Large pancreatic cancer in the elderly

Objective To elucidate contributing factors that lead to successful management of large pancreatic cancer in geriatric patients. Methods The study involved 74 patients with larger pancreatic malignancy. Risks and benefits of pancreaticoduodenectomy at an advanced age were analyzed retrospectively in 35 patients older than 70 years of age. Of them, 15 elderly patients were radically resected by “3 steps procedure”. Conventional and regional pancreaticoduodenectomy was performed in 30 and 5 patients, respectively. The results achieved in these patients were compared with those observed in 39 younger patients. Results The 30-day mortality and morbidity rates for the elderly patients with large pancreatic cancer were 5.9% and 26.4% respectively; while for the younger patients, they were 5.2% and 18.4% respectively. A statistically significant correlation was observed between the presence of risk factors, the occurrence of complications, and the mortality rate. No difference was found between the two age groups when the risk factors were absent. The 5-year survival rate in the elderly patients and the younger patients was 11.7% and 15.7% respectively, with the difference being not significant. Conclusion Curative pancreaticoduodenectomy can be carried out safely in older patients, with long-term results comparable to those achieved in the younger patients. The preoperative interventional chemotherapy can provide an inflammatory edema wall between the tumor and portal vein, so as to decrease the portal vein resection rates.     

Clinical pharmacology of cancer therapies in older adults

This abbreviated review outlines the physiologic changes associated with aging, and examines how these changes may affect the pharmacokinetics and pharmacodynamics of anticancer therapies. We also provide an overview of studies that have been conducted evaluating the pharmacology of anticancer therapies in older adults, and issue a call for further research.     

Management and geriatric assessment of cancer in the elderly

Due to the demographic evolution, the management of elderly patients with cancer currently represents a major challenge for the medical community. Aging may be associated with an increased rate of health problems possibly resulting in a loss of independence. These problems can interfere with cancer treatment strategies. Therefore, treatment decision making requires a multidisciplinary and multidimensional assessment of both the characteristics of the malignant disease and the host’s general health status. Several oncological groups have developed specific programs for elderly cancer patients. Based on a multidimensional geriatric assessment tool, they aim to establish the best pattern of care for the population of elderly patients with cancer. Clinical research in geriatric oncology is also a very exciting field, particularly regarding the conception of clinical trials specifically designed for elderly patients. The particular aspects of the management of elderly patients with cancer and some critical challenges of clinical research will be presented and discussed in this review.     

老年患者的大胰癌外科治疗

目的 探讨老年患者胰腺癌接受胰十二指肠切除术,以期明确手术成功的相关因素。方法 本研究包括74例大胰癌患者。35例年龄大于70岁,30例为标准胰十二指肠切除术和5例为区域性胰十二指肠切除术,其中15例按“三步法”予以切除。这组患者的结果与另外39例非老年患者作比较。结果 老年患者的30天手术死亡率与并发症率分别为5.9％和26.4％;而在非老年患者中分别为5.2％和18.4％。危险因素、并发症率和死亡率差别有统计学意义。老年患者和非老年患者的5年生存率分别为11.7％和15.7％,无显著性差异。结论 本研究表明老年患者可安全接受根治性胰十二指肠切除术,而长期效果与非老年患者相似。减黄可改善肝、肾功能,增加患者对手术的耐受。术前介入化疗可在肿瘤与门静脉间产生“炎性水帘”,从而减少门静脉切除率。     

Lung cancer in men aged 75 or older

Sixty-seven cases of lung cancer occurring in men aged 75 or older were examined at autopsy. There is a similar incidence of epidermoid and small cell carcinoma, but a lower incidence of adenocarcinoma and a slightly higher incidence of large cell carcinoma in this elderly group of patients compared to the incidence of various histologic types occurring in patients of all ages. The various organs involved by metastatic tumor are similar to those seen in lung cancer in general; the overall metastatic disease is less widespread in the older group.     

Sick role and the cancer patient

This paper examines the concept of the sick role and its effect on the cancer patient. The hypothesis is put forward that lack of control and the creation of a feeling of helplessness can adversely affect the illness career of the cancer sufferer. Some of the various strategies used by cancer patients as ways of regaining a degree of control and overriding the paternalistic approach of the health care professions are examined and the importance of patient empowerment is emphasized.     

