The Relevance and Added Value of Geriatric Medicine (GM): Introducing GM to Non-Geriatricians

Geriatric Medicine (GM) holds a crucial role in promoting health and managing the complex medical, cognitive, social, and psychological issues of older people. However, basic principles of GM, essential for optimizing the care of older people, are commonly unknown or undermined, especially in countries where GM is still under development. This narrative review aims at providing insights into the role of GM to non-geriatrician readers and summarizing the main aspects of the added value of a geriatric approach across the spectrum of healthcare. Health practitioners of all specialties are frequently encountered with clinical conditions, common in older patients (such as cancer, hypertension, delirium, major neurocognitive and mental health disorders, malnutrition, and peri-operative complications), which could be more appropriately managed under the light of the approach of GM. The role of allied health professionals with specialized knowledge and skills in dealing with older people’s issues is essential, and a multidisciplinary team is required for the delivery of optimal care in response to the needs and aspirations of older people. Thus, countries should assure the educational background of all health care providers and the specialized health and social care services required to meet the demands of a rapidly aging society

Comprehensive geriatric assessment and assessment of quality of life and treatment tolerance in elderly patients with inoperable non-small cell lung cancer receiving chemotherapy

The aim of the current study was to evaluate the role of a Comprehensive Geriatric Assessment (CGA) and its domains, such as functional independence, comorbidity, polypharmacy, depression, cognitive impairment, malnutrition and presence of geriatric syndromes as prognostic and provleptic tools in elderly patients with advanced non-small cell lung cancer (NSCLC) receiving chemotherapy. Cancer is a disease of the elderly with 60% of new diagnosis and 70% of cancer deaths occuring in patients over the age of 65 years. Lung cancer is the commonest type of cancer in developed world and the leading cause of cancer deaths with a median age at diagnosis of 71 years in US. NSCLC representing 85% of lung cancer cases is usually diagnosed in advanced stage, where combination chemotherapy offers a survival benefit in molecular-unselected patients with good perfomance status. Older patients are under-represented in clinical trials while data from elderly-specific trials are conflicting. Therefore, the optimal management for this population remains unclear. Ageing is a highly individualized process and the chronologic age does not always reflect the actual “biologic” age. Olders consists a heterogeneous population depending on their model of ageing. A CGA is proposed for the multidimensional assessment