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Resume But Definir les amenagements du traitement medical par les anti-angiogeniques, l’inhibiteur de mTOR ou les immunotherapies systemiques lors de la prise en charge du cancer du rein metastatique chez les patients âges. Methode Recherche bibliographique a partir de la base de donnees bibliographiques Medline (NLM outil Pubmed) et Embase a partir des mots-cles suivants : cancer du rein metastatique, personne âge, traitement. Resultats Les criteres de selections du traitement medical du cancer du rein metastatique chez les patients âges sont le score IMDC necessairement complete par le performance status, le profil de tolerance du traitement, les interactions medicamenteuses plus frequentes, l’observance du traitement, la capacite de gestion de ses effets secondaires et la preference des patients. Chacun de ces criteres est detaille de maniere critique. Conclusion L’efficacite et la tolerance de traitements medicaux du cancer du rein metastatique n’ont pas ete rapportees comme differentes en fonction de l’âge. Aucune adaptation posologique n’est recommandee de principe. Toutefois, la prevention et le traitement precoce des effets secondaires des traitements doivent etre renforces chez les patients âges.

Resume Objectif Les therapies ablatives (TA) dans le cancer du rein se developpent. Il parait important de faire un point dans cette evolution pour des techniques en cours d’evaluation. L’objectif de cet article est d’identifier les indications actuelles des TA dans le cancer du rein. Materiel et methodes Une recherche bibliographique a partir de Medline et Embase a ete realisee et les articles ont ete selectionnes sur leur methodologie, leur langue de publication et leur pertinence. Resultats L’indication de TA doit etre retenue sur des criteres tumoraux et patients precis. Il faut disposer d’une evaluation initiale de qualite (imagerie, histologie, fonction renale et etat general). La meilleure efficacite des TA est obtenue pour les caracteristiques tumorales suivantes : tumeur solide, taille Conclusion La TA doit trouver sa place dans l’arsenal therapeutique des tumeurs du rein

Resume But Decrire l’epidemiologie du cancer du rein (CaR) et son histoire naturelle chez le patient âge. Proposer des adaptations de l’evaluation geriatrique specifiques du CaR. Rappeler les options therapeutiques et la conduite des traitements propres aux patients âges. Methode Recherche bibliographique a partir de la base de donnees bibliographiques Medline (NLM outil Pubmed) et Embase, ainsi que sur les sites internet des societes savantes de geriatrie, de l’Institut National du Cancer a partir des mots-cles suivants : personne âgee, geriatrie, cancer du rein, petite masse renale, diagnostic, traitement. Resultats Le CaR connait en France une augmentation d’incidence avec un pic entre 70 et 80 ans. Cette augmentation d’incidence se fait essentiellement par le diagnostic de petites masses renales (PMR). La mortalite specifique du CaR augmente avec l’âge (au moins entre 75 et 95 ans). La biopsie de la tumeur, a fortiori d’une PMR, devrait etre envisagee chez le patient âge. L’evaluation geriatrique des patients porteurs d’un CaR ne presente pas de particularite en dehors de des appreciations specifiques de la fonction renale et du risque operatoire. Nous ne disposons pas d’essai therapeutiques prospectifs dedies aux patients âges ayant un CaR localise. Le traitement chirurgical necessite de recourir a une rehabilitation amelioree (dont les modalites sont en cours de definition) dans lequel les geriatres tiennent une place de choix tout au long du parcours de soins. La place des traitements ablatifs percutanes doit etre mieux precisee chez les patients âges. Cependant, devant une mortalite specifique faible, la surveillance des PMR (au moins initialement) est une option probablement appropriee, certainement sous-utilisee, meme si ses consequences sur la qualite de vie restent a preciser. Le double objectif general de l’onco-geriatrie doit presider aux choix des soins chez le patient âge ayant un CaR : premierement le respect des attentes propres a chaque patient et deuxiemement la recherche du benefice clinique global ; objectifs qui n’ont aucune raison d’etre reserves aux patients âges. Conclusion Le CaR est en passe de devenir un cancer majoritairement du patient âge. Il repond aux recommandations diagnostiques et therapeutiques generales en cours. Il est souhaitable que la recherche clinique aide a mieux definir les places respectives de la biopsie des tumeurs renales et de leur traitement percutane.

