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Geriatric radiotherapy in a war-torn country: Experience from Iraq
JGO-00525; No. of pages: 7; 4C: Journal of Geriatric Oncology xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Journal of Geriatric Oncology
Geriatric radiotherapy in a war-torn country: Experience from Iraq Ali H. Gendari a, Hazha A. Ameen b, Zhian S. Ramzi b, Asso F. Amin b, Shwan A. Mohammed c, Sazgar S. Majeed c, Jalil S. Ali c, Nyan O. Saeed c, Bamo M. Muhsin c, Kamaran A. Mohammed c, Layth Mula-Hussain d,⁎ a
Mosul Oncology Hospital, Mosul, Nineveh, Iraq University of Sulaimani, Sulaimani, Kurdistan, Iraq Zhianawa Cancer Center, Sulaimani, Kurdistan, Iraq d Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada b c
a r t i c l e
i n f o
Article history: Received 21 December 2017 Received in revised form 19 February 2018 Accepted 13 March 2018 Available online xxxx Keywords: Geriatric Radiotherapy Oncology Iraq
a b s t r a c t Introduction: Cancer prevalence and geriatric patients (GP) are increasing and about half of the patients with cancer will be offered radiotherapy (RT). Addressing GP and their RT needs is an important issue in order to understand this heterogeneous group of patients. Materials and Methods: A descriptive cross-sectional study, using a convenience sample from Sulaimani city's inhabitants, aged 70-year and more, who were treated with RT at the only city's RT center, Zhianawa Cancer Center (ZCC), in 2015. Results: 153 patients' charts were reviewed. GP represented 20% of the patients referred to ZCC. Male: Female ratio was 3:1. One third presented with distant metastases, and 46% were treated with curative intent versus 54% with palliative intent. 94% completed the planned sessions of the curative RT vs 90% of the palliative RT. 23% of GP who were referred for RT didn't receive it. 9% got interruptions during RT course. 10% of GP living N40 km away from the treatment center refused treatment. Mean time interval between the date of referral and the date of starting treatment in the palliative setting was 19 days. Only 41% of patients with curative setting had regular follow-up. Conclusions: Being the 1st study in this regard in a war-torn nation, Iraq, our results demonstrated that GP is a sizable group of ZCC patients and that RT is a valuable modality in GP cancer treatment. “Age per se” is not a factor to avoid this modality when there is an indication to use it. Longer distance to reach the center was a challenge in some of our GP. Due to inadequate number of RT machines, GP have to wait long time before getting their RT, even for palliative purposes. Further studies in this field are warranted. © 2018 Published by Elsevier Ltd.
1. Introduction Cancer is the second most common cause of death after age 65 [1], and most common cancers become more frequent with age. The older patient population with cancer is a heterogeneous group, ranging from competent, active, and fit individuals to those who are frail and cognitively impaired. Older adults with cancer have different needs than younger adults [2]. Radiotherapy (RT) is a well-established treatment in cancer and about half of patients with cancer will be offered RT at some point along the course of their diseases and the role of RT in the treatment of older patients with cancer is on the rise [3]. Compared with developed countries, the population of the Middle East (ME) is relatively young and the percentage of population over age of 65 in the ME and Northern Africa (MENA) is estimated at 4.7% [4]. However, ME population will further age in the near future and
⁎ Corresponding author. E-mail address: [email protected] (L. Mula-Hussain).
life expectancy has steadily increased in the ME [5]. As aging is the main risk factor for cancer, the incidence and prevalence of this disease is increasing among all the populations in ME. Longevity brings with it chronic disease and increased resource utilization, and the ME is currently ill-prepared to handle either. The treatment of an older person needs to be individualized, based on life-expectancy, treatment tolerance, and aggressiveness of the cancer. These developments represent huge challenges to the national health services. Based on the latest annual report of the Ministry of Health in Iraq in 2016 [6], reported deaths were 140,111 and cancer caused 9.05% of all deaths in Iraq; cancer is the second leading cause of death, just after cerebrovascular diseases at 10.69%. Based on the latest cancer registry in Iraq in 2012, the crude incidence rate of all cancers was 61.69 per 100,000 population (53.31 for males and 70.59 for females). No information about the prevalence of cancer in Iraq is in the official reports by Ministry of Health in Iraq. In 2012, Iraq was estimated to have 34,207,248 in population and among them, 603,090 are 70 years and above (i.e., 1.76%, with distribution of 302,987 males and 300,103 females) [7].
https://doi.org/10.1016/j.jgo.2018.03.006 1879-4068/© 2018 Published by Elsevier Ltd.
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
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Iraq, a war-torn country since 1980 (and in particular after 1999 onward), now has many life challenges that have consequences on the nation's development and its civil services. Electricity, wealth, transportation, and curfews, not far from the medical services and supplies, all are examples of affected sectors in this country. In cancer care, as an example, there is shortage of radiotherapy machines, and the current functional units are 22% of the ideal requirement for a population of over 34 million [8]. Sulaimani Governorate is one of the Iraqi governorates in the NorthEastern of the border with Iran (Kurdistan region). Its area is 17,023 sq km (3.9% of Iraq area) and its population about 1,931,561 (around 6% of the total of Iraqi population, as in the estimation in 2012). It is a governorate where gender distribution is almost equivalent while the geographical distribution is more in the urban (70%) than the rural (30%) [9]. The authors of this study try to explore the issue of the geriatric patients (GP) from RT point of view, by addressing this subject in one of the tertiary cancer centers for one year of time. 2. Materials and Methods After obtaining approval from the ethics and research committee at the University of Sulaimani (UoS), this project was launched. The period of the study was one year duration (12 months from June 2016 through June 2017). It is a descriptive cross-sectional study. Materials were the patients' archives in Zhianawa Cancer Center (ZCC), an accredited teaching center by UoS. ZCC is the only-tertiary RT facility in Sulaimani city. Convenience sample was taken including all GPs aged 70 years and more living in Sulaimani governorate referred to ZCC during the period January 2015 through December 2015. Patients aged 69 years or less or those from other areas of Kurdistan or Iraq were excluded. Of 153 patients' chart reviews done, 91 patients were called and interviewed successfully. A uniform questionnaire was used during the interviews for geriatric assessment by assessing frailty, geriatric syndrome, comorbidities and performance status. Eight major medical conditions were listed to assess comorbidities: 1-Cardiovascular disease and hypertension. 2- Hearing and vision abnormalities. 3-Diabetes mellitus. 4Anemia. 5-Liver disease. 6-Renal impairment. 7-Neuropathy. 8-Lung disease. Data were collected regarding frailty and its phenotypes (weight loss, decreased mobility, fatigue, osteoporosis, incontinence), those with three of these conditions would be characterized as frail, those with one or two conditions defined as pre-frail and those without any of these symptoms classified as non-frail or robust. Type of radiotherapy used was 3D-RT in most of the cases, in a linear accelerator (LINAC) machines. The fractionations were mostly high dose per fraction (hypo-fractionated) in the palliative settings and conventional dose per fraction in the curative settings. Statistical analysis and data entry was performed using Microsoft Office Excel 2010.