of elders, consisted of validated questionnaires and instruments for the evaluation of functional, emotional and cognitive status, the comorbid diseases, the nutritional status, polypharmacy, presence of geriatric syndromes and socio-economic issues, aiming to guide personalized treatment decision.In this study, 201 patients with advanced NSCLC receiving first-line (n=138) or salvage chemotherapy (n=63) within five phase II and III elderly-specific trials condacted by the Hellenic Oncology Researsh Group (HORG) were prospectively assessed with a baseline CGA and categorised into three groups, as fit (30,3%) vulnerable (45,8%) or frail (23,9%), according to Balducci criteria. Median age was 75 years (range 65-92), while 53% and 42% were over the age of 75 and 80 years, respectively. The univariate and multivariate analysis of CGA domains indicated a significant correlation for severe treatment-related toxicity with age ≥ 75 years, impaired ECOG PS of 2, non-fitness according to CGA and treatment with combination of a classic cytotoxic and a biologic agent, while disease stage and combination treatment were significantly correlated with response to treatment. ECOG PS, combination treatment and cognitive status were identified as significant prognostic factors for survival. The results of the current study revealed that a CGA in older patients with advanced NSCLC is feasible and offers valuable prognostic information for treatment toxicity and survival that can help individualize treatment decision in everyday clinical practice. In addition, the study results can contribute to future clinical research by using the identified prognostic biomarkers as stratification factors of older patients participating in clinical trials but also as domains that merit furter evaluation within ongoing research on the development of optimal tools for geriatric assessment.Σκοπός της ερευνητικής εργασίας ήταν η αξιολόγηση της Πολυδιάστατης Γηριατρικής Αξιολόγησης και των επιμέρους παραμέτρων αυτής όπως η λειτουργική ανεξαρτησία, η συνοδός νοσηρότητα, η πολυφαρμακία, η τυχόν υποκείμενη καταθλιπτική συνδρομή, η διανοητική έκπτωση, η διαταραχή της θρέψης και η παρουσία γηριατρικών συνδρόμων, ως προγνωστικά και προβλεπτικά εργαλεία για την εκτίμηση της τοξικότητας από τη χημειοθεραπεία, ηλικιωμένων ασθενών με ανεγχείρητο Μη-Μικροκυτταρικό Καρκίνο του Πνεύμονα. Ο καρκίνος είναι νόσος των ηλικιωμένων με το 60% των νέων διαγνώσεων καρκίνου και το 70% της θνησιμότητας από καρκίνο να αφορούν ασθενείς άνω των 65 ετών. O καρκίνος του πνεύμονα είναι ο συχνότερος καρκίνος στον ανεπτυγμένο κόσμο με μέση ηλικία διάγνωσης τα 71 έτη. Ο μή-μικροκυτταρικός τύπος αποτελεί το 85% περίπου των διαγνώσεων καρκίνου πνεύμονα και η διάγνωσή του γίνεται κατά κανόνα σε προχωρημένα στάδια με τη συνδυασμένη κυτταροτοξική χημειοθεραπεία να αποτελεί τη θεραπεία εκλογής σε μή μοριακά επιλεγμένους ασθενείς με καλή λειτουργική