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

Feasibility within-subject RCT of neuromuscular electrical stimulation; an Intervention to Maintain and improve neuroMuscular function during period of Immobility (IMMI)

INTRODUCTION

Neuromuscular electrical stimulation (NMES) is a potentially effective intervention to improve outcomes after a fragility fracture, but its feasibility in this group has not been established.

METHODS

A feasibility study was conducted in two phases: 1) in the hospital only, and 2) hospital, rehabilitation centres, and participants' homes. Patients with fragility fracture were randomised to receive NMES for 6 weeks/discharge either to the right or left leg, with the other leg serving as control. Patients who had no mobility issues had contraindications to NMES and were unable to give consent were excluded. NMES was applied to quadriceps and tibialis anterior muscles for 30 min, 3 days/week. Sessions were progressed to achieve 60 min, 5-7 days/week. Feasibility outcomes included participant characteristics, recruitment rate, tolerability, and number of NMES sessions. Clinical outcomes included muscle strength, and ADL at six months.

RESULTS

Overall, 1052 patients were identified, of whom 113 (11%) were eligible, and 29 (3%) were recruited (median Clinical Frailty Score 3, median Barthel ADL score 93/100). The recruitment rate was 0.45/week in phase 1 and 0.9/week in phase 2. Fifty-three percent achieved the target of 24 NMES sessions. However, 5/29 withdrew due to intolerance of NMES. Leg muscle strength improved in both treated and untreated legs, with marginally greater improvement observed in the tibialis anterior of treated legs.

CONCLUSION

Although it would be feasible to evaluate the specific effect of NMES in fragility fracture patients in a multi-centre trial using home-based NMES, this would be possible only in a minority of mildly frail fragility fracture patients with little premorbid disability.

Behavior change theory and behavior change technique use in cancer rehabilitation interventions: a secondary analysis

BACKGROUND

There is limited evidence depicting ways that behavioral theory and techniques have been incorporated into cancer rehabilitation interventions. Examining their use within cancer rehabilitation interventions may provide insight into the active ingredients that can maximize patient engagement and intervention effectiveness.

AIM

This secondary analysis aimed to describe the use of behavior change theory and behavior change techniques (BCTs) in two previously conducted systematic reviews of cancer rehabilitation interventions.

DESIGN

Secondary analysis of randomized controlled trials (RCTs) drawn from two systematic reviews examining the effect of cancer rehabilitation interventions on function and disability.

SETTING

In-person and remotely delivered rehabilitation interventions.

POPULATION

Adult cancer survivors.

METHODS

Data extraction included: behavior change theory use, functional outcome data, and BCTs using the Behavior Change Technique Taxonomy (BCTTv1). Based on their effects on function, interventions were categorized as "very", "quite" or "non-promising". To assess the relative effectiveness of coded BCTs, a BCT promise ratio was calculated (the ratio of promising to non-promising interventions that included the BCT).

RESULTS

Of 180 eligible RCTs, 25 (14%) reported using a behavior change theory. Fifty-four (58%) of the 93 BCTs were used in least one intervention (range 0-29). Interventions reporting theory use utilized more BCTs (median=7) compared to those with no theory (median=3.5; U=2827.00, P=0.001). The number of BCTs did not differ between the very, quite, and non-promising intervention groups (H(2)=0.24, P=0.85). 20 BCTs were considered promising (promise ratio >2) with goal setting, graded tasks, and social support (unspecified) having the highest promise ratios.

CONCLUSIONS

While there was a wide range of BCTs utilized, they were rarely based on theoretically-proposed pathways and the number of BCTs reported was not related to intervention effectiveness.

CLINICAL REHABILITATION IMPACT

Clinicians should consider basing new interventions upon a relevant behavior change theory. Intentionally incorporating the BCTs of goal setting, graded tasks, and social support may improve intervention efficacy.

Impact of a multimodal effort re-education programme on functionality, physical performance, and functional capacity in cancer patients with dyspnoea: a randomised experimental study

BACKGROUND

In recent years, there has been a significant increase in the survival rates of cancer patients. However, this has also led to an increase in side effects, such as dyspnoea, which can negatively impact of patients. We propose a programme for re-educating effort. The main objective is to test the effectiveness of this programme in improving respiratory symptoms and functionality in cancer patients.

METHODOLOGY

Experimental, prospective, longitudinal, randomised study with a parallel fixed-assignment scheme (CG-IG). The patients were selected from the Medical Oncology Service of the University Hospital Complex of Salamanca (CAUSA), Spain. Two parallel intervention programmes were designed for the two study groups (Conventional Clinical Practice-Effort Re-education Programme). Primary variables: dyspnoea (MRC), functionality (Barthel); secondary variables: physical performance (SPPB) and functional capacity (ECOG) and the socio-demographic variables (age, sex, anatomopathological diagnosis, and number of treatment lines).

