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.

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.

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.

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.

This paper reviews the adverse outcomes associated with polypharmacy and presents polypharmacy definitions offered by the geriatrics literature, examining the strengths and weaknesses of the various definitions, as well as exploring the relationships among these definitions and what is known about the prevalence and impact of polypharmacy in the geriatric-oncology population.

Learning Objectives

After completing this course, the reader will be able to: Differentiate the multiple definitions of polypharmacy in order to be able to recognize it in your patient population.Discuss the current data available in evaluating polypharmacy specifically in older adults with cancer and incorporate the data in your evaluation of older patients.Summarize the agents or drug classes that may be deemed inappropriate in older adults to avoid prescribing medications for older patients that may lead to adverse drug events.

This article is available for continuing medical education credit at CME.TheOncologist.com

The definition of “polypharmacy” ranges from the use of a large number of medications; the use of potentially inappropriate medications, which can increase the risk for adverse drug events; medication underuse despite instructions to the contrary; and medication duplication. Older adults are particularly at risk because they often present with several medical conditions requiring pharmacotherapy. Cancer-related therapy adds to this risk in older adults, but few studies have been conducted in this patient population. In this review, we outline the adverse outcomes associated with polypharmacy and present polypharmacy definitions offered by the geriatrics literature. We also examine the strengths and weaknesses of these definitions and explore the relationships among these definitions and what is known about the prevalence and impact of polypharmacy.

Purpose

To determine the predictors of distress in older patients with cancer.

Patients and Methods

Patients age ≥ 65 years with a solid tumor or lymphoma completed a questionnaire that addressed these geriatric assessment domains: functional status, comorbidity, psychological state, nutritional status, and social support. Patients self-rated their level of distress on a scale of zero to 10 using a validated screening tool called the Distress Thermometer. The relationship between distress and geriatric assessment scores was examined.

Results

The geriatric assessment questionnaire was completed by 245 patients (mean age, 76 years; standard deviation [SD], 7 years; range, 65 to 95 years) with cancer (36% stage IV; 71% female). Of these, 87% also completed the Distress Thermometer, with 41% (n = 87) reporting a distress score of ≥ 4 on a scale of zero to 10 (mean score, 3; SD, 3; range, zero to 10). Bivariate analyses demonstrated an association between higher distress (≥ 4) and poorer physical function, increased comorbid medical conditions, poor eyesight, inability to complete the questionnaire alone, and requiring more time to complete the questionnaire. In a multivariate regression model based on the significant bivariate findings, poorer physical function (increased need for assistance with instrumental activities of daily living [P = .015] and lower physical function score on the Medical Outcomes Survey [P = .018]) correlated significantly with a higher distress score.

Conclusion

Significant distress was identified in 41% of older patients with cancer. Poorer physical function was the best predictor of distress. Further studies are needed to determine whether interventions that improve or assist with physical functioning can help to decrease distress in older adults with cancer.

Purpose

To determine the impact of age and health status on adjuvant treatment recommendations for older patients with breast cancer from the perspective of medical oncologists and primary care physicians with geriatric expertise.

Patients and Methods

One hundred fifty-one oncologists and 158 primary care physicians with geriatric expertise participated in an online survey. The survey described hypothetical patients of varying ages (70, 75, 80, and 85 years) and health status (good, average, and poor) who had node-positive, hormone receptor–positive, human epidermal growth factor receptor 2 (HER-2)/neu–negative; and hormone receptor–negative, HER-2/neu–positive breast cancers. The effects of patient age and health status on the survey participants’ adjuvant treatment recommendations were examined using generalized estimation equation methods.

Results

The majority of both oncologists and primary care physicians recommended some form of adjuvant therapy for patients of all ages (70, 75, 80, and 85 years) and health status. Both oncologists and primary care providers were less likely to recommend adjuvant treatment as a patient's age increased or health status declined (P < .0001). There were no significant differences in treatment recommendations among primary care physicians and oncologists for patients with hormone receptor–negative, HER-2/neu–positive tumors (P = .54). However, primary care providers were more likely than oncologists to recommend no adjuvant treatment for patients age 75 years or older with hormone receptor–positive, HER-2/neu–negative tumors (P < .01).

Conclusion

Age and health status influence oncologists’ and primary care providers’ adjuvant treatment recommendations. Evidence-based guidelines for breast cancer treatment in older adults taking into account age and health status are needed.

Efforts to integrate geriatric oncology principles in the training of all medical oncologists are underway.