Mathilde Gisselbrecht

Preferences about information and decision-making among older patients with and without cancer

Background information of older patients with cancer is crucial to ensure optimal care. Objectives to compare older patients with and without cancer regarding their preferences about medical information, decision-making and surrogate designation. Design an intention-to-act questionnaire was completed by patients ≥70 y enroled in the ELderly CAncer PAtients cohort between January and June 2013 and by patients in the same age group enroled in a cross-sectional survey conducted in 2005 in acute geriatric wards. Setting Henri-Mondor Teaching Hospital in the Paris conurbation, France. Results the group with cancer had 133 patients [mean age, 79.6 ± 6.5 y; 54.9% women]. The main tumour sites were colorectal [24.1%], breast [23.3%] and prostate [15.8%]; 34.8% had metastases. All these patients wanted full information, 74.2% wanted to participate in decisions about their care, 87.2% would designate a family member to serve as a surrogate in life-threatening situations and 15% had already designated a surrogate. Compared to patients without cancer, those with cancer more often wanted to receive information in a life-threatening situation [93.6% versus 79.2%; P < 0.001]. Factors independently associated with patients wanting their informed consent to be obtained for all interventions were having children [adjusted odds ratio (aOR), 2.13; 95% confidence interval, 1.24; 3.66; P = 0.006], higher Mini Mental State Examination score [aORper point, 1.09; 1.02; 1.17], younger age in the group without cancer [aOR>82 y vs. ≤82 y, 0.50; 0.29-0.88] and being cancer-free [≤82 y, aOR, 0.30; 0.14-0.63; >82 y, aOR, 0.41; 0.17-0.97]. Conclusion older patients with cancer expressed a strong preference for receiving information and participating in decisions about their care.

Alterations in comprehensive geriatric assessment decrease survival of elderly patients with cancer

INTRODUCTION A comprehensive geriatric assessment (CGA) evaluating several domains of health is recommended for elderly patients with cancer. Effects of altered domains on the risk of death in this population need to be clarified. The aim of this study was to estimate the independent association of each CGA domain to overall survival (OS). METHOD Patients included in the ONCODAGE cohort completed a CGA at baseline. Cox models (one per domain) estimated the hazard ratio (HR) of death for each CGA domain. Directed Acyclic Graphs (DAGs) selected specific sets of adjustment factors for each model. RESULTS The analysis included 1264 patients (mean age: 78 years, women: 70%). Median follow-up was 5.2 years, and 446 patients died. Each altered domain had a detrimental effect on survival, sometimes dependent on gender, age, education or time from inclusion. Nutritional status had a time-varying effect, with higher mortality rates if altered only within the first 3 years of follow-up. In case of altered mobility, the risk of death was higher only for the youngest patients and, in case of altered autonomy, only for the youngest women. An altered neurological state led to higher mortality rates; this effect increased with the level of education. Patients with altered psychological status or more than four comorbidities at baseline had also higher mortality rates. CONCLUSIONS Patients with an altered CGA domain have a higher risk of death than those without any alteration. The effect of some alterations is different in some subgroups or at a given time of the treatments.

L’évaluation gériatrique et les scores pronostiques chez le patient âgé atteint de cancer : une aide à la décision thérapeutique ?

Cancer is a disease of the elderly as demonstrated by the epidemiological evolution of Western countries. Indeed, two third of cancers newly diagnosed occur over 65 years. However, older cancer patients have been often excluded from clinical trials in oncology and the extrapolation of cancer treatments in this population remains difficult in practice. Scientific societies recommend that a comprehensive geriatric assessment (CGA) be performed in patients aged 70 and over and selected using screening tools for frailty such as the G8 index. The CGA allows to detect aging-related vulnerabilities in various domains (comorbidities, polypharmacy, autonomy, nutrition, mobility, cognition, mood, social) and associated with adverse outcomes during cancer treatment (reduced overall survival, perioperative complications, toxicity-related chemotherapy). The CGA is allow to elaborate a personalized treatment plan in geriatric oncology. However, to date, no algorithms based on CGA is validated to guide therapeutic decision in geriatric oncology. The collaboration between geriatrician and oncologist remains essential to elaborate an appropriate therapeutic strategy and limit the situations of over- and under-treatment. This article presents the set of tools and scores used in geriatric oncology to guide the therapeutic decision.