A specialized home care intervention improves survival among older post-surgical cancer patients

Peri-operative score for elderly patients with resectable hepatocellular carcinoma

BACKGROUND

Liver resection is the mainstay for a curative treatment for patients with resectable hepatocellular carcinoma (HCC), also in elderly population. Despite this, the evaluation of patient condition, liver function and extent of disease remains a demanding process with the aim to reduce postoperative morbidity and mortality.

AIM

To identify new perioperative risk factors that could be associated with higher 90- and 180-d mortality in elderly patients eligible for liver resection for HCC considering traditional perioperative risk scores and to develop a risk score.

METHODS

A multicentric, retrospective study was performed by reviewing the medical records of patients aged 70 years or older who electively underwent liver resection for HCC; several independent variables correlated with death from all causes at 90 and 180 d were studied. The coefficients of Cox regression proportional-hazards model for six-month mortality were rounded to the nearest integer to assign risk factors' weights and derive the scoring algorithm.

RESULTS

Multivariate analysis found variables (American Society of Anesthesiology score, high rate of comorbidities, Mayo end stage liver disease score and size of biggest lesion) that had independent correlations with increased 90- and 180-d mortality. A clinical risk score was developed with survival profiles.

CONCLUSION

This score can aid in stratifying this population in order to assess who can benefit from surgical treatment in terms of postoperative mortality.

What Nursing-Sensitive Outcomes Have Been Investigated to Date among Patients with Solid and Hematological Malignancies? A Scoping Review

Nursing-sensitive outcomes are those outcomes attributable to nursing care. To date three main reviews have summarized the evidence available regarding the nursing outcomes in onco-haematological care. Updating the existing reviews was the main intent of this study; specifically, the aim was to map the state of the art of the science in the field of oncology nursing-sensitive outcomes and to summarise outcomes and metrics documented as being influenced by nursing care. A scoping review was conducted in 2021. The MEDLINE, Cumulative Index to Nursing and Allied Health, Web of Science, and Scopus databases were examined. Qualitative and quantitative primary and secondary studies concerning patients with solid/haematological malignancies, cared for in any setting, published in English, and from any time were all included. Both inductive and deductive approaches were used to analyse the data extracted from the studies. Sixty studies have been included, mostly primary (n = 57, 95.0%) with a quasi- or experimental approach (n = 26, 55.3%), conducted among Europe (n = 27, 45.0%), in hospitals and clinical wards (n = 29, 48.3%), and including from 8 to 4615 patients. In the inductive analysis, there emerged 151 outcomes grouped into 38 categories, with the top category being 'Satisfaction and perception of nursing care received' (n = 32, 21.2%). Outcome measurement systems included mainly self-report questionnaires (n = 89, 66.9%). In the deductive analysis, according to the Oncology Nursing Society 2004 classification, the 'Symptom control and management' domain was the most investigated (n = 44, 29.1%); however, the majority (n = 50, 33.1%) of nursing-sensitive outcomes that emerged were not includible in the available framework. Continuing to map nursing outcomes may be useful for clinicians, managers, educators, and researchers in establishing the endpoints of their practice. The ample number of instruments and metrics that emerged suggests the need for more development of homogeneous assessment systems allowing comparison across health issues, settings, and countries.

Long-Term Risk of Being Bedridden in Elderly Patients Who Underwent Oncologic Surgery: A Retrospective Study Using a Japanese Claims Database

BACKGROUND

Although functional outcomes are important in surgery for elderly patients, the long-term functional prognosis following oncologic surgery is unclear. We retrospectively investigated the long-term, functional and survival prognosis following major oncologic surgery according to age among elderly patients.

METHODS

We used a Japanese administrative database to identify 11,896 patients aged ≥ 65 years who underwent major oncological surgery between June 2014 and February 2019. We investigated the association between age at surgery and the postoperative incidence of bedridden status and mortality. Using the Fine-Gray model and restricted cubic spline functions, we conducted a multivariable, survival analysis with adjustments for patient background characteristics and treatment courses to estimate hazard ratios for the outcomes.

RESULTS

During a median follow-up of 588 (interquartile range, 267-997) days, 657 patients (5.5%) became bedridden and 1540 (13%) died. Patients aged ≥ 70 years had a significantly higher incidence of being bedridden than those aged 65-69 years; the subdistribution hazard ratios of the age groups of 70-74, 75-79, 80-84, and ≥ 85 years were 3.20 (95% confidence interval [CI], 1.53-6.71), 3.86 (95% CI 1.89-7.89), 6.26 (95% CI 3.06-12.8), and 8.60 (95% CI 4.19-17.7), respectively. Restricted cubic spline analysis demonstrated an increase in the incidence of bedridden status in patients aged ≥ 65 years, whereas mortality increased in patients aged ≥ 75 years.

CONCLUSIONS

This large-scale, observational study revealed that older age at oncological surgery was associated with poorer functional outcomes and higher mortality among patients aged ≥ 65 years.

Self-performed Five Times Sit-To-Stand test at home as (pre-)screening tool for frailty in cancer survivors: Reliability and agreement assessment

AIMS AND OBJECTIVES

The self-performance of a Five-Times-Sit-To-Stand (FTSTS)-test, without the usual supervision by a medical professional, provides valuable opportunities for clinical practice and research. This study aimed: (1) to determine the validity of the self-performed FTSTS test in comparison to a supervised reference test and (2) to determine the reliability of a self-performed FTSTS test by cancer survivors.

BACKGROUND

Early detection of frailty in cancer survivors may enable prehabilitation interventions before surgery or intensive treatment, improving cancer outcomes.

DESIGN

A repeated measures reliability and agreement study, with one week in between measures, was performed.

METHODS

Cancer survivors (n = 151) performed two FTSTS tests themselves. One additional reference FTSTS test was supervised by a physical therapist. The intraclass correlation coefficient (ICC), structural error of measurement (SEM) and minimally important clinical difference (MID) were calculated comparing a self-performed FTSTS test to the reference test, and comparing two self-performed FTSTS tests. The Guidelines for Reporting Reliability and Agreement Studies (GRASS) have been used.

RESULTS

Mean age of cancer survivors was 65.6 years (SD = 9.3), 54.6% were female, median time since diagnosis was 2 years [IQR = 1], and tumour type varied (e.g., breast cancer (31.8%), prostate cancer (17.2%), gastrointestinal cancer (11.9%) and haematological cancer (11.9%)). Validity of the self-performed FTSTS test at home was acceptable in comparison with the reference test (ICC = .74; SEM = 3.2; MID = 3.6) as was the reliability of the self-performed FTSTS test (ICC = .70; SEM = 2.2; MID = 3.8).

CONCLUSIONS

The self-performed FTSTS test is a valid and reliable measure to assess lower body function and has potential to be used as objective (pre-)screening tool for frailty in cancer survivors.

RELEVANCE TO CLINICAL PRACTICE

The self-performed FTSTS test at home may indicate the cancer survivors in need of prehabilitation in advance of surgery or intensive treatment. The feasibility, short amount of time needed and potential cost-effectiveness of the self-performed FTSTS test can make it a valuable contribution to personalised care and precision medicine.

