MON 2011 - Slide 17 - L. Repetto - Spotlight session - Cancer in the older person

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  • The specific questions of geriatric oncology
  • A clinical decision is based on cancer-related and patient-related elements. In older individuals life expectancy and tolerance of treatment are the basis of many decisions, especially related to adjuvant chemotherapy or chronic tumors (low grade lymphoma, prostate cancer, breast cancer metastatic to the bones.
  • The geriatric assessment has revealed a number of important and unexpected conditions in cancer patients aged 70+, in three prospective studies
  • The specific questions of geriatric oncology


  • 1. Lazzaro Repetto UOC Oncologia Istituto Nazionale Ricovero e Cura Anziani Istituto di Ricovero e Cura a Carattere Scientifico, Roma Cancer in the older person 4th ESO-EONS Masterclass in Oncology Nursing 2-7 April 2011 Ermatingen (Lake Constance), Switzerland
  • 2. Jemal et al, CA, ,2005, 55, 10
  • 3. Assessing the Older Patient for Cancer Treatment 15% of all population 60% of all cases of cancer 70% of all death for cancer
  • 4. Cancer in Senior Adults: open questions
    • How to define a Senior Adult in oncology/hematology?
    • How to evaluate patients and plan for treatment?
    • Where are we going with geriatric evaluation in oncology/hematology?
  • 5. As a guide, two ages are important milestones: 70 years because the prevalence of age-related changes strongly increases 85 years because the prevalence of frailty strongly increases There is No Short Definition of Elderly Cancer Patients Do these age limits fit requirements of onco-hematologist ?
  • 6. Cancer in Senior Adults: unsolved questions
    • 4/5 patients are 70 to 85 yrs.
    • At the best, we have evidence based treatment only for patients up to 75 yrs.
    • After 75 yrs, >50% of the pts do not received standard treatment or treatment at all, due to the fear of toxicity.
  • 7. Clinical approach to geriatric patient
  • 8.  
  • 9.  
  • 10. Same Chronological Age; Different Functional Age Do we have clinical options available for both?
    • CANCER
    CLINICAL DECISIONS Disease based perspective Individual based perspective
  • 12.
    • Use of comprehensive geriatric assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG)
    • M Extermann, M Aapro, R Bernabei, HJ Cohen, JP Droz, S Lichtman, V Mor, S Monfardini, L Repetto, L S ørbve, E Topinkova; Task Force on CGA of the International Society of Geriatric Oncology
    Extermann et al. Crit Rev Oncol Hematol . 2005;55(3):241-252.
  • 13. Geriatric assessment and detection of unexpected conditions
    • INCOME
  • 15.  
  • 16. Cancer and CGA: specific questions
    • Is the patient going to die with cancer or of cancer
    • Is the patient going to live long enough to suffer of cancer
    • Is the patient going to tolerate the treatment of cancer
    • What are the long term complications of cancer treatment
    • What is the status of the patient care-giver
  • 17.
    • Assess:
    • Life expectancy
      • Using specific histograms
    • Comorbidity that would interfere with cancer treatment and tolerability
      • Malnutrition/polypharmacy/lack of social support/mood disorders
    • Risk of morbidity from cancer
      • Stage/Prog Factors/Risk of Relapse/Type of Treatment
    • Patients goals and wishes
    Clinical approach to geriatric patient
  • 18.  
  • 19. Clinical approach to geriatric patient
    • Categorize patient at:
    • Moderate/high risk of dying or suffering for cancer or its complications
      • Action: Evaluate function and comorbidity to plan treatment
    • Low risk of dying or suffering for cancer or its complications or due to limited life expectancy low risk of developing morbidity from cancer
      • Action: Symptom management/supportive care
  • 20.  
  • 21. Categorize patients with CGA Balducci L, et al. Oncologist. 2000;5:224-237
    • Group 1
      • functionally independent, no serious comorbidity
      • standard cancer treatment
    • Group 2
      • partially dependent, ≤2 comorbid conditions
      • modified cancer treatment
    • Group 3
      • dependent, ≥3 comorbid conditions, any geriatric syndrome
      • palliative treatment
  • 22. Balducci L, et al. Oncologist. 2000;5:224-237. Assessment Group 1 Life expectancy >Cancer Life-prolonging treatment Palliation Group 2 Group 3 <Cancer Treatment tolerance Yes No Comprehensive Geriatric Assessment (CGA) (frail elderly)
  • 23. CGA and Outcomes in clinical oncology
    • CGA is especially beneficial for frail individuals.
    • Frail Cancer patients have an approximately 50% risk for mortality at 2 years.
    • We lack data on frailty assessment in cancer pts.
