Integrating a Cancer-Specific Geriatric Assessment Into Survivorship Care

Age-related health deficits and five-year mortality among older, long-term cancer survivors

INTRODUCTION

Geriatric assessment evaluates multiple domains of health that, together, are superior to using chronologic age for predicting outcomes, such as hospitalization and mortality among patients with cancer. Most studies have not included comparison groups of individuals without cancer and assessed domains around the time of initial cancer diagnosis. Further, the potential for brief, self-reported measures to capture deficits that similarly predict mortality has not been well examined. This study compared age-related health deficit prevalence between older, long-term cancer survivors and individuals without a cancer history, and estimated associations between deficits and mortality risk among survivors.

MATERIALS AND METHODS

Analyses included participants in the Cancer Prevention Study (CPS)-II Nutrition Cohort who were cancer-free at enrollment in 1992/1993 and completed the Patient Reported Outcome Measurement Information System® (PROMIS®) global health questionnaire in 2011. Age-related deficits in five domains (comorbidities, functional status, mental health, malnutrition/weight loss, and social support) were self-reported. Cancer information was self-reported and confirmed via medical records or state cancer registries. Vital status through 2016 and cause of death was ascertained by linkage with the National Death Index.

RESULTS

Analyses included 9979 participants (median age = 80) diagnosed with invasive cancer 5-20 years prior to completing the 2011 survey and 63,578 participants without a cancer history (median age = 79). Overall deficits in the five domains were similar among long-term cancer survivors and controls. However, survivors of specific cancer types - non-Hodgkin lymphoma (NHL), lung, and kidney cancer - were more likely to report deficits in mental health and functional status than the control group. Among all survivors, each domain was independently associated with all-cause mortality, particularly functional status (hazard ratio [HR] = 2.02; 95% confidence interval [CI]: 1.80-2.27) and mental health (HR = 1.84; 95% CI: 1.65-2.04). Mortality risk increased with the number of deficits.

DISCUSSION

These results suggest that, several years after treatment, NHL, lung, and kidney cancer survivors are still more likely to experience age-related deficits compared to other similarly-aged individuals. Furthermore, results show that shorter, self-reported physical and mental health assessments, such as the PROMIS® global health questions, are predictive of mortality among older, long-term cancer survivors and, therefore, may be useful in clinical and research settings.

Falls, walking or balance problems, and limitations in activities of daily living (ADLs) among older endometrial cancer survivors

PURPOSE

Functional status deficits are important quality of life concerns for older cancer survivors. We examined the prevalence of falls, walking/balance problems, and limitations in activities of daily living (ADLs) among older women with a history of endometrial cancer.

METHODS

Cancer registry records from the Surveillance, Epidemiology, and End Results (SEER) program linked with Medicare Health Outcomes Survey (MHOS) data were used to identify endometrial cancer survivors aged ≥ 65 years who completed a survey ≥ 1 year after their cancer diagnosis (N = 3766), as well as an age- and race-matched group of women without a cancer history (N = 3766). We estimated prevalence ratios (PRs) to compare the prevalence of falls, walking or balance problems, and limitations in ADLs (bathing, dressing, eating, getting in/out of chairs, walking, using the toilet) between groups.

RESULTS

Difficulty with walking or balance was more common among survivors than the noncancer group (43% vs 36%; PR = 1.19; 95% CI: 1.10-1.27). Fall prevalence was similar between groups (endometrial cancer: 25%; noncancer: 26%; PR = 0.98; 95% CI: 0.89-1.08). Nearly half of endometrial cancer survivors (47%) reported at least one ADL limitation, with several activities (getting in/out of a chair, walking, bathing, using the toilet) more often limited among survivors than among women without cancer.

CONCLUSION

Functional impairments, especially problems with walking and/or balance, are common among older endometrial cancer survivors. Our results highlight the importance of addressing functional problems during the ongoing survivorship care of women with a history of endometrial cancer, with referral to rehabilitation or other relevant services when indicated.

Geriatric principles for patients with cancer

Cancer is primarily a disease of older persons. Given the heterogeneity of aging, physiological age, rather than chronological age, better expresses the cumulative effect of environmental, medical, and psychosocial stressors, which modifies life expectancy. Comprehensive geriatric assessment, a tool that helps ascertain the physiological age of older individuals, is the gold standard for assessing older adults with cancer. Several international organizations recommend using the geriatric assessment domains to identify unrecognized health problems that can interfere with treatment and predict adverse health-related outcomes, aiding complex treatment decision making. More recently, it has been shown that geriatric assessment-guided interventions improve quality of life and mitigate treatment toxicity without compromising survival. In this review, we discuss the role of comprehensive geriatric assessment in cancer care for older adults and provide the reader with useful information to assess potential treatment risks and benefits, anticipate complications, and plan interventions to better care for older people with cancer.

