Gaps in nutritional research among older adults with cancer

E-PROOF: E-intervention for protein intake and resistance training to optimize function: A study protocol

BACKGROUND

Accounting for more than 60% of cancer survivors, older (≥65 years) cancer survivors have a 2- to 5-fold risk of physical function impairment, compared to cancer-free peers. One strategy to improve physical function is dietary and resistance training interventions, which improve muscle strength and mass by stimulating muscle protein synthesis. The E-PROOF (E-intervention for Protein Intake and Resistance Training to Optimize Function) study will examine the feasibility, acceptability, and preliminary efficacy of a 12-week randomized controlled trial of an online, tailored nutritional and resistance training education and counseling intervention to improve physical function and associated health outcomes (muscle strength, health-related quality of life (HRQoL), self-efficacy, and weight management).

METHODS

In this study, 70 older cancer survivors will be randomized to one of two groups: experimental (receiving remote behavioral counseling and evidence-based education and resources), and control (general survivorship education). We will examine the intervention effects on physical function, muscle strength, HRQoL, self-efficacy, weight, and waist circumference during a 12-week period between the experimental and control groups. Three months following the end of the intervention, we will conduct a follow-up assessment to measure physical function, muscle strength, and HRQoL.

SIGNIFICANCE AND IMPACT

This study is the first synchronous, online protein-focused diet and resistance training intervention among older cancer survivors. This novel study advances science by promoting independent health behaviors among older cancer survivors to improve health outcomes, and provide foundational knowledge to further address this growing problem on a wider scale through online platforms.

The association between food access and frailty among older adults with gastrointestinal malignancies-The CARE Registry

BACKGROUND

Food access is associated with higher gastrointestinal (GI) cancer mortality; however, its association with frailty, which is a predictor of premature mortality among older adults with cancer, is less understood.

METHODS

The authors included 880 adults aged 60 years and older who were recently diagnosed with GI cancers and were undergoing self-reported geriatric assessment at their first prechemotherapy visit to the University of Alabama at Birmingham oncology clinic. Food access was measured using the 2019 US Department of Agriculture Economic Research Service designation low-income, low-access (LILA), classifying census tracts based on income and/or access to food stores at various distances. The primary outcome was frailty on the CARE (Cancer and Aging Resilience Evaluation) Frailty Index, a composite of the proportion of impaired geriatric assessment measures. The authors examined the LILA-frailty association with modified Poisson regression accounting for census-tract clustering.

RESULTS

The median patient age was 69 years, 58.1% were men, 22.5% were non-Hispanic Black, 29.2% had colorectal cancer, 28.0% had pancreatic cancer, 70.1% presented with stage III/IV disease, and 34.9% were frail. A higher proportion in LILA areas were non-Hispanic Black (44.1% vs. 10.8%; p < .001) and had less education (high school or less: 48.1% vs. 37.9%; p = .020). Adjusting for age, race and ethnicity, sex, cancer type and stage, and education, an LILA designation was associated with 58% greater odds of worsening frailty status (95% confidence interval, 1.18-2.12). An analysis of LILA subcategories revealed that associations were maintained across all LILA measures.

CONCLUSIONS

Poor food access was associated with a greater risk of frailty among newly diagnosed older adults with GI cancers before they received systemic treatment. Intervening on local food access, particularly in LILA areas, may be a target for improving rates of frailty and promoting health equity in this population.

Cardiovascular Concerns, Cancer Treatment, and Biological and Chronological Aging in Cancer: JACC Family Series

Cardiovascular disease (CVD) and cancer are leading causes of death globally, particularly among the rapidly growing population of older adults (OAs). CVD is a leading cause of mortality among cancer survivors, often accelerated by cancer treatments associated with short- or long-term cardiotoxicity. Moreover, there is a dynamic relationship among CVD, cancer, and aging, characterized by shared risk factors and biological hallmarks, that plays an important role in caring for OAs, optimizing treatment approaches, and developing preventive strategies. Assessment of geriatric domains (eg, functional status, comorbidities, cognition, polypharmacy, nutritional status, social support, psychological well-being) is critical to individualizing treatment of OAs with cancer. The authors discuss considerations in caring for an aging population with cancer, including methods for the assessment of OAs with CVD and/or cardiovascular risk factors planned for cancer therapy. Multidisciplinary care is critical in optimizing patient outcomes and maintaining quality of life in this growing vulnerable population.

Accelerated Aging in Cancer Survivors: Cellular Senescence, Frailty, and Possible Opportunities for Interventions

The population of cancer survivors has markedly increased due to the rapid improvements in cancer treatment. However, cancer survivors experience accelerated aging, which leads to chronic diseases and other age-related conditions, such as frailty. Those conditions may persist years after cancer diagnosis and treatment. Cellular senescence, a hallmark of aging, is one of the mechanisms that contribute to accelerated aging in cancer survivors. Several aging measures, including measures based on clinical markers and biomarkers, have been proposed to estimate the aging process, and some of them have shown associations with mortality and frailty in cancer survivors. Several anti-aging interventions, including lifestyle changes and anti-aging drugs, have been proposed. Future research, particularly in large-scale studies, is needed to determine the efficiency of these aging measures and anti-aging interventions before considering their application in clinics. This review focuses on the mechanisms of cellular senescence and accelerated aging in cancer survivors, assessment of the aging process using clinical markers and biomarkers, and the high prevalence of frailty in that population, as well as possible opportunities for anti-aging interventions. A deeper understanding of aging measures and anti-aging interventions in cancer survivors will contribute to the development of effective strategies to mitigate accelerated aging in cancer survivors and improve their quality of life.

