A 73-year-old woman has been diagnosed with a mammographically detected grade 3, 2.2-cm invasive ductal carcinoma that is sentinel lymph node negative, estrogen receptor positive (80%), progesterone ...receptor negative, and human epidermal growth factor receptor 2 negative (0 by immunohistochemistry). A gene expression assay (Oncotype DX, Genomic Health, Redwood City, CA) showed a recurrence score of 28. Except for well-controlled hypertension and some aches and pains in her hands and knees, she has no other major illnesses. Her medications include an antihypertensive, vitamin D, and calcium. She discontinued cigarette smoking 20 years ago and has an occasional glass of wine. She describes her health as good, is fully functional, drives, has had no falls, and provides the majority of care for her sick husband. Her blood pressure is 146/88, her body mass index is 29.7, and her physical examination is normal. She is aware of the benefits and risks of adjuvant endocrine therapy and has been referred to discuss the role of chemotherapy.
Limited tools exist to predict the risk of chemotherapy toxicity in older adults with early-stage breast cancer.
Patients of age ≥ 65 years with stage I-III breast cancer from 16 institutions treated ...with neoadjuvant or adjuvant chemotherapy were prospectively evaluated for geriatric and clinical features predictive of grade 3-5 chemotherapy toxicity. Logistic regression with best-subsets selection was used to identify and incorporate independent predictors of toxicity into a model with weighted variable scoring. Model performance was evaluated using area under the ROC curve (AUC) and goodness-of-fit statistics. The model was internally and externally validated.
In 473 patients (283 in development and 190 in validation cohort), 46% developed grade 3-5 chemotherapy toxicities. Eight independent predictors were identified (each assigned weighted points): anthracycline use (1 point), stage II or III (3 points), planned treatment duration > 3 months (4 points), abnormal liver function (3 points), low hemoglobin (3 points), falls (4 points), limited walking (3 points), and lack of social support (3 points). We calculated risk scores for each patient and defined three risk groups: low (0-5 points), intermediate (6-11 points), or high (≥ 12 points). In the development cohort, the rates of grade 3-5 chemotherapy toxicity for these three groups were 19%, 54%, and 87%, respectively (
< .01). In the validation cohort, the corresponding toxicity rates were 27%, 45%, and 76%. The AUC was 0.75 (95% CI, 0.70 to 0.81) in the development cohort and 0.69 (95% CI, 0.62 to 0.77) in the validation cohort. Risk groups were also associated with hospitalizations and reduced dose intensity (
< .01).
The Cancer and Aging Research Group-Breast Cancer (CARG-BC) score was developed and validated to predict grade 3-5 chemotherapy toxicity in older adults with early-stage breast cancer.
Background
The loss of muscle mass, known as sarcopenia, is a natural process of aging that is associated with adverse health outcomes regardless of age. Because cancer is a disease of aging, ...interest in sarcopenia and its potential impact in multiple cancer populations has increased significantly. Bioelectrical impedance analysis (BIA) is a guideline‐accepted method for sarcopenia detection. This systematic review assesses the literature pertaining to BIA use in the detection of sarcopenia in adults with cancer.
Materials and Methods
In this systematic review, a search of the literature for randomized controlled trials and observational studies was conducted using MEDLINE, Cochrane CENTRAL, and EMBASE, through July 15, 2019. The study is registered at Prospero (CRD 42019130707). For study inclusion, patients had to be aged 18 years or older and diagnosed with solid or hematological neoplasia, and BIA had to be used to detect sarcopenia.
Results
Through our search strategy, 5,045 articles were identified, of which 24 studies were selected for inclusion in the review (total number of 3,607 patients). In five studies, BIA was rated comparable to axial computed tomography (CT) scan, calf circumference, or grip strength for sarcopenia screening. In 14 studies, BIA‐identified sarcopenia was associated with adverse clinical outcomes.
Conclusion
BIA is an accurate method for detecting sarcopenia in adults with cancer prior to treatment and is a viable alternative to CT, dual‐energy x‐ray absorptiometry, and magnetic resonance imaging in oncology clinical practice.
Implications for Practice
Bioelectrical impedance analysis (BIA) is an attractive method for identifying sarcopenic patients in clinical practice because it provides an affordable, noninvasive test that can be completed within a few minutes during a clinic visit. BIA does not require highly skilled personnel, and results are immediately available. This systematic review summarizes the literature pertaining to BIA assessment of sarcopenia in adults with cancer, with a focus on its use in diverse cancer populations.
