Effect of Intensive Chemotherapy on Physical, Cognitive, and Emotional Health of Older Adults with Acute Myeloid Leukemia

Measurement of the major ignored burden of multiple myeloma, pernicious anaemia and of other haematological conditions on partners and family members: A cross-sectional study

BACKGROUND

Having a haematological condition can adversely affect the quality of life (QoL) of family members/partners of patients. It is important to measure this often ignored burden in order to implement appropriate supportive interventions.

OBJECTIVE

To measure current impact of haematological conditions on the QoL of family members/partners of patients, using the Family Reported Outcome Measure-16 (FROM-16).

METHODS

A cross-sectional study, recruited online through patient support groups, involved UK family members/partners of people with haematological conditions completing the FROM-16.

RESULTS

183 family members/partners (mean age = 60.5 years, SD = 13.2; females = 62.8%) of patients (mean age = 64.1, SD = 12.8; females = 46.4%) with 12 haematological conditions completed the FROM-16. The FROM-16 mean total score was 14.0 (SD = 7.2), meaning 'a moderate effect on QoL'. The mean FROM-16 scores of family members of people with multiple myeloma (mean = 15.8, SD = 6.3, n = 99) and other haematological malignancies (mean = 13.9, SD = 7.8, n = 29) were higher than of people with pernicious anaemia (mean = 10.7, SD = 7.5, n = 47) and other non-malignant conditions (mean = 11, SD = 7.4, n = 56, p < .01). Over one third (36.1%, n = 183) of family members experienced a 'very large effect' (FROM-16 score>16) on their quality of life.

CONCLUSIONS

Haematological conditions, in particular those of malignant type, impact the QoL of family members/partners of patients. Healthcare professionals can now, using FROM-16, identify those most affected and should consider how to provide appropriate holistic support within routine practice.

"A strong reason why I enjoy coming to work": Clinician acceptability of a palliative and supportive care intervention (PACT) for older adults with acute myeloid leukemia and their care partners

INTRODUCTION

Studies about clinician acceptability of integrative palliative care interventions in the inpatient and outpatient cancer settings are limited. In this study, we examined clinician acceptability of a NIH-funded interdisciplinary PAlliative and Supportive Care inTervention (PACT) for older adults with acute myeloid leukemia (AML) and their care partners that transcends both inpatient and outpatient settings.

MATERIALS AND METHODS

Data was collected using semi-structured interviews with clinicians who were directly involved in PACT. The domains of the Theoretical Framework of Acceptability were used to guide the qualitative analysis.

RESULTS

The clinicians consisted of occupational therapists (37%), physical therapists (25%), registered nurses (25%), and a clinical rehabilitation manager (13%). Five themes were identified in the thematic analysis: (1) Emotions and affect towards the intervention, (2) Intervention coherence and self-efficacy, (3) Barriers, burden, and opportunity costs of delivering the intervention, (4) Usefulness and effectiveness of the intervention, and (5) Recommendations to improve intervention delivery.

DISCUSSION

All clinicians found the PACT intervention highly acceptable and expressed the positive impact of the intervention on job fulfillment and satisfaction. Our findings provide evidence to inform the delivery and implementation of future large scale integrative palliative care intervention trials.

Cognitive Function in Adults With Acute Myeloid Leukemia Treated With Chemotherapy: A Systematic Review

BACKGROUND

Chemotherapy is essential for treating acute myeloid leukemia (AML). Previous studies concluded that survivors of cancer who were treated with chemotherapy experience cognitive impairment. Therefore, it is important to understand cognitive function in survivors of AML.

OBJECTIVE

The aim of this study was to explore distributions and correlates of cognitive function, and prediction of cognitive function on other outcomes in adults with AML who were treated with chemotherapy.

METHODS

A health science librarian systematically searched PubMed, CINAHL, PsycINFO, and EMBASE databases. Two reviewers independently conducted the title, abstract, and full-text screening. Data were extracted and synthesized based on the aims of the review.

RESULTS

A total of 10 articles were included. Findings indicate that up to 62.2% of adults with AML experienced impaired cognitive function after starting chemotherapy. Three studies found cognitive function remained stable over time. Education and cytokines were potential correlates of cognitive function. Worse cognitive function may predict lower physical performance and higher mortality, although the results were inconsistent across studies.

CONCLUSION

Impaired cognitive function was observed in adults with AML who were treated with chemotherapy. However, no study used a validated subjective cognitive-function-specific patient-reported questionnaire, and previous studies focusing on cognitive function included relatively young samples. Hence, further research on cognitive function in older adults with AML is needed.

IMPLICATIONS FOR PRACTICE

Because of the high prevalence of cognitive impairment identified, it is important to screen cognitive function in adults with AML who are planning to receive chemotherapy to intervene and provide support earlier.

Exercise and inflammatory cytokine regulation among older adults with myeloid malignancies

Tumor necrosis factor (TNF)α is a major regulator of inflammation. However, the epigenetic regulation of TNFα in the context of an exercise intervention among older adults with cancer is understudied. In this exploratory analysis, we used data from a single-arm mobile health (mHealth) exercise intervention among older adults with myeloid malignancies to 1) assess changes in TNFα promoter methylation, TNFα mRNA expression, serum TNFα and other related-cytokine levels after intervention; and 2) assess correlations between blood markers and exercise levels. Twenty patients were included. From baseline to post-intervention, there was no statistical changes in TNFα promoter methylation status at seven CpG sites, TNFα mRNA expression, and serum TNFα levels. Effect sizes, however, were moderate to large for several CpG sites (-120, -147, -162, and -164; Cohen's d = 0.44-0.75). Median serum TNFα sR1 levels increased (83.63, IQR 130.58, p = 0.06; Cohen's d = 0.18) but not the other cytokines. Increases in average daily steps were correlated with increases in TNFα promoter methylation at CpG sites -147 (r = 0.48; p = 0.06) and -164 (r = 0.51; p = 0.04). Resistance training minutes were negatively correlated with TNFα promoter methylation at CpG site -120 (r = -0.62; p = 0.02). All effect sizes were moderate to large. In conclusion, after a mHealth exercise intervention, we demonstrated changes with moderate to large effect sizes in several CpG sites in the TNFα promoter region. Exercise levels were correlated with increases in TNFα promoter methylation. Larger exercise trials are needed to better evaluate TNFα regulation to inform interventions to augment TNFα regulation in order to improve outcomes in older adults with cancer.

Treating acute myelogenous leukemia in patients aged 70 and above: Recommendations from the International Society of Geriatric Oncology (SIOG)

Acute myeloid leukemia (AML) treatment is challenging in older patients. There is a lack of evidence-based recommendations for older patients ≥70, a group largely underrepresented in clinical trials. With new treatment options being available in recent years, recommendations are needed for these patients. As such the International Society of Geriatric Oncology (SIOG) assembled a task force to review the evidence specific to treatment and outcomes in this population of patients ≥70 years. Six questions were selected by the expert panel in domains of (1) baseline assessment, (2) frontline therapy, (3) post-remission therapy, (4) treatment for relapse, (5) targeted therapies, and (6) patient reported outcome/function and enhancing treatment tolerance. Information from current literature was extracted, combining evidence from systematic reviews/meta-analyses, decision models, individual trials targeting these patients, and subgroup data. Accordingly, recommendations were generated using a GRADE approach upon reviewing current evidence by consensus of the whole panel. It is our firm recommendation and hope that direct evidence should be generated for patients aged ≥70 as a distinct group in high need of improvement of their survival outcomes. Such studies should integrate information from a geriatric assessment to optimize external validity and outcomes.

Associations of frailty with symptoms, and HRQOL in older cancer survivors after cancer treatments: a systematic review and meta-analyses

PURPOSE

Frailty in older adult cancer survivors after cancer treatments is associated with various health outcomes. However, there is less agreement on how frailty affects symptoms and health-related quality of life (HRQOL). This systematic review and meta-analysis aimed to evaluate the current literature on frailty, symptoms, and HRQOL, as well as the associations of frailty with these factors in older adult cancer survivors with chemotherapy.

