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Soto-Perez-de-Celis E, Dale W, Katheria V, Kim H, Fakih M, Chung VM, Lim D, Mortimer J, Cabrera Chien L, Charles K, Roberts E, Vazquez J, Moreno J, Lee T, Fernandes Dos Santos Hughes S, Sedrak MS, Sun CL, Li D. Outcome prioritization and preferences among older adults with cancer starting chemotherapy in a randomized clinical trial. Cancer 2024. [PMID: 38630903 DOI: 10.1002/cncr.35333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 04/19/2024]
Abstract
INTRODUCTION Older adults with cancer facing competing treatments must prioritize between various outcomes. This study assessed health outcome prioritization among older adults with cancer starting chemotherapy. METHODS Secondary analysis of a randomized trial addressing vulnerabilities in older adults with cancer. Patients completed three validated outcome prioritization tools: 1) Health Outcomes Tool: prioritizes outcomes (survival, independence, symptoms) using a visual analog scale; 2) Now vs. Later Tool: rates the importance of quality of life at three times-today versus 1 or 5 years in the future; and 3) Attitude Scale: rates agreement with outcome-related statements. The authors measured the proportion of patients prioritizing various outcomes and evaluated their characteristics. RESULTS A total of 219 patients (median [range] age 71 [65-88], 68% with metastatic disease) were included. On the Health Outcomes Tool, 60.7% prioritized survival over other outcomes. Having localized disease was associated with choosing survival as top priority. On the Now vs. Later Tool, 50% gave equal importance to current versus future quality of life. On the Attitude Scale, 53.4% disagreed with the statement "the most important thing to me is living as long as I can, no matter what my quality of life is"; and 82.2% agreed with the statement "it is more important to me to maintain my thinking ability than to live as long as possible". CONCLUSION Although survival was the top priority for most participants, some older individuals with cancer prioritize other outcomes, such as cognition and function. Clinicians should elicit patient-defined priorities and include them in decision-making.
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Affiliation(s)
- Enrique Soto-Perez-de-Celis
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Tlalpan, Mexico City, Mexico
| | - William Dale
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Vani Katheria
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Heeyoung Kim
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Marwan Fakih
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Vincent M Chung
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Dean Lim
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | - Joanne Mortimer
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
| | | | | | - Elsa Roberts
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Jessica Vazquez
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Jeanine Moreno
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Ty Lee
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | | | - Mina S Sedrak
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Can-Lan Sun
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
| | - Daneng Li
- Center for Cancer and Aging, City of Hope, Duarte, California, USA
- Department of Medical Oncology and Therapeutics Research, City of Hope, Duarte, California, USA
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Ng XR, Tey YXS, Lew KJ, Lee PSS, Lee ES, Sim SZ. Cross-sectional study assessing health outcome priorities of older adults with multimorbidity at a primary care setting in Singapore. BMJ Open 2023; 13:e079990. [PMID: 38081675 PMCID: PMC10729092 DOI: 10.1136/bmjopen-2023-079990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/27/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES Managing older adults with multimorbidity may be challenging due to the conflicting benefits and harms of multiple treatments. Thus, it is important to identify patients' health outcome priorities to align treatment goals with their health preferences. This study aimed to use the Outcome Prioritisation Tool (OPT) to describe the health outcome priorities of older adults with multimorbidity and determine the factors associated with these priorities. Additionally, it aimed to assess the ease of completing the OPT in Singapore's primary care population. DESIGN Cross-sectional study conducted from January to March 2022. SETTING A public primary care centre in Singapore. PARTICIPANTS 65 years and older with multimorbidity. OUTCOME MEASURES Primary outcome measure was the most important health outcome priorities on the OPT. Secondary outcome measures were factors affecting these priorities and ease of completing the OPT. RESULTS We enrolled 180 participants (mean age: 73.2±6.1 years). Slightly more than half (54.4%) prioritised 'staying alive', while the remainder (45.6%) prioritised 'maintaining independence' (25.6%), 'relieving pain' (10.6%) and 'relieving other symptoms' (9.4%). Participants with six or more chronic conditions were three times (OR 3.03 (95% CI1.09 to 8.42)) more likely to prioritise 'staying alive' compared with participants with three conditions. Most participants (69.4%) agreed that the OPT was easy to complete, and the mean time taken to complete the OPT was 3.8±1.6 minutes. CONCLUSION 'Staying alive' was the most important health outcome priority, especially for older adults with six or more chronic conditions. The OPT was easily completed among older adults with multimorbidity in primary care. Further qualitative studies can be conducted to understand the factors influencing patients' priorities and explore the relevance of the OPT in guiding treatment decisions.
