今日の臨床サポート

高齢者のがん治療

著者: 水谷友紀 杏林大学医学部 総合医療学/腫瘍内科学

監修: 高野利実 がん研有明病院 乳腺内科

著者校正/監修レビュー済:2021/06/09
参考ガイドライン:
  1. NCCN GUIDELINES FOR SPECIFIC POPULATIONS:Older Adult Oncology
  1. Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy:ASCO Guideline for Geriatric Oncology
  1. ESMO HANDBOOK OF CANCER IN THE SENIOR PATIENT
  1. 日本臨床腫瘍学会日本癌治療学会高齢者のがん薬物療法ガイドライン

概要・推奨   

  1. 高齢がん患者の診療を行う際には、「がん」という疾患だけでなく、「高齢者」という個体も一緒に診療する必要がある
  1. 生理的予備能の低下や併存症の有無などには個人差が大きく、これらを暦年齢のみで予測することは困難であるため、高齢者総合的機能評価(Comprehensive Geriatric AssessmentCGA)を用いて身体的、精神的、社会的な機能を多角的に評価したうえで診療方針を決めることを推奨するまた、CGAで同定された脆弱性に対して、具体的な介入を行うことが望ましい
  1. 高齢がん患者の価値観を踏まえたうえで、生存期間の延長以外にも自立生活や認知機能の維持なども考慮することが求められる
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
水谷友紀 : 未申告[2021年]
監修:高野利実 : 講演料(第一三共,日本イーライリリー,中外製薬,エーザイ,セルトリオン・ヘルスケア・ジャパン),研究費・助成金など(中外製薬,小野薬品工業,MSD,第一三共,エーザイ)[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 「令和元年版高齢社会白書」によれば、令和元年における65歳以上の高齢者人口は3,558万人であり、総人口に占める割合(高齢化率)は28.1%となった[1]。人口の高齢化は世界的規模で進んでおり、2040年までに世界の平均寿命は80歳に至ると予想されている[2]。がんは加齢に関係する疾患であるため、人口の高齢化に伴って、がんを罹患した高齢者(以下、高齢がん患者)の割合は増加し、2030年までに、がん患者の約70%が65歳以上の高齢者になると見込まれている[3]
  1. 先進国における退職年齢が60~65歳であることを根拠に、WHOは先進国における高齢者を60~65歳以上と定義している[4]。わが国では、「高齢者の医療の確保に関する法律」で65歳以上を高齢者と定義している一方で、「高齢者の居住の安定確保に関する法律」では60歳以上が法の対象であり、また、「道路交通法」では加齢による身体機能の低下を自覚させる目的の講習の対象を70歳以上としているなど、高齢者の定まった定義(下限年齢)はない。
  1. 日本老年学会・日本老年医学会は「高齢者に関する定義検討ワーキンググループからの提言」において、65~74歳の前期高齢者では心身の健康が保たれているというデータを根拠として、75歳以上を高齢者とすることを提唱している[5]
  1. 医療の提供の対象とする場合には、さまざまな違い・バラツキを有する個人に対して「医学的・社会的」な観点から高齢者を定義する必要があるため、「暦年齢」以外の因子も含めて高齢者を定義する必要がある。
  1. 高齢者は、加齢による予備能・臓器機能の低下、複数の併存疾患を持っていること、それに伴い常用薬剤数が増え相互作用や薬物有害反応が起こりやすいこと、せん妄・転倒・尿失禁などの高齢者特有の症状(老年症候群)が生じ得ること、介護者の有無により栄養状態や服薬状況が異なり得ること、就労していない場合は経済状況が悪いこと、がん以外の要因で死亡するケースが多いなどの点で非高齢者と診療方針が異なる[6]
高齢者機能評価  
  1. 高齢者総合的機能評価(comprehensive geriatric assessment:CGA)は、患者が有する身体的・精神的・社会的な機能を多角的に評価し、脆弱な点が見つかれば、それに対するサポートを行う診療手法である[7][8]。具体的な評価項目(ドメイン)としては、生活機能、併存症、薬剤、栄養、認知機能、気分、社会支援、老年症候群(転倒、せん妄、失禁、骨粗鬆症など)である。老年医学領域では日常的に行われている。
 
 
  1. がん領域ではCGAに慣れている医療者が少ないため、まずは評価だけでも実施してみる、というのが世界的な流れであった(注:がん領域では、CGAから「総合的」が抜け、高齢者機能評価(Geriatric assessment:GA)と表記されることが多い)。さまざまな研究の結果、CGAは、1)重篤な有害事象を予測する因子になり得る、2)生命予後を予測する因子になり得る、3)通常の診療では気づかない障害を明らかにする、4)治療方針を決定する際の参考情報となる、ことが示された。この結果、国内外のガイドラインでは、高齢がん患者に対してCGAを実施することが推奨されている。

