Undertreatment Of Older Patients Research Articles

Bioethics of over- and undertreatment in older adults with cancer.

9046 Background: Over-/undertreatment are pervasive in older adults with cancer, despite oncologists prescribing with best intentions. What “ought” to be prescribed with limited evidence creates challenges in adhering to the principles of bioethics: beneficence, nonmaleficence, justice, and respect for autonomy. Our objective for this study was to elucidate whether and how tensions among these ethical principles can contribute to over-/undertreatment in older patients. Methods: We designed a modified Delphi study, convening a panel of 13 experts in biomedical ethics (5 male, 8 female; 4 MD, 4 PhD, 2 MD/MA, 1 MD/PhD, 1 JD/MDiv, 1 DNP) from U.S. and Canadian institutions for three iterative rounds of data collection. In the first round—an electronic questionnaire—we presented definitions of overtreatment and undertreatment in older adults with cancer (DuMontier, J Clin Oncol, 2020) and asked questions delineating which ethical principles related to each definition, followed by questions regarding how over-/undertreatment might occur from conflicts among different ethical principles. Consensus for each question was defined as ≥75% of experts answering “agree” or “strongly agree”. The second round consisted of a virtual synchronous focus group of 9 of the panel experts led by a qualitative researcher to review round one results and discuss questions that did not reach consensus, followed by a second questionnaire including these questions. Results: After the first round, experts reached consensus that bioethical principles applied to over-/undertreatment in older adults with cancer. Specifically, 92% felt that overtreatment can occur when oncologists overemphasize beneficence that values the potential benefit of cancer treatments, while underemphasizing non-maleficence with respect to treatment adverse effects. Moreover, 77% felt that overtreatment can also occur when oncologists prioritize patient autonomy (preference to be treated) over non-maleficence (oncologists' concerns that treatment harms outweigh benefits). 84% felt that undertreatment can occur due to a lack of justice in equitable consideration of cancer treatments that could provide similar benefits in older adults as they would in younger adults. Moreover, 77% felt that undertreatment can occur when oncologists underemphasize patient autonomy, failing to consider patient preferences regarding which benefits to pursue and risks to take. Data collection for the second questionnaire and qualitative analysis of the focus group are underway. Conclusions: Our findings suggest that tension in ethical principles can lead to over- and undertreatment in older adults with cancer. The “right” treatment in older patients in the context of limited evidence is not simply one that aims to aggressively target their cancer, but that balances both benefits and harms in light of the whole patient and their preferences, while not restricting therapies based on age alone.

Patterns of Treatment and Outcomes in Older Men With Penile Cancer: A SEER Dataset Analysis.

PurposeTo evaluate clinicopathologic and treatment characteristics from a population-based cohort of penile cancer, with an emphasis in older adults, due to incomplete evidence to guide therapy in this age subgroup.Materials and MethodsPatients with malignant penile tumors diagnosed 2004-2016 were identified in the Surveillance, Epidemiology and End Results Program (SEER)-18 dataset. Demographic and treatment characteristics were obtained. Population was analyzed by age at diagnosis (<65 vs ≥65 years). We examined univariate associations between age groups with Chi-square analysis. To study survival, we calculated Kaplan-Meier survival curves, but due to the high number of competing events, we also performed a univariate competing risk analysis using the cumulative incidence function, and a multivariate analysis using the Fine-Gray method. We also described competing mortality due to penile cancer and other causes of death.ResultsWe included 3,784 patients. Median age was 68 years, 58.7% were aged ≥65. Older patients were less likely to have received chemotherapy (p<0.001), primary site surgery (p = 0.002), or therapeutic regional surgery (p <0.001). Median overall survival (OS) in patients <65 years was not reached (95% CI incalculable) vs 49 months in those ≥65 years (95% CI 45-53, p <0.0001). On univariate analysis, age was associated with a lower incidence of penile cancer death. On multivariate analysis, stage at diagnosis, and receipt of primary site surgery were associated with a higher incidence of penile cancer death. Estimated penile cancer-specific mortality was higher in patients <65 years in stages II-IV. Estimated mortality due to other causes was higher in older patients across all stages.ConclusionsOlder patients are less likely to receive surgery, chemotherapy and radiotherapy for penile cancer. Primary surgical resection was associated with better penile cancer-specific mortality on multivariate analysis. Competing mortality risks are highly relevant when considering OS in older adults with penile cancer. Factors associated with undertreatment of older patients with penile cancer need to be studied, in order to develop treatment strategies tailored for this population.

