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Evaluating Onco-Geriatric Scores and Medication Risks to Improve Cancer Care for Older Patients

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Evaluating Onco-Geriatric Scores and Medication Risks to Improve Cancer Care for Older Patients Evaluating onco-geriatric scores and medication risks to improve cancer care for older patients Dissertation zur Erlangung des Doktorgrades (Dr. rer. nat.) der Mathematisch-Naturwissenschaftlichen Fakultät der Rheinischen Friedrich-Wilhelms-Universität Bonn vorgelegt von IMKE ORTLAND aus Quakenbrück Bonn 2019 Angefertigt mit Genehmigung der Mathematisch-Naturwissenschaftlichen Fakultät der Rheinischen Friedrich-Wilhelms-Universität Bonn. Diese Dissertation ist auf dem Hochschulschriftenserver der ULB Bonn elektronisch publiziert. https://nbn-resolving.org/urn:nbn:de:hbz:5-58042 Erstgutachter: Prof. Dr. Ulrich Jaehde Zweitgutachter: Prof. Dr. Andreas Jacobs Tag der Promotion: 28. Februar 2020 Erscheinungsjahr: 2020 Danksagung Auf dem Weg zur Promotion haben mich viele Menschen begleitet und in ganz unterschiedlicher Weise unterstützt. All diesen Menschen möchte ich an dieser Stelle ganz herzlich danken. Mein aufrichtiger Dank gilt meinem Doktorvater Prof. Dr. Ulrich Jaehde für das in mich gesetzte Vertrauen, sowie für die Überlassung dieses spannenden Dissertationsthemas. Die uneingeschränkte Unterstützung, wertvollen Diskussionen und die mitreißende Begeisterung für die Wissenschaft haben mich während aller Phasen der Dissertation stets motiviert, unterstützt und sehr viel Wertvolles gelehrt. Prof. Dr. Andreas Jacobs danke ich herzlich für die Initiierung dieses interessanten Projekts, für die stetige Begeisterung und Unterstützung, sowie für das mir entgegengebrachte Vertrauen. Die ausgezeichnete Zusammenarbeit mit dem Johanniter Krankenhaus Bonn hat ganz maßgeblich zum Gelingen dieser Arbeit beigetragen. Auch danke ich Prof. Dr. Andreas Jacobs herzlich für die Bereitschaft, das Koreferat dieser Arbeit zu übernehmen. Ebenfalls danke ich herzlich Prof. Dr. Yon-Dschun Ko für seine fortwährende Motivation und seinen Einsatz, sowie für das mir geschenkte Vertrauen, dieses Projekt am Johanniter Krankenhaus zu realisieren. Ebenfalls danke ich Prof. Dr. Yon-Dschun Ko herzlich für die Beteiligung an der Prüfungskommission. Prof. Dr. Gerd Bendas danke ich ganz herzlich für die Beteiligung an der Prüfungskommission. Für das Korrekturlesen gilt mein großer Dank Corinna Vučur und Anna Barnert – für die Zeit, die sie für mich geopfert haben und insbesondere für die wertvollen Kommentare und konstruktive Kritik. Unserer Masterstudentin Monique Mendel Ott danke ich von Herzen für die engagierte Vorarbeit für das Projekt. Dies hat mir den Einstieg in das Thema Onkogeriatrie und in die Arbeit am Johanniter Krankenhaus sehr erleichtert. Den Mitarbeitern des Johanniter Krankenhauses Bonn danke ich ganz besonders für die freundliche Aufnahme auf den Stationen und in der onkologischen Ambulanz, ihr Interesse an dem Projekt und die engagierte Unterstützung trotz des oftmals intensiven Klinikalltags. Auch gebührt mein großer Dank den onkologischen Praxen des Bonns/Rhein-Sieg-Kreises für die freundliche Unterstützung bei der Datenerhebung. Insbesondere danke ich von ganzem Herzen allen Patienten für ihr entgegengebrachtes Vertrauen und die Bereitwilligkeit, sich trotz ihrer schwierigen Situation die Zeit zu nehmen, an meinem Projekt teilzunehmen. Ich bedanke mich zudem herzlich bei der Herbert-Worch-Stiftung für die finanzielle Förderung dieses Projekts. Ganz herzlich danke ich meinen Freunden und Kollegen des AK Jaehde für die wundervollen, gemeinsamen Jahre. Durch die warme Atmosphäre, die inspirierenden fachlichen Diskussionen, die stets freundschaftliche Zusammenarbeit, gegenseitige Hilfe und die gute Laune im Team, bin ich jeden Tag mit Freude zum Institut gekommen. Ganz besonders danke ich meinen Weggefährten im „Bungalow“ und in unserem „Lieblingsbüro“ für die großartige Zeit – Patricia, Kerstin, Achim und Eduard. Schlussendlich danke ich aus tiefstem Herzen meiner Familie und meinen Freunden. Insbesondere meinen Eltern, für ihre bedingungslose Unterstützung an jedem Tag meines Lebens sowie ihre stets aufmunternden Worte und meinen Schwestern, die mich immer gelehrt haben, das Leben mit Humor zu nehmen. Besonders danke ich Sören für seine Anteilnahme, sein Verständnis und seinen Glauben an mich während des langen Wegs bis zur Vollendung der Promotion. Für meine Eltern Table of contents I Table of contents 1 Introduction ............................................................................................................... 1 1.1 Older cancer patients .................................................................................................. 1 1.2 Medication risks in older cancer patients ................................................................... 