Geriatric risk factors for serious COVID-19 outcomes among older adults with cancer

Elkrief, A. et al. (2022). Geriatric risk factors for serious COVID-19 outcomes among older adults with cancer. The Lancet Health Longevity. DOI:https://doi.org/10.1016/S2666-7568(22)00009-5

The researchers’ primary objective at the outset of this study was to determine whether a measure of geriatric risk could capture risk of severe clinical outcomes among older patients with cancer and COVID-19. Additionally, they also sought to describe the presentation, complications and effect of COVID-19 on subsequent cancer care among older adults with cancer.

Patients of 60 years of age and above who were categorised as high risk- using a novel geriatric risk index comprising age, performance status and commodities- had significantly higher COVID-19 severity, including hospitalisation, need for intensive care and mechanical ventilation, and death, within 30 days due to any cause than patients categorised as standard risk or intermediate risk (Source: Elkrief et al, 2022).

Elkrief and colleagues’ study examines the relationship between their novel geriatric risk index and adverse outcomes from COVID-19 among older adults with cancer, as well as the frequency of atypical presentations in this population.

Summary

Background

Older age is associated with poorer outcomes of SARS-CoV-2 infection, although the heterogeneity of ageing results in some older adults being at greater risk than others. The objective of this study was to quantify the association of a novel geriatric risk index, comprising age, modified Charlson comorbidity index, and Eastern Cooperative Oncology Group performance status, with COVID-19 severity and 30-day mortality among older adults with cancer.

Methods

In this cohort study, we enrolled patients aged 60 years and older with a current or previous cancer diagnosis (excluding those with non-invasive cancers and premalignant or non-malignant conditions) and a current or previous laboratory-confirmed COVID-19 diagnosis who reported to the COVID-19 and Cancer Consortium (CCC19) multinational, multicentre, registry between March 17, 2020, and June 6, 2021. Patients were also excluded for unknown age, missing data resulting in unknown geriatric risk measure, inadequate data quality, or incomplete follow-up resulting in unknown COVID-19 severity. The exposure of interest was the CCC19 geriatric risk index. The primary outcome was COVID-19 severity and the secondary outcome was 30-day all-cause mortality; both were assessed in the full dataset. Adjusted odds ratios (ORs) and 95 per cent CIs were estimated from ordinal and binary logistic regression models.

Findings

5671 patients with cancer and COVID-19 were included in the analysis. Median follow-up time was 56 days (IQR 22–120), and median age was 72 years (IQR 66–79). The CCC19 geriatric risk index identified 2365 (41·7 per cent) patients as standard risk, 2217 (39·1 per cent) patients as intermediate risk, and 1089 (19·2 per cent) as high risk. 36 (0·6 per cent) patients were excluded due to non-calculable geriatric risk index. Compared with standard-risk patients, high-risk patients had significantly higher COVID-19 severity (adjusted OR 7·24; 95 per cent CI 6·20–8·45). 920 (16·2 per cent) of 5671 patients died within 30 days of a COVID-19 diagnosis, including 161 (6·8 per cent) of 2365 standard-risk patients, 409 (18·5 per cent) of 2217 intermediate-risk patients, and 350 (32·1 per cent) of 1089 high-risk patients. High-risk patients had higher adjusted odds of 30-day mortality (adjusted OR 10·7; 95 per cent CI 8·54–13·5) than standard-risk patients.

Interpretation

The CCC19 geriatric risk index was strongly associated with COVID-19 severity and 30-day mortality. Our CCC19 geriatric risk index, based on readily available clinical factors, might provide clinicians with an easy-to-use risk stratification method to identify older adults most at risk for severe COVID-19 as well as mortality.

Geriatric risk factors for serious COVID-19 outcomes among older adults with cancer: a cohort study from the COVID-19 and Cancer Consortium [paper]

NIHR: Breast cancer surgery is safer for older women than has been assumed

NIHR | October 2020 |Breast cancer surgery is safer for older women than has been assumed

Between 2013-2018 over 3000 women aged 70 or over with operable breast cancer were recruited to a NIHR- funded cohort study. The majority (83.4 %) of the women underwent surgery; with researchers tracking their progress for two years. One of the study’s key findings is that no deaths were attributable to surgery for breast cancer. According to the authors of the study, this suggests that surgery for breast cancer in women in this age group is perhaps safer than thought.

