[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.

[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.

[Ablative therapy in kidney cancer: Indications]. / Thérapies ablatives dans le cancer du rein : indications.

BACKGROUND: Ablative therapies (AT) in kidney cancer are rising. It's important to evaluate the situation of this therapy. The aim of this study is to identify the best indications for AT treatment for kidney cancer. METHODS: Review of literature using Medline and Embase databases. Study were selected based on scientific relevance. Clinical keys centered on the best requirements to indicate ablative therapies. RESULTS: AT is indicated according to specific tumor and patients criteria. A good initial evaluation is essential (imaging, pathology, renal function and general condition of the patient). AT gets the best results when applied to the following tumor criteria: solid tumor, length<3cm, exophytic localization, RENAL score<8. In few cases, AT could be discussed as an alternative to the reference treatment, sparing surgery: life expectancy evaluated between 3 and 7 years, chronic renal failure or single kidney, transplanted kidney, familial tumors. AT can be used in first line, post-surgery after local recurrence or for distant metastasis. Like every other innovative technic, indications of AT would be adjust with learning curve and cost-effectiveness. CONCLUSION: AT have to be included as a valid treatment for kidney cancer<4cm. The respect of actual indications and collection of results of AT compared to surveillance and surgery, would determinate the evolution of AT indications in the future.

[Prostate cancer in elderly subjects: how diagnosis should be made, why and how geriatric assessment should be implemented]. / Cancer de la prostate chez les sujets âgés: comment faire le diagnostic, pourquoi et comment mettre en place une évaluation gériatrique.

Managing an elderly subject with prostate cancer brings into play the notion of likelihood of survival before any diagnostic or therapeutic decision can be made. The diagnostic strategy must be specified for each patient in accordance with the clinical presentation so as to determine whether prostate biopsies are indicated in this elderly population. To estimate the likelihood of survival, one must make use of geriatric assessment techniques comprising medical strategies ranging from screening for frailty to detailed geriatric evaluation for the most complex patients. The many tools available for estimating the likelihood of survival requires a critical review of their advantages and disadvantages in daily clinical practice.

[Geriatric evaluation in oncology in the elderly subject]. / L'évaluation gériatrique en cancérologie chez le sujet âgé.

The heterogeneity of the elderly population makes the simple application of standard therapeutic programs in oncological management complex, particularly if they have been validated on young populations. The NCCN and the SIOG recommend using a geriatric evaluation before setting up an individualized care program. Geriatric assessment has demonstrated its efficacy in a number of domains. This concept covers two broad activities: the Multidimensional Geriatric Evaluation (MGE), which is a standardized geriatric evaluation for detecting co-morbidities and broad geriatric syndromes, and the Detailed Geriatric Evaluation (DGE). The objective of the DGE is to inventory the patient's various problems, distinguish somatic and/or psychiatric pathologies from the physiological consequences of aging, assess the functional impact of diseases, understand how these diseases interfere with one another, assess their consequences on the patient's social environment, and prioritize the patient's different health issues. The DGE is a medical action organized into five phases designed to set up care so that the recommendations made can be followed.

[Lung cancer in the elderly subject]. / Cancer bronchique du sujet âgé.

INTRODUCTION: In France, the average age for the diagnosis of bronchial carcinoma is 64. It is 76 in the population of over 70. In fact, its incidence increases with age linked intrinsic risk of developing a cancer and with general ageing of the population. Diagnosis tools are the same for elderlies than for younger patients, and positive diagnosis mainly depends on fibreoptic bronchoscopy, complications of which being comparable to those observed in younger patients. STATE OF THE ART: The assessment of dissemination has been modified in recent years by the availability of PET scanning which is increasingly becoming the examination of choice for preventing unnecessary surgical intervention, a fortiori in elderly subjects. Cerebral imaging by tomodensitometry and nuclear magnetic resonance should systematically be obtained before proposing chirurgical treatment. An assessment of the general state of health of the elderly subject is an essential step before the therapeutic decision is made. This depends on the concept of geriatric evaluation: Geriatric Multidimensional Assessment, and the Comprehensive Geriatric Assessment which concerns overall competence of the elderly. PERSPECTIVES: This is a global approach that allows precise definition and ranking of the patient's problems and their impact on daily life and social environment. Certain geriatric variables (IADL, BADL, MMSE, IMC etc) may be predictive of survival rates after chemotherapy or the incidence of complications following thoracic surgery. The main therapeutic principles for the management of bronchial carcinoma are applicable to the elderly subject; long term survival without relapse after surgical resection is independent of age. Whether the oncological strategy is curative or palliative, the elderly patient with bronchial carcinoma should receive supportive treatments. They should be integrated into a palliative programme if such is the case. In fact, age alone is not a factor that should detract from optimal oncological management. CONCLUSIONS: The development of an individual management programme for an elderly patient suffering from bronchial carcinoma should be based on the combination of oncological investigation and comprehensive geriatric assessment.

Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: the OFELY study.

Several epidemiological studies have identified clinical factors that predict the risk of hip fractures in elderly women independently of the level of bone mineral density (BMD), such as low body weight, history of fractures, and clinical risk factors for falls. Their relevance in predicting all fragility fractures in all postmenopausal women, including younger ones, is unknown. The objective of this study was to identify independent predictors of all osteoporosis-related fractures in healthy postmenopausal women. We prospectively followed for 5.3 +/- 1.1 years a cohort of 672 healthy postmenopausal women (mean age 59.1 +/- 9.8 years). Information on social and professional conditions, demographic data, current and past medical history, fracture history, medication use, alcohol consumption, caffeine consumption, daily calcium intake, cigarette smoking, family history of fracture, and past and recent physical activity was obtained. Anthropometric and total hip bone mineral density measurements were made. Incident falls and fractures were ascertained every year. We observed 81 osteoporotic fractures (annual incidence, 21 per 1000 women/year). The final model consisted of seven independent predictors of incident osteoporotic fractures: age > or = 65 years, odds ratio estimate (OR), 1.90 [95% confidence interval (CI) 1.04-3.46], past falls, OR, 1.76 (CI 1.00-3.09), total hip bone mineral density (BMD) < or = 0.736 g/cm(2), OR, 3.15 (CI 1.75-5.66), left grip strength < or = 0.60 bar, OR, 2.05 (CI 1.15-3.64), maternal history of fracture, OR, 1.77 (CI 1.01-3.09), low physical activity, OR, 2.08 (CI 1.17-3.69), and personal history of fragility fracture, OR, 3.33 (CI 1.75-5.66). In contrast, body weight, weight loss, height loss, smoking, neuromuscular coordination assessed by three tests, and hormone replacement therapy were not independent predictors of all fragility fractures after adjustment for all variables. We found that some--but not all--previously reported clinical risk factors for skeletal fragility predicted all fragility fractures independently of BMD in healthy postmenopausal women, although they differed somewhat from those predicting specifically hip fractures in elderly women. These risk factors appear to reflect quality of bone structure (previous fragility fracture), lifestyle habits (physical activity), muscle function and health status (grip strength), heredity (maternal history of fracture), falls, and aging. Measurements of these variables should be included in the clinical assessment of the risk of osteoporotic fractures in postmenopausal women.

In vivo hippocampal (31)P NMR metabolites in Alzheimer's disease and ageing.

Memory loss is the most common early symptom of Alzheimer's disease (AD). For this study, we chose the hippocampi as regions of interest. The hippocampus, which is closely associated with memory processing, is known to be vulnerable to damage in the early stage of AD. We considered both inter-group (patients vs controls) and intra-group (right vs left hippocampus) comparisons. We examined seven patients meeting the DSM-III-R criteria of senile dementia and the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS - ADRDA) criteria of probable AD, and II aged controls. This study focused on the measurement of phosphorus 31 ((31)P) Nuclear Magnetic Resonance (NMR) spectroscopy metabolites in each hippocampus. We found significant differences in phosphorus metabolites for both intra-group comparison (pH shifted towards relative alkalosis in the left hippocampus of patients) and inter-group consideration (reduced phosphodiesters [Pde]and elevated gamma adenosine triphosphate (ATP) in the right hippocampus, higher inorganic phosphate (pHi) in the left hippocampus for patients as compared to controls). We suggest energy failure and membrane functional breakdown in patients compared to aged controls.

