Practical Assessment and Management of Vulnerabilities in Older Patients Receiving Chemotherapy: ASCO Guideline for Geriatric Oncology

Real-world implementation of geriatric assessment in cancer care among older adults: the role of implementation science frameworks

PURPOSE OF REVIEW

The evidence supporting geriatric assessment (GA) in cancer care is well established, and GA is recommended by the American Society of Clinical Oncology, the International Society of Geriatric Oncology, and other oncology bodies. However, effective implementation of GA remains inadequate. Using selected papers indexed in Medline from the most recent 18 months to July 2024, including two outstanding interest papers, this review aimed to describe enablers and barriers to GA implementation in oncology and contrasts implementation with and without an implementation science framework. Finally, we make recommendations on applying an implementation science framework to facilitate integrating GA in oncology.

RECENT FINDINGS

Implementation science frameworks have been widely employed in health services research, but their use in geriatric oncology, particularly to guide GA implementation and evaluation, is limited. Lack of time in busy practices coupled with workforce shortages adds to the challenges of GA implementation and adoption. A variety of screening and assessment tools such as the G8, electronic rapid fitness assessment, and Eastern Cooperative Oncology Group are often used in lieu of geriatrician review and to streamline GA. When effectively implemented in oncology, GA informs care and treatment decisions for improved outcomes.

SUMMARY

Despite the benefits for older adults, embedding GA into routine clinical practice is critical yet not common practice. The variety of available GA tools, logistics, and individual beliefs are some of the identified barriers to GA adoption in oncology. Enablers include organization readiness, adaptability, communication, and the use of multidisciplinary teams. Further research is needed to examine how implementation science frameworks could provide guidance and structure for successful GA implementation in oncology.

Supporting older adults with cancer and their support person through geriatric assessment and remote exercise and education: The SOAR study protocol

INTRODUCTION

Frail older adults receiving cancer treatment are at heightened risk of adverse outcomes. Despite the known benefits of exercise during cancer treatment to improve well-being, few exercise studies focus on frail older adults receiving cancer treatment and their support person. Geriatric assessment (GA) is often recommended prior to the start of treatment for frail adults with cancer, but combining the GA with a planned exercise regimen remains unexplored. This study aims to determine the feasibility and acceptability of implementing geriatric assessment and management (GAM) in combination with virtual chair-based exercise (CBE) and health education for frail older adults with cancer and their support persons.

MATERIALS AND METHODS

This phase 2 randomized controlled trial will include patients aged 70 years and above with a lung, gastrointestinal, or genitourinary cancer referred for first- or second-line chemotherapy, immunotherapy, or targeted therapy. Patients must be frail (≥3 on the Vulnerable Elders Survey), sedentary on the Godin Leisure Time Activity Questionnaire (<90 min of moderate/intense activity per week), have English proficiency with ability to consent, a physician-estimated life expectancy of at least six months, and deemed safe to exercise. Each older adult will be invited to bring a support person to participate in the study. Patients will be randomized 1:1 to GAM combined with online CBE and health education for 12 weeks or waitlist control. Participating support persons will follow the same intervention group. Primary endpoints for feasibility and acceptability will be recruitment rate, retention, adherence, and data collection. Outcome measures include physical activity, function, fatigability, quality of life, treatment toxicity, and unplanned hospital visits. Outcome measures will be used to obtain estimates of the effect size and feasibility analysis needed for designing a phase 3 study. The study will take place at two hospitals in Toronto, Canada.

DISCUSSION

This study will investigate the feasibility, acceptability, and obtain preliminary estimates of the outcomes of GAM plus CBE and health education in preventing functional decline and improving quality of life in frail older adults receiving cancer treatment and their support persons. The results will help to design a definitive phase 3 randomized controlled trial.

TRIAL REGISTRATION

The trial is registered at ClinicalTrials.gov (Registration Number: NCT05509751).

The development and validation testing of a comprehensive frailty assessment in women with breast cancer

BACKGROUND

Women with breast cancer are known to suffer from disease and treatment, and the generic measurement tools may underestimate their frailty. A specific instrument comprehensively measuring frailty among women with breast cancer has not yet been developed. This study aims to develop and validate the tool of breast cancer comprehensive frailty scale (BCCFS).

METHODS

A descriptive and explorative study design was used. We collected the data through systematic literature and modified Delphi method. After an initial search and screening process, a total of 33 articles were included for review and consideration in the item design. Ten experts were invited to generate and validate initial items. The validity was assessed using a sample of 205 women with breast cancer in Taiwan. Its validity was then tested using item analysis, exploratory factor analysis, confirmatory factor analysis, criterion-related validity and areas under the receiver-operating characteristic, while its reliability was evaluated through internal consistencies and test-retest analyses.

RESULTS

A three-factor solution with 16 items was chosen and accounted for approximately 58.57% of the total variance by exploratory factor analysis (KMO = 0.85; Bartlett's Test of Sphericity: χ2 = 2881.34, p < 0.001). The factors were interpreted as (1) deterioration of body and mobility, (2) negative emotions, and (3) cognitive impairment. The goodness of fit indices of the confirmatory factor analysis were as follows: chi-square = 234.498 (p < 0.01), normed chi-square = 2.322, SRMR = 0.055, RMSEA = 0.08, CFI = 0.930, and LI = 0.917. The Cronbach's alpha calculated for the BCCFS (16 items) was 0.91 (95% confidence interval: 0.89 to 0.93), and the test-retest reliability coefficient was 0.60. Using the G8 screening tool as a standard indicator of frailty, analysis of receiver operating characteristic curve showed that 31.5 was the best cut point (area under curve = 0. 816, 95% confidence interval: 0.757 to 0.874) with a sensitivity of 63.5% and specificity of 84.4%.

CONCLUSION

The instrument exhibited acceptable psychometric properties, proving it to be a valuable tool for evaluating frailty in women with breast cancer. Further assessments of its reliability, validity, and generality from health providers' views in different contexts and cultures are recommended.

