The impact of comorbidity on cancer survival: a review
TL;DR: In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology, and it is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comor bidity.
Abstract: Background A number of studies have shown poorer survival among cancer patients with comorbidity. Several mechanisms may underlie this finding. In this review we summarize the current literature on the association between patient comorbidity and cancer prognosis. Prognostic factors examined include tumor biology, diagnosis, treatment, clinical quality, and adherence. Methods All English-language articles published during 2002-2012 on the association between comorbidity and survival among patients with colon cancer, breast cancer, and lung cancer were identified from PubMed, MEDLINE and Embase. Titles and abstracts were reviewed to identify eligible studies and their main results were then extracted. Results Our search yielded more than 2,500 articles related to comorbidity and cancer, but few investigated the prognostic impact of comorbidity as a primary aim. Most studies found that cancer patients with comorbidity had poorer survival than those without comorbidity, with 5-year mortality hazard ratios ranging from 1.1 to 5.8. Few studies examined the influence of specific chronic conditions. In general, comorbidity does not appear to be associated with more aggressive types of cancer or other differences in tumor biology. Presence of specific severe comorbidities or psychiatric disorders were found to be associated with delayed cancer diagnosis in some studies, while chronic diseases requiring regular medical visits were associated with earlier cancer detection in others. Another finding was that patients with comorbidity do not receive standard cancer treatments such as surgery, chemotherapy, and radiation therapy as often as patients without comorbidity, and their chance of completing a course of cancer treatment is lower. Postoperative complications and mortality are higher in patients with comorbidity. It is unclear from the literature whether the apparent undertreatment reflects appropriate consideration of greater toxicity risk, poorer clinical quality, patient preferences, or poor adherence among patients with comorbidity. Conclusion Despite increasing recognition of the importance of comorbid illnesses among cancer patients, major challenges remain. Both treatment effectiveness and compliance appear compromised among cancer patients with comorbidity. Data on clinical quality is limited.
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TL;DR: Geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments and clinicians should take into account GA results when recommending chemotherapy.
Abstract: Purpose To provide guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. Methods An Expert Panel was convened to develop clinical practice guideline recommendations based on a systematic review of the medical literature. Results A total of 68 studies met eligibility criteria and form the evidentiary basis for the recommendations. Recommendations In patients ≥ 65 years receiving chemotherapy, geriatric assessment (GA) should be used to identify vulnerabilities that are not routinely captured in oncology assessments. Evidence supports, at a minimum, assessment of function, comorbidity, falls, depression, cognition, and nutrition. The Panel recommends instrumental activities of daily living to assess for function, a thorough history or validated tool to assess comorbidity, a single question for falls, the Geriatric Depression Scale to screen for depression, the Mini-Cog or the Blessed Orientation-Memory-Concentration test to screen for cognitive impairment, and an assessment of unintentional weight loss to evaluate nutrition. Either the CARG (Cancer and Aging Research Group) or CRASH (Chemotherapy Risk Assessment Scale for High-Age Patients) tools are recommended to obtain estimates of chemotherapy toxicity risk; the Geriatric-8 or Vulnerable Elders Survey-13 can help to predict mortality. Clinicians should use a validated tool listed at ePrognosis to estimate noncancer-based life expectancy ≥ 4 years. GA results should be applied to develop an integrated and individualized plan that informs cancer management and to identify nononcologic problems amenable to intervention. Collaborating with caregivers is essential to implementing GA-guided interventions. The Panel suggests that clinicians take into account GA results when recommending chemotherapy and that the information be provided to patients and caregivers to guide treatment decision making. Clinicians should implement targeted, GA-guided interventions to manage nononcologic problems. Additional information is available at www.asco.org/supportive-care-guidelines .
835 citations
TL;DR: In the context of cancer patients, this article found that patients who have comorbidity are less likely to receive treatment with curative intent, with the result that they have poorer survival, poorer quality of life and higher health care costs.
Abstract: Answer questions and earn CME/CNE Comorbidity is common among cancer patients and, with an aging population, is becoming more so. Comorbidity potentially affects the development, stage at diagnosis, treatment, and outcomes of people with cancer. Despite the intimate relationship between comorbidity and cancer, there is limited consensus on how to record, interpret, or manage comorbidity in the context of cancer, with the result that patients who have comorbidity are less likely to receive treatment with curative intent. Evidence in this area is lacking because of the frequent exclusion of patients with comorbidity from randomized controlled trials. There is evidence that some patients with comorbidity have potentially curative treatment unnecessarily modified, compromising optimal care. Patients with comorbidity have poorer survival, poorer quality of life, and higher health care costs. Strategies to address these issues include improving the evidence base for patients with comorbidity, further development of clinical tools to assist decision making, improved integration and coordination of care, and skill development for clinicians. CA Cancer J Clin 2016;66:337-350. © 2016 American Cancer Society.
438 citations
TL;DR: The use of a geriatric assessment-based approach to cancer care is discussed, and clinicians are provided with tools to better assess the risks and benefits of treatment to engage in shared decision making and provide better personalised care for older people with cancer.
Abstract: As the worldwide population ages, oncologists are often required to make difficult and complex decisions regarding the treatment of older people (aged 65 years and older) with cancer. Chronological age alone is often a poor indicator of the physiological and functional status of older adults, and thus should not be the main factor guiding treatment decisions in oncology. By contrast, a geriatric assessment can provide a much more comprehensive understanding of the functional and physiological age of an older person with cancer. The geriatric assessment is a multidimensional tool that evaluates several domains, including physical function, cognition, nutrition, comorbidities, psychological status, and social support. In this Series paper, we discuss the use of a geriatric assessment-based approach to cancer care, and provide clinicians with tools to better assess the risks and benefits of treatment to engage in shared decision making and provide better personalised care for older people with cancer.
