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

CT-Based Body Composition and Frailty as Predictors of Survival Among Older Adults With Gastrointestinal Malignancies

BACKGROUND

Older adults with cancer are at an increased risk of treatment related toxicities and early death. Routinely collected clinico-demographic characteristics inadequately explain this increased risk limiting accurate prognostication. Prior studies have suggested that altered body composition and frailty are independently associated with worse survival among older adults with cancer; however, their combined influence remains unclear.

METHODS

We used data from a single-institution prospective cohort study of older adults (≥ 60 years) who underwent geriatric assessment (GA) at the time of initial consultation with a medical oncologist from September 2017 to December 2020 and available baseline abdominal computed tomography within 60 days of GA. Using multi-slice CT images from T12 to L5 level, we assessed volumetric measures of skeletal muscle (SMV), visceral adipose tissue (VATV), subcutaneous adipose tissue (SATV) and averaged skeletal muscle density (SMD), computing sex-specific z for each measure. Frailty was measured using a 44-item frailty index using the deficit accumulation approach. Primary outcome of interest was overall survival (OS) defined as time from GA to death or last follow up. We used multivariable Cox regression model to study the independent association between the above four body composition measurements and OS adjusted for baseline confounders and frailty.

RESULTS

We included 459 patients with a mean age of 69.7 ± 7.5 years, 60% males and 77% non-Hispanic Whites. Most had colorectal (27%) or pancreatic cancer (20%) and 48% had stage IV disease. Over a median follow up of 39.4 months, 209 patients (46%) died. In multivariable Cox regression models adjusted for age, sex, race, cancer type, cancer stage and frailty, skeletal muscle volume (HR 0.74; 95% CI 0.58-0.96; p = 0.02, per 1 SD increment) was independently associated with OS. The addition of body composition variables to baseline clinico-demographic variables and frailty led to a slightly improved model discrimination.

CONCLUSIONS

SMV is independently associated with OS among older adults with newly diagnosed gastrointestinal cancers. Capturing body composition measurements in oncology practice may provide additional prognostic information for older adults with cancer above and beyond what is captured in routine clinical assessment including frailty.

Associations of frailty with survival, hospitalization, functional decline, and toxicity among older adults with advanced non-small cell lung cancer

INTRODUCTION

Among older adults with cancer receiving chemotherapy, frailty indices predict OS and toxicity. Given the increased use of immunotherapy and targeted therapy for advanced non-small cell lung cancer (aNSCLC), we evaluated frailty and Karnofsky Performance Status (KPS) among older adults with aNSCLC receiving chemotherapy, immunotherapy, and/or targeted therapy.

METHODS

Patients aged ≥ 65 with aNSCLC starting systemic therapy with non-curative intent underwent geriatric assessments over 6 months. We developed a deficit-accumulation frailty index to categorize patients as robust, pre-frail, or frail. To evaluate associations between frailty and KPS with OS, we used Cox proportional hazards models adjusted for race, insurance, and treatment. We used logistic regression to evaluate hospitalizations, functional decline, and severe toxicity.

RESULTS

Among 155 patients (median age 73), 45.8% were robust, 36.1% pre-frail, and 18.2% frail; 34.8% had a KPS ≥ 90, 32.9% had a KPS of 80, and 32.3% had a KPS ≤ 70. The median OS was 17.9 months. Pre-frail/frail patients had worse OS compared to robust patients (adjusted hazard ratio [HR] 2.09, 95% CI, 1.31-3.34) and were more likely to be hospitalized (adjusted odds ratio [OR] 2.21, 95% CI, 1.09-4.48), functionally decline (adjusted OR 2.29, 95% CI, 1.09-4.78), and experience grade ≥ 3 hematologic toxicity (adjusted OR 5.18, 95% CI, 1.02-26.03). KPS was only associated with OS.

CONCLUSIONS

Our frailty index was associated with OS, hospitalization, functional decline, and hematologic AEs among older adults with aNSCLC receiving systemic therapies, while KPS was only associated with OS. Pretreatment frailty assessment may help identify older adults at risk for poor outcomes to optimize decision-making and supportive care.

