Treatment Decisions For Older Adults Research Articles

Clinical Frailty Scale - frailty assessment and rehabilitation potential

Background: Studies show a significant increase in frailty prevalence among older adults worldwide. Fortunately, several well-established and user-friendly screening tools can effectively identify frailty in older adults. Objectives: This article examines the Clinical Frailty Scale's effectiveness in informing treatment decisions for older adults in ambulatory care settings, analyzing its potential to improve patient care. Methods: On April 1, 2024, the PubMed database was searched for articles on the Clinical Frailty Scale in elderly patients. The 116 most pertinent and current articles, written in English and published within the past few years, were analyzed, and 38 were selected and categorized by content and topic. Limitations: This study is limited because it is not a meta-analysis and thus does not examine the quality of the evidence presented in each article. Conclusions: Frailty research has illuminated aging and its potential biological causes. The Clinical Frailty Scale effectively identifies vulnerable individuals. By using the CFS to assess frailty risk, healthcare providers can personalize treatment plans and improve overall care for older adults.

Management of Stable Angina in the Older Adult Population.

As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient's priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.

Abstract PD6-01: PD6-01 Association between the CARG-BC score and clinical decline after adjuvant chemotherapy in fit older adults with breast cancer: Results from the Hurria Older PatiEnts (HOPE) Prospective Study

Abstract Association between the CARG-BC score and clinical decline after adjuvant chemotherapy in fit older adults with breast cancer: Results from the Hurria Older PatiEnts (HOPE) Prospective Study Background: We previously developed and validated a risk prediction model for grade 3-5 chemotherapy toxicity in patients age ≥65 with early breast cancer, known as the Cancer and Aging Research Group-Breast Cancer (CARG-BC) score. The CARG-BC score is calculated by combining eight clinical variables that classify patients as low, intermediate, and high risk for grade 3-5 chemotherapy toxicity. However, whether this score can also identify individuals most likely to experience a clinical decline after chemotherapy remains unknown. Here, we evaluated the association between the CARG-BC score and decline in health status. Methods: This is a pre-specified secondary analysis of the Hurria Older PatiEnts (HOPE) with Breast Cancer Study (NCT01472094). This multicenter, prospective cohort study gathered biological and clinical data from women ≥65 with stage I-III breast cancer scheduled to receive neo/adjuvant chemotherapy. Health status was measured pre- (≤14 days) and post-chemotherapy (≤30 days) using a Deficit Accumulation Index (DAI), derived from geriatric assessment data (Cohen et al Cancer 2017). The DAI categorized patients as robust (0.0< 0.2), prefrail (0.2< 0.35), or frail (≥0.35). Baseline clinical characteristics, blood biomarkers of inflammation (interleukin-6 [IL-6] and C-reactive protein [CRP]), and CARG-BC scores (classified as low [0-5], intermediate [6-11] or high [≥12]) were collected pre-chemotherapy. The population of interest was older women who were clinically fit (defined as robust per the DAI) pre-chemotherapy. The primary outcome was chemotherapy-induced decline in health status, a dichotomized (yes/no) variable defined as a decline in DAI from robust pre-chemotherapy to pre-frail or frail post-chemotherapy. Multivariable logistic regression was used to examine the association between baseline CARG-BC score and chemotherapy-induced decline in health status. Results: Of 392 women included in this analysis, 316 (80.6%) were clinically fit based on DAI assessment pre-chemotherapy. The median age was 70 (range 65-86), 61.7% had stage II or III disease, 31% had HR+/HER2+ disease, 22% had HR-/HER2- disease, 36% received an anthracycline, and 74% received prophylactic WBC growth factors. At baseline, 38.7% had low, 53.4% had intermediate, and 7.9% had high CARG-BC scores. Among the 316 clinically fit patients, 80 (25.3%) experienced a decline in health status at the end of chemotherapy. In univariate analysis, we observed that patients with high IL-6 (odds ratio [OR]=2.24, 95% CI: 1.32-3.79, p=0.003), high CRP (OR=1.84, 95%: CI 1.10-3.09, p=0.02), and intermediate (OR=3.29, 95% CI 1.72-6.29, p< 0.001) or high (OR=6.29, 95% CI 2.36-16.71, p< 0.001) CARG-BC scores were more likely to experience chemotherapy-induced decline in health status. After adjusting for IL-6 and CRP, patients with both intermediate (OR=3.25, 95% CI 1.68-6.27, p< 0.001) and high (OR=5.17, 95% CI 1.90-14.02, p=0.001) CARG-BC scores had significantly higher odds of experiencing chemotherapy-induced clinical decline as compared to patients with low CARG-BC scores. Conclusions: In this cohort of older women with early breast cancer who were clinically fit pre-chemotherapy, 25% experienced a decline in health status after neo/adjuvant chemotherapy. Women with an intermediate/high CARG-BC score prior to chemotherapy had 3-5-fold increased odds of experiencing chemotherapy-induced decline in health status independent of baseline clinical characteristics and biomarkers of inflammation. These findings may be useful to clinicians for predicting individual probability of chemotherapy-induced clinical decline and informing treatment decisions in older adults with early breast cancer. Table 1. Univariate and multivariable association of the CARG-BC score with chemotherapy-induced decline in health status. Multivariable analysis adjusted for baseline demographic, clinical, and inflammatory levels (IL-6 and CRP); *CARG-BC score is calculated using 8 independent predictors (each assigned weighted points): anthracycline use (1 point), stage II or III (3 points), planned treatment duration > 3 months (4 points), abnormal liver function (3 points), low hemoglobin (3 points), falls (4 points), limited walking (3 points), and lack of social support (3 points). The total CARG-BC risk score is the sum of each point derived from these 8 predictors. Each patient’s total CARG-BC score can then be classified into three risk groups: low (0-5 points), intermediate (6-11 points), or high (≥ 12 points). Citation Format: Jingran Ji, Canlan Sun, Hyman B. Muss, Harvey J. Cohen, Mina S. Sedrak. PD6-01 Association between the CARG-BC score and clinical decline after adjuvant chemotherapy in fit older adults with breast cancer: Results from the Hurria Older PatiEnts (HOPE) Prospective Study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr PD6-01.

Experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss: a qualitative systematic review protocol.

The objective of this review is to critically analyze and synthesize the experiences and perceptions of health care professionals making decisions that result in treatment recommendations for older adults living with memory loss who are experiencing health problems. Health care professionals provide care to older adults living with memory loss and other coexisting health conditions across all clinical settings. Older adults living with memory loss most commonly experience impaired independent decision-making, which can challenge health care professionals when decisions about treatment need to be made. These challenges contribute to older adults with memory loss receiving inappropriate treatment and experiencing higher morbidity than those without memory loss. To date, existing reviews have not focused on the experiences and perceptions of health care professionals who are making treatment decisions when older adults living with memory loss experience health problems. A deeper exploration of this evidence is needed to understand health care professionals' experiences and perceptions of treatment decision-making to support the goal of improving care for older adults. This systematic review will consider studies across all clinical settings focused on the experiences and perceptions of health care professionals making treatment decisions for older adults with memory loss who are experiencing health problems. We will conduct a comprehensive systematic search using CINAHL, MEDLINE, PsycINFO, Scopus, and ProQuest Dissertations and Theses. Two reviewers will independently appraise the selected studies and extract qualitative data using the recommended JBI method for study selection, critical appraisal, data extraction, and data synthesis. The ConQual approach will be applied to provide a level of confidence for the review findings. PROSPERO CRD42021271485.

Markers and associations of nutrition identified in a senior adult oncology clinic

Approximately half of all cancers occur in adults older than 65 and it is estimated that 70% of all cancers will occur among people aged 65 years or older by 2030. [1] Cancer treatment decisions for older adults are complicated by the patients' comorbidities, physical and functional impairments, and poorer social support systems. [2] Nutrition and frailty are known to negatively impact cancer outcomes. [3,4] These factors are influenced by social determinants of health such as the inequitable distribution of both healthcare resources and access to food.

Patient, Family Member and Physician Perspectives and Experiences with AML Treatment Decision-Making.

