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E Learning General OncoGeriatrics PDF
E Learning General OncoGeriatrics PDF
E Learning General OncoGeriatrics PDF
An Introduction
Concluding remarks
LEARNING OBJECTIVES
Understand how comprehensive geriatric assessment works and what its uses are in
oncology – including in predicting chemotherapy toxicity
GERIATRIC ONCOLOGY
1. Delivorias A, Sabbati G. EU Demographic Indicators: Situation, Trends And Potential Challenges, March 2015; https://epthinktank.eu/2015/03/20/eu-
demographic-indicators-situation-trends-and-potential-challenges/. Accessed May 2017. Copyright © European Union, 2014. All rights reserved;
2. Iris Hoßmann, Europe’s Demographic Future Berlin Institut. 2008
GERIATRIC ONCOLOGY
Immunosuppression
GERIATRIC ONCOLOGY
Reprinted from The Cell, Vol 153, issue 6, Lopez-Otin C, et al., The Hallmarks of Aging, 1194-1217, Copyright 2013, with permission from Elsevier.
GERIATRIC ONCOLOGY
Lowsky J, et al., Gerontol A Biol Sci Med Sci (2014) 69 (6):640-649, by permission of Oxford University Press
GERIATRIC ONCOLOGY
Aging leads to decline in organ function – including kidney function, heart, respiratory
and nervous system, along others
This decline can be less than obvious based on tests alone, as under normal
circumstances, function may be adequate for necessity
Reprinted from The Lancet, Vol.381, Issue 9868, Clegg A, et al., Frailty in elderly people, 752-762,
Copyright 2013, with permission from Elsevier.
GERIATRIC ONCOLOGY
Independent
Functional abilities
Dependent
Reprinted from The Lancet, Vol.381, Issue 9868, Clegg A, et al., Frailty in elderly people, 752-762, Copyright 2013, with permission from Elsevier.
GERIATRIC ONCOLOGY
It identifies problems that are not identified by routine patient history and
physical examination
GERIATRIC ONCOLOGY
CGA is classically divided into “domains”, with each domain corresponding to one
aspect of aging-related issues
During CGA, there is no definitive evidence to determine the specific use of a set of
tools over another
GERIATRIC ONCOLOGY
Domains Scales
Functional status Eastern Cooperative Oncology Group performance status, Katz basic Activities of
Daily Living Scale, Simplified Lawton’s Instrumental Activities of Daily Living Scale
Comorbidities Charlson comorbidity index
Medications Number, type, indication
Cognitive function Folstein Mini-Mental State Examination, Schultz-Larsen Mini-Mental State
Examination
Geriatric syndrome Repeated falls, fecal and/or urinary incontinence
Depression/mood Geriatric Depression Scale 5, Emotional questionnaire
Nutrition Body mass index
Mobility Timed Up and Go test
Situational Accessibility of services, mobility, social environment, accessibility of home rooms
assessment
Ferrat E, et al., Performance of Four Frailty Classifications in Older Patients With Cancer: Prospective Elderly Cancer Patients Cohort StudyJ Clin Oncol.
2017;35(7):766–777. Reprinted with permission. © 2017 American Society of Clinical Oncology
GERIATRIC ONCOLOGY
Comprehensive Geriatric Assessment –
Comparison of 4 tools for evaluation of frailty
All tools predict 6-month hospital admission
Ferrat E, et al., Performance of Four Frailty Classifications in Older Patients With Cancer: Prospective Elderly Cancer Patients Cohort StudyJ Clin Oncol.
2017;35(7):766–777. Reprinted with permission. © 2017 American Society of Clinical Oncology
GERIATRIC ONCOLOGY
IADL
Maione P, et al., J Clin Oncol, 23(28) 2005: 6865-6872Reprinted with permission. © (2005) American Society of Clinical Oncology. All rights reserved.
GERIATRIC ONCOLOGY
Life expectancy is also deeply affected by other domains such as functionality, social
status and cognition
GERIATRIC ONCOLOGY
Comprehensive Geriatric Assessment – Comorbidity
Condition Assigned weight
Myocardial infarction 1
Congestive heart failure 1
Peripheral vascular disease 1 The Charlson Index measures risk of death
Cerebrovascular disease 1 in the next year
Dementia 1
Chronic pulmonary disease 1 During CGA, these and other comorbidities
Connective tissue disease 1 should be identified and optimal
Ulcer disease 1 management initiated
Liver disease, mild 1
Diabetes 1 In certain situations, depending on the
Hemiplegia 2 seriousness of the comorbidities, treatment
Renal disease, moderate or severe 2
Diabetes with end organ damage 2
of cancer should be delayed, modulated or
Any malignancy 2 entirely foregone
Leukaemia 2
Malignant lymphoma 2
Liver disease, moderate or severe 3
Metastatic solid malignancy 6
Albertsen PC, et al., J Clin Oncol, 29(10), 2011: 1335–1341. Reprinted with permission. © (2011) American Society of Clinical Oncology. All rights reserved.
