BSCThesis_11324066

Discipline of Radiation Therapy SS Research Thesis 2014-2015 1
Discipline of
Radiation therapy
Marie Murphy, Bsc. (Hon.) Radiation Therapy
DEBATE:Should a Geriatric Assessmentbe carried out on
all Older Patients undergoing Chemo-radiotherapy?
I declare that this
work has not
previously been
submitted as an
exercise for a
degree at this or
any other
University.
It is entirely my
own work, except
where duly
acknowledged.
I agree that the
library may lend or
copy this thesis
upon request.
Signed:
Marie Murphy
ABSTRACT:
Background: The multidimensional Geriatric Assessment(GA) is a term used by geriatricians to
describe a multidisciplinary evaluation of an older individual's functional status,comorbid medical
conditions,cognition, psychological state,social support,nutritional status,and a review of the
patient's medications. GA is an approach developed and used by the geriatricians to set up an
individualised and proactive care plan and a GA is now suspected to be of similar use in oncology.
Materials and Methods: Of the thirty-two included studies; ten assessed the effect of a GA on
final treatment decision, while twenty-four examined overall patient outcome after a GA. Studies
were recruited through a database search strategy with defined inclusion/exclusion criteria.
Results: GA altering treatment decision varied from 21-49%. The GA results more commonly led
to a decrease in the aggressiveness oftreatments especially with regard to systemic treatments.
Impaired Instrumental Activities of Daily Living(IADL) and Activities of Daily Living(ADL)
scores were seen to be strongly associated with Overall Survival(OS), worse Quality of Life(QoL)
and along with malnutrition were also correlated with higher grade 3-4 toxicities.
Conclusion: There is mounting data regarding the use of GA in oncology practice; however,
additional research is needed to continue to strengthen the evidence base.

INTRODUCTION
Cancer is considered an age-related disease and due to
worldwide aging populations it is becoming an increasing
concern. It is expected that 20% of the population of the
United States will be over the age of 65 before the year
2030, and will account for 70% of all cancers.[1] The fastest
growing subset ofthis older population being ≥85years old,
an increase from 100,000 people in 1900 to an expected 7.3
million by the year 2020.[2] 60% of all cancer incidences
and 70% of mortality occur in patients > 65 years of age,
with the median age at the time of cancer diagnosis being 68
years.[2]
Unfortunately, despite the compelling demographics, the
enrolment of older adults in registration trials remains
dismal. From 2007 to June 2010, only 33% of patients
included in the registration trials were ≥65 years.[3]
Although new agents may be successful in the treatment of
healthier, youngeradults, information is limited on how to
apply this to older adults who represent the majority of
patients receiving treatment. Thus,treatment decisions are
based on evidence from trials which do not answer age-
specific concerns.[4] The diversity of the older population
should be accounted for in clinical trials of cancer treatment,
for adequate patient stratification. The international Society
of Geriatric oncology suggested developing therapeutic
studies designed specifically for older adults who may not
be eligible for a typical clinical trials as a result of
comorbidity or functional status.[5]
There are many age specific concerns associated with the
older cancer patients.With increasing age, physiologic
reserve decreases; howeverthis varies with each
individual.[6] Similarly, variations in functional status,
cognition, and comorbidity accompany increased age, and
may affect life expectancy, risk of subsequent functional
decline, hospitalization, and other morbidity.[7, 8] These
age-related changes can influence tolerance to cancer
therapy, as well as the overall risk-benefit ratio of cancer
treatment. Although older adults have been identified as
being vulnerable to side effects from cancer therapy, few
oncology studies to date have specifically incorporated
baseline metrics for measuring health conditions other than
functional status (ECOG or KPS) to identify individuals
most at risk. An analysis of 784,000 cancer patients
suggests that carefulattention to and management of
comorbidities could provide substantialsurvival benefits, on
the order of those provided by cancer treatment itself.[1]
Indeed, the literature suggests,alarmingly, that elderly
cancer patients,even those with little or no baseline
comorbidity, are less likely to receive curative intent
treatment. At the same time, there are real concerns
regarding potentially increased treatment related toxicity in
the elderly and/orin patients with comorbidities. There is
currently no standardized assessment forassessing the
comorbidities of older cancer patients,although it is widely
recognized that chronological age does not capture the
heterogeneous physiologic and functional status ofolder
adults. Integrating a “geriatric assessment” into oncology
research and clinical practice could help fill this void.
Geriatric Assessment (GA) covers factors that predict
morbidity and mortality in older adults, including functional
status,comorbidity, cognition, psychologicalstate,
nutritional status,socialsupport and a review of the patient's
medications This assessment provides a broader overall
understanding ofindividual characteristics that affect life
expectancy.[9] GA is an approach developed and used by
the geriatricians to set up an individualised and proactive
care plan as a GA detects unsuspected conditions in more
than 50% of patients older than 65 years that may affect
their ability to complete cancer treatment.[4]
However the cut-off point at which an adult is considered
‘old’ has not been well defined. So it is not known exactly
with subgroup ofpatients should receive a GA. From a
practical point of view, a chronological landmark is the age
of 70.[10] After this age, there is an increased incidence of
age-related physiological changes potentially leading to
increased treatment-related toxicity. Hence age 70 is a
reference point commonly used in oncology.[10]]
Definitions of vulnerability and frailty in elderly cancer
patients are still in the process of being defined and
validated, as ageing is a highly individualised process and
all the changes involved in this process cannot be predicted
solely on the basis of chronological age. Fit patients are
relatively well-defined, but frail patients may or may not
“appear” frail.[11Thus, it is clear that there is an emerging
need for developing tools to better evaluate a patient’s
‘functional age’ rather than chronological age. [10]
Systematic use of the GA, can allow physicians to select
appropriate patients to reduce under- or overutilization of
treatments in elderly cancer patients. Models of GA have
evolved in different healthcare settings to meet differing
needs [12, 13] and just as the stage of the disease and
tumour response must be assessed,oncologists need to learn
how to stage the functional age and anticipate the functional
response to treatment.
Aims and Objectives
The aims and objectives of this debate are:
1. To establish the effectiveness and outcomes of a GA in an
oncology setting by:
a. Analysing published evidence determining the
effect on GA has on mortality and OS.
b. Analysing published evidence evaluating the
endpoints of a GA in relation to QoL and treatment
toxicities.

