Comprehensive Geriatric Assesment (CGA) In Older Patients with Malignant Hemopathies
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1 BHSSeminar#7 Generalskills Comprehensive Geriatric Assesment (CGA) In Older Patients with Malignant Hemopathies Prof.&&&Dominique&&BRON& Inst.&J.&Bordet&&7&ULB& 24th&of&May&2014& 1
2 WHY WHEN HOW WhyCGA?! Malignanciesincidenceincreaseinolderpts! HematologicmalignanciesremainCurableinolderpts!! ChronologicalAgedoesnotmeananything! WhenCGA?! Assoonasatreatmentisrequired HowCGA?! Geriatricians?OncoCgeriaCnurse?Hematologist? WhichResults???
3 WHY WHEN HOW Proportion of population 60 years (%) Year
4 WHY WHEN HOW Cancerisadiseaseoftheelderly Incidence Mortality Over 65 Under Cases (%) Ovarian Breast NHL Lung Colorectal Ovarian Breast NHL Lung Colorectal NHL = non-hodgkin s lymphoma Ferlay J, et al. Eucan IARC CancerBase. 4 Lyon: IARC Press; Updated September 29, 2000.
5 WHY WHEN HOW Hematologicmalignancies accountfor10%ofcancersand7%ofcancermortality Diagnosis MedianAge(yrs) MDS 75 AML 70 MM 70 NHL 67 CLL 72 5
6 WHY WHEN HOW Chronologicalagedoesnotmeananything! Poormarrow,renal,neurological Tolerance 6
7 WHY WHEN HOW Patients % Current practice Pegf-G primary prophyl. Elderly patients 2 Younger patients 1 16% 15% 23% 8% 21% 14% Dose delays Dose reductions Dose delays Dose reductions >3 days 15% >3 days 15% 7 1. Schwenkglenks et al. EBCC 2008:62; 2. Aapro et al. SABCS 2007: % 15%
8 WHY WHEN HOW Vulnerable?Unfit?»Group What Wat slifeexpectancywiththedisease? 8
9 GROUP 1 Go-go GROUP 2 Slow-go GROUP 3 No-go Functionally independent Without comorbidity standard cancer treatment 70C79y=75% 80C88y=20% 90+y=5% Intermediate Frail patients milder therapy, i.e. dose reduction Dependent in > 1 ADL > 3 comorbid conditions > 1 geriatric syndrome palliative treatment Balducci, The Oncologist 2000
10 WHY WHEN HOW However,Clinicaljudgementisnotreliable! Physicians judgementandcomprehensivegeriatricassessment Fit patients Jugement clinique 64,3% CGA 26,5% & & & &Wedding&U,&CriFcal&Reviews&in&Oncology/Hematology,&2007& 10
11 WHY WHEN HOW GERIATRICSYNDROME Dependance Fallsandtroubleinwalking Neglectandfailuretothrive 11
12 WHY WHEN HOW Impactofheathstatusonlifeexpectancy 12 Walter LC et al. JAMA 2001, 285,
13 WHY WHEN HOW Toprolongsurvival?Tocure? Maintenance/improvementofqualityoflife? Benefit Anemia Cardiotoxicity Neurotoxicity Risk =>Dependence' 13
14 WHY WHEN HOW Dose- intensity and overal survival with R-CHOP? Bosly 2007
15 WHY WHEN HOW 15
16 CGA:Comprehensive GeriatricAssessment FuncMonalevaluaMon AGE,PS, PhysiologicalevaluaMon ComorbidcondiMons, Weight,nutriMonalstatus PsychologicalevaluaMon Minimentalstatus(MMS), Geriatricdepressionscale(GDS) SocioeconomicevaluaMon
17 ACTIVITIESOFDAILYLIVING continence grooming dressing feeding toileting transferring Katz 1963
18 INSTRUMENTALADL
19 TOOL (range) SCORE INTERPRETATION ADL (6-24) - Dependent - Independent - Score Score 6 TOOL (range) SCORE INTERPRETATION IADL (0-8) - Dependent - Independent - Score Score 8 TOOL (range) SCORE INTERPRETATION MMSE (0-30) - Normal - Mild cognitive impairment - Severe cognitive impairment - Score 24 - Score Score 17
20 OS WHY WHEN HOW 1 ADL 2 ADL Independent Independent Incontinence only 1 ADL or mild cognitive impairment 2 ADL or dementia N = 9008 age 65y Timetodeath(months) *Vulnerable: need for assistance in 1 (or 2 if incontinence) activities of mobility or daily living or cognitive impairment without dementia or bowel + urinary incontinence **Frail: need for assistance in 2 (or 3 if incontinence) activities of mobility or daily living or dementia or bowel + urinary incontinence Rockwood K et al. Lancet 1999, 353,
21 TOOL (range) SCORE INTERPRETATION MNA-SF (0-14) - Normal not at risk - At risk for malnutrition - Malnourished - Score 12 or more - Score Score 0-7 MNA (0-30) - Normal not at risk - At risk for malnutrition - Malnourished - Score 24 - Score from 17 to Score < 17 TOOL (range) SCORE INTERPRETATION GDS (0-15) - No depression - At risk for depression - Score Score 5
22 WHY WHEN Malnutrition Mortality, % No malnutrition 205 patients without cancer aged 75 years Months after admission 22 Cederholm&T&et&al.&&Am.&J.&Med&1995,&98,&67773&
