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1.  Toxicity of Bevacizumab in Combination with Chemotherapy in Older Patients 
The Oncologist  2013;18(4):408-414.
Heart disease is more common in those who do not receive bevacizumab. Older patients who receive bevacizumab with chemotherapy have higher odds of developing a grade 3–5 toxicity compared with those who receive chemotherapy alone.
Learning Objectives
Compare characteristics of older patients that receive bevacizumab plus chemotherapy to those treated with chemotherapy alone for advanced NSCLC and CRC.Compare outcomes between older patients treated with bevacizumab plus chemotherapy to chemotherapy alone for advanced NSCLC and CRC.Describe toxicities in older patients treated with bevacizumab plus chemotherapy for advanced NSCLC and CRC.
Background.
Bevacizumab leads to improved survival for patients with metastatic colorectal cancer (CRC) or non-small cell lung cancer (NSCLC) when added to chemotherapy. Little is known about factors associated with receipt of bevacizumab, or whether bevacizamab is associated with increased toxicity when added to chemotherapy.
Patients and Methods.
We conducted a prospective study of patients aged ≥65 years, which evaluated the association between geriatric assessment (GA) metrics and chemotherapy toxicity. We examined differences in characteristics and outcomes of patients with CRC and NSCLC cancers who received bevacizumab with chemotherapy versus chemotherapy alone.
Results.
From a total of 207 patients, 27 (13%) received bevacizumab plus chemotherapy and 180 (87%) received chemotherapy alone. Groups were similar in sociodemographic and cancer characteristics. There were no baseline differences in GA domains except that patients with heart disease were less likely to receive bevacizumab (4% vs. 26%, p = .01). Seventy-eight percent of patients who had bevacizumab had grade 3–5 toxicity compared to only 57% who received chemotherapy alone (p = .06). Patients receiving bevacizumab were more likely to develop grade 3 hypertension than those who received chemotherapy alone (15% vs. 2%, p < .01). In multivariable analysis, factors associated with grade 3 or more toxicity included: bevacizumab (OR: 2.86, p = .04), CRC (OR: 2.54, p < .01), and baseline anemia (OR: 2.58, p = .03).
Conclusion.
Heart disease was more common in those who did not receive bevacizumab. Older patients who receive bevacizumab with chemotherapy have a higher odds of developing a grade 3–5 toxicity compared with those who receive chemotherapy alone.
doi:10.1634/theoncologist.2012-0351
PMCID: PMC3639527  PMID: 23576485
Chemotherapy; Geriatric assessment; Bevacizumab; Drug toxicity; Health services for the aged
2.  A Novel Approach to Improve Health Status Measurement in Observational Claims-based Studies of Cancer Treatment and Outcomes 
Journal of geriatric oncology  2013;4(2):157-165.
Objectives
To develop and provide initial validation for a multivariate, claims-based prediction model for disability status (DS), a proxy measure of performance status (PS), among older adults. The model was designed to augment information on health status at the point of cancer diagnosis in studies using insurance claims to examine cancer treatment and outcomes.
Materials and Methods
We used data from the 2001–2005 Medicare Current Beneficiary Survey (MCBS), with observations randomly split into estimation and validation subsamples. We developed an algorithm linking self-reported functional status measures to a DS scale, a proxy for the Eastern Cooperative Oncology Group (ECOG) PS scale. The DS measure was dichotomized to focus on good [ECOG 0–2] versus poor [ECOG 3–4] PS. We identified potential claims-based predictors, and estimated multivariate logistic regression models, with poor DS as the dependent measure, using a stepwise approach to select the optimal model. Construct validity was tested by determining whether the predicted DS measure generated by the model was a significant predictor of survival within a validation sample from the MCBS.
Results and Conclusion
One-tenth of beneficiaries met the definition for poor DS. The base model yielded high sensitivity (0.79) and specificity (0.92); positive predictive value=48.3% and negative predictive value=97.8%, c-statistic=0.92 and good model calibration. Adjusted poor claims-based DS was associated with an increased hazard of death (HR=3.53, 95% CI 3.18, 3.92). The ability to assess DS should improve covariate control and reduce indication bias in observational studies of cancer treatment and outcomes based on insurance claims.