IntroductionTreatment decisions in older adults with acute myeloid leukemia (AML) are challenging, particularly for those who are not candidates for intensive chemotherapy (IC), and the trade-offs patients, their families and physicians consider when choosing a treatment option are not well understood. This qualitative research explored the value of extending survival and the treatment decision-making process from a multi-stakeholder perspective.MethodsOverall, 28 patients with AML (≥ 65 years old, unsuitable for IC), 25 of their relatives and 10 independent physicians from the US, UK and Canada took part in one-on-one, 60-minute qualitative interviews.ResultsAcross all stakeholders, improved health-related quality of life (HRQoL), extended survival and relief of AML symptoms were recognized as most important in AML treatment decision-making. However, extending survival in ‘good health’ was more important than extending survival alone, particularly because of the extra time it gives patients and their relatives together, and allows patients to achieve important goals. Patients’ limited understanding of available treatment options, paired with incorrect perceptions of treatment side effects, impacted their involvement in the treatment decision-making process. Patients and physicians perceived physicians to have the most influence in the decision-making process despite their priorities not always aligning.ConclusionThese findings illustrate the importance of having structured discussions which explicitly assess patients’ goals and their understanding and expectations of treatments and also the need for patient friendly resources about the lived experience of AML and available treatment options. These measures will help to ensure that patients are fully involved in the shared decision-making process.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40487-022-00200-9.

Validation of the Cancer and Aging Research Group (CARG) model to identify risks of chemotherapy toxicities in Asian older adults.

12043 Background: Older adults are at an increased risk of chemotherapy related toxicities. Identification of risk factors can facilitate oncologists in tailoring treatment, potentially mitigate the risk of chemotherapy toxicity and improve social economic outcomes. Tools like the Karnofsky Performance Status (KPS) and Geriatric Assessment (GA) are used in clinical practice to guide treatment decisions for older adults with cancer. The CARG model incorporating the GA and clinical variables was developed and validated to predict for grade 3-5 toxicities, although this has not yet been validated in Asians. Methods: Patients ≥70 years old with solid malignancies receiving chemotherapy at the National University Cancer Institute, Singapore were recruited between June 2017 and January 2018. The study aims to verify the application of the CARG model, KPS, GA and oncologists’ estimate of toxicity in a multi-ethnic Asian population. The risks of chemotherapy toxicity were calculated using the CARG model (low risk: 0-5, medium risk: 6-9, high risk: ≥10). A GA including a physician rated KPS score (low risk: 90-100, medium risk:80, high risk: ≤70) and a timed up and go (TUG) test (low risk: ≤12s, high risk: > 12s) were performed for all patients. The attending oncologist (blinded to the CARG score) was asked to give an estimated likelihood (low/medium/high) of chemotoxicity. Chemotherapy related toxicities were captured by chart review based on the National Cancer Institute Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. The area under the receiver operating characteristic (ROC) curve and a univariate analysis of predictors of toxicity were calculated. Results: A total of 200 patients were included. Median age was 74 (range: 70-89). The ethnic makeup of the population consisted of Chinese (N = 177; 88.5%), Malay (N = 17; 8.5%), Indians (N = 4; 2%) and other ethnicities. Majority of patients were males (N = 110; 55%), had metastatic disease at diagnosis (N = 114; 57%) and had gastrointestinal cancers (N = 80; 40%). 75% (N = 150) had polychemotherapy and 55% (N = 110) received full dose chemotherapy. More than half of patients (68.5%) experienced G3-5 toxicities, with 65.5% requiring hospitalization. The CARG model predicted 22.5% of patients as low, 50.5% as medium and 27% as high risk of chemotoxicity. The area under ROC for the CARG model was 0.74 (95% CI, 0.67-0.82). A one-point increase in the CARG score was associated with a 15% increase in the odds of G3-5 toxicities. 84.5% of patients needed > 12s for the TUG test. The TUG score, KPS and oncologist’s prediction of toxicity was predictive of an increased risk of G3-5 toxicities (p < 0.01). Conclusions: This study confirms the validity of the CARG predictive model in Asians and can streamline healthcare delivery in older adults. Development of a more robust predictive model incorporating the KPS and TUG into the CARG model could be considered.

