Multidisciplinary assessment of patients with extensive stage small cell lung cancer: A geriatric tumor board

GB, a 74-year-old female with no significant past medical history and active tobacco use disorder of 61 pack-years, underwent a screening computed tomography (CT) of the chest in July 2024. The CT revealed a new, 4.3 × 2.5–cm, spiculated mass in the right upper lobe along with adjacent septal thickening, emphysema, and multiple, stable, subcentimeter pulmonary nodules (Figure 1). (Top Left) Axial CT of the upper thorax on lung windows demonstrates spiculated mass in the right upper lobe along the bronchovascular bundle (yellow arrow). (Top Right) FDG-PET/CT–fused axial image of the upper thorax demonstrates intensely FDG-avid mass in the right upper lobe (blue arrow), corresponding to the primary tumor, as well as intensely FDG-avid prevascular and paratracheal lymphadenopathy (green arrow). (Bottom Left) FDG-PET/CT–fused axial image of the midthorax demonstrates intensely FDG-avid right hilar lymphadenopathy (green arrow) as well as an FDG-avid focus in a thoracic vertebral body (blue arrow), both of which are highly suspicious for metastatic disease. (Bottom Right) FDG-PET/CT–fused axial image of the pelvis demonstrates a rounded focus of intense FDG avidity in the right iliac bone (green arrow) that is highly suspicious for an osseous metastasis. CT indicates computed tomography; FDG, fluorodeoxyglucose; PET, positron emission tomography. A positron-emission tomography–CT confirmed the size and location of the lung lesion, showing intense fluorodeoxyglucose uptake and extensive lymphadenopathy above and below the diaphragm. The scan also revealed numerous additional foci of increased skeletal fluorodeoxyglucose uptake in the axial and left iliac crest regions (Figure 1). A staging brain magnetic resonance image (MRI) showed no suspicious lesions. GB underwent a diagnostic bronchoscopy and endobronchial ultrasound 1 month after her initial presentation. A biopsy of the station 4R lymph node revealed an aggressive neuroendocrine tumor, which tested positive for thyroid transcription factor 1, synaptophysin, and insulinoma-associated protein 11, with an elevated Ki-67 proliferative index. The final diagnosis was extensive-stage small cell lung cancer (ES-SCLC) with bone and liver metastases. Given her advanced age, physicians referred GB to the geriatric-oncology multidisciplinary clinic (GO-MDC) to assess her frailty and stratify her chemotherapy toxicity risk. We used the Katz Index of Independence in Activities of Daily Living (ADL) and the Lawton–Brody Instrumental Activities of Daily Living (IADLs) scale to assess independence in ADLs and IADLs, respectively. GB had urge incontinence but was independent in all other ADLs (bathing, dressing, toileting, transferring, and feeding). She managed all IADLs (telephone use, shopping, food preparation, housekeeping, laundry, transportation, responsibility for medication, and handling of finances) by herself. GB is the caregiver to her husband, and she easily performed physical activities between 4 and 10 metabolic equivalents of task. We use the Timed Up and Go test to assess gait stability and fall risk. However, the patient refused to participate in this test during the visit. She was noted to have swift movements during posture change from sitting to standing and could walk without any evidence of gait instability. She had a seemingly normal gait speed when she got up to leave the room at the end of the appointment. We used the Mini-Cog, a quick screening tool for detecting cognitive impairment. GB scored 1 of 5 points (1 of 3 points on word recall and no points on clock draw). Her daughter did not raise any concerns about cognitive decline. She confirmed that the patient manages the household chores very efficiently and has no difficulty managing the finances or the care of her husband. The patient declined further testing with the Montreal Cognitive Assessment test. We screened for depression with the Patient Health Questionnaire 9, and the low score (3 of 27) supported the patient's history of not having depressed moods. Apart from tobacco use disorder (61 pack-years), the patient had no other comorbidities. GB did not have any prescriptions. She occasionally used over-the-counter acetaminophen for minor aches and pains. The Mini-Nutritional Assessment tool, a validated nutrition screening and assessment tool for the geriatric population, did not identify any risk for malnutrition. The patient had a close-knit family, and her children were fully invested in providing emotional support and practical help as needed. GB wanted treatment for her malignant disease and remains a full code. We used the information obtained from the comprehensive geriatric assessment (CGA) to calculate frailty using the 10-item frailty index designed specifically for older adults with cancer.1 This frailty index quantifies frailty into six stages based on the frailty score. GB's frailty score of 0.1 was in the range of very fit. CGA provides valuable information that assists in estimating life expectancy. A person's nonmalignant comorbidity burden and functional status help determine whether they are in the upper, middle, or lower quartile of life expectancy for their age bracket. Being in the upper or middle quartile of life expectancy for any age indicates greater physiologic reserve and better chances of tolerating