Management of pancreatic cancer in the elderly

Table 1 Pharmacokinetic changes in the elderly

Physiological process	Situation in the elderly	Changes	Effect
Absorption	Decreased	Atrophy of the intestinal mucosa Decreases in gastrointestinal motility	Reduced absorption of protein, vitamins and drugs
		Decreased splanchnic blood flow
		Decreased secretion of digestive enzymes
Metabolism	Decreased	Reduced liver size	Reduced protein synthesis
		Reduced hepatic blood flow	Reduced activation/deactivation of drugs and carcinogens
		Reduced activity of cytochrome p450-dependant reactions
Drug distribution	Decreased	Reduced total body water	Reduced Vd of water-soluble drugs
		Reduced concentration of plasma albumin	Increased Vd of liposoluble drugs
		Reduced red blood cell concentration
Excretion	Decreased	Reduced glomerular filtration rate	Reduced elimination of drugs and of their active metabolites
		Reduced tubular function

Vd: Volume of distribution.

Table 2 Elements of a comprehensive geriatric assessment

Parameter assessed	Elements and tools of the assessment
Demographic and social status	Questions on living situation, marital status, educational level, safety of the environment, financial resources, caregiver burden
Functional status	Performance status index
	ADLs
	IADLs
	Barthel index
	Pepper assessment tool for disability
	Visual and/or hearing impairment, regardless of use of glasses or hearing aid
	Mobility problem (requiring help or use of walking aid)
	Timed Get Up and Go
	One-leg standing balance test
	Walking problems, gait assessment, and gait speed
	Karnofsky health care professional-rated performance rating scale
Comorbidity	Charlson comorbidity index
	CIRS
	No. of comorbid conditions
	Summary of comorbidities
	NYHA
Cognition	Mini Mental State Examination Informant Questionnaire on Cognitive Decline in the Elderly Modified Mini Mental State Examination
	Clock-drawing test
	Blessed Orientation-Memory-Concentration
Emotional conditions (Depression)	Geriatric Depression Scale
	Hospital Anxiety and Depression Scale
	Mental health index
	Presence of depression (as a geriatric syndrome)
Nutrition	Weight loss (unintentional loss in 3 or 6 mo)
	Mini Nutritional Assessment Short Nutritional
	DETERMINE Nutritional Index
Polypharmacy	Number of medications
	Appropriateness of medications
	Risk of drug interactions
Geriatric syndromes	Dementia
	Delirium
	Depression
	Falls
	Neglect and abuse
	Spontaneous bone fractures and osteoporosis
	Incontinence (fecal and/or urinary)
	Constipation
	Sarcopenia

Data adapted from Wildiers et al[25]. ADL: Activity of daily living; CIRS: Cumulative Illness Rating Scale; CIRS-G: Cumulative Illness Rating Scale-Geriatrics; DETERMINE: Disease, Eating poorly, Tooth loss/mouth pain, Economic hardship, Reduced social contact, Multiple medicines, Involuntary weight loss/gain, Needs assistance in self-care, Elder years > 80; ECOG: Eastern Cooperative Oncology Group; IADL: Instrumental activity of daily living; PS: Performance status; NYHA: New York Heart Association.

Table 3 Baseline characteristics of the Patients in the ACCORD-11 and MPACT trials

Variable	ACCORD-11(FOLFIRINOX)	MPACT (Gemcitabine-Nab-paclitaxel)
Age
Median year (min, max)	61 (25, 76)	63 (27, 88)
≥ 65-yr-old	29.0%	42%
≥ 75-yr-old	-	10%
Performance status (ECOG)
0	37.4%	16%
1	61.9%	44%
2		32%
3		7%