Predicting outcome in older patients with cancer: Comprehensive geriatric assessment and clinical judgment.

OBJECTIVES: Comprehensive Geriatric Assessment (CGA) has been incorporated into geriatric oncology to prevent unfavorable outcome from anticancer treatment. This study determined the value of CGA and medical oncologist's clinical judgment in predicting unfavorable outcome and explored whether treatment decisions can be based on CGA. PATIENTS AND METHODS: In this prospective cohort study, a multidomain CGA was performed by a geriatric nurse and geriatrician in 110 consecutive patients aged ≥70 years, newly referred to a multidisciplinary oncology clinic. CGA domains included comorbidity, polypharmacy, mood, cognition, nutrition, functionality and physical performance. Medical oncologist's clinical judgment on expected tolerance of standard treatment was noted (N = 62). Unfavorable outcome was defined as any ≥grade three chemotherapy toxicity, dose reduction, postponement of treatment, death before start of treatment and early progression before first evaluation of treatment (N = 80). RESULTS: CGA identified multidomain problems in 77 out of 110 patients (70.0%) and the medical oncologist had doubts about standard treatment tolerance in 30 out of 62 patients (48.4%). Unfavorable outcome occurred in 48 out of 80 patients (60%) who received anticancer treatment but could not be predicted by CGA, medical oncologists' clinical judgment or their combination. There was discrepancy between CGA and clinical judgment in 24 out of 62 patients (38.7%). CONCLUSION: Neither CGA, medical oncologist's clinical judgment or a combination could predict unfavorable outcome in our heterogeneous sample. CGA and clinical judgment did not align in more than one-third of patients.

Computed Tomography-Based Body Composition Is Not Consistently Associated with Outcome in Older Patients with Colorectal Cancer.

BACKGROUND: Current literature is inconsistent in the associations between computed tomography (CT)-based body composition measures and adverse outcomes in older patients with colorectal cancer (CRC). Moreover, the associations with consecutive treatment modalities have not been studied. This study compared the associations of CT-based body composition measures with surgery- and chemotherapy-related complications and survival in older patients with CRC. MATERIALS AND METHODS: A retrospective single-center cohort study was conducted in patients with CRC aged ≥65 years who underwent elective surgery between 2010 and 2014. Gender-specific standardized scores of preoperative CT-based skeletal muscle (SM), muscle density, intermuscular adipose tissue (IMAT), visceral adipose tissue (VAT), subcutaneous adipose tissue, IMAT percentage, SM/VAT, and body mass index (BMI) were tested for their associations with severe postoperative complications, prolonged length of stay (LOS), readmission, and dose-limiting toxicity using logistic regression and 1-year and long-term survival (range 3.7-6.6 years) using Cox regression. Bonferroni correction was applied to account for multiple testing. RESULTS: The study population consisted of 378 patients with CRC with a median age of 73.4 (interquartile range 69.5-78.4) years. Severe postoperative complications occurred in 13.0%, and 39.4% of patients died during follow-up. Dose-limiting toxicity occurred in 77.4% of patients receiving chemotherapy (n = 53). SM, muscle density, VAT, SM/VAT, and BMI were associated with surgery-related complications, and muscle density, IMAT, IMAT percentage, and SM/VAT were associated with long-term survival. After Bonferroni correction, no CT-based body composition measure was significantly associated with adverse outcomes. Higher BMI was associated with prolonged LOS. CONCLUSION: The associations between CT-based body composition measures and adverse outcomes of consecutive treatment modalities in older patients with CRC were not consistent or statistically significant. IMPLICATIONS FOR PRACTICE: Computed tomography (CT)-based body composition, including muscle mass, muscle density, and intermuscular, visceral, and subcutaneous adipose tissue, showed inconsistent and nonsignificant associations with surgery-related complications, dose-limiting toxicity, and overall survival in older adults with colorectal cancer. This study underscores the need to verify whether CT-based body composition measures are worth implementing in clinical practice.

Cellular senescence and chronological age in various human tissues: A systematic review and meta-analysis.

Senescent cells in tissues and organs are considered to be pivotal to not only the aging process but also the onset of chronic disease. Accumulating evidence from animal experiments indicates that the magnitude of senescence can vary within and between aged tissue samples from the same animal. However, whether this variation in senescence translates across to human tissue samples is unknown. To address this fundamental question, we have conducted a systematic review and meta-analysis of all available literature investigating the magnitude of senescence and its association with chronological age in human tissue samples. While senescence is higher in aged tissue samples, the magnitude of senescence varies considerably depending upon tissue type, tissue section, and marker used to detect senescence. These findings echo animal experiments demonstrating that senescence levels may vary between organs within the same animal.

The Dutch Hip Fracture Audit: evaluation of the quality of multidisciplinary hip fracture care in the Netherlands.

