Philippe Caillet

Comprehensive Geriatric Assessment in the Decision-Making Process in Elderly Patients With Cancer: ELCAPA Study

PURPOSE To identify Comprehensive Geriatric Assessment (CGA) components independently associated with changes in planned cancer treatment. PATIENTS AND METHODS We prospectively included 375 consecutive elderly patients with cancer (ELCAPA01 study) assessed by geriatricians using the CGA. Multivariate analysis was used to identify factors associated with changes in the cancer treatment (intensification, decrease, or delayed > 2 weeks). Change was defined as a difference between the initial treatment proposal and the final treatment selected in a multidisciplinary meeting. RESULTS Mean age was 79.6 years (standard deviation [SD], 5.6 years), and 197 (52.5%) were women. The most common tumor location was the digestive system (58.7%). The mean number of comorbidities was 4.2 (SD, 2.7) per patient, and the mean Cumulative Illness Rating Scale for Geriatrics score was 11.8 (SD, 5.3). After the CGA, the initial cancer treatment plan was modified for 78 (20.8%) of 375 patients (95% CI, 16.8 to 25.3), usually to decrease treatment intensity (63 [80.8%] of 78 patients). By univariate analysis, cancer treatment changes were associated with Eastern Cooperative Oncology Group performance status ≥ 2 (73.3% in the group with changes v 41.1% in the in the group without changes; P < .001), dependency for one or more activities of daily living (ADL; 59.0% v 24.2%; P < .001), malnutrition (81.8% v 51.2%; P < .001), cognitive impairment (38.5% v 24.9%; P = .023), depression (52.6% v 21.7%; P < .001), and greater number of comorbidities (mean, 4.8 [SD, 2.9] v 4.0 [SD, 2.6]; P = .02). By multivariate analysis, factors independently associated with cancer treatment changes were a lower ADL score (odds ratio [OR], 1.25 per 0.5-point decrease; CI, 1.04 to 1.49; P = .016) and malnutrition (OR, 2.99; CI, 1.36 to 6.58; P = .007). CONCLUSION Functional status assessed by the ADL score and malnutrition were independently associated with changes in cancer treatment.

Optimal management of elderly cancer patients: usefulness of the Comprehensive Geriatric Assessment

Background Cancer is common in older patients, who raise specific treatment challenges due to aging-related, organ-specific physiologic changes and the presence in most cases of comorbidities capable of affecting treatment tolerance and outcomes. Identifying comorbid conditions and physiologic changes due to aging allows oncologists to better assess the risk/benefit ratio and to adjust the treatment accordingly. Conducting a Comprehensive Geriatric Assessment (CGA) is one approach developed for this purpose. We reviewed the evidence on the usefulness of CGA for assessing health problems and predicting cancer treatment outcomes, functional decline, morbidity, and mortality in older patients with solid malignancies. Methods We searched Medline for articles published in English between January 1, 2000 and April 14, 2014, and reporting prospective observational or interventional studies of CGA feasibility or effectiveness in patients aged ≥65 years with solid malignancies. We identified studies with at least 100 patients, a multivariate analysis, and assessments of at least five of the following CGA domains: nutrition, cognition, mood, functional status, mobility and falls, polypharmacy, comorbidities, and social environment. Results All types of CGA identified a large number of unrecognized health problems capable of interfering with cancer treatment. CGA results influenced 21%–49% of treatment decisions. All CGA domains were associated with chemotoxicity or survival in at least one study. The abnormalities that most often predicted mortality and chemotoxicity were functional impairment, malnutrition, and comorbidities. Conclusion The CGA uncovers numerous health problems in elderly patients with cancer and can affect treatment decisions. Functional impairment, malnutrition, and comorbidities are independently associated with chemotoxicity and/or survival. Only three randomized published studies evaluated the effectiveness of CGA-linked interventions. Further research into the effectiveness of the CGA in improving patient outcomes is needed.

