Acute megakaryocytic leukemia. Description of a case initially seen as preleukemia syndrome.

A 52-year-old man had aregenerative anemia unresponsive to pyridoxine hydrochloride. Acute leukemia developed, and he died four months after diagnosis. At autopsy he had acute megakaryocytic leukemia with involvement of bone marrow, liver, spleen, adrenals, kidneys, and thyroid. Chromosomal analysis revealed absence of both diploid and Ph1 chromosomes. A mode of 45 chromosomes and aneuploidy were present. This is similar to the only other case with chromosomal studies. Of the 15 acceptable documented cases, eight were men and seven were women. Their age varied from 28 to 76 (mean, 55) years. Only two were less than 40 years of age. Most had pancytopenia, and all were dead within six months of diagnosis.

The application of the principles of geriatrics to the management of the older person with cancer.

Is the patient going to die of cancer or with cancer? Is the patient going to suffer pain and disability due to cancer? Is the patient able to tolerate aggressive life-prolonging treatment? This paper tries to reply to the fundamentals of these questions by introducing the multidimensional assessment that evaluates areas where age-related changes are more likely. Chronologic age cannot be used to predict the degree of comorbidity and of functional deterioration of the single individual up to age 85 at least. Assessment of aging includes health, functional status, nutrition, cognition, socio-economic and emotion evaluations. This multidisciplinary assessment is referred to as comprehensive geriatric assessment (CGA). The risk of comorbid conditions increases with age and may result in underdiagnosis: in older patients, new symptoms may not be clearly recognized by the patient and may be dismissed by practitioners as manifestations of preexisting conditions. A meaningful assessment of comorbidity may be obtained with a comorbidity index. The Charlson scale and the Chronic Illness Rating Scale - Geriatric (CIRS-G), have enjoyed the widest acceptance. The Instrumental Activities of Daily Living (IADL) and the Activities of Daily Living (ADL) are the most sensitive assessment of function in older individuals. IADLs include shopping, managing finances, housekeeping, laundry, meal preparation, ability to use transportation and telephone and ability to take medications: in simple words, the IADLs are those skills a person needs to live independently. ADLs include feeding, grooming, transferring, toileting and are the skills necessary for basic living. Though a correlation exists among comorbidity, performance status, ADL and IADL, this correlation is not strong enough to be reflected in a single parameter. The Folstein Mini Mental Status (MMS), is the instrument of most frequent use to screen older individuals for dementia. The main problem with the MMS is lack of sensitivity to early stages of dementia. The Geriatric Depression Scale (GDS), a simple tool that can be completed by most patients at home, doubles the rate of detection of depression. The Mini Nutritional assessment is very sensitive to screen older persons for malnutrition. The risk of polypharmacy increases with age and partly results from the fact that older patients visit different practitioners. A CGA should also include evaluation of the so called Geriatric Syndromes like delirium, incontinence, osteoporosis, all of which represent a hallmark of frailty. The CGA may help the management of older individuals with cancer in at least three areas: detection of frailty, treatment of unsuspected conditions, removal of social barrier to treatment.

Cancer and age in the USA.

Cancer in the older person has become an increasingly common problem with the aging of the population. The goal of this paper is to review the influence of age on cancer biology and cancer management. Specific interactions of cancer and aging include: Increased incidence of cancer with the age: This association may be reported to three factors: duration of carcinogenesis; increased susceptibility of older tissues to late stage carcinogens, and systemic effects of aging, including immune-senescence and enhanced cytokine production. Biological behavior of cancer: With aging, the prognosis of certain neoplasms, including acute myelogenous leukemia and large-cell non-Hodgkin's lymphoma worsens, whereas the behavior of other tumors becomes more indolent. In these biologic variations one may recognize both a 'seed" effect (different tumor cells) and a "soil" effect (different ways in which the older tumor host handles tumor growth. Goals of prevention and treatment: Given the limited life-expectancy of older individuals and reduced tolerance of clinical intervention, the main goal is compression of morbidity, rather than prolongation of survival. Cancer prevention in the older person: In virtue of increased susceptibility to environmental carcinogens, the older person appears an ideal candidate for primary prevention of cancer, including chemoprevention; though randomized controlled studies have not been performed, the older person may benefit from secondary prevention (screening), when the average life-expectancy is 3 years or longer. Cancer treatment: The risk of surgical complications increases only slightly with age for elective surgery, but increases dramatically for emergency surgery. Radiation therapy appears a valuable method of cancer treatment in patients of all ages. Chemotherapy can be made safer by the following provisions: use of hemopoietic growth factors for patients aged 70 and older receiving moderately toxic chemotherapy (CHOP and CHOP-like); maintenance of hemoglobin levels at 12 g/dl with erythropoietin; adjustment of the dose of renally excreted agents to the glomerular filtration rate; selection of the best candidates for chemotherapy based on comprehensive geriatric assessment.

