Accuracy of oncologists' estimates of expected survival time in advanced cancer.

BACKGROUND: To evaluate the claim that oncologists overestimate expected survival time (EST) in advanced cancer. METHODS: We pooled 7 prospective studies in which observed survival time (OST) was compared with EST (median survival in a group of similar patients estimated at baseline by the treating oncologist). We hypothesized that EST would be well calibrated (approximately 50% of EST longer than OST) and imprecise (<30% of EST within 0.67 to 1.33 of OST), and that multiples of EST would provide well-calibrated scenarios for survival time: worst-case (approximately 10% of OST <1/4 of EST), typical (approximately 50% of OST within half to double EST), and best-case (approximately 10% of OST >3 times EST). Associations between baseline characteristics and calibration of EST were assessed. RESULTS: Characteristics of 1,211 patients: median age 66 years, male 61%, primary site lung (40%) and upper gastrointestinal (16%). The median OST was 8 months, and EST was 9 months. Oncologists' estimates of EST were well calibrated (50% longer than OST) and imprecise (28% within 0.67 to 1.33 of OST). Scenarios for survival time based on simple multiples of EST were well calibrated: 8% of patients had an OST less than 1/4 their EST (worst-case), 56% had an OST within half to double their EST (typical), and 11% had an OST greater than 3 times their EST (best-case). Calibration was independent of age, sex, and cancer type. CONCLUSIONS: Oncologists were no more likely to overestimate survival time than to underestimate it. Simple multiples of EST provide well-calibrated estimates of worst-case, typical, and best-case scenarios for survival.

The effect of comprehensive geriatric assessment on care received, treatment completion, toxicity, cancer-related and geriatric assessment outcomes, and quality of life for older adults receiving systemic anti-cancer treatment: A systematic review.

INTRODUCTION: This systematic review aims to summarise the available literature on the effect of geriatric assessment (multidimensional health assessment across medical, social, and functional domains; "GA") or comprehensive geriatric assessment (geriatric assessment with intervention or management recommendations; "CGA") compared to usual care for older adults with cancer on care received, treatment completion, adverse treatment effects, survival and health-related quality of life. MATERIALS AND METHODS: A systematic search of MEDLINE, EMBASE, CINAHL, and PubMed was conducted to identify randomised controlled trials or prospective cohort comparison studies on the effect of GA/CGA on care received, treatment, and cancer outcomes for older adults with cancer. RESULTS: Ten studies were included: seven randomised controlled trials (RCTs), two phase II randomised pilot studies, and one prospective cohort comparison study. All studies included older adults receiving systemic therapy, mostly chemotherapy, for mixed cancer types (eight studies), colorectal cancer (one study), and non-small cell lung cancer (one study). Integrating GA/CGA into oncological care increased treatment completion (three of nine studies), reduced grade 3+ chemotherapy toxicity (two of five studies), and improved quality of life scores (four of five studies). No studies found significant differences in survival between GA/CGA and usual care. GA/CGA incorporated into care decisions prompted less intensive treatment and greater non-oncological interventions, including supportive care strategies. DISCUSSION: GA/CGA integrated into the care of an older adult with cancer has the potential to optimise care decisions, which may lead to reduced treatment toxicity, increased treatment completion, and improved health-related quality of life scores.

Older adults' preferred and perceived roles in decision-making about palliative chemotherapy, decision priorities and information preferences.

AIM: Patients with cancer have varied preferences for involvement in decision-making. We sought older adults' preferred and perceived roles in decision-making about palliative chemotherapy; priorities; and information received and desired. METHODS: Patients ≥65y who had made a decision about palliative chemotherapy with an oncologist completed a written questionnaire. Preferred and perceived decision-making roles were assessed by the Control Preferences Scale. Wilcoxon rank-sum tests evaluated associations with preferred role. Factors important in decision-making were rated and ranked, and receipt of, and desire for information was described. RESULTS: Characteristics of the 179 respondents: median age 74y, male (64%), having chemotherapy (83%), vulnerable (Vulnerable Elders Survey-13 score ≥ 3) (52%). Preferred decision-making roles (n = 173) were active in 39%, collaborative in 27%, and passive in 35%. Perceived decision-making roles (n = 172) were active in 42%, collaborative in 22%, and passive in 36% and matched the preferred role for 63% of patients. Associated with preference for an active role: being single/widowed (p = .004, OR = 1.49), having declined chemotherapy (p = .02, OR = 2.00). Ranked most important (n = 159) were "doing everything possible" (30%), "my doctor's recommendation" (26%), "my quality of life" (20%), and "living longer" (15%). A minority expected chemotherapy to cure their cancer (14%). Most had discussed expectations of cure (70%), side effects (88%) and benefits (82%) of chemotherapy. Fewer had received quantitative prognostic information (49%) than desired this information (67%). CONCLUSION: Older adults exhibited a range of preferences for involvement in decision-making about palliative chemotherapy. Oncologists should seek patients' decision-making preferences, priorities, and information needs when discussing palliative chemotherapy.