RESULTS

The study sample consisted of 182 patients, with 12 excluded, resulting in a final sample size of n = 170. Sex distribution (CG: 52.9% male and 47.1% female; IG: 49.4% male and 50.6% female). The primary oncological diagnosis was lung cancer, and the most frequent tumour stages were III and IV. Statistically significant differences were found between the IG and CG scores (p < 0.001, d = 0.887, 95% CI) and between the IG and CG scores (p = 0.004, d = 0.358, 95% CI), indicating that the IG performed better.

CONCLUSION

The results of this study support the beneficial effects of an exercise re-education programme, carried out by an interdisciplinary team in improving the autonomy of oncology patients with dyspnoea.

TRIAL REGISTRATION

The clinical trial was registered in ClinicalTrials.gov (NCT04186754). (03 September 2019).

Home-based aerobic exercise feasibility in oxaliplatin-receiving newly-diagnosed cancer survivors

PURPOSE

Physical activity (PA) is beneficial but difficult to maintain during chemotherapy. This pilot RCT explored the feasibility of the MI-Walk intervention-an 8-week motivational enhancement therapy- and home-based brisk walking intervention-among gastrointestinal (GI) cancer survivors receiving chemotherapy.

METHODS

Sixty stage II-IV GI cancer survivors were recruited from 5 sites at their second infusion visit. Participants were randomized to receive PA education alone or the MI-Walk intervention: motivational enhancement therapy consisting of 3 motivational interviewing and self-efficacy-enhancing counseling sessions, a Fitbit Charge 2, exercise diaries, telephone follow-up, scripted motivational email messages, and optional weekly walking groups.

RESULTS

The enrollment and completion rates were 62% and 90%, respectively. The MI-Walk participants (n = 29; mean age = 56.79, SD = 11.72; 97% white; 79% male) reported a baseline moderate-vigorous PA duration of 250.93 (SD = 636.52) min/wk. The mean MI-Walk Intervention acceptability score was 50.32 (SD = 12.02) on a scale of 14-70. Mean Fitbit and counseling helpfulness scores on a 5-point scale were 3.67 (SD = 1.43) and 3.44 (SD = 1.36), respectively. Participants' Fitbit moderate-vigorous PA 8-week averages ranged from 0 to 716.88 min/wk; 64% of participants adhered to ≥127 min/wk. Several characteristics (e.g., age, comorbidity, PA level, employment status, BMI, education level, gender, symptoms) were associated with enrollment, attrition, and intervention acceptability and adherence (p < 0.05).

CONCLUSION

Enrollment and retention were adequate. The Fitbit and counseling were the most helpful. Acceptability and adherence varied based on participant characteristics; therefore, intervention tailoring and further research among cancer survivors less physically active at baseline and most in need of complex exercise intervention are needed.

CLINICALTRIALS

gov NCT03515356.

Cancer rehabilitation services for older women with breast cancer: Impact on health-related quality of life outcomes

BACKGROUND

Older breast cancer survivors (BCS, age ≥ 65) are vulnerable to experiencing persistent symptoms and associated declines in health-related quality of life (HRQOL). In research trials, cancer rehabilitation interventions (physical or occupational therapy, PT/OT) have been shown to enhance HRQOL, but the impact of community-based PT/OT services for older BCS is unknown. We performed a retrospective, observational study to better understand the impact of PT/OT services on the HRQOL of older BCS.

METHODS

Outcomes and covariates were extracted from the outpatient rehabilitation medical record. HRQOL outcomes included: PROMIS® global physical health (GPH), global mental health (GMH), physical function (PF), and ability to participate in social roles and activities (SRA). Linear mixed-effect models were used to examine change in HRQOL outcomes and explore the influence of patient age and service type (PT/OT). ICD-10 codes were examined and compared between service types to describe the impairments treated.

RESULTS

PT/OT cases (N = 694) were 71.79 ± 5.44 years old and participated in a median of 11 visits (IQR: 7.0-17.25) over 9.71 weeks (IQR: 6.29-15.29). Most (84.4%) attended PT (n = 579; 84%) versus OT (n = 115; 16%). Overall, significant improvement was observed in each HRQOL outcome (GPH: +3.00, p < 0.001; GMH: +1.80, p < 0.001; PF: +1.97, p < 0.001; SRA: +2.34, p < 0.001). Service type influenced only GPH (p = 0.041); mean improvement was +3.24 (SE: 0.290, p < 0.001) for PT cases and + 1.78 for OT cases (SE: 0.651, p = 0.007). PT cases commonly received treatment for weakness/atrophy, pain, walking, and posture; OT cases commonly received treatment for lymphedema and scarring/fibrosis. No age effects were observed.

