Gilles Albrand

Screening for Vulnerability in Older Cancer Patients: The ONCODAGE Prospective Multicenter Cohort Study

Background Geriatric Assessment is an appropriate method for identifying older cancer patients at risk of life-threatening events during therapy. Yet, it is underused in practice, mainly because it is time- and resource-consuming. This study aims to identify the best screening tool to identify older cancer patients requiring geriatric assessment by comparing the performance of two short assessment tools the G8 and the Vulnerable Elders Survey (VES-13). Patients and Methods The diagnostic accuracy of the G8 and the (VES-13) were evaluated in a prospective cohort study of 1674 cancer patients accrued before treatment in 23 health care facilities. 1435 were eligible and evaluable. Outcome measures were multidimensional geriatric assessment (MGA), sensitivity (primary), specificity, negative and positive predictive values and likelihood ratios of the G8 and VES-13, and predictive factors of 1-year survival rate. Results Patient median age was 78.2 years (70-98) with a majority of females (69.8%), various types of cancer including 53.9% breast, and 75.8% Performance Status 0-1. Impaired MGA, G8, and VES-13 were 80.2%, 68.4%, and 60.2%, respectively. Mean time to complete G8 or VES-13 was about five minutes. Reproducibility of the two questionnaires was good. G8 appeared more sensitive (76.5% versus 68.7%, P =  0.0046) whereas VES-13 was more specific (74.3% versus 64.4%, P<0.0001). Abnormal G8 score (HR = 2.72), advanced stage (HR = 3.30), male sex (HR = 2.69) and poor Performance Status (HR = 3.28) were independent prognostic factors of 1-year survival. Conclusion With good sensitivity and independent prognostic value on 1-year survival, the G8 questionnaire is currently one of the best screening tools available to identify older cancer patients requiring geriatric assessment, and we believe it should be implemented broadly in daily practice. Continuous research efforts should be pursued to refine the selection process of older cancer patients before potentially life-threatening therapy.

Multidisciplinary Approach to the Geriatric Oncology Patient

Given the dramatic demographic shift observed in developed countries, the medical community, especially oncologists, geriatricians, and primary care providers, are confronted with the expanding challenge of the management of elderly people with cancer. Ageing is associated with the accumulation of multiple and various medical and social problems. With a prevalence comparable to that of other chronic conditions in this age group, such as diabetes or dementia, cancer holds a prominent place among diseases of the elderly. The care of elderly cancer patients is fundamentally interdisciplinary. Communication and collaboration between geriatricians/primary care providers and oncologists represent key features of effective care in geriatric oncology. The combination of the disease-oriented approach of oncologists and the patient-oriented approach of geriatricians is the most powerful way to better serve this specific population. The medical approach of elderly cancer patients should ideally be under the lead of geriatricians or primary care providers sensitive to geriatric issues. Oncologists should manage the biologic consequences of the interplay between cancer and ageing. Close collaboration between clinicians will help promote active dedicated clinical research and the development of guidelines on the management of elderly people with cancer.

Early Breast Cancer in the Elderly

Breast cancer is a common tumour in the elderly and management of early disease in particular is a major challenge for oncologists and geriatricians alike. The process should begin with the Comprehensive Geriatric Assessment (CGA), which should be undertaken before any decisions about treatment are made. The important role of co-morbidities and their effect on life expectancy also need to be taken into account when making treatment decisions.The primary treatments for early breast cancer are surgery, adjuvant radiotherapy and adjuvant systemic therapy. Unfortunately, lack of a specific literature relating to early breast cancer in the elderly means formulating an evidence-based approach to treatment in this context is difficult. We have developed a new approach based on the CGA and comprehensive oncological assessment. This approach facilitates the development of an individualized oncogeriatric care plan and follow-up based on several considerations: the average patient’s life expectancy at a given age; the patient’s co-morbidities, level of dependence, and the impact of these considerations on diagnostic and therapeutic options as well as life expectancy; and the potential benefit-risk balance of treatment.In the elderly patient with breast cancer, the standard primary therapy is surgical resection (mastectomy or breast-conserving therapy). While node dissection is a major component of staging and local control of breast cancer, no data are available to guide decision-making in women aged >70 years. Primary endocrine therapy (tamoxifen) should be offered to elderly women with estrogen receptor (ER)-positive breast cancer only if they are unfit for or refuse surgery. Trials are needed to evaluate the clinical effectiveness of aromatase inhibitors as primary therapy for infirm older patients with ER-positive tumours. Breast irradiation should be recommended to older women with a life expectancy >5 years, particularly those with large tumours, positive lymph nodes or negative hormone receptors.Adjuvant hormone therapy remains a reasonable therapeutic option in elderly women with positive hormone receptor tumours. Aromatase inhibitors have demonstrated a better toxicity profile and effectiveness as adjuvant therapy than tamoxifen in young postmenopausal women but have not been specifically studied in the elderly population. The efficacy of adjuvant chemotherapy for breast cancer has been established by meta-analysis and numerous randomized trials but, again, women aged ≥70 years have rarely been included in such trials. At present, it is difficult to provide a validated recommendation for use of adjuvant chemotherapy in elderly patients with breast cancer.There are no follow-up recommendations specifically for elderly patients after treatment of early breast cancer. However, American Society of Clinical Oncology breast cancer surveillance guidelines suggest physician office visits every 3–6 months for 3 years, followed by visits every 6–12 months for 2 years, then annually. Women taking aromatase inhibitors should also undergo bone mineral density measurement every 2 years.The new approach to assessment and management of early breast cancer in the elderly outlined in this article should be considered an intermediate step because additional evidence to support clinical practice is still needed. Bearing this in mind, physicians should encourage enrolment of elderly breast cancer patients in clinical trials.

