[Mirror survey of patients with urge urinary incontinence and healthcare professionals]. / Enquête miroir auprès de patients et de professionnels de santé portant sur l'incontinence urinaire par urgenturie ou mixte.

BACKGROUND: This survey assessed how much of a taboo surrounds urge or mixed urinary incontinence (UI), through questions to affected patients and healthcare professionals using online questionnaires, with the objective to contrast the patients' perceptions with that of the doctors. METHODS: This quantitative study was preceded by a qualitative phase carried out with general practitioners, specialists, and UI patients. Following these phases, questionnaires were made available on the internet. They covered questions pertaining to perceptions of UI, degree of embarrassment and its consequences, patient-doctor relationship, and treatments. RESULTS: Overall, 310 UI patients of male or female gender participated in the study, as did 101 general practitioners, 50 urologists, and 30 gynecologists. The analysis revealed that 60% of patients felt embarrassment about UI, the condition representing for them a taboo topic similar to cancer. This taboo was shown to be seen further enhanced by doctors. UI was associated with a loss of self-esteem (51%) and restriction to daily life (44%). The patients' answers revealed that UI was only brought up by doctors in 6% of cases, whereas the patient was the first to bring it up in 55%, primarily with their general practitioner (80%). Thus, in 4 out of 10 cases, the issue was not addressed; 49% of patients stated they did not discuss their condition with their partner and 33% did not discuss it with anybody. CONCLUSION: UI is still a major taboo and we have a long way to go to change attitudes. LEVEL OF EVIDENCE: 3.

[Epidemiological, pathological and prognostic characteristics of bladder cancer in elderly patients]. / Spécificités épidémiologiques, pathologiques et pronostiques du cancer de la vessie chez les patients âgés.

AIM: To define and present explanations for the epidemiological, pathological and prognostic differences in bladder cancer in elderly patients. METHOD: Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, carcinogenesis, elderly, epidemiology, prognosis. RESULTS: Bladder cancer is a growing concern for the elderly first and foremost and with an impact, mainly those who are consumers or former users of tobacco, whose therefore frequently have comorbidities associated with this consumption. The initiated carcinogenesis extends with the life length of patients, increasing the prevalence of bladder cancer. Aging promotes carcinogenesis by both potentiating its genetic abnormalities and reducing the immune system performance of the aged host to destroy cancer cells. The delay in the diagnosis of bladder cancer in elderly patients is explained and make up for the time could improve the prognosis. CONCLUSION: Regardless of variations in therapeutic effect and morbidity and mortality of treatments, aging promotes the occurrence and aggressiveness of bladder cancer. The incentive to stop exposure to carcinogens and the search for bladder cancer in patients with hematuria should not reduce with advanced age but instead be promoted in order to improve the prognosis.

[Evaluation of the elderly patient with cancer]. / Évaluation du patient âge présentant un cancer.

PURPOSE: To explain the notion of frailty, then to explain how crucial is the detection of frailty detection in the elderly patient, and, in cases of suspected frailty, how crucial is the need for geriatric assessment. To describe (i) how this assessment of the elderly cancer patient is performed, (ii) how the results of this geriatric assessment must drive the decision making, and (iii) the role of the geriatrician in the care pathway. METHOD: Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific geriatric societies, from the National Cancer Institute using the following keywords: elderly, geriatrics, cancer, frailty, assessment, decision making. RESULTS: The goal of frailty detection is to optimize care, to maintain the independence and the survival of the patient. The prevalence of frailty increases with the age and the diagnosis of cancer. Detection of frailty in the elderly patient with cancer is performed using the G8 questionnaire recommended by the INCa. In case of anomaly or clinical justification, the patient receives a geriatric assessment, which is a multidimensional and multidisciplinary procedure. The clinician can call on the UCOG of the region in which he practices. The relevance of medical decisions will be based on the results of this geriatric assessment. The geriatrician plays a crucial role and will be involved throughout the care. CONCLUSION: The detection of frailty in the elderly patient with cancer is obligatory. Consecutive geriatric assessment can be performed by the UCOG of the region. The results of the geriatric assessment must serve as a basis for any therapeutic decision making and the preservation of the independence of the patient must remain the priority.