CONCLUSIONS

In this large study of older BCS who participated in community-based PT/OT services across the United States, we observed significant improvements in HRQOL outcomes that are important to older BCS and their providers. Although more research is needed, these findings suggest that improved access to PT/OT could help address unmet HRQOL needs among this population.

Impact of Real-World Outpatient Cancer Rehabilitation Services on Health-Related Quality of Life of Cancer Survivors across 12 Diagnosis Types in the United States

Compared to adults without cancer, cancer survivors report poorer health-related quality of life (HRQOL), which is associated with negative treatment outcomes and increased healthcare use. Cancer-specialized physical and occupational therapy (PT/OT) could optimize HRQOL; however, the impact among survivors with non-breast malignancies is unknown. This retrospective (2020-2022), observational, study of medical record data of 12 cancer types, examined pre/post-HRQOL among cancer survivors who completed PT/OT. PROMIS® HRQOL measures: Global Health (physical [GPH] and mental [GMH]), Physical Function (PF), and Ability to Participate in Social Roles and Activities (SRA) were evaluated using linear mixed effect models by cancer type, then compared to the minimal important change (MIC, 2 points). Survivors were 65.44 ± 12.84 years old (range: 19-91), male (54%), with a median of 12 visits. Improvements in GPH were significant (p < 0.05) for all cancer types and all achieved MIC. Improvements in GMH were significant for 11/12 cancer types and 8/12 achieved MIC. Improvements in PF were significant for all cancer types and all achieved the MIC. Improvements in SRA were significant for all cancer types and all groups achieved the MIC. We observed statistically and clinically significant improvements in HRQOL domains for each of the 12 cancer types evaluated.

In-Clinic versus Hybrid Cancer Rehabilitation Service Delivery during the COVID-19 Pandemic: An Outcome Comparison Study

Diminished health-related quality of life (HRQOL) is common among cancer survivors but often amendable to rehabilitation. However, few access real-world rehabilitation services. Hybrid delivery modes (using a combination of in-clinic and synchronous telehealth visits) became popular during the COVID-19 pandemic and offer a promising solution to improve access beyond the pandemic. However, it is unclear if hybrid delivery has the same impact on patient-reported outcomes and experiences as standard, in-clinic-only delivery. To fill this gap, we performed a retrospective, observational, comparative outcomes study of real-world electronic medical record (EMR) data collected by a national outpatient rehabilitation provider in 2020-2021. Of the cases meeting the inclusion criteria (N = 2611), 60 were seen to via hybrid delivery. The outcomes evaluated pre and post-rehabilitation included PROMIS® global physical health (GPH), global mental health (GMH), physical function (PF), and the ability to participate in social roles and activities (SRA). The patient experience outcomes included the Net Promoter Survey (NPS®) and the Select Medical Patient-Reported Experience Measure (SM-PREM). A linear and logistic regression was used to examine the between-group differences in the PROMIS and SM-PREM scores while controlling for covariates. The hybrid and in-clinic-only cases improved similarly in all PROMIS outcomes (all p < 0.05). The association between the delivery mode and the likelihood of achieving the minimal important change in the PROMIS outcomes was non-significant (all p > 0.05). No between-group differences were observed in the NPS or SM-PREM scores (all p > 0.05). Although more research is needed, this real-world evidence suggests that hybrid rehabilitation care may be equally beneficial for and acceptable to cancer survivors and supports calls to expand access to and reimbursement for telerehabilitation.

Patient-Reported Outcomes Measurement Information System in patients with gastrointestinal cancer: a scoping review

PURPOSE

The purpose of this study was to identify and evaluate the use of the Patient-Reported Outcomes Measurement Information System in patients with gastrointestinal cancer, as well as provide references for analyzing treatment outcomes, gauging prognostic risk, and assessing clinical symptoms and function in gastrointestinal cancer patients.

METHODS

PubMed, Web of Science, ProQuest, Embase, and CINAHL were systematically searched using keywords and controlled vocabulary through January 2023.

RESULTS

The scoping review collected 30 studies published from 2012 to 2022, including observational studies (n = 21), interventional studies (n = 4), and mixed studies (n = 5). Outcome indicators included mood, pain, fatigue, sleep, the ability to perform activities of daily living, social functioning, and other health problems.

CONCLUSION

Being a self-report questionnaire, the Patient-Reported Outcomes Measurement Information System offers a full assessment of patient's symptoms and quality of life, and accurately captures their actual thoughts, feelings, and experiences. Individuals with gastrointestinal cancer made frequent use of the Patient-Reported Outcomes Measurement Information System to provide an accurate measure of their health status.

