Multidisciplinary decision-making and course of treatment in older patients with colorectal cancer: Effect of geriatrician input.

INTRODUCTION: We evaluated the effect of the inclusion of a geriatrician in the multidisciplinary cancer team (MDT) on decision-making for chemotherapy with curative intent in older patients with colorectal cancer. MATERIALS AND METHODS: We audited all patients aged 70 years and older with colorectal cancer discussed at MDT meetings between January 2010 and July 2018; selection was limited to those patients for whom guidelines recommended chemotherapy with curative intent as part of the primary treatment. We assessed how treatment decisions came about, and what the course of treatment was in the period before (2010-2013) and after (2014-2018) the geriatrician joined the MDT meetings. RESULTS: There were 157 patients included: 80 patients from 2010 to 2013 and 77 patients from 2014 to 2018. Age was mentioned significantly less often as the reason to withhold chemotherapy in the 2014-2018 cohort (10% vs 27% in 2010-2013, p = 0.04). Instead, patient preferences, physical condition, and comorbidities were the main reasons stated for withholding chemotherapy. Although a similar proportion of patients started chemotherapy in both cohorts, patients treated in 2014-2018 required many fewer treatment adaptations and were thus more likely to complete their treatments as planned. DISCUSSION: Over time and by incorporating a geriatrician's input, the multidisciplinary selection of older patients with colorectal cancer for chemotherapy with curative intent has improved. By basing decisions on an assessment of the patient's ability to tolerate treatment rather than using a more general parameter such as age, both overtreatment of not-so-fit patients and undertreatment of fit-but-old patients can be prevented.

A meta-analysis on the role older adults with cancer favour in treatment decision making.

INTRODUCTION: In the complex setting of oncological treatment decision making, balancing professional guidance while respecting patient involvement can be a challenge. We set out to assess the role adults with cancer favour in treatment decision making (TDM), including differences across age groups and change over time. MATERIALS AND METHODS: A systematic search was performed in MEDLINE and Embase, for studies on role preference of (older) adults with cancer in oncological treatment decision making. A meta-analysis was conducted based on Control Preference Scale (CPS) data, a questionnaire on patient role preference in TDM. RESULTS: This meta-analysis includes 33 studies reporting CPS data comprising 17,197 adults with cancer. Mean age was 60.6 years old for studies that specified age (24 studies, 6155 patients). During the last decade, patients' role preference shifted towards significantly more active involvement in TDM (p = 0.006). No age-dependent subgroup differences have been identified; both younger and older adults, defined as, respectively, below and above 65 years old, favour active involvement in treatment decision making. DISCUSSION: Over time, adults with cancer have shifted towards more active role preference in treatment decision making. In current cancer care, a large majority prefers taking an active role, irrespective of age.

Nutritional status and interventions for patients with cancer - A systematic review.

BACKGROUND: Malnourishment is commonly seen in ageing, cancer and many chronic conditions, and is associated with poorer prognosis. AIM: We set out to collect all currently available evidence on the association between nutritional status assessed with a validated screening tool and prognosis or course of treatment in older patients with cancer, and on the benefit of nutritional interventions in improving these outcomes. METHODS: A systematic search in MEDLINE and EMBASE. RESULTS: We included 71 studies on the association between nutritional status and outcome in (older) patients with cancer and 17 studies on the benefit of nutritional interventions in improving outcomes in this patient population. There is a significant association between nutritional status and increased intermediate- and long-term mortality (hazard ratio 1.87 (95% confidence interval 1.62-2.17). Those with poorer nutritional status were less likely to complete oncologic treatment according to plan and had higher health care consumption. Benefit of dietary interventions was limited although dietary counselling may lead to improved quality of life while nutritional support may lead to a decrease in post-operative complication rates. CONCLUSION: Nutritional status is associated with poorer survival, decreased treatment completion and higher health care consumption and nutritional interventions are only able to negate these negatives outcome to a very limited degree.

[Diagnostics in very old patients; when to apply it or not in cases of suspected malignancy?] / Diagnostiek bij zeer oude ouderen.

This paper focuses on considerations regarding diagnostics in case of a suspected malignancy in a very old or frail patient. The patient's preference and life-perspective lie at the core of shared decision-making. From a medical point of view, the estimated life-expectancy may be so short that further diagnostic testing for a malignancy may only be useful when there are treatable symptoms in play. In other cases, prior to diagnostics there may already be a suspicion that there will be no feasible oncologic treatment options. From the perspective of advance care planning and symptomatic treatment, it can nonetheless still be useful to confirm the presence of a malignancy through imaging diagnostics. Obtaining tissue for further specification in very old or frail patients is only useful when an easily tolerated, yet effective treatment is likely or possible, such as endocrine treatment in case of prostate cancer or breast cancer.

The effect of a geriatric evaluation on treatment decisions and outcome for older cancer patients - A systematic review.

AIM: The aim of this systematic review is to summarise all available data on the effect of a geriatric evaluation on the multidisciplinary treatment of older cancer patients, focussing on oncologic treatment decisions, the implementation of non-oncologic interventions and the impact on treatment outcome. METHODS: A systematic search in MEDLINE and EMBASE for studies on the effect of a geriatric evaluation on oncologic and non-oncologic treatment decisions and outcome for older cancer patients. RESULTS: 36 publications from 35 studies were included. After a geriatric evaluation, the oncologic treatment plan was altered in a median of 28% of patients (range 8-54%), primarily to a less intensive treatment option. Non-oncologic interventions were recommended in a median of 72% of patients (range 26-100%), most commonly involving social issues (39%), nutritional status (32%) and polypharmacy (31%). Effect on treatment outcome was varying, with a trend towards a positive effect on treatment completion (positive effect in 75% of studies) and treatment-related toxicity/ complications (55% of studies). CONCLUSION: A geriatric evaluation affects oncologic and non-oncologic treatment and appears to improve treatment tolerance and completion for older cancer patients. Fine-tuning the decision-making process for this growing patient population will require more specific and robust data on the effect of a geriatric evaluation on relevant oncologic and non-oncologic outcomes such as survival and quality of life.

Update in geriatrics: What geriatric oncology can learn from general geriatric research.

Life expectancy has been steadily increasing for decades and this trend is likely to continue in coming years. In fact, there is more than a 50% probability that by 2030 female life expectancy could break the 90 year barrier, with more than half of the expected gains due to enhanced longevity above the age of 65 years. The resultant aging of societies means that health care will be faced with a rising number of increasingly older patients, who are also likely to have higher levels of multimorbidity. Most issues regarding assessment, prognostication and, management of older patients are not unique to geriatric oncology and thus there is opportunity to learn from progress in other fields. The purpose of this paper is to provide an update on research, reviews, and debate in general geriatrics that may be relevant to clinicians and researchers active in geriatric oncology. The selection of topics was based on a general search of the table of contents of widely read geriatrics and internal medicine journals, and includes geriatric co-management, improving research for older patients, caregiver issues, eliciting patient preferences, and shared-decision making.