Background Studies have documented the underrepresentation of women and blacks in clinical trials, and their recruitment is now federally mandated. However, little is known about the level of participation of elderly patients. We determined the rates of enrollment of patients 65 years of age or older in trials of treatment for cancer. Methods We analyzed data on 16,396 patients consecutively enrolled in 164 Southwest Oncology Group treatment trials between 1993 and 1996 according to sex, race (black or white), and age under 65 years or 65 or older. These rates were compared with the corresponding rates in the general population of patients with cancer, derived from the 1990 U.S. Census and from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program for the period from 1992 through 1994. Fifteen types of cancer were included in the analysis. Results The overall proportions of women and blacks enrolled in Southwest Oncology Group trials were similar to or the same as the estimat...

https://www.nejm.org/doi/pdf/10.1056/NEJM199912303412706

Underrepresentation of patients 65 years of age or older in cancer-treatment trials.

Methods: A cross-sectional analysis was conducted on a nationally random sample of 1217103 Medicare feefor-service beneficiaries aged 65 and older living in the United States and enrolled in both Medicare Part A and Medicare Part B during 1999. Multiple logistic regression was used to analyze the influence of age, sex, and number of types of chronic conditions on the risk of incurring inpatient hospitalizations for ambulatory care sensitive conditions and hospitalizations with preventable complications among aged Medicare beneficiaries. Results: In 1999, 82% of aged Medicare beneficiaries had 1 or more chronic conditions, and 65% had multiple chronic conditions. Inpatient admissions for ambulatory care sensitive conditions and hospitalizations with preventable complications increased with the number of chronic conditions. For example, Medicare beneficiaries with 4 or more chronic conditions were 99 times more likely than a beneficiary without any chronic conditions to have an admission for an ambulatory care sensitive condition (95% confidence interval, 86-113). Per capita Medicare expenditures increased with the number of types of chronic conditions from $211 among beneficiaries without a chronic condition to $13973 among beneficiaries with 4 or more types of chronic conditions. Conclusions: The risk of an avoidable inpatient admission or a preventable complication in an inpatient setting increases dramatically with the number of chronic conditions. Better primary care, especially coordination of care, could reduce avoidable hospitalization rates, especially for individuals with multiple chronic conditions.

/pdf/prevalence-expenditures-and-complications-of-multiple-4mi1gwp4mw.pdf

Prevalence, expenditures, and complications of multiple chronic conditions in the elderly

Purpose By 2030, the United States' population will increase to approximately 365 million, including 72 million older adults (age ≥ 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 9...

Future of Cancer Incidence in the United States: Burdens Upon an Aging, Changing Nation

Context Patients with cancer often have other medical ailments, referred to as comorbidity. Comorbidity may impact treatment decision-making, prognosis, and quality of care assessment. Objective To assess whether comorbidity information can provide important prognostic information in a hospital-based cancer registry. Design, setting, and participants An observational prospective cohort study using comorbidity data collected by trained hospital-based cancer registrars. Comorbidity was obtained through medical record review using the Adult Comorbidity Evaluation 27, a validated chart-based comorbidity instrument. A total of 17,712 patients receiving care between January 1, 1995, and January 31, 2001, for the primary diagnosis of new cancer of the prostate, lung (nonsmall cell), breast, digestive system, gynecological, urinary system, or head and neck were included. Main outcome measure Duration in months of overall survival. Results A total of 19,268 patients were included in the study; median duration of follow-up was 31 months. Of these patients, 1556 (8.0%) were excluded due to missing or unknown data. Severity of comorbidity strongly influenced survival in a dose-dependent fashion and the impact of comorbidity was independent of cancer stage. Compared with patients without comorbidity, the adjusted hazard ratio associated with mild comorbidity was 1.21 (95% confidence interval [CI], 1.13-1.30), moderate comorbidity was 1.86 (95% CI, 1.73-2.00), and severe comorbidity was 2.56 (95% CI, 2.35-2.81). Adjusted Kaplan-Meier survival curves revealed that at any point in time the patients with more severe levels of comorbidity had worse survival (partial chi2(3) due to comorbidity, 523.54; P Conclusions Comorbidity is an important independent prognostic factor for patients with cancer. The inclusion of comorbidity in hospital-based cancer registries will increase the value and use of observational research.

https://jamanetwork.com/journals/jama/articlepdf/198808/JOC32516.pdf

Prognostic importance of comorbidity in a hospital-based cancer registry

Objective. —To provide recommendations for cancer surveillance and risk reduction for individuals carrying mutations in the BRCA1 or BRCA2 genes. Participants. —A task force with expertise in medical genetics, oncology, primary care, gastroenterology, and epidemiology convened by the Cancer Genetics Studies Consortium (CGSC), organized by National Human Genome Research Institute (previously the National Center for Human Genome Research). Evidence. —Studies evaluating cancer risk, surveillance, and risk reduction in individuals genetically susceptible to breast and ovarian cancer were identified using MEDLINE (National Library of Medicine) and from bibliographies of articles thus identified. Indexing terms used were "genetics" in combination with "breast cancer," "ovarian cancer," and "screening," or "surveillance" in combination with "cancer family" and " BRCA1 " and " BRCA2 ." For studies evaluating specific interventions, quality of evidence was assessed using criteria of the US Preventive Services Task Force. Consensus Process. —The task force developed recommendations through discussions over a 14-month period. Conclusions. —Efficacy of cancer surveillance or other measures to reduce risk in individuals who carry cancer-predisposing mutations is unknown. Based on expert opinion concerning presumptive benefit, early breast cancer and ovarian cancer screening are recommended for individuals with BRCA1 mutations and early breast cancer screening for those with BRCA2 mutations. No recommendation is made for or against prophylactic surgery (eg, mastectomy, oophorectomy); these surgeries are an option for mutation carriers, but evidence of benefit is lacking, and case reports have documented the occurrence of cancer following prophylactic surgery. It is recommended that individuals considering genetic testing be counseled regarding the unknown efficacy of measures to reduce risk and that care for individuals with cancer-predisposing mutations be provided whenever possible within the context of research protocols designed to evaluate clinical outcomes.