doi:10.1016/j.jgo.2012.12.005
PMCID: PMC3685201  PMID: 23795223
Medicare; cancer; health status; observational study; treatment selection bias; functional status
3.  Challenges in the Management of Older Patients with Colon Cancer 
The majority of patients with colon cancer are over the age of 65. Their treatment poses multiple challenges to the oncologist, as these patients may have age-related comorbidities, polypharmacy, and physical or physiologic changes associated with older age. These challenges include limited data on the ability to predict tolerance to anti-cancer therapy and the appropriate use of treatment modalities in the setting of comorbidity and concurrent frailty. The low number of older patients enrolled on large clinical trials results in a paucity of evidence to guide the oncologist in the appropriate management of this population. In early stage disease, clinical dilemmas arise regarding the ability of older patients to undergo successful curative surgical procedures and the risk/benefit ratio of adjuvant chemotherapy. The management of metastatic disease raises questions regarding the clinical benefit of various anti-cancer therapies and the role of combination therapy with possible increased toxicity in the non-curative setting. Overall, the available evidence demonstrates that fit older patients are able to tolerate treatment and derive similar clinical benefits as younger patients. Limited data are available to guide treatment for less fit, more vulnerable older patients. This lack of data leads to variations in treatment patterns in older adults, making them less likely to receive standard therapies. This review will provide an overview of the available data regarding the management of older adults with colon cancer in the adjuvant and metastatic settings.
PMCID: PMC3932187  PMID: 22308516
Colon cancer; Elderly; Older Adults
4.  Cognitive function in older women with breast cancer treated with standard chemotherapy and capecitabine on Cancer and Leukemia Group B 49907 
Cognitive changes in older women receiving chemotherapy are poorly understood. We examined self-reported cognitive function for older women who received adjuvant chemotherapy on Cancer and Leukemia Group B (CALGB) 49907. CALGB 49907 randomized 633 women aged ≥65 with stage I–III breast cancer to standard adjuvant chemotherapy (cyclophosphamide–methotrexate–5-fluoro-uracil or doxorubicin–cyclophosphamide) versus capecitabine. We examined self-reported cognitive function in 297 women (CALGB 361002) who enrolled on the quality of life substudy and had no gross impairment on cognitive screening. Women were evaluated using an 18-item instrument at six time points (baseline through 24 months). At each time point for each patient, we calculated a cognitive function score (CFS) defined as the mean response of items 1–18 and defined impairment as a score >1.5 standard deviations above the overall average baseline score. Differences in scores by patient characteristics were evaluated using a Kruskal–Wallis test. A linear mixed-effects model was used to assess CFSs by treatment over time. Among 297 women, the median age was 71.5 (range 65–85) and 73 % had performance status of 0. Baseline depression and fatigue were reported in 6 and 14 % of patients, respectively. The average CFS at baseline was 2.08 (corresponding to “normal ability”), and baseline cognitive function did not differ by treatment regimen (p = 0.350). Over 24 months, women reported minimal changes at each time point and insignificant differences by treatment arm were observed. In a healthy group of older women, chemotherapy was not associated with longitudinal changes in self-reported cognitive function.
doi:10.1007/s10549-013-2562-6
PMCID: PMC3920483  PMID: 23681403
Cognitive function; Older women; Breast cancer; Age
5.  A planned, prospective comparison of short-term quality of life outcomes among older breast cancer patients treated with standard chemotherapy in a randomized clinical trial vs. an observational study: CALGB #49907 and #369901✰ 
Journal of geriatric oncology  2013;4(4):353-361.
Objectives
Patients ≥65 years old (“older”) are often not included in randomized clinical trials (RCT), but when they are, care in an RCT might improve quality of life (QoL). We conducted a prospective comparison of QoL among older women receiving standard chemotherapy from the same cooperative group physicians in an RCT vs. an observational study (“off-trial”).
Methods
Older women with invasive, non-metastatic breast cancer (n = 150 RCT; 530 off-trial) were included. Linear mixed-effects models tested associations between chemotherapy on- vs. off-trial and changes in EORTC (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire) QoL scores over 24 months, controlling for pre-treatment QoL, age, education, tumor factors, comorbidity, and other covariates.
Results
Anthracycline regimens were used by 58% of women treated on-trial vs. 54% of those treated off-trial. Women in the RCT reported an adjusted mean increase of 13.7 points (95% CI 10.2, 17.1) in global QoL at 24 months (vs. mid-treatment), while women treated off-trial had only an adjusted improvement of 7.0 points (95% CI 3.5, 10.4; p = .007 for difference in mean changes). Women in the RCT had significantly greater improvement in emotional function than those treated off-trial, controlling for baseline; they also had greater reductions in therapy side effects and fatigue at 24 months than women off-trial, controlling for covariates.