2. To establish whether the domains assessed in a GA are
adequate to alter a patient’s final treatment decision:
a. Analysing published evidence assessing the
domains evaluated in a GA.
b. Analysing published evidence on the role a GA
has on final treatment decision.
MATERIALS AND METHODS
Search strategy for identificationof studies
The PubMed, Google Scholar, Science Direct, and
EMBASE databases and the Cochrane library were searched
using specific search terms. (See Appendix) Each study was
examined for the inclusion/exclusion criteria.
Type of Studies
Peer-reviewed studies acquired were geriatric assessment
within oncology studies,(prospective, retrospective,single
and multi-institution studies were considered). Reports of
prospective trials and randomized controlled trails (RCTs)
evaluating geriatric assessment validity in the older patient
with cancer had to be complete and published in peer
reviewed journals. Studies involving all older cancer
patients aged 70+ male or female were included. Studies
must include patients treated with Radiotherapy alone or
Chemo Radiotherapy (CRT) combined. Abstracts from
unpublished trials and posterpresentations on the described
topic were ineligible. Systematic reviews and literature
reviews were excluded. Non-English studies and studies
with a patient cut off age of below 70 were excluded as
SIOG and the EORTC consider70 years to be the cut-off
point for elderly patients.[10] Studies whom also included
surgery as a treatment type have been excluded. Opinionated
studies on the GA were excluded.
Type of Participants
Participants had to be age ≥70 years [10], Male or Female,
with any proven cancer type; stage or grade undergoing RT
alone or CRT as their treatment type. All cancer sites were
eligible. Studies examining geriatric assessment exclusively
outside of oncology were eliminated.
Type of Interventions
Patients that underwent a full GA were eligible. For
comparison studies patients could be assessed using a full
GA, an abbreviated GA (aGA) or various other screening
tools including the VES-13, G8 and others.Studies
examining screening tools must be carried out in comparison
to the full GA. Studies examining the validity of singular
screening tools with no comparison to the full GA were
deemed ineligible
Outcome measures
The included studies on carrying out a GA in the oncology
setting reported on the overall patient outcomes; mortality,
OS, QoL and toxicities. The overall survival should have
increased for patients who underwent a GA before
beginning treatment. Treatment related toxicities should also
be reduced for these patients.
Studies reported on the effect, if any, of a GA on the final
therapeutic treatment decision.
Statistical Analysis
The included GA studies analysed survival rates using the
Kaplan-Meier Method.Treatment related toxicities were
noted based on their grade, Studies used Chi-square tests
and descriptive analysis to reflect this.
Prospective studies and RCT study quality was appraised
using a scale devised by Down et al. (See Appendix)
RESULTS
One-hundred full-text articles were assessed foreligibility
within the inclusion/exclusion criteria, with sixty-eight
articles excluded based on the given criteria. Of the
remaining thirty-two articles, ten examined the impact of a
GA on final therapeutic decision with the rest looking at the
effect of a GA on patient outcomes including toxicity,
survival and mortality. There was an overlap between the
study endpoints ofinterest. Study quality differed
dramatically with scores ranging from 13- 23.
Argument 1: (Table 1) GA can effectively impact
the decision making process and thus alter the
final treatment decision.
For
Of the ten studies included, seven studies [14-20] reported a
change or modification in the final therapeutic treatment
decision. GA altering treatment decision varied from a mean
of 21% to 49%, The GA results more commonly led to less
aggressive treatments especially with regard to systemic
treatments. In the smaller trials the influence of a GA on
treatment decisions was much higher ranging from 39% to
83%. [14, 18-20] Study quality was also low with scores
ranging from 14-18. In Horgan et al’s study[18] when the
treatment plan was decided before the GA it altered the
decision in only one patient whereas when the treatment
plan was undecided at time of referral, the GA impacted the
final treatment decision in 83% of cases.In Girre’s study
[19] 39% of patients had a modified treatment plan after
GA, in the case of CRT, 67% of cases were modified with
no chemo being administered due to functional status and
comorbidity. However the initial and final treatment

decisions were made by two different physicians,similar to
Chaibi et al.[20] Most common modifications in relation to
RT after a GA were; no RT given in 40%, RT instead of
surgery/chemo in 48%, RT instead of CRT in one case and a
reduction in RT dose in 10%.[15]
Against
Decoster et al found that the addition of information
provided by a GA further changed treatment decision in
only 5% of cases.[21] In larger trails by Kenis et al[16] and
Decoster et al[15] modifications were mainly chemotherapy
related and where no GA was carried out RT decisions were
only altered in 0.4% of cases.Caillet at al[17] also had
similar results with the most common change in treatment
decision being a switch from chemotherapy to supportive
care. Few modifications were made for RT where only 1
patient received supportive care over RT due to a dramatic
decline in comorbidities.[17] Studies similarly suggested the
impact of a GA may be limited to patients of more toxic
treatments such as chemotherapy and targeted therapy.[15,
22, 23] Barthelemy et al [21] and Decoster et al[15] showed
that a large proportion of patients considered fit after a GA
did not receive standard treatment.
Argument 2 (Table 1): GA can significantly
improve the overall patient outcome in terms of
toxicity, OS, mortality and QoL.
For
Nine of the twenty-four studies included examined the effect
of GA on toxicities. Geriatric factors were predictive of
severe toxicity or unexpected hospitalization. The most
frequent radiation induced toxicities being; digestive,
urologic, fatigue, and pain.[24]. Hamaker et al[23] found
that the proportion of patients who experienced higher grade
toxicities increased rapidly with the number of geriatric
conditions.Several studies found impaired cognitive
function and impaired autonomy to be predictive factors of
increased toxicity.[25, 26] 50–80% of patients were also
found to experience nausea and vomiting after
radiotherapy.[27] Commonly Extermann among others
found Instrumental Activities of Daily Living(IADL),
Activities of Daily Living(ADL), ECOG
PS(EasternCooperativeOncologyGroup Performance Status)
and MNA(MiniNutritionAssessment) all to have
associations with higher grade toxicities.[22, 25, 28-30]
In relation to survival and mortality, Clough Gorr et al[26]
like Hamaker[23] provided evidence to suggest that GA
domains are associated with poor treatment tolerance or
mortality. Similarly in another Clough-Gorr et al[31] study
mortality was consistently two times higher in women with
≥ 3 GA Deficits.[32] Impaired IADL and ADL results[30,
33-36] were seen to have significant association with OS.
Similarly a correlation was noted between unfit patient
groups and poor survival.[33, 37] Little is known about the
effect of cognitive function on survival in elderly cancer
patients however dementia is well known to be an
independent prognostic factor for survival.[32, 38]
Cognitive impairment was also shown to be an indicator of
poor survival[23, 32], while severe depressive symptoms
showed a borderline significant association.[32, 38]
According to Hamaker et al[23] however, age over 75 years
remained the most associated risk of higher mortality.
Maione et al assessed QoL[39] using the EORTC QLQ-C30.
PS was significantly correlated with QoL.
Against
Four studies indicated a weak correlation between a GA in
relation to patient outcome and toxicity. Biesma et al[29]
showed that patients with better ADL, IADL or physical
functioning were more likely to finish all chemotherapy
cycles, thus experience less toxicities. However, there was
no association between GA scores and treatment. Shin et
al[28] also said that an ECOG PS ≥2 was the only
independent factor for increased toxicity. The risk of
toxicity was also not significant to the frailty category.[33,
37] However, definitions of frailty in elderly cancer patients
are still not validated.
According to Hamaker et al mortality was only associated
with cancer related factors. [13] Chronological age did not
appear to have any prognostic value[28] and frailty was not
associated with mortality.[23] Corsetti et al[40] stated no
overall difference in survival between frail and non-frail
patients or those who were IADL impaired. Advanced
tumour stage is already a well-established risk factor for low
survival rates,[26, 31, 32, 38, 41] but there are limited data
available to provide evidence that depression[23, 32, 38],
polypharmacy[41], ECOG PS≥2[23, 32, 38, 39, 42], low
MNA scores[32, 38, 43] and ‘Get Up and Go’ (GUG) tests
are associated with early mortality in older patients with
cancer.
DISCUSSION
For the Motion
Should a GA be carried out in all older patients undergoing
CRT? As shown in Table 2, GA can additionally influence
treatment decisions in older patients with cancer[14-20],
varying from a mean of 21% to 49% either by decreasing or
increasing the treatment intensity.[15, 20] GA can
theoretically form an important part of the decision making
process to tailor treatment and trigger targeted GA-driven
interventions.A GA with a follow-up may have the potential
to improve treatment prognosis in elderly cancer
patients.[14] However it may be the patients with more
complex oncological treatment who could experience the
greatest benefit.[14, 15, 22]
In Horgan et al’s study[18]when the treatment plan was
decided before the GA treatment was modified in only 1