Resume But Decrire l’epidemiologie du cancer de la prostate (CaP) et son histoire naturelle chez le patient âge. Proposer des adaptations de l’evaluation geriatrique specifiques du CaP. Rappeler les options therapeutiques et la conduite des traitements propres aux patients âges. Methode Recherche bibliographique a partir de la base de donnees bibliographiques Medline (NLM outil Pubmed) et Embase, ainsi que sur les sites internet des societes savantes de geriatrie, de l’Institut National du Cancer a partir des mots cles suivants : personne âgee, geriatrie, cancer de la prostate, diagnostic, traitement. Resultats L’âge median au diagnostic du CaP est 69 ans, faisant du CaP le type meme du cancer du sujet âge. La mortalite specifique du CaP augmente avec l’âge. Cela traduit deux caracteristiques. Premierement, un diagnostic des formes de stade et de grade eleves plus frequent chez les patients âges que chez les patients plus jeunes. Deuxiemement, un recours aux options therapeutiques curatives moins frequent chez les patients âges que chez les patients plus jeunes. La SIOG propose une evaluation geriatrique specifique pour les patients presentant un CaP ; elle peut etre une aide, mais la recommandation d’une evaluation initiale des troubles cognitifs est critiquable. Nous ne disposons pas d’etudes therapeutiques, ne serait ce que prospective, dediees aux patients âges. Cependant, un double objectif doit presider aux choix des soins chez le patient âge : premierement le respect des attentes propres a chaque patient et deuxiemement la recherche du benefice clinique global ; objectifs qui n’ont aucune raison d’etre reserves aux patients âges. Conclusion Le CaP chez le patient âge repond aux recommandations diagnostiques et therapeutiques generales en cours. Le respect de ces recommandations devrait permettre de corriger a la fois le diagnostic tardif et le sous-traitement observes.

Resume But Presenter dans un premier temps les donnees epidemiologiques du vieillissement et des cancers et en decrire les evolutions attendues. Presenter dans un second temps les donnees biologiques et genetiques concernant le vieillissement et les relations entre veillissement et oncogenese. Methode Recherche bibliographique a partir de la base de donnees bibliographiques Medline (NLM outil Pubmed) et Embase, ainsi que sur les sites internet des societes savantes de geriatrie, des Nations Unies, de la Banque Mondiale, de l’Organisation mondiale de la sante, de l’Institut National du Cancer, de la Ligue Contre le Cancer a partir des mots-cles suivants : vieillissement, personne âgee, cancer, epidemiologie, biologie, genetique. Resultats On observe un vieillissement de toute la population mondiale tres marquee et croissant. En France, les nouveaux cas de cancers sont diagnostiques dans 62,4 % chez des patients de plus de 65 ans et dans 11,5 % chez des patients de plus de 80 ans. La mortalite par cancer y survient dans 75,3 % chez des patients de plus de 65 ans et dans 24,8 % chez des patients de plus de 80 ans. La mortalite specifique par cancer est toujours superieure chez les patients âges de plus de 75 ans par rapport aux patients plus jeunes ; cela traduit, entre autre, une discrimination selon l’âge qui est appelee âgisme. On a pu etablir que le vieillissement cellulaire est marque par 9 grandes familles d’anomalies biologiques et genomiques. Vieillissement biologique et oncogenese sont etroitement intriques avec des relations de mieux en mieux etablies. Ils sont tous deux le produit de la selection naturelle et sont observes chez toutes les especes ayant a la fois des tissus de renouvellement et une distinction entre tissu germinal et tissu somatique. Conclusion Les donnees epidemiologiques predisent que la cancerologie, dont la cancerologie urologique, est en passe de devenir tres majoritairement de la cancerologie geriatrique ; il est indispensable et urgent que la societe y soit preparee et que chaque soignant y soit aussi prepare, c’est-a-dire, forme. Les donnees biologiques et genetiques plaident pour une grande intrication entre vieillissement et oncogenese ; les recherches menees dans chacun de ces domaines devraient etre rapprochees pour un benefice reciproque.

Resume But Expliquer la notion de fragilite, puis expliquer le caractere indispensable de la detection de fragilites chez le patient âge et, en cas de fragilite suspectee, la necessite d’une evaluation geriatrique. Decrire les modalites de cette evaluation du patient âge presentant un cancer, la place que doivent tenir les resultats de cette evaluation dans la prise de decision therapeutique, ainsi que le role du geriatre dans le parcours de soin. Methode Recherche bibliographique a partir de la base de donnees bibliographiques Medline (NLM outil Pubmed) et Embase, ainsi que sur les sites internet des societes savantes de geriatrie, de l’Institut national du cancer a partir des mots-cles suivants : personne âgee, geriatrie, cancer, fragilite, evaluation, decision. Resultats La detection de fragilites a pour objectif d’optimiser les soins pour maintenir l’independance, voire la survie, du patient. La prevalence de la fragilite augmente avec l’âge et le diagnostic de cancer. La detection des fragilites du patient âge presentant un cancer est realisee a l’aide du questionnaire G8 recommande par l’INCa. En cas d’anomalie ou de justification clinique, le patient recoit alors une evaluation geriatrique, procedure multidimentionnelle et multidisciplinaire. Le clinicien peut faire appel pour cela a l’UCOG de la region dans laquelle il exerce. La pertinence des decisions de soin se fondera sur les resultats de cette evaluation. Le geriatre se positionne comme un partenaire crucial qui sera implique dans tout le parcours de soins. Conclusion La detection de fragilites chez le patient âge presentant un cancer est une obligation. L’evaluation consecutive peut etre assuree l’UCOG de la region consideree. Les resultats de l’evaluation serviront de base pour toute prise de decision therapeutique et la preservation de l’independance du patient restera la priorite.