Predicting the Risks of Aggressive-Intent Chemotherapy Toxicity in Older Patients With Lymphoma: A Prospective Observational Pilot Study

IntroductionLymphoma is a disease of older patients and while treatment is subtype specific, curative or aggressive intent combination chemotherapy is often recommended. However, there has been limited evidence on which to base treatment decisions for older adults. Our objectives were to assess the utility of risk stratification measures and serial functional tests in predicting chemotherapy toxicity and as well the feasibility of conducting these in older adults undergoing chemotherapy for lymphoproliferative disorders. Materials and MethodsThis prospective cohort study recruited lymphoma patients 70 years or older planned for systemic chemotherapy. The Cancer and Aging Research Group (CARG) risk stratification tool and Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) were calculated at baseline. The Clinical Frailty Scale (CFS), Charlson Comorbidity Index score, grip strength and gait speed test, and toxicity events, were assessed at baseline and serially throughout treatment. Sarcopenia was calculated on CT scans at baseline, midway through treatment, and 1-month after completion of therapy. The primary endpoint was to assess the feasibility of applying these measures in busy ambulatory clinics. These measures were also correlated with clinical outcomes including ≥grade 3 adverse events (AEs), hospitalizations and emergency department visits, dose changes or delays, and overall survival. ResultsIn total, 30 patients were enrolled (mean age 78.1 ± 6.4 years), of whom 20 were treated with curative intent. A total of 16 patients (53%) experienced grade ≥3 AEs, 9 (56%) of which led to a chemotherapy delay. On univariable analyses, CFS score, a high CARG score, medium to high CRASH score, and the gait speed were associated with grade ≥3 AEs, while only CFS remained significant on multivariable analysis. On univariable analysis, patients with a medium to high risk CRASH score were more likely than low risk patients to have an unplanned emergency department visit or hospitalization. ConclusionsThe CFS seems to predict toxicity in this cohort study, with gait speed, CARG and CRASH scores being potentially additional predictive methods of evaluation.

The Use and Knowledge of Validated Geriatric Assessment Instruments Among US Community Oncologists.

The use of a standardized geriatric assessment (GA) to inform treatment decisions in older adults with cancer improves quality of life, reduces treatment-related toxicity, and is guideline-recommended. This study aimed to assess community oncologists' knowledge and utilization of GAs. Between September 2019 and February 2020, practicing US-based oncologists were invited to attend live meetings and complete web-based surveys designed to collect information on treatment decision making and various practice-based challenges in oncology care. Among the 349 oncologists surveyed, 74% practiced in a community setting. Sixty percent did not use a formal GA to inform treatment decisions for any of their older patients; the most common reasons for not using a GA were "Too cumbersome to incorporate into routine practice" (44%) and "Adds no value beyond the comprehensive history and physical exam" (36%). Validated GA instruments used in routine clinical practice included: Mini-Mental State Exam (54%), Comprehensive Geriatric Assessment (23%), Cancer and Aging Research Group toxicity tool (12%), and Chemotherapy Risk Assessment Scale for High-Age Patients tool (9%). Nineteen percent of oncologists were not aware of any validated GA instruments. Eastern Cooperative Oncology Group performance status and comorbidities were the most frequently used assessment factors to inform treatment decisions (88% and 73%, respectively). Many oncologists have not incorporated GA tools because of perceptions that GAs are difficult to implement or do not add any value. Increasing education of the benefits of GA-directed therapy could help to increase GA utilization among community oncologists.

Anticholinergic Burden and Associated Healthcare Resource Utilization in Older Adults with Overactive Bladder.