Home Cancer Care Research: A Bibliometric and Visualization Analysis (1990-2021)

Home cancer care research (HCCR) has accelerated, as considerable attention has been placed on reducing cancer-related health costs and enhancing cancer patients' quality of life. Understanding the current status of HCCR can help guide future research and support informed decision-making about new home cancer care (HCC) programs. However, most current studies mainly detail the research status of certain components, while failing to explore the knowledge domain of this research field as a whole, thereby limiting the overall understanding of home cancer care. We carried out bibliometric and visualization analyses of Scopus-indexed papers related to home cancer care published between 1990-2021, and used VOSviewer scientometric software to investigate the status and provide a structural overview of the knowledge domain of HCCR (social, intellectual, and conceptual structures). Our findings demonstrate that over the last three decades, the research on home cancer care has been increasing, with a constantly expanding stream of new papers built on a solid knowledge base and applied to a wide range of research themes.

Developing and Field Testing BOLSTER: A Nurse-Led Care Management Intervention to Support Patients and Caregivers following Hospitalization for Gynecologic Cancer-Associated Peritoneal Carcinomatosis

Introduction: Peritoneal carcinomatosis (PC) afflicts women with advanced gynecologic cancers. Patients with PC often require ostomies, gastric tubes, or catheters to palliate symptoms, yet patients and caregivers report feeling unprepared to manage these devices. The purpose of this study was to develop and field test the Building Out Lifelines for Safety, Trust, Empowerment, and Renewal (BOLSTER) intervention to support patients and their caregivers after hospitalization for PC. Materials and Methods: We adapted components of the Standard Nursing Intervention Protocol with stakeholders and topical experts. We developed educational content; built a smartphone application to assess patients' symptoms; and assessed preliminary feasibility and acceptability in two single-arm prepilot studies. Eligible participants were English-speaking adults hospitalized for gynecologic cancer-associated PC and their caregivers. Feasibility criteria were a ≥50% consent-to-approach ratio and ≥80% outcome measure completion. The acceptability criterion was ≥70% of participants recommending BOLSTER. Results: During the first prepilot, BOLSTER was a 10-week intervention. While 7/8 (87.5%) approached patients consented, we experienced high attrition to hospice. Less than half of patients (3/7) and caregivers (3/7) completed outcome measures. For the second prepilot, BOLSTER was a four-week intervention. All (7/7) approached patients consented. Two withdrew before participating in any study activity because they were "too overwhelmed." We excluded data from one caregiver who completed baseline measures with the patient's assistance. All remaining patients (5/5) and caregivers (4/4) completed outcome measures and recommended BOLSTER. Conclusion: BOLSTER is a technology-enhanced, nurse-led intervention that is feasible and acceptable to patients with gynecologic cancer-associated PC and their caregivers.

Effectiveness of Geriatric Assessment-Driven Interventions on Survival and Functional and Nutritional Status in Older Patients with Head and Neck Cancer: A Randomized Controlled Trial (EGeSOR)

Simple Summary

Due to population ageing, there is an increasing number of older patients with head and neck cancers (HNC). Management of HNCs is complex. This population may be frailer than other patients with solid cancer. The Geriatric Assessment (GA) is a multidimensional diagnostic and therapeutic tool focused on frailty to propose a coordinated treatment plan and long-term follow-up. Several trials assessed the efficacy of GA-driven interventions on diverse outcomes but no recent randomized controlled trial demonstrated the impact on mortality, functional, or nutritional status as a primary outcome in this particular population. This trial highlighted several difficulties in implementation of geriatric interventions and suggested that the assessment of other models as co-management with oncologists and/or experienced practice nurses could be useful in clinical routine practice.

Abstract

This study assesses the efficacy of Geriatric Assessment (GA)-driven interventions and follow-up on six-month mortality, functional, and nutritional status in older patients with head and neck cancer (HNC). HNC patients aged 65 years or over were included between November 2013 and September 2018 by 15 Ear, Nose, and Throat (ENT) and maxillofacial surgery departments at 13 centers in France. The study was of an open-label, multicenter, randomized, controlled, and parallel-group design, with independent outcome assessments. The patients were randomized 1:1 to benefit from GA-driven interventions and follow-up versus standard of care. The interventions consisted in a pre-therapeutic GA, a standardized geriatric intervention, and follow-up, tailored to the cancer-treatment plan for 24 months. The primary outcome was a composite criterion including six-month mortality, functional impairment (fall in the Activities of Daily Living (ADL) score ≥2), and weight loss ≥10%. Among the patients included (n = 499), 475 were randomized to the experimental (n = 238) or control arm (n = 237). The median age was 75.3 years [70.4–81.9]; 69.5% were men, and the principal tumor site was oral cavity (43.9%). There were no statistically significant differences regarding the primary endpoint (n = 98 events; 41.0% in the experimental arm versus 90 (38.0%); p = 0.53), or for each criterion (i.e., death (31 (13%) versus 27 (11.4%); p = 0.48), weight loss of ≥10% (69 (29%) versus 65 (27.4%); p = 0.73) and fall in ADL score ≥2 (9 (3.8%) versus 13 (5.5%); p = 0.35)). In older patients with HNC, GA-driven interventions and follow-up failed to improve six-month overall survival, functional, and nutritional status.

Functional Improvement Trajectories After Surgery (FIT After Surgery) study: protocol for a multicentre prospective cohort study to evaluate significant new disability after major surgery in older adults

INTRODUCTION

Older adults prioritise surviving surgery, but also preservation of their functional status and quality of life. Current approaches to measure postoperative recovery, which focus on death, complications and length of hospitalisation, may miss key relevant domains. We propose that postoperative disability is an important patient-centred outcome to measure intermediate-to-long recovery after major surgery in older adults.

METHODS AND ANALYSIS

The Functional Improvement Trajectories After Surgery (FIT After Surgery) study is a multicentre cohort study of 2000 older adults (≥65 years) having major non-cardiac surgery. Its objectives are to characterise the incidence, trajectories, risk factors and impact of new significant disability after non-cardiac surgery. Disability is assessed using WHO Disability Assessment Schedule (WHODAS) 2.0 instrument and participants' level-of-care needs. Disability assessments occur before surgery, and at 1, 3, 6, 9 and 12 months after surgery. The primary outcome is significantly worse WHODAS score or death at 6 months after surgery. Secondary outcomes are (1) significantly worse WHODAS score or death at 1 year after surgery, (2) increased care needs or death at 6 months after surgery and (3) increased care needs or death at 1 year after surgery. We will use multivariable logistic regression models to determine the association of preoperative characteristics and surgery type with outcomes, joint modelling to characterise longitudinal time trends in WHODAS scores over 12 months after surgery, and longitudinal latent class mixture models to identify clusters following similar trajectories of disability.

ETHICS AND DISSEMINATION

The FIT After Surgery study has received research ethics board approval at all sites. Recruitment began in December 2019 but was placed on hold in March 2020 because of the COVID-19 pandemic. Recruitment was gradually restarted in October 2020, with 1-year follow-up expected to finish in 2023. Publication of the primary results is anticipated to occur in 2024.