3 1.2.1 Polymedication ..................................................................................................... 4 1.2.2 Potentially inadequate medication ...................................................................... 4 1.2.3 Drug-drug interactions ......................................................................................... 5 1.3 Geriatric assessment ................................................................................................... 6 1.3.1 Usefulness ............................................................................................................ 8 1.3.2 Implementation into daily routine ..................................................................... 10 1.4 Onco-geriatric scores ................................................................................................. 10 2 Aim .......................................................................................................................... 13 3 Methods .................................................................................................................. 15 3.1 Evaluation of onco-geriatric scores ........................................................................... 15 3.1.1 Study design ....................................................................................................... 15 3.1.2 Pilot study ........................................................................................................... 16 3.1.3 Course of the study ............................................................................................ 16 3.1.4 Patients ............................................................................................................... 18 3.1.4.1 Inclusion and exclusion criteria ................................................................... 18 3.1.4.2 Recruitment ................................................................................................ 18 3.1.4.3 Sample size determination ......................................................................... 19 3.1.4.4 Documentation ........................................................................................... 19 3.1.5 Risk assessment .................................................................................................. 19 3.1.5.1 The CARG score ........................................................................................... 20 3.1.5.2 The CRASH score ......................................................................................... 22 3.1.5.3 Physicians’ judgment .................................................................................. 25 II Table of contents 3.1.6 Outcome measurement ..................................................................................... 25 3.1.6.1 Toxicity ........................................................................................................ 26 3.1.6.2 Patient-reported symptom burden ............................................................ 28 3.1.6.3 Alterations of planned treatment ............................................................... 30 3.1.7 Statistical analysis ............................................................................................... 31 3.1.7.1 Relationship between risk assessments ..................................................... 31 3.1.7.2 Predictive performance .............................................................................. 33 3.1.7.3 Time until occurrence of first toxicity ......................................................... 34 3.1.7.4 Predictive factors of toxicity ....................................................................... 35 3.1.7.5 Comparison of toxicity and symptom burden ............................................ 35 3.1.7.6 Missing Data and study drop-out ............................................................... 35 3.2 Medication risk analysis............................................................................................. 35 3.2.1 Study design ....................................................................................................... 36 3.2.2 Medication ......................................................................................................... 36 3.2.2.1 Polymedication ........................................................................................... 37 3.2.2.2 Potentially inadequate medication ............................................................. 38 3.2.2.3 Relevant potential drug-drug interactions ................................................. 38 3.2.3 Statistical analysis ............................................................................................... 39 4 Results ..................................................................................................................... 41 4.1 Evaluation of onco-geriatric scores ..........................................................................
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