Association of Limited Health Literacy With Frailty, Health-Related Quality of Life, and Health Care Utilization Among Older Adults With Cancer: The Cancer and Aging Resilience Evaluation Registry

PURPOSE

Limited health literacy-ability to obtain, process, and understand health information-can hinder communication, access to medical treatment, and identification and management of comorbidities. Older adults have high rates of poor health literacy, but its role in aging-related outcomes among older adults with cancer is understudied.

METHODS

We included 876 older adults age 60 years and older with cancer from the Cancer and Aging Resilience Evaluation Registry completing self-reported geriatric assessment, including health literacy, at first visit to medical oncology. The exposure was limited health literacy. Outcomes were frailty, physical/mental health-related quality of life (HRQOL), and health care utilization. We used modified Poisson regression to examine the association of exposure on outcomes adjusting for age, race-ethnicity, sex, and cancer type/stage.

RESULTS

Median age at enrollment was 68; 57.8% were male; 20.2% were non-Hispanic Black. The most prevalent cancers were advanced-stage (46.8% stage IV) colorectal (26.9%) and pancreatic (19.0%). Those with limited health literacy were older (70 v 68 years; P < .001), male (63.0% v 55.1%; P = .026), non-Hispanic Black (28.8% v 16.1%; P < .001), ≤high school educated (62.3% v 28.1%; P < .001), and retired/disabled (86.3% v 71.2%; P < .001). In multivariable analysis, limited health literacy was associated with higher prevalence of frailty (prevalence ratio [PR], 2.64 [95% CI, 2.15 to 3.26]), impaired physical (PR, 1.90 [95% CI, 1.59 to 2.27]) and mental (PR, 2.08 [95% CI, 1.76 to 2.47]) HRQOL, and hospitalization in the last year (PR, 1.28 [95% CI, 1.10 to 1.48]) versus adequate health literacy.

CONCLUSION

Older adults with cancer and limited health literacy had higher adjusted prevalence of frailty, impaired physical and mental HRQOL, and recent hospitalization. Interventions to address limited health literacy should be explored in this vulnerable and growing cancer population.

Evaluating concordance between International Myeloma Working Group (IMWG) frailty score and simplified frailty scale among older adults with multiple myeloma

INTRODUCTION

Several frailty assessment tools exist for classifying older adults with multiple myeloma (MM) by their frailty status, such as the International Myeloma Working Group (IMWG) frailty score and the simplified frailty scale. The level of agreement between the IMWG frailty score and the simplified frailty scale remains unknown.

MATERIALS AND METHODS

In a cross-sectional analysis of a prospective cohort study, we identified adults ≥50y initiating a new treatment regimen for MM who underwent a baseline geriatric assessment (GA). Using data from the GA and electronic health records, we measured IMWG frailty score and the simplified frailty scale, and classified patients by frailty status. We merged the fit and intermediate-fit categories of IMWG frailty score to create a binary category (frail, non-frail) for comparison with simplified frailty scale and measured their agreement using Cohen's Kappa statistic. We tested the diagnostic utility of simplified frailty scale as a screening tool using IMWG frailty score as the gold standard, using sensitivity, specificity, and decision curve analysis (DCA).

RESULTS

Three hundred older adults were included with a median age at diagnosis of 64y; 56 % were male and 63 % were non-Hispanic White. By IMWG frailty score, 41 % were fit, 38 % intermediate-fit, and 21 % frail, while simplified frailty scale indicated 22 % frail and 78 % non-frail patients. The agreement between IMWG frailty score and simplified frailty scale was moderate (κ = 0.43); 19 % of the patients were misclassified. Despite discordance, when testing simplified frailty scale as a screening tool, we found a sensitivity of 56 % and specificity of 87 % to diagnose frailty. Substituting patient-reported performance status (PS) instead of physician reported ECOG PS led to a sensitivity of 91 % and specificity of 61 %. DCA showed that using simplified frailty scale (with patient reported PS) as a screening tool led to a 43-44 % reduction in the number of unnecessary GAs across reasonable threshold probabilities.

DISCUSSION

IMWG frailty score and simplified frailty scale have limited agreement with each other. This creates a possibility of misclassification bias and poses difficulty in comparing existing literature on frail patients with MM. Despite discordance, simplified frailty scale may have a potential role as a screening tool, when using patient-reported PS.

