ABSTRACT
Purpose or Objective A growing number of elderly patients every year is treated with radiation therapy (RT), but little is known about side effects and outcome of irradiation in this potentially frail population. The identification of predictive factors of toxicity and frailty could offer a personalized treatment approach, thanks also to a multidisciplinary management of patients with increased risk of adverse outcomes. In this study we investigated the correlation of patient parameters with acute toxicities in elderly aged > 75 years treated with curative RT. Materials and Methods A prospective observational study was designed in our Center for patients with > 75years, candidate for curative RT. To these patients the radiation oncologist submitted the Geriatric 8 questionnaire (G8q) before and at the end of RT. Patients with G8 score < 14 were then evaluated by a multidimensional geriatric assessment, investigating cognitive (MMSE, GDS), functional (ADL, IADL, Tinetti) and nutritional (MNA short) domains, to define the frailty phenotype. In this setting, we retrospectively analyzed parameters like body mass index (BMI), number of comorbidities, total blood count, neutrophil lymphocyte ratio (NLR), platelet lymphocyte ratio (PLR) and basal G8 score, and correlated these parameters to acute toxicity. Results G8q was administered to 150 patients from December 2019 to April 2021. In this study we included 98 patients who started and completed RT in our Unit in this period. Of them, 38 (38.8%) had a baseline G8 score < 14 (range 4-14) and 23 agreed to underwent a multidimensional assessment, while 15 could not be evaluated due to COVID-19 dispositions or their refusal. Eleven patients resulted fit, while 12 patients were classified as vulnerable. Acute toxicity grade was < grade 2 in 67 patients (68.4%) (Table 1). We evaluated associations between BMI, number of comorbidities, total blood count, NLR, PLR, G8 score and acute toxicity (Table 2). Total blood count, NLR, PLR and G8 score resulted not significantly correlated to toxicity. Instead, a higher BMI was associated with worse acute toxicity (p=0.031): considering the 31 patients reporting toxicity > grade 2, 17 patients were over-weighted (54.8%), 1 patient was under-weighted (3.2%). Overall, the 63.3% of population (62 patients) was over-weighted, with a median BMI of 26.3. (Table Presented) (Table Presented) Conclusion Although G8q considers under-weight as a possible responsible of frailty, our study suggested that attention should be paid to over-weight too, due to its prevalence in elderly patients. Furthermore our results suggested that in elderly patients > 75years the BMI correlates with worse acute toxicity, according to literature data. The 38.8% of patients needed a multidimensional evaluation;this approach resulted useful in order to obtain compliance to the treatment without increased toxicity. The study is still ongoing and further analysis will be done.
ABSTRACT
Background : Dexamethasone is part of the standard treatment of COVID-19 patients who need oxygen support. COVID-19 patients have a high risk of venous and arterial thrombosis, therefore adequate anticoagulation is of vital importance. Direct oral anticoagulants (DOACs) are generally not recommended in patients with dexamethasone due to possible drug-drug interactions which may decrease DOACs plasma levels. Therefore, data on the interaction between dexamethasone and DOACs is urgently needed. Aims : To assess DOAC plasma levels in patients with simoultaneous use of dexamethasone. Methods : Trough and peak DOAC plasma levels, by means of antiactivated factor X (anti-Xa) were prospectively collected in hospitalized COVID-19 patients treated with dexamethasone and DOACs (apixaban, rivaroxaban and edoxaban) and in hospitalized COVID-19 patients treated with DOACs only, to assess whether these values were within reference range. Results : Data were collected across two centres in Italy and the Netherlands. A total of 20 patients, 16 with DOACs and dexamethasone and 4 with DOACs only were enrolled. Twelve patients were on anticoagulant treatment for atrial fibrillation, seven for venous thromboembolism, and one for myocardial infarction. In 15 patients DOACs were started during the hospitalization. None of the patients had trough DOAC plasma levels below reference range. Only one patient (6.3%) treated with rivaroxaban had peak levels below reference range. Six patients (37.5%) in the dexamethasone group and two control patients (50%) had peak or trough DOAC plasma levels above reference range. Conclusions : In COVID-19 patients, the effect of dexamethasone use on DOAC plasma levels seems limited. This suggests that DOACs can be safely started or continued in COVID-19 patients treated with dexamethasone.
ABSTRACT
Purpose or Objective The concept of frailty is a complex, multidimensional and cyclical state of vulnerability that has recognized as one of the most important issues in health care that can affect treatment approach and clinical outcomes. Despite the high cancer prevalence in elderly people, the optimal treatment for elderly patients remains challenging, due to the incidence of age-related pathologies that could affect patient's functional capabilities. In this contest, the aim of the study was the identification of frail patients, candidate for curative radiotherapy (RT) and to measure through multidisciplinary and multidimensional approach the impact of frailty on toxicities and outcomes. Materials and Methods A prospective observational study was designed in our Center for all patients with >75years, candidate for curative RT. Frail patients were identified by the radiation oncologist, before and at the end of RT, by Geriatric8 questionnaire (G8q). All frail patients (score <14) were then evaluated by a multidimensional geriatric assessment, investigating cognitive (MMSE, GDS), functional (ADL, IADL, Tinetti) and nutritional (MNA short) domains, to define the frailty phenotype. The geriatric assessment was repeated at 6 and 12 months after RT (Figure 1). $Φgure Results From December 2019 to January 2021 G8q was submitted to 135 patients. Fifty-eight patients (43%) were baseline identified as frail (G8 score range 3-14). Of the 58, 28 patients (48.3%) agreed to undergo a multidimensional geriatric assessment, while 30 (51.7%) could not be evaluated due to COVID-19 dispositions or their refusal. Following the evaluation, frail patients were classified as fit (12 patients) or vulnerable (16 patients) according to score obtained in different domains (Table 1). Both fit and vulnerable patients were carefully monitored during RT according to geriatric prescriptions. The 58 frail patients, except 4 that refused RT before starting, completed treatment without acute toxicity > grade 2 (RTOG). The G8q repeated at the end of RT resulted worse in 12 patients, while 7 patients showed a benefit from RT, reporting a G8 score improvement. Considering all patients, 9 no-frail patients reported a worse G8 score at the end of RT and 2 patients an improvement. Still now, only 6 vulnerable patients repeat the 6-month assessment and the G8 score resulted lower in all the patients (less 1-5 points). (Table presented.) Conclusion The number of elderly oncologic patients is progressively increasing and the importance of ensure older-person-centered care plans is growing day by day. This study is still ongoing. Preliminary results confirmed that G8q represents a simple tool to identify frail patients in daily practice, and that thanks to this evaluation most of elderly patients with indication to curative RT did not showed a fragile phenotype. Finally, the support of a multidisciplinary approach in vulnerable patients resulted useful in order to obtain their compliance to the treatment without increased toxicity.