This study is part of a wider- Bridging the Age Gaps in Breast Cancer- project which aims to examine the characteristics and outcomes (survival, quality of life and adverse events) of women aged at least 70 years in the UK undergoing surgery for breast cancer.

Researchers found:

• Fewer than one in five women (19.3%) had an adverse outcome, such as a dangerous blood clot (DVT) or wound pain.
• a woman’s age predicted what surgery she would receive. The oldest women in the group were twice as likely to have a mastectomy than the youngest women (59.1% vs 29.9%). Younger women were more likely to have breast-conserving surgery, with less breast tissue removed. This may relate to the lack of screening in older women, so cancers tend to be found when they are bigger and women feel a lump.
• older women were less likely to have lymph glands under the armpit removed (axillary surgery) than younger women (91.4% vs 98.6%). The aim of axillary surgery is to find out if the cancer has spread, and to remove any cancer in the axilla.
• just 2.8% of the women in this study who had a mastectomy went on to have reconstructive sugery. This compares to one in five (20%) women overall in the UK.
• quality of life was lower after surgery particularly for those who had more breast tissue removed as in mastectomy.
• the risk of being unable to carry out some standard day to day tasks was higher after surgery.

Morgan, J. L., George, J., Holmes, G., Martin, C., Reed, M. W., Ward, S., … & Wyld, L. (2020). Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study. British Journal of Surgery.

Abstract

Background

Breast cancer surgery in older women is variable and sometimes non‐standard owing to concerns about morbidity. Bridging the Age Gap in Breast Cancer is a prospective multicentre cohort study aiming to determine factors influencing treatment selection and outcomes from surgery for older patients with breast cancer.

Methods

Women aged at least 70 years with operable breast cancer were recruited from 57 UK breast units between 2013 and 2018. Associations between patient and tumour characteristics and type of surgery in the breast and axilla were evaluated using univariable and multivariable analyses. Oncological outcomes, adverse events and quality‐of‐life (QoL) outcomes were monitored for 2 years.

Results

Among 3375 women recruited, surgery was performed in 2816 patients, of whom 24 with inadequate data were excluded. Sixty‐two women had bilateral tumours, giving a total of 2854 surgical events. Median age was 76 (range 70–95) years. Breast surgery comprised mastectomy in 1138 and breast‐conserving surgery in 1716 procedures. Axillary surgery comprised axillary lymph node dissection in 575 and sentinel node biopsy in 2203; 76 had no axillary surgery. Age, frailty, dementia and co‐morbidities were predictors of mastectomy. Age, frailty and co‐morbidity were significant predictors of no axillary surgery. The rate of adverse events was moderate, with no 30‐day mortality. Long‐term QoL and functional independence were adversely affected by surgery.

Conclusion

Breast cancer surgery is safe in women aged 70 years or more, with serious adverse events being rare and no mortality. Age, ill health and frailty all influence surgical decision‐making. Surgery has a negative impact on QoL and independence, which must be considered when counselling patients about choices.

Full paper BJS Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study

Further information on the project is available from the University of Sheffield’s Medical School Bridging the Age Gap in Breast Cancer

Cancer Research UK: GPs say elderly are not seeking help for potential cancer symptoms

Cancer Research UK| October 2020 | GPs say elderly are not seeking help for potential cancer symptoms

More than half (53 per cent) of GPs recently surveyed by Cancer Research mentioned that they were concerned that less older people are contacting them than before the pandemic. The leading cancer charity surveyed 1000 GPs online in September.

Respondents were asked to compare their experience prior to the pandemic.The findings also indicate a range of groups that GPs have concerns about during the pandemic these included:

• patients with learning difficulties (40%)
• those whose first language is not English (35%)
• ethnic minorities (22%)
• people from poorer backgrounds (23%)
• those with existing health conditions (21%)

“I’m really concerned that less of my older patients are contacting the surgery and it’s worrying that colleagues across the UK are reporting this too. GP surgeries and hospitals are changing the way they do things to help keep patients and staff safe and people should be reassured that it’s safe to visit them. The first contact is likely to be by phone, and where appropriate a face to face will follow.

