research Articles

Geriatric assessments and medication management in elderly oncology patients.

Geriatric assessments and medication management in elderly oncology patients.

Endoscopic ultrasound: A safe procedure for elderly oncology patients?

e21531 Background: Endoscopic ultrasound (EUS) has many indications in the management of gastrointestinal tumors, and has become pivotal in guiding therapy. While studies show that surgery in the elderly with malignancy causes increased morbidity and costs, no studies exist to assess the safety of EUS in this group. Methods: A single center retrospective analysis of patients who underwent EUS by two advanced endoscopists from April 2015 to December 2015 was performed. Patient demographics, procedure indications, final diagnoses, procedure length, sedation type, ASA classification, and intra-procedural complications, peri-procedural (immediate) complications, and post-procedural (24 hours after) complications were collected. Statistical analysis was done with Chi-square and comparison of mean tests. Results: 111 patients were identified with either a confirmed or suspected gastrointestinal malignancy out of 200 total patients included in the study. These patients included 38 with suspected pancreatic adenocarcinoma, one of which revealed pancreatic gastrinoma; 27 with suspected gastric adenocarcinoma or for staging; 17 with suspicious esophageal masses or for staging of squamous cell carcinoma or adenocarcinoma; 9 duodenal masses, 3 colorectal masses, 2 mediastinal masses, 1 biliary mass, 3 potential metastatic lesions to the GI system, and 8 patients with abdominal lymphadenopathy suspicious for malignancy. Patients over 65 years tended to have a lower risk of intra-procedure complications compared to those under 65, irrespective of all other factors including gender, performing endoscopist, and length of procedure (8.3% vs. 18.3%, p = 0.09). No significant differences were found in peri- and post-procedural complications between the over age 65 and under age 65 groups (4.0% vs. 1.6%, p = 0.44; 5.9% vs. 15.2%, p = 0.19). Conclusions: Due to the poor performance status often seen in the elderly oncology population, complications often arise from invasive procedures leading to increased morbidity, mortality, and costs. EUS aids in diagnosis, staging, and therapeutic decision-making of patients with gastrointestinal malignancies, and as this study shows, can be performed in older patients without incurring increased risks.

P016 Impact of Pain and Anticipatory Grief on Quality of Life in Elderly Oncology Patients

P016 Impact of Pain and Anticipatory Grief on Quality of Life in Elderly Oncology Patients

Efficacy and safety of ultrasound-guided placement of central venous port systems via the right internal jugular vein in elderly oncologic patients: our single-center experience and protocol.

Ultrasound-guidance has become the routine method for internal jugular vein (IJV) catheterization reducing dramatically failure and complication rates for central venous port (CVP) placement. The aim of this study was to determine the safety and efficacy of ultrasound-guided IJV CVP placement in elderly oncologic patients. Between January 2013 and December 2015, 101 elderly oncological patients underwent right IJV CVP placement under ultrasound-guidance. The length of catheter introduction ranged from 18 to 21cm. Intraoperative fluoroscopy (IF) was always performed intraoperatively. Chest X-ray (CXR) was always performed 30min after the end of the procedure. The morbidity rate was 1.98%; two arterial punctures were reported with one self-limiting hematoma. Two patients (1.98%) had catheter misplacements, recognized by intraoperative IF. No patients (0%) experienced pneumothorax (PNX), confirmed at CXR. Patients were all discharged at maximum 6h from the procedure. The risk of catheter misplacement, PNX, and arterial/nerve puncture remains present with this technique. Lower rates of catheter misplacement have been reported after right IJV puncture, probably for its straight vertical course. Our results are in accordance with literature (1 counter-lateral subclavian vein and 1 counter-lateral internal jugular vein misplacements). All misplacements were detected intraoperatively. The PNX rates after cannulation of the IJV vary between 0.0 and 0.5%. We had no PNX occurrence. Ultrasonography (US) has improved safety and effectiveness of port system placements. While routine post-procedural CXR seems avoidable, IF should be considered mandatory.

1321P - OncoSTRIP for optimizing pharmacotherapy in elderly oncology patients with polypharmacy

1321P - OncoSTRIP for optimizing pharmacotherapy in elderly oncology patients with polypharmacy

The link between self-perceptions of aging, cancer view and physical and mental health of older people with cancer: A cross-sectional study.

