Evaluation of the Frail Old Cancer Patient

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Evaluation of the Frail Old Cancer Patient

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1. Evaluation of the Frail Old Cancer Patient Silvio Monfardini Division of Medical Oncology Istituto Oncologico Veneto Italy

2. THE FRAIL PATIENT No broadly accepted definition Combination of aging, disease and other factors that make some people vulnerable to stress Poor tolerance to stress and at high risk of loss of independence

4. Fried et al. Frailty in older adults. Evidence for a phenotype. J Gerontol. Med. Sci. 2001 Loss of 10% or more of body weight in over 1 year low energy level difficulty in initiating movements slow movements decreased grip strenght Frailty is defined by three or more of these criteria

5. Is frailty a disease? By the Fried definition, frailty is not a disease but rather a sort of being in the middle state between being functional and nonfunctional, and between being healthy and being sick.

6. Who are Elderly Frail Cancer Patients? ( The operational concept of aging in Medical Oncology)

7. Activity of daily living(ADL) Based on 6 criteria Dressing Toilet Use Bathing with sponge, bath, or shower Transferring (in and out of bed or chair) Urine and Bowel Continence Eating

8. Cumulative illness rating scale for geriatrics (CIRS-G)*

9. The basic components of the Comprehensive Geriatric Assessment(CGA) Functional status ADL (Activity of Daily Living), IADL (Instrumental Activity of Daily Living) Comorbidity (number, type and rating of comorbid conditions) Cognition (Mini-Mental Status Examination) Depression (Geriatric Depression Scale) Polypharmacy Nutrition (Mini-Nutritional Assessment) Presence of Geriatric Syndromes (dementia, delirium, depression, failure to thrive, neglect or abuse, osteoporosis, falls, incontinence) Socio-economic factors

10. An operational definition of frailty for the Elderly Cancer Patient

12. CLINICAL VALUE OF SUBDIVIDING ELDERLY CANCER PATIENTS AS FIT, VULNERABLE AND FRAIL IN A GERIATRIC ONCOLOGY CLINIC. Vamvakas L,Monfardini S.et.al. SIOG 2005 INTRODUCTION AND AIMS The aim of this work was to determine the relative amount of Fit, Frail and Vulnerable patients and to verify the therapeutic approach for each subgroup in a Geriatric Oncology Clinic.

13. RESULTS Frail Patients according to MGE

17. RATIONALE RATIONALE Management of frail elderly patients: adapted treatment or only supportive care? Few data on outcome and survival. Management of frail elderly patients: adapted treatment or only supportive care? Few data on outcome and survival.

18. RESULTS: PATIENTS A total of 364 elderly patients underwent Multidimensional Geriatric Assessment: fit (26.4%), vulnerable (49.5%) and frail patients (24.2%) 88 eligible frail patients had a median age of 79 years (range, 70-93), 43.2% males.

21. RESULTS:Chemotherapy Six patients (20%) derived some clinical benefit but only two (6.7%) showed a radiological response. Twenty patients interrupted chemotherapy prematurely due to either toxicity/death (23.3%) or refusal/drop out (43.3%).

23. DISCUSSION Frailty was observed in 1/4 of all patients our elderly but it did not prevent treatment of tumor with either chemo- or endocrine therapy in 66% of cases.

25. Definition of frailty from oncological causes

26. ONCOLOGICAL CAUSES OF FRAILTY (COMORBIDITY GRADE 4) Liver failure from primary or metastatic disease Pulmonary insufficiency from primary or metastatic disease Brain or meningeal extensive primary or metastatic disease

27. ONCOLOGICAL CAUSES OF FRAILTY EXAMPLES OF INFLUENCE ON ADLS Cachexia Uncontrolled pain Loss of mobility from refractory pathological fractures Esofageal stenosis Intestinal obstruction Recurrent peritoneal effusion

28. ONCOLOGICAL CAUSES OF FRAILTY TO BE CONSIDERED IN GERIATRIC SYNDROMES Neoplastic urinary incontinence (due to neoplasia or surgical or RT sequelae) Neoplastic rectal incontinence (due to neoplasia or surgical or RT sequelae)

29. Treatment of elderly cancer patients:we probably only know the tip of the iceberg,frail are in the base

30. Clinical trials in the elderly frail patients are lacking Elderly frail patients excluded from clinical trials Results from trials conducted with younger adults may not2 be applicable to the majority of elderly cancer patients Different chemotherapy regimens should also be tested in elderly frail patients3

31. Example: A trial designed for frail elderly patients

32. Barriers to the informed consent to be overcome in elderly (frail) cancer patients before trials entry

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