[Onco-urology of the aging patient: Epidemiological and biological aspects]. / Onco-urologie du sujet âgé : aspects épidemiologiques et biologiques.

PURPOSE: First, to present the epidemiological data of aging and of cancers and to describe the respectives expected evolutions. Second, to present biological and genetic data on aging and on the relationships between aging and oncogenesis. METHOD: Bibliographic search from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as from the web sites of geriatric scientific societies, the United Nations, the World Bank, the World Health Organization, the Institut National du Cancer and the Ligue Contre le Cancer from the following keywords: aging, elderly, cancer, epidemiology, biology, genetics. RESULTS: The entire world population is aging very significantly and very rapidly. In France, new cases of cancer are diagnosed in 62.4% of cases in patients over 65 and in 11.5% of cases in patients over 80 years. Cancer mortality occurs in 75.3% of cases in patients over 65 years of age and in 24.8% of cases in patients over 80 years of age. Cancer-specific mortality is consistently higher in patients older than 75 years compared to younger patients; this reflects, among other things, an age discrimination which is called agism. It has been established that cellular aging is marked by 9 major families of biological and genomic abnormalities. Biological aging and oncogenesis are intertwined with increasingly well established relationships. They are both the product of natural selection and they are found in all species with both renewal tissues and a distinction between germinal tissue and somatic tissue. CONCLUSION: Epidemiological data predict that oncology, including urological oncology, is becoming very predominantly geriatric oncology; it is critical and urgent that society be prepared for it and that every care-giver be prepared, that is, be specifically trained. Biological and genetic data argue for a great entanglement between aging and oncogenesis; research in each of these areas should be reconciled for mutual benefit.

[Geriatric specificities of prostate cancer]. / Spécificités gériatriques du cancer de la prostate.

PURPOSE: To describe the epidemiology of prostate cancer (PCa) and its natural history in the elderly patient. To propose adaptations of geriatric evaluation specific to PCa. Recall therapeutic options and the treatment options specific to elderly patients. METHOD: Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific societies of geriatrics, from the National Cancer Institute using the following keywords: elderly, geriatrics, prostate cancer, diagnosis, treatment. RESULTS: The median age at diagnosis for PCa is 69 years old, making PCa the very type of cancer of the elderly. The specific mortality of the disease increases with age. This translates two of its characteristics. First, a diagnosis at higher grade and stage is more common in older patients than in younger patients. Secondly, use of curative therapeutic options is less common in elderly patients than in younger patients. SIOG recommends a specific geriatric assessment for patients with PCa, which may be useful, but the need for an initial detection of cognitive disorders is open to criticism. There is no therapeutic trial, if only prospective, dedicated to elderly patients with PCa. However, decision-making in the elderly patient with PCa must pursue two goals: first, the respect of the expectations specific to each patient and secondly, the search for the global clinical benefit; goals that should not be restricted to elderly patients. CONCLUSION: PCa in the elderly patient follow the current guidelines for diagnostic and for treatment. Compliance with these guidelines should eliminate both the late diagnosis and the under-treatment actually observed.

[Optimizing the management of bladder cancer in older patients]. / Optimisation de la prise en charge du cancer de la vessie chez les patients âgés.

AIM: To define and present potential improvements for the management of bladder cancer in older patients. METHOD: Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: bladder cancer, treatment, BCG, chemotherapy, cystectomy, and elderly. RESULTS: The oncological principles of medico-surgical management of bladder cancer do not differ according to age. On the other hand, the patient comorbidities have been likely to alter the tolerance of these treatments. At the NMIBC stages, no adaptation of the standard treatment has demonstrated any interest. At the MIBC stages, the prognosis was improved by geriatric multidisciplinary perioperative management. CONCLUSION: The indications and principles of surgical treatments must be identical regardless of the patient age. At the NMIBC stages, adjuvant therapy, including BCG therapy, should not be questioned because of the age of the patient. On the other hand, at the localized MIBC stages, neoadjuvant and adjuvant chemotherapy should not be considered as a standard and their indications assessed individually after geriatric assessment.

[Geriatric specificities of localized renal cell carcinoma]. / Spécificités gériatriques du cancer du rein localisé.