Increased Morbidity and Mortality After Hepatectomy for Colorectal Liver Metastases in Frail Patients is Largely Driven by Worse Outcomes After Minor Hepatectomy: It's Not "Just a Wedge"

BACKGROUND

Frailty is associated with postoperative mortality, but its significance after hepatectomy for colorectal liver metastases (CRLM) is poorly defined. This study evaluated the impact of frailty after hepatectomy for CRLM.

METHODS

The study identified 8477 patients in National Surgical Quality Improvement Program databases from 2014 to 2019 and stratified them by frailty score using the risk analysis index as very frail (>90th percentile), frail (75th-90th percentile), or non-frail (< 75th percentile). Multivariate regression models determined the impact of frailty on perioperative outcomes, including by the extent of hepatectomy.

RESULTS

The procedures performed were 2752 major hepatectomies (left hepatectomy, right hepatectomy, trisectionectomy) and 5725 minor hepatectomies (≤2 segments) for 870 (10.3%) very frail, 1680 (19.8%) frail, and 5927 (69.9%) non-frail patients. Postoperatively, the very frail and frail patients experienced more complications (very frail [41.8%], frail [35.1%], non-frail [31.0%]), which resulted in a longer hospital stay (very-frail [5.7 days], frail [5.8 days], non-frail [5.1 days]), a higher 30-day mortality (very-frail [2.2%], frail [1.3%], non-frail [0.5%]), and more discharges to a facility (very frail [6.8%], frail [3.7%], non-frail [2.6%]) (p < 0.05) although they underwent similarly extensive (major vs. minor) hepatectomies. In the multivariate analysis, frailty was independently associated with complications (very-frail [odds ratio {OR}, 1.70], frail [OR, 1.25]) and 30-day mortality (very-frail [OR, 4.24], frail [OR, 2.41]) (p < 0.05). After minor hepatectomy, the very frail and frail patients had significantly higher rates of complications and 30-day mortality than the non-frail patients, and in the multivariate analysis, frailty was independently associated with complications (very frail [OR, 1.97], frail [OR, 1.27]) and 30-day mortality (very frail [OR, 6.76], frail [OR, 3.47]) (p < 0.05) after minor hepatectomy.

CONCLUSIONS

Frailty predicted significantly poorer outcomes after hepatectomy for CRLM, even after only a minor hepatectomy.

Training of advanced practice nurses in oncology for the best care: a systematic review

OBJECTIVE

To search for evidence on the training of advanced practice nurses, through clinical practice and nursing care with cancer patients.

METHOD

Systematic review, searching the databases: MEDLINE-PubMed, LILACS, Web of Science, Scopus, CINAHL and Cochrane CENTRAL. A manual search of the reference list and Google Scholar was also carried out. To assess the methodological quality of the studies, the following tools were used: Cochrane Collaboration Risk of Bias Tool (RoB 1) for randomized controlled trials and Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) for quasi-experimental studies.

RESULTS

A total of 12 experimental studies were identified. The main intervention identified in the studies was educational guidance. The studies showed improvement in pain control or other symptoms related to disease and/or treatment, satisfaction and improvement in the quality of life of cancer patients.

CONCLUSION

It is observed that there are studies that demonstrate the value of advanced practice nursing in oncology, through differentiated clinical training and advanced professional performance. Registration number of the systematic review: CRD42018098906.

Effectiveness of person- and family-centred care transition interventions on patient- oriented outcomes: A systematic review

AIM

The aim was to critically analyse the body of evidence regarding the effectiveness of PFCC transition interventions on the quality of care and the experience of patients.

DESIGN

We conducted a systematic review using the Cochrane Handbook's guidelines and adhered to a standardized reporting format: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

METHODS

Four databases and grey literature were searched. Following a two-step screening process, data from the eligible studies were extracted. Risk of bias and quality of the studies were also assessed. Narrative synthesis and vote counting were used for the data analysis.

RESULTS

A total of 28 articles met our inclusion criteria. Interventions varied in regards to the extent of the PFCC focus and the comprehensiveness of the transition of care. Educating patients to promote self-management was the most commonly included component and it was described in all 28 interventions.

Perioperative Geriatric Assessment as A Predictor of Long-Term Hepatectomy Outcomes in Elderly Patients with Hepatocellular Carcinoma

This retrospective study recorded pertinent baseline geriatric assessment variables to identify risk factors for recurrence-free survival (RFS) and overall survival (OS) after hepatectomy in 100 consecutive patients aged ≥70 years with hepatocellular carcinoma. Patients had geriatric assessments of cognition, nutritional and functional statuses, and comorbidity burden, both preoperatively and at six months postoperatively. The rate of change in each score between preoperative and postoperative assessments was calculated by subtracting the preoperative score from the score at six months postoperatively, then dividing by the score at six months postoperatively. Patients with score change ≥0 comprised the maintenance group, while patients with score change <0 comprised the reduction group. The change in Geriatric 8 (G8) score at six months postoperatively was the most significant predictive factor for RFS and OS among the tested geriatric assessments. Five-year RFS rates were 43.4% vs. 6.7% (maintenance vs. reduction group; HR, 0.19; 95%CI, 0.11-0.31; p < 0.001). Five-year OS rates were 73.8% vs. 17.8% (HR, 0.12; 95%CI, 0.06-0.25; p < 0.001). Multivariate Cox proportional hazards analysis showed that perioperative maintenance of G8 score was an independent prognostic indicator for both RFS and OS. Perioperative changes in G8 scores can help forecast postoperative long-term outcomes in these patients.

Physician Assistants and Nurse Practitioners in Primary Care Plus: A Systematic Review

Introduction

Shifting specialist care from the hospital to primary care/community care (also called primary care plus) is proposed as one option to reduce the increasing healthcare costs, improve quality of care and accessibility. The aim of this systematic review was to get insight in primary care plus provided by physician assistants or nurse practitioners.

Methods

Scientific databases and reference list were searched. Hits were screened on title/abstract and full text. Studies published between 1990-2018 with any study design were included. Risk of bias assessment was performed using QualSyst tool.

Results

Search resulted in 5.848 hits, 15 studies were included. Studies investigated nurse practitioners only. Primary care plus was at least equally effective as hospital care (patient-related outcomes). The number of admission/referral rates was significantly reduced in favor of primary care plus. Barriers to implement primary care plus included obtaining equipment, structural funding, direct access to patient-data. Facilitators included multidisciplinary collaboration, medical specialist support, protocols.

Conclusions and Discussion

Quality of care within primary care plus delivered by nurse practitioners appears to be guaranteed, at patient-level and professional-level, with better access to healthcare and fewer referrals to hospital. Most studies were of restricted methodological quality. Findings should be interpreted with caution.

Frailty as a Predictor of Postoperative Morbidity and Mortality Following Liver Resection

BACKGROUND

Liver resection is commonly performed among patients at risk of being frail. Frailty can be used to assess perioperative risk. Thus, we evaluated frailty as a predictor of postoperative complications following liver resection using a validated modified frailty index (mFI).

METHODS

A retrospective cohort of consecutive patients undergoing liver resection (2011-2018) were stratified according to the mFI and classified as the following: high (≥.27) and low mFI (<.27). The effect of mFI on postoperative complications (Clavien-Dindo) was evaluated using multiple logistic regression, expressed as odds ratios (OR) and 95% CI.