Geriatric assessment for the practicing clinician: The why, what, and how

Older adults with cancer heterogeneously experience health care, treatment, and symptoms. Geriatric assessment (GA) offers a comprehensive evaluation of an older individual's health status and can predict cancer-related outcomes in individuals with solid tumors and those with hematologic malignancies. In the last decade, randomized controlled trials have demonstrated the benefits of GA and GA management (GAM), which uses GA information to provide tailored intervention strategies to address GA impairments (e.g., implementing physical therapy for impaired physical function). Multiple phase 3 clinical trials in older adults with solid tumors and hematologic malignancies have demonstrated that GAM improves treatment completion, quality of life, communication, and advance care planning while reducing treatment-related toxicity, falls, and polypharmacy. Nonetheless, implementation and uptake of GAM remain challenging. Various strategies have been proposed, including the use of GA screening tools, to identify patients most likely to benefit from GAM, the systematic engagement of the oncology workforce in the delivery of GAM, and the integration of technologies like telemedicine and mobile health to enhance the availability of GA and GAM interventions. Health inequities in minoritized groups persist, and systematic GA implementation has the potential to capture social determinants of health that are relevant to equitable care. Caregivers play an important role in cancer care and experience burden themselves. GA can guide dyadic supportive care interventions, ultimately helping both patients and caregivers achieve optimal health.

Intrinsic capacity and survival among older adults with gastrointestinal malignancies: The Cancer and Aging Resilience Evaluation registry

BACKGROUND

Intrinsic capacity (IC) was introduced by the World Health Organization (WHO) as a marker of healthy aging, and is defined as the combination of an individual's physical, mental, and psychological capacities. This study aimed to assess IC via a patient-reported geriatric assessment (GA) and evaluate its association with survival among older adults with gastrointestinal (GI) malignancies.

METHODS

Data were used from a single-institution prospective registry of older adults undergoing GA before cancer therapy. Key domains of IC (vitality, locomotion, and sensory [hearing and visual], psychological, and cognitive capacities) were captured via GA, and each was given a score of 0 or 1 (0, impaired) to compute the total IC score (range, 0-6, where 6 indicates no impairment and ≤5 indicates impairment in ≥1 domains). A frailty index (FI) was measured via the deficit accumulation method. Cox regression models and Kaplan-Meier curves were used to examine the impact of IC impairment on survival.

RESULTS

The study included 665 patients; the median age was 68 years, 57.4% were men, and 72.9% were White. The median IC score was 4, and 79.3% of participants showed impairment in ≥1 domains of IC. Most commonly impaired domains were locomotion (48.7%) and vitality (43.9%). IC was inversely associated with FI (Spearman coefficient, -0.75; p < .001). IC impairment was associated with inferior overall survival (score, 4-5: adjusted hazard ratio [aHR], 1.7; 95% CI, 1.11-2.48; score, 2-3: aHR, 1.9; 95% CI, 1.30-2.85; score, 0-1: aHR, 1.9; 95% CI, 1.11-2.48).

CONCLUSIONS

IC impairment is associated with frailty and reduced overall survival in older patients with GI malignancies. GA can be used to screen for IC impairment as recommended by the WHO.

PLAIN LANGUAGE SUMMARY

The World Health Organization introduced intrinsic capacity as a marker of healthy aging. Intrinsic capacity is the combination of an individual's physical, mental, and psychological capacities. It contains six key domains: vitality, locomotion, and sensory (hearing and visual), psychological, and cognitive capacities. Older adults with cancer are susceptible to a decrease in intrinsic capacity as a result of cancer and the aging process. In this study, we aimed to assess the intrinsic capacity for patients with gastrointestinal cancer and also identify whether there exists any association of intrinsic capacity with overall survival. We identified that approximately 80% of this population had one or more impaired domains, and more intrinsic capacity impairment was associated with reduced overall survival.

The association between social vulnerability and geriatric assessment impairments among older adults with gastrointestinal cancers-The CARE Registry

BACKGROUND

Older adults comprise the majority of patients with gastrointestinal (GI) cancer. Geriatric assessments (GAs) are recommended for older adults with cancer in part to detect aging-related impairments (e.g., frailty) associated with early mortality. Social factors like social vulnerability may also influence aging-related impairments. However, the association between social vulnerability and aging outcomes among older adults with cancer is understudied.

