How are caregivers involved in treatment decision making for older people with dementia and a new diagnosis of cancer?

OBJECTIVE: To explore how caregivers are involved in making treatment decisions for older people living with dementia and a new diagnosis of cancer. METHOD: A systematic review of PubMed, CINAHL, PsycINFO, Web of Science, and Scopus databases was conducted. Studies recruiting formal or informal caregivers for older people with dementia and a diagnosis of cancer were considered for inclusion. RESULTS: Of 1761 articles screened, 36 full texts were assessed for eligibility, and six were included in the review. This review has identified that health care professionals (HCPs) are often unaware of the coexistence or severity of dementia in cancer patients, and therefore fail to properly address care needs as a result. While caregivers are relied on to help make decisions, they have unmet information needs and feel excluded from decision-making. CONCLUSION: Treatment decision making in the context of older adults with dementia and a new diagnosis of cancer needs further research. This will help HCPs to understand their needs and improve the experience of decision making for both caregivers and the people that they care for.

Quality of life versus length of life considerations in cancer patients: A systematic literature review.

OBJECTIVE: Patients with cancer face difficult decisions regarding treatment and the possibility of trading quality of life (QoL) for length of life (LoL). Little information is available regarding patients' preferences and attitudes toward their cancer treatment and the personal costs they are prepared to exchange to extend their life. The aim of this review is to determine the complex trade-offs and underpinning factors that make patients with cancer choose quality over quantity of life. METHODS: A systematic review of the literature was conducted using MeSH terms: cancer, longevity or LoL, QoL, decision making, trade-off, and health utility. Articles retrieved were published between 1942 and October 2018. RESULTS: Out of 4393 articles, 30 were included in this review. Older age, which may be linked to declining physical status, was associated with a preference for QoL over LoL. Younger patients were more likely to undergo aggressive treatment to increase survival years. Preference for QoL and LoL was not influenced by gender, education, religion, having children, marital status, or type of cancer. Patients with better health valued LoL and inversely those with poorer physical status preferred QoL. CONCLUSION: Baseline QoL and future expectations of life seem to be key determinants of preference for QoL versus LoL in cancer patients. In-depth studies are required to understand these trade-offs and the compromises patients are willing to make regarding QoL or LoL, especially in older patients with naturally limited life expectancy.

Treatment choices for older women with primary operable breast cancer and cognitive impairment: Results from a prospective, multicentre cohort study.

OBJECTIVES: The presence of dementia co-existing with a diagnosis of breast cancer may render management more challenging and have a substantial impact on oncological outcomes. The aim of this study was to examine the treatment and outcomes of older women with co-existing cognitive impairment and primary breast cancer. MATERIALS AND METHODS: A prospective, multicentre UK cohort study of women aged 70 years or over with primary operable breast cancer. Patients with and without cognitive impairment were compared to assess differences in treatment and survival outcomes. RESULTS: In total, 3416 women were recruited between 2013 and 2018. Of these, 478 (14%) had a diagnosis of dementia or cognitive impairment, subcategorised as mild, moderate and severely impaired. Up to 85% of women with normal cognition underwent surgery compared to 74%, 61% and 40% with mild, moderate, and severe impairment (p = 0.001). Among women at higher risk of recurrence, the uptake of chemotherapy was 25% for cognitively normal women compared to 20%, 22% and 12% for mild, moderate and severe impairment groups (p = 0.222). Radiotherapy use was similar in the subgroups. Although patients with cognitive impairment had shorter overall survival (HR: 2.10, 95% CI: 1.77-2.50, p < 0.001), there were no statistically significant differences in breast cancer specific or progression-free survival. CONCLUSION: Cognitive impairment appears to play a significant part in deciding how to treat older women with breast cancer. Standard treatment may be over-treatment for some women with severe dementia and careful consideration must be given to a more tailored approach in these women.

Bridging the age gap in breast cancer. Impacts of omission of breast cancer surgery in older women with oestrogen receptor positive early breast cancer. A risk stratified analysis of survival outcomes and quality of life.

