Effectiveness of Therapeutic Patient Education Interventions for Older Adults with Cancer: A Systematic Review.

The incidence of cancer increases with age and demographics shows that the population of western countries is dramatically ageing. The new discipline of Geriatric Oncology is emerging aiming at providing tailored and patient-centred support to older adults with cancer. With the development of oral cancer therapy and outpatient treatments, Therapeutic Patient Education (TPE), aiming at enabling the patient and their relatives to cope with the disease in partnership with health professionals, appears to be an interesting and useful tool. The purpose of this paper is to search for evidence of the effectiveness of educational interventions for patients in older adults with cancer. The first screening found 2,617 articles, of which 150 were eligible for review. Among them, fourteen finally met the inclusion criteria: experimental and quasi-experimental studies enrolling older adults (over 65 years old), suffering from cancer and receiving an educational intervention. The types of educational intervention were diverse in these studies (support by phone and web base material). The results appear to be positive on anxiety, depression and psychological distress, patient knowledge and pain. However, data currently available on the effectiveness of a TPE program in Geriatric Oncology is lacking. Further studies are needed to assess the effectiveness of TPE programs adapted to the specific circumstances of the older adult.

No Difference in the Phenotypic Expression of Frailty among Elderly Patients Recently Diagnosed with Cancer Vs Cancer Free Patients.

OBJECTIVES: To examine frailty determinants differences in patients with a recent diagnosis of cancer compared to non-cancer patients among older adult. Revealing those differences will allow us to individualize the exact frailty management in those patients diagnosed with cancer. DESIGN: This is an observational cross-sectional, monocentric study. SETTING: Patients were evaluated at the Geriatric Frailty Clinic (GFC), in the Toulouse University Hospital, France, between October 2011 and February 2016. PARTICIPANTS: 1996 patients aged 65 and older were included (1578 patients without cancer and 418 patients with solid and hematological cancer recently diagnosed). MEASUREMENTS: Frailty was established according to the frailty phenotype. The frailty phenotype measures five components of frailty: weight loss, exhaustion, low physical activity, weakness and slow gait. Frailty phenotype was categorized as robust, pre-frail and frail. RESULTS: In a multinomial logistic regression, cancer, compared to the non-cancer group, is not associated with an increased likelihood of being classified as pre frail (RRR 0.9, 95% CI [0.5 ; 1.6 ], p 0.9) or frail (RRR 1.2, 95% CI [0.7 ; 2.0], p 0.4) rather than robust. When considering each Fried criterion, a significant higher odd of weight loss was observed in older patients with cancer compared to the non-cancer patients (OR 2.3, 95% CI [1.8; 3.0], p <0.001) but no statistically significant differences was found among the four other Fried criteria. Sensitivity analysis on the frailty index showed that cancer was not associated with a higher FI score compared to non-cancer (ß 0.002, 95%CI [-0.009; 0.01], p 0.6). CONCLUSION: In this real-life study evaluating elderly patients with and without cancer, we didn't confirm our hypothesis, in fact we found that cancer was not associated with frailty severity using both a phenotypic model and a deficit accumulation approach. Cancer may contribute, at least additively, to the development of frailty, like any other comorbidity, rather than a global underlying condition of vulnerability.

Increased ischemic stroke, acute coronary artery disease and mortality in patients with granulomatosis with polyangiitis and microscopic polyangiitis.

OBJECTIVE: The aim of our study was to assess major cardiovascular event incidence, predictors, and mortality in ANCA-associated vasculitis (AAV). METHODS: We conducted a retrospective cohort study of all GPA or MPA, according to Chapel Hill Consensus Conference classification criteria, diagnosed between 1981 and 2015. Major cardiovascular event was defined as acute coronary artery disease, or ischemic stroke, or peripheral vascular disease requiring a revascularization procedure. We calculated the comparative morbidity/mortality figure (CMF) and we used Cox proportional hazards regression models to assess the risk of coronary artery disease, ischemic stroke associated with AAV, after adjusting for covariates. RESULTS: 125 patients, 99 GPA (79,2%) and 26 MPA (20,8%), were followed 88.4 ±â€¯78.3 months. Ischemic stroke incidence was four times higher than in the general population (CMF 4,65; 95% CI 4,06-5,31). Coronary artery disease incidence was four times higher than in the general population (CMF 4,22; 95% CI 1,52-11,68). Smoking habits and history of coronary artery disease were strongly associated with coronary artery disease occurrence (adjusted HR 8.8; 95% CI 2.12-36.56, and adjusted HR 10.3; 95% CI 1.02-104.5, respectively). ENT flare-up was an independent protective factor for coronary artery disease occurrence. We did not identify factors significantly associated with stroke occurrence. The age-adjusted mortality rate was 22.5 per 1000 person-years. Mortality in AAV was 1.5 times higher than in the general population (CMF 1.56; 95% CI 1.34-1.83). CONCLUSION: AAV have a significantly increased risk of mortality, ischemic stroke, and coronary artery disease.

