Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score

BACKGROUND:

Tools are lacking to assess the individual risk of severe toxicity from chemotherapy. Such tools would be especially useful for older patients, who vary considerably in terms of health status and functional reserve.

METHODS:

The authors conducted a prospective, multicentric study of patients aged ≥70 years who were starting chemotherapy. Grade 4 hematologic (H) or grade 3/4 nonhematologic (NH) toxicity according to version 3.0 of the Common Terminology Criteria for Adverse Events was defined as severe. Twenty‐four parameters were assessed. Toxicity of the regimen (Chemotox) was adjusted using an index to estimate the average per‐patient risk of chemotherapy toxicity (the MAX2 index). In total, 562 patients were accrued, and 518 patients were evaluable and were split randomly (2:1 ratio) into a derivation cohort and a validation cohort.

RESULTS:

Severe toxicity was observed in 64% of patients. The Chemotherapy Risk Assessment Scale for High‐Age Patients (CRASH) score was constructed along 2 subscores: H toxicity and NH toxicity. Predictors of H toxicity were lymphocytes, aspartate aminotransferase level, Instrumental Activities of Daily Living score, lactate dehydrogenase level, diastolic blood pressure, and Chemotox. The best model included the 4 latter predictors (risk categories: low, 7%; medium‐low, 23%; medium‐high, 54%; and high, 100%, respectively; P_trend < .001). Predictors of NH toxicity were hemoglobin, creatinine clearance, albumin, self‐rated health, Eastern Cooperative Oncology Group performance, Mini‐Mental Status score, Mini‐Nutritional Assessment score, and Chemotox. The 4 latter predictors provided the best model (risk categories: 33%, 46%, 67%, and 93%, respectively; P_trend < .001). The combined risk categories were 50%, 58%, 77%, and 79%, respectively; P_trend < .001). Bootstrap internal validation and independent sample validation demonstrated stable risk categorization and P_trend < .001.

CONCLUSIONS:

The CRASH score distinguished several risk levels of severe toxicity. The split score discriminated better than the combined score. To the authors' knowledge, this is the first score systematically integrating both chemotherapy and patient risk for older patients and has a potential for future clinical application. Cancer 2011. © 2011 American Cancer Society.     

Palliative treatment of Erdheim–Chester disease with radiotherapy: A Rare Cancer Network study

A retrospective study of the use of palliative external beam radiotherapy (EBRT) in nine patients with Erdheim–Chester disease was conducted through the Rare Cancer Network. Patients received EBRT for bone pain, brain infiltration, or retro-orbital involvement. EBRT typically provided short-term palliation, with later recurrence of symptoms in most cases.     

Concerns of former breast cancer patients about disease recurrence: a validation and prevalence study

Objective: The present study has three aims: first, to evaluate the psychometric properties of the Dutch version of the CARS (CARS‐DLV). Second, to measure the prevalence of concerns about disease recurrence in former breast cancer patients and identify potential predictors and third, to establish how fear of recurrence was effecting quality of life. Methods: A prospective study was carried out on breast cancer patients (n=136) who had undergone curative treatment. Eligible patients completed an extensive questionnaire consisting of the CARS (fear of recurrence), HADS (anxiety and depression), BPI (pain), RAND (quality of life), LOT (optimism) and the PCS (catastrophzing). Results: This study confirmed the good internal consistency, test–retest stability and construct validity of the CARS (Dutch Language version). Moderate to high levels of fear of disease recurrence were found in 56% of 136 breast cancer survivors. Worries about health and death were the most prominent. Pain was a strong predictor of overall fear and of fear on the four sub domains of the CARS. The prevalence of fear decreased significantly with age. Education level, living arrangements and time since the last treatment did not predict the prevalence of overall fear. Fear of recurrence was negatively correlated with quality of life. Conclusion: The CARS‐DLV proved to be a valuable instrument to measure women's' concerns about breast cancer recurrence. More than half of former breast cancer patients indicated moderate to severe concerns about disease recurrence. Health and death worries were the most prominent. The levels of worry were independent of the time since diagnosis. Copyright © 2008 John Wiley & Sons, Ltd.     

Communication, quality of life and age: results of a 5-year prospective study in breast cancer patients.

