Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical ...practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .
Factors captured in a geriatric assessment can predict morbidity and mortality in older adults, but are not routinely measured in cancer clinical trials. This study evaluated the implementation of a ...geriatric assessment tool in the cooperative group setting.
Patients age ≥ 65 with cancer, who enrolled on cooperative group cancer trials, were eligible to enroll on Cancer and Leukemia Group B (CALGB) 360401. They completed a geriatric assessment tool before initiation of protocol therapy, consisting of valid and reliable geriatric assessment measures which are primarily self-administered and require minimal resources and time by healthcare providers. The assessment measures functional status, comorbidity, cognitive function, psychological state, social support, and nutritional status. The protocol specified criteria for incorporation of the tool in future cooperative group trials was based on the time to completion and percent of patients who could complete their portion without assistance. Patient satisfaction with the tool was captured.
Of the 93 patients who enrolled in this study, five (5%) met criteria for cognitive impairment and three did not complete the cognitive screen, leaving 85 assessable patients (median age, 72 years). The median time to complete the geriatric assessment tool was 22 minutes, 87% of patients (n = 74) completed their portion without assistance, 92% (n = 78) were satisfied with the questionnaire length, 95% (n = 81) reported no difficult questions, and 96% (n = 82) reported no upsetting questions. One hundred percent of health care professionals completed their portion.
This brief, primarily self-administered geriatric assessment tool met the protocol specified criteria for inclusion in future cooperative group clinical trials.
Selecting the most appropriate end points for clinical trials is important to assess the value of new treatment strategies. Well-established end points for clinical research exist in oncology but may ...not be as relevant to the older cancer population because of competing risks of death and potentially increased impact of therapy on global functioning and quality of life. This article discusses specific clinical end points and their advantages and disadvantages for older individuals. Randomized or single-arm phase II trials can provide insight into the range of efficacy and toxicity in older populations but ideally need to be confirmed in phase III trials, which are unfortunately often hindered by the severe heterogeneity of the older cancer population, difficulties with selection bias depending on inclusion criteria, physician perception, and barriers in willingness to participate. All clinical trials in oncology should be without an upper age limit to allow entry of eligible older adults. In settings where so-called standard therapy is not feasible, specific trials for older patients with cancer might be required, integrating meaningful measures of outcome. Not all questions can be answered in randomized clinical trials, and large observational cohort studies or registries within the community setting should be established (preferably in parallel to randomized trials) so that treatment patterns across different settings can be compared with impact on outcome. Obligatory integration of a comparable form of geriatric assessment is recommended in future studies, and regulatory organizations such as the European Medicines Agency and US Food and Drug Administration should require adequate collection of data on efficacy and toxicity of new drugs in fit and frail elderly subpopulations.
Background
To determine long‐term quality‐of‐life (QOL) trajectories among breast cancer survivors aged 65+ (older) evaluating the effects of personality and social support.
Methods
Older women ...(N = 1280) newly examined with invasive, nonmetastatic breast cancer completed baseline assessments. Follow‐up data were collected 6 and 12 months later and then annually for up to 7 years (median 4.5 years). Quality of life was assessed using EORTC‐QLQ‐C30 emotional, physical, and cognitive scales. Optimism (Life Orientation Test), Coping (Brief COPE), and social support (Medical Outcomes Study) were assessed at baseline. Group‐based trajectory modeling identified QOL trajectories; multinomial regression evaluated effects of predictors on trajectory groups. Age, education, systemic therapy, comorbidity, and reported precancer function (SF‐12) were considered as controlling variables.
Results
Three trajectories were identified for each QOL domain: “maintained high,” “phase shift” (lower but parallel scores to “maintained high” group), and “accelerated decline” (lowest baseline scores and steepest decline). Accelerated decline in emotional, physical, and cognitive function was seen in 6.9%, 31.8%, and 7.6% of older survivors, respectively. Maladaptive coping and lower social support increased adjusted odds of being in the accelerated decline group for all QOL domains; lower optimism was only related to decline in emotional function. Chemotherapy was related to physical and cognitive but not emotional function trajectories.
Conclusions
Personality and social resources affect the course of long‐term emotional well‐being of older breast cancer survivors; treatment is more important for physical and cognitive than emotional function. Early identification of those vulnerable to deterioration could facilitate clinical and psychological support.
To explore the impact of varying hemoglobin levels on mortality, function, and cognition in a representative population of older persons.