Effectiveness of STOPP/START criteria in primary prevention of polypharmacy and under-treatment in older patients

STOPP/START criteria appear to be a useful tool to curb inappropriate prescribing (IP), which encompasses errors of both, over and under-treatment. This study aimed to find out whether application of STOPP/START reduces the IP effectively in primary care. This prospective cross-sectional study was conducted in two family health centers (FHCs) in Istanbul. All older adults who applied to FHCs between 01-07-2018 and 01-07-2020 were enrolled. The potential inappropriate medications (PIMs) and potential prescription omissions (PPOs) were identified according to STOPP/START version 2 criteria. Mean drug consumptions before and after STOPP/START were compared using Student's t-test. Among 1023 participants there were 626 females and 397 males. The mean age was 73.33±7.30 years. The number of the patients seen at FHCs was 657 (64.2%) while 366 (35.8%) of them were visited at home. Of the patients, 383 (37.8) were 75 years old or older and 631 (62.2%) of them were under 75. Overall number of drugs consumed per patient was 5.49±3.93 while it was 6.01±3.71 and 4.55±4.138 for outpatients and home patients respectively (p<0.001). By application of STOPP criteria, among the 5616 medications consumed by the overall patients, 881(%15.6) of them were found to be potentially inappropriate. 424 (41.4%) patients were using at least one PIM. This ratio was 354 (53.8%) in outpatients and 70 (19%) in home patients. START criteria identified 380 (%7.4) PPOs. There were 246 (24.0%) patients at least with one PPO; 155 (42.3%) of whom were home patients and 91 (13.8%) were outpatients. Regarding the age groups; PIM ratio was 35.5% in patients under 75 and 52.1% over 75 whereas PPO ratio was 22.5% under 75 and 26.8% over 75. This study supports the data reporting the effectiveness of STOPP/START criteria in primary care units in implementing appropriate prescription criteria.

Tolerability of lithium: A naturalistic discontinuation study in older inpatients (≥60 years).

Lithium is one of the most effective treatment options in both bipolar disorder and treatment-resistant depression. The use of lithium in older patients declined during the last decades, probably resulting in undertreatment of older patients. To investigate how well lithium is tolerated in old age, we aimed to determine the frequency, reasons, and possible predictors of discontinuation due to adverse effects in a cohort of inpatients ≥60 years who had started with lithium. We performed a retrospective cohort study based on chart reviews. Participants were in treatment at Parnassia Group at The Hague, The Netherlands. After inclusion (between January 2010 and December 2016), participants were followed until April 2017, when we performed data extraction and analysis. In our sample of 135 patients (median age 69 years, median follow-up duration 18 months), 49 (36.3%) participants discontinued lithium. Only a minority (11 [8.1%]) of the participants discontinued solely due to adverse effects. The majority discontinued lithium due to psychiatric (18, 5%) reasons (most commonly mentioned within this subgroup: lack of effectiveness and noncompliance) or a combination of reasons (7.4%). None of the factors we studied (age, gender, Charlson Comorbidity Index, polypharmacy, renal function, and neurological history) were significantly associated with discontinuation due to adverse effects. The frequency of lithium discontinuation in our cohort was in range with frequencies reported in younger patients. Older age itself should not be a reason to withhold lithium treatment.

Under-Treatment of Older Patients with Newly Diagnosed Epithelial Ovarian Cancer Remains an Issue.