BackgroundBladder anticholinergics are the most widely used drugs to treat overactive bladder (OAB) but can contribute to cumulative anticholinergic burden, which may be associated with adverse outcomes.ObjectiveThis study aimed to evaluate the association between cumulative anticholinergic burden and healthcare resource utilization (HRU) and costs in older adults with OAB.Materials and MethodsThis was a retrospective, observational study that used data from the UK Clinical Practice Research Datalink (CPRD) GOLD database. Participants were aged ≥ 65 years with ≥ 3 years of continuous enrolment before and ≥ 2 years after the index date (date of OAB diagnosis or first prescription for any OAB drug between 1 April 2007 and 31 December 2015). The primary endpoint was the association between cumulative anticholinergic burden (assessed using the Anticholinergic Cognitive Burden [ACB] scale during the 3-year pre-index period) and HRU (GP consultations, specialist referrals, urological tests, hospital admissions) over the 2-year post-index period.ResultsData from 23,561 adults were included in the analysis. Mean (SD) ACB scores in the pre- and post-index periods were 1.0 (1.1) and 2.4 (1.7), respectively; urological drugs contributed most (58.8%) to the latter. For the primary endpoint, higher pre-index ACB scores were associated with higher post-index HRU and costs. Mean (SD) ACB scores in the post-index period were 1.2 (1.3) and 2.5 (1.7) in those treated with mirabegron (beta-3 agonist) or bladder anticholinergics, respectively.LimitationsThe generalizability of the results outside the UK is unclear.ConclusionsIn older adults with OAB, higher anticholinergic burden before initiating OAB drugs is associated with higher HRU and costs. When making treatment decisions in older adults, consideration should be given to assessing the existing anticholinergic burden and using OAB treatments that do not add to this burden.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40266-021-00884-0.

The association between geriatric assessment, body composition measures, and treatment-related toxicity in elderly cancer patients: A prospective cohort study.

12047 Background: Treatment decisions in older adults with cancer are confounded by limited evidence due to their under-representation in clinical trials and as associations between geriatric assessment findings, body composition measures, treatment-related toxicity, and treatment effectiveness have yet to be fully elucidated. We investigated the relationship between geriatric assessment results, skeletal muscle measures, and treatment-related toxicity in older adults with cancer. Methods: This prospective single-center cohort study included patients with cancer > 65 years of age with advanced lung, breast, or genitourinary (GU) cancer who received systemic treatment (chemotherapy, biologic therapy, immunotherapy, or combination), and had available CT scans. Patients completed the Comprehensive Geriatric assessment (CGA) and 36-item Carolina Frailty Index (CFI) was calculated to classify them as robust ( < 0.2), pre-frail (0.2-0.35), or frail ( > 0.35). For each patient, skeletal muscle area (SMA) and density (SMD) were analyzed from CT scan L3 lumbar segments using Slice-O-Matic software. SMA and height (m2) were used to calculate skeletal muscle index (SMI). Skeletal muscle gauge (SMG) was created by multiplying SMI x SMD. Sarcopenia was defined as having SMI < 41 cm2/m2 for males and < 38 cm2/m2 for females. The associations between study variables and the occurrence of at least one adverse event (AE) grade ≥2 were analyzed using the Pearson's chi-squared test. The study was approved by the IRB of Rambam Health Care Campus. All patients signed an informed consent. Results: Overall, 51 patients (recruited between 5/2015 and 1/2020) were included in the final analysis. Median (interquartile [IQR]) age was 72 (68-76) years; 59% were male; 51%, 28%, and 22% had lung, breast, and GU cancer respectively. The most common treatment received was doublet chemotherapy (49%). All patients except 3 (6%) completed the CGA and CFI was calculated; 29%, 26%, and 39% were classified as robust, pre-frail, and frail, respectively. Median (IQR) SMG was 1251 (1104-1497) AU; median (IQR) SMI was 42 (39-48) cm2/m2; 31% were defined as sarcopenic. Overall, 45% of patients experienced at least one AE grade ≥2; 24% experienced at least one AE grade≥3. No statistically significant association was found between treatment-related toxicity and sex, age, tumor type, treatment, or CFI category. Yet, having low SMG (categorically, by tertile) was significantly associated with having at least one AE grade≥2 (p = 0.03) as was being sarcopenic (p = 0.02). Conclusions: Low SMG and sarcopenia are associated with treatment-related toxicity in older patients with cancer. Further research and better understanding of this association could help optimize treatment decisions (e.g., choice of regimen, dosing) and interventions in this population.

Impact of a comprehensive geriatric assessment on decision-making in older patients with hematological malignancies.

