Older Adults with Cancer: A Randomized Controlled Trial of Occupational and Physical Therapy

OBJECTIVES

The impact of occupational therapy (OT) and physical therapy (PT) on functional outcomes in older adults with cancer is unknown.

DESIGN

Two-arm single-institution randomized controlled trial of outpatient OT/PT.

SETTING

Comprehensive cancer center with two off-site OT/PT clinics.

PARTICIPANTS

We recruited adults 65 years and older with a recent diagnosis or recurrence of cancer within 5 years, with at least one functional limitation as identified by a geriatric assessment. Participants were randomized to OT/PT or usual care.

INTERVENTION

Rehabilitation consisted of individualized OT and PT that addressed functional activities and strength/endurance needs.

MEASUREMENTS

Primary outcome was functional status as measured by the Nottingham Extended Activities of Daily Living scale. Secondary outcomes were Patient-Reported Outcomes Measurement Information System-Global Mental Health (GMH) and Global Physical Health (GPH), ability to participate in Social Roles (SR), physical function, and activity expectations and self-efficacy (Possibilities for Activity Scale [PActS]).

RESULTS

Among those recruited (N = 63), only 45 patients (71%) were evaluable due to loss of follow-up and/or nonreceipt of intervention. The median age was 74 years; 53% were female, and 91% were white. Overall, 30% patients had hematologic malignancies, 30% breast cancer, and 16% colorectal cancers. A total of 65% were in active treatment; 49% had stage 3 or 4 disease. At follow-up, both OT/PT (P = .02) and usual care (P = .03) groups experienced a decline in functional status. PActS scores between groups (P = .04) was significantly improved in the intervention group. GMH and SR met criteria for minimally important clinical difference favoring the intervention, but not statistical significance. Several barriers were noted in the implementation of the intervention program: recruitment, concerns about cost, distance, scheduling, and limited treatment provided.

CONCLUSION

OT/PT may positively influence activity expectations and self-efficacy. Future research needs to address significant barriers to implementation to increase use of OT/PT services and access to quality care. J Am Geriatr Soc 67:953-960, 2019.

Assessment of Sarcopenia Measures, Survival, and Disability in Older Adults Before and After Diagnosis With Cancer

IMPORTANCE

Progressive loss of muscle mass and strength, known as sarcopenia, is a well-known phenomenon of aging; however, little is known about the trajectory of sarcopenia measures before and after cancer diagnosis and its contribution to subsequent disability.

OBJECTIVE

To examine the rate of decline of sarcopenia measures (ie, appendicular lean mass [ALM], muscle strength, and physical performance) in older adults with cancer both before and after the cancer diagnosis compared with the trajectory of a population without cancer, and secondarily to assess the association of sarcopenia measures with overall survival and major disability in patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This matched cohort study included participants from the Health, Aging, and Body Composition (Health ABC) study, which included 3075 community-dwelling older adults aged 70 to 79 years recruited from a random sample of white Medicare beneficiaries and all eligible black residents in and around Pittsburgh, Pennsylvania, and Memphis, Tennessee, beginning in January 1997 and observed for 17 years until December 2013. Data were analyzed from May 2018 to February 2020.

EXPOSURES

The development of an adjudicated cancer diagnosis confirmed with pathology or cytology reports during the first 7 years of follow-up.

MAIN OUTCOMES AND MEASURES

Annual assessments of ALM, hand grip strength, and gait speed were the primary outcome measures. Linear mixed-effect models were used to compare the change in ALM, hand grip strength, and gait speed between individuals who developed cancer and those who did not, adjusted for multiple comparisons (P < .01). Multivariable Cox regression was used to examine the association of sarcopenia measures with overall survival and major disability from date of cancer diagnosis.

RESULTS

Of the 3075 included patients, 1491 (48.5%) were male, 1281 (41.7%) were black, and the mean (SD) age was 74.1 (2.9) years. A total of 515 patients (16.7%) developed cancer within the first 7 years of the study. The most common cancers were prostate (117 [23.2%]), colorectal (63 [12.5%]), lung (61 [12.1%]), and breast (61 [12.1%]) cancer, and 165 patients (32.0%) were diagnosed as having metastatic disease. Compared with controls without cancer, patients with a cancer diagnosis had a steeper decline in gait speed (β = -0.02; 95% CI, -0.03 to -0.01; P < .001) but not ALM (β = -0.02; 95% CI, -0.07 to 0.04; P = .49) or hand grip strength (β = -0.21; 95% CI, -0.43 to 0; P = .05) prior to cancer diagnosis. After cancer diagnosis, there was a decline in ALM (β = -0.14; 95% CI, -0.23 to -0.05; P < .001) but not hand grip strength (β = -0.02; 95% CI, -0.37 to 0.33; P = .92) or gait speed (β = 0; 95% CI, -0.01 to 0.02; P = .51). Declines in ALM after a cancer diagnosis were most striking in patients with metastases (β = -0.32; 95% CI, -0.53 to -0.10; P = .003). Slow gait speed was associated with a 44% increase in mortality (hazard ratio, 1.44; 95% CI, 1.05 to 1.98; P = .02) and a 70% increase in disability (hazard ratio, 1.70; 95% CI, 1.08 to 2.68; P = .02) but not low ALM or hand grip strength.

CONCLUSIONS AND RELEVANCE

Accelerated losses in differing sarcopenia measures exist both prior to and after a cancer diagnosis and may present opportunities for targeted interventions to improve outcomes.

Embracing the complexity: Older adults with cancer-related cognitive decline-A Young International Society of Geriatric Oncology position paper

Cancer-related cognitive decline (CRCD) may have particularly significant consequences for older adults, impacting their functional and physical abilities, level of independence, ability to make decisions, treatment adherence, overall quality of life, and ultimately survival. In honor of Dr. Hurria's work we explore and examine multiple types of screening, assessment and non-pharmacologic treatments for CRCD. We then suggest future research and clinical practice questions to holistically appreciate the complexity of older adults with cancer's experiences and fully integrate the team-based approach to best serve this population.

Abstract P3-08-73: Muscle measures, body composition, and function in patients with early breast cancer

Introduction: Sarcopenia and muscle composition are associated with treatment-related toxicities and adverse events in women with EBC (Shachar 2017). We investigated the relationship of muscle mass with other measures of body composition as well as comorbidities, physical function, fatigue, and quality of life. Methods: Women age 21 or older were enrolled in intervention studies (NCT02167932, NCT02328313) investigating home-based walking during chemotherapy for early breast cancer (stage I-III). Prior to the start of chemotherapy, patients completed the Short Physical Performance Battery (SPPB) and the Timed Up and Go (TUG) test. When available from staging, transverse views of computed tomography (CT) through L3 lumbar segments were analyzed using Slice-O-Matic software (Tomovision Quebec, Canada) to ascertain skeletal muscle area (SMA= -29 to +150 Hounsfield Units), skeletal muscle density (SMD= average attenuation of skeletal muscle in HU), skeletal muscle index (SMI= SMA/height2), and skeletal muscle gauge (SMG= SMI x SMD). BSA and BMI were calculated using standard formulas. Descriptive statistics (mean and standard deviation (SD)) were estimated and simple linear regression models were used to evaluate associations of body composition, function and quality of life and continuous muscle measures. Pearson correlation coefficients were estimated to assess the relationship between muscle metrics. Results: In 99 patients, mean age was 56 (SD 13), BMI was 30 (SD 7), 47% were obese (≥30 kg/m2), and 54% had stage III breast cancer. Mean SMI was 45.3 (SD. 8.5), 26% were sarcopenic (SMI &lt;40cm2/m2), mean SMD was 31.2 (SD 9.8), 77% had low SMD (HU &lt;37.8), and mean SMG was 1413.8 (SD 71.2) [normal SMG is &gt;1512 Arbitrary Units]. For each additional comorbidity, mean SMD decreased by 1.91 (p=.003), mean BSA increased by 0.035 (p=.02), and mean BMI increased by 1.31 (p=.005). Lower SMD and SMG were seen for patients with TUG &gt;14 seconds (-5.70, p=.04 and -325.4, p=.02, respectively). The mean SMD increased by 1.22 (p=.02) for each additional point on the SPPB scale. For the correlation between BMI and muscle matrices, there was a strong positive correlation for SMI (+0.648 p&lt;.0001) and a moderate negative correlation for SMD (-0.490 p&lt;.0001). Between BSA and muscle matrices, there was a moderate positive correlation for SMI (+0.433 p&lt;.0001), a strong negative correlation for SMD (-0.572 p &lt;.0001), and a low negative correlation for SMG (-0.282 p=.004). Conclusion: Our study showed that sub-optimal muscle metrics, especially lower muscle mass and density, were correlated worse physical function in women with EBC. We also show that muscle metrics are associated with conventional measures of body composition.