METHODS

A review was conducted on peer-reviewed publications from 2008 to 2023, using seven electronic databases. Meta-analyses were performed using random effects models to determine pooled effect estimates for frailty prevalence, symptom severity, and HRQOL scores.

RESULTS

A total of 26 studies involving older cancer survivors were included in the analysis. Most of these studies were conducted in Western countries and focused on White survivors, particularly those with breast cancer. The mean pooled prevalence of frailty was 43.5%. Among frail survivors, the most common symptoms reported after cancer treatments were pain (36.4%), neuropathy (34.1%), and fatigue (21.3%). Frailty was associated with higher pooled mean symptom severity (B = 1.23, p = 0.046) and lower functional HRQOL (B = - 0.31, p = 0.051, with marginal significance) after cancer treatments.

CONCLUSION

Frail older cancer survivors are at high risk of adverse symptoms and poor HRQOL after cancer treatment. Further research on screening for frailty is needed to prevent older adults from developing worse symptoms burden and maintain HRQOL. It is also essential to understand the mechanisms of the associations between frailty, symptoms and HRQOL in this population.

Determining treatment tolerance and fitness for intensive chemotherapy in older adults with AML: a call to action

ABSTRACT

Determining fitness for intensive chemotherapy in an older adult with acute myeloid leukemia (AML) is an unanswered age-old question. Geriatric assessment captures any variation in multidimensional health, which can influence treatment tolerance. A prospective study is necessary to validate fitness criteria, determine whether geriatric assessment-based fitness performs superiorly to other criteria, and what components of geriatric assessment are associated with treatment tolerance. A validation study should enroll diverse patients from both academic and community centers and patients receiving intensive and lower-intensity chemotherapy. Geriatric assessment should include at minimum measures of comorbidity burden, cognition, physical function, and emotional health, which in previous smaller studies have shown to be associated with mortality in AML. These assessments should be completed before or within a few days of initiation of chemotherapy to reduce the influence of chemotherapy on the assessment results. Treatment tolerance has been measured by rates of toxicities in patients with solid malignancies; however, during the initial treatment of AML, rates of toxicities are very high regardless of treatment intensity. Early mortality, frequently used in previous studies, can provide a highly consequential and easily identifiable measure of treatment tolerance. The key end point to assess treatment tolerance, thus, should include early mortality. Other end points may include decline in function and quality of life and treatment modifications or cessation due to toxicities. Validating fitness criteria can guide treatment selection and supportive care interventions and are crucial to guide fitness-based trial eligibility, inform the interpretation of trial results, and facilitate drug labeling.

Longitudinal changes in cognitive and physical function and health-related quality of life in older adults with acute myeloid leukemia

INTRODUCTION

Many older adults with acute myeloid leukemia (AML) do not receive chemotherapy because of physicians' and patients' concern for toxicities and functional decline. This highlights the critical and urgent need to generate knowledge of functional changes following new treatments.

MATERIALS AND METHODS

As a part of a pragmatic single-center trial, 59 older adults ≥60 years with AML completed geriatric assessment and health-related quality of life measures before treatment and at one month and three months after chemotherapy initiation. Changes in scores of various geriatric assessment measures were computed by subtracting the baseline score from the one-month and three-month scores for each patient. Established cut-offs were used to determine a clinically meaningful change (improvement or worsening). This study provides results of descriptive exploratory analyses.

RESULTS

Patients experienced significant comorbidity burden and a high prevalence of functional impairments before treatment, with 56% of patients having ≥2 comorbid conditions, 69% having abnormal cognitive function (using Montreal Cognitive Assessment), 69% having impaired objective physical function (using Short Physical Performance Battery), and 64% having a positive depression screen (Patient Health Questionnaire-9). Patients (n = 53) received treatment with predominantly low-intensity chemotherapy; six patients received intensive chemotherapy. Among those who completed some or all of the three-month evaluation (N = 43), from baseline before treatment to three months later, cognitive function improved (38.7%) or remained stable (38.7%), objective physical function improved (51.6%) or remained stable (22.6%), and depression scores improved (9.4%) or remained stable (53.1%). Global health status score and role functioning moderately improved by a score of >16.

DISCUSSION

An exploratory analysis of our phase 2 trial demonstrated improvement or stabilization of cognitive and physical function and depression score at three months in a high proportion of older survivors of AML, despite a high prevalence of frailty and significant comorbidity burden at baseline. These results demonstrate success of treatment in improving cognitive and physical function and depression score, and, if confirmed in larger studies, should encourage oncologists to offer chemotherapy to older adults with AML.

CLINICAL TRIAL REGISTRATION

The study is registered in the ClinicalTrials.gov ID: NCT03226418.

Baseline correlates of frailty and its association with survival in United States veterans with acute myeloid leukemia

Frailty is an important construct to measure in acute myeloid leukemia (AML). We used the Veterans Affairs Frailty Index (VA-FI) - calculated using readily available data within the VA's electronic health records - to measure frailty in U.S. veterans with AML. Of the 1166 newly diagnosed and treated veterans with AML between 2012 and 2022, 722 (62%) veterans with AML were classified as frail (VA-FI > 0.2). At a median follow-up of 252.5 days, moderate-severely frail veterans had significantly worse survival than mildly frail, and non-frail veterans (median survival 179 vs. 306 vs. 417 days, p < .001). Increasing VA-FI severity was associated with higher mortality. A model with VA-FI in addition to the European LeukemiaNet (ELN) risk classification and other covariates statistically outperformed a model containing the ELN risk and other covariates alone (p < .001). These findings support the VA-FI as a tool to expand frailty measurement in research and clinical practice for informing prognosis in veterans with AML.

Geriatric Assessment in Acute Myeloid Leukemia

BACKGROUND

Acute myeloid leukemia (AML) is a heterogenous disease that affects mostly older adults with varying baseline health and functional status. Treatment options have expanded for older adults, ranging from less intensive chronic therapies to intensive induction strategies with curative intent. Despite this, outcomes remain poor with advancing age due to underlying disease biology and variability in treatment tolerance. Reliance on chronological age alone, however, increases risks of both over- and under-treatment. Strategies to better characterize fitness in the context of therapy are needed to optimize decision-making and enhance clinical trial design.

SUMMARY

Geriatric assessment (GA) is a series of validated tools that evaluate multiple health and functional domains of an older adult including physical function, comorbidities, cognition, nutrition, psychological health, and social support. While studies of GA in AML remain limited, current evidence shows that it is feasible to perform GA among older adults starting therapy for AML. GA measures including those assessing physical function, cognition, and mood are associated with mortality and toxicity in both intensive and less intensive treatment settings.

KEY MESSAGES

In this review, we discuss the existing evidence to support use of GA in AML and highlight implications for clinical practice and future research.

Dynamic changes in physical function during intensive chemotherapy affect transplant outcomes in older adults with AML

Introduction

Intensive chemotherapy (IC) can affect all geriatric assessment (GA) domains in older adults with acute myeloid leukemia (AML), but data on the effects of these changes on transplant outcomes are lacking.

Methods

Therefore, we prospectively assessed the prognostic role of GA domains at diagnosis and allogeneic hematopoietic stem cell transplantation (allo-HSCT) in 51 patients with AML aged ≥60 years who achieved complete remission after IC. We performed both baseline and pre-allo-HSCT GA; moreover, physical function, including a short physical performance battery (SPPB), cognitive function, psychological function, nutritional status, and social support were examined.

Results

All GA domains showed dynamic changes between the two time points. The directions of change were statistically significant for social support, self-reported physical and psychological functions, and distress, but not for nutritional status, cognitive function, or physical function. Among all GA domains at each time point, only poor physical function and its submaneuvers at diagnosis but not at allo-HSCT were significantly associated with inferior survival. In particular, since the direction of change varied between patients, we found that patients whose physical function improved before allo-HSCT were more likely to survive longer than those with persistently impaired SPPB (55.6% vs. 28.6%, p=0.268). Finally, persistent impairment in SPPB (28.6% vs. 65.9%, p=0.006), tandem stand (0% vs. 63.3%, p=0.012), sit-and-stand (41.2% vs. 70.6%, p=0.009), and gait speed (38.5% vs. 68.4%, p=0.027) further strongly predicted inferior survival.