To describe the epidemiology of prostate cancer (PCa) and its natural history in the elderly patient. To propose adaptations of geriatric evaluation specific to PCa. Recall therapeutic options and the treatment options specific to elderly patients.Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific societies of geriatrics, from the National Cancer Institute using the following keywords: elderly, geriatrics, prostate cancer, diagnosis, treatment.The median age at diagnosis for PCa is 69 years old, making PCa the very type of cancer of the elderly. The specific mortality of the disease increases with age. This translates two of its characteristics. First, a diagnosis at higher grade and stage is more common in older patients than in younger patients. Secondly, use of curative therapeutic options is less common in elderly patients than in younger patients. SIOG recommends a specific geriatric assessment for patients with PCa, which may be useful, but the need for an initial detection of cognitive disorders is open to criticism. There is no therapeutic trial, if only prospective, dedicated to elderly patients with PCa. However, decision-making in the elderly patient with PCa must pursue two goals: first, the respect of the expectations specific to each patient and secondly, the search for the global clinical benefit; goals that should not be restricted to elderly patients.PCa in the elderly patient follow the current guidelines for diagnostic and for treatment. Compliance with these guidelines should eliminate both the late diagnosis and the under-treatment actually observed.

First, to present the epidemiological data of aging and of cancers and to describe the respectives expected evolutions. Second, to present biological and genetic data on aging and on the relationships between aging and oncogenesis.Bibliographic search from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as from the web sites of geriatric scientific societies, the United Nations, the World Bank, the World Health Organization, the Institut National du Cancer and the Ligue Contre le Cancer from the following keywords: aging, elderly, cancer, epidemiology, biology, genetics.The entire world population is aging very significantly and very rapidly. In France, new cases of cancer are diagnosed in 62.4% of cases in patients over 65 and in 11.5% of cases in patients over 80 years. Cancer mortality occurs in 75.3% of cases in patients over 65 years of age and in 24.8% of cases in patients over 80 years of age. Cancer-specific mortality is consistently higher in patients older than 75 years compared to younger patients; this reflects, among other things, an age discrimination which is called agism. It has been established that cellular aging is marked by 9 major families of biological and genomic abnormalities. Biological aging and oncogenesis are intertwined with increasingly well established relationships. They are both the product of natural selection and they are found in all species with both renewal tissues and a distinction between germinal tissue and somatic tissue.Epidemiological data predict that oncology, including urological oncology, is becoming very predominantly geriatric oncology; it is critical and urgent that society be prepared for it and that every care-giver be prepared, that is, be specifically trained. Biological and genetic data argue for a great entanglement between aging and oncogenesis; research in each of these areas should be reconciled for mutual benefit.

To describe the epidemiology of renal cell carcinoma (RCC) and its natural history in the elderly patient. To propose adaptations of geriatric evaluation specific to RCC. Recall therapeutic options and the treatment options specific to elderly patients.Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific societies of geriatrics, from the National Cancer Institute using the following keywords: elderly, geriatrics, renal cell carcinoma, small renal mass, diagnosis, treatment.The incidence of RCC increases in France and peaks between 70 and 80 years. This increase in incidence is mainly due to the diagnosis of small renal masses (SMR). The specific mortality of RCC increases with age (at least between 75 and 95 years). Tumor biopsy, especially of SMR, should be considered in the elderly patient. The geriatric assessment of patients with CaR has no specificity apart from specific evaluation of renal function and operative risk. There is no prospective therapeutic trials dedicated to elderly patients with localized RCC. Surgical treatment requires the use of fast track protocol (the modalities of which are being elaborated) in which geriatricians play a key role throughout the process. The role of percutaneous ablative treatment should be better defined in elderly patients. However, given their low specific mortality, surveillance of SRM (at least initially) is probably an interesting option, certainly under-used, although its impact on quality of life remains to be clarified. The overarching goal of geriatric oncology must guide the decisions of care in the older patient with CaR: first, the respect of patient-specific expectations and secondly the search for an overall clinical benefit; objectives that have no reason to be restricted to elderly patients.RCC is becoming a predominantly elderly cancer. It responds to the current general diagnostic and therapeutic guidelines. It is desirable that clinical research help to better define the respective roles of percutaneous biopsy and treatment of localized RCC.

