Martine Puts

International Society of Geriatric Oncology Consensus on Geriatric Assessment in Older Patients With Cancer

PURPOSE To update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on geriatric assessment (GA) in older patients with cancer. METHODS SIOG composed a panel with expertise in geriatric oncology to develop consensus statements after literature review of key evidence on the following topics: rationale for performing GA; findings from a GA performed in geriatric oncology patients; ability of GA to predict oncology treatment–related complications; association between GA findings and overall survival (OS); impact of GA findings on oncology treatment decisions; composition of a GA, including domains and tools; and methods for implementing GA in clinical care. RESULTS GA can be valuable in oncology practice for following reasons: detection of impairment not identified in routine history or physical examination, ability to predict severe treatment-related toxicity, ability to predict OS in a variety of tumors and treatment settings, and ability to influence treatment choice and intensity. The panel recommended that the following domains be evaluated in a GA: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and presence of geriatric syndromes. Although several combinations of tools and various models are available for implementation of GA in oncology practice, the expert panel could not endorse one over another. CONCLUSION There is mounting data regarding the utility of GA in oncology practice; however, additional research is needed to continue to strengthen the evidence base.

Endocrine and inflammatory markers as predictors of frailty

Objective  To examine the association of serum concentrations of 25‐hydroxyvitamin D [25(OH)D], interleukin‐6 (IL‐6), C‐reactive protein (CRP) and IGF‐1 with prevalent and incident frailty.

Use of Geriatric Assessment for Older Adults in the Oncology Setting: A Systematic Review

Background Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult’s medical, psychological, social, and functional capacity. No systematic review of the use of geriatric assessment in oncology has been conducted. The goals of this systematic review were: 1) to provide an overview of all geriatric assessment instruments used in the oncology setting; 2) to examine the feasibility and psychometric properties of those instruments; and 3) to systematically evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes (including the impact on treatment decision making, toxicity of treatment, and mortality). Methods We searched Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library for articles published in English, French, Dutch, or German between January 1, 1996, and November 16, 2010, reporting on cross-sectional, longitudinal, interventional, or observational studies that assessed the feasibility or effectiveness of geriatric assessment instruments. The quality of articles was evaluated using relevant quality assessment frameworks. Results We identified 83 articles that reported on 73 studies. The quality of most studies was poor to moderate. Eleven studies examined psychometric properties or diagnostic accuracy of the geriatric assessment instruments used. The assessment generally took 10–45min. Geriatric assessment was most often completed to describe a patient’s health and functional status. Specific domains of geriatric assessment were associated with treatment toxicity in 6 of 9 studies and with mortality in 8 of 16 studies. Of the four studies that examined the impact of geriatric assessment on the cancer treatment decision, two found that geriatric assessment impacted 40%–50% of treatment decisions. Conclusion Geriatric assessment in the oncology setting is feasible, and some domains are associated with adverse outcomes. However, there is limited evidence that geriatric assessment impacted treatment decision making. Further research examining the effectiveness of geriatric assessment on treatment decisions and outcomes is needed.

An update on a systematic review of the use of geriatric assessment for older adults in oncology

BACKGROUND Our previous systematic review of geriatric assessment (GA) in oncology included a literature search up to November 2010. However, the quickly evolving field warranted an update. Aims of this review: (i) provide an overview of all GA instruments developed and/or in use in the oncology setting; (ii) evaluate effectiveness of GA in predicting/modifying outcomes (e.g. treatment decision impact, treatment toxicity, mortality, use of care). MATERIALS AND METHODS Systematic review of literature published between November 2010 and 10 August 2012. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of GA instruments were included. DATA SOURCES MEDLINE, EMBASE, PsycINFO, CINAHL and Cochrane Library. Two researchers independently reviewed abstracts, abstracted data and assessed the quality using standardized forms. A meta-analysis method of combining proportions was used for the outcome impact of GA on treatment modification with studies included in this update combined with those included in our previous systematic review on the use of GA. RESULTS Thirty-five manuscripts reporting 34 studies were identified. Quality of most studies was moderate to good. Eighteen studies were prospective, 11 cross-sectional and 5 retrospective. Three studies examined treatment decision-making impact and found decisions changed for fewer than half of assessed patients (weighted percent modification is 23.2% with 95% confidence interval (20.3% to 26.1%). Seven studies reported conflicting findings regarding predictive ability of GA for treatment toxicity/complications. Eleven studies examined GA predictions of mortality, and reported that instrumental activities of daily living, poor performance status and more numerous GA deficits were associated with increased mortality risk. Other outcomes could not be meta-analyzed. CONCLUSION Consistent with our previous review, several domains of GA are associated with adverse outcomes. However, further research examining effectiveness of GA on treatment decisions and oncologic outcomes is needed.

