Chemotherapy and radiation treatment decision-making experiences of older adults with cancer: A qualitative study

Purpose

Little is known about the perspectives of older adults (OAs) with newly-diagnosed cancer on their experiences with cancer treatment decision-making. The objective of this study was to explore the factors that were important for accepting or refusing cancer treatment by older adults undergoing chemotherapy and/or radiation therapy.

A qualitative investigation of breast cancer survivors’ experiences with breastfeeding

Introduction  This is an exploratory, qualitative investigation of breast cancer survivors’ experiences with breastfeeding. Previous studies have focused on the physiology of lactation after surgery and treatment, but have not explored factors influencing breastfeeding decisions and behavior. Methods  We used purposeful sampling to identify 11 breast cancer survivors who had a child after their diagnosis and treatment. Participants were recruited from among those in the Women’s Healthy Eating and Living (WHEL) study and a Young Survival Coalition (YSC) affiliate. We conducted semi-structured, open-ended telephone interviews lasting 45–75 min. We used social cognitive theory (SCT) to structure questions regarding influences on breastfeeding behavior. We transcribed interviews and used cross-case, inductive analysis to identify themes. Results  Ten of 11 participants initiated breastfeeding. The following main themes emerged: 1) Cautiously hopeful, 2) Exhausting to rely on one breast, 3) Motivated despite challenges, 4) Support and lack of support, and 5) Encouraging to others. Discussion/Conclusions  Study participants were highly motivated to breastfeed but faced considerable challenges. Participants described problems that are not unique to women with breast cancer, but experienced these to a much greater degree because they relied mostly or entirely on one lactating breast. This study revealed a need for improved access to information and support and greater sensitivity to the obstacles faced by breast cancer survivors. Implications for cancer survivors  Results of this qualitative analysis indicate that interventions to support the efforts of breast cancer survivors who are interested in breastfeeding are warranted. Additional research would aid in the development of such interventions.     

Symptom distress in older adults during cancer therapy: Impact on performance status and quality of life

BackgroundThis study aims to identify a sub-group of older patients who experience a higher level of symptoms of distress during cancer therapy. The symptoms that had the greatest impact on the patients' performance status and quality of life (QoL) are also identified.MethodsThis cross-sectional study used secondary data from a convenience sample of 120 patients, 65 years of age and older, receiving cancer therapy. The measuring instruments used included the Symptom Distress Scale, the Karnofsky Performance Scale (KPS) and the Functional Assessment of Cancer Therapy-General (FACT-G). Hierarchical cluster analysis was used to categorize the patients into groups.ResultsThe patients had multiple symptoms, with a mean number of 5 ± 3 symptoms per patient. Mood disturbance was the most prevalent (87%), while nausea (28%) was the least prevalent. Approximately 28% and 72% of the patients fell into the high-symptom and low-symptom groups, respectively. The high-symptom group reported significantly lower mean KPS scores, and FACT-G sub-scale and total scores (p < 0.01). Impaired mobility had the strongest standardized coefficients in the KPS (? 0.63; p < 0.01), the FACT-G functional (? 0.49; p < 0.05) and the physical (? 0.45; p < 0.05) sub-scales. Concentration difficulties had the strongest standardized coefficients (? 0.47; p < 0.01) in the FACT-G total.ConclusionMost of the older patients in this study reported suffering from a multitude of symptoms, with mood disturbance being the most prevalent. The older patients in the high-symptom group had a significantly lower performance status and QoL compared to the patients in the low-symptom group.     

The experiences of unpartnered men with prostate cancer: a qualitative analysis

Purpose  

The purpose of this study was to examine how men without partners make decisions about prostate cancer treatment, manage treatment side effects, and obtain information and support.     

Impact of treatment on elder-relevant physical function and quality of life outcomes in older adults with metastatic castration-resistant prostate cancer