Conclusion
There may be different QoL trajectories for older women undergoing breast cancer chemotherapy on- vs. off-trial. If confirmed, the results suggest that the extra monitoring and communication within an RCT could provide the infrastructure for interventions to address symptoms and improve QoL for the growing older cancer population.
doi:10.1016/j.jgo.2013.05.004
PMCID: PMC3910230  PMID: 24472479
Older patients; Breast cancer; Chemotherapy; Quality of Life; Randomized clinical trials; Observational studies
6.  Managing Breast Cancer in the Older Patient 
Breast cancer is a disease associated with aging, with almost one-half of all new breast cancer cases diagnosed annually in the United States occurring in women age 65 and older. Recent data suggest that although breast cancer outcomes in younger women have shown substantial improvement as a result of advances in treatment and screening, the benefits in older women have been less pronounced. Although older adults have been under-represented on cancer clinical trials there is an emerging body of literature to help guide treatment decisions. For early stage breast cancer, the discussion regarding treatment options involves balancing the reduction in risk of recurrence gained by specific therapies with the potential for increased treatment-related toxicity potentially exacerbated by physiological decline or comorbidities that often co-exist in the older population. A key component of care of the older adult is the recognition that chronologic age alone cannot guide the management of an older individual with breast cancer; rather, treatment decisions must also take into account an individual’s functional status, estimated life expectancy, the risks and benefits of the therapy, potential barriers to treatment, and patient preference. This article reviews the available evidence for therapeutic management of early-stage breast cancer in older adults, and highlights data from geriatric oncology literature that provides a basis on which to facilitate evidence-based treatment.
PMCID: PMC3906632  PMID: 24472802
breast cancer; older patient; therapeutic management; geriatric oncology
7.  Survivorship education for Latina breast cancer survivors: Empowering Survivors through education 
Psicooncologia  2013;10(1):57-68.
Objectives
Nueva Luz is an English and Spanish quality of life (QOL) intervention developed to address the educational needs of Latina breast cancer survivors and provide strategies to assist in their transition into survivorship.
Methods
A qualitative approach was used to evaluate the English and Spanish educational intervention (Nueva Luz). A purposive sample of eight Latina breast cancer survivors was selected from the group who received the intervention to participate in a digitally recorded interview. Data was analyzed using thematic analysis.
Results
Findings provide evidence that the one-on-one tailored approach is a feasible and acceptable method of providing a bilingual psychosocial intervention. The provision of printed bilingual information along with the verbal instruction from a bilingual and culturally competent health care provider can be effective in helping Latina breast cancer survivor’s transition successfully into survivorship, improve QOL and contribute to better patient outcomes
Conclusions
The study informs our understanding of the cultural context in patient education content and delivery of psychosocial interventions. The findings may also have relevance for other ethnic minority cancer survivors.
doi:10.5209/rev_PSIC.2013.v10.41947
PMCID: PMC3888314  PMID: 24416043
8.  Feasibility of Computer-Based Self-Administered Cancer-Specific Geriatric Assessment in Older Patients With Gastrointestinal Malignancy 
The Oncologist  2013;18(1):64-72.
A computer-based cancer specific geriatric assessment was developed and tested among patients age 70 and older receiving treatment for gastrointestinal malignancies at the Dana-Farber Cancer Institute. The feasibility endpoints were met, although half of the sample required assistance and the results did not affect immediate clinical decision-making.
Background.
The Cancer-Specific Geriatric Assessment (CSGA) is a primarily self-administered paper survey of validated measures.
Methods.
We developed and tested the feasibility of a computer-based CSGA in patients ≥70 years of age who were receiving treatment for gastrointestinal malignancies at the Dana-Farber Cancer Institute. From December 2009 to June 2011, patients were invited to complete the CSGA at baseline (start of new treatment) and follow-up (at the first of 4 months later or within 4 weeks of completing treatment). Feasibility endpoints were proportion of eligible patients consented, proportion completing CSGA at baseline and follow-up, time to complete CSGA, and proportion of physicians reporting CSGA results that led to a change in clinical decision-making.
Results.