23 CharlsonComorbidityIndex(CCI) Tablefrom:hkp://nephron.org/cgiCbin/rpa_sdm.cgi,accessedMarch132010
24
25 CIRS : First investigated in elderly subjects (n=141) by Miller et al. 1992; used in modified version (CIRS-G) - predict survival and dependency
26 CIRS: Should it be used in CLL patients? GCLLSG CLL8 TRIAL FCR/FC; 2009 data set Patients with CIRS 0-6 Goede et al., Oral presentation, EHA Annual Meeting 2012
27 WHY WHEN HCSCT SorrorComorbidityIndex A:grade3C4toxicity B:nonCrelapsemortality C:overallsurvival 27 Sorror&et&al.&Cancer&2008;112: &
28 WHY WHEN HOW? ESAS Falls IADL MNA BFI EORTC Qlq-C30 SRH? TICS ADL HADS DOS MUST Karnofsky Index Barthel Index ECOG-PS CIRS GDS Mini-COG Clock drawing test Charlson Index MMSE 28
29 A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0 = severe loss of appetite 1 = moderate loss of appetite 2 = normal appetite B Weight loss during the last 3 months? 0 = weight loss >3kg 1 = does not know 2 = weight loss between 1 and 3 kg 3 = no weight loss C Mobility 0 = bed or chair bound 1 = able to get out of bed/chair but does not go out 2 = goes out E Neuropsychological problems 0 = severe dementia or depression 1 = mild dementia or depression 2 = no psychological problems F Body Mass Index (weight in kg/height in m 2 ) 0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or greater H Takes more than 3 medications per day 0 = yes 1 = no P In comparison with other people of the same age, how does the patient consider his/her health status? 0,0 = not as good 0,5 = does not know 1,0 = as good 2,0 = better Age 0 = >85 1 = = <80 Soubeyran P, Bellera CA, Gregoire F, et al. Validation of a screening test for elderly patients in oncology. J Clin Oncol 2008,26.
30 WHY WHEN HOW S Dubruylle, SIOG
31 CHARACTERISTICSASSOCIATEDWITHMORTALITYAMONGELDERLY PATIENTSWITHMALIGNANTHEMOPATHIES:COXREGRESSION (introducmon) Exp 95%CI P SociodemographiccharacterisMcs Age Gender to 0.962to DiseaseYrelatedcharacterisMcs FavorablePrognosisvs.Unfavorableprognosis Fulltreatmentchoicevs.Dosereduc@on IntolerancetotreatmentvsNointolerance to 0.557to 0.503to < Screeningtool G8test to ComprehensiveGeriatricAssessment ComprehesiveGeriatricAssessmentwithout Neuropsychologicalfactors Neuropsychologicalfactors to 1.130to St&Dubruylle&,&2014&
32 WHY WHEN HematoYoncologist HOW? Physiotherapist Social assistant General PracMMoner Onco geriatric Nurse NeuroC Psychologist Gériatrician report
33 Relevantpointstoconsiderbefore CLLtreatment: 1. DoesthepaMentrequiresatreatment? 2. How«fit»isthepaMent? 3. DoesthepaMentpresentshighriskfeatures? 4.DoesthepaMentwantsatreatment? Ref : IWCLL guidelines Hallek et al; BLOOD 2008 ESMO guidelines Eichhorst et al; Ann Oncol 2010 Update on therapy Gribben and O brien ; J Clin Oncol 2011
34 FCRYSurvivalandTimetoFail(MDACC) > 70 yrs n 0.2 Pts. Event Survival Time to Fail Years Pts. Died Age < >70 Group Descriptive statistics for each group (UD FCR) No.uncsd N.censrd Total N Years Courtesy of M.
35 CLL8:HematologicalToxicityaccordingtoages Adverse Events FC treat FC treat Pvalue RFC RFC Pvalue Ages <70 >70y <70 >70y neutropenia Febrile neutr
36 IbruMnibfor1 st YlineandR/RCLL/SLL: (ByrdetalY#189,ASH2013) 22CmonthOSrate 1 st Yline:96% R/R:85% MedianOSnotreached 22YmonthPFSrate 1 st Yline:96% R/R(inclhighrisk):76% Effec@veinrelapsingdel17PC/=p Safety:noevidenceofcumula@ve toxicity
37 PATIENT Assessment Disease CharacterisMcs PATIENT QualityofLife
38 QUALITY» oflifeis moreimportant than «QUANTITY» oflife
39 Thank you for your attention 39
40 REFERENCES : Martine Extermann et al. Use of comprehensive geriatric assessment in older cancer patients: Recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG) Critical Reviews in Oncology/Hematology (2005) 55: Marije E. Hamaker et al. The G8 screening tool detects relevant geriatric impairments and predicts survival in elderly patients with a haematological malignancy Annals of hematology (Feb 2014, on line) Pallis A.G. et al Questionnaires and instruments for multidimentional assessment of the older cancer patient : what clinicians ned to know European journal of cancer (2010) 46 :
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