To explain the notion of frailty, then to explain how crucial is the detection of frailty detection in the elderly patient, and, in cases of suspected frailty, how crucial is the need for geriatric assessment. To describe (i) how this assessment of the elderly cancer patient is performed, (ii) how the results of this geriatric assessment must drive the decision making, and (iii) the role of the geriatrician in the care pathway.Bibliographic research from the Medline bibliographic database (NLM Pubmed tool) and Embase, as well as on the websites of scientific geriatric societies, from the National Cancer Institute using the following keywords: elderly, geriatrics, cancer, frailty, assessment, decision making.The goal of frailty detection is to optimize care, to maintain the independence and the survival of the patient. The prevalence of frailty increases with the age and the diagnosis of cancer. Detection of frailty in the elderly patient with cancer is performed using the G8 questionnaire recommended by the INCa. In case of anomaly or clinical justification, the patient receives a geriatric assessment, which is a multidimensional and multidisciplinary procedure. The clinician can call on the UCOG of the region in which he practices. The relevance of medical decisions will be based on the results of this geriatric assessment. The geriatrician plays a crucial role and will be involved throughout the care.The detection of frailty in the elderly patient with cancer is obligatory. Consecutive geriatric assessment can be performed by the UCOG of the region. The results of the geriatric assessment must serve as a basis for any therapeutic decision making and the preservation of the independence of the patient must remain the priority.

To define the necessary arrangements of medical treatment with anti-angiogenics, mTOR inhibitor or systemic immunotherapies in the management of metastatic renal cell carcinoma in elderly patients.Bibliographical search was performed from the Medline bibliographic database (NLM Pubmed tool) and Embase focused on: metastatic renal cell carcinoma, elderly, treatment.The selection criteria for the medical treatment of metastatic renal cell carcinoma in elderly patients are the IMDC score, necessarily complemented by performance status, the tolerability profile of treatments, more frequent drug interactions, treatment adherence, management capacity of side effects, and patient preference. Each of these criteria is detailed in critical ways.The efficacy and tolerability of medical treatments for metastatic renal cancer have not been reported as different depending on age. No dosage adjustment is recommended in principle. However, prevention and early treatment of side effects of treatment should be strengthened in elderly patients.

Ablative therapies (AT) in kidney cancer are rising. It's important to evaluate the situation of this therapy. The aim of this study is to identify the best indications for AT treatment for kidney cancer.Review of literature using Medline and Embase databases. Study were selected based on scientific relevance. Clinical keys centered on the best requirements to indicate ablative therapies.AT is indicated according to specific tumor and patients criteria. A good initial evaluation is essential (imaging, pathology, renal function and general condition of the patient). AT gets the best results when applied to the following tumor criteria: solid tumor, length3cm, exophytic localization, RENAL score8. In few cases, AT could be discussed as an alternative to the reference treatment, sparing surgery: life expectancy evaluated between 3 and 7 years, chronic renal failure or single kidney, transplanted kidney, familial tumors. AT can be used in first line, post-surgery after local recurrence or for distant metastasis. Like every other innovative technic, indications of AT would be adjust with learning curve and cost-effectiveness.AT have to be included as a valid treatment for kidney cancer4cm. The respect of actual indications and collection of results of AT compared to surveillance and surgery, would determinate the evolution of AT indications in the future.

Resume Sans co-morbidite, un homme de 75 ans a une probabilite de vie voisine de 9 a 14 ans. Elle n’est que de 5 ans en cas de co-morbidites importantes. Pour un homme de 80 ans sans co-morbidite, la probabilite de vie est voisine de 11 ans. La prise en charge d’un malade âge atteint d’un cancer de la prostate fait intervenir la notion de probabilite de survie avant toute decision diagnostique et therapeutique. La strategie diagnostique doit etre precisee pour chaque patient en fonction de la presentation clinique afi n de determiner l’indication des biopsies prostatiques dans cette population âgee. Afi n de pouvoir estimer la probabilite de survie, il est necessaire de recourir aux techniques de l’evaluation geriatrique qui se composent de strategies medicales allant du depistage de la fragilite a l’evaluation geriatrique approfondie des patients les plus complexes. L’existence de nombreux outils d’estimation de la probabilite de survie necessitait une lecture critique de leurs avantages et inconvenients en pratique clinique quotidienne.

