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Ramsdale E, Mohamed M, Holmes HM, Zubkoff L, Bauer J, Norton SA, Mohile S. Decreasing polypharmacy in older adults with cancer: A pilot cluster-randomized trial protocol. J Geriatr Oncol 2024; 15:101687. [PMID: 38302299 PMCID: PMC10923001 DOI: 10.1016/j.jgo.2023.101687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 11/02/2023] [Accepted: 12/07/2023] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Polypharmacy is prevalent in older adults with cancer and associated with multiple adverse outcomes. A single-site, cluster-randomized clinical trial will enroll older adults with cancer and polypharmacy starting chemotherapy and will assess the effectiveness and feasibility of deprescribing interventions by comparing two arms: a pharmacist-led deprescribing intervention and a patient educational brochure. MATERIALS AND METHODS The study will be conducted in two phases. In phase I, focus groups and semi-structured individual interviews will guide adaptation of deprescribing interventions for the oncology clinic (phase Ia), and eight patients will undergo the pharmacist-led deprescribing intervention with iterative adaptations (phase Ib). In phase II, a pilot cluster-randomized trial (n = 72) will compare a pharmacist-led deprescribing intervention with a patient education brochure, with treating oncologists as the cluster. Both efficacy (relative dose intensity of planned chemotherapy, potentially inappropriate medications successfully deprescribed, chemotherapy toxicity, functional status, hospitalizations, falls, and symptoms) and implementation outcomes (barriers and facilitators) will be assessed. DISCUSSION This study is anticipated to provide pilot data to inform a nationwide randomized clinical trial of deprescribing in older adults starting cancer treatment. The cluster randomization is intended to provide an initial estimate for the intervention effect as well as oncologists' intra-class correlation coefficient. Deprescribing interventions may improve outcomes in older adults starting cancer treatment, but these interventions are understudied in this population, and it is unknown how best to implement them into oncology practice. The results of this trial will inform the design of large, randomized phase III trials of deprescribing. CLINICALTRIALS gov Identifier:NCT05046171. Date of registration: September 16, 2021.
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Affiliation(s)
- Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA.
| | - Mostafa Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Holly M Holmes
- Division of Geriatric and Palliative Medicine, McGovern Medical School, TX, USA
| | - Lisa Zubkoff
- Department of Medicine, University of Alabama at Birmingham, AL, USA
| | - Jessica Bauer
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
| | - Sally A Norton
- School of Nursing, University of Rochester Medical Center, NY, USA
| | - Supriya Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical Center, NY, USA
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Pollock Y, Smith MR, Saad F, Chowdhury S, Oudard S, Hadaschik B, Olmos D, Lee JY, Uemura H, Bhaumik A, Londhe A, Rooney B, Brookman-May SD, De Porre P, Mundle SD, Small EJ. Clinical characteristics associated with falls in patients with non-metastatic castration-resistant prostate cancer treated with apalutamide. Prostate Cancer Prostatic Dis 2023; 26:156-161. [PMID: 36209239 DOI: 10.1038/s41391-022-00592-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 08/05/2022] [Accepted: 08/31/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The phase III SPARTAN study demonstrated that apalutamide significantly improves metastasis-free survival and overall survival vs. placebo in patients with non-metastatic castration-resistant prostate cancer (nmCRPC). However, patients receiving apalutamide experienced falls more frequently vs. those receiving placebo (15.6% vs. 9.0%). METHODS 806 patients with nmCRPC randomized to apalutamide in SPARTAN and treated with apalutamide in addition to ongoing androgen deprivation therapy (ADT) were included in this post-hoc analysis investigating clinical variables associated with a subsequent fall. Time to a fall was assessed with Cox proportional-hazards models adjusted for baseline characteristics and time-varying factors. Statistical inference was based on final multivariable models. RESULTS Falls were reported for 125/803 (15.6%) patients treated with apalutamide and ADT. Most falls were grade 1 or 2 and did not require hospitalization. Median time from randomization to first fall was 9.2 months (range 0.1-25.3 months). In the final multivariable model of both baseline and after-baseline covariates, baseline patient characteristics (older age, poor Eastern Cooperative Oncology Group performance status, history of neuropathy, and α-blocker use before study treatment) remained significantly associated with fall; after-baseline clinical characteristics significantly associated with time to fall were development of neuropathy, arthralgia, and weight loss before fall. CONCLUSIONS This analysis identified risk factors for fall among nmCRPC patients treated with apalutamide. Clinical management can minimize these identified risks while enhancing patient outcomes. Preventive interventions should be considered when the identified baseline conditions and post-treatment neuropathy, arthralgia, or weight decrease are present, to reduce risk of fall. TRIAL REGISTRATION ClinicalTrials.gov: NCT01946204.
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Affiliation(s)
- YaoYao Pollock
- The Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
- St. Joseph Health Medical Group, Providence St. Joseph Health, Santa Rosa, CA, USA.
| | - Matthew R Smith
- Massachusetts General Hospital Cancer Center and Harvard Medical School, Boston, MA, USA
| | - Fred Saad
- Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Simon Chowdhury
- Guy's, King's and St. Thomas' Hospitals, Great Maze Pond, London, UK
| | - Stéphane Oudard
- Georges Pompidou Hospital, University de Paris, Paris, France
| | - Boris Hadaschik
- University of Duisburg-Essen, Essen, and Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - David Olmos
- Spanish National Cancer Research Centre (CNIO), Madrid and Biomedical Research Institute of Málaga (IBIMA), Málaga, Spain
| | - Ji Youl Lee
- Department of Urology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hiroji Uemura
- Yokohama City University Medical Center, Yokohama, Japan
| | | | - Anil Londhe
- Janssen Research & Development, Titusville, NJ, USA
| | | | - Sabine D Brookman-May
- Janssen Research & Development, Los Angeles, CA, USA
- Ludwig-Maximilians-University, Munich, Germany
| | | | | | - Eric J Small
- The Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA
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Kenis C, Decoster L, Flamaing J, Debruyne PR, De Groof I, Focan C, Cornélis F, Verschaeve V, Bachmann C, Bron D, Van den Bulck H, Schrijvers D, Langenaeken C, Specenier P, Jerusalem G, Praet JP, De Cock J, Lobelle JP, Wildiers H, Milisen K. Incidence of falls and fall-related injuries and their predictive factors in frail older persons with cancer: a multicenter study. BMC Geriatr 2022; 22:877. [PMCID: PMC9675153 DOI: 10.1186/s12877-022-03574-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 10/29/2022] [Indexed: 11/21/2022] Open
Abstract
Background Falls and fall-related injuries are a major public health problem. Data on falls in older persons with cancer is limited and robust data on falls within those with a frailty profile are missing. The aim of this study is to investigate the incidence and predictive factors for falls and fall-related injuries in frail older persons with cancer. Methods This study is a secondary data analysis from data previously collected in a large prospective multicenter observational cohort study in older persons with cancer in 22 Belgian hospitals (November 2012–February 2015). Patients ≥70 years with a malignant tumor and a frailty profile based on an abnormal G8 score were included upon treatment decision and evaluated with a Geriatric Assessment (GA). At follow-up, data on falls and fall-related injuries were documented. Results At baseline 2141 (37.2%) of 5759 included patients reported at least one fall in the past 12 months, 1427 patients (66.7%) sustained an injury. Fall-related data of 3681 patients were available at follow-up and at least one fall was reported by 769 patients (20.9%) at follow-up, of whom 289 (37.6%) fell more than once and a fall-related injury was reported by 484 patients (62.9%). Fear of falling was reported in 47.4% of the patients at baseline and in 55.6% of the patients at follow-up. In multivariable analysis, sex and falls history in the past 12 months were predictive factors for both falls and fall-related injuries at follow-up. Other predictive factors for falls, were risk for depression, cognitive impairment, dependency in activities of daily living, fear of falling, and use of professional home care. Conclusion Given the high number of falls and fall-related injuries and high prevalence of fear of falling, multifactorial falls risk assessment and management programs should be integrated in the care of frail older persons with cancer. Further studies with long-term follow-up, subsequent impact on cancer treatment and interventions for fall prevention, and integration of other important topics like medication and circumstances of a fall, are warranted. Trial registration B322201215495.