Camera-Based Short Physical Performance Battery and Timed Up and Go Assessment for Older Adults With Cancer

This paper presents an automatic camera-based device to monitor and evaluate the gait speed, standing balance, and 5 times sit-stand (5TSS) tests of the Short Physical Performance Battery (SPPB) and the Timed Up and Go (TUG) test. The proposed design measures and calculates the parameters of the SPPB tests automatically. The SPPB data can be used for physical performance assessment of older patients under cancer treatment. This stand-alone device has a Raspberry Pi (RPi) computer, three cameras, and two DC motors. The left and right cameras are used for gait speed tests. The center camera is used for standing balance, 5TSS, and TUG tests and for angle positioning of the camera platform toward the subject using DC motors by turning the camera left/right and tilting it up/down. The key algorithm for operating the proposed system is developed using Channel and Spatial Reliability Tracking in the cv2 module in Python. Graphical User Interfaces (GUIs) in the RPi are developed to run tests and adjust cameras, controlled remotely via smartphone and its Wi-Fi hotspot. We have tested the implemented camera setup prototype and extracted all SPPB and TUG parameters by conducting several experiments on a human subject population of 8 volunteers (male and female, light and dark complexions) in 69 test runs. The measured data and calculated outputs of the system consist of tests of gait speed (0.041 to 1.92 m/s with average accuracy of >95%), and standing balance, 5TSS, TUG, all with average time accuracy of >97%.

Preferences on Delivery of Cancer Rehabilitation Services for Cancer-Related Disability Among Older Individuals Surviving Breast Cancer: A Qualitative Study

Background

Older individuals surviving breast cancer often encounter cancer-related disability as a short-term or long-term effect of cancer and related treatment. Cancer rehabilitation interventions have the potential to prevent, mitigate, or remediate cancer-related disability. However, use of these services remains limited. Understanding the priorities and perspectives of older individuals surviving breast cancer is key to developing effective and implementable cancer rehabilitation interventions. This qualitative descriptive study examined individuals' preferred and valued methods of cancer rehabilitation intervention delivery.

Methods

Using a qualitative descriptive design, older individuals surviving breast cancer (n=14) completed a single telephone-based semi-structure interview. Interviews explored survivors' preferences for cancer rehabilitation service delivery. Interview transcriptions were thematically analyzed. Open codes were inductively generated and reviewed for agreement by an independent reviewer. The codes were deductively organized. Differences were resolved through consensus meetings.

Results

Findings revealed preferred intervention delivery characteristics for intervention setting, mode of delivery, format, and timing. Participants predominantly preferred interventions delivered in community-based settings, with both in-person and remote components. Participants also appeared to value one-on-one interventions and those delivered post-treatment. Survivors' overarching preferences were based on desire for patient-centric care, one-on-one therapist time, complex medical schedules, and financial concerns.

Discussion

Study findings provide guidance on the modification of existing and creation of new cancer rehabilitation interventions addressing cancer-related disability in older individuals surviving breast cancer. Adoption of stakeholder-driven intervention delivery characteristics may improve value and acceptability of interventions. Future intervention research should incorporate and test these characteristics to ensure their effectiveness in real-world settings.

Associations of Age and Sex with the Efficacy of Inpatient Cancer Rehabilitation: Results from a Longitudinal Observational Study Using Electronic Patient-Reported Outcomes

Cancer rehabilitation is thought to increase the quality of life (QOL) and functioning of cancer survivors. It remains, however, uncertain whether subgroups benefit equally from rehabilitation. We wished to investigate the outcomes of multimodal rehabilitation according to age, sex and functioning. Patients of an Austrian rehabilitation center routinely completed the EORTC QLQ-C30 and the hospital anxiety and depression scale (HADS) questionnaires prior to (T1), and after rehabilitation (T2). To compare the outcomes between age groups (i.e., <40, 41–69, and ≥70 years), sex, and the Norton scale risk status, repeated measures of analyses of variance were calculated. A total of 5567 patients with an average age of 60.7 years were included, of which 62.7% were female. With T1 indicating the cancer survivors’ needs, older and high-risk patients reported lower functioning (all p < 0.001) and a higher symptom burden for most scales (all p < 0.05) before rehabilitation. Regardless of age, sex or risk status, the patients showed at a least small to medium improvement during rehabilitation for anxiety, depression, and most functioning and symptom scales. Some between-group differences were observed, none of which being of a relevant effect size as determined with the Cohen’s d. In conclusion, QOL is improved by rehabilitation in all patients groups, independently from age, sex, or the risk status.