Medical conditions and physical function deficits among multiple primary cancer survivors

PURPOSE

Survivors of multiple primary cancers make up a sizable proportion of all cancer survivors, yet little is known about the health of this population. We examined the prevalence of medical conditions and physical function deficits among multiple primary survivors compared with single primary survivors and individuals without a cancer history.

METHODS

Participants were enrolled in the Cancer Prevention Study (CPS)-II Nutrition Cohort in 1992/1993. Prevalent medical conditions (diabetes, heart conditions, cerebrovascular conditions, emphysema/chronic bronchitis, osteoporosis, osteoarthritis), physical function limitations, use of a cane or walker, balance difficulties, and falls within the past year were assessed on a follow-up survey completed in 2011. We estimated age- and sex-adjusted prevalence ratios (PRs), comparing multiple primary survivors (N = 1003) to single primary survivors (N = 12,849) and participants without cancer (N = 63,578).

RESULTS

The prevalence of medical conditions did not differ substantially between multiple primary survivors and either comparison group. However, multiple primary survivors were more likely to report severe limitations in physical function than the single primary (PR = 1.48 (95% CI, 1.28-1.71)) and no-cancer (PR = 1.64 (95% CI, 1.42-1.88)) groups. Using a cane or walker and balance difficulties were also significantly more common among multiple primary survivors.

CONCLUSIONS

Despite a similar prevalence of comorbid medical conditions, severe functional limitations were significantly more common among multiple primary survivors than single primary survivors or individuals without cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Assessment of functional status and treatment of physical deficits may be an especially critical component of care for older patients with a history of multiple cancer diagnoses.

Grassroots inter-professional networks: the case of organizing care for older cancer patients

Purpose

The purpose of this paper of inter-professional networks is to analyze the evolution of relationships between professional groups enacting new forms of collaboration to address clinical imperatives.

Design/methodology/approach

This paper uses a case study based on semi-structured interviews with physicians and nurses, document analysis and informal discussions.

Findings

This study documents how two inter-professional networks were developed through professional agency. The findings show that the means by which networks are developed influence the form of collaboration therein. One of the networks developed from day-to-day, immediately relevant, exchange, for patient care. The other one developed from more formal and infrequent research and training exchanges that were seen as less decisive in facilitating patient care. The latter resulted in a loosely knit network based on a small number of ad hoc referrals while the other resulted in a tightly knit network based on frequent referrals and advice seeking.

Practical implications

Developing inter-professional networks likely require a sustained phase of interpersonal contacts characterized by persuasion, knowledge sharing, skill demonstration and trust building from less powerful professional groups to obtain buy-in from more powerful professional groups. The nature of the collaboration in any resulting network depends largely on the nature of these initial contacts.

Originality/value

The literature on inter-professional healthcare networks focusses on mandated networks such as NHS managed care networks. There is a lack of research on inter-professional networks that emerged from the bottom up at the initiative of healthcare professionals in response to clinical imperatives. This study looks at some forms of collaboration that these “grass-root” initiatives engender and how they are consolidated.

The Role of the Advanced Practice Nurse in Geriatric Oncology Care

OBJECTIVES

To describe how the Advanced Practice Nurse (APN) is uniquely suited to meet the needs of older adults throughout the continuum of cancer, to explore the progress that APNs have made in gero-oncology care, and make suggestions for future directions.

DATA SOURCE

Google Scholar, PubMed, and CINAHL. Search terms included: "gero-oncology," "geriatric oncology," "Advanced Practice Nurse," "Nurse Practitioner," "older adult," "elderly," and "cancer."

CONCLUSION

Over the last decade, APNs have made advances in caring for older adults with cancer by playing a role in prevention, screening, and diagnosis; through evidence-based gero-oncology care during cancer treatment; and in designing tailored survivorship care models. APNs must combat ageism in treatment choice for older adults, standardize comprehensive geriatric assessments, and focus on providing person-centered care, specifically during care transitions.

IMPLICATIONS FOR NURSING PRACTICE

APNs are well-positioned to help understand the complex relationship between risk factors, geriatric syndromes, and frailty and translate research into practice. Palliative care must expand beyond specialty providers and shift toward APNs with a focus on early advanced care planning. Finally, APNs should continue to establish multidisciplinary survivorship models across care settings, with a focus on primary care.