Older people may suffer from stigmas linked to cancer and aging. Although some studies suggested that a negative view of cancer may increase the level of depression, such an association has never been studied in the elderly population. Similarly, even though it is established that a negative self-perception of aging has deleterious consequences on mental and physical health in normal aging, the influence in pathological contexts, such as oncology, has not been studied. The main aim of this study is thus to analyze the effect of these two stigmas on the health of elderly oncology patients. 101 patients suffering from a cancer (breast, gynecological, lung or hematological) were seen as soon as possible after their diagnosis. Their self-perception of age, cancer view and health (physical and mental) was assessed. Multiple regressions showed that patients with a more negative self-perception of aging and/or more negative cancer view reported poorer global health. We also observed that negative self-perception of aging was associated with worse physical and mental health, whereas negative cancer views were only linked to worse mental health. No interaction was observed between these two stigmas, suggesting that their action is independent. Older patients with cancer face double stigmatization, due to negative self-perception of aging and cancer, and these stigmas have impacts on global and mental health. Self-perception of aging is also linked to physical health. Longitudinal studies will be necessary to analyze the direction of the association between this double stigmatization and health.

Inclusion of elderly patients in oncology clinical trials

Physicians need clinical trials assessing benefits and harms of treatments to avoid under-treatment or over-treatment of elderly patients. The main objectives of this report were to examine how data regarding elderly oncology patients were presented in medical literature; and to assess the evolution of this presentation between two time periods. All phases I, II and III trials dedicated to the treatment of cancer among elderly patients published between 2001 and 2004 and between 2011 and 2014 were reviewed. All phase III clinical trials assessing cancer treatments among adults in the same periods were also reviewed to evaluate potential subgroup analyses in elderly patients in these studies. Key characteristics of interest were extracted by two investigators before descriptive and comparative analyses were undertaken. A total of 1084 trials were included: 366 and 718 from the first and second time period, respectively. Twenty-seven and 193 of these trials were phase I and II trials dedicated to elderly or frail patients, respectively. A large proportion of phase III trials published between 2011 and 2014 reported at least one analysis dedicated to elderly patients (46.7%) versus 19.3% during the first time period. The use of subgroup analyses of elderly patients in phase III trials was the most frequent source of information. Subgroup analyses were more frequent among trials with industrial funding, trials published in high impact factor journal, intercontinental trials and trials with large sample size. The age threshold defining the elderly subgroup increased over time. Elderly patients have become a topic of interest during the past decade. However, data available are mostly extracted from subgroup analyses, which can only be regarded as preliminary evidence.

Sarcopenia predicts 1-year mortality in elderly patients undergoing curative gastrectomy for gastric cancer: a prospective study

One-year mortality is vital for elderly oncologic patients undergoing surgery. Recent studies have demonstrated that sarcopenia can predict outcomes after major abdominal surgeries, but the association of sarcopenia and 1-year mortality has never been investigated in a prospective study. We conducted a prospective study of elderly patients (≥65years) who underwent curative gastrectomy for gastric cancer from July 2014 to July 2015. Sarcopenia was determined by the measurements of muscle mass, handgrip strength, and gait speed. Univariate and multivariate analyses were used to identify the risk factors associated with 1-year mortality. A total of 173 patients were included, in which 52 (30.1%) patients were identified as having sarcopenia. Twenty-four (13.9%) patients died within 1year of surgery. Multivariate analysis showed that sarcopenia was an independent risk factor for 1-year mortality. Area under the receiver operating characteristic curve demonstrated an increased predictive power for 1-year mortality with the inclusion of sarcopenia, from 0.835 to 0.868. Solely low muscle mass was not predictive of 1-year mortality in the multivariate analysis. Sarcopenia is predictive of 1-year mortality in elderly patients undergoing gastric cancer surgery. The measurement of muscle function is important for sarcopenia asa preoperative assessment tool.

