Age and clinical decision making in oncology patients.

BACKGROUND: Ageism is a cultural bias that might inappropriately steer oncologists away from recommending aggressive treatments for older patients. The extent to which older patients might prefer less aggressive cancer therapies is unknown. Our lack of knowledge about patients' personal preferences for therapy may perpetuate this bias. PURPOSE: We conducted a study to determine 1) if age influences patient acceptance of cancer therapy and 2) if the older patients would be more or less likely to trade increased survival for maintaining quality of life than their younger counterparts. METHODS: Using an interview format, 244 cancer patients of all ages treated at a tertiary care cancer center read two sets of hypothetical vignettes. The first set consisted of four vignettes that varied in terms of stage of disease and treatment toxicity. Patients were asked to make hypothetical decisions about treatment given with respect to varying levels of either increasing cure or extending survival. The second set of vignettes presumed acceptance of cancer therapy. Within each vignette, two hypothetical treatments (mild versus severe) with different probabilities of 1-year survival were contrasted. The point at which patients shifted preferences from a treatment with mild versus severe side effects was the dependent measure. Mixed analysis of variance (ANOVA) procedures (F test) assessed the impact of age (< 65 years versus > or = 65 years) and patient disease stage (early versus advanced) on hypothetical decisions about treatment. All P values are two sided. RESULTS: In the treatment-preference vignettes, there was no effect of either age [F(1,239) = 2.14; P = .14] or patient stage [F(1,239) = .40; P = .53] on treatment acceptance. Older adults were as likely as their younger counterparts to agree to chemotherapy for both curative and control purposes. In the switch-point vignettes, younger adults switched to a more toxic treatment to gain survival advantage at an earlier point than the older patients in both the early-disease vignette [F(1,232) = 3.88; P = .05] and the advanced-disease vignette [F(1,232) = 4.43; P = .036]. There was neither an effect of disease stage on treatment decisions nor an interaction between disease stage and age. CONCLUSIONS AND IMPLICATIONS: In a tertiary care setting, older adults do not differ from their younger counterparts in terms of acceptance of chemotherapy. However, when treatment is presumed, they differ in terms of willingness to trade survival for current quality of life. Generalization of findings is limited by the relatively small sample of older adults (n = 43) and the referral population from which the sample was drawn. Replication with a larger older adult sample in a community setting is needed.

Chemotherapy in older cancer patients.

Results of chemotherapy studies in elderly patients are variable and frequently contradictory. One reason is that elderly patients with other underlying diseases are often excluded. Many of the protocols are not designed to evaluate only elderly patients, and even the definition of elderly is not uniform. Taking these limitations into account, when chemotherapy is used as the definitive form of treatment in elderly patients with lymphoma and leukemia, treatment related toxicity appears to be greater than in younger patients. When chemotherapy is used palliatively in elderly patients with solid tumors, it is usually well tolerated except for some increased hematologic toxicity.

Common emergencies in cancer medicine: hematologic and gastrointestinal syndromes.

A myriad of both primary and secondary hematologic and gastrointestinal system-related clinical problems may exist in the cancer patient. This review outlines a standard approach to the prompt diagnosis and therapeutic intervention for these clinical issues.

Cutaneous T-cell lymphomas.

Cutaneous T-cell lymphoma, which usually presents as mycosis fungoides or Sézary syndrome, remains a mostly incurable, yet highly treatable group of diseases. The myriad of active therapies continues to grow, and new insights into the mechanism of systemic and topical therapies are being elucidated. Multimodality treatment initiated for early-stage disease may help improve long-term survival. The need for randomized prospective trials is obvious and should become a priority. Further development of molecular genetic techniques and cell-surface phenotyping has enhanced our understanding of these diseases and will hopefully allow for the development of more effective and specific treatments.

Re-validation and shortening of the Functional Assessment of Anorexia/Cachexia Therapy (FAACT) questionnaire.

PURPOSE: The original Functional Assessment of Anorexia/Cachexia Therapy (FAACT) was designed to measure general aspects of quality of life (QOL) as well as specific anorexia/cachexia-related concerns. Our primary purpose was to reduce the number of anorexia/cachexia subscale items in a manner that either retains or improves reliability, validity and precision. METHODS: The FAACT was administered using an interactive computer program that allowed immediate entry of the data. A total of 213 patients were recruited. RESULTS: A combined empirical and conceptual approach led to the reduction of the anorexia/cachexia subscale (A/CS) from 18 to 12 items. A 26-item trial outcome index (TOI) combining physical well-being (PWB), functional well-being (FWB), and the A/CS-12 was highly reliable and sensitive to change in performance status rating (PSR). We found that PWB, FWB, and A/CS-12 subscales performed differently. Specifically, PWB and FWB scores decreased in patients whose (PSR) worsened. However, although A/CS-12 scores were responsive to change in PSR over time, average A/CS-12 scores of all patients, even those whose PSR worsened, improved over the course of treatment. CONCLUSIONS: Elimination of six items from the anorexia/cachexia subscale of the FAACT was accomplished without loss of internal consistency or sensitivity to change in performance status. The A/CS-12 subscale provides unique, important information not captured by a generic chronic illness questionnaire.