Sarcopenia is a natural process of aging that is associated with adverse health outcomes. Because cancer is a disease of aging, interest in sarcopenia and its potential impact in multiple cancer populations has increased. Bioelectrical impedance analysis (BIA) is a guideline‐accepted method for sarcopenia screening. This systematic review assesses the literature pertaining to BIA use in the detection of sarcopenia in adults with cancer.
To evaluate cardiopulmonary function (as measured by peak oxygen consumption VO(2peak)) across the breast cancer continuum and its prognostic significance in women with metastatic disease.
Patients ...with breast cancer representing four cross-sectional cohorts--that is, (1) before, (2) during, and (3) after adjuvant therapy for nonmetastatic disease, and (4) during therapy in metastatic disease--were studied. A cardiopulmonary exercise test (CPET) with expired gas analysis was used to assess VO(2peak). A Cox proportional hazards model was used to estimate the risk of death according to VO(2peak) category (< 15.4 v ≥ 15.4 mL · kg(-1) · min(-1)) with adjustment for clinical factors.
A total of 248 women (age, 55 ± 8 years) completed a CPET. Mean VO(2peak) was 17.8 ± a standard deviation of 4.3 mL · kg(-1) · min(-1), the equivalent of 27% ± 17% below age-matched healthy sedentary women. For the entire cohort, 32% had a VO(2peak) less than 15.4 mL · kg(-1) · min(-1)--the VO(2peak) required for functional independence. VO(2peak) was significantly different across breast cancer cohorts for relative (mL · kg(-1) · min(-1)) and absolute (L · min(-1)) VO(2peak) (P = .017 and P < .001, respectively); VO(2peak) was lowest in women with metastatic disease. In patients with metastatic disease (n = 52), compared with patients achieving a VO(2peak) ≤ 1.09 L · min(-1), the adjusted hazard ratio for death was 0.32 (95% CI, 0.16 to 0.67, P = .002) for a VO(2peak) more than 1.09 L · min(-1).
Patients with breast cancer have marked impairment in VO(2peak) across the entire survivorship continuum. VO(2peak) may be an independent predictor of survival in metastatic disease.
Background
Current guidelines recommend a comprehensive geriatric assessment (CGA) for the management of older adults with cancer. We evaluated the effect of CGA conducted by a geriatric oncology ...service (GOS) on the management of older adults with cancer. We also queried patients about their perceptions of the value of this process.
Methods
This was a prospective quality assessment study of 498 consecutive older adults with cancer who were referred to the GOS from May 2020 through December 2021. Treating physicians requested a consultation and the GOS conducted a CGA and assessed patient preferences. The GOS provided recommendations on cancer treatment and geriatric interventions. Patient perspectives on the consultation were evaluated using collaboRATE and modified Patient Assessment of Care for Chronic Conditions (PACIC) subscales.
Results
A 10‐item frailty index based on a CGA (FI‐CGA‐10) Oncologist, 26, e1751 (2021) in the 498 patients showed that 19% of patients were fit, 40% pre‐frail, and 41% frail. Prior to CGA the intent of the proposed cancer treatment was curative in 56% (n = 280), life‐extending in 40% (n = 201), and palliative in 3.4% (n = 17). After a CGA consultation, a cancer treatment decision was changed in 45% of patients. The intent of treatment after the CGA consultation was curative in 45%, life‐extending in 34%, and palliative in 21%. At least one referral to relevant disciplines was recommended for 88% of patients and was implemented in 43%. As part of the GOS consultation educational support was provided to 97% of patients. Based on the collaboRATE and PACIC tools, patients perceived the GOS consultation positively and helpful for facilitating shared decision‐making and patient‐centered care.
Conclusion
Our institutional experience demonstrated the valuable effect of the CGA consultation on oncologic decision‐making and geriatric interventions in a patient‐centered manner.
See related Editorial by Fernandes Dos Santos Hughes et al. in this issue.
