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    Dr. Aulia - Cancer and Chemotherapy in Elderly

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    The document discusses cancer treatment in elderly patients from a geriatrician's perspective. It notes that elderly cancer patients are more heterogeneous and have greater risks of functional dependence, malnutrition, and comorbidities. A comprehensive geriatric assessment can help identify those at risk of toxicity and poor outcomes from chemotherapy. Key domains of the assessment that often predict mortality and toxicity include functional impairment, malnutrition, and comorbidities. The assessment helps determine if patients are fit, vulnerable, or frail and the appropriate treatment approach.

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    Dr. Aulia - Cancer and Chemotherapy in Elderly

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    COVID RSHJ
    82 views36 pages
    The document discusses cancer treatment in elderly patients from a geriatrician's perspective. It notes that elderly cancer patients are more heterogeneous and have greater risks of functional dependence, malnutrition, and comorbidities. A comprehensive geriatric assessment can help identify those at risk of toxicity and poor outcomes from chemotherapy. Key domains of the assessment that often predict mortality and toxicity include functional impairment, malnutrition, and comorbidities. The assessment helps determine if patients are fit, vulnerable, or frail and the appropriate treatment approach.

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    dr. Aulia - Cancer and Chemotherapy in Elderly

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    The document discusses cancer treatment in elderly patients from a geriatrician's perspective. It notes that elderly cancer patients are more heterogeneous and have greater risks of functional dependence, malnutrition, and comorbidities. A comprehensive geriatric assessment can help identify those at risk of toxicity and poor outcomes from chemotherapy. Key domains of the assessment that often predict mortality and toxicity include functional impairment, malnutrition, and comorbidities. The assessment helps determine if patients are fit, vulnerable, or frail and the appropriate treatment approach.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    82 views36 pages

    Dr. Aulia - Cancer and Chemotherapy in Elderly

    Uploaded by

    COVID RSHJ
    The document discusses cancer treatment in elderly patients from a geriatrician's perspective. It notes that elderly cancer patients are more heterogeneous and have greater risks of functional dependence, malnutrition, and comorbidities. A comprehensive geriatric assessment can help identify those at risk of toxicity and poor outcomes from chemotherapy. Key domains of the assessment that often predict mortality and toxicity include functional impairment, malnutrition, and comorbidities. The assessment helps determine if patients are fit, vulnerable, or frail and the appropriate treatment approach.

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    of 36

    Cancer and Chemotherapy

    in elderly:
    geriatrician’s perspective
    Aulia Rizka

    Internist,

    Aulia Rizka
    Internist, Geriatrician

    Division of Geriatric Department of Internal Medicine


    Faculty of Medicine Universitas Indonesia
    Cipto Mangunkusumo General Hospital
    Outline

    Why elderly cancer patient is


    different and how GA can help

    How to screen those who


    need GA

    Benefit of GA and intervention


    What do we need?
    A BETTER INTEGRATED APPROACH
    BETWEEN ONCOLOGY AND GERIATRICS,
    WORLDWIDE
    The lesson from
    Maria
    71 old year woman, first

    diagnosis with diffuse large B-


    cell lymphoma of the tonsil
    Cancer and aging

    56% all
    cancer and
    Median 70% cancer
    age of Ca death
    11 fold diagnosis:
    increase risk 68 year
    of cancer
    Current Dilemma and Extreme Position

    THERAPEUTIC INTERMEDIATE BLIND THEURAPEUTIC


    NIHILISM POSITION NIHILISM
    Why elderly
    cancer
    patient is
    different?
    Decrease in capacity - heterogeneity

    Muravchik, Anesthesia 5th ed, 2000


    Need of
    Comprehensive
    50% functional dependence
    and risk of malnutrition Geriatric Assesment
    20% depression
    40% significant comorbidities

    10% cognitive dysfunctions


    Comprehensive Geriatric Assesment

    Anamnesis dan PJ Klinis, AMT, MMSE, GDS


    SISTEM
    PSIKO-KOGNITIF
    FISIK, BIOLOGIK

    SOSIAL
    FUNGSIONAL

    NUTRISI
    Anamnesis, kunjungan rumah
    ADL, IADL, MNA
    Final goal of cancer therapy

    Better Treated Patients Maintain Quality of Life


    13

    Fit patient Frail patient

    Don’t be undertreated Don’t be overtreated


    How to design screening tool?