Resume La population âgee, sensible et soumise aux effets indesirables des medicaments, constitue une cible privilegiee pour l’education therapeutique du patient (ETP). L’ETP oblige le professionnel de sante a la connaissance des produits et techniques de soins, mais aussi a la connaissance du patient et de ses representations. Le pharmacien, encore peu present dans les programmes d’ETP, cherche pourtant a les integrer pour y apporter sa connaissance du medicament. Mais sait-il ce que l’objet medicament represente chez le patient ? L’objectif de ce travail a ete d’etudier les differences de representations sur le medicament entre des professionnels du medicament (preparateur en pharmacie et pharmaciens) et des patients âges (selectionnes de maniere stricte selon le MMSE, les capacites auditives, visuelles, l’autonomie…). Le but, a terme, est d’integrer les donnees analysees a la construction de programmes d’ETP en geriatrie. Une demarche qualitative avec des entretiens ouverts a ete mise en place. Un diaporama de photographies d’objets de la vie courante et de medicaments a servi de support pour connaitre les representations des individus. Une analyse lexicale, via le logiciel Sphinx Plus 2®, des corpus de textes recueillis dans les deux echantillons d’individus, a permis une exploitation de nos donnees. Il existe des differences lexicales significatives (Test du χ2) entre les deux echantillons concernant les medicaments. Cette difference n’est pas retrouvee pour les objets de la vie courante. Un lexique propre a chaque groupe a pu etre mis en evidence et analyse. Le medicament issu de la prescription medicale n’est pas dans un rapport classique a la consommation. Forme, couleur, environnement semblent etre des elements indispensables a l’appropriation d’un traitement par un patient. Le medicament est a la fois objet de technique et d’imaginaire : cela doit inciter le professionnel du medicament a etre a l’ecoute des representations de son patient afin d’ameliorer son message, a posteriori different de celui de son interlocuteur.

Resume La prevalence du syndrome d’apnees du sommeil chez les sujets âges de plus de 65 ans est importante. Depuis le debut des annees 2000, l’inclusion dans les programmes d’evaluation geriatrique de procedures de depistage, de diagnostic et de prise en charge des pathologies du sommeil s’est considerablement developpee. Il est donc maintenant necessaire de faire le lien entre geriatres et specialistes du sommeil en explicitant les grandes regles de la realisation d’une evaluation geriatrique d’autant que cette derniere a deja demontre son efficacite dans de nombreux domaines. Ce concept recouvre deux grandes activites : l’evaluation geriatrique multidimensionnelle qui est une evaluation geriatrique standardisee de detection des comorbidites, du statut fonctionnel et des grands syndromes geriatriques et l’evaluation geriatrique approfondie dont l’objet est de repertorier les differents problemes du malade, de distinguer les pathologies somatiques et/ou psychiatriques des consequences physiologiques du vieillissement, d’apprecier l’impact fonctionnel des pathologies, de comprendre l’interference de ces pathologies entre elles, d’apprecier leurs consequences sur l’environnement social du malade et enfin de hierarchiser les differents problemes de sante du patient. L’evaluation geriatrique approfondie est une action medicale organisee en cinq phases permettant la mise en place et le suivi de recommandations adaptees a chaque individu.

En France, la population âgee continue de croitre et c’est parmi ces sujets que l’incidence du cancer du sein chez les femmes est majeure. Dans cet article, nous presentons les differentes formes de l’evaluation geriatrique et leurs interets avant la prise de decision therapeutique. Nous decrivons le role de l’evaluation geriatrique en precisant l’impact des comorbidites, des syndromes geriatriques et de la dependance sur la survie avant la realisation d’une chirurgie, d’une radiotherapie et l’initiation des therapeutiques adjuvantes. Enfin, comme illustration, nous presentons les resultats d’une evaluation geriatrique approfondie (EGA) realisee sur une cohorte de femmes âgees atteintes d’un cancer du sein non metastatique.

The heterogeneity of the elderly population makes the simple application of standard therapeutic programs in oncological management complex, particularly if they have been validated on young populations. The NCCN and the SIOG recommend using a geriatric evaluation before setting up an individualized care program. Geriatric assessment has demonstrated its efficacy in a number of domains. This concept covers two broad activities: the Multidimensional Geriatric Evaluation (MGE), which is a standardized geriatric evaluation for detecting co-morbidities and broad geriatric syndromes, and the Detailed Geriatric Evaluation (DGE). The objective of the DGE is to inventory the patient's various problems, distinguish somatic and/or psychiatric pathologies from the physiological consequences of aging, assess the functional impact of diseases, understand how these diseases interfere with one another, assess their consequences on the patient's social environment, and prioritize the patient's different health issues. The DGE is a medical action organized into five phases designed to set up care so that the recommendations made can be followed.