Evaluation of claims-based frailty measurements in older patients with cancer: a retrospective cohort study

BACKGROUND

Frailty is associated with poor outcomes in older adults with cancer. Several efforts have been made to assess frailty using the administrative claims data based on the number of clinical diagnosis codes, yet the literature reporting on this is scarce. This study aimed to evaluate the impact of frailty measures using administrative databases in Japan.

DESIGN

A retrospective cohort study.

SETTING AND PARTICIPANTS

5176 patients with cancer aged ≥65 years who underwent cancer treatment in hospitals.

METHODS

The Electronic Frailty Index (eFI) and Veterans Affairs Frailty Index (VA-FI), based on diagnostic codes recorded were calculated. We plotted Kaplan-Meier survival curves and calculated hazard ratios (HR) using Cox regression analyses. The primary outcome was mortality, whereas the composite secondary outcome included a decline in care-need level, admission to a long-term care facility (LTCF) or mortality.

RESULTS

The Kaplan-Meier survival curve demonstrated a significant association between the eFI and VA-FI and each research outcome. Compared to the lowest frailty group, the highest frailty group exhibited an HR of 2.59 [95% confidence interval (CI), 1.66-4.06] for eFI and 2.45 (95%CI, 1.02-5.91) for VA-FI in relation to a decline in care-need level, an LTCF admission and mortality. The trend test indicated a significant increase in the rate of each outcome with higher frailty levels.

CONCLUSIONS

Higher frailty levels are associated with an increased risk of composite outcomes in older adults with cancer. This study suggests the potential application of frailty measurements in oncology care settings.

Real-Life Management of Patients Aged 80 Years Old and Over With Multiple Myeloma: Results of the EMMY Cohort

INTRODUCTION

Multiple myeloma patients aged 80 years and older are a population more prone to comorbidities and frailty. We aim to describe the real-life management and outcomes of this population. EMMY is a descriptive large-scale study.

PATIENTS

Between 2017 and 2021 we included 4383 patients of which 894 (20.3%) were aged ≥ 80 years. Four cohorts of patients aged ≥ 80 years were analysed: line 1 (L1), line 2 (L2), line 3 (L3) or line 4+ (L4+).

RESULTS

The proportion of patients ≥ 80 years old was 20.8% in L1, 21.3% in L2, 20.9% in L3 and 17.8% in L4+. L1 patients received more treatment including a proteasome inhibitor (PI) (42.9%), L2 patients received mainly an immunomodulator (IMID) (65.9%) or an anti-CD38 (31.5%). For L3, IMID was used in 71.4% than an anti-CD38 (33.5%). L4+ patients received a PI (40.6%), IMID (33.2%) or an anti-CD38 (29.1%). Regarding efficacy, the median progression-free survival was 18.4 months in L1, 15.1 months in L2, 10.4 months in L3 and 6.5 months in L4+. The median overall survival was 49 months in L1, 31.3 months in L2, 21.4 months in L3 and 13.6 months in L4+.

CONCLUSION

EMMY cohort confirmed that patients ≥ 80 years of age represent an important proportion of MM patients, in the de novo or relapse setting. This study is an important step in improving our comprehension and management of treatment in elderly patients.

Clinical profile, staging and oncological treatment of ten leading cancer types between young vs older patients from 2000 to 2019 in Brazil

INTRODUCTION

Cancer has become a public health problem worldwide, affecting individuals of different age groups, including children, young adults and older patients.

OBJECTIVE

To determine the clinical profile, staging and standard of oncological treatment of the 10 most frequent primary sites of cancer in young patients (< 60 years) vs older patients (≥ 60 years old) diagnosed between 2000 and 2019 in Brazil.

MATERIALS AND METHODS

This cross-sectional study used data from the secondary database of the Hospital Cancer Registry, available on the web www.inca.org.br. Patients with cancer who were older than 18 years were included. Patients with non-melanoma skin cancer and with incomplete data on primary site and staging were excluded.

RESULTS

The database had data from 1,891,912 eligible patients, of which 1,461,080 (77.2 %) corresponded to the ten leading cancer types which were to be evaluated in this study. Cancers of the breast, prostate, cervix, lung, colon, stomach, rectum, oesophagus, thyroid and larynx were the 10 most frequent cancer types identified. The mean of age of patients was 58.8 ± 14.2 years and most of them were female (59.8 %). Those in the older group were more commonly reported (50.8 %) and this group included more former or current smokers (48.4 % vs 40.8 %, p < 0.001). Young patients received more all-oncological treatment: surgery (53.2 % vs 41.1 %, p < 0.001), radiotherapy (47.3 % vs 46.3 %, p < 0.001) and chemotherapy (53.6 % vs 39.3 %, p < 0.001) than older patients.

CONCLUSION

Evaluating cancer patients by age group may enhance cancer surveillance, redirecting control strategies and prioritising patients with more common primary site types.

Aiming for patient safety indicators in radiation oncology - Results from a systematic literature review as part of the PaSaGeRO study

BACKGROUND

Patient Safety Indicators (PSIs) allow the evaluation of safety levels in healthcare settings. Despite their use in various medical fields, a specific and comprehensive PSI catalogue for radiation oncology (RO) is lacking. The Patient Safety in German Radiation Oncology (PaSaGeRO) study aims for the development of a specific PSI catalogue in radiation oncology.

OBJECTIVES

The primary objective of this systematic literature review as part of the PaSaGeRO study is to identify, formulate, and categorize PSIs specific to RO to bridge existing gaps in comprehensive patient safety evaluation.

METHODS

An electronic search in PubMed included studies from 1989 onwards, in English or German, focusing on safety and quality indicators in RO, patient safety measures, or risk analyses. Exclusions were non-transferable, country-specific measures, techniques exclusive to specific departments, and legally mandated procedures. Additional sources were identified through reference tracking and professional society websites. Two experts independently extracted PSIs from the included references.