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文献 

著者: Kyle J Foreman, Neal Marquez, Andrew Dolgert, Kai Fukutaki, Nancy Fullman, Madeline McGaughey, Martin A Pletcher, Amanda E Smith, Kendrick Tang, Chun-Wei Yuan, Jonathan C Brown, Joseph Friedman, Jiawei He, Kyle R Heuton, Mollie Holmberg, Disha J Patel, Patrick Reidy, Austin Carter, Kelly Cercy, Abigail Chapin, Dirk Douwes-Schultz, Tahvi Frank, Falko Goettsch, Patrick Y Liu, Vishnu Nandakumar, Marissa B Reitsma, Vince Reuter, Nafis Sadat, Reed J D Sorensen, Vinay Srinivasan, Rachel L Updike, Hunter York, Alan D Lopez, Rafael Lozano, Stephen S Lim, Ali H Mokdad, Stein Emil Vollset, Christopher J L Murray
雑誌名: Lancet. 2018 Nov 10;392(10159):2052-2090. doi: 10.1016/S0140-6736(18)31694-5. Epub 2018 Oct 16.
Abstract/Text BACKGROUND: Understanding potential trajectories in health and drivers of health is crucial to guiding long-term investments and policy implementation. Past work on forecasting has provided an incomplete landscape of future health scenarios, highlighting a need for a more robust modelling platform from which policy options and potential health trajectories can be assessed. This study provides a novel approach to modelling life expectancy, all-cause mortality and cause of death forecasts -and alternative future scenarios-for 250 causes of death from 2016 to 2040 in 195 countries and territories.
METHODS: We modelled 250 causes and cause groups organised by the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) hierarchical cause structure, using GBD 2016 estimates from 1990-2016, to generate predictions for 2017-40. Our modelling framework used data from the GBD 2016 study to systematically account for the relationships between risk factors and health outcomes for 79 independent drivers of health. We developed a three-component model of cause-specific mortality: a component due to changes in risk factors and select interventions; the underlying mortality rate for each cause that is a function of income per capita, educational attainment, and total fertility rate under 25 years and time; and an autoregressive integrated moving average model for unexplained changes correlated with time. We assessed the performance by fitting models with data from 1990-2006 and using these to forecast for 2007-16. Our final model used for generating forecasts and alternative scenarios was fitted to data from 1990-2016. We used this model for 195 countries and territories to generate a reference scenario or forecast through 2040 for each measure by location. Additionally, we generated better health and worse health scenarios based on the 85th and 15th percentiles, respectively, of annualised rates of change across location-years for all the GBD risk factors, income per person, educational attainment, select intervention coverage, and total fertility rate under 25 years in the past. We used the model to generate all-cause age-sex specific mortality, life expectancy, and years of life lost (YLLs) for 250 causes. Scenarios for fertility were also generated and used in a cohort component model to generate population scenarios. For each reference forecast, better health, and worse health scenarios, we generated estimates of mortality and YLLs attributable to each risk factor in the future.
FINDINGS: Globally, most independent drivers of health were forecast to improve by 2040, but 36 were forecast to worsen. As shown by the better health scenarios, greater progress might be possible, yet for some drivers such as high body-mass index (BMI), their toll will rise in the absence of intervention. We forecasted global life expectancy to increase by 4·4 years (95% UI 2·2 to 6·4) for men and 4·4 years (2·1 to 6·4) for women by 2040, but based on better and worse health scenarios, trajectories could range from a gain of 7·8 years (5·9 to 9·8) to a non-significant loss of 0·4 years (-2·8 to 2·2) for men, and an increase of 7·2 years (5·3 to 9·1) to essentially no change (0·1 years [-2·7 to 2·5]) for women. In 2040, Japan, Singapore, Spain, and Switzerland had a forecasted life expectancy exceeding 85 years for both sexes, and 59 countries including China were projected to surpass a life expectancy of 80 years by 2040. At the same time, Central African Republic, Lesotho, Somalia, and Zimbabwe had projected life expectancies below 65 years in 2040, indicating global disparities in survival are likely to persist if current trends hold. Forecasted YLLs showed a rising toll from several non-communicable diseases (NCDs), partly driven by population growth and ageing. Differences between the reference forecast and alternative scenarios were most striking for HIV/AIDS, for which a potential increase of 120·2% (95% UI 67·2-190·3) in YLLs (nearly 118 million) was projected globally from 2016-40 under the worse health scenario. Compared with 2016, NCDs were forecast to account for a greater proportion of YLLs in all GBD regions by 2040 (67·3% of YLLs [95% UI 61·9-72·3] globally); nonetheless, in many lower-income countries, communicable, maternal, neonatal, and nutritional (CMNN) diseases still accounted for a large share of YLLs in 2040 (eg, 53·5% of YLLs [95% UI 48·3-58·5] in Sub-Saharan Africa). There were large gaps for many health risks between the reference forecast and better health scenario for attributable YLLs. In most countries, metabolic risks amenable to health care (eg, high blood pressure and high plasma fasting glucose) and risks best targeted by population-level or intersectoral interventions (eg, tobacco, high BMI, and ambient particulate matter pollution) had some of the largest differences between reference and better health scenarios. The main exception was sub-Saharan Africa, where many risks associated with poverty and lower levels of development (eg, unsafe water and sanitation, household air pollution, and child malnutrition) were projected to still account for substantive disparities between reference and better health scenarios in 2040.
INTERPRETATION: With the present study, we provide a robust, flexible forecasting platform from which reference forecasts and alternative health scenarios can be explored in relation to a wide range of independent drivers of health. Our reference forecast points to overall improvements through 2040 in most countries, yet the range found across better and worse health scenarios renders a precarious vision of the future-a world with accelerating progress from technical innovation but with the potential for worsening health outcomes in the absence of deliberate policy action. For some causes of YLLs, large differences between the reference forecast and alternative scenarios reflect the opportunity to accelerate gains if countries move their trajectories toward better health scenarios-or alarming challenges if countries fall behind their reference forecasts. Generally, decision makers should plan for the likely continued shift toward NCDs and target resources toward the modifiable risks that drive substantial premature mortality. If such modifiable risks are prioritised today, there is opportunity to reduce avoidable mortality in the future. However, CMNN causes and related risks will remain the predominant health priority among lower-income countries. Based on our 2040 worse health scenario, there is a real risk of HIV mortality rebounding if countries lose momentum against the HIV epidemic, jeopardising decades of progress against the disease. Continued technical innovation and increased health spending, including development assistance for health targeted to the world's poorest people, are likely to remain vital components to charting a future where all populations can live full, healthy lives.
FUNDING: Bill & Melinda Gates Foundation.

Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.
PMID 30340847  Lancet. 2018 Nov 10;392(10159):2052-2090. doi: 10.1016/・・・
著者: Benjamin D Smith, Grace L Smith, Arti Hurria, Gabriel N Hortobagyi, Thomas A Buchholz
雑誌名: J Clin Oncol. 2009 Jun 10;27(17):2758-65. doi: 10.1200/JCO.2008.20.8983. Epub 2009 Apr 29.
Abstract/Text PURPOSE: By 2030, the United States' population will increase to approximately 365 million, including 72 million older adults (age > or = 65 years) and 157 million minority individuals. Although cancer incidence varies by age and race, the impact of demographic changes on cancer incidence has not been fully characterized. We sought to estimate the number of cancer patients diagnosed in the United States through 2030 by age and race.
METHODS: Current demographic-specific cancer incidence rates were calculated using the Surveillance Epidemiology and End Results database. Population projections from the Census Bureau were used to project future cancer incidence through 2030.
RESULTS: From 2010 to 2030, the total projected cancer incidence will increase by approximately 45%, from 1.6 million in 2010 to 2.3 million in 2030. This increase is driven by cancer diagnosed in older adults and minorities. A 67% increase in cancer incidence is anticipated for older adults, compared with an 11% increase for younger adults. A 99% increase is anticipated for minorities, compared with a 31% increase for whites. From 2010 to 2030, the percentage of all cancers diagnosed in older adults will increase from 61% to 70%, and the percentage of all cancers diagnosed in minorities will increase from 21% to 28%.
CONCLUSION: Demographic changes in the United States will result in a marked increase in the number of cancer diagnoses over the next 20 years. Continued efforts are needed to improve cancer care for older adults and minorities.

