Assessing Toxicity Risk in Senior Chemotherapy Patients (AT RISC) a pilot prospective audit

Transcription

1 Assessing Toxicity Risk in Senior Chemotherapy Patients (AT RISC) a pilot prospective audit Dr Laird Cameron MBChB BSc, Dr Annie Wong MBChB, Dr C Barrow MBChB, Dr K Clarke MBChB, Dr B Luey MBChB, Dr A Fenton MBBS, Dr K Gregory MD, Dr Anne O Donnell MD Wellington Blood and Cancer Centre, Wellington Hospital, CCDHB NZSO July 2013

2 Introduction NZ population is aging 1 and cancer incidence rises with age 2 Elderly patients can derive the same survival benefits from chemotherapy 3 Chronological age does not equal physiological age 4 Elderly patients are at increased risk of chemotherapy toxicity 5 1.Statistics New Zealand Smith et JCO Sargent et al NEJM Soubeyran JCO Muss et al JCO 2007

3 Introduction National Cancer Institute: Common Terminology Criteria for Adverse Events (NCI CTCAE) Grade 1: Mild Grade 2: Moderate Grade 3: Severe Grade 4: Life threatening Grade 5: Fatal

4 Introduction Performance status can be used to predict toxicity in chemotherapy patients 6 6. Schag et al JCO 1984

5 Introduction Chemotherapy toxicity predictive scores in CRASH Score 7 the elderly. 518 pts predict risk of G4H/G3-4NH toxicity Bloods: lymphocyte, AST, LDH, CrCl, Alb IADL, DBP, Chemotox, MMSE, ECOG, Nutritional assessment, self rated health assessment Difficult to implement Hurria score pts predict risk of G3-5 toxicity during new line of chemo Needs validation before use in NZ setting 7. Extermann et al Cancer Hurria et al JCO 2011

6 Introduction Hurria: Factors validated for predictive score Age (> 72) Cancer type (GI/GU 2, other 0) Chemotherapy Dosing (standard) Polychemotherapy Physiology Haemoglobin (< 110g/L M, < 100g/L F) Creatinine clearance (<34ml/min) Function Self reported hearing impairment (fair or worse) Falls in last 6 months (1 or more) Taking medications (need assistance) Walking 1 block (limited) Decreased social activity due to physical/emotional health (limited, at least sometimes)

7 Introduction Hurria score vs KPS

8 Method 7 months (Oct 2012 May 2013) at Wellington Hospital Patients >65yr old starting new line of chemotherapy for any solid tumour. Clinicians completed audit tool Retrospective data collection for Grade 3-5 Toxicity Hospital admission or clinic visits To define the toxicity rates, patients were censored at the first G3-5 toxicity Toxicity defined by CTCAE v3.0 Clinicians estimated perceived risk of toxicity Feasibility questionnaire

9 Results Patient selection 65 audited 15 not yet completed chemotherapy 50 completed chemotherapy 46 included in data analysis 4 discontinued chemotherapy in cycle 1, clearly due to progressive disease

10 Results Patient characteristics Age mean (SD,range) ATRISC (n=46) 73 (5.7, 65 to 90) Hurria (n=500) 73 (6.2, 65 to 91) Sex (% Female) Ethnicity (%) NZ European 84 Maori 1 Pacific Island 5 Asian 1 Other 8 KPS (%) range % >70 White 85 Black 8 Asian 5 Other % >70.

11 Results Tumour and treatment characteristics ATRISC (n=46) Hurria (n=500) Cancer type (%) Breast Lung GI GYN GU 3 10 Other 12 6 Cancer Stage (%) I 0 5 II 5 12 III IV st Line Chemotherapy (%) Standard dose chemotherapy (%) Combination chemotherapy (%) Primary GCSF prophylaxis (%) 6 18

12 Results Toxicity ATRISC (n=46) Hurria (n=500) Overall Grade 3 to 5 Toxicity n (%) 32 (70) 265 (53) Type n (%) Haematologic Non-Haematologic Fatigue Renal/electrolyte Non Neutropenic Infection VTE Gastro Neuropathy Nausea 14 (30) 23 (50) 5 (11) 2 (4) 5 (11) 1 (2) 6 (13) 1(2) 1 (2) 131 (26) 217 (43) 81 (16) 80 (16) 48 (10) 22 (4) 22 (4) 13 (3) 12 (2) Grade 5 n (%) Nil 10 (2)

13 Results Patients (%) Toxicity clustered by Hurria score Grade 3 to 5 Toxicity ATRISC LOW MED HIGH Total Risk Score (Median 7.5) HIGH Hurria MED LOW (Median 7.0)

14 Results Patients (%) Toxicity clustered by KPS Grade 3-5 Toxicity (%) ATRISC <70 Physician-Rated KPS (%) Hurria

15 Patient Number Patient number Results Toxicity clustered by clinician estimate Registrar Estimated Toxicity n= Toxicity Estimation (%) Toxicity No Toxicity Consultant Estimated Toxicity n= Toxicity Estimation (%)

16 Results Feasibility 11 Clinicians surveyed. Question Easy to use? How much time did it add to the consult? Complete all parts easily? Main barrier? Response 100% Yes 75% <5min. 75% Yes Remembering to include it in the consult.

17 Conclusion Feasibility Pilot study: easily implemented. Clinicians cannot reliably predict toxicity in this elderly population. Our numbers are small and we have not attempted to draw statistically significant conclusions No suggestion of correlation between Hurria risk score and toxicity. This may be related to differences in our tumour types. Before widespread clinical use, an adequately powered study needs to be conducted in our local population

18 Thank you for your attention

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23 Elderly patients under-represented in cancer-related treatment trials