Hematological treatment decisions in older adults with hematological malignancies are complex. Our objective is to study the impact of a comprehensive geriatric assessment on hematological treatment decision in older patients and the factors associated with change in treatment plan. We conducted a cross-sectional analysis of patients aged 65years and above with hematological malignancies, hospitalized between 2008 and 2019 at the University Cancer Institute of Toulouse. They were assessed by a geriatrician/nurse team using a comprehensive geriatric assessment (CGA). A penalized logistic regression model with elastic net regularization was used to identify factors associated with change in hematological treatment plan. A total of 424 patients were included. Main hematological malignancies were lymphoma (36.1 %), acute myeloid leukemia (26.9 %) and myelodysplastic syndrome (19.8%). Change in hematological treatment plan was suggested after CGA for 92 patients (21.7%). Factors associated with change in treatment plan were functional impairment according to ADL and IADL scale, mobility impairment, the presence of comorbidity defined by the Charlson score >1 and increasing age. A CGA has a significant impact on hematological treatment decision in older patients. Functional and mobility impairment, comorbidities and age are predictive factors of change in treatment plan.

Disentangling and Quantifying Mechanisms of Increased Fall Risk Among Older Adults With Depression

Background: Older adults with depression are up to four times more likely to fall, yet the mechanisms by which depression increases fall risk are unclear. This study sought to quantify and compare the relative strength of selected mechanisms mediating the association between depression and falls. Methods: We used longitudinal linked data (2006 – 2010) from the Health and Retirement Study and Prescription Drug Study. The analytic sample included non-institutionalized adults age > 65 with data on physical functioning and medication use (n=3,565). Falls and injurious falls over the past two years were self-reported outcomes. Depression was measured using the Composite International Diagnostic Interview (CIDI). We used causal mediation analysis to estimate the total and direct associations between depression and falls and compared strength of three potential mediating mechanisms – frailty, cognition, and antidepressant (AD) use. Results: Of 190 participants reporting depression in 2006, 85 (44.7%) fell and 30 (15.8%) were injured from a fall between 2008 and 2010. Depressed individuals were 92% more likely to fall compared to non-depressed (OR=1.92, p<.01). We found significant indirect effects of AD use (indirect OR=1.17, p<.01) and frailty (OR=1.12, p=.013) representing 19% and 13% of the total effect of depression on falls, respectively. Cognition was not a significant mediator. Results were similar for falls leading to injury. Discussion: Results suggest that AD use and frailty explain a significant portion of the elevated risk for falls among depressed individuals. Identification of these and other mechanisms may inform clinical treatment decisions for older adults with depression.

Differences in Cause-Specific Mortality Between Frail Men and Women in the United States

While frailty is associated with risk of numerous adverse health outcomes including mortality, little is known about the most common specific causes of death among frail older adults or how these causes might differ by gender. This information may be important to understanding the frailty syndrome and to informing screening and treatment. We used linked data from the Health and Retirement Study (2004 – 2012) and the National Death Index (NDI). We analyzed data from HRS participants age 65 and older who completed a general health interview and physiological measures (n=10,490). Frailty was operationalized using the phenotype criteria – low weight, low energy expenditure, exhaustion, slow gait, and weakness. Causes of death were determined using International Classification of Diseases (v10) codes from death certificates. We used Cox proportional hazards to compare incidence of cause-specific mortality by frailty status and gender. The attributable risk of mortality due to frailty in the sample was 16.6% among women and 17.3% among men. Overall, frail older adults had greater risk of death from heart disease (hazard ratio (HR): 2.97; 95% CI: 2.18, 4.04), cancer (HR: 2.81; 95% CI: 2.01, 3.93), and dementia 2.86 (95% CI: 1.46, 5.58) but not cerebrovascular disease or accidents. Frail women were more approximately 29% more likely to die from heart disease than frail men. Findings suggest that frailty is a significant risk factor for mortality from several different causes, especially among women. Findings may help inform screening and treatment decisions for older adults at risk for frailty.