RESULTS

Out of 157 included publications and nine secondary sources, we identified and formulated 145 PSIs. These were categorized into patient-specific processes (82, 56%), quality and risk management (42, 28%), human resources (15, 10%), and institutional culture (13, 9%).

CONCLUSION

The hereby developed PSIs provides a base for professionals to systematically evaluate and improve safety practices, addressing previously unmet needs in this field. By offering clear guidance on safety assessment, the catalogue has the potential to drive significant improvements in patient care and safety outcomes in RO. Funded by Deutsche Krebshilfe. Registered in the German Clinical Trials Register (DRKS00034690).

Clinical, Diagnostic and Therapeutic Framework of mHSPC and nmCRPC: A Multidisciplinary Consensus Project of the Italian Society for Uro-Oncology (SIUrO)

The recent evidences provided in metastatic hormone sensitive prostate cancer (nmHSPC) and in nonmetastatic castration resistant (nmCRPC) introduced the possibility to adopt Androgen Receptor Signaling inhibitor (ARSi) alone (both settings) or with chemotherapy (in mHSPC). In daily clinical practice there are some opening questions regarding the inclusion of next generation imaging, mainly PSMA-PET, how integrate local treatment as radiotherapy, how to select patients or drugs in a multiple-choice scenario, and how to manage patients with comorbidities and polypharmacy. These issues led the Italian Society for Uro-Oncology (SIUrO) to develop a consensus project involving all of the most important Italian scientific societies engaged in the multidisciplinary and multiprofessional management of the disease. This paper describes the items and statements approved, with the aim to support clinicians in managing metastatic hormone sensitive and nonmetastatic castration resistant prostate cancer patients.

Impact of Lookback Duration on the Performance of a Claims-Based Frailty Proxy in Women With Stage I-III Breast Cancer

BACKGROUND

Frailty is an important prognostic indicator in older women with breast cancer. The Faurot frailty index, a validated claims-based frailty proxy measure, uses healthcare billing codes during a user-specified ascertainment window to predict frailty. We assessed how the duration of frailty ascertainment affected the ability of the Faurot frailty index to predict one-year mortality in women with stage I-II breast cancer.

METHODS

We included 128 857 women (66+ years) with stage I-III breast cancer in the SEER-Medicare database (2003-2019). The Faurot frailty index was calculated using 3-, 6-, 8-, and 12-month ascertainment windows prior to diagnosis or using all-available lookback. Associations between the Faurot frailty index using each window and one-year all-cause mortality were estimated using Kaplan-Meier curves. Discrimination of one-year mortality risk was assessed using C-statistics.

RESULTS

Five percent of women died during the year following diagnosis. Higher Faurot scores were associated with increased mortality risk for all frailty ascertainment windows. Differences in one-year mortality risk for women with high vs. low Faurot frailty scores were reduced when using all-available lookback (16% vs. 2%, difference = 15%, 95% CI 0.14-0.15) compared to shorter windows (e.g., 8 months: 25% vs. 2%, difference = 23%, 95% CI 0.22-0.24). C-statistics ranged from 0.758 (all-available lookback) to 0.770 (12 months) and were robust in subgroups defined by age, race, ethnicity, region, stage, and cancer subtype.

CONCLUSIONS

The Faurot frailty index performed well across 3- to 12-month frailty ascertainment windows in women with breast cancer. Researchers should employ this index to address confounding by frailty in studies of cancer populations.

Protocol of a decisional intervention for older adults with newly diagnosed acute myeloid leukemia and their caregivers: UR-GOAL 3

INTRODUCTION

Therapeutic advances have allowed more adults aged ≥60 years with acute myeloid leukemia (AML) to receive life-prolonging treatments, with improvement in overall survival. In contrast to other cancers, the onset of AML is often sudden, high-risk treatment decisions must be made quickly, and survival is often compromised due to aging-related conditions (e.g., functional impairments). Studies have demonstrated that up to 78 % of older adults with AML and their caregivers experience significant psychological distress. Distress is associated with poor quality of life, increased healthcare utilization, and increased mortality. Shared decision making (SDM) can reduce patient and caregiver distress and is essential to achieve goal-concordant care. Therefore, interventions to alleviate distress and optimize SDM in older adults with AML and their caregivers are needed. We will conduct a multicenter randomized controlled trial to evaluate the efficacy of University of Rochester-Geriatric Oncology assessment for Acute myeloid Leukemia (UR-GOAL) compared to an attention control for reducing patient distress and improving observed SDM, patient-perceived SDM, and decisional conflict.

MATERIAL AND METHODS

We will recruit 300 patients aged ≥60 years with newly diagnosed AML, their caregivers (one caregiver per patient when available), and up to 40 oncologists from four institutions: (1) Patients will view an educational video about AML diagnosis, treatment, and prognosis; complete the Best Worst Scaling values clarification process; and review a summary report of their values with tailored question prompts and resources; (2) Caregivers will view the same educational video and receive the same summary report as patients; and (3) Oncologists will review a summary report of the patient's aging-related conditions, perception of prognosis, and values. Patients, caregivers, and oncologists will then meet during clinical visits to discuss aging-related conditions, prognosis, and patient values, and reach a treatment decision. The primary outcome measure is distress (Distress Thermometer). Secondary outcome measures include observed SDM, patient perceived SDM, and decisional conflict.

DISCUSSION

This study will address significant knowledge gaps related to reducing distress and decisional conflict and improving SDM in older adults with AML. If successful, this research will inform future decisional interventions for a broader group of patients.

Characteristics, Treatment and Outcomes of Stage I to III Colorectal Cancer in Patients Aged over 80 Years Old

BACKGROUND

Colorectal cancer primarily affects older adults and poses treatment challenges due to age-related comorbidities and frailty, which hinder surgical and chemotherapy options for many elderly patients. This study aims to analyze treatment and disease patterns in elderly colorectal cancer patients, aged over 80 years old, to inform personalized therapies that accommodate their unique clinical needs and improve their outcomes.

