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Yellow leaves or none or few

Grand Rounds February 2014
by

Erika Ramsdale

on 12 March 2016

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Transcript of Yellow leaves or none or few

Yellow leaves, or none, or few:
Assessing older cancer patients

That time of year thou mayst in me behold
When yellow leaves, or none, or few, do hang
Upon those boughs which shake against the cold,
Bare ruin'd choirs, where late the sweet birds sang.
In me thou see'st the twilight of such day
As after sunset fadeth in the west;
Which by and by black night doth take away,
Death's second self, that seals up all in rest
In me thou see'st the glowing of such fire,
That on the ashes of his youth doth lie,
As the death-bed whereon it must expire
Consum'd with that which it was nourish'd by.

This thou perceiv'st, which makes thy love more strong,
To love that well which thou must leave ere long.

Shakespeare
Erika Ramsdale, M.D.
Medicine Grand Rounds

Objectives:
Discuss the differences in geriatric and oncologic assessment
Introduce the Comprehensive Geriatric Assessment (CGA) and its components
Identify existing and emerging resources for assessment of older cancer patients
Oncologist
Geriatrician
There are differences in how we see the older cancer patient
Cancer and its treatment affect every part of the body
The patient as emergent and complex system
Focus is on static, quantitative data
Focus on narrative, qualitative data

Functional Status: the ECOG Performance Status
Repetto et al, JCO 2002:

363 pts with solid or heme malignancies
74% had ECOG PS of 0-1
Of those:
9.3% dependent in ≥1 ADL
37.7% dependent in ≥1 IADL
Reliance on evidence-based medicine
Evidence-based medicine insufficient*
*Ramsdale, E. and W. Dale. Evidence-based guidelines and quality measures in the care of older adults. Virtual Mentor. 2013 Jan 1;15(1):51-5.
Lewis JH, Kilgore ML, Goldman DP, et al. Participation of patients 65 years of age or older in cancer clinical trials. J Clin Oncol 2003;21:1383-9.

The elderly are clearly under-represented in clinical trials:
So let's just relax the inclusion criteria!
Heterogeneity
Competing risk
What is CGA?

A comprehensive evaluation of an older individual’s:
functional status,
comorbid conditions,
cognition,
psychological state and functioning,
social support,
nutritional status, and
medications/polypharmacy.

Comprehensive Geriatric Assessment (CGA)
ECOG and Karnofsky performance status
Patient- and physician-reported
Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL)
Objective measures:
Six-minute walk
Timed Up and Go
Gait speed
Short Physical Performance Battery (SPPB)
Screening tools
Best validated in cancer population: Vulnerable Elders Survey-13

How do we measure functional status?
Inherently difficult to describe and measure
Several models:
"Frailty phenotype": Fried et al using data from Cardiovascular Health study
Deficit accumulation model: the Frailty Index
Balducci criteria:
Age ≥ 85 years
Dependence in ≥1 ADL
≥3 comorbidities
Presence of a geriatric syndrome (delirium, dementia, depression, osteoporosis, incontinence, falls, neglect/abuse, failure to thrive)

What about "frailty"?
Fried's Frailty Phenotype
L.P. Fried, et al., "Frailty in older adults: Evidence for a phenotype,"J Gerontol A Biol Sci Med Sci, 56(3): M146-56, 2001.
VULNERABLE ELDERS SURVEY-13
p=0.016

Vulnerable Elders Survey-13 (VES-13) in a colorectal cancer cohort
Ramsdale, E., BN Polite, KA Bylow, et al. “The Vulnerable Elders Survey-13 (VES-13) Predicts Mortality in Older Patients with Later Stage Colorectal Cancer Receiving Chemotherapy: A Prospective Pilot Study.” J Am Geriatr Soc. 2013: 61(11):2043-4.
Frailty Index
. . . our experience suggests that, when some sufficiently large number (roughly, about 40) of variables are considered, the variables can be selected at random, and still yield comparable results of the risks of adverse outcomes.
Rockwood, Kenneth, and Arnold Mitnitski. "Frailty in relation to the accumulation of deficits." The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 62.7 (2007): 722-727.
FI = # deficits ÷ total # of variables
Charlson Index
22 weighted diagnoses
Heavily weighted toward cancer diagnoses
Cumulative Illness Rating Scale - Geriatrics (CIRS-G)
Cumbersome but very detailed
Derived comorbidity scores for specific subgroups
HCT-CI for stem cell transplant patients

How do we quantify comorbidities?
Geriatric Depression Scale (GDS)

Hospital Anxiety and Depression Scale (HADS)

Cancer Worry Scale (CWS)

Tools to assess psychological/emotional functioning
Mini-mental status exam (MMSE)
Ceiling and floor effects
Montreal Cognitive Assessment (MoCA)
Slightly lengthier, but can detect mild cognitive impairment (MCI)
Mini-Cog
Clock draw and 3-word recall
Similar sensitivity as MMSE for dementia

Measuring cognitive status
There are multiple tools for every component of the CGA.
And so on . . .
So what can we do with the CGA?
Comorbidities are independent of functional status
Extermann M, Overcash J, Lyman GH, Parr J, Balducci L. Comorbidity and functional status are independent in older cancer patients. J Clin Oncol. 1998 Apr;16(4):1582-7.
Assessment of competing risks
What is going to be the cause of death: cancer or something else?
http://www.eprognosis.org
Assessment of risks of (cancer) treatment
Given clinical heterogeneity, how do we assess the risk/benefit ratio of treatments?
Toxicity
Assessment of risks of (cancer) treatment
Given clinical heterogeneity, how do we assess the risk/benefit ratio of treatments?
Clinical trajectory
Late Ripeness
Czeslaw Milosz
Not soon, as late as the approach of my ninetieth year,
I felt a door opening in me and I entered
the clarity of early morning.

One after another my former lives were departing,
like ships, together with their sorrow.

And the countries, cities, gardens, and bays of seas
assigned to my brush came closer,
ready now to be described better than they were before.
Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol 2011;29:3457-65.
Cancer and Aging Research Group
n=500 pts ≥65 years
Not disease-specific
Endpoint: Grades 3-5 toxicity



CARG tool
Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective multicenter study. J Clin Oncol 2011;29:3457-65.

CARG score, KPS, and chemotherapy toxicity
http://www.mycarg.org/Chemo_Toxicity_Calculator
Cancer and Aging Research Group (CARG) tool
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