Simple SummaryCancer treatment and survival in older women is topical and important in an era where the proportion of older adults being treated for cancer in the clinic is rising. As survival outcomes in older women continue to lag behind those of younger and middle-aged women, further investigation is required into current treatment practices to identify target areas to address this deficit. We present treatment patterns, tolerance and outcomes of 280 women aged 65 and above treated for newly diagnosed ovarian cancer at two UK cancer centres between 2009 and 2015. We demonstrate that older women continue to receive lower rates of standard care first line therapy. When adjusted for stage at diagnosis, surgical outcome and chemotherapy given, age was not an independent risk factor for poorer overall survival.Older women with ovarian cancer have disproportionately poorer survival outcomes than their younger counterparts and receive less treatment. In order to understand where the gaps lie in the treatment of older patients, studies incorporating more detailed assessment of baseline characteristics and treatment delivery beyond the scope of most cancer registries are required. We aimed to assess the proportion of women over the age of 65 who are offered and receive standard of care for first-line ovarian cancer at two UK NHS Cancer Centres over a 5-year period (December 2009 to August 2015). Standard of care treatment was defined as a combination of cytoreductive surgery and if indicated platinum-based chemotherapy (combination or single-agent). Sixty-five percent of patients aged 65 and above received standard of care treatment. Increasing age was associated with lower rates of receiving standard of care (35% > 80 years old versus 78% of 65–69-year-olds, p = 0.000). Older women were less likely to complete the planned chemotherapy course (p = 0.034). The oldest women continue to receive lower rates of standard care compared to younger women. Once adjusted for Federation of Gynaecology and Obstetrics (FIGO) stage, Eastern Cooperative Oncology Group (ECOG) performance status and first-line treatment received, age was no longer an independent risk factor for poorer overall survival. Optimisation of vulnerable patients utilising a comprehensive geriatric assessment and directed interventions to facilitate the delivery of standard of care treatment could help narrow the survival discrepancy between the oldest patients and their younger counterparts.

Undertreatment and overtreatment in older patients treated with chemotherapy

BackgroundInconsistent doses and schemes are commonly used in older patients receiving cancer chemotherapy. We performed this study in patients with cancer and age ≥ 70 years to determine the frequency of undertreatment and overtreatment as well as factors influencing the decision to modify chemotherapy doses. Patients and MethodsPatients aged ≥70 years starting new chemotherapy regimens were prospectively included in a multicentre study. The schedule and drug doses were determined by the treating oncologist. Pre-chemotherapy assessment included sociodemographics, treatment details and geriatric assessment (GA) variables. Association between these factors and undertreatment (use of less intensive cancer treatment [LICT] in a fit patient) or overtreatment (use of standard cancer treatment in an unfit older patient) were examined by multivariate logistic regression. ResultsThree- hundred ninety-seven patients were included, 43% of whom received LICT. If not adjusted for GA, toxicity did not differ between those receiving LICT (38%) or standard doses of chemotherapy (37%). If the dose of chemotherapy was analyzed according to the results of GA 61 (15%) patients had been undertreated and 133 (34%) had been overtreated. Undertreatment was related with increasing age and decreased renal function. Factors related with overtreatment were younger age, curative intention of treatment, prescription of G-CSF as primary prophylaxis and adequate cognitive status. Overtreated patients had more grade 3–4 toxicity than those receiving treatment adapted to fragility (42% vs 31%; p < 0.05). ConclusionsThe use of chemotherapy without considering GA leads to overtreatment more commonly than undertreatment in older patients with cancer. Oncologists should take into account the results of GA to stratify patients and to avoid under or overtreatment.

Undertreatment of Older Patients with Newly-Diagnosed Multiple Myeloma: Real World Evidence from a Canadian Registry Cohort

Introduction Multiple myeloma (MM) is a malignant plasma cell disease and is considered a disease of older patients as the median age at diagnosis is 70 years. In recent years, the overall survival of patients with MM has improved due to the increasing number of treatment options and better supportive care. However, older patients (age &amp;gt;65) have not benefitted equally from the same gains. There is a paucity of information regarding clinical outcomes in this age cohort given that older patients are often under-represented in clinical trials and prospective studies. Real-world data may allows us to examine the trends in practice patterns over time and help us understand disparities in treatment options and overall patient outcomes in older patients with MM at a population level. Methods We conducted a retrospective population-based study using administrative data from the Institute of Clinical Evaluative Sciences (ICES), which maintains a central database of health records for all patients in the publicly funded health care system for the province of Ontario, Canada. All patients with newly-diagnosed multiple myeloma, identified using the ICD-O-3 code 9732/3 (Multiple Myeloma) between the years 2007-2017, were included to form the cohort. Autologous transplant within one year of diagnosis was captured in the database using a combination of physician billing codes and hospital procedure/discharge codes. Novel drugs usage for transplant ineligible patients was defined as the receipt of thalidomide, lenalidomide and bortezomib in any combination within one year of diagnosis. No treatment was defined as patients that did not receive a transplant, novel drugs or non-novel drugs (melphalan and cyclophosphamide) within one year following diagnosis. Results A total of 11,875 patients with newly-diagnosed myeloma were identified between the years 2007-2017. The proportion of newly-diagnosed MM patients who were older (age &amp;gt;65 years) increased from 60% of those diagnosed in 2007 to 68% of those diagnosed in 2017. The rates of autologous transplantation in older patients with MM increased from 4 to 10%. Overall those who underwent transplant had improved outcomes with decreasing one-year mortality from nearly 24% in 2007 down to 3% in 2017. Novel drugs were increasingly being used in older patients that were transplant ineligible with up to 42% receiving it within one year of diagnosis in 2017. In transplant ineligible older adults using novel drugs, one- year mortality ranged from 15% to 24%. The rates of older adults with newly-diagnosed MM not treated within one year of diagnosis was on average 49% although that number marginally declined from 54% in 2007 to 47% in 2017. Among those that did not receive treatment, 48% of individuals on average (range 40-57%) were not alive at one-year following diagnosis. Conclusion Our results demonstrate that although gains are being made in older adults with newly-diagnosed MM with increasing rates of transplantation and novel-drug usage over the last decade, there remains a sizeable cohort of older patients that do not receive any treatment within one year of diagnosis. While a limitation of our study may be the inclusion of some smouldering cases of myeloma, the mortality for older patients not treated continues to remain high with approximately half the patients not alive at one year following diagnosis. This study represents one of the largest cohort studies done to date over a decade demonstrating the ongoing low rates of no treatment and high rates of one-year mortality for older patients with MM. Further identification of factors associated with no treatment, transplantation and novel drug usage in older patients with MM are currently being explored. Table. Disclosures Mian: Amgen: Consultancy; Janssen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria. Pond:Roche Canada: Employment, Other: Stock; Takeda (DSMC membership): Other: Honorarium.