Of the 49 eligible patients, 38 consented (76% were treatment naive). Median age was 77 years (range: 70–89 years), and 48% were diagnosed with colorectal cancer. Mean physician-rated Karnofsky Performance Status was 87.5 at baseline (SD 8.4) and 83.5 at follow-up (SD 8). At baseline, 92% used a touchscreen computer; 97% completed the CSGA (51% independently). At follow-up, all patients used a touchscreen computer; 71% completed the CSGA (41% independently). Mean time to completion was 23 minutes at baseline (SD 8.4) and 20 minutes at follow-up (SD 5.1). The CSGA added information to clinical assessment for 75% at baseline (n = 27) and 65% at follow-up (n = 17), but it did not alter immediate clinical decision-making.
Conclusion.
The computer-based CSGA feasibility endpoints were met, although approximately half of patients required assistance. The CSGA added information to clinical assessment but did not affect clinical decision-making, possibly due to limited alternate treatment options in this subset of patients.
doi:10.1634/theoncologist.2012-0241
PMCID: PMC3556258  PMID: 23287880
Gastrointestinal cancer; Geriatric oncology; Geriatric assessment; Clinical decision-making
9.  Early breast cancer in the older woman 
Clinics in geriatric medicine  2011;28(1):10.1016/j.cger.2011.10.002.
SYNOPSIS
Breast cancer is a disease associated with aging; there is a rise in both breast cancer incidence and mortality with increasing age. With the aging of the US population, the number of older adults diagnosed with breast cancer and the number of breast cancer survivors is on the rise. The majority of cases of breast cancer are diagnosed with early stage (non-metastatic) potentially curable disease. This article will review the treatment of early stage breast cancer in older adults including a focus on the risks and benefits of surgery, radiation therapy, endocrine therapy, chemotherapy, and trastuzumab. Although the majority of studies to date demonstrate that older adults experience similar benefits from most multimodality treatments for breast cancer as compared to younger adults, these studies have primarily been performed in healthy and fit older adults. There are limited data at the extremes of age or in those patients with significant comorbidity or functional decline. A primary question facing the doctor and patient is whether the breast cancer is likely to impact the patient’s life expectancy or quality of life. If so, then the risks and benefits of treatment must be considered with a final decision regarding therapy made in the context of the patient’s preferences. This article will review the toxicities (both short- and long-term) from common cancer therapies in early breast cancer. Finally, the decision as to type of secondary screening and prevention of future breast cancers must also be weighed against the life expectancy of the older adult.
doi:10.1016/j.cger.2011.10.002
PMCID: PMC3874410  PMID: 22326036
10.  Geriatric Assessment in Oncology Practice 
Journal of the American Geriatrics Society  2009;57(0 2):10.1111/j.1532-5415.2009.02503.x.
There is no standard tool for assessing the “functional age” of an older adult with cancer, although it is widely recognized that chronological age does not capture the heterogeneous physiologic and functional status of older adults. Integrating a “geriatric assessment” into oncology research and clinical practice would help fill this void. Geriatric assessment covers factors that predict morbidity and mortality in older adults, including functional status, comorbidity, cognition, psychological state, nutritional status, and social support. This assessment provides a broader overall understanding of individual characteristics that affect life expectancy. In addition, this assessment identifies areas of vulnerability among older adults for which further evaluation or intervention is indicated. In this article, we will discuss the utility of a geriatric assessment in oncology practice, review data that attest to the benefits of the assessment, and issue a call for further research into how we can integrate this assessment into oncology care. Doing so will help us to develop targeted interventions and optimize cancer outcomes in this rapidly growing population.
doi:10.1111/j.1532-5415.2009.02503.x
PMCID: PMC3845875  PMID: 20122022
geriatric assessment; cancer; aging; oncology
11.  In Reply 
The Oncologist  2013;18(12):1331.
It remains challenging to incorporate comprehensive geriatric assessment (CGA) into prospective clinical trials, but efforts continue to test the efficacy of CGA-guided interventions for information about how the CGA data should be utilized to modify treatment.
doi:10.1634/theoncologist.2013-0303
PMCID: PMC3868429  PMID: 24336119
12.  Feasibility and toxicity of dose-dense adjuvant chemotherapy in older women with breast cancer 
Breast cancer research and treatment  2008;117(1):10.1007/s10549-008-0116-0.
Introduction
The objective of this study was to examine the feasibility and toxicity of adjuvant dose-dense chemotherapy in older women with breast cancer.
Methods
A search of the Memorial Sloan-Kettering Cancer Center (MSKCC) breast cancer database was performed to identify all patients age 60 and older who underwent an initial consultation with a breast medical oncologist between October 1, 2002 and June 28, 2005. Inclusion criteria were: (1) age ≥ 60, (2) follow-up care obtained at MSKCC, (3) intent to treat with adjuvant dose-dense AC-T (doxorubicin 60 mg/m2 and cyclophosphamide 600 mg/m2 every 2 weeks for 4 cycles followed by paclitaxel 175 mg/m2 every 2 weeks for 4 cycles, with white blood cell growth factor support).