PMID 19403886  J Clin Oncol. 2009 Jun 10;27(17):2758-65. doi: 10.1200/・・・
著者: Hans Wildiers, Pieter Heeren, Martine Puts, Eva Topinkova, Maryska L G Janssen-Heijnen, Martine Extermann, Claire Falandry, Andrew Artz, Etienne Brain, Giuseppe Colloca, Johan Flamaing, Theodora Karnakis, Cindy Kenis, Riccardo A Audisio, Supriya Mohile, Lazzaro Repetto, Barbara Van Leeuwen, Koen Milisen, Arti Hurria
雑誌名: J Clin Oncol. 2014 Aug 20;32(24):2595-603. doi: 10.1200/JCO.2013.54.8347.
Abstract/Text PURPOSE: To update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on geriatric assessment (GA) in older patients with cancer.
METHODS: SIOG composed a panel with expertise in geriatric oncology to develop consensus statements after literature review of key evidence on the following topics: rationale for performing GA; findings from a GA performed in geriatric oncology patients; ability of GA to predict oncology treatment–related complications; association between GA findings and overall survival (OS); impact of GA findings on oncology treatment decisions; composition of a GA, including domains and tools; and methods for implementing GA in clinical care.
RESULTS: GA can be valuable in oncology practice for following reasons: detection of impairment not identified in routine history or physical examination, ability to predict severe treatment-related toxicity, ability to predict OS in a variety of tumors and treatment settings, and ability to influence treatment choice and intensity. The panel recommended that the following domains be evaluated in a GA: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and presence of geriatric syndromes. Although several combinations of tools and various models are available for implementation of GA in oncology practice, the expert panel could not endorse one over another.
CONCLUSION: There is mounting data regarding the utility of GA in oncology practice; however, additional research is needed to continue to strengthen the evidence base.

PMID 25071125  J Clin Oncol. 2014 Aug 20;32(24):2595-603. doi: 10.1200・・・
著者: Martine Extermann, Etienne Brain, Beverly Canin, Meena Nathan Cherian, Kwok-Leung Cheung, Nienke de Glas, Beena Devi, Marije Hamaker, Ravindran Kanesvaran, Theodora Karnakis, Cindy Kenis, Najia Musolino, Anita O'Donovan, Enrique Soto-Perez-de-Celis, Christopher Steer, Hans Wildiers, International Society of Geriatric Oncology
雑誌名: Lancet Oncol. 2021 Jan;22(1):e29-e36. doi: 10.1016/S1470-2045(20)30473-3.
Abstract/Text In 2011, the International Society of Geriatric Oncology (SIOG) published the SIOG 10 Priorities Initiative, which defined top priorities for the improvement of the care of older adults with cancer worldwide.1 Substantial scientific, clinical, and educational progress has been made in line with these priorities and international health policy developments have occurred, such as the shift of emphasis by WHO from communicable to non-communicable diseases and the adoption by the UN of its Sustainable Development Goals 2030. Therefore, SIOG has updated its priority list. The present document addresses four priority domains: education, clinical practice, research, and strengthening collaborations and partnerships. In this Policy Review, we reflect on how these priorities would apply in different economic settings, namely in high-income countries versus low-income and middle-income countries. SIOG hopes that it will offer guidance for international and national endeavours to provide adequate universal health coverage for older adults with cancer, who represent a major and rapidly growing group in global epidemiology.

Copyright © 2021 Elsevier Ltd. All rights reserved.
PMID 33387502  Lancet Oncol. 2021 Jan;22(1):e29-e36. doi: 10.1016/S147・・・
著者: L Decoster, K Van Puyvelde, S Mohile, U Wedding, U Basso, G Colloca, S Rostoft, J Overcash, H Wildiers, C Steer, G Kimmick, R Kanesvaran, A Luciani, C Terret, A Hurria, C Kenis, R Audisio, M Extermann
雑誌名: Ann Oncol. 2015 Feb;26(2):288-300. doi: 10.1093/annonc/mdu210. Epub 2014 Jun 16.
Abstract/Text BACKGROUND: Screening tools are proposed to identify those older cancer patients in need of geriatric assessment (GA) and multidisciplinary approach. We aimed to update the International Society of Geriatric Oncology (SIOG) 2005 recommendations on the use of screening tools.
MATERIALS AND METHODS: SIOG composed a task group to review, interpret and discuss evidence on the use of screening tools in older cancer patients. A systematic review was carried out and discussed by an expert panel, leading to a consensus statement on their use.
RESULTS: Forty-four studies reporting on the use of 17 different screening tools in older cancer patients were identified. The tools most studied in older cancer patients are G8, Flemish version of the Triage Risk Screening Tool (fTRST) and Vulnerable Elders Survey-13 (VES-13). Across all studies, the highest sensitivity was observed for: G8, fTRST, Oncogeriatric screen, Study of Osteoporotic Fractures, Eastern Cooperative Oncology Group-Performance Status, Senior Adult Oncology Program (SAOP) 2 screening and Gerhematolim. In 11 direct comparisons for detecting problems on a full GA, the G8 was more or equally sensitive than other instruments in all six comparisons, whereas results were mixed for the VES-13 in seven comparisons. In addition, different tools have demonstrated associations with outcome measures, including G8 and VES-13.
CONCLUSIONS: Screening tools do not replace GA but are recommended in a busy practice in order to identify those patients in need of full GA. If abnormal, screening should be followed by GA and guided multidisciplinary interventions. Several tools are available with different performance for various parameters (including sensitivity for addressing the need for further GA). Further research should focus on the ability of screening tools to build clinical pathways and to predict different outcome parameters.