METHODS

The authors included 908 older adults aged 60 years and older who were recently diagnosed with GI cancer undergoing GA at their first prechemotherapy visit to the University of Alabama at Birmingham oncology clinic. The primary exposure of interest was the social vulnerability index (SVI). Outcomes were frailty (frail vs. robust/prefrail) and total number of GA impairments (range, 0-13). The authors examined the association between SVI and outcomes using Poisson regression with robust variance estimation and generalized estimating equations.

RESULTS

The median age at GA was 69 years (interquartile range, 64-75 years), 58.2% of patients were male, 22.6% were non-Hispanic Black, 29.1% had colorectal cancer, 28.2% had pancreatic cancer, and 70.3% had stage III/IV disease. Adjusting for age, sex, cancer type, and disease stage, each decile increase in the SVI was associated with an 8% higher prevalence of frailty (prevalence ratio, 1.08; 95% confidence interval, 1.05-1.11) and a 4% higher average count of total GA impairments (risk ratio, 1.04; 95% confidence interval, 1.02-1.06). The results were attenuated after further adjustment for race and education.

CONCLUSIONS

Greater social vulnerability was associated with a higher prevalence of frailty and an increasing average number of GA impairments among older adults with GI cancers before systemic treatment. Intervening on social vulnerability may be a target for improving the risk of frailty and GA impairments, but associations of race and education should be further evaluated.

Association between frailty and overall survival among older adults with hepatocellular carcinoma

INTRODUCTION

Older adults undergoing cancer treatment often experience more treatment-related toxicities and increased risk of mortality compared to younger patients. The role of frailty among older individuals as a predictor of outcomes has gained growing significance. We evaluated the association between frailty and overall survival (OS) in patients with hepatocellular carcinoma (HCC) ≥60 years.

MATERIALS AND METHODS

Older adults ≥60 years with HCC enrolled in a prospective single-institution registry underwent a patient-reported geriatric assessment (GA) covering multiple health domains related to prior to their initial medical oncology appointment. Frailty was measured using a 44-item deficit accumulation frailty index. We categorized patients as robust, pre-frail, and frail using standard cutpoints. The primary outcome was overall survival (OS). Univariable and multivariable models were built to evaluate the association between frailty and OS after adjusting for potential confounders.

RESULTS

Total of 116 older adults with HCC with a median age of 67 years were enrolled; 82% male, 27% Black, and 78% with stage III/IV disease. Overall, 19 (16.3%) were robust, 39 (33.6%) pre-frail, and 58 (50.1%) frail. There were 76 patients receiving liver directed therapy. Of these, 13 (17%) were robust, 26 (34%) were pre-frail, and 37 (49%) were frail. Over a median follow up of 0.9 years, 53 patients died. After adjusting for age, stage, etiology, and Child-Pugh class, being frail (vs. robust) was associated with worse OS (hazard ratio (HR) 2.6 [95% CI 1.03-6.56]; p = 0.04).

DISCUSSION

Half of the participants in this study were frail, which was independently associated with worse survival in adults ≥60 years of age with HCC. Identification of pre-treatment frailty may allow opportunities to guide treatment decisions and prognostication.

Patient and staff perspectives on the concept of frailty and its role in assessment and decision making in treatment for older people with lung cancer

PURPOSE

Frailty influences outcomes in patients with cancer and should be considered when making decisions about treatment but concerns have been raised about possible negative consequences of doing this. Many patients with lung cancer have attributes of frailty and this study explores patient and staff perspectives on its role in decision making in older people with lung cancer.

METHODS

The study adopted a two-phase qualitative approach using semi-structured telephone interviews and an in-person focus group. Data was analysed using framework techniques.

RESULTS

Three key themes were identified: describing frailty, assessing frailty and perceptions of frailty. Each presented opportunities and challenges for using frailty in the context of treatment decision making. Frailty was described in relation to diverse attributes which made it difficult to define and assess. It was also associated with negative connotations, particularly by patients.

CONCLUSION

Frailty has the potential to inform decision making that balances the wish to provide optimum treatment against risks to patients who may not be able to tolerate it. The challenge for healthcare staff is to incorporate frailty assessment into clinical practice in a way that is acceptable to patients and avoids potential unintended harms.