Resume Introduction En France, l’âge moyen du diagnostic du cancer bronchique est de 64 ans. Il est de 76 ans dans la population des plus de 70 ans, son incidence etant liee a l’augmentation avec l’âge du risque intrinseque de developper un cancer et au vieillissement de la population. Les methodes de diagnostic ne different pas chez le sujet âge et chez le sujet plus jeune, et la fibroscopie bronchique reste notamment la pierre angulaire du diagnostic, avec des taux de complications comparables. Etat des connaissances Le bilan d’extension a ete profondement modifie ces dernieres annees avec l’avenement du TEP-Scan, qui semble de plus en plus devenir l’examen de reference et permet de limiter les interventions chirurgicales inutiles, a fortiori chez les sujets âges. L’exploration encephalique par scanner ou mieux par IRM est egalement imperative avant de proposer un acte chirurgical. Avant la decision therapeutique l’evaluation de l’etat de sante du sujet âge est une etape fondamentale. Elle repose sur le concept de l’evaluation geriatrique : l’evaluation geriatrique standardisee de depistage (Geriatric Multidimentionnal Assessment) , et l’evaluation geriatrique approfondie (Comprehensive Geriatric Assessment) qui releve de la competence geriatrique. Perspectives C’est une approche globale du malade qui permet notamment de preciser et de hierarchiser les differents problemes du malade et leur impact fonctionnel sur les activites de la vie quotidienne, l’environnement social du malade… Certaines variables geriatriques (IADL, BADL, MMSE, IMC, etc.) peuvent etre predictives du taux de survie apres chimiotherapie ou du taux de complications postoperatoires apres une chirurgie thoracique. Les grands principes therapeutiques du cancer bronchique sont applicables chez le sujet âge ; la survie a long terme sans recidive apres resection chirurgicale est independante de l’âge. Que la strategie oncologique soit curative ou palliative, le malade âge atteint d’un cancer bronchique doit beneficier de soins de support. Ils s’integreront dans une demarche palliative si tel est le cas. En fait, l’âge seul n’est pas le facteur permettant de recuser une prise en charge oncologique optimale. Conclusions L’elaboration du programme personnalise de soins d’un malade âge atteint d’un cancer bronchique devrait etre basee sur le couplage : evaluation oncologique – evaluation geriatrique approfondie.

Peu de personnes âgees atteintes de cancer sont incluses dans des essais cliniques. Ainsi, la connaissance sur l’efficacite et la tolerance des traitements est-elle mediocre dans cette population de patients. Les barrieres a l’inclusion des patients sont l’âge, les comorbidites, les criteres d’inclusion, les toxicites, les a priori des patients, des familles et des medecins sur la strategie therapeutique a adopter chez les personnes âgees. Une inclusion optimale des personnes âgees peut etre obtenue en evaluant leur etat de sante et en adaptant les options therapeutiques. Le depistage des problemes geriatriques doit concerner au moins les domaines suivants: les comorbidites, le risque iatrogene, la dependance, les fonctions cognitives, les fonctions renales et cardiaques, l’etat nutritionnel. Les outils d’evaluation sont discutes, et leur choix doit faire l’objet d’un consensus dans la communaute oncogeriatrique.

L’augmentation de l’incidence des cancers avec l’avance en âge et l’augmentation de la dependance avec l’âge va entrainer un nombre croissant de sujet âge atteint de cancer, affecte de dependance. La prise en charge oncologique de cette population est complexe car elle ne depend pas de standards therapeutiques oncologiques. La dependance n’est pas toujours le reflet d’une fragilite ou d’un ensemble de comorbidites, elle est peut etre liee a l’agressivite du cancer, a la fatigue. Elle est predictive de la survie, de la tolerance a la chirurgie ou la radiotherapie. L’evaluation de la dependance revet donc une importance fondamentale dans les processus decisionnels en oncogeriatrie.

SummaryMemory loss is the most common early symptom of Alzheimer's disease (AD). For this study, we chose the hippocampi as regions of interest. The hippocampus, which is closely associated with memory processing, is known to be vulnerable to damage in the early stage of AD. We considered both inter-group (patients vs controls) and intra-group (right vs left hippocampus) comparisons. We examined seven patients meeting the DSM-III-R criteria of senile dementia and the National Institute of Neurological and Communicative Disorders and Stroke-Alzheimer's Disease and Related Disorders Association (NINCDS — ADRDA) criteria of probable AD, and II aged controls. This study focused on the measurement of phosphorus 31 (31P) Nuclear Magnetic Resonance (NMR) spectroscopy metabolites in each hippocampus. We found significant differences in phosphorus metabolites for both intra-group comparison (pH shifted towards relative alkalosis in the left hippocampus of patients) and inter-group consideration (reduced phosphodiesters [Pde]and elevated gamma adenosine triphosphate (ATP) in the right hippocampus, higher inorganic phosphate (pHi) in the left hippocampus for patients as compared to controls). We suggest energy failure and membrane functional breakdown in patients compared to aged controls.

Managing an elderly subject with prostate cancer brings into play the notion of likelihood of survival before any diagnostic or therapeutic decision can be made. The diagnostic strategy must be specified for each patient in accordance with the clinical presentation so as to determine whether prostate biopsies are indicated in this elderly population. To estimate the likelihood of survival, one must make use of geriatric assessment techniques comprising medical strategies ranging from screening for frailty to detailed geriatric evaluation for the most complex patients. The many tools available for estimating the likelihood of survival requires a critical review of their advantages and disadvantages in daily clinical practice.