    Identify
    Problems with
    predictors od
    ECOG PS and
    unacceptable
    KPS
    events

    Identify specific
    vulnerable
    profile
    Another approach
    Predictors of early death

    MNA and TGUG


    add to
    Stage and Sex
    for prediction
    of early death

    P Soubeyran, J Clin Oncol 2012; 30: 1829-34


    Another approach
    Predictors of functional decline

    IADL and GDS15 are


    the only predictors
    of early
    functional decline

    S Hoppe, J Clin Oncol 2013; 31: 3877-82


    Another approach
    17
    Predictors of toxicity
    IADL, MMS, MNA and MAX2
    or
    IADL and physical activities
    predict severe toxicity

    Martine Extermann, Cancer 2012;118:3377-86 Arti Hurria, J Clin Oncol 2011;29:3457-65


    Another approach
    18
    Predictors of hospitalization for toxicity

    OR 95% CI P-value
    MNA <24 4.194 1.7 - 10.3 0.0018
    Platelets 3.763 1.3 - 10.8 0.0140
    Treatment 0.509 0.26 - 0.99 0.0465
    strategy

    Thrombocytopenia and Malnutrition


    predict severe toxicity

    T Warkus, Proc SIOG 2011


    Most CGA tools
    are useful CGA is
    time-consuming

    Need for Screening tools


    G8 questionnaire
    Eight questions
    Performed by a nurse
    5 to 10 min
    Appetite, weight loss, BMI
    Mobility
    Mood and cognition
    Number of medications
    Self-related health
    Age

    Abnormal if ≤14
    Preliminary analysis
    Se: 89.6% ; Sp: 60.4%

    Carine Bellera, Ann Oncol 2012;23:2066-72


    What does G8 detect ?

     Detection of
     Abnormal MNA 94,4%
     Abnormal ADL 93,6%
     Abnormal TGUG 91,3%
     Abnormal GDS15 84,8%
     Abnormal IADL 84,5%
     Abnormal MMS 80,5%
     CIRS-G grade 3 – 4 77,4%
    What to do after G8 +
    Geriatric assessment (GA)1

    - Functional status
    - Comorbidity Remaining life expectancy
    - Polypharmacy Detection of unidentified problems
    Optimization before treatment
    - Cognitive function/
    Prediction of adverse outcomes
    dementia Treatment planning
    - Nutritional status Baseline information
    Shared decision-making
    - Depression
    - Social support FRAILTY

    1Wildiers et al, JCO, 2014


     Each CGA domain was associated
    with chemotoxicity and survival in at
    least one study
     The domains most often predicting
    mortality and chemotoxicity:
    functional impairment
    malnutrition
    comorbidities
    25
    "Comprehensive" Geriatric Assessment
    Assessment Instrument Administration Prognosis

    Dependency, PS, Activity of Daily Living (ADL), Instrumental


    Self administered +
    functional status ADL

    Charlson Comorbidity Index (CCI), Cumulative Self- or interviewer-


    Comorbidity +
    Illness rating Scale-Geriatric (CIRS-G) administered or chart-based

    Economic / social
    Life conditions, relatives, care-givers ?
    support
    +
    Cognition Folstein Mini-mental State Examination (MMSE) Interviewer-administered
    functional status
    Depression Geriatric Depression Scale (GDS) Self administered +
    Polypharmacy List ?

    Nutrition Mini Nutritional Assessment (MNA), BMI Interviewer-administered +

    Geriatric +
    Dementia, delirium, falls
    syndromes functional status
    Mobility/falls Timed-up-and-go-test, Tinetti Performance-tests ?
    26
    Will the patient tolerate
    and benefit from treatment? GA

    Fit Vulnerable Frail


    Independence 1 functional dependence Dependence
    No comorbidity ± 1-2 comorbidities ≥ 3 comorbidities
    Geriatric syndrome

    LE > cancer LE < cancer


    if poor
    Standard treatment Adjusted treatment tolerance BSC
    Similar treatment Decreased Poor treatment
    tolerance/benefit treatment tolerance tolerance

    Balducci Oncologist 2000


    The Present:
    Geriatric Assessment Items
    Predictive of Chemotherapy Toxicity
    Risk Factors Aaldriks Aparicio Extermann Freyer Hurria Kanesvaran Soubeyran Puts