PATIENTS AND METHODS

The medical records of all patients aged 80 years old and above, and those aged 65 to 75 years old, who were diagnosed with colorectal cancer at a cancer center in Canada over a seven year period, were retrospectively reviewed.

RESULTS

No significant differences in the initial presentation, location, grade or stage at colorectal cancer diagnosis were observed between age groups. Patients aged 80 years old and above were less likely to receive neoadjuvant and adjuvant chemotherapy treatments for stage II disease (19.2% versus. 58.6%, p = 0.002; 7.9% versus. 40.0%, p = 0.002). There were also differences in the intensity of chemotherapy received and the frequency of dose reductions (76.0% vs. 10.0%, p = 0.0001), neoadjuvant and adjuvant radiation therapy (34.6% vs. 65.5%, p = 0.02) and surgical management (83.7% vs. 95.3%, p = 0.006). Despite these differences in treatments, recurrence rates were not statistically significant between the two groups. However, overall survival was reduced in the older age group.

CONCLUSIONS

Treatment plans for patients aged 80 years old and above should be tailored to the patient's colorectal cancer presentation, comorbidity status and life expectancy, weighing the impact of cancer treatments on the patient's short- and long-term outcomes.

Efficacy, safety, and patient-reported outcomes across young to older age groups of patients with HR+/HER2- advanced breast cancer treated with ribociclib plus endocrine therapy in the randomized MONALEESA-2, -3, and -7 trials

BACKGROUND

Ribociclib + endocrine therapy (ET) showed significant progression-free survival (PFS) and overall survival (OS) benefits in the MONALEESA trials in patients with HR+ /HER2 - advanced breast cancer (ABC). We report efficacy, safety, and patient-reported outcomes (PROs) across age groups, including older patients, in these trials.

METHODS

Data from the MONALEESA-2, -3, and -7 trials for pre- and postmenopausal patients receiving first-line treatment for ABC were pooled and analyzed by age (<65y, 65-74y, and ≥75y). PFS, OS, time to first chemotherapy (TTC), and time to definitive deterioration (TTD) in PROs were evaluated using Kaplan-Meier methods; a Cox regression model stratified by study and liver/lung metastasis was used for hazard ratios.

RESULTS

Among 1229 patients included, 63 % were < 65y, 27 % were 65-74y, and 10 % were ≥ 75y. Baseline characteristics were generally well balanced. Regardless of patient age, ribociclib+ET showed a consistent PFS and OS benefit and delayed TTC. With ribociclib+ET, the most common first subsequent treatment was ET. Safety results were consistent with those in the overall trial population; no new signals were identified. Rates of discontinuation due to AEs with ribociclib+ET were numerically higher in patients ≥ 75y. Among patients who discontinued treatment due to AEs, the percentage without prior dose reduction was higher in those ≥ 75y. A PRO benefit with ribociclib+ET was observed across all age groups for pain and fatigue scores.

CONCLUSIONS

This analysis demonstrated that ribociclib+ET is an effective and well-tolerated treatment for patients of all age groups with HR+ /HER2 - ABC, including older patients. (MONALEESA-2, NCT01958021; MONALEESA-3, NCT02422615; MONALEESA-7, NCT02278120).

Distribution of Geriatric 8 screening tool scores in elderly and non-elderly patients with cancer

INTRODUCTION

Population aging and increased cancer incidence have made the treatment of cancer in older individuals an increasingly important issue. Geriatric 8 (G8) is a screening tool developed to identify patients who would benefit most from a comprehensive geriatric assessment (GA). Previous G8 studies have involved older patients, but the age-related significance and usefulness of G8 is unknown. In this study, G8 screening was administered to patients who were 30 years of age or over with cancer to examine a G8 score in each 10 years age group and its correlation with other GA tools.

MATERIALS AND METHODS

The study was conducted at Fukuoka University Hospital from January 2020 to March 2022 and enrolled 715 patients aged ≥ 30 years undergoing surgery for primary gastrointestinal cancer or malignant disease. The relationship between age, G8, instrumental activities of daily living (IADL), activities of daily living (ADL), and the Charlson Comorbidity Index (CCI) was investigated.

RESULTS

The median age of the patients was 69 years (34-98 years). Functional disability in ADLs was present in 43 patients (6%) and in IADLs in 72 patients (10.1%). The mean G8 score by age group was 13.7, 13.1, 13.3, 13.3, 12.4, 11.3, and 9.25 for ages 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, and 90-100 years, respectively. For each of the ADL/IADL items, the group with functional disability had significantly lower G8 scores than the group without functional disability (p < 0.001). The relationship between the G8 score and CCI by age group showed that the G8 score decreased as the CCI score increased. Assessments divided into age groups of 65, 70, and 75 years showed significant differences between groups for most ADL/IADL items and G8 scores, even when divided by age 65.

DISCUSSION

G8 scores were lower in patients with ADL/IADL disabilities and decreased with age in both the presence and absence of disabilities. The G8 total score decreased significantly after the age of 70 years. Performing G8 in patients < 65 years of age does not decrease sensitivity; however, the functional decline is so slight that it appears reasonable to restrict G8 screening to patients ≥ 65 years of age.

