Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.
JAMA Oncol. 2018 May 1;4(5):686-693. doi: 10.1001/jamaoncol.2017.5674.
As the population ages, cognitive impairment has promised to become increasingly common among patients with cancer. Little is known about how specific domains of cognitive impairment may be associated with survival among older patients with hematologic cancers.
To determine the prevalence of domain-specific cognitive impairment and its association with overall survival among older patients with blood cancer.
DESIGN, SETTING, AND PARTICIPANTS: This prospective observational cohort study included all patients 75 years and older who presented for initial consultation in the leukemia, myeloma, or lymphoma clinics of a large tertiary hospital in Boston, Massachusetts, from February 1, 2015, to March 31, 2017. Patients underwent screening for frailty and cognitive dysfunction and were followed up for survival.
The Clock-in-the-Box (CIB) test was used to screen for executive dysfunction. A 5-word delayed recall test was used to screen for impairment in working memory. The Fried frailty phenotype and Rockwood cumulative deficit model of frailty were also assessed to characterize participants as robust, prefrail, or frail.
Among 420 consecutive patients approached, 360 (85.7%) agreed to undergo frailty assessment (232 men [64.4%] and 128 women [35.6%]; mean [SD] age, 79.8 [3.9] years), and 341 of those (94.7%) completed both cognitive screening tests. One hundred twenty-seven patients (35.3%) had probable executive dysfunction on the CIB, and 62 (17.2%) had probable impairment in working memory on the 5-word delayed recall. Impairment in either domain was modestly correlated with the Fried frailty phenotype (CIB, ρ = 0.177; delayed recall, ρ = 0.170; P = .01 for both), and many phenotypically robust patients also had probable cognitive impairment (24 of 104 [23.1%] on CIB and 9 of 104 [8.7%] on delayed recall). Patients with impaired working memory had worse median survival (10.9 [SD, 12.9] vs 12.2 [SD, 14.7] months; log-rank P < .001), including when stratified by indolent cancer (log-rank P = .01) and aggressive cancer (P < .001) and in multivariate analysis when adjusting for age, comorbidities, and disease aggressiveness (odds ratio, 0.26; 95% CI, 0.13-0.50). Impaired working memory was also associated with worse survival for those undergoing intensive treatment (log-rank P < .001). Executive dysfunction was associated with worse survival only among patients who underwent intensive treatment (log-rank P = .03).
These data suggest that domains of cognitive dysfunction may be prevalent in older patients with blood cancer and may have differential predictive value for survival. Targeted interventions are needed for this vulnerable patient population.
随着人口老龄化，认知障碍有望在癌症患者中变得越来越普遍。对于特定领域的认知障碍如何与老年血液癌患者的生存相关，知之甚少。
确定特定领域认知障碍的患病率及其与老年血液癌患者总体生存率之间的关系。
设计、地点和参与者：本前瞻性观察队列研究纳入了 2015 年 2 月 1 日至 2017 年 3 月 31 日期间在马萨诸塞州波士顿一家大型三级医院的白血病、骨髓瘤或淋巴瘤诊所首次就诊的所有 75 岁及以上的患者。患者接受了虚弱和认知功能障碍的筛查，并进行了生存随访。
使用 Clock-in-the-Box (CIB) 测试筛查执行功能障碍。使用 5 字延迟回忆测试筛查工作记忆障碍。还评估了 Fried 虚弱表型和 Rockwood 累积缺陷虚弱模型，以将参与者描述为健壮、虚弱前期或虚弱。
在接触的 420 名连续患者中，有 360 名（232 名男性[64.4%]和 128 名女性[35.6%]；平均[SD]年龄，79.8[3.9]岁）同意进行虚弱评估，其中 341 名（94.7%）完成了两项认知筛查测试。127 名患者（35.3%）在 CIB 上有明显的执行功能障碍，62 名（17.2%）在 5 字延迟回忆测试中有明显的工作记忆障碍。在 Fried 虚弱表型方面，两个领域的认知障碍都有中度相关性（CIB，ρ=0.177；延迟回忆，ρ=0.170；均为 P=0.01），许多表型健壮的患者也有明显的认知障碍（CIB 上有 24 名[104 名患者中的 23.1%]，延迟回忆上有 9 名[104 名患者中的 8.7%]）。工作记忆障碍患者的中位生存期较差（10.9[SD，12.9] vs 12.2[SD，14.7]个月；对数秩 P<0.001），包括按惰性癌症（对数秩 P=0.01）和侵袭性癌症（P<0.001）分层，以及在调整年龄、合并症和疾病侵袭性的多变量分析中（优势比，0.26；95%CI，0.13-0.50）。在接受强化治疗的患者中，工作记忆障碍也与较差的生存相关（对数秩 P<0.001）。执行功能障碍仅与接受强化治疗的患者的生存相关（对数秩 P=0.03）。
这些数据表明，血液癌老年患者可能存在认知功能障碍的不同领域，并且可能对生存有不同的预测价值。需要为这一脆弱的患者群体提供有针对性的干预措施。