Discussion

This study showed that IC courses can induce dynamic changes in different directions in the GA domains of each patient and that changes in objectively measured physical function can predict transplant outcomes.

Exercise and epigenetic ages in older adults with myeloid malignancies

BACKGROUND

Older adults with myeloid malignancies are susceptible to treatment-related toxicities. Accelerated DNAm age, or the difference between DNA methylation (DNAm) age and chronological age, may be used as a biomarker of biological age to predict individuals at risk. In addition, cancer treatment can also lead to accelerated DNAm age. Exercise is a promising intervention to reduce or prevent functional, psychological, and cognitive impairments in older patients with myeloid malignancies, yet there is little evidence of the effects of exercise on DNAm age. We explored (1) the associations of accelerated DNAm age with physical, psychological, and cognitive functions at baseline; (2) changes in DNAm age from baseline to post-intervention; and (3) the associations of changes in accelerated DNAm age with changes in functions from baseline to post-intervention.

METHODS

We enrolled older patients with myeloid malignancies to a single-arm pilot study testing a mobile health (mHealth) exercise intervention that combines an exercise program (EXCAP©®) with a mobile application over 2 cycles of chemotherapy (8-12 weeks). Patients completed measures of physical, psychological, and cognitive functions and provided blood samples for analyses of DNAm age at baseline and post-intervention. Paired t-tests or Wilcoxon signed rank tests assessed changes in DNAm ages, and Spearman's correlation assessed the relationships between accelerated ages and functions.

RESULTS

We included 20 patients (mean age: 72 years, range 62-80). Accelerated GrimAge, accelerated PhenoAge, and DunedinPACE were stable from baseline to post-intervention. At baseline, DunedinPACE was correlated with worse grip strength (r = -0.41, p = 0.08). From baseline to post-intervention, decreases in accelerated GrimAge (r = -0.50, p = 0.02), accelerated PhenoAge (r = - 0.39, p = 0.09), and DunedinPace (r = - 0.43, p = 0.06) were correlated with increases in distance walked on 6-min walk test. Decreases in accelerated GrimAge (r = - 0.49, p = 0.03), accelerated PhenoAge (r = - 0.40, p = 0.08), and DunedinPace (r = - 0.41, p = 0.07) were correlated with increases in in grip strength.

CONCLUSIONS

Among older adults with myeloid malignancies receiving chemotherapy, GrimAge and PhenoAge on average are stable after a mHealth exercise intervention. Decreases in accelerated GrimAge, accelerated PhenoAge, and DunedinPACE over 8-12 weeks of exercise were correlated with increased physical performance. Future trials assessing the effects of exercise on treatment-related toxicities should evaluate DNAm age. Trial registration Clinicaltrials.gov identifier: NCT04981821.

Advance care planning in older patients with acute myeloid leukemia and myelodysplastic syndromes

INTRODUCTION

Older patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) have worse survival rates compared to younger patients, and experience more intense inpatient healthcare at the end of life (EOL) compared to patients with solid tumors. Advance care planning (ACP) has been shown to limit aggressive and burdensome care at EOL for patients with AML and MDS. The purpose of this study was to better understand ACP from the perspective of clinicians, older patients with AML and MDS, and their caregivers.

MATERIALS AND METHODS

We conducted semi-structured interviews with 45 study participants. Interviews were audio-recorded and transcribed. Open coding and focused content analysis were used to organize data and develop and contextualize categories and subcategories.

RESULTS

Guided by our specific aims, we developed four themes: (1) The language of ACP and medical order for life-sustaining treatment (MOLST) does not resonate with patients, (2) There is no uniform consensus on when ACP is currently happening, (3) Oncology clinician-perceived barriers to ACP (e.g., patient discomfort, patient lack of knowledge, and lack of time), and (4) Patients felt that they are balancing fear and hope when navigating their AML or MDS diagnosis.

DISCUSSION

The results of this study can be used to develop interventions to promote serious illness conversations for patients with AML and MDS and their caregivers to ensure that patient care aligns with patient values.

How Caregivers Cope and Adapt When a Family Member Is Diagnosed With a Hematologic Malignancy: Informing Supportive Care Needs

BACKGROUND

Informal family caregivers (FCs) of adults with various diseases including hematologic malignancy (HM) experience low quality of life and psychological well-being. Although HMs are life-threatening cancers associated with high mortality, numerous symptoms, and lengthy hospitalizations and are therefore likely to be challenging for FCs to cope with, there is scant research exploring FC experiences.

OBJECTIVE

The aim of this study was to describe the coping and adaptation of FCs of patients during diagnosis and treatment of HM.

METHODS

This study used a qualitative descriptive design to analyze semi-structured interview responses from FCs (N = 28) within 3 months of the patients' HM diagnosis. A content analysis was conducted to generate common themes.

RESULTS

Family caregivers endorsed adaptive and maladaptive coping. Adaptive strategies included taking one day at a time, spirituality, engaging in pastimes, and utilizing emotional and instrumental family and community support. Maladaptive coping included wishful thinking, harmful habits, avoidance, and lacking or being unable to accept family and community support.

CONCLUSIONS

Findings highlight the complexities of caregiver burden as they support their loved ones with HM.

IMPLICATIONS FOR PRACTICE

Family caregivers would benefit from receiving an interdisciplinary family-centered approach as their HM person is initiating treatment. Nurses should consider assessing the FCs' psychosocial needs to help facilitate appropriate services, such as palliative care consultations, social work referrals, support groups, and/or counseling.

Geriatric assessment for older adults receiving less intensive therapy for acute myeloid leukemia: Report of CALGB 361101

Baseline geriatric assessment measures are associated with survival among older AML patients treated with nonintensive chemotherapy.

Baseline global quality of life is associated with survival among older AML patients treated with nonintensive chemotherapy.

Geriatric assessment (GA) predicts survival among older adults with acute myeloid leukemia (AML) treated intensively. We evaluated the predictive utility of GA among older adults treated with low-intensity therapy on a multisite trial. We conducted a companion study (CALGB 361101) to a randomized phase 2 trial (CALGB 11002) of adults ≥60 years and considered “unfit” for intensive therapy, testing the efficacy of adding bortezomib to decitabine therapy. On 361101, GA and quality of life (QOL) assessment was administered prior to treatment and every other subsequent cycle. Relationships between baseline GA and QOL measures with survival were evaluated using Kaplan-Meier estimation and Cox proportional hazards models. One-hundred sixty-five patients enrolled in CALGB 11002, and 96 (52%) of them also enrolled in 361101 (median age, 73.9 years). Among participants, 85.4% completed ≥1 baseline assessment. In multivariate analyses, greater comorbidity (hematopoietic cell transplantation-specific comorbidity index >3), worse cognition (Blessed Orientation-Memory-Concentration score >4), and lower European Organization for Research and Treatment of Cancer global QOL scores at baseline were significantly associated with shorter overall survival (P < .05 each) after adjustment for Karnofsky Performance Status, age, and treatment arm. Dependence in instrumental activities of daily living and cognitive impairment were associated with 6-month mortality (hazard ratio [HR], 3.5; confidence interval [CI], 1.2-10.4; and HR, 3.1; CI, 1.1-8.6, respectively). GA measures evaluating comorbidity, cognition, and self-reported function were associated with survival and represent candidate measures for screening older adults planned to receive lower-intensity AML therapies. This trial was registered at www.clinicaltrials.gov as #NCT01420926 (CALGB 11002).

A single-arm pilot study of a mobile health exercise intervention (GO-EXCAP) in older patients with myeloid neoplasms

Our mobile health exercise intervention adapted for older patients with myeloid neoplasms is feasible, usable, and safe.