Clinical mechanism of muscle mass loss during neoadjuvant chemotherapy in older patients with esophageal cancer: a prospective cohort study

In older patients with locally advanced esophageal cancer (LAEC), loss of skeletal muscle mass during neoadjuvant chemotherapy (NAC) is associated with poor clinical outcomes. This study aimed to investigate factors associated with loss of skeletal muscle mass during NAC in older patients with LAEC. This was a single-center exploratory prospective cohort study. Consecutive patients aged ≥65 years with LAEC scheduled for curative esophagectomy after NAC were enrolled between October 2021 and December 2023. As a primary endpoint, loss of skeletal muscle mass index (ΔSMI: pre-NAC minus post-NAC value) was calculated from computed tomography images before and after NAC. Significant pre-NAC and during-NAC factors with ΔSMI were detected with a multivariate regression model. Statistical significance was considered as two-tailed P <0.05. A total of 69 patients were analyzed. The mean age was 72.9 years, and 53 (77%) were male. Mean SMI before and after NAC was 43.1 and 40.9 cm2/m2, and mean ΔSMI was 2.2 cm2/m2. In multivariate analysis, ΔSMI was associated with increased sitting time during NAC (per 1 min/day, adjusted coefficient 0.007, 95% confidence interval [CI] 0.001 to 0.013, P = 0.016), decreased Geriatric Nutritional Risk Index during NAC (per 1 score, adjusted coefficient -0.146, 95% CI -0.213 to -0.013, P = 0.002), and worsening decreased appetite during NAC (vs. no worsening, adjusted coefficient 1.571, 95% CI 0.279 to 2.862, P = 0.018). It was hypothesized that the inactivity-related mechanism and malnutrition-related mechanism are important for skeletal muscle mass loss during NAC in older patients with LAEC.

How I treat older patients with Ph/BCR-ABL-negative acute lymphoblastic leukemia

ABSTRACT

Despite advancements in new treatments, management of older patients with acute lymphoblastic leukemia (ALL) remains an unmet medical need. With increasing age, patients with ALL have a significantly lower complete remission rate, higher early mortality and relapse rate, and poorer survival than younger patients. This is attributed to a higher prevalence of adverse prognostic factors among older individuals and reduced tolerance to chemotherapy. Progress has been made in tailoring moderately intensive chemotherapy protocols for Philadelphia chromosome (Ph)/BCR::ABL-negative ALL in older patients, and recent phase 2 studies have explored integrating immunotherapy into initial treatment with very promising results. However, establishing new standard regimens for this age group remains and improving general management strategy is a pending task.

Patterns of social support among older adults with cancer and associations with patient-reported outcomes: A latent class analysis

INTRODUCTION

Social support can play an important role in the care of older adults living with cancer. However, different patterns of social support, such as emotional, instrumental, informational, appraisal, and giving support need to be considered to facilitate adjustments to cancer. This study aimed to explore the distinct patterns of social support among older adults with cancer and examine the socio-demographic variables and patient-reported outcomes that may be associated with patterns of social support.

MATERIALS AND METHODS

Data were used from 7,097 respondents from the Experience of Cancer Patients in Transition Study administered in 2016. Socio-demographic variables included sex, age, marital status, place of residence, and income, alongside patient-reported outcomes. Latent class analysis was used to identify distinct social support patterns. Multivariable multinomial regression models were then used to determine predictors of these latent classes.

RESULTS

Three latent classes of social support were identified: "low," "moderate," and "high" emotional support. Having "high" emotional support did not necessarily mean patients had the highest levels of all social support attributes. For example, the "low" emotional support group exhibited the highest appraisal support (16 % of class members) and giving support (42 % of class members). While most socio-demographic variables were not significant predictors of the latent classes, statistically significant differences were found in emotional health.

DISCUSSION

Assessing social support requires consideration of the different patterns of support, as the presence of one attribute (e.g., appraisal or giving support) does not ensure the coverage of others (e.g., emotional support). Comprehensive assessments of these varied support patterns are recommended to better address the psychological and emotional challenges associated with a cancer diagnosis and to inform subsequent interventions.

High Prevalence of Malnutrition in Geriatric Patients With Solid Organ Cancer-An Institutional Study

PURPOSE

The demographic transition toward aging heralds an increase in the number of geriatric patients with cancer in India. Comprehensive geriatric assessment (CGA) is a sine qua non for treatment planning and shared decision making in these patients. We aimed to study the prevalence of malnutrition and the associated risk factors in geriatric patients with solid organ cancer.

METHODS

In this observational study, treatment-naïve geriatric patients with cancer underwent CGA. We performed a Mini Nutritional Assessment (MNA) to diagnose malnutrition. Data analysis was done using descriptive statistics, Pearson's chi-square, Spearman correlation, and multivariable regression analysis to assess the factors associated with malnutrition.

RESULTS

One hundred forty-two patients were included in the analysis. The median age was 67 (range, 60-88) years, with a male preponderance of 73.2% (n = 104) and a stage IV disease of 75.4% (n = 107). Most patients, 91.6% (n = 130), had abnormal MNA scores. Nearly one third of the patients, 35.2% (n = 50), were underweight (BMI <18.5 kg/m2). Poor performance status (PS) was seen in 66.2% (n = 94) of the patients. Poor appetite 79.6% (n = 113) was the most common risk factor, followed by addictions (74.6%, n = 106), chronic constipation (35.9%, n = 51), and polypharmacy (21.8%, n = 31). Cognitive impairment and depression were seen in 35.2% (n = 50) and 57.1% (n = 81) of the patients, respectively. The study found a significant correlation of MNA with age (P = .048), depression (P < .001), PS (P < .001), functional decline (P < .001), and cognition (P < .001).

CONCLUSION

There exists a widespread prevalence of malnutrition and amenable risk factors in geriatric patients with cancer. Nutritional assessment is essential, and interventions should be implemented to improve clinical outcomes.

Prognostic value of electronic health records-based frailty measures for all-cause mortality in older patients with non-small cell lung cancer

INTRODUCTION

Frailty screening is important to guide treatment decisions for older patients with non-small cell lung cancer (NSCLC). However, the performance of frailty measures (FMs) remains unclear. This study aimed to evaluate the prognostic value of FMs based on electronic health records (EHR) data in clinical settings for all-cause mortality in older patients with NSCLC.