PURPOSE: To describe the epidemiology of renal cell carcinoma (RCC) and its natural history in the elderly patient. To propose adaptations of geriatric evaluation specific to RCC. Recall therapeutic options and the treatment options specific to elderly patients. METHOD: Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific societies of geriatrics, from the National Cancer Institute using the following keywords: elderly, geriatrics, renal cell carcinoma, small renal mass, diagnosis, treatment. RESULTS: The incidence of RCC increases in France and peaks between 70 and 80 years. This increase in incidence is mainly due to the diagnosis of small renal masses (SMR). The specific mortality of RCC increases with age (at least between 75 and 95 years). Tumor biopsy, especially of SMR, should be considered in the elderly patient. The geriatric assessment of patients with CaR has no specificity apart from specific evaluation of renal function and operative risk. There is no prospective therapeutic trials dedicated to elderly patients with localized RCC. Surgical treatment requires the use of fast track protocol (the modalities of which are being elaborated) in which geriatricians play a key role throughout the process. The role of percutaneous ablative treatment should be better defined in elderly patients. However, given their low specific mortality, surveillance of SRM (at least initially) is probably an interesting option, certainly under-used, although its impact on quality of life remains to be clarified. The overarching goal of geriatric oncology must guide the decisions of care in the older patient with CaR: first, the respect of patient-specific expectations and secondly the search for an overall clinical benefit; objectives that have no reason to be restricted to elderly patients. CONCLUSION: RCC is becoming a predominantly elderly cancer. It responds to the current general diagnostic and therapeutic guidelines. It is desirable that clinical research help to better define the respective roles of percutaneous biopsy and treatment of localized RCC.

[Specificity of the management of metastatic renal cancer in the older patient]. / Spécificité de la prise en charge du cancer du rein métastatique chez le patient âgé.

AIM: To define the necessary arrangements of medical treatment with anti-angiogenics, mTOR inhibitor or systemic immunotherapies in the management of metastatic renal cell carcinoma in elderly patients. METHOD: Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: metastatic renal cell carcinoma, elderly, treatment. RESULTS: The selection criteria for the medical treatment of metastatic renal cell carcinoma in elderly patients are the IMDC score, necessarily complemented by performance status, the tolerability profile of treatments, more frequent drug interactions, treatment adherence, management capacity of side effects, and patient preference. Each of these criteria is detailed in critical ways. CONCLUSION: The efficacy and tolerability of medical treatments for metastatic renal cancer have not been reported as different depending on age. No dosage adjustment is recommended in principle. However, prevention and early treatment of side effects of treatment should be strengthened in elderly patients.

Bevacizumab+chemotherapy versus chemotherapy alone in elderly patients with untreated metastatic colorectal cancer: a randomized phase II trial-PRODIGE 20 study results.

Background: Metastatic colorectal cancer frequently occurs in elderly patients. Bevacizumab in combination with front line chemotherapy (CT) is a standard treatment but some concern raised about tolerance of bevacizumab for these patients. The purpose of PRODIGE 20 was to evaluate tolerance and efficacy of bevacizumab according to specific end points in this population. Patients and methods: Patients aged 75 years and over were randomly assigned to bevacizumab + CT (BEV) versus CT. LV5FU2, FOLFOX and FOLFIRI regimen were prescribed according to investigator's choice. The composite co-primary end point, assessed 4 months after randomization, was based on efficacy (tumor control and absence of decrease of the Spitzer QoL index) and safety (absence of severe cardiovascular toxicities and unexpected hospitalization). For each arm, the treatment will be consider as inefficient if 20% or less of the patients met the efficacy criteria and not safe if 40% or less met the safety criteria. Results: About 102 patients were randomized (51 BEV and 51 CT), median age was 80 years (range 75-91). Primary end point was met for efficacy in 50% and 58% and for safety in 61% and 71% of patients in BEV and CT, respectively. Median progression-free survival was 9.7 months in BEV and 7.8 months in CT. Median overall survival was 21.7 months in BEV and 19.8 months in CT. The 36-month overall survival rate was 27% in BEV and 10.1% in CT. Severe toxicities grade 3/4 were mainly non-hematologic toxicities (80.4% in BEV, 63.3% in CT). Conclusion: Bevacizumab combined with CT was safe and efficient. Both arms met the primary safety and efficacy criteria.