Citation Format: Gabriel F. P. Aleixo, Allison M Deal, Grant R Williams, Hyman B Muss, Kirsten A Nyrop, Ji Hye Park, Hyeon Yu, Shlomit S Shachar. Muscle measures, body composition, and function in patients with early breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-73.

Abstract P3-08-48: Adiposity, comorbidities, and function in patients with early breast cancer

Introduction: Visceral adipose tissue (VAT) is correlated with lower overall survival and higher chemotherapy toxicity in women with breast cancer (Del Fabbro 2012, Feliciano 2019). In a sample of women scheduled for chemotherapy for early breast cancer (EBC) (stage I-III), we evaluate whether VAT or superficial adipose tissue (SAT) are associated with comorbidities, function, and clinically-used body metrics, Body Mass Index (BMI) and Body Surface Area (BSA).Methods: Women age 21 or older were enrolled in intervention studies (NCT02167932, NCT02328313) to encourage home-based walking during chemotherapy for EBC. Prior to chemotherapy initiation, patients had abdominal computerized tomography (CT) scans and completed Timed Up and Go (TUG) and Short Physical Performance Battery (SPPB) tests. Axial CT images were evaluated at the L3 level using Slice-O-Matic software (Tomovision Quebec, Canada). Superficial adipose tissue(SAT) was calculated from extra-muscular tissue with densities ranging from -190 to -30 Hounsfield Units (HU). Visceral adipose tissue (VAT) was calculated from non-subcutaneous tissue with densities from -150 to -50 HU, with values in cm2. BSA and BMI were calculated using standard formulas. Descriptive statistics(mean and standard deviation (SD)) were estimated and simple linear regression models were used to evaluate associations of comorbidities, function, and clinically-used body metrics and continuous adiposity measures. Pearson correlation coefficients were estimated to assess the relationship between adiposity measures.Results: In a sample of 99 women, mean age was56 (SD 13.1), BMI was 30 (SD 7), 47% were obese (≥30 kg/m2), and mean number of comorbidities was1.3 (SD 1.5).The mean VAT was 113.9 (SD 71.2), 50% had high VAT (&gt;100 cm2), and the mean SAT was 294.2 (SD 71.2). For each additional comorbidity, mean VAT increased by 16.68, and SAT increased by 21.6. Both arthritis and high blood pressure were associated with higher VAT (+67.2 p&lt;.0001 and +67.3 p&lt;.0001, respectively) and higher SAT (+94.3 p=.002 and +104.3 p=.0008, respectively). Peripheral vascular disease and emphysema/chronic bronchitis were associated with higher VAT (+57.7 p=.01 and +100.8 p=.02, respectively), but not higher SAT. Higher VAT was seen for patients with TUG &gt;14 seconds +57.87 (p=.004). For each additional point on the SPPB scale, the mean VAT decreased by 12.14(p=.002). For each additional comorbidity, BSA increased 0.035(p=.004) and BMI increased 1.31(p=.003). Strong positive correlations with VAT were seen for BSA (.697 p&lt;.001), BMI (0.681 p&lt;.001) and SAT (0.636 p&lt;0001), as well as SAT with BSA (0.813 p&lt;.0001) and BMI (.855 p&lt;.0001). Conclusion: Comorbidities, function and commonly-used body metrics (BSA, BMI) are associated with adiposity metrics (VAT, SAT). All of these body composition metrics are associated with measures of function.

Citation Format: Gabriel F. P. Aleixo, Allison M Deal, Shlomit S Shachar, Hyman B Muss, Kirsten A Nyrop, Ji Hye Park, Hyeon Yu, Grant R Williams. Adiposity, comorbidities, and function in patients with early breast cancer [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P3-08-48.

Pain in older survivors of hematologic malignancies after blood or marrow transplantation: A BMTSS report

BACKGROUND

Blood or marrow transplantation (BMT) is increasingly offered to older adults with hematologic malignancies; however, their risk for severe pain is poorly understood. Using the Bone Marrow Transplant Survivor Study, the current study investigated the prevalence and predictors of pain after BMT (allogeneic or autologous) as well as its association with physical performance impairments and frailty.

METHODS

The cohort included 736 patients with hematologic malignancies who underwent BMT at an age ≥ 60 years at 1 of 3 transplant centers between 1974 and 2014 and survived ≥2 years after BMT; 183 unaffected siblings also participated. Study participants reported on 4 pain domains (nonminor everyday pain, moderate to severe bodily pain, prolonged pain, and moderate to extreme pain interference), and the presence of 1 or more domains was indicative of a severe and/or life-interfering pain composite variable.

RESULTS

Overall, 39.4% of the BMT survivors reported severe pain with 2.6-fold greater odds of reporting pain in comparison with sibling controls. Among BMT recipients, those with less education, lower incomes, and active chronic graft-versus-host disease had higher odds of reporting pain. In multivariable analyses, BMT survivors with pain were more likely to have impaired physical performance and were more likely to meet the frailty criteria. BMT survivors reported higher use of pain medications (17.8% vs 9.3%) and opioid pain medications (6.5% vs 2.2%) in comparison with sibling controls.

CONCLUSIONS

Nearly 40% of older BMT survivors who were followed for a median of 5 years after BMT reported pain, and BMT survivors had 2.6-fold higher odds of reporting severe, nonminor or life-interfering pain in comparison with siblings.

Myosteatosis and prognosis in cancer: Systematic review and meta-analysis

BACKGROUND

The evidence that body composition parameters influence multiple cancer outcomes is rapidly expanding. Excess adiposity deposits in muscle tissue, termed myosteatosis, can be detected in CT scans through variations in the density of muscle tissues (Hounsfield Units). Patients with similar muscle mass but different amounts of intramuscular adipose infiltration have increased chemotherapy toxicity, time to tumor progression and other adverse outcomes among different cancer types. Our review examines the impact of myosteatosis on overall survival (OS) in patients with cancer.

METHODS

A systematic search of the literature was conducted on PubMed/ MEDLINE, Cochrane CENTRAL, and EMBASE. Meta-analysis was conducted using a random-effects model. Risk of bias was evaluated using the Newcastle-Ottawa Quality assessment for cohort studies, funnel plot (publication bias), and GRADE summary of findings tool from Cochrane.

RESULTS

A total of 4880 articles were screened from which 40 articles selected, including 21,222 patients. The overall mean proportion of patients with myosteatosis was 48 % (range 11-85 %). Using skeletal muscle density (SMD), patients classified as having myosteatosis had 75 % greater mortality risk compared to non-myosteatosis patients (HR 1.75 95 % CI 1.60-1.92, 40 studies) (p < .00001) (i2 = 62 %). Specifically, myosteatosis was prognostic for worse OS in patients with gynecological, renal, periampullary/pancreatic, hepatocellular, gastroesophageal, and colorectal carcinoma, and lymphomas.

CONCLUSION

Our analysis of the literature shows that cancer patients with myosteatosis have shorter survival. Our findings suggest that in oncological practice, muscle density assessment is valuable as a prognostic parameter.

The project ENABLE Cornerstone randomized pilot trial: Protocol for lay navigator-led early palliative care for African-American and rural advanced cancer family caregivers

BACKGROUND

Patients newly-diagnosed with advanced cancer often rely on family caregivers to provide daily support to manage healthcare needs and maintain quality of life. Early telehealth palliative care has been shown to effectively provide an extra layer of support to family caregivers, however there has been little work with underserved populations, especially African-Americans and rural-dwellers. This is concerning given the lack of palliative care access for these underserved groups.

STUDY DESIGN

Single-site, small-scale pilot randomized controlled trial (RCT) of Project ENABLE (Educate, Nurture, Advise, Before Life Ends) Cornerstone, a lay navigator-led, early palliative care coaching intervention for family caregivers of African-American and rural-dwelling patients with newly-diagnosed advanced cancer. Family caregivers are paired with a trained lay navigator overseen by specialist palliative care clinicians and receive a series of brief in-person and telehealth sessions focusing on stress management and coping, caregiving skills and organization, getting help, self-care, and preparing for the future/advance care planning. This pilot trial is assessing acceptability of the intervention, feasibility of recruitment and data collection procedures, and preliminary efficacy compared to usual care on caregiver and patient quality of life and mood over 24 weeks.

CONCLUSION

Once acceptability and feasibility are determined and issues addressed, the ENABLE Cornerstone intervention for underserved family caregivers of persons with advanced cancer will be primed for a fully powered efficacy RCT. Given its use of lay navigators and telehealth delivery, the intervention is potentially highly scalable and capable of overcoming many of the geographic, human resource, and cultural obstacles to accessing early palliative care support.