aggressive cancer chemotherapy. We used Walter and Covinsky's life tables2 and estimated GB’s life expectancy to be in the upper quartile of her age (approximately 17 years if we considered only her nonmalignant comorbidity burden). To further gauge the efficacy of cancer treatment, we used the Lee index to calculate the estimated 4-year all-cause mortality. It was approximately 15%–20%. In summary, the patient was fit according to the CGA parameters used in the frailty index.1 The Cancer and Aging Research Group Chemotherapy Toxicity Tool (CARG-TT), a calculated score that predicts for grade 3 or higher chemotherapy toxicity, indicated an intermediate risk for GB.3 We discussed in detail that GB has incurable or ES-SCLC. The goal of treatment is to control the cancer with treatment and maintain her quality of life. Based on CGA assessment and an intermediate risk of grade 3 or higher toxicity, we recommended systemic, palliative chemotherapy with carboplatin, etoposide, and an immune checkpoint inhibitor with growth factor support. After a risk/benefit discussion, GB opted for the palliative treatment. After visiting the GO-MDC, she began systemic therapy with carboplatin with an area under the curve of 5 on day 1, atezolizumab 1200 mg on day 1, and etoposide 80 mg/m2 on days 1–3 every 21 days. Apart from mild fatigue and grade 2 anemia, she did not have any significant toxicity. She received cycle 4 of induction chemoimmunotherapy without further dose reduction on October 30, 2024. There was a significant reduction of the mass in the right upper lobe, mediastinal lymphadenopathy, and a liver lesion consistent with treatment response observed on a November 20, 2024, follow-up torso CT (Figure 2). The patient received maintenance atezolizumab, which is being administered every 21 days. Because of a lack of survival benefit from prophylactic cranial radiation (PCI) in ES-SCLC, PCI was declined. (Top Left) Axial CT of the chest on lung windows demonstrates complete resolution of the right upper lobe mass after four cycles of chemoimmunotherapy (yellow arrow). (Top Right) Axial CT of the chest on bone windows after four cycles of chemoimmunotherapy demonstrates sclerosis in the thoracic vertebral body at the site of prior FDG avidity, suggesting bone remodeling at the site of treated disease (green arrow) as well as resolution of the previously seen right hilar lymphadenopathy (blue arrow). (Bottom Left) Axial CT of the pelvis on bone windows after four cycles of chemoimmunotherapy demonstrates sclerosis in the right iliac bone (yellow arrow) at the site of previously FDG-avid focus, suggesting bone remodeling at the site of treated disease. CT indicates computed tomography, FDG, fluorodeoxyglucose; PET, positron emission tomography. Health care providers use CGA to evaluate older cancer patients' ability to tolerate aggressive cancer treatments like chemotherapy. CGA evaluates several domains of functionality in older patients and often uncovers concerning health issues, including cognitive decline, physical frailty, malnutrition, polypharmacy, mood disorders, and inadequate social support, which can influence patients' prognosis. Identifying these problems ensures timely intervention and contributes to improved quality of life. This multidisciplinary approach analyzes data from older patients with cancer and helps create personalized treatment plans. Cognitive impairment can affect decision making and may worsen with chemotherapy. When CGA detects cognitive decline, it highlights the need for a designated power of attorney to assist with decision making and help select treatment options that align with the patient's goals of care.4 Geriatric assessment also includes mood assessment. Studies have demonstrated that depression significantly affects the prognosis of patients who have cancer, regardless of age. Initiating pharmacologic treatment for depression and offering counseling to depressed patients with cancer can improve their prognosis.5, 6 Malnutrition, such as sarcopenia and progressive weight loss, leads to frailty and increases the risk of chemotherapy toxicity. The ability of CGA to detect these issues allows for timely nutrition intervention and physical therapy, which can help build and sustain physical strength and stamina before and during cancer treatment.7, 8 Multiple chronic conditions often increase with age and decrease physiologic reserve, which can affect survival in older patients with cancer. Assessing serious multimorbidity through geriatric assessment facilitates discussions about appropriate goals of care and aids in decision making with regard to nonaggressive treatments.9, 10 Polypharmacy increases the risk of drug interactions and adverse side effects from chemotherapy. Detecting this during the geriatric assessment can help minimize the risks of adverse outcomes.11 Geriatric assessment also offers the opportunity to evaluate the support system in older patients who have cancer. Social isolation, a factor identified in both geriatric and oncology literature, is associated with an increased risk of mortality. Involving a social worker early in cancer treatment ensures the creation of a viable support system to prevent noncompliance and delays in treatment.12, 13 In the current patient, the geriatric assessment revealed no significant deficits in any category except cognition. GB's low performance did not align with the history