Application of interdisciplinary collaborative hospice care for terminal geriatric cancer patients: a prospective randomized controlled study.

BACKGROUND: Hospice care (HC) is specialized medical care for terminal patients who are nearing the end of life. Interdisciplinary collaborative hospice care (ICHC) is where experts from different disciplines and patients/caregivers form a treatment team to establish shared patient care goals. However, the ICHC efficacy has not been frequently studied in the terminal geriatric cancer patient (TGCP) population. This study aimed to gain insight into ICHC provided to TGCPs by an ICHC team and identify factors to ameliorate multidimensional HC. METHODS: 166 TGCPs were randomized by a computer-generated random number table using an allocation ratio of 1:1. The patients were divided into the ICHC group and life-sustaining treatment (LST) group. The scores of these questionnaires, such as EORTC, QLQ-C30, Hamilton anxiety scale, the median survival time (MST), symptoms improvement, the median average daily cost of drugs (MADDC), the median total cost of drugs (MTDC) in the last 2 days, and medical care satisfaction were observed in both groups. RESULTS: After treatment, the improvement of emotional function and symptoms in the ICHC group were statistically higher than those in the LST group (P < 0.05). The MADDC and the MTDC in the last 2 days were statistically lower in the ICHC group than those in the LSTs group (P < 0.01). In addition, the overall satisfaction situation and the cooperation ability in the ICHC group were statistically higher than those in the LST group (P < 0.01). CONCLUSION: The ICHC could provide TGCPs with coordinated, comfortable, high-quality, and humanistic care.

Comparing the symptoms experience of cancer and non-cancer older adult patients in Turkish cancer patients: A cross-sectional study.

This cross-sectional study was conducted with 160 older people to compare the symptoms experience of cancer and with non-cancer older adult patients. A patient information form and The Rotterdam Symptom Checklist (RSCL) were used to gain information on the experience of their symptoms. The most prevelant symptoms of older cancer patients were tiredness (53.8%), decreased sexual interest (51.2%) and lack of energy (41.2%), for non-cancer older adult patients was a decreased sexual interest (75.0%). Cancer patients proportionately reported more symptoms than non-cancer patients which was reflected in their higher RSCL score. These findings reflect that a greater number of cancer patients report a higher average of symptoms, especially those that are physical in nature: tiredness, lack of energy, head ache, acid ingestion, loss of hair, burning eyes and sore mouth. Oncology nurses, who are an important part of the health care team should be able to assess the symptom burden of older patients during their treatment before, during and after chemotherapy.

Evaluation of a comprehensive geriatric assessment tool in geriatric cancer patients undergoing adjuvant chemotherapy: a pilot study.

PURPOSE: It is recommended to use comprehensive geriatric assessment (CGA) in clinical oncology practice to improve care for geriatric cancer patients and to identify medical and social issues that may need further intervention. The purpose of this pragmatic pilot study was to evaluate the effectiveness of the Hurria et al. CGA in cancer patients 70 years of age or older undergoing adjuvant chemotherapy, as well as the feasibility of integrating it into a busy clinic practice and the psychosocial impact on these patients. METHOD: Twenty-five patients were recruited. Descriptive analysis was performed via a geriatric assessment questionnaire completed by the participants prior to their first adjuvant chemotherapy treatment and during follow-up, 2 to 6 weeks after last treatment. Additionally, study staff performed a geriatric healthcare assessment at both time points. RESULTS: The results of this pilot study show that administration is feasible despite some challenges. Administration of a CGA in a clinic setting presented some logistical issues with regard to time and space available in clinic. Analysis of patient data indicated only minor variations in patient domains from pre-chemo to post-chemo confirming previous research. Participants expressed gratitude for the extra time spent with them at a stressful time in their lives. CONCLUSION: Further information regarding the usefulness of a comprehensive geriatric assessment with regard to improving treatment selection, identifying undetected medical problems, and avoiding toxicity will be obtained if the administration of comprehensive geriatric questionnaires is incorporated into the clinic setting and considered into the allocated time for staff workload.

Ayurveda Rasayana Therapy (ART) leads to tumor regression and increased survival in chemo-intolerance high-grade stage IV follicular lymphoma: A case study.