224 citations
University of North Carolina at Chapel Hill1, Thomas Jefferson University2, University of Rochester3, University of California, San Francisco4, Yale University5, American Society of Clinical Oncology6, Duke University7, City of Hope National Medical Center8, University of Texas Health Science Center at Houston9
TL;DR: The relevance of comorbidities in cancer is discussed, the commonly used tools to measure Comorbidity are examined, and the future direction of comorebidity research is discussed.
187 citations
Cites background from "The impact of comorbidity on cancer..."
...Most observational studies have found that patients with cancer and comorbidities have poorer survival than those without comorbidity [8]....
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...Several studies have found a higher prevalence of comorbidity in early stage cancers [8]....
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...However, whether this is a direct result of increased toxicity, decreased functional status, or is related to poor adherence is unclear [8]....
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...8-fold higher mortality risk [8]....
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TL;DR: The adjusted overall survival of lung cancer patients was negatively associated with the existence of different comorbid conditions such as congestive heart failure, diabetes with complications, moderate or severe liver disease, dementia, renal disease, and cerebrovascular disease, depending on the stage.
Abstract: Background: As the population of the United States ages, there will be increasing numbers of lung cancer patients with comorbidities at diagnosis. Comorbid conditions are important factors in both the choice of the lung cancer treatment and outcomes. However, the impact of individual comorbid conditions on patient survival remains unclear.
Methods: A population-based cohort study of 5,683 first-time diagnosed lung cancer patients was captured using the Nebraska Cancer Registry (NCR) linked with the Nebraska Hospital Discharge Data (NHDD) between 2005 and 2009. A Cox proportional hazards model was used to analyze the effect of comorbidities on the overall survival of patients stratified by stage and adjusting for age, race, sex, and histologic type.
Results: Of these patients, 36.8% of them survived their first year after lung cancer diagnosis, with a median survival of 9.3 months for all stages combined. In this cohort, 26.7% of the patients did not have any comorbidity at diagnosis. The most common comorbid conditions were chronic pulmonary disease (52.5%), diabetes (15.7%), and congestive heart failure (12.9%). The adjusted overall survival of lung cancer patients was negatively associated with the existence of different comorbid conditions such as congestive heart failure, diabetes with complications, moderate or severe liver disease, dementia, renal disease, and cerebrovascular disease, depending on the stage.
Conclusions: The presence of comorbid conditions was associated with worse survival. Different comorbid conditions were associated with worse outcomes at different stages.
Impact: Future models for predicting lung cancer survival should take individual comorbid conditions into consideration. Cancer Epidemiol Biomarkers Prev; 1–7. ©2015 AACR.
138 citations
References
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TL;DR: The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death fromComorbid disease for use in longitudinal studies and further work in larger populations is still required to refine the approach.
39,961 citations
"The impact of comorbidity on cancer..." refers background or methods in this paper
...The score can theoretically range from 0–33 but was collapsed into categories of 0, 1–2, 3–4, and $5 in its initial presentation.(22,23)...
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...The original Charlson measure was constructed to predict 1-year mortality in 559 medical patients as well as 10-year mortality rates for death attributable to comorbid diseases among 685 breast cancer patients.(22) The index is based on 19 distinct medical disease categories....
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TL;DR: The findings challenge the single-disease framework by which most health care, medical research, and medical education is configured, and a complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.
4,839 citations
"The impact of comorbidity on cancer..." refers background in this paper
...Multimorbidity refers to the coexistence of $2 illnesses without identifying an index disease.(14) Comorbidity must also be distinguished from complications that arise as a consequence of the cancer or its treatment....
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TL;DR: The new edition of this classic text remains the definitive dictionary in epidemiology, and the dictionary goes beyond simple definitions, as it place each term firmly and clearly in its fuller epidemiologic context.
Abstract: The new edition of this classic text remains the definitive dictionary in epidemiology. In fact, it is more than a dictionary, with some reviewers remarking that if they had to limit their professional library to one volume, this would be the book they would choose. In the complex field of epidemiology, the definition and concise explanation of terms is a key to understanding epidemiologic concepts, and the dictionary goes beyond simple definitions, as it place each term firmly and clearly in its fuller epidemiologic context. The new edition sees Miguel Porta as editor, with the legendary John Last remaining as associate editor. There are a large number of new terms, and the new edition features new artwork and fresh, new, clean design. There is nothing else like it in epidemiology.
2,198 citations
TL;DR: There is substantial under representation of patients 65 years of age or older in studies of treatment for cancer, and the reasons should be clarified, and policies adopted to correct this underrepresentation.
Abstract: 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...
2,063 citations
TL;DR: A Cumulative Illness Rating Scale, designed to meet the need for a brief, comprehensive and reliable instrument for assessing physical impairment, has been developed and tested and is well suited to a variety of research uses.
Abstract: A Cumulative Illness Rating Scale, designed to meet the need for a brief, comprehensive and reliable instrument for assessing physical impairment, has been developed and tested. The scale format provides for 13 relatively independent areas grouped under body systems. Ratings are made on a 5-point “degree of severity” scale, ranging from “none” to “extremely severe.” Findings, in terms of reliability and validity, reflect statistical significance at the P < .01 level. As a rapid assessment technique which is objective and easily quantified, the scale is well suited to a variety of research uses.
2,023 citations