IntroductionUnderstanding physical function (PF) and quality of life (QoL) treatment effects are important in treatment decision-making for older adults with cancer. However, data are limited for older men with metastatic castration-resistant prostate cancer (mCRPC). We evaluated the effects of treatment on PF and QoL in older men with mCRPC.Materials and MethodsMen aged 65+ with mCRPC were enrolled in this multicenter prospective observational study. PF measures included instrumental activities of daily living, grip strength, chair stands, and gait speed. QoL measures included fatigue, pain, mood, and Functional Assessment of Cancer Therapy (FACT)-General total and sub-scale scores. Outcomes were collected at baseline, three, and six months. Linear mixed effects regression models were used to examine PF and QoL differences over time across various treatment cohorts.ResultsWe enrolled 198 men starting chemotherapy (n = 71), abiraterone (n = 37), enzalutamide (n = 67), or radium-223 (n = 23). At baseline, men starting chemotherapy had worse measures of PF, QoL, pain, and mood than the other groups. Over time, all PF measures remained stable, pain improved, but functional wellbeing (FWB) and mood worsened significantly for all cohorts. However, change over time in all outcomes was not appreciably different between treatment cohorts. Worst-case sensitivity analyses identified attrition (ranging from 22 to 42% by six months) as a major limitation of our study, particularly for the radium-223 cohort.DiscussionFWB and mood were most prone to deterioration over time, whereas pain improved with treatment. Although patients initiating chemotherapy had worse baseline PF and QoL, chemotherapy was not associated with significantly greater worsening over time compared to other common therapies for mCRPC. These findings may assist in treatment discussions with patients. However, given the modest sample size, attrition, and timeframe of follow-up, the impact of treatment on PF and QoL outcomes in this setting requires further study, particularly for radium-223.     

Interferon-beta treatment of metastatic prostate cancer

A limited clinical trial of Interferon-beta (Human Fibroblast Interferon) in the treatment of advanced, hormone-refractory prostate cancer was conducted by the National Prostate Cancer Project (NPCP Protocol 2100). Sixteen patients with metastatic prostate cancer who had failed prior hormone therapy were entered into the study. Treatment consisted of 6 X 10(6) units of Interferon-beta intravenously three times per week for 12 weeks. Chills and fever were seen in ten of the 16 patients (62.5%), and mild hematologic toxicity occurred in four patients. No complete or partial responses were observed. Three patients had stable disease by NPCP criteria for a mean duration of 6.3 months. Progression of disease was seen in 13 of the 16 patients, eight of whom progressed during therapy. The results of this study suggest that Interferon-beta has limited efficacy in the treatment of advanced, hormone-refractory prostate cancer.     

How we treat metastatic colon cancer in older adults

The past decade has seen unprecedented advancements in our ability to treat patients with metastatic colorectal cancer. When applying these advances—hepatic resection and multi-agent chemotherapy—to the care of older patients, it is essential to first perform some assessment of function beyond performance status and to elicit feedback from the patient about how he/she values quality versus quantity of life. For robust older patients with potentially surgically resectable oligometastatic cancer, we recommend a standard approach of surgery with perioperative chemotherapy. However, operative risk increases with age, and careful discussion about prognosis is warranted. For patients with unresectable cancer, first-line chemotherapy with either 5-fluoruracil/leucovorin alone, or with a 20% dose reduced FOLFOX or FOLFIRI regimen, is well tolerated by older patients. Either dose escalation or addition of a second drug can typically be undertaken after 1–2 cycles. First-line bevacizumab with chemotherapy is warranted in those with low risk for atherothrombotic complications. EGFR inhibitors with combination chemotherapy for KRAS wild type cancers offer the best response rates, but toxicity can be difficult and may be best reserved for second-line in all but the fittest elderly. In second-line, we routinely offer continued chemotherapy with the agents that the patient has not yet received. The role of aflibercept and regorafenib has not been well studied in the elderly, but they are both reasonable options for patients with good function and no contraindication. With this cautious approach older patients can be expected to maintain a good quality of life during treatment for metastatic colorectal cancer.     

State-of-the-art treatment of metastatic hormone-refractory prostate cancer

Initial therapy for advanced prostate cancer includes androgen ablation by surgical or medical castration. Still, nearly all men with metastases will progress to hormone-refractory prostate cancer (HRPC). Current U.S. Food and Drug Administration-approved agents for the treatment of HRPC include mitoxantrone and estramustine, although the vinca alkaloids and the taxanes have shown promising activity in single-agent phase II trials. Combinations of these agents induce a biochemical response in greater than 50% of patients, but the median duration of response is approximately 6 months. Overall survival of patients treated with these combinations is approximately 18-24 months. Studies are ongoing to develop novel therapies that target specific molecular pathways or mechanisms of chemotherapy resistance. Novel agents under development include growth factor receptor inhibitors, antisense oligonucleotides, bisphosphonates, and cell differentiating agents. Evaluation and incorporation of these agents into existing treatment regimens will guide us in the development of more active regimens in the treatment of HRPC.     