Estimating survival time in older adults receiving chemotherapy for advanced cancer.

PURPOSE: We determined the accuracy of oncologists' estimates of expected survival time (EST) for older adults with advanced cancer, and explored predictors of survival from a geriatric assessment (GA). METHODS: Patients aged ≥65 years starting a new line of palliative chemotherapy were eligible. For each patient at enrolment, oncologists estimated EST and rated frailty (Canadian Study on Health and Aging Clinical Frailty Scale, 1 = very fit, to 7 = severely frail), and a researcher completed a GA. We anticipated estimates of EST to be: imprecise [<33% between 0.67 and 1.33 times the observed survival time (OST)]; unbiased (approximately 50% of participants living longer than their EST); and, useful for estimating individualised worst-case (10% living ≤» times their EST), typical (50% living half to double EST), and best-case (10% living ≥3 times EST) scenarios for survival time. Logistic regression was used to identify independent predictors of OST. RESULTS: The 102 participants [median age 74 years, vulnerable to frail (4-7 on scale) 35%] had a median OST of 15 months. 30% of estimates of EST were within 0.67-1.33 times the OST. 54% of participants lived longer than their EST, 9% lived ≤1/4 of their EST and 56% lived half to double their EST. Follow-up was insufficient to observe those living ≥3 times their EST. Independent predictors of OST were frailty (HR 4.16, p < .0001) and cancer type (p = .003). CONCLUSIONS: Oncologists' estimates of EST were imprecise, but unbiased and accurate for formulating scenarios for survival. A pragmatic frailty rating was identified as a potentially useful predictor of OST.

Predicting chemotherapy toxicity in older adults: Comparing the predictive value of the CARG Toxicity Score with oncologists' estimates of toxicity based on clinical judgement.

AIM: The Cancer and Aging Research Group's (CARG) Toxicity Score was designed to predict grade ≥3 chemotherapy-related toxicity in adults aged ≥65 yrs. commencing chemotherapy for a solid organ cancer. We aimed to evaluate the CARG Score and compare it to oncologists' estimates for predicting severe chemotherapy toxicity in older adults. METHODS: Patients aged ≥65 yrs. starting chemotherapy for a solid organ cancer had their CARG Score (range 0-23) calculated. Their treating oncologist, blinded to these results, independently estimated each patient's risk of severe chemotherapy toxicity (0-100%). Toxicities were captured prospectively. The predictive value of the CARG Score and oncologists' estimates was estimated using logistic regression and in terms of Area Under the Receiver Operating Characteristic curve (AU-ROC). RESULTS: 126 patients from ten oncologists at two sites participated. The median age was 72 yrs. (range 65-84). The median CARG Score was 7 (range 0-17); the median oncologist estimate of risk was 30% (range 3-80%), and these measures were not correlated (r = -0.01). 64 patients (52%) experienced grade ≥ 3 toxicity. Rates of severe toxicity in low-, intermediate-, and high-risk groups by CARG Score were 58%, 47%, and 58% respectively, and 63%, 44%, and 67% by oncologist estimate. Severe chemotherapy toxicity was not predicted by the CARG Score (OR 1.04, 95%CI 0.92-1.18, p = .54, AU-ROC 0.52), or oncologists' estimates (OR 1.00, 95%CI 0.98-1.02, p = .82, AU-ROC 0.52). CONCLUSION: Neither the CARG Score, nor oncologists' estimates based on clinical judgement, predicted severe chemotherapy-related toxicity in our population of older adults with cancer. Methods to improve risk prediction are needed.