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Affiliation(s)
- Cindy Kenis
- grid.410569.f0000 0004 0626 3338Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium ,grid.410569.f0000 0004 0626 3338Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven - University of Leuven, Leuven, Belgium
| | - Lore Decoster
- grid.8767.e0000 0001 2290 8069Department of Medical Oncology, Oncologisch Centrum, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Johan Flamaing
- grid.410569.f0000 0004 0626 3338Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven – University of Leuven, Leuven, Belgium
| | - Philip R. Debruyne
- grid.5115.00000 0001 2299 5510Department of Medical Oncology, Kortrijk Cancer Centre, AZ Groeninge, Kortrijk, Belgium & Medical Technology Research Centre (MTRC), School of Life Sciences, Faculty of Science and Engineering, Anglia Ruskin University, Cambridge, UK
| | - Inge De Groof
- Department of Geriatric Medicine, St. Augustinus, Wilrijk, Belgium
| | - Christian Focan
- grid.433083.f0000 0004 0608 8015Department of Oncology, Clinique CHC Montlégia, Liège, Belgium
| | - Frank Cornélis
- grid.48769.340000 0004 0461 6320Department of Medical Oncology, Cliniques Universitaires Saint-Luc, UCLouvain, Brussels, Belgium
| | - Vincent Verschaeve
- grid.490655.bDepartment of Medical Oncology, GHDC Grand Hôpital de Charleroi, Charleroi, Belgium
| | | | - Dominique Bron
- grid.418119.40000 0001 0684 291XDepartment of Hematology, ULB Institut Jules Bordet, Brussels, Belgium
| | - Heidi Van den Bulck
- grid.414579.a0000 0004 0608 8744Department of Medical Oncology, Imelda hospital, Bonheiden, Belgium
| | - Dirk Schrijvers
- grid.417406.00000 0004 0594 3542Department of Medical Oncology, ZNA Middelheim, Antwerp, Belgium
| | - Christine Langenaeken
- grid.420031.40000 0004 0604 7221Department Medical Oncology, AZ Klina, Brasschaat, Belgium
| | - Pol Specenier
- grid.411414.50000 0004 0626 3418Department of Medical Oncology, University Hospital Antwerp, Antwerp, Belgium
| | - Guy Jerusalem
- grid.411374.40000 0000 8607 6858Department of Medical Oncology, Centre Hospitalier Universitaire Sart Tilman and Liege University, Liege, Belgium
| | - Jean-Philippe Praet
- grid.50545.310000000406089296Department of Geriatric Medicine, CHU St-Pierre, Free Universities Brussels, Brussels, Belgium
| | - Jessie De Cock
- grid.8767.e0000 0001 2290 8069Department of Geriatric Medicine, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jean-Pierre Lobelle
- grid.5596.f0000 0001 0668 7884Department of Oncology, Laboratory of Experimental Oncology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Hans Wildiers
- grid.410569.f0000 0004 0626 3338Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Department of Oncology, KU Leuven – University of Leuven, Leuven, Belgium
| | - Koen Milisen
- grid.410569.f0000 0004 0626 3338Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium ,grid.5596.f0000 0001 0668 7884Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven - University of Leuven, Leuven, Belgium
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Zhao J, Wang G, Chen L, Yu S, Li W. Risk factors for falls in hospitalized patients with cancer: A systematic review and meta-analysis. Asia Pac J Oncol Nurs 2022; 9:100107. [PMID: 36033969 PMCID: PMC9398916 DOI: 10.1016/j.apjon.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 06/05/2022] [Indexed: 11/17/2022] Open
Abstract
A primary cancer diagnosis has been confirmed as an important risk factor for falls, and the incidence of falls has been shown to be higher in patients who have undergone cancer treatment than in those who have not undergone cancer treatment. Falls during hospitalization increase the medical costs of additional treatment and falls-related mortality. Many falls are preventable and a good understanding of the predictors of falls in this population is needed. However, the risk factors for falls have not yet been identified. The purpose of this review was to identify the risk factors for falls in hospitalized patients with cancer. Eleven English and Chinese electronic databases were searched from their inception to April 2022 and the methodological quality of the included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Five studies involving 1237 patients with cancer were included. The meta-analysis identifies eleven risk factors for falls in hospitalized patients with cancer, including age, history of falls, opiates, benzodiazepines, steroids, antipsychotics, sedatives, radiation therapy, chemotherapy, the use of an assistive device and length of hospitalization. Based on the evidence presented in this article, healthcare workers have the capacity to help reduce fall risk through the development of preventive support strategies in this population. Multicenter, prospective studies of patients with cancer should be conducted to further identify and validate their risk factors for falls.
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Affiliation(s)
- Jing Zhao
- Department of Nursing, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
- Corresponding author.
| | - Guozhou Wang
- Department of Intensive Care Unit, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Lei Chen
- Department of Intensive Care Unit, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Simiao Yu
- Department of Intensive Care Unit, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
| | - Wenli Li
- Department of Intensive Care Unit, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin’s Clinical Research Center for Cancer, Tianjin, China
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Schoenbeck KL, Fiala MA, Wildes TM. Bortezomib in first-line therapy is associated with falls in older adults with multiple myeloma. J Geriatr Oncol 2021; 12:1005-1009. [PMID: 33750674 PMCID: PMC8419206 DOI: 10.1016/j.jgo.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/05/2021] [Accepted: 02/08/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Bortezomib is a common multiple myeloma therapy that can cause treatment-related peripheral neuropathy, a risk factor for falls. The relationship between bortezomib and falls in older patients with multiple myeloma is unknown. METHODS We analyzed the SEER-Medicare database for patients aged 65 or older diagnosed with multiple myeloma between 2007 and 2013. Claims were analyzed for myeloma treatments, falls, and covariates of interest. We evaluated accidental falls occurring within 12 months after starting first-line multiple myeloma treatment with bortezomib. RESULTS Bortezomib was used in first-line therapy for 2052 older adults with new diagnoses of multiple myeloma. Claims for falls were reported in 157 (8%) patients within 12 months after starting bortezomib, compared to 102 (5%) patients not receiving bortezomib (p < 0.001). Bortezomib was associated with a 36% increased risk of falls after controlling for covariates (aHR 1.36; 95% CI 1.05-1.75; p = 0.018). In a landmark analysis of those who survived 12 months after starting treatment, the median overall survival of those with a fall was 35.7 months compared to 49.1 months for those without (p < 0.0001). A fall in the first year after diagnosis was associated with a 26% increased risk in hazard for death (aHR 1.26; 95% CI 1.02-1.56; p = 0.033). CONCLUSION In older adults with multiple myeloma, bortezomib was associated with an increased risk of having a diagnostic code for falls. Decreased overall survival was seen in those who fell within the year of starting therapy. Prospective trials involving fall assessments and fall-prevention interventions are needed in this population.