GERIATRIC ONCOLOGY
Albertsen PC, et al., J Clin Oncol, 29(10), 2011: 1335–1341. Reprinted with permission. © (2011) American Society of Clinical Oncology. All rights reserved.
GERIATRIC ONCOLOGY
Comprehensive Geriatric Assessment – Estimating life expectancy
Four-Year Mortality Index for Older Adults
Parameter Result Points
• Lee index predicts mortality in
1. Age (years) 60–64 1 4 and 10 years
65–69 2
70–74
75–79
3
4
• It integrates age, comorbidity,
80–84 5 cognition and functionality
≥85 7
2. Sex (Male/Female) Male 2
Age group (y)
3. BMI [703 × (weight in pounds/height in inches2)] BMI <25 1
4. Has a doctor ever told you that you have diabetes or high Diabetes 1 ≥80 (n=2579) AUC =
blood sugar? (Y/N) 80 0.7239
70–79 (n=4921)
5. Has a doctor told you that you have cancer or a malignant Cancer 2 50–69 (n=12125)
=6
50
=9
25
= 12
≥14
0
0 1 2 3 4 5 6 7 8 9 10
Time since baseline interview (Years)
Don’t forget that elderly persons may have different priorities when making
decisions – such as maintaining functionality and independence – that may,
to them, be more important than living longer
GERIATRIC ONCOLOGY
Reprinted from Cancer Treatment Reviews, Vol. 40, Issue 6, Lange M, et al., Cognitive dysfunctions in elderly cancer patients:
A new challenge for oncologists ,810–817, copyright 2014, with permission from Elsevier.
GERIATRIC ONCOLOGY
Malnutrition is a significant problem among elderly persons, especially those with cancer
Kaiser MJ, et al., J Am Geriatr Soc 2010;58(9):1734–8 © 2010, Copyright the Authors. Journal compilation. © 2010, The American Geriatrics Society
GERIATRIC ONCOLOGY
Ahmed T Clin Interv Aging. 2010; 5: 207–216. Licensed under CC-BY-NC V3.0. https://creativecommons.org/licenses/by-nc/3.0/
GERIATRIC ONCOLOGY
Long-standing
Self-critical
vulnerabilities (eg,
cognitions
cognitive style)
Low rate of
Stressful life events Limitation of
positive Depression
and loss of social roles activities
outcomes
Changes in health,
physical ability, or
cognitive ability
Fiske A, et al., Annu Rev Clin Psychol. 2009; 5: 363–389. Reproduced with permission from Annual review of Clinical Psychology, Volume 5, © by Annual reviews,
http://www.annualreviews.org
GERIATRIC ONCOLOGY
Elderly patients are likely to have less social support due to widowhood, death of
friends and other family members
Elderly abuse (physical, economic and emotional) also remains a problem, as well as
the disempowerment of independent patients by their family members after a diagnosis
of cancer
GERIATRIC ONCOLOGY
Elderly patients often use multiple drugs besides those associated with cancer
treatment, putting them at risk of polypharmacy
Polypharmacy may be defined in different ways but is, at its core, the discord of
number of medication and utility of medications
E.g., a 75-year-old man with metastatic lung cancer takes statins to control his
cholesterol
GERIATRIC ONCOLOGY
The concept of geriatric syndrome differ from those of disease and syndrome
Geriatric
syndrome
Screening Tools – G8
Multiple screening tools – shortened forms of CGA, which select patients who need full
CGA or not at any given time point – are available
Screening Tools – G8
A score of <14 is abnormal and
correlates with OS
Kenis C, et al., J Clin Oncol, 32 (1), 2014: 19-26. Reprinted with permission. © (2014) American Society of Clinical Oncology. All rights reserved.
GERIATRIC ONCOLOGY
First visit to discuss treatment:
• Patient history
• Cancer
• G8 screening tool
• Life expectancy
G8 ≤14 G8 >14
Decision making
• Evaluate patient autonomy or need
for surrogate decision making
Full CGA • Prognosis vs. life expectancy
• Identification of • Benefit vs. toxicity of treatment
domains • Discuss patient’s priorities and
goals
• Possible social and economic No need of full CGA
• Proposed geriatric
issues that may affect
interventions
No treatment Treatment
Elderly patients can expect a higher rate of neutropenia, fatigue, cardiac toxicity and
neuropathy than younger patients
Elderly patients more often need dose reductions, delays and permanent interruptions
than younger patients
Validated
GERIATRIC ONCOLOGY
Hurria A, et al., Validation of a Prediction Tool for Chemotherapy Toxicity in Older Adults With CancerJ Clin Oncol. 2016;34(20):2366-71. Reprinted with
permission. © 2016 American Society of Clinical Oncology
GERIATRIC ONCOLOGY
Concluding Remarks
More initiatives are necessary to educate oncologists and integrate geriatrics into usual
oncology practice and services
Together, this will allow closing of the gap that currently exists between younger and
older patients, and will lead to better outcomes
THANK YOU!