Key clinical message: Ayurveda Rasayana Therapy (ART) may serve as a safe and effective alternative treatment option for chemo-intolerance high-grade stage IV follicular lymphoma patients for increasing survival and tumor regression. Abstract: Follicular lymphoma (FL), also called follicle center lymphoma/nodular lymphoma, observed in the B lymphocytes (B-cells). Available therapeutic options for follicular lymphoma are associated with various side effects and, patients with co-morbidities can seldom tolerate the chemotherapy regimens. Rasayana therapy not only resulted in tumor regression and improved survival but also dealt with the adverse effects of previous chemotherapy drugs. Herein, we present a case of a 74-year-old female diagnosed with Follicular lymphoma who had undergone three cycles of chemotherapy with unresolved disease outcome and serious adverse events. The patient refused to undergo further cycles of chemotherapy. Her family decided to start Ayurveda treatment for her as an alternative therapy for cancer care. On thorough case taking considering the Ayurveda parameters personalized Rasayana therapy as planned for the patient with an aim for improvement in Quality of Life (QoL), increasing survival, and optimizing body's immune response to fight the tumor. After treatment of 8 months, this case demonstrated partial tumor response as evidenced by PET-CT-scan. Quality of Life as evaluated using FACT-G was also seen improved besides significant improvement in physical performance status evaluated using ECOG. The patient showed a survival of 3.5 years after starting Ayurveda Rasayana Therapy (ART). Rasayana therapy was well tolerated by the patient. This case report indicates the potential role of ART as a therapeutic option in geriatric cancer patients who are not eligible for cytotoxic interventions. Case warrants further systematic investigation to evaluate the potential role of ART in the treatment of geriatric cancer patients.

Treating Mental Health and Quality of Life in Older Cancer Patients with Cognitive Behavioral Therapy: A Systematic Review and Meta-Analysis.

BACKGROUND: Cognitive behavioral therapy (CBT) has been successfully utilized in improving mental health (MH) and quality of life (QoL) in the general population, regardless of age. Cancer, which is most frequently diagnosed in older adults, is a debilitating illness that has a detrimental and long-lasting effect on patients' MH and QoL. While numerous studies have demonstrated CBT's efficacy, little evidence exists for its role in older cancer patients. This study, using MH and QoL metrics, evaluates the effectiveness of CBT for older adult cancer patients. METHODS: Focusing on MH and QoL and an average age of over 60 years old, a final analysis was performed on 17 clinical trials with a total of 124 effect sizes, including 3073 participants receiving CBT. "Metaphor" and "Robumeta" packages in R Statistical Software (version 4.2.2) were used for analysis, which included robust variance estimation (RVE) in intercept-only meta-regression, and univariate meta-regression for moderator analysis. RESULTS: With 17 clinical trials and 124 effect sizes, our results show that CBT moderately improves MH and QoL in cancer patients d = 0.19, 95% CI 0.0166-0.364, p < 0.0399. The delivery format was shown to be a strong moderator of CBT effectiveness with interpersonal technological interventions combined with pre-programmed segments having a very strong treatment effect size (d = 1.7307, 95% CI 1.5244-1.937, p < 0.001). CONCLUSIONS: The use of CBT in older adult cancer patients statistically improves MH and QoL, with delivery format and stages of treatment having important roles. Tech-only interpersonal interventions combined with pre-programmed CBT provide an avenue for targeting older adult cancer patients.

Aging microenvironment and antitumor immunity for geriatric oncology: the landscape and future implications.

The tumor microenvironment (TME) has been extensively investigated; however, it is complex and remains unclear, especially in elderly patients. Senescence is a cellular response to a variety of stress signals, which is characterized by stable arrest of the cell cycle and major changes in cell morphology and physiology. To the best of our knowledge, senescence leads to consistent arrest of tumor cells and remodeling of the tumor-immune microenvironment (TIME) by activating a set of pleiotropic cytokines, chemokines, growth factors, and proteinases, which constitute the senescence-associated secretory phenotype (SASP). On the one hand, the SASP promotes antitumor immunity, which enhances treatment efficacy; on the other hand, the SASP increases immunosuppressive cell infiltration, including myeloid-derived suppressor cells (MDSCs), regulatory T cells (Tregs), M2 macrophages, and N2 neutrophils, contributing to TIME suppression. Therefore, a deeper understanding of the regulation of the SASP and components contributing to robust antitumor immunity in elderly individuals with different cancer types and the available therapies is necessary to control tumor cell senescence and provide greater clinical benefits to patients. In this review, we summarize the key biological functions mediated by cytokines and intercellular interactions and significant components of the TME landscape, which influence the immunotherapy response in geriatric oncology. Furthermore, we summarize recent advances in clinical practices targeting TME components and discuss potential senescent TME targets.

Early Palliative Care for the Geriatric Patient with Cancer.

Older adults with cancer present with complex multidimensional problems. Therefore, early integration of palliative care for the older adult with cancer is important, and a multidisciplinary team approach is critical for optimum care. The importance of incorporating geriatric and palliative concerns in assessment, as well as early involvement of the multidisciplinary team, is discussed as a manner of addressing the needs of older adults with cancer. Concerns related to metabolic changes that can occur with aging, as well as risk for polypharmacy and inappropriate prescribing for older adults, are also reviewed.

Stereotactic Radiosurgery for Women Older than 65 with Breast Cancer Brain Metastases.