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Affiliation(s)
- Kelly L Schoenbeck
- University of California San Francisco, San Francisco, CA, United States of America.
| | - Mark A Fiala
- Washington University School of Medicine, St Louis, MO, United States of America; Saint Louis University, St Louis, MO, United States of America
| | - Tanya M Wildes
- Washington University School of Medicine, St Louis, MO, United States of America
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Tennison JM, Ng AH, Rianon NJ, Liu DD, Bruera E. Patient-Reported Continuity of Care and Functional Safety Concerns After Inpatient Cancer Rehabilitation. Oncologist 2021; 26:887-896. [PMID: 34080755 DOI: 10.1002/onco.13843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 05/21/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Patients with cancer have been noted to have inadequate continuity of care after discharge from hospital. We sought to assess patient-reported continuity of care and functional safety concerns after acute inpatient rehabilitation. METHODS This was a prospective study that used cross-sectional surveys at a National Cancer Institute Comprehensive Cancer Center. All patients who were admitted to acute inpatient rehabilitation from September 5, 2018, to February 7, 2020, met the inclusion criteria, and completed two surveys (assessing continuity of care and functional safety concerns) upon discharge and 1 month after discharge were included in the study. RESULTS A total of 198 patients completed the study, and no major concerns were reported by the patients. The greatest concern was a lack of adequate communication management among different providers, reported by only 10 (5.0%) patients. The combined fall and near-fall rate within 1 month after discharge was (25/198) 13%. Brain metastasis, a comorbidity of depression, and a history of falls were significantly associated with a higher risk of falls or near falls within 1 month after discharge. CONCLUSION Although overall patients with cancer reported adequate continuity of care and feeling safe to function at home after acute inpatient rehabilitation, it is important to be aware that fall or near-fall events within 1 month after acute inpatient rehabilitation are associated with brain metastasis, comorbidity of depression, and a history of falls. Thus, patients with these risk factors may benefit from including more focused fall prevention education and interventions. IMPLICATIONS FOR PRACTICE Patients with cancer often have extensive problems that require care from multiple health care providers simultaneously, and a high level of coordination is needed for adequate transition of care from the inpatient to the outpatient setting. This transition of care period is prone to inadequate continuity of care and, for older adults, a particular risk for falls. Assessment for risk of fall is also an important factor to consider when evaluating patients to continue oncology treatments. There is a gap in knowledge regarding patient-reported continuity of care and functional safety concerns after acute inpatient cancer rehabilitation.
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Affiliation(s)
- Jegy M Tennison
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Amy H Ng
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nahid J Rianon
- Department of Family & Community Medicine and Joan & Stanford Alexander Division of Geriatric and Palliative Medicine, McGovern Medical School, The University of Texas Houston Health Science Center, Houston, Texas, USA
| | - Diane D Liu
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Feng LR, Barb JJ, Allen H, Regan J, Saligan L. Steroid Hormone Biosynthesis Metabolism Is Associated With Fatigue Related to Androgen Deprivation Therapy for Prostate Cancer. Front Cell Dev Biol 2021; 9:642307. [PMID: 34079794 PMCID: PMC8166231 DOI: 10.3389/fcell.2021.642307] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background Androgen deprivation therapy (ADT) is a cornerstone treatment for prostate cancer. Despite the clinical benefits, ADT is associated with multiple adverse effects including fatigue. The goal of the study was to examine metabolomic changes to better understand cancer-related fatigue specific to ADT treatment. Methods A total of 160 plasma samples collected from participants with (+ADT, n = 58) or without neoadjuvant ADT (−ADT, n = 102) prior to radiation therapy for treatment of non-metastatic localized prostate cancer were included in the study. Fatigue and sleep-related impairment were measured using the Patient Reported Outcomes Measurement Information System. Plasma metabolites were identified and measured using untargeted ultrahigh-performance liquid chromatography/mass spectrometry metabolomics analyses. Partial least square discriminant analysis was used to identify discriminant metabolite features, and the diagnostic performance of selected classifiers was quantified using AUROC curve analysis. Pathway enrichment analysis was performed using metabolite sets enrichment analyses. Findings Steroid hormone biosynthesis pathways, including androstenedione metabolism as well as androgen and estrogen metabolism, were overrepresented by metabolites that significantly discriminated samples in the +ADT from the −ADT group. Additional overrepresented metabolic pathways included amino acid metabolism, glutathione metabolism, and carnitine synthesis. Of the metabolites that were significantly different between the groups, steroid hormone biosynthesis metabolites were most significantly correlated with fatigue severity. Sleep-related impairment was strongly correlated with fatigue severity and inversely correlated with ADT-induced reduction in androsterone sulfate. Conclusions Patients with non-metastatic prostate cancer receiving neoadjuvant ADT prior to radiation therapy reported relatively more severe fatigue. Increased fatigue in this population may be attributable to sleep-related impairment associated with alterations in steroid hormone biosynthesis. Findings in this study provide a basis for further research of changes in sleep patterns and their role in this specific subcategory of cancer-related fatigue caused by the treatment.
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Affiliation(s)
- Li Rebekah Feng
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Jennifer J Barb
- Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Hannah Allen
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Jeniece Regan
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
| | - Leorey Saligan
- National Institute of Nursing Research, National Institutes of Health, Bethesda, MD, United States
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“Life Isn't as Carefree as It Used to Be”: A Mixed-Methods Evaluation of the Experiences of Women With Fear of Falling During Cancer Survivorship. REHABILITATION ONCOLOGY 2021. [DOI: 10.1097/01.reo.0000000000000217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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9
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Williams GR, Al-Obaidi M, Dai C, Mir N, Challa SA, Daniel M, Patel H, Barlow B, Young-Smith C, Gbolahan O, Paluri R, Bhatia S, Giri S. Association of malnutrition with geriatric assessment impairments and health-related quality of life among older adults with gastrointestinal malignancies. Cancer 2020; 126:5147-5155. [PMID: 32885848 PMCID: PMC7747231 DOI: 10.1002/cncr.33122] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 06/29/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND A majority of older adults with cancer develop malnutrition; however, the implications of malnutrition among this vulnerable population are poorly understood. The goal of this study was to quantify the prevalence of nutrition related-symptoms and malnutrition among older adults with gastrointestinal (GI) malignancies and the association of malnutrition with geriatric assessment (GA) impairment, health-related quality of life (HRQoL), and health care utilization. METHODS We performed a cross-sectional study of older adults (≥60 years) who were referred to the GI Oncology clinic at the University of Alabama at Birmingham. Participants underwent the Cancer & Aging Resilience Evaluation survey that includes the abbreviated Patient-Generated Subjective Global Assessment of nutrition. Nutrition scores were dichotomized into normal (0-5) and malnourished (≥6), and multivariate analyses adjusted for demographics, cancer type, and cancer stage were used to examine associations with GA impairment, HRQoL, and health care utilization. RESULTS A total of 336 participants were included (men, 56.8%; women, 43.2%), with a mean age of 70 years (standard deviation, ±7.2 years) and colorectal cancer (33.6%) and pancreatic cancer (24.4%) being the most common diagnoses. Overall, 52.1% of participants were identified as malnourished. Malnutrition was associated with a higher prevalence of several GA impairments, including 1 or more falls (adjusted odds ratio [aOR], 2.1), instrumental activities of daily living impairment (aOR, 4.1), and frailty (aOR, 8.2). Malnutrition was also associated with impaired HRQoL domains; both physical (aOR, 8.7) and mental (aOR, 5.0), and prior hospitalizations (aOR, 2.2). CONCLUSION We found a high prevalence of malnutrition among older adults with GI malignancies that was associated with increased GA impairments, reduced HRQoL, and increased health care utilization.