The Effect of Vinyasa Yoga Practice on the Well-Being of Breast-Cancer Patients during COVID-19 Pandemic

BACKGROUND

Vinyasa yoga practice improves body fitness and potentially positively affects practitioners' well-being and health. Due to the diverse intensity of practice and positions customized to the practitioner's needs, it can also support cancer patients. Undertaking physical activity that has a potentially positive effect on well-being and health was particularly important during the self-isolation that followed the COVID-19 pandemic. The purpose of this study was to evaluate the impact of three-month mild and moderate intensity vinyasa yoga practice on breast-cancer patients' stress perception, self-confidence, and sleep quality during COVID-19 induced self-isolation.

METHODS

Female breast-cancer patients participated in twelve-weeks of online vinyasa practice during the COVID-19 induced self-isolation period. Meetings were held once a week, where 60-min vinyasa yoga sequences were followed by 15 min of relaxation. Patients completed pre- and post-intervention surveys to evaluate changes in the following outcomes: stress perception, self-confidence, and sleep quality. Forty-one female patients enrolled in the Vinyasa course completed the pre-intervention survey, while 13 attended all the meetings and completed the post-intervention survey.

RESULTS

The effect of the twelve-week yoga and relaxation practice significantly reduced sleep problems and stress of oncological patients. The participants also declared an improvement in their general well-being and self-acceptance.

CONCLUSION

Dynamic forms of yoga combined with mindfulness techniques can be applied to patients treated for oncological diseases. It contributes to improving their well-being. However, in-depth studies are needed to analyze the complexity of this effect.

[Cancer in older adults in Latin America: interdisciplinary cooperation between oncology and geriatrics]

Latin America, like the rest of the world, is currently facing the consequences of population aging. Among these consequences is a rise in incidence in malignant neoplasms among older adults, with an anticipated increase in oncologic health service requirements in this population. Geriatric oncology is a recently created discipline which integrates geriatric principles into oncology care to offer older adults with cancer individualized treatments. This multidisciplinary approach is now recommended as part of routine oncology care by international associations. Although several geriatric oncology clinical, educational and research initiatives exist in Latin America, the number and availability of specialized facilities and personnel is limited in comparison to those in high-income regions. In this manuscript, we review international recommendations for the implementation of geriatric oncology principles into routine clinical practice, describe resources available for geriatric oncology in Latin America, and provide recommendations to improve multidisciplinary care for older adults with cancer in the region.

Patient-reported geriatric assessment-based frailty index among older adults with gastrointestinal malignancies

BACKGROUND

Older adults with cancer are at increased risk of treatment-related toxicities and excess mortality. We evaluated whether a patient-reported geriatric assessment (GA) based frailty index can identify those at risk of adverse outcomes.

METHODS

Older adults (≥60 years) enrolled in a single-institutional prospective registry underwent patient-reported GA at initial evaluation in our medical oncology clinic. Using deficit accumulation method, we constructed a 44-item frailty index (CARE-FI), categorizing patients as robust, pre-frail, and frail. The primary outcome was overall survival (OS). Secondary outcomes included (a) functional decline at 3 months post-therapy (b) incident grade ≥3 treatment-related toxicities at six-month post-treatment. We used multivariate Cox and logistic regression models respectively to study the impact of frailty on primary and secondary outcomes.

RESULTS

We identified 589 older adults with a median age of 69 years; 55% males and 73% Whites. Overall, 168 (29%) were pre-frail and 230 (39%) frail. Being frail (vs. robust) was associated with worse OS (Hazards Ratio, HR 1.83, 95% Confidence Interval, CI 1.34-2.49, p < 0.001) after adjusting for age, sex, race/ethnicity, cancer type, cancer stage, and line of therapy. Similarly, frailty was associated with increased risk of functional decline (OR 3.01; 95% CI 1.33-6.81; p = 0.008) and grade ≥3 non-hematologic toxicities (OR 3.65; 95% CI 1.54-8.69; p = 0.003) but not hematologic toxicities (OR 1.01; 95% CI 0.46-2.22; p = 0.97).

CONCLUSIONS

Our frailty index using a patient-reported GA is a robust predictor of survival, functional decline, and treatment related toxicity among older adults with GI malignancies.

Differences in Pretreatment Frailty Across Gastrointestinal Cancers in Older Adults: Results From the Cancer and Aging Resilience Evaluation Registry

PURPOSE

Frailty predicts poor outcomes in older adults with cancer, but how it differs between different cancer types is unknown. We examined differences in pretreatment frailty between colorectal (CRC), pancreatic, and hepatobiliary cancers.

METHODS

We included older adults age 60 years or older with the above cancer types enrolled in the Cancer and Aging Resilience Evaluation registry. Frailty was defined using a 44-item Cancer and Aging Resilience Evaluation frailty index constructed on the basis of the principles of deficit accumulation (including several geriatric assessment impairments encompassing malnutrition, functional status, comorbidities, anxiety, depression, cognitive complaints, health-related quality of life, falls, ability to walk one block, interference in social activities, and polypharmacy). Multivariable logistic regression models were used to examine the adjusted odds ratio (aOR) of frailty between cancer types.