patient whereas when the treatment plan was undecided at
time of referral, the findings in the GA impacted the final
treatment decision in 83% of cases.A modified approach
was opted in the cases of patients with poor PS and
significant comorbidities. This argues for a combined
assessment to identify potential markers before assessment
and then follow with a full GA before making the final
decision. Although results of previous studies showthat a
GA usually resulted in a switch to less aggressive
treatments, it has been outlined that elderly patients are at an
increased risk for under-treatment because of their
sensitivity and undertreatment can be a reason for decrease
in survival.[44] Barthelemy et al [21] and Decoster et al[15]
showed that a large proportion of patients considered fit
after a GA did not receive standard treatment.
Modifications in treatment decisions mainly concerned
chemotherapy patients,[15, 19] while fewer changes were
visible in radiotherapy.[17] The most common change being
from chemotherapy to supportive care[17, 20]. The
predictive value of a GA for chemotherapy-related toxicity
suggests that foroptimal decision-making regarding
treatment risks and potential benefits, a GA should be
considered as the standard assessment for all elderly cancer
patients if chemotherapy is planned.[23] Radiation Therapy
is generally well-tolerated with 75 – 90% of older patients
completing therapy and considered to be a less toxic
treatment over chemotherapy.[45] Toxicity from radiation
can also be more pronounced with concurrent
chemotherapy.[46]In addition patients age 70-79 are most
likely to benefit from the approach.[44]
The proportion of patients that experienced grade 3–4
toxicity increases with the number of geriatric
conditions[23, 31] Polypharmacy is the only individual
factor predictive of grade 3–4 toxicity, in patients using five
or more types of medication.[23, 41]More than half of
patients present with IADL and ADL disability,
malnourishment and 40% with an ECOG PS ≥2.[17, 19, 22,
39, 42, 43] [30]. According to Shin et al[28] ECOG PS ≥2 is
the only independent factor for chemo toxicity. Results here
are also in keeping with Repetto et al suggesting ADL to be
more informative than PS for characterising functional
status ofelderly cancer patients[42] One study[40] had no
survival difference among frail or non-frail patients or those
who were IADL impaired versus not.[33]
Blanc et al[47] uncovered that patients were also less likely
to have psychological support and a cognitive assessment.
Nonsignificant trends were found for depression.[17, 19]
Abnormal GDS(GeriatricDepressionScore) and cognitive
impairment have also been shown as indicators for poor
survival.[32, 36, 38, 41] Patients with worse emotional
functioning (QLQ-C30), role functioning or GDS were more
likely to have grade ≥2 psychiatric toxicity.[29] These
results suggest that cognitive function should be taken into
account when choosing a treatment regimen, therefore
allowing recognition of persons at a higher risk for treatment
related complications.
Chronological age alone should not be considered a reason
to give in-optimal treatment [48]. Pelvical Helical IMRT for
patients aged 70 and older is feasible with full standard
radiation doses.[24] Clinical advantages ofIMRT should be
employed for older patients to better tailor treatment into
sparing digestive organs and bone marrow and to prevent
any exacerbation of pre-existing comorbidities.[24] Also,
limiting the volume of irradiated bone marrow is associated
with reduced rates of hematologic toxicities and could
improve tolerance to chemotherapy. However, under-
treatment of pain remains a considerable problem in the
elderly population with cancer. Thus palliative care teams
should play an important role in the MDT approach both for
support and symptom control.[44] Results shows that a
single 8Gy fraction compared to 20Gy multi-fractions, in
elderly patients, produced no significant difference in terms
of pain reduction.[49] A single fraction is not effective for
neuropathic pain[50] but relief of other pain can be achieved
by single treatment [51] and a quicker response can be
observed in comparison to multiple fractionation.[50]
The number of treatment modifications clearly indicates the
need for a specific GA to address the issues individual to
oncology.The commonly used oncology performance status
measure; KPS did not identify older adults at an increased
risk for chemo toxicity, reflecting the limitations of trying to
use one global assessment measure of functional status to
describe the heterogeneity of the geriatric population.
Furthermore KPS may be misleading as it is difficult to
discriminate between a KPS of 60% and 80%. In another
study,over 50% of women with breast cancer over the age
of 70 years died from causes otherthan breast cancer.
Highlighting the fact that the majority of older people with
cancer can die with, rather than from the disease,[20]
Stressing the importance that comorbidities must be taken
into account in treatment decisions for older patients with
cancer.[52]
It is worth noting that planned hospitalisation is organised
for patients receiving more intense treatment regimens
however patients treated before the GA often need
unplanned hospitalisation in geriatric departments for
emergency reasons.Therefore showing the need for a GA to
firstly alter the final treatment decision and also to decrease
the pressure put on cost and resources in already busy
geriatric oncology departments with unplanned hospital
admissions.[20, 53, 54] Assessing patients formodifiable
geriatric conditions seems appropriate when aiming to
optimize quality of hospital, palliative and supportive care
for these older cancer patients [14, 44, 55] A recent 2013
trial from Aparicio[25] suggested that geriatric factors are
predictive of severe toxicity or unexpected hospitalization.
Analysis of data reveals a significant reduction in
institutionalisation for patients who are in receipt of a GA.
Also patients who are living alone showan improved