Participants in this prospective cohort study included 1 744 ...men and women, aged 71 years or older, from a random household sample living in Durham and surrounding counties in North Carolina. Hemoglobin levels were obtained from participants at baseline in 1992. Functional status was measured at the 4-year follow-up interview using Katz and instrumental activities of daily living. Cognition was measured using the Short Portable Mental Status Questionnaire (SPMSQ). Death was determined by search of the National Death Index, and all deaths through 2000 are included.
Using World Health Organization (WHO) criteria, the prevalence of anemia was 24%. There was a strong racial difference with an odds ratio, adjusted for age, education, estimated glomerular filtration rate and comorbidity of 3.0 (95% CI, 2.3-3.9) in African Americans compared with Caucasians. The risk ratio for 8-year mortality was 1.7 (95% CI, 1.5-2.0) for anemic subjects (
P = .0001) and did not differ by sex or race. Anemia was strongly associated with poorer physical function (
P = .0001) and cognitive function (
P = .0001), and predicted decreases in both over a 4-year period.
In an elderly community-based population, anemia is more prevalent in African Americans and is independently associated with increased mortality over 8 years for both races and sexs. Anemia also is a risk factor for functional and cognitive decrease.
Objectives
To analyze self‐reported changes in physical function in older women with breast cancer receiving adjuvant chemotherapy.
Design
Secondary analysis of the Cancer and Leukemia Group B ...(CALGB) 49907 prospective randomized clinical trial.
Setting
CALGB institutions in the United States.
Participants
Women aged 65 and older with Stage I to III breast cancer enrolled in CALGB 49907 who had physical function data from before and after receipt of adjuvant chemotherapy (N=256; mean age 71.5, range 65–85).
Measurements
Participants were administered the physical function subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire before chemotherapy, at the end of chemotherapy, and 12 months after chemotherapy initiation. Functional decline was defined as a more than 10‐point decrease from baseline at each time point. Resilience was defined as return to within 10 points of baseline. Multivariable regression was used to examine pretreatment characteristics associated with physical function changes.
Results
Of 42% of participants who had physical function decline from before to the end of chemotherapy, 47% recovered by 12 months (were resilient). Almost one‐third experienced functional decline from before chemotherapy to 12 months later. Pretreatment fatigue was a risk factor for functional decline from before to the end of chemotherapy (P=.02). Risk factors for functional decline at 12 months included pretreatment dyspnea (P=.007) and being unmarried (P=.01).
Conclusion
Functional decline was common in older women receiving adjuvant chemotherapy for breast cancer in a clinical trial. Although half recovered their physical function, one‐third had a clinically meaningful decline at 12 months. Strategies are needed to prevent functional decline in older adults receiving chemotherapy. J Am Geriatr Soc 67:920–927, 2019.
While moderate- to vigorous-intensity physical activities (MVPA) confer the greatest health benefits, evidence suggests that light-intensity activities are also beneficial, particularly for older ...adults and individuals with moderate to severe comorbidities.
PURPOSETo examine cross-sectional and longitudinal associations between light-intensity activity and physical function in older cancer survivors at increased risk for age- and treatment-related comorbidities, including accelerated functional decline.
METHODSThe analysis included data from 641 breast, prostate, and colorectal cancer survivors (54% female) age 65 yr and older who participated in a 1-yr home-based diet and exercise intervention designed to reduce the rate of physical function decline. ANCOVA was used to compare means of physical function across levels of PA intensity (low–light LLPA1.5–2.0 METs; high–light HLPA2.1–2.9 METs; MVPA≥3.0 METs).
RESULTSIn cross-sectional analyses, increasing tertiles of light-intensity activity were associated with higher scores for all three measures of physical function (all P values <0.005), after adjusting for age, sex, body mass index, comorbidity, symptoms, and MVPA. Associations were stronger for HLPA than for LLPA. Compared with survivors who had decreased MVPA or maintained stable MVPA and HLPA at the postintervention follow-up, those who had increased HLPA, but had decreased MVPA or maintained stable MVPA, reported higher physical function scores (LS means 95% confidence intervalSF-36 Physical Function Subscale−5.58 −7.96 to −3.20 vs −2.54 −5.83 to 0.75, P = 0.14; Basic Lower Extremity Function−2.00 −3.45 to −0.55 vs 0.28 −1.72 to 2.28, P = 0.07; Advanced Lower Extremity Function−2.58 −4.00 to −1.15 vs 0.44 −1.52 to 2.40, P = 0.01).
CONCLUSIONSOur findings suggest that increasing light-intensity activities, especially HLPA, may be a viable approach to reducing the rate of physical function decline in individuals who are unable or reluctant to initiate or maintain adequate levels of moderate-intensity activities.
Disease drivers of aging Hodes, Richard J.; Sierra, Felipe; Austad, Steven N. ...
