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Background: Establishing an accurate prognosis remains challenging in older cancer patients because of the population’s heterogeneity. Using machine learning, we developed and externally validated a new predictive score (the “Geriatric Cancer Scoring System”, GCSS) to refine individualized prognosis for older patients with cancer during the first year following a geriatric assessment (GA). Methods: Data were collected from two French prospective multicentre cohorts of cancer patients aged 70 and over referred for GA: ELCAPA (training set, n=2012) and ONCODAGE (validation set, n=1397). Candidate predictors included baseline oncological and geriatric factors and routine biomarkers. Predictive models were built using Cox regression, single decision tree (DT), and random survival forest (RSF) methods, comparing their predictive performance for 3-, 6- and 12-month mortality by computing externally validated Harrell’s C-indices. Findings: At 12 months, respectively 875 (43%) and 219 (16%) patients in the training and validation sets had died (mean age at baseline: 81±6 and 78±5, respectively; women: 47% and 70%; metastatic cancer: 50% and 34%). Tumour site/metastatic status, cancer treatment, weight loss >3 kg (previous 3 months), 5 or more prescription drugs, Eastern Cooperative Oncology Group-Performance Status ≥2, Activities of Daily Living score ≤5, impaired timed up-and-go test, low creatinine clearance and elevated CRP/albumin were identified as independent predictors in the Cox model. DT and RSF identified more complex combinations of features, with the G-8 score, the tumour site/metastatic status and the CRP/albumin ratio contributing most to the predictions. The RSF approach gave the highest C-index (3 months: 0.91 [RSF], 0.88 [Cox], 0.87 [DT]; 12 months: 0.86 [RSF], 0.82 [Cox], 0.81 [DT]) and was thus retained as the final model. Interpretation: The GCSS based on a random forest machine learning approach gave an accurate externally validated 3-, 6- and 12-month mortality prediction. The GCSS might improve decision-making processes and counselling in older cancer patients. Funding Information: The ELCAPA study was funded by the French National Cancer Institute (Institut National du Cancer, INCa); Canceropole Ile-de-France; and Gerontopole Ile-de-France (Gerond’If). The ONCODAGE project was funded by the French National Cancer Institute (Institute National du Cancer); and SIRIC BRIO (Site de Recherche Integree sur le Cancer – Bordeaux Recherche Integree Oncologie; grant: INCa-DGOS-Inserm 6046). Declaration of Interests: None declared. Ethics Approval Statement: Two French prospective multicentre cohorts were considered in the present study. The study protocols were approved by the appropriate independent ethics committees (ELCAPA: CPP Ile-de-France I, Paris, France; ONCODAGE: CPP Sud-Ouest et Outre Mer III).

Objective The role of treatment with renin-angiotensin-aldosterone system blockers at the onset of COVID-19 infection is not known in geriatric population. The aim of this study was to assess the relationship between angiotensin receptor blockers (ARB) and an ACE inhibitor (ACEI) use and in-hospital mortality in geriatric patients hospitalized for COVID-19. Design This observational retrospective study was conducted in a French geriatric department. Patients were included between March 17 and April 18, 2020. Setting and Participants: All consecutive 201 patients hospitalized for COVID-19 (confirmed by RT-PCR methods) were included. All non-deceased patients had 30 days of follow-up and no patient was lost to follow-up. Methods Demographic, clinical, biological data and medications were collected. In-hospital mortality of patients treated or not by ACEI/ARB was analyzed using multivariate Cox models. Results Mean age of the population was 86.3 (8.0) years old, 62.7% of patients were institutionalized, 88.6% had dementia and 53.5% had severe disability (ADL score < 2). Sixty-three patients were treated with ACEI/ARB and 138 were not. Mean follow-up was 23.4 (10.0) days, 66 (33.8%) patients died after an average of 10.0 days (6.0). Lower mortality rate was observed in patients treated with ACEI/ARB compared with patients not treated with ARB nor ACEI (22.2% (14) vs. 37.7% (52), HR = 0.54 (95% CI = 0.30-0.97), p=0.03). In a multivariate Cox regression model including age, sex, ADL score, Charlson index, renal function, dyspnea, CRP and white blood cells count, use of ACEI/ARB was significantly associated with lower in-hospital mortality (HR = 0.52 (0.27−0.99), p=0.048). Conclusion and Implications In very old subjects hospitalized in geriatric settings for COVID-19, mortality was significantly lower in subjects treated with ARB or ACEI prior to the onset of infection. The continuation of ACEI/ARB therapy should be encouraged during periods of coronavirus outbreak in older subjects., In very old subjects hospitalized for COVID-19 in geriatric settings, mortality was significantly lower in those treated with ARB or ACEI prior to the onset of infection.