RESULTS

Of 409 patients, 58 (14%) had high mFI. There were no differences in type of liver resection (laparoscopic: 57% vs 55%, P = .766), number of segments resected (3 vs 4, P = .417), or operative time (257 vs 293 minutes, P = .097) between the high and low mFI groups, respectively. High mFI patients had a longer median length of hospital stay (9.5 vs 5 days, P < .001) and higher proportion of postoperative complications (79% vs 46%, P < .001), including minor complications (69% vs 42%, P < .001), major complications (50% vs 13%, P < .001), and 90-day postoperative mortality (12% vs 3.4%, P = .04). On multivariable analysis, longer operating time (OR 1.15, 95% CI, 1.03 to 1.27), higher number of segments resected (OR 1.43, 95% CI, 1.12 to 1.82), and high mFI (OR 6.74, 95% CI, 2.76 to 16.51) were independent predictors of major postoperative complications.

DISCUSSION

mFI predicts postoperative outcomes following liver resection and can be used as a risk stratification tool for patients being considered for surgery.

Symptom clusters in hospitalized older adults: Characteristics and outcomes

Hospital care in medical patients relies mostly on objective measures with limited assessment of subjective symptoms. We subgrouped 331 hospitalized older adults with medical diagnosis (age 75.5 ± 7.1) according to the severity of multiple symptoms to explore if these subgroups differed in health-related characteristics on admission and functional outcomes one month post-discharge. Cluster analysis identified three subgroups based on experiences with five highly distressing symptoms (fatigue, dyspnea, dizziness, sleep disturbance, pain): low levels of all symptoms, high levels of all symptoms; moderate levels of four symptoms with high dyspnea. Belonging in different subgroups was accompanied by different levels of cognitive and mental, but not physical or health status. Patients in the subgroup "Moderate Levels with High Dyspnea" had significantly lower risk of decline in post-discharge instrumental activities of daily living than other subgroups. Better understanding of older hospitalized adults' symptom profiles may yield important information on health condition and recovery.

Capacity to Provide Geriatric Specialty Care for Older Adults in Community Oncology Practices

BACKGROUND

American Society of Clinical Oncology guidelines recommend that patients ≥65 years of age starting chemotherapy undergo a geriatric assessment (GA) to inform and guide management; however, little is known about resources available in community oncology practices to implement these guidelines and to facilitate geriatric oncology research.

MATERIALS AND METHODS

Oncology practices within the National Cancer Institute Community Oncology Research Program (NCORP) were electronically surveyed in 2017 regarding the availability of specialty providers, supportive services, and practice characteristics, as part of a larger survey of cancer care delivery research capacity.

RESULTS

Of the 943 NCORP practices, 504 (54%) responded to the survey, representing 210 practice groups. The median new cancer cases per year ≥65 years of age was 457 (interquartile range 227-939). Of respondents, only 2.0% of practices had a fellowship-trained geriatric oncologist on staff. Geriatricians were available for consultation or comanagement at 37% of sites, and of those, only 13% had availability within the oncology clinic (5% of overall). Practice size of ≥1,000 new adult cancer cases (ages ≥18) per year was associated with higher odds (1.81, confidence interval 1.02-3.23) of geriatrician availability. Other multidisciplinary care professionals that could support GA were variably available onsite: social worker (84%), nurse navigator (81%), pharmacist (77%), dietician (71%), rehabilitative medicine (57%), psychologist (42%), and psychiatrist (37%).

CONCLUSION

Only a third of community oncology practices have access to a geriatrician within their group and only 5% of community sites have access within the oncology clinic. Use of primarily self-administered GA tools that direct referrals to available services may be an effective implementation strategy for guideline-based care.

IMPLICATIONS FOR PRACTICE

Only a minority of community oncology practices in the U.S. have access to geriatric specialty care. Developing models of care that use patient-reported measures and/or other geriatric screening tools to assess and guide interventions in older adults, rather than geriatric consultations, are likely the most practical methods to improve the care of this vulnerable population.

Palliative Care and End-of-Life Considerations for the Frail Patient

Patients with frailty experience substantial physical and emotional distress related to their condition and face increased morbidity and mortality compared with their nonfrail peers. Palliative care is an interdisciplinary medical specialty focused on improving quality of life for patients with serious illness, including those with frailty, throughout their disease course. Anesthesiology providers will frequently encounter frail patients in the perioperative period and in the intensive care unit (ICU) and can contribute to improving the quality of life for these patients through the provision of palliative care. We highlight the opportunities to incorporate primary palliative care, including basic symptom management and straightforward goals-of-care discussions, provided by the primary clinicians, and when necessary, timely consultation by a specialty palliative care team to assist with complex symptom management and goals-of-care discussions in the face of team and/or family conflict. In this review, we apply the principles of palliative care to patients with frailty and synthesize the evidence regarding methods to integrate palliative care into the perioperative and ICU settings.

A Randomized Trial of Real-Time Geriatric Assessment Reporting in Nonelectively Hospitalized Older Adults with Cancer

BACKGROUND

Hospitalized older adults have significant geriatric deficits that may lead to poor outcomes. We conducted a randomized trial to investigate the effectiveness of providing clinicians with a real-time geriatric assessment (GA) report in nonelectively hospitalized older patients with cancer.

SUBJECTS, MATERIALS, AND METHODS

We developed a web-based software platform for administering a modified GA (Cancer 2005;104:1998-2005) to older (>70 years) nonelectively hospitalized patients with pathologically confirmed malignancy. Patients were randomized to have their GA report provided to their treating clinicians (Intervention arm) or not provided (Control arm).

RESULTS

Our study included 135 patients, median age 76 years, 52% female, 75% white, 21% black, 79% greater than high school education, 59% married, and 17% living alone. All patients had at least one GA-identified deficit, including physical function deficits (90%), cognitive impairment (22%), >5 comorbidities (28%), polypharmacy (>9 medications; 38%), weight loss ≥10% in the past 6 months (40%), anxiety (32%), or depression (30%). There was no difference between the Intervention (6%) and Control arms (9%) in the proportion of patients who were referred by their clinical team for an intervention to address a deficit (p = .53).

CONCLUSION

Many older nonelectively hospitalized patients with cancer have geriatric deficits that are amenable to evidence-based interventions. Real-time GA reports provided to the care team prior to discharge did not influence provider referral for such interventions. There is a need for systems-level interventions to address deficits in this vulnerable patient population.

IMPLICATIONS FOR PRACTICE

Geriatric deficits are common in hospitalized older adults with cancer and lead to poor outcomes. Addressing modifiable deficits represents an appealing way to improve outcomes. Widespread geriatrician consultation is impractical owing to resource and personnel constraints. This work tested whether prompt delivery of a mostly self-administered, web-based geriatric assessment report to clinicians improved referral rates for evidence-informed interventions. It confirmed frequent geriatric deficits and high readmission rates in this population but found that real-time geriatric assessment reporting did not influence provider referral for evidence-informed interventions on geriatric assessment identified deficits. These findings highlight the need for systems-level intervention to improve outcomes in this vulnerable patient population.