Results
One hundred sixty-two patients (mean age 66, range 60–76) with breast cancer, stages I (n = 5), II (n = 111), and III (n = 46) according to the sixth edition of the AJCC staging system, were included in this analysis. Forty-one percent (n = 67) experienced a grade 3 or 4 toxicity, 9% a grade 3 infection (n = 14), 6% grade 3 fatigue (n = 9), 5% neutropenic fever (n = 8), and 4% thromboembolic events (n = 7). Twenty-two percent (n = 36) did not complete the planned 8 cycles of treatment. There was no statistically significant association between age and either toxicity or treatment discontinuation. In multivariate analysis including age, pretreatment hemoglobin, and comorbidity, the presence of comorbidity (Charlson score ≥ 1) and a lower baseline hemoglobin score were associated with an increased risk of any grade 3 or 4 toxicity.
Conclusions
We found that the risk of toxicity depended more on comorbid medical conditions and baseline hemoglobin value than age in this cohort of older adults receiving dose-dense adjuvant chemotherapy.
doi:10.1007/s10549-008-0116-0
PMCID: PMC3811071  PMID: 18622739
Breast Cancer; Dose-Dense Chemotherapy; Older Patient
13.  Use of Complementary Medications among Older Adults with Cancer 
Cancer  2012;118(19):4815-4823.
BACKGROUND
Little is known about complementary medication use among older adults with cancer, particularly those undergoing chemotherapy. The purpose of this study was to evaluate the prevalence of complementary medication use and to identify factors associated with its use among older adults with cancer.
METHODS
The prevalence of complementary medication use (defined as herbal agents, minerals, or other dietary supplements excluding vitamins) was evaluated in a cohort of adults aged ≥65 years who were about to start chemotherapy for their cancer. The association between complementary medication use and patient characteristics (sociodemographics; comorbidity; functional, nutritional, psychological, and cognitive status); medication use (number of medications and concurrent vitamin use); and cancer characteristics (type and stage) was analyzed.
RESULTS
The cohort included 545 patients [mean age 73 years (range 65–91); 52% female] with cancer (61% Stage IV). Seventeen percent (N=93) of these patients reported using ≥1 complementary medications [mean number of complementary medications among users was 2 (range 1–10)]. Complementary medication use was associated with: 1) earlier cancer stage, with 29% of those with stages I–II vs. 17% with III–IV (OR=2.05, 95% CI:1.21–3.49); and 2) less impairment with instrumental activities of daily living (OR=1.39, 95% CI:1.12–1.73).
CONCLUSIONS
Complementary medication use was reported by 17% of older adults with cancer and was more common among those with less advanced disease (receiving adjuvant potentially curative treatment) and higher functional status. Further studies are needed to determine the association between complementary medication use and cancer outcomes among older adults.
doi:10.1002/cncr.27427
PMCID: PMC3366170  PMID: 22359348
Herbals; Complementary Medicine; Older Adults; Cancer; Chemotherapy
14.  Cardiovascular Outcomes in Women With Advanced Breast Cancer Exposed to Chemotherapy 
Purpose
Quantify incidence of cardiovascular outcomes in patients with advanced breast cancer receiving cardiotoxic and non-cardiotoxic chemotherapy.
Methods
Identified all women at a Midwestern health system with initial diagnosis of AJCC stage III/IV breast cancer (1995–2003) and random sample of 50 women initially diagnosed with stage I/II who progressed to stage III/IV. Calculated rate of new cardiovascular outcomes (heart failure, dysrhythmia and ischemia events) for cardiotoxic (anthracycline or trastuzumab) and non-cardiotoxic agents.
Results
Of 315 patients, 90.5% (N=285) received systemic cancer therapy; 67.7% (n=193) received cardiotoxic drugs. Older patients were less likely to receive cardiotoxic agents (86.4% ≤ 59 years vs. 31.9% aged 70+). Adjusting for age, race, stage, surgery/radiation, ER/PR status and diagnosis year, rate of new cardiac events was higher in patients exposed to cardiotoxic drugs compared to those exposed to non-cardiotoxic drugs (adjusted hazard ratio=2.5, 95% CI 0.9, 7.2). Patients with cardiac event history (relative risk=3.2, 95% CI 2.0–5.1) and those with heart failure history (relative risk=5.9, 95% CI 2.4–14.6) were more likely to receive non-cardiotoxic treatment. Heart failure events occurred steadily over time; after 3 years follow-up 16% exposed to cardiotoxic drugs experienced an event, and 8% of those exposed to non-cardiotoxic drugs experienced an event.