Markers of Frailty in Cancer Treatment Election: A Case Report

Management of elderly oncology patients presents some difficulties when deciding if a patient is suitable for curative treatment or not. Apart from the tumour characteristics, there might be some other factors that influence in this decision, as previous illnesses, disability or general life expectancy. Standardized geriatric assessment must be applied in these cases, evaluating frailty in the elderly as one important prognosis factor, as it has been related to higher mortality and worst treatment tolerance. As symptoms, signs and exploratory findings can have common characteristics both for cancer and frailty, it is necessary to find other paths for approaching the frailty diagnosis that may influence the kind of treatment that a cancer patient receives. Biochemical markers are being developed, but in most cases they are not specific for cancer or frailty. Cardiovascular risk of patient, taking account on the analytic evolution of cardiovascular risks factors in the years previous to the neoplasia diagnosis, can help in the evaluation of the patient´s prognosis. DNA methylation pattern changes with age, and is also altered in cancer patients. This fact relates the apparition of cancer with aging. Further research must investigate on this subject, in order to identify possible methylation patterns that can discriminate frail cancer patients and non frail ones.

P-157: Physical performance measures compare favorably with geriatric assessment in elderly oncological patients

P-157: Physical performance measures compare favorably with geriatric assessment in elderly oncological patients

Cancer in the older person

SummaryThe challenges of treating malignant disease in the elderly population have gained greater prominence over the last 5–10 years. Developed nations all have ageing populations, and cancer in older people is an increasing physical and financial burden on both healthcare systems and populations.When assessing oncology patients, oncologists have traditionally used the Eastern Cooperative Oncology Group or Karnofsky performance status. However, it has been shown that sometimes this does not detect potential problems in older patients, and that a comprehensive geriatric assessment may be a better tool. However good surgeons and oncologists are at adapting their services for older patients, there is little value if they are inappropriately referred or filtered out by either primary or secondary care.Surgery forms the basis of most curative treatment options. The elderly have more peri-operative risk factors including multiple co-morbidities, poly-pharmacy, malnutrition, frailty, cognitive dysfunction and an increased anaesthetic risk, which can create obstacles.Treating older patients with systemic cytotoxic therapy often relies on extrapolating evidence from younger patients. In previous decades, the majority of trials had upper age limits of 65 or 70 years. More recent trials normally include patients of all ages, and entry is based on performance status. Radiotherapy may be chosen as a potentially curative option in patients with an operable tumour, who are unfit. However, oncologists should not underestimate the burden that multiple frequent visits to hospital for treatment may have on an elderly patient population.This article looks at the assessment of elderly oncology patients, referral patterns, surgery, systemic therapies, radiotherapy, supportive therapies and long-term side-effects from treatment.

The importance of caregivers in improving the care of geriatric oncology patients.

223 Background: Geriatric patients with cancer have special needs. The diagnosis of cancer is stressful for patients and their caregivers. A new age of medicine has emerged to facilitate caregivers in aiding elderly oncology patients through oncology programs. Many caregivers need support themselves. The purpose of this study is to evaluate our geriatric oncology program’s effectiveness and to demonstrate specific factors that caregivers believe have the greatest positive impact. The aim is to determine different interventions that can be implemented to help caregivers of geriatric oncology patients. Methods: This is a qualitative study that used a questionnaire completed by caregivers of patients enrolled in a geriatric oncology program directed towards easing the stressors encountered when caring for patients. Caregivers rated the effectiveness of the program by responding to 12 statements and 2 open-ended questions via telephone. Results: There were 94 patients in the program from November 2012 to November 2013. After excluding patients that did not meet criteria 71 caregivers were available. Analysis of results from 37 out of 71 caregivers enrolled identified six areas that the program most helped them with: time management of caregivers (82.8%), delivery of decision-making information (97.3%), resources available to caregivers and patients (88.23%), establishing goals of care (94.59%), and pain control for patients (100%). 83.78% of respondents agreed that the well-being and quality of their life improved with the program. Analysis on the patient survey conducted for the same time period also showed significant improvement. Conclusions: Caregivers play a vital role in cancer management of geriatric patients. In order to help both the patients and their caregivers, programs have emerged focusing on the teamwork of social workers, clinicians, and counselors. Caregivers express that this approach helps them effectively provide care to patients, and helps them get through this stressful period. The specific areas found to be most positively impacted by this type of organized program are what oncology departments may focus on in order to improve quality of life for caregivers which may ultimately improve the patient’s care.