Frailty and Comprehensive Geriatric Assessment

Frailty is defined as a reduced physiologic reserve vulnerable to external stressors. For older individuals, frailty plays a decisive role in increasing adverse health outcomes in most clinical situations. Many tools or criteria have been introduced to define frailty in recent years, and the definition of frailty has gradually converged into several consensuses. Frail older adults often have multi-domain risk factors in terms of physical, psychological, and social health. Comprehensive geriatric assessment (CGA) is the process of identifying and quantifying frailty by examining various risky domains and body functions, which is the basis for geriatric medicine and research. CGA provides physicians with information on the reversible area of frailty and the leading cause of deterioration in frail older adults. Therefore frailty assessment based on understanding CGA and its relationship with frailty, can help establish treatment strategies and intervention in frail older adults. This review article summarizes the recent consensus and evidence of frailty and CGA.

Improving management of comorbidity in patients with colorectal cancer using comprehensive medical assessment: a pilot study

BACKGROUND

Screening for and active management of comorbidity soon after cancer diagnosis shows promise in altering cancer treatment and outcomes for comorbid patients. Prior to a large multi-centre study, piloting of the intervention (comprehensive medical assessment) was undertaken to investigate the feasibility of the comorbidity screening tools and proposed outcome measures, and the feasibility, acceptability and potential effect of the intervention.

METHODS

In this pilot intervention study, 72 patients of all ages (36 observation/36 intervention) with newly diagnosed or recently relapsed colorectal adenocarcinoma were enrolled and underwent comorbidity screening and risk stratification. Intervention patients meeting pre-specified comorbidity criteria were referred for intervention, a comprehensive medical assessment carried out by geriatricians. Each intervention was individually tailored but included assessment and management of comorbidity, polypharmacy, mental health particularly depression, functional status and psychosocial issues. Recruitment and referral to intervention were tracked, verbal and written feedback were gathered from staff, and semi-structured telephone interviews were conducted with 13 patients to assess screening tool and intervention feasibility and acceptability. Interviews were transcribed and analysed thematically. Patients were followed for 6-12 months after recruitment to assess feasibility of proposed outcome measures (chemotherapy uptake and completion rates, grade 3-5 treatment toxicity, attendance at hospital emergency clinic, and unplanned hospitalisations) and descriptive data on outcomes collated.

RESULTS

Of the 29 intervention patients eligible for the intervention, 21 received it with feedback indicating that the intervention was acceptable. Those in the intervention group were less likely to be on 3+ medications, to have been admitted to hospital in previous 12 months, or to have limitations in daily activities. Collection of data to measure proposed outcomes was feasible with 55% (6/11) of intervention patients completing chemotherapy as planned compared to none (of 14) of the control group. No differences were seen in other outcome measures. Overall the study was feasible with modification, but the intervention was difficult to integrate into clinical pathways.

CONCLUSIONS

This study generated valuable results that will be used to guide modification of the study and its approaches prior to progressing to a larger-scale study.

TRIAL REGISTRATION

Retrospective, 26 August 2019, ACTRN12619001192178.

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.

Predictive value of each geriatric assessment domain for older patients with cancer: A systematic review

BACKGROUND

A geriatric assessment (GA) is increasingly used to help guide treatment decisions in older patients with cancer. However, there is no consensus regarding which domains should be included in the GA. In addition, the field of geriatric oncology moves very fast and as a result many new studies have been published since the last review in 2015. Therefore, the objective of this systematic review is to evaluate which domains of the GA could predict patient-related treatment outcomes of older patients with cancer and thereby should be included in a GA.

METHODS

A systematic literature search was performed for publications in English or Dutch between September 2006 and July 2017 addressing the association between individual domains of the GA and mortality, postoperative complications, or systemic treatment-related outcomes in older patients with cancer.

RESULTS

Eight different domains were evaluated in 46 publications, namely functional status, nutritional status, cognition, mood, physical function, fatigue, social support, and falls. All eight domains were predictive for at least one of the investigated outcomes but the results were quite variable across studies. Physical function and nutritional status were the domains most often associated with mortality and systemic treatment-related outcomes, and the domain physical function was most often associated with postoperative complications.

CONCLUSION

Overall, this review demonstrates that the GA should minimally consist of physical function and nutritional status, when the aim is to predict patients-related outcomes of older patients with cancer, although the results are quite heterogeneous. For the other domains, the findings are too inconsistent to draw conclusions about their overall predictive ability.

[Prehabilitation, therapeutic innovation]

The concept of prehabilitation emerged in the United States in the 1940s to maintain the performance of American soldiers notably through good nutrition and sport. It was then a question of optimising the patient's health status in a pre-treatment situation and reducing surgical stress. The specific collaborative programme Proadapt, comprising multiprofessional expertise, was put in place for elderly patients in 2016.

"Not just another meta-analysis": Sources of heterogeneity in psychosocial treatment effect on cancer survival

Background

Currently, there are eight meta‐analyses that address the question whether psychosocial intervention can prolong survival with widely disparate conclusions. One reason for inconsistent findings may be the methods by which previous meta‐analyses were conducted.

Methods

Databases were searched to identify valid randomized controlled trials that compared psychosocial intervention with usual care. Hazard ratios (HRs) and their confidence intervals were pooled to estimate the strength of the treatment effect on survival time, and z‐tests were performed to assess possible heterogeneity of effect sizes associated with different patient and treatment characteristics.

Results

Twelve trials involving 2439 cancer patients that met screening criteria were included. The overall effect favored the treatment group with a HR of 0.71 (95% Cl 0.58‐0.88; P = 0.002). An effect size favoring treatment group was observed in studies sampling lower vs higher percentage of married patients’ (NNT = 4.3 vs NNT = 15.4), when Cognitive‐Behavioral Therapy was applied at early vs late cancer stage (NNT = 2.3 vs NNT = −28.6), and among patients’ older vs younger than 50 (NNT = 4.2 vs NNT = −20.5).

Conclusions

Psychosocial interventions may have an important effect on survival. Reviewed interventions appear to be more effective in unmarried patients, patients who are older, and those with an early cancer stage who attend CBT. Limitations of previous meta‐analysis are discussed.

Detection of a novel, primate-specific 'kill switch' tumor suppression mechanism that may fundamentally control cancer risk in humans: an unexpected twist in the basic biology of TP53

The activation of TP53 is well known to exert tumor suppressive effects. We have detected a primate-specific adrenal androgen-mediated tumor suppression system in which circulating DHEAS is converted to DHEA specifically in cells in which TP53 has been inactivated DHEA is an uncompetitive inhibitor of glucose-6-phosphate dehydrogenase (G6PD), an enzyme indispensable for maintaining reactive oxygen species within limits survivable by the cell. Uncompetitive inhibition is otherwise unknown in natural systems because it becomes irreversible in the presence of high concentrations of substrate and inhibitor. In addition to primate-specific circulating DHEAS, a unique, primate-specific sequence motif that disables an activating regulatory site in the glucose-6-phosphatase (G6PC) promoter was also required to enable function of this previously unrecognized tumor suppression system. In human somatic cells, loss of TP53 thus triggers activation of DHEAS transport proteins and steroid sulfatase, which converts circulating DHEAS into intracellular DHEA, and hexokinase which increases glucose-6-phosphate substrate concentration. The triggering of these enzymes in the TP53-affected cell combines with the primate-specific G6PC promoter sequence motif that enables G6P substrate accumulation, driving uncompetitive inhibition of G6PD to irreversibility and ROS-mediated cell death. By this catastrophic 'kill switch' mechanism, TP53 mutations are effectively prevented from initiating tumorigenesis in the somatic cells of humans, the primate with the highest peak levels of circulating DHEAS. TP53 mutations in human tumors therefore represent fossils of kill switch failure resulting from an age-related decline in circulating DHEAS, a potentially reversible artifact of hominid evolution.

