Transplantation and Cellular Therapy for Older Adults-The MSK Approach

PURPOSE OF REVIEW

Hematologic malignances more commonly affect older individuals and often present with advanced, higher risk disease than younger patients. Allogeneic and autologous hematopoietic cell transplantation is well-established treatment modalities with curative potential following either frontline treatments for these diseases or salvage therapy in the relapsed or refractory setting. More recently, novel cellular immunotherapy such as chimeric antigen receptor T-cell therapy has been shown to lead to high response rate and durable remission in many patients with advanced blood cancers.

RECENT FINDINGS

Given unique characteristics of older patients, how best to deliver these higher-intensity and time sensitive treatment modalities for them remains challenging. Moreover, their short-term and potential long-term impact on their functional status, cognitive status, and quality of life may be significant considerations for many older patients. All these issues contributed to the lack of access and significant underutilization of these potential curative treatment strategies. In this review, we present up to date evidence to support potential benefits of transplantation and cellular therapy for older adults, their steady improving outcomes, and most importantly, highlight the use of geriatric assessment to help select appropriate older patients and optimize them prior to and following transplantation and cellular therapy. We specifically describe our approach at Memorial Sloan Kettering Cancer Center and encouraging early results from its implementation.

Preoperative frailty predicts postoperative falls in older patients with cancer

INTRODUCTION

Patient falls in the hospital lead to adverse outcomes and impaired quality of life. Older adults with cancer who are frail may be at heightened risk of falls in the postoperative period. We sought to evaluate the association between degree of preoperative frailty and risk of inpatient postoperative falls and other outcomes among older adults with cancer.

MATERIALS AND METHODS

We identified 7,661 patients aged 65 years or older who underwent elective cancer surgery from 2014 to 2020, had a hospital stay of ≥1 day, and had Memorial Sloan Kettering-Frailty Index (MSK-FI) data to allow assessment of frailty. Univariable logistic regression analysis was performed to evaluate the association between frailty and falls. Multivariable logistic regression analysis was performed to evaluate the composite outcome of 30-day readmission or 90-day death, with frailty, falls, and the interaction between frailty and falls as predictors; the analysis was adjusted for age, sex, race, and preoperative albumin level.

RESULTS

In total, 7,661 patients were included in the analysis. Seventy-one (0.9%) had a fall, of whom eight (11%) were readmitted to the hospital within 30 days and seven (10%) died within 90 days. Higher MSK-FI score was associated with higher risk of falls (odds ratio [OR], 1.40 [95% confidence interval [CI], 1.21-1.59]). The risk of falls for a patient with an MSK-FI score of 1 was 0.6%, compared with 1.7% for a patient with an MSK-FI score of 4. Poor outcome was associated with frailty (OR, 1.07 [95% CI, 1.02-1.13]) but not with falls (OR, 1.17 [95% CI, 0.57-2.22]).

DISCUSSION

Preoperative frailty is associated with risk of inpatient postoperative falls and with other adverse outcomes after surgery among older adults with cancer. Screening for frailty in the preoperative setting would enable healthcare institutions to implement interventions aimed at reducing the incidence of inpatient postoperative falls to reduce fall-related adverse events.

Cognitive function and ability to complete a web-based geriatric assessment among older adults with cancer

BACKGROUND

The purpose of this study was determined whether cognitive impairment is associated with time taken to complete the electronic rapid fitness assessment (eRFA). We hypothesized that taking more time to complete the eRFA will indicate worsened cognitive function.

METHODS

We retrospectively identified patients who presented to the Memorial Sloan Kettering Cancer Center Geriatrics Service for preoperative evaluation and completed the eRFA as a part of their preoperative assessment from February 2015 to December 2020. Cognitive function was assessed using the Mini-Cog©, which is a screening test for cognitive function status. Patients in this study underwent elective surgery and had a hospital length of stay ≥1 day. Time to complete the eRFA was automatically recorded by a web-based tool; assistance with eRFA completion was self-reported by the patient. In total, 2599 patients were included, of which 2387 had available Mini-Cog© scores.

RESULTS

Overall, 50% of surveys were completed without assistance, 37% were completed with assistance, and 13% were completed by somebody else; Mini-Cog© scores were lower, corresponding to worsened cognitive function status, in patients requiring assistance (median score respectively, 5 vs. 4 vs. 3; p-value <0.0001; rates of cognitive impairment 7.5%, 22%, and 38%). Among patients who completed the questionnaire independently, greater cognitive impairment was associated with longer time to complete the eRFA (change in score per 5 min = -0.09; 95% CI -0.14, -0.03; p = 0.002).

CONCLUSIONS

We found evidence that requirement for assistance in completing web-based questionnaires, and time taken to complete a questionnaire, predict which patients benefit from more comprehensive cognitive function assessments. Future studies should further validate this finding in a more diverse population and establish optimal clinical pathways.

Differential use of postoperative psychosocial and physical services among older adults with head and neck cancer

INTRODUCTION

Older adults undergoing head and neck cancer (HNC) surgery often have significant functional and mental health impairments. We examined use of postoperative physical, nutritional, and psychosocial services among a cohort of older adults with HNC comanaged by geriatricians and surgeons.

MATERIALS AND METHODS

Our sample consisted of older adults who were referred to the Geriatrics Service at Memorial Sloan Kettering Cancer Center between 2015 and 2019 and took a geriatric assessment (GA) prior to undergoing HNC surgery. Physical, nutritional, and psychosocial service utilization was assessed. Physical services included a physical, occupational, or rehabilitation consult during the patient's stay. Nutritional services consisted of speech and swallow or nutritional consult. Psychosocial services consisted of psychiatry, psychology, or a social work consult. Relationships between each service use, geriatric deficits, demographic, and surgical characteristics were assessed using Wilcoxon rank-sum test or Chi-square test.

RESULTS

In total, 157 patients were included, with median age of 80 and length of stay of six days. The most common GA impairments were major distress (61%), depression (59%), social activity limitation (SAL) (54%), and deficits in activities of daily living (ADL) (44%). Nutritional and physical services were used much more frequently than psychosocial services (80% and 85% vs 31%, respectively). Receipt of services was associated with longer median length of hospital stay, operation time, and greater deficits in ADLs. SAL was associated with physical and psychosocial consult and lower Timed Up and Go (TUG) score; instrumental ADL (iADL) deficits were associated with physical services; and depression and distress were associated with psychosocial services.

DISCUSSION

The burden of psychosocial deficits is high among older adults with HNC. Future work is needed to understand the limited utilization of psychosocial services in this population as well as whether referral to psychosocial services can reduce the burden of these deficits.

Comparison of short-term outcomes and survival between minimally invasive colectomy and open colectomy in patients 80 years of age and older

We investigated the short- and long-term outcomes of patients 80 years of age and older with colon cancer who underwent robotic colectomy versus laparoscopic colectomy. Data for patients treated at a comprehensive cancer center between January 2006 and November 2018 were collected retrospectively. Outcomes from minimally invasive laparoscopic or robotic colectomy were compared. Survival was analyzed by the Kaplan-Meier method with significance evaluated by the log-rank test. The laparoscopic (n = 104) and the robotic (n = 75) colectomy groups did not differ across baseline characteristics. Patients who underwent a robotic colectomy had a shorter median length of hospital stay (5 versus 6 days; p < 0.001) and underwent fewer conversions to open surgery (3% versus 17%; p = 0.002) compared to the laparoscopic cohort. The groups did not differ in postoperative complication rates, overall survival or disease-free survival. Elderly patients undergoing robotic colectomy for colon cancer have a shorter hospital stay and lower rates of conversion without compromise to oncologic outcomes.