Risk and prognostic factors of status epilepticus in the elderly: A case–control study

Purpose:  The aim of this study was to assess the risk and prognostic factors of status epilepticus (SE) among elderly inpatients.

Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: The ELCAPA-02 study

BACKGROUND/OBJECTIVE G-8 screening tool showed good screening properties for identifying vulnerable elderly patients with cancer who would benefit from a comprehensive geriatric assessment (CGA). We investigated whether tumour site and metastatic status affected its accuracy. MATERIALS AND METHODS DESIGN Cross-sectional analysis of a prospective cohort study. SETTING Geriatric-oncology clinics of two teaching hospitals in the urban area of Paris. PARTICIPANTS Patients aged 70 or over (n = 518) with breast ( n= 113), colorectal (n = 108), urinary-tract (n = 89), upper gastrointestinal/liver (n = 85), prostate (n = 69), or other cancers (n = 54). MEASUREMENTS Reference standard for diagnosing vulnerability was the presence of at least one abnormal test among the Activities of Daily Living (ADLs), Instrumental ADL, Mini-Mental State Examination, Mini Nutritional Assessment, Cumulative Illness Rating Scale-Geriatrics, Timed Get-Up-and-Go, and Mini-Geriatric Depression Scale. Sensitivity, specificity and likelihood ratios of G-8 scores ≤ 14 were compared according to tumour site and patient characteristics. RESULTS Median age was 80; 48.2% had metastases. Prevalence of vulnerability and abnormal G-8 score was 84.2% (95% confidence interval [95% CI], 81-87.3) and 79.5% (95% CI, 76-83). The G-8 was 86.9% sensitive (95% CI, 83.4-89.9) and 59.8% specific (95% CI, 48.3-70.4). G-8 performance varied significantly (all p values < 0.001) across tumour sites (sensitivity, 65.2% in prostate cancer to 95.1% in upper gastrointestinal/liver cancer; and specificity, 23.1% in colorectal cancer to 95.7% in prostate cancer) and metastatic status (sensitivity and specificity, 93.8% and 53.3% in patients with metastases vs. 79.5% and 63.3% in those without, respectively). Differences remained significant after adjustment on age and performance status. CONCLUSION These G-8 accuracy variations across tumour sites should be considered when using G-8 to identify elderly patients with cancer who could benefit from CGA.

Geriatric syndromes increased the nutritional risk in elderly cancer patients independently from tumoursite and metastatic status. The ELCAPA-05 cohort study

BACKGROUND & AIMS We assessed the prevalence and risk factors of malnutrition in elderly cancer patients. METHODS We studied a prospective cohort of solid cancer patients aged ≥70 years at referral to two geriatric oncology clinics between 2007 and 2010. Nutrition was evaluated using the Mini-Nutritional Assessment (MNA) using validated cut-offs (<17: malnutrition, 17-23.5: at-risk for malnutrition). Patients with non-digestive tumours (breast, prostate, urinary tract) and with digestive (colorectal, upper digestive tract and liver) were analysed separately using multinomial logistic regression. RESULTS Of 643 consecutive patients, 519 had available data (median age, 80; men, 48.2%; metastases, 46.3%; digestive cancer 47.8%). In non-digestive group, 13.3% had malnutrition versus 28.6% in digestive group. The link between metastasis and malnutrition was significantly higher in non-digestive group (adjusted odds ratio [ORa ], 25.25; 95%CI: 5.97-106.8) than in digestive group (ORa, 2.59; 1.08-6.24; p for heterogeneity = 0.04). Other factors independently associated with malnutrition were cognitive impairment (ORa MMMSE ≤ 24 versus > 24 in non-digestive group: 16.68; 4.89-56.90 and in digestive group: 3.93; 1.34-11.50), and depressed mood (ORa MiniGDS ≥1 versus <1 in non-digestive group: 11.11; 3.32-37.17 and in digestive group: 3.25; 1.29-8.15) and fall risk (ORa fall risk versus no fall risk in non-digestive group: 4.68; 1.77-12.37; in digestive group: 100% of malnourished patients were fallers). CONCLUSION We highlighted, in elderly cancer patients, the high prevalence of malnutrition and that geriatrics syndromes (i.e. cognitive impairment, depressed mood and fall risk) were independent risk factors for malnutrition. Moreover, metastatic status was significantly much more strongly associated with malnutrition in non-digestive than digestive tumours.

