Integrating Frailty Assessment to Enhance Care in Cancer Patients with Borderline Eastern Cooperative Oncology Group Performance Status.

BACKGROUND: The (ECOG) performance status (PS) is commonly used to evaluate the functional ability of patients undergoing antitumor therapy. An ECOG PS of 2, indicating patients capable of self-care but restricted strenuous activity, can complicate treatment decisions owing to concerns regarding treatment-related toxicity. We investigated whether frailty assessment could help discriminate treatment tolerance and survival outcomes in patients with an ECOG PS of 2. METHODS: We prospectively included 45 consecutive patients, aged ≥65 years, with an ECOG PS of 2, and newly diagnosed solid cancer scheduled for chemotherapy. Frailty was assessed using an eight-indicator geriatric assessment. The primary outcome was overall survival (OS) based on frailty status; secondary outcomes included treatment tolerance and toxicity. RESULTS: The median patient age was 73 years (range 65-94), and 71% had stage IV disease. Predominant frailty-related deficits were functional decline (96%), malnutrition (78%), and polypharmacy (51%). The median OS was 12.6 months (95% confidence interval [CI]: 6.8-18.4). Patients with 4-6 deficits had significantly lower OS than those with 1-3 deficits (9.9 months vs. 20.0 months, adjusted hazard ratio 2.51, 95% CI: 1.16-5.44, P = .020). Frailty significantly correlated with reduced 12-week chemotherapy competence (52% vs. 85%, adjusted odds ratio [OR] .14, 95% CI: .03-.70, P = .016) and enhanced risk of unexpected hospitalization (60% vs. 20%, adjusted OR 6.80, 95% CI: 1.64-28.1, P = .008). CONCLUSION: Our findings highlight the multifaceted nature of patients with an ECOG PS of 2 and emphasize the importance of frailty assessment for treatment outcomes.

Frailty assessment by two screening instruments in non-elderly patients with head and neck cancer.

PURPOSE: Frailty assessment is often overlooked in non-elderly patients with cancer, possibly due to the lack of an effective frailty screening tool. This study aimed to evaluate the performance of two modern frailty screening tools, the Flemish version of the Triage Risk Screening Tool (fTRST) and the modified 5-Item Frailty Index (mFI-5), compared to the gold standard comprehensive geriatric assessment (GA) among non-elderly patients with head and neck cancer (HNC). METHODS: We prospectively included 354 consecutive patients aged < 65 years with newly diagnosed HNC scheduled for definitive concurrent chemoradiotherapy (CCRT) at three academic hospitals in Taiwan between January 2020 and December 2022. Frailty assessment using the GA, fTRST, and mFI-5 was performed in all patients to evaluate the relationship between frailty and treatment outcomes. RESULTS: The prevalence of frailty was 27.1%, 37.0%, and 42.4% based on GA, mFI-5, and fTRST, respectively. mFI-5 and fTRST demonstrated good predictive value in identifying frail patients compared to the GA. Patients with frailty, as defined by GA, mFI-5, and fTRST, exhibited higher risks of treatment-related complications, incomplete treatment, and poorer baseline quality of life (QoL). However, only GA showed significant prognostic value for overall survival. CONCLUSIONS: Frailty assessment using fTRST and mFI-5 is valuable for predicting treatment-related adverse events, treatment tolerance, and QoL in non-elderly patients with HNC. Incorporating frailty assessment into the management of non-elderly cancer patients can aid in the identification of high-risk individuals. However, the performance of these tools varies, highlighting the need for further validation and refinement.

Long-term use and risk of major adverse cardiac events: Comparing enzalutamide and abiraterone in chemotherapy-naïve patients with metastatic castration-resistant prostate cancer.

This is a retrospective cohort study by analyzing a multi-institutional electronic medical records database in Taiwan to compare long-term effectiveness and risk of major adverse cardiac events (MACE) in chemotherapy-naïve metastatic castration-resistant prostate cancer (mCRPC) patients treated with enzalutamide (ENZ) or abiraterone (AA). Patients aged 20 years and older and newly receiving androgen receptor targeted therapies ENZ or AA from September 2016 to December 2019 were included. We followed patients from initiation of therapies to the occurrence of outcomes (prostate-specific antigen (PSA) response rate, PSA progression free survival (PFS), overall survival (OS), and MACE), death, the last clinical visit, or December 31, 2020. We performed multivariable Cox proportional hazard models to compare ENZ and AA groups for the measured outcomes. A total of 363 patients treated with either ENZ (n = 157) or AA (n = 206) were identified. The analysis found a significantly higher proportion of patients with a PSA response rate higher than 50% among those receiving ENZ than among those receiving AA (ENZ vs AA: 75.80% vs 63.59%, P = .01). However, there was no significant difference in PSA PFS (adjusted hazard ratio: 0.86; 95% CI 0.63-1.17) and OS (0.68: 0.41-1.14) between the use of ENZ and AA in chemotherapy-naïve mCRPC patients. Regarding the cardiovascular (CV) safety outcome, there was a significantly lower risk of MACE in patients receiving ENZ, compared to patients receiving AA (0.20: 0.07-0.55). The findings suggest that enzalutamide may be more efficacious for PSA response and suitable for chemotherapy-naïve mCRPC patients with high CV risk profile.