Geriatric assessment domain impairments are highly prevalent; there is a need for supportive care interventions to mitigate toxicities.

Many older patients with myeloid neoplasms experience treatment-related toxicities. We previously demonstrated that a home-based, progressive aerobic walking and resistance exercise program (EXCAP) improved physical and psychological outcomes in patients with cancer. However, older patients have more difficulty adhering to exercise than younger patients. Reasons may include low motivation, difficulty with transportation, and limited access to exercise professionals. To improve exercise adherence, we integrated a mobile app with EXCAP (GO-EXCAP) and assessed its feasibility and usability in a single-arm pilot study among older patients with myeloid neoplasms undergoing outpatient chemotherapy. GO-EXCAP intervention lasts for 2 cycles of treatment, and the primary feasibility metric was data reporting on the app. Usability was evaluated via the system usability scale (SUS). Patients were interviewed at mid and postintervention to elicit their feedback, and deductive thematic analysis was applied to the transcripts. Twenty-five patients (mean age, 72 years) were recruited. Recruitment and retention rates were 64% and 88%, respectively. Eighty-two percent (18/22) of patients entered some exercise data on the app at least half of the study days, excluding hospitalization (a priori, we considered 70% as feasible). Averaged daily steps were 2848 and 3184 at baseline and after intervention, respectively. Patients also performed resistance exercises 26.2 minutes per day, 2.9 days per week at low intensity (rate of perceived exertion 3.8/10). Usability was above average (SUS, 70.3). In qualitative analyses, 3 themes were identified, including positive experience with the intervention, social interactions, and flexibility. The GO-EXCAP intervention is feasible and usable for older patients with myeloid neoplasms undergoing outpatient chemotherapy. This trial was registered at www.clinicaltrials.gov as #NCT04035499.

Older patients' and their caregivers' understanding of advanced care planning

PURPOSE OF REVIEW

The aim of this study was to review the recent literature (2019-2021) on older patients' and their caregivers' understanding of advance care planning.

RECENT FINDINGS

Recent studies highlight the continued gaps in knowledge about advance care planning for older adults with cancer and their caregivers both domestically and abroad. The recent literature also revealed that there is a lack of research methodology to assess knowledge of advance care planning reliably and validly in older adults with cancer and their caregivers given the lack of uniform scales to measure knowledge of advance care planning.

SUMMARY

Older adults with cancer are at an elevated risk of death from their illness, and it is essential they understand how advance care planning can improve their quality of life, facilitate goal congruent care and ultimately decrease medical expenditures at end of life. In order to engage in a process such as advance care planning, patients must know what it is and how it can be helpful to them. The lack of understanding about advance care planning presents a significant barrier to patients engaging in the process. Public health campaigns to increase advance care planning knowledge are needed to ensure that older adults with cancer and their caregivers understand how this service can be helpful to them as they approach end of life.

Geriatric assessment predicts non-fatal toxicities and survival for intensively treated older adults with AML

Given a few prospective studies with conflicting results, we investigated the prognostic value of multi-parameter geriatric assessment (GA) domains on tolerance and outcomes after intensive chemotherapy in older adults with acute myeloid leukemia (AML). Newly diagnosed AML aged over 60 years who received intensive chemotherapy consisting of cytarabine and idarubicin (n=105) were enrolled prospectively. Pretreatment GA included evaluations for social and nutritional support, cognition, depression, distress, and physical function. The median age was 64 years (range, 60-75), and 93% had an Eastern Cooperative Oncology Group score <2. Between 32.4% and 69.5% of patients met the criteria for impairment for each domain of GA. Physical impairment by the Short Physical Performance Battery (SPPB) and cognitive dysfunction by the Mini-Mental State Examination in the Korean version of the CERAD Assessment Packet (MMSE-KC) were significantly associated with non-fatal toxicities, including grade III-IV infections (SPPB, P=0.024; MMSE-KC, P=0.044), acute renal failure (SPPB, P=0.013), and/or prolonged hospitalization (³40 days) during induction chemotherapy (MMSE-KC, P=0.005). Reduced physical function by SPPB and depressive symptoms by the Korean version of the short form of geriatric depression scales (SGDS-K) were significantly associated with inferior survival (SPPB, P=0.027; SGDS-K, P=0.048). Gait speed or sit-and-stand speed was the single powerful tool to predict survival outcomes. Notably, the addition of SPPB and SGDS-K, gait speed and SGDS-K, or sit-and-stand speed and SGDS-K significantly improved the power of existing survival prediction models. In conclusion, GA improved risk stratification for treatment decisions and may inform interventions to improve outcomes for older adults with AML. This study was registered at the Clinical Research Information Service (KCT0002172).

Palliative care and coping in patients with acute myeloid leukemia: Mediation analysis of data from a randomized clinical trial

BACKGROUND

It has been shown previously that integrated palliative care for patients with acute myeloid leukemia (AML) during intensive chemotherapy leads to improvements in quality of life (QOL) and mood. Coping has been shown to mediate palliative care interventions in advanced cancer; the mechanisms by which improvements occur among patients with AML remain unexplained.

METHODS

The authors conducted a secondary analysis of data from a multisite randomized trial of integrated palliative and oncology care (IPC; n = 86) versus usual care (n = 74) for hospitalized patients with AML undergoing intensive chemotherapy. IPC patients met with palliative care at least twice weekly during their initial and subsequent hospitalizations. Patients completed the Functional Assessment of Cancer Therapy-Leukemia, the Hospital Anxiety and Depression Scale, and the Brief Coping Orientation to Problems Experienced Inventory to assess QOL, mood, and coping at the baseline and at weeks 2, 4, 12, and 24. Linear regression models were used to assess the effect of IPC on coping. Causal mediation regression models were used to examine whether changes in coping mediated intervention effects on patient-reported outcomes at week 2.

RESULTS

One hundred sixty eligible patients (68.1%) were enrolled. Those randomized to IPC reported improvements in approach-oriented coping (P < .01) and reductions in avoidant coping (P < .05). These changes in coping mediated the intervention effects on QOL (95% CI, 2.14-13.63), depression (95% CI, -2.05 to -0.27), and anxiety symptoms (95% CI, -1.25 to -0.04). Changes in approach-oriented and avoidant coping accounted for 78% of the total palliative care intervention effect on QOL, for 66% of the effect on depression, and for 35% of the effect on anxiety symptoms.

CONCLUSIONS

Palliative care integrated during intensive chemotherapy for patients with AML facilitates coping strategy use. Improvement in coping skills accounts for a substantial proportion of the effect from a palliative care intervention on patient-reported outcomes.

A comprehensive approach to therapy of haematological malignancies in older patients

Haematological malignancies are a heterogeneous group of diseases with diverse incidence. In Europe, the median age at diagnosis across all disease entities is 69 years. Incidence generally increases with age, reaching a maximum at 75-99 years, with the notable exceptions of Hodgkin lymphoma and acute lymphocytic leukaemia. Overall survival for patients aged 75 years and older with haematological malignancies is generally poor, particularly for acute leukaemias. Understanding the heterogeneity in outcomes for haematological malignancies, treatment challenges, and management of frailty and comorbidities among older patients could help physicians to better address the haematological cancer burden and mortality in ageing populations. The aim of this Series paper is to provide an updated overview of the knowledge accumulated over the past decade regarding treatment options and broader management considerations in older adults with haematological malignancies, focusing on the most common entities encountered across lymphoma, acute leukaemia, chronic leukaemia, and multiple myeloma disease categories. Future strategies, such as increasing enrolment rates of older adults in clinical trials and incorporating patient-reported outcome measurements in daily clinical practice, will assist in providing more individualised health care.

The Relationship Between Frailty and Emotional Health in Older Patients with Advanced Cancer

BACKGROUND

Aging-related deficits that eventually manifest as frailty may be associated with poor emotional health in older patients with advanced cancer. This study aimed to examine the relationship between frailty and emotional health in this population.