MATERIALS AND METHODS

We retrospectively analyzed 4253 patients aged ≥65 years, newly diagnosed with NSCLC (2007-2018) using EHR data from the National Cancer Center, Korea. Frailty was measured by either laboratory tests (frailty index based on routine laboratory tests [FI-Lab]), comorbidities and performance status (electronic Frailty index [eFI]), or both (combined frailty index [FI-combined]). Patients were categorized as frail or non-frail. Cox proportional hazards models and C-index were used to estimate the predictive ability of FMs for all-cause mortality in 1 year, 3 years, and 5 years post-diagnosis, adjusting for age, sex, and SEER stage.

RESULTS

EHR-based FMs could enhance the prognostic ability to predict the survival of older patients with NSCLC. In the total population, FI-Lab showed the largest predictive value, especially for 1-year mortality with an adjusted hazard ratio for frail vs. non-frail groups of 2.25 (95 % CI 2.02-2.51) and C-index of 0.74 compared to 0.72 in the base model (p-value<0.001). FI-Lab could improve the prognostic ability for 1-year mortality in patients with regional and distant SEER stages and those receiving systemic therapy, whereas FI-combined could improve the prediction of 3-year and 5-year mortality in patients with localized disease and receiving surgery.

DISCUSSION

Easy-to-use FMs derived from EHR data can enhance the prediction of all-cause mortality in older patients with NSCLC. Oncologists can utilize comprehensive FMs comprising comorbidities, functional status, and subclinical tests or FI-Lab, depending on the patient's medical condition, to facilitate shared cancer care planning.

Spanish Society of Medical Oncology recommendations for comprehensive assessment and care of cancer survivors' needs

This article reviews the contemporary and inclusive definition of cancer survivorship, including patients with and without disease who have completed or continue to undergo treatment. The Spanish Society of Medical Oncology (SEOM) describes in this article the needs of these patients and outlines a care model based on an estimation of cancer incidence and identification of patient needs, to enable the provision of practical actions to achieve effective care. The objectives of this review are to identify the main effects of cancer on survivors and to establish appropriate ways of measuring these effects, as well as discussing the management of physical, psychological and social, occupational, financial, and other health-related needs. We suggest a multidisciplinary care model and training programs for the different professionals involved in care, and highlight challenges and the future role of the SEOM and health-care policy in ensuring optimum care of cancer survivors.

Clin-STAR Corner: Practice Changing Advances at the Interface of Oncology and Geriatrics

Cancer and aging are inextricably linked, and older adults are a significant proportion of those diagnosed, treated, and living with and beyond a cancer diagnosis. Several large prospective studies have enhanced our understanding of how to improve the assessment, treatment, and outcomes of older adults with cancer starting therapy. This article summarizes three recent high-impact trials that produced practice-changing implications for the management of older adults with cancer that led to guideline updates. The key findings from these trials highlight that geriatric assessment-guided interventions in older adults with cancer: (1) facilitated higher rates of chemotherapy completion at planned doses with less modification among patients, (2) reduced grade 3 hematologic and non-hematologic toxicity during treatment delivery among patients of all stages of cancer receiving chemotherapy, and (3) influenced treatment decisions among advanced cancer patients receiving supportive care leading to reduced toxicity through reduced intensity of therapy without compromise of survival.

Systemic treatment among frail older patients with cancer: An observational cohort

INTRODUCTION

In the past, certain oncological therapies were not offered to frail older patients. However, the advancement of geriatric oncology, tailored chemotherapy regimens, the introduction of new treatments, and the optimization of supportive care have contributed to enhancing the therapeutic margin. We aimed to evaluate the benefit of systemic treatment among older adults by assessing the three-month survival of older frail patients with metastatic cancer.

MATERIALS AND METHODS

This retrospective cohort study included patients aged 70 and over with metastatic cancer who underwent pre-therapeutic geriatric assessment at Gustave Roussy Hospital between May 2020 and May 2022 and were categorized as "frail" according to the SIOG-1 classification, whether they received systemic treatment (ST group) or exclusive supportive care (SC group).

RESULTS

The ST group included 77 patients, and the SC group included 44 patients. Patients in the ST group had a median age of 80.6 years (82.7 years in SC group). The three-month overall survival rate was 81.8 % [95 % Confidence Interval (CI) 71.8; 88.9] in the ST group. The median survival rate was 10.6 months [95 % CI 6.3; 12.6] in the ST group. In multivariate analysis within the ST group, loss of autonomy assessed by activity of daily living (ADL) (HR 2.16 [1.09; 4.28]) and more frailty factors (HR 1.40 [1.01; 1.95]) were associated with lower three-month survival.

DISCUSSION

Older frail patients with metastatic cancer may benefit from systemic oncologic treatment. The introduction of such treatment for patients with loss of autonomy in ADL or cumulative frailty factors should be considered only with caution.

[Implementation of geriatric oncology in a remote hospital in French Guiana]

INTRODUCTION

The aim was to analyze the implementation of the Onco-Geriatrics model in a remote ultramarine territory: West-French Guiana. The population is socially precarious in terms of income, social coverage and administrative status, and most often speaks a non-French language and has a non-Western culture.

METHODS

Narrative description of the implementation and retrospective study of anonymized data from the database of older patients managed for cancer between September 2014 and December 2020.

RESULTS

A total of 574 new patients were managed. Of these, 107 were aged 70 and over; 78 (73 %) had a G8 test. Forty-two patients had a multidimensional geriatric assessment (MGA). More than half the patients had dependency criteria, malnutrition and a high number of severe comorbidities. Difficulties encountered were language, level of education, clinical context (in 18 patients), but also insufficient involvement of health professional and the consequences of health organization and gradual implementation.

DISCUSSION

Implementation was impacted by the fact that quality criteria for implementation were not sufficient. Studies in high-middle-income countries in South America suggest that initial implementation of the MGA may be preferable, that frailty screening tests and the MGA procedure can be adapted to non-Western populations, and that the use of new technologies can improve the management of older patients in this context.