Cancer stage distribuon among GPs Early, 7.10% Distant (M1) 34.60%
Locally advanced, 58.10% Fig. 1. Cancer stage distribution among older patients with cancer.
shown in (Fig. 2). The most common primary tumor type presented with stage IV was the prostatic carcinoma (28.3%), followed by lung cancer (20.7%). Distribution of the types of malignancies among male and female GPs are shown in (Fig. 3) and (Fig. 4) respectively. Lung, head and neck and prostate cancer constituted about 65% among males while breast, skin and lung cancer constituted the main bulk in females. Distribution of cancer types in the curative setting and the RT fields in the palliative setting are shown in (Fig. 5) and (Fig. 6), respectively. The lung, prostate, skin and laryngeal cancer constituting 64% of GPs sampled who were treated with curative intent, while palliative treatment for bone metastases was the most common RT field site in patients treated with palliative intent. Rate of patients treated by RT with curative intent is 46% vs. 53% for those who were treated by RT with palliative intent. Distribution according to the age group is shown in (Table 2).
Percentage 30 25 20 15 10 5 0
Cancer types
Fig. 2. Cancer types' distribution among patients with stage IV disease (CUP: Cancer of Unknown Primary).
3. Results Among a total of 762 patients, 153 were GPs referred to ZCC in 2015, and this represented 20% of the whole Sulaimani's patients. Results of our cohort revealed the following: Age range (70–99 years) with a median age of 77 years. Number of patients according to the age group is shown in (Table 1). 75% (115 patients) of geriatric group sampled were males, 25% (38 patients) were females with Male: Female ratio were 3:1. Cancer stage distribution among GPs is shown in (Fig. 1). Cancer types' distribution among patients with stage IV (distant disease) is
Bladder 2%
Male
Colorectal 3% CUP 5% Thymus 1% Stomach 7%
Lung 26%
Prostate 24%
Age range
Number
Percentage
70–80 N80
112 41
73% 27%
Esophagus 4%
Head and Neck 16%
Skin 8%
Table 1 Number of patients according to the age group.
Brain 1% Breast 1%
Hematological 2%
Fig. 3. Cancer distribution in older males.
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
A.H. Gendari et al. / Journal of Geriatric Oncology xxx (2018) xxx–xxx
Female
Gynecological 5%
Bladder 8%
Head and Neck 8% Stomach 5%
Brain 8%
Table 2 Age distribution according to the treatment intent. Age group
Number of curative patients
Number of palliative patients
70–79 80–84 ≥85
40 8 2
43 8 14
Breast 19%
Skin 16%
Rectum 5% Haematological 5%
Lung 13%
Table 3 Age group distribution according to the treatment intent.
Esophagus 8%
Curative
Fig. 4. Cancer distribution in older females.
Endometruim 2%
3
Bladder 2%
Tumour sites
Stomach 2%
Breast 6% Esophagus 4% Larynx 10%
Prostate 17%
Oropharynx 2% Oral cavity
Lung 19%
Lip 2%
2%
Fig. 5. Distribution of patients in the curative RT setting.
Rate of patients who completed the curative RT course was 90% vs. 81.2% for the palliative RT course. Distribution according to the age group is shown in (Table 3). The mean prescribed dose in the curative setting was 5395 cGy and the mean actual delivered dose was 5297 cGy. The mean prescribed dose in palliative setting was 2506 cGy and the mean actual delivered dose was 2357 cGy. The mode of dose fractionation distribution in the palliative setting was 30 Gy/10 fractions. Patients who received palliative RT for bone metastasis were 24 patients, just 3 of them (12.5%) received the single dose of 8 Gy dose fractionation. Mean time interval between the date of referral and the date of starting treatment in the palliative setting was 19 days. Mean time interval between the date of CT-Simulation and the date of starting treatment in the curative setting was 35 days. Rate of patients who received curative RT course and had follow-up after the curative RT course was 41% (21 patients). Rate of GPs who referred to ZCC but didn't receive RT was 23.3% (36 patients). The causes of not receiving RT is shown in the (Fig. 7).
Palliave RT field miscellaneous 11% Stomach 8%
Bone mets 37%
Head and neck 15%
Not complete full course
Complete full course
Not complete full course
70–79 80–84 ≥85
48 8 3
3 4 0
37 8 12
15 0 0
Rate of patients who received RT course but had interruptions during the RT course was 9.4%. The causes of interruptions is shown in the (Fig. 8). Karnofsky Performance Status (KPS) categories distribution is shown in (Fig. 9). Increasing age was associated with worsening KPS. Rate of patients who refused RT and their residency area situated N40 km (KM) away from ZCC was 85% (6 patients) of all patients who refuse RT course, which was equal to 10% of all patients who lived in areas situated N40 KM away from ZCC. Frailty status was as follows: 23% of GPs sampled were classified as non-frail, 46% as pre-frail and 31% as frail. Description of the male and
Poor performance, 7%
Causes of not recieving RT
Seek RT elsewhere, Paent 8% refusal, 8% Other treatment modality, 9%
Death, 38% No RT indicaon, 30%
Fig. 7. Causes of not receiving RT.
RT related toxicity,11%
Causes of interrupons during RT
Poor Paents refusal,25% Performance, 37% Passed away,27%
Lung 12% Esophagus 6%
Complete full course
Rectum 6%
Brain 8% Skin 18%
Palliative
Age group
Brain mets 11%
Fig. 6. RT field distribution in palliative settings.
Fig. 8. Causes of interruptions during RT.
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
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Percentage of paents
.
45 40 35 30 25 20 15 10
5 0
10
20
30
40
50
70-79
60
70
80
90
100
80-84
Fig. 9. KPS distribution according to the age group.