Preoperative frailty vs. cognitive impairment: Which one matters most for postoperative delirium among older adults with cancer?

INTRODUCTION

Limited data are available to explore the association between preoperative frailty and cognitive impairment with postoperative delirium among older adults with cancer. We explored this association in a single Comprehensive Cancer Center where postoperative delirium and frailty are assessed in routine care using the Confusion Assessment Method (CAM) and Memorial Sloan Kettering Frailty Index (MSK-FI), respectively.

MATERIALS AND METHODS

Retrospective study on patients with cancer, aged 65+, who underwent surgery from April 2018 to March 2019 with hospital stay ≥1 day. We used logistic regression with postoperative delirium as the outcome, primary predictor MSK-FI, adjusted for age, operative time, and preoperative albumin. As the MSK-FI includes a component related to cognitive impairment, we additionally evaluated the impact of this component, separately from the rest of the score, on the association between frailty and postoperative delirium.

RESULTS

Among 1,257 patients with available MSK-FI and CAM measures, 47 patients (3.7%) had postoperative delirium. Increased frailty was associated with increased risk of postoperative delirium (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.26, 1.81; p < 0.001). However, this was largely related to the effect of cognitive impairment (OR 15.29; 95% CI 7.18; 32.56; p < 0.001). In patients with cognitive impairment, the association between frailty and postoperative delirium was not significant (OR 0.97; 95% CI 0.65, 1.44; p-value = 0.9), as having cognitive impairment put patients at high risk for postoperative delirium even without taking into account the other components of the MSK-FI. While the association between frailty and postoperative delirium in patients with intact cognitive function was statistically significant (OR 1.58; 95% CI 1.27, 1.96; p < 0.001), it was not clinically meaningful, particularly considering the low risk of delirium among patients with intact cognitive function (e.g., 1.3% vs 3.2% for MSK-FI 1 vs 3).

DISCUSSION

Cognitive function should be a greater focus than frailty, as measured by the MSK-FI, in preoperative assessment for the prediction of postoperative delirium.

Preoperative glucose in surgical oncology patient is not associated with postoperative outcomes after adjustment for frailty

BACKGROUND

Observational studies have shown associations between even small elevations in preoperative glucose and poorer outcomes, including increased length of stay (LOS) and higher mortality. This has led to calls for aggressive glycemic control in the preoperative period, including delay of treatment until glucose is reduced. However, it is not known whether there is a direct causal effect of blood glucose or whether adverse outcomes result from overall poorer health in patients with higher glucose.

METHODS

Analysis was performed using a retrospective database of patients aged 65 and older who underwent cancer surgery. The last measured preoperative glucose was the exposure variable. The primary outcome was extended LOS (>4 days). Secondary outcomes included mortality, acute kidney injury (AKI), major postoperative complications during the admission period, and readmission within 30 days. The primary analysis was a logistic regression with prespecified covariates: age, sex, surgical service, and the Memorial Sloan Kettering-Frailty Index. In an exploratory analysis, lasso regression was used to select covariates from a list of 4160 candidate variables.

RESULTS

This study included 3796 patients with a median preoperative glucose of 104 mg/dL (interquartile range: 93-125). Higher preoperative glucose was univariately associated with increased odds of LOS > 4 days (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.22-1.73), with similar results for AKI, readmission, and mortality. Adjustment for confounders eliminated these associations for LOS (OR: 0.97 [95% CI: 0.80-1.18]) and attenuated all other glucose-outcome associations. Lasso regression gave comparable results to the primary analysis. Using the upper bound of the respective 95% confidence interval, we estimated that, at best, successful reduction of elevated preoperative glucose would reduce the risk of LOS > 4 days, 30-day major complication, and 30-day mortality by 4%, 0.5%, and 1.3%, respectively.

CONCLUSIONS

Poor outcomes following cancer surgery in older adults with elevated glucose are most likely related to poorer overall health in these patients rather than a direct causal effect of glucose. Aggressive glycemic management in the preoperative period has very limited potential benefits and is therefore unwarranted.

Healthcare providers' experiences of continuing care for older adults with cancer during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic has caused great strain on older adults with cancer and their healthcare providers. This study explored healthcare providers' reported changes in cancer care, clinical barriers to care, patient questions, and the overall experiences of caring for older adults with cancer during the COVID-19 crisis.

METHODS

The Advocacy Committee of the Cancer and Aging Research Group and the Association of Community Cancer Centers developed a survey for healthcare providers of adults with cancer, inquiring about their experiences during the pandemic. Responses from the survey's four open-ended items were analyzed by four independent coders for identification of common themes using deductive and inductive methods.

RESULTS

Participants (n = 137) represented a variety of demographic and clinical experiences. Six overall themes emerged, including (1) telehealth use, (2) concerns for patient mental health, (3) patient physical and social isolation, (4) patient fear of contracting COVID-19, (5) continued disruptions to cancer care, and (6) patients seeking guidance, particularly regarding COVID-19 vaccination. Questions fielded by providers focused on the COVID-19 vaccination's safety and efficacy during older adults' cancer treatment.

CONCLUSIONS

Additional resources (e.g., technology support, established care guidelines, and sufficient staffing) are needed to support older adults with cancer and healthcare providers during the pandemic. Future research should explore universally effective in-person and virtual treatment strategies for older adults with cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Persistence of telehealth barriers, particularly a lack of infrastructure to support telehealth visits, social isolation, and restrictive visitor policies as a result of COVID-19, negatively impacted the mental health of older adults with cancer.

Healthcare providers' attitudes towards delay in cancer treatment during COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has created unprecedented obstacles leading to delays in treatment for older adults with cancer. Due to limited resources at the height of the pandemic, healthcare providers were constantly faced with ethical dilemmas regarding postponing or rescheduling care for their patients.

MATERIALS AND METHODS

Two survey-based studies were conducted at different time-points during the pandemic looking at factors affecting oncology care providers' attitudes towards delay in treatment for older adults with cancer. Eligible participants were recruited by email sent through professional organizations' listservs, email blasts, and social media. Change in provider attitude over time was analyzed by comparing responses from the 2020 and 2021 surveys. Data analysis included descriptive statistics and chi-squares.

RESULTS

In 2020, 17.5% of respondents were strongly considering/considering postponing cancer treatment for younger patients (age 30 and below), while 46.2% were considering delaying treatment for patients aged >85. These responses were in stark contrast to the results of the 2021 survey, where only 1.4% of respondents strongly considered postponing treatment for younger patients, and 13.5% for patients aged >85.

DISCUSSION

All recommendations to postpone treatment for older adults with cancer must be made after mutual discussion with the patient. Throughout the COVID-19 pandemic, oncology care providers had to consider multiple factors while treating patients, frequently making most decisions without appropriate institutional support.

The association between perioperative frailty and ability to complete a web-based geriatric assessment among older adults with cancer

INTRODUCTION

The aim of this study was to assess the degree to which patient frailty is associated with both need for assistance and time required to complete the eRFA, a web-based GA tool.

MATERIALS AND METHODS

We retrospectively identified patients who underwent surgery for cancer from 2015 to 2020, had a hospital length of stay ≥1 day, and completed the eRFA before surgery. Frailty was assessed using two methods: the MSK-FI (score 0-11) and the AGD (score 0-13). Time to complete the eRFA was automatically recorded by a web-based tool; assistance with eRFA completion was self-reported by the patient.

