Rupal Ramani

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.

BACKGROUND: Older adults with cancer are vulnerable to functional decline, which places greater onus on caregivers. Few studies have prospectively examined burden in caregivers of older cancer patients. The objective of this study was to determine the factors associated with high caregiver burden. METHODS: In total, 100 caregivers of patients aged ≥65 years with cancer, who were recruited at a single institution, completed questionnaires gauging their perception of the patient's physical, emotional, and social health. The association between these items, cancer-related factors, sociodemographic factors, and caregiver burden (measured using the Caregiver Strain Index [CSI]) was determined through multivariate analysis. RESULTS: The median patient age was 70 years (range, 65-91 years), 70% of patients had advanced disease, and 98% were receiving treatment. Caregivers were mostly women (73%), spouses (68%), and lived with the patient (79%). The median amount of care provided was 10 hours per week. The mean CSI score (± standard deviation) was 3.1 ± 3.2. Most caregivers (75%) reported some burden, with 15% reporting high caregiver burden (CSI score, ≥7). In multivariate analysis, employed caregivers (odds ratio, 4.5; 95% confidence interval, 1.1-18.4; P = .04) and those caring for patients who required more help with instrumental activities of daily living (Older Americans Resources and Services-Instrumental Activities of Daily Living score, <12 of a possible 14; odds ratio, 12.4; 95% confidence interval, 2.4-62.5; P < .001) were more likely to experience high caregiver burden (CSI score, ≥7). CONCLUSIONS: Caregiver burden is common in those who care for older cancer patients. High burden is more likely in employed caregivers and in those who care for patients who require increased functional assistance. Further studies are needed to determine the unique challenges experienced by caregivers of older adults with cancer and potential interventions to alleviate burden in these caregivers.

OBJECTIVES: To evaluate the prevalence of polypharmacy and potentially inappropriate medication (PIM) use and the association between these and chemotherapy-related adverse events in older adults with cancer undergoing chemotherapy. DESIGN: Secondary analysis of prospectively collected data. SETTING: Outpatient oncology clinics in seven academic medical centers. PARTICIPANTS: Adults aged 65 and older with cancer undergoing chemotherapy. MEASUREMENTS: Measures included number of daily medications (polypharmacy); PIM use based on three indices (Beers, Zhan, and Drugs to Avoid in the Elderly criteria), and use of six "high risk" medication classes for adverse drug events (anticoagulants, antiplatelet agents, opioids, insulin, oral hypoglycemics, antiarrhythmics). Using multivariate logistic regression, the relations were evaluated between these criteria and Grade 3 to 5 chemotherapy-related toxicity and between these criteria and hospitalization during chemotherapy. RESULTS: Participants (N=500; mean age 73, 61% Stage IV disease) took a mean of 5±4 daily medications (range 0-23). PIM use was common (up to 29% according to Beers criteria). No association was found between number of daily medications (reference 0-3 medications) and toxicity (4-9 medications, odds ratio (OR)=1.34, 95% confidence interval (CI)=0.92-1.97; ≥10 medications, OR=0.82, 95% CI=0.45-1.49) or hospitalization (≥4 medications, OR=1.34, 95% CI=0.82-2.18, P=.24). There was also no association between PIM use and toxicity (P=.93) or hospitalization (P=.98). No medication class was associated with either outcome. CONCLUSIONS: Polypharmacy and PIM use were common but were not associated with chemotherapy-related toxicity or hospitalization in older adults with cancer.

OBJECTIVE: In older men with prostate cancer, aging is associated with reduced anxiety and increased depression. The purpose of this study was to examine the association among age, anxiety, and depression in a cohort of older adults receiving chemotherapy. METHODS: This is a secondary analysis of a prospective longitudinal study investigating chemotherapy toxicity in older adults with cancer. Baseline data (pre-chemotherapy) included: age, sociodemographics, tumor and treatment factors, functional status, comorbidities, psychological state (measured by the Hospital Anxiety and Depression Scale), and social support. Univariate and multiple regression analyses were conducted to test the relationship between age, anxiety, and depression. RESULTS: The average age of the 500 patients (56% females) was 73.1. The majority had late stage disease: 22% Stage III and 61% stage IV. Clinically significant depression was reported in 12.6%. Clinically significant anxiety was reported in 20.9%. In univariate analyses, there was no association between anxiety and age, or depression and age. In multivariable analyses, older age (p=0.05) was associated with decreased anxiety, as well as lack of social support (p<0.01) and increased number of comorbidities (p<0.01). In multivariable analysis, depression was associated with lack of social support (p<0.01), increased number of comorbidities (p<0.01), and advanced stage (p<0.01). CONCLUSIONS: This study supports previous research that anxiety decreases with age in older adults with cancer. However, depression remained constant with increasing age. Greater resources and attention to identifying and treating the psychological sequelae of cancer in older adults are warranted.