female gender related to frailty diagnosis is shown in the (Table 4). The prevalence of frailty was similar between males and females. With regards to the prevalence of frailty related to marital status showed in (Table 5); it was observed that, despite the small number of unmarried elderly people in the sample, all of them were pre-frail or frail (P-value N 0.05). The most prevalent frailty phenotypes were fatigue and weight loss, (Fig. 10) shows frailty phenotypes prevalence. Comorbidities distribution among called GPs is shown in (Fig. 11). With regards to comorbidities, 27% of the called patients were comorbidity-free, 73% of them were with comorbidities; for those with comorbidities, 45% of them were with ≥2 comorbidities. The prevalence of frailty in older patients with comorbidities was 45% while the prevalence of frailty in older patients without comorbidities was just 7%. The most frequent comorbidities were cardiovascular and hypertension disease and vision and/or hearing impairment. The called lung cancer patients were 11 patients, 10 of them (91%) were with comorbidities. With regards to geriatric syndromes, 72.6% GPs sampled reported one or more geriatric syndromes, 27.4% were geriatric syndromes free, 58.2% were with ≥2 geriatric syndromes. There was a high prevalence of depression. Geriatric syndromes prevalence is shown in (Fig. 12). Sociodemographic findings were as follows: 98.4% and 92.8% were married in males and females respectively. The patients who have low income and/or living in a poor living condition constitute 72.5% of the called geriatric sample, and 5.4% of the geriatric patients sampled were neglected or having suboptimal care given by their family. Treatment decisions were done by physician in 97.8% of the patients while
Table 4 Description of the Males and Females related to Frailty diagnosis. Sex
Male Female
Frailty diagnosis Non-frail
Pre-frail
Frail
22% 25%
44% 50%
33% 25%
Table 5 Distribution of frailty according to the marital status. Marital status
Non-frail
Pre-frail
Frail
Unmarried Married
0 21
3 39
3 25
in 2.2% of the patients, the decisions were decided by patient or the patient proxy. 4. Discussion Giampiero et al. [10] reported in the Italian Geriatric Oncology Group (GROG) study that 30% of patients seen at the Italian RT centers were over 70 years. Due to the fact that our population is younger, it was not surprising to find out that GP represent 20% of the referred patients. Giampiero also stated that the first GROG study showed that 57% of GP received curative RT courses vs. 42% received palliative RT courses. Our data showed that the rate of curative and palliative RT courses were 46% and 53% respectively; this may be explained by the fact that our patients in Iraq are presenting with more advanced stages, as highlighted by other colleagues [8] and this will increase the rate of patients in palliative settings. Patrizia et al. [11] in the GROG study showed that 79% of GPs sampled aged 70–80 years and 21% aged N80 years and our data is consistent with these data. Petruzzelli et al. [12] reviewed 191 GP charts from the year 2005–2007 and found that male patients were 52.4% vs. 47.6% were female. Breast cancer was the most frequent tumors in women while prostate and lung cancer were the most frequent in men. The majority (81%) concluded the entire cycle of RT. A total of 57% of patients were prescribed curative RT, and 43% palliative RT, with no differences between men and women. Also, they observed that for patients aged over 85 years, palliative prescription increased (52% vs. 43% for age below 85) while curative-intent prescription decreased compared to the age 80–85 group. Petruzzelli's findings were somewhat consistent with our data apart from Male:Female ratio, as that ratio in Petruzzelli's study was 1.09:1 while in our data is 3:1. Even, this gender ratio in our study does not match with the gender ratio in incidence of cancer in Iraq. Based on the latest Iraqi cancer registry in 2012, there was 21,101 new cases in Iraq; males were 43.92% and females were 56.08%. For the care services, there is no genderbased difference in all the cancer care services in Iraqi health facilities. However, the 3:1 ratio might be explained by the following factors: Breast cancer, the most common cancer world-wide, is more prevalent in the older age group in western countries, unlike the case in our country, where breast cancer in Iraq affects largely those in a non-geriatric age group. This can decrease the prevalence of older women with cancer in comparison with the men. Skin cancer (including melanoma and non-melanoma skin cancers) is another example that is more prevalent in Iraqi men (as they are largely working out-door and more exposed to sun in comparison to Iraqi women). Skin cancer in
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
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Perecntage of paents 41%
45 40 35 30 25 20 15 10 5 0
41% 37% 32%
10%
Weight loss
Fague
Decreased molity
Osteoporosis
Inconnence
Frailty phenotypes Fig. 10. Frailty phenotypes prevalence among pre-frail and frail patients.
2012 was the 9th in ranks of cancers in Iraq; among the 677 registered cases in that year, 361 were males and 316 were females and of the 677 cases, those who are 70+ were 202 (highest group), and among the latter, 36.31% in males (110 in total) and 30.66% in females (92 in total). Regarding cancer types prevalence in male and female gender, our data clearly consistent with the Petruzelli finding which showed that the most common cancer type in males is prostate (28%) and lung cancer (24%) and breast cancer (25%) in females as our data showed that prostate and lung cancer was the most common in males with prevalence rate of 26% and 24% respectively and breast cancer prevalence rate in females was 19%. From the (Table 2), we can easily extrapolate that patients with age ≥ 85 years and received RT are 16 patients; among them, only 2 patients received curative RT courses while the remaining 14 patients received palliative RT courses, so the rate of curative RT in patients ≥85-year old dropped down to 12.5% versus 87.5% for palliative RT. This is consistent with Petruzelli study where for patients aged over 85 years, palliative prescription increased (52% vs. 43% for age below 85) while curative intent prescription decreased compared to the age 80–85 group. The more of the decrease in our data may be due to the shorter life expectancy in our society, compared to the western societies. From (Table 3), which shows age group distribution according to the
treatment intent and by the comparison between the planned dose and the actual delivered dose in curative and/or palliative setting, we can extrapolate that the younger the age group had more of a chance to complete the curative RT course. Also, we can extrapolate that the majority of patients receive the actual planned course and just 10% of patients with curative setting did not receive the planned RT dose vs. 18.7% of patients with palliative setting did not receive the planned RT dose. The reason why the percentage in palliative setting is higher than in the curative setting can be explained by the fact that patients with palliative setting presented in more advanced stage disease and were more likely to die during the palliative RT course. Regarding the time interval from the date of referral until the start of palliative RT course and from the date of CT-Simulation until the start of curative RT course can be explained by huge workload in ZCC with its limited resources. Regarding the (41%) of GPs who were treated with curative intent and had follow-up, this clearly constituting low percentage of those patients and our suggestion here is to educate the patients about the importance of having proper follow-up after completing the RT course to ensure proper management of side effects and complications of RT and detection of disease recurrence. Regarding cancer stage distribution among GPs sampled, our data showed that the most common cancer type presented with stage IV disease is prostate cancer, which were
Percentage of patients 45
40.6%
40 35
34%
30 25 19.7%
21.9%
20 14.2%
15
7.6%
10 5
4.3%
3.3%
0
Types of comorbidies
Fig. 11. Comorbidities distribution.
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
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Percentage of paents 40% 37.30% 35% 30.70%
30.70%
31.00%
29.60%
30% 26.30% 24.10%
25% 20% 15%
14.20% 12.00%
10% 6.50% 5%
7.60%
4.30%
0%
Geriatric syndrome phenotypes Fig. 12. Geriatric syndrome phenotypes distribution.