Are frailty markers useful for predicting treatment toxicity and mortality in older newly diagnosed cancer patients? Results from a prospective pilot study

INTRODUCTION The concept of frailty may be useful to characterize vulnerability. The aim of this pilot study was to explore the association between frailty/functional status and treatment toxicity at 3 months and mortality at 6 months. METHODS Patients aged ≥65 years referred to the Jewish General Hospital, Montreal, with a new cancer diagnosis. Seven frailty markers and 4 functional status measures were examined. Logistic regression was used to examine the association between frailty/functional status and toxicity, and Cox models for time to death. RESULTS 112 participated, median age 74.1, 31 had toxicity and 15 died. At baseline, 88% had ≥1 frailty marker. Low grip strength predicted toxicity (OR 8.47, 95%CI: 1.3-53.6), ECOG performance status and ADL disability predicted time to death. CONCLUSION The majority had ≥1 frailty marker. Low grip strength predicted toxicity, none of the functional measures did. Further researcher investigating the usefulness of frailty markers is needed.

A systematic review of factors influencing older adults’ decision to accept or decline cancer treatment

BACKGROUND Cancer is a disease that affects mostly older adults. Older adults often have other chronic health conditions in addition to cancer and may have different health priorities, both of which can impact cancer treatment decision-making. However, no systematic review of factors that influence an older cancer patients decision to accept or decline cancer treatment has been conducted. MATERIALS AND METHODS Systematic review of the literature published between inception of the databases and February 2013. Dutch, English, French or German articles reporting on qualitative studies, cross-sectional, longitudinal observational or intervention studies describing factors why older adults accepted or declined cancer treatment examining actual treatment decisions were included. Ten databases were used. Two independent reviewers reviewed manuscripts and performed data abstraction using a standardized form and the quality of studies was assessed with the Mixed Methods Appraisal Tool. RESULTS Of 17,343 abstracts reviewed, a total of 38 studies were included. The majority focused on breast and prostate cancer treatment decisions and most studies used a qualitative design. Important factors for accepting treatment were convenience and success rate of treatment, seeing necessity of treatment, trust in the physician and following the physicians recommendation. Factors important for declining cancer treatment included concerns about the discomfort of the treatments, fear of side effects and transportation difficulties. CONCLUSION Although the reasons why older adults with cancer accepted or declined treatment varied considerably, the most consistent determinant was physician recommendation. Further studies using large, representative samples and exploring decision-making incorporating health literacy and comorbidity are needed.

Changes in the prevalence of chronic disease and the association with disability in the older Dutch population between 1987 and 2001