Risk Factors for Immune Checkpoint Inhibitor Immunotherapy Toxicity Among Older Adults with Cancer

OBJECTIVES

Immune checkpoint inhibitor immunotherapy (IO) is revolutionizing cancer care but can lead to significant toxicity. This study seeks to describe potential risk factors for immune-related adverse events (irAEs) specifically among older adults.

MATERIALS AND METHODS

This was a retrospective study at a single academic comprehensive cancer center based on chart review data abstracted by physicians. For patients aged ≥70 years, frequency, type, and grade of irAEs and their association with baseline patient demographics, comorbidities, mobility, and functional status were characterized using bivariate analysis. Based on those results, multivariable logistic regressions were constructed to model the association between these characteristics with any grade and grade 3 or higher irAEs.

RESULTS

Data were analyzed for 238 patients aged ≥70 years who received IO for mostly (≥90%) advanced cancer between 2011 and 2018. Thirty-nine percent of older adults experienced an irAE and 13% experienced one that was grade 3 or higher. In the multivariable analysis, depression was associated with an increased incidence of any grade irAE, while decreased life-space mobility was associated with an increased incidence of grade ≥3 irAEs.

CONCLUSION

Most characteristics of special interest among older adults, include fall risk, weight loss, cognitive limitations, and hearing loss, were not associated with irAEs in our study. However, decreased life-space mobility and depression are potential risk factors for IO toxicity among older adults with advanced cancer. Interventions designed to evaluate and mitigate modifiable risk factors for treatment-related toxicity are needed, and the results of this study may be useful for guiding those efforts.

Linking clinical and population-based data in older patients with cancer in Belgium: Feasibility and clinical outcomes

INTRODUCTION

Geriatric screening and geriatric assessment (GS/GA) have proven their benefits in the care for older patients with cancer. However, less is known about the predictive value of GS/GA for outcomes. To research this, clinical data on GS/GA can be enriched with population-based data. In this article we describe the methods and feasibility of data linkage, and first clinical outcomes (GS/GA results and overall survival).

MATERIALS AND METHODS

A large cohort study consisting of patients aged ≥70 years with a new cancer diagnosis was established using linked data from clinical and population-based databases. Clinical data were derived from a previous prospective study where older patients with cancer were screened with G8, followed by GA in case of an abnormal result (GS/GA study; 2009-2015). These data were linked to cancer registration data from the Belgian Cancer Registry (BCR), reimbursement data of the health insurance companies (InterMutualistic Agency, IMA), and hospital discharge data (Technical Cell, TCT). Cox regression analyses were conducted to evaluate the prognostic value of the G8 geriatric screening tool.

RESULTS

Of the 8067 eligible patients with a new cancer diagnosis, linkage of data from the GS/GA study and data from the BCR was successful for 93.7%, resulting in a cohort of 7556 patients available for the current analysis. Further linkage with the IMA and TCT database resulted in a cohort of 7314 patients (96.8%). Based on G8 geriatric screening, 67.9% of the patients had a geriatric risk profile. Malnutrition and functional dependence were the most common GA-identified risk factors. An abnormal baseline G8 score (≤14/17) was associated with lower overall survival (adjusted HR [aHR] = 1.62 [1.50-1.75], p < 0.001).

DISCUSSION

Linking clinical and population-based databases for older patients with cancer has shown to be feasible. The GS/GA results at cancer diagnosis demonstrate the vulnerability of this population and the G8 score showed prognostic value for overall survival. The established cohort of almost 8000 patients with long-term follow-up will serve as a basis in the future for detailed analyses on long-term outcomes beyond survival.

The clinical decision‐making process of healthcare professionals within a personalized home‐based rehabilitation during sequential chemoradiotherapy for stage III non‐small lung cancer: A case study

INTRODUCTION

The purpose of this case study was to demonstrate the clinical decision-making process of healthcare professionals within a rehabilitation program during chemoradiotherapy (CHRT) for a high-risk patient diagnosed with stage III non-small cell lung cancer (NSCLC). The course of CHRT and patient's preferences, facilitators, and barriers were considered.

CASE-DESCRIPTION

The patient was a 69-year-old man with a history of rheumatoid arthritis diagnosed with stage III NSCLC.

INTERVENTION

A home-based, personalized, and partly supervised rehabilitation program during CHRT, including aerobic, resistance, and breathing exercises, as well as nutritional counseling.

OUTCOMES

The patient suffered from side effects of CHRT, which required adjustments in the context and intensity of the exercises. An important facilitator for the patient was encouraged by his wife in following the home-based rehabilitation program. During home visits, the patient and physiotherapists performed the exercises together to help him to overcome the burden and motivate the patient to adhere to the rehabilitation program.

CONCLUSION

This case study demonstrates that physical exercise training could be performed by adjusting training intensity and the way in which the physical exercise training was delivered, while the patient experienced side effects from CHRT. In addition, the involvement and support of (in)formal caregivers seems essential for adherence to rehabilitation.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BACKGROUND

Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy.