mostly bony metastases. In spite of the fact that prostate cancer itself is not number one among cancers in Iraq (it is seventh of the top ten cancers in Iraq [7], unlike many other nations), in our data prostate cancer was number one among the stage IV diseases. Giampero [10] et al. showed that the causes of not receiving RT were as follows: tumor extent 26%, different therapeutic options 16%, no RT indication 15%, patient refusal 15%, poor general condition 13%, and other causes 15%. In comparison with our data, it shows that the most common cause of not receiving RT is the death of patients (38%) who were scheduled for RT but died during the long waiting time, and the second most common cause was that there was no RT indication (30%) and the third most common cause was the different therapeutic option (9%). Iraqi cancer control plan in 2010 estimated (based on the general recommendation by the World Health Organization and the International Atomic Energy Agency) that the need for radiotherapy units (functional machines) is one unit per 0.5 million pop, This means that Iraq needs at least 68 machines for radiotherapy (depending on the formula used and the population in 2012) to fulfill the needs of patients with cancer and currently only 15 units are working, so these working units covering only 22% of the actual need and this may explain the fact that many patients died during the long waiting time to get their therapy. Regarding the interruptions during RT, our data showed the most common causes of interruptions were poor performance (37%) and dying (27%), while RT toxicity and patient refusal were less frequent causes. This can be explained by the fact that the majority of GPs are frail or pre-frail with high prevalence of comorbidities and more advanced diseases. Ten percent of GPs sampled who were living in regions situated 40 KM or more away from the ZCC refused RT; this may by explained from logistic point of view, such as lacking family or partner support or community support or the unavailability of public transportation. Daniela et al. [13] showed that the majority of older people were married and the prevalence of frailty was (4%) non-frail, (49.5%) prefrail, and (46.5%) frail. Between both sexes, the prevalence of frailty was very similar, it was also observed that despite the small number
of single older people in the sample, 83.3% of those were frail. Also this study showed that most prevalent frailty phenotype was fatigue. Handforth et al. [14] showed that the prevalence of frailty and prefrailty in older patients with cancer were 42% and 43% respectively. These data are consistent with our data. Bergman et al. [15] showed that individuals with cardiovascular disease, renal failure, strokes, osteoarthritis and depression are significantly more likely to be classified as frail than people without these conditions, even after adjusting for age and sex. Data on the comparison of the phenotype of frailty with the comorbidities were not analyzed because the cross-sectional design of the study does not allow one to infer causality. Periodic comprehensive geriatric assessments by a multidisciplinary team may be able to slow the functional decline and prevent frailty and thus decrease the rate of institutionalization and hospitalization, positively changing rates of morbidity and mortality in this portion of the population. Our patients showed a high comorbidity index. Several reports have shown a high prevalence of comorbid conditions among older patients with cancer [16–18]. Lung cancer cases had significantly more comorbidity than controls. Patients with lung cancer have a high comorbidity burden caused by other smoking-related diseases such as chronic pulmonary disease and cardiovascular disease [19]. Smoking was thus an important cause of the comorbidity–lung cancer association. Regina et al. study [20] showed that the most prevalent comorbidities were cardiovascular disease (34%) and diabetes mellitus (13%), which was also consistent with our data apart from hearing and vision problem which also comes in the 2nd most prevalent comorbidity in our study. Regarding geriatric syndromes, there was a high prevalence of geriatric syndrome in our GPs. Kellie et al. [21] found that there was high prevalence of depression, weight loss and use of high-risk medications, while falls and pressure sores were rare. Steffen et al. [22] showed that prevalence of depression among hospitalized older adults is over 30%. These data are somewhat consistent with our data as it showed that the most common geriatric syndrome phenotypes were depression (37.3%), frailty (31%), motility problems and sleep disorder (both with 30.7%), polypharmacy (29.6%), osteoporosis (24.1%), followed by falls (14.2%), dementia (12%), pressure sores (7.6%), incontinence (6.5%)
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
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and delirium (4.3%). On the other hand Barua et al. [23] stated that the prevalence of depression among older patients is 10.3%. Our data's high percentage of depression may be a manifestation of living in a war torn region and there may be some post-traumatic stress disorder diagnoses in this population as well. Geriatric patients with low income or living in a poor general condition represent the majority of our GPs sampled; this may be explained by the fact of the economic crisis in Kurdistan region as most of the retired geriatric patients receive very low pensions. In addition, 5.4% of the GPs sampled are neglected or having suboptimal care given by their family this is an important point that needs to be evaluated and considered by the physician during decision making process. In the majority of cases the physician made the treatment decisions as this is culturally expected in Iraq. Disclosures and Conflict of Interest Statements The authors have declared no conflict of interest. Authors' Contributions Conception and design: Ali H Gendari and Layth Mula-Hussain. Data collection: Ali H Gendari, Shwan A Mohammed, Sazgar S Majeed, Jalil S Ali, Nyan O Saeed, Bamo M Muhsin, and Kamaran A Mohammed. Analysis and interpretation of data: Ali H Gendari, Hazha A Ameen, Zhian S Ramzi, Asso F Amin, and Layth Mula-Hussain. Manuscript writing: Ali H Gendari, Hazha A Ameen, Zhian S Ramzi, Asso F Amin, and Layth Mula-Hussain. Approval of final article: Ali H Gendari, Hazha A Ameen, Zhian S Ramzi, Asso F Amin, Shwan A Mohammed, Sazgar S Majeed, Jalil S Ali, Nyan O Saeed, Bamo M Muhsin, Kamaran A Mohammed and Layth MulaHussain. All authors read and approved the final manuscript. Acknowledgement Authors are acknowledging the College of Medicine at the University of Sulaimani and the Zhianawa Cancer Center for allowing us to accomplish this research project. References [1] Franceschi S, La Vecchia C. Cancer epidemiology in the elderly. Crit Rev Oncol Hematol Sep 2001;39(3):219–26.