Cachexia and Sarcopenia in Older Adults with Cancer: A Comprehensive Review

Cancer cachexia is a syndrome characterized by weight loss with accompanying loss of muscle and/or fat mass and leads to impaired patient function and physical performance and is associated with a poor prognosis. It is prevalent in older adults with cancer; age-associated physiologic muscle wasting and weakness, also known as sarcopenia, can compound deficits associated with cancer cachexia in older adults and makes studying this condition more complex in this population. Multiple measurement options are available to assess the older patient with cancer and cachexia and/or sarcopenia including anthropometric measures, imaging modalities such as Dual X-ray absorptiometry (DEXA) and Computed Tomography (CT), muscular strength and physical performance testing, and patient-reported outcomes (PROs). A geriatric assessment (GA) is a useful tool when studying the older patient with cachexia given its comprehensive ability to capture aging-sensitive PROs. Interventions focused on nutrition and increasing physical activity may improve outcomes in older adults with cachexia. Efforts to develop targeted pharmacologic therapies with cachexia have not been successful thus far. Formal treatment guidelines, an updated consensus definition for cancer cachexia and the development of a widely adapted assessment tool, much like the GA utilized in geriatric oncology, could help advance the field of cancer cachexia over the next decade.

Bioelectrical Impedance Analysis for the Assessment of Sarcopenia in Patients with Cancer: A Systematic Review

BACKGROUND

The loss of muscle mass, known as sarcopenia, is a natural process of aging that is associated with adverse health outcomes regardless of age. Because cancer is a disease of aging, interest in sarcopenia and its potential impact in multiple cancer populations has increased significantly. Bioelectrical impedance analysis (BIA) is a guideline-accepted method for sarcopenia detection. This systematic review assesses the literature pertaining to BIA use in the detection of sarcopenia in adults with cancer.

MATERIALS AND METHODS

In this systematic review, a search of the literature for randomized controlled trials and observational studies was conducted using MEDLINE, Cochrane CENTRAL, and EMBASE, through July 15, 2019. The study is registered at Prospero (CRD 42019130707). For study inclusion, patients had to be aged 18 years or older and diagnosed with solid or hematological neoplasia, and BIA had to be used to detect sarcopenia.

RESULTS

Through our search strategy, 5,045 articles were identified, of which 24 studies were selected for inclusion in the review (total number of 3,607 patients). In five studies, BIA was rated comparable to axial computed tomography (CT) scan, calf circumference, or grip strength for sarcopenia screening. In 14 studies, BIA-identified sarcopenia was associated with adverse clinical outcomes.

CONCLUSION

BIA is an accurate method for detecting sarcopenia in adults with cancer prior to treatment and is a viable alternative to CT, dual-energy x-ray absorptiometry, and magnetic resonance imaging in oncology clinical practice.

IMPLICATIONS FOR PRACTICE

Bioelectrical impedance analysis (BIA) is an attractive method for identifying sarcopenic patients in clinical practice because it provides an affordable, noninvasive test that can be completed within a few minutes during a clinic visit. BIA does not require highly skilled personnel, and results are immediately available. This systematic review summarizes the literature pertaining to BIA assessment of sarcopenia in adults with cancer, with a focus on its use in diverse cancer populations.

Healthy lifestyle discussions between healthcare providers and older cancer survivors: Data from 12 cancer centers in the Southeastern United States

Background

Little is known about the prevalence of healthy lifestyle (HLS) discussions between providers and older cancer survivors.

Methods

We utilized cross‐sectional data from older cancer survivors (≥65 years) seen at 12 southeastern cancer centers during 2013‐2015. Data on demographics, time since diagnosis, weight, height, and healthy behaviors were collected. Respondents were asked if providers (oncologists, other physicians, and/or nurses) discussed exercise, healthy diet, weight management, and/or smoking cessation during clinical encounters. Descriptive statistics and bivariate associations between HLS topics and survivor characteristics were calculated.

Results

Among 1460 cancer survivors, mean age was 74 years (SD 6), most were white (81%), and >1 year postdiagnosis (84%). The majority (71%) reported discussing at least one of three HLS topics (exercise 49%, healthy diet 53%, vegetable consumption 28%); 17% received counseling on all three. Weight loss was recommended to 33% of overweight/obese survivors and smoking cessation to 85% of current smokers. Oncologists and nurses discussed HLS less frequently compared to other physicians. Younger survivors (65‐74 years) received recommendations for exercise, weight loss, and tobacco cessation more often than older survivors (≥75 years). Compared to white respondents, minorities reported discussions on all topics more often except for tobacco cessation. Excluding tobacco cessation, survivors with recent cancer diagnoses (<1 year) reported HLS discussions more often than survivors >1 year postdiagnosis.

Conclusion

Despite the American Cancer Society's recommendations, older survivors reported a low prevalence of HLS discussions with their providers, with some variation by demographic groups. Strategies are needed to promote these important discussions in this population.

Lay navigation across the cancer continuum for older cancer survivors: Equally beneficial for Black and White survivors?

OBJECTIVES

The Patient Care Connect Program (PCCP), through lay navigators' distress assessments and assistance, was shown to lower healthcare utilization and costs in older cancer survivors. PCCP benefits and assistance needs for disadvantaged minorities (e.g., Black) vs. Whites are unknown.

MATERIALS AND METHODS

We examined the PCCP impact with retrospective analyses of Medicare claims (2012-2015). Outcomes were quarterly costs and utilization (emergency room (ER), hospitalizations) for navigated and matched survivors. Repeated measures generalized linear models with normal (costs), and Poisson (utilization) distributions assessed differences in trends overall and separately for Blacks and Whites. With distress data for navigated survivors, we assessed high distress (score > 3), ≥1 distress cause (overall, by domain), and ≥ 1 assistance request by minority group.

RESULTS

Beneficiaries were: 772 Black and 5350 White navigated, and 770 Black and 5348 White matched survivors. Impact was: i) costs: -$557.5 Blacks (p < .001), -$813.4 Whites (p < .001); ii) ER: Incidence Rate Ratio (IRR) 0.97 Blacks (NS), 0.93 Whites (p < .001); iii) hospitalizations: IRR 0.97 Blacks (NS), 0.91 Whites (p < .001). There was no significant difference in impact across minority groups. No significant differences were found in high distress (29% Black, 25.1% White), ≥1 distress cause (61.6% Black, 57.8% White), or ≥ 1 assistance request (64.5% Black, 59.1% White). Blacks were more likely to have ≥1 distress cause in the Practical domain.

CONCLUSION

The PCCP may benefit both Black and White older cancer survivors. Programs should consider the proportion of older survivors with high distress, and the specific needs of minorities.

An examination of the relationship between patient satisfaction with healthcare and quality of life in a geriatric population with cancer in the Southeastern United States

BACKGROUND

Understanding factors that impact patient satisfaction with cancer care within the growing population of older adults living with cancer will contribute to tailoring programs that address patient needs and expectations. Further, patient satisfaction is a determinant of healthcare organizations' institutional performance. The purpose of this study was to investigate the relationship between patient satisfaction with care and health-related quality of life (HRQoL) among Medicare recipients with common cancers types (breast, prostate, or lung cancer).

METHODS

Cross-sectional analysis of survey data from 637 Medicare beneficiaries (≥65 years) with breast (n = 304), lung (n = 158), or prostate cancer (n = 175) in twelve hospitals in the Southeastern United States. Participants responded eighteen satisfaction questions across five domains. HRQoL was measured with the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the SF-12.v2 instrument.

RESULTS

SF-12 scores were positively associated with satisfaction domain scores. The magnitude of these associations was small with covariate-adjusted effect sizes r ranging from 0.05 to 0.12. Satisfaction scores were highest within the Quality of Care domain and lowest within the Patient Engagement domain.

CONCLUSIONS

Patient satisfaction domains had only modest association with HRQoL, indicating that these constructs should not be assumed to correlate. Satisfaction domains, including how patients access care, coordinate care, and engage within the healthcare system, were identified as potential areas for improvement. Patient satisfaction assessment across age groups may inform oncology care providers on ways in which their patients perceive the quality of care received, which ultimately affect healthcare organizations' accreditation, ranking, and reimbursement.

Arti Hurria and the progress in integrating the geriatric assessment into oncology: Young International Society of Geriatric Oncology review paper

Until recently, the progress in the diagnosis and management of cancer has not been matched by similar progress in the assessment of the increasing numbers of older and more complex patients with cancer. Dr. Arti Hurria identified this gap at the outset of her career, which she dedicated toward studying the geriatric assessment (GA) as an improvement over traditional methods used in oncology to assess vulnerability in older patients with cancer. This review documents the progress of the GA and its integration into oncology. First, we detail the GA's origins in the field of geriatrics. Next, we chronicle the early rise of geriatric oncology, highlighting the calls of early thought-leaders to meet the demands of the rapidly aging cancer population. We describe Dr. Hurria's early efforts toward meeting these calls though the implementation of the GA in oncology research. We then summarize some of the seminal studies constituting the evidence base supporting GA's implementation. Finally, we lay out the evolution of cancer-focused guidelines recommending the GA, concluding with future needs to advance the next steps toward more widespread implementation in routine cancer care. Throughout, we describe Dr. Hurria's vision and its execution in driving progress of the GA in oncology, from her fellowship training to her co-authored guidelines recommending GA for all older adults with cancer-published in the year of her untimely death.

