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
WHY WHEN HOW WhyCGA?! Malignanciesincidenceincreaseinolderpts! HematologicmalignanciesremainCurableinolderpts!! ChronologicalAgedoesnotmeananything! WhenCGA?! Allpa@entsabove70C75y?! Assoonasatreatmentisrequired HowCGA?! Op@malTools?! Geriatricians?OncoCgeriaCnurse?Hematologist? WhichResults???
WHY WHEN HOW TheEuropeanUnionpopula@onisageing 29 27 Proportion of population 60 years (%) 25 23 21 19 17 15 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008 2011 2014 2017 2020 2023 Year
WHY WHEN HOW Cancerisadiseaseoftheelderly Incidence Mortality Over 65 Under 65 100 80 Cases (%) 60 40 20 0 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; 1999. Updated September 29, 2000.
WHY WHEN HOW Hematologicmalignancies accountfor10%ofcancersand7%ofcancermortality Diagnosis MedianAge(yrs) MDS 75 AML 70 MM 70 NHL 67 CLL 72 5
WHY WHEN HOW Chronologicalagedoesnotmeananything! Poormarrow,renal,neurological Tolerance Comorbidi@es(=polymedica@on) Geriatricsyndromes(falls,cogni@vetroubles, incon@nence,demen@a,dependance) SocioCeconomicallimita@ons 6
WHY WHEN HOW Patients % 35 30 25 20 15 10 5 0 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 2007:1088 29% 15%
WHY WHEN HOW Doesyourpa@entbelongtothe«Fit? Vulnerable?Unfit?»Group What sthelifeexpectancyofyourpa@ent? Wat slifeexpectancywiththedisease? Willthediseasekillyourpa@ent? Doesyourpa@entwantatreatment? 8
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
WHY WHEN HOW However,Clinicaljudgementisnotreliable! Physicians judgementandcomprehensivegeriatricassessment selectdifferentpa@entsasfitforchemotherapy(n=200) Fit patients Jugement clinique 64,3% CGA 26,5% & & & &Wedding&U,&CriFcal&Reviews&in&Oncology/Hematology,&2007& 10
WHY WHEN HOW GERIATRICSYNDROME Dependance Fallsandtroubleinwalking Incon@nence Denutri@on Neglectandfailuretothrive Cogni@vefunc@ondisturbances Demen@a "Pallia@vecare! =Pallia@onofsymptoms 11
WHY WHEN HOW Impactofheathstatusonlifeexpectancy 12 Walter LC et al. JAMA 2001, 285, 2750-2756
WHY WHEN HOW Toprolongsurvival?Tocure? Maintenance/improvementofqualityoflife? Benefit Neutropenicinfec@on Anemia Mucosi@s Cardiotoxicity Neurotoxicity Risk =>Dependence' 13
WHY WHEN HOW Dose- intensity and overal survival with R-CHOP? Bosly 2007
WHY WHEN HOW 15
CGA:Comprehensive GeriatricAssessment FuncMonalevaluaMon AGE,PS, Instrumentaldailyac@vity(IADL,ADL) PhysiologicalevaluaMon ComorbidcondiMons, Weight,nutriMonalstatus PsychologicalevaluaMon Minimentalstatus(MMS), Geriatricdepressionscale(GDS) SocioeconomicevaluaMon Income,Transporta@on,Family
ACTIVITIESOFDAILYLIVING continence grooming dressing feeding toileting transferring Katz 1963
INSTRUMENTALADL
TOOL (range) SCORE INTERPRETATION ADL (6-24) - Dependent - Independent - Score 7 24 - Score 6 TOOL (range) SCORE INTERPRETATION IADL (0-8) - Dependent - Independent - Score 0 7 - Score 8 TOOL (range) SCORE INTERPRETATION MMSE (0-30) - Normal - Mild cognitive impairment - Severe cognitive impairment - Score 24 - Score 18 23 - Score 17
OS WHY WHEN HOW Influenceoffunc@onalityandcogni@on 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, 205-206