outcome if they are in receipt of a GA compared to those
who are not.[56]
A balance between potential benefits and adverse effects
must be made when deciding on the treatment regimen for
each patient. Especially in the case of geriatric patents where
short term QoL and the ability to continue to manage their
daily activities may be more important that a modest
survival advantage.Anotherencouraging sign of potential
effectiveness of a GA is the significant improvement in QoL
on the Fact-B Scale.[14] Perceived social support in elderly
persons is important for QoL and for survival and is
associated with better outcome by improving compliance
with medical treatment and availability of help and support
in the application of cancer treatments.[57-59] Maione et
al[39] assessed QoL using the EORTC QLQ-C30 and PS
was significantly correlated with QoL, ADL and IADL
scores.
Ultimately longitudinal evidence exists that GA domains are
associated with poor treatment tolerance and predict
mortality. Specifically, GA can identify reversible problems
that may interfere with cancer treatment, such as poor
mental health, insufficient social support,or functional
limitations[26] and may establish eligibility for curative
treatments.[60]
Against the Motion
Despite its potential benefits in QoL, impact on treatment
decisions and association with adverse toxicities, the impact
on survival and mortality is more heterogeneous; observed
in some trials and not others.[13, 28, 40] The widespread
implantation of a GA into oncological practice is hampered
by both the time [16] and expertise required to complete it.
Thus,its practicality as a guide is limited in treatment
decision making.[23, 61] This has led cancer specialists to
search for possible screening tools.If such a tool has
sufficient predictive value for relevant outcome measures, it
could replace the GA. Several screening tools currently exist
including the G8[62, 63], VulnerableElderlySurvey-13[64-
66], abbreviatedGeriatricAssessment[67],
miniGeriatricAssessment, [68],
TriageRiskScreeningTool[69] and GroigenFrailtyIndex[23,
70], to name a few. However, each requires validation in a
larger scale prospective study before their use can be
implemented. So far the aGA, VES-13 and G8 look most
promising[63, 71] but for now findings suggest that it might
be beneficial to carry out a full GA for all elderly cancer
patients[72] since available screening methods require
further assessment.[73]
Anothermajor challenge faced by oncologists is the distinct
lack of data from clinical trials in this particular age group
(70+)[3] and thus lack of standard guidelines for cancer care
in this age group and ultimately leading to an inaccurate
assessment oflife expectancy and impact of comorbidities.
Over the last 10-15 year various studies have been carried
out in an attempt to elucidate barriers contributing to the
poor representation of the elderly in trials. Potential
approaches to improving trial participation in the elderly
include first increasing the opportunity for enrolment.[74]
It has also been noted that a Geriatric group of unfit patients
were independent predictors of mortality. It is of paramount
importance to identify real ‘’Frail’’ patients[60, 75] as
treatment decisions were cannot based on the results of
Geriatric screening and MDT reviews. Data suggests that
treating unfit patients with intensive therapy compared with
palliative care provides no further survival benefit and
poorer functional status was associated with reduced
survival.[76]
Limitations and future work
The limitations of this study include; Patient selection bias
was present as only vulnerable patients or patients with
complex treatment decisions were chosen in some trails.
Some patients who had a modified treatment plan after GA
had their initial and final treatment decision made by
different physicians.Some trials had small sample sizes
reducing their overall impact and significance. Due to the
lack of RCTs study quality was limited, and although the
Downs and Black scale was carried out,it was found to be
very subjective. No randomized control trail as yet been
carried out specific to oncology.
There is a need for future economic evaluation considering
the demographic changes and potential healthcare costs in
an ageing population. Further evaluation is also warranted to
address the outstanding question as to who should optimally
be treated with a GA. Future studies also need to determine
the resource time needed to carry out a full GA and to guide
and test interventions to improve the care of older cancer
patients.QoL also requires further investigation in future
clinical trials.
CONCLUSION
Despite the potential benefits of a GA to influence treatment
decisions and impact positively on patient QoL and
comorbidities, its overall impact on survival and mortality is
more heterogeneous.Therefore prospective multicentre
RCTs are necessary to determine the full impact of a GA in
older patients with cancer undergoing CRT.

LIST OF ABBREVIATIONS
GA- Geriatric Assessment
QoL-Quality of Life
OS-Overall Survival
RCTs-Randomised Control Trials
SIOG-International Society of Geriatric Oncology
aGA- abbreviated Geriatric Assessment
VES-13- Vulnerable Elderly Survye-13
G8-G8 Screening Tool
ADL-Activities of Daily Living
IADL-Instrumental Activities of Daily Living
KPS- Karnofsky Performance Status
MNA-Mini Nutritional Assessment
MMSE-Mini Mental State Examination
GFI- Groningen Frailty indicator
GDS- Geriatric Depression Scale
ECOG- Eastern Cooperative Oncology Group
PS-Performance Status
FS-functional Status
CRT-Chemotherapy Radiation Therapy
GUG- ‘Get Up and Go’ Test
MDT-Multi Disciplinary Team
BCS- Breast Conserving Surgery
WHO-PS- World Health Organisation-Performance
Status
MGA-Mini Geriatric Assessment
TRST-Triage Risk Screening Tool
ACKNOWLEDGEMENTS
Firstly, I would like to thank my Family for all their support
and also the Trinity Ladies Football Team for all their
encouragement. I would especially like to thank Denise who
was always there when I needed her. I would also like to
thank the Discipline of Radiation Therapy and especially my
supervisorAnita O’ Donovan for all her sound and calming
advice. Finally I would like to extend the most heartfelt
appreciation to all my classmates. You really made college
life unforgettable.

FIGURES and TABLES
Table 1: Argument Table; For and Against Statements that represent each side of the
argument
FOR AGAINIST
Argument 1: GA can effectively
impact the decision making
process for health professionals
and thus alter the final treatment
decision.
GA can effectively impact the
decision making process and thus
alter the final treatment
decision.[1-7]
A GA has no proven benefit that it
aids or alters the final treatment
decision for patients. [1-3, 8-10]
Argument 2: GA can significantly
improve the overall patient
outcome in terms of toxicity, OS,
mortality and QoL.
There is a significant
improvement in overall patient
outcome including toxicity[9-13],
survival/mortality[9, 12, 14-27]
and QoL[26] after the patient has
undergone a full GA.
GA, while proven useful in
general medicine, has not yet been
proven to have any benefit on
such outcomes in patients in
oncology including toxicity [16,
21, 28, 29], OS/Mortality [22, 30-
32] and QoL.[28]

Table 2: Results Table of Argument 1
Author Year Txt
Modification
%(number) of
cases
Intensified Less
Intensity
Delay
Extermann
[14]
2004 4/15 26.6% - - -
Decoster[15] 2013 31/505 6.1% 25.8% - -
Kenis[16] 2013 282/1115 25% - - -
Caillet[17] 2011 78/375 21% 2% 17% 2%
Horgan[18] 2011 6/30 20% 3% 17% 0%
Girre[19] 2008 36/93 39% 2% 37% 0%
Chaibi[20] 2011 79/161 49% 28% 18% 3%

Table 3: Results Table of Argument 2(Toxicity, Survival/Mortality)
ECOG PS- Eastern Cooperative
Oncology Group Performance Status
ADL- Activities of Daily Living
IADL- instrumental Activities of
Daily Living
MMSE-Mini Mental State
Examination
MNA- Mini Nutritional Assessment
GDS- Geriatric Depression Score
MH15-Mental Health
GUG- ‘Get Up and Go’ Test
Author (year) Associations with
Mortality/OS
Predictors of
Worse Toxicity
Shin et al (2012)[28] ECOG PS ≥2 ECOG PS ≥2
Biesma (2011)[29] ADL, IADL
Extermann et al (2012)[22] MMSE,MNA and
ECOG PS
MMSE,MNA and
ECOG PS
Hurria et al (2011)[53]
Soubeyran et al
(2011)[36]
Poor;MMSE ADL,
IADL GDS
Clough Gorr et.al (2010)[26] Impaired cognitive
function/impaired
autonomy/lower
MH15 scores
Freyer et al (2005)[27] Polypharmacy,
depression and
advanced tumour
stage
Polypharmacy,
depression and
advanced tumour
stage
Wedding et al (2007)[34] IADL (PS/FS)
Aaldriks et al (2011)[43] MNA and Frailty
Winklemann et al (2010)[30] IADL (PS/FS) IADL (PS/FS)
Clough Gorr et al (2012)[31] ≥ 3 GA Deficits,
increased age and
increased stage.
Aparicio et al (2013)[25] MMSE and IADL MMSE and IADL
Olivieri et al (2012)[37] age >70 years and
treatment group
Hamaker et al(2014)[23] cognitive impairment
and severe
depressive,age over
75 years
Polypharmacy
Kanversan et al (2011)[32] age, abnormal
albumin level, poor
ECOG PS, abnormal
GDS, advanced stage
cancer, Malnutrition,
Cognitive
impairment
Girones et al (2012)[38] ECOG PS, weight
loss,delirium,
incontinence,
dementia and
depression
Hamaker et al (2011)[13] Only cancer related
factors
Soubeyran et al (2012)[61] male gender,
advanced tumour
stage,poor MNA,
and long GUG