RESULTS

A total of 505 patients were included (mean age 70 years, 59% male): 211 (41.8%) CRC, 178 (35.2%)pancreatic cancer, and 116 (23.0%) hepatobiliary cancer. Patients with pancreatic cancer had the highest prevalence of frailty (23.3% CRC, 40.6% pancreatic, 34.3% hepatobiliary; P = .001). Both pancreatic (aOR, 2.18; 95% CI, 1.38 to 3.45), and hepatobiliary cancer (aOR, 1.73; 95% CI, 1.03 to 2.93) were independently associated with higher odds of frailty relative to CRC. Frailty was driven by higher rates of malnutrition and instrumental activities of daily living impairments in patients with pancreatic cancer and higher number of comorbidities in patients with hepatobiliary cancer.

CONCLUSION

Older adults with pancreatic and hepatobiliary cancers are at high-risk of pretreatment frailty. Early interventions to improve nutritional and functional status and optimization of comorbidities may help improve outcomes.

Examining the impact of physical function performance in predicting patient outcomes after lung-sparing surgery for malignant pleural mesothelioma

PURPOSE

The purpose of this study was to examine the impact of physical function performance and pulmonary function on patient outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM).

MATERIALS AND METHODS

A retrospective review of 54 patients with MPM from 2015 to 2020 was performed. The primary objective was to assess whether physical function, as measured by the Eastern Cooperative Oncology Group Performance Status (ECOG), and pulmonary function tests were predictive of postoperative patient outcomes (ventilator days, chest tube days, hospital length of stay). A secondary objective was to explore demographic and preoperative variables that best predict postoperative physical function and patient outcomes.

RESULTS

Data include 54 patients who underwent extended pleurectomy-decortication. Preoperative ECOG was a significant predictor of postoperative patient outcomes while preoperative lung function lacked predictive ability. Preoperative ECOG was also predictive of preoperative lung function. Age on the day of surgery was the best predictor of postoperative physical function, which was significantly reduced postoperatively.

CONCLUSIONS

Preoperative physical function performance was a significant predictor of postoperative outcomes. The results of our study highlight the importance of physical function in patients with MPM and support the need for early rehabilitation and further research to determine optimal rehabilitation interventions.IMPLICATIONS FOR REHABILITATIONPreoperative physical function can predict outcomes after lung-sparing surgery for malignant pleural mesothelioma (MPM).Physical function in patients with MPM should be carefully examined.To accurately reflect patients' abilities, patient assessment should include both patient-reported outcomes and performance-based measures.Patients with MPM should receive rehabilitation early after diagnosis and throughout the continuum of care.

Systematic Review of Functional Outcomes in Cancer Rehabilitation

OBJECTIVE

To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019.

STUDY SELECTION

Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion.

DATA EXTRACTION

Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV).

DATA SYNTHESIS

Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome.

CONCLUSIONS

These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

Development of an intervention influencing activity limitations in older breast cancer survivors: A modified Delphi study

INTRODUCTION

Older breast cancer survivors have difficulty accessing rehabilitation interventions addressing activity limitations. Stakeholder input may improve accessibility of interventions. We sought expert consensus on intervention content and delivery features (e.g., where, mode, duration) to inform development of more accessible interventions for this population.

MATERIALS AND METHODS

We conducted a modified Delphi process with patient, clinical, administrative, and research experts. In Round 1, experts evaluated content and delivery features according to domains of feasibility and prioritization. In Round 2, panelists were asked to re-rank or confer agreement of content and delivery features that met Round 1 consensus. Ranking was based on median score. Consensus was defined as a percentage of panelists that ranked an option within one unit of the median. For nominal data, consensus was defined as percent agreement.

RESULTS

Panelists (n = 20) prioritized physical activity strategies (Median Rank: 2; Consensus: 85%) and adaptive skills training (3; 65%). Panelists also prioritized delivery through outpatient services (1; 100%), post-treatment (1; 100%), combination mode of delivery (100%), duration of three months or less (100%) and occurring one to two days per week (100%).

DISCUSSION

Cancer rehabilitation interventions should be designed with input from stakeholders. The stakeholder intervention priorities identified in this study (e.g., content, setting, and mode) may improve relevance and accessibility of future cancer rehabilitation interventions. Interventions delivered in outpatient clinics and post-treatment using virtual and in-person visits may improve accessibility. Future research should examine the effectiveness and implementation of these intervention characteristics.