COMPREHENSIVE GERIATRIC ASSESSMENT (CGA): IS IT NECESSARY FOR TREATMENT OF CANCER PATIENTS? INTERDISCIPLINARY EFFORTS AND IMPORTANCE OF ITS IMPLEMENTATION IN A CANCER CENTER PROGRAM IN LATIN AMERICA

CGA is gaining importance in treatment of elderly cancer patients, since ageing is a global phenomenon. That shift in demographics has huge impact in healthcare. However, the more reliable validated way to apply CGA in Geriatric Oncology is an open research field so far. The efforts to find the best interdisciplinary approach for conducting CGA in daily clinical practice demand a worldwide multi-institutional collaboration. This presentation will review some topics in Geriatric Oncology, highlighting strategies and difficulties of implementing such a unit. Daily routine of a interdisciplinary Geriatric Oncologic team work will be discussed, to put into the context of a high volume cancer hospital, the daily needs of caring for elderly oncology patients. Attending public will discuss, among other topics: a) epidemiology of aging and cancer around the world; b) efforts to better care in geriatric oncology; c) CGA in cancer patients; d) important points in geriatric oncology in different settings (public or private; acute or intensive care unit, ambulatory, nursery, hospice, home care); e) administrative and financial support for geriatric oncology. In A. C. Camargo Cancer Center, in Sao Paulo, Brazil, we are starting a project hoping for government grant, aiming to: □ Detect predictive factors of complications in oncological treatment □ Propose treatment protocols adapted to functional capacity, to avoid over and under treatment. □ Offer ways to rehabilitation of reversible vulnerability and frailty, with combined interprofessional work. □ Prevent additional common complications in elderly: falls, polypharmacy, undernutrition, depression, sarcopenia, for example. □ Detect early signs of psychological or cognitive alterations that may contribute to additional deficits. □ Offer home, ambulatory and hospital support to all patients, specially for the ones that cannot receive specific cancer treatment. □ Combine assistance to comorbidities with the oncology team. Topics above will be illustrated by our experience, initiated in 2010, in the implementation of a Geriatric Oncology Unit in A. C. Camargo Cancer Center – one of the largest oncology hospitals in Latin America – specially how to apply a time-consuming elderly evaluation in a high volume cancer center for multidisciplinary treatment. In our initial retrospective cohort, the incorporation of CGA in daily practice was feasible and useful to predict needs and complications of systemic cancer treatment, like dose adjustment, ability to complete proposed treatment, and hospitalisation. Next step should be to look for correlations with markers of efficacy, such as survival and quality of life. We believe that the comparison of different approaches in Geriatric Oncology may help to improve their applications in many settings and services, with good ideas being applied with local contextualisation. Those efforts will directly benefit elderly cancer patients. Disclosure of interest: None declared

The role of age on dose-limiting toxicities in phase I dose-escalation trials.

Elderly oncology patients are not enrolled in early-phase trials in proportion to the numbers of geriatric patients with cancer. There may be concern that elderly patients will not tolerate investigational agents as well as younger patients, resulting in a disproportionate number of dose-limiting toxicities (DLT). Recent single-institution studies provide conflicting data on the relationship between age and DLT. We retrospectively reviewed data about patients treated on single-agent, dose-escalation, phase I clinical trials sponsored by the Cancer Therapy Evaluation Program (CTEP) of the National Cancer Institute. Patients' dose levels were described as a percentage of maximum tolerated dose, the highest dose level at which <33% of patients had a DLT, or recommended phase II dose (RP2D). Mixed-effect logistic regression models were used to analyze relationships between the probability of a DLT and age and other explanatory variables. Increasing dose, increasing age, and worsening performance status (PS) were significantly related to an increased probability of a DLT in this model (P < 0.05). There was no association between dose level administered and age (P = 0.57). This analysis of phase I dose-escalation trials, involving more than 500 patients older than 70 years of age, is the largest reported. As age and dose level increased and PS worsened, the probability of a DLT increased. Although increasing age was associated with occurrence of DLT, this risk remained within accepted thresholds of risk for phase I trials. There was no evidence of age bias on enrollment of patients on low or high dose levels.