Opioids and benzodiazepines in oncology: Perspectives on coprescribing and mitigating risks

INTRODUCTION

Opioids and benzodiazepines are commonly prescribed for cancer symptoms. In combination, they can increase the risk of adverse events, particularly for older adults with multimorbidity, who represent most patients with cancer. We aimed to understand cancer care providers' practices for opioid and benzodiazepine coprescribing and mitigating potential harms.

MATERIALS AND METHODS

We interviewed oncology and palliative care providers from two health systems. Interviews focused on attitudes about and current practices for coprescribing opioids and benzodiazepines. We analyzed interview transcripts using a staged approach to thematic analysis.

RESULTS

Twenty providers (10 oncology, 10 palliative care) participated. We identified three key themes. (1) Reluctance to prescribe benzodiazepines: providers reported rarely coprescribing because they do not routinely prescribe benzodiazepines, which were viewed as having a poor safety profile. (2) Medication safety precautions: these included starting at a low dose and titrating up slowly, consolidating prescriptions under one provider whenever possible, and providing patient and caregiver education around side effects, overdose, and naloxone. Compared to oncologists, palliative care providers more often described providing naloxone to patients and caregivers. (3) Risk assessment and monitoring: most providers mentioned checking state Prescription Drug Monitoring Program databases and conducting chart reviews to identify evidence of substance misuse history. Several oncologists expressed discomfort in asking about substance misuse history due to concerns about stigma. Providers described sometimes relying on their perception of a patient's trustworthiness, with some acknowledging the potential for bias.

DISCUSSION

We highlight opportunities to improve medication review and reconciliation practices in oncology, increase uptake of naloxone in oncology practice, systematize efforts to screen patients for substance misuse, and strengthen integration of addiction and psychiatry services into oncology and palliative care settings. Regular use of geriatric assessment in oncology would also address many of the safety concerns we observed.

Safety and quality of life with maintenance olaparib plus bevacizumab in older patients with ovarian cancer: subgroup analysis of PAOLA‑1/ENGOT-ov25

BACKGROUND

In PAOLA-1/ENGOT-ov25, the addition of olaparib to bevacizumab maintenance improved overall survival in patients with newly diagnosed advanced ovarian cancer. We describe the safety profile and quality of life (QoL) of this combination in older patients in PAOLA-1.

METHODS

Safety (CTCAE v4.03) and QoL (EORTC QoL Questionnaires Core 30 and Ovarian 28) data were collected. We compared safety by age (≥70 vs <70 years) in the olaparib-containing arm. QoL by treatment arm was assessed in older patients. Geriatric features, including Geriatric Vulnerability Score (GVS), were also gathered.

RESULTS

Of 806 patients randomized, 142 were ≥70 years old (olaparib-containing arm: n = 104; placebo arm: n = 38). Older patients treated with olaparib exhibited a similar safety profile to younger patients, except for higher rates of all grades of lymphopenia and grade ≥3 hypertension (31.7% vs 21.6%, P =.032 and 26.9% vs 16.7%, P =.019, respectively). No hematological malignancy was reported. Two years after randomization, mean Global Health Status and cognitive functioning seemed better with olaparib than bevacizumab alone (adjusted mean difference: +4.47 points [95% CI, -0.49 to 9.42] and +4.82 [-0.57 to 10.21], respectively), and other QoL items were similar between arms. In the olaparib-containing arm, older patients with baseline GVS ≥ 1 (n = 48) exhibited increased toxicity and poorer QoL than those with GVS of 0 (n = 34).

CONCLUSION

Among older patients in PAOLA-1, olaparib plus bevacizumab had a manageable safety profile and no adverse impact on QoL. Additional data are required to confirm these results in more vulnerable patients.(ClinicalTrials.gov Identifier: NCT02477644).

A Prospective Monocentric Study of Invasive Breast Carcinoma Diagnosed at 80 Years and Older: Survival Outcomes and Peculiar Challenges

Background: The lengthening of the lifespan led to an increase in breast cancer (BC) diagnosed in very old age, but the treatment recommendations in this patient group usually lack evidence-based practice. We conducted a prospective observational monocentric study specifically targeting patients diagnosed with invasive BC at 80 years of age or older. Methods: We enrolled 88 patients consecutively observed for a new BC diagnosis at 80 years or older. The aim was to investigate progression-free (PFS) and overall survival (OS), with a long follow-up period, along with clinico-pathological characteristics of the population. Results: At the end of the 5-year follow-up, the estimated OS and PFS probabilities were 82.9% (95% CI: 71.3-95.3%) and 64.0% (95% CI: 51.7-79.2%), respectively. After 8.5 years from the BC diagnosis, 48.9% died. The cause of death was BC in 32.6% of patients, different from BC in 13.9%, and unknown in the remaining. Surgery was performed in 69.3% of the cases and was associated with improved 12-month PFS (p < 0.001). Adjuvant systemic therapy and radiotherapy were omitted in 32% and 93% of eligible patients, respectively. A higher rate of metastatic disease at the diagnosis was observed in comparison with data described in younger people, as well as a significantly high rate of drop-out (27.3%). Conclusions: Ultra-old patients have a not negligible life expectancy; therefore, the oncologic treatment should be optimal and should adequately fight BC, always considering the quality of life of these frail patients. Future research should focus on developing personalized treatment protocols that incorporate comprehensive geriatric assessments and quality-of-life metrics. Additionally, larger, multicentric studies are needed to validate our findings and explore the role of emerging therapies in this age group.

Associations of frailty with survival, hospitalization, functional decline, and toxicity among older adults with advanced non-small cell lung cancer

INTRODUCTION

Among older adults with cancer receiving chemotherapy, frailty indices predict OS and toxicity. Given the increased use of immunotherapy and targeted therapy for advanced non-small cell lung cancer (aNSCLC), we evaluated frailty and Karnofsky Performance Status (KPS) among older adults with aNSCLC receiving chemotherapy, immunotherapy, and/or targeted therapy.