  • 24. Commonly observed geriatric syndromes GER. SYNDROMES CLINICAL DESCRIPTION Delirium Delirium is a transient organic mental syndrome of acute onset, characterized by global impairment of cognitive functions, reduced level of consciousness, attention abnormalities, increased or decreased psychomotor activity and a disordered sleep-wake cycle. Falls A fall is a sudden, unintentional change in position causing an individual to land at a lower level, for example on an object, floor or ground, that is not consequence of a sudden onset of paralysis, epileptic seizure, or overwhelming external force. Frailty According to phenotypic definition, frailty is defined as the presence of > 3 of 5 components: muscle weakness and slow walking speed, exhaustion, low physical activity, and unintentional weight loss. The definition of frailty based on frailty index (FI) is based on deficit accumulation using 70 deficits from clinical examination . Dizziness Painless head discomfort with many causes including disturbances of vision, brain, balance (vestibular) system of the inner ear, and gastrointestinal system. Dizziness is a medically indistinct term used to describe a variety of conditions ranging from lightheadedness, unsteadiness to vertigo . Urinary incontinence The inability to control urination or bladder control. The severity of urinary incontinence ranges from occasionally leaking urine to unpredictable episodes of strong urinary urgency. Syncope Partial or complete loss of consciousness with a temporary interruption of awareness of oneself and ones surroundings.
  • 25. IV. Geriatric syndrome of Frailty in Older Cancer Patients
    • The term frailty is frequently used to describe patients:
      • in poor overall health,
      • vulnerable to the effects of environmental stressors,
      • at high risk for worsened morbidity, disability, and mortality.
    • Frailty may be present in apparently healthy persons and become evident following a destabilizing event that exceeds a critical stress threshold:
      • surgery, chemotherapy, etc.
    Fisher AL. J Am Geriatr Soc. 2005 - Hogan DB, et al. Aging Clin Exp Res 2003 - Chin A, et al. J Clin Epidemiol. Canadian Study of Health and Aging Working Group. Int Psychogeriatr. 2001.
  • 26. Usefulness of frailty markers in the assessment of the health and functional status of older cancer patients referred for chemotherapy: a pilot study. Retornaz F, et al. J Gerontol A Biol Sci Med Sci. 2008: 63(5):518-22
    • Assessing 7 frailty markers ( nutrition, mobility, strength, energy, physical activity, mood and cognition ) , 88% of older cancer pts (>70 yrs) had at least one altered marker and were considered potentially vulnerable.
    • The use of frailty markers allows to detect functional dependency among older cancer patients without any ADL or IADL deficiency.
    • We need a better definition of frailty and more reliable tools to categorize cancer pts and to predict adverse outcomes.
  • 27. V. CGA and Outcomes in clinical oncology
    • Approx. 80% of older cancer pts are ADL independent and 50% are IADL independent.
    • There is no evidence of any change in ADLs and IADLs scores even in older cancer patients suffering from severe toxicity due to chemotherapy (*).
    • In the Cardiovascular Health Study frail persons were at a significantly higher risk of adverse outcomes (falls, worsening mobility, ADL dependence, hospitalization and 3yr mortality) (**).
    • At the moment, the literature is lacking similar evidence in older cancer patients.
    *Hurria A, JAGS 2006. - ** Fried LP, J Gerontol Med Sci 2001.
  • 28. Prognostic and Predictive Potentials of CGA in older cancer patients.
    • To identify risk factors for grade 3-5 chemo tox and develop a risk-stratification schema
    • 500 patients aged 65+ yrs were recruited from 7 Institutions, assessed with CGA and treated with different cht regimens for different cancer types.
    • Multivariate logistic regression identified 7 independent risk factors for grade 3-5 chemo toxicity
      • age >73yrs, cancer type, standard dose, polychemotherapy, falls in the last 6 months, IADL disability and decreased social activity.
    • This tool, based on the number of risk factors (1 to 7), predicts the risk of severe chemotherapy related toxicity from 23% to 100%.
    Hurria ASCO annual meeting 2010
  • 29. Prognostic and Predictive Potentials of CGA in older cancer patients.
    • To assess the individual risk of severe toxicity from cht ( defined by CTC v. 3.0., as Gr. 4 hemat. or Gr. 3-4 non-hemat. tox) in older pts with diverse health conditions and functional reserve measured by CGA.
    • Several variables were analyzed.
        • age, sex, BMI, diastolic BP (DBP), cancer stage, comorbidity (CIRS-G), polymedication, CBC, liver tests, LDH, creatinine clearance (CrCl), albumin, self-rated health, ECOG PS, IADL, GDS, MMS, MNA, marrow invasion, previous cht, and tumor response
        • Cht related toxicity (chemotox) was adjusted using the MAX2 score (*).
    • Using this tool, the CRASH score
      • LDH, diastolic BP, and chemotox were the best predictive variable for significant differences in the risk of severe haematological toxicity.
      • ECOG-PS, MMS, MNA and chemotox were the best predictive variables for severe non-haematological toxicity.
    • The CRASH score identifies four categories (0-3, 4-6, 7-9, >9) of older patients with different risk of severe toxicity (from 61% to 100%) (**).
    *Extermann EJC 2004 - **Extermann ASCO annual meeting 2010
  • 30. Cancer in Senior Adults: conclusions
    • Use CGA to define a Senior Adult in oncology/hematology.
    • Assess for frailty.
    • CGA has prognostic and predictive potentials.
  • 31. grazie