Conclusions
Patients with cardiac comorbidity are less likely to receive cardiotoxic agents. Use of cardiotoxic agents is common, treatment is related to patient and tumor characteristics and is associated with substantial risk of cardiotoxicity that persists during patient’s remaining lifespan.
doi:10.1002/pds.3239
PMCID: PMC3785307  PMID: 22419528
breast cancer; chemotherapy; cardiotoxic agents; cardiotoxicity risk
16.  Geriatric Oncology Research to Improve Clinical Care 
Nature reviews. Clinical oncology  2012;9(10):571-578.
Summary
The incidence of cancer increases with advanced age. The Cancer and Aging Research Group (CARG), in partnership with the National Institute on Aging and National Cancer Institute, held a conference in September of 2010 which summarized the gaps in knowledge in geriatric oncology and recommendations to close these gaps. One recommendation was that the comprehensive geriatric assessment (CGA) should be incorporated within geriatric oncology research. The information from the CGA can be used to stratify patients into risk categories to better predict their tolerance of cancer treatment. CGA can also be used to follow functional consequences from treatment. Other recommendations were to design trials for older adults with study endpoints that address the needs of the older and/or vulnerable adult with cancer and to build better infrastructure to accommodate the needs of older adults to improve their representation in trials. In this review, we utilize a case-based approach to highlight gaps in knowledge regarding the care of older adults with cancer, discuss our current state of knowledge regarding best practice patterns, and identify opportunities for research in geriatric oncology. More evidence regarding the treatment of older patients with cancer is urgently needed given the rapid aging of the population.
doi:10.1038/nrclinonc.2012.125
PMCID: PMC3738437  PMID: 22825377
18.  New Treatment Approaches for Older Adults with Multiple Myeloma 
Journal of geriatric oncology  2012;3(3):279-290.
The incidence of multiple myeloma (MM) increases with age, and with the aging of the population, the number of adults with MM is expected to double in the next 20 years. Novel agents, including the immunomodulatory agents thalidomide and lenalidomide, and the proteosome inhibitor bortezomib have dramatically changed the treatment of multiple myeloma in the past decade. The purpose of this review was to examine the recent clinical therapeutic trials in older adults with MM. A number of trials have evaluated the addition of novel agents to the traditional backbone of melphalan and prednisone. The combination of thalidomide with melphalan and prednisone has been evaluated in 7 randomized trials. The combination improves response rates and, in meta-analyses, survival, but at the expense of increased toxicity. Other combination regimens which include lenalidomide or bortezomib likewise are associated with higher response rates, but at the expense of greater toxicity. High dose dexamethasone is excessively toxic in older adults and should be avoided. The roles for high-dose therapy with autologous stem cell transplant or intermediate-dose melphalan with autologous stem cell transplant in older adults with MM in the era of modern therapy remain to be defined. In summary, there are a number of new therapeutic options for older adults with MM, allowing an individualized treatment strategy based on the patient's comorbidities and goals of care.
doi:10.1016/j.jgo.2012.02.001
PMCID: PMC3458649  PMID: 23024730
multiple myeloma; geriatrics; aging; chemotherapy; immunomodulatory agents; proteosome inhibitors
19.  Senior Adult Oncology 
PMCID: PMC3656650  PMID: 22308515
NCCN Clinical Practice Guidelines; NCCN Guidelines; senior adult; elderly; advanced age; older patient; comprehensive geriatric assessment; cancer treatment
20.  Biological, Clinical, and Psychosocial Correlates at the Interface of Cancer and Aging Research 
In September 2010, the Cancer and Aging Research Group, in collaboration with the National Cancer Institute and the National Institute on Aging, conducted the first of three planned conferences to discuss research methodology to generate the highest quality research in older adults with cancer and then disseminate these findings among those working in the fields of cancer and aging. Conference speakers discussed the current level of research evidence in geriatric oncology, outlined the current knowledge gaps, and put forth principles for research designs and strategies that would address these gaps within the next 10 years. It was agreed that future oncology research trials that enroll older adults should include: 1) improved standardized geriatric assessment of older oncology patients, 2) substantially enhanced biological assessment of older oncology patients, 3) specific trials for the most vulnerable and/or those older than 75 years, and 4) research infrastructure that specifically targets older adults and substantially strengthened geriatrics and oncology research collaborations. This initial conference laid the foundation for the next two meetings, which will address the research designs and collaborations needed to enhance therapeutic and intervention trials in older adults with cancer.
doi:10.1093/jnci/djs145
PMCID: PMC3328422  PMID: 22457474
21.  Second Malignancies Among Elderly Survivors of Cancer 
The Oncologist  2011;16(11):1572-1581.