    Daily Activities
    X X X X X X X
    (ADL & IADLs)
    Hearing
    X X
    (Fair or Deaf)

    Nutrition X X X X X

    Cognition X X X X X X

    Psychological
    X X X X X X
    Status
    Social
    X X
    Activities
    Aaldriks et al, Crit Rev Oncol Hematol 2011 Hurria et al, J Clin Oncol 2011
    Aparicio et al, J Clin Oncol 2013 Kanesvaran et al, J Clin Oncol 2011
    Extermann et al, Cancer 2012 Soubeyran et al, J Clin Oncol 2012
    Freyer et al, Annals of Oncology 2005 Puts et al, Ann Oncol 2014
    CRASH (Chemotherapy Risk Assessment
    Scale for High-Age Patients) -study
    design
    Laboratory data: WBC,
    Hgb, lymphocyte
    count, AST, LDH,
    albumin, CrCl

    Cancer-
    Clinical data: Grade 4 specific data:
    Age, Sex, DBP, Heme and Stage, bone
    BMI, 3-4 Non- marrow
    Comorbidity Heme invasion, prior
    score, toxicity chemo, and
    polypharmacy response to
    therapy
    Geriatric assessment:
    ECOG PS, Lawton’s
    IADLs, Folstein MMSE,
    MNA, GDS

    Presented by: Arati. V. Rao MD


    Extermann M et al. Cancer
    CRASH Score

    https://www.moffitt.org/eforms/crashscoreform/

    Extermann et al. Cancer, 2012


    30
    A True Predictive Model for
    Chemo-Related Grade 3-5 Toxicity
    1. 58% grade ≥ 3 toxicity
    2. Risk increased w/
    increasing risk score
    3. AUC/ROC 0.65 (95%CI
    0.58-0.71) ~
    development cohort 0.72
    (95%CI 0.68-0.77) (P =
    .09)
    4. No association between
    PS and chemo toxicity
    (P = .25)

    Hurria J Clin Oncol 2016


    31
    CGA impact on treament decision & interventions
    • Systematic review (Medline & Embase)
    – 1,654 reports  10 studies
    • 3 w/ CGA performed by geriatrician
    • 7 w/ GA performed by cancer specialist, healthcare worker or (research) nurse
    • Change in oncologic treatment: 6 studies
    – Modification of initial treatment plan: 39% patients
    • 2/3 w/ less intensive treatment (irrespective of performer)
    • High role of functional & nutritional status
    • Implementation of non-oncologic interventions defined
    according to CGA: 7 studies
    – All but one: interventions suggested for > 70% patients
    • Social 38%, medication 37%, nutritional 26%
    • Psychological, cognitive impairment, mobility and falls risk, previously unidentified
    comorbid conditions: all ~ 20% Hamaker Acta Oncol 2014
    Effect of CGA intervention.
    Impact of intervention
    40%

    35%
    P = 0.006 p
    30%

    25%

    20%

    15%

    10%

    5%

    0%

    Tx as planned 6mo deaths


    control CGA intervention

    Also trend toward less severe toxicity


    Kalsi et al., BJC 2015
    33

    Tumour General
    extent health
    T&N status
    Geriatric assessment
    Life expectancy
    Treatment toxicity

    Tumour Patient
    biology preference
    Luminal A/B & acceptability
    HER2 & TNBC
    Gene expression profile
    We need an Orchestra

    Epidemiology.
    Clinical and
    Clinical Oncol. Laboratory
    (Surgical, Research Geriatrics,
    Medical Gerontology
    Oncology, RT)

    GERIATRIC
    ONCOLOGY
    Rehabilitation,
    pharmacy, Palliative care
    nutrition, Supportive therapy
    social services
    Primary care

    Clinical Oncologists, Geriatricians and other partners


    Key Messages
     Under and over treatment in elderly cancer patient is
    prevalent
     Screening by G8 (by nurse, doctor, internist) if positive
    must be followed by GA
     Geriatric Assessment shows benefit in identifying which
    patient should get standard treatment and Best
    Supportive Care
     Geriatric Intervention may reduce chemotoxicity and
    support to finished treatment as planned
     Team collaboration is key to success
    Thank you
    Slides from Advanced Course on Geriatric Oncology (SIOG)

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