provided by the patient's daughter or her high functional status. Normal aging causes cognitive changes, such as a decrease in processing speed starting in the 20s and continuing throughout life, as well as some memory decline. New learning, measured by free recall (the ability to remember a list of words), declines gradually up to age 60 years and then more rapidly after that.14 GB's ability to remember only one of three words may be explained by this. Executive function, which includes cognitive skills for problem solving, decision making, planning, attention, and mental flexibility, also declines with age, especially after 70 years. In addition, visuospatial orientation diminishes with age.15 These changes can lead to inferior performance on cognitive tests, especially timed ones, and may explain GB's difficulty showing the correct time on the clock during the Mini-Cog test. However, research suggests that older adults may perform poorly on standardized neuropsychological tests but function as well as younger adults in real-life situations.16 The average age of patients diagnosed with SCLC has increased, with the proportion of those older than 70 years increasing from 23% in 1975 to 44% in 2010, and almost one half of patients with SCLC are older than 70 years.17, 18 Unfortunately, substantial proportions of people with SCLC do not fit within the standard inclusion criteria for clinical trials, specifically, those who are older and/or have a poor Eastern Cooperative Oncology Group (ECOG) performance status (PS). Historically, these two often unrelated categories of patients have frequently been combined in studies. Individual trials have used various definitions of older patient, further complicating the development of clear guidance on managing and treating these challenging patients. Most studies have defined older patients as aged 65 years and older, which aligns with the World Health Organization definition. There are scant data on which to base treatment decisions in individuals older than 80 years. Approximately 40% of patients with SCLC are older than 70 years. In these older patients, treatment of SCLC is more challenging, given the decline in physiologic reserve, increased comorbidities, polypharmacy, cognitive decline, and other age-related medical and social issues. Most of data on the treatment of older patients come from retrospective studies. There are limited prospective data available to guide treatment decisions in this special population. Based on available data, standard approaches are feasible in carefully selected, fit older patients.19 Older patients with ES-SCLC and ECOG PS 0–1/fit patients may be offered standard treatment with carboplatin and etoposide plus immunotherapy (atezolizumab or durvalumab) followed by maintenance immunotherapy. However, the classic tools developed to assess functional status in cancer, such as the ECOG-PS20 and the Karnofsky performance status21 lack validation in an older population. More recently, tools have been developed that focus on an older population. For example, the Cancer and Aging Research Group Toxicity Tool (CARG-TT)3 and the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score compile components of the CGA to predict chemotoxicity.22 The elements of CGA require time and training to deliver. Working together, oncology and geriatric co-management can bring CGA reliably to an older population to modify the outcomes. CARG-TT is a prechemotherapy assessment tool to predict moderate-to-severe chemotherapy toxicity. It is calculated from demographics, tumor, and treatment variables; laboratory test results; and CGA variables (function, comorbidity, cognition, psychological state, social activity/support, and nutritional status). The CARG-TT score ranges from 0 to 19. Each risk category is associated with a percentage likelihood of developing moderate-to-severe toxicity. Low risk is a score of 0–5 (<30%), intermediate risk is a score of 6–9 (40%–60%), and high risk is a score of 10–19 (>70%).3 CGA performed in the GO-MDC, as elaborated in this revealed that this patient had very functional status without impairment noted in cognitive nutritional and She had social support from her She was noted to have life expectancy independent of cancer She was to be a fit older using the information from a the CARG-TT tool an intermediate risk of chemotherapy toxicity (Figure the patient was offered chemoimmunotherapy for ES-SCLC. with from of use for the are available at indicates Cancer and Aging Research Cancer are no studies that specifically the and efficacy of chemoimmunotherapy in older patients with ES-SCLC. However, trials CGA in older patients with other have demonstrated that including of systemic therapy and to physical therapy, nutritional and psychological in better treatment and without The evidence from the of older patients in the plus and plus trials and 13 In the of patients with ES-SCLC and an ECOG PS of were defined as in the of patients were aged 65 years and was to evaluate the of age on but to be no in the benefit of chemoimmunotherapy in older younger patients. evidence and trials are developed for this population, more data is evidence to support the use of chemoimmunotherapy in carefully patients aged 65 years and older with ES-SCLC. We patient with ES-SCLC by using a comprehensive geriatric and her fit for treatment. Based on this she received standard We used the geriatric