Impact of comprehensive geriatric assessment on quality of life, overall survival, and unplanned admission in patients with non-small cell lung cancer treated with stereotactic body radiotherapy

doi:10.1016/j.jgo.2018.05.009

Journal of Geriatric Oncology

Volume 9, Issue 6, November 2018, Pages 575-582

https://doi.org/10.1016/j.jgo.2018.05.009 Get rights and content

Abstract

Objectives

Overall survival ﴾OS﴿ for patients with localized non-small cell lung cancer ﴾NSCLC﴿ treated with stereotactic body radiotherapy ﴾SBRT﴿ is poorer than for patients undergoing surgery. Patients who undergo SBRT are often ineligible for surgery due to significant comorbidities that can impact their mortality. A comprehensive geriatric assessment (CGA) that identifies and treats aging related comorbidities could improve OS and quality of life (QoL). This randomized study investigated if a CGA added to SBRT impacts QoL, survival, and unplanned admissions.

Materials and Methods

From January 2015 to June 2016, 51 patients diagnosed with T1-2N0M0 NSCLC treated with SBRT were enrolled. The patients were randomized 1:1 to receive SBRT +/− CGA. EuroQoL Group 5D (EQ-5D) health index and visual analogue scale (VAS) scores were assessed at start of SBRT, at five weeks, and every third month for a year after SBRT.

Results

There were 26 and 25 patients randomized to receive ± CGA, respectively. The repeated measures one-way analysis of variance (ANOVA) test of the EQ-5D health index and VAS scores did not show statistically significant differences between groups. For the EQ-5D VAS scores at twelve months follow-up there was a small difference between the groups although not statistically significant. Even though more patients deceased in the no-CGA group, no statistically significant difference in survival rates and unplanned admission rate was observed between groups.

Conclusion

In patients with localized NSCLC treated with SBRT, a CGA did not impact the overall QoL, the prevalence/length of unplanned admissions, or survival. There was an indication of small differences in QoL and survival in the data, but such differences can only be validated in larger studies.

Introduction

Lung cancer remains the leading cause of cancer-related death in Denmark [1]. Patients diagnosed with the disease in an early stage may be cured. The standard treatment for patients with localized non-small cell lung cancer (NSCLC) is lobectomy. For frail patients not fit for surgery the treatment of choice is stereotactic body radiotherapy (SBRT) [2,3].

In general, overall survival (OS) for patients treated with SBRT for localized NSCLC is poorer than patients undergoing lobectomy [4]. However, a propensity score matched study showed that OS and cancer-specific survival (CSS) were similar after SBRT and surgery [5]. The poor survival after SBRT compared to surgery is to a large extent explained by comorbidity [6]. However, a recent study by Klement et al. demonstrated that comorbidity could not predict the risk of early death during the first six months after SBRT and all patients with localized NSCLC should be offered SBRT irrespectively of their comorbid status [7]. However, comorbidity was still associated with OS and the authors suggested that a possible solution to prevent death in this group of patient could be a comprehensive geriatric assessment (CGA).

CGA used by geriatricians is a systematic evaluation of multimorbidity, physical and cognitive functions, nutritional status, polypharmacy, and need of social support with the aim of a multidimensional intervention if needed to improve the functional capacity, the quality of life (QoL), and the autonomy of the patient [8]. CGA used in geriatric patients has improved survival and decreased the need for unplanned admission [9]. The International Society of Geriatric Oncology recommends that a CGA be performed in older patients who are offered cancer treatment in order to optimize their condition [10]. However, the CGA has not yet been well investigated in clinical trials for frail patients with localized NSCLC.

QoL and unplanned admission are important endpoints in lung cancer studies in addition to traditional OS and CSS [11]. In the group of frail patients with NSCLC treated with SBRT, QoL may be particular important since comorbidity may influence QoL. In a cross-sectional study, health-related QoL in patients surviving NSCLC was high with a mean EuroQoL Group 5D (EQ-5D) health index score of 0.74 [12]. However, the study included patients who underwent different lung cancer treatments [12]. The SPACE (Stereotactic Precision and Conventional radiotherapy Evaluation) study demonstrated improved QoL and less toxicity for patients with localized NSCLC treated with SBRT compared with patients treated with conventional radiotherapy [13]. To our knowledge no studies have investigated if a CGA leads to a further improvement of QoL for this group of frail patients.

This randomized study investigated if CGA and interventions as needed can impact on QoL, OS, CSS and unplanned admissions for patients with localized NSCLC treated with SBRT.

Section snippets

Materials and Methods

This was a single institutional randomized pilot study in patients receiving SBRT for localized NSCLC. All patients were recruited at the Department of Oncology, Odense University Hospital (OUH), Denmark. The standard arm was SBRT without CGA and the experimental arm was SBRT with CGA. The study was approved by the Danish Data Protection Agency and by the local ethical committee with project ID S-20140187. The study has been carried out in accordance to The Code of Ethics of the World Medical

Results

In total, 51 patients were enrolled. As seen in the CONSORT (Consolidated Standards of Reporting Trials) diagram, 26 and 25 patients were randomized to the SBRT with CGA (CGA group) and SBRT without CGA (no-CGA group) groups, respectively (Fig. 1). Four patients in the CGA group did not receive the allocated CGA but participated in the planned follow-up program.

The median potential follow-up time was 22.4 months (13.7–30.7 months) for the CGA group and 23.4 months (14.0–31.0 months) for the

Discussion

To our knowledge, this is the first randomized study in which a CGA was performed in patients with localized NSCLC treated with SBRT. In summary, no statistical differences were observed for the EQ-5D health index or VAS scores between the CGA and no-CGA groups. There was a clinical reduction of EQ-5D VAS scores at twelve months follow-up in the no-CGA group which was not the case for the CGA group. Despite more patients in the no-CGA group dying within the first twelve months after SBRT there

Conflicts of Interest

None.

Author Contribution

All authors have made a significant contribution to this manuscript, have seen and approved the final manuscript, and agree to its submission to the Journal of Geriatric Oncology.

Acknowledgement

The study was made as part of AgeCare (Academy of Geriatric Cancer Research), an international research collaboration based at Odense University Hospital, Denmark.

The study was supported by a grant from the Danish Cancer Society, a grant for CIRRO (Danish Center for Interventional Research in Radiation Oncology), a grant from the Region of Southern Denmark, and a grant for Danish Cancer Research Fund.