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[2] Pierre Scalliet TP. Radiotherapy in the elderly. In: Balducci Lodovico, Gary H, William B, editors. Comprehensive geriatric oncology. London: Taylor & Francis; 2006. p. 812. [3] National Cancer Institute. Radiation therapy forcancer: Q & A. Available at: http:// www.cancer.gov/cancertopics/factsheet/Therapy/radiation. [Accessed 1/5, 2017]. [4] The World Bank annual report 2012. Main report. Available at: http:// openknowledge.worldbank.org/handle/10986/11844. [Accessed 2/7, 2017]. [5] Hajjar RR, Atli T, Al-Mandhari Z, Oudrhiri M, Balducci L, Silbermann M. Prevalence of aging population in the Middle East and its implications on cancer incidence and care. Ann Oncol Oct 2013;24(Suppl. 7):vii11–24. [6] Iraqi Ministry of Health. Annual statistical report; 2016. [7] Iraqi cancer registry. Baghdad: Iraqi Ministry of Health; 2012. [8] Mula-Hussein Layth, editor. Cancer care in Iraq. Germany: LAP LAMBERT Academic Publishing; 2012. [9] Inter-Agency Information and Analysis Unit. Sulaymaniyah governorate profile; 2010. [10] Ausili-Cefaro G, Olmi P. The role of radiotherapy in the management of elderly cancer patients in light of the GROG experience. Crit Rev Oncol Hematol Sep 2001;39 (3):313–7. [11] Olmi Patrizia, Cefaro Giampiero Ausili, Cerrotta Anna Marie. Radiotherapy in the elderly: the achievements of the Geriatric Radiation Oncology Group (GROG). In: Balducci Lodovico, Gary H, William B, editors. Comprehensice geriatric oncology. London: Taylor & Francis; 2006. p. 492. [12] Petruzzelli MF, Tramacere F, Gianicolo EA, Portaluri M. Pattern of care and results of radiotherapy in patients 80 years old and over. Clin Ter 2010;161(6):e149-4. [13] Oliveira DR, Bettinelli LA, Pasqualotti A, Corso D, Brock F, Erdmann AL. Prevalence of frailty syndrome in old people in a hospital institution. Rev Lat Am Enfermagem Jul-Aug 2013;21(4):891–8. [14] Handforth C, Clegg A, Young C, Simpkins S, Seymour MT, Selby PJ, et al. The prevalence and outcomes of frailty in older cancer patients: a systematic review. Ann Oncol Jun 2015;26(6):1091–101. [15] Bergman H, Ferrucci L, Guralnik J, Hogan DB, Hummel S, Karunananthan S, et al. Frailty: an emerging research and clinical paradigm–issues and controversies. J Gerontol A Biol Sci Med Sci Jul 2007;62(7):731–7. [16] Ogle KS, Swanson GM, Woods N, Azzouz F. Cancer and comorbidity: redefining chronic diseases. Cancer Feb 1 2000;88(3):653–63. [17] Koroukian SM, Murray P, Madigan E. Comorbidity, disability, and geriatric syndromes in elderly cancer patients receiving home health care. J Clin Oncol May 20 2006;24(15):2304–10. [18] Wedding U, Roehrig B, Klippstein A, Steiner P, Schaeffer T, Pientka L, et al. Comorbidity in patients with cancer: prevalence and severity measured by cumulative illness rating scale. Crit Rev Oncol Hematol Mar 2007;61(3):269–76. [19] Janssen-Heijnen ML, Houterman S, Lemmens VE, Louwman MW, Maas HA, Coebergh JW. Prognostic impact of increasing age and co-morbidity in cancer patients: a population-based approach. Crit Rev Oncol Hematol Sep 2005;55(3): 231–40. [20] Girones R, Torregrosa D, Diaz-Beveridge R. Comorbidity, disability and geriatric syndromes in elderly breast cancer survivors. Results of a single-center experience. Crit Rev Oncol Hematol Mar 2010;73(3):236–45. [21] Flood KL, Carroll MB, Le CV, Ball L, Esker DA, Carr DB. Geriatric syndromes in elderly patients admitted to an oncology-acute care for elders unit. J Clin Oncol May 20 2006;24(15):2298–303. [22] Steffens DC, Skoog I, Norton MC, Hart AD, Tschanz JT, Plassman BL, et al. Prevalence of depression and its treatment in an elderly population: the Cache County study. Arch Gen Psychiatry Jun 2000;57(6):601–7. [23] Barua A, Ghosh MK, Kar N, Basilio MA. Prevalence of depressive disorders in the elderly. Ann Saudi Med Nov-Dec 2011;31(6):620–4.
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
Contents lists available at ScienceDirect
Journal of Geriatric Oncology
Geriatric radiotherapy in a war-torn country: Experience from Iraq Ali H. Gendari a, Hazha A. Ameen b, Zhian S. Ramzi b, Asso F. Amin b, Shwan A. Mohammed c, Sazgar S. Majeed c, Jalil S. Ali c, Nyan O. Saeed c, Bamo M. Muhsin c, Kamaran A. Mohammed c, Layth Mula-Hussain d,⁎ a
Mosul Oncology Hospital, Mosul, Nineveh, Iraq University of Sulaimani, Sulaimani, Kurdistan, Iraq Zhianawa Cancer Center, Sulaimani, Kurdistan, Iraq d Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada b c
a r t i c l e
i n f o
Article history: Received 21 December 2017 Received in revised form 19 February 2018 Accepted 13 March 2018 Available online xxxx Keywords: Geriatric Radiotherapy Oncology Iraq
a b s t r a c t Introduction: Cancer prevalence and geriatric patients (GP) are increasing and about half of the patients with cancer will be offered radiotherapy (RT). Addressing GP and their RT needs is an important issue in order to understand this heterogeneous group of patients. Materials and Methods: A descriptive cross-sectional study, using a convenience sample from Sulaimani city's inhabitants, aged 70-year and more, who were treated with RT at the only city's RT center, Zhianawa Cancer Center (ZCC), in 2015. Results: 153 patients' charts were reviewed. GP represented 20% of the patients referred to ZCC. Male: Female ratio was 3:1. One third presented with distant metastases, and 46% were treated with curative intent versus 54% with palliative intent. 94% completed the planned sessions of the curative RT vs 90% of the palliative RT. 23% of GP who were referred for RT didn't receive it. 9% got interruptions during RT course. 10% of GP living N40 km away from the treatment center refused treatment. Mean time interval between the date of referral and the date of starting treatment in the palliative setting was 19 days. Only 41% of patients with curative setting had regular follow-up. Conclusions: Being the 1st study in this regard in a war-torn nation, Iraq, our results demonstrated that GP is a sizable group of ZCC patients and that RT is a valuable modality in GP cancer treatment. “Age per se” is not a factor to avoid this modality when there is an indication to use it. Longer distance to reach the center was a challenge in some of our GP. Due to inadequate number of RT machines, GP have to wait long time before getting their RT, even for palliative purposes. Further studies in this field are warranted. © 2018 Published by Elsevier Ltd.
1. Introduction Cancer is the second most common cause of death after age 65 [1], and most common cancers become more frequent with age. The older patient population with cancer is a heterogeneous group, ranging from competent, active, and fit individuals to those who are frail and cognitively impaired. Older adults with cancer have different needs than younger adults [2]. Radiotherapy (RT) is a well-established treatment in cancer and about half of patients with cancer will be offered RT at some point along the course of their diseases and the role of RT in the treatment of older patients with cancer is on the rise [3]. Compared with developed countries, the population of the Middle East (ME) is relatively young and the percentage of population over age of 65 in the ME and Northern Africa (MENA) is estimated at 4.7% [4]. However, ME population will further age in the near future and
⁎ Corresponding author. E-mail address: [email protected] (L. Mula-Hussain).
life expectancy has steadily increased in the ME [5]. As aging is the main risk factor for cancer, the incidence and prevalence of this disease is increasing among all the populations in ME. Longevity brings with it chronic disease and increased resource utilization, and the ME is currently ill-prepared to handle either. The treatment of an older person needs to be individualized, based on life-expectancy, treatment tolerance, and aggressiveness of the cancer. These developments represent huge challenges to the national health services. Based on the latest annual report of the Ministry of Health in Iraq in 2016 [6], reported deaths were 140,111 and cancer caused 9.05% of all deaths in Iraq; cancer is the second leading cause of death, just after cerebrovascular diseases at 10.69%. Based on the latest cancer registry in Iraq in 2012, the crude incidence rate of all cancers was 61.69 per 100,000 population (53.31 for males and 70.59 for females). No information about the prevalence of cancer in Iraq is in the official reports by Ministry of Health in Iraq. In 2012, Iraq was estimated to have 34,207,248 in population and among them, 603,090 are 70 years and above (i.e., 1.76%, with distribution of 302,987 males and 300,103 females) [7].
https://doi.org/10.1016/j.jgo.2018.03.006 1879-4068/© 2018 Published by Elsevier Ltd.