Muscle composition and outcomes in patients with breast cancer: meta-analysis and systematic review

PURPOSE

Breast cancer is the most common cancer and leading cause of cancer death in women. Body composition parameters, especially those related to muscle, have become a growing focus of cancer research. In this review, we summarize the literature on breast cancer and muscle parameters as well as combine their outcomes for overall survival (OS), time to tumor progression (TTP), and chemotherapy toxicity in a meta-analysis.

METHODS

A systematic search of the literature for randomized controlled trials and observational studies was conducted on MEDLINE, Cochrane CENTRAL, and EMBASE through May 1, 2019. Two reviewers independently searched and selected. Meta-analysis was conducted using a random-effects model. The risk of bias was evaluated using the Newcastle-Ottawa quality assessment for cohorts and GRADE summary of findings tool from Cochrane.

RESULTS

A total of 754 articles were screened from which 6 articles and one abstract were selected. Using skeletal muscle index (SMI), patients classified as sarcopenic had a 68% greater mortality risk compared to non-sarcopenic patients (HR 1.68 95% CI 1.09-2.59, 5 studies) (p = .02) (i² = 70%). Low muscle density was not predictive of OS (HR 1.44 95% CI 0.77-2.68, 2 studies) (p = .25) (i² = 87%). Patients with sarcopenia (56%) had more grade 3-5 toxicity compared to non-sarcopenic (25%) (RR 2.17 95% CI 1.4-3.34, 3 studies) (p = .0005) (i² = 0%). TTP was nearly 71 days longer in advanced/metastatic patients classified as non-sarcopenic compared to patients with sarcopenia (MD - 70.75 95% CI - 122.32 to - 19.18) (p = .007) (i² = 0%).

CONCLUSION

Our synthesis of the literature shows that patients with sarcopenia have more severe chemotherapy toxicity as well as shorter OS and TTP, and that low muscle density is prognostic of OS for women with metastatic breast cancer. Our findings suggest that in clinical practice, body composition assessment is valuable as a prognostic parameter in breast cancer.

Cumulative burden of new-onset chronic health conditions (CHCs) among older cancer survivors

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Background: In the US there are an estimated 11 million survivors of cancer diagnosed at ≥65y of age. Description of the morbidity in these survivors has been limited to single complications or to prevalence of comorbidities. The cumulative burden of CHCs remains unstudied, and is critically needed to inform healthcare delivery in this burgeoning population. Methods: Using SEER-Medicare, we identified 300,082 patients with breast (34%), prostate (33%), colorectal (16%), non-small cell lung (NSCLC 10%) or non-Hodgkin lymphoma (NHL 7%) diagnosed between 2000 and 2011 at age > 65y (mean age at diagnosis: 75y; 47% males, 88% non-Hispanic whites). An age-, race-, and sex-similar non-cancer cohort (n = 97,842) was assembled. New-onset non-malignant health conditions (n = 109) were consolidated into 10 organ-specific CHCs. Inpatient CHC visits were used to describe severe CHCs. The cumulative incidence (CI) and cumulative burden (CB) of CHCs was described up to 10y from cancer diagnosis and by attained age – up to six months prior to death or until 12/31/2013. Subsequent malignant neoplasms (SMNs) were described 10y from primary cancer diagnosis. Results: The 10y CI of any CHC and severe CHC was 98% (95%CI 98-99%) and 73% (72-73%) in cancer patients and 92% (91-92%) and 55% (54-55%) in non-cancer controls (hazard ratio [HR10y]: 1.65, 95%CI 1.64-1.66). Cardiovascular conditions were the largest contributor to severe non-malignant CHCs (10y CI: 49%-69%). Prostate cancer survivors had the highest 10y CI for SMNs (19.4%). The CI for severe CHCs was 44% by age 80y and 85% by age 90y, compared to 34% and 54% in controls (p < 0.001). The 10y CB of CHCs was highest among NSCLC (42 CHCs/survivor) and NHL (41 CHCs/survivor) survivors; in comparison, the 10y CB was 31 CHCs/individual in controls. Colorectal cancer survivors had greatest overall burden at age 80y (27 CHCs/survivor) and 90y (36 CHCs/survivor), compared to 13 and 16 CHCs/individual in controls. Conclusions: The cumulative burden of new-onset multimorbidity among older cancer survivors is substantially greater than that of their non-cancer counterparts, providing quantifiable evidence that survivor-adapted healthcare management policies and risk-based interventions are needed.

Impact of body composition on outcomes from anti-programmed death-1 (PD-1) treatment

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Background: Obesity is associated with improved outcomes in melanoma patients (pts) treated with PD-1, whereas low muscle mass, known as sarcopenia, has been associated with poor outcomes in many cancers. We sought to assess the impact of body composition on PD-1 outcomes. Methods: We analyzed pre-treatment CT scans at the L3 slice using Slice-o-matic software (Tomovision V. 5.0) to determine skeletal muscle, visceral adipose, and subcutaneous adipose tissue parameters for 104 pts with metastatic melanoma who received PD-1 monotherapy. We assessed sarcopenia using skeletal muscle index (SMI=skeletal muscle area/m2). We also quantified total adipose tissue index (TATI), and skeletal muscle gauge (SMG = SMI x skeletal muscle density [SMD]). We stratified pts into high/low groups using previously published cutoffs and assessed toxicity (tox), progression-free and overall survival (PFS/OS), and response rate (RR) by group. Results: Sarcopenia (low SMI) was negatively associated with any tox (39% vs. 60%, p=0.04) but not OS, PFS, or RR. Adiposity (TATI) was not associated with outcomes. By contrast, SMG was significantly associated with OS (median 35.5 vs. 16.0m, p=0.01 for high vs. low SMG). Interestingly, when incorporating TATI with SMG, we found that high SMG/high TATI pts (high muscle/high fat) have superior clinical outcomes (Table). Notably, low SMG/high TATI pts (low muscle/high fat) had seemingly the worst outcomes. Conclusions: We found that high SMG, a measure incorporating muscle area and density, was associated with improved OS in PD1 treated pts. Further, pts with high adiposity and high SMG had superior outcomes, potentially identifying the population responsible for the favorable effect of obesity in these pts. Validation and combination treated cohorts will be presented. [Table: see text]

Immunotherapy in Older Adults with Cancer

PURPOSE OF REVIEW

The purpose of this review is to examine the latest research and data on the use of immunotherapy in older adults with cancer in order to identify key gaps in the literature for future research.

RECENT FINDINGS

Immune checkpoint inhibitors are gaining approval and being incorporated into routine clinical use for numerous malignancies across age groups due to their overall efficacy and favorable side effect profiles. Although immune checkpoint inhibitors appear both safe and effective in older adults, deliberate study of immunotherapies in older adults is highly warranted given the paucity of data in a population with unique immunobiology that comprises the majority of the cancer population worldwide.

Catalyzing Research to Optimize Cancer Survivors' Participation in Work and Life Roles

Participation refers to a state of health in which a person is able to fully engage in roles and life situations. Adults living with and beyond cancer often report persistent participation restrictions that affect their productivity and quality of life. The American Occupational Therapy Foundation convened a group of scientists from seven different disciplines in a Planning Grant Collective (PGC) to stimulate research to identify scalable ways to preserve and optimize participation among cancer survivors. Participants identified challenges, prioritized solutions, and generated novel research questions that move beyond symptom and impairment mitigation as outcomes to identify interventions that improve participation in roles and life situations. This article summarizes the PGC discussion and recommendations regarding three challenges: (a) the dynamic and multi-faceted nature of participation, (b) a need to integrate the concept of participation within the culture of oncology, and (c) identification of priority areas in which new lines of research regarding participation would be most impactful.

Geriatric Assessment Predicts Hospitalization Frequency and Long-Term Care Use in Older Adult Cancer Survivors

PURPOSE

The association between geriatric assessment (GA)-identified impairments and long-term health care use in older cancer survivors remains unknown. Our objective was to evaluate whether a GA performed at cancer diagnosis was predictive of hospitalizations and long-term care (LTC) use in older adult cancer survivors.

METHODS

Older adults with GA performed between 3 months before through 6 months after diagnosis were included (N = 125). Patients with Medicare Parts A and B coverage and no managed care were identified. Hospitalizations and LTC use (skilled nursing or assisted living) were assessed up to 5 years postdiagnosis. GA risk measures were evaluated in separate Poisson models estimating the relative risk (RR) for hospital and LTC visits, adjusting for age and Charlson comorbidity score.