BACKGROUND: Breast cancer is the second most common cause of brain metastases (BM). Despite increasing incidence of BM in older women, there are limited data on the optimal management of BM in this age group. In this study, we assessed the survival outcomes and treatment patterns of older breast cancer patients ≥65 years old with BM compared to younger patients at our institution. METHODS: An IRB-approved single-institutional retrospective review of biopsy-proven breast cancer patients with BM treated with 1- to 5-fraction stereotactic radiation therapy (SRS) from 2015 to 2020 was performed. Primary endpoint was intracranial progression-free survival (PFS) defined as the time interval between the end of SRS to the date of the first CNS progression. Secondary endpoints were overall survival (OS) from the end of SRS and radiation treatment patterns. Kaplan-Meier estimates and Cox proportional hazard regression method were used for survival analyses. RESULTS: A total of 112 metastatic breast cancer patients with BMs were included of which 24 were ≥65 years old and 88 were <65 years old. Median age at RT was 72 years (range 65-84) compared to 52 years (31-64) in younger patients. There were significantly higher number of older women with ER/PR positive disease (75% vs. 49%, p = 0.036), while younger patients were more frequently triple negative (32% vs. 12%, p = 0.074) and HER2 positive (42% vs. 29%, p = 0.3). Treatment-related adverse events were similar in both groups. Overall, 14.3% patients had any grade radiation necrosis (RN) (older vs. young: 8.3% vs. 16%, p = 0.5) while 5.4% had grade 3 or higher RN (0% vs. 6.8%, p = 0.7). Median OS after RT was poorer in older patients compared to younger patients (9.5 months vs. 14.5 months, p = 0.037), while intracranial PFS from RT was similar between the two groups (9.7 months vs. 7.1 months, p = 0.580). On univariate analysis, significant predictors of OS were age ≥65 years old (hazard risk, HR = 1.70, p = 0.048), KPS ≤ 80 (HR = 2.24, p < 0.001), HER2 positive disease (HR = 0.46, p < 0.001), isolated CNS metastatic disease (HR = 0.29, p < 0.001), number of brain metastases treated with RT (HR = 1.06, p = 0.028), and fractionated SRS (HR = 0.53, p = 0.013). On multivariable analysis, KPS ≤ 80, HER2 negativity and higher number of brain metastases predicted for poorer survival, while age was not a significant factor for OS after adjusting for other variables. Patients who received systemic therapy after SRS had a significantly improved OS on univariate and multivariable analysis (HR = 0.32, p < 0.001). Number of brain metastases treated was the only factor predictive of worse PFS (HR = 1.06, p = 0.041), which implies a 6% additive risk of progression for every additional metastasis treated. CONCLUSIONS: Although older women had poorer OS than younger women, OS was similar after adjusting for KPS, extracranial progression, and systemic therapy; and there was no difference in rates of intracranial PFS, neurological deaths, and LMD in the different age groups. This study suggests that age alone may not play an independent role in treatment-selection and that outcomes for breast cancer patients with BMs and personalized decision-making including other clinical factors should be considered. Future studies are warranted to assess neurocognitive outcomes and other radiation treatment toxicities in older patients.

Comprehensive Geriatric Assessment and Quality of Life Aspects in Patients with Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma (HNSCC).

To define frailty in older cancer patients, the aim of this study was to assess the geriatric status and quality of life (QoL) aspects in patients suffering from recurrent/metastatic head and neck squamous cell carcinoma (r/m HNSCC) under palliative treatment. A comprehensive geriatric assessment (CGA) was performed on 21 r/m HNSCC patients at two defined assessments, and the QoL aspects and the impact of descriptive data were evaluated. The Kolmogorov-Smirnov test, Spearman's rho correlation, and two-way mixed ANOVA were used for statistical analysis. All patients were found to be "frail". Pain, fatigue, and the burden of illness were the highest-rated symptoms. Oral function and orofacial appearance were highly impaired. A significant impact of descriptive data on the CGA and QoL results was found (all p ≤ 0.05). Thus, the CGA results revealed high frailty, severe comorbidities, and high impairments in QoL aspects. The CGA and QoL results were negatively affected by the primary HNSCC treatment approach, the need for prosthetic treatment, and worse oral functional capacity. Therefore, frailty in r/m HNSCC patients seems to be multidimensional. The evaluation of the CGA and QoL aspects in r/m HNSCC patients can be recommended to detect special needs, organize aftercare, and improve the support for frail and vulnerable cancer patients to create a multidisciplinary treatment approach.

Prevalence, severity, and nature of risk factors associated with drug-drug interactions in geriatric patients receiving cancer chemotherapy: A prospective study in a tertiary care teaching hospital.