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Affiliation(s)
- Xin Rong Ng
- National Healthcare Group Polyclinics, Singapore
| | | | - Kaiwei Jeremy Lew
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | | | - Eng Sing Lee
- Clinical Research Unit, National Healthcare Group Polyclinics, Singapore
| | - Sai Zhen Sim
- National Healthcare Group Polyclinics, Singapore
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Seghers PAL, Hamaker ME, van der Wal-Huisman H, Stegmann ME, Portielje JEA, de Graeff P, Festen S. Development and testing of the Outcome Prioritization Tool adjusted to older patients with cancer: A pilot study. J Geriatr Oncol 2023; 14:101590. [PMID: 37481403 DOI: 10.1016/j.jgo.2023.101590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 06/20/2023] [Accepted: 07/07/2023] [Indexed: 07/24/2023]
Affiliation(s)
| | - Marije E Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, 3582 KE Utrecht, the Netherlands
| | - Hanneke van der Wal-Huisman
- Department of Surgery, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, the Netherlands
| | - Mariken E Stegmann
- University of Groningen, University Medical Center Groningen, Department of General Practice and Elderly Care Medicine, 9700 RB Groningen, the Netherlands
| | - Johanneke E A Portielje
- Department of Medical Oncology, Leiden University Medical Center-LUMC, 2333 ZA Leiden, the Netherlands
| | - Pauline de Graeff
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, 9700 RB Groningen, the Netherlands
| | - Suzanne Festen
- University of Groningen, University Medical Center Groningen, University Center for Geriatric Medicine, 9700 RB Groningen, the Netherlands.
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Arends SAM, Thodé M, Pasman HRW, Francke AL, Jongerden IP. How physicians see nurses' role in decision-making about life-prolonging treatments in patients with a short life expectancy: An interview study. PATIENT EDUCATION AND COUNSELING 2023; 114:107863. [PMID: 37356117 DOI: 10.1016/j.pec.2023.107863] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 06/27/2023]
Abstract
OBJECTIVE Exploring physicians' views on hospital nurses' role in decision-making about potentially life-prolonging treatments in patients with a short life expectancy. METHODS A qualitative study using semi-structured interviews with hospital physicians. Data were collected from May to September 2019 and analyzed following principles of thematic analysis. RESULTS Fifteen physicians working in different hospitals and specialisms participated. Physicians stated that they are responsible for the final decision about potentially life-prolonging treatments. They considered nurses' role in decision-making to be complementary to the roles of both patients and the physicians themselves, especially when there are doubts or complex situations. Physicians varied in how important they found nurses' involvement in the decision-making process: some physicians saw the involvement of nurses as "situation-dependent", while others viewed nurses' involvement as standard practice. Furthermore, physicians mentioned practical obstacles to involving nurses, like the limited time available to both nurses and physicians themselves. CONCLUSION Physicians recognize a complementary role for nurses in decision-making about potentially life-prolonging treatment, especially in cases with doubts or complex situations. PRACTICE IMPLICATIONS Physicians and nurses should engage with each other to make nurses' involvement less situation-dependent. This inter-professional collaboration regarding decision-making about life-prolonging treatments should be stimulated, supported and maintained.
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Affiliation(s)
- Susanne A M Arends
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands.