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
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A.H. Gendari et al. / Journal of Geriatric Oncology xxx (2018) xxx–xxx
Iraq, a war-torn country since 1980 (and in particular after 1999 onward), now has many life challenges that have consequences on the nation's development and its civil services. Electricity, wealth, transportation, and curfews, not far from the medical services and supplies, all are examples of affected sectors in this country. In cancer care, as an example, there is shortage of radiotherapy machines, and the current functional units are 22% of the ideal requirement for a population of over 34 million [8]. Sulaimani Governorate is one of the Iraqi governorates in the NorthEastern of the border with Iran (Kurdistan region). Its area is 17,023 sq km (3.9% of Iraq area) and its population about 1,931,561 (around 6% of the total of Iraqi population, as in the estimation in 2012). It is a governorate where gender distribution is almost equivalent while the geographical distribution is more in the urban (70%) than the rural (30%) [9]. The authors of this study try to explore the issue of the geriatric patients (GP) from RT point of view, by addressing this subject in one of the tertiary cancer centers for one year of time. 2. Materials and Methods After obtaining approval from the ethics and research committee at the University of Sulaimani (UoS), this project was launched. The period of the study was one year duration (12 months from June 2016 through June 2017). It is a descriptive cross-sectional study. Materials were the patients' archives in Zhianawa Cancer Center (ZCC), an accredited teaching center by UoS. ZCC is the only-tertiary RT facility in Sulaimani city. Convenience sample was taken including all GPs aged 70 years and more living in Sulaimani governorate referred to ZCC during the period January 2015 through December 2015. Patients aged 69 years or less or those from other areas of Kurdistan or Iraq were excluded. Of 153 patients' chart reviews done, 91 patients were called and interviewed successfully. A uniform questionnaire was used during the interviews for geriatric assessment by assessing frailty, geriatric syndrome, comorbidities and performance status. Eight major medical conditions were listed to assess comorbidities: 1-Cardiovascular disease and hypertension. 2- Hearing and vision abnormalities. 3-Diabetes mellitus. 4Anemia. 5-Liver disease. 6-Renal impairment. 7-Neuropathy. 8-Lung disease. Data were collected regarding frailty and its phenotypes (weight loss, decreased mobility, fatigue, osteoporosis, incontinence), those with three of these conditions would be characterized as frail, those with one or two conditions defined as pre-frail and those without any of these symptoms classified as non-frail or robust. Type of radiotherapy used was 3D-RT in most of the cases, in a linear accelerator (LINAC) machines. The fractionations were mostly high dose per fraction (hypo-fractionated) in the palliative settings and conventional dose per fraction in the curative settings. Statistical analysis and data entry was performed using Microsoft Office Excel 2010.
Cancer stage distribuon among GPs Early, 7.10% Distant (M1) 34.60%
Locally advanced, 58.10% Fig. 1. Cancer stage distribution among older patients with cancer.
shown in (Fig. 2). The most common primary tumor type presented with stage IV was the prostatic carcinoma (28.3%), followed by lung cancer (20.7%). Distribution of the types of malignancies among male and female GPs are shown in (Fig. 3) and (Fig. 4) respectively. Lung, head and neck and prostate cancer constituted about 65% among males while breast, skin and lung cancer constituted the main bulk in females. Distribution of cancer types in the curative setting and the RT fields in the palliative setting are shown in (Fig. 5) and (Fig. 6), respectively. The lung, prostate, skin and laryngeal cancer constituting 64% of GPs sampled who were treated with curative intent, while palliative treatment for bone metastases was the most common RT field site in patients treated with palliative intent. Rate of patients treated by RT with curative intent is 46% vs. 53% for those who were treated by RT with palliative intent. Distribution according to the age group is shown in (Table 2).
Percentage 30 25 20 15 10 5 0
Cancer types
Fig. 2. Cancer types' distribution among patients with stage IV disease (CUP: Cancer of Unknown Primary).
3. Results Among a total of 762 patients, 153 were GPs referred to ZCC in 2015, and this represented 20% of the whole Sulaimani's patients. Results of our cohort revealed the following: Age range (70–99 years) with a median age of 77 years. Number of patients according to the age group is shown in (Table 1). 75% (115 patients) of geriatric group sampled were males, 25% (38 patients) were females with Male: Female ratio were 3:1. Cancer stage distribution among GPs is shown in (Fig. 1). Cancer types' distribution among patients with stage IV (distant disease) is
Bladder 2%
Male
Colorectal 3% CUP 5% Thymus 1% Stomach 7%
Lung 26%
Prostate 24%
Age range
Number
Percentage
70–80 N80
112 41
73% 27%
Esophagus 4%
Head and Neck 16%
Skin 8%
Table 1 Number of patients according to the age group.
Brain 1% Breast 1%
Hematological 2%
Fig. 3. Cancer distribution in older males.
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
A.H. Gendari et al. / Journal of Geriatric Oncology xxx (2018) xxx–xxx
Female
Gynecological 5%
Bladder 8%
Head and Neck 8% Stomach 5%
Brain 8%
Table 2 Age distribution according to the treatment intent. Age group
Number of curative patients
Number of palliative patients
70–79 80–84 ≥85
40 8 2
43 8 14
Breast 19%
Skin 16%
Rectum 5% Haematological 5%
Lung 13%
Table 3 Age group distribution according to the treatment intent.
Esophagus 8%
Curative
Fig. 4. Cancer distribution in older females.
Endometruim 2%
3
Bladder 2%
Tumour sites
Stomach 2%
Breast 6% Esophagus 4% Larynx 10%
Prostate 17%
Oropharynx 2% Oral cavity
Lung 19%
Lip 2%
2%
Fig. 5. Distribution of patients in the curative RT setting.
Rate of patients who completed the curative RT course was 90% vs. 81.2% for the palliative RT course. Distribution according to the age group is shown in (Table 3). The mean prescribed dose in the curative setting was 5395 cGy and the mean actual delivered dose was 5297 cGy. The mean prescribed dose in palliative setting was 2506 cGy and the mean actual delivered dose was 2357 cGy. The mode of dose fractionation distribution in the palliative setting was 30 Gy/10 fractions. Patients who received palliative RT for bone metastasis were 24 patients, just 3 of them (12.5%) received the single dose of 8 Gy dose fractionation. Mean time interval between the date of referral and the date of starting treatment in the palliative setting was 19 days. Mean time interval between the date of CT-Simulation and the date of starting treatment in the curative setting was 35 days. Rate of patients who received curative RT course and had follow-up after the curative RT course was 41% (21 patients). Rate of GPs who referred to ZCC but didn't receive RT was 23.3% (36 patients). The causes of not receiving RT is shown in the (Fig. 7).
Palliave RT field miscellaneous 11% Stomach 8%
Bone mets 37%
Head and neck 15%
Not complete full course
Complete full course
Not complete full course
70–79 80–84 ≥85
48 8 3
3 4 0
37 8 12
15 0 0
Rate of patients who received RT course but had interruptions during the RT course was 9.4%. The causes of interruptions is shown in the (Fig. 8). Karnofsky Performance Status (KPS) categories distribution is shown in (Fig. 9). Increasing age was associated with worsening KPS. Rate of patients who refused RT and their residency area situated N40 km (KM) away from ZCC was 85% (6 patients) of all patients who refuse RT course, which was equal to 10% of all patients who lived in areas situated N40 KM away from ZCC. Frailty status was as follows: 23% of GPs sampled were classified as non-frail, 46% as pre-frail and 31% as frail. Description of the male and
Poor performance, 7%
Causes of not recieving RT
Seek RT elsewhere, Paent 8% refusal, 8% Other treatment modality, 9%
Death, 38% No RT indicaon, 30%
Fig. 7. Causes of not receiving RT.