Table 4: Study Characteristics Table for Studies included for Argument 1
Ca- Cancer
CRT-Chemoradiation
MedOncDept- Medical Oncology Department
Onc.Dept- Oncology Department
Publication Setting Study Types of Number
of
Age,
Median
Number of Down et
al
Study Year Population Treatment Patients years(range) Assessed
conditions/AIM
Score
Extermann et
al[22]
2012 Multi-centre Various Chemo 518 75.5-(70-92) 1 17
Extermann
at.al[14]
2004 Onc.Dept Breast Ca Various 15-Jan 79(72-87) 2 14
Hamaker et.al[23] 2014 MedOncDept Breast Ca Chemo 73 (65-80+) 2 23
Barthelemy et
al[21]
2011 Med Onc Early Breast Ca Chemo 192 75.1(70-98) 2 18
Kenis
et.al[16]
2013 Various Various(6) surgery/crt 1967 76(70-96) 3 21
Decoster et.al[15] 2013 Onc.Dept Various Various 937 76(70-95) 1 21
Calliet
et al[17]
2011 Onc.Dept Various Various 375 79.6(70-99) 2 18
Horgan et al[18] 2011 MedOncDept Various Various 30 79(70-88) 2 21
Girre et
al[19]
2008 Onc.Dept Various Various 105 79(70-97) 1 18
Chaibi
et al[20]
2011 Onc.Dept Various Various 161 82.4 (73-97) 1 17

Table 5: Study Characteristics Table for Studies included for Argument 2 (Toxicities)
DLBCL- Diffuse Large B-cell Lymphoma
NSCLC-non small cell lung cancer
MedOncDept- Medical Oncology Department
Onc.Dept- Oncology Department
Ca- Cancer
of
Age,
Median
Number of Down et
al
conditions/AIM
Score
Spina et
al[33]
2012 Med.
Onc
DLBCL Chemo 100 75(70-89) 2 19
Aparicio et al[25] 2013 Med.
Onc
Colrectal Chemo 123 80(75-91) 1 20
Olivieri et al[37] 2012 Med.
Onc
DLBCL Chemo 91 <85 2 17
Shin et
al[28]
2012 Med Onc various Various 64 71(65-80) 2 21
Clough Gorr
et.al[26]
2010 Various Breast Ca Various 660 (65-80+) 2 13
Biesma et al[29] 2011 Onc.Dept NSCLC Various 181 74(70-87) 3 18
Extermann et
al[22]
2012 Multi-centre Various Chemo 518 75.5-(70-92) 1 17
Hurria
et al[53]
2011 Onc.Dept(7) Various Chemo 500 73(65-91) 2 21

Table 6: Study Characteristics Table for Studies included for Argument 2 (Survival/Mortality)
of
Age,
Median
Number of Down et
al
conditions/AIM
Score
Soubeyran et al[36] 2011 9EORTC centres DLBCL/NHL CRT 32 79(70-92) 6 22
Repetto et.al[42] 2002 Multi Instit. Various Various 655 72 1 13
Aaldriks et al[43] 2011 Med Onc Various Chemo 202 77.2(71-92) 3 17
Freyer
et al[27]
2005 Multi-centre Ad.Ovarian Ca Various 83 76(70-90) 2 16
Wedding et al[34] 2007 Med Onc Various Chemo 195 (60-80+) 3 17
Kanesvaran
et.al[32]
2011 Onc.Dept Various Various 249 77(70-94) 2 20
Girones et al[38] 2012 Onc.Dept Lung Ca Various 83 77( 1 17
Hamaker et.al[13] 2011 Onc.Dept Various Various 292* 74.9 (65-96.2) 2 21
Soubeyran et al[61] 2012 Med Onc Various Chemo 364 77.45(70-99.4) 1 20
Corsetti et al[40] 2011 Onc.Dept Lymphoma Chemo 31 72(55-84) 1 14
Wedding et al[35] 2007 Onc.Dept Various Chemo 427 18-80+ 3 17
Maione et al[39] 2005 Med Onc AD. NSCLC Chemo 229 74(70-84) 2 21
Clough Gorr et
al[26]
2012 Onc.Dept Breast Ca Various 660 (72.6-75.6) 2 14
Marchesi et.al[60] 2013 Various B-NHL Various 73 78 (75-88) 3 18
Olivieri et al[37] 2012 Med.
Onc
DLBCL Chemo 91 <85 2 17
Spina et
al[33]
2012 Med.
Onc
DLBCL Chemo 100 75(70-89) 2 19
Clough Gorr
et.al[26]
2010 Onc Dept Breast Ca Various 660 (65-80+) 2 13
Winklemann et.
Al[30]
2010 MedOncDept Lymphoma Chemo 143 (18-80+) 4 16

APPENDICES
Assessing the quality of studies using the scale by Downs
et al [77]
Reporting
1. Is the hypothesis/aim/objective ofthe study clearly
described?
2. Are the main outcomesto be measured clearly described
in the Introduction or Methodssection?
If the main outcomes are first mentioned in the Results
section,the question should be answered no.
3. Are the characteristicsof the patientsincluded in the
study clearly described?
In cohort studies and trials, inclusion and/or exclusion
criteria should be given. In case-controlstudies,a case-
definition and the source for controls should be given.
4. Are the interventionsofinterest clearly described?
Treatments and placebo (where relevant) that are to be
compared should be clearly described.
5. Are the distributionsofprincipal confoundersin each
group of subjects to be compared clearly described?
A list of principal confounders is provided.
6. Are the main findingsof the study clearly described?
Simple outcome data (including denominators and
numerators) should be reported for all major findings so that
the reader can check the major analyses and conclusions.
(This question does not cover statistical tests which are
considered below).
7. Does the study provide estimates of the random
variability in the data for the main outcomes?
In non-normally distributed data the inter-quartile range of
results should be reported. In normally distributed data the
standard error, standard deviation or confidence intervals
should be reported. If the distribution of the data is not
described, it must be assumed that the estimates used were
appropriate and the question should be answered yes.
8. Have all important adverse events that may be a
consequence of the intervention been reported?
This should be answered yes if the study demonstrates that
there was a comprehensive attempt to measure adverse
events.(A list of possible adverse events is provided).
9. Have the characteristicsof patientslost to follow-up been
described?
This should be answered yes where there were no losses to
follow-up or where losses to follow-up were so small that
findings would be unaffected by their inclusion. This should
be answered no, where a study does not report the number of
patients lost to follow-up.
10. Have actual probability values been reported (e.g.0.035
rather than <0.05) for the main outcomes except where the
probability value is less than 0.001?
External validity
All the following criteria attempt to address the
representativeness ofthe findings of the study and whether
they may be generalised to the population from which the
study subjects were derived.
11. Were the subjects asked to participate in the study
representative of the entire population from which they were
recruited?
The study must identify the source population for patients
and describe how the patients were selected. Patients would
be representative if they comprised the entire source
population, an unselected sample of consecutive patients,or
a random sample. Random sampling is only feasible where a
list of all members of the relevant population exists. Where
a study does not report the proportion of the source
population from which the patients are derived, the question
should be answered as unable to determine.
12. Were those subjects who were prepared to participate
representative of the entire population from which they were
recruited?
The proportion of those asked who agreed should be stated.
Validation that the sample was representative would include
demonstrating that the distribution of the main confounding
factors was the same in the study sample and the source
population.
13. Were the staff, places, and facilities where the patients
were treated, representative of the treatment the majority of
patients receive?
For the question to be answered yes the study should
demonstrate that the intervention was representative of that
in use in the source population. The question should be
answered no if, for example, the intervention was
undertaken in a specialist centre unrepresentative of the
hospitals most of the source population would attend.
Internal validity - bias
14. Was an attempt made to blind study subjects to the
intervention they have received?
For studies where the patients would have no way of
knowing which intervention they received, this should be
answered yes.

15. Was an attempt made to blind those measuring the main
outcomes of the intervention?
16. If any of the results of the study were based on “data
dredging”, was this made clear? Any analyses that had not
been planned at the outset of the study should be clearly
indicated. If no retrospective unplanned subgroup analyses
were reported, then answer yes.
17. In trials and cohort studies, do the analysesadjust for
different lengthsof follow-up of patients,or in case-control
studies, is the time period between the intervention and
outcome the same for cases and controls?
Where follow-up was the same for all study patients the
answer should yes.If different lengths of follow-up were
adjusted for by, for example, survival analysis the answer
should be yes.Studies where differences in follow-up are
ignored should be answered no.
18. Were the statistical testsused to assess the main
outcomes appropriate?
The statistical techniques used must be appropriate to the
data. For example non- parametric methods should be used
for small sample sizes. Where little statisticalanalysis has
been undertaken but where there is no evidence of bias, the
question should be answered yes. If the distribution of the
data (normal or not)is not described it must be assumed that
the estimates used were appropriate and the question should
be answered yes.
19. Was compliance with the intervention/sreliable?
Where there was non-compliance with the allocated
treatment or where there was contamination of one group,
the question should be answered no. For studies where the
effect of any misclassification was likely to bias any
association to the null, the question should be answered yes.
20. Were the main outcome measures used accurate (valid
and reliable)?
For studies where the outcome measures are clearly
described, the question should be answered yes. For studies
which refer to other work or that demonstrates the outcome
measures are accurate, the question should be answered as
yes.
Internal validity - confounding (selection bias)
21. Were the patientsin different intervention groups(trials
and cohort studies) or were the cases and controls(case-
control studies) recruited from the same population?
For example, patients for all comparison groups should be
selected from the same hospital. The question should be
answered unable to determine for cohort and case- control
studies where there is no information concerning the source
of patients included in the study.
22. Were study subjects in different intervention groups
(trials and cohort studies) or were the cases and controls
(case-control studies) recruited over the same period of
time?
For a study which does not specify the time period over
which patients were recruited, the question should be
answered as unable to determine.
23. Were study subjects randomised to intervention groups?
Studies which state that subjects were randomised should be
answered yes except where method of randomisation would
not ensure random allocation. For example alternate
allocation would score no because it is predictable.
24. Was the randomised intervention assignment concealed
from both patients and health care staff until recruitment
was complete and irrevocable?
All non-randomised studies should be answered no. If
assignment was concealed from patients but not from staff,
it should be answered no.
25. Was there adequate adjustment for confounding in the
analyses from which the main findings were drawn?
This question should be answered no for trials if: the main
conclusions of the study were based on analyses of
treatment rather than intention to treat; the distribution of
known confounders in the different treatment groups was
not described; or the distribution of known confounders
differed between the treatment groups but was not taken into
account in the analyses.In non- randomised studies if the
effect of the main confounders was not investigated or con-
founding was demonstrated but no adjustment was made in
the final analyses the question should be answered as no.
26. Were losses of patients to follow-up taken into account?
If the numbers of patients lost to follow-up are not reported,
the question should be answered as unable to determine. If
the proportion lost to follow-up was too small to affect the
main findings, the question should be answered yes.
Power
27. Did the study have sufficient power to detect a clinically
important effect where the probability value for a difference
being due to chance is less than 5%?
Sample sizes have been calculated to detect a difference of
x% and y%.
Each trial receives a score 0 to 31 points,with high scores
indicating high quality in trail conduction or reporting.

Database search terms divided into searches for treatment decisions and patient outcome.
Treatment Decision
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Effect In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Treatment Outcome In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Treatment Decision In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Final Treatment Decision In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Final Therapeutic Treatment decision In older cancer
Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Final Treatment Decision in Radiation Therapy In older
cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Final Treatment Decision in Chemotherapy In older cancer
Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Final Treatment Decision in Combined Therapy In older
cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Final Treatment Decision in Combined Chemo Radio
Therapy In older cancer Patient
Patient Outcome
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Overall Patient Outcome In the older cancer patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) side effects (AND) radiation therapy In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) side effects (AND) Chemotherapy In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Toxicity (AND) Radiation Therapy In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Toxicity (AND) Chemotherapy In older cancer Patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Overall Survival in the older cancer patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Mortality in the older cancer patient
 Geriatric Assessment (AND) Cancer (OR) Oncology (AND) Quality of Life in the older cancer patient