Palliative Radiation Therapy in Older Adults With Cancer: Age-Related Considerations

There are many additional considerations when treating older adults with cancer, especially in the context of palliative care. Currently, radiation therapy is underutilised in some countries and disease sites, but there is also evidence of unnecessary treatment in other contexts. Making rational treatment decisions for older adults necessitates an underlying appraisal of the person's physiological reserve capacity. This is termed ‘frailty’, and there is considerable heterogeneity in its clinical presentation, from patients who are relatively robust and suitable for standard treatment, to those who are frail and perhaps require a different approach. Frailty assessment also presents an important opportunity for intervention, when followed by Comprehensive Geriatric Assessment (CGA) in those who require it. Generally, a two-step approach, with a short initial screening, followed by CGA, is advocated in geriatric oncology guidelines. This has the potential to optimise care of the older person, and may also reverse or slow the development of frailty. It therefore has an important impact on the patient's quality of life, which is especially valued in the context of palliative care. Frailty assessment also allows a more informed discussion of treatment outcomes and a shared decision-making approach. With regards to the radiotherapy regimen itself, there are many adaptations that can better facilitate the older person, from positioning and immobilisation, to treatment prescriptions. Treatment courses should be as short as possible and take into account the older person's unique circumstances. The additional burden of travel to treatment for the patient, caregiver or family/support network should also be considered. Reducing treatments to single fractions may be appropriate, or alternatively, hypofractionated regimens. In order to enhance care and meet the demands of a rapidly ageing population, future radiation oncology professionals require education on the basic principles of geriatric medicine, as many aspects remain poorly understood.

3 QUESTIONS ON... How to Make Treatment Decisions for Older Adults When Data Is Lacking

3 QUESTIONS ON... How to Make Treatment Decisions for Older Adults When Data Is Lacking

Low-Dose Lenalidomide Maintenance after Induction Therapy in Older Patients with Primary CNS Lymphoma

Introduction The challenges posed by the increasing incidence of hematologic malignancies in older patients are significant and while during the past 20 years there has been a dramatic expansion in the therapeutic armamentarium against hematologic malignancies, there is a need for data to guide treatment decisions for older adults, particularly with respect to the use of novel targeted or immunotherapeutic agents. To a large extent, this is a consequence of the under-representation of this growing demographic in cancer-related clinical trials.Management of primary CNS lymphoma (PCNSL) in patients age ≥ 70 years represents a significant problem. While it is established that older PCNSL patients benefit from high-dose methotrexate-based induction regimens, whole brain irradiation consolidation is not a favored option because of excessive neurotoxicity. While there is evidence that high‐dose chemotherapy improves outcomes in patients age < 70, dose‐intensive chemotherapy is not an option for most older PCNSL patients. Given that the median age of PCNSL at diagnosis is ~ 60 years, determination of the optimal consolidative approach for older patients is an important question. This problem is particularly significant given that the incidence of PCNSL continues to rise in this older age group.While PCNSL increasingly appears to be a curable brain tumor, outcomes for patients age > 60 remain poor, with 1-year progression-free survival (PFS) of ~ 40% and median overall survival of 14-30 months. Population-based registry data suggests a median overall survival for PCNSL patients age > 70 of approximately 7 months over the past decade. New therapeutic approaches are needed for the particularly vulnerable older PCNSL patient population.Given the evidence for activity of low-dose lenalidomide in relapsed primary and secondary CNS lymphoma, in 2011, we began using low-dose lenalidomide as maintenance in consecutive older PCNSL patients (age ≥ 70 years, HIV negative) following standard methotrexate/rituximab-based induction, in lieu of surveillance, whole brain irradiation or high-dose chemotherapeutic consolidation. Here we report on the characteristics, outcomes, toxicities, progression-free and overall survival of the first 11 PCNSL patients, age ≥ 70, to receive lenalidomide maintenance after high-dose methotrexate-based induction at our institution.Results Eleven patients age > 70 received low-dose lenalidomide maintenance 5-10 mg/d on a 21-d cycle after induction therapy for PCNSL.Median age of the cohort is 77 years (range 70-86). Median Karnofsky performance status (KPS) is 60 (range 50-80); median IELSG prognostic risk score is 4 (range 3-5). The median methotrexate dose administered was 2.5 grams/m2 (range 0.5 - 8). With overall median follow-up of 30 months, median time on lenalidomide maintenance is 14.8 months (range 0.9 - 65.2). Two patients received lenalidomide plus maintenance rituximab, every 6 months. Median PFS is 48 months (range 16.8 - 84.8). Median OS has not been reached, and there have been no deaths (Figure 1). Four patients experienced disease progression on lenalidomide; 3 of them continued maintenance lenalidomide after salvage and 1 received maintenance pomalidomide. Lenalidomide maintenance has generally been well-tolerated. However, 5 toxicities potentially related to therapy have mandated cessation of lenalidomide: 1 grade 2 arthralgia, 1 subdural hematoma, 1 pneumonia, 1 grade 3 fatigue, 1 deep vein thrombosis.Conclusions These encouraging preliminary results of prolonged PFS and OS with low-dose lenalidomide illustrate the feasibility and challenges, as well as suggest a potential benefit of maintenance therapy with low-dose lenalidomide in older patients with PCNSL. Nine of 11 patients were able to complete at least 8 months of lenalidomide maintenance after induction therapy. Toxicities were manageable and strikingly, there have been no deaths. Recently, lenalidomide has been shown to enhance the proliferation, survival, and chemotactic responses in T-cells isolated from older subjects. This suggests a potential mechanistic basis by which low-dose lenalidomide may improve immunity in the elderly and potentiate response to chemotherapy. Future studies are needed to prospectively test the benefit and mechanisms of lenalidomide maintenance in older patients with PCNSL. [Display omitted] DisclosuresRubenstein:Genentech: Research Funding; Celgene: Research Funding. Mannis:AbbVie: Membership on an entity's Board of Directors or advisory committees; Agios: Research Funding; NKarta: Membership on an entity's Board of Directors or advisory committees.