Les projections demographiques et l’incidence des cancers chez les 75 ans et plus font que la prise en charge des cancers dans cette population sera un des grands enjeux de la geriatrie et de l’oncologie dans les decennies a venir. Les malades âges atteints d’un cancer peuvent cumuler outre leur cancer, de la fragilite, des co-morbidites, des grands syndromes geriatriques interagissant avec l’evolution de la maladie et sa prise en charge therapeutique. L’evaluation geriatrique (EG) est la technique medicale la plus adaptee a identifier les malades âges a risque de decompensation lors d’un traitement oncologique classique. Il faut donc s’orienter vers une prise en charge adaptee individualisee dependant des particularites du malade âge. Dans une vision d’efficience l’evaluation geriatrique doit se derouler selon des etapes hierarchisees. La premiere etape aura pour objectif de detecter le malade âge relevant de l’EG, elle fera appel a des outils simples. La deuxieme etape se basera sur l’evaluation geriatrique multidimensionnelle, elle aura pour objectif soit de valider des prises en charge preexistantes, soit de les amender, soit d’orienter le patient vers une comprehensive geriatric assessment. Cette connaissance fin de l’ etat de sante du malade permettra en confrontation avec les donnees oncologiques de determiner le Programme Personnalise de Soins.

The heterogeneity of the elderly population makes the simple application of standard therapeutic programs in oncological management complex, particularly if they have been validated on young populations. The NCCN and the SIOG recommend using a geriatric evaluation before setting up an individualized care program. Geriatric assessment has demonstrated its efficacy in a number of domains. This concept covers two broad activities: the Multidimensional Geriatric Evaluation (MGE), which is a standardized geriatric evaluation for detecting co-morbidities and broad geriatric syndromes, and the Detailed Geriatric Evaluation (DGE). The objective of the DGE is to inventory the patient's various problems, distinguish somatic and/or psychiatric pathologies from the physiological consequences of aging, assess the functional impact of diseases, understand how these diseases interfere with one another, assess their consequences on the patient's social environment, and prioritize the patient's different health issues. The DGE is a medical action organized into five phases designed to set up care so that the recommendations made can be followed.

Several epidemiological studies have identified clinical factors that predict the risk of hip fractures in elderly women independently of the level of bone mineral density (BMD), such as low body weight, history of fractures, and clinical risk factors for falls. Their relevance in predicting all fragility fractures in all postmenopausal women, including younger ones, is unknown. The objective of this study was to identify independent predictors of all osteoporosis-related fractures in healthy postmenopausal women. We prospectively followed for 5.3 +/- 1.1 years a cohort of 672 healthy postmenopausal women (mean age 59.1 +/- 9.8 years). Information on social and professional conditions, demographic data, current and past medical history, fracture history, medication use, alcohol consumption, caffeine consumption, daily calcium intake, cigarette smoking, family history of fracture, and past and recent physical activity was obtained. Anthropometric and total hip bone mineral density measurements were made. Incident falls and fractures were ascertained every year. We observed 81 osteoporotic fractures (annual incidence, 21 per 1000 women/year). The final model consisted of seven independent predictors of incident osteoporotic fractures: age > or = 65 years, odds ratio estimate (OR), 1.90 [95% confidence interval (CI) 1.04-3.46], past falls, OR, 1.76 (CI 1.00-3.09), total hip bone mineral density (BMD) < or = 0.736 g/cm(2), OR, 3.15 (CI 1.75-5.66), left grip strength < or = 0.60 bar, OR, 2.05 (CI 1.15-3.64), maternal history of fracture, OR, 1.77 (CI 1.01-3.09), low physical activity, OR, 2.08 (CI 1.17-3.69), and personal history of fragility fracture, OR, 3.33 (CI 1.75-5.66). In contrast, body weight, weight loss, height loss, smoking, neuromuscular coordination assessed by three tests, and hormone replacement therapy were not independent predictors of all fragility fractures after adjustment for all variables. We found that some--but not all--previously reported clinical risk factors for skeletal fragility predicted all fragility fractures independently of BMD in healthy postmenopausal women, although they differed somewhat from those predicting specifically hip fractures in elderly women. These risk factors appear to reflect quality of bone structure (previous fragility fracture), lifestyle habits (physical activity), muscle function and health status (grip strength), heredity (maternal history of fracture), falls, and aging. Measurements of these variables should be included in the clinical assessment of the risk of osteoporotic fractures in postmenopausal women.