The nationwide Dutch Hip Fracture Audit (DHFA) is initiated to improve the quality of hip fracture care by providing insight into the actual quality of hip fracture care in daily practice. The baseline results demonstrate variance in practice, providing potential starting points to improve the quality of care. PURPOSE: The aim of this study is to describe the development and initiation of the DHFA. The secondary aim is to describe the hip fracture care in the Netherlands at the start of the audit and to assess whether there are differences in processes at baseline between hospitals. METHODS: Eighty-one hospitals were asked to register their consecutive hip fracture patients since April 2016. In 2017, the first full calendar year, the case ascertainment was determined at audit level. Three quality indicators were used to describe and assess the care process at audit and hospital level: the proportion of completed variables at discharge and at 3 months after operation, time to surgery and orthogeriatric management. RESULTS: Sixty (74%) hospitals documented 14,274 patients in the DHFA by December 2017. In 2017, the case ascertainment was 58% and the average proportion of completed variables was 77%: 91% at discharge and 30% at 3 months. The median time to operation was 18 h (IQR 7-23) for American Society of Anesthesiologists score (ASA) 1-2 patients and 21 h (IQR 13-27) for ASA 3-4 patients. Of patients aged 70 years and older, 78% received orthogeriatric management. At hospital level, all three indicators showed significant practice variance. CONCLUSION: Not all hospitals participate in the DHFA, and the data gathering process needs to be further optimized. However, the baseline results demonstrate an apparent variance in hip fracture practice between hospitals in the Netherlands, providing potential starting points to improve the quality of hip fracture care.

Physical and Nutritional Prehabilitation in Older Patients With Colorectal Carcinoma: A Systematic Review.

BACKGROUND AND PURPOSE: Sarcopenia and malnourishment are highly prevalent in older patients with colorectal cancer (CRC), who form a growing group of patients at risk of adverse outcome after surgery. Intervention on physical function and/or nutritional status may decrease the risk of postoperative complications. However, the overall effect of preoperative physical and nutritional interventions (better known as prehabilitation) in older patients with CRC remains unknown. The objective was to review the literature on physical and nutritional prehabilitation performed as observational cohort studies or randomized controlled trials in patients 60 years and older undergoing elective CRC surgery. METHODS: We searched PubMed, Embase.com, CINAHL, and the Cochrane Library from inception to July 16, 2015, for relevant literature. Search terms included colorectal cancer, aged, pre- and perioperative period, surgery, physical activity, and nutrition. RESULTS: A total of 6 studies were included: 1 study applied a physical intervention, 3 studies applied a nutritional intervention, and 2 studies applied a combination of both interventions. None of the preoperative interventions significantly reduced length of stay, mortality, or readmission rates. CONCLUSIONS: Physical and nutritional prehabilitation in older patients with CRC has not shown a significant reduction in postoperative complications or length of stay. One study that examined the effect of a perioperative nutritional supplement reported a reduction in postoperative complications. Future research should explore targeted combined interventions, taking into account physical and nutritional patient requirements.

Muscle Strength and Muscle Mass in Older Patients during Hospitalization: The EMPOWER Study.

BACKGROUND: Low muscle strength and muscle mass are associated with an increased length of hospital stay and higher mortality rate in inpatients. To what extent hospitalization affects muscle strength and muscle mass is unclear. OBJECTIVE: We aimed to assess muscle strength and muscle mass at admission and during hospitalization in older patients and its relation with being at risk of geriatric conditions. METHODS: The EMPOWER study included patients aged 70 years and older, admitted to 4 wards of the VU University Medical Center in the Netherlands between April and December 2015. At admission, patients were screened for being at risk of 4 geriatric conditions: delirium, falls, malnutrition, and functional disability. At admission and at discharge, muscle strength and muscle mass were assessed. RESULTS: A total of 373 patients (mean age, standard deviation [SD]: 79.6, 6.38 years) were included at admission, and 224 patients (mean age, SD: 80.1, 6.32 years) at discharge. At admission, lower muscle strength in both female and male patients and low muscle mass in male patients were associated with being at risk of a higher cumulative number of geriatric conditions. Muscle strength increased during hospitalization, but no change in muscle mass was observed. Changes in muscle measures were not associated with being at risk of geriatric conditions. DISCUSSION: Older patients with lower muscle strength and muscle mass at admission were at risk of a higher cumulative number of geriatric conditions. However, being at risk of geriatric conditions did not forecast further decrease in muscle strength and muscle mass during hospitalization.

Postgraduate education in internal medicine in Europe.

BACKGROUND: Limited information exists on the framework and content of postgraduate education in internal medicine in Europe. This report describes the results of a survey of postgraduate training in internal medicine in the European countries. METHODS: Two online questionnaire-based surveys were carried out by the European Board of Internal Medicine, one on the practice of internists and the other on postgraduate training in internal medicine. The national internal medicine societies of all 30 member countries of the European Federation of Internal Medicine were invited to participate. The responses were reviewed by internal medicine residents from the respective countries and summaries of the data were sent to the national societies for approval. Descriptive analysis of the data on postgraduate training in internal medicine was performed. RESULTS: Twenty-seven countries (90%) completed the questionnaire and approved their datasets. The length of training ranged from four to six years and was commonly five years. The majority of countries offered training in internal medicine and a subspecialty. A common trunk of internal medicine was frequently a component of subspecialty training programmes. Hospital inpatient service was the predominant setting used for training. A final certifying examination was in place in 14 countries. CONCLUSION: Although some similarities exists, there appear to be significant differences in the organisation, content and governance of postgraduate training in internal medicine between the European countries. Our findings will prove invaluable for harmonisation of training and qualification in internal medicine in Europe.