| | - Maureen Thodé
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Section General Internal Medicine, Department of Internal Medicine, Amsterdam, the Netherlands
| | - H Roeline W Pasman
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands
| | - Anneke L Francke
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands; Netherlands Institute for Health Services Research - Nivel, Utrecht, the Netherlands
| | - Irene P Jongerden
- Amsterdam UMC, Location Vrije Universiteit Amsterdam, Department of Public and Occupational Health, Amsterdam, the Netherlands; Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, the Netherlands; Expertise Center for Palliative Care, Amsterdam, the Netherlands
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Islam Z, Pollock K, Patterson A, Hanjari M, Wallace L, Mururajani I, Conroy S, Faull C. Thinking ahead about medical treatments in advanced illness: a qualitative study of barriers and enablers in end-of-life care planning with patients and families from ethnically diverse backgrounds. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-135. [PMID: 37464868 DOI: 10.3310/jvfw4781] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Background This study explored whether or not, and how, terminally ill patients from ethnically diverse backgrounds and their family caregivers think ahead about deterioration and dying, and explored their engagement with health-care professionals in end-of-life care planning. Objective The aim was to address the question, what are the barriers to and enablers of ethnically diverse patients, family caregivers and health-care professionals engaging in end-of-life care planning? Design This was a qualitative study comprising 18 longitudinal patient-centred case studies, interviews with 19 bereaved family caregivers and 50 public and professional stakeholder responses to the findings. Setting The study was set in Nottinghamshire and Leicestershire in the UK. Results Key barriers - the predominant stance of patients was to live with hope, considering the future only in terms of practical matters (wills and funerals), rather than the business of dying. For some, planning ahead was counter to their faith. Health-care professionals seemed to feature little in people's lives. Some participants indicated a lack of trust and experienced a disjointed system, devoid of due regard for them. However, religious and cultural mores were of great importance to many, and there were anxieties about how the system valued and enabled these. Family duty and community expectations were foregrounded in some accounts and concern about being in the (un)care of strangers was common. Key enablers - effective communication with trusted individuals, which enables patients to feel known and that their faith, family and community life are valued. Health-care professionals getting to 'know' the person is key. Stakeholder responses highlighted the need for development of Health-care professionals' confidence, skills and training, Using stories based on the study findings was seen as an effective way to support this. A number of behavioural change techniques were also identified. Limitations It was attempted to include a broad ethnic diversity in the sample, but the authors acknowledge that not all groups could be included. Conclusions What constitutes good end-of-life care is influenced by the intersectionality of diverse factors, including beliefs and culture. All people desire personalised, compassionate and holistic end-of-life care, and the current frameworks for good palliative care support this. However, health-care professionals need additional skills to navigate complex, sensitive communication and enquire about aspects of people's lives that may be unfamiliar. The challenge for health-care professionals and services is the delivery of holistic care and the range of skills that are required to do this. Future work Priorities for future research: How can health professionals identify if/when a patient is 'ready' for discussions about deterioration and dying? How can discussions about uncertain recovery and the need for decisions about treatment, especially resuscitation, be most effectively conducted in a crisis? How can professionals recognise and respond to the diversity of faith and cultural practices, and the heterogeneity between individuals of beliefs and preferences relating to the end of life? How can conversations be most effectively conducted when translation is required to enhance patient understanding? Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. X. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Zoebia Islam
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Anne Patterson
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Matilda Hanjari
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Louise Wallace
- Faculty of Wellbeing, Education and Language Studies, The Open University, Milton Keynes, UK
| | - Irfhan Mururajani
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
| | - Simon Conroy
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Christina Faull
- Leicestershire and Rutland Organisation for the Relief of Suffering (LOROS) Hospice, Leicester, UK
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van der Velden NC, van Laarhoven HW, Nieuwkerk PT, Kuijper SC, Sommeijer DW, Ottevanger PB, Fiebrich HB, Dohmen SE, Creemers GJ, de Vos FY, Smets EM, Henselmans I. Attitudes Toward Striving for Quality and Length of Life Among Patients With Advanced Cancer and a Poor Prognosis. JCO Oncol Pract 2022; 18:e1818-e1830. [DOI: 10.1200/op.22.00185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE: When deliberating palliative cancer treatment, insight into patients' attitudes toward striving for quality of life (QL) and length of life (LL) may facilitate goal-concordant care. We investigated the (1) attitudes of patients with advanced cancer toward striving for QL and/or LL and whether these change over time, and (2) characteristics associated with these attitudes (over time). METHODS: We performed a secondary analysis of a randomized controlled trial on improving shared decision making (SDM), without differentiation between intervention arms. Patients (n = 173) with advanced cancer, a median life expectancy of < 12 months without anticancer treatment, and a median survival benefit of < 6 months from systemic therapy were included in seven Dutch hospitals. We used audio-recorded consultations and surveys at baseline (T0), shortly after the consultation (T2), at 3 and 6 months (T3 and T4). Primary outcomes were patients' attitudes toward striving for QL and LL (Quality Quantity Questionnaire; T2, T3, and T4). RESULTS: Overall, patients' attitudes toward striving for QL became less positive over 6 months ( P < .01); attitudes toward striving for LL did not change on group level. Studying individual patients, 76% showed changes in their attitudes toward striving for QL and/or LL at some point during the study, which occurred in various directions. More helplessness/hopelessness ( P < .001), less fighting spirit ( P < .05), less state anxiety ( P < .001), and more observed SDM ( P < .05) related to more positive attitudes toward striving for QL. Lower education, less helplessness/hopelessness, more fighting spirit, and more state anxiety ( P < .001) related to more positive attitudes toward striving for LL. CONCLUSION: Oncologists may explore patients' attitudes toward striving for QL and LL repeatedly and address patients' coping style and emotions during SDM to facilitate goal-concordant care throughout the last phase of life.