κατάσταση. Οι ηλικιωμένοι ασθενείς γενικά υπο-αντιπροσωπεύονται στις κλινικές μελέτες ενώ τα δεδομένα από τυχαιοποιημένες μελέτες χημειοθεραπείας σε ηλικιωμένους με μεταστατικό ΜΜΚΠ είναι αντικρουόμενα, με συνέπεια η βέλτιστη θεραπευτική επιλογή για αυτό τον πληθυσμό να αποτελεί αντικείμενο συνεχιζόμενης έρευνας. Η διαδικασία της γήρανσης είναι εξατομικευμένη και η χρονολογική ηλικία δεν αντανακλά πάντοτε τη “βιολογική” ηλικία. Έτσι υπάρχει μεγάλη ετερογένεια στον πληθυσμό των ηλικιωμένων ανάλογα με το μοντέλο γήρανσης. Για την πολύπλευρη αξιολόγηση του ηλικιωμένου ογκολογικού ασθενή προτείνεται η εφαρμογή της Πολυδιάστατης Γηριατρικής Αξιολόγησης (ΠΓΑ) η οποία αποτελείται από σταθμισμένα ερωτηματολόγια και δοκιμασίες που αξιολογούν τη λειτουργική, συναισθηματική και γνωστική κατάσταση, τα συνοδά νοσήματα, τη θρέψη, τη πολυφαρμακία, τη παρουσία γηριατρικών συνδρόμων και την οικογενειακή και κοινωνικο-οικονομική κατάσταση, με στόχο την εξατομίκευση της θεραπευτικής αντιμετώπισης.Στη παρούσα μελέτη, 201 ασθενείς με εκτεταμένο ΜΜΚΠ που υποβλήθηκαν σε χημειοθεραπεία πρώτης γραμμής (ν=138) ή σε θεραπεία διάσωσης (ν=63) στα πλαίσια πέντε κλινικών μελετών φάσης ΙΙ και ΙΙΙ της ΕΟΕΟ ειδικά σχεδιασμένων για ηλικιωμένους ασθενείς εκτιμήθηκαν προοπτικά με την εφαρμογή ΠΓΑ και ταξινομήθηκαν σε τρεις κατηγορίες, ως «ικανοί» ή «fit» (30,3%), «ευπαθείς» ή «vulnerable» (45,8%) και «εύθραυστοι» ή «frail» (23,9%), σύμφωνα με τα κριτήρια Balducci. Η μέση ηλικία των ασθενών ήταν τα 75 έτη (65 ως 92 έτη) ενώ 53% και 42% αυτών ήταν άνω των 75 και 80 ετών, αντίστοιχα. Σύμφωνα με τη μονοπαραγοντική και πολυπαραγοντική ανάλυση των παραμέτρων της ΠΓΑ, οι κύριοι προβλεπτικοί παράγοντες για σοβαρού βαθμού τοξικότητα από τη θεραπεία ήταν η ηλικία ≥ 75 ετών, το επηρεασμένο PS=2, η κατηγορία non-fit και η χορήγηση θεραπείας με συνδυασμό κλασσικού κυταροτοξικού και βιολογικού παράγοντα, ενώ σημαντικοί προβλεπτικοί παράγοντες για ανταπόκριση στη θεραπεία ήταν το στάδιο της νόσου και η θεραπεία με συνδυασμό αντινεοπλασματικών παραγόντων. Προγνωστικοί παράγοντες για την επιβίωση των ασθενών ήταν η λειτουργική κατάσταση κατά PS, η χορήγηση συνδυασμένης χημειοθεραπείας και η γνωσιακή κατάσταση.Τα αποτελέσματα της παρούσας μελέτης κατέδειξαν ότι η διενέργεια της ΠΓΑ σε ηλικιωμένους ασθενείς με εκτεταμένο ΜΜΚΠ είναι εφικτή και μπορεί να δώσει σημαντικές πληροφορίες με προβλεπτική αξία για την τοξικότητα από τη θεραπεία και προγνωστική αξία για την έκβαση της νόσου. Οι πληροφορίες αυτές μπορούν να χρησιμοποιηθούν στη καθημερινή κλινική πρακτική για την εξατομίκευση της θεραπείας των ηλικιωμένων ασθενών. Επίσης, μπορούν να συμβάλλουν στη κλινική έρευνα με την πιθανή χρήση των προγνωστικών παραμέτρων ως παραγόντων διαστρωμάτωσης των ηλικιωμένων ασθενών σε κλινικές μελέτες αλλά και ως παράμετροι που προτείνεται να αξιολογηθούν περαιτέρω στα πλαίσια της έρευνας για την ανάπτυξη των βέλτιστων εργαλείων γηριατρικής αξιολόγησης

Malignant Transformation of Schneiderian Papilloma Presenting With Progressive Binocular Diplopia and Blepharoptosis

Sinonasal tumors arising from Schneiderian papillomas, most frequently associated with squamous cell carcinoma (SCC), are rare and often present with non-specific symptoms, even in an advanced stage. Herein, we report the case of a 61-year-old male who presented with a four-month history of progressive binocular diplopia, blepharoptosis, and amblyopia, and upon the essential diagnostic work-up he was subsequently diagnosed with SCC arising from an SP. Surgical management was not warranted due to the extent of the disease, so induction chemotherapy with cisplatin and 5-fluorouracil (5-FU) was commenced, followed by definitive concurrent chemoradiotherapy (CRT). The patient was still alive at 25 months after his first presentation, receiving supportive care. Our case highlights the importance of early recognition of neuro-ophthalmological disorders related to sinonasal carcinomas, as diagnostic delay may lead to both functional complications and higher morbidity

Periodontal disease preceding osteonecrosis of the jaw (ONJ) in cancer patients receiving antiresorptives alone or combined with targeted therapies: Report of 5 cases and literature review

Objective We present clinical and radiologic data of periodontal tissue involvement preceding the appearance of osteonecrosis of the jaw (ONJ) in 5 patients with solid tumors, who received antiresorptives alone or in combination with targeted therapies. Study Design Five patients with osteonecrosis before dental extraction were studied. Results Periodontal involvement was evidenced by pain, bleeding, fistula, purulence, swelling, periodontal pocket, and tooth mobility. Combined endoperiodontal lesions were considered in 1 patient. Duration of symptoms before ONJ diagnosis lasted 8 to 24 weeks. Routine therapy was performed in 2 of 5 patients. Widening of the periodontal ligament was observed in 4 patients, and dense alveolar bone was seen in 1 patient. Local complications of ONJ required dental extractions in 4 of 5 patients. Spontaneous tooth exfoliation was observed in 1 patient. Alveolar bone biopsies, after the extraction in 2 patients, confirmed osteonecrosis. Osteonecrosis healed in 2 patients - 1 after the dental extraction and 1 after 3 dental extractions and surgical debridement. Postextraction socket healed in 1 patient, and the area with exposed bone remained asymptomatic. Osteonecrosis progressed in 2 patients. Conclusions Clinical and radiologic signs of periodontal tissue involvement, before dental extraction in patients treated with antiresorptives alone or in combination with targeted therapy, may represent developing osteonecrosis. © 2015 Elsevier Inc

Biweekly Carboplatin Plus Gemcitabine as First-Line Treatment of Elderly Patients With Advanced Squamous Non–Small-cell Lung Cancer: A Multicenter Phase I-II Trial by the Hellenic Oncology Research Group

In the present phase I/II study, the biweekly carboplatin (area under the curve, 2.5) plus gemcitabine (1100 mg/m2) combination in patients aged ≥ 70 years with advanced and metastatic squamous non–small-cell lung cancer achieved an overall response rate of 35.8%, a median progression-free survival of 6.7 months, and a median overall survival of 13.3 months, with favorable toxicity. Background The present study was a phase I/II study to determine the maximum tolerated doses (MTDs) and dose-limiting toxicities of the biweekly carboplatin/gemcitabine combination and evaluate its safety and efficacy in patients aged ≥ 70 years with advanced squamous non–small-cell lung cancer (NSCLC). Patients and Methods Patients aged ≥ 70 years with advanced or metastatic squamous NSCLC received escalated doses of carboplatin (area under the curve [AUC] 2-2.5 intravenously) and gemcitabine (800-1100 mg/m2 intravenously) every 2 weeks (phase I). In the phase II, the drugs were administered at their previously defined MTDs (carboplatin, AUC 2.5; gemcitabine, 1100 mg/m2). The primary endpoint was the overall response rate. Results A total of 69 patients were enrolled (phase I, n = 15). The median age was 76 years (range, 70-84 years); 52 patients had stage IV disease, and 61 and 8 patients had Eastern Cooperative Oncology Group performance status of 0 to 1 and 2, respectively. The MTDs could not be reached at the predefined last dose levels. The dose-limiting toxicities were grade 5 renal toxicity and grade 3 thrombocytopenia. In the phase II study, the overall response rate was 35.8% (95% confidence interval [CI], 23.0%-48.8%). In the intention-to-treat analysis, the median progression-free survival was 6.7 months (95% CI, 4.2-8.8 months), and the median overall survival was 13.3 months (95% CI, 7.1-19.6 months). Grade 3 or 4 neutropenia was observed in 7 patients (12.3%), grade 3 or 4 thrombocytopenia in 4 patients (7.1%), and grade 2 or 3 fatigue in 10 patients (17.5%). One toxic death occurred in the phase I of the study. Conclusion The biweekly regimen of gemcitabine and carboplatin showed satisfactory efficacy and a favorable toxicity profile in elderly patients with advanced or metastatic squamous cell NSCLC. © 2016 Elsevier Inc

A dose escalation study of biweekly oral vinorelbine and gemcitabine in patients with solid tumors.

To determine the maximum tolerated doses (MTDs) and the dose-limiting toxicities of a biweekly administration of oral vinorelbine and gemcitabine in patients with advanced solid tumors.info:eu-repo/semantics/publishe