'Someone who cares:' a qualitative investigation of cancer patients' experiences of psychotherapy

Although psychotherapy for cancer patients is known to be effective, there is little in the research to indicate what elements of their therapy patients find most helpful. To explore this question, we interviewed cancer patients diagnosed with metastatic disease who had been offered two different forms of individual psychotherapy as part of a larger funded study. These interviews were then transcribed and analysed using grounded theory. Our aim was to explore patients' psychotherapy experience from their perspective and to determine what common elements in the two approaches they felt were of greatest benefit. Results indicated that patients offered cognitive behavioural therapy had similar experiences to those who received a type of relaxation therapy that included time for non-specific, patient-centred 'chat'. Central to participants' experiences was the opportunity both therapies gave them to enter a relationship in which they could safely share their thoughts and feelings with someone who seemed genuinely interested in understanding their cancer experience and 'truly cared'. These findings suggest that the unique perspectives of cancer patients can add considerably to our understanding of individual psychotherapy in cancer care settings and how this might be improved.     

Evolving treatment paradigms for locally advanced and metastatic prostate cancer

While men with early stage prostate cancer typically enjoy long-term survival after definitive management, for those who present with locally advanced or metastatic disease, survival is compromised. Multimodality therapy can prolong survival in these patients, with state-of-the-art options including intensity-modulated radiation or brachytherapy in conjunction with androgen ablation, adjuvant androgen ablation and/or chemotherapy with radical retropubic prostatectomy. In addition, novel biological therapies are being explored to target the unique molecular changes in prostate cancer cells and their interactions with the microenvironment. With these advances the outlook will undoubtedly improve, even for patients presenting with advanced disease. Careful application of these emerging therapies to a select group of prostate cancer patients most likely to obtain benefit from them is the challenge for urologists, medical oncologists and radiation oncologists for the future.     

New treatment options for patients with metastatic castration-resistant prostate cancer

Chemotherapy for men with metastatic castration-resistant prostate cancer (CRPC) conferred no survival advantage until 2004 when docetaxel was shown to improve survival when compared with mitoxantrone, which was approved for palliation of symptomatic disease in 1996. Since then, clinical trials have concentrated on three main populations of patients with metastatic CRPC: those who are chemotherapy naïve and are asymptomatic or minimally symptomatic, those who need docetaxel therapy, and those who have received docetaxel previously and/or those with symptomatic disease. Over the last year, four Phase III therapeutic trials have met their primary endpoint of improved overall survival: sipuleucel-T in the pre-chemotherapy setting, cabazitaxel and abiraterone in the post-docetaxel setting, and radium-223 for those with symptomatic bone metastases who have received or are not suitable to receive docetaxel. In addition to these therapeutic trials, a Phase III head-to-head trial of denosumab compared to zoledronic acid showed that denosumab was superior to zoledronic acid in delaying or preventing skeletal related events. As a result, the treatment paradigm for metastatic CRPC is changing rapidly. This paper reviews the data from these five completed Phase III trials and places these new agents, as well as those in ongoing Phase III trials, in the context of the old treatment paradigm for metastatic CRPC and discusses some of the challenges ahead for determining optimal timing and sequencing of treatments for metastatic CRPC.     

Castration-resistant metastatic prostate cancer: current status and treatment possibilities

Prostate cancer (PCa) is the most common cancer in the male population in Western countries, second to skin cancer. Hormonal therapy allows long-lasting and effective control of cancer-related symptoms in advanced stages; however, in almost all patients with metastatic PCa the disease will progress when it becomes castration-resistant (CRPC). Chemotherapy with docetaxel was a turning point in CRPC, as, for the first time, it resulted in an increased survival time in comparison with mitoxantrone and prednisone. Combination therapy with docetaxel and prednisone is the first-line treatment of choice. Once the cancer has progressed, there is no clear alternative, although some new agents have shown promise in the treatment of this type of cancer. This review will provide an overview of the current status of CRPC, including clinical status, prognosis, firstline treatment and new second-line treatment options.     

Evolving treatment paradigms for locally advanced and metastatic prostate cancer

While men with early stage prostate cancer typically enjoy long-term survival after definitive management, for those who present with locally advanced or metastatic disease, survival is compromised. Multimodality therapy can prolong survival in these patients, with state-of-the-art options including intensity-modulated radiation or brachytherapy in conjunction with androgen ablation, adjuvant androgen ablation and/or chemotherapy with radical retropubic prostatectomy. In addition, novel biological therapies are being explored to target the unique molecular changes in prostate cancer cells and their interactions with the microenvironment. With these advances the outlook will undoubtedly improve, even for patients presenting with advanced disease. Careful application of these emerging therapies to a select group of prostate cancer patients most likely to obtain benefit from them is the challenge for urologists, medical oncologists and radiation oncologists for the future.     