Simple Summary Screening tools have been developed to identify patients warranting complete geriatric assessment (GA). However, GA lacks standardization and does not capture important aspects of geriatric oncology practice such as actual treatment decisions based on GA findings, expert-based clinical classifications, and/or broader approaches to frailty. We compared the diagnostic performance of screening tools G8 and modified G8 according to: (1) the detection of ≥1 or (2) ≥2 GA impairments, (3) the prescription of ≥1 geriatric intervention and identification of an unfit profile according to (4) a latent class typology, expert-based classifications from (5) Balducci, (6) the International Society of Geriatric Oncology task force (SIOG), and (7) a GA frailty index according to the Rockwood accumulation of deficits. Our findings support the clinical value of the original and modified G8 for detecting a variety of health profiles evocative of frailty in older cancer patients, with evidence of better diagnostic performance of the modified G8 than that of the original G8. Abstract Screening tools have been developed to identify patients warranting a complete geriatric assessment (GA). However, GA lacks standardization and does not capture important aspects of geriatric oncology practice. We measured and compared the diagnostic performance of screening tools G8 and modified G8 according to multiple clinically relevant reference standards. We included 1136 cancer patients ≥ 70 years old referred for GA (ELCAPA cohort; median age, 80 years; males, 52%; main locations: digestive (36.3%), breast (16%), and urinary tract (14.8%); metastases, 43.5%). Area under the receiver operating characteristic curve (AUROC) estimates were compared between both tools against: (1) the detection of ≥1 or (2) ≥2 GA impairments, (3) the prescription of ≥1 geriatric intervention and the identification of an unfit profile according to (4) a latent class typology, expert-based classifications from (5) Balducci, (6) the International Society of Geriatric Oncology task force (SIOG), or using (7) a GA frailty index according to the Rockwood accumulation of deficits principle. AUROC values were ≥0.80 for both tools under all tested definitions. They were statistically significantly higher for the modified G8 for six reference standards: ≥1 GA impairment (0.93 vs. 0.89), ≥2 GA impairments (0.90 vs. 0.87), ≥1 geriatric intervention (0.85 vs. 0.81), unfit according to Balducci (0.86 vs. 0.80) and SIOG classifications (0.88 vs. 0.83), and according to the GA frailty index (0.86 vs. 0.84). Our findings demonstrate the robustness of both screening tools against different reference standards, with evidence of better diagnostic performance of the modified G8.

Angiogenesis inhibition is a major antitumor strategy that has emerged during the last decade. Oral tyrosine kinase inhibitors (TKI) targeting the VEGF receptor, including sunitinib, sorafenib, axitinib, regorafenib, pazopanib, and vandetanib reduce tumor growth and metastasis. These agents are approved for the treatment of metastatic diseases in first or second-line. They display a narrow therapeutic index. However, data in the elderly and/or in patients with multiple illnesses remain scarce. This population is classically excluded from clinical trials. The aim of this review is to provide an overview of existing literature regarding antiangiogenic TKI tolerance in the elderly (>70 years old). We also highlight key points of the pre-therapeutic evaluation and summarize the management of common toxicities.