The types and rates of second malignancies following cancers commonly seen in older adults are described and the literature on these malignancies is reviewed.
The U.S. population is aging, life expectancy is increasing, and cancer is a disease associated with aging. Advances in screening and therapeutics have led to a growing number of cancer survivors who are at risk for the development of secondary malignancies. Although the risks for the development of second malignancies following a first diagnosis of cancer are well described for survivors of childhood malignancies, there are fewer data for malignancies common in older adults. With the aging of the U.S. population, and with improving survival statistics in many adult malignancies, there is an increasing need to identify those second malignancies that might develop in the older adult survivor of cancer. In this paper, we describe the types and rates of second malignancies following cancers commonly seen in older adults and review the literature on these malignancies. Comparisons are made between older and younger adults with regard to the risks for developing treatment-related cancers with different modalities. Recommendations for early detection of second malignancies are summarized, though there remains an unmet need for evidence-based guidelines for screening for second malignancies in the older adult in particular.
doi:10.1634/theoncologist.2011-0214
PMCID: PMC3233292  PMID: 22042787
Neoplasms; Second primary; Geriatrics; Antineoplastic agents; Neoplasms; Radiation induced; Lymphoma; Carcinoma
22.  Implementing a Geriatric Assessment in Cooperative Group Clinical Cancer Trials: CALGB 360401 
Journal of Clinical Oncology  2011;29(10):1290-1296.
Purpose
Factors captured in a geriatric assessment can predict morbidity and mortality in older adults, but are not routinely measured in cancer clinical trials. This study evaluated the implementation of a geriatric assessment tool in the cooperative group setting.
Patients and Methods
Patients age ≥ 65 with cancer, who enrolled on cooperative group cancer trials, were eligible to enroll on Cancer and Leukemia Group B (CALGB) 360401. They completed a geriatric assessment tool before initiation of protocol therapy, consisting of valid and reliable geriatric assessment measures which are primarily self-administered and require minimal resources and time by healthcare providers. The assessment measures functional status, comorbidity, cognitive function, psychological state, social support, and nutritional status. The protocol specified criteria for incorporation of the tool in future cooperative group trials was based on the time to completion and percent of patients who could complete their portion without assistance. Patient satisfaction with the tool was captured.
Results
Of the 93 patients who enrolled in this study, five (5%) met criteria for cognitive impairment and three did not complete the cognitive screen, leaving 85 assessable patients (median age, 72 years). The median time to complete the geriatric assessment tool was 22 minutes, 87% of patients (n = 74) completed their portion without assistance, 92% (n = 78) were satisfied with the questionnaire length, 95% (n = 81) reported no difficult questions, and 96% (n = 82) reported no upsetting questions. One hundred percent of health care professionals completed their portion.
Conclusion
This brief, primarily self-administered geriatric assessment tool met the protocol specified criteria for inclusion in future cooperative group clinical trials.
doi:10.1200/JCO.2010.30.6985
PMCID: PMC3083997  PMID: 21357782
23.  Predicting Chemotherapy Toxicity in Older Adults With Cancer: A Prospective Multicenter Study 
Journal of Clinical Oncology  2011;29(25):3457-3465.
Purpose
Older adults are vulnerable to chemotherapy toxicity; however, there are limited data to identify those at risk. The goals of this study are to identify risk factors for chemotherapy toxicity in older adults and develop a risk stratification schema for chemotherapy toxicity.
Patients and Methods
Patients age ≥ 65 years with cancer from seven institutions completed a prechemotherapy assessment that captured sociodemographics, tumor/treatment variables, laboratory test results, and geriatric assessment variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status). Patients were followed through the chemotherapy course to capture grade 3 (severe), grade 4 (life-threatening or disabling), and grade 5 (death) as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events.