ICP Monitoring and Phase-Contrast MRI to Investigate Intracranial Compliance.

OBJECTIVE: The amplitude of intracranial pressure (ICP) can be measured by ICP monitoring. Phase-contrast magnetic resonance imaging (PCMRI) can quantify blood and cerebrospinal fluid (CSF) flows. The aim of this work was to investigate intracranial compliance at rest by combining baseline ICP monitoring and PCMRI in hydrocephalus patients. MATERIALS AND METHODS: ICP monitoring was performed before infusion testing to quantify ΔICP_rest at the basal condition in 33 suspected hydrocephalus patients (74 years). The day before, patients had had a PCMRI to assess total cerebral blood flow (tCBF), intracranial blood volume change (stroke volume SVblood), and cervical CSF volume change (the stroke volume CSV). Global (blood and CSF) intracranial volume change (ΔIVC) during each cardiac cycle (CC) was calculated. Finally, Compliance: C_rest = ΔIVC/ΔICP_rest was calculated. The data set was postprocessed by two operators according to blind analysis. RESULTS: Bland-Altman plots showed that measurements presented no significant difference between the two operators. ΔICP_rest = 2.41 ± 1.21 mmHg, tCBF = 469.89 ± 127.54 mL/min, SVblood = 0.82 ± 0.32 mL/cc, CSV = 0.50 ± 0.22 mL/cc, ΔIVC = 0.44 ± 0.22 mL, and C_rest = 0.23 ± 0.15 mL/mmHg. There are significant relations between SVblood and CSV and also SVblood and tCBF. CONCLUSIONS: During "basal" condition, the compliance amplitude of the intracranial compartment is heterogeneous in suspected hydrocephalus patients, and its value is lower than expected! This new parameter could represent new information, complementary to conventional infusion tests. We hope that this information can be applied to improve the selection of patients for shunt surgery.

Drug Prescription Including Interactions with Anticancer Treatments in the Elderly: A Global Approach.

BACKGROUND: Consequences of inappropriate prescriptions and polymedication in patients suffering from cancer are beginning to be well documented. However, the methods used to evaluate these consequences are often discussed. Few studies evaluate the risk of interaction with anticancer drugs in elderly patients suffering from cancer. OBJECTIVES: To describe the prevalence (i) of polypharmacy, (ii) of potentially inappropriate drug prescriptions and (iii) of drug interactions involving anticancer treatments, using a multiple reference tools. DESIGN: A retrospective, cross-sectional, multicenter study performed from January to December 2012. PARTICIPANTS: Patients aged 65 years or older suffering from cancer presented at the oncogeriatric multidisciplinary meeting. MEASUREMENTS: Polymedication (>6 drugs), potentially inappropriate prescriptions and drug interactions involving anticancer treatment were analyzed in combination with explicit and implicit criteria within a global approach. RESULTS: Among the 106 patients included in this study, polypharmacy was present in 60.4% of cases, potentially inappropriate drug prescription in 63.1% and drug interactions in 16% of case, of which 47% involved anti-cancer treatments. Twenty-seven major drug interactions were identified and eight interactions involved chemotherapy. CONCLUSION: Polymedication, inappropriate prescribing and drug interactions involving anti-cancer drugs are common and largely underestimated in elderly cancer patients.

Methodology of phase II clinical trials in metastatic elderly breast cancer: a literature review.