Dr Richard Roope, Cancer Research UK’s GP advisor

Read the full press release from Cancer Resarch UK

Advancing Care, Advancing Years: Improving Cancer Treatment and Care for an Ageing Population

Cancer Research UK | June 2018 | Advancing Care, Advancing Years: Improving Cancer Treatment and Care for an Ageing Population 

A new report presents the findings of  research commissioned by Cancer Research UK (CRUK) and conducted by the University of Birmingham’s Health Services Management Centre and ICF International, which sought to understand the specific needs of older patients, and to explore the process of clinical decision-making for older people with cancer across the UK.

This research involved a literature review, clinical observations at eight case study sites, interviews with 15 national decision-makers and 80 health professionals, and three UK-wide surveys (of primary care professionals, secondary care professionals and older people affected by cancer). The direction of the research was also informed by engagement with a group of older people affected by cancer, and by extensive engagement and interviews with national policymakers.

This research involved a literature review, clinical observations at eight case study sites, interviews with 15 national decision-makers and 80 health professionals, and three UK-wide surveys (of primary care professionals, secondary care professionals and older people affected by cancer). The direction of the research was also informed by engagement with a group of older people affected by cancer, and by extensive engagement and interviews with national policymakers.

The report is available from CRUK 

What factors affect quality of life in older patients with cancer?

A new study provides insights on the factors that affect health-related quality of life in older adults with cancer. The findings support the importance of addressing persistent symptoms, managing comorbidities, promoting leisure-time physical activity, and addressing financial challenges. | Cancer  | Story via ScienceDaily

Abstract

As the population of older adults with cancer continues to grow, the most important factors contributing to their health-related quality of life (HRQOL) remain unclear.

Methods

A total of 1457 older adults (aged ≥65 years) with cancer participated in a telephone survey. Outcomes were measured using the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-Item Short Form Survey from the Medical Outcomes Study. Statistical techniques used to identify factors in 4 domains (physical, psychological, social, and spiritual) most strongly associated with HRQOL included linear models, recursive partitioning, and random forests. Models were developed in a training data set (920 respondents) and performance was assessed in a validation data set (537 respondents).

Results

Respondents were a median of 19 months from diagnosis, and 28.1% were receiving active treatment. The most relevant factors found to be associated with PCS were symptom severity, comorbidity scores, leisure-time physical activity, and having physical support needs. The most relevant factors for MCS were having emotional support needs, symptom severity score, and the number of financial hardship events. Results were consistent across modeling techniques. Symptoms found to be strongly associated with PCS included fatigue, pain, disturbed sleep, and drowsiness.

Symptoms found to be strongly associated with MCS included fatigue, problems remembering things, disturbed sleep, and lack of appetite.

Conclusions

The findings of the current study support the importance of addressing persistent symptoms, managing comorbidities, promoting leisure-time physical activity, and addressing financial challenges. A long-term comprehensive approach is needed to ensure the well-being of older adults with cancer.

 

Full reference: Maria Pisu et al. | Most impactful factors on the health-related quality of life of a geriatric population with cancer |Cancer |  First publishd 18 December 2017

Association between self-perception of aging, view of cancer and health of older patients in oncology

The authors hypothesize that more negative self-perception of aging (SPA) and view of cancer could be linked to worse physical and mental health outcomes in cancer patients | BMC Cancer

Image source: Danilo Vidovic – Flickr // CC BY 2.0

Identifying older people affected by cancer who are more at risk of negative health outcomes is a major issue in health initiatives focusing on medical effectiveness. In this regard, psychological risk factors such as patients’ perception of their own aging and cancer could be used as indicators to improve customization of cancer care.

Negative SPA and/or view of cancer at baseline are associated with negative evolution of patients’ physical and mental health. Moreover, when the evolution of SPA and cancer view were taken into account, these two stigmas are still linked with the evolution of mental health. In comparison, only a negative evolution of SPA was linked to worse physical health outcomes.