[Renal differential aging processes and ofloxacin pharmacokinetics in the elderly]. / Vieillissement différentiel rénal et pharmacocinétique de population de l'ofloxacine chez le sujet agé.

Ageing generates an important inter- and intra-individual variability in drug pharmacokinetics. The increasing frequency of ofloxacin adverse effects in elderly patients results from increased ofloxacin plasma levels about two or threefold over normal concentrations. A retrospective study of ofloxacin population pharmacokinetics in 17 elderly patients (83.6 +/- 6.8 years) shows the existence of three subgroups according to ofloxacin total clearance [group 1: 1.44 l/h, group 2: 4.37 l/h and group 3: 15.08 l/h] reflecting the important inter-individual variability. No correlation between this clearance and creatinine clearance, nor between this clearance and age, could be established, showing the limits of traditional drug monitoring in the elderly. Ofloxacin pharmacokinetic parameters estimated by the non-parametric software NPEM2 in the 17 elderly patients (absorption rate constant, Ka: 2.668 +/- 1.256 h-1; apparent volume of distribution related to weight, Vs: 1.272 +/- 0.778 l/kg; elimination rate constant, Ks: 0.265 +/- 0.247 10(-3) min/ml/h) are clearly different from those estimated in young adults. These results show the limits of classic drug monitoring in the elderly, and also the interest of adaptive control of a drug regimen.

Low-level scattering and localized defects.

We investigate the origin of low-level scattering from high-quality coatings produced by ion-assisted deposition and ion plating. For this purpose we use the polarization ratio of light scattering to separate surface and bulk effects that characterize the intrinsic action of the thin-film materials. In the first step the method is tested and validated at scattering levels greater than 10(-5). In the second step it is applied at low levels, and the results reveal some anomalies. To conclude, we perform a detailed analysis of scattering resulting from the presence of a few localized defects in the coatings.

Synthesis and research of the optimum conditions for the optical monitoring of non-quarter-wave multilayers.

Many optical filtering problems require the use of assemblies of layers with thicknesses that bear no obvious relationship to each other. Here we present the results obtained for a number of examples in which optical monitoring is performed with a change of control wavelengths for each layer of the stack. For this, it is necessary to determine for each layer the different wavelengths that provide an extremum of transmittance when the required thickness is achieved. We show that this leads, in some cases, to making the benefit of error compensation analogous to the well-known method used in the production of quarter-wave stacks. Because ion-assisted deposition and ion-plating techniques are suitable from the point of view of refractive-index reproducibility, optical monitoring can be used at a good level of performance. However, the production of high-quality optical thin films needs more than just the choice of a monitoring process. In particular, problems of uniformity are critical for high-performance coatings. Here we show how uniformity can be determined for each material involved.

Surface optical coatings by ion assisted deposition techniques: study of uniformity.

Uniformity of layers produced by IAD strongly depends on the characteristics of the ion beam: optical characterization is made by guided wave measurements. The thickness and refractive index including anisotropy must be considered separately to interpret the measured uniformity.

In situ and air index measurements: influence of the deposition parameters on the shift of TiO2/SiO2 Fabry-Perot filters.

We measure the refractive index of thin films of TiO2 and SiO2 for given deposition parameters. Two complementary methods are used. The first is a postdeposition technique which uses the measurements of reflectance and transmittance in air. The second, in contrast, makes use of in situ measurements (under vacuum and during the actual deposition of the layer). The differences between the values deduced from the two methods can be explained by the amount of atmospheric moisture adsorbed by films. One tries to minimize these shifts for the two materials by choosing deposition parameters. The difficulties come from the absorption losses which must be as small as possible. We use the measured refractive indices of individual layers to give good numerical prediction of the wavelength shift (observed during the admittance of air after deposition in the vacuum chamber) of the transmittance peak of multidielectric Fabry-Perot filters.