The influence of body mass index on survival in breast cancer patients

INTRODUCTION

More than half of breast cancer survivors (BCSs) are obese at diagnosis and experience approximately 50% to 96% of weight gain during treatment that could physically affect their survival. The aim of the study was to evaluate the influence of body mass index (BMI) on physical, anthropometric, and physiological parameters in BCSs.

PATIENTS AND METHODS

A cross-sectional study was conducted with 147 BCSs. Health-related fitness, anthropometric measures, cardiovascular state, and cancer-related fatigue (CRF) were assessed for our analysis and 3 groups were formed.

RESULTS

Tests of force handgrip (affected side: F = 3.44; P < .05; nonaffected side: F = 3.067; P < .05), functional capacity (F = 3.239; P = .043), and endurance of trunk flexors (×2 = 8.264; P = .016) were significantly lower in obese BCSs compared with the normal-weight group, whereas systolic (F = 5.839; P = .004) and diastolic blood pressure (F = 8.794; P < .001), waist circumference (F = 85.81; P < .001), and arm circumference at 10 cm (affected side: F = 23.530; P < .001; nonaffected side: F = 17.095; P < .001) and 5 cm (affected side: F = 21.751; P < .001; nonaffected side: F = 22.490; P < .001) were significantly greater in BCSs with higher BMI compared with other groups. No significant differences were observed between groups regarding lower limb endurance, resting heart rate or CRF.

CONCLUSION

This study demonstrated the influence of obesity on health-related fitness, anthropometric measures, and cardiovascular state.

Differences in the symptom experience of older oncology outpatients

CONTEXT

The relatively low number of older patients in cancer trials limits knowledge of how older adults experience symptoms associated with cancer and its treatment.

OBJECTIVES

This study evaluated for differences in the symptom experience across four older age groups (60-64, 65-69, 70-74, ≥75 years).

METHODS

Demographic, clinical, and symptom data from 330 patients aged >60 years who participated in one Australian and two U.S. studies were evaluated. The Memorial Symptom Assessment Scale was used to evaluate the occurrence, severity, frequency, and distress of 32 symptoms commonly associated with cancer and its treatment.

RESULTS

On average, regardless of the age group, patients reported 10 concurrent symptoms. The most prevalent symptoms were physical in nature. Worrying was the most common psychological symptom. For 28 (87.5%) of the 32 Memorial Symptom Assessment Scale symptoms, no age-related differences were found in symptom occurrence rates. For symptom severity ratings, an age-related trend was found for difficulty swallowing. As age increased, severity of difficulty swallowing decreased. For symptom frequency, age-related trends were found for feeling irritable and diarrhea, with both decreasing in frequency as age increased. For symptom distress, age-related trends were found for lack of energy, shortness of breath, feeling bloated, and difficulty swallowing. As age increased, these symptoms received lower average distress ratings.

CONCLUSION

Additional research is warranted to examine how age differences in symptom experience are influenced by treatment differences, aging-related changes in biological or psychological processes, or age-related response shift.

Survey of willingness to accept chemotherapy among elderly Malaysian patients

BACKGROUND

The geriatric population in Malaysia is predicted to increase from 4% of the total population in 1998 to 9.8% by 2020, in parallel with developments in the socioeconomy. Cancer is expected to be a major medical issue among this population. However, the decision for treatment in Malaysia is always decided by the caregivers instead of the elderly patients themselves.

OBJECTIVE

The aim of the study was to assess the willingness to accept chemotherapy among elderly Malaysians.

MATERIALS AND METHODS

In this cross-sectional study, patients aged 60 and above from various clinics/wards were recruited. Those giving consent were interviewed using a questionnaire.

RESULTS

A total of 75 patients were recruited, 35 patients (47%) with a history of cancer. The median age was 73 years old. There were 29 Chinese (38.7%), 22 Indian (29.3%), 20 Malay (26.7%) and four other ethnicity patients. Some 83% and 73% of patients willing to accept strong and mild chemotherapy, respectively. Patients with cancer were more willing to accept strong and mild chemotherapy compared to the non-cancer group (88.6% vs 62.5%, P=0.005, 94% vs 80%, P=0.068). On sub-analysis, 71.4% and 42.9% of Chinese patients without a history of cancer were not willing to receive strong and mild chemotherapy, respectively.

CONCLUSIONS

The majority of elderly patients in UMMC were willing to receive chemotherapy if they had cancer. Experience with previous treatment had positive influence on the willingness to undergo chemotherapy.