RESULTS

The mean age of patients was 74 years, and the majority were female (80%) and white (90%). Breast cancer (64%) and early-stage disease (stages 0 to III, 77%) were common. Prefrail/frail status (RR, 2.5; P < .001), instrumental activities of daily living impairment (RR, 5.47; P < .001), and limitations in climbing stairs (RR, 2.94; P < .001) were associated with increased hospitalizations. Prefrail/frail status (RR, 1.86; P < .007), instrumental activities of daily living impairment (RR, 4.58; P < .001), presence of falls (RR, 6.73; P < .001), prolonged Timed Up and Go (RR, 5.45; P < .001), and limitations in climbing stairs (RR, 1.89; P < .005) were associated with LTC use.

CONCLUSION

GA-identified impairments were associated with increased hospitalizations and LTC use among older adults with cancer. GA-focused interventions should be targeted toward high-risk patients to reduce long-term adverse health care use in this vulnerable population.

Senior Sway: Using a Mobile Application to Measure Fall Risk

BACKGROUND AND PURPOSE

The Senior Sway mobile application uses the iPhone/iPad gyroscope to assess postural sway and motion reaction time. Impairment in postural sway and motion reaction time have the potential to increase risk for future falls. Senior Sway thereby has the potential to provide a quick, easy to use, objective measure for predicting falls in older adults. The purpose of this study was to evaluate the feasibility of the Senior Sway mobile application and its associations with fall risk in community-dwelling older adults.

METHODS

Adults older than 62 years were recruited from senior centers and community events. Descriptive and bivariate statistics were used to examine feasibility on the basis of enrollment, time required, satisfaction with application, and association with fall risk.

RESULTS AND DISCUSSION

Fifty-seven adults were recruited. Use of the Senior Sway mobile application was feasible. Ninety-one percent said that they liked the application and reported length of time of assessment was "just right." The average Senior Sway score was 64.0 (range: 47.8-84.0), which was significantly associated with the 30-second sit-to-stand test. In addition, the motor reaction time score was associated with the Timed Up and Go.

CONCLUSIONS

Senior Sway is a promising application to improve identification of adults at risk for falls and need for rehabilitation but warrants further research.

Medicare and patient spending among beneficiaries diagnosed with chronic myelogenous leukemia

BACKGROUND

The authors examined Medicare spending and patient spending in older patients with chronic myelogenous leukemia (CML) over the first 5 years from the time of CML diagnosis in the tyrosine kinase inhibitor (TKI) era.

METHODS

Medicare beneficiaries with CML who were diagnosed between 2007 and 2012 at age >65 years were identified from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (805 beneficiaries). A noncancer Medicare beneficiary sample was frequency-matched based on age, sex, and race/ethnicity (805 individuals). Patients were followed until 5 years from diagnosis, disenrollment, death, or December 31, 2014, whichever came first. Total Medicare spending, service-specific spending, and amount owed by patients was estimated monthly and then summed over 60 months and averaged to generate annual spending.

RESULTS

The median age at the time of diagnosis of CML was 76 years (range, 66-102 years). Overall, 51.4% of patients received TKIs (27.8% received imatinib alone), 28% received non-TKI therapy, and 21% received no treatment. The 5-year survival rate for patients with ≥85% time receiving TKIs was 79% compared with 76% for noncancer controls versus 62% for those with <85% time receiving TKIs. Annual Medicare spending was found to be significantly higher for patients treated with TKIs ($143,053) compared with those treated without TKIs ($41,268 vs $10,498 for noncancer controls). Annual patient cost responsibility was $11,712 per patient receiving any TKIs versus $7330 for those receiving non-TKI outpatient chemotherapy versus $3561 for noncancer controls.

CONCLUSIONS

Older patients with CML with adequate time receiving TKI therapy have 5-year survival rates that are comparable to those of their counterparts without cancer. However, TKI use is accompanied with significant Medicare and patient spending; patients receiving multiple TKIs (ie, dasatinib or nilotinib along with imatinib) constitute the group with the highest spending.

Unmet social support needs among older adults with cancer

BACKGROUND

Adequate social support for older adults is necessary to maintain quality of life and reduce mortality and morbidity. However, little is known regarding the social support needs of older adults with cancer. The objective of the current study was to examine social support needs, specifically the unmet needs, among older adults with cancer.

METHODS

Medicare beneficiaries (those aged ≥65 years) with cancer were identified from the University of Alabama at Birmingham Health System Cancer Community Network. Social support needs were assessed using a modified version of the Medical Outcomes Study Social Support Survey. The authors defined an "unmet need" if participants reported having some/a little/never availability of support and requiring support for that need.

RESULTS

Of the 1460 participants in the current study, the average age was 74 years (standard deviation, 5.8 years). Approximately two-thirds of participants (986 participants; 67.5%) reported having at least 1 social support need, with the highest needs noted in the emotional (49.5%) and physical (47.4%) support subdomains. Of those individuals with a support need, approximately 45% had at least 1 unmet need, with the greatest percentages noted in the medical (39%) and informational (36%) subdomains. Multivariable analyses demonstrated that participants who were nonwhite, were divorced or never married, or had a high symptom burden were at greatest risk of having unmet social support needs across subdomains.

CONCLUSIONS

In this population of older adults with cancer, the authors found high levels of unmet social support needs, particularly in the medical and informational support subdomains. Participants who were nonwhite, were divorced or never married, or had a high symptom burden were found to be at greatest risk of having unmet needs.

Accurate Therapeutic Response Assessment of Pancreatic Ductal Adenocarcinoma Using Quantitative Dynamic Contrast-Enhanced Magnetic Resonance Imaging With a Point-of-Care Perfusion Phantom: A Pilot Study

OBJECTIVES

The aim of this study was to test the feasibility of dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with concurrent perfusion phantom for monitoring therapeutic response in patients with pancreatic ductal adenocarcinoma (PDAC).

MATERIALS AND METHODS

A prospective pilot study was conducted with 8 patients (7 men and 1 woman) aged 46 to 78 years (mean age, 66 years). Participants had either locally advanced (n = 7) or metastatic (n = 1) PDAC, and had 2 DCE-MRI examinations: one before and one 8 ± 1 weeks after starting first-line chemotherapy. A small triplicate perfusion phantom was imaged with each patient, serving as an internal reference for accurate quantitative image analysis. Tumor perfusion was measured with K using extended Tofts model before and after phantom-based data correction. Results are presented as mean ± SD and 95% confidence intervals (CIs). Statistical difference was evaluated with 1-way analysis of variance.

RESULTS

Tumor-size change of responding group (n = 4) was -12% ± 4% at 8 weeks of therapy, while that of nonresponding group (n = 4) was 18% ± 15% (P = 0.0100). Before phantom-based data correction, the K change of responding tumors was 69% ± 23% (95% CI, 32% to 106%) at 8 weeks, whereas that of nonresponding tumors was -1% ± 41% (95% CI, -65% to 64%) (P = 0.0247). After correction, the data variation in each group was significantly reduced; the K change of responding tumors was 73% ± 6% (95% CI, 64% to 82%) compared with nonresponding tumors of -0% ± 5% (95% CI, -7% to 8%) (P < 0.0001).

CONCLUSIONS

Quantitative DCE-MRI measured the significant perfusion increase of PDAC tumors responding favorably to chemotherapy, with decreased variability after correction using a perfusion phantom.

Post-Acute Care among Older Adults with Stage I to III Colorectal Cancer

BACKGROUND

Little information is available on the long-term use of post-acute care among older patients with colorectal cancer (CRC), relative to individuals without cancer. This study examines the use of post-acute care among older cancer survivors (>65 y) with CRC and compares it with noncancer patients up to 5 years from surgery.

DESIGN

Retrospective cohort.

SETTING

SEER-Medicare.

PARTICIPANTS

Patients treated for stage I to III CRC between January 1, 2000, and December 31, 2011 (n = 40 812) and noncancer Medicare beneficiaries hospitalized for noncancer treatment matching on age, sex, race, comorbidity, and Medicaid dual eligibility.

MEASUREMENTS

Incident post-acute care claims (skilled nursing, long-term care facility, and home health) from 0 to 100 days, 101 to 365 days, and 1 to 5 years from hospitalization.

RESULTS

The median age was 77 years. All patients had surgery, 34% received chemotherapy, and 27% received surgery and adjuvant therapy. The cumulative incidence of any post-acute care within 100 days of hospitalization was 45.7% for stage III, 37.9% for stage I/II, and 39% for controls (p < .001). Within the CRC cohort only, the cumulative incidence of post-acute care was 2.9% (stage I/II) and 4.2% (stage III, p < .001) from 101 to 365 days and 15.8% (stage I/II) and 16.9% (stage III, p < .001) from 1 to 5 years. Increasing age, ostomies, and neoadjuvant or adjuvant therapy were associated with increased hazard of all post-acute patients within 100 days from hospitalization. From 1 to 5 years from diagnosis, adjuvant therapy was associated with greater exclusive home health care use.