RESULTS

In total, 3456 patients were included (median age, 78 years). Overall, 58% of surveys were completed without assistance, 30% were completed with assistance, and 12% were completed by someone other than the patient. Younger age (median age: without assistance, 77 years; with assistance, 80 years; completed by someone else, 80 years) and lower frailty score (median AGD: 4, 6, and 8, respectively; median MSK-FI: 2, 3, and 3, respectively) were associated with independency (all p < 0.001). Higher frailty score was associated with longer time to complete the eRFA (all nonlinear association p < 0.001).

CONCLUSION

Frail patients are more likely to benefit from completion of GA to determine appropriate treatment. Given that not all cancer patients have a caregiver who can assist completing a digital questionnaire, innovative solutions are needed to help frail patients complete the eRFA without assistance.

Development and implementation of an interdisciplinary telemedicine clinic for older patients with cancer-Preliminary data

BACKGROUND

Frailty assessment is an important marker of the older adult's fitness for cancer treatment independent of age. Pretreatment geriatric assessment (GA) is associated with improved mortality and morbidity outcomes but must occur in a time sensitive manner to be useful for cancer treatment decision making. Unfortunately, time, resources and other constraints make GA difficult to perform in busy oncology clinics. We developed the Cancer and Aging Interdisciplinary Team (CAIT) clinic model to provide timely GA and treatment recommendations independent of patient's physical location.

METHODS

The interdisciplinary CAIT clinic model was developed utilizing the surge in telemedicine during the COVID-19 pandemic. The core team consists of the patient's oncologist, geriatrician, registered nurse, pharmacist, and registered dietitian. The clinic's format is flexible, and the various assessments can be asynchronous. Patients choose the service method-in person, remotely, or hybrid. Based on GA outcomes, the geriatrician provides recommendations and arrange interventions. An assessment summary including life expectancy estimates and chemotoxicity risk calculator scores is conveyed to and discussed with the treating oncologist. Physician and patient satisfaction were assessed.

RESULTS

Between May 2021 and June 2022, 50 patients from multiple physical locations were evaluated in the CAIT clinic. Sixty-eight percent was 80 years of age or older (range 67-99). All the evaluations were hybrid. The median days between receiving a referral and having the appointment was 8. GA detected multiple unidentified impairments. About half of the patients (52%) went on to receive chemotherapy (24% standard dose, 28% with dose modifications). The rest received radiation (20%), immune (12%) or hormonal (4%) therapies, 2% underwent surgery, 2% chose alternative medicine, 8% were placed under observation, and 6% enrolled in hospice care. Feedback was extremely positive.

CONCLUSIONS

The successful development of the CAIT clinic model provides strong support for the potential dissemination across services and institutions.

The development of an electronic geriatric assessment tool: Comprehensive health assessment for my plan (CHAMP)

INTRODUCTION

Geriatric assessment (GA) provides information on key health domains of older adults and is recommended to help inform cancer treatment decisions and cancer care. However, GA is not feasible in many health institutions due to lack of geriatric staff and/or resources. To increase accessibility to GA and improve treatment decision making for older adults with cancer (≥65 years), we developed a self-reported, electronic geriatric assessment tool: Comprehensive Assessment for My Plan (CHAMP).

MATERIALS AND METHODS

Older adults with cancer were invited to join user-centered design sessions to develop the layout and content of the tool. Subsequently, they participated in usability testing to test the usability of the tool (ease of use, acceptability, etc.). Design sessions were also conducted with oncology clinicians (oncologists and nurses) to develop the tool's clinician interface. GA assessment questions and GA recommendations were guided by a systematic review and Delphi expert panel.

RESULTS

A total of seventeen older adults participated in the study. Participants were mainly males (82.4%) and 75% were aged 75 years and older. Nine oncology clinicians participated in design sessions. Older adults and clinicians agreed that the tool was user-friendly. Domains in the final CHAMP tool (with questions and recommendations) included functional status, falls risk, cognitive impairment, nutrition, medication review, social supports, depression, substance use disorder, and miscellaneous items.

DISCUSSION

CHAMP was designed for use by older adults and oncologists and may enhance access to GA for older adults with cancer. The next phase of the CHAMP study will involve field validation in oncology clinics.

Differences in urban and suburban/rural settings regarding care provision and barriers of cancer care for older adults during COVID-19

PURPOSE

Care for older adults with cancer became more challenging during the COVID-19 pandemic, particularly in urban hotspots. This study examined the potential differences in healthcare providers' provision of as well as barriers to cancer care for older adults with cancer between urban and suburban/rural settings.

METHODS

Members of the Advocacy Committee of the Cancer and Aging Research Group, with the Association of Community Cancer Centers, surveyed multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Respondents were recruited through organizational listservs, email blasts, and social media messages. Descriptive statistics and chi-square tests were used.

RESULTS

Complete data was available from 271 respondents (urban (n = 144), suburban/rural (n = 127)). Most respondents were social workers (42, 44%) or medical doctors/advanced practice providers (34, 13%) in urban and suburban/rural settings, respectively. Twenty-four percent and 32.4% of urban-based providers reported "strongly considering" treatment delays among adults aged 76-85 and > 85, respectively, compared to 13% and 15.4% of suburban/rural providers (Ps = 0.048, 0.013). More urban-based providers reported they were inclined to prioritize treatment for younger adults over older adults than suburban/rural providers (10.4% vs. 3.1%, p = 0.04) during the pandemic. The top concerns reported were similar between the groups and related to patient safety, treatment delays, personal safety, and healthcare provider mental health.

CONCLUSION

These findings demonstrate location-based differences in providers' attitudes regarding care provision for older adults with cancer during the COVID-19 pandemic.

Correlation of an Electronic Geriatric Assessment With Receipt of Adjuvant Radiation and Chemotherapy in Older Adults With Head and Neck Cancer

Purpose

Treatment patterns for head and neck squamous cell carcinoma (HNSCC) vary among older adults because of concerns about their health status. Geriatric assessment may guide treatment for older adults with HNSCC by assessing their health status.

Methods and Materials

We conducted a retrospective review of adjuvant treatment received by older patients with HNSCC who completed a novel geriatric assessment, the electronic Rapid Fitness Assessment, before treatment. The electronic Rapid Fitness Assessment yields an accumulated geriatric deficits (AGD) score. Higher AGD score indicates greater frailty. Comparators were age and performance status. The Wilcoxon rank sum test compared differences between those who did and did not receive adjuvant radiation therapy and chemotherapy.

Results

The cohort included 73 patients, of whom 56 (77%) had oral cavity cancer. The most common geriatric deficits were major distress, social activity limitation, depression, and impaired activities of daily living. AGD score, age, and performance status were not associated with receipt of adjuvant radiation. Patients who received adjuvant chemotherapy had a significantly lower median AGD score than those who did not (3 vs 6; P = .044), but there was no association with age and performance status. Of the 17 patients with newly diagnosed disease and either positive margins or extranodal extension, only 9 received adjuvant radiation and only 3 received systemic therapy. Most often, systemic therapy was omitted because of patient preference or comorbidities and poor performance status. There was a nonstatistically significant lower AGD score between patients who did and did not receive standard fractionated radiation therapy (median, 4 vs 6.5; P = .13).

Conclusions

Receipt of adjuvant chemotherapy was associated with frailty. Rates of chemotherapy utilization were very low, indicating the need for novel strategies to mitigate the toxicity burden in this patient population. Receipt of adjuvant radiation therapy was not associated with frailty; however, there was a trend toward lower frailty among those who did receive radiation therapy.