Effects of comorbidity on screening and early diagnosis of cancer in elderly people

There is currently little data showing that older adults can derive benefit from cancer screening. Advancing age is associated with an increasing prevalence of cancer and other chronic conditions, or comorbidity, and questions remain about the interactions between comorbidity and cancer screening in the elderly population. In this Review, we assess the available evidence on the effects of comorbidity on cancer screening in elderly individuals. In view of the high heterogeneity of existing data, consistent recommendations cannot be made. Decisions on cancer screening in older adults should be based on an appropriate assessment of each individuals health status and life expectancy, the benefits and harms of screening procedures, and patient preferences. We suggest that Comprehensive Geriatric Assessment might be a necessary step to identify candidates for cancer screening in the elderly population. Specific clinical trials should be done to improve the evidence and show the effectiveness and cost-effectiveness of cancer screening in older adults.

Management of Prostate Cancer in Elderly Patients: Recommendations of a Task Force of the International Society of Geriatric Oncology

CONTEXT Prostate cancer is the most frequent male cancer. Since the median age of diagnosis is 66 yr, many patients require both geriatric and urologic evaluation if treatment is to be tailored to individual circumstances including comorbidities and frailty. OBJECTIVE To update the 2014 International Society of Geriatric Oncology (SIOG) guidelines on prostate cancer in men aged >70 yr. The update includes new material on health status evaluation and the treatment of localised, advanced, and castrate-resistant disease. DATA ACQUISITION A multidisciplinary SIOG task force reviewed pertinent articles published during 2013-2016 using search terms relevant to prostate cancer, the elderly, geriatric evaluation, local treatments, and castration-refractory/resistant disease. Each member of the group proposed modifications to the previous guidelines. These were collated and circulated. The final manuscript reflects the expert consensus. DATA SYNTHESIS Elderly patients should be managed according to their individual health status and not according to age. Fit elderly patients should receive the same treatment as younger patients on the basis of international recommendations. At the initial evaluation, screening for cognitive impairment is mandatory to establish patient competence in making decisions. Initial evaluation of health status should use the validated G8 screening tool. Abnormal scores on the G8 should lead to a simplified geriatric assessment that evaluates comorbid conditions (using the Cumulative Illness Score Rating-Geriatrics scale), dependence (Activities of Daily Living) and nutritional status (via estimation of weight loss). When patients are frail or disabled or have severe comorbidities, a comprehensive geriatric assessment is needed. This may suggest additional geriatric interventions. CONCLUSIONS Advances in geriatric evaluation and treatments for localised and advanced disease are contributing to more appropriate management of elderly patients with prostate cancer. A better understanding of the role of active surveillance for less aggressive disease is also contributing to the individualisation of care. PATIENT SUMMARY Many men with prostate cancer are elderly. In the physically fit, treatment should be the same as in younger patients. However, some elderly prostate cancer patients are frail and have other medical problems. Treatment in the individual patient should be based on health status and patient preference.

Impact of comorbidities on the treatment of non-Hodgkin's lymphoma: a systematic review.

Treating non-Hodgkin’s lymphoma in patients with comorbidities can be challenging because of possible interactions that may alter the treatment efficacy. We conducted a systematic review to determine the impact of comorbidities on various outcomes, evaluate the current data, and provide recommendations for future research. Twenty-one articles were selected. However, the study populations and design were greatly heterogeneous, and the quality of reporting was generally weak. The majority of studies demonstrated significant impact of comorbidity on survival, reporting poorer survival rates for patients with comorbidities compared to those with no comorbidities. However, the existing evidence is limited and of insufficient quality to establish solid conclusions and to guide treatment decisions. Prospective, well-designed studies are warranted.