老年肺癌综合评估方法的研究进展

肺癌已是老年人死亡率最高的疾病之一。晚期老年肺癌患者往往合并营养不良、衰弱、多重用药、精神心理痛苦等问题,这些问题成为制约老年肺癌患者生活质量的重要因素。老年综合征和老年综合评估是解决老年人临床常见问题的策略和方式,是老年医学核心技术之一。应用合适的评估方法能够有效筛查老年患者潜在问题,同时加以合理应对可改善其生活质量。本文拟对现有的综合评估方法在老年肺癌患者中的应用及对这些问题的解决方案加以论述,以期为临床进行老年肺癌患者的综合管理,提高生存质量提供理论依据。     

New transurethral system for interstitial radiation of prostate cancer

Direct endoscopic implantation of radioactive materials for carcinoma of the prostate without an open operation was accomplished by the use of modified existing transurethral instrumentation and techniques. The closed approach seems applicable particularly to the geriatric population, which is afflicted more commonly but is frequently not treated because of concurrent diseases or because the patient had transurethral resection of the prostate as a diagnostic procedure. Eleven patients were implanted using the transurethral route. Implantations were accomplished successfully with extremely low morbidity. Along with more conventional dosimetry studies, computer tomography was used to assess the placement of seeds. The direct visualization of the method suggests a potential for greater precision of seed placement as illustrated by computer tomography. In addition, this new instrumentation and method offers a low-risk procedure for carcinoma of the prostate that can be performed on an outpatient basis for selected patients.     

Dying with cancer: the influence of age, comorbidity, and cancer site

BACKGROUND: Cancer survival is influenced by age, comorbidity, and type of cancer. A population-based study was conducted to compare the interplay between age and mortality for different cancers. METHODS: This study analyzed 784,378 cases, comprising 22 of the commonest SEER cancers diagnosed between 1984 and 1993. Competing hazards and proportional hazard analyses for cancer-specific and comorbid death were performed. RESULTS: Median follow-up was up to 159 months, and the median age of diagnosis was 67 years. Cancer-specific and comorbid deaths accumulated most within the first years of diagnosis. With the more biologically aggressive cancers, cancer deaths invariably exceeded comorbid deaths. For the remaining 70% of cancers, comorbidity remained the dominant mode of death. Deaths attributable to both cancer and comorbidity accumulated mostly after the seventh decade of life. Cancer site had a 3-fold greater effect on overall survival than age at diagnosis and a 30-fold effect with cancer-specific survival; age at diagnosis had a 5-fold greater effect on comorbid deaths than site. CONCLUSIONS: Both the age of the affected individual and the biology of the particular cancer have major influences on cancer survival and mode of death. Cancer is largely a disease of the elderly. Within affected individuals, fatalities attributable to cancer and comorbidity appeared inter-related, with cancer-specific deaths dominating for more lethal cancers and comorbid deaths dominating for the remaining majority. For these reasons, further improvements in overall survival may be best anticipated from better geriatric and general medical management as much as from better cancer management.     

The treatment of early breast cancer in women over the age of 70

One third of all breast cancers are diagnosed in women aged 70 or over. Older women are a heterogeneous population who are under-represented in clinical trials, and as a result uncertainty can exist as to what represents optimal treatment. This minireview, from an international authorship, summarises the existing evidence surrounding the management of early breast cancer in women aged 70 and over. The use of primary surgery and endocrine therapy, and adjuvant chemotherapy, radiotherapy, endocrine therapy and trastuzumab are discussed. Reference is made to ongoing clinical trials in this area and areas of controversy are highlighted.     

Loss of physical functioning among geriatric cancer patients: relationships to cancer site, treatment, comorbidity and age

This study investigated differences in physical functioning and physical role limitations according to cancer site and treatment modality in a sample of 590 patients 65 years and older diagnosed with breast, colon, lung or prostate cancer. Analysis of covariance procedures were utilised to test for differences in levels of physical functioning and physical role limitations according to cancer site and treatment modality, adjusting for differences in age, comorbid conditions and retrospective physical functioning. Physical functioning and physical role limitations were measured using two subscales of the Medical Outcomes Studies MOS 36-item Short Form Health Survey (SF-36). Physical functioning prior to diagnosis, and to a lesser degree comorbidity, contributed significantly to current levels of physical functioning and physical role limitations. Patients with lung cancer reported lower physical functioning and physical role limitation scores than patients with prostate cancer, and patients treated with surgery only reported lower physical functioning and physical role limitation scores than patients treated with neither surgery nor radiation. No gender differences were observed among the reduced sample consisting of patients with colon or lung cancer. It is important not only that physicians and oncologists are cognizant of the fact that some cancers (particularly lung cancer) may be more physically debilitating than others, but that the patient’s history of comorbid conditions and pre-existing physical limitations may be important factors in predicting current physical functioning.     

Coping with the cancer experience. II. Evaluating an education and support programme for cancer patients and their sitgnificant others

As reported, cancer patients and their significant others need information promoting their understanding of events throughout the illness, and support in mobilizing coping strategies when they consider the situational demands to exceed their personal resources. In the present study the provision of information was merged into the field of education and combined with emotional support to facilitate efforts to cope with the cancer experience. A patient education programme entitled Learning to live with cancer was developed (part I) and evaluated (part II).
Cancer patients and their significant others (n = 127) participated in group sessions. Open interviews organizxed around experiences of increased knowledge and understanding, decreased confusion and anxiety, and enhanced coping capacity related to participation in the programme were conducted with the participants. The interviews were analysed using the Grounded Theory approach. The findings indicate that supportive education, sensitively responsive to expressed learning needs and learning capability, has the power to promote proper understanding and facilitate coping efforts. Becoming familiar with facts and feelings reinforced confidence in evolving appropriate coping strategies for living with cancer.     