PURPOSE: As the incidence of invasive breast cancer will increase with age, the number of elderly patients with a diagnosis metastatic breast cancer will also rise. But the use of cytotoxic drugs in elderly metastatic breast cancer patients is not systematic and is dreaded by medical oncologists. The need for prospective oncologic data from this population seems increasingly obvious. The main objective of this review is to investigate design and characteristics of phase II trials that assess activity and feasibility of chemotherapies in elderly advanced/metastatic breast cancer patients. METHODS: An electronic search in PUBMED allowed us to retrieve articles published in English language on phase II trials in elderly metastatic breast cancer between January 2002 and May 2016. Sixteen publications were finally included in this review. RESULTS: The primary endpoint was a simple, a composite, and a co-primary endpoints in 11, three, and two studies, respectively. Efficacy was the primary objective in 15 studies: simple (n = 10), composite (n = 3), co-primary endpoints (n = 2). Composite or co-primary endpoints combined efficacy and toxicity. Thirteen studies used multistage designs. CONCLUSIONS: Only five studies evaluated the feasibility, i.e., to jointly assess efficacy and tolerance to treatment (toxicity, quality of life, etc) as primary endpoint. Development of elderly specific phase III clinical trials might be challenging, it therefore seems essential to conduct phase II clinical trials evaluating jointly efficacy and toxicity in a well-defined geriatric population. Use of multistage designs that take into account heterogeneity would allow to identify a subpopulation at interim analysis and to reduce the number of patients exposed to an inefficient or a toxic treatment regimen. It is crucial to evaluate new therapies (targeted therapies, immunotherapies) using adequate methodologies (Study design, endpoint).

Visual Impairment Screening at the Geriatric Frailty Clinic for Assessment of Frailty and Prevention of Disability at the Gérontopôle.

OBJECTIVES: To evaluate visual performance and factors associated with abnormal vision in patients screened for frailty at the Geriatric Frailty Clinic (GFC) for Assessment of Frailty and Prevention of Disability at Toulouse University Hospital. DESIGN: Retrospective, observational cross-sectional, single-centre study. SETTING: Institutional practice. PARTICIPANTS: Patients were screened for frailty during a single-day hospital stay between October 2011 and October 2014 (n = 1648). MEASUREMENTS: Collected medical records included sociodemographic data (including living environment and educational level), anthropometric data, and clinical data. The general evaluation included the patient's functional status using the Activities of Daily Living (ADL) scale and the Instrumental Activity of Daily Living (IADL) scale, the Mini-Mental State Examination (MMSE) for cognition testing, and the Short Physical Performance Battery (SPPB) for physical performance. We also examined Body Mass Index (BMI), the Mini-Nutritional Assessment (MNA), and the Hearing Handicap Inventory for the Elderly Screening (HHIE-S) tool. The ophthalmologic evaluation included assessing visual acuity using the Snellen decimal chart for distant vision, and the Parinaud chart for near vision. Patients were divided into groups based on normal distant/near vision (NDV and NNV groups) and abnormal distant/near vision (ADV and ANV groups). Abnormal distant or near vision was defined as visual acuity inferior to 20/40 or superior to a Parinaud score of 2, in at least one eye. Associations with frailty-associated factors were evaluated in both groups. RESULTS: The mean age of the population was 82.6 ± 6.2 years. The gender distribution was 1,061 females (64.4%) and 587 males (35.6%). According to the Fried criteria, 619 patients (41.1%) were pre-frail and 771 (51.1%) were frail. Distant and near vision data were available for 1425 and 1426 patients, respectively. Distant vision was abnormal for 437 patients (30.7%). Near vision was abnormal for 199 patients (14%). Multiple regression analysis showed that abnormal distant vision as well as abnormal near vision were independently associated with greater age (P < 0.01), lower educational level (P < 0.05), lower performance on the MMSE (P < 0.001), and lower autonomy (P < 0.02), after controlling for age, gender, educational level, Fried criteria, and MMSE score. CONCLUSION: The high prevalence of visual disorders observed in the study population and their association with lower autonomy and cognitive impairment emphasises the need for systematic screening of visual impairments in the elderly. Frailty was not found to be independently associated with abnormal vision.

Body Composition and Anti-Neoplastic Treatment in Adult and Older Subjects - A Systematic Review.