Full text
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
An accumulating body of evidence supports the hypothesis that cancer and/or cancer treatment is associated with accelerated aging. The majority of these data come from the pediatric literature; ...however, a smaller yet growing body of literature points toward similar findings in the geriatric population. This is a key survivorship issue the growing number of older adults with cancer face, along with the short- and long-term impact of cancer therapy on the aging process. This article will review clinical and biologic markers of aging in older adults with cancer, use cardiovascular disease as a model of accelerated aging, and discuss potential interventions to decrease the risk.
Older adults are often exposed to multiple medications, some of which could be inappropriate or have the potential to interact with each other. Older cancer patients may be at increased risk for ...medication-related problems due to exposure to cancer-directed treatment.
We described patterns of potentially inappropriate medication (PIM) use and potential drug-chemotherapy interactions among adults age 66+ years diagnosed with stage I-III breast, stage II-III colon, and stage I to II lung cancer. Within the Surveillance, Epidemiology, and End Results-Medicare database, patients had to have Medicare Part D coverage with 1+ prescription in the diagnosis month and Medicare Parts A/B coverage in the prior 12 months. We estimated monthly prevalence of any and cancer-related PIM from 6 months pre- to 23 months postcancer diagnosis and 12-month period prevalence of potential drug-chemotherapy interactions.
Overall, 19,318 breast, 7,283 colon, and 7,237 lung cancer patients were evaluated. Monthly PIM prevalence was stable prediagnosis (37%-40%), but increased in the year following a colon or lung cancer diagnosis, and decreased following a breast cancer diagnosis. Changes in PIM prevalence were driven primarily by cancer-related PIM in patients on chemotherapy. Potential drug-chemotherapy interactions were observed in all cohorts, with prevalent interactions involving hydrochlorothiazide, warfarin, and proton-pump inhibitors.
There was a high burden of potential medication-related problems among older cancer patients; future research to evaluate outcomes of these exposures is warranted.
Older adults diagnosed with cancer have unique medication management needs. Thus, pharmacy specialists should be integrated into multidisciplinary teams caring for these patients.
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Background
A frailty index (FI) based on domain‐level deficits identified through a comprehensive geriatric assessment (CGA) has been previously developed and validated in general geriatric patients. ...Our objectives were to construct an FI‐CGA and to assess its construct validity in the geriatric oncology setting.
Methods
Five hundred forty consecutive Japanese patients with cancer who underwent a CGA on a geriatric oncology service were included (median age 80 years, range 66–96 years). We developed a 10‐item frailty index based on deficits in 10 domains (FI‐CGA‐10): cognition, mood, communication, mobility, balance, nutrition, basic and instrumental activities of daily living, social support, and comorbidity. Deficits in each domain were scored as 0 (no problem), 0.5 (minor problem), and 1.0 (major problem). Scores were calculated by dividing the sum of the scores for each domain by 10 and then categorized as fit (<0.2), pre‐frail (0.2–0.35), and frail (>0.35). Construct validity was tested by correlating the FI‐CGA‐10 with other established frailty measures.
Results
FI‐CGA‐10 was well approximated by the gamma distribution. Overall, 20% of patients were fit, 41% were pre‐frail, and 39% were frail. FI‐CGA‐10 was correlated with Canadian Study of Health and Aging (CSHA) Clinical Frailty Scale (r = 0.83), CSHA rules‐based frailty definition (r = 0.67), and CSHA Function Score (r = 0.77). Increasing levels of frailty were significantly associated with functional and cognitive impairments, high comorbidity burden, poor self‐rated health, and low estimated survival probabilities.
Conclusion
The FI‐CGA‐10 is a user‐friendly and construct‐validated measure for quantifying frailty from a CGA.
Implications for Practice
This article describes the construction of a user‐friendly 10‐item frailty index based on a comprehensive geriatric assessment (FI‐CGA‐10) for older adults with cancer: cognition, mood, communication, mobility, balance, nutrition, basic and instrumental activities of daily living, social support, and comorbidity. The FI‐CGA‐10 simplifies the original FI‐CGA used in the general geriatric setting while maintaining its content validity. The index's construct validity was demonstrated in a cohort of older adults with various cancer types. The advantage of the FI‐CGA‐10 is that a frailty score can be calculated more readily and interpreted in a more clinically sensible manner than the original FI‐CGA.
Frailty is associated with chemotherapy intolerance, postoperative complications, and death. This study aimed to construct an easy‐to‐use frailty index based on a comprehensive geriatric assessment that would be applicable in the geriatric oncology setting.
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