Home-based geriatric oncology care: A feasibility study

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Background: The Comprehensive Geriatric Assessment (CGA) improves the outcomes of older patients with cancer, and by identifying of geriatric impairments the CGA can guide the development of supportive interventions. However, the implementation of these interventions in a real-world setting can be burdensome for patients, particularly when additional visits are required in an often frail population. Therefore, our team developed a collaborative model for home-based delivery of CGA-guided interventions. Methods: We performed a retrospective review of community-dwelling patients aged ≥ 70 years with an active cancer diagnosis who were deemed to be frail by a CGA and who received home-based CGA-guided supportive interventions under a collaborative care model established by the geriatric oncology and the palliative home care teams at Hartford HealthCare Cancer Institute between October 2020 and April 2022. The collaboration is based on multidisciplinary discussion of the CGA results / interventions and weekly rounds to discuss patient’s progress and emerging needs. Results: A total of 182 patients received a CGA during the study period, 54% (n = 99) were determined to be frail based on impairment in ≥ 7 geriatric domains. Among all eligible patients, 19 patients (19%) were included in the collaborative model. The median age of enrolled patients was 84 years (74-90), 12/19 (63%) had metastatic cancer, 7/19 (37%) received systemic treatment, and 8/19 (42%) received radiation. The average number of geriatric impairments per patients was 9.5 (7-12). Geriatric impairments addressed at home were skilled nursing (19/19), physical therapy (18/19), occupational therapy (12/19), speech-language-pathology (2/19), nutrition (5/19), or social worker (11/19) support at home. The average number of unplanned hospitalizations was 1.16 per patient (range 0-4), and the average unplanned emergency room visit was 0.89 per person (range 0-4) during study time. Transition to hospice occurred in 8/19 patients (42%), the median time to transition to hospice was 33.5 days (15-167). Conclusions: This study demonstrates the feasibility of a collaborative model for home-based geriatric oncology care in a real-world setting to help reduce the burden of care on patients and ensure patient-centered delivery of CGA-guided interventions. Findings underscore the need for future work to evaluate the impact of this novel geriatric oncology care model on patient outcomes.

Real-world Impact of Age at Diagnosis on Treatment Patterns and Survival Outcomes of Patients with Metastatic Pancreatic Ductal Adenocarcinoma

BACKGROUND

Sixty-eight percent of patients with pancreatic ductal adenocarcinoma (PDAC) are 65 years and older. Older adults are under-represented in clinical trials and their care is complicated with multiple age-related conditions. Research suggests that older patients can experience meaningful responses to treatment for PDAC. The objective of this study was to evaluate the characteristics, rate of treatment, and survival outcomes of patients with metastatic PDAC (mPDAC) based on age at diagnosis.

MATERIALS AND METHODS

Data were extracted for patients diagnosed with mPDAC between January 1, 2015, and March 31, 2020, from the Flatiron Health database. Patients were stratified into 3 age groups: <70 years old, 70-79 years, and ≥80 years. The proportion of patients who received first-line therapy, the types of regimens received in the metastatic setting, overall survival (OS) from the start of treatment were evaluated.

RESULTS

Of the 8382 patients included, 71.3% (n = 5973) received treatment. Among patients who received treatment 55.5% (n = 3313) were aged <70 years at diagnosis, 33.0% (n = 1972) were 70-79 years, and 11.5% (n = 688) were ≥80 years. Patients ≥80 years of age were more likely to receive gemcitabine monotherapy and less likely to receive FOLFIRINOX. Among first-line treated patients, median OS significantly decreased with age. However, when comparing patients treated with the same first-line regimen, no significant differences in median OS were observed by age.

CONCLUSIONS

This study highlights that older adults with mPDAC can benefit substantially by receiving appropriate levels of treatment.

Development of memorial Sloan Kettering (MSK) surgery stress score for older adults with cancer

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Background: The stress from oncologic surgeries for older adults may lead to poor surgical outcomes. In this study, we aim to develop a MSK Surgery Stress Score to measure the complexity of surgery for these patients. The score could then be used for future analyses using datasets where patients undergoing a variety of procedures. Methods: This is a retrospective analysis of adults aged 75 and older who underwent elective cancer surgery in our institution with hospital length of stay of at least one day in 2015 to 2020. Based on surgery stress score developed by Haga et al., we explored various models including at least one or some of these variables as linear or non-linear terms: operation time, weight (kg), blood loss (cc), type of surgery, body mass index, and incision score. The primary outcome of interest evaluated was defined as the composite outcome of death within 90-day of surgery, readmission or emergency room visit or major complications (grade 3-5) within 30 days of surgery. We additionally explored models for a secondary outcome, where minor complications (grade 1-2) were included in the definition, and lastly, we looked at major complications alone as a tertiary outcome. For each of the model and outcomes, we used a logistic regression. We then used the logit transformation of the predicted probability to represent the proposed surgery stress score. Using this score, we evaluated the area under the curve (AUC) for each outcome. Results: In total, 1573 patients were included in the study. The median age was 80 (quartiles 77, 83) and just under half (49%) were male. The median (quartile) operation time was 181 minutes (115, 259), weight was 71 kg (62, 84), blood loss was 100 mL (50, 300), and just over (51%) of patient underwent an abdominopelvic procedure. The rate of 90-day mortality was 3.8%, while the rate of 30-day major complication, readmission and emergency room visit was 7.4%, 10% and 13%, respectively Furthermore, 21%, and 35% experienced primary, and secondary outcomes, respectively. Overall, 18 predictive models for each of the outcomes were developed and assessed. AUC for our different models ranged from 0.59 to 0.73 for the different definitions of our outcomes. Among the various models, the one defined using whether patients underwent an abdominopelvic procedure, incision score, operation time, weight, and blood loss (the latter two both included as non-linear terms) appeared to the front runner. Conclusions: We explored potential models to be used as the MSK Surgery Stress Score. Currently the model is being optimized by additional work. Following optimization of the model, future studies should validate this score in other cohorts of older surgical patients with cancer.

The association between perioperative frailty and ability to complete a web-based geriatric assessment in older adults with cancer

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Background: With expansion of web-based geriatric assessment (GA), the aim of our study is to assess whether patients’ independency and time to complete electronic Rapid Fitness Assessment (eRFA), a web-based GA at our institution, is associated with frailty. Methods: Retrospective study of 3456 patients with cancer who underwent cancer surgery in 2015-2020 with hospital length of stay of 1+ days and completed the eRFA prior to surgery. Frailty was assessed by two methods: Memorial Sloan Kettering Frailty Index (MSK-FI, score 0-11) and accumulative geriatric deficits (AGD, score 0-13). In both measures, higher score is reflective of higher degree of frailty. Patient’s independency to complete the eRFA was self-reported (no help, some help, someone else). Time to complete the eRFA was captured by the system based on survey start time and submission time. Association between characteristics and patient’s independency to complete the eRFA were assessed using Kruskal Wallis test for continuous variable and Chi-square test for categorical variables. Analysis into time to complete the eRFA excluded surveys completed by someone else (n = 407), those completed in < 2 min (n = 1) or > 40 min (n = 82). Association between time to complete the eRFA and frailty was assessed using two separate linear regression models with frailty—MSK-FI and AGD, separately—as the outcome, and minutes to complete the eRFA as the predictor, in surveys completed with no help and some help, separately. Time to complete the eRFA was included in the model as a non-linear term with restricted cubic splines with knots at the tertiles. Results: Among our cohort, the median age at the time of survey completion was 78 (quartiles 75, 82), just under half (49%) of patients were male. Survey completion corresponded to 58% with no help, 30% with some help, and 12% by someone else. Independency in completing the eRFA was associated with younger age (median ages: no help 77, some help 80, someone else 80), and lower frailty (median AGD: no help 4, some help 6, someone else 8; median MSK-FI: no help 2, some help 3, someone else 3) (all p < 0.001). Longer time to complete the eRFA was associated with higher degree of frailty measured by MSK-FI and AGD (all non-linear association p < 0.001). For example, for surveys completed with no help in 5, 10, and 15 minutes, the estimated MSK-FI is 1.4 (95% CI 1.3, 1.6); 2.3 (95% CI 2.2, 2.4); and 2.3 (95% CI 2.1, 2.6), and the estimated AGD is 3.1 (95% CI 2.9, 3.3); 5.1 (95% CI 4.9, 5.4), and 5.1 (95% CI 4.7, 5.5). Conclusions: Patients who needed assistance or took a longer time to complete the assessment were more likely to have a higher degree of frailty. To avoid burdening the hospital, placing undue stress on patients, and possibly inaccurate responses, we should test solutions that may enhance the ability of frail patients to complete the eRFA faster and without assistance from others, such as by using voice assistants.

Relationship between diabetes and its severity, frailty and adverse surgical outcomes among older adults with cancer

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Background: Presence and severity of comorbid conditions impact surgical outcomes of older adults with cancer. The aim of our study is to evaluate the relationship between diabetes mellitus (DM), and preoperative HgbA1c (pHgbA1c) with frailty and adverse surgical outcomes among older adults with cancer. Methods: Retrospective study of patients aged 65 and older who underwent elective cancer surgery with at least one-day hospital stay in 2015-18 at our institution. For our primary aim, we assessed the association between DM and frailty, sociodemographic and clinical characteristics by reporting the characteristics stratified by presence of DM. Frailty was assessed using the Memorial Sloan Kettering Frailty Index (MSK-FI), which composes of 10 comorbidities and one functional component. This score ranges from 0-11, with higher score corresponding to greater frailty. Our secondary aim to assess the association between pHgbA1c and frailty was evaluated by a linear regression with pHgbA1c as the outcome and MSK-FI as the predictor. For our tertiary aim to assess the association between pHgbA1c and adverse surgical outcomes, we used a univariable logistic regression model with the outcome as the composite definition of 30-day readmission, 30-day emergency room visit, 30-day major complication, or 90-day mortality, and pHgbA1c as the predictor. We also used a multivariable logistics regression model, adjusting for age, gender, American Society of Anesthesiologist Performance Status (ASA-PS), and operation time.Analyses related to pHgbA1c excluded patients without pHgbA1c records. Results: Among 4417 patients, 1024 (23%) had DM and among those 403 (39%) had pHgbA1c values recorded. The results showed patients with DM were older, had higher ASA-PS, more comorbidities and higher MSK-FI scores than those without DM. Moreover, pHgbA1c was not found to be statistically associated with degree of frailty (β for one unit change in MSK-FI 0.11, 95% CI 0.00, 0.21; p = 0.057). Lastly, in both unadjusted and adjusted models pHgbA1c was not associated with adverse surgical outcomes (OR for both models, 0.99, 95% CI 0.83, 1.16, p = 0.9). Conclusions: In this cohort of patients whose pHgbA1c values were recorded, pHgbA1c was not associated with adverse surgical outcomes. Further studies are needed to confirm this study with more focus on perioperative care process of patients with DM and find cohorts whose pHgbA1c measurements can better predict frailty and adverse surgical outcomes.

The association between Memorial Sloan Kettering Frailty Index with 30-day survival among patients aged ≥ 75 with cancer and COVID-19

BACKGROUND

Advanced age and multiple comorbidities have been established as a risk factor for more severe disease and increased mortality among patients with COVID-19, yet the impact of frailty in patients with cancer 75 years and older who are admitted, remains unclear.

METHODS

To better understand the clinical presentation and course of illness for this population, we conducted a chart review of patients with cancer age 75 and older who were admitted to a comprehensive cancer center within 72 h of a confirmed COVID-19 diagnosis over a three-month period (March 1, 2020-May 31, 2020). Frequency and proportion of characteristics were reported. We additionally assessed the association between frailty and 30-day mortality using univariable logistic regression.

RESULTS

Our cohort consisted of 70 patients. We found evidence that increased frailty based on MSK-FI was associated with increased risk of 30-day mortality (OR 1.37, 95% CI 1.00, 1.87; p-value = 0.051), though this did not meet conventional levels of significance.

CONCLUSION

Our analysis showed evidence of some association between degree of frailty and 30-day survival among older patients with cancer aged ≥75 who were admitted with COVID-19 infection. This finding illustrates the importance of frailty screening in the care management of older patients with cancer and COVID-19.

The Role of Ablative Radiotherapy in Older Adults With Limited Metastatic Disease

For patients with oligometastatic cancer, radiotherapy presents a promising avenue for achieving meaningful symptom relief and durable disease control. Data from recently published and ongoing randomized studies are helping to define the appropriate contexts for effective intervention with stereotactic ablative body radiotherapy (SABR) in the oligometastatic setting. Importantly, older adults represent a significant portion of patients with oligometastatic disease, yet often comprise a minority of patients in clinical trials. Moreover, older adults of the same chronologic age may have variable degrees of fitness and frailty. In this review, we highlight the specific challenges and considerations for the use of radiotherapy for older adults with oligometastatic disease-noting the importance of geriatric assessments in clinical decision-making about the appropriateness of SABR and other metastasis-directed therapies in this population. We then review data from existing trials, including a subset analysis of adverse events and survival estimates among older adults enrolled in the landmark SABR-COMET trial. Finally, we discuss future directions for research, including the need for focused clinical trials in older adult cohorts. Ultimately, a multidisciplinary approach is critical when carefully balancing the potential risks and benefits of this emerging treatment paradigm in the older adult population.

Geriatric risk factors for serious COVID-19 outcomes among older adults with cancer: a cohort study from the COVID-19 and Cancer Consortium

BACKGROUND

Older age is associated with poorer outcomes of SARS-CoV-2 infection, although the heterogeneity of ageing results in some older adults being at greater risk than others. The objective of this study was to quantify the association of a novel geriatric risk index, comprising age, modified Charlson comorbidity index, and Eastern Cooperative Oncology Group performance status, with COVID-19 severity and 30-day mortality among older adults with cancer.

METHODS

In this cohort study, we enrolled patients aged 60 years and older with a current or previous cancer diagnosis (excluding those with non-invasive cancers and premalignant or non-malignant conditions) and a current or previous laboratory-confirmed COVID-19 diagnosis who reported to the COVID-19 and Cancer Consortium (CCC19) multinational, multicentre, registry between March 17, 2020, and June 6, 2021. Patients were also excluded for unknown age, missing data resulting in unknown geriatric risk measure, inadequate data quality, or incomplete follow-up resulting in unknown COVID-19 severity. The exposure of interest was the CCC19 geriatric risk index. The primary outcome was COVID-19 severity and the secondary outcome was 30-day all-cause mortality; both were assessed in the full dataset. Adjusted odds ratios (ORs) and 95% CIs were estimated from ordinal and binary logistic regression models.

FINDINGS

5671 patients with cancer and COVID-19 were included in the analysis. Median follow-up time was 56 days (IQR 22-120), and median age was 72 years (IQR 66-79). The CCC19 geriatric risk index identified 2365 (41·7%) patients as standard risk, 2217 (39·1%) patients as intermediate risk, and 1089 (19·2%) as high risk. 36 (0·6%) patients were excluded due to non-calculable geriatric risk index. Compared with standard-risk patients, high-risk patients had significantly higher COVID-19 severity (adjusted OR 7·24; 95% CI 6·20-8·45). 920 (16·2%) of 5671 patients died within 30 days of a COVID-19 diagnosis, including 161 (6·8%) of 2365 standard-risk patients, 409 (18·5%) of 2217 intermediate-risk patients, and 350 (32·1%) of 1089 high-risk patients. High-risk patients had higher adjusted odds of 30-day mortality (adjusted OR 10·7; 95% CI 8·54-13·5) than standard-risk patients.

INTERPRETATION

The CCC19 geriatric risk index was strongly associated with COVID-19 severity and 30-day mortality. Our CCC19 geriatric risk index, based on readily available clinical factors, might provide clinicians with an easy-to-use risk stratification method to identify older adults most at risk for severe COVID-19 as well as mortality.

FUNDING

US National Institutes of Health National Cancer Institute Cancer Center.

Outcomes following head and neck cancer surgery among older adults as determined by an electronic geriatric assessment

PURPOSE

Older adults with head and neck cancer have increased postoperative complications, longer hospital stays, and higher rates of mortality. Geriatric assessment (GA) provides a measure of overall health status and is preferable to using age alone for assessing fitness for surgery. We sought to determine whether a patient's frailty as determined by a novel electronic GA is associated with outcomes after head and neck cancer (HNC) surgery.

METHODS

We conducted a retrospective review of 159 patients aged 75 and older referred to the Geriatrics Service at Memorial Sloan Kettering Cancer Center for pre-operative evaluation prior to undergoing HNC surgery. All patients completed the electronic Rapid Fitness Assessment (eRFA) within 60 days prior to surgery. The accumulated geriatric deficit (AGD) score includes twelve domains from the eRFA with a point assigned for each domain in which there is a deficit and a final point related to comorbidities. Three other metrics were individually assessed: age, Karnofsky Performance Scale (KPS), and number of comorbidities. We utilized multivariable linear regression and t-tests to determine whether frailty is associated with longer length of hospital stay, 30-day intensive care unit (ICU) admission, and 30-day and 90-day postoperative mortality.

RESULTS

Patients with a higher AGD score spent more time in the hospital post-operatively (1.0 day increase per unit increase in AGD; 95% CI: 0.21-1.9; p = 0.015). Lower KPS was also associated with statistically significant longer length of stay (-2.70 day change per increasing index KPS; 95% CI: -4.30 - -1.00; days; p = 0.002), while age and comorbidity were not found to be statistically associated with length of stay. Higher AGD score remained significantly associated with longer length of stay on multivariable analysis (0.93 day increase per unit increase in AGD; 95% CI 0.15-1.71; p = 0.019). AGD was the only metric associated with increased risk of ICU admission (6.6 vs 5.0 geriatric deficits for those admitted vs not admitted to ICU; p = 0.024).

CONCLUSIONS

Frailty is associated with increased length of hospital stay and ICU admission in older adults with HNC undergoing surgery. GA can be used to counsel patients on the expected postoperative course.

Surgical resection for intraductal papillary mucinous neoplasm in the older population

BACKGROUND

Surgery for intraductal papillary mucinous neoplasm (IPMN) in older adults requires a careful balance of risk and benefit. We sought to analyze patient outcomes in the older individuals after pancreatic resection for IPMN.

METHODS

Retrospective analysis of a prospectively maintained database was performed for patients 65 years or older undergoing IPMN resection between January 1, 2012 and December 31, 2017. Statistical analysis was performed based on age and Memorial Sloan Kettering Frailty Index (MSKFI) score.

RESULTS

148 patients underwent resection of an IPMN, including five patients who required two operations for recurrent disease. Median age at surgery was 74 (range, 65-90 years), and 52% were male. Most patients underwent pancreaticoduodenectomy (53%) or distal pancreatectomy/splenectomy (35%). An associated adenocarcinoma was seen on pathology for 56 patients (37%). Median hospital length of stay was 7 days (range, 4-46 days). Grade 3 or higher post-operative complications on the Clavien-Dindo classification scale were seen in 20%. No patient died within 30-days. Patient outcomes were evaluated by age, split at age ≥75 (considered "elderly"), and separately by MSKFI score. No differences in post-operative morbidity or mortality was seen when stratified by age (65 - 74 vs > 75 years) or by MSKFI frailty score.

CONCLUSION

Pancreatic resection can be safely performed in selected patients 65 years and older with low morbidity and mortality. More analysis is needed to determine if MSKFI score is a useful predictor of complications in older individuals.

Remote Monitoring of the Performance Status and Burden of Symptoms of Patients With Gastrointestinal Cancer Via a Consumer-Based Activity Tracker: Quantitative Cohort Study

BACKGROUND

The number of older patients with gastrointestinal cancer is increasing due to an aging global population. Minimizing reliance on an in-clinic patient performance status test to determine a patient's prognosis and course of treatment can improve resource utilization. Further, current performance status measurements cannot capture patients' constant changes. These measurements also rely on self-reports, which are subjective and subject to bias. Real-time monitoring of patients' activities may allow for a more accurate assessment of patients' performance status while minimizing resource utilization.

OBJECTIVE

This study investigates the validity of consumer-based activity trackers for monitoring the performance status of patients with gastrointestinal cancer.

METHODS

A total of 27 consenting patients (63% male, median age 58 years) wore a consumer-based activity tracker 7 days before chemotherapy and 14 days after receiving their first treatment. The provider assessed patients using the Eastern Cooperative Oncology Group Performance Status (ECOG-PS) scale and Memorial Symptom Assessment Scale-Short Form (MSAS-SF) before and after chemotherapy visits. The statistical correlations between ECOG-PS and MSAS-SF scores and patients' daily step counts were assessed.

RESULTS

The daily step counts yielded the highest correlation with the patients' ECOG-PS scores after chemotherapy (P<.001). The patients with higher ECOG-PS scores experienced a higher fluctuation in their step counts. The patients who walked more prechemotherapy (mean 6071 steps per day) and postchemotherapy (mean 5930 steps per day) had a lower MSAS-SF score (lower burden of symptoms) compared to patients who walked less prechemotherapy (mean 5205 steps per day) and postchemotherapy (mean 4437 steps per day).

CONCLUSIONS

This study demonstrates the feasibility of using inexpensive, consumer-based activity trackers for the remote monitoring of performance status in the gastrointestinal cancer population. The findings need to be validated in a larger population for generalizability.

Association of frailty with 90-day postoperative mortality & geriatric comanagement among older adults with cancer

INTRODUCTION

Geriatric medical comanagement of older surgical patients with cancer is associated with lower 90-day postoperative mortality. Here, we investigate the hypothesis that this association varies on the basis of the degree of a patient's frailty.

METHODS

Frailty was assessed using the Memorial Sloan Kettering Frailty Index. Our hypothesis was evaluated using two approaches, both adjusted for age, sex, American Society of Anesthesiologists Physical Status, preoperative albumin, operating room duration, and estimated blood loss. A logistic regression was performed with 90-day mortality as the outcome and geriatric comanagement, continuous Memorial Sloan Kettering Frailty Index, and an interaction term between these two variables as the primary predictors. We then categorized frailty into four levels and, within each level, performed logistic regression with geriatric comanagement as the primary predictor and 90-day mortality as the outcome. Finally, we extracted the effect size and used a meta-analytic approach to test for heterogeneity.

RESULTS

Of 1687 patients aged ≥75 years who underwent elective cancer surgery with a length of stay of ≥1 day, 931 (55%) received comanagement; 31 patients (3.3%) who received comanagement died within 90 days, compared with 72 (9.5%) who did not. Ninety-day mortality was not statistically significantly different by degree of frailty in either analysis (interaction P = 0.4; test of heterogeneity P = 0.8).

CONCLUSION

Geriatric comanagement is valuable for all older surgical patients, not just the frail, and should be provided to as large a portion of the older surgical population as possible. Further research should examine predictors of response to geriatric comanagement.

Disparities in Care Management During Terminal Hospitalization Among Adults With Metastatic Cancer From 2010 to 2017

IMPORTANCE

Many patients with metastatic cancer receive high-cost, low-value care near the end of life. Identifying patients with a high likelihood of receiving low-value care is an important step to improve appropriate end-of-life care.

OBJECTIVE

To analyze patterns of care and interventions during terminal hospitalizations and examine whether care management is associated with sociodemographic status among adult patients with metastatic cancer at the end of life.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective, population-based cross-sectional study used data from the Healthcare Cost and Utilization Project to analyze all-payer, encounter-level information from multiple inpatient centers in the US. All utilization and hospital charge records from national inpatient sample data sets between January 1, 2010, and December 31, 2017 (n = 58 761 097), were screened. The final cohort included 21 335 patients 18 years and older at inpatient admission who had a principal diagnosis of metastatic cancer and died during hospitalization. Data for the current study were analyzed from January 1, 2010, to December 31, 2017.

EXPOSURES

Patient demographic characteristics, patient insurance status, hospital location, and hospital teaching status.

MAIN OUTCOMES AND MEASURES

Receipt of systemic therapy (including chemotherapy and immunotherapy), receipt of invasive mechanical ventilation, emergency department (ED) admission, time from hospital admission to death, and total charges during a terminal hospitalization.

RESULTS

Among 21 335 patients with metastatic cancer who had terminal hospitalizations between 2010 and 2017, the median age was 65 years (interquartile range, 56-75 years); 54.0% of patients were female; 0.5% were American Indian, 3.3% were Asian or Pacific Islander, 14.1% were Black, 7.5% were Hispanic, 65.9% were White, and 3.1% were identified as other; 58.2% were insured by Medicare or Medicaid, and 33.2% were privately insured. Overall, 63.2% of patients were admitted from the ED, 4.6% received systemic therapy, and 19.2% received invasive mechanical ventilation during hospitalization. Racial and ethnic minority patients had a higher likelihood of being admitted from the ED (Asian or Pacific Islander patients: odds ratio [OR], 1.43 [95% CI, 1.20-1.72]; P < .001; Black patients: OR, 1.39 [95% CI, 1.27-1.52]; P < .001; and Hispanic patients: OR, 1.45 [95% CI, 1.28-1.64]; P < .001), receiving invasive mechanical ventilation (Black patients: OR, 1.59 [95% CI, 1.44-1.75]; P < .001), and incurring higher total charges (Asian or Pacific Islander patients: OR, 1.35 [95% CI, 1.13-1.60]; P = .001; Black patients: OR, 1.23 [95% CI, 1.13-1.34]; P < .001; and Hispanic patients: OR, 1.50 [95% CI, 1.34-1.69]; P < .001) compared with White patients. Privately insured patients had a lower likelihood of being admitted from the ED (OR, 0.47 [95% CI, 0.44-0.51]; P < .001), receiving invasive mechanical ventilation (OR, 0.75 [95% CI, 0.69-0.82]; P < .001), and incurring higher total charges (OR, 0.64 [95% CI, 0.59-0.68]; P < .001) compared with Medicare and Medicaid beneficiaries.

CONCLUSIONS AND RELEVANCE

In this study, patients with metastatic cancer from racial and ethnic minority groups and those with Medicare or Medicaid coverage were more likely to receive low-value, aggressive interventions at the end of life. Further studies are needed to evaluate the underlying factors associated with disparities at the end of life to implement prospective interventions.

Electronic Geriatric Assessment: Is It Feasible in a Multi-Institutional Study That Included a Notable Proportion of Older African American Patients? (Alliance A171603)

PURPOSE

This study determined whether an electronic version of the geriatric assessment is feasible in a multi-institutional, diverse setting.

METHODS

Ten sites within the Alliance for Clinical Trials in Oncology participated. Patients who had active cancer or a history of cancer and were 65 years of age or older were eligible. The geriatric assessment was completed with an electronic data capture system that had been loaded onto iPads. Feasibility was defined a priori as completion in at least 70% of patients either with or without help. To enhance racial diversity, the original sample size was later changed and augmented by 50% with the intention of increasing enrollment of older minority patients.

RESULTS

A total of one hundred fifty-four patients were registered with a median age of 72 years (range, 65-91 years). Forty-three (28%) identified themselves as African American or Black. One hundred forty-one patients (92%) completed the electronic geriatric assessment. Feasibility was observed across all subgroups, regardless of race, education, performance status, comorbidities, and cognition; 124 patients (81%) completed the geriatric assessment without help. Reasons for not completing the geriatric assessment are as follows: clinic visit did not occur (n = 6), no iPad connection to the Internet (n = 3), patient declined (n = 2), prolonged hospitalization (n = 1), and patient died (n = 1). Reasons for needing help, as reported by study personnel, were as follows: the patient preferred that research personnel ask the questions (n = 9), vision problem (n = 3), lack of comfort with the iPad (n = 2), questions were not clear (n = 1), less proficient in English (n = 1), and challenge in pressing the green button to go to the next question (n = 1).

CONCLUSION

The electronic geriatric assessment is feasible in a multi-institutional setting that includes a notable proportion of African American or Black patients.

Intraoperative haemodynamics and postoperative intensive care unit admission in older patients with cancer

PURPOSE

Research on the impact of various intraoperative haemodynamic variables on the incidence of postoperative ICU admission among older patients with cancer is limited. In this study, the relationship between intraoperative haemodynamic status and postoperative intensive care unit admission among older patients with cancer is explored.

METHODS

Patients aged ≥75 who underwent elective oncologic surgery lasting ≥120min were analysed. Chi-squared and t-tests were used to assess the associations between intraoperative variables with postoperative intensive care unit admission. Multivariable regressions were used to analyse potential predict risk factors for postoperative intensive care unit admission.

RESULTS

Out of 994 patients, 48 (4.8%) were admitted to the intensive care unit within 30 days following surgery. Intensive care unit admission was associated with the presence of ≥4 comorbid conditions, intraoperative blood loss ≥100mL, and intraoperative tachycardia and hypertensive urgency. On multivariable analysis, operation time ≥240min (Odds Ratio [OR] = 2.29, p = 0.01), and each minute spent with intraoperative hypertensive urgency (OR = 1.06, p = 0.01) or tachycardia (OR = 1.01, p = 0.002) were associated with postoperative intensive care unit admission.

CONCLUSION

Intraoperative hypertensive urgency and tachycardia were associated with postoperative intensive care unit admission in older patients undergoing cancer surgery.

Assessment of Frailty Can Guide Decision Making for Utilization of Sentinel Lymph Node Biopsy in Patients with Thick Melanoma

BACKGROUND

Sentinel lymph node biopsy (SLNB) is often omitted in selected patients with advanced primary melanoma, although the justification/criteria for omission have been debated.

OBJECTIVE

We sought to determine whether assessment of frailty could serve as an objective marker to guide selection for SLNB in patients with advanced primary melanoma.

METHODS

Patients presenting with clinical stage IIC (ulcerated, > 4 mm Breslow thickness) cutaneous melanoma from January 1999 through June 2019 were included. Frailty was assessed using the Memorial Sloan Kettering Frailty Index (MSK FI), a composite score of functional status and medical comorbidities. Five-year melanoma-specific survival (MSS) and overall survival (OS) were estimated using Cox regression, and predictors of OS were identified using competing risk models.

RESULTS

MSS did not differ between patients who did (n = 451) or did not undergo SLNB (n = 179) [63.2% vs. 65.0%, p = 0.14]; however, omission of SLNB was associated with decreased 5-year OS (29% vs. 44%, p < 0.001). In a multivariable competing risk model, selection for SLNB omission was an independent predictor of death from non-melanoma causes (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.2-2.3, p < 0.001). After incorporation of the MSK FI score into the multivariable model in this subset, MSK FI (HR 2.4, 95% CI 1.5-4.1, p < 0.001), but not SLNB omission, was an independent predictor of poorer OS.

CONCLUSION

We observed worse OS in patients with thick melanoma selected not to undergo SLNB, which was attributed to death due to non-melanoma causes. Formal assessment of frailty may provide an objective prognostic measure to guide selective use of SLNB in these patients.

Disparity between the use of postoperative psychosocial and physical services among older adults with head and neck cancer

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Background: It is unclear whether older adults undergoing head and neck cancer (HNC) surgery have significant functional and mental health impairments perioperatively. We examined postoperative physical, nutritional and psychosocial service use among a cohort of older adults with HNC co-managed by geriatricians and surgeons. Methods: Our sample consisted of older adults who were referred to the Geriatrics Service at MSKCC between 2015-2019 and took a geriatric assessment (GA) prior to undergoing HNC surgery. Physical, nutritional and psychosocial service utilization during the patient’s stay was assessed. Physical services included a physical, occupational or rehabilitation consult. Nutritional services consisted of speech and swallow or nutritional consult. Psychosocial services consisted of a psychiatry, psychology, or social work consult. All patients were comanaged by geriatricians and surgeons. Relationships between each service use, all 12 geriatric deficits, demographic, and surgical characteristics were assessed using chi-squared analysis and t-test for continuous variables. Results: 159 patients (median age 81) were included. The median time in the OR was 342 min and the median length of stay (LOS) was 6 days. The most common GA impairments were major distress (61%), depression (59%), Social Activity Limitation (SAL) (53%) and deficits in Activities of Daily Living (ADL) (44%). Nutritional and physical services were used much more frequently than psychosocial services (79% and 85% vs 31%; p=.01 and p=.003, respectively). Lower ADL, increasing OR time and LOS were statistically associated with utilization of the three services and SAL was associated with a greater proportion of physical and psychosocial consults (Table). No demographic characteristics were associated with any of the services. Only 38% of patients with major distress and 40% of patients with depression had a mental health consult. In comparison, 93% of patients with an abnormal TUG had a physical consult and 92% of patients with weight loss greater than 10 pounds prior to surgery got a nutritional consult. Conclusions: Many older adults with head and neck cancer experience aging-related impairments. Physical impairments are more commonly addressed than psychosocial impairments. Future studies should aim to identify and overcome barriers to addressing psychosocial issues in HNC patients. [Table: see text]

Disparities in end-of-life inpatient care received by patients with metastatic cancer, 2010 to 2017

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Background: Many patients with metastatic cancer receive high-cost, low-value care near the end of life. We examined interventions during terminal hospitalizations for patients with metastatic cancer to identify those with high likelihood of receiving futile care. Methods: A retrospective population-based cohort analysis of encounter-level data from the National Inpatient Sample was conducted, including records from 2010-2017 for patients ages ≥18 with metastatic cancer who died during hospitalization. We fit multivariable binomial logistic regression models to examine associations between exposures, including patient demographics, and the main outcome of aggressive, low-value, and high-cost medical care (Table). Results: Out of 321,898 hospitalizations among patients with metastatic cancer, 21,335 (6.6%) were terminal. Of these, 65.9% were white, 14.1% Black, 7.5% Hispanic, 58.2% were insured by Medicare or Medicaid, and 33.2% were privately insured. Overall, 63.2% were admitted from the Emergency Department (ED), 4.6% received systemic therapy, and 19.2% received invasive ventilation. Median total charges were $43,681. Black patients and publicly insured patients had higher likelihoods of admission from the ED and receiving ventilation, as well as higher total charges; similar trends emerged among patients of Asian race and Hispanic ethnicity. Patients hospitalized at urban teaching hospitals had higher likelihoods of receiving systemic therapy, ventilation, and incurring higher total charges (Table). Conclusions: Metastatic cancer patients of racial and ethnic minority groups and those with Medicare or Medicaid were more likely to receive low-value, aggressive interventions at the end of life. Further studies are needed to determine the underlying causes of these disparities in order to implement prospective interventions and advance appropriate end-of-life care.[Table: see text]

Association of Memorial Sloan Kettering-Frailty Index with the postoperative intensive and specialized advanced care units admission among older adults with cancer

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Background: Understanding factors associated with poor surgical outcomes of older adults with cancer is necessary in identifying high risk patients and finding ways to mitigate poor outcomes following surgery. In this study, we evaluated whether frailty is associated with intensive postoperative healthcare utilization for this vulnerable population. Methods: This was a single hospital, retrospective cohort study, using the Memorial Sloan Kettering Frailty Index (MSK-FI) to define frailty, with higher MSK-FI corresponding to increased frailty. Multivariable logistic regression with random intercept models were used to assess the association between frailty and 30-day postoperative Intensive Care Unit (ICU) admission, and Specialized Advanced Care Unit (SACU) admission, separately. Covariates included surgical department, age, sex, surgical stress score, preoperative albumin level, and whether patients took a Beers criteria medication prior to surgery. Results: We identified 4417 patients over the age of 65 undergoing elective surgery between January 2015 and December 2018 at our institution and had a length of stay of at least one day. A quarter of patients had an MSK-FI score of 3 or greater. Among our patients, 3.8% (95% CI 3.2%, 4.4%), and 5.4% (95% CI 4.8%, 6.1%) were admitted to the ICU, and the SACU, respectively. We found evidence of an association between greater frailty and increased risk of ICU admission (OR per one-point increase in MSK-FI 1.44; 95% CI 1.31, 1.59; p-value < 0.001), and SACU admission (OR per one point increase in MSK-FI 1.46; 95% CI 1.33, 1.60; p-value < 0.001). For example, for a patient with an MSK-FI score of 2, the predicted risk of ICU admission is 2.2% and SACU admission is 1.1%, compared to 4.5% and 2.2%, respectively, for a patient with an MSK-FI score of 4, when all continuous covariates are set to the mean and the categorical covariates are set to the mode. Conclusions: Frailty based on the MSK-FI is associated with intensive postoperative care utilization in this population of older adults with cancer. Future studies should assess the impact of this information on surgery decision making for this vulnerable population.