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Affiliation(s)
- Naomi C.A. van der Velden
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Hanneke W.M. van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Pythia T. Nieuwkerk
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Steven C. Kuijper
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Dirkje W. Sommeijer
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
- Department of Medical Oncology, Flevoziekenhuis, Almere, the Netherlands
| | - Petronella B. Ottevanger
- Department of Medical Oncology, Radboud University Medical Center, Radboud University, Nijmegen, the Netherlands
| | | | - Serge E. Dohmen
- Department of Medical Oncology, BovenIJ Ziekenhuis, Amsterdam, the Netherlands
| | - Geert-Jan Creemers
- Department of Medical Oncology, Catharina Ziekenhuis, Eindhoven, the Netherlands
| | - Filip Y.F.L. de Vos
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Ellen M.A. Smets
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - Inge Henselmans
- Department of Medical Psychology, Amsterdam Public Health Research Institute, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
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Seghers PAL(N, Wiersma A, Festen S, Stegmann ME, Soubeyran P, Rostoft S, O’Hanlon S, Portielje JEA, Hamaker ME. Patient Preferences for Treatment Outcomes in Oncology with a Focus on the Older Patient-A Systematic Review. Cancers (Basel) 2022; 14:cancers14051147. [PMID: 35267455 PMCID: PMC8909757 DOI: 10.3390/cancers14051147] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary In oncology, treatment outcomes can be competing, which means that one treatment could benefit one outcome, like survival, and negatively influence another, like independence. The choice of treatment therefore depends on the patient’s preference for outcomes, which needs to be assessed explicitly. Especially in older patients, patient preferences are important. Our systematic review summarizes all studies that assessed patient preferences for various treatment outcome categories. A total of 28 studies with 4374 patients were included, of which only six studies included mostly older patients. Although quality of life was only included in half of the studies, overall quality of life (79%) was most frequently prioritized as highest or second highest, followed by overall survival (67%), progression- and disease-free survival (56%), absence of severe or persistent treatment side effects (54%), treatment response (50%), and absence of transient short-term side effects (16%). In shared decision-making, these results can be used by healthcare professionals to better tailor the information provision and treatment recommendations to the individual patient. Abstract For physicians, it is important to know which treatment outcomes are prioritized overall by older patients with cancer, since this will help them to tailor the amount of information and treatment recommendations. Older patients might prioritize other outcomes than younger patients. Our objective is to summarize which outcomes matter most to older patients with cancer. A systematic review was conducted, in which we searched Embase and Medline on 22 December 2020. Studies were eligible if they reported some form of prioritization of outcome categories relative to each other in patients with all types of cancer and if they included at least three outcome categories. Subsequently, for each study, the highest or second-highest outcome category was identified and presented in relation to the number of studies that included that outcome category. An adapted Newcastle–Ottawa Scale was used to assess the risk of bias. In total, 4374 patients were asked for their priorities in 28 studies that were included. Only six of these studies had a population with a median age above 70. Of all the studies, 79% identified quality of life as the highest or second-highest priority, followed by overall survival (67%), progression- and disease-free survival (56%), absence of severe or persistent treatment side effects (54%), and treatment response (50%). Absence of transient short-term side effects was prioritized in 16%. The studies were heterogeneous considering age, cancer type, and treatment settings. Overall, quality of life, overall survival, progression- and disease-free survival, and severe and persistent side effects of treatment are the outcomes that receive the highest priority on a group level when patients with cancer need to make trade-offs in oncologic treatment decisions.
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Affiliation(s)
| | - Anke Wiersma
- Department of Internal Medicine, Diakonessenhuis, 3582 KE Utrecht, The Netherlands;
| | - Suzanne Festen
- University Center for Geriatric Medicine, University Medical Hospital Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Mariken E. Stegmann
- Department of General Practice and Elderly Care Medicine, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
| | - Pierre Soubeyran
- Department of Oncology, Institut Bergonié, Université de Bordeaux, 33076 Bordeaux, France;
| | - Siri Rostoft
- Department of Geriatric Medicine, Oslo University Hospital, 0424 Oslo, Norway;
- Institute of Clinical Medicine, University of Oslo, 0318 Oslo, Norway
| | - Shane O’Hanlon
- Department of Geriatric Medicine, St. Vincent’s University Hospital, D04 T6F4 Dublin, Ireland;
- School of Medicine, University College Dublin, D04 V1W8 Dublin, Ireland
| | - Johanneke E. A. Portielje
- Department of Medical Oncology, Leiden University Medical Center-LUMC, 2333 ZA Leiden, The Netherlands;
| | - Marije E. Hamaker
- Department of Geriatric Medicine, Diakonessenhuis, 3582 KE Utrecht, The Netherlands
- Correspondence: (P.A.L.S.); (M.E.H.)
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