© The Author 2014. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: journals.permissions@oup.com.
PMID 24936581  Ann Oncol. 2015 Feb;26(2):288-300. doi: 10.1093/annonc/・・・
著者: C Kenis, D Bron, Y Libert, L Decoster, K Van Puyvelde, P Scalliet, P Cornette, T Pepersack, S Luce, C Langenaeken, M Rasschaert, S Allepaerts, R Van Rijswijk, K Milisen, J Flamaing, J-P Lobelle, H Wildiers
雑誌名: Ann Oncol. 2013 May;24(5):1306-12. doi: 10.1093/annonc/mds619. Epub 2013 Jan 4.
Abstract/Text BACKGROUND: To evaluate the large-scale feasibility and usefulness of geriatric screening and assessment in clinical oncology practice by assessing the impact on the detection of unknown geriatric problems, geriatric interventions and treatment decisions.
PATIENTS AND METHODS: Eligible patients who had a malignant tumour were ≥70 years old and treatment decision had to be made. Patients were screened using G8; if abnormal (score ≤14/17) followed by Comprehensive Geriatric Assessment (CGA). The assessment results were communicated to the treating physician using a predefined questionnaire to assess the topics mentioned above.
RESULTS: One thousand nine hundred and sixty-seven patients were included in 10 hospitals. Of these patients, 70.7% had an abnormal G8 score warranting a CGA. Physicians were aware of the assessment results at the time of treatment decision in two-thirds of the patients (n = 1115; 61.3%). The assessment detected unknown geriatric problems in 51.2% of patients. When the physician was aware of the assessment results at the time of decision making, geriatric interventions were planned in 286 patients (25.7%) and the treatment decision was influenced in 282 patients (25.3%).
CONCLUSION: Geriatric screening and assessment in older patients with cancer is feasible at large scale and has a significant impact on the detection of unknown geriatric problems, leading to geriatric interventions and adapted treatment.

PMID 23293115  Ann Oncol. 2013 May;24(5):1306-12. doi: 10.1093/annonc/・・・
著者: Supriya Gupta Mohile, Carla Velarde, Arti Hurria, Allison Magnuson, Lisa Lowenstein, Chintan Pandya, Anita O'Donovan, Rita Gorawara-Bhat, William Dale
雑誌名: J Natl Compr Canc Netw. 2015 Sep;13(9):1120-30. doi: 10.6004/jnccn.2015.0137.
Abstract/Text BACKGROUND: Structured care processes that provide a framework for how oncologists can incorporate geriatric assessment (GA) into clinical practice could improve outcomes for vulnerable older adults with cancer, a growing population at high risk of toxicity from cancer treatment. We sought to obtain consensus from an expert panel on the use of GA in clinical practice and to develop algorithms of GA-guided care processes.
METHODS: The Delphi technique, a well-recognized structured and reiterative process to reach consensus, was used. Participants were geriatric oncology experts who attended NIH-funded U13 or Cancer and Aging Research Group conferences. Consensus was defined as an interquartile range of 2 or more units, or 66.7% or greater, selecting a utility/helpfulness rating of 7 or greater on a 10-point Likert scale. For nominal data, consensus was defined as agreement among 66.7% or more of the group.
RESULTS: From 33 invited, 30 participants completed all 3 rounds. Most experts (75%) used GA in clinical care, and the remainder were involved in geriatric oncology research. The panel met consensus that "all patients aged 75 years or older and those who are younger with age-related health concerns" should undergo GA and that all domains (function, physical performance, comorbidity/polypharmacy, cognition, nutrition, psychological status, and social support) should be included. Consensus was met for how GA could guide nononcologic interventions and cancer treatment decisions. Algorithms for GA-guided care processes were developed.
CONCLUSIONS: This Delphi investigation of geriatric oncology experts demonstrated that GA should be performed for older patients with cancer to guide care processes.

Copyright © 2015 by the National Comprehensive Cancer Network.
PMID 26358796  J Natl Compr Canc Netw. 2015 Sep;13(9):1120-30. doi: 10・・・
著者: Supriya G Mohile, William Dale, Mark R Somerfield, Mara A Schonberg, Cynthia M Boyd, Peggy S Burhenn, Beverly Canin, Harvey Jay Cohen, Holly M Holmes, Judith O Hopkins, Michelle C Janelsins, Alok A Khorana, Heidi D Klepin, Stuart M Lichtman, Karen M Mustian, William P Tew, Arti Hurria
雑誌名: J Clin Oncol. 2018 Aug 1;36(22):2326-2347. doi: 10.1200/JCO.2018.78.8687. Epub 2018 May 21.
Abstract/Text Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .

PMID 29782209  J Clin Oncol. 2018 Aug 1;36(22):2326-2347. doi: 10.1200・・・
著者: Christine M Walko, Howard L McLeod
雑誌名: J Clin Oncol. 2014 Aug 20;32(24):2581-6. doi: 10.1200/JCO.2014.55.9047.
Abstract/Text Minimizing toxicity while maximizing efficacy is a common goal in the treatment of any condition but its importance is underscored in the discipline of oncology because of the serious nature of many chemotherapeutic toxicities and the risk of cancer recurrence or disease progression. The challenge of achieving an optimal therapeutic index is especially augmented in the elderly population because of age-related metabolism changes and interacting concurrent medications. Additional factors, such as germline mutations in drug-metabolizing enzymes and other pharmacogenomic alterations, may have more pronounced effects in elderly patients, given their predisposition to altered pharmacokinetics and pharmacodynamics with resulting increased risk of toxicity. Examples of the possible interplay of these factors will be discussed using tamoxifen, paclitaxel, codeine, and fluorouracil as starting points. Limited participation of the elderly in many cancer trials, especially trials assessing drug exposure, makes much knowledge on the interaction of these patient and environmental factors speculative in nature but presents an opportunity for future research to achieve better optimization of chemotherapeutic agents in the elderly.

PMID 25071134  J Clin Oncol. 2014 Aug 20;32(24):2581-6. doi: 10.1200/J・・・
著者: Laura L Sessums, Hanna Zembrzuska, Jeffrey L Jackson
雑誌名: JAMA. 2011 Jul 27;306(4):420-7. doi: 10.1001/jama.2011.1023.
Abstract/Text CONTEXT: Evaluation of the capacity of a patient to make medical decisions should occur in the context of specific medical decisions when incapacity is considered.
OBJECTIVE: To determine the prevalence of incapacity and assessment accuracy in adult medicine patients without severe mental illnesses.
DATA SOURCES: MEDLINE and EMBASE (from their inception through April 2011) and bibliographies of retrieved articles.
STUDY SELECTION: We included high-quality prospective studies (n = 43) of instruments that evaluated medical decision-making capacity for treatment decisions.
DATA EXTRACTION: Two authors independently appraised study quality, extracted relevant data, and resolved disagreements by consensus.
DATA SYNTHESIS: Incapacity was uncommon in healthy elderly control participants (2.8%; 95% confidence interval [CI], 1.7%-3.9%) compared with medicine inpatients (26%; 95% CI, 18%-35%). Clinicians accurately diagnosed incapacity (positive likelihood ratio [LR+] of 7.9; 95% CI, 2.7-13), although they recognized it in only 42% (95% CI, 30%-53%) of affected patients. Although not designed to assess incapacity, Mini-Mental State Examination (MMSE) scores less than 20 increased the likelihood of incapacity (LR, 6.3; 95% CI, 3.7-11), scores of 20 to 24 had no effect (LR, 0.87; 95% CI, 0.53-1.2), and scores greater than 24 significantly lowered the likelihood of incapacity (LR, 0.14; 95% CI, 0.06-0.34). Of 9 instruments compared with a gold standard, only 3 are easily performed and have useful test characteristics: the Aid to Capacity Evaluation (ACE) (LR+, 8.5; 95% CI, 3.9-19; negative LR [LR-], 0.21; 95% CI, 0.11-0.41), the Hopkins Competency Assessment Test (LR+, 54; 95% CI, 3.5-846; LR-, 0; 95% CI, 0.0-0.52), and the Understanding Treatment Disclosure (LR+, 6.0; 95% CI, 2.1-17; LR-, 0.16; 95% CI, 0.06-0.41). The ACE was validated in the largest study; it is freely available online and includes a training module.
CONCLUSIONS: Incapacity is common and often not recognized. The MMSE is useful only at extreme scores. The ACE is the best available instrument to assist physicians in making assessments of medical decision-making capacity.