Translation and Validation of the Activities of Daily Living Scale with Iranian Elderly Cancer Patients Treated in an Oncology Unit

This study evaluated the validity and reliability of applying the Katz's Activities of Daily Living (ADL) scale in an Iranian sample of elderly oncologic patients following initial cancer treatment. The scale was translated with the forward-backward procedure to give an Iranian version. The ADL scale was then applied in a random sample of 400 oncologic patients aged 60 and older following initial cancer treatment. Assessment of the scale stability was twice, with a 14-days (two weeks) interval, to 30 (of the 400) eligible elderly cancer patients in March 2012. To measure treatment effects, the index was run with 150 patients in a three month recall, following oncology processing. Exploratory and confirmatory factor analysis was performed for assessment of construct validity of the Katz's ADL. Reliability was measured with internal consistency (Cronbach's alpha co-efficient), and test/retest (Spearman's r value) of the instrument. Criterion validity was evaluated by comparing the Katz with Physical Function (PF) subscale of SF 36. Known-group validity was approved by comparing of Katz' ADL between quartile groups of PF subscale of SF 36. In our study the ADL demonstrated a high degree of internal homogeneity (Cronbach's alpha 0.923). There was a high correlation between scores of two time measurement of Katz's ADL (p value of two- related- samples test was 0.3). Construct validity showed a correlation coefficient of 0.572 between the ADL and PF scores. In factor analysis, 2 factors were extracted. Evidence for the reliability of the questionnaire was good and known group validity was approved by significant differences of ADL score between quartiles of the PF subscale of SF36. The results suggest that the Iranian version of ADL applied for oncologic older adult patients following initial cancer treatment is a reliable and a valid clinical instrument and comparable to those reported in other studies.

The role of age on dose-limiting toxicities (DLTs) in phase I dose-escalation trials.

9517 Background: Elderly oncology patients are not enrolled on phase I trials in proportion to the prevalence of cancer in the age-matched population. They are excluded from these trials based on the perception that these patients will have an increased number of and more severe toxicities, per dose level, than younger patients. We hypothesize that if other patient characteristics are accounted for, then age will not be an independent predictor of dose limiting toxicities (DLTs). Methods: We retrospectively reviewed data from 162 single- agent dose-escalation phase I clinical trials performed at the Cancer Therapy Evaluation Program/National Cancer Institute. Several baseline patient characteristics, including age, were collected. Patient dose levels were described as %MTD and an analysis of age, dose and DLTs was performed. Results: Data was obtained from 5,401 patients who were divided into five age groups, with 556 pts &lt; 40 years old, 2,438 between 40-59, 1,481 between 60-69, 836 between 70-79 and 90 pts &gt; 79. Proportion of DLT occurring in each age group and %MTD are described in the Table. Conclusions: This analysis of DLTs occurring in nearly 1000 patients over 70 years of age on phase I dose-escalation trials is the largest reported. A logistic regression model will be performed to determine if age, by itself, predicts for DLTs and what concurrent patient characteristics contribute to their occurrence. [Table: see text]

Drugs prescribed for elderly oncologic patients hospitalized in the geriatric oncology unit of Institut Jules Bordet: Polypharmacy and impact of clinical pharmacist

P77 Drugs prescribed for elderly oncologic patients hospitalized in the geriatric oncology unit of Institut Jules Bordet: Polypharmacy and impact of clinical pharmacist C. Deliens, M.C. Vanderbeeken, A. Georgala, O. Filleul, B. Papadopoulou, G. Deliens, A. De Beer, D. de Valeriola, M. Piccart, A. Awada, Y. Lalami, J.P. Praet, L. Dal Lago. Division of Pharmacy, Institut Jules Bordet, Universite Libre de Bruxelles, Brussels, Belgium, 2 Department of Medicine, Institut Jules Bordet, Universite Libre de Bruxelles, Brussels, Belgium, Department of Infectious Diseases, Institut Jules Bordet, Universite Libre de Bruxelles, Brussels, Belgium, UR2NF, Neuropsychology and Functional Neuroimaging Research Unit, Universite Libre de Bruxelles, Brussels, Belgium, Department of Geriatric Medicine, C.H.U. St.-Pierre, Brussels, Belgium