METHODS

A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months.

DISCUSSION

If successful, GEMS would be an option for a standardized APP-led survivorship care intervention.

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

Dietary behavior and urinary gallic acid concentration differences among underserved elder racial and ethnic minorities in New York City

Purpose

Diet and nutrition are important for cancer prevention. To investigate associations between dietary behavior, demographics, and risk of cancer, we assessed dietary behavior and urinary concentration of gallic acid, a polyphenol with anticancer properties found in various fruits and vegetables, in racial and ethnic minorities.

Methods

Ninety-one (91) participants were recruited from senior centers in East Harlem, New York City, a racially diverse and underserved community. A National Institute of Health (NIH)—validated dietary survey questionnaire—was used to collect dietary fruits and vegetables consumption data. Demographic and cancer information were also collected. All 91 participants completed the survey and forty-five (45) participants provided urine samples for gallic acid analysis.

Results

Gender differences were significantly associated with dietary behavior and urinary gallic acid concentration (UGAC). Female participants had a higher total daily intake of fruits and a significantly higher UGAC compared to male participants (p < 0.05). Age was negatively associated with the serving quantity of French fries/fried potatoes and white potatoes (p < 0.05), while positively associated with the daily intake frequency and daily intake of fruits (p < 0.05). Furthermore, Asian race was associated with higher daily intake frequencies of fruits and vegetable soup (p < 0.05), compared to other races. In a multivariate analysis, a significant association was observed between the serving quantities of fruits and other vegetables and UGAC (p < 0.05) after controlling for demographic characteristics.

Conclusion

The observed differences in dietary behavior and UGAC in this study provide limited information on the association between demographic differences and cancer prevalence in elder racial and ethnic minorities. Future research should investigate this association further for potential implications in cancer prevention.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10552-022-01581-y.

The nutritional needs of older cancer survivors

Older adults comprise a large proportion of cancer survivors, and older cancer survivors have distinct nutritional needs. Herein, we summarize nutritional needs of older cancer survivors, describe approaches to identify nutritional impairments, and provide guidelines for clinicians to address nutritional needs.

Nutritional Status Predicts Fatty Acid Uptake from Fish and Soybean Oil Supplements for Treatment of Cancer-Related Fatigue: Results from a Phase II Nationwide Study

Cancer-related fatigue is a prevalent and debilitating condition that persists for years into survivorship. Studies evaluating both fish oil supplementation on fatigue and associations between fish oil consumption and fatigue have shown mixed effects; it is unknown what factors contribute to these differential effects. Herein, we investigate whether the nutritional status of cancer survivors was associated with serum omega-3 concentration or change in serum omega-3s throughout a fish oil supplementation study, and then if any of these factors were associated with fatigue. Breast cancer survivors 4-36 months post-treatment with moderate-severe fatigue were randomized to take 6 g fish oil, 6 g soybean oil, or 3 g of each daily for 6 weeks. Baseline nutritional status was calculated using the Controlling Nutritional Status tool (serum albumin, lymphocytes, cholesterol). At baseline and post-intervention, serum fatty acids were quantified and fatigue was assessed using the Multidimensional Fatigue Symptom Inventory. Participants (n = 85) were 61.2 ± 9.7 years old with a body mass index of 31.9 ± 6.7 kg/m²; 69% had a good nutritional score and 31% had light-moderate malnutrition. Those with good nutritional status had greater total serum omega-3s at baseline (p = 0.013) and a greater increase in serum omega-3s with supplementation (p = 0.003). Among those who were supplemented with fish oil, greater increases in serum omega-3s were associated with greater improvements in fatigue. In conclusion, good nutritional status may increase uptake of fatty acid supplements, increasing their ability to improve fatigue.

Quality of care of consultations from the geriatric oncology clinic: "Are we addressing the needs of patients?"

INTRODUCTION

A comprehensive geriatric assessment (CGA) is recommended for older adults with cancer in the pre-treatment setting to optimize care. A CGA systematically evaluates multiple domains to develop a holistic view of the patient's health and facilitate timely interventions to ameliorate patient outcomes. For a CGA to be most effective, optimization of each abnormal domain should occur. However, there is limited literature exploring this issue.

MATERIALS AND METHODS

Consultations of patients seen in a Geriatric Oncology clinic from June 2015 to June 2018 were reviewed. The percentage of "no recommendations made" in the consultation letter following the identification of impairment in each of eight geriatric domains was calculated. Trends over time were examined by stratifying the data into three periods ("Year 1", "Year 2", and "Year 3") and conducting a logistic regression analysis.

RESULTS

A total of 365 consultation notes were reviewed. The patients were predominately older (mean age 79.9 years), male (66.9%), with genitourinary (38.6%) or gastrointestinal (23.3%) cancers. The most common stage was metastatic (40.6%). The most common treatment intent and modality were palliative (50.4%) and hormonal (50.9%), respectively. The geriatric domains that had the greatest frequency of impairments were medication optimization (76.2%), functional status (68.8%), and falls risk (64.9%). The domains that had the highest frequency of "no recommendations made" following identification of impairment were nutrition (39.8%), social support (39.5%), and mood (26.4%). The prevalence of "no recommendations made" decreased over time in social support (54.6% in Year 1 to 27.8% in Year 3, p = 0.043) and possibly nutrition (53.1% in Year 1 to 34.3% in Year 3, p = 0.088) but not for mood (p = 0.64).