Skeletal muscle density performance for screening frailty in older adults with cancer and the impact of diabetes: The CARE Registry

INTRODUCTION

Skeletal muscle density (SMD) measurements from imaging scans identify myosteatosis and could screen patients for geriatric assessment. We assessed SMD performance as a screening tool to identify older adults with cancer likely to be frail and who could benefit from in-depth assessment; we compared performance by sex and diabetes status.

MATERIALS AND METHODS

We analyzed patients in the Cancer & Aging Resilience Evaluation (CARE) Registry. Frailty and diabetes were captured using a patient-reported geriatric assessment (CARE tool). Frailty was defined using CARE frailty index (CARE-FI) based on principles of deficit accumulation. SMD was calculated from computed tomography scans (L3 vertebrae). Analyses were conducted by sex and diabetes status. Scatterplots and linear regression described crude associations between SMD and frailty score. Classification performance (frail vs. non-frail) was analyzed with (1) area under the receiver operating characteristic curves (AUC) and confidence intervals (CIs); and (2) sensitivity/specificity for sex-specific SMD quartile cut-offs (Q1, median, Q3). Performance was compared between patients with and without diabetes using differences and estimated CIs (2000 bootstrap replicates). We additionally calculated positive and negative likelihood ratios (LR+, LR-).

RESULTS

The analytic cohort included 872 patients (39% female, median age 68 years, 27% with diabetes) with predominately stage III/IV gastrointestinal cancer; >60% planning to initiate first-line chemotherapy. SMD was negatively associated with frailty score; models were best fit in male patients with diabetes. AUC estimates for female (range: 0.58-0.62) and male (0.58-0.68) patients were low. Q3 cut-offs had high sensitivity (range: 0.76-0.89), but poor specificity (0.25-0.34). Diabetes did not impact estimates for female patients. Male patients with diabetes had greater sensitivity estimates compared to those without (sensitivity differences: 0.23 [0.07, 0.38], 0.08 [-0.07, 0.24], and 0.11 [0.00, 0.22] for Q1, median, Q3, respectively). LR estimates were most notable for male patients with diabetes (LR+ = 2.92, Q1 cut-off; LR- = 0.46, Q3 cut-off).

DISCUSSION

Using SMD alone to screen older patients for geriatric assessment requires improvement. High-sensitivity cut-off points could miss 11-24% of patients with frailty, and many non-frail patients may be flagged. Screening with SMD is practical but work is needed to understand clinical andresource impacts of different cut-off points. Future research should evaluate performance with additional clinical data and in subgroups.

The Impact of Frailty on Chemotherapy Outcomes in Patients With Digestive System Tumors: A Systematic Review and Meta-analysis

BACKGROUND

The prevalence of patients with digestive system tumors has been high. In recent years, frailty has been considered to be associated with poor prognosis of digestive system tumors, but there are conflicting research results. A better understanding of the relationship between frailty and outcomes after chemotherapy can help advance the development of oncology care.

OBJECTIVE

The aim of this study was to evaluate the effects of prechemotherapy frailty on chemotherapy toxicity, overall mortality, unplanned hospitalization, and overall survival in patients with digestive system tumors.

METHODS

Up to April 2023, observational studies assessing the impact of frailty on chemotherapy outcomes in patients with digestive system tumors were collected through searching 10 online research databases. Two evaluators independently extracted literature based on the inclusion and exclusion criteria and evaluated the quality of the studies using the Newcastle-Ottawa Scale.

RESULTS

Eventually, 11 cohort studies encompassing 2380 patients were included. The meta-analysis revealed that the frail group exhibited an increased risk of overall mortality, with poorer overall survival than the nonfrail group.

CONCLUSION

Frailty increases the risk of chemotherapy-induced toxic effects, unplanned hospitalization, and death in patients. However, because of this study's limited number of participants, large-sample, multicenter studies to verify these findings are required.

IMPLICATIONS FOR PRACTICE

This study provides theoretical support for incorporating frailty assessment into the nursing evaluation of patients with digestive system tumors before chemotherapy. This integration aids in predicting patients at a high risk of chemotherapy toxicity, mortality, and unplanned hospitalization, therefore providing corresponding interventions in advance to reduce adverse outcomes.