RT related toxicity,11%
Causes of interrupons during RT
Poor Paents refusal,25% Performance, 37% Passed away,27%
Lung 12% Esophagus 6%
Complete full course
Rectum 6%
Brain 8% Skin 18%
Palliative
Age group
Brain mets 11%
Fig. 6. RT field distribution in palliative settings.
Fig. 8. Causes of interruptions during RT.
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Percentage of paents
.
45 40 35 30 25 20 15 10
5 0
10
20
30
40
50
70-79
60
70
80
90
100
80-84
Fig. 9. KPS distribution according to the age group.
female gender related to frailty diagnosis is shown in the (Table 4). The prevalence of frailty was similar between males and females. With regards to the prevalence of frailty related to marital status showed in (Table 5); it was observed that, despite the small number of unmarried elderly people in the sample, all of them were pre-frail or frail (P-value N 0.05). The most prevalent frailty phenotypes were fatigue and weight loss, (Fig. 10) shows frailty phenotypes prevalence. Comorbidities distribution among called GPs is shown in (Fig. 11). With regards to comorbidities, 27% of the called patients were comorbidity-free, 73% of them were with comorbidities; for those with comorbidities, 45% of them were with ≥2 comorbidities. The prevalence of frailty in older patients with comorbidities was 45% while the prevalence of frailty in older patients without comorbidities was just 7%. The most frequent comorbidities were cardiovascular and hypertension disease and vision and/or hearing impairment. The called lung cancer patients were 11 patients, 10 of them (91%) were with comorbidities. With regards to geriatric syndromes, 72.6% GPs sampled reported one or more geriatric syndromes, 27.4% were geriatric syndromes free, 58.2% were with ≥2 geriatric syndromes. There was a high prevalence of depression. Geriatric syndromes prevalence is shown in (Fig. 12). Sociodemographic findings were as follows: 98.4% and 92.8% were married in males and females respectively. The patients who have low income and/or living in a poor living condition constitute 72.5% of the called geriatric sample, and 5.4% of the geriatric patients sampled were neglected or having suboptimal care given by their family. Treatment decisions were done by physician in 97.8% of the patients while
Table 4 Description of the Males and Females related to Frailty diagnosis. Sex
Male Female
Frailty diagnosis Non-frail
Pre-frail
Frail
22% 25%
44% 50%
33% 25%
Table 5 Distribution of frailty according to the marital status. Marital status
Non-frail
Pre-frail
Frail
Unmarried Married
0 21
3 39
3 25
in 2.2% of the patients, the decisions were decided by patient or the patient proxy. 4. Discussion Giampiero et al. [10] reported in the Italian Geriatric Oncology Group (GROG) study that 30% of patients seen at the Italian RT centers were over 70 years. Due to the fact that our population is younger, it was not surprising to find out that GP represent 20% of the referred patients. Giampiero also stated that the first GROG study showed that 57% of GP received curative RT courses vs. 42% received palliative RT courses. Our data showed that the rate of curative and palliative RT courses were 46% and 53% respectively; this may be explained by the fact that our patients in Iraq are presenting with more advanced stages, as highlighted by other colleagues [8] and this will increase the rate of patients in palliative settings. Patrizia et al. [11] in the GROG study showed that 79% of GPs sampled aged 70–80 years and 21% aged N80 years and our data is consistent with these data. Petruzzelli et al. [12] reviewed 191 GP charts from the year 2005–2007 and found that male patients were 52.4% vs. 47.6% were female. Breast cancer was the most frequent tumors in women while prostate and lung cancer were the most frequent in men. The majority (81%) concluded the entire cycle of RT. A total of 57% of patients were prescribed curative RT, and 43% palliative RT, with no differences between men and women. Also, they observed that for patients aged over 85 years, palliative prescription increased (52% vs. 43% for age below 85) while curative-intent prescription decreased compared to the age 80–85 group. Petruzzelli's findings were somewhat consistent with our data apart from Male:Female ratio, as that ratio in Petruzzelli's study was 1.09:1 while in our data is 3:1. Even, this gender ratio in our study does not match with the gender ratio in incidence of cancer in Iraq. Based on the latest Iraqi cancer registry in 2012, there was 21,101 new cases in Iraq; males were 43.92% and females were 56.08%. For the care services, there is no genderbased difference in all the cancer care services in Iraqi health facilities. However, the 3:1 ratio might be explained by the following factors: Breast cancer, the most common cancer world-wide, is more prevalent in the older age group in western countries, unlike the case in our country, where breast cancer in Iraq affects largely those in a non-geriatric age group. This can decrease the prevalence of older women with cancer in comparison with the men. Skin cancer (including melanoma and non-melanoma skin cancers) is another example that is more prevalent in Iraqi men (as they are largely working out-door and more exposed to sun in comparison to Iraqi women). Skin cancer in
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
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Perecntage of paents 41%
45 40 35 30 25 20 15 10 5 0
41% 37% 32%
10%
Weight loss
Fague
Decreased molity
Osteoporosis
Inconnence
Frailty phenotypes Fig. 10. Frailty phenotypes prevalence among pre-frail and frail patients.
2012 was the 9th in ranks of cancers in Iraq; among the 677 registered cases in that year, 361 were males and 316 were females and of the 677 cases, those who are 70+ were 202 (highest group), and among the latter, 36.31% in males (110 in total) and 30.66% in females (92 in total). Regarding cancer types prevalence in male and female gender, our data clearly consistent with the Petruzelli finding which showed that the most common cancer type in males is prostate (28%) and lung cancer (24%) and breast cancer (25%) in females as our data showed that prostate and lung cancer was the most common in males with prevalence rate of 26% and 24% respectively and breast cancer prevalence rate in females was 19%. From the (Table 2), we can easily extrapolate that patients with age ≥ 85 years and received RT are 16 patients; among them, only 2 patients received curative RT courses while the remaining 14 patients received palliative RT courses, so the rate of curative RT in patients ≥85-year old dropped down to 12.5% versus 87.5% for palliative RT. This is consistent with Petruzelli study where for patients aged over 85 years, palliative prescription increased (52% vs. 43% for age below 85) while curative intent prescription decreased compared to the age 80–85 group. The more of the decrease in our data may be due to the shorter life expectancy in our society, compared to the western societies. From (Table 3), which shows age group distribution according to the
treatment intent and by the comparison between the planned dose and the actual delivered dose in curative and/or palliative setting, we can extrapolate that the younger the age group had more of a chance to complete the curative RT course. Also, we can extrapolate that the majority of patients receive the actual planned course and just 10% of patients with curative setting did not receive the planned RT dose vs. 18.7% of patients with palliative setting did not receive the planned RT dose. The reason why the percentage in palliative setting is higher than in the curative setting can be explained by the fact that patients with palliative setting presented in more advanced stage disease and were more likely to die during the palliative RT course. Regarding the time interval from the date of referral until the start of palliative RT course and from the date of CT-Simulation until the start of curative RT course can be explained by huge workload in ZCC with its limited resources. Regarding the (41%) of GPs who were treated with curative intent and had follow-up, this clearly constituting low percentage of those patients and our suggestion here is to educate the patients about the importance of having proper follow-up after completing the RT course to ensure proper management of side effects and complications of RT and detection of disease recurrence. Regarding cancer stage distribution among GPs sampled, our data showed that the most common cancer type presented with stage IV disease is prostate cancer, which were
Percentage of patients 45
40.6%
40 35
34%
30 25 19.7%
21.9%
20 14.2%
15
7.6%
10 5
4.3%
3.3%
0
Types of comorbidies
Fig. 11. Comorbidities distribution.
