Independence and health related quality of life in 200 onco-geriatric surgical patients within 6 months of follow-up: Who is at risk to lose?

AIMS: Comprehensive Geriatric Assessment (CGA) provides information on aspects of older patients to predict risks and benefits of interventions. METHODS: To evaluate the application of CGA (including quality of life (QOL)) for the risk prediction of postoperative dependence and QOL in elderly patients with malignant tumours, a prospective observational study including 200 patients >70 years was performed. The primary outcome was postoperative activities of daily living (ADL < 95), secondary outcome was QOL at 6 months. Multivariate regression was performed to assess the impact of associated factors (socio-demographic, clinical, functional, cognitive variables, resilience, and EORTC-QLQ-C30 QOL). RESULTS: Median age of patients was 75 (70-88) years with 69% males. The majority of operations was for colon carcinoma; morbidity was 24.8%, mortality 1.5%. Impairment in ADL (<95) affected 6.7% (13/195) pre-, and 9.7% (12/124) post-operatively. Analyzing factors predicting loss of ADL, the following reached significance: BMI (OR: 1.7; p = 0.019), ADL (OR: 0.67; p = 0.0317), and of the QLQ-C30: diarrhea (OR: 1.04; p = 0.013), emotional functioning (OR: 0.91; p = 0.0242), physical functioning (OR: 0.92; p = 0.027). QOL paralleled ADL (pre-op: 65.4 to 67 postoperatively, respectively); predictive were: Karnofsky Index (Parameter Estimate (PE): 0.55; p = 0.0003) and (QLQ-C30) emotional functioning (PE: 0.14; p = 0.0208). CONCLUSIONS: Those considered for oncologic surgery can be assured that few lose independence. CGA/QOL highlight signs of vulnerability and options for pre-habilitation. Registries including a minimal CGA data set will make pre-selections reproducible and objectify risk/benefit estimations - relevant for those withheld from potentially curative surgery.

Comorbidity as a prognostic variable in multiple myeloma: comparative evaluation of common comorbidity scores and use of a novel MM-comorbidity score.

Comorbidities have been demonstrated to affect progression-free survival (PFS) and overall survival (OS), although their impact in multiple myeloma (MM) patients is as yet unsettled. We (1) assessed various comorbidities, (2) compared established comorbidity indices (CIs; Charlson comorbidity index (CCI), hematopoietic cell transplantation-specific comorbidity index (HCT-CI)), Kaplan Feinstein (KF) and Satariano index (SI) and (3) developed a MM-CI (Freiburger comorbidity index, FCI) in 127 MM patients. Univariate analysis determined moderate or severe pulmonary disease (hazard ratio (HR): 3.5, P<0.0001), renal impairment (via estimated glomerular filtration rate (eGFR); HR: 3.4, P=0.0018), decreased Karnofsky Performance Status (KPS, HR: 2.7, P=0.0004) and age (HR: 2, P=0.0114) as most important variables for diminished OS. Through multivariate analysis, the eGFR ⩽30 ml/min/1.73m(2), impaired lung function and KPS ⩽70% were significant for decreased OS, with HRs of 2.9, 2.8 and 2.2, respectively. Combination of these risk factors within the FCI identified significantly different median OS rates of 118, 53 and 25 months with 0, 1 and 2 or 3 risk factors, respectively, (P<0.005). In light of our study, comorbidities are critical prognostic determinants for diminished PFS and OS. Moreover, comorbidity scores are important treatment decision tools and will be valuable to implement into future analyses and clinical trials in MM.

Extramedullary vs medullary relapse after autologous or allogeneic hematopoietic stem cell transplantation (HSCT) in multiple myeloma (MM) and its correlation to clinical outcome.

Risk-adapted treatment of multiple myeloma (MM) includes autologous (auto-) and allogeneic (allo-) hematopoietic stem cell transplantation (HSCT). Case reports on extramedullary (EM) compared to bone marrow (BM) relapse after HSCT suggest a dismal prognosis. We compared the outcome of 78 MM patients relapsing after auto- (group A: n = 53) or allo- (group B: n = 25) HSCT, stratified into BM (64 patients) vs EM (14 patients) relapse. The relapse-specific groups were also compared with respect to risk factors, including age, beta2-microglobulin, pretreatment, cytogenetics and stage. EM relapse sites were lungs (5), soft tissue (4), pericardium (2), bone (1), skin (1) and CNS (1). As of May 2004, the overall (OS) and progression-free (PFS) survival after HSCT in patients relapsing from EM sites was not significantly different from BM relapse patients, both after auto- and allo-HSCT. Although MM patients relapsing from EM sites after allo-HSCT used to be regarded as having few therapeutic options, we observed encouraging responses to donor lymphocyte infusions (DLI). Treatment responses to DLIs were observed in 5/9 (56%) BM relapse patients, and in 3/4 (75%) EM relapse patients. These observations suggest that EM relapse after HSCT is common and needs an individualized diagnostic and therapeutic approach in MM during clinical follow-up after HSCT.