Oncologists' perceptions on the usefulness of geriatric assessment measures and the CARG toxicity score when prescribing chemotherapy for older patients with cancer.

BACKGROUND: The use of geriatric assessment (GA) and the Cancer and Aging Research Group (CARG) Toxicity Score by Australian oncologists is low. We sought oncologists' views about the value of GA and the CARG Score when making decisions about chemotherapy for their older patients. METHODS: Patients aged ≥65 yrs. with a plan to start chemotherapy for a solid organ cancer underwent a GA and had their CARG Score calculated. Results of the GA and CARG Score were provided to treating oncologists who then completed a questionnaire on the value of these measures for each patient. RESULTS: We enrolled 30 patients from eight oncologists. Patients had a median age of 76 years and most (77%) were ECOG performance status 0 or 1. Risk category for severe chemotherapy toxicity by CARG Score was low in 7 patients (23%), intermediate in 18 (60%), and high in 5 (17%). The GA provided oncologists new information for 12 patients (40%), most frequently in the domains of function and nutrition. Knowledge of the GA prompted supportive interventions for 7 patients (23%). Oncologists considered modifications to recommended chemotherapy based on the CARG Score for 2 patients (7%) (one more intensive and one less intensive), and based on GA for no patients. Oncologists judged the GA and CARG Score as useful in 26 (87%) and 25 (83%) patients, respectively. CONCLUSION: Although oncologists valued the GA and CARG Score, they rarely used them to modify chemotherapy. The GA provided new information that prompted supportive interventions in one quarter of patients.

Decision-making in geriatric oncology: systemic treatment considerations for older adults with colon cancer.

INTRODUCTION: Colon cancer is common and can be considered a disease of older adults with more than half of cases diagnosed in patients aged over 70 years. Decision-making about treatment with chemotherapy for older adults may be complicated by age-related physiological changes, impaired functional status, limited social supports, concerns regarding the occurrence of and ability to tolerate treatment toxicity, and the presence of comorbidities. This is compounded by a lack of high quality evidence guiding cancer treatment decisions for older adults. Areas covered: This narrative review evaluates the evidence for adjuvant and palliative systemic therapy in older adults with colon cancer. The value of an adequate assessment prior to making a treatment decision is addressed, with emphasis on the geriatric assessment. Guidance in making a treatment decision is provided. Expert commentary: Treatment decisions should consider goals of care, a patient's treatment preferences, and weigh up relative benefits and harms.

Patients' preferred and perceived roles in making decisions about adjuvant chemotherapy for non-small-cell lung cancer.

BACKGROUND: People with cancer have varying preferences for involvement in decision-making between active, collaborative and passive roles. We sought the preferred and perceived involvement in decision-making among patients considering adjuvant chemotherapy (ACT) after resection of early non-small cell lung cancer (NSCLC). METHODS: Patients considering ACT for NSCLC were asked to complete a self-administered questionnaire at baseline and 6 months. Preferred and perceived decision-making roles were assessed by the Control Preferences Scale (CPS). We examined differences between preferred and perceived roles, differences in preferred roles over time, determinants of preferences, and differences in treatment preferences between patients preferring active and less active roles. RESULTS: 98 patients completed the baseline questionnaire; 75 completed the 6 month questionnaire. Most patients were male (55%) with a median age of 64 years (range, 43-79 years). Preferred role in decision-making at baseline (n=98) was active in 27%, collaborative in 47%, and passive in 27%. Perceived decision-making roles matched the preferred role in 79% of patients. Individuals' role preferences often varied between baseline and 6 months, but there was no consistent direction to the change (25% changed preference to more active involvement, 22% to less active). Preferring a more active role was associated with university education (OR 2.9, p=0.02), deciding not to have ACT (OR 5.0, p<0.01), and worse health-related quality of life (HRQL) during ACT: physical well-being (OR 4.4, p=0.05), overall well-being (OR 5.5, p=0.02), sleep (OR 8.4, p<0.01) and shortness of breath (OR 7.6, p=0.01). Patients who preferred an active decision-making role judged larger survival benefits necessary to make ACT worthwhile than those preferring a passive role. CONCLUSION: Most patients with resected NSCLC preferred and perceived a collaborative role in decision-making about ACT. Clinicians should elicit and consider patients' preferences for involvement in decision-making when discussing ACT for NSCLC.