Adaptation and Implementation of a Transitional Care Protocol for Patients Undergoing Complex Abdominal Surgery

BACKGROUND

Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery.

APPROACH

The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC). Adaptation was accomplished using a modification of the Replicating Effective Programs (REP) model, which has four phases: (1) preconditions, (2) preimplementation, (3) implementation, and (4) maintenance and evolution. A random sample of five patients each month was selected to complete a phone survey regarding patient satisfaction. Preimplementation planning allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. The adapted protocol specifically addressed surgical issues such as nutrition, fever, ostomy output, dehydration, drain character/output, and wound appearance. After protocol launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions.

OUTCOMES

Survey responders reported 100% overall satisfaction with the transitional care program.

KEY INSIGHTS

The adaptable nature of sC-TraC may allow for low-resource hospitals, such as rural or inner-city medical centers, to use the methodology provided in this study for implementation of local phone-based transitional care protocols. In addition, as the C-TraC program has begun to disseminate nationally across US Department of Veterans Affairs (VA) hospitals and rural health settings, sC-TraC may be implemented using the existing transitional care infrastructure in place at these hospitals.

Communication about geriatric assessment domains in advanced cancer settings: "Missed opportunities"

OBJECTIVES

Older patients with advanced cancer often have age-related health issues (e.g., memory impairment) that influence their cancer treatment decisions. Communication about these age-related concerns can potentially lead to further assessment and subsequent clinical interventions to improve treatment decision-making and patients' quality of life. Yet, little is known about the communication of age-related concerns between oncologists, patients, and caregivers.

MATERIALS AND METHODS

This study is a secondary analysis of data from the Values and Options in Cancer Care (VOICE) study. Audio-recorded and transcribed outpatient clinical oncology encounters with 37 patients with advanced cancer ≥60 years of age were content-analyzed. Two trained coders used a structured coding scheme based on pre-specified geriatric assessment (GA) domains to examine the transcripts for the frequency and quality of communication about age-related concerns. Atlas.ti version 6 was used for all analyses.

RESULTS

The median age of the patients was 66 years (range = 60-90 years); patients were mostly female (26/37), married (22/37), and White (36/37). Out of 37 audio-recorded visits, 31 had at least one mention of an age-related concern with a total of 70 mentions. Oncologists initiated communication about age-related concerns half of the time (53%). When age-related concerns were mentioned, half of the time (50%) the oncologist did not implement further evidence-based interventions to address the age-related concern (e.g., conduct a cognitive screen for a memory concern).

CONCLUSION

Interventions are needed to improve the frequency and quality of the communication about age-related concerns to improve the care of older adults with cancer.

Systematic review of care needs for older patients treated with anticancer drugs

OBJECTIVE

When treated with anticancer therapies, a number of issues are raised for older patients such as physical needs (coping with symptoms and side-effects) or psychological needs. Geriatric tailored interventions addressing these needs may be effective in terms of improving quality of life of our patients.

METHODS

A systematic review was performed in September 2017 in MEDLINE. All reports assessing older patients with cancer care needs in the context of anticancer systemic therapy were reviewed.

RESULTS

A total of 357 articles were analyzed. From these, 35 studies were included in the analysis. Compared to younger patients, the elderly had less supportive care needs. While older patients asked for less information than their younger counterparts, they still requested information on diagnosis, seriousness of the disease, chances of cure, spread of the disease, recovery, courses of illness, possible consequences, treatment procedures, treatment options, possible side effects and how to deal with them, and what they could do in daily life. When taking into consideration the various needs as assessed by the "Supportive Care Needs Survey", physical and daily living were the most frequently reported needs with emphasis on nutrition, coping with physical symptoms, dealing with side effects of treatment, and performing usual physical tasks and activities.

CONCLUSION

Information demand seemed moderate but a great deal of attention was paid to nutrition and well-being.

Geriatric assessment with management intervention in older adults with cancer: a randomized pilot study

BACKGROUND

Older adults receiving cancer therapy have heightened risk for treatment-related toxicity. Geriatric assessment (GA) can identify impairments, which may contribute to vulnerability and adverse outcomes. GA management interventions can address these impairments and have the potential to improve outcomes when implemented.

METHODS

We conducted a randomized pilot study comparing GA with management interventions versus usual care in patients with stage III/IV solid tumor malignancies (N = 71). In all patients, a trained coordinator conducted and scored a baseline GA with pre-determined cutoffs for impairment. For patients randomized to the intervention arm, an algorithm was used to identify GA management recommendations based upon identified impairments. Recommendations were relayed to the primary oncologist for implementation. GA was repeated at 3 months. The primary outcome was grade 3-5 chemotherapy toxicity. Secondary outcomes included feasibility, hospitalizations, dose reductions, dose delays, and early treatment discontinuation.

RESULTS

The mean participant age was 76 (70-89). The total number of GA management recommendations relayed was 409, of which 35.4% were implemented by the primary oncologist. Incidence of grade 3-5 chemotherapy toxicity did not differ between the two groups. Prevalence of hospitalization, dose reductions, dose delays, and early treatment discontinuation also did not differ between the two groups.

CONCLUSIONS

An algorithm can be used to guide GA management recommendations in older adults with cancer. However, reliance upon the primary oncologist for execution resulted in a low prevalence of implementation. Future work should aim to understand barriers to implementation and explore alternate models of implementing geriatric-focused care for older adults with cancer.

Palliative Care in Surgery: Defining the Research Priorities

OBJECTIVE

To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field.

BACKGROUND

Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care.

METHODS

The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps.

RESULTS

To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients.

CONCLUSIONS

Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.

Impact of geriatric assessment for the therapeutic decision-making of breast cancer: results of a French survey. AFSOS and SOFOG collaborative work

BACKGROUND

Cancer management in the elderly is often considered as suboptimal, highly variable, and rarely evidence-based. Data are needed to understand decision-making processes in this population.

MATERIALS AND METHODS

A survey was performed in France to describe decision-making in gynaecologic patients over 70. It followed a three-step method: (1) 101 representative physicians questioned about treatment decision criteria; (2) simplified individual data were collected; (3) as well as detailed data patients receiving chemotherapy. This analysis refers to breast cancer subgroup of patients.