Background The expression of depressive symptoms in older people with cancer is heterogeneous because of specific features of age or cancer comorbidity. We aimed to identify depressive symptom profiles in this population and describe the associated features including survival. Materials and methods Patients ≥70 years who were referred to geriatric oncology clinics were prospectively included in the ELCAPA study. In this subanalysis, depressive symptoms were used as indicators in a latent class analysis. Multinomial multivariable logistic regression and Cox models examined the association of each class with baseline characteristics and mortality. Results For the 847 complete-case patients included (median age, 79 years; interquartile range, 76-84; women, 47.9%), we identified five depressive symptom classes: "no depression/somatic only" (38.8%), "no depression/pauci-symptomatic" (26.4%), "severe depression" (20%), "mild depression" (11.8%), and "demoralization" (3%). Compared with the no depression/pauci-symptomatic class, the no depression/somatic only and severe depression classes were characterized by more frequent comorbidities with poorer functional status and higher levels of inflammation. "Severe" and "mild" depression classes also featured poorer nutritional status, more medications, and more frequent falls. Severe depression was associated with poor social support, inpatient status, and increased risk of mortality at 1 year (adjusted hazard ratio, 1.62, 95% confidence interval, 1.06-2.48) and 3 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.06-2.10). Conclusion A data-driven approach based on depressive symptoms identified five different depressive symptom profiles, including demoralization, in older patients with cancer. Severe depression was independently and substantially associated with poor survival. Implications for practice Older patients with cancer present with distinct profiles of depressive symptomatology, including different severity levels of depression and the demoralization syndrome. Clinicians should use a systematic assessment of depressive symptoms to adequately highlight these distinct profiles. Geriatric and oncological features are differently associated with these profiles. For instance, severe depression was associated with more frequent comorbidities with poorer functional, poor nutritional status, polypharmacy, frequent falls, inpatient status and poor social support. Also, severe depression was independently and substantially associated with poor survival so that the identification and management of depression should be considered a high priority in this population.

Summary Introduction Coming from literature and medicine and medical humanities north American seminars, narrative medicine has applied narratology for analyzing patients’ discourse and has been taught during a decade. Methods At Paris Descartes School of Medicine a twenty-hour narrative medicine elective program including whole class lectures and writing and reading small group exercises for second year medical students has been assessed using satisfaction questionnaires. Results Although several students were uncomfortable with the first writing and reading exercises, the whole satisfaction scores demonstrate that this new program is very well appreciated even when students did not choose this program because they were interested with the patient physician relationship. These results have been confirmed when all students state this program should be continued and when half of them state this program should be offered to more students or made mandatory. Discussion The primary focus on literary characteristics of patients’ and physicians’ discourses, without ignoring psychoanalysis theory, has shown to be safe for young students. Writing exercises are encouraged but not mandatory, and reading is optional if ever they feel embarrassed after producing their own texts. Narrative medicine impact on students’ attitudes and behaviors has now to be assessed before implementing new educational programs.

Objectifs L’objectif principal etait l’identification de profils distincts de symptomatologie depressive chez les patients âges atteints de cancer. Les objectifs secondaires etaient l’identification des facteurs associes a ces profils et de leur impact pronostique. Methode L’etude portait sur les 1086 patients inclus dans la cohorte ELCAPA de 2007 a 2012, âges de 70 ans ou plus, atteints d’un cancer, et ayant eu une evaluation geriatrique dont une evaluation thymique avant traitement. Les profils ont ete identifies par une analyse en classes latentes (ACL) construite avec les symptomes depressifs comme indicateurs, le choix du meilleur modele etant guide par des criteres de parcimonie (critere d’Akaike modifie et BIC ajuste) et d’ajustement (« Bootstrap Likelihood Ratio Test »). Les caracteristiques demographiques, oncologiques, geriatriques et biologiques associees aux classes obtenues ont ete decrites par la regression logistique multinomiale uni et multivariee. La valeur pronostique des clusters a ete exploree par une analyse de survie univariee (medianes de survie et courbes de Kaplan–Meier), et multivariee (modele semi-parametrique de Cox), a un et trois ans. Resultats Nous avons identifies cinq profils de symptomatologie depressive sur 847 cas-complets (âge median 79 ans ; 47,9 % de femmes) : 1 « somatique » (35,8 %), 2 « pauci-symptomatique » (26,4 %), 3 « depression majeure » (19,9 %), 4 « depression mineure » (13,8 %) et 5 « demoralisation » (4,1 %). La classe 5 « demoralisation » etait caracterisee par un profil atypique associant la presence de cognitions depressives et l’absence d’anhedonie. En comparaison a la classe 2 « pauci-symptomatique », les patients des classes 1 « somatique » et 3 « depression majeure » avaient un niveau de comorbidite et de retentissement fonctionnel plus eleve (p = 0,028 et 0,004). Les patients de la classe 1 « somatique » avaient plus de metastases et un statut nutritionnel altere (p = 0,03 et 0,028). Les patients des classes 3 « depression majeure » et 4 « depression mineure » avaient aussi un statut nutritionnel plus altere (p Conclusion Cinq profils differents de symptomatologie depressive ont ete identifies chez les sujets âges atteints de cancer. Des differences portant sur le statut nutritionnel, la polymedication, le niveau de comorbidite et leur retentissement fonctionnel, la presence d’une hospitalisation a l’evaluation et l’environnement social etaient associees a la presence de ces differents profils. Une depression « majeure » (classe 3) etait un facteur independant de mauvais pronostic, ce qu’aucune etude originale n’avait confirme dans une population de sujets âges.