https://jamanetwork.com/journals/jama/articlepdf/414827/jama_277_12_035.pdf

Recommendations for follow-up care of individuals with an inherited predisposition to Cancer. II. BRCA1 and BRCA2

Context Postmenopausal women aged 55 years and older have 66% of incident breast tumors and experience 77% of breast cancer mortality, but other age-related health problems may affect tumor prognosis and treatment decisions. Objective To document the comorbidity burden of postmenopausal breast cancer patients and evaluate its relationship with age on disease stage, treatment, and early mortality. Design and Setting Data were collected on breast cancer patients’ comorbidities by retrospective hospital medical records review and merged with information on patients’ tumor characteristics collected from 6 regional National Cancer Institute Surveillance, Epidemiology, and End Results cancer registries. Patients were followed up until death or for 30 months from breast cancer diagnosis. Participants Population-based random sample of 1800 postmenopausal breast cancer patients diagnosed in 1992 stratified by 3 age groups: 55 to 64 years, 65 to 74 years, and 75 years and older. Main Outcome Measures Extent of disease, therapy received, comorbidity, cause of death, and survival. Results Seventy-three percent (1312 of 1800) of the sample was diagnosed with stage I and II breast cancer, 10% (n=188) with stage III and IV breast cancer, and 17% (n=300) did not have a stage assignment. Of the 1017 patients with stage I and stage II node-negative breast cancer, 95% received therapy in agreement with the National Institutes of Health consensus statement recommendation for early-stage breast cancer. Patients in older age groups were less likely to receive therapy consistent with the consensus statement (P,.001), and women aged 70 years and older were significantly less likely to receive axillary lymph node dissection as determined by logistic regression analysis (P,.01). Diabetes, renal failure, stroke, liver disease, a previous malignant tumor, and smoking were significant in predicting early mortality in a statistical model that included age and disease stage. Breast cancer was the underlying cause of death for 135 decedents (51.3%). Heart disease (n=45, 17.1%) and previous cancers (n=22, 8.4%) were the next major underlying causes. In the 30-month follow-up period, 263 patients (15%) died. Conclusion Patient care decisions occur in the context of breast cancer and other age-related conditions. Comorbidity in older patients may limit the ability to obtain prognostic information (ie, axillary lymph node dissection), tends to minimize treatment options (eg, breast-conserving therapy), and increases the risk of death from causes other than breast cancer.

/pdf/effect-of-age-and-comorbidity-in-postmenopausal-breast-4htdi56jc8.pdf

Effect of Age and Comorbidity in Postmenopausal Breast Cancer Patients Aged 55 Years and Older

Cytosine arabinoside with daunorubicin or adriamycin for therapy of acute myelocytic leukemia: a CALGB study

Cytosine arabinoside (NSC-63878) and daunorubicin (NSC-83142) therapy in acute nonlymphocytic leukemia.

Over 43% of the newly diagnosed breast cancers in the US occur in women 65 years or older. Yet little attention is devoted to the age-associated aspects of this malignancy. This study uses data on more than 125,000 women diagnosed from 1973 to 1984 to examine the influence of advancing age on breast cancer. The National Cancer Institute's Surveillance, Epidemiology, and End Results Program provides information on disease stage, surgery, histologic type, and survival time to compare and contrast women in all age groups. Women who present initially with distant disease are more likely to be elderly. Certain surgical procedures are used less frequently for older women. No unusual age variations in histologic features are noted. Elderly women do as well as younger patients in survival time for localized and regional stages of breast cancer; for distant disease, they fare worse. Results emphasize the need to focus on elderly women for screening, early detection, diagnostic evaluation, and therapy.

Breast cancer in aging women. A population-based study of contrasts in stage, surgery, and survival.

To determine the relation between breast self-examination performance and the clinical and pathological stage of breast cancer at first diagnosis, we studied 335 patients with breast cancer. Approximately one fourth of the patients reported that they had been practicing monthly breast self-examination, and half that they had never practiced breast self-examination. More frequent performance of breast self-examination was associated with more favorable clinical stage and fewer axillary-lymph-node metastases on histologic examination. On pathological examination, the age-adjusted maximum tumor diameter of patients practicing monthly breast self-examination was 1.97±0.22 cm (mean ± S.E.M.) as compared to 2.47±0.20 for those performing selfexamination less often than monthly and 3.59±0.15 for patients never performing breast self-examination. These data associating more favorable clinical and pathological stages of breast cancer with more frequent breast self-examination need to be extended by determ...

Jerome W. Yates

Papers

Effect of Age and Comorbidity in Postmenopausal Breast Cancer Patients Aged 55 Years and Older

Cytosine arabinoside with daunorubicin or adriamycin for therapy of acute myelocytic leukemia: a CALGB study

Cytosine arabinoside (NSC-63878) and daunorubicin (NSC-83142) therapy in acute nonlymphocytic leukemia.

Breast cancer in aging women. A population-based study of contrasts in stage, surgery, and survival.

Breast self-examination practices and breast-cancer stage.