CONCLUSIONS

Nutrition, social supports and mood were the CGA domains with the highest proportion of "no recommendations made" following an identification of impairment. This is the first quality assurance study to identify social supports, mood, and nutrition domains as less frequently addressed following an identification of an impairment amongst older patients with cancer. Subsequent prospective research is required to understand reasons for these observations and identification of barriers to address these geriatric domains amongst older adults with cancer.

A comprehensive overview of the complex relationship between epigenetics, bioactive components, cancer, and aging

Among age-related diseases, the incidence of cancer increases significantly due to the overlap of some molecular pathways between cancer and aging. While the genetic influence on the human lifespan is estimated to be about 20-25%, epigenetic changes play an important role in modulating individual health status, aging. Aging and age-related conditions are processes that can be modified by both genetic, environmental factors, including dietary habits. Epigenetics is a new discipline has significant potential to be applied for the prevention, management of certain carcinomas and diseases. Epigenetic modifications may play an important role in disease occurrence and pathogenesis. Some nutritional components can be significantly effective in the prevention of breast, skin, esophagus, colorectal, prostate, pancreatic, lung cancers. It contains minerals, vitamins, and some bioactive components (curcumin, indole 3 carbinol, di-indolylmethane, sulforaphane, epigallocatechin-3-gallate, genistein, resveratrol, pterostilbene, apigenin, etc.) regulatory processes. However, compelling evidence suggests that dietary habits can manipulate the aging process and/or its consequences, have health benefits. Aging processes become complex when combined with the relational role of bioactive nutritional components on gene expression. In this review, the relationship between epigenetic processes caused by DNA methylylation, histone modification, non-coding m-RNA, and telomerase activity, the risk of aging and cancer is discussed.

Survival of colorectal cancer patients in Brunei Darussalam: comparison between 2002-09 and 2010-17

Background

Colorectal cancer (CRC) is a major cause of cancer-related mortality worldwide. It is the second leading cause of cancer death in men and women in Brunei Darussalam in 2017, posing a major burden on society.

Methods

This retrospective cohort study (n = 1035 patients diagnosed with CRC in Brunei Darussalam from 1st January 2002 until 31st December 2017) aims to compare the overall survival rates of CRC patients (2002–2017), to compare survival rates between two study periods (2002–2009 and 2010–2017) and to identify prognostic factors of CRC. Kaplan-Meier estimator and log-rank tests were performed to analyse the overall survival rates of CRC patients. Multiple Cox regression was performed to determine the prognostic factors of CRC with adjusted hazard ratios (Adj. HRs) reported.

Results

The 1-, 3- and 5-year survival rates of CRC patients are 78.6, 62.5, and 56.0% respectively from 2002 to 2017. The 1-, 3-, and 5-year survival rates of CRC patients for 2002–2009 are 82.2, 69.6, and 64.7%; 77.0, 59.1, and 51.3% for 2010–2017 respectively. A significant difference in CRC patients’ survival rate was observed between the two study periods, age groups, ethnic groups, cancer stages, and sites of cancer (p < 0.05). The Adjusted Hazard Ratios (Adj. HRs) were significantly higher in the 2010–17 period (Adj. HR = 1.78, p < 0.001), older age group ( ≥ 60 years) (Adj. HR = 1.93, p = 0.005), distant cancer (Adj. HR = 4.69, p < 0.010), tumor at transverse colon and splenic flexure of colon (Adj. HR = 2.44, p = 0.009), and lower in the Chinese(Adj. HR = 0.63, p = 0.003).

Conclusion

This study highlights the lower survival rates of CRC patients in 2010–2017, Malays, older patients, distant cancer, and tumors located at the latter half of the proximal colon (transverse colon), and predominantly LCRC (splenic flexure, descending colon, sigmoid colon, overlapping lesion colon and colon (NOS), as well as the rectosigmoid junction and rectum (NOS)). Age, ethnicity, cancer stage, and tumor location are significant prognostic factors for CRC. These findings underscore the importance of public health policies and programmes to enhance awareness on CRC from screening to developing strategies for early detection and management, to reduce CRC-associated mortality.

Association of Dietary Quality, Inflammatory Markers, and Physical Functioning among Older Female Cancer Survivors