Management of Early Head and Neck Cancer in Elderly Patients.

Head and neck squamous cell carcinoma (HNSCC) frequently affects elderly patients. Given the frailty and comorbid conditions of this population as well as the potential toxicities associated with treatment, there is a risk of undertreatment in older patients. However, there is growing evidence that benefit with standard treatment is similar in the elderly and in younger patients. Few prospective trials specifically target the elderly, which forces clinicians to rely on subgroup analyses and retrospective data. Therefore, adequate pretreatment assessments are vital to anticipate factors that may contribute to morbidity during therapy. In addition, supportive care during treatment is essential. For patients of all ages who present with early or localized disease, curative treatment should be offered whenever possible. With more precise surgical and radiologic techniques, the ability to provide curative treatment while minimizing long-term toxicity has greatly improved. Not only our techniques but also our understanding of the disease have improved. Human papillomavirus (HPV)-related HNSCC has changed the treatment paradigm of advanced-stage disease because of the inherently better prognosis compared with tobacco- and alcohol-related HNSCC. How this will affect early-stage disease remains to be seen, but de-escalated therapy may prove a suitable strategy in eligible elderly patients. With improved therapies and understanding of the disease, additional prospective trials must be carried out in the elderly population.

Undertreatment of Older Patients With Newly Diagnosed Multiple Myeloma in the Era of Novel Therapies

BackgroundWith the expanding armamentarium of therapeutic agents for multiple myeloma (MM), it is important to identify any undertreated patient populations to mitigate outcome disparities. Materials and MethodsWe extracted the data for all plasma cell myeloma cases (International Classification of Disease for Oncology, third revision [ICD-O-3] code 9732) in the Surveillance, Epidemiology, End Results (SEER)–Medicare database from 2007 to 2011. The ICD-O-3 histologic code 9732 captures both active MM and smoldering/asymptomatic myeloma. We defined active MM as either claims indicating receipt of treatments approved for MM or ICD-9 codes for MM-defining clinical features, referred to as the CRAB criteria (calcium [elevated], renal failure, anemia, bone lesions). Multivariate logistic regression was performed to determine the variables that were independently associated with receipt of no treatment. ResultsOf the initial 4187 patients included in the present study, 373 had no claims indicating receipt of treatments approved for MM and had no ICD-9 codes associated with the CRAB criteria and were excluded from the analyses. Of the 3814 patients with active MM, 1445 (38%) did not have any claims confirming that they had received systemic treatment. Older age, poor performance indicators, comorbidities, African-American race, and lower socioeconomic status, including enrollment in Medicaid, were statistically significant factors associated with the receipt of no systemic treatment. ConclusionsIn the present retrospective study of data from the SEER–Medicare database, we found that age, health status, race, and socioeconomic status were associated with receipt of MM treatment. These factors have previously been linked to reduced usage of specific treatments for MM, such as stem cell transplantation. To the best of our knowledge, however, ours is the first study to show their association with the receipt of any MM therapy.