Retrospective analysis of treatment tolerability in elderly oncological patients receiving cytotoxic therapy in a community setting.

e19598 Background: Cancer is highly prevalent in those above the age of 65 years. Elderly oncological patients are under-represented in clinical trials and there is a lack of clinical data to guide treatment decisions in this group of patients. We evaluated the cytotoxic treatment tolerability in this group of patients in a community hospital. Methods: Cytotoxic chemotherapies and tyrosine kinase inhibitors administered in Gold Coast Hospital to patients above 65 years of age between March 2010 and March 2011 were included. Data including number of comorbidities, concurrent medicines, ECOG status and treatment drug dose adjustment were obtained. The outcomes of treatment including treatment completion, early termination and its reason, toxicities and hospital admissions during treatment were also collected. Results: A total of 206 patients were identified. Majority had an ECOG score of 0 to 1 (89%) and number of co-morbidities between 0 and 3 (96%). Eighty percent of patients had initial or subsequent treatment dose reduction. Despite this, 53% of patients (n=109) did not complete the planned treatment; 68% had disease progression but 31% was due to treatment intolerance. There was a high number of reported grade 3 and 4 toxicities (n=84) and hospitalisations during treatment (n=154). Conclusions: There is a high rate of dose reduction and noncompletion of cytotoxic treatments even in a relatively healthy elderly population. We propose further prospective study incorporating in-depth geriatric assessment to evaluate elderly patients suitability for cytotoxic treatments. [Table: see text]

Clinical aspects of the management of elderly women diagnosed with gynecologic malignancies: Treatment decisions and choices

Abstract The number of elderly women diagnosed with gynecologic cancer is increasing. This paper reviews the current trends in the management of elderly gynecologic cancer patients. Our goal is to identify critical issues that must be weighed when selecting treatment for elderly gynecologic oncology patients. As individuals continue to achieve longer lifespans, and the population of elderly women continues to grow, gynecologic oncologists will face new challenges regarding treatment. Due to minimal inclusion in randomized controlled trials and the influence of selection bias in many of the current studies, little evidence-based data is available regarding the most effective treatment options for this population. It is therefore unclear whether treatment should differ from that offered to younger populations, and if so under what circumstances. As of yet, there are no validated measures by which to determine tolerability and success of aggressive therapies for this population. Ultimately, each patient must be evaluated individually with regards to risk factors and prognosis, and therapy should not be withheld from elderly individuals solely on the basis of age alone.

Losartan vs. amlodipine treatment in elderly oncologic hypertensive patients: A randomized clinical trial

Elderly neoplastic patients frequently may show hypertension and hyperuricemia, before and after chemotherapeutic treatments. The purpose of this study was to evaluate the efficacy of losartan which is an antihypertensive drug with uricosuric properties vs. amlodipine in hypertensive neoplastic elderly patients. This was an open-labeled, randomized, comparative trial. The study was performed as a 30-day study. Seventy patients with cancer were randomly assigned to receive losartan or amlodipine. Blood pressure (BP), blood urea nitrogen (BUN) levels, creatinine, serum and urinary uric acid, creatinine and uric acid clearance were determined before and after chemotherapy. One day after chemotherapy in losartan group vs. amlodipine group we observed a significant difference in urinary uric acid ( p < 0.001) of 18 mg/24 h vs. 40 mg/24 h. Thirty days after chemotherapy we observed a significant difference in azotemia of 0.0 mg/dl vs. 3.8 mg/dl ( p < 0.001), serum uric acid of 0.05 mg/dl vs. 0.49 mg/dl ( p < 0.001), urinary uric acid ( p < 0.001) of 23 mg/24 h vs. 0.0 mg/24 h, GFR of 2 ml/min/1.73 m 2 vs. −8 ml/min/1.73 m 2 ( p < 0.05) and systolic BP (SBP) of 3.6 mmHg vs. 0.8 mmHg ( p < 0.05). The findings of the present study support the effective role of losartan compared to amlodipine in treating hypertension and hyperuricemia in elderly patients under chemotherapeutic treatment.