One area within geriatric oncology that is understudied and undertreated is the dietary quality of older cancer survivors. Most older adults with cancer experience nutritional deficits due to their age and cancer treatment. Research has shown the impact of competing comorbidities, polypharmacy, and decline in functional and cognitive status on older adults' nutritional needs. This study sought to examine the diet quality of older female cancer survivors, and its association with inflammatory markers and physical functioning. Participants completed surveys online, by mail, or phone. Additional participant information was obtained through medical records. Descriptive statistics, Pearson's correlations, forward linear regressions were used to analyze these data. Older female cancer survivors (≥65) that had completed their initial cancer treatment in the past 5 years were recruited through cancer clinic visits and medical records. The study was conducted from November 2018 through January 2020. Self-reported physical functioning (RAND-36), diet quality (DHQ-II, HEI-2015), and BMI were obtained from surveys. Participant diagnosis, comorbidities, and inflammatory marker (c-reactive protein (CRP)) were obtained through electronic medical records; albumin was collected as a marker correlated with inflammation. The average age of participants (n = 171) was 73.6 ± 8.4 years. Mean physical functioning score was 60 ± 24 out of 100. Mean total HEI scores were 66.39 + 10.0 out of 100. Positive correlations were observed between total HEI scores and physical functioning, self-rated health, albumin, education, and income. Negative correlations were observed between physical functioning and BMI, self-rated health, albumin, and age. Regressions indicated that individuals who had higher HEI scores were more likely to report higher physical functioning (β = 0.38, P < 0.001). Identifying dietary quality and markers to overall assess inflammation is pertinent to improve the long-term health of cancer survivors. The strong correlations between physical function, HEI, and albumin demonstrates the relationship albumin has with inflammation and its subtle impact it can have on older cancer survivors. Along with CRP, serum albumin should be interpreted in the context of the patient's overall health. Future larger cohort studies of older cancer survivors with longitudinal measurements are warranted.

Strategies to Prevent or Remediate Cancer and Treatment-Related Aging

Up to 85% of adult cancer survivors and 99% of adult survivors of childhood cancer live with an accumulation of chronic conditions, frailty, and/or cognitive impairments resulting from cancer and its treatment. Thus, survivors often show an accelerated development of multiple geriatric syndromes and need therapeutic interventions. To advance progress in this area, the National Cancer Institute convened the second of 2 think tanks under the auspices of the Cancer and Accelerated Aging: Advancing Research for Healthy Survivors initiative. Experts assembled to share evidence of promising strategies to prevent, slow, or reverse the aging consequences of cancer and its treatment. The meeting identified research and resource needs, including geroscience-guided clinical trials; comprehensive assessments of functional, cognitive, and psychosocial vulnerabilities to assess and predict age-related outcomes; preclinical and clinical research to determine the optimal dosing for behavioral (eg, diet, exercise) and pharmacologic (eg, senolytic) therapies; health-care delivery research to evaluate the efficacy of integrated cancer care delivery models; optimization of intervention implementation, delivery, and uptake; and patient and provider education on cancer and treatment-related late and long-term adverse effects. Addressing these needs will expand knowledge of aging-related consequences of cancer and cancer treatment and inform strategies to promote healthy aging of cancer survivors.

Modification of systemic anti-cancer therapies and weight loss, a population-level real-world evidence study

Background:

Involuntary weight loss may occur during systemic anti-cancer therapy (SACT), causing treatment disruption and poorer prognoses. There remain gaps in clinical awareness as to which patients may benefit from nutritional interventions that aim to prevent unintended weight loss during SACT.

We utilised England’s population-level cancer registry data, conducting a pan-cancer assessment of patient weight loss during SACT. We aimed to identify cancers with weight loss-associated treatment modifications, potential beneficiaries of nutritional intervention.

Methods:

This cross-sectional study used England’s Cancer Analysis System database, including SACT-treated adults with one tumour and ⩾2 weight recordings between 2014 and 2018. Binary weight loss (threshold: 2.5%) was derived from patients’ most negative weight change from first SACT weight recording. The Martin et al. body mass index-adjusted weight loss grading system (BMI-WLG) was assigned. We describe binary weight loss, BMI-WLG and treatment modification status by cancer. Multivariate logistic regression models of weight loss (binary and BMI-WLG) and a composite outcome of patient treatment-modification status by cancer were produced.

Results:

Our study population contained 200,536 patients across 18 cancers; 28% experienced binary weight loss during SACT. Weight loss patients were more likely to have multiple types of treatment modifications recorded across all cancers. Regression analyses included 86,991 patients. Binary weight loss was associated (p < 0.05) with higher likelihood of treatment modification in; colon [Odds Ratio (OR) = 1.72, 95% confidence interval (CI): 1.42, 2.07]; gynaecologic (excl. ovarian) (OR = 1.48, 95% CI: 1.08, 2.01); stomach (OR = 1.6, 95% CI: 1.04, 2.06); lung (OR = 1.38, 95% CI: 1.21, 1.58); leukaemia (OR = 1.30, 95% CI: 1.09, 1.55); head and neck (OR = 1.30, 95% CI: 1.02, 1.65) and oesophageal (OR = 1.29, 95% CI: 1.01, 1.64) cancers. In lung, colon, and grouped gastro-intestinal cancers, association between BMI-WLG and treatment modification increased by WLG.

Discussion:

Our study is a wide assessment of weight loss during SACT using England’s cancer registry data. Across different cancers we found patients have weight loss-associated treatment modifications during SACT, a precursor to poorer prognoses. Our findings highlight cancers that may benefit from improved nutritional intervention during SACT.

Association of malnutrition with geriatric assessment impairments and health-related quality of life among older adults with gastrointestinal malignancies

BACKGROUND

A majority of older adults with cancer develop malnutrition; however, the implications of malnutrition among this vulnerable population are poorly understood. The goal of this study was to quantify the prevalence of nutrition related-symptoms and malnutrition among older adults with gastrointestinal (GI) malignancies and the association of malnutrition with geriatric assessment (GA) impairment, health-related quality of life (HRQoL), and health care utilization.