Inside the Black Box: A Narrative Review on Comprehensive Geriatric Assessment-Driven Interventions in Older Adults with Cancer

Simple Summary

Comprehensive geriatric assessment is defined as a multi-dimensional, multi-disciplinary diagnostic and therapeutic process that is conducted to determine the medical, mental, and functional problems that older people with frailty have so that a coordinated and integrated plan for treatment and follow-up can be developed. Progress has been made in the definition of the best way to detect problems, but the benefits are mostly based on prognosis stratification and on the adaptation of cancer treatment. The present review aims to evaluate the level of evidence regarding geriatric interventions proposed following the detection of a problem in cancer patients. This review highlights the scarcity of published studies on this topic. Comprehensive geriatric assessment-based interventions have not yet demonstrated their specific impact. Multi-domain interventions seem promising, especially when they are based on global assessments. However, standardization seems difficult considering the lack of evidence for each domain.

Abstract

There is a consensus that the use of comprehensive geriatric assessment (CGA) is good clinical practice for older patients with solid tumors or hematological malignancies. To be complete, a CGA must include a geriatric assessment and an intervention plan. According to the SIOG consensus, a CGA should assess several domains: functional status, comorbidity, cognition, mental health status, fatigue, social status and support, nutrition, and the presence of geriatric syndromes. Progress has been made in the definition of the best way to detect problems, but the benefits are mostly based on prognosis stratification and on the adaptation of cancer treatment. The present review aims to evaluate the level of evidence regarding geriatric interventions proposed following the detection of a problem in cancer patients in each domain mentioned in the SIOG consensus. An online search of the PubMed database was performed using predefined search algorithms specific for each domain of the CGA. Eligible articles had to have well-defined interventions targeting specific domains of the CGA. We screened 1864 articles, but only a few trials on single-domain interventions were found, and often, these studies involved small groups of patients. This review highlights the scarcity of published studies on this topic. The specific impacts of CGA-based interventions have not yet been demonstrated. Multi-domain interventions seem promising, especially when they are based on global assessments. However, standardization seems difficult considering the lack of evidence for each domain. New studies are necessary in multiple care contexts, and innovative designs must be used to balance internal and external validity. An accurate description of the intervention and what “usual care” means will improve the external validity of such studies.

Occupational therapy intervention for cancer patients following hospital discharge: How and when should we intervene? A systematic review

INTRODUCTION

Advances in cancer treatment over the last decade have led to increased survival rates. As a result, survivors are living longer with and beyond cancer, often with greater levels of morbidity. Occupational therapists, with their focus on remedial and compensatory strategies to improve function and participation, are well suited to assess and intervene with this population. Despite this, little research exists to demonstrate the efficacy of interventions and value of the occupational therapy role. This systematic review aimed to review how and when occupational therapists provide services for adult patients with cancer and identify where they add the most value.

METHODS

A systematic search was conducted of six electronic databases. Eligible studies reported on occupational therapy interventions targeting management of cancer symptoms, rehabilitation or environmental modifications for adult cancer patients discharged from acute hospital services. Data extraction and quality assessment were undertaken by two reviewers. Narrative synthesis summarised the attributes and treatment outcomes of each intervention.

RESULTS

Nine articles were included from a total of 309 articles retrieved. Eight different interventions were reported for people with cancer (n = 531). Small sample sizes and methodological quality precluded any formal analysis; however, intervention components that showed positive results were person-centred, individualised and included regular monitoring and flexibility in care, with input from multidisciplinary health professionals. Therapists also need to reflect upon the optimal duration of interventions and selection of outcome measures that specifically match intervention components.

CONCLUSION

Despite inconclusive support of any particular type of intervention, this systematic review identified several successful intervention components for occupational therapists working with people with or beyond cancer. Overall, findings suggest that monitored tailored programmes compensating for fluctuations in a patient's condition have efficacy to improve patient outcomes and should be considered when delivering intervention with patients post hospital discharge.

Impact of lay navigation on utilization and Medicare spending for cancer survivors in the "Deep South"

PURPOSE

Though lay navigation programs have proven beneficial for individuals during cancer treatment, little is known about the effects of lay navigation on health care utilization and Medicare spending among older adults during cancer survivorship.

METHODS

This retrospective cohort study used administrative claims data to evaluate a lay navigation program implemented from 2012 to 2015 at 12 academic and community cancer centers in the Southeast. Medicare beneficiaries age ≥65 years navigated during survivorship were compared to propensity score-matched, non-navigated cancer survivors. Quarterly trends in Medicare spending were estimated using repeated measures mixed models. Rate ratios (RRs) and 95% confidence intervals (CIs) were estimated using repeated measures generalized linear models for quarterly emergency room (ER) visits and hospitalizations.