BACKGROUND: Previous studies have employed short follow-up periods or examined only certain aspects of quality of life (QoL). This study aimed to examine the effect of communication on breast cancer patients' QoL and to investigate the role of age in this relationship. PATIENTS AND METHODS: In a prospective, observational study breast cancer patients were sent questionnaires, including the European Organisation for Research and Treatment of Cancer QLQ-C30, over 5 years. RESULTS: Forty-five per cent of the sample reported that some aspect of the communication they received was unclear and 59% wanted to speak with medical staff more. Patients under 50 years rated social and psychological help as more important, they were more aware of such services, had greater contact with support groups but were less satisfied with the information they received. Seventeen of the 27 QoL variables were significantly worse (P <0.01), up to 4 years after diagnosis, for those patients reporting unclear information. For patients over 50 years, QoL was significantly (P <0.001) worse when communication was unsatisfactory. Operation method or arm problems did not mitigate the association between communication and QoL. CONCLUSIONS: Communication is clearly a vital clinical skill that may play a role in patient QoL.     

The performance of three oncogeriatric screening tools - G8, optimised G8 and CARG - in predicting chemotherapy-related toxicity in older patients with cancer. A prospective clinical study

BackgroundOlder patients are vulnerable to chemotherapy-related toxicity (CRT). Therefore we evaluated screening tools in their power to predict CRT.MethodsPatients with cancer aged ≥65 years completed three screening questionnaires (G8, optimised G8 and Cancer and Ageing Research Group (CARG). Additionally, Comprehensive geriatric assessment (CGA) for verification of supportive care needs was undertaken on patients with impaired G8 scores. During chemotherapy treatment patients were assessed, capturing grade 0–5 CRT as defined by NCI CTCAE 4.Results104 patients with non-haematological cancers were included at three study sites. Median age was 73 years (range 65–85). Onco-geriatric screening detected 74% as impaired using G8 and optimised G8 questionnaires and 86% using CARG screening. Grade 3–5 toxicity affected 64.4% of all patients. G8 (OR 0.3 95% CI [0.1;1.0]) and optimised G8 (OR 0.4 95% CI [0.1; 1.5]) did not reliably predict CRT, whereas screening with CARG demonstrated a strong prediction of severe CRT: OR 4.2, 95% CI [1.1, 15.9]. CGA was undertaken on 66 patients, revealing deficiencies in nutritional (83%) and functional-status (54%) and occurrence of relevant comorbidity (53%).ConclusionThe CARG tool could be useful for predicting CRT. CGA showed clinically relevant supportive care needs in patients with a positive G8 screening.     

Neurocognitive functioning and health-related quality of life in patients treated with stereotactic radiotherapy for brain metastases: a prospective study

Background

Stereotactic radiotherapy (SRT) is expected to have a less detrimental effect on neurocognitive functioning and health-related quality of life (HRQoL) than whole-brain radiotherapy. To evaluate the impact of brain metastases and SRT on neurocognitive functioning and HRQoL, we performed a prospective study.

Methods

Neurocognitive functioning and HRQoL of 97 patients with brain metastases were measured before SRT and 1, 3, and 6 months after SRT. Seven cognitive domains were assessed. HRQoL was assessed with the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and BN20 questionnaires. Neurocognitive functioning and HRQoL over time were analyzed with linear mixed models and stratified for baseline Karnofsky performance status (KPS), total metastatic volume, and systemic disease.

Results

Median overall survival of patients was 7.7 months. Before SRT, neurocognitive domain and HRQoL scores were lower in patients than in healthy controls. At group level, patients worsened in physical functioning and fatigue at 6 months, while other outcome parameters of HRQoL and cognition remained stable. KPS < 90 and tumor volume >12.6 cm³ were both associated with worse information processing speed and lower HRQoL scores over 6 months time. Intracranial tumor progression was associated with worsening of executive functioning and motor function.

Conclusions

Prior to SRT, neurocognitive functioning and HRQoL are moderately impaired in patients with brain metastases. Lower baseline KPS and larger tumor volume are associated with worse functioning. Over time, SRT does not have an additional detrimental effect on neurocognitive functioning and HRQoL, suggesting that SRT may be preferred over whole-brain radiotherapy.