Understanding health outcome preferences of older adults diagnosed with multiple myeloma

INTRODUCTION

Health outcome preferences of older adults with cancer vary based on burden/intensity of treatment and its impact on health outcomes such as survival, quality of life, and functional and cognitive well-being. We studied the association between age and health outcome preferences of adults with multiple myeloma (MM).

MATERIALS AND METHODS

Using a single center prospective cohort study, we identified adults ≥50y with MM who underwent geriatric assessment (GA) within 30 days of initiating a new line of therapy. We assessed health outcome preferences using a nine-item health outcome preference scale where patients were asked to prioritize varying treatment outcomes in a Likert scale. We compared the response patterns for each item by age group (50-69y vs ≥70y) using Mantel-Haenszel chi-squared test. For items significant in bi-variable analysis, we built proportional odds models to study the association between age and health outcome preferences adjusting for sex, race, frailty, and high risk cytogenetics.

RESULTS

We included 119 patients with a median age of 65y. Of these, 58% were male, 56% were non-Hispanic White, and 28% were frail. Older adults (≥70y) versus younger adults (50-69y) were more likely to prioritize health outcomes such as quality of life (53% vs. 34%), functional independence (74% vs. 33%), maintaining cognitive ability (79% vs. 54%), and living free from pain (50% vs 18%) over longer survival (all p values <0.05). In multivariable models, each one interquartile range (IQR) increase in age was associated with increased odds of prioritization of functional independence [adjusted odds ratio (aOR) 2.55, 95% confidence interval (CI) (1.44-4.53)], maintaining cognitive ability [aOR 1.75, 95% CI (1.01-3.02)], and willingness to take milder/ fewer treatments [aOR 2.40, 95% CI (1.36-4.26)] over longer survival. Similarly, each IQR increase in age was associated with decreased odds of prioritization of survival over quality of life [aOR 0.45, 95% CI (0.26-0.78)] and survival over being free from pain [aOR 0.39, 95% CI (0.22-0.69)].

DISCUSSION

Three out of four older adults (age ≥ 70y) with MM rated other outcomes, particularly functional and cognitive well-being, above survival. Determining the most significant treatment outcomes for older adults with MM can aid in establishing treatment goals and enhance shared decision-making.

Geriatric assessment-identified impairments and frailty in adults with cancer younger than 65: An opportunity to optimize oncology care

INTRODUCTION

Frailty, a state of increased vulnerability to stressors due to aging or treatment-related accelerated aging, is associated with declines in physical, cognitive and/or social functioning, and quality of life for cancer survivors. For survivors aged <65 years, little is known about frailty status and associated impairments to inform intervention. We aimed to evaluate the prevalence of frailty and contributing geriatric assessment (GA)-identified impairments in adults aged <65 versus ≥65 years with cancer.

MATERIALS AND METHODS

This study is a secondary analysis of clinical trial data (NCT04852575). Participants were starting a new line of systemic therapy at a community-based oncology private practice. Before starting treatment, participants completed an online patient-reported GA and the Physical Activity (PA) Vital Sign questionnaire. Frailty score and category were derived from GA using a validated deficit accumulation model: frail (>0.35), pre-frail (0.2-0.35), or robust (0-0.2). PA mins/week were calculated, and participants were coded as either meeting/not-meeting guidelines (≥90 min/week). We used Spearman (ρ) correlation to examine the association between age and frailty score and chi-squared/Fisher's-exact or ANOVA/Kruskal-Wallis statistic to compare frailty and PA outcomes between age groups.

RESULTS

Participants (n = 96) were predominantly female (62%), Caucasian (68%), beginning first-line systemic therapy (69%), and 1.75 months post-diagnosis (median). Most had stage III to IV disease (66%). Common cancer types included breast (34%), gastrointestinal (23%), and hematologic (15%). Among participants <65, 46.8% were frail or pre-frail compared to 38.7% of those ≥65. There was no association between age and frailty score (ρ = 0.01, p = 0.91). Between age groups, there was no significant difference in frailty score (p = 0.95), the prevalence of frailty (p = 0.68), number of GA impairments (p = 0.33), or the proportion meeting PA guidelines (p = 0.72). However, older adults had more comorbid conditions (p = 0.03) and younger adults had non-significant but clinically relevant differences in functional ability, falls, and PA level.