RESULTS

Main decision criteria were performance status, comorbidities, and renal function. In adjuvant setting, the main concern was life expectancy, whereas it was quality of life in metastatic setting. Of the 631 patients entered in the simplified analysis, 41% had been evaluated by a geriatrician, 67% received chemotherapy. In the detailed analysis, patients older than 75 were more likely to receive a monochemotherapy and to be treated with weekly/divided dose. In adjuvant setting, respectively, 19, 55, and 26% of the patients were treated with regimen validated in the elderly, validated in a younger population, and not validated. A G-CSF was prescribed in 48% of the patients, as primary prophylaxis in 78 and in 41% of patients with a risk of febrile neutropenia < 10%.

CONCLUSION

Geriatric covariates become an increasing concern in the decision-making process. This survey also suggests an insufficient use of validated chemotherapy regimens. To date, age remains a risk factor for heterogeneity in oncologic practice justifying a persistent effort for elaborating and disclosing specific recommendations.

[Geriatric assessment and prognostic scores in older cancer patient: Additional support to the therapeutic decision?]

Cancer is a disease of the elderly as demonstrated by the epidemiological evolution of Western countries. Indeed, two third of cancers newly diagnosed occur over 65 years. However, older cancer patients have been often excluded from clinical trials in oncology and the extrapolation of cancer treatments in this population remains difficult in practice. Scientific societies recommend that a comprehensive geriatric assessment (CGA) be performed in patients aged 70 and over and selected using screening tools for frailty such as the G8 index. The CGA allows to detect aging-related vulnerabilities in various domains (comorbidities, polypharmacy, autonomy, nutrition, mobility, cognition, mood, social) and associated with adverse outcomes during cancer treatment (reduced overall survival, perioperative complications, toxicity-related chemotherapy). The CGA is allow to elaborate a personalized treatment plan in geriatric oncology. However, to date, no algorithms based on CGA is validated to guide therapeutic decision in geriatric oncology. The collaboration between geriatrician and oncologist remains essential to elaborate an appropriate therapeutic strategy and limit the situations of over- and under-treatment. This article presents the set of tools and scores used in geriatric oncology to guide the therapeutic decision.

Home Health Agency Performance in the United States: 2011-15

OBJECTIVES

To evaluate home health agency quality performance.

DESIGN

Observational study.

SETTING

Home health agencies.

PARTICIPANTS

All Medicare-certified agencies with at least 6 months of data from 2011 to 2015.

MEASUREMENTS

Twenty-two quality indicators, five patient survey indicators, and their composite scores.

RESULTS

The study included 11,462 Medicare-certified home health agencies that served 92.4% of all ZIP codes nationwide, accounting for 315.2 million people. The mean composite scores were 409.1 ± 22.7 out of 500 with the patient survey indicators and 492.3 ± 21.7 out of 600 without the patient survey indicators. Home health agency performance on 27 quality indicators varied, with the coefficients of dispersion ranging from 4.9 to 62.8. Categorization of agencies into performance quartiles revealed that 3,179 (27.7%) were in the low-performing group (below 25th percentile) at least one time during the period from 2011-12 to 2014-15 and that 493 were in the low-performing group throughout the study period. Geographic variation in agency performance was observed. Agencies with longer Medicare-certified years were more likely to have high-performing scores; agencies providing partial services, with proprietary ownership, and those with long travel distances to reach patients had lower performance. Agencies serving low-income counties and counties with lower proportions of women and senior residences and greater proportions of Hispanic residents were more likely to attain lower performance scores.

CONCLUSION

Home health agency performance on several quality indicators varied, and many agencies were persistently in the lowest quartile of performance. Still, there is a need to improve the quality of care of all agencies. Many parts of the United States, particularly lower-income areas and areas with more Hispanic residents, are more likely to receive lower quality home health care.

A Mobile Health Application to Track Patients After Gastrointestinal Surgery: Results from a Pilot Study

INTRODUCTION

Many surgical readmissions are preventable. Mobile health technology can identify nascent complications and potentially prevent readmission.

METHODS

We performed a pilot study of a new mobile health application in adults undergoing major abdominal surgery. Patients reported their pain, answered surveys, photographed their wound, were reminded to stay hydrated, and used a Fitbit™ device. Abnormal responses triggered alerts for further evaluation. Patients were followed postoperatively for 30 days and compliance with app use was tracked.

RESULTS

Thirty-one patients participated. Most were female (58%) and white (61%). Six (19%) had an ostomy as part of their surgery. 83.9% of patients completed an app-related task at least 70% of the time and 89% said using the app was easy to use. Patients generated an average of 1.1 alerts. One patient was readmitted and generated seven alerts prior to readmission. Patients participated most in collecting Fitbit data (84.8% of days) and completing a single-item photoaffective meter, but had more difficulty uploading photographs (51.4% completed). Eighty-nine percent of patients found the application easy to use.

CONCLUSIONS

A novel mobile health app can track patient recovery from major abdominal surgery, is easy to use, and has potential to improve outcomes. Further studies using the app are planned.

Optimal Modified Frailty Index Cutoff in Older Gastrointestinal Cancer Patients

The newly characterized modified frailty index (mFI) is a robust predictor of postoperative outcomes for surgical patients. The present study investigates the optimal cutoff for mFI specifically in older gastrointestinal (GI) cancer patients undergoing surgery. All patients more than 60 years old who underwent surgery for a GI malignancy (esophagus, stomach, colon, rectum, pancreas, liver, and bile duct) were identified in the 2005 to 2012 National Surgical Quality Improvement Program, Participant Use Data File (NSQIP PUF). Patients undergoing emergency procedures, of American Society of Anesthesiologists (ASA) five status, or diagnosed with preoperative sepsis were excluded. Logistic regression modeling and 10-fold cross validation were used to identify an optimal mFI cutoff. A total of 41,455 patients (mean age 72, 47.4% female) met the eligibility criteria. Among them, 19.0 per cent (n = 7891) developed a major postoperative complication and 2.8 per cent (n = 1150) died within 30 days. A random sampling by a cancer site was performed to create 90 per cent training and 10 per cent test sample datasets. Using 10-fold cross validation, logistical regression models evaluated the association between mFI and endpoints of 30-day mortality and major morbidity at various cutoffs. Optimal cutoffs for 30-day mortality and major morbidity were mFI ≥ 0.1 and ≥0.2, respectively. After adjusting for age, sex, ASA, albumin ≥3g/dl, and body mass index ≥ 30 kg/m2, mFI ≥ 0.1 was associated with increased mortality (odds ratio (OR) 1.49, 1.30–1.71 95% confidence interval (CI), P < 0.001) and mFI ≥ 0.2 was associated with increased morbidity (OR 1.52, 1.39–1.65 95% CI, P < 0.001). For older GI cancer patients, a very low mFI was a predictor of poor postoperative outcomes with an optimal cutoff of two or more mFI characteristics.

Workforce characteristics and interventions associated with high-quality care and support to older people with cancer: a systematic review

OBJECTIVES

To provide an overview of the evidence base on the effectiveness of workforce interventions for improving the outcomes for older people with cancer, as well as analysing key features of the workforce associated with those improvements.

DESIGN

Systematic review.