Results
In total, 500 patients with a mean age of 73 years (range, 65 to 91 years) with stage I to IV lung (29%), GI (27%), gynecologic (17%), breast (11%), genitourinary (10%), or other (6%) cancer joined this prospective study. Grade 3 to 5 toxicity occurred in 53% of the patients (39% grade 3, 12% grade 4, 2% grade 5). A predictive model for grade 3 to 5 toxicity was developed that consisted of geriatric assessment variables, laboratory test values, and patient, tumor, and treatment characteristics. A scoring system in which the median risk score was 7 (range, 0 to 19) and risk stratification schema (risk score: percent incidence of grade 3 to 5 toxicity) identified older adults at low (0 to 5 points; 30%), intermediate (6 to 9 points; 52%), or high risk (10 to 19 points; 83%) of chemotherapy toxicity (P < .001).
Conclusion
A risk stratification schema can establish the risk of chemotherapy toxicity in older adults. Geriatric assessment variables independently predicted the risk of toxicity.
doi:10.1200/JCO.2011.34.7625
PMCID: PMC3624700  PMID: 21810685
24.  Breast Cancer Adjuvant Chemotherapy Decisions in Older Women: The Role of Patient Preference and Interactions With Physicians 
Journal of Clinical Oncology  2010;28(19):3146-3153.
Purpose
Breast cancer chemotherapy decisions in patients ≥ 65 years old (older) are complex because of comorbidity, toxicity, and limited data on patient preference. We examined relationships between preferences and chemotherapy use.
Methods
Older women (n = 934) diagnosed with invasive (≥ 1 cm), nonmetastatic breast cancer from 2004 to 2008 were recruited from 53 cooperative group sites. Data were collected from patient interviews (87% complete), physician survey (93% complete), and charts. Logistic regression and multiple imputation methods were used to assess associations between chemotherapy and independent variables. Chemotherapy use was also evaluated according to the following two groups: indicated (estrogen receptor [ER] negative and/or node positive) and possibly indicated (ER positive and node negative).
Results
Mean patient age was 73 years (range, 65 to 100 years). Unadjusted chemotherapy rates were 69% in the indicated group and 16% in the possibly indicated group. Women who would choose chemotherapy for an increase in survival of ≤ 12 months had 3.9 times (95% CI, 2.4 to 6.3 times; P < .001) higher odds of receiving chemotherapy than women with lower preferences, controlling for covariates. Stronger preferences were seen when chemotherapy could be indicated (odds ratio [OR] = 7.7; 95% CI, 3.8 to 16; P < .001) than when treatment might be possibly indicated (OR = 1.9; 95% CI, 1.0 to 3.8; P = .06). Higher patient rating of provider communication was also related to chemotherapy use in the possibly indicated group (OR = 1.9 per 5-point increase in communication score; 95% CI, 1.4 to 2.8; P < .001) but not in the indicated group (P = .15).
Conclusion
Older women's preferences and communication with providers are important correlates of chemotherapy use, especially when benefits are more equivocal.
doi:10.1200/JCO.2009.24.3295
PMCID: PMC2903313  PMID: 20516438
25.  Geriatric Oncology Research in the Cooperative Groups: A Report of a SIOG Special Meeting 
Journal of geriatric oncology  2010;1(1):40-44.
Purpose
The purpose of this meeting was to bring together geriatric oncology researchers in the cooperative groups to discuss the design of clinical trials to improve our knowledge of the efficacy and toxicity of cancer therapeutics in older adults with cancer.
Design
Meeting of cooperative group leaders in geriatric oncology research
Results
Several strategies were suggested to improve our knowledge of the efficacy and toxicity of cancer therapeutics in older adults. These include: 1) developing therapeutic studies for older adults who are not eligible for standard clinical trials (because of comorbidity or functional status), or for patients who are deemed to be at high risk for toxicity from standard therapy (frail or vulnerable); 2) identifying the age group of older adults who are underrepresented on clinical trials and developing trials specifically for these patients; 3) designing trials to include a certain proportion of older adults for subset analyses; and 4) including a geriatric assessment in therapeutic clinical trials in order to identify factors other than chronologic age that identify those older adults who are “vulnerable” (at risk for toxicity) and “fit” (able to tolerate cancer therapy without significant toxicity).
Conclusions
To address knowledge gaps in geriatric oncology, national and international cooperative group leaders discussed strategies in clinical trial design to improve the evidence-based research and accrual of older adults. Linking the efforts among cooperative groups will expedite this progress, and this conference was a major first step toward this goal.
doi:10.1016/j.jgo.2010.03.005
PMCID: PMC3014580  PMID: 21218146

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