Angiogenesis inhibition is a major antitumor strategy that has emerged during the last decade. Oral tyrosine kinase inhibitors (TKI) targeting the VEGF receptor, including sunitinib, sorafenib, axitinib, regorafenib, pazopanib, and vandetanib reduce tumor growth and metastasis. These agents are approved for the treatment of metastatic diseases in first or second-line. They display a narrow therapeutic index. However, data in the elderly and/or in patients with multiple illnesses remain scarce. This population is classically excluded from clinical trials. The aim of this review is to provide an overview of existing literature regarding antiangiogenic TKI tolerance in the elderly (70 years old). We also highlight key points of the pre-therapeutic evaluation and summarize the management of common toxicities.

9537 Background: Given the median age of 70 years in patients (pts) presenting NSCLC, the impact of age on outcomes including efficacy and toxicity of erlotinib remains unclear. In the BR21 study, ...

Isolated systolic hypertension is an important cardiovascular risk factor in the elderly. In addition to systolic blood pressure, pulse pressure, pulse wave velocity, and carotid wave reflections are also strong cardiovascular risk factors in the elderly, as a consequence of the two main determinants of systolic hypertension: increased arterial stiffness and early wave reflections. Taken together, all these findings should help to optimize drug treatment, which has been shown to produce important but thus far insufficient beneficial effects on cardiovascular morbidity and mortality.

170 Background: Older age is a cause of disparity in cancer treatment decision and treatment guidelines for patients with comorbidities, polypharmacy, denutrition or psycho-social frailty are needed. A pre-therapeutic multidimensional assessment might improve the complex patient management. We developed an experimental program of integrated medicine called ARIANE. We report 18 months activity of this outpatient setting evaluation, its feasibility and impact on treatment decision-making. Methods: Complex patients with predefined cancer treatment strategy entered into the program. A one-day evaluation combined consultations of cardiologist, geriatrician, diabetologist, anesthetist, pharmacist, pain specialist, dietician, psychologist and social worker. Evaluation of performance status, EKG, ejection fraction, ASA score, diabetes, social vulnerability and malnutrition was performed including a geriatric assessment, which focused on items like comorbidity (CIRS-G), dependance (ADL, IADL), fails (Up and Go Test), cognitive impairment (MMSE, Clock Drawing Test) and depression (GDS scale). A pharmacist assessed the risk of drug-drug interactions. Results: Eighty-seven pts, median age 81 years (range 25-94), 76% male, 51% PS 0-1, 77% grade 3 or 4 comorbidity were included. Genito-urinary, lung cancers and sarcoma represented 77% of pts. Eighty-two percent of pts were assessed by at least ≥ 7 participants. Identified factors of vulnerability were polypharmacy (n=65; 75%; >3 drugs), social distress or severe malnutrition (both n=21; 24%), depression (n=17; 19.5%) and cognitive impairment (n=13; 15%). We identified drug interaction in 18 pts (27%). The risk assessment resulted in anticancer treatment changes in 47/87 patients (54%): protocol adaptation (n=19/87; 22%), less aggressive treatment (n=15/87; 17.2%), or more intensive therapy (n=13/87; 15%). Conclusions: A one-day multidisciplinary risk assessment is an answer to the complexity of unfit cancer patients and improves the safety of anticancer treatments.

e20523 Background: Elderly people represent a growing population susceptible to be treated with sunitinib (SU). The aim of this retrospective study was to explore the relationship between SU exposu...