Performance of Four Frailty Classifications in Older Patients With Cancer: Prospective Elderly Cancer Patients Cohort Study

Purpose Frailty classifications of older patients with cancer have been developed to assist physicians in selecting cancer treatments and geriatric interventions. They have not been compared, and their performance in predicting outcomes has not been assessed. Our objectives were to assess agreement among four classifications and to compare their predictive performance in a large cohort of in- and outpatients with various cancers. Patients and Methods We prospectively included 1,021 patients age 70 years or older who had solid or hematologic malignancies and underwent a geriatric assessment in one of two French teaching hospitals between 2007 and 2012. Among them, 763 were assessed using four classifications: Balducci, International Society of Geriatric Oncology (SIOG) 1, SIOG2, and a latent class typology. Agreement was assessed using the κ statistic. Outcomes were 1-year mortality and 6-month unscheduled admissions. Results All four classifications had good discrimination for 1-year mortality (C-index ≥ 0.70); discrimination was best with SIOG1. For 6-month unscheduled admissions, discrimination was good with all four classifications (C-index ≥ 0.70). For classification into three (fit, vulnerable, or frail) or two categories (fit v vulnerable or frail and fit or vulnerable v frail), agreement among the four classifications ranged from very poor (κ ≤ 0.20) to good (0.60 < κ ≤ 0.80). Agreement was best between SIOG1 and the latent class typology and between SIOG1 and Balducci. Conclusion These four frailty classifications have good prognostic performance among older in- and outpatients with various cancers. They may prove useful in decision making about cancer treatments and geriatric interventions and/or in stratifying older patients with cancer in clinical trials.

Assessment of Solid Cancer Treatment Feasibility in Older Patients: A Prospective Cohort Study

PURPOSE To assess solid cancer treatment feasibility in older patients. METHODS Between 2007 and 2010, 385 consecutive elderly patients (mean age: 78.9 ± 5.4 years; 47.8% males) with solid malignancies referred to two geriatric oncology clinics were included prospectively. We recorded feasibility of first-line chemotherapy (planned number of cycles in patients without metastases and three to six cycles depending on tumor site in patients with metastases), surgery (patient alive 30 days after successfully performed planned surgical procedure), radiotherapy (planned dose delivered), and hormonal therapy (planned drug dose given), and we recorded overall 1-year survival. RESULTS Main tumor sites were colorectal (28.6%), breast (23.1%), and prostate (10.9%), and 47% of patients had metastases. Planned cancer treatment was feasible in 65.7% of patients with metastases; this proportion was 59.0% for chemotherapy, 82.6% for surgery, 100% for radiotherapy, and 85.2% for hormonal therapy. In the group without metastases, feasibility proportions were 86.8% overall, 72.4% for chemotherapy, 95.7% for surgery, 96.4% for radiotherapy, and 97.9% for hormonal therapy. Factors independently associated with chemotherapy feasibility were good functional status defined as Eastern Cooperative Oncology Group performance status <2 (p < .0001) or activities of daily living >5 (p = .01), normal mobility defined as no difficulty walking (p = .01) or no fall risk (p = .007), and higher creatinine clearance (p = .04). CONCLUSION Feasibility rates were considerably lower for chemotherapy than for surgery, radiotherapy, and hormonal therapy. Therefore, utilization of limited geriatric oncology resources may be optimized by preferential referral of elderly cancer patients initially considered for chemotherapy to geriatric oncology clinics.

Geriatric assessment findings independently associated with clinical depression in 1092 older patients with cancer: the ELCAPA Cohort Study

We aim to assess the prevalence and associated factors of clinical depression in older patients with cancer.