BACKGROUND: The estimation of the risk of poor tolerance and overdose of antineoplastic agents protocols represents a major challenge in oncology, particularly in older patients. We hypothesize that age-related modifications of body composition (i.e. increased fat mass and decreased lean mass) may significantly affect tolerance to chemotherapy. METHOD: We conducted a systematic review for the last 25 years (between 1990 and 2015), using US National library of Medicine Medline electronic bibliographic database and Embase database of cohorts or clinical trials exploring (i) the interactions of body composition (assessed by Dual X-ray Absorptiometry, Bioelectrical Impedance Analyses, or Computerized Tomography) with pharmacokinetics parameters, (ii) the tolerance to chemotherapy, and (iii) the consequences of chemotherapies or targeted therapies on body composition. RESULTS: Our search identified 1504 articles. After a selection (using pre-established criteria) on titles and abstract, 24 original articles were selected with 3 domains of interest: impact of body composition on pharmacokinetics (7 articles), relationship between body composition and chemotoxicity (14 articles), and effect of anti-cancer chemotherapy on body composition (11 articles). The selected studies suggested that pharmacokinetic was influenced by lean mass, that lower lean mass could be correlated with toxicity, and that sarcopenic patients experienced more toxicities that non-sarcopenic patients. Regarding fat mass, results were less conclusive. No studies specifically explored the topic of body composition in older cancer patients. CONCLUSIONS: Plausible pathophysiological pathways linking body composition, toxicity, and pharmacokinetics are sustained by the actual review. However, despite the growing number of older cancer patients, our review highlighted the lack of specific studies in the field of anti-neoplastic agents toxicity regarding body composition conducted in elderly.

Impact of an oncogeriatric consulting team on therapeutic decision-making.

Increased life expectancy and cancer incidence imply the need to develop a specialized care policy for elderly patients with cancer. We created an oncogeriatric consulting team (OGCT) in Toulouse University Hospital to carry out comprehensive gerontological assessment at the bedside of hospitalized patients. We analyze the impact on the final cancer treatment decision of this mobile geriatric assessment. We carried out a descriptive, retrospective real-life analysis of a patient cohort over a two-year period. The OGCT assessed 124 patients, of whom the majority were women (54.8%), median age 81 years, living at home (95.2%) and with family caregivers (86.5%). Nearly all were frail (96.7% according to the classification of Balducci and colleagues) and 3.2% were vulnerable. The team's decisions were analyzed for patients who had not yet been treated (n=107). After analysis, the team's proposal was in line with the initial cancer treatment plan in 68.2% of cases (n=73). In cases where there was a disagreement, the final decision was in line with the mobile team's proposal in 17.75% of 107 patients (n=19). The decision of the team was followed more often when their assessment proposed strictly palliative treatment. The decision to give elderly patients specific cancer treatment seems in our experience rather to be a matter for the oncologists, and is not very susceptible to modification by geriatric opinion. On the other hand, the geriatrician appears to be more credible and his/her opinion more likely to be followed when the patient is considered too frail and less aggressive, or even exclusively palliative, treatment is proposed.

[Reynolds syndrome revealing a malignant thymoma]. / Un syndrome de Reynolds révélant un thymome malin.

INTRODUCTION: Thymomas, benign or malignant, may be associated with autoimmune diseases. They are classically associated with myasthenia gravis, neuromyotonia, or pure red cell aplasia. CASE REPORT: We here report, to the best of our knowledge, the first description of an association between thymoma and Reynolds syndrome (systemic sclerosis associated with primary biliary cirrhosis) in an 80-year-old woman. CONCLUSION: The suspected pathogenesis of this association could be a thymus escape of auto-reactive T lymphocytes and the consecutive development of an auto-immune disorder.

[Mood and cognitive disorders, and androgen deprivation]. / Troubles de l'humeur et cognitifs et suppression androgénique.

Prostate cancer has become a chronic disease. In this context, it is important to take into account the quality of life of patients and their family in the therapeutic approach. Recent studies have demonstrated the importance of depression and the risk of suicide in patients with prostate cancer as well as the repercussions of the disease on the spouse and their relationship. The implication of hormonal treatment in the increase in risk of depression is difficult to affirm. Few studies have investigated this subject and they present methodological biases. Some authors report an increased risk of cognitive decline in patients on androgen deprivation. However, even if certain physiopathological hypotheses have been put forward, the imputability of the treatment on the alteration of cognitive functions has not been clearly established. Urologists are at the forefront of diagnosis and treatment of prostate cancer occurring most often in elderly subjects. Therefore, given the prevalence of depression syndromes and/or the alteration of cognitive functions in this population, the urologist must be aware of these different factors, which are potentially aggravated by the introduction of androgen deprivation. Based on a review of the recent literature, the authors suggest using a simple depression screening tool: confirmation of the diagnosis and management is within the competence of the general practitioner. As for the risk of cognitive decline, it seems difficult to imagine, and not necessarily relevant, to systematically propose a battery of neuropsychometric screening tests. On the other hand, giving the patient the G8 screening test can allow the urologist to assess whether the patient needs a geriatric consultation or not.