METHODS

We performed a cross-sectional study of older adults (≥60 years) who were referred to the GI Oncology clinic at the University of Alabama at Birmingham. Participants underwent the Cancer & Aging Resilience Evaluation survey that includes the abbreviated Patient-Generated Subjective Global Assessment of nutrition. Nutrition scores were dichotomized into normal (0-5) and malnourished (≥6), and multivariate analyses adjusted for demographics, cancer type, and cancer stage were used to examine associations with GA impairment, HRQoL, and health care utilization.

RESULTS

A total of 336 participants were included (men, 56.8%; women, 43.2%), with a mean age of 70 years (standard deviation, ±7.2 years) and colorectal cancer (33.6%) and pancreatic cancer (24.4%) being the most common diagnoses. Overall, 52.1% of participants were identified as malnourished. Malnutrition was associated with a higher prevalence of several GA impairments, including 1 or more falls (adjusted odds ratio [aOR], 2.1), instrumental activities of daily living impairment (aOR, 4.1), and frailty (aOR, 8.2). Malnutrition was also associated with impaired HRQoL domains; both physical (aOR, 8.7) and mental (aOR, 5.0), and prior hospitalizations (aOR, 2.2).

CONCLUSION

We found a high prevalence of malnutrition among older adults with GI malignancies that was associated with increased GA impairments, reduced HRQoL, and increased health care utilization.

Nutrition in Cancer Therapy in the Elderly-An Epigenetic Connection?

The continuous increase in life expectancy results in a steady increase of cancer risk, which consequently increases the population of older adults with cancer. Older adults have their age-related nutritional needs and often suffer from comorbidities that may affect cancer therapy. They frequently are malnourished and present advanced-stage cancer. Therefore, this group of patients requires a special multidisciplinary approach to optimize their therapy and increase quality of life impaired by aging, cancer, and the side effects of therapy. Evaluation strategies, taking advantage of comprehensive geriatric assessment tools, including the comprehensive geriatric assessment (CGA), can help individualize treatment. As epigenetics, an emerging element of the regulation of gene expression, is involved in both aging and cancer and the epigenetic profile can be modulated by the diet, it seems to be a candidate to assist with planning a nutritional intervention in elderly populations with cancer. In this review, we present problems associated with the diet and nutrition in the elderly undergoing active cancer therapy and provide some information on epigenetic aspects of aging and cancer transformation. Nutritional interventions modulating the epigenetic profile, including caloric restriction and basal diet with modifications (elimination diet, supplementary diet) are discussed as the ways to improve the efficacy of cancer therapy and maintain the quality of life of older adults with cancer.

CANcer BEhavioural nutrition and exercise feasibility trial (CanBenefit); phase I qualitative interview findings

BACKGROUND

Older people with lung cancer are often frail and unfit due to their cancer and co-morbidities and may tolerate cancer treatments poorly. Physical activity (PA) and a healthy diet offer quality of life benefit to people with cancer before, during, and post treatment. However, older adults are poorly represented in the clinical trials on which recommendations were made.

OBJECTIVE

To assess the acceptability, usefulness, and practicality of delivering a tailored wellbeing (PA and nutrition) intervention for older adults with lung cancer before, during, and after cancer treatments (chemotherapy and/or immunotherapy).

METHODS

Semi-structured interviews conducted with nine patients with lung cancer and three patients with mesothelioma, ≥70 years and ten informal carers, and nine Multidisciplinary Team (MDT) members. A topic guide covered the acceptability, usefulness, and practicality of a wellbeing intervention as well as specific feedback on individual components. Data were subjected to thematic analysis.

FINDINGS

Four themes were generated: current lack of wellbeing care in clinical work; preferred "can have" dietary and "can do" PA advice; peer support as facilitating factor; and barriers to compliance including patients' psychological and physical issues as well as current cancer pathway and staffing issues.

CONCLUSION

Older adults with lung cancer would welcome a proactive, clear and instructive, wellbeing intervention. Many barriers to compliance exist, particularly before and during cancer treatments due to the psycho-social impact of diagnosis, and the effects of cancer treatment. The intervention must be tailored to individual need and address physical limitations, psychological and social welfare in addition to PA and nutritional advice.

Prevalence of lifestyle behaviors and associations with health-related quality of life among older female cancer survivors

PURPOSE

Healthy lifestyles including maintaining a normal weight, consuming a healthy diet, and being physically active can improve prognosis and health-related quality of life (HRQoL) among cancer survivors. The largest proportion of cancer survivors are older adults (≥ 65 years), yet their lifestyle behaviors are understudied. This study sought to examine the lifestyle behaviors (maintaining healthy weight, diet quality, physical activity) of older female cancer survivors and identify associations with HRQoL.

METHODS

Older female cancer survivors (n = 171) completed surveys to assess HRQoL (RAND-36), unintentional weight loss, body mass index (BMI), diet quality (HEI-2015), and physical activity. Demographic information and medical record data were also collected. Descriptive analyses, correlations, and stepwise linear regressions were utilized.