Comprehensive Geriatric Assessment: Diagnostic, Therapeutic, and Prognostic Value.

Statistics on the geriatric population usually pertain to individuals aged 65 years and older. Chronological age, however, especially between ages 65 to 79 years, is a rather crude measure of physiologic aging, with some individuals still being vigorous, active, and independent and others experiencing great physical and psychosocial losses. As a specialty, geriatric medicine best addresses the needs of the latter group of persons, frequently referred to as the "frail elderly." The frail elderly are able to maintain their homeostasis in a nonstressed environment but have a strong inclination to decompensate when faxed with stressors which would not have been as taxing at a younger age. This propensity is due to more limited and easily exhaustible physiologic reserves.

Pharmacology of Chemotherapy in the Older Cancer Patient.

BACKGROUND: The incidence of cancer among the elderly population is increasing. The aging process can deplete functional reserve of many organ systems and thus affects the treatment goals for this age-group. METHODS: The pharmacologic consequences of the aging process on elderly cancer patients are reviewed, and guidelines are suggested for assessing and treating this patient population with antitumor drugs. RESULTS: Individualized management of the older cancer patient reflects the results of a comprehensive geriatric assessment. Factors that affect treatment decisions include estimates of the extent of treatment toxicity, the impact of treatment on quality of life, estimates of life expectancy, and the influence of age on pharmacokinetic parameters. CONCLUSIONS: Management of older patients with cancer includes individual assessments that consider the effects of aging on the pharmacodynamics, therapies, and complications of treatment for this population. Treatment can be made safer and more effective by adjusting chemotherapy dosage, maintaining hemoglobin levels, and using hemopoietic growth factors when appropriate.

Secondary Prevention of Breast Cancer in the Older Woman: Issues Related to Screening.

With advancing age, the prevalence of breast cancer and consequently the positive predictive value of screening tests increase. However, limited life expectancy may reduce the benefit of cancer screening. The integration of serial mammography, yearly or every two years, with yearly physical examination of the breast, reduces the breast cancer related mortality among women aged 50 to 70 years and may be beneficial for older women. Of all age-related barriers to screening, the lack of physician support has been the most significant. A reversal in this trend was witnessed by a recent increase in mammography use by women aged 69 to 75 years. On the basis of existing data, it is reasonable to recommend screening for women up to age 75 years and for older women whose life-expectancy is estimated at three years or longer.

Cancer screening in the older patient.

Effective treatment of several types of malignant diseases has developed substantially over the past four decades, with ever improving survival rates for cancers found in early stages. Among older patients, however, the cancer death rates remain elevated. This article explores the value of early screening for several types of malignant disease in the older patient.

Prognostic evaluation in geriatric oncology: problems and perspectives.

The optimal management of older patients with malignant diseases may be prevented by two antithetic conditions: inadequate treatment and excessive treatment. A likely root of this problem appears to be paucity of prognostic information, which may hamper management-related decisions in the older person with cancer. The prognostic value of performance status and nutritional status may fade with aging, while the influence of mental, emotional and socioeconomic status on the outcome of neoplastic diseases may become more prominent. The Comprehensive Geriatric Evaluation (CGE), which encompasses emotional mental and social domains in addition to physical health and function, may prove a valuable clue for the selection of those older patients who are suitable candidates for antineoplastic treatment.

Disposable insulin syringe reuse and aseptic practices in diabetic patients.

Diabetic patients are traditionally taught to discard plastic syringe/needle units after a single use and to employ aseptic technique for administering insulin injections. We surveyed 87 diabetic outpatients for compliance with aseptic recommendations. We then studied prospectively the effects of reusing disposable syringes in 56 diabetic patients who reused syringes a mean of 6.6 times for 8.3 months and an aggregate of 23,664 injections. Almost half (49%) of diabetic patients in a combined university clinic and private practice reused supposedly disposable insulin syringes a mean of 3.9 times. Compliance with standard aseptic precautions was poor, with only 29% of patients following recommended practices. No adverse effect of syringe reuse was identified. The authors conclude that diabetic patients frequently reuse disposable syringes, without apparent harmful effect.