Chemotherapy Toxicity Risk Score for Treatment Decisions in Older Adults with Advanced Solid Tumors.

The decision whether to treat older adults with advanced cancer with standard therapy (ST) or reduced therapy (RT) is complicated by heterogeneity in aging. We assessed the potential utility of the chemotherapy toxicity risk score (CTRS) [J Clin Oncol 2011;29:3457-3465] for treatment decisions in older adults. This was a prospective observational study of patients aged ≥65 years receiving first-line chemotherapy for advanced cancer for which combination chemotherapy is the standard of care. Patients were categorized as high risk (CTRS ≥10), for whom RT (dose-reduced combination or single-agent chemotherapy) is deemed appropriate, or nonhigh risk (CTRS <10), for whom ST is deemed appropriate for toxicity. The primary objective was to estimate the agreement in chemotherapy choice (ST vs. RT) between the treating physician and the CTRS using a κ statistic. Fifty-eight patients (median age, 71 years) were enrolled. Thirty-eight patients received ST (21 had CTRS <10, and 17 had CTRS ≥10), and 20 patients received RT (12 had CTRS ≥10, and 8 had CTRS <10), with minimal agreement in chemotherapy choice (κ = 0.14; 95% CI, -0.10 to 0.38). Grade 3-4 toxicity and hospitalization occurred in 60% and 27% of 55 patients with follow-up data, respectively. Among patients receiving ST, patients with CTRS ≥10 had a higher incidence of toxicity (88% vs. 40%, p = .006) and hospitalization (50% vs. 15%, p = .03) than those with CTRS <10. Older patients with cancer with a high CTRS who receive combination chemotherapy have an exceedingly high rate of severe toxicity and hospitalization. The potential utility of the chemotherapy toxicity risk score (CTRS) in old adults with advanced solid tumors receiving first-line chemotherapy was assessed. Little agreement was found between chemotherapy treatment decisions based on the clinical impression versus what was recommended based on the CTRS. Among patients treated with standard-dose combination chemotherapy, patients with CTRS ≥10 had a very high incidence of grade 3-4 toxicities and hospitalization, which was significantly greater than that of patients with a low CTRS (<10). These findings suggest that the addition of CTRS to the clinical impression has a potential to improve treatment decisions.

Benefit‐Based Approach to Blood Pressure Control in Older Adults

Benefit‐Based Approach to Blood Pressure Control in Older Adults

Geriatric oncology: an overview.

Geriatric oncology: an overview.