Colorectal cancer screening: factors associated with colonoscopy after a positive faecal occult blood test.

BACKGROUND: Contextual socio-economic factors, health-care access, and general practitioner (GP) involvement may influence colonoscopy uptake and its timing after positive faecal occult blood testing (FOBT). Our objectives were to identify predictors of delayed or no colonoscopy and to assess the role for GPs in colonoscopy uptake. METHODS: We included all residents of a French district with positive FOBTs (n = 2369) during one of the two screening rounds (2007-2010). Multilevel logistic regression analysis was performed to identify individual and area-level predictors of delayed colonoscopy, no colonoscopy, and no information on colonoscopy. RESULTS: A total of 998 (45.2%) individuals underwent early, 989 (44.8%) delayed, and 102 (4.6%) no colonoscopy; no information was available for 119 (5.4%) individuals. Delayed colonoscopy was independently associated with first FOBT (odds ratio, (OR)), 1.61; 95% confidence interval ((95% CI), 1.16-2.25); and no colonoscopy and no information with first FOBT (OR, 2.01; 95% CI, 1.02-3.97), FOBT kit not received from the GP (OR, 2.29; 95% CI, 1.67-3.14), and socio-economically deprived area (OR, 3.17; 95% CI, 1.98-5.08). Colonoscopy uptake varied significantly across GPs (P=0.01). CONCLUSION: Socio-economic factors, GP-related factors, and history of previous FOBT influenced colonoscopy uptake after a positive FOBT. Interventions should target GPs and individuals performing their first screening FOBT and/or living in socio-economically deprived areas.

Prognostic value of comorbidities in older patients with cancer: the ELCAPA cohort study.

BACKGROUND: In older patients, comorbidities competed with cancer for mortality risk. We assessed the prognostic value of comorbidities in older patients with cancer. PATIENTS AND METHODS: We analysed all patients >70 years of age with colorectal, breast, prostate, or lung cancer included in the prospective ELCAPA cohort. The Cumulative Illness Rating Scale-Geriatrics (CIRS-G) score was used to assess comorbidities. The primary endpoint was overall survival (OS) at 3, 12, and 36 months. The adjusted difference in the restricted mean survival time (RMST) was used to assess the strength of the relationship between comorbidities and survival. RESULTS: Of the 1551 patients included (median age 82 years; interquartile range 78-86 years), 502 (32%), 575 (38%), 283 (18%), and 191 (12%) had colorectal, breast, prostate, and lung cancer, respectively, and 50% had metastatic disease. Hypertension, kidney failure, and cognitive impairment were the most common comorbidities (67%, 38%, and 29% of the patients, respectively). A CIRS-G score >17, two or more severe comorbidities, more than seven comorbidities, heart failure, and cognitive impairment were independently associated with shorter OS. The greatest effect size was observed for CIRS-G >17 (versus CIRS-G <11): at 36 months, the adjusted differences in the RMST (95% confidence interval) were -6.0 months (-9.3 to -2.6 months) for colorectal cancer, -9.1 months (-13.2 to -4.9 months) for breast cancer, -8.3 months (-12.8 to -3.9 months) for prostate cancer, and -5.5 months (-9.9 to -1.1 months) for lung cancer (P < 0.05 for all). CONCLUSIONS: Comorbidities' type, number, and severity were independently associated with shorter OS. A 17-point cut-off over 56 for the total CIRS-G score could be considered in clinical practice.

Immune risk phenotype is associated with nosocomial lung infections in elderly in-patients.