METHODS

Relevant databases were searched for primary research, published in English, reporting on older people and cancer and the outcomes of interventions to improve workforce knowledge, attitudes or skills; involving a change in workforce composition and/or skill mix; and/or requiring significant workforce reconfiguration or new roles. Studies were also sought on associations between the composition and characteristics of the cancer care workforce and older people's outcomes. A narrative synthesis was conducted and supported by tabulation of key study data.

RESULTS

Studies (n=24) included 4555 patients aged 60+ from targeted cancer screening to end of life care. Interventions were diverse and two-thirds of the studies were assessed as low quality. Only two studies directly targeted workforce knowledge and skills and only two studies addressed the nature of workforce features related to improved outcomes. Interventions focused on discrete groups of older people with specific needs offering guidance or psychological support were more effective than those broadly targeting survival outcomes. Advanced Practice Nursing roles, voluntary support roles and the involvement of geriatric teams provided some evidence of effectiveness.

CONCLUSIONS

An array of workforce interventions focus on improving outcomes for older people with cancer but these are diverse and thinly spread across the cancer journey. Higher quality and larger scale research that focuses on workforce features is now needed to guide developments in this field, and review findings indicate that interventions targeted at specific subgroups of older people with complex needs, and that involve input from advanced practice nurses, geriatric teams and trained volunteers appear most promising.

Symptom Burden and Functional Dependencies Among Cancer Patients in Botswana Suggest a Need for Palliative Care Nursing

BACKGROUND

Palliative care and cancer nursing in sub-Saharan Africa is hampered by inadequate clinical resources and evidence base but is central to symptom management amid the growing cancer burden.

OBJECTIVE

The aim of this study is to describe symptom burden and functional dependencies of cancer patients in Botswana using the Memorial Symptom Assessment Scale-Short Form (MSAS-SF) and Enforced Social Dependency Scale (ESDS).

METHODS

A cross-sectional multisite study was conducted in Gaborone, Botswana, from June to August 2013 using MSAS-SF, ESDS, and Eastern Cooperative Oncology Group (ECOG) performance status at 1 time point. Descriptive statistics, tests of association, correlation, and scale validity were used.

RESULTS

Among the 100 cancer patients, 65 were women, 21 were inpatients, 48 were human immunodeficiency virus-positive, 23 had gynecological malignancies, 34 had stage 4 disease, and 54 received chemotherapy only. Sixty-four reported pain; 54, neuropathies; 51, weight loss; and 51, hunger. Most distressing symptoms were weight loss, body image, skin changes, and pain. Recreational/social role was most affected by cancer. Cronbach's α for both the MSAS-SF and ESDS was .91. Variations in means for MSAS-SF and ESDS were associated with ECOG grade 2 (P < .05); the ECOG moderately correlated (0.35) with MSAS-SF (P < .01). No associations with human immunodeficiency virus status were found.

CONCLUSIONS

Patients reported distressing levels of cancer pain, weight loss, hunger, and dependency in recreational/social activities. The Setswana translations of the MSAS-SF and ESDS were found reliable to assess cancer patients' symptoms and function.

IMPLICATIONS FOR PRACTICE

Nurses trained in palliative care are needed to meet cancer patients' pain and symptom management care needs.

Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self-management, discharge planning, structured follow-up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995-2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane "Risk of Bias"). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random-effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: -0.02 [-0.05, 0.00]; NNT: 50), 6, 12 and 18 months post-discharge, a lower rate of ED visits at 3 months (RD: -0.08 [-0.15, -0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: -0.08 [-0.14, -0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: -1.33; [-2.15, -0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.

[Geriatric assessment of patients with hematological neoplasms]

Hematological malignancies are typical diseases of the elderly. The aging of the population in the Western World results in a significant increase in the number of elderly patients with hematological malignant diseases. This has important consequences for medicine. One consequence of this development is that the need for tools for the evaluation of both functional and global status of the elderly increases. The use of these tools enables the hematologist to better stratify the patients, to individualize therapy better, to possibly modify therapy in order to improve implementation of supportive measures and interventions, to minimize toxicity and side effects and ultimately to tailor the treatment to the individual patient. Several tools are available for geriatric assessment (GA) and there is strong evidence that an effective GA can detect previously unknown problems. The targeted intervention improves the prognosis and compliance of therapy in elderly patients with hematological malignant diseases.

Palliative Care in Surgery: Defining the Research Priorities

Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet, these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social, and spiritual well-being and quality of life. To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. The objective of this article was to describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. We propose a research agenda to address these gaps and provide a road map for future investigation.

Psychosocial Concerns in the Postoperative Oncology Patient

OBJECTIVES

To describe psychosocial concerns associated with the postoperative cancer patient and to discuss current psychosocial evidence-based approaches to manage these psychosocial concerns.

DATA SOURCES

Published peer-reviewed literature.

CONCLUSION

The postoperative phase of cancer care may be associated with a range of overlapping acute and chronic psychosocial concerns related to the surgery itself, the cancer diagnosis, and the need for ongoing cancer treatments. The postoperative period of cancer care represents an essential time to detect unmet psychosocial concerns and begin timely interventions for these concerns.

IMPLICATIONS FOR NURSING PRACTICE

Nurses are in a key position to detect, triage, refer, or manage psychosocial concerns in the postoperative patient with cancer. Current psychosocial evidence-based approaches may be used by surgical oncology nurses or other nurses who care for cancer patients during postoperative recovery.

Modified Frailty Index Predicts Morbidity and Mortality After Pancreaticoduodenectomy

BACKGROUND

Pancreatic cancer is a disease of older adults, who may present with limited physiologic reserve. The authors hypothesized that a frailty index can predict postoperative outcomes after pancreaticoduodenectomy (PD).

METHODS

All patients who underwent PD were identified in the 2005-2012 NSQIP Participant Use File. Patients undergoing emergency procedures, those with an American Society of Anesthesiologists (ASA) classification of five, and those with a diagnosis of preoperative sepsis were excluded from the study. A modified frailty index (mFI) was defined by 11 variables within the National Surgical Quality Improvement Program (NSQIP) previously used for the Canadian Study of Health and Aging-Frailty Index. An mFI score of 0.27 or higher was defined as a high mFI. Uni- and multivariate analyses were performed to evaluate postoperative outcomes.

RESULTS

This study enrolled 9986 patients (age 65 ± 12 years, 48.8% female) who underwent PD. Of these patients, 6.4% (n = 637) had a high mFI (>0.27). Increasing mFI was associated with higher prevalence of postoperative morbidity (p < 0.001) and 30-days mortality (p < 0.001). In the univariate analysis, high mFI was associated with increased morbidity (odds ratio [OR] 1.68; 95% confidence interval [CI] 1.43-1.97; p < 0.001) and 30-days mortality (OR 2.45; 95% CI 1.74-3.45; p < 0.001). After adjustment for age, sex, ASA classification, albumin level, and body mass index (BMI), high mFI remained an independent preoperative predictor of postoperative morbidity (OR 1.544; 95% CI 1.289-1.850; p < 0.0001) and 30-days mortality (OR 1.536; 95% CI 1.049-2.248; p = 0.027).

CONCLUSIONS

High mFI is associated with postoperative morbidity and mortality after PD and can aid in preoperative risk stratification.