CONCLUSIONS

Survivorship planning among older CRC patients should include discussions of post-acute care following cancer therapy, even several years after treatment. J Am Geriatr Soc 67:937-944, 2019.

Frailty and health-related quality of life in older women with breast cancer

PURPOSE

In older women, breast cancer and its treatment can have profound impact on their physical, mental, and social health, especially in frail patients. This study evaluated the association between frailty and long-term health-related quality of life (HRQOL) in older women undergoing breast cancer treatment.

METHODS

Using the Carolina Senior Registry (CSR), participants with breast cancer were contacted to complete a follow-up HRQOL questionnaire (median 4 years). Baseline Geriatric Assessment (GA) variables were used to calculate the Carolina Frailty Index (CFI) and categorize participants as robust, pre-frail, or frail. Outcomes included HRQOL domains of physical function, social roles, fatigue, depression, anxiety, pain, and sleep disturbance assessed using PROMIS® instruments. Regression modeling compared outcomes between frailty groups using adjusted mean differences (AMD).

RESULTS

Of 190 eligible patients, 63 completed follow-up HRQOL survey. Mean age was 70 years (range 65-86) and 91% were white. Based on the CFI, 49 (78%) patients were robust, 11 (18%) pre-frail, and 3 (5%) frail. After controlling for age and cancer stage, patients identified as pre-frail/frail reported worse physical function (AMD - 9.2, p < 0.001) and social roles (AMD - 7.2, p = 0.002) and more fatigue (AMD 7.6, p = 0.008), depression (AMD 5.6, p = 0.004), and sleep disturbance (AMD 6.9, p = 0.008) compared to robust patients at follow-up.

CONCLUSIONS

Frailty in older women with breast cancer was associated with worse long-term HRQOL outcomes. Further research is needed to develop interventions for frail patients at-risk for reduced HRQOL.

Immune checkpoint inhibitors in the management of malignancies in transplant recipients

Cancer immunotherapy, an area of active research, has thus far yielded several exciting breakthroughs in cancer treatment strategies. So far, immune checkpoint inhibitors have been the most promising method of cancer immunotherapy. CTLA-4, PD-1 and PD-L1 are the immune checkpoint molecules against which monoclonal antibodies act against and revolutionised the treatment of several malignancies. However, it is still unclear whether using these monoclonal antibodies in patients with malignancy and a history of transplant is as beneficial as in patients without a history of transplantation. The reason being, with the therapeutic benefit, also comes the inherent disadvantage of transplant rejection because of the activation of T-cells against donor antigens. So, transplant-related complications limit the usage of the checkpoint blockade therapy to treat malignancies. Here, we review the data published in this context and suggest optimal approaches to using the currently available repertoire of immunotherapies.

Financial Toxicity in Adults With Cancer: Adverse Outcomes and Noncompliance

PURPOSE:

Because of the escalating cost of cancer care coupled with high insurance deductibles, premiums, and uninsured populations, patients with cancer are affected by treatment-related financial harm, known as financial toxicity. The purpose of this study was to describe individuals reporting financial toxicity and to identify rates of and reasons for affordability-related treatment noncompliance.

METHODS:

From May 2010 to November 2015, adult patients (age ≥ 18 years) with cancer were identified from a Health Registry/Cancer Survivorship Cohort. Financial toxicity was defined as agreement with the phrase "You have to pay for more medical care than you can afford" from the Patient Satisfaction Questionnaire-18. Logistic regression and Fisher exact tests were used to compare groups.

RESULTS:

Of 1,988 participants, 524 (26%) reported financial toxicity. Patients reporting financial toxicity were more likely age 65 years or younger, female, nonwhite, non-English speaking, not married, less educated, and to have received a diagnosis more recently (all P < .001). Participants with financial toxicity were more likely to report noncompliance with medication, owing to inability to afford prescription drugs (relative risk [RR], 3.55; 95% CI, 2.53 to 4.98), and reported forgoing mental health care (RR, 3.89; 95% CI, 2.04 to 7.45), doctor's visits (RR, 2.98; 95% CI, 1.97 to 4.51), and medical tests (RR, 2.54; 95% CI, 1.49 to 4.34). The most endorsed reasons for delayed care were not having insurance coverage and being unable to afford household expenses.

CONCLUSION:

More than 25% of adults with cancer reported financial toxicity that was associated with an increased risk for medical noncompliance. Financial toxicity remains a major issue in cancer care, and efforts are needed to ensure patients experiencing high levels of financial toxicity are able to access recommended care.

Impact of Guideline-Discordant Treatment on Cost and Health Care Utilization in Older Adults with Early-Stage Breast Cancer

BACKGROUND

National Comprehensive Cancer Network (NCCN) guideline-based treatment is a marker of high-quality care. The impact of guideline discordance on cost and health care utilization is unclear.

MATERIALS AND METHODS

This retrospective cohort study of Medicare claims data from 2012 to 2015 included women age ≥65 with stage I-III breast cancer receiving care within the University of Alabama at Birmingham Cancer Community Network. Concordance with NCCN guidelines was assessed for treatment regimens. Costs to Medicare and health care utilization were identified from start of cancer treatment until death or available follow-up. Adjusted monthly cost and utilization rates were estimated using linear mixed effect and generalized linear models.

RESULTS

Of 1,177 patients, 16% received guideline-discordant treatment, which was associated with nonwhite race, estrogen receptor/progesterone receptor negative, human epidermal growth receptor 2 (HER2) positive, and later-stage cancer. Discordant therapy was primarily related to reduced-intensity treatments (single-agent chemotherapy, HER2-targeted therapy without chemotherapy, bevacizumab without chemotherapy, platinum combinations without anthracyclines). In adjusted models, average monthly costs for guideline-discordant patients were $936 higher compared with concordant (95% confidence limits $611, $1,260). For guideline-discordant patients, adjusted rates of emergency department visits and hospitalizations per thousand observations were 25% higher (49.9 vs. 39.9) and 19% higher (24.0 vs. 20.1) per month than concordant patients, respectively.

CONCLUSION

One in six patients with early-stage breast cancer received guideline-discordant care, predominantly related to undertreatment, which was associated with higher costs and rates of health care utilization. Additional randomized trials are needed to test lower-toxicity regimens and guide clinicians in treatment for older breast cancer patients.

IMPLICATIONS FOR PRACTICE

Previous studies lack details about types of deviations from chemotherapy guidelines that occur in older early-stage breast cancer patients. Understanding the patterns of guideline discordance and its impact on patient outcomes will be particularly important for these patients. This study found 16% received guideline-discordant care, predominantly related to reduced intensity treatment and associated with higher costs and rates of health care utilization. Increasing older adult participation in clinical trials should be a priority in order to fill the knowledge gap about how to treat older, less fit patients with breast cancer.

Patient-Reported Comorbidity and Survival in Older Adults with Cancer

BACKGROUND

Our ability to optimize the care of older adults with cancer and comorbid illnesses is insufficient because most clinical trials lack systematic measurement. The primary purpose of this study was to evaluate the association between patient-reported comorbidity and all-cause mortality using various comorbidity scoring algorithms.

MATERIALS AND METHODS

The Carolina Senior Registry was linked with the North Carolina Central Cancer Registry to obtain mortality data. Comorbidity was assessed using the patient-reported Older Americans Resources and Services Questionnaire subscale that assesses 13 specific conditions and the degree to which each impairs activities. Multivariable Cox proportional hazard regression models were used to evaluate the association between comorbidities and all-cause mortality.

RESULTS

The study sample included 539 patients; the median age was 72 years, 72% were female, and 47% had breast cancer. Overall, 92% reported ≥1 comorbid condition, with a mean of 2.7 conditions (range 0-10), with arthritis and hypertension the most common (52% and 50%, respectively). Approximately 60% reported a functional limitation related to comorbidity. After adjusting for time from diagnosis to geriatric assessment, age, cancer type, and stage, the risk of death increased by 5% for each unit increase in comorbidity burden score (adjusted hazard ratio [HR] = 1.05, 95% confidence interval [CI]: 1.01-1.10) and 12% for each comorbid condition impacting function (HR = 1.12, 95% CI: 1.02-1.23).

CONCLUSION

Comorbid conditions in older adults with cancer are highly prevalent and associated with all-cause mortality, particularly those conditions that impair function. Routine comorbidity assessment should be included in clinical trials and can be measured via a simple one-page patient-reported questionnaire.