DISCUSSION

In our cohort, the prevalence of frailty was similar among adults with cancer <65 when compared to those older than 65, however, types of GA impairments differed. These results suggest GA and the associated frailty index could be useful to identify needs for intervention and inform clinical decisions during cancer treatment regardless of age. Additional research is needed to confirm our findings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Patient-reported frailty phenotype (PRFP) vs. International Myeloma Working Group frailty index (IMWG FI) proxy: A comparison between two approaches to measuring frailty

INTRODUCTION

Frailty assessments may help to identify patients at highest risk for treatment-related toxicity, early treatment discontinuation due to toxicity, and death in Multiple Myeloma. We aimed to compare the patient-reported frailty phenotype (PRFP) and a modified version of the International Myeloma Working Group frailty index (IMWG FI) in terms of their strengths, limitations, and classification of frailty in a cohort of patients with relapsed/refractory multiple myeloma (RRMM).

MATERIALS AND METHODS

Data were pooled from six RRMM Phase 3 randomized clinical trials submitted to the Food and Drug Administration for regulatory review between 2010 and 2021. Patients were classified as fit, intermediate fit/pre-frail, or frail using both PRFP and the IMWG FI proxy. Agreement between the two approaches in classification of patient frailty was assessed using weighted Cohen's kappa. A contingency table and Venn diagram were generated to analyze overlap in categorization of patient frailty across the different severity groups. Descriptive statistics were used to summarize and compare the clinical and demographic characteristics of patients categorized as frail by PRFP vs. IMWG FI proxy.

RESULTS

Of the 2,750 patients included in this analysis, IMWG FI proxy classified 16.4% (452) patients as frail, 28.1% (772) as intermediate fit/pre-frail, and 55.5% (1,526) as fit. Meanwhile, PRFP classified 21.7% (597) of patients as frail, 24.5% (675) as intermediate fit/pre-frail, and 53.8% (1478) as fit. Fair agreement was observed between PRFP and IMWG FI proxy (weighted Cohen's Kappa = 0.34 [0.31-0.37]). On average, patients who were categorized as frail by IMWG FI proxy were older and had higher Charlson Comorbidity Index scores than patients classified as frail by PRFP. In contrast, patients who were classified as frail by PRFP had worse EORTC QLQ-C30 Physical Functioning subscale summary scores as compared to patients in the IMWG FI proxy frail group (median score of 40 vs. 47 out of 100).

DISCUSSION

Our analysis found fair concordance between IMWG FI proxy and PRFP. This demonstrates that while both frailty models measure the same underlying construct, the variables that constitute each approach may result in differing frailty categorizations for the same patient. Further prospective studies are needed to establish and compare the predictive and prognostic abilities of the different frailty indices in MM.

Anxiety is Associated With Geriatric Assessment Impairments and Reduced Quality of Life Among Older Adults With Colorectal Cancer: Results From the CARE Registry

BACKGROUND

Colorectal cancer (CRC) preferentially affects older adults. Modifiable factors, such as anxiety, can be measured as part of cancer-specific geriatric assessments (GA) completed prior to the start of treatment. We hypothesized that anxiety is prevalent among older adults with CRC and is associated with increased depression, increased frailty, and impaired health-related quality of life (HRQOL).

PATIENTS AND METHODS

Patients ≥60 years old with newly diagnosed CRC completed a cancer-specific GA called the Cancer and Aging Resilience Evaluation (CARE). Between September 2017 and February 2023, we analyzed patients with CRC who had not yet received any systemic treatment. Anxiety was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety 4-item short form and reported as t-scores. We used modified Poisson models with robust variance estimation to assess for differences in the prevalence of depression, frailty, and impaired HRQOL.

RESULTS

We analyzed 277 older adults with CRC. The median age of the study sample was 68 years. 57% were male, 72% were non-Hispanic White, and most had advanced CRC (35% stage III and 39% stage IV). Moderate/severe anxiety was present in 17% of older adults with newly diagnosed CRC. In adjusted models, as compared to patients without moderate/severe anxiety, patients with moderate/severe anxiety had significantly increased risk of depression (prevalence ratio [PR] 7.60, CI 4.90-11.78), frailty (PR 4.93, CI 3.01-8.07), impaired physical HRQOL (PR 3.57, CI 2.03-6.28), and impaired mental HRQOL (PR 3.82, CI 2.12-6.89).