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Affiliation(s)
- Grant R. Williams
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
- Institute for Cancer Outcomes & Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Mustafa Al-Obaidi
- Institute for Cancer Outcomes & Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Chen Dai
- Institute for Cancer Outcomes & Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Nabiel Mir
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Sai Alekha Challa
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Michael Daniel
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL
| | - Harita Patel
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL
| | - Brett Barlow
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Crystal Young-Smith
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Olumide Gbolahan
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Ravi Paluri
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Smita Bhatia
- Institute for Cancer Outcomes & Survivorship, University of Alabama at Birmingham, Birmingham, AL
| | - Smith Giri
- Institute for Cancer Outcomes & Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
- Division of Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
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Factors associated with falls in older women with breast cancer: the use of a brief geriatric screening tool in clinic. Breast Cancer Res Treat 2020; 184:445-457. [PMID: 32794062 DOI: 10.1007/s10549-020-05862-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Unintentional falls and breast cancer are common among older women, but the associations between them are understudied. We aimed to identify factors associated with falls in older women with breast cancer. METHODS We retrospectively reviewed clinical records of older women with breast cancer at Duke Medical Center who had completed the Senior Adult Oncology Program geriatric assessment. Characteristics were compared between women had had at least one fall in the past year and those who did not. Pearson's Chi-square tests and t tests were used for comparison of groups' characteristics. Logistic regression determined factors associated with falling. RESULTS We identified 425 women, age 76.2 years (range 65-89 years), at the time of the assessment. 118 (27.8%) women reported a fall in the prior year. Age, race, ethnicity, and time since diagnosis (all p > 0.05) were similar between groups. In univariate analyses, metastatic disease (p = 0.023) and history of endocrine therapy (p = 0.042) were more common among women who fell. Women who fell had lower systolic (p = 0.001), diastolic (p < 0.001) blood pressures, and SpO2 (p = 0.018). Women who had fallen had a higher Charlson Comorbidity Index (CCI: p = 0.033), and were more likely to report using a walking aide (p < 0.001), nutritional issues (p = 0.006), and depression symptoms (p = 0.038). In multivariate analysis, falling was associated with low DBP (OR 0.93; p = 0.0017), low SpO2 (OR 0.79; p = 0.0169), a higher CCI (OR 1.23; p = 0.0076), and depression symptoms (OR 1.61; p = 0.039). CONCLUSIONS Among older women with breast cancer, depressive symptoms, higher comorbidity level, and vital sign measurements were associated with having fallen.
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Torbahn G, Strauss T, Sieber CC, Kiesswetter E, Volkert D. Nutritional status according to the mini nutritional assessment (MNA)® as potential prognostic factor for health and treatment outcomes in patients with cancer - a systematic review. BMC Cancer 2020; 20:594. [PMID: 32586289 PMCID: PMC7318491 DOI: 10.1186/s12885-020-07052-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 06/08/2020] [Indexed: 02/08/2023] Open
Abstract
Background Patients with cancer have an increased risk of malnutrition which is associated with poor outcome. The Mini Nutritional Assessment (MNA®) is often used in older patients with cancer but its relation to outcome is not known. Methods Four databases were systematically searched for studies relating MNA-results with any reported outcome. Two reviewers screened titles/abstracts and full-texts, extracted data and rated the risk of bias (RoB) independently. Results We included 56 studies which varied widely in patient and study characteristics. In multivariable analyses, (risk of) malnutrition assessed by MNA significantly predicts a higher chance for mortality/poor overall survival (22/27 studies), shorter progression-free survival/time to progression (3/5 studies), treatment maintenance (5/8 studies) and (health-related) quality of life (2/2 studies), but not treatment toxicity/complications (1/7 studies) or functional status/decline in (1/3 studies). For other outcomes – length of hospital stay (2 studies), falls, fatigue and unplanned (hospital) admissions (1 study each) – no adjusted results were reported. RoB was rated as moderate to high. Conclusions MNA®-result predicts mortality/survival, cancer progression, treatment maintenance and (health-related) quality of life and did not predict adverse treatment outcomes and functional status/ decline in patients with cancer. For other outcomes results are less clear. The moderate to high RoB calls for studies with better control of potential confounders.
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Affiliation(s)
- G Torbahn
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany.
| | - T Strauss
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany
| | - C C Sieber
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany.,Kantonsspital Winterthur, Brauerstrasse 15, 8400, Winterthur, Switzerland
| | - E Kiesswetter
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany
| | - D Volkert
- Institute for Biomedicine of Aging, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90408, Nuremberg, Germany
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Morris R, Lewis A. Falls and Cancer. Clin Oncol (R Coll Radiol) 2020; 32:569-578. [PMID: 32291190 DOI: 10.1016/j.clon.2020.03.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/04/2020] [Accepted: 03/26/2020] [Indexed: 11/26/2022]
Abstract
Falls among older people are common and are associated with substantial morbidity, mortality and healthcare costs. Increasingly cancer is becoming a disease of older people and fall rates are higher in elders living with cancer. Cancer and its treatments potentiate important risk factors for falls, including muscle weakness, poor balance, proprioception, cognitive impairment and functional disability. Sarcopenia refers to the progressive deterioration in muscle strength, mass and quality with ageing. Chronic conditions and cancer amplify this decline and are associated with a greater negative effect on function. Age-related impairments of lower limb neurological function are commonly exacerbated by neurotoxic chemotherapy, resulting in gait and balance deficits. Postural instability and falls erode confidence and result in a negative cycle of diminishing activity levels, further deconditioning and a higher risk of further falls. Cancer-related fatigue, sleep and mood disturbances compound this progressive frailty, further worsening treatment tolerance and outcomes. Cognitive impairment is a potent risk factor for falling and is frequently associated with gait abnormalities. The well-recognised effects of cancer treatment on working memory, attention, processing speed and executive function are often apparent (when their presence is sought) before treatment and may be as much the result of the cancer itself as they are 'chemo brain'. Structured exercise programmes focusing on progressively challenging strength and balance training are of proven benefit in falls prevention. Regular aerobic exercise accrues additional benefits in improved cardiorespiratory resilience and concomitant positive effects on treatment tolerance. Increased activity levels positively influence cognition, mood and foster an improved sense of well-being. Simple, practicable clinic-based tests of physical functioning, cognition and neurological function can help to identify those at high risk of falls and functional decline. The use of such instruments can aid judicious treatment planning and identify those most likely to benefit from more detailed specialist comprehensive geriatric assessment.