External validation of the Besançon nomogram in Asian patients with advanced pancreatic cancer receiving second-line chemotherapy: A multi-institute experience in Taiwan.

BACKGROUND: Determining survival outcome in advanced pancreatic ductal adenocarcinoma (aPDAC) patients receiving second-line (L2) chemotherapy is important for clinical decision-making. The Besançon group from France recently proposed a prognostic nomogram to predict overall survival (OS) for aPDAC patients receiving L2 chemotherapy. The present study aimed to externally validate the performance of the Besançon nomogram in predicting OS in an Asian cohort. METHODS: We retrospectively enrolled 349 patients who received L2 chemotherapy for aPDAC between 2010 and 2016 at four institutes in Taiwan. The performance of the Besançon model in this cohort was evaluated with C-index and calibration plots. RESULTS: The median OS time in our patient cohort was 4.5 months (95% confidence interval [CI], 3.0-5.0). Using the Besançon nomogram-predicted risk groups, the median OS times in the low, intermediate, and high-risk groups were 6.7 (95% CI, 5.3-8.2), 3.2 (95% CI, 2.4-3.9), and 1.7 months (95% CI, 0.6-2.7), respectively. The C-index of the predicted six- and 12-month survival probabilities for the Besançon nomogram were 0.766 (95% CI, 0.715-0.816) and 0.698 (95% CI, 0.641-0.754), respectively. The calibration plot showed that the observed six-month survival probability was close to the diagonal line, while that for 12-month survival deviated below the diagonal line compared to the survival probability predicted by the Besançon nomogram. CONCLUSIONS: Although the Besançon nomogram tended to over-estimate the 12-month survival probability, our study demonstrated that the nomogram is a reliable and readily applicable model to estimate survival outcomes of aPDAC patients receiving L2 chemotherapy.

Three-dimensional identification of the cystic infundibulum-cystic duct junction: a technique for identification of the cystic duct in laparoscopic cholecystectomy.

OBJECTIVE: The main cause of bile duct injury (BDI) at laparoscopic cholecystectomy is misidentification of the common bile duct as the cystic duct (CD). The aim of this article is to introduce a modified technique, i.e., three-dimensional identification of the cystic infundibulum (CI)-CD junction, to prevent misidentification-induced BDI during laparoscopic cholecystectomy. METHODS: The CI was extensively dissected to expose its anterior, interior-superior and inferior-dorsal aspects. With the CI nearly circularly dissected out, the CI and the appearance-indicated CI-CD junction might be three-dimensionally identified and the reality of the CI-CD junction as well as the reality of the CD could be precisely judged. RESULTS: Overall 10 BDIs were documented in this group. Since BDI occurred in 8 of 4382 patients receiving laparoscopic cholecystectomy, the technique for prevention of misidentification-induced BDI was established. Among the late batch of 7618 patients, only two BDIs were noted. CONCLUSIONS: Three-dimensional identification of the CI-CD junction is a reliable, feasible and relatively low experience-dependent technique to prevent most of misidentification-induced BDI.

Non-image diagnosis of bile duct injury during laparoscopic cholecystectomy.

OBJECTIVE: To evaluate the role of simple non-image technique in intraoperative diagnosis of bile duct injury (BDI). METHODS: BDI was highly suspected at the original laparoscopic cholecystectomy (LC) when the following 3 abnormal findings were noted: the "cystic duct" stump (the common bile duct stump actually) markedly retracted down to the duodenum; bile leakage from the porta hepatis; abnormal mucosal patch attached to the "cystic duct" stump of the removed gallbladder. All cases of suspected BDI were converted to have laparotomy. image techniques such as intraoperative cholangiography or ultrasonography were not utilized for recognition of BDI in all 9 patients. RESULTS: BDI in 4 of the 9 patients was suspected according to 1-3 abnormal intraoperative findings described above. The four patients were subjected immediately to converted laparotomy. Abnormal findings were not observed or misinterpreted in the other 5 misdiagnosed patients. CONCLUSIONS: Timely recognizing whether BDI occurs should be considered as a routine procedure of LC. Negligence of operators to the abnormalities of the original LC is the main cause of misdiagnosis for BDI. Simple non-Image approaches such as close observation of these abnormalities can make timely diagnosis for most BDIs during the original LC.