CONCLUSION

Among older adults with CRC, anxiety is associated with increased depression and frailty as well as reduced HRQOL.

Management of Older Adults With Colorectal Cancer: The Role of Geriatric Assessment

Older adults share a growing burden of cancer morbidity and mortality. This is present across the spectrum of oncologic diagnoses and is particularly true with colorectal cancer (CRC), where older adults continue to share the burden of diagnoses. However, optimal cancer treatment decision making in older adults remains a significant challenge, as the majority of previous clinical trials shaping the current treatment landscape have focused on younger patients, often with more robust performance status and fewer medical comorbid conditions. The heterogeneous aging process of older adults with CRC necessitates a personalized treatment approach, as approximately three-quarters of older adults with CRC also have a concominant geriatric syndrome and more than half of older adults with CRC are pre-frail or frail. Treatment decisions shoud be multifaceted, including consultation with the patient and their familes regarding their wishes, with consideration of the patient's quality of life, functional status, medical comorbid conditions, social support, and treatment toxicity risk. Geriatric assessment is a systematic and validated approach to assess an older adults's potential strengths and vulnerabilities, which can in turn be used to assist with comprehensive cancer care planning and support. In this review, we will summarize current treatment approaches for older adults with CRC, with a particular focus on the incorporation of the geriatric assessment.

Association of unmet basic resource needs with frailty and quality of life among older adults with cancer-Results from the CARE registry

BACKGROUND

Basic resource needs related to transportation, housing, food, and medications are important social determinants of health and modifiable indicators of poverty, but their role in modifying the risk of frailty and health-related quality of life (HRQoL) remains unknown. The goal of our study was to examine the prevalence of unmet basic needs and their association with frailty and HRQoL in a cohort of older adults with cancer.

METHODS

The CARE registry prospectively enrolls older adults (≥60 years) with cancer. Assessments of transportation, housing, and material hardship were added to the CARE tool in 8/2020. The 44-item CARE Frailty Index was used to define frailty, and subdomains of physical and mental HRQoL were assessed using the PROMIS® 10-global. Multivariable analysis examined the association between unmet needs with frailty and HRQoL subdomains, adjusting for covariates.

RESULTS

The cohort included 494 participants. Median age of 69 years, 63.6% were male and 20.2% were Non-Hispanic (NH) Black. Unmet basic needs were reported in 17.8% (transportation 11.5%, housing 2.8%, and material hardship 7.5%). Those with unmet needs were more often NH Black (33.0% vs. 17.8%, p = 0.006) and less educated (

CONCLUSIONS

Unmet basic needs represent a novel exposure that is independently associated with frailty and low HRQoL and warrants the development of targeted interventions.

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Key Words

• aging
• basic resource needs
• cancer
• concrete resource needs
• frailty
• geriatric oncology

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MESH Headings

• Humans
• Male
• Aged
• Female
• Quality of Life
• Frailty/epidemiology
• Neoplasms/epidemiology
• Neoplasms/therapy
• Ethnicity
• Registries

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Grants

• K08 CA234225 NCI NIH HHS
• T32 HS013852 AHRQ HHS
• Doris Duke Charitable Foundation
• National Cancer Institute

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Affiliation(s)

Grant R. Williams Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA O'Neal Comprehensive Cancer CenterUniversity of AlabamaBirminghamAlabamaUSA
Mackenzie Fowler Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA
Smith Giri Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA O'Neal Comprehensive Cancer CenterUniversity of AlabamaBirminghamAlabamaUSA
Chen Dai Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA
Christian Harmon Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA
Mustafa Al‐Obaidi Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA
Coryn Stephenson University of MissouriColumbiaMissouriUSA
Kira Bona Division of Population SciencesDana‐Farber Cancer InstituteBostonMassachusettsUSA
Wendy Landier Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA O'Neal Comprehensive Cancer CenterUniversity of AlabamaBirminghamAlabamaUSA
Smita Bhatia Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA O'Neal Comprehensive Cancer CenterUniversity of AlabamaBirminghamAlabamaUSA
Julie Wolfson Institute for Cancer Outcomes & SurvivorshipUniversity of AlabamaBirminghamAlabamaUSA O'Neal Comprehensive Cancer CenterUniversity of AlabamaBirminghamAlabamaUSA

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