11516 Background: Accurate prognosis is crucial to decision making in oncology, but remains challenging in older patients due to the heterogeneity of this population and the lack of ability of current models to capture complex interactions between oncological and geriatric predictors. We aimed to develop new predictive algorithms based on machine learning to refine individualized prognosis in older patients with cancer. Methods: Data were collected from 3409 patients ≥70 years referred to geriatric oncology clinics for completion of a geriatric assessment (GA), including 2012 and 1397 patients from the ELCAPA (training set) and ONCODAGE (validation set) French prospective cohorts, respectively. Candidate predictors included baseline oncological and geriatric parameters, G-8 score and routine biological data (CRP/albumin ratio). Prognostic models for 12-months mortality were built using Cox regression model, single decision tree (DT) and random survival forest (RSF). Models performance was compared based on externally validated Harrell’s C-indexes. Results: During the 1-year study period, 875 (43%) and 219 (16%) patients died in the training and validation sets, respectively (mean age: 81±6 / 78±5, women 47% / 70%, metastasis 50% / 34%). Cox model identified 9 independent predictors of mortality: tumor site/metastatic status, anticancer treatment, weight loss > 3kg, drugs > 5, renal failure, increased CRP/Albumin, ECOG-PS≥2, ADL≤5 and altered TGUG. DT identified more complex combinations between features, yielding 16 patient groups with highly differentiated survival, notably depending on the G-8 ( < 10 vs. ≥10 as the root node). RFS had the highest C-index (0.86 [RFS], 0.82 [Cox], 0.81 [DT]), identifying the G-8, CRP/albumin and tumor site/metastasis as the most important features. Conclusions: While Cox modeling confirmed known independent prognostic factors, DT revealed more complex interactions between them and random forest achieved superior prognostic performance by better capturing patient’s complexity. The latter model has been implemented into an interactive web interface for easy and direct use in clinical practice. Clinical trial information: NCT02884375.

ObjectiveDirect oral anticoagulants have been evaluated in the general population, but proper evidence for their safe use in the geriatric population is still missing. We compared the bleeding risk of a direct oral anticoagulant (rivaroxaban) and vitamin K antagonists (VKAs) among French geriatric patients with non-valvular atrial fibrillation (AF) aged ≥80 years.MethodsWe performed a sequential observational prospective cohort study, using data from 33 geriatric centres. The sample comprised 908 patients newly initiated on VKAs between September 2011 and September 2014 and 995 patients newly initiated on rivaroxaban between September 2014 and September 2017. Patients were followed up for up to 12 months. One-year risks of major, intracerebral, gastrointestinal bleedings, ischaemic stroke and all-cause mortality were compared between rivaroxaban-treated and VKA-treated patients with propensity score matching and Cox models.ResultsMajor bleeding risk was significantly lower in rivaroxaban-treated patients (7.4/100 patient-years) compared with VKA-treated patients (14.6/100 patient-years) after multivariate adjustment (HR 0.66; 95% CI 0.43 to 0.99) and in the propensity score–matched sample (HR 0.53; 95% CI 0.33 to 0.85). Intracerebral bleeding occurred less frequently in rivaroxaban-treated patients (1.3/100 patient-years) than in VKA-treated patients (4.0/100 patient-years), adjusted HR 0.59 (95% CI 0.24 to 1.44) and in the propensity score–matched sample HR 0.26 (95% CI 0.09 to 0.80). Major lower bleeding risk was largely driven by lower risk of intracerebral bleeding.ConclusionsOur study findings indicate that bleeding risk, largely driven by lower risk of intracerebral bleeding, is lower with rivaroxaban than with VKA in stroke prevention in patients ≥80 years old with non-valvular AF.