When My Mother Wanted to Die

When My Mother Wanted to Die

Predictors of care for patients with cancer of unknown primary site in three Australian hospitals.

Cancer of unknown primary site (CUP) is a medically challenging malignancy with a poor prognosis. We describe an incident tertiary CUP patient cohort and identify factors predictive of specific types of health care. We reviewed the medical records of 217 patients diagnosed with CUP (2006-2011) in three public hospitals in New South Wales, Australia. We systematically abstracted data and performed multivariable logistic regression to identify factors predictive of tumor biopsy, surgery, chemotherapy, radiotherapy and palliative care. The median age at CUP diagnosis was 75 years (range 23-98) and 52% were male. The most common mode of presentation was emergency department admission (57%). Serum tumor markers were performed in 42%, fine needle aspiration alone in 15% and core biopsy in 52%. Younger age, health service referral, oncologist review and a family history of cancer predicted receipt of a biopsy (77%). Cancer-related surgery (17%) was more likely in younger patients, those presenting with pain, and those with single lymph node metastases. Younger age and good performance score predicted receipt of chemotherapy (22%). The location of metastases predicted receipt of radiotherapy (28%). Older age, emergency presentation, poor performance score and no oncology review predicted receipt of palliative care only (52%); 77% were referred for palliative care during hospitalization. The determinants of care were generally consistent with international CUP clinical guidelines. Areas of future research include potential underinvestigation and undertreatment of older patients, overuse of certain low-value diagnostic tests, suboptimal use of immunohistochemistry and mammography and underreferral to palliative care.

Therapeutic options in older patients with metastatic non-small cell lung cancer.

The increase in life expectancy, with its concomitant increase in the risk of cancer, has led to an increased incidence of lung cancer in older people. The median age at diagnosis of lung cancer is between 63 and 70 years. For a long time, there has been a pessimistic attitude by doctors, patients and their relatives and thus an undertreatment of older patients. Older patients have some specific differences compared with younger patients: more comorbidities with concomitant medications that may interfere with chemotherapy, geriatric syndromes, frailty and so on. The first trial devoted to older patients with advanced non-small cell lung cancer (NSCLC) was a comparison between vinorelbine and best supportive care. There was a significant benefit of survival in the chemotherapy arm. Doublet therapy with gemcitabine plus vinorelbine did not give better results than either of these drugs alone. Thus, the recommendations for the treatment of older patients with advanced NSCLC were to give monotherapy. In some clinical trials not dedicated to older patients it appeared that patients might benefit from platinum-based doublet therapy like their younger counterparts. A randomized trial conducted by the French intergroup, IFCT, in patients aged at least 70 years comparing vinorelbine or gemcitabine alone with monthly carboplatin combined with weekly paclitaxel demonstrated that there was a highly significant benefit of survival in the doublet arm. This study resulted in a modification of the recommendations on the treatment of older patients with advanced NSCLC.

Acute myeloid leukemia: treatment over 60.

Undertreatment of older patients with acute myeloid leukemia (AML) can explain, in part, their inferior outcome when compared to that of younger patients. In agreement with the benefit seen by patients under age 60 from high-dose cytosine arabinoside (Ara-C), there are dose effects in the over 60s, in particular for daunorubicin, in induction treatment and for the duration of postremission treatment. The use of these effects can partly overcome the mostly unfavorable disease biology in older age AML, as expressed by the absence of favorable and the over-representation of adverse chromosomal abnormalities as well as the expression of drug resistance. We recommend an adequate dosage of 60 mg/m2 daunorubicin on 3 days in combination with standard dose Ara-C and 6-thioguanine given for induction and consolidation, and followed by a prolonged monthly maintenance chemotherapy for at least 1 year's duration. Further improvements in supportive care may help to deliver additional antileukemic cytotoxicity. As a novel approach, nonmyeloablative preparative regimens may open up the possibility of allogeneic transplantation for older patients with AML. Other new options like multidrug resistance modulators, antibody targeted therapies and molecular targeting are under clinical investigation. A questionnaire study in patients with AML showed that, according to patients' self-assessment, intensive and prolonged treatment did not result in a diminished quality of life. This finding did not vary by age, under or over 60 years. As the median age in this disease is more than 60 years, the adequate management of AML in older patients remains the major challenge.

Undertreatment of older patients with congestive heart failure

Undertreatment of older patients with congestive heart failure