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Effects of comprehensive geriatric assessment-guided interventions on physical performance and quality of life in older patients with advanced cancer: A randomized controlled trial (PROGNOSIS-RCT)
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Older patients with frailty starting oncological treatment are at higher risk of experiencing declining physical performance, loss of independence, and quality of life (QoL). This study examines whether comprehensive geriatric assessment (CGA)-guided interventions added to standard oncological care can prevent declining physical performance and QoL in older patients with frailty initiating palliative treatment.
Patients aged ≥70 years, with a Geriatric-8 score of ≤14, initiating palliative oncological treatment were enrolled in an open label randomized controlled trial and randomized 1:1 to receive either CGA-guided interventions in addition to oncological standard care or oncological care alone. Baseline characteristics, physical performance measures, and QoL questionnaires were retrieved before group allocation. CGA was performed using a fixed set of domains and validated tests by a geriatrician-led team. The primary endpoint, physical performance, was measured by the 30-s chair stand test (30s-CST) at three months. Additional outcomes included 30s-CST at six months, handgrip strength test, and QoL. Outcomes were analyzed using linear mixed regression models. The trial was registered at clinicaltrials.org (NCT04686851).
From November 1, 2020 to May 31, 2022, 181 patients were included; 88 in the interventional arm and 93 in the control arm. Median age was 77 (interquartile range [IQR] 73–81) years, 69% were male, median Geriatric-8 score was 12 (IQR 10–13), 69% had a Performance Status of 0–1, and the median 30s-CST was 9 (IQR 5–11) repetitions. The between-group difference in 30s-CST at three months was 0.67 (95%CI: −0.94 − 2.29) and 1.57 (95%CI: −0.20 − 3.34) at six months, which were not statistically significant. Subgroup analysis including participants with a baseline Geriatric-8 of 12–14 found borderline significant between-group differences in 30s-CST scores at three and six months of 2.04 (95% confidence interval [CI]: -0.07 − 4.2, P = 0.06) and 2.25 (95%CI: 0.01–4.5, P = 0.05), respectively. No within-group or between-group differences in the summary score or the Elderly Functional Index score (measuring QoL) were found.
This study did not find significant between-group differences in the 30s-CST in older patients receiving palliative care. However, a tendency towards improved physical performance was seen in the least frail. These patients may represent a target group wherein CGA interventions provide particular benefit.
Geriatric assessment and the variance of treatment recommendations in geriatric patients with gastrointestinal cancer—a study in AIO oncologists
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Geriatric assessment (GA) is recommended to detect vulnerabilities for elderly cancer patients. To assess whether results of GA actually influence the treatment recommendations, we conducted a case vignette-based study in medical oncologists.
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Data on 164 treatment recommendations were analyzed. The recommendations had a significantly higher variance for elderly patients than for ‘standard’ patients (944 versus 602, P < 0.0001) indicating a lower agreement between oncologists. Knowledge on GA had marginal influence on the treatment recommendation or its variance (944 versus 940, P = 0.92). There was no statistically significant influence of the working place or the years of experience in oncology on the variance of recommendations. The geriatric tools were rated approximately two times higher as being ‘meaningful’ (53%) and ‘useful for the presented cases’ (49%) than they were ‘used in clinical practice’ (19%). The most commonly used geriatric tool in patient care was the MNA (30%).
The higher variance of treatment recommendations indicates that it is less likely for elderly patients to get the optimal recommendation. Although the proposed therapeutic regimen varied higher in elderly patients and the oncologists rated the GA results as ‘useful’, the GA results did not influence the individual recommendations or its variance. Continuing education on GA and research on implementation into clinical practice are needed.
Quality of Life After Stereotactic Body Radiation Therapy or Surgery for Early-Stage NSCLC: A Systematic Review
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Studies with less than 50% criteria satisfied were scored as “low quality.” A total of 25 prospective studies met the inclusion criteria and were included in this study for analysis.6,13–36 Publication years ranged from 2003 to 2022.
Quality of life (QOL) is a key consideration for patients with early-stage NSCLC choosing between treatment options. Currently, it is not well established whether stereotactic body radiation therapy (SBRT) or surgery offers superior QOL in early-stage NSCLC. The objective of this systematic review is to summarize the prospective literature on QOL in patients with early-stage NSCLC after treatment with SBRT or surgery. A comprehensive literature review using PubMed and EMBASE was performed in April 2022. Prospective studies evaluating QOL data across multiple time points in patients with early-stage NSCLC after SBRT or surgery were included. A total of 25 studies involving 1597 SBRT patients and 1652 surgery patients met the inclusion criteria. Across most studies, QOL remained stable after treatment with SBRT. After surgery, QOL initially decreased; however, it often returned to baseline in the next 6 to 12 months. Utilization of video-assisted thoracoscopic surgery and sublobar resection reduced the magnitude of the initial decrease in QOL after surgery and led to faster recovery to baseline. Owing to the heterogeneity of patient populations between studies evaluating SBRT versus surgery, direct comparisons between the two treatments remain difficult to make. Clinicians should appropriately counsel patients with this information to help guide patient-centered discussions on choosing the optimal treatment modality.
International efforts in geriatric radiation oncology
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There is also a need for regular re-evaluation of GA domains during radiation therapy, as the toxicity of treatment can result in multidimensional declines, necessitating supportive care and appropriate interventions [6], particularly for certain treatment sites that are known to add appreciable toxicity e.g. concurrent chemoradiation for head and neck cancer. There is a known notable lack of literature in geriatric radiation oncology, with few published studies to date investigating the role of GA in radiation therapy [9,28]. A total of twelve non-randomized studies were included in a 2018 systematic review by Szumacher et al.
Geriatric assessment (GA) has been recommended to form part of treatment decision making for older adults with cancer. However despite consensus guidelines from various organizations, GA does not appear to be a part of routine practice in radiation oncology. The aim of the current study was to explore the implementation of GA in radiation oncology.
This anonymous international survey investigated current use of GA in patients presenting for radiation therapy aged 65 years and over, in accordance with Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines. The survey was designed, using Qualitrics™, an online survey tool. It was distributed via SIOG, social media and radiation oncology professional organizations. Survey responses were analyzed using simple descriptive statistics. An additional analysis by creating a dichotomous variable based on awareness of major clinical practice guidelines and current use of GA.
Among 158 respondents, there was relatively low awareness of GA guidelines and low uptake of validated tools and processes. A minority of participants, only 16%, stated that they had a specialized geriatric oncology program in their institution. Approximately a third (34%) of respondents were unaware of any GA clinical practice guidelines. With regard to what way participants assess older patients differently to younger patients, 16% reported formally using specific validated tools, whereas 73% reported an informal assessment based on their own judgment, with 5% reporting no difference between younger and older patients. Regarding the use of validated screening tools for geriatric impairments, over half reported using none (57%). Regarding GA implementation, the main barriers highlighted included a lack of clinical/support staff, a lack of training, knowledge, understanding or experience about GA and a lack of time.
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Traitements par radiothérapie stéréotaxique: indications et situations cliniques particulières
2021, Revue des Maladies Respiratoires Actualites
La lobectomie avec curage ganglionnaire reste le traitement de référence pour les cancers pulmonaires primitifs non à petites cellules (NSCLC) T1-T2 N0 mais la radiothérapie stéréotaxique (RTS) a été validée depuis quelques années comme une alternative de traitement par les autorités de santé pour les patients non opérables. Le choix de la dose et du fractionnement de la radiothérapie doit tenir compte de la situation clinique du patient, de la taille et de la localisation de la tumeur traitée. Au délà des indications de RTS bien validées par les sociétés savantes le traitement des lésions en verre dépoli ne fait pas l’objet d’un haut niveau de preuve dans la littérature mais est néanmoins régulièrement proposée pour les patients inopérables. En ce qui concerne les traitements de rattrapage après radiothérapie stéréotaxique, la réirradiation offre de nouvelles perspectives avec des résultats encourageants pour les récidives locales. Mais la majorité des récidives sont régionales ou à distance et un traitement systémique adjuvant par immunothérapie est particulièrement intéressant dans cette population fragile ne pouvant pas recevoir de chimiothérapie la plupart du temps.. Enfin le recours à un traitement par radiothérapie stéréotaxique reste primordial chez les patients octogénaires ou nonagénaires car l’évolution spontanée des NSCLC sans traitement reste très péjorative. Malgré leurs fragilités gériatriques, leurs comorbidités et la quantité de vie restante, la majorité des patients vont mourir de leur cancer pulmonaire.
© 2021 SPLF. Publié par Elsevier Masson SAS. Tous droits réservés.
Lobectomy with radical lymph node dissection remains the gold standard treatment for stage I primary non-small cell lung cancer (NSCLC) but in recent years, stereotaxic radiotherapy (SBRT) have gradually taken their place in this indication. The choice of doses and fractionation and the stereotactic radiotherapy technique should be considered taking into account the patient’s clinical situation and the tumour to be treated (size and topography.)
Some specials clinical setting as the treatment of ground glass opacity remain questionable without a lot of evidence in scientifics publications but offer a real alternative of treatment for inoperables patients. In regards to catch-up treatments, reirradiations offer new perspectives in case of local failure after stereotactic radiotherapy with promising results. But the majority of relapses are regional or metastatic and systemic treatment especially adjuvant immunotherapy is a very interesting treatment option for this frail patients, not enough fit to receive chemotherapy.
The spontaneous evolution of NSCLC lung tumors without treatment remain very negative; The use of local non-surgical treatments as SBRT is an major option for the care of elderly patients who are not eligible for surgery. Despite their comorbidities, frailty and their poor remaining survival the majority of this patients will die of their lung cancer.
© 2021 SPLF. Published by Elsevier Masson SAS. All rights reserved.