RESULTS

Medicare spending for navigated (n = 3255) versus non-navigated older cancer survivors (n = 3255) was initially higher but declined faster by $513 per patient per quarter (95% CI -$616, -$410). Per patient per quarter risk of ER visits decreased by 11% (RR 0.89, 95% CI 0.86, 0.92) and hospitalizations decreased by 16% (RR 0.84, 95% CI 0.81, 0.88) over time comparing navigated versus non-navigated patients. Similar results were seen for patients enrolled in navigation post-treatment (N = 1893).

CONCLUSIONS

In older cancer survivors receiving care in the Deep South, patients receiving lay navigation compared to those non-navigated had significant reductions in Medicare spending, hospitalizations, and ER visits.

IMPLICATIONS FOR CANCER SURVIVORS

Though much emphasis has been placed on lay navigation during initial cancer treatment, navigation is needed throughout survivorship due to the high costs and health care utilization that persist post-treatment.

Perspectives on functional status in older adults with cancer: An interprofessional report from the International Society of Geriatric Oncology (SIOG) nursing and allied health interest group and young SIOG

Most adults with cancer are over 65 years of age, and this cohort is expected to grow exponentially. Older adults have an increased burden of comorbidities and risk of experiencing adverse events on anticancer treatments, including functional decline. Functional impairment is a predictor of increased risk of chemotherapy toxicity and shorter survival in this population. Healthcare professionals caring for older adults with cancer should be familiar with the concept of functional status and its implications because of the significant interplay between function, cancer, anticancer treatments, and patient-reported outcomes. In this narrative review, we provide an overview of functional status among older patients with cancer including predictors, screening, and assessment tools. We also discuss the impact of functional impairment on patient outcomes, and describe the role of individual members of an interprofessional team in addressing functional impairment in this population, including the use of a collaborative approach aiming to preserve function.

Development of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm

PURPOSE

Participation in exercise or rehabilitation services is recommended to optimize health, functioning, and well-being across the cancer continuum of care. However, limited knowledge of individual needs and complex decision-making are barriers to connect the right survivor to the right exercise/rehabilitation service at the right time. In this article, we define the levels of exercise/rehabilitation services, provide a conceptual model to improve understanding of individual needs, and describe the development of the Exercise in Cancer Evaluation and Decision Support (EXCEEDS) algorithm.

METHODS

From literature review, we synthesized defining characteristics of exercise/rehabilitation services and individual characteristics associated with safety and efficacy for each service. We developed a visual model to conceptualize the need for each level of specialized care, then organized individual characteristics into a risk-stratified algorithm. Iterative review with a multidisciplinary expert panel was conducted until consensus was reached on algorithm content and format.

RESULTS

We identified eight defining features of the four levels of exercise/rehabilitation services and provide a conceptual model of to guide individualized navigation for each service across the continuum of care. The EXCEEDS algorithm includes a risk-stratified series of eleven dichotomous questions, organized in two sections and ten domains.

CONCLUSIONS

The EXCEEDS algorithm is an evidence-based decision support tool that provides a common language to describe exercise/rehabilitation services, a practical model to understand individualized needs, and step-by-step decision support guidance. The EXCEEDS algorithm is designed to be used at point of care or point of need by multidisciplinary users, including survivors. Thus, implementation may improve care coordination for cancer exercise/rehabilitation services.

Cancer Rehabilitation and Palliative Care-Exploring the Synergies

With perpetual research, management refinement, and increasing survivorship, cancer care is steadily evolving into a chronic disease model. Rehabilitation physicians are quite accustomed to managing chronic conditions, yet, cancer rehabilitation remains unexplored. Palliative care physicians, along with rehabilitationists, are true generalists, who focus on the whole patient and their social context, in addition to the diseased organ system. This, together with palliative care's expertise in managing the panoply of troubling symptoms that beset patients with malignancy, makes them natural allies in the comprehensive management of this patient group from the moment of diagnosis. This article will explore the under-recognized and underused parallels and synergies between the two specialties as well as identifying potential challenges and areas for future growth.

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.

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

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

The Who, What, Why, When, Where, and How of Team-Based Interdisciplinary Cancer Rehabilitation

OBJECTIVE

To review the key components necessary for successful application of rehabilitation principles to oncology survivors.

DATA SOURCES

Validated databases, including PubMed, MEDLINE, and Scopus.

CONCLUSION

Rehabilitation is an essential component of cancer care that addresses functional needs for oncology survivors and is best accomplished via an interdisciplinary team. Interdisciplinary care, provided by nursing, physiatry, rehabilitation therapy, and exercise physiology, are critical components for comprehensive intervention. Challenges exist in implementing services, but opportunity also exists within the post-acute care sector.

IMPLICATIONS FOR NURSING PRACTICE

Nurses play an important role in the screening, assessment, and treatment of cancer-related functional impairments.

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

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