Ageing generates an important inter- and intra-individual variability in drug pharmacokinetics. The increasing frequency of ofloxacin adverse effects in elderly patients results from increased ofloxacin plasma levels about two or threefold over normal concentrations. A retrospective study of ofloxacin population pharmacokinetics in 17 elderly patients (83.6 +/- 6.8 years) shows the existence of three subgroups according to ofloxacin total clearance [group 1: 1.44 l/h, group 2: 4.37 l/h and group 3: 15.08 l/h] reflecting the important inter-individual variability. No correlation between this clearance and creatinine clearance, nor between this clearance and age, could be established, showing the limits of traditional drug monitoring in the elderly. Ofloxacin pharmacokinetic parameters estimated by the non-parametric software NPEM2 in the 17 elderly patients (absorption rate constant, Ka: 2.668 +/- 1.256 h-1; apparent volume of distribution related to weight, Vs: 1.272 +/- 0.778 l/kg; elimination rate constant, Ks: 0.265 +/- 0.247 10(-3) min/ml/h) are clearly different from those estimated in young adults. These results show the limits of classic drug monitoring in the elderly, and also the interest of adaptive control of a drug regimen.

Specifications on laser damage thresholds have become usual and necessary today for most optical coatings and related applications, such as American (NIF) or French (ARTHEMIS) programmes. Thanks to a support from le Centre d’Etudes Atomiques, France, our laboratory has been concerned by damage phenomena in optical coatings produced by different techniques (Electron Beam Deposition, Ion Assisted Deposition, Ion Plating) and materials (ZnS, Cryolithe, MgF2, Ta2O5, SiO2, HfO2) at LOSCM.

Planar optics offer an easy method for highly increasing the sensitivity of optical multilayers to absorption and scattering from interfaces and bulks. In this aim we developed in Marseilles two techniques that enable to measure the attenuation of a guided mode inside a multilayer planar waveguide1. The first technique is based on photothermal measurements that result from an absorption process, while the second involves a camera reading that registers scattering data. Though the principles of these two techniques are different, they should lead to the same value of attenuation coefficient, which is confirmed by experiment. At the present time these techniques allow to measure imaginary indices up to some 10-8 at the wavelength 515 nm.

Many studies are devoted to the study of light scattering1 in multilayer optics, and enable to improve our knowledge of microstructural parameters such as interface roughnesses and bulk inhomogeneities inside the stacks. However these studies are mainly based on the intensity of the scattered light, while phase measurements may provide additional and precious information when analysing the scattering data.

In the last Tucson meeting, we showed that the macroscopic roughness spectra measured with light scattering at visible wavelengths were perfectly extrapolated at high spatial frequencies by microscopic roughness spectra measured with Atomic Force Microscopy1. These results have been largely confirmed by numerous experiments2,3 and allow us today to characterize thin films microstructure from a macroscopic to a microscopic scale.

Light scattering from random continuous profiles is rather well understood today and can be predicted with high accuracy1,2. However, for high-quality coatings produced on super smooth substrates (< 0.2 nm roughness), pratically the whole scattering originates from a few localized defects in the stacks. Such discrete irregularities can be detected by the presence of a “ripple” in the angular scattering3 measured with high resolution (0.01°). Therefore the characterization tools must be improved in order to reach the size, refractive index and density of localized defects that still play a key role for many applications4 such as laser damage.

It is essential that patients' age, as well as period of hospitalisation and pathologies, be taken into account when assessing a departmental activity. The older the inpatients in internal medicine departments, the greater their need for care

To meet specifications that are required for demultiplexing in optical telecommunication, we are interested in complex multilayer systems with narrow pass band and high rejection. For spatial application, these filters must have very good optical and mechanical properties and we are led to use hard materials such as oxides. However, these materials deposited with classical vacuum evaporation-condensation techniques have a refractive index highly sensitive to atmospheric conditions. Optical properties of these systems are then very different in vacuum and in air. We show here that a solution consists in using new deposition techniques such as Ion Assisted Deposition. Some examples of multilayers produced with this deposition technique are given and optical performances that we reach are pratically independant of thermodynamical surrounding conditions.

For the development of optical coatings (as high power laser mirrors) of higher and higher performances, it is necessary to use more and more powerful characterization means for optical thin films. The highly sensitive and simple technique of Photothermal Deflection Spectroscopy (P.D.S.) gives the absorption losses down to ultra low level. We show that this method can be applied to transparent single layers. Techniques used for photothermal signal calibration are presented. Photothermal signal versus wavelength for absorbing layers (extinction coefficients from some 10-3) is compared with absorption spectra obtained by classical spectrophotometry. Experimental results are given which show the sensi-tivity of the method. Extinction coefficients that do not exceed some 10-7 can be measured. P.D.S. can also give absorption losses for multilayer coatings. Some results on narrow band filters are presented.

Uniformity of layers produced by I. A. D. strongly depends on the characteristics of the ion beam: optical characterization is made by guided wave measurements.