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¹: On behalf of the Academy of Geriatric Cancer Research ﴾AgeCare﴿, Sdr. Boulevard 29, 5000 Odense C, Denmark.

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Impact of comprehensive geriatric assessment on quality of life, overall survival, and unplanned admission in patients with non-small cell lung cancer treated with stereotactic body radiotherapy

Abstract

Objectives

Materials and Methods

Results

Conclusion

Introduction

Section snippets

Materials and Methods

Results

Discussion

Conflicts of Interest

Author Contribution

Acknowledgement

J Thorac Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

J Thorac Oncol

Ann Oncol

J Chronic Dis

Ann Oncol

Ann Epidemiol

Am J Med

Radiother Oncol

Int J Radiat Oncol Biol Phys

Radiother Oncol

J Thorac Oncol

Int J Radiat Oncol Biol Phys

NORDCAN—a Nordic tool for cancer information, planning, quality control and research

Acta Oncol

Stereotactic radiotherapy for early stage non-small cell lung cancer

Radiat Oncol J

Stereotactic body radiotherapy or stereotactic ablative radiotherapy versus surgery for patients with T1-3N0M0 non-small cell lung cancer: a systematic review and meta-analysis

Oncol Targets Ther

Impacts of geriatric evaluation and management programs on defined outcomes: overview of the evidence

J Am Geriatr Soc

Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials

BMJ

International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer

J Clin Oncol