IMPLICATIONS FOR PRACTICE

In order to optimize and personalize the care of older adults with cancer, systematic measurement of comorbidities is necessary in both clinical trials and routine practice. Patient-reported comorbid conditions in older adults with cancer are highly prevalent and are associated with increased risk of all-cause mortality, particularly for those conditions that impair function. Comorbidity can be systematically measured via a one-page patient-reported questionnaire and should be incorporated into future clinical trials and considered for use in oncology clinics to aid in assessing older adults with cancer.

New-Onset Cardiovascular Morbidity in Older Adults With Stage I to III Colorectal Cancer

Purpose

We sought to determine the long-term risk of cardiovascular disease (CVD)—stroke and myocardial infarction—and congestive heart failure (CHF) in older patients with colorectal cancer, as well as to understand the roles that preexisting comorbidities and cancer therapy play in increasing this risk.

Patients and Methods

We evaluated individuals from the SEER-Medicare database with incident stage I to III colorectal cancer at age older than 65 years between January 1, 2000, and December 31, 2011 (n = 72,408) and compared these patients with a matched cohort of Medicare patients without cancer (n = 72,408).

Results

Median age at diagnosis of colorectal cancer was 78 years (range, 66 years to 106 years), and median follow-up was 8 years since diagnosis. The 10-year cumulative incidence of new-onset CVD and CHF were 57.4% and 54.5% compared with 22% and 18% for control, respectively ( P < .001). The interaction between hypertension and chemotherapy was significant ( P < .001) for CVD, and that between diabetes and chemotherapy was significant ( P < .001) for CHF. Within the first 2 years since diagnosis, exposure to capecitabine alone increased CHF hazard (hazard ratio [HR], 3.6; 95% CI, 12.76 to 4.38) compared with exposure to fluorouracil alone. Conversely, patients who were treated with fluorouracil alone had a higher CVD hazard at < 2 years and > 2 years since diagnosis compared with patients who received capecitabine alone (< 2 years HR, 0.63; 95% CI, 0.53 to 0.75; > 2 years HR, 0.72; 95% CI, 0.62 to 0.84).

Conclusion

Older patients with colorectal cancer are at increased risk of developing CVD and CHF. Diabetes and hypertension interact with chemotherapy to increase the risk of cardiovascular morbidity. Future studies should assess the potential for personalized therapeutic options for those with preexisting morbidities and for structured monitoring for patients with a history of exposure to chemotherapy regimens, as well as explore the management of preexisting comorbidities to address long-term cardiovascular morbidity.

Most impactful factors on the health-related quality of life of a geriatric population with cancer

BACKGROUND

As the population of older adults with cancer continues to grow, the most important factors contributing to their health-related quality of life (HRQOL) remain unclear.

METHODS

A total of 1457 older adults (aged ≥65 years) with cancer participated in a telephone survey. Outcomes were measured using the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-Item Short Form Survey (SF-12) from the Medical Outcomes Study (version 2). Statistical techniques used to identify factors in 4 domains (physical, psychological, social, and spiritual) most strongly associated with HRQOL included linear models, recursive partitioning, and random forests. Models were developed in a training data set (920 respondents) and performance was assessed in a validation data set (537 respondents).

RESULTS

Respondents were a median of 19 months from diagnosis, and 28.1% were receiving active treatment. The most relevant factors found to be associated with PCS were symptom severity, comorbidity scores, leisure-time physical activity, and having physical support needs. The most relevant factors for MCS were having emotional support needs, symptom severity score, and the number of financial hardship events. Results were consistent across modeling techniques. Symptoms found to be strongly associated with PCS included fatigue (adjusted proportion of summary score's variance [R² ] = 0.34), pain (adjusted R² = 0.32), disturbed sleep (adjusted R² = 0.16), and drowsiness (adjusted R² = 0.16). Symptoms found to be strongly associated with MCS included fatigue (adjusted R² = 0.23), problems remembering things (adjusted R² = 0.17), disturbed sleep (adjusted R² = 0.16), and lack of appetite (adjusted R² = 0.16).

CONCLUSIONS

The findings of the current study support the importance of addressing persistent symptoms, managing comorbidities, promoting leisure-time physical activity, and addressing financial challenges. A long-term comprehensive approach is needed to ensure the well-being of older adults with cancer. Cancer 2018;124:596-605. © 2017 American Cancer Society.

Chemotherapy Toxicity Risk Score for Treatment Decisions in Older Adults with Advanced Solid Tumors

BACKGROUND

The decision whether to treat older adults with advanced cancer with standard therapy (ST) or reduced therapy (RT) is complicated by heterogeneity in aging. We assessed the potential utility of the chemotherapy toxicity risk score (CTRS) [J Clin Oncol 2011;29:3457-3465] for treatment decisions in older adults.

MATERIALS AND METHODS

This was a prospective observational study of patients aged ≥65 years receiving first-line chemotherapy for advanced cancer for which combination chemotherapy is the standard of care. Patients were categorized as high risk (CTRS ≥10), for whom RT (dose-reduced combination or single-agent chemotherapy) is deemed appropriate, or nonhigh risk (CTRS <10), for whom ST is deemed appropriate for toxicity. The primary objective was to estimate the agreement in chemotherapy choice (ST vs. RT) between the treating physician and the CTRS using a κ statistic.

RESULTS

Fifty-eight patients (median age, 71 years) were enrolled. Thirty-eight patients received ST (21 had CTRS <10, and 17 had CTRS ≥10), and 20 patients received RT (12 had CTRS ≥10, and 8 had CTRS <10), with minimal agreement in chemotherapy choice (κ = 0.14; 95% CI, -0.10 to 0.38). Grade 3-4 toxicity and hospitalization occurred in 60% and 27% of 55 patients with follow-up data, respectively. Among patients receiving ST, patients with CTRS ≥10 had a higher incidence of toxicity (88% vs. 40%, p = .006) and hospitalization (50% vs. 15%, p = .03) than those with CTRS <10.

CONCLUSION

Older patients with cancer with a high CTRS who receive combination chemotherapy have an exceedingly high rate of severe toxicity and hospitalization.

IMPLICATIONS FOR PRACTICE

The potential utility of the chemotherapy toxicity risk score (CTRS) in old adults with advanced solid tumors receiving first-line chemotherapy was assessed. Little agreement was found between chemotherapy treatment decisions based on the clinical impression versus what was recommended based on the CTRS. Among patients treated with standard-dose combination chemotherapy, patients with CTRS ≥10 had a very high incidence of grade 3-4 toxicities and hospitalization, which was significantly greater than that of patients with a low CTRS (<10). These findings suggest that the addition of CTRS to the clinical impression has a potential to improve treatment decisions.

Patient-Reported Comorbidity and Survival in Older Adults with Cancer

BACKGROUND

Our ability to optimize the care of older adults with cancer and comorbid illnesses is insufficient because most clinical trials lack systematic measurement. The primary purpose of this study was to evaluate the association between patient-reported comorbidity and all-cause mortality using various comorbidity scoring algorithms.

MATERIALS AND METHODS

The Carolina Senior Registry was linked with the North Carolina Central Cancer Registry to obtain mortality data. Comorbidity was assessed using the patient-reported Older Americans Resources and Services Questionnaire subscale that assesses 13 specific conditions and the degree to which each impairs activities. Multivariable Cox proportional hazard regression models were used to evaluate the association between comorbidities and all-cause mortality.

RESULTS

The study sample included 539 patients; the median age was 72 years, 72% were female, and 47% had breast cancer. Overall, 92% reported ≥1 comorbid condition, with a mean of 2.7 conditions (range 0-10), with arthritis and hypertension the most common (52% and 50%, respectively). Approximately 60% reported a functional limitation related to comorbidity. After adjusting for time from diagnosis to geriatric assessment, age, cancer type, and stage, the risk of death increased by 5% for each unit increase in comorbidity burden score (adjusted hazard ratio [HR] = 1.05, 95% confidence interval [CI]: 1.01-1.10) and 12% for each comorbid condition impacting function (HR = 1.12, 95% CI: 1.02-1.23).

CONCLUSION

Comorbid conditions in older adults with cancer are highly prevalent and associated with all-cause mortality, particularly those conditions that impair function. Routine comorbidity assessment should be included in clinical trials and can be measured via a simple one-page patient-reported questionnaire.

IMPLICATIONS FOR PRACTICE

In order to optimize and personalize the care of older adults with cancer, systematic measurement of comorbidities is necessary in both clinical trials and routine practice. Patient-reported comorbid conditions in older adults with cancer are highly prevalent and are associated with increased risk of all-cause mortality, particularly for those conditions that impair function. Comorbidity can be systematically measured via a one-page patient-reported questionnaire and should be incorporated into future clinical trials and considered for use in oncology clinics to aid in assessing older adults with cancer.