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Affiliation(s)
- R Morris
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK.
| | - A Lewis
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
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Mohamed MR, Ramsdale E, Loh KP, Arastu A, Xu H, Obrecht S, Castillo D, Sharma M, Holmes HM, Nightingale G, Juba KM, Mohile SG. Associations of Polypharmacy and Inappropriate Medications with Adverse Outcomes in Older Adults with Cancer: A Systematic Review and Meta-Analysis. Oncologist 2020; 25:e94-e108. [PMID: 31570516 PMCID: PMC6964156 DOI: 10.1634/theoncologist.2019-0406] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 07/11/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Polypharmacy (PP) and potentially inappropriate medications (PIM) are highly prevalent in older adults with cancer. This study systematically reviews the associations of PP and/or PIM with outcomes and, through a meta-analysis, obtains estimates of postoperative outcomes associated with PP in this population. MATERIALS AND METHODS We searched PubMed, Embase, Web of Science, and Cochrane Register of Clinical Trials using standardized terms for concepts of PP, PIM, and cancer. Eligible studies included cohort studies, cross-sectional studies, meta-analyses, and clinical trials which examined outcomes associated with PP and/or PIM and included older adults with cancer. A random effects model included studies in which definitions of PP were consistent to examine the association of PP with postoperative complications. RESULTS Forty-seven articles met the inclusion criteria. PP was defined as five or more medications in 57% of the studies. Commonly examined outcomes included chemotherapy toxicities, postoperative complications, functional decline, hospitalization, and overall survival. PP was associated with chemotherapy toxicities (4/9 studies), falls (3/3 studies), functional decline (3/3 studies), and overall survival (2/11 studies). A meta-analysis of four studies indicated an association between PP (≥5 medications) and postoperative complications (overall odds ratio, 1.3; 95% confidence interval [1.3-2.8]). PIM was associated with adverse outcomes in 3 of 11 studies. CONCLUSION PP is associated with postoperative complications, chemotherapy toxicities, and physical and functional decline. Only three studies showed an association between PIM and outcomes. However, because of inconsistent definitions, heterogeneous populations, and variable study designs, these associations should be further investigated in prospective studies. IMPLICATIONS FOR PRACTICE Polypharmacy and potentially inappropriate medications (PIM) are prevalent in older adults with cancer. This systematic review summarizes the associations of polypharmacy and PIM with health outcomes in older patients with cancer. Polypharmacy and PIM have been associated with postoperative complications, frailty, falls, medication nonadherence, chemotherapy toxicity, and mortality. These findings emphasize the prognostic importance of careful medication review and identification of PIM by oncology teams. They also underscore the need to develop and test interventions to address polypharmacy and PIM in older patients with cancer, with the goal of improving outcomes in these patients.
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Affiliation(s)
- Mostafa R. Mohamed
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Erika Ramsdale
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Asad Arastu
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Huiwen Xu
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
- Department of Public Health, University of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Spencer Obrecht
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
| | - Daniel Castillo
- MLIS‐Miner Library, University of Rochester School of Medicine and DentistryRochesterNew YorkUSA
| | - Manvi Sharma
- Department of Pharmacy Administration, University of Mississippi School of Pharmacy, UniversityMississippiUSA
| | - Holly M. Holmes
- The University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Ginah Nightingale
- Department of Pharmacy Practice, Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Katherine M. Juba
- Department of Pharmacy, University of Rochester Medical CenterRochesterNew YorkUSA
- Department of Pharmacy Practice, Wegmans School of PharmacyRochesterNew YorkUSA
| | - Supriya G. Mohile
- James P. Wilmot Cancer Center, University of Rochester Medical CenterRochesterNew YorkUSA
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van Walree IC, Scheepers E, van Huis-Tanja L, Emmelot-Vonk MH, Bellera C, Soubeyran P, Hamaker ME. A systematic review on the association of the G8 with geriatric assessment, prognosis and course of treatment in older patients with cancer. J Geriatr Oncol 2019; 10:847-858. [DOI: 10.1016/j.jgo.2019.04.016] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/17/2019] [Accepted: 04/20/2019] [Indexed: 12/13/2022]
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Screening and Examination of Fall Risk in Older Cancer Survivors. REHABILITATION ONCOLOGY 2019. [DOI: 10.1097/01.reo.0000000000000166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE The aim of the study was to identify risk factors for falls among cancer survivors. DESIGN Integrative literature review. METHODS We searched PubMed, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and PEDro for studies investigating fall risk in cancer. Reports of randomized controlled trials, descriptive studies (quantitative and qualitative), and theoretical papers meeting predetermined criteria were included. Quality ratings of included studies were done, and data were extracted and compiled by two independent reviewers. FINDINGS Twenty-nine articles met inclusion criteria. Literature quality was moderate (median quality score: 1.67 out of 3 possible points). Heterogeneity of statistics and reporting methods precluded calculation of summary effect sizes, but physical function, cognitive function, balance/gait, and certain medication types appear to increase fall risk. CONCLUSIONS AND CLINICAL RELEVANCE Modifiable risk factors, such as those identified in this review, represent tangible intervention targets for rehabilitation professionals for decreasing the risk of falls among cancer survivors.
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Huang MH, Blackwood J, Godoshian M, Pfalzer L. Factors associated with self-reported falls, balance or walking difficulty in older survivors of breast, colorectal, lung, or prostate cancer: Results from Surveillance, Epidemiology, and End Results-Medicare Health Outcomes Survey linkage. PLoS One 2018; 13:e0208573. [PMID: 30566443 PMCID: PMC6300321 DOI: 10.1371/journal.pone.0208573] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/20/2018] [Indexed: 01/19/2023] Open
Abstract
Background Cancer and its treatment affect body systems that are important in preventing falls and controlling balance/walking. This study examined factors associated with self-reported falls and balance/walking difficulty in the past 12 months in older survivors of four major cancers. Methods This was a cross-sectional study analyzing population-based data from Surveillance, Epidemiology, and End Results–Medicare Health Outcomes Survey (SEER-MHOS). Data from cohorts 9 to 14 (January 2006 to December 2013) were extracted. Inclusion criteria were: age ≥65 years at cancer diagnosis, first MHOS completed during years 1–5 post-cancer diagnosis, first primary breast (n = 2725), colorectal (n = 1646), lung (n = 752), and prostate (n = 4245) cancer, and availability of cancer staging information. Primary outcomes were self-reported falls and balance/walking difficulty in the past 12 months. Multivariable logistic regression was constructed for each cancer type to examine independent factors associated with falls and balance/walking difficulty. Results In all cancer types, advancing age at cancer diagnosis and dependence in activities of daily living were significant independent factors associated with increased odds of reporting falls and balance/walking difficulty in the past 12 months. Additionally, depression was independently associated with falls and sensory impairment in feet was independently linked to balance/walking difficulty in all cancer types. Other independent factors of falls and balance/walking difficulty varied across cancer types. In breast cancer only, localized or regional cancer stage was significantly associated with increased odds of reporting falls and balance/walking difficulty, whereas treatment with radiation decreased the odds of falling. No association between falls and balance/walking difficulty with time since cancer diagnosis, cancer stage, or cancer treatment was found in colorectal, lung, and prostate cancer. Conclusion There exists some heterogeneity in factors associated with self-reported falls and balance/walking difficulty between different cancer types. Future research is necessary to ascertain factors predictive of falls and balance/walking difficulty in older cancer survivors, particularly factors related to cancer diagnosis and treatment.