REFERENCES
1. Movsas,B. and M. Extermann, Introduction:
Cancer, aging,and comorbidities.Semin Radiat
Oncol, 2012. 22(4): p. 263-4.
2. Services, U.S.D.o.H.a.H. Administration on Aging
(AoA). 2014 30th October 2014]; Available from:
http://www.aoa.gov/.
3. Scher, K.S. and A. Hurria, Under-representation of
olderadultsin cancer registration trials:known
problem, little progress. J Clin Oncol, 2012.
30(17): p. 2036-8.
4. Ilene Browner. Applicationsin Geriatric Oncology.
2014 30th October 2014].
5. Hurria, A., H.J. Cohen, and M. Extermann,
Geriatric oncology research in the cooperative
groups: A report of a SIOG special meeting.
Journal of Geriatric Oncology, 2010. 1(1): p. 40-
44.
6. Pal, S.K., V. Katheria, and A. Hurria, Evaluating
the olderpatient with cancer: understanding frailty
and the geriatric assessment. CA Cancer J Clin,
2010. 60(2): p. 120-32.
7. Walter LC, B.R., Counsell SR, et al., Development
and validation ofa prognostic index for 1-year
mortality in olderadultsafter hospitalization. The
Journal of the American Medical Association,
2001. 285: p. 2987-2994.
8. Inouye SK, P.P., Robison JT, et al Importance of
functional measures in predicting mortality among
olderhospitalized patients. The Journal of the
AMerican Medical Association,1998. 279: p.
1187-1193.
9. Hurria, A., Geriatric assessment in oncology
practice.J Am Geriatr Soc, 2009. 57 Suppl 2: p.
S246-9.
10. Pallis, A.G., et al., EORTC elderly task force
position paper:approach to the older cancer
patient.Eur J Cancer, 2010. 46(9): p. 1502-13.
11. Balducci, L. and J. Yates, General guidelinesfor
the management of olderpatientswith cancer.
Oncology (Williston Park), 2000. 14(11a): p. 221-
7.
12. Falandry, C., et al., Development of a geriatric
vulnerability score in elderly patientswith
advanced ovarian cancertreated with first-line
carboplatin:a GINECO prospective trial. Ann
Oncol, 2013. 24(11): p. 2808-13.
13. Hamaker, M.E., et al., The value of a
comprehensive geriatric assessment for patient
care in acutely hospitalized olderpatientswith
cancer. Oncologist, 2011. 16(10): p. 1403-12.
14. Extermann, M., et al., A comprehensive geriatric
intervention detectsmultiple problemsin older
breast cancerpatients. Crit Rev Oncol Hematol,
2004. 49(1): p. 69-75.
15. Decoster, L., et al., The influence of clinical
assessment (including age) and geriatric
assessment on treatment decisionsin older patients
with cancer. J Geriatr Oncol, 2013. 4(3): p. 235-41.
16. Kenis, C., et al., Relevance of a systematic geriatric
screening and assessment in olderpatientswith
cancer: results of a prospective multicentric study.
Ann Oncol, 2013. 24(5): p. 1306-12.
17. Caillet, P., et al., Comprehensive geriatric
assessment in the decision-making processin
elderly patients with cancer: ELCAPA study. J Clin
Oncol, 2011. 29(27): p. 3636-42.
18. Horgan, A.M., et al., Impact and feasibility of a
comprehensive geriatric assessment in the
oncology setting:a pilot study. Am J Clin Oncol,
2012. 35(4): p. 322-8.
19. Girre, V., et al., Does a geriatric oncology
consultation modify the cancer treatment plan for
elderly patients? J Gerontol A Biol Sci Med Sci,
2008. 63(7): p. 724-30.
20. Chaibi, P., et al., Influence of geriatric consultation
with comprehensive geriatric assessment on final
therapeutic decision in elderly cancer patients. Crit
Rev Oncol Hematol, 2011. 79(3): p. 302-7.
21. Barthelemy, P., et al., Adjuvant chemotherapy in
elderly patients with early breast cancer. Impact of
age and comprehensive geriatric assessment on
tumor board proposals. Crit Rev Oncol Hematol,
2011. 79(2): p. 196-204.
22. Extermann, M., et al., Predicting the risk of
chemotherapy toxicity in older patients:the
Chemotherapy Risk Assessment Scale for High-Age
Patients (CRASH) score. Cancer, 2012. 118(13): p.
3377-86.
23. Hamaker, M.E., et al., Baseline comprehensive
geriatric assessment is associated with toxicity and
survival in elderly metastatic breast cancer patients
receiving single-agent chemotherapy:resultsfrom
the OMEGA study of the Dutch breast cancer
trialists' group. Breast, 2014. 23(1): p. 81-7.
24. Bibault J-E, N.P., Tresch E, Cordoba A, Leblanc E,
et al., Feasibility Study of Pelvic Helical IMRT for
Elderly Patients with Endometrial Cancer. . PLoS
ONE 2014. 9(11): p. e113279.
25. Aparicio, T., et al., Geriatric factors predict
chemotherapy feasibility:ancillary results of
FFCD 2001-02 phase III study in first-line
chemotherapy for metastatic colorectal cancerin
elderly patients. J Clin Oncol, 2013. 31(11): p.
1464-70.
26. Clough-Gorr, K.M., et al., Older breast cancer
survivors: geriatric assessment domains are
associated with poor tolerance of treatment
adverse effects and predict mortality over 7 years
of follow-up. J Clin Oncol, 2010. 28(3): p. 380-6.
27. Feyer PC, M.E., Molassiotis A, et al.,
Radiotherapy-induced nausea and vomiting
(RINV): MASCC/ESMO guidelines for antiemetics
in radiotherapy:update 2009. Support Care
Cancer, 2011. 19 ((Suppl 1)): p. S5-S14.
28. Shin, D.-Y., et al., Toxicities and functional
consequences of systemic chemotherapy in elderly
Korean patients with cancer: A prospective cohort
study using Comprehensive Geriatric Assessment.
Journal of Geriatric Oncology, 2012. 3(4): p. 359-
367.
29. Biesma, B., et al., Quality of life, geriatric
assessment and survival in elderly patientswith
non-small-cell lung cancer treated with
carboplatin-gemcitabine or carboplatin-paclitaxel:
NVALT-3 a phase III study. Ann Oncol, 2011.
22(7): p. 1520-7.

30. Winkelmann, N., et al., Results of comprehensive
geriatric assessment effect survival in patients with
malignant lymphoma. J Cancer Res Clin Oncol,
2011. 137(4): p. 733-8.
31. Clough-Gorr, K.M., et al., Examining five- and ten-
year survival in older women with breast cancer
using cancer-specific geriatric assessment. Eur J
Cancer, 2012. 48(6): p. 805-12.
32. Kanesvaran, R., et al., Analysis of prognostic
factors of comprehensive geriatric assessment and
development of a clinical scoring system in elderly
Asian patientswith cancer. J Clin Oncol, 2011.
29(27): p. 3620-7.
33. Spina, M., et al., Modulated chemotherapy
according to modified comprehensive geriatric
assessment in 100 consecutive elderly patients with
diffuse large B-cell lymphoma. Oncologist, 2012.
17(6): p. 838-46.
34. Wedding, U., et al., Age, severe comorbidity and
functional impairment independently contribute to
poor survival in cancerpatients.J Cancer Res Clin
Oncol, 2007. 133(12): p. 945-50.
35. Wedding, U., et al., Co-morbidity and functional
deficits independently contribute to quality oflife
before chemotherapy in elderly cancer patients.
Support Care Cancer, 2007. 15(9): p. 1097-104.
36. Soubeyran, P., et al., Diffuse large B-cell and
peripheral T-cell non-Hodgkin'slymphoma in the
frail elderly. Journal of Geriatric Oncology. 2(1): p.
36-44.
37. Olivieri, A., et al., Tailored therapy in an
unselected population of91 elderly patientswith
DLBCL prospectively evaluated using a simplified
CGA. Oncologist, 2012. 17(5): p. 663-72.
38. Gironés, R., et al., Comprehensive Geriatric
Assessment (CGA) of elderly lung cancer patients:
A single-centerexperience. Journal of Geriatric
Oncology, 2012. 3(2): p. 98-103.
39. Maione, P., et al., Pretreatment quality of life and
functional statusassessment significantly predict
survival of elderly patientswith advanced non-
small-cell lung cancer receiving chemotherapy:a
prognostic analysisof the multicenterItalian lung
cancer in the elderly study. J Clin Oncol, 2005.
23(28): p. 6865-72.
40. Corsetti, M.T., et al., Hematologic improvement
and response in elderly AML/RAEB patients
treated with valproic acid and low-dose Ara-C.
Leuk Res, 2011. 35(8): p. 991-7.
41. Freyer, G., et al., Comprehensive geriatric
assessment predictstolerance to chemotherapy and
survival in elderly patientswith advanced ovarian
carcinoma: a GINECO study. Ann Oncol, 2005.
16(11): p. 1795-800.
42. Repetto, L., et al., Comprehensive geriatric
assessment addsinformation to Eastern
Cooperative Oncology Group performance status
in elderly cancer patients:an Italian Group for
Geriatric Oncology Study. J Clin Oncol, 2002.
20(2): p. 494-502.
43. Aaldriks, A.A., et al., Predictive value of geriatric
assessment for patientsolderthan 70 years, treated
with chemotherapy. Crit Rev Oncol Hematol, 2011.
79(2): p. 205-12.
44. Terret, C., et al., Multidisciplinary approach to the
geriatric oncology patient. J Clin Oncol, 2007.
25(14): p. 1876-81.
45. Lee, J.C., et al., Postmastectomy radiotherapy
reduces locoregional recurrence in elderly women
with high-risk breast cancer. Clin Oncol (R Coll
Radiol), 2005. 17(8): p. 623-9.
46. Bellon, J.R., et al., Concurrent radiation therapy
and paclitaxel or docetaxel chemotherapy in high-
risk breast cancer. International Journal of
Radiation Oncology*Biology*Physics, 2000.
48(2): p. 393-397.
47. Blanc, M., et al., Influence of the geriatric
oncology consultation on the final therapeutic
decision in elderly subjects with cancer: analysisof
191 patients. J Nutr Health Aging, 2014. 18(1): p.
76-82.
48. Zachariah B, B.L., Venkattaramanabalaji GV,
Casey L, Greenberg and e.a. HM, Radiotherapy for
cancer patients aged 80 and older: a study of
effectiveness and side effects. . International Journal
of Radiation Oncology • Biology • Physics,1997.
39: p. 1125-1129.
49. F.M. Giugliano, R.D.F., L. Iadanza, V. Borzillo,
L.Cutillo and P. Muto, Elderly Patients with
Painful Bone Metastases. The Impact of
Comorbidity on the Choice of Radiation Therapy
Regimen. Journal of Palliative Care and Medicine
2014. 4(5).
50. Roos DE, T.S., O'Brien PC et al. , Randomized trial
of 8 Gy in 1 versus 20Gy in 5 fractions of
radiotherapy for neuropathic pain due to bone
metastases (Trans-Tasman Radiation Oncology
Group, TROG 96.05). Int J Radiat Oncol Biol Phys,
2005. 75: p. 54-63.
51. DJ, C., A randomized trial of a single treatment
versus conventional fractionation in the palliative
radiotherapy of painful bone metastases. . Journal
of Clinical Oncoloy, 1989. 1: p. 59-62.
52. Pierga, J.Y., et al., Characteristics and outcome of
1755 operable breast cancers in women over 70
years of age. Breast, 2004. 13(5): p. 369-75.
53. Hurria, A., et al., Predicting chemotherapy toxicity
in older adults with cancer: a prospective
multicenter study. J Clin Oncol, 2011. 29(25): p.
3457-65.
54. Falandry, C., et al., Impact of geriatric risk factors
on pegylated liposomal doxorubicin tolerance and
efficacy in elderly metastatic breast cancer
patients:final results of the DOGMES multicentre
GINECO trial. Eur J Cancer, 2013. 49(13): p.
2806-14.
55. C. Terret, G.A., J.P. Droz, Multidisciplinary
geriatric assessment reveals unknown medical
problems in elderly cancer patients Journal of
Clinical Oncoloy, 2004. 22(14S): p. 8167.
56. Ellis, G., et al., Comprehensive geriatric
assessment for older adults admitted to hospital.
Cochrane Database Syst Rev, 2011(7): p.
Cd006211.
57. Valentiny, C., G. Kemmler, and R. Stauder, Age,
sex and gender impact multidimensional geriatric