老年肺癌患者预后因素分析

背景与目的全球肺癌的发病率及死亡率最高,老年肺癌的发病人数亦在增加。虽然国际上有几项大样本研究了老年NSCLC的预后因素,结果不尽一致。本文旨在分析我国老年肺癌患者(≥65岁)的预后因素。方法收集2000年1月～2004年12月在湖北省肿瘤医院就诊的肺癌患者278例,其中≥65岁的老年肺癌患者140例(研究组),≤64岁的肺癌患者138例(对照组),分析临床资料、预后因素,并比较生存时间的差异。结果对于Ⅱ～ⅢA期患者,研究组的中位生存期为27月(95%CI:24.0～30.1),明显低于对照人群的35个月(95%CI:32.0～38.0),P=0.039。但对于ⅢB～Ⅳ期患者,不论采用序贯放化疗、单纯放疗、化疗或姑息治疗,老年组的预后(11个月,95%CI:9.2～12.8)与非老年组的预后(12个月95%CI:11.1～13.9)无明显差异,P=0.92。在研究组和对照组,最常见的毒副作用均为恶心呕吐,但组间无明显差异;其次为骨髓抑制中的白细胞减少,研究组明显高于对照组(x~2=4.3,P=0.04)。老年组食欲下降和疲乏的发生率要高,但无统计学差异。结论两组生存时间相似,研究组中位生存期14.0个月(95%CI:11.6～16.4),对照组中位生存期16个月(95% CI:13.1～18.9),无显著性差异(Log Rank=3.4,P=0.067)。两组有显著意义的预后因素均为性别、临床分期和采用以手术为主的治疗。对于Ⅱ～ⅢA期老年肺癌患者,由于未能接受以手术为主的综合治疗,预后要比年轻患者差,但对于ⅢB～Ⅳ期患者,不论采用序贯放化疗、单纯放疗、化疗或姑息治疗,老年组的预后(11个月,95%CI:9.2～12.8)与非老年组的预后(12个月,95%CI:11.1～13.9)无明显差异,Log Rank= 0.01,P=0.92,提示年龄不是影响预后的主要因素。但老年肺癌患者的耐受性差,不能接受强化治疗。     

Misunderstanding in cancer patients: Why shoot the messenger?

Aim: We aimed to document the prevalence of misunderstanding in cancer patients and investigate whether patient denial is related to misunderstanding.Patients and methods: Two hundred forty-four adult cancer outpatients receiving treatment completed a survey assessing levels of understanding and denial. Doctors provided the facts against which patient responses were compared. Multiple logistic regression analyses determined the predictors of misunderstanding.Results: Most patients understood the extent of their disease (71%, 95% CI: 65%–77%) and goal of treatment (60%, 95% CI: 54%–67%). Few correctly estimated the likelihood of treatment achieving cure (18%, 95% CI: 13%–23%), prolongation of life (13%, 95% CI: 8%–17%) and palliation (18%, 95% CI: 10%–27%). Patient denial predicted misunderstanding of the probability that treatment would cure disease when controlling for other patient and disease variables (OR = 2.20, 95% CI: 0.99–4.88, P = 0.05). Patient ratings of the clarity of information received were also predictive of patient understanding.Conclusions:Patient denial appears to produce misunderstanding, however, doctors' ability to communicate effectively is also implicated. The challenge that oncologists face is how to communicate information in a manner which is both responsive to patients' emotional status and sufficiently informative to allow informed decision-making to take place.     

The impact of low-grade toxicity in older people with cancer undergoing chemotherapy

Background:

Significant toxicity in chemotherapy trials is usually defined as grade ⩾3. In clinical practice, however, multiple lower grade toxicities are often considered meaningful. The purpose of this observational cohort study was to identify which level of toxicity triggers treatment modification and early discontinuation of chemotherapy in older people.

Methods:

Patients aged 65+ were recruited in a central London hospital. A total of 108 patients were recruited at the start of new chemotherapy treatment between October 2010 and July 2012.

Results:

Mean age was 72.1±5 years, median 72 and range 65–86 years. Of the patients, 50.9% (55) were male with gastrointestinal (49), gynaecological (18), lung (15) and other cancers (26). Chemotherapy was palliative in 59.3% (64/108), curative/ neoadjuvant/adjuvant in the others. Mean number of cycles completed was 4.2±3. Treatment modifications due to toxicity occurred in 60 (55.6%) patients, 35% (21/60) of whom had no greater than grade 2 toxicity. Early treatment discontinuation because of toxicity occurred in 23 patients (21.3%), 39.1% (9/23) of whom had no greater than grade 2 toxicity.

Conclusions:

Many older patients did not complete treatment as planned. Treatment was modified/discontinued even for one or two low-grade toxicities. Further work is required to clarify whether low-grade toxicity has a greater clinical impact in older people, or whether clinicians have a lower threshold for modifying/discontinuing treatment in older people.