TOOL (range) SCORE INTERPRETATION MNA-SF (0-14) - Normal not at risk - At risk for malnutrition - Malnourished - Score 12 or more - Score 8 11 - Score 0-7 MNA (0-30) - Normal not at risk - At risk for malnutrition - Malnourished - Score 24 - Score from 17 to 23.5 - Score < 17 TOOL (range) SCORE INTERPRETATION GDS (0-15) - No depression - At risk for depression - Score 0 4 - Score 5
WHY WHEN Influenceof(Mal)nutri@on 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&
CharlsonComorbidityIndex(CCI) Tablefrom:hkp://nephron.org/cgiCbin/rpa_sdm.cgi,accessedMarch132010
CIRS : First investigated in elderly subjects (n=141) by Miller et al. 1992; used in modified version (CIRS-G) - predict survival and dependency
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
WHY WHEN HCSCT SorrorComorbidityIndex A:grade3C4toxicity B:nonCrelapsemortality C:overallsurvival 27 Sorror&et&al.&Cancer&2008;112:1992 2001&
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
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 = 80-85 2 = <80 Soubeyran P, Bellera CA, Gregoire F, et al. Validation of a screening test for elderly patients in oncology. J Clin Oncol 2008,26.
WHY WHEN HOW S Dubruylle, SIOG 2013 30
CHARACTERISTICSASSOCIATEDWITHMORTALITYAMONGELDERLY PATIENTSWITHMALIGNANTHEMOPATHIES:COXREGRESSION (introducmon) Exp 95%CI P SociodemographiccharacterisMcs Age Gender 1.117 2.499 1.022to 0.962to 1.221 6.491 0.015 0.060 DiseaseYrelatedcharacterisMcs FavorablePrognosisvs.Unfavorableprognosis Fulltreatmentchoicevs.Dosereduc@on IntolerancetotreatmentvsNointolerance 7.168 1.536 1.302 2.654to 0.557to 0.503to 19.361 4.236 3.368 <0.0001 0.407 0.587 Screeningtool G8test 1.129 0.928to 1.374 0.225 ComprehensiveGeriatricAssessment ComprehesiveGeriatricAssessmentwithout Neuropsychologicalfactors Neuropsychologicalfactors 1.228 3.560 0.860to 1.130to 1.753 11.210 0.259 0.030 St&Dubruylle&,&2014&
WHY WHEN HematoYoncologist HOW? Physiotherapist Diéte@cian Social assistant General PracMMoner Onco geriatric Nurse NeuroC Psychologist Gériatrician Mul@disciplinary report
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
FCRYSurvivalandTimetoFail(MDACC) 1.0 0.8 0.6 0.4 > 70 yrs Propor@o n 0.2 Pts. Event 300 106 Survival 300 170 Time to Fail 0.0 0 1 2 3 4 5 6 7 8 9 10 11 12 Years 1.0 0.8 0.6 0.4 0.2 Pts. Died Age 186 52 <60 43 29 60-69 41 25 >70 Group Descriptive statistics for each group (UD FCR) No.uncsd N.censrd Total N 1 52 134 186 2 29 44 73 3 25 16 41 0.0 0 1 2 3 4 5 6 7 8 9 10 11 Years Courtesy of M.
CLL8:HematologicalToxicityaccordingtoages Adverse Events FC treat FC treat Pvalue RFC RFC Pvalue Ages <70 >70y <70 >70y neutropenia 61 78 0.04 75 83 0.2 Febrile neutr 19 35 0.03 32 44 0.1 infec@ons 0.7 5.4 0.02 1.9 4.7 0.1
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
PATIENT Assessment Disease CharacterisMcs PATIENT QualityofLife
QUALITY» oflifeis moreimportant than «QUANTITY» oflife
Thank you for your attention 39
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: 241 252 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 : 1049-1054 40