Annals of the New York Academy of Sciences,
December 2016, Volume:
1386, Issue:
1
Journal Article
Peer reviewed
Open access
It has long been known that aging, at both the cellular and organismal levels, contributes to the development and progression of the pathology of many chronic diseases. However, much less research ...has examined the inverse relationship—the contribution of chronic diseases and their treatments to the progression of aging‐related phenotypes. Here, we discuss the impact of three chronic diseases (cancer, HIV/AIDS, and diabetes) and their treatments on aging, putative mechanisms by which these effects are mediated, and the open questions and future research directions required to understand the relationships between these diseases and aging.
Although allogeneic hematopoietic stem cell transplantation (HCT) can be a curative therapy for hematologic disorders, it is associated with treatment-related complications and losses in ...cardiorespiratory fitness and physical function. High-intensity interval training (HIIT) may be a practical way to rapidly improve cardiorespiratory fitness and physical function in the weeks prior to HCT. The primary aim of this study was to assess the feasibility of implementing a pre-HCT home-based HIIT intervention. The secondary aim was to evaluate pre to post changes in cardiorespiratory fitness and physical function following the intervention.
This was a single-arm pilot study with patients who were scheduled to undergo allogeneic HCT within six months. Patients were instructed to complete three 30-minute home-based HIIT sessions/week between the time of study enrollment and sign-off for HCT. Sessions consisted of a 5-minute warm-up, 10 high and low intervals performed for one minute each, and a 5-minute cool-down. Prescribed target heart rates (HR) for the high- and low-intensity intervals were 80-90% and 50-60% of HR reserve, respectively. Heart rates during HIIT were captured via an Apple Watch and were remotely monitored. Feasibility was assessed via retention, session adherence, and adherence to prescribed interval number and intensities. Paired t-tests were used to compare changes in fitness (VO2peak) and physical function Short Physical Performance Battery (SPPB), 30-second sit to stand, and six-minute walk test (6MWT) between baseline and sign-off. Pearson correlations were used to determine the relationship between intervention length and changes in cardiorespiratory fitness or functional measures.
Thirteen patients (58.8±11.6 years) participated in the study, and nine (69.2%) recorded their training sessions throughout the study. Median session adherence for those nine participants was 100% (IQR: 87-107). Adherence to intervals was 92% and participants met or exceeded prescribed high-intensity HR on 68.8±34.8% of intervals. VO2peak improved from baseline to sign-off (14.6±3.1 mL/kg/min to 17.9±3.3 mL/kg/min; p<0.001). 30-second sit to stand and SPPB chair stand scores significantly improved in adherent participants. Improvements in 30-second sit to stand (13.8±1.5 to 18.3±3.3 seconds) and 6MWT (514.4±43.2 to 564.6±19.3) exceeded minimal clinically important improvements established in other chronic disease populations, representing the minimum improvement considered meaningful to patients.
Findings demonstrate that implementing a pre-HCT home-based remotely monitored HIIT program is feasible and may provide benefits to cardiorespiratory fitness and physical function.
A phase III trial (Cancer and Leukemia Group B CALGB-49907) was conducted to test whether older patients with early-stage breast cancer would have equivalent relapse-free and overall survival with ...capecitabine compared with standard chemotherapy. The quality of life (QoL) substudy tested whether capecitabine treatment would be associated with a better QoL than standard chemotherapy.
QoL was assessed in 350 patients randomly assigned to either standard chemotherapy (cyclophosphamide, methotrexate, and fluorouracil CMF or doxorubicin and cyclophosphamide AC; n = 182) or capecitabine (n = 168). Patients were interviewed by telephone before treatment (baseline), midtreatment, within 1 month post-treatment, and at 12, 18, and 24 months postbaseline by using questionnaires from the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30), a breast systemic adverse effects scale (EORTC BR23), and the Hospital Anxiety and Depression Scale (HADS).
Compared with patients who were treated with standard chemotherapy, patients who were treated with capecitabine had significantly better QoL, role function, and social function, fewer systemic adverse effects, less psychological distress, and less fatigue during and at the completion of treatment (P ≤ .005). Capecitabine treatment was associated with less nausea, vomiting, and constipation and with better appetite than standard treatment (P ≤ .004), but worse hand-foot syndrome and diarrhea (P < .005). These differences all resolved by 12 months.
Standard chemotherapy was superior to capecitabine in improving relapse-free and overall survival for older women with early-stage breast cancer. Although capecitabine was associated with better QoL during treatment, QoL was similar for both groups at 1 year. The brief period of poorer QoL with standard treatment is a modest price to pay for a chance at improved survival.
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