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Affiliation(s)
- Min H. Huang
- Physical Therapy Department, College of Health Sciences, University of Michigan–Flint, Flint, MI, United States of America
- * E-mail:
| | - Jennifer Blackwood
- Physical Therapy Department, College of Health Sciences, University of Michigan–Flint, Flint, MI, United States of America
| | - Monica Godoshian
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States of America
| | - Lucinda Pfalzer
- Physical Therapy Department, College of Health Sciences, University of Michigan–Flint, Flint, MI, United States of America
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Joint pain and falls among women with breast cancer on aromatase inhibitors. Support Care Cancer 2018; 27:2195-2202. [PMID: 30306326 DOI: 10.1007/s00520-018-4495-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 10/03/2018] [Indexed: 01/08/2023]
Abstract
PURPOSE Arthralgia is common among women with breast cancer on adjuvant aromatase inhibitor (AI) therapy. Pain is associated with falls in the general population; however, little is known about the relationship between arthralgia and falls among AI users. Our objective was to determine whether joint pain severity and interference predict future falls. METHODS We conducted a prospective cohort study of postmenopausal women with stage I-III estrogen receptor-positive breast cancer who were prescribed a third-generation AI. Arthralgia symptoms were measured at baseline using a modified version of the Brief Pain Inventory. Fall occurrence was obtained at 24-month follow-up. RESULTS Among 667 participants (median age 63 years, interquartile range 57-69 years), 232 (35%, 95% CI 31 to 39%) reported falls 12-24 months after baseline. Among women who fell, 65 (28%) reported seeking medical assistance. After controlling for multiple fall risk factors, we found significant non-linear associations between baseline joint pain severity and risk of falls (p = 0.001). Women with joint pain severity scores ≥ 4 had a more than twofold increase in fall risk compared to those without pain (41% vs. 20%). We observed a similar relationship for pain interference and fall risk (p < 0.001). Fewer than half of participants reported having been asked about falls in the past 12 months by their primary care physician (44%) or oncologist (36%). CONCLUSION Joint pain increases the risk of falls among women with breast cancer on adjuvant AI therapy. Health care providers should evaluate and manage arthralgia symptoms and implement fall-prevention strategies for those who are at increased risk.
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Fahimnia S, Mirhedayati Roudsari H, Doucette J, Shahrokni A. Falls in Older Patients with Cancer Undergoing Surgery: Prevalence and Association with Geriatric Syndromes and Levels of Disability Assessed in Preoperative Evaluation. Curr Gerontol Geriatr Res 2018; 2018:5713285. [PMID: 29887887 PMCID: PMC5977004 DOI: 10.1155/2018/5713285] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 04/15/2018] [Indexed: 11/20/2022] Open
Abstract
Falls are common among older adults. However, not much is known about the prevalence of falls among older patients with cancer. In 2015, older patients with cancer referred to Geriatrics service for preoperative evaluation were assessed for fall history, basic and instrumental activities of daily living (ADL and IADL), KPS, and use of assistive device. Of 806 patients, 215 (26.7%) patients reported fall. Incidence of last fall inside and outside home was 54.4% and 45.5%, respectively. Among patients with no falls, 33.6% had KPS ≤ 80 compared to 59.6% with one-time fall and 60.7% with multiple falls (p < 0.001). Among IADL, 8.5% of patients with no falls were unable to do shopping compared with 14.7% in one-time fall and 18.8% in multiple fallers (p < 0.001). In ADL items, the percentage of patients who were limited a lot in walking outside was 10.7% in no falls, 20.2% in one-time fall, and 27.1% in multiple fallers groups (p < 0.001). Only 17.8% of patients with no falls were using canes while 27.7% of patients with one-time fall and 38.8% with multiple falls were using canes (p < 0.001). Falls are prevalent among older patients with cancer. Fall history and number of falls are associated with functional status.
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Affiliation(s)
- Somayeh Fahimnia
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hadi Mirhedayati Roudsari
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Doucette
- Department of Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Armin Shahrokni
- Department of Geriatrics Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Predictors of falls in older survivors of breast and prostate cancer: A retrospective cohort study of surveillance, epidemiology and end results-Medicare health outcomes survey linkage. J Geriatr Oncol 2018; 10:89-97. [PMID: 29752141 DOI: 10.1016/j.jgo.2018.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 03/03/2018] [Accepted: 04/25/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVES To identify predictors of falls in older breast and prostate cancer survivors. METHODS This retrospective cohort study analyzed population-based Surveillance, Epidemiology and End Results-Medicare Health Outcomes Survey (SEER-MHOS) linkage. Inclusion criteria were age >65 years at cancer diagnosis, first primary female breast or prostate cancer, cancer staging information available, completion of baseline MHOS during years 2-3 and follow-up MHOS during years 4-5 post-diagnosis, and falls information available. Data from 437 breast and 660 prostate cancer survivors were analyzed. Multivariable logistic regression was constructed to evaluate variables from baseline MHOS with relation to falls from follow-up MHOS. Model accuracy was assessed using area under receiver-operating-characteristic curve (AUC). RESULTS At follow-up MHOS, 26% of breast and 22% of prostate cancer survivors reported falls in the past 12 months. In breast cancer, a history of falls (odds ratio (OR) = 4.95, 95% confidence interval (CI) = 2.44-10.04) and sensory impairment in feet (OR = 3.33, 95%CI = 1.51-7.32) were significant predictors of falls. In prostate cancer, a history of falls (OR = 3.04, 95%CI = 1.79-5.15), unmarried (OR = 1.82, 95%CI = 1.12-2.95), lower physical summary score of quality-of-life(OR = 0.96, 95%CI = 0.94-0.98), urinary incontinence (OR = 1.69, 95%CI = 1.08-2.65), older age at diagnosis (OR = 1.05, 95%CI = 1.01-1.09), and shorter time post-diagnosis (OR = 0.96, 95%CI = 0.93-0.99) were significant predictors of falls. AUC was 0.67 and 0.77 for breast and prostate cancer, respectively, indicating moderate accuracy of models in detecting fallers. CONCLUSIONS Asking older breast and prostate cancer survivors about falls in the past 12 months is imperative in fall prevention. Further examination of deficits specific to each cancer is necessary to assess fall risks.
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Factors associated with falls in older adults with cancer: a validated model from the Cancer and Aging Research Group. Support Care Cancer 2018; 26:3563-3570. [PMID: 29705872 DOI: 10.1007/s00520-018-4212-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/13/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Falls in older adults with cancer are common, yet factors associated with fall-risk are not well-defined and may differ from the general geriatric population. This study aims to develop and validate a model of factors associated with prior falls among older adults with cancer. METHODS In this cross-sectional secondary analysis, two cohorts of patients aged ≥ 65 with cancer were examined to develop and validate a model of factors associated with falls in the prior 6 months. Potential independent variables, including demographic and laboratory data and a geriatric assessment (encompassing comorbidities, functional status, physical performance, medications, and psychosocial status), were identified. A multivariate model was developed in the derivation cohort using an exhaustive modeling approach. The model selected for validation offered a low Akaike Information Criteria value and included dichotomized variables for ease of clinical use. This model was then applied in the validation cohort. RESULTS The development cohort (N = 498) had a mean age of 73 (range 65-91). Nearly one-fifth (18.2%) reported a fall in the prior 6 months. The selected model comprised nine variables involving functional status, objective physical performance, depression, medications, and renal function. The AUC of the model was 0.72 (95% confidence intervals 0.65-0.78). In the validation cohort (N = 250), the prevalence of prior falls was 23.6%. The AUC of the model in the validation cohort was 0.62 (95% confidence intervals 0.51-0.71). CONCLUSION In this study, we developed and validated a model of factors associated with prior falls in older adults with cancer. Future study is needed to examine the utility of such a model in prospectively predicting incident falls.