A prospective study examining elder-relevant outcomes in older adults with prostate cancer undergoing treatment with chemotherapy or abiraterone

BackgroundTreatment of metastatic castration-resistant prostate cancer (mCRPC) with chemotherapy improves disease control and survival in fit older men (age 65 +) but its impact on function is not clear. We hypothesized that chemotherapy would impair daily function in older men with mCRPC.MethodsMen aged 65 + with mCRPC starting chemotherapy or abiraterone were enrolled in this prospective observational pilot study. Daily function was evaluated with the OARS Instrumental Activities of Daily Living (IADL) scale. Three objective measures were used to assess physical function. Patients completed Functional Assessment of Cancer Therapy questionnaires measuring prostate-specific and general quality-of-life (QOL). Vulnerability was evaluated using the Vulnerable Elders Survey (VES-13). Assessments were completed before each cycle of chemotherapy or every 2–3 months for those receiving abiraterone. We compared outcomes pre- and post-treatment and with published minimal clinically important differences.ResultsWe evaluated 29 and 7 men on 1st-line and 2nd-line chemotherapy (median 6 and 7 cycles, respectively) and 11 men receiving abiraterone for a median 7 months. IADL scores declined slightly after 1st-line chemotherapy (mean − 0.31 points, 95% confidence interval 0.39, − 1.02). Physical performance remained stable over time. Both general and prostate-specific QOL improved with 1st-line chemotherapy. For all but one outcome (Timed Chair Stands), vulnerable men had similar changes over time compared to non-vulnerable men. Second-line chemotherapy and abiraterone were generally well-tolerated.ConclusionIADL function declined slightly whereas physical function remained stable and QOL improved during chemotherapy. Vulnerable and non-vulnerable older men with mCRPC appear to tolerate 1st-line chemotherapy fairly well.     

Ipilimumab: A potential immunologic agent in the treatment of metastatic castration-resistant prostate cancer

Immunotherapy has garnered an important place in the therapeutic landscape of treatment in prostate cancer since approval of sipuleucel-T. Ipilimumab is a checkpoint inhibitor that is currently approved for the treatment of advanced melanoma. In the June issue of Lancet Oncology, Kwon and colleagues report the phase III trial using ipilimumab in a post-docetaxel metastatic castration-resistant prostate cancer population. While the primary endpoint of overall survival was not met, several lessons are learned from the analysis of this trial. Perhaps better refinement of a more favorable group of patients who may potentially benefit from an immunologic treatment should be advocated.     

Predictive factors for tolerance to taxane based chemotherapy in older adults affected by metastatic prostate cancer (ANCHISES-NCT05471427): A prospective observational trial including patients with metastatic hormone sensitive and castrate resistant prostate cancer treated with taxane chemotherapy

IntroductionTaxane-based chemotherapy is one of the main cornerstones for treatment of metastatic prostate cancer (mPCa). In aged and well-fit patients, an indication for taxane chemotherapy should remain similar to the general population. Aiming to explore predictive factors of fitness to taxane chemotherapy in older adult patients, a prospective observational study was carried out in our institution.Materials and methodsWe collected data from a prospective mono-centric database of patients aged ≥70 years old that were treated in our department. All patients underwent taxane treatment (either docetaxel or cabazitaxel, the latter only in second line setting) starting with standard treatment schedules (75 mg/m² or 25 mg/m² every three weeks, respectively). Data about G8 score post treatment decreases were collected and reported. We explored associations between baseline age, G8 score, and Charlson Comorbidity Index (CCI) with taxane dose reduction (DR), treatment temporary suspension (TS), or definitive interruption (TDI). Logistic regression analysis was performed to explore potential predictive factors for tolerability in patients treated with docetaxel.ResultsOne hundred-eighteen patients underwent taxane chemotherapy between 2011 and 2022, the majority of cases in metastatic castrate resistant prostate cancer (mCRPC) setting (85.6%). In the overall population, DR was performed in 40.7% of cases, and TS and TDI were deemed necessary in 28% and 22.9% of patients, respectively. Forty-seven percent of patients reported a significant deterioration in terms of G8 score (from > to ≤14). Sixty-two percent of the overall population were deemed fit for further treatment after taxane chemotherapy. Rate of DR, TS, and TDI was 29.4%, 11.8% and 9.2% in the docetaxel subgroup, vs 48%, 60% and 12% of patients treated with cabazitaxel, respectively. Lower baseline G8 was reported as a continuous variable and the only independent predictive factor for TDI in docetaxel subgroup (odds ratio [OR] 0.41, 95% confidence interval [CI] 0.25–0.68, p = 0.0008).DiscussionOur data suggest that tolerability of taxane regimens in a pre-treated population of older patients with prostate cancer is acceptable, despite a non-negligible rate of TDI. Taxane chemotherapy should not be denied a priori in order to avoid undertreatment of older adult patients.