BACKGROUND most studies of older populations in developed countries show a decrease in the prevalence of disabilities, and an increase in chronic diseases over the past decades. Data in the Netherlands, however, mostly show an increase in the prevalence of chronic diseases and mixed results with regard to the prevalence of disability. This study aims at comparing changes in the prevalence, as well as the association between chronic diseases and disability between 1987 and 2001 in the older Dutch population using data representative of the general population. Most studies, so far, have only dealt with self-reported diseases, but in this study, we will use both self-reported and GP-registered diseases. STUDY DESIGN data from the first (1987) and second (2001) Dutch National Survey of General Practice were used. In 1987, 103 general practices, compared to 104 in 2001, participated. Approximately 5% of the listed persons aged 18 years and over was asked to participate in an extensive health interview survey. An all-age random sample was drawn by the researchers from the patients listed in the participating practices (in 1987 n = 2, 708; in 2001 n = 3, 474). Both surveys are community based, with an age range between 55 and 97 years. Data on chronic diseases were based on GP registries and self-report. RESULTS the prevalence of disability and of asthma/COPD, cardiac disease, stroke, and osteoarthritis decreased between 1987 and 2001, while the prevalence of diabetes increased. Changes were largely similar for GP-registered and self-reported diseases. Cardiac disease, asthma/COPD, and depression led to less disability, whereas low back pain and osteoarthritis led to more disability. CONCLUSIONS in general, there were reductions in GP-registered chronic diseases as well as in self-reported diseases and disability. Results suggest that the disabling impact of fatal diseases decreased, while the impact of non-fatal diseases increased.

Factors influencing adherence to cancer treatment in older adults with cancer: a systematic review

BACKGROUND Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer. PATIENTS AND METHODS Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011. RESULTS Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies. CONCLUSION Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.BACKGROUND Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer. PATIENTS AND METHODS Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011. RESULTS Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies. CONCLUSION Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.

Medication Problems in Older, Newly Diagnosed Cancer Patients in Canada: How Common are They?: A Prospective Pilot Study

BackgroundPrescribing for older patients is challenging and complex. Cancer patients are at a considerable increased risk of drug-related problems because they typically receive a large number of medications during their cancer treatment, both for the cancer itself and for supportive care. Few studies have examined the scope of this problem in older newly diagnosed cancer patients.ObjectiveTo investigate the number and severity of potential drug problems and factors associated with the occurrence of potential drug problems in older newly diagnosed cancer patients.MethodsThis prospective pilot study was conducted in newly diagnosed cancer patients aged ≥65 years recruited in the Segal Cancer Centre, Jewish General Hospital, Montreal, Quebec, Canada. Vigilance Santé software was used to identify the presence and type of potential drug problems. Logistic regression analyses were used to identify factors associated with the presence of one or more severe or moderately severe potential drug problems.ResultsThere were 112 participants with a mean age of 74.2 years, and 70% were women. A total of 103 patients (92%) were taking medications. The median number of medications per patient was 5 (interquartile range 3–9) and a total of 247 potential drug problems were identified. Sixty-four patients (62.1%) had a potential drug problem of any level of severity and 49 patients had a potential moderate/severe drug problem identified (47.6%). Two (0.8%) potential drug problems of the most severe level were identified, 122 warnings (49.4%) of all potential problems were of moderate severity and 123 warnings (49.8%) were at the least severe level. Factors associated with having one or more moderate/severe potential drug problems were taking five or more drugs and age ≥76 years.ConclusionThe majority of older newly diagnosed cancer patients in this study were taking at least one medication and the median number of medications per patient was 5. Published studies have shown that medication problems are common in community-dwelling older persons, but they are mostly of low severity. In this group of older newly diagnosed cancer patients, potential medication problems were also found to be common; however, half of the potential problems identified were of moderate severity.

Does frailty predict hospitalization, emergency department visits, and visits to the general practitioner in older newly-diagnosed cancer patients? Results of a prospective pilot study

Research on the use of health care by older newly-diagnosed cancer patients is sparse. We investigated whether frailty predicts hospitalization, emergency department (ED) and general practitioner (GP) visits in older cancer patients in a prospective pilot study. Newly-diagnosed cancer patients aged 65 years and over were recruited in the Segal Cancer Centre, Jewish General Hospital, Montreal, Canada. One hundred ten patients participated, mean age 74.1, 70% women. During 1 year follow-up, 52 patients (47.3%) had cancer-related hospitalizations, 23 patients (20.9%) had ED visit and 17 patients (15.5%) had GP visit. No frailty marker predicted hospitalization or visits to the GP. Cognitive impairment suspicion was the only frailty marker that predicted ED visits (odds ratio 4.97; 95%CI 1.14-21.69). Although health care use was considerable in this sample, most frailty markers were not associated with health care use in this pilot study.