assessment in elderly cancerpatients. Journal of
Geriatric Oncology. 3(1): p. 17-23.
58. Extermann, M. and A. Hurria, Comprehensive
geriatric assessment for olderpatientswith cancer.
J Clin Oncol, 2007. 25(14): p. 1824-31.
59. Pinquart, M., et al., Social support and survival in
patientswith acute myeloid leukaemia. Support
Care Cancer, 2007. 15(1): p. 81-7.
60. Marchesi, F., et al., A retrospective study on 73
elderly patients(≥ 75 years) with
aggressive B-cell non Hodgkin lymphoma: Clinical
significance of treatment intensity and
comprehensive geriatric assessment. Journal of
Geriatric Oncology, 2013. 4(3): p. 242-248.
61. Soubeyran, P., et al., Predictorsof early death risk
in olderpatientstreated with first-line
chemotherapy for cancer. J Clin Oncol, 2012.
30(15): p. 1829-34.
62. Liuu, E., et al., Accuracy of the G-8 geriatric-
oncology screening tool for identifying vulnerable
elderly patientswith cancer according to tumour
site: The ELCAPA-02 study. Journal of Geriatric
Oncology. 5(1): p. 11-19.
63. Bellera, C.A., et al., Screening oldercancer
patients:first evaluation ofthe G-8 geriatric
screening tool. Ann Oncol, 2012. 23(8): p. 2166-
72.
64. Mohile, S.G., et al., A pilot study of the vulnerable
elders survey-13 compared with the comprehensive
geriatric assessment for identifying disability in
olderpatientswith prostate cancer who receive
androgen ablation. Cancer, 2007. 109(4): p. 802-
10.
65. Castagneto,B., et al., The importance of negative
predictive value (NPV) of vulnerable elderly survey
(VES 13) as a pre-screening test in older patients
with cancer. Med Oncol, 2013. 30(4): p. 708.
66. Luciani, A., et al., Detecting disabilitiesin older
patientswith cancer: comparison between
comprehensive geriatric assessment and vulnerable
elders survey-13. J Clin Oncol, 2010. 28(12): p.
2046-50.
67. Overcash, J.A., et al., The abbreviated
comprehensive geriatric assessment (aCGA) for
use in the older cancer patient asa prescreen:
scoring and interpretation. Crit Rev Oncol
Hematol, 2006. 59(3): p. 205-10.
68. Aparicio, T., et al., A mini geriatric assessment
helpstreatment decision in elderly patientswith
digestive cancer. A pilot study. Crit Rev Oncol
Hematol, 2011. 77(1): p. 63-9.
69. Kenis, C., et al., Performance of two geriatric
screening toolsin older patientswith cancer. J Clin
Oncol, 2014. 32(1): p. 19-26.
70. Baitar, A., et al., Evaluation of the Groningen
Frailty Indicatorand the G8 questionnaire as
screening toolsfor frailty in older patientswith
cancer. Journal of Geriatric Oncology. 4(1): p. 32-
38.
71. Kellen, E., et al., Identifying an accurate pre-
screening tool in geriatric oncology. Critical
Reviews in Oncology/Hematology, 2010. 75(3): p.
243-248.
72. Merli, F., et al., Cyclophosphamide,doxorubicin,
vincristine,prednisone and rituximab versus
epirubicin,cyclophosphamide,vinblastine,
prednisone and rituximab for the initial treatment
of elderly "fit" patients with diffuse large B-cell
lymphoma: results from the ANZINTER3 trial of
the Intergruppo Italiano Linfomi. Leuk Lymphoma,
2012. 53(4): p. 581-8.
73. Hamaker, M.E., et al., Frailty screening methods
for predicting outcome of a comprehensive
geriatric assessment in elderly patients with
cancer: a systematic review. The Lancet Oncology,
2012. 13(10): p. e437-e444.
74. Turner, N., et al., Breast cancer in the elderly:
which lessons have we learned? Future Oncol,
2013. 9(12): p. 1871-81.
75. Tucci, A., et al., A comprehensive geriatric
assessment is more effective than clinical judgment
to identify elderly diffuse large cell lymphoma
patients who benefit from aggressive therapy.
Cancer, 2009. 115(19): p. 4547-53.
76. To, T.H.M., et al., Infancy of an Australian
geriatric oncology program—characteristicsofthe
first 200 patients.Journal of Geriatric Oncology,
2010. 1(2): p. 81-86.
77. Sara H Downs, N.B., The feasibility of creating a
checklist for the assessment of the methodological
quality both of randomised and non-randomised
studies of health care interventions. Journal of
Epidemiology and Community Health 1998. 52: p.
377-384.

BSCThesis_11324066

Recommended

Recommended

More Related Content

What's hot

What's hot (15)

Viewers also liked

Viewers also liked (20)

Similar to BSCThesis_11324066

Similar to BSCThesis_11324066 (20)

BSCThesis_11324066