PMID 21791691  JAMA. 2011 Jul 27;306(4):420-7. doi: 10.1001/jama.2011.・・・
著者: Terri R Fried, Elizabeth H Bradley, Virginia R Towle, Heather Allore
雑誌名: N Engl J Med. 2002 Apr 4;346(14):1061-6. doi: 10.1056/NEJMsa012528.
Abstract/Text BACKGROUND: The questions patients are asked about their preferences with regard to life-sustaining treatment usually focus on specific interventions, but the outcomes of treatment and their likelihood affect patients' preferences.
METHODS: We administered a questionnaire about treatment preferences to 226 persons who were 60 years of age or older and who had a limited life expectancy due to cancer, congestive heart failure, or chronic obstructive pulmonary disease. The study participants were asked whether they would want to receive a given treatment, first when the outcome was known with certainty and then with different likelihoods of an adverse outcome. The outcome without treatment was specified as death from the underlying disease.
RESULTS: The burden of treatment (i.e., the length of the hospital stay, extent of testing, and invasiveness of interventions), the outcome, and the likelihood of the outcome all influenced treatment preferences. For a low-burden treatment with the restoration of current health, 98.7 percent of participants said they would choose to receive the treatment (rather than not receive it and die), but 11.2 percent of these participants would not choose the treatment if it had a high burden. If the outcome was survival but with severe functional impairment or cognitive impairment, 74.4 percent and 88.8 percent of these participants, respectively, would not choose treatment. The number of participants who said they would choose treatment declined as the likelihood of an adverse outcome increased, with fewer participants choosing treatment when the possible outcome was functional or cognitive impairment than when it was death. Preferences did not differ according to the primary diagnosis.
CONCLUSIONS: Advance care planning should take into account patients' attitudes toward the burden of treatment, the possible outcomes, and their likelihood. The likelihood of adverse functional and cognitive outcomes of treatment requires explicit consideration.

PMID 11932474  N Engl J Med. 2002 Apr 4;346(14):1061-6. doi: 10.1056/N・・・
著者: Arti Hurria, Kayo Togawa, Supriya G Mohile, Cynthia Owusu, Heidi D Klepin, Cary P Gross, Stuart M Lichtman, Ajeet Gajra, Smita Bhatia, Vani Katheria, Shira Klapper, Kurt Hansen, Rupal Ramani, Mark Lachs, F Lennie Wong, William P Tew
雑誌名: J Clin Oncol. 2011 Sep 1;29(25):3457-65. doi: 10.1200/JCO.2011.34.7625. Epub 2011 Aug 1.
Abstract/Text PURPOSE: Older adults are vulnerable to chemotherapy toxicity; however, there are limited data to identify those at risk. The goals of this study are to identify risk factors for chemotherapy toxicity in older adults and develop a risk stratification schema for chemotherapy toxicity.
PATIENTS AND METHODS: Patients age ≥ 65 years with cancer from seven institutions completed a prechemotherapy assessment that captured sociodemographics, tumor/treatment variables, laboratory test results, and geriatric assessment variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status). Patients were followed through the chemotherapy course to capture grade 3 (severe), grade 4 (life-threatening or disabling), and grade 5 (death) as defined by the National Cancer Institute Common Terminology Criteria for Adverse Events.
RESULTS: In total, 500 patients with a mean age of 73 years (range, 65 to 91 years) with stage I to IV lung (29%), GI (27%), gynecologic (17%), breast (11%), genitourinary (10%), or other (6%) cancer joined this prospective study. Grade 3 to 5 toxicity occurred in 53% of the patients (39% grade 3, 12% grade 4, 2% grade 5). A predictive model for grade 3 to 5 toxicity was developed that consisted of geriatric assessment variables, laboratory test values, and patient, tumor, and treatment characteristics. A scoring system in which the median risk score was 7 (range, 0 to 19) and risk stratification schema (risk score: percent incidence of grade 3 to 5 toxicity) identified older adults at low (0 to 5 points; 30%), intermediate (6 to 9 points; 52%), or high risk (10 to 19 points; 83%) of chemotherapy toxicity (P < .001).
CONCLUSION: A risk stratification schema can establish the risk of chemotherapy toxicity in older adults. Geriatric assessment variables independently predicted the risk of toxicity.

PMID 21810685  J Clin Oncol. 2011 Sep 1;29(25):3457-65. doi: 10.1200/J・・・
著者: Martine Extermann, Ivette Boler, Richard R Reich, Gary H Lyman, Richard H Brown, Joseph DeFelice, Richard M Levine, Eric T Lubiner, Pablo Reyes, Frederic J Schreiber, Lodovico Balducci
雑誌名: Cancer. 2012 Jul 1;118(13):3377-86. doi: 10.1002/cncr.26646. Epub 2011 Nov 9.
Abstract/Text 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.