BACKGROUND: Nosocomial infections are extremely common in the elderly and may be related to ageing of the immune system. The Immune Risk Phenotype (IRP), which predicts shorter survival in elderly patients, has not been evaluated as a possible risk factor for nosocomial infection. Our aim was to assess the prevalence of nosocomial infections in elderly in-patients and to investigate potential relationships between nosocomial infections and the immunophenotype, including IRP parameters. RESULTS: We included 252 consecutive in-patients aged 70 years or over (mean age, 85 ± 6.2 years), between 2006 and 2008. Among them, 97 experienced nosocomial infections, yielding a prevalence rate of 38.5% (95% confidence interval, 32.5-44.5). The main infection sites were the respiratory tract (21%) and urinary tract (17.1%) When we compared immunological parameters including cell counts determined by flow cytometry in the groups with and without nosocomial infections, we found that the group with nosocomial infections had significantly lower values for the CD4/CD8 ratio and naive CD8 and CD4 T-cell counts and higher counts of memory CD8 T-cells with a significant increase in CD28-negative CD8-T cells. Neither cytomegalovirus status (positive in 193/246 patients) nor presence of the IRP was associated with nosocomial infections. However, nosocomial pneumonia was significantly more common among IRP-positive patients than IRP-negative patients (17/60 versus 28/180; p = 0.036). CONCLUSION: Immunological parameters that are easy to determine in everyday practice and known to be associated with immune system ageing and shorter survival in the elderly are also associated with an elevated risk of nosocomial pneumonia in the relatively short term.

Immunotherapy in older patients with cancer.

Ageing implicates a remodeling of our immune system, which is a consequence of the physiological senescence of our cells and tissues coupled with environmental factors and chronic antigen exposure. An immune system that senesces includes more differentiated cells with accumulation of highly differentiated CD4 and CD8 T cells. The pool of naive T cells decreases with the exponential thymic involution induced by age. Differentiated T cells have similar, if not higher, functional capacities but scarce studies are looking at the impact of senescence among specific T cells. After a stimulation, other immune cells (monocytes, dendritic cells and NK) are functionally altered during ageing. It is as if the immune system was more efficient at the basal level, but less efficient after a stimulation in the old compared to young people, likely due to less reserve. Concerning the clinical impact, older people are more prone to certain pathogens and their clinical manifestations differ from the younger people. Severe flu and VZV reactivation are more frequent with an altered cellular response to vaccination. Vaccination failure can have detrimental consequences in people presenting frailty criteria. Old people frailty is majored by their comorbidities and diseases like cancer. Thus, chemotherapies are employed with circumspection in older patients. The use of anti-PD-1/PD-L1 immunotherapies is therefore attractive, because of less side effects with a better response compared to chemotherapy. Old persons inclusion is lacking in current studies and clinical trials. Some subgroups or pooled analyses confirm the gain in response without increased toxicities in older patients but their inclusion criteria differ from the real-life practice. Specific studies focusing on this population are needed because of the increasing cancer incidence with age and the overall ageing of the population.

[Specificities of chemotherapy in elderly cancer patients]. / Spécificités de la prise en charge par chimiothérapie chez le sujet âgé.

The management of cancer in the elderly patients is becoming a major problem of public health. The population is becoming older, the risk of cancer is increasing with age and therapeutic tools are improving. The numerous pharmacological changes of age might influence the pharmacokinetic and pharmacodynamic variables of many drugs, in particular the agents of chemotherapy. The development of news drugs, with less toxicity, administrated weekly or orally, and of supportive care (hematological growth factors, nutritional support) allows proposing specific treatment to elderly patients with cancer. However, evidence-based medicine data are lacking to define optimal schedules in this population due to low inclusion rates in clinical trials. This paper explores the specificities of chemotherapy in elderly patients with cancer.

[Status epilepticus in the elderly patients. A retrospective study of 63 in-patients]. / Etat de mal épileptique de la personne âgée. Etude rétrospective de 63 patients hospitalisés.

INTRODUCTION: Status epilepticus is quite frequent in the elderly but rarely studied despite the poor functional prognosis and significant mortality. METHODS: We retrospectively evaluated the clinical manifestations and electroencephalogram findings observed over a two-year period in 63 consecutive inpatients aged over 70 years presenting status epilepticus. The variables studied included age, sex, the number of concomitant chronic active diseases, previous neurological disorders, brain lesions on CT or MRI, the use and withdrawal of medications and outcome. RESULTS: The incidence of status epilepticus was 1%; two-thirds in women and one-third in men. The mean age was 83 years. Complex partial status epilepticus was noted in 91% with predominant features of confusion (89%), impairment of consciousness (75%) or psychiatric symptoms (46%). Etiologies were often multifactorial and acute symptomatic. Etiology was metabolic in 60%, drug-induced in 51%, demential in 44%, cerebrovascular in 37%, infectious in 30% and other neurological disorders in 28% of the cases. Antiepileptic drugs used to treat status epilepticus were benzodiazepine (60%), often in association with lamotrigine (51%), valproate (46%) or phenytoin (25%). Maintenance of an antiepileptic drug was found in 70% of cases. Complications were loss of autonomy (86%), malnutrition (67%), infections (51%), dementia (30%), pressure sores (14%), and recurrent epilepsy (13%). Mortality was 32% of cases and it was higher in men. CONCLUSION: These findings have shown some special features of status epilepticus among the elderly but other prospective studies are needed to confirm these results and to identify optimal management to decrease mortality, and improve the poor functional prognosis.