INTRODUCTION: Polypharmacy increases hazard of drug-drug interactions(DDIs), hospitalization, treatment toxicity, and mortality in elderly individuals with cancer. The present study explores and analyzes prevalence and severity of DDIs in geriatric cancer patients subjected to anticancer chemotherapy, their mechanisms, stratification of severity, and correlation between DDI risk and number of medications taken. METHODS: This was a cross-sectional study conducted between January-July 2019 at the Medical Oncology/Hematology and Radiation-Oncology Departments, All India Institute of Medical Sciences(AIIMS) Rishikesh. The study included a convenience sampling of 126 geriatric cancer patients. RESULTS: 126 patients were enrolled in present study. DDIs were identified in 97.6% of elderly cancer patients, and 88.9% had at least one DDI with antineoplastic medications. Highest number of DDIs involving antineoplastic medications in any given patient was 12. DDIs involving medications used for treatment of non-cancerous diseases were observed in 83.3% of patients; highest number of interactions identified in any given patient was 15. Out of 473 interactions, 237(50.1%) DDIs were attributable to pharmacodynamic mechanisms of action. 126(27%) of DDIs involved pharmacokinetic mechanisms and 110(23.6%) involved unknown mechanisms. In this present study, total number of DDIs could be positively correlated with total number of medications and number of health problems. CONCLUSIONS: Geriatric cancer patients are at high risk of DDIs ascribable to polypharmacy. Physicians may utilize online DDI checking softwares to alert themselves, characterize potential DDIs, and modify medications judiciously. An integrative and algorithmic approach with inclusion of geriatricians, oncologists, cardiologists, general practitioners, and clinical pharmacologists/ pharmacists is imperative to optimize drug therapy.

Is there a role for specialized geriatric centers in treating geriatric cancer patients?

As the population with colorectal cancer ages, the tailored approach required to manage older patients becomes all the more important for all providers and institutions treating colorectal cancer to adopt and improve the outcomes and well-being of this important and increasingly prevalent population. Joint guidelines from the American College of Surgeons and American Geriatric Association should be followed. Older cancer patients undergoing colorectal cancer surgery should be referred to centers with expertise in minimally invasive surgery. Likewise, older rectal cancer patients should be referred to centers with expertise in treating rectal cancer.

The Intersection of Oncology Prognosis and Cancer Rehabilitation.

PURPOSE OF REVIEW: This review examines the delivery of rehabilitation care to cancer patients with relation to disease prognosis. This includes the evaluation when patients are referred for rehabilitation services and the effectiveness of rehabilitation interventions across the cancer continuum. RECENT FINDINGS: Although prognosticating life expectancy is difficult, referrals for rehabilitation interventions appear to be affected by physician attitudes towards patients with advanced disease, in part because of misconceptions about the nature of rehabilitation for oncology patients. Rehabilitation may also be underutilized in long-term survivors with no evidence of disease. Despite this, our review found that rehabilitation in advanced disease, end-of-life, geriatric cancer patients, and in long-term survivors can be beneficial. There is a relative dearth in studies on rehabilitation interventions specifically at the end-of-life. SUMMARY: Cancer rehabilitation can be helpful to patients along the spectrum of cancer prognoses. Examining more accurate ways to prognosticate life expectancy, improving communication and education between oncologists and rehabilitation team members, and modifying survivorship plans to include patient education on functional changes over time may improve the delivery of rehabilitation care.

[Update on oncological pain in the elderly]. / Actualización del dolor oncológico en el anciano.

Pain is a prevalent symptom in cancer geriatric patients, appearing in up to 90% of patients with terminal cancer. This requires a multidimensional approach, as there is a high percentage of inappropriate assessments and treatments. Unrecognized or poorly treated pain in the geriatric population, especially in cancer patients, leads to the development of disabling symptoms such as depression, anxiety, isolation, sleep disturbances, and appetite, and very especially, loss of functional capacity and quality of life. In this review an analysis is made on the most relevant studies on the diagnosis and management of cancer pain in the geriatric population.

Effect of immediate rubber drainage on the dental apicoectomy in geriatric cancer patients : report of cases

The apicoectomy is an operation in which the root apex is removed and the adjacent periapical pathologic tissue is curetted. In this operation, there are several factors that may lead to the surgical wound infection, such as, local, systemic, environmental, endogenous and surgical factor. The systemic medical and surgical factor that may compromise patients' defense are more important cause of the wound infection. The postoperative infection is likely to occur owing to poor systemic condition(especially geriatric cancer patient with operation, radiotherapy and chemotherapy), postoperative accumulation of hematoma and seroma and other contaminated factors. So, the authors established the immediate rubber drainage into the sutured wound of dental apicoectomy for the prevention of postoperative infection. The results are more favorable without the wound infection in total 31 cases of the dentistry of Dong San Medical Center and Wonju Christian Hospital.