METHODS

Patients aged ≥ 65 with aNSCLC starting systemic therapy with non-curative intent underwent geriatric assessments over 6 months. We developed a deficit-accumulation frailty index to categorize patients as robust, pre-frail, or frail. To evaluate associations between frailty and KPS with OS, we used Cox proportional hazards models adjusted for race, insurance, and treatment. We used logistic regression to evaluate hospitalizations, functional decline, and severe toxicity.

RESULTS

Among 155 patients (median age 73), 45.8% were robust, 36.1% pre-frail, and 18.2% frail; 34.8% had a KPS ≥ 90, 32.9% had a KPS of 80, and 32.3% had a KPS ≤ 70. The median OS was 17.9 months. Pre-frail/frail patients had worse OS compared to robust patients (adjusted hazard ratio [HR] 2.09, 95% CI, 1.31-3.34) and were more likely to be hospitalized (adjusted odds ratio [OR] 2.21, 95% CI, 1.09-4.48), functionally decline (adjusted OR 2.29, 95% CI, 1.09-4.78), and experience grade ≥ 3 hematologic toxicity (adjusted OR 5.18, 95% CI, 1.02-26.03). KPS was only associated with OS.

CONCLUSIONS

Our frailty index was associated with OS, hospitalization, functional decline, and hematologic AEs among older adults with aNSCLC receiving systemic therapies, while KPS was only associated with OS. Pretreatment frailty assessment may help identify older adults at risk for poor outcomes to optimize decision-making and supportive care.

Real-world data of first-line treatment with pembrolizumab for NSCLC with high PD-L1 expression in elderly patients: a subgroup analysis of HOT/NJLCG2001

BACKGROUND

In the first-line treatment of elderly patients with advanced-stage non-small cell lung cancer (NSCLC) with high programmed death-ligand 1 (PD-L1) expression (tumor proportion score ≥ 50%), this study aimed to determine whether pembrolizumab monotherapy (MONO) or pembrolizumab plus platinum-based chemotherapy (COMB) should be selected.

METHODS

We performed a retrospective multicenter study (sub-analysis of the HOT/NJLCG2001 trial) of 299 patients with NSCLC with high PD-L1 expression who received MONO or COMB as the first-line treatment between December 2018 and January 2020. We selected patients aged 75 years and older and assessed the clinical efficacy and toxicity.

RESULTS

In total, 81 (median age: 79 years) and 19 (median age: 76 years) patients received MONO and COMB, respectively. Twenty patients with a performance status (PS) score of 2-3 were enrolled in the MONO group. The median progression-free survival (PFS) was 7.8 and 8.9 months in the MONO and COMB groups, respectively. The median overall survival (OS) was 14.6 and 20.3 months, and the 2-year survival rates were 38.8 and 49.9%, respectively. Furthermore, 29.6% and 26.3% of patients discontinued treatment due to adverse events, respectively. In MONO, patients with PS 0-1 had a longer PFS (10.5 months) and OS (21.7 months) than those with PS 2-3 (0.7 and 1.6 months, respectively).

CONCLUSION

Some elderly patients with NSCLC and high PD-L1 expression might benefit from COMB; however, MONO is considered the preferred treatment. MONO may not be an effective or feasible treatment for patients with PS 2-3, even with high PD-L1 expression.

Addressing Ageism With Geriatric Assessment in Clinical Practice and Research

Addressing ageism in clinical practice & research: #awareness #education #language and #geriassessment.

Frailty in Older Adults with Prostate Cancer

Older adults with all stages of prostate cancer are prone to developing frailty. These patients should have a frailty assessment and be managed by a multidisciplinary team. Lifestyle measures and tailoring of cancer-related treatment to the patient's fitness level can help in mitigating the adverse effects of frailty.

SOHO State of the Art Updates and Next Questions | Diffuse Large B-Cell Lymphoma in Older Adults: A Comprehensive Review

Older adults (OA) with DLBCL are a heterogenous population with suboptimal outcomes. In this review, we identify and address the unique challenges encountered in the care of OA with DLBCL. We elaborate on the role and limitations of current geriatric assessment (GA) tools and ways to incorporate fitness in therapeutic decision making. We suggest best practices to implement GA in routine practice and clinical trials. The most widely used tool is simplified GA (sGA) which categorizes patients into fit, unfit and frail groups. Patients who are fit benefit from full dose/curative approach, whereas consideration should be made to reduce the intensity of chemotherapy for unfit patients. Frail patients with DLBCL are a major unmet need without any satisfactory treatment options. Ongoing investigations combining novel therapies into chemotherapy-free regimens are underway with promising early results. In the relapsed/refractory (R/R) setting, anti-CD19 CAR-T cell therapy (CART) is now the standard of care for primary refractory disease or relapse within 12 months of completing therapy. Autologous stem cell transplant is still a consideration for fit OA with relapse >12 months after completing therapy. The recent approval of bispecific antibodies is a welcome advance that will greatly benefit OA not eligible for CART. Other regimens available for patients ineligible for CART or for those who experience progression post-CART include polatuzumab-rituximab±bendamustine, tafasitamab-lenalidomide, loncastuximab or chemotherapy-based approaches such as rituximab-gemcitabine-oxaliplatin. We discuss the changing paradigm in R/R DLBCL and spotlight emerging data from recent congresses that can improve outcomes in this vulnerable population.

Prediction of moderate and severe toxicities of chemotherapy in older patients with cancer: a propensity weighted analysis of ELCAPA cohort

BACKGROUND

Currently available predictive models for chemotherapy-related toxicity are not sufficiently discriminative in older patients with cancer and do not consider moderate toxicities. The purpose of this study was to identify factors associated with moderate and severe chemotherapy toxicities in older patients with cancer.

MATERIALS AND METHