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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

DISCUSSION

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

Building a SW program in a private hem/onc practice: Using the PHQ-9 as a starting point

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Background: Hematology/oncology patients historically have high need for social work support. Community practices lack the structure and financial support of hospital practices, often hindering the growth of social work programs. PHQ-9 is a 9-question multipurpose tool for depression screening, diagnosing, monitoring and intervening. This project assessed using the PHQ-9 as a central focus to build a SW program: staff education, EHR automaticity improvement, and enhancement of patient navigation to improve PHQ-9 compliance and patient interventions. Methods: In a multi-office Hem/Onc practice, patients complete the PHQ-9 self-assessment tool, data is entered by MAs, and MD completes an action item according to score. Interventions, which began 1/1/22, included having patients complete the PHQ-9 via a PRO application before visit, interfacing of PRO application with EHR (MA adds score to treatment plan), educating MAs importance of mental health monitoring in health care setting, generating new workflow for MA to send EHR message to SW and notify MD if high score obtained, rapid cycle review of data with MDs, and building out of SW department to accept referrals. Our primary endpoint was % of PHQ-9s completed of those scheduled (every six months). Secondary endpoint was total number of patients internally referred for SW services since 4/1/22 (when psychotherapy services became available). Results: From 7/1/21-12/31/21 (before implementation), of 22,492 visits, 72% had a PHQ-9 reported (with no ongoing monitoring or intervention). From 1/1/22-5/31/22, 88% of 18,655 visits had a PHQ-9 reported. 1,114 patients had a score of 10 or greater on the PHQ-9 between 1/1/22-5/31/22, and of those patients, 100% were assessed for social work intervention. 724 patients were offered referral for mental health services externally; 390 patients have been recommended for internal SW referral (72 have registered for psychotherapy to begin 7/1/22). Conclusions: Our results illustrate the ability to achieve engagement of a SW program in a private practice setting over a limited time by using the PHQ-9 as a primary focus. Education of all staff involved in the process is paramount and will be emphasized when rolling out future components of the SW program: support groups, educational lecture series, and other concrete services.

Is ECOG-PS ≥3 appropriate to guide rehabilitation referral decisions? Using patient-reported outcome measures to examine the prevalence of functional disability in patients with ECOG-PS 0-2

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Background: Outpatient physical or occupational therapy (PT/OT) can optimize cancer patients’ performance status and ability to complete instrumental activities of daily living (IADL). The American College of Sports Medicine recommends referral to PT/OT for those with Eastern Cooperative Oncology Group performance status (ECOG-PS) ≥3/5. However, ECOG-PS alone may not accurately indicate needs for PT/OT. We used functional patient reported outcome measures (F-PROM) to quantify the prevalence of functional disability for cancer patients with favorable ECOG-PS (0-2) starting a new line of systemic therapy. Methods: Patients with cancer at a multi-office community-based oncology private practice who were enrolled in a clinical trial (NCT04852575) completed a validated online geriatric assessment (the Cancer Aging Resiliency Evaluation) including F-PROM before starting a new line of systemic treatment. F-PROM included: Patient Reported Outcome Measurement System (PROMIS) - Cognitive Function (4 item, T-score = 41-80); impact of physical/emotional problems on social activities (social impact, 1-item); ability to walk one block (1-item); pain (0-10); and ability to perform nine IADL (3-point Likert scale). We extracted clinical characteristics from medical records, then used descriptive statistics and established F-PROM disability cut off to quantify the prevalence of functional disability. Results: Most patients (N = 86) were female (58%) and diagnosed with stage 3 or 4 (68%) breast (33%) or gastrointestinal cancer (24%). The mean±SD age was 64.3±10.7 years. ECOG was 0 (66%) or 1 (34%); none had ECOG-PS of >2. Across F-PROM, prevalence of disability ranged 24% (cognitive function) to 42% (social impact), see Table. IADL disability was reported by 31% of patients; median number of unique IADL disabilities was 3 (IQR = 1-4). Most common IADL disabilities were housework (29%), shopping (19%), ability to get to places out of walking distance (16%), and meal preparation (14%). Conclusions: Despite favorable ECOG-PS (0-1), 24 to 41% of patients starting a new line of systemic therapy in this study had one or more needs amendable to PT/OT. Future work should identify strategies to integrate F-PROM into routine oncology practice to identify rehabilitation needs and evaluate if subsequent PT/OT improves patient outcomes. Clinical trial information: NCT04852575. [Table: see text]

Prevalence of frailty for middle-aged and older adults starting a new line of systemic cancer treatment: Is age just a number?

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Background: Frailty is associated with adverse outcomes and increased risk of mortality for older adults (>60 years) with cancer. Geriatric assessment (GA) has gained popularity in routine cancer care as a clinical tool to screen for frailty in older adults starting a new line of cancer treatment, and to guide clinical decision making during systemic therapy. Emerging research indicates GA may also be useful to identify frailty in middle-aged adults (40-60 years) with cancer, but more research is needed. In this study, we used GA data to compare the prevalence of frailty between middle-aged and older adults starting a new line of systemic cancer treatment. Methods: Participants included adult patients with cancer due to begin a new line of systemic therapy at a multi-office community-based oncology private practice and enrolled in a clinical trial (NCT04852575). At baseline, participants completed an online version of the Cancer and Aging Resilience Evaluation (CARE) — a patient-reported GA adapted from the Cancer and Aging Research Group. Frailty score was constructed using a 44-item deficit accumulation method and categorized as frail (>0.35), pre-frail (0.2-0.35) or robust (0-0.2) using published cutoffs. We grouped participants by age, middle-aged (40-60 years) or older-aged (>60 years), then used independent t-test and chi-squared statistic to compare frailty scores (continuous) prevalence of frailty (categorical) between groups. Hypothesis testing was two sided and the level of significance was 0.05. Results: Participants ( n=96) were predominantly female (62%), Caucasian (68%) and beginning first line systemic therapy (69%) for either newly diagnosed cancer or new recurrence of disease; median time since diagnosis was 1 month. Common cancer types included: breast (34%), gastrointestinal (23%), hematologic (15%) and lung (12%). Disease stage was predominantly stage 3 (28%) or stage 4 (38%). When comparing middle-aged ( n=31, Mage = 54.74 ± 4.79, range = 41.23 – 59.98 years) vs. older adult -groups ( n=65, Mage = 70.27 ± 5.91, range = 60.64 – 84.29 years), there was no significant difference in mean frailty score ( p = 0.22) or the proportion categorized as frail vs. pre-frail vs. robust ( p = 0.32); see Table. Stage of disease and prevalence of common cancer types was similar between age groups (p>.05). Conclusions: In our cohort, middle and older aged patients who completed patient-report GA had similar prevalence of frailty before starting systemic therapy. Using the GA as a functional-age assessment to detect frailty for adults of varied ages could allow for earlier intervention aimed at impacting tolerance to therapy. Clinical trial information: NCT04852575. [Table: see text]

Evaluation of compliance of next-generation sequencing (NGS) testing in stage IV genitourinary (GU) cancer patients (pts) and the effect of an EHR prompt (EP) on increasing frequency

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Background: Previous reports have found that NGS testing on stage IV GU cancer patients is performed less commonly than expected based on the prevalence of GU tumors in comparison to other tumor types. In addition, most of the data on NGS testing frequency has been in the academic setting. This study will look at NGS testing in stage IV GU pts in the private practice setting. Methods: In the retrospective portion of the study, we used algorithms in Flatiron’s OncoEMR to identify baseline NGS testing frequency in all stage IV GU cancer patients. In the prospective portion, we used an EP to communicate with doctors about their stage IV GU cancer pts with upcoming appointments. Our primary endpoint was to determine the percentage of stage IV GU pts who had NGS testing; our secondary endpoint was to determine how often NGS testing would provide an alternative therapeutic option. Results: 91 stage IV GU cancer pts were identified retrospectively from 6/1/2020-12/31/2020. 20 (22%) of them had had NGS testing: 12 of 68 (18%) prostate cancer pts, 6 of 13 (46%) bladder cancer pts and 2 of 10 (20%) kidney cancer pts. Prospectively, 65 patients with Stage IV GU cancer and upcoming appointments were identified between 8/23/2021-9/13/2021. 17 (26%) had previously had NGS testing: 10 of 46 (22%) prostate pts, 4 of 9 (44%) bladder pts, and 3 of 10 (30%) kidney pts. The EP prompted additional testing of 10 pts. Of the total 27 pts, 8 (30%) were found to have actionable mutations: 7 of 17 (41%) prostate pts and 1 of 6 (17%) bladder pts. 6 of the 8 actionable mutations were either BRCA1/BRCA2 or PALB2. Conclusions: Our results supported those previously reported in academic settings which found that GU cancers were less likely than other metastatic cancers to have NGS testing performed. Prostate cancer was the least likely of the GU cancers to have NGS testing, however, the findings highlight the importance of germline testing in this population. A longer term study may have further borne out the benefits of EP. Improved communication (huddles, multidisciplinary rounds, etc.) would likely increase compliance with NGS testing as would automated order sets and “hard stops” in the EMR. As trials and standard options for GU cancers increase, physician ordering of NGS will follow. Universal NGS testing should be the goal of all stage IV GU patients to maximize therapeutic options.

Utilization of next generation sequencing (NGS) in stage IV gastrointestinal (GI) cancer patients (pts) and efficacy of electronic reminder notification (ERN) in improving utilization of NGS in the private practice community-based setting

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Background: NGS testing allows for identification of genetic mutations/alterations that can be important in determining treatment options for advanced cancer pts. The National Comprehensive Cancer Network (NCCN) includes NGS testing as part of standard of care for many tumor types including stage IV pancreatic cancer, colon cancer, and rectal cancer and all other GI solid tumor types. Previous reports have described the utilization of NGS in clinical practice at academic centers. To our knowledge this is the first report in the private practice setting. Methods: For the historical portion, we established baseline data to quantify NGS testing frequency in stage IV GI tumor pts in our community based oncology practice by performing a retrospective chart review. In the prospective portion, the intervention of an ERN was used to alert treating physicians if NGS had not been done. Primary endpoint is the percent (%) of pts with NGS sent compared to historical control. Secondary endpoint is the % of pts with targeted therapy options made available to them. Results: In a private practice multi-office setting, 200 charts of pts with stage IV GI cancer using Flatiron’s OncoEMR software were reviewed for the retrospective cohort between July 1 to December 31, 2020. Of the 200, 44.5% (89 pts) had colon cancer, 17.5% (35 pts) had pancreatic cancer, 15% (30 pts) had rectal cancer, and 23% (46 pts) had other types of GI cancer. Of these, 87 (43.5%) pts had NGS testing; of which 41 of 89 (46.0%) are colon pts, 13 of 35 (37.1%) are pancreatic pts and 16 of 30 (53.3%) are rectal pts. For the prospective portion, between July 1 and August 15, 2021 each physician’s schedule was evaluated and an ERN was sent shortly before each Stage IV GI pt was to be seen. A total of 114 pts were reviewed, and 92 (79%) had NGS sent. Of these, 47 pts of 54 (87%) are colon pts, 12 of 15 (80%) are pancreatic pts, 16 of 21(76%) are rectal pts, and 17 of 24 (70%) are pts with other GI cancer. 2% of pts with NGS testing had a potentially actionable mutation identified. Conclusions: NGS testing is standard of care for pts with stage IV GI cancer that wish to pursue therapy. ERN was minimally helpful in increasing NGS testing. This may be in part due to the effect of the practice's emphasis on NGS testing, which increased its baseline prospective testing rate. Increased use of a team based approach in the office would be a key element to increasing compliance with the current workflow as well as use of pathways which embed the NGS testing into the treatment plan. A more robust EMR would also be vital in increasing NGS testing rates by the use of automatic reminders or order sets. Better support of the physician and use of multiple touch points is necessary until full automation is utilized for NGS testing.

Patient-Centered Standards for Medically Integrated Dispensing: ASCO/NCODA Standards

PURPOSE

To provide standards for medically integrated dispensing of oral anticancer drugs and supportive care medications.

METHODS

An Expert Panel was formed, and a systematic review of the literature on patient-centered best practices for the delivery of oral anticancer and supportive care drugs was performed to April 2019 using PubMed and Google Scholar. Available patient-centered standards, including one previously developed by the National Community Oncology Dispensing Association (NCODA), were considered for endorsement. Public comments were solicited and considered in preparation of the final manuscript.

RESULTS

A high-quality systematic review that was current to May 2016 was adopted into the evidence base. Five additional primary studies of multifaceted interventions met the inclusion criteria. These studies generally included a multicomponent intervention, often led by an oncology pharmacist, and also included patient education and regular follow-up and monitoring. These interventions resulted in significant improvements to patient quality and safety and demonstrated improvements in adherence and other patient outcomes.

CONCLUSION

The findings of the systematic review were consistent with the NCODA patient-centered standards for patient relationships and education, adherence, safety, collection of data, documentation, and other areas. NCODA standards were adopted and used as basis for these American Society of Clinical Oncology/NCODA standards. Additional information is available at www.asco.org/mid-standards .

Co-management of elevated glucose in chemotherapy patients in the community: Working with primary care physicians

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Background: Approximately 8-18% of oncology patients also have diabetes. A diabetes diagnosis increases the risk of recurrence by 21% and decreases both overall and cancer-related 5-year survival. Chemotherapy has also been associated with hyperglycemia in non-diabetic patients. At one office in a multi-site outpatient oncology practice in central New Jersey, 13% of 904 chemotherapy patients treated between August 1, 2018 and October 31, 2018 had blood glucose greater than 200 mg/dL. Community practice models post a challenge to coordinated multidisciplinary care. Methods: Between 12/1/18 and 4/1/19, weekly lab reports were run revealing all active chemotherapy patients with glucose levels greater than 200. The initial run in period was 12/1/18-1/31/19, and follow up for the group (while on chemotherapy) was from 2/1/19-4/1/19. Patients and their primary medical doctors (PMDs) were contacted within 2 weeks of lab draw, labs and recent chemotherapy history shared and all communication was documented. Patients with > one blood glucose above 200 were contacted monthly. Concurrent steroid use with chemotherapy and addition/adjustment of antihyperglycemics was also studied. Results: Of 324 patients who entered into the study between 12/1/18 and 1/3/19, 42 had baseline elevated glucose levels. 36 (85%) of the 42 were on concomitant corticosteroids. During the follow up period, 10 (23%) had elevated glucose levels over 200, 32 (76%) patients had levels under 200 consistently. 12 of the 32 (30%) of those patients had documented diabetic medication adjustments. Oncology/PCP communication was documented in 35 (83%) charts compared with 0% prior to the intervention, amongst our office and PMDs. Percentage of patients who saw their PCP during the intervention time will also be presented. Conclusions: Working more closely with PCPs and better electronic data sharing is needed in the community setting. Accurate medication lists and history sharing are critical to optimal multidisciplinary community care. Management of elevated glucose in oncology patients is challenging and multi factorial.

Treatment outcome for metastatic papillary renal cell carcinoma patients

BACKGROUND

Most clinical trial reports in metastatic renal cell carcinoma (RCC) do not distinguish between histologic subtypes, making it difficult to assess specific treatment efficacy. The current retrospective study sought to define clinical features and outcome data for metastatic papillary RCC.

METHODS

Clinical features, treatment outcome, and survival were evaluated in 38 patients with metastatic papillary RCC who underwent clinical evaluation at Memorial Sloan-Kettering Cancer Center (MSKCC) between 1985 and 2005. Twenty-three of 513 individuals were identified from a clinical trial database, 14 of 1895 from a surgery database, and 1 of 357 from a pathology database. A literature review of systemic therapy in metastatic papillary RCC was performed.

RESULTS

Among the 38 patients, 30 had been treated at MSKCC with various systemic therapies, including cytokines. Twelve therapies resulted in stable disease, 30 in initial progression of disease, and 1 in an unknown response. One patient had a partial response to sunitinib, a novel multitargeted tyrosine kinase inhibitor. The median overall survival time for the entire study group was 8 months (95% confidence interval, 5-12). A literature review on treatment of metastatic papillary RCC produced 4 reports, confirming a lack of efficacy for systemic therapy.

CONCLUSIONS

A resistance to systemic therapy characterizes patients with metastatic papillary RCC. Further understanding of the genetics and molecular biology and subtypes involved may provide the basis for more effective agents. Treatment with targeted therapies or other experimental agents is warranted.

Long-term response with sunitinib for metastatic renal cell carcinoma

A 65-year-old man with metastatic renal cell carcinoma developed progressive disease after treatment with interferon-alpha. He began treatment with sunitinib, a multitargeted tyrosine kinase inhibitor, on clinical trial. The patient achieved a partial response after two cycles of therapy, with a durable response continuing after 2 years of treatment. This case report illustrates the long-term response to sunitinib for patients with metastatic renal cell carcinoma.

A phase II trial of 17-(Allylamino)-17-demethoxygeldanamycin in patients with papillary and clear cell renal cell carcinoma

The aim of this study was to determine the antitumor activity of 17-(Allylamino)-17-demethoxyge-ldanamycin (17-AAG), a heat shock protein 90(hsp90) inhibitor in patients with metastatic papillary renal cell carcinoma (RCC) or metastatic clear cell RCC. Eligible patients were divided into 2 cohorts based on histological subtype: papillary or clear cell RCC. All patients had advanced RCC with measurable disease, a Karnofsky performance status of at least 70, and no evidence of brain metastases. Twelve patients with clear cell RCC and 8 patients with papillary RCC were treated with 17-AAG on this phase II trial. 17-AAG was given intravenously at 220 mg/m(2) twice weekly for 2 weeks followed by a week of rest. Cycle length was 21 days. No patient in either cohort achieved a complete or partial response. Toxicities included elevated liver function tests, optic neuritis, dyspnea, fatigue, and gastrointestinal side effects. Six of the 20 patients required dose reduction. At the dose and schedule used in this trial, 17-AAG did not achieve objective response in the treatment of clear cell or papillary renal cell carcinoma patients.

Incidence of late-relapse germ cell tumor and outcome to salvage chemotherapy

PURPOSE

To define the incidence, clinical features, and outcome to salvage chemotherapy in patients with late-relapse germ cell tumor (GCT) after a complete response to first-line chemotherapy.

PATIENTS AND METHODS

Two patient populations were examined. First, retrospective analysis of 246 patients treated on a clinical trial with salvage chemotherapy was performed; 29 patients with late-relapse GCT were identified and evaluated for treatment outcome and survival. Salvage regimens included paclitaxel, ifosfamide, and cisplatin, single agents, or a high-dose chemotherapy program. Second, the incidence of late relapse was assessed by retrospective analysis of 551 patients after a complete response (CR) to first-line chemotherapy.

RESULTS

Twenty-nine patients received salvage chemotherapy on a clinical trial for late relapse GCT. The median survival was 23.9 months. At a median follow-up of 50.6 months, there were nine survivors. The chemotherapy regimens varied, but the only CRs were observed in patients treated with paclitaxel, ifosfamide, and cisplatin. Seven (50%) of 14 patients treated with paclitaxel, ifosfamide, and cisplatin achieved a continuous CR. Among the second population of 551 patients who had previously achieved a CR to a first-line chemotherapy trial, 17 were identified as having a late relapse (3%). The median time to relapse for these 17 patients was 7.8 years.

CONCLUSION

Late-relapse GCT is uncommon and is associated with a poor prognosis resulting from a high degree of resistance to chemotherapy. Chemotherapy with paclitaxel, ifosfamide, and cisplatin followed by surgery may be effective in patients with late-relapse GCT who are not considered candidates for primary surgery.