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Abstract
OBJECTIVE To examine the prevalence of falls, factors associated with falls and the relationship between falls and survival in older adults with multiple myeloma. METHODS In an analysis of the Surveillance, Epidemiology and End Results (SEER)-Medicare Health Outcomes Survey (MHOS)-linked database, we examined 405 older adults with multiple myeloma (MM) and 513 matched non-cancer controls. The primary outcome was self-reported within the past 12 months. Age, race, gender, symptoms, and comorbidities were self-reported in the MHOS. Survival was calculated from SEER data. RESULTS Of the patients with MM, 171 were within 1 year of diagnosis (cohort 1) and 234 were ≥1 year postdiagnosis (cohort 2). Patients in cohorts 1 and 2 were more likely to have fallen than controls (26% and 33% vs 23%, P = .012). On multivariate analysis, among patients with myeloma (combined cohorts 1 and 2), factors associated with falls included self-report of fatigue (aOR 2.52 [95% CI 1.34-4.93]), depression (aOR 1.90 [95% CI 1.14-3.18]), or poorer general health (aOR 1.86 [95% CI 1.05-3.36]). Falls were not associated with survival. CONCLUSIONS Older adults with MM have a greater prevalence of falls than matched controls. Self-reported fatigue, depression, and poorer general health are associated with greater odds of falls.
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Affiliation(s)
- Tanya M Wildes
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis MO
| | - Mark A. Fiala
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis MO
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Zhang X, Sun M, Liu S, Leung CH, Pang L, Popat UR, Champlin R, Holmes HM, Valero V, Dinney CP, Tripathy D, Edwards BJ. Risk factors for falls in older patients with cancer. BMJ Support Palliat Care 2017; 8:34-37. [DOI: 10.1136/bmjspcare-2017-001388] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/27/2017] [Accepted: 08/02/2017] [Indexed: 02/05/2023]
Abstract
ObjectivesA rising number of patients with cancer are older adults (65 years of age and older), and this proportion will increase to 70% by the year 2020. Falls are a common condition in older adults. We sought to assess the prevalence and risk factors for falls in older patients with cancer.MethodsThis is a single-site, retrospective cohort study. Patients who were receiving cancer care underwent a comprehensive geriatric assessments, including cognitive, functional, nutritional, physical, falls in the prior 6 months and comorbidity assessment. Vitamin D and bone densitometry were performed.AnalysisDescriptive statistics and multivariable logistic regression.ResultsA total of 304 patients aged 65 or above were enrolled in this study. The mean age was 78.4±6.9 years. They had haematological, gastrointestinal, urological, breast, lung and gynaecological cancers. A total of 215 patients with available information about falls within the past 6 months were included for final analysis. Seventy-seven (35.8%) patients had at least one fall in the preceding 6 months. Functional impairment (p=0.048), frailty (p<0.001), dementia (p=0.021), major depression (p=0.010) and low social support (p=0.045) were significantly associated with the fall status in the univariate analysis. Multivariate logistic regression analysis identified frailty and functional impairment to be independent risk factors for falls.ConclusionsFalls are common in older patients with cancer and lead to adverse clinical outcomes. Major depression, functional impairment, frailty, dementia and low social support were risk factors for falls. Heightened awareness and targeted interventions can prevent falls in older patients with cancer.
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Turner JP, Tervonen HE, Shakib S, Singhal N, Prowse R, Bell JS. Factors associated with use of falls risk-increasing drugs among patients of a geriatric oncology outpatient clinic in Australia: a cross-sectional study. J Eval Clin Pract 2017; 23:361-368. [PMID: 27554195 DOI: 10.1111/jep.12624] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 07/11/2016] [Accepted: 07/12/2016] [Indexed: 01/01/2023]
Abstract
Older people with cancer are at increased risk of falling. Falls risk-increasing drugs (FRIDs), comprising psychotropics and medications that cause orthostatic hypotension, are a potentially modifiable risk factor for falls. The objective of this study was to determine the prevalence and factors associated with use of FRIDs in older people with cancer. Patients aged ≥70 years who presented to a hospital outpatient clinic between January 2009 and July 2010 were included in the study. Information on current medication use, falls in previous 6 months, and frailty criteria was collected. Multinomial logistic regression was used to compute odds ratios (OR) and 95% confidence intervals (CIs) for factors associated with levels of FRID use. Overall, 76.1% (n = 293) of 383 patients used FRIDs. This comprised psychotropics (31.2%, n = 120) and medications causing orthostatic hypotension (69.9%, n = 269). In total, 24.0% (n = 92) patients reported falling in the previous 6 months. Risk factors for falling were associated with use of psychotropics but not orthostatic hypotension drugs. Patients with a history of falls had increased odds of using psychotropics (≥3 psychotropics; OR 13.50; 95%CI, 2.64-68.94). Likewise, frail patients had increased odds of using psychotropics (≥3 psychotropics; OR 27.78; 95%CI, 6.06-127.42). Risk factors for falling were associated with the use of psychotropics. This suggests that clinicians either do not recognize or underestimate the contribution of medications to falls in this high-risk patient group. Further efforts are needed to rationalize medication regimens at the time of patients' first presentation to outpatient oncology services.
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Affiliation(s)
- Justin P Turner
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
| | - Hanna E Tervonen
- School of Health Sciences, Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia
| | - Sepehr Shakib
- Department of Clinical Pharmacology, Faculty of Health Science, University of Adelaide, Adelaide, South Australia, Australia
| | - Nimit Singhal
- Department of Medical Oncology, Royal Adelaide Hospital, Adelaide, South Australia, Australia.,Faculty of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Robert Prowse
- Department of Geriatric and Rehabilitation Medicine, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, South Australia, Australia
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Is my older cancer patient on too many medications? J Geriatr Oncol 2017; 8:77-81. [DOI: 10.1016/j.jgo.2016.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 10/03/2016] [Accepted: 10/31/2016] [Indexed: 12/20/2022]
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Yamazaki Y, Hayashida CT, Yontz V. Insights about Fall Prevention of Older Adults in the State of Hawai'i. HAWAI'I JOURNAL OF MEDICINE & PUBLIC HEALTH : A JOURNAL OF ASIA PACIFIC MEDICINE & PUBLIC HEALTH 2017; 76:3-8. [PMID: 28090397 PMCID: PMC5226015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The senior population in Hawai'i is growing at a dramatic pace. In the older population, falls and fall-related injuries are leading causes of morbidity and mortality. Moreover, the health care costs for falls are very high. The State of Hawai'i has taken measures to prevent falls through the promotion of medication reviews, vision checks, home assessments, and exercise. However, current published examinations of fall preventive measures have been insufficient, and more research is needed to confirm risk factors, effectiveness of preventive measures, and to explore future objectives. This paper examined the validity of fall risk factors and fall preventive measures for Hawai'i's seniors by conducting mail questionnaire surveys to a sample of seniors using medical alert services from one company in Hawai'i. The results of chi-square analysis suggest that having reduced ability to perform Activities of Daily Living (ADL) and reduced Instrumental Activities of Daily Living (IADL) were associated with a greater risk of falls (P < .01). In addition, those who fell were more likely to talk about fall preventions with their family members or friends and health providers compared with those who did not (P = .048 and .003, respectively). Evidence-based exercise programs for strengthening muscles and controlling physical balance may be needed to improve ADL and IADL. Furthermore, the results suggest that seniors do not accept that they are at risk of falling before they actually fall. Public health providers should consider how they approach seniors, and how they inform them of the importance of fall prevention across the life span.