RESULTS

Physical and mental HRQoL of the sample (mean age = 74.50 years) were low: 41.94 ± 10.50 and 48.47 ± 7.18, respectively, out of 100. Physical activity was low: 75.3%, 54.2%, and 68.1% reported no strenuous, moderate, and mild physical activity, respectively. Mean BMI was 27.71 ± 6.24 (overweight) with 64% of the participants being overweight or obese. Mean HEI-2015 scores were 66.54 ± 10.0. Engagement in moderate physical activity was associated with higher physical HRQoL (β = 0.42, p = 0.004). Being white (β = 0.53, p < 0.001), older (β = 0.27, p = 0.025), and having higher HEI scores (β = 0.30, p = 0.011) were associated with higher mental HRQoL.

CONCLUSIONS

Older cancer survivors report poor diet quality, high rates of being overweight or obese, and low levels of physical activity that impact their HRQoL. Results indicate the need for tailored health coaching for older cancer survivors regarding their lifestyle behaviors to improve prognosis and HRQoL.

Lessons Learned from Arti-Collaborating to Improve Care: the Past, Present, and Future of the Cancer and Aging Research Group

Dr Arti Hurria, who died tragically in November 2018, was a driving force in the growing field of geriatric oncology. She led the field through her commitment to her goals, collaboration with her colleagues, and the creation of the Cancer and Aging Research Group (CARG). As two of her closest colleagues, we are carrying her work forward with our colleagues through an infrastructure grant we led with Arti from the National Institute on Aging (R21/33; CARinG). This grant will provide a national structure for continuing to build the field through research, mentorship, and dissemination. We miss our friend dearly but are committed to carrying her legacy forward through CARG. J Am Geriatr Soc 67:879-883, 2019.

Physical activity and nutrition interventions for older adults with cancer: a systematic review

Purpose

The aim of this review was to summarize the current literature for the effectiveness of activity and nutritional based interventions on health-related quality of life (HRQoL) in older adults living with and beyond cancer (LWBC).

Methods

We conducted systematic structured searches of CINAHL, Embase, Medline, Cochrane CENTRAL databases, and bibliographic review. Two independent researchers selected against inclusion criteria: (1) lifestyle nutrition and/or activity intervention for people with any cancer diagnosis, (2) measured HRQoL, (3) all participants over 60 years of age and (4) randomized controlled trials.

Results

Searches identified 5179 titles; 114 articles had full text review, with 14 studies (participant n = 1660) included. Three had nutrition and activity components, one, nutrition only and ten, activity only. Duration ranged from 7 days to 1 year. Interventions varied from intensive daily prehabilitation to home-based gardening interventions. Studies investigated various HRQoL outcomes including fatigue, general and cancer-specific quality of life (QoL), distress, depression, global side-effect burden and physical functioning. Eight studies reported significant intervention improvements in one or more QoL measure. Seven studies reported using a psychosocial/theoretical framework. There is a gap in tailored nutrition advice.

Conclusions

Among the few studies that targeted older adults with cancer, most were activity-based programmes with half reporting improvements in QoL. Future research should focus on or include tailored nutrition components and consider appropriate behaviour change techniques to maximize potential QoL improvement.

Implications for Cancer Survivors

More research is needed to address the research gap regarding older adults as current recommendations are derived from younger populations.

Electronic supplementary material

The online version of this article (10.1007/s11764-020-00883-x) contains supplementary material, which is available to authorized users.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Behavioral, psychological, and supportive care interventions in geriatric oncology: The Cancer and Aging Research Group infrastructure core

Current research efforts focusing on improving outcomes of older adults with cancer lack the appropriate infrastructure to support this growing need. The Cancer and Aging Group R21/33 National Institute of Health (NIH)/National Institute of Aging (NIA) grant aims to support development of geriatric oncology research through dedicated cores. The mission of the Core on Behavioral, Psychological, and Supportive Care Interventions will be to provide guidance in the field of non-pharmacological interventions. The Core will provide investigators with expertise, advocacy, and support in study design, development, and execution.

Achieving sequential therapy in advanced gastric cancer: the importance of appropriate patient management for the elderly and/or those with ascites

Treatment options for patients with advanced gastric cancer (AGC) are limited. One approach to improving survival in patients with AGC is to optimize the available agents via sequential therapy. However, clinical trial reports of first-line chemotherapy indicate that elderly patients and patients with massive ascites are less likely to receive subsequent lines of therapy. In addition, clinical trials of second- and third-line chemotherapy generally exclude these two patient populations because they are likely to have poor performance status and additional issues that are difficult to manage. Good patient management is likely to be key to the successful use of sequential therapy in these two patient populations by minimizing adverse effects to allow patients to derive benefit from the additional treatment. This narrative review summarizes the available information on AGC treatment and patient management in elderly patients and patients with massive ascites. The available data suggest that elderly patients benefit from chemotherapy; however, monitoring toxicity is essential to avoid chemotherapy-related toxicities. Important aspects of patient management for elderly patients include symptom monitoring, nutritional support, and fall prevention. The available data for patients with massive ascites show limited success for a range of treatment approaches, including systemic chemotherapy. The management of ascites is also challenging, with no clear guidance on the preferred strategies. To address these gaps in knowledge, future clinical trials should incorporate more inclusive eligibility criteria to enroll populations of patients with AGC that are more reflective of the real-world population with respect to age, complications, and overall health status.

