Laurent Cany

Predictors of Early Death Risk in Older Patients Treated With First-Line Chemotherapy for Cancer

PURPOSE Objective factors for making choices about the treatment of elderly patients with cancer are lacking. This investigation aimed to help physicians select appropriate treatments through the identification of factors that predict early death (< 6 months) after initiation of chemotherapy treatment. PATIENTS AND METHODS Previously untreated patients greater than 70 years of age who were scheduled for first-line chemotherapy for various types of cancer were included. Baseline abbreviated comprehensive geriatric assessment (aCGA), including the Mini-Mental State Exam, Timed Get Up and Go (GUG), Activities of Daily Living (ADL), Instrumental Activities in Daily Living (IADL), Mini Nutritional Assessment (MNA), Geriatric Depression Scale (GDS15), and comorbidities index (Cumulative Index Rating Scale-Geriatric), was carried out. Prognostic factors of early death were sought from aCGA results and traditional oncology measures. RESULTS A total of 348 patients were included across 12 centers in Southwest France (median age, 77.45 years; ratio of men to women, 1.47; advanced disease, 65%). Abnormal aCGA scores were observed for 18.1% of patients on the ADL, 73.0% of patients on the IADL, 24.1% of patients on the GUG, 19.0% of patients on the MMS, 44.0% of patients on the GDS15, and 64.9% of patients on the MNA. Advanced disease (odds ratio [OR], 3.9; 95% CI, [1.58 to 9.73]), a low MNA score (OR 2.77; 95% CI, [1.24 to 6.18]), male sex (OR, 2.40; 95% CI, [1.2 to 4.82]), and long GUG (OR, 2.55; 95% CI, [1.32 to 4.94] were associated with higher risk of early death. CONCLUSION In patients greater than 70 years of age with cancer, advanced disease, a low MNA score, and poor mobility predicted early death. We recommend that the MNA and GUG, performed by a trained nurse, be maintained as part of routine pretreatment workup in these patients to identify at-risk patients and to inform the decision-making process for chemotherapy.

Functional Decline in Older Patients With Cancer Receiving First-Line Chemotherapy

PURPOSE To determine factors associated with early functional decline during first-line chemotherapy in older patients. PATIENTS AND METHODS Patients age ≥ 70 years receiving first-line chemotherapy for cancer were prospectively considered for inclusion across 12 centers in France. Functional decline was defined as a decrease of ≥ 0.5 points on the Activities of Daily Living (ADL) scale between the beginning of chemotherapy and the second cycle. Factors associated with functional decline were sought from pretreatment abbreviated comprehensive geriatric assessment, including ADL, Instrumental ADL (IADL), Mini-Nutritional Assessment (MNA), Mini-Mental State Examination (MMSE), Geriatric Depression Scale (GDS15), and Timed Get Up and Go (GUG) test, and from comorbidities (Cumulative Illness Rating Scale-Geriatrics), MAX2 index, and baseline biologic and clinical information. RESULTS Of 364 included patients, 50 experienced functional decline (16.7%; median, 0.5 points). Abnormal preadmission performance status, IADL, GDS15, MMSE, GUG, and MNA were associated with increased likelihood of functional decline (univariate analysis). In the multivariate model adjusted for baseline ADL and MAX2 index, high baseline GDS (odds ratio [OR], 2.16; 95% CI, 1.09 to 4.30; P = .03) and low IADL scores (OR, 2.87; 95% CI, 1.06 to 7.79; P = .04) were independently associated with increased risk of functional decline. CONCLUSION Our results outline associations between baseline depression, instrumental dependencies, and early functional decline during chemotherapy for older patients. ADL should be sequentially evaluated early during treatment. Baseline evaluation of GDS15 and IADL may be proposed to anticipate this event.

Nutritional Advice in Older Patients at Risk of Malnutrition during Treatment for Chemotherapy: A Two-Year Randomized Controlled Trial

Objective We tested the effect of dietary advice dedicated to increase intake in older patients at risk for malnutrition during chemotherapy, versus usual care, on one-year mortality. Method We conducted a multicentre, open-label interventional, stratified (centre), parallel randomised controlled trial, with a 1∶1 ratio, with two-year follow-up. Patients were aged 70 years or older treated with chemotherapy for solid tumour and at risk of malnutrition (MNA, Mini Nutritional Assessment 17–23.5). Intervention consisted of diet counselling with the aim of achieving an energy intake of 30 kCal/kg body weight/d and 1.2 g protein/kg/d, by face-to-face discussion targeting the main nutritional symptoms, compared to usual care. Interviews were performed 6 times during the chemotherapy sessions for 3 to 6 months. The primary endpoint was 1-year mortality and secondary endpoints were 2-year mortality, toxicities and chemotherapy outcomes. Results Between April 2007 and March 2010 we randomised 341 patients and 336 were analysed: mean (standard deviation) age of 78.0 y (4·9), 51.2% male, mean MNA 20.2 (2.1). Distribution of cancer types was similar in the two groups; the most frequent were colon (22.4%), lymphoma (14.9%), lung (10.4%), and pancreas (17.0%). Both groups increased their dietary intake, but to a larger extent with intervention (p<0.01). At the second visit, the energy target was achieved in 57 (40.4%) patients and the protein target in 66 (46.8%) with the intervention compared respectively to 13 (13.5%) and 20 (20.8%) in the controls. Death occurred during the first year in 143 patients (42.56%), without difference according to the intervention (p = 0.79). No difference in nutritional status changes was found. Response to chemotherapy was also similar between the groups. Conclusion Early dietary counselling was efficient in increasing intake but had no beneficial effect on mortality or secondary outcomes. Cancer cachexia antianabolism may explain this lack of effect. Trial Registration ClinicalTrials.gov NCT00459589

Evaluation of efficacy and safety of FOLFIRI for elderly patients with gastric cancer: A first-line phase II study

OBJECTIVE Current chemotherapy protocols for gastric cancer present high toxicity. The FOLFIRI regimen has shown promising results with elderly colorectal cancer patients and for gastric cancer patients but this is the first report on elderly gastric cancer patients. DESIGN In this multicenter non-randomized phase II trial, we administered the FOLFIRI chemotherapy protocol (irinotecan [180 mg/m(2)], fluorouracil [5-FU] [400 mg/m(2)] and folinic acid 400 mg/m(2) or 200mg/m(2) of l-folinic acid) to patients aged over 70 years with locally-advanced or metastatic gastric cancer combined with Comprehensive Geriatric Assessment (CGA). Responses were assessed at 2 months. RESULTS Forty-two patients received eight cycles of the FOLFIRI regimen, with 82.5% of patients showing disease control: 10 patients (26%) showing objective (partial or complete) responses and 23 (57.5%) showing stable disease. One-year overall survival (OS) was 41.5% [95%CI 26.5-56.0] and one-year progression-free survival (PFS) was 31.8% [95%CI 18.4-46.1%]. We observed 10 Grade 3/4 hematologic toxicities with one febrile neutropenia. CGA data demonstrated that geriatric functions were not altered by treatment and that nutritional status improved over treatment. CONCLUSIONS Results show excellent disease control and relatively high survival rates with limited toxicity similar to younger patients indicating that this regimen should be considered as a possible treatment in advanced gastric cancer of the elderly.

Quality of life in patients with aggressive non-Hodgkin's lymphoma. Validation of the medical outcomes study short form 20 and the Rotterdam symptom checklist in older patients

In the elderly population, cancer treatment aims to cure and/or maintain Quality of Life (QoL). However, there is little QoL data to provide evidence for QoL benefits for some of the cancer treatments. This pilot study developed valid QoL questionnaires in French, for patients over 65 years with a diagnosis of large cell lymphoma, part of the Lymâge phase II study. They were asked to complete two questionnaires, the Medical Outcomes Study Short Form 20 (MOS SF20; generic) and the Rotterdam symptom checklist (RSCL; cancer-specific). Between June 1995 and April 1997, questionnaires were returned by 63 of 89 patients. This article reports the process undertaken to adapt the English version to a French setting, and provides the results of factor analysis, convergent and discriminant validity and reliability. Our data suggest that QoL questionnaires can be used in elderly patients. These two questionnaires are validated in French and would help us to analyse the QoL of elderly patients with the development of new treatments as done in the Lymâge study.

Predictive factors of depressive symptoms of elderly patients with cancer receiving first-line chemotherapy

Depression is the most common psychiatric disorder in geriatrics and oncology. For elderly cancer patients, it has a significant impact on quality of life, morbidity, and mortality. Nevertheless, depression is under‐diagnosed and under‐treated. Cancer management is key in improving the quality of care in this population. We aim to identify sociodemographic, clinical, and treatment‐related factors of depression in elderly patients during chemotherapy, thus allowing early detection of patients in need of specific treatment. Further, we investigate whether chemotherapy efficacy and safety are associated with depression.

Phase II study of FOLFIRI chemotherapy as first-line treatment for elderly patients (pts) with advanced gastric cancer (AGC).

4150 Background: 58% of gastric cancers occur after 70 and 28% after 80. Trials demonstrated efficacy of FOLFIRI association in gastric cancer. Efficacy of this regimen in pts older than 70 with AGC and good physiological status has to be evaluated in terms of efficacy and toxicity. As few trials reported benefits of geriatric assessment, we assessed their prognostic impact. Methods: We investigated efficacy of bimonthly 48-h regimen with irinotecan, folinic acid and fluorouracil by conducting a multicenter two-stage phase 2 trial. Primary endpoint: 2-month objective response rate (ORR). Secondary endpoints: OS; PFS; toxicity; identification of geriatric parameters predicting chemotherapy-induced toxicity; 4 geriatric evaluations (baseline; after cycles 1 and 3; end of treatment) were realized evaluating cognitive function (MMSE), nutritional status (MNA), comorbidity (CIRS-G), mobility (get up and go), autonomy (ADL, IADL), quality of life (QLQ-C30), thymic function (GDS-15). Results: Since 2005, 43 elde...

Evaluation of medical students’ hospital training: Interest of students’ essays

To evaluate the impact of teaching during hospital training in an adult cancer ward, 107 consecutive students were asked to freely select the chart of a patient representative of their course and to write comments on it, at the end of their course. Students selected charts of young patients rather than older ones (P less than 0.0001). Most of the patients had a poor prognosis (69%). Students frequently emphasized psychosocial aspects of cancer and patients information (patient-student relationship: 50%; diagnosis acceptance: 36%; information: 19%), but rarely considered post-treatment sequelae of cured patients (4%), palliative care (9%), and truth (10%). The selection of a large majority of poor prognosis patients led us to invite them to attend consultations to meet patients who are cured or in fair condition. Other topics must be emphasized (palliative care, truth, and post-treatment morbidity). Finally, such an evaluation provides good information on the course of the students and is easily performed and analysed.