Quality of life in geriatric oncology—An evaluation of standard questionnaires in elderly men with urological malignancies

Quality of life (QOL) is a critical issue in elderly patients with cancer. In the geriatric population, cancer is often associated with other chronic conditions possibly affecting QOL. This prospective study aimed to evaluate the validity of two QOL questionnaires, EORTC QLQ-C30 and SF-36, in older cancer patients. Seventy-two of 87 male patients with genitourinary cancer (median age, 76 years) completed the questionnaires (83% response rate). Internal consistency reliability was high (α≥0.7), except for SF-36 cognitive function (α=0.62) and QLQ-C30 general health status (α=0.57). QLQ-C30 and SF-36 appear similarly reliable for QOL assessment in this population. However, cognitive function and functional status, two factors likely to influence the value of QOL self-assessment, are poorly taken into account whereas they are correctly explored by the comprehensive geriatric assessment (CGA) procedure. QOL assessment in elderly cancer patients should therefore be associated with CGA to better meet the expectations of clinicians.

Role of Geriatric Oncologists in Optimizing Care of Urological Oncology Patients

CONTEXT Urological cancers are common. Since the median age of diagnosis is 60-70 yr, many patients require geriatric as well as urological evaluation if treatment is to be tailored to individual health status including comorbidities and frailty. OBJECTIVE To review the most important features of geriatric assessment and its expected benefits. We also consider ways in which collaboration between urologists and geriatricians and geriatric teams can benefit patient well-being. EVIDENCE ACQUISITION Members of a multidisciplinary International Society of Geriatric Oncology task force reviewed articles published in 2010-2017 using search terms relevant to urological cancers, the elderly, and geriatric evaluation. The final manuscript reflects their expert consensus. EVIDENCE SYNTHESIS Elderly patients should be managed according to their individual health status and not according to age. As a first step, screening for cognitive impairment is mandatory to establish patient competence in making decisions. Initial evaluation of health status should use a validated screening tool, the G8 screening tool being generally preferred. Abnormal scores on the G8 should lead to a geriatric assessment that evaluates comorbid conditions and functional, nutritional, mental, and medicosocial status. When patients are frail or disabled or have severe comorbidities, comprehensive geriatric assessment is required. Diagnosis of health status impairment shows the need for geriatric interventions. This overall approach is realistic in the setting of a department of urological oncology and given the involvement of a multidisciplinary team including trained nurses and other professionals and collaboration with geriatricians. Mutual education and support of all those involved in managing elderly urological cancer patients is the key to effective care. CONCLUSIONS Advances in geriatric evaluation and cancer treatment are contributing to more appropriate management of elderly patients with urological cancers. Better understanding of the role of all participants and professional collaboration are vital to the individualization of care. PATIENT SUMMARY Many patients with urological cancers are elderly. In those physically fit, treatment should generally be the same as that in younger patients. Some elderly cancer patients are frail and have other medical problems. Treatment in individual patients should be based on health status and patient preference.

Quelle évaluation gérontologique faut-il utiliser pour les essais multicentriques?

RésuméPeu de personnes âgées atteintes de cancer sont incluses dans des essais cliniques. Ainsi, la connaissance sur l’efficacité et la tolérance des traitements est-elle médiocre dans cette population de patients. Les barrières à l’inclusion des patients sont l’âge, les comorbidités, les critères d’inclusion, les toxicités, les a priori des patients, des familles et des médecins sur la stratégie thérapeutique à adopter chez les personnes âgées. Une inclusion optimale des personnes âgées peut être obtenue en évaluant leur état de santé et en adaptant les options thérapeutiques. Le dépistage des problèmes gériatriques doit concerner au moins les domaines suivants: les comorbidités, le risque iatrogène, la dépendance, les fonctions cognitives, les fonctions rénales et cardiaques, l’état nutritionnel. Les outils d’évaluation sont discutés, et leur choix doit faire l’objet d’un consensus dans la communauté oncogériatrique.AbstractFew elderly cancer patients are included in clinical trials, resulting in scarce data on the effectiveness and tolerance of treatments in this patient population. Barriers that exclude these patients from trials include age, comorbidities, inclusion criteria, toxicity, and the preconceptions of patients, families and physicians about the clinical management of elderly patients. Reaching an optimal level of senior participation in clinical trials requires carefully evaluating health status and tailoring treatment options. Screening for geriatric disorders must assess, at a minimum, the following areas: comorbidities, multiple medication, dependency, cognitive, renal and cardiac function, and nutritional status. The appropriate assessment tools are under debate, and the geriatric oncology community must achieve consensus on their use.

Health Status Evaluation of Elderly Patients with Genitourinary Tumors

In addition to accurate cancer evaluation, aging people require geriatric assessment that explores non-cancer-related parameters with significant impact on the cancer treatment decision-making process and patient’s outcomes. Emphasis should put specifically on the patient’s performances in functional, cognitive, physical domains, as well as on his comorbidity and socio-environmental situation. To date, different kinds of geriatric assessment tools have been developed from the gold standard that is the comprehensive geriatric assessment approach to elementary screening tools. This chapter first reviews components, methods, and objectives of geriatric assessment in geriatric oncology. Then, we focus on areas that should be more specifically explored in older patients with genitourinary tumors according to the treatment option, surgery, radiation therapy, and/or medical therapy. This chapter provides additional tools, which could significantly improve the value of geriatric assessment in this setting.