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Percentage of paents 40% 37.30% 35% 30.70%
30.70%
31.00%
29.60%
30% 26.30% 24.10%
25% 20% 15%
14.20% 12.00%
10% 6.50% 5%
7.60%
4.30%
0%
Geriatric syndrome phenotypes Fig. 12. Geriatric syndrome phenotypes distribution.
mostly bony metastases. In spite of the fact that prostate cancer itself is not number one among cancers in Iraq (it is seventh of the top ten cancers in Iraq [7], unlike many other nations), in our data prostate cancer was number one among the stage IV diseases. Giampero [10] et al. showed that the causes of not receiving RT were as follows: tumor extent 26%, different therapeutic options 16%, no RT indication 15%, patient refusal 15%, poor general condition 13%, and other causes 15%. In comparison with our data, it shows that the most common cause of not receiving RT is the death of patients (38%) who were scheduled for RT but died during the long waiting time, and the second most common cause was that there was no RT indication (30%) and the third most common cause was the different therapeutic option (9%). Iraqi cancer control plan in 2010 estimated (based on the general recommendation by the World Health Organization and the International Atomic Energy Agency) that the need for radiotherapy units (functional machines) is one unit per 0.5 million pop, This means that Iraq needs at least 68 machines for radiotherapy (depending on the formula used and the population in 2012) to fulfill the needs of patients with cancer and currently only 15 units are working, so these working units covering only 22% of the actual need and this may explain the fact that many patients died during the long waiting time to get their therapy. Regarding the interruptions during RT, our data showed the most common causes of interruptions were poor performance (37%) and dying (27%), while RT toxicity and patient refusal were less frequent causes. This can be explained by the fact that the majority of GPs are frail or pre-frail with high prevalence of comorbidities and more advanced diseases. Ten percent of GPs sampled who were living in regions situated 40 KM or more away from the ZCC refused RT; this may by explained from logistic point of view, such as lacking family or partner support or community support or the unavailability of public transportation. Daniela et al. [13] showed that the majority of older people were married and the prevalence of frailty was (4%) non-frail, (49.5%) prefrail, and (46.5%) frail. Between both sexes, the prevalence of frailty was very similar, it was also observed that despite the small number
of single older people in the sample, 83.3% of those were frail. Also this study showed that most prevalent frailty phenotype was fatigue. Handforth et al. [14] showed that the prevalence of frailty and prefrailty in older patients with cancer were 42% and 43% respectively. These data are consistent with our data. Bergman et al. [15] showed that individuals with cardiovascular disease, renal failure, strokes, osteoarthritis and depression are significantly more likely to be classified as frail than people without these conditions, even after adjusting for age and sex. Data on the comparison of the phenotype of frailty with the comorbidities were not analyzed because the cross-sectional design of the study does not allow one to infer causality. Periodic comprehensive geriatric assessments by a multidisciplinary team may be able to slow the functional decline and prevent frailty and thus decrease the rate of institutionalization and hospitalization, positively changing rates of morbidity and mortality in this portion of the population. Our patients showed a high comorbidity index. Several reports have shown a high prevalence of comorbid conditions among older patients with cancer [16–18]. Lung cancer cases had significantly more comorbidity than controls. Patients with lung cancer have a high comorbidity burden caused by other smoking-related diseases such as chronic pulmonary disease and cardiovascular disease [19]. Smoking was thus an important cause of the comorbidity–lung cancer association. Regina et al. study [20] showed that the most prevalent comorbidities were cardiovascular disease (34%) and diabetes mellitus (13%), which was also consistent with our data apart from hearing and vision problem which also comes in the 2nd most prevalent comorbidity in our study. Regarding geriatric syndromes, there was a high prevalence of geriatric syndrome in our GPs. Kellie et al. [21] found that there was high prevalence of depression, weight loss and use of high-risk medications, while falls and pressure sores were rare. Steffen et al. [22] showed that prevalence of depression among hospitalized older adults is over 30%. These data are somewhat consistent with our data as it showed that the most common geriatric syndrome phenotypes were depression (37.3%), frailty (31%), motility problems and sleep disorder (both with 30.7%), polypharmacy (29.6%), osteoporosis (24.1%), followed by falls (14.2%), dementia (12%), pressure sores (7.6%), incontinence (6.5%)
Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006
A.H. Gendari et al. / Journal of Geriatric Oncology xxx (2018) xxx–xxx
and delirium (4.3%). On the other hand Barua et al. [23] stated that the prevalence of depression among older patients is 10.3%. Our data's high percentage of depression may be a manifestation of living in a war torn region and there may be some post-traumatic stress disorder diagnoses in this population as well. Geriatric patients with low income or living in a poor general condition represent the majority of our GPs sampled; this may be explained by the fact of the economic crisis in Kurdistan region as most of the retired geriatric patients receive very low pensions. In addition, 5.4% of the GPs sampled are neglected or having suboptimal care given by their family this is an important point that needs to be evaluated and considered by the physician during decision making process. In the majority of cases the physician made the treatment decisions as this is culturally expected in Iraq. Disclosures and Conflict of Interest Statements The authors have declared no conflict of interest. Authors' Contributions Conception and design: Ali H Gendari and Layth Mula-Hussain. Data collection: Ali H Gendari, Shwan A Mohammed, Sazgar S Majeed, Jalil S Ali, Nyan O Saeed, Bamo M Muhsin, and Kamaran A Mohammed. Analysis and interpretation of data: Ali H Gendari, Hazha A Ameen, Zhian S Ramzi, Asso F Amin, and Layth Mula-Hussain. Manuscript writing: Ali H Gendari, Hazha A Ameen, Zhian S Ramzi, Asso F Amin, and Layth Mula-Hussain. Approval of final article: Ali H Gendari, Hazha A Ameen, Zhian S Ramzi, Asso F Amin, Shwan A Mohammed, Sazgar S Majeed, Jalil S Ali, Nyan O Saeed, Bamo M Muhsin, Kamaran A Mohammed and Layth MulaHussain. All authors read and approved the final manuscript. Acknowledgement Authors are acknowledging the College of Medicine at the University of Sulaimani and the Zhianawa Cancer Center for allowing us to accomplish this research project. References [1] Franceschi S, La Vecchia C. Cancer epidemiology in the elderly. Crit Rev Oncol Hematol Sep 2001;39(3):219–26.
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Please cite this article as: Gendari AH, et al, Geriatric radiotherapy in a war-torn country: Experience from Iraq, J Geriatr Oncol (2018), https://doi. org/10.1016/j.jgo.2018.03.006