Engaging older patients with cancer and their caregivers as partners in cancer research

Active patient partner engagement with SCOREboard – a diverse group of older patients with cancer, caregivers of older patients with cancer, survivors, and patient advocates – to conduct the largest randomized geriatric assessment clinical trial to date, has been shown to be feasible and resulted in tangible and invaluable benefits for both the research team and patient partners alike. Actively engaging patient partners should be an essential component in the development, conduct, and completion of all clinical research.

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.

Validity of the Mini-Nutritional Assessment Scale for Evaluating Frailty Status in Older Adults

OBJECTIVES

Comprehensive Geriatric Assessment (CGA) may not be performed in clinical practice as it takes too much time and requires special training. The Mini-Nutritional Assessment (MNA) is widely used to assess nutritional status in older adults. We aimed to determine whether or not the MNA can estimate frailty status defined by the Fried criteria.

SETTING AND PARTICIPANTS

Six hundred two outpatients aged 65 years or older who underwent the CGA were included the study.

MEASURES

Frailty status was defined by 5 dimensions including shrinking, exhaustion, low levels of activity, weakness, and slowness: 0 for robust, 1-2 for prefrail, and 3-5 for frail. MNA was performed in all participants even if their MNA-Short Form scores were ≥12.

RESULTS

Of the 602 outpatients, of whom the mean age was 74.2 ± 8.2 years, 190 participants (31.6%) were considered frail and 218 (36.2%) prefrail. Internal consistency of the MNA had a Cronbach-alpha of 0.701. Interclass correlation coefficient for the test-retest reliability was found as 0.697. MNA with a cut-off point of 22.5 had a sensitivity of 72.1% and a specificity of 91.2% to detect frail participants. MNA with a cut-off point of 25.5 had a sensitivity of 66.9% and a specificity of 85.4% to detect prefrailty. For the estimation of frailty and prefrailty, the area under the receiver operating characteristics curve of MNA was 0.903 and 0.834, respectively.

CONCLUSIONS

MNA can be a useful tool for frailty screening indicating that 2 common geriatric syndromes, malnutrition and frailty, can be identified by MNA simultaneously in clinical practice.

Functional Decline and Resilience in Older Women Receiving Adjuvant Chemotherapy for Breast Cancer

OBJECTIVES

To analyze self-reported changes in physical function in older women with breast cancer receiving adjuvant chemotherapy.

DESIGN

Secondary analysis of the Cancer and Leukemia Group B (CALGB) 49907 prospective randomized clinical trial.

SETTING

CALGB institutions in the United States.

PARTICIPANTS

Women aged 65 and older with Stage I to III breast cancer enrolled in CALGB 49907 who had physical function data from before and after receipt of adjuvant chemotherapy (N=256; mean age 71.5, range 65-85).

MEASUREMENTS

Participants were administered the physical function subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire before chemotherapy, at the end of chemotherapy, and 12 months after chemotherapy initiation. Functional decline was defined as a more than 10-point decrease from baseline at each time point. Resilience was defined as return to within 10 points of baseline. Multivariable regression was used to examine pretreatment characteristics associated with physical function changes.

RESULTS

Of 42% of participants who had physical function decline from before to the end of chemotherapy, 47% recovered by 12 months (were resilient). Almost one-third experienced functional decline from before chemotherapy to 12 months later. Pretreatment fatigue was a risk factor for functional decline from before to the end of chemotherapy (P=.02). Risk factors for functional decline at 12 months included pretreatment dyspnea (P=.007) and being unmarried (P=.01).

CONCLUSION

Functional decline was common in older women receiving adjuvant chemotherapy for breast cancer in a clinical trial. Although half recovered their physical function, one-third had a clinically meaningful decline at 12 months. Strategies are needed to prevent functional decline in older adults receiving chemotherapy. J Am Geriatr Soc 67:920-927, 2019.

Preventing Treatment-Related Functional Decline: Strategies to Maximize Resilience

The majority of patients with cancer are older adults. A comprehensive geriatric assessment (CGA) will help the clinical team identify underlying medical and functional status issues that can affect cancer treatment delivery, cancer prognosis, and treatment tolerability. The CGA, as well as more abbreviated assessments and geriatric screening tools, can aid in the treatment decision-making process through improved individualized prediction of mortality, toxicity of cancer therapy, and postoperative complications and can also help clinicians develop an integrated care plan for the older adult with cancer. In this article, we will review the latest evidence with regard to the use of CGA in oncology. In addition, we will describe the benefits of conducting a CGA and the types of interventions that can be taken by the interprofessional team to improve the treatment outcomes and well-being of older adults.

Geriatric Assessment and Tools for Predicting Treatment Toxicity in Older Adults With Cancer

Cancer is a disease of older adults, and the majority of new cancer cases and deaths occur in people 65 years or older. However, fewer data are available regarding the risks and benefits of cancer treatment in older adults, and commonly used assessments in oncology fail to adequately evaluate factors that affect treatment efficacy and outcomes in the older patients. The geriatric assessment is a multidisciplinary evaluation that provides detailed information about a patient's functional status, comorbidities, psychological state, social support, nutritional status, and cognitive function. Among older patients with cancer, geriatric assessment has been shown to identify patients at risk of poorer overall survival, and geriatric assessment-based tools are significantly more effective in predicting chemotherapy toxicity than other currently utilized measures. In this review, we summarize the components of the geriatric assessment and provide information about existing tools used to predict treatment toxicity in older patients with cancer.