Full reference: Schroyen, S. et al. (2017) Association between self-perception of aging, view of cancer and health of older patients in oncology: a one-year longitudinal study. BMC Cancer. 17:614

Risk factors for falls in older patients with cancer

A rising number of patients with cancer are older adults (65 years of age and older), and this proportion will increase to 70% by the year 2020. Falls are a common condition in older adults. We sought to assess the prevalence and risk factors for falls in older patients with cancer | BMJ Supportive & Palliative Care

This is a single-site, retrospective cohort study. Patients who were receiving cancer care underwent a comprehensive geriatric assessments, including cognitive, functional, nutritional, physical, falls in the prior 6 months and comorbidity assessment. Vitamin D and bone densitometry were performed.

Falls are common in older patients with cancer and lead to adverse clinical outcomes. Major depression, functional impairment, frailty, dementia and low social support were risk factors for falls. Heightened awareness and targeted interventions can prevent falls in older patients with cancer.

Full reference: Zhang, X. et al. (2017) Risk factors for falls in older patients with cancer. BMJ Supportive & Palliative Care. Published Online: 31 August 2017.

Outcome and toxicity of radical radiotherapy or concurrent Chemoradiotherapy for elderly cervical cancer women

Concurrent chemoradiotherapy (CCRT) is the standard treatment for local advanced cervical cancer. However, for elderly patients, studies are limited and the outcomes are controversial | BMC Cancer

Methods: We retrospectively analyzed the elderly cervical cancer patients treated with radical RT or CCRT between January 2006 and December 2014. For external beam radiotherapy, 50Gy in 25 fractions or 50.4Gy in 28 fractions were delivered via 3-dimensional conformal radiation therapy or intensity modulated radiation therapy. High-dose-rate intracavitary brachytherapy was performed with a dose of 30-36Gy in 5–7 fractions to point A. Concurrent chemotherapy regimens included weekly cisplatin and paclitaxel.

Conclusion: Elderly cervical cancer patients could tolerate radical RT and CCRT very well and get a favored survival. Compared with RT, CCRT could improve the survival of elder cervical cancer patients with similar nonhematological toxicity. CCRT should be considered in elderly cervical cancer patients.

Full reference: Wang, W. et al. (2017) Outcome and toxicity of radical radiotherapy or concurrent Chemoradiotherapy for elderly cervical cancer women. BMC Cancer 17:510

Patterns of care and predictors of adjuvant therapies in elderly patients with glioblastoma

Amsbaugh, M.J. et al. Cancer | Published online: 27 April 2017

Background: The objectives of this study were to characterize patterns of care and to identify predictors for adjuvant therapy in elderly patients with glioblastoma in the modern era.

Conclusions: In this analysis of elderly patients who had glioblastoma diagnosed from 2004 through 2012, a significant increase in the receipt of combined-modality therapy was observed. Combined-modality treatment produces improved survival outcomes and should be considered as adjuvant treatment for carefully selected elderly patients.

Read the abstract here

One Hospital System’s Journey to Reduce Clostridium Difficile

Delaney, M.B. Journal of Emergency Nursing | Published online: 4 April 2017

Problem: Albert Einstein defines insanity as doing the same thing over again but expecting different results. Although the United States claims to reduce antibiotic abuse, practice strict isolation, and clean meticulously, the burden of Clostridium difficile outpaces goals. Unless innovative approaches are tried, we risk culling elderly, immunosuppressed, and otherwise debilitated populations. Emergency departments are a primary access point for patients who are unable to wait for primary care. As a result, many patients with diarrhea are seen in emergency departments.

Methods: This article describes one hospital system’s quality improvement trial of disposable commode pails (DCPs) for high-acuity patients in 3 of 5 institutions. The rationale was to prevent staff from touching surfaces heavily contaminated with C difficile. Staff members were not to wash or reuse commode buckets between patients. Instead, DCPs were substituted, and only the commode chairs were wiped. For quantitative date, C difficile infections (CDIs) were compared across hospitals. Staff members were surveyed for qualitative data.

Read the full abstract here