Chronological Age and Risk of Chemotherapy Nonfeasibility: A Real-Life Cohort Study of 153 Stage II or III Colorectal Cancer Patients Given Adjuvant-modified FOLFOX6.

Objectives: To assess nonfeasibility of adjuvant-modified FOLFOX6 chemotherapy in patients with stage II or III colorectal cancer. Methods: Consecutive patients managed between 2009 and 2013 in 2 teaching hospitals in the Paris urban area were included in the CORSAGE (COlorectal canceR, AGe, and chemotherapy fEasability study) cohort study. Nonfeasibility was defined by the frequencies of empirical first-cycle dose reduction (>15%), early discontinuation (<12 cycles), and low relative dose intensity (RDI) (<0.85). Risk factors for chemotherapy nonfeasibility were identified using multivariate logistic regression. Results: Among 153 patients, 56.2% were male (median age, 65.6 y; 35.3%≥70 y; 7.3% with performance status [PS]≥2). For 5-fluorouracil (5-FU), 20.9% of patients had first-cycle dose reduction and 28.1% early discontinuation; RDI was 0.91 (25th to 75th percentiles, 0.68 to 0.99). Factors independently associated with first-cycle 5-FU dose reduction were aged 65 to 69 years versus those younger than 65 years (adjusted odds ratio [aOR], 5.5; 95% confidence interval [CI], 1.5-19.9) but not age 70 years and older, PS≥2 (aOR, 6.02; 95% CI, 1.15-31.4), higher Charlson Comorbidity Index (aOR1-point increase, 1.4; 95% CI, 1.05-1.82), or larger number of medications (aOR 1-medication increase, 1.19; 95% CI, 1.00-1.42). Oxaliplatin dose reduction occurred in 52.3% of patients and early discontinuation in 62.7%; the latter was more common in the 70 years and older group (92.6% vs. 74.6% in the <65-y group; P=0.01); RDI was 0.7 (95% CI, 0.55-0.88). Conclusions: In the real-world setting, compared with their younger and older counterparts, patients aged 65 to 69 years given modified FOLFOX6 for stage II or III colorectal cancer had higher frequencies of 5-FU nonfeasibility defined based on first-cycle dose reduction, early discontinuation, and RDI; and these differences were independent from PS, comorbidities, and number of medications.

Impaired mobility, depressed mood, cognitive impairment and polypharmacy are independently associated with disability in older cancer outpatients: The prospective Physical Frailty in Elderly Cancer patients (PF-EC) cohort study

OBJECTIVE To assess the prevalence of disability and the oncologic factors associated with disability in older outpatients with cancer. MATERIALS AND METHODS The Physical Frailty in Elderly Cancer patients (PF-EC) study (France) is a prospective bicentric observational cohort study. Two hundred and ninety outpatients with cancer were included. A cross-sectional analysis of oncologic factors and geriatric variables associated with disability that were collected using a comprehensive geriatric assessment (CGA) was conducted. Disability was defined as impairment in activities of daily living (ADL) and/or instrumental activities of daily living (IADL), simplified to four items. Univariate and multivariate logistic models of disabled patients were performed. The three final multivariate models were compared using the area under the receiver operating characteristic curve (AUC/ROC) of the logistic model. RESULTS The mean age was 80.6years, and 51% of the patients were women with various types of cancer. The prevalence of disability was 67.6%. No oncologic factors (cancer site, cancer extension) were associated with disability. Impaired mobility, poor functional status, depressive mood, cognitive impairment and polypharmacy were independently associated with disability (P<0.05). The AUC/ROC of the final models was similar. CONCLUSION Disability was highly prevalent in older cancer outpatients before cancer treatment but was not associated with oncologic factors. Impaired mobility, depressed mood, cognitive impairment and polypharmacy were the geriatric variables significantly and independently associated with disability. Identifying these factors prior to cancer treatment could enable the implementation of corrective actions to improve patient autonomy before treatment and during follow-up.