The impact of skeletal muscle on the pharmacokinetics and toxicity of 5-fluorouracil in colorectal cancer

PURPOSE

Great heterogeneity exists in the ability of adults with cancer to tolerate chemotherapy. Variability in body composition may affect rates of metabolism of cytotoxic agents and contribute to the variable chemotherapy toxicity observed. The objective of this exploratory study was to examine the association of low skeletal muscle, commonly known as sarcopenia, on the pharmacokinetics (PKs) of 5-fluorouracil (5FU) in patients receiving FOLFOX for colorectal cancer.

METHODS

We performed a secondary analysis of a completed multicenter trial that investigated PK-guided 5FU dosing in patients receiving mFOLFOX6 +/- bevacizumab for colorectal cancer. Cycle 1 PK samples were obtained 2-44 h after the start of the 5FU infusion (steady state).

RESULTS

No significant differences in first cycle 5FU area-under-the-concentration-time-curve (AUC) were found between sarcopenic and non-sarcopenic patients (17.3 vs. 19.3 AUC, p = 0.43). Patients with grade 3/4 toxicity had a higher dose of 5FU per kg lean body mass (LBM) (105 vs. 93 mg/kg, p = 0.06), most notably for hematological toxicities (110 vs. 94 mg/kg, p = 0.002); however, no correlation between the dose/LBM and 5FU AUC was found.

CONCLUSIONS

Although our results did not confirm the impact of low skeletal muscle on PKs of 5FU, further research exploring the impact of body composition on chemotherapy PKs and related toxicities is warranted with the potential for alternative dosing strategies in sarcopenic patients to reduce unnecessary toxicities while maintaining efficacy.

Beyond sarcopenia: Characterization and integration of skeletal muscle quantity and radiodensity in a curable breast cancer population

Skeletal muscle loss, commonly known as sarcopenia, is highly prevalent and prognostic of adverse outcomes in oncology. However, there is limited information on adults with early breast cancer and examination of other skeletal muscle indices, despite the potential prognostic importance. This study characterizes and examines age-related changes in body composition of adults with early breast cancer and describes the creation of a novel integrated muscle measure. Female patients diagnosed with stage I-III breast cancer with abdominal computerized tomography (CT) scans within 12 weeks from diagnosis were identified from local tumor registry (N = 241). Skeletal muscle index (muscle area per height [cm² /m² ]), skeletal muscle density, and subcutaneous and visceral adipose tissue areas, were determined from CT L3 lumbar segments. We calculated a novel integrated skeletal measure, skeletal muscle gauge, which combines skeletal muscle index and density (SMI × SMD). 241 patients were identified with available CT imaging. Median age 52 years and range of 23-87. Skeletal muscle index and density significantly decreased with age. Using literature based cut-points, older adults (≥65 years) had significantly higher proportions of sarcopenia (63 vs 28%) and myosteatosis (90 vs 11%) compared to younger adults (<50 years). Body mass index was positively correlated with skeletal muscle index and negatively correlated with muscle density. Skeletal muscle gauge correlated better with increasing age (ρ = 0.52) than with either skeletal muscle index (ρ = 0.20) or density (ρ = 0.46). Wide variations and age-related changes in body composition metrics were found using routinely obtained abdominal CT imaging. Skeletal muscle index and density provide independent, complementary information, and the product of the two metrics, skeletal muscle gauge, requires further research to explore its impact on outcomes in women with curable breast cancer.

Frailty and inflammatory markers in older adults with cancer

We examined the associations between frailty and inflammatory markers, in particular neutrophil lymphocyte ratio (NLR), in elderly cancer patients. We conducted cross-sectional analyses of data derived from the Carolina Seniors Registry (CSR), a database of geriatric assessments (GA) in older adults (≧65 years) with cancer. We included patients in the CSR who had a GA and complete blood count test before initiation of therapy. The primary outcome was frailty, determined using the 36-item Carolina Frailty Index (CFI). In our sample of 133 patients, the median age was 74, and 54% were robust, 22% were pre-frail, and 24% were frail. There was a significant positive correlation between CFI and NLR (r = 0.22, p = 0.025). In multivariable analysis, patients in the top tertile of NLR had an odds ratio of 3.8 (95% CI = 1.1-12.8) for frail/pre-frail status, adjusting for age, sex, race, education level, marital status, cancer type and stage. In bivariable analyses, higher NLR was associated with lower instrumental activity of daily living (IADL) score (p = 0.040) and prolonged timed up and go (p = 0.016). This study suggests an association between frailty and inflammation in older adults with cancer.

Geriatric syndromes and association with distress in older cancer patients

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Background: Geriatric syndromes are multifactorial conditions affecting the elderly that are associated with decreased quality of life and poor outcomes. We sought to quantify the prevalence of geriatric syndromes in a group of navigated cancer patients and identify conditions associated with distress. Methods: Distress assessments were conducted between January 2012 and December 2015 on enrollment into the PCCP, a lay-navigation program that serves Medicare recipients in the UAB Health System Cancer Community Network. Assessments were made using a modified Distress Tool, which captures sources of distress in multiple domains. We identified questionnaire items related to common geriatric syndromes including functional decline, sensory impairment, cognitive and mood changes, sleep problems, incontinence, pressure ulcers, and malnutrition. Prevalence of geriatric syndromes was indicated by reported distress for an item that mapped to one of the above syndromes. Results: 8,014 patients were surveyed; 53 % of patients were 65- 74 yoa with 47% > 74 yoa while 52% were female. The most common cancer types were breast (18%), lung (17%), and gastrointestinal (16%). Of all surveyed patients, 1,779 (22%) reported distress related to at least one geriatric syndrome. The most common complaint was decline in functional ability relating to ADLs (11%) and IADLs (7%). Conclusions: Geriatric syndromes, such as functional disability, contribute to distress in older patients with cancer patients. Early screening and identification may lead to timely intervention to help improve quality of life. Further research is needed to describe the relationship between these syndromes and health outcomes, such as their association with health care utilization in older adults with cancer.

Frailty and skeletal muscle in older adults with cancer

OBJECTIVE

Computerized tomography (CT) imaging is routine in oncologic care and can be used to measure muscle quantity and composition that may improve prognostic assessment of older patients. This study examines the association of single-slice CT-assessed muscle measurements with a frailty index in older adults with cancer.

MATERIALS AND METHODS

Using the Carolina Senior Registry, we identified patients with CT imaging within 60days ± of geriatric assessment (GA). A 36-item Carolina Frailty Index was calculated. Cross-sectional skeletal muscle area (SMA) and Skeletal Muscle Density (SMD) were analyzed from CT scan L3 lumbar segments. SMA and patient height (m²) were used to calculate skeletal muscle index (SMI). Skeletal Muscle Gauge (SMG) was calculated by multiplying SMI×SMD.

RESULTS

Of the 162 patients, mean age 73, 53% were robust, 27% pre-frail, and 21% frail. Significant differences were found between robust and frail patients for SMD (29.4 vs 24.1 HU, p<0.001) and SMG (1188 vs 922AU, p=0.003), but not SMI (41.9 vs 39.5cm²/m², p=0.29). After controlling for age and gender, for every 5 unit decrease in SMD, the prevalence ratio of frailty increased by 20% (PR=1.20 [1.09, 1.32]) while the prevalence of frailty did not differ based on SMI.

CONCLUSIONS

Muscle mass (measured as SMI) was poorly associated with a GA-based frailty index. Muscle density, which reflects muscle lipid content, was more associated with frailty. Although frailty and loss of muscle mass are both age-related conditions that are predictive of adverse outcomes, our results suggest they are separate entities.

Data Linkage to Improve Geriatric Oncology Research: A Feasibility Study

Older adults (aged 65 years and older) diagnosed with cancer account for most cancer-related morbidity and mortality in the United States but are often underrepresented on clinical trials. Recent attention from a variety of professional, research, regulatory, and patient advocacy groups has centered on data linkage and data sharing as a means to capture patient information and outcomes outside of clinical trials to accelerate progress in the fight against cancer. The development of a more robust observational research data infrastructure would help to address gaps in the evidence base regarding optimal approaches to treating cancer among the growing and complex population of older adults. To demonstrate the feasibility of building such a resource, we linked information from a sample of older adults with cancer in North Carolina using three distinct, but complementary, data sources: (a) the Carolina Senior Registry, (b) the North Carolina Central Cancer Registry, and (c) North Carolina fee-for-service Medicare claims data. A description of the linkage process, metrics, and characteristics of the final cohort is reported. This study highlights the potential for data linkage to improve the characterization of health status among older adults with cancer and the possibility to conduct passive follow-up for outcomes of interest over time. Extensions of these linkage efforts in partnership with other institutions will enhance our ability to generate evidence that can inform the management of older adults with cancer.