assessment to guide decision between treatment, dose or especially SCLC is and patients diagnosed with SCLC are older and have comorbidities. goal in a geriatric assessment is to treatment according to patient's functional nutritional and cognitive and their risk of grade 3 toxicity 1 approach to managing older patients with SCLC based on in ADLs and IADLs or no conditions deficits in other domains of CGA or score low to intermediate risk survival to younger patients for toxicity, and adverse to palliative care impairment in function, help with especially and deficits in other such as nutrition status or score intermediate risk for toxicity, and adverse or support for physical therapy to for nutritional to palliative care patients with ECOG PS conditions and in domains of geriatric assessment or score high risk if functional decline by then chemotherapy with or without immunotherapy care not tolerate on for toxicity if treatment is to palliative care is a inhibitor for in patients with ES-SCLC who are chemotherapy. It in from Multiple 2 trials and and have demonstrated that given before chemotherapy significantly including anemia, and In patients had lower of and cell and than those consistent efficacy and in older adults 65 years and The and clinical highlights and in patients without increased serious adverse also factor like bone and data further support and benefit in and bone function, treatment and quality of life in older patients with ES-SCLC. PCI brain in patients with ES-SCLC who to initial studies indicated that PCI brain and improved that PCI brain from to and improved survival from to These to PCI More data survival benefit in the patients who had ES-SCLC without brain identified on to PCI or and no survival PCI brain concerns about toxicity, especially in older, patients. the use of often in older adults at higher risk. Cancer both approaches and decision making based on age, performance comorbidities, and PCI remains in brain but survival benefit remains with The Oncology Group prophylactic cranial (PCI) with in patients who have SCLC and ES-SCLC without brain after initial this has to patients with as the primary end The are not The whether can PCI and side effects Approximately of patients after of maintenance immunotherapy for or is without treatment. We clinical for all patients treatment according to Cancer on the time to from to chemotherapy. A 3 from carboplatin plus etoposide in patients who had previously to plus etoposide but had disease at days after the of treatment therapy improved both the response and was no significant in The lack of survival benefit may be to a in the in which almost 40% of patients received carboplatin plus etoposide as treatment. Toxicity with higher of grade and in patients who received Patients with a can be with plus For patients with a to plus etoposide, a has substantial In a 2 of patients with SCLC and no brain disease had on or after chemotherapy with or without an of with a of response of and with of patients for at 6 patients with a the was in those with a the was This to of a 3 mg/m2 plus mg/m2 on a cycle of combined and or in patients with SCLC to any significant in efficacy between the two 4 in both is a that both 3 which is on all SCLC and which is on to the of SCLC The 2 patients with SCLC who had disease after at two systemic one of which have been a of of patients had received immunotherapy patients had a PS of and patients with previously brain were 10 every 2 is the The was with a response of The was in patients with disease and in patients with disease. The was The and at were and respectively. in of patients grade 1, grade grade The of were and The of was 13 and the was 4 days. all during the in of patients, all of which were grade 1 or with a of 5 during cycle is also in the based on two 3 trials, with an that ranges from to and an of approximately 6 has and as the only by the for patients with options for the treatment of patients with SCLC are based on 2 studies of and or treatments be based on the patient's functional status and clinical in approximately of patients, are are to with a therapy the treatment SCLC is by the of and SCLC is by of protein 1, and are based on the transcription 1 and factor 1 the transcription factor 2 3 and and These for The has high and is an in is a are and is in clinical may have higher and of from the and trials indicated that patients with the had the with the of an immune checkpoint inhibitor to chemotherapy. In the indicated in all the immunotherapy showed improved the had the survival benefit with all other in the immunotherapy this of SCLC cancer is not available in clinical There are clinical trials that are treatments based on the of The Oncology Group to maintenance for patients with ES-SCLC based on After initial the patients to combined with or cell The and evaluates as well as of to improve and The are in older patients with ES-SCLC by treatment age-related comorbidities, and toxicity use combined plus etoposide and immunotherapy as therapy, and cognitive like growth and toxicity help especially in older adults at risk for decline. the past 2 evidence has CGA as for chemotherapy toxicity, and personalized treatment. identify frailty, functional and geriatric to therapy, care and improve the and the CGA to assess and treatment decisions for older patients with as an for The other no of

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.