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Affiliation(s)
- Yuka Yamazaki
- Department of Public Health Sciences, University of Hawai'i, Honolulu, HI
| | - Cullen T Hayashida
- Department of Public Health Sciences, University of Hawai'i, Honolulu, HI
| | - Valerie Yontz
- Department of Public Health Sciences, University of Hawai'i, Honolulu, HI
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Campbell G, Hagan T, Gilbertson-White S, Houze M, Donovan H. Cancer and treatment-related symptoms are associated with mobility disability in women with ovarian cancer: A cross-sectional study. Gynecol Oncol 2016; 143:578-583. [PMID: 27653982 DOI: 10.1016/j.ygyno.2016.09.013] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/07/2016] [Accepted: 09/10/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To examine the prevalence of symptom-related mobility disability and identify specific symptoms and other factors associated with mobility disability among a national sample of ovarian cancer (OC) survivors. METHODS Descriptive, correlational secondary analysis of a National Ovarian Cancer Coalition mailed survey of women with a history of OC (n=713). We used the Symptom Representation Questionnaire (SRQ), the MD Anderson Symptom Inventory (MDASI) Interference Scale, and medical and demographic information to determine prevalence of symptom-related mobility disability. We constructed a multiple linear regression model to determine the relative contributions of specific symptoms and other factors to mobility disability. RESULTS A majority of the sample (60.0%) reported symptom-related mobility disability. Independent predictors included: > one comorbidity (β=0.112, p=0.001), active OC (β=0.111, p=0.037), abdominal bloating (β=0.097, p=0.006), fatigue (β=0.314, p<0.001), lack of appetite (β=0.072, p=0.045), numbness/tingling (β=0.134, p<0.001), and pain (β=0.194, p<0.001). The model explained 41.5% of the variance in symptom-related mobility disability (R2=0.415). Unexpectedly, age (β=-0.028, p=0.412) and current chemotherapy (β=0.107, p=0.118) were not significant predictors. CONCLUSIONS Symptom-related mobility disability is common among women with OC and is associated with medical comorbidities, abdominal bloating, fatigue, lack of appetite, numbness/tingling, and pain. Longitudinal research should clarify the relationship of these symptoms to mobility disability and determine whether effective symptom management minimizes disability.
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Affiliation(s)
- Grace Campbell
- University of Pittsburgh School of Nursing, 336 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, United States.
| | - Teresa Hagan
- Massachusetts General Hospital, Harvard Medical School, Yawkey Center, 55 Fruit Street, Boston, MA 02114, United States.
| | - Stephanie Gilbertson-White
- University of Iowa College of Nursing, 50 Newton Road, 444 College of Nursing Building, Iowa City, IA 52242, United States.
| | - Martin Houze
- University of Pittsburgh School of Nursing, 336 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, United States.
| | - Heidi Donovan
- University of Pittsburgh School of Nursing, 336 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, United States.
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Burhenn PS, McCarthy AL, Begue A, Nightingale G, Cheng K, Kenis C. Geriatric assessment in daily oncology practice for nurses and allied health care professionals: Opinion paper of the Nursing and Allied Health Interest Group of the International Society of Geriatric Oncology (SIOG). J Geriatr Oncol 2016; 7:315-24. [DOI: 10.1016/j.jgo.2016.02.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 01/19/2016] [Accepted: 02/10/2016] [Indexed: 12/14/2022]
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Sattar S, Alibhai SMH, Spoelstra SL, Fazelzad R, Puts MTE. Falls in older adults with cancer: a systematic review of prevalence, injurious falls, and impact on cancer treatment. Support Care Cancer 2016; 24:4459-69. [PMID: 27450557 DOI: 10.1007/s00520-016-3342-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/10/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE The purpose of this systematic review was to update and expand the existing systematic review with the aim to answer the following questions: (1) How often do older adults (OA)s with cancer fall? (2) What are the predictors of falls in OA with cancer? (3) What is the rate of injurious falls and predictors of injurious falls in OA with cancer? (4) What are the circumstances and outcomes of falls in this population? (5) How do falls in cancer patients affect subsequent cancer treatment? METHODS Medline, Pubmed, Embase, and CINAHL were searched. Eligible studies included clinical trials, cross-sectional, cohort, case-control, and qualitative studies in which the entire sample or a sub-group of the sample were OA aged 60 and above, had cancer, in which falls were examined as a primary or secondary outcome and published in English. RESULTS Twenty-seven studies met our inclusion criteria with most involving the outpatient setting. Fall rates and injurious fall rates varied widely. Consistent predictors of falls were prior falls among outpatients and cognitive impairment among inpatients. There were no data on impact of falls on cancer treatment. Data on circumstances of falls were limited. CONCLUSION Falls and fall-related injuries are common in older cancer patients. However, little is known about circumstances of falls and impact of falls on cancer treatment. Many known fall predictors in community-dwelling OA have not been explored in oncology. More research is needed to address gaps in these areas.
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Affiliation(s)
- Schroder Sattar
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite, Toronto, ON, 130M5T 1P8, Canada.
| | - Shabbir M H Alibhai
- Department of Medicine and Institute of Health Policy, Management, and Evaluation, University Health Network and University of Toronto, 200 Elizabeth Street, Toronto, M5G 2C4, Canada
| | - Sandra L Spoelstra
- Kirkhof College of Nursing, Grand Valley State University, 301 Michigan Street, NE, Michigan, MI, 49502, USA
| | - Rouhi Fazelzad
- Library and Information Services, University Health Network, 5-407, 610 University Avenue, Toronto, ON, M5G 2M9, Canada
| | - Martine T E Puts
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite, Toronto, ON, 130M5T 1P8, Canada
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Korc-Grodzicki B, Holmes HM, Shahrokni A. Geriatric assessment for oncologists. Cancer Biol Med 2015; 12:261-74. [PMID: 26779363 PMCID: PMC4706523 DOI: 10.7497/j.issn.2095-3941.2015.0082] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 10/21/2015] [Indexed: 01/18/2023] Open
Abstract
The world is experiencing aging of its population. Age-specific incidence rates of cancer are higher and cancer is now recognized as a part of aging. Treating older patients can be challenging. The clinical behavior of some tumors changes with age and the aging process itself brings physiological changes leading to decline in the function of organs. It is essential to identify those patients with longer life expectancy, potentially more likely to benefit from aggressive treatment vs. those that are more vulnerable to adverse outcomes. A primary determination when considering therapy for an older cancer patient is a patient's physiologic, rather than chronologic age. In order to differentiate amongst patients of the same age, it is useful to determine if a patient is fit or frail. Frail older adults have multiple chronic conditions and difficulties maintaining independence. They may be more vulnerable to therapy toxicities, and may not have substantial lasting benefits from therapy. Geriatric assessment (GA) may be used as a tool to determine reversible deficits and devise treatment strategies to mitigate such deficits. GA is also used in treatment decision making by clinicians, helping to risk stratify patients prior to potentially high-risk therapy. An important practical aspect of GA is the feasibility of incorporating it into a busy oncology practice. Key considerations in performing the GA include: available resources, patient population, GA tools to use, and who will be responsible for using the GA results and develop care plans. Challenges in implementing GA in clinical practice will be discussed.
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Affiliation(s)
- Beatriz Korc-Grodzicki
- 1 Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA ; 2 Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Holly M Holmes
- 1 Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA ; 2 Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Armin Shahrokni
- 1 Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, NY 10065, USA ; 2 Division of Geriatric and Palliative Medicine, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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