BACKGROUND: Age-related breast cancer treatment variance is widespread with many older women having primary endocrine therapy (PET), which may contribute to inferior survival and local control. This propensity-matched study determined if a subgroup of older women may safely be offered PET. METHODS: Multicentre, prospective, UK, observational cohort study with propensity-matched analysis to determine optimal allocation of surgery plus ET (S+ET) or PET in women aged ≥70 with breast cancer. Data on fitness, frailty, cancer stage, grade, biotype, treatment and quality of life were collected. Propensity-matching (based on age, health status and cancer stage) adjusted for allocation bias when comparing S+ET with PET. FINDINGS: A total of 3416 women (median age 77, range 69-102) were recruited from 56 breast units-2854 (88%) had ER+ breast cancer: 2354 had S+ET and 500 PET. Median follow-up was 52 months. Patients treated with PET were older and frailer than patients treated with S+ET. Unmatched overall survival was inferior in the PET group (hazard ratio, (HR) 0.27, 95% confidence interval (CI) 0.23-0.33, P < 0.001). Unmatched breast cancer-specific survival (BCSS) was also inferior in patients treated with PET (HR: 0.41, CI: 0.29-0.58, P < 0.001 for BCSS). In the matched analysis, PET was still associated with an inferior overall survival (HR = 0.72, 95% CI: 0.53-0.98, P = 0.04) but not BCSS (HR = 0.74, 95% CI: 0.40-1.37, P = 0.34) although at 4-5 years subtle divergence of the curves commenced in favor of surgery. Global health status diverged at certain time points between groups but over 24 months was similar when adjusted for baseline variance. INTERPRETATION: For the majority of older women with early ER+ breast cancer, surgery is oncologically superior to PET. In less fit, older women, with characteristics similar to the matched cohort of this study (median age 81 with higher comorbidity and functional impairment burdens, the BCSS survival differential disappears at least out to 4-5 year follow-up, suggesting that for those with less than 5-year predicted life-expectancy (>90 years or >85 with comorbidities or frailty) individualised decision making regarding PET versus S+ET may be appropriate and safe to offer. The Age Gap online decision tool may support this decision-making process (https://agegap.shef.ac.uk/). TRIAL REGISTRATION NUMBER: ISRCTN: 46099296.

Bridging the Age Gap in breast cancer: Impact of chemotherapy on quality of life in older women with early breast cancer.

INTRODUCTION: Older patients with early breast cancer (EBC) derive modest survival benefit from chemotherapy but have increased toxicity risk. Data on the impact of chemotherapy for EBC on quality of life in older patients are limited, but this is a key determinant of treatment acceptance. We aimed to investigate its effect on quality of life in older patients enrolled in the Bridging the Age Gap study. MATERIALS AND METHODS: A prospective, multicentre, observational study of EBC patients ≥70 years old was conducted in 2013-2018 at 56 UK hospitals. Demographics, patient, tumour characteristics, treatments and adverse events were recorded. Quality of life was assessed using the European Organisation for Research and Treatment of Cancer Quality-of-Life Questionnaires (EORTC-QLQ) C30, BR23 and ELD 15 plus the Euroqol-5D (eq-5d) over 24 months and analysed at each time point using baseline adjusted linear regression analysis and propensity score-matching. RESULTS: Three thousand and four hundred sixteen patients were enrolled in the study; 1520 patients undergoing surgery and who had high-risk EBC were included in this analysis. 376/1520 (24.7%) received chemotherapy. At 6 months, chemotherapy had a significant negative impact in several EORTC-QLQ-C30 domains, including global health score, physical, role, social functioning, cognition, fatigue, nausea/vomiting, dyspnoea, appetite loss, diarrhoea and constipation. Similar trends were documented on other scales (EORTC-QLQ-BR23, EORTC-QLQ-ELD15 and EQ-5D-5L). Its impact was no longer significant at 18-24 months in unmatched and matched cohorts. CONCLUSIONS: The negative impact of chemotherapy on quality-of-life is clinically and statistically significant at 6 months but resolves by 18 months, which is crucial to inform decision-making for older patients contemplating chemotherapy. TRIAL REGISTRATION NUMBER ISRCTN: 46099296.

Kikuchi- Fujimoto disease of mesenteric lymph nodes mimicking acute appendicitis.

Kikuchi-Fujimoto disease, or histiocytic necrotising lymphadenopathy of unknown aetiology, is a rare, benign and self-limiting cause of lymphadenopathy often involving the cervical nodes, and rarely presenting with mesenteric lymphadenopathy. We present a 26-year-old Caucasian male, who presented with right iliac fossa pain and low grade pyrexia, mimicking acute appendicitis. He underwent a laparatomy and an extended right hemi-colectomy for a caecal mass. Histology of the specimen showed lymph nodes with extensive areas of necrosis, with abnormal architecture suggesting Kikuchi-Fujimoto lymphadenopathy. This was further confirmed by immunohistochemistry. In this context maintenance of a high index of suspicion of this condition can avoid major surgical interventions. We describe the management of our case of Kikuchi-Fujimoto's disease involving the mesenteric nodes and provide an up to date review of the pertinent literature on this subject.

Quality of life following live donor renal transplantation: a single centre experience.

BACKGROUND: The aim of this study was to examine the quality of life (QoL) of the live donor renal transplant (LDRTx) recipients pre- and post-transplantation and correlate with their pre-transplant (pre-Tx) dialysis status and immunosuppressive regimens post-transplantation (post-Tx). MATERIAL/METHODS: 57 LDRTx recipients and 38 healthy individuals as controls participated in the study. The Kidney Transplant Questionnaire (KTQ) and the Medical Outcome Survey Short Form 36 (SF-36) questionnaires were used to assess QoL. RESULTS: The post-Tx scores in all SF-36 dimensions were significantly higher in the LDRTx recipients, but remained lower than that of the control group. However, in the KTQ, all dimensions except Appearance (p=0.035), significantly increased post-Tx Patients transplanted pre-emptively and those on tacrolimus-based immunosuppressive drugs had significantly better QoL. CONCLUSIONS: LDRTx significantly improved QoL, which was best with preemptive transplantation and tacrolimus-based immunosuppressive regimens.