Copyright © 2011 American Cancer Society.
PMID 22072065  Cancer. 2012 Jul 1;118(13):3377-86. doi: 10.1002/cncr.2・・・
著者: Warren B Chow, Ronnie A Rosenthal, Ryan P Merkow, Clifford Y Ko, Nestor F Esnaola, American College of Surgeons National Surgical Quality Improvement Program, American Geriatrics Society
雑誌名: J Am Coll Surg. 2012 Oct;215(4):453-66. doi: 10.1016/j.jamcollsurg.2012.06.017. Epub 2012 Aug 21.
Abstract/Text
PMID 22917646  J Am Coll Surg. 2012 Oct;215(4):453-66. doi: 10.1016/j.・・・
著者: Allison Dalton, Zdravka Zafirova
雑誌名: Anesthesiol Clin. 2018 Dec;36(4):599-614. doi: 10.1016/j.anclin.2018.07.008. Epub 2018 Oct 12.
Abstract/Text As the population ages, more geriatric patients will be presenting for surgical procedures. Preoperative evaluation seeks to assess patients for geriatric syndromes: frailty, sarcopenia, functional dependence, and malnutrition. Age-related changes in physiology increase risk for central nervous system, cardiovascular, pulmonary, renal, hepatic, and endocrine morbidity and mortality. Identification of various comorbidities allows for preoperative optimization and for opportunities for intervention including nutritional supplementation and prehabilitation, which may improve postoperative outcomes.

Copyright © 2018 Elsevier Inc. All rights reserved.
PMID 30390781  Anesthesiol Clin. 2018 Dec;36(4):599-614. doi: 10.1016/・・・
著者: Josef Coresh, L A Stevens
雑誌名: Curr Opin Nephrol Hypertens. 2006 May;15(3):276-84. doi: 10.1097/01.mnh.0000222695.84464.61.
Abstract/Text PURPOSE OF REVIEW: Estimation of the glomerular filtration rate (GFR) is central to the diagnosis, evaluation and management of chronic kidney disease. This review summarizes recent data on the performance of equations using serum creatinine to estimate the GFR, particularly the Modification of Diet in Renal Disease (MDRD) Study equation.
RECENT FINDINGS: During 2005 GFR estimation has received substantial attention with a focus on comparing the MDRD Study equation with the Cockcroft-Gault equation. Several large studies (n>500) have appeared. Most studies discuss creatinine calibration but few were able to standardize measurements. Studies that did calibrate the creatinine had improved performance. Overall, the MDRD Study equation performed well in populations with a low range of GFR and often outperformed the Cockcroft-Gault equation. Both equations have lower precision in high GFR populations, and the MDRD equation under-estimated the GFR in a number of studies. Efforts are underway to develop improved prediction equations by pooling data across many study populations.
SUMMARY: Equations for estimating the GFR from serum creatinine are useful for systematic staging of chronic kidney disease. The MDRD Study equation and systematic creatinine assay calibration improve the level of precision and accuracy in many settings. GFR estimates are less useful in the normal range of GFR, however, and are sensitive to the population under study.

PMID 16609295  Curr Opin Nephrol Hypertens. 2006 May;15(3):276-84. doi・・・
著者: Stuart M Lichtman, R Donald Harvey, Marie-Anne Damiette Smit, Atiqur Rahman, Michael A Thompson, Nancy Roach, Caroline Schenkel, Suanna S Bruinooge, Patricia Cortazar, Dana Walker, Louis Fehrenbacher
雑誌名: J Clin Oncol. 2017 Nov 20;35(33):3753-3759. doi: 10.1200/JCO.2017.74.4102. Epub 2017 Oct 2.
Abstract/Text Purpose Patients with organ dysfunction, prior or concurrent malignancies, and comorbidities are often excluded from clinical trials. Excluding patients on the basis of these factors results in clinical trial participants who are healthier and younger than the overall population of patients with cancer. Methods ASCO and Friends of Cancer Research established a multidisciplinary working group that included experts in trial design and conduct to examine how eligibility criteria could be more inclusive. The group analyzed current eligibility criteria; conducted original data analysis; considered safety concerns, potential benefits, research, and potential hurdles of this approach through discussion; and reached consensus on recommendations regarding updated eligibility criteria that prioritize inclusiveness without compromising patient safety. Results If renal toxicity and clearance are not of direct treatment-related concern, then patients with lower creatinine clearance values of > 30 mL/min should be included in trials. Inclusion of patients with mild to moderate hepatic dysfunction may be possible when the totality of the available nonclinical and clinical data indicates that inclusion is safe. Ejection fraction values should be used with investigator assessment of a patient's risk for heart failure to determine eligibility. Patients with laboratory parameters out of normal range as a result of hematologic disease should be included in trials. Measures of patient functional status should be included in trials to better assess fit versus frail patients. Conclusion Expanding inclusion of these patients will increase the number and diversity of patients in clinical trials and result in a more appropriate population of patients.

PMID 28968172  J Clin Oncol. 2017 Nov 20;35(33):3753-3759. doi: 10.120・・・

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