Multidisciplinary development of the Geriatric Core Dataset for clinical research in older patients with cancer: A French initiative with international survey.

BACKGROUND: To define a core set of geriatric data to be methodically collected in clinical cancer trials of older adults, enabling comparison across trials. PATIENTS AND METHODS: Following a consensus approach, a panel of 14 geriatricians from oncology clinics identified seven domains of importance in geriatric assessment. Based on the international recommendations, geriatricians selected the mostly commonly used tools/items for geriatric assessment by domain (January-October 2015). The Geriatric Core Dataset (G-CODE) was progressively developed according to RAND appropriateness ratings and feedback during three successive Delphi rounds (July-September 2016). The face validity of the G-CODE was assessed with two large panels of health professionals (55 national and 42 international experts) involved both in clinical practice and cancer trials (March-September 2017). RESULTS AND DISCUSSION: After the last Delphi round, the tools/items proposed for the G-CODE were the following: (1) social assessment: living alone or support requested to stay at home; (2) functional autonomy: Activities of Daily Living (ADL) questionnaire and short instrumental ADL questionnaire; (3) mobility: Timed Up and Go test; (4) nutrition: weight loss during the past 6 months and body mass index; (5) cognition: Mini-Cog test; (6) mood: mini-Geriatric Depression Scale and (7) comorbidity: updated Charlson Comorbidity Index. More than 70% of national experts (42 from 20 cities) and international experts (31 from 13 countries) participated. National and international surveys showed good acceptability of the G-CODE. Specific points discussed included age-year cut-off, threshold of each tool/item and information about social support, but no additional item was proposed. CONCLUSION: We achieved formal consensus on a set of geriatric data to be collected in cancer trials of older patients. The dissemination and prospective use of the G-CODE is needed to assess its utility.

Geriatric analysis from PRODIGE 20 randomized phase II trial evaluating bevacizumab + chemotherapy versus chemotherapy alone in older patients with untreated metastatic colorectal cancer.

BACKGROUND: Older patients have frailty characteristics that impair the transposition of treatment results found in younger patients. Predictive factors are needed to help with treatment choices for older patients. The PRODIGE 20 study is a randomized phase II study that evaluated chemotherapy associated with bevacizumab (BEV) or not (CT) in patients aged 75 years or older. PATIENTS AND METHODS: Patients underwent a geriatric assessment at randomization and at each evaluation. The predictive value of geriatric and oncologic factors was determined for the primary composite end-point assessing safety and efficacy of treatment (BEV or CT) simultaneously and also progression-free survival (PFS) and overall survival (OS). RESULTS: 102 patients were randomized (51 BEV and 51 CT; median age 80 years [range 75-91]). On multivariate analysis, baseline normal independent activity of daily living (IADL) score and no previous cardiovascular disease predicted the primary end-point. High (versus low) baseline Köhne score predicted short PFS and baseline Spitzer quality of life (QoL) score <8, albumin level ≤35 g/L, CA19.9 >2 LN levels above normal and high baseline Köhne score predicted short OS. Survival without deteriorated QoL and autonomy was similar with BEV and CT. On subgroup analyses, the benefit of bevacizumab seemed to be maintained in patients with baseline impaired IADL or nutritional status. CONCLUSION: Normal IADL score was associated with a good efficacy and safety of both BEV and CT. Köhne criteria may be relevant prognostic factors in older patients. Adding bevacizumab to chemotherapy does not impair patient autonomy or QoL.