METHODS

This was a secondary analysis of baseline data from a nationwide cluster randomized trial. Patients were aged ≥70 years with incurable stage III/IV solid tumors or lymphomas, had ≥1 geriatric assessment (GA) domain impairment, and had completed the Geriatric Depression Scale, Generalized Anxiety Disorder-7, and Distress Thermometer. Frailty was assessed using a Deficit Accumulation Index (DAI; range 0-1) based on GA, which did not include emotional health variables (depression and anxiety), and participants were stratified into robust, prefrail, and frail categories. Multivariate logistic regression models examined the association of frailty with emotional health outcomes. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported.

RESULTS

Five hundred forty-one patients were included (mean age: 77 years; 70-96). DAI ranged from 0.04 to 0.94; 27% of patients were classified as robust, 42% prefrail, and 31% frail. Compared with robust patients, frail patients had an increased risk of screening positive for depression (aOR = 12.8; 95% CI = 6.1-27.0), anxiety (aOR = 6.6; 95% CI = 2.2-19.7), and emotional distress (aOR = 4.62; 95% CI = 2.9-8.3). Prefrail compared with robust patients also had an increased risk of screening positive for depression (aOR = 2.22; 95% CI = 1.0-4.8) and distress (aOR = 1.71; 95% CI = 1.0-2.8).

CONCLUSION

In older patients with advanced cancer, frailty is associated with poorer emotional health, which indicates a need for an integrated care approach to treating these patients.

IMPLICATIONS FOR PRACTICE

A relationship exists between frailty and poor emotional health in older adults with advanced cancer. Identifying areas of frailty can prompt screening for emotional health and guide delivery of appropriate interventions. Alternatively, attention to emotional health may also improve frailty.

Diverse patient trajectories during cytotoxic chemotherapy: Capturing longitudinal patient-reported outcomes

Background

High‐value cancer care balances effective treatment with preservation of quality of life. Chemotherapy is known to affect patients’ physical and psychological well‐being negatively. Patient‐reported outcomes (PROs) provide a means to monitor declines in a patients’ well‐being during treatment.

Methods

We identified 741 oncology patients undergoing chemotherapy in our electronic health record (EHR) system who completed Patient‐Reported Outcomes Measurement Information System (PROMIS) surveys during treatment at a comprehensive cancer center, 2013–2018. PROMIS surveys were collected before, during, and after chemotherapy treatment. Linear mixed‐effects models were performed to identify predictors of physical and mental health scores over time. A k‐mean cluster analysis was used to group patient PROMIS score trajectories.

Results

Mean global physical health (GPH) scores were 48.7 (SD 9.3), 47.7 (8.8), and 48.6 (8.9) and global mental health (GMH) scores were 50.4 (8.6), 49.5 (8.8), and 50.6 (9.1) before, during, and after chemotherapy, respectively. Asian race, Hispanic ethnicity, public insurance, anxiety/depression, stage III cancer, and palliative care were predictors of GPH and GMH decline. The treatment time period was also a predictor of both GPH and GMH decline relative to pre‐treatment. Trajectory clustering identified four distinct PRO clusters associated with chemotherapy treatment.

Conclusions

Patient‐reported outcomes are increasingly used to help monitor cancer treatment and are now a part of care reimbursement. This study leveraged routinely collected PROMIS surveys linked to EHRs to identify novel patient trajectories of physical and mental well‐being in oncology patients undergoing chemotherapy and potential predictors. Supportive care interventions in high‐risk populations identified by our study may optimize resource deployment.

Novelty and impact

This study leveraged routinely collected patient‐reported outcome (PROMIS) surveys linked to electronic health records to characterize oncology patients’ quality of life during chemotherapy. Important clinical and demographic predictors of declines in quality of life were identified and four novel trajectories to guide personalized interventions and support. This work highlights the utility of monitoring patient‐reported outcomes not only before and after, but during chemotherapy to help advert adverse patient outcomes and improve treatment adherence.

Developing and adapting a mobile health exercise intervention for older patients with myeloid neoplasms: A qualitative study

INTRODUCTION

Older patients with myeloid neoplasms (MN) receiving outpatient chemotherapy are at risk of experiencing treatment-related toxicities such as functional decline. A mobile health (mHealth) exercise intervention may ameliorate these toxicities. This qualitative study aimed to inform the design of a mHealth exercise intervention for this population.

METHODS

This was a qualitative study of thirteen patients aged ≥60 years receiving hypomethylating agents for MN. EXCAP©® is a home-based walking and progressive resistance exercise program. We combined EXCAP©® with a mobile app; the combination (GO-EXCAP Mobile App) has not been previously tested. A brief verbal description about the intervention was provided to the participants but they did not perform it. Participants were interviewed and inductive thematic analysis was used to analyze the data.

RESULTS

Mean age was 71.6 (SD 8.5). Three themes were identified: 1) Perceptions of the intervention feasibility, 2) Ways to leverage the app to deliver the exercise intervention, and 3) Personalized exercise goals. Walking and resistance exercises were perceived to be feasible. Patients were comfortable initiating the intervention in cycle 2 of chemotherapy, with exercise increments occurring from week 2-4 of the cycle. Ways to leverage the app to deliver EXCAP©® include 1) Video feature for exercise demonstration and interactions, and 2) Exercise data and symptom surveys to be communicated to the exercise physiologist and primary oncology team. Preservation of existing function and activity was an important goal to participants.

CONCLUSIONS

Our findings provide insights about the preferences of older adults with MN for a mHealth exercise intervention.

Real-world treatment patterns and healthcare resource use in patients with acute myeloid leukemia in Western Europe

Aim: Assess treatment patterns and healthcare resource utilization (HRU) in patients with treatment-naive (TN) or relapsed/refractory (R/R) acute myeloid leukemia (AML) in Europe. Patients & methods: Cross-sectional, retrospective, web-based survey of AML-treating healthcare professionals (HCPs) in 12 European countries. Results: 320 HCPs provided information on 1280 TN or R/R patients. Patients ineligible versus eligible for intensive induction therapy required more general practitioner visits (4.1 vs 2.4), more uses of healthcare-related transport (6.9 vs 4.5), but less hospitalization (11.4 vs 27.5 days). Differences were observed in HRU and treatment patterns across countries. Conclusions: This analysis of 'real-world' patients with TN or R/R AML in Europe demonstrates substantial healthcare use, including higher use of resources in patients ineligible for intensive induction therapy.

Characteristics Associated With Functional Changes During Systemic Cancer Treatments: A Systematic Review Focused on Older Adults

BACKGROUND

Maintaining functional status is important to older adults with cancer, but data are limited on how systemic treatments affect functional status. We systematically reviewed changes in functional status during systemic cancer treatments and identified characteristics associated with functional decline and improvement.

METHODS

We searched PubMed, Embase, Web of Science, and Cochrane Register of Controlled Trials for articles examining characteristics associated with functional changes in older adults during systemic cancer treatment published in English between database inception and January 11, 2019 (PROSPERO CRD42019123125). Findings were summarized with descriptive statistics. Study characteristics between older adult-specific and non-older adult-specific studies were compared using the Fisher exact test.

RESULTS

We screened 15,244 titles/abstracts and 519 full texts. The final analysis included 44 studies, which enrolled >8,400 patients; 39% of studies focused on older adults (1 study enrolled adults aged ≥60 years, 10 enrolled adults aged ≥65 years, and 6 enrolled adults aged ≥70 years). Almost all studies (98%) used patient-reported outcomes to measure functional status; only 20% used physical performance tests. Reporting of functional change was heterogeneous, with 48% reporting change scores. Older adult-specific studies were more likely to analyze functional change dichotomously (29% vs 4%; P=.008). Functional decline ranged widely, from 6% to 90%. The most common patient characteristics associated with functional decline were older age (n=7 studies), worse performance status (n=4), progressive disease status (n=4), pain (n=4), anemia (n=4), and worse nutritional status (n=4). Twelve studies examined functional improvement and identified 11 unique associated characteristics.

CONCLUSIONS

Functional decline is increasingly recognized as an important outcome in older adults with cancer, but definitions and analyses are heterogeneous, leading to a wide range of prevalence. To identify patients at highest risk of functional decline during systemic cancer treatments, trials need to routinely analyze functional outcomes and measure characteristics associated with decline (eg, nutrition).

Managing Anxiety from Cancer (MAC): A pilot randomized controlled trial of an anxiety intervention for older adults with cancer and their caregivers

OBJECTIVE

Anxiety is common in older adults with cancer (OACs) and their caregivers and is associated with poor outcomes including worse physical symptoms, poor treatment adherence and response, and longer hospitalizations. This study examined the feasibility, acceptability, adherence, and preliminary efficacy of a cognitive-behavioral therapy (CBT) intervention for OACs and their caregivers.

METHOD

Patients with active cancer age 65 years and older and their caregivers were randomized to Managing Anxiety from Cancer (MAC), a seven-session CBT-based psychotherapy intervention delivered over the telephone or usual care. Patients and caregivers completed the intervention separately with licensed social workers. Self-report measures of anxiety, depression, and quality of life were administered after randomization and following intervention completion. Analyses were conducted separately for patients and caregivers and at the dyad level. Hierarchical Linear Modeling accounted for the within-dyad intraclass correlation coefficients (ICCs) by random intercepts associated with the dyads.

RESULTS

Twenty-nine dyads were randomized; 28 (96.6%) patients and 26 (89.7%) caregivers completed all study procedures. Of dyads randomized to MAC, 85.7% (n = 12) of patients and caregivers completed all seven sessions. Most patients (≥50%) and over 80% of caregivers rated the overall intervention and intervention components as "moderately" to "very" helpful. MAC was associated with a greater reduction in anxiety among dyads than usual care, the effect of MAC was greater in caregivers than in patients, and improvement in patient anxiety was associated with the reduction in caregiver anxiety. However, these results did not reach statistical significance.

SIGNIFICANCE OF RESULTS

This pilot study demonstrates the feasibility of MAC and suggests strategies for improving acceptability, with a focus on adherence. Furthermore, these results indicate that MAC is promising for the reduction of anxiety in OAC-caregiver dyads and may be particularly beneficial for OAC caregivers. Larger randomized controlled trials are needed to evaluate the efficacy of MAC.

Conversion between the Modified Mini-Mental State Examination (3MSE) and the Mini-Mental State Examination (MMSE)

BACKGROUND

The Modified Mini-Mental State Examination (3MSE) and the Mini-Mental State Examination (MMSE) are two commonly used instruments for assessing cognitive function. Although conversion between 3MSE and MMSE is useful in applications such as integrative data analysis, there are limited published reports on the topic. Our objective is to provide a dual tool: (1) an item-level conversion tool to score responses for deriving both 3MSE and MMSE measures, and (2) cross-walk tables to facilitate quick conversion between 3MSE and MMSE.

METHODS

An SAS program tool allows scoring of 3MSE item-level responses into MMSE score. Using integrated data sets (n = 8346), actual 3MSE and MMSE scores obtained from the same individuals were linked to form cross-walk tables.

RESULTS

An SAS conversion program was made available. Cross-walk tables were derived. Validation sample shows bias is -0.11 (standard deviation = 1.02) in 3MSE→MMSE; the converse had substantially large bias.

DISCUSSION

The 3MSE→MMSE conversion table can be used in clinical practice and legacy system data.

Conventional chemotherapy for acute myeloid leukemia in older adults: Impact on nutritional, cognitive, and functional status

OBJECTIVES

The impact of conventional treatment for acute myeloid leukemia (AML) on the nutritional, cognitive, and functional status of elderly patients is seldom studied. This assessment was performed in the context of the LAMSA 2007 trial.

METHODS

The trial enrolled 424 patients with de novo AML. Among them, 316 benefited from geriatric assessment (GA) including nutritional, cognitive, and functional status and were scored according to Eastern Cooperative Oncology Group (ECOG) and sorror for the prediction of treatment toxicity, morbidity, and mortality. Patients were investigated at diagnosis for three times during follow-up.

RESULTS

This study showed that AML and its treatment have no impact on cognitive (P = .554) nor functional status (P = .842 for Activity of Daily Living and P = .087 for Instrumental Activities of Daily Living). The nutritional status improved over time (P = .041). None of these three parameters at baseline, associated or not with ECOG and sorror scores, impacted survivals or toxicities.

CONCLUSIONS

The cognitive, functional, and nutritional status had no impact in this cohort of fit elderly AML patients without unfavorable cytogenetics. The GA tools used provided no additional information compared with ECOG and sorror scores, to predict toxicity, morbidity, or mortality due to intensive chemotherapy.

A new tool for comprehensive geriatric assessment in elderly patients with acute myeloid leukemia: a pilot study from China

BACKGROUND

Acute myeloid leukemia (AML) is a common type of hematological malignancy in elderly people. Geriatricians have developed comprehensive geriatric assessment (CGA) methods for elderly patients; however, the tools used for CGA in AML are not uniform. Thus, we aimed to validate the instrumental activities of daily living (IADL) scales, age, comorbidities (Charlson Comorbidity Index), and albumin (IACA) index, which is a new tool for CGA, in elderly patients with AML.

METHODS

Patients aged ≥60 years who had been diagnosed with AML were screened for eligibility. Among the IACA low-, intermediate-, and high-risk groups, continuous variables were compared using the Mann-Whitney U test, and categorical variables were compared using χ and Fisher exact tests. In addition, probabilities of overall survival (OS) were estimated using the Kaplan-Meier method.

RESULTS

A total of 21, 34, and 6 patients were categorized into IACA low-risk (0 point), intermediate-risk (1-2 points), and high-risk (≥3 points) groups, respectively. The rates of relapse/progression-related mortality were 23.8%, 58.8%, and 100.0% in the IACA low-, intermediate-, and high-risk groups, respectively (χ = 12.81, P < 0.001). The 2-year probabilities of OS were 47.7% (95% confidence interval [CI] 22.8%-72.6%) and 20.2% (95% CI 5.9%-34.5%) in the IACA low- and intermediate-risk groups, respectively (χ = 5.99, P = 0.014), which were significantly higher than those in the high-risk group (low-risk [47.7% (95% CI 22.8%-72.6%)] vs. high-risk [0], χ = 20.80, P < 0.001; intermediate-risk [20.2% (95% CI 5.9%-34.5%)] vs. high-risk [0], χ = 7.56, P = 0.006; respectively). In the IACA low-risk group, the 2-year probability of OS in patients receiving induction chemotherapy (50.8% [95% CI 24.1%-77.5%]) was significantly higher than that in those receiving best supportive care (0, χ = 25.74, P < 0.001).

CONCLUSION

We suggest that the IACA index might be a simple and effective tool for comprehensive geriatric assessment in elderly AML patients.

How to select older patients with acute myeloid leukemia fit for intensive treatment?

Outcomes of the treatment of older patients with acute myeloid leukemia (AML) are unsatisfactory due to a higher incidence of negative patient- and disease-related risk factors connected with aging. Prediction of poor tolerance to aggressive treatment and low response to standard intensive chemotherapy are the main root causes why the treatment decision is challenging. For a long time, negative prognostic factors for treatment outcomes, overall survival, and early death such as the age itself, low-performance status, high-comorbidity burden, adverse cytogenetics, and secondary AML have been known, and they are routinely taken into account during therapeutic balance. In consideration of the risk factors and specific laboratory results, prognostic models have been created. Despite the abovementioned facts, the survival of older patients with AML remains very poor, that holds true even for the intensive therapy. For that reason, there is an increased effort to find a better approach how to select patients who would benefit from intensive treatment without decreasing their quality of life through severe complications with risk of high treatment-related mortality. Based on the results of clinical studies, the geriatric assessment could be the missing step which would help select older patients who are really fit for intensive treatment and who will benefit from it the most. This review focuses on the risk factors that should be taken under advisement when the decision about the treatment is made. With reference to the published information, we propose an algorithm how to identify fit, vulnerable, and frail patients.

Health-Related Quality of Life and Treatment of Older Adults with Acute Myeloid Leukemia: a Young International Society of Geriatric Oncology Review Paper

PURPOSE OF REVIEW

The treatment landscape for older patients with acute myeloid leukemia (AML) is evolving. Many treatments have comparable efficacy making their impact on quality of life (QoL) an important differentiating factor. In this review, we discuss QoL in older adults with AML, focusing on therapeutic and observational trials that have incorporated QoL assessments.

RECENT FINDINGS

Health-related quality of life (HRQoL) is a multi-dimensional concept incorporating physical, mental, emotional, and social functioning domains. HRQoL components overlap with components of geriatric assessment, a multidisciplinary diagnostic process that identifies underlying vulnerabilities of older adults and guides subsequent management strategies. HRQoL questionnaires may be general, cancer-specific, leukemia-specific, or symptom-focused. Therapeutic and observational cohort studies suggest HRQoL improves, or at least remains stable, during intensive and lower-intensity therapies. Nonetheless, HRQoL is not routinely incorporated in AML therapeutic trials. HRQoL assessments can inform both decision-making and management for older adults with AML.

Geriatric assessment and quality of life changes in older adults with newly diagnosed multiple myeloma undergoing treatment

OBJECTIVE

Multiple myeloma (MM) is a cancer of older adults with a median age at diagnosis of 70 years. Our study aimed to understand the changes that occurred in geriatric domains and quality of life parameters as older adults underwent treatment for MM over 6-months following initial diagnosis.

METHODS

This was a secondary analysis of a prospective cohort study of 40 adults aged ≥65 with newly-diagnosed MM who completed the Cancer and Aging Research Group geriatric assessment and the Functional Assessment of Cancer Therapy (General and subscale Gynecologic Oncology Group-Neurotoxicity) quality of life tool at baseline and at 6 months following treatment initiation.

RESULTS

Thirty-six participants completed 6-months of follow-up. There was no significant change in geriatric domains, including dependence in instrumental activities of daily living (IADLs). Compared to baseline, mental health improved at 6-months of follow-up (Mental Health Inventory-17 score, median 77.1 versus 84.3 at baseline and 6-months respectively, p < .001). Objective physical performance as measured by the Timed Up and Go test showed a trend towards improvement (12.3 versus 11.0 s, p = .057) and remained stable or improved in almost all (30/32, 93.8%) of the adults using the minimum clinically important difference threshold.

CONCLUSION

From baseline to 6-months of follow-up, older adults with MM showed improvement in mental health but otherwise remained stable with regards to function and overall quality of life. Timed Up and Go Test may provide a dynamic indicator of functional status and needs to be further evaluated in future studies.

A Preliminary Study of the Comfort in Patients with Leukemia Staying in a Positive Pressure Isolation Room

Background and Aim: Patients with leukemia who are isolated in positive pressure rooms for infection prevention usually experience significant physical and psychological distress. This study aimed to examine changes in leukemia patients' comfort level during chemotherapy in isolation wards. Methods: A longitudinal survey was conducted with measures which were repeated four times. Data were collected before chemotherapy, on the first and second week after receiving chemotherapy in positive pressure isolation rooms, and on the third week in the non-isolated hematology ward. Each patient received six questionnaires measuring demographic data, comfort status, functional status, fatigue related to cancer therapy, anxiety level, and distress symptoms. A mixed model with repeated measure analysis was used to examine the changing trajectories in physical and psychological health. Results: Twenty-one patients completed the study. During the process, the highest score for comfort level was shown before chemotherapy, and this decreased from the second week under isolation. Anxiety and uncertainty (p < 0.05) declined over time, and emotional states improved during the recovery period in the third and fourth weeks outside isolation. Physical well-being (p < 0.01), cancer-related fatigue (p < 0.05), hemoglobin (p < 0.01) and white blood cell count (p < 0.05) began to rise two weeks after chemotherapy. Conclusion: Comfort levels declined after chemotherapy until the third week of treatment. Anxiety, fatigue and distress symptoms varied across the four time points of chemotherapy from isolation to return to the non-isolated ward. Health care professionals should be aware of psychological symptoms when patients are in isolation rooms, and interventions for promoting a humanized environment, quality of life, and comfort should be considered and provided along with the treatment stages of chemotherapy.

Geriatric assessment in older patients with a hematologic malignancy: a systematic review

The aim of this systematic review is to give an update of all currently available evidence on the relevance of a geriatric assessment in the treatment of older patients with hematologic malignancies. A systematic search in MEDLINE and EMBASE was performed to find studies in which a geriatric assessment was used to detect impaired geriatric domains or to address the association between geriatric assessment and survival or clinical outcome measures. The literature search included 4,629 reports, of which 54 publications from 44 studies were included. Seventy-three percent of the studies were published in the last 5 years. The median age of the patients was 73 years (range, 58-86) and 71% had a good World Health Organization (WHO) performance status. The median prevalence of geriatric impairments varied between 17% and 68%, even in patients with a good WHO performance status. Polypharmacy, nutritional status and instrumental activities of daily living were most frequently impaired. Whereas several geriatric impairments and frailty (based on a frailty screening tool or summarized geriatric assessment score) were predictive for a shorter overall survival, WHO performance status lost its predictive value in most studies. The association between geriatric impairments and treatment-related toxicity varied, with a trend towards a higher risk of (non-)hematologic toxicity in frail patients. During the follow-up, frailty seemed to be associated with treatment non-completion, especially when patients were malnourished. Patients with a good physical capacity had a shorter stay in hospital and a lower rate of hospitalization. Geriatric assessment, even in patients with a good performance status, can detect impaired geriatric domains and these impairments may be predictive of mortality. Moreover, geriatric impairments suggest a higher risk of treatment-related toxicity, treatment non-completion and use of healthcare services. A geriatric assessment should be considered before starting treatment in older patients with hematologic malignancies.

Treatment of acute promyelocytic leukemia in older patients: recommendations of an International Society of Geriatric Oncology (SIOG) task force

Approximately one third of patients diagnosed with acute promyelocytic leukemia (APL) are above the age of sixty. It is important to ensure older adults receive optimal diagnosis and management since this subtype of acute myeloid leukemia - given appropriate treatment - is highly curable with lower risk of adverse events compared to other types of leukemia. Historically, older age has been a risk factor for early death and poorer overall survival. However, prospects have changed with the introduction of all-trans retinoic acid (ATRA) and arsenic trioxide (ATO). APL is curable in the majority of patients regardless of age, and the threshold of fitness that makes ATRA/ATO therapy possible is likely to be lower than for cytotoxic chemotherapy. APL frequently presents as a medical emergency and rapid diagnosis and intervention - typically involving referral to a specialist centre - is a major determinant of outcome. After diagnosis, management of APL in older adults presents particular challenges. Geriatric assessment, including evaluation of frailty, comorbidities and polypharmacy can assist in providing optimal supportive care for older adults during remission induction and may help individualize therapy in the post-remission phase. Here, we review the available evidence, highlighting areas of consensus, gaps in evidence and opportunities for research to enhance diagnosis, management and survivorship for older patients.

Decitabine in combination with low-dose cytarabine, aclarubicin and G-CSF tends to improve prognosis in elderly patients with high-risk AML

We evaluated the risk status and survival outcomes of 125 elderly acute myeloid leukemia (AML) patients treated with decitabine in combination with low-dose cytarabine, aclarubicin, and G-CSF (D-CAG). The risk status was evaluated by determining the frequency of recurring gene mutations using next-generation sequencing (NGS) analysis of 23 selected genes and cytogenetic profiling of bone marrow samples at diagnosis. After a median follow-up of 12 months (range: 2-82 months), 86 patients (68.8%) had achieved complete remission after one cycle of induction, and 94 patients (75.2%) had achieved it after two cycles. The median overall survival (OS) and disease-free survival (DFS) were 16 and 12 months, respectively. In 21 AML patients aged above 75 years, the median OS and DFS were longer in the low- and intermediate-risk group than the high-risk group, but the differences were not statistically significant. The median OS and DFS were similar in patients with or without TET2, DNMT3A, IDH2, TP53 and FLT3 mutations. Multivariate analysis showed that patient age above 75 years, high-risk status, and genetic anomalies, like deletions in chromosomes 5 and/or 7, were significant variables in predicting OS. D-CAG regimen tends to improve the prognosis of a subgroup of elderly patients with high-risk AML.

[Cross-speciality geriatrics: A health-care challenge for the 21st century]

Increasing numbers of older persons are being treated by specialties other than Geriatric Medicine. Specialists turn to Geriatric Teams when they need to accurately stratify their patients' risk and prognosis, predict the potential impact of their, often, invasive interventions, optimise their clinical status, and contribute to discharge planning. Oncology and Haematology, Cardiology, General Surgery, and other surgical departments are examples where such collaborative working is already established, to a varying extent. The use of the term "Cross-speciality Geriatrics" is suggested when geriatric care is provided in clinical areas traditionally outside the reach of Geriatric Teams. The core principles of Geriatric Medicine (comprehensive geriatric assessment, patient-centred multidisciplinary targeted interventions, and input at point-of-care) are adapted to the specifics of each specialty and applied to frail older patients in order to deliver a holistic assessment/treatment, better patient/carer experience, and improved clinical outcomes. Using Comprehensive Geriatric Assessment methodology and Frailty scoring in such patients provides invaluable prognostic information, helps in decision making, and enables personalised treatment strategies. There is evidence that such an approach improves the efficiency of health care systems and patient outcomes. This article includes a review of these concepts, describes existing models of care, presents the most commonly used clinical tools, and offers examples of excellence in this new era of geriatric care. In an ever ageing population it is likely that teams will be asked to provide Cross-specialty Geriatrics across different Health Care systems. The fundamentals for its implementation are in place, but further evidence is required to guide future development and consolidation, making it one of the most important challenges for Geriatrics in the coming years.

Geriatric assessment among older adults receiving intensive therapy for acute myeloid leukemia: Report of CALGB 361006 (Alliance)

OBJECTIVE

To demonstrate feasibility of performing geriatric assessment (GA) in the National Clinical Trials Network (NCTN) and to explore the utility of GA to characterize treatment tolerance.

MATERIALS AND METHODS

We conducted a multisite companion study (CALGB 361006) to CALGB 11001, a phase 2 trial of adults ≥60 years old with newly diagnosed FLT3- mutated AML, testing the efficacy of adding sorafenib to intensive chemotherapy. On 361006, a GA was administered prior to induction and prior to post-remission therapy. The GA is divided into items requiring administration by a health care professional (HCP) and patient self-administered questionnaires. Feasibility outcomes were recruitment rate, time to GA completion, difficulty with GA administration, percent of patients requiring assistance, and satisfaction. Change in GA measures pre- and post-induction were compared using Wilcoxon signed rank test and McNemar's tests.

RESULTS

The recruitment rate was 80% (N = 43, median age 68 years). Median completion time of the GA was 30 min; (10 and 21 min for HCP and patients, respectively). HCP reported no difficulty completing assessments (100%). Most patients completed questionnaires without assistance (77%), and were satisfied with the length (89%). Self-reported physical function, mental health, social activity and nutritional parameters worsened after induction.

CONCLUSION

GA is feasible to administer in the setting of intensive induction for older adults with AML in the NCTN and provides evidence of the impact of induction therapy on physical and emotional health.

Ready for prime time: role for geriatric assessment to improve quality of care in hematology practice

Older adults represent the growing majority of patients diagnosed with hematologic disorders, yet they remain underrepresented on clinical trials. Older patients of the same chronologic age differ from one another with varying comorbidity and functional reserve. The concepts of frailty and resilience are important to patient-centered care and are patient and setting specific. The use of geriatric assessment to inform tailored decision making and management can personalize care for older adults with hematologic malignancies. This article will highlight available evidence to support the role of geriatric assessment measures to enhance quality of care for older adults diagnosed with hematologic malignancies.

Evidence-Based Minireview: Longitudinal geriatric assessment in quality care for older patients with hematologic malignancies

A 65-year-old women was diagnosed with acute myeloid leukemia (AML; normal cytogenetics, NPM1 mutated, FLT3-ITD wild type). Preinduction screening geriatric assessment (GA) did not reveal any significant deficit, because she was independent of basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs), had normal cognition, and scored 10 (range 0-12) on the short physical performance battery (SPPB). She underwent standard 7 + 3 induction and achieved a complete remission, although her course was complicated by neutropenic sepsis and bacteremia. She is being evaluated for postremission therapy. Would you recommend a follow-up GA at this time?

Ready for prime time: role for geriatric assessment to improve quality of care in hematology practice

These 2 reviews respectively examine the value and utility of geriatric assessment (GA) tools and discuss the role of GA in the clinical management of patients with hematologic malignancies.

Anxiety and depression predict unfavorable survival in acute myeloid leukemia patients

This study aimed to investigate the prevalence/severity of anxiety and depression, and also their correlations with clinical characteristics and survival profiles in acute myeloid leukemia (AML) patients.In all, 208 AML patients and 200 age and sex-matched healthy controls (HCs) were recruited in this study. Anxiety and depression were assessed by the Hospital Anxiety and Depression Scale (HADS) in AML patients before initiating therapy and in HCs after being enrolled. Treatment response was assessed, and event-free survival (EFS), and also the overall survival (OS) were calculated.The HADS-anxiety score (P < .001), anxiety prevalence (P < .001), and anxiety severity (P < .001) were increased in AML patients than those in HCs. The HADS-depression score (P < .001), depression prevalence (P < .001), and also depression severity (P < .001) were higher in AML patients compared with HCs. No correlation of anxiety or depression with clinical characteristics was found in AML patients (all P > .05). Moreover, the anxiety (P = .178) and depression (P = .512) rates were similar between complete remission (CR) patients and non-CR patients. Additionally, the EFS was worse in anxiety patients compared with nonanxiety patients (P = .013). The OS was shorter in anxiety patients compared with nonanxiety patients (P = .015) and was also worse in depression patients compared with nondepression patients (P = .007).Anxiety and depression are much more frequent and severe in AML patients compared to HCs, and both of them predict unfavorable survival profiles in AML patients.

Suppression of HSP70 inhibits the development of acute lymphoblastic leukemia via TAK1/Egr-1

Acute lymphoblastic leukemia (ALL), usually treated with chemotherapy, has limited therapeutic effects and high toxicity. Upregulation of HSP70 induces tumor development, however, the molecular mechanism of HSP70 in ALL remains unclear. In our research, we aimed to investigate the role of HSP70 in ALL, specifically the molecular mechanisms underlying cell apoptosis and proliferation. We found that HSP70 expression in leukomonocytes from ALL patients was increased compared with the control group. HSP70 expression in NALM-6 and BE-13 was also up-regulated contrast with AHH-1. Inhibition of HSP70 significantly promoted cell apoptosis and suppressed cell proliferation in ALL cell lines. Suppression of HSP70 decreased TAK1 and increased Egr-1 protein expression. Further experiments indicated that overexpression of TAK1 ameliorated the effect of HSP70 inhibition on Egr-1 protein expression, cell apoptosis and proliferation. In order to determine whether the effect of HSP70 inhibition on apoptosis and proliferation of ALL cell lines could be achieved via regulation of Egr-1, we performed a loss-of-function experiment for Egr-1. Egr-1 suppression was found to reverse the effect of HSP70 inhibition on cell apoptosis and proliferation in ALL. Taken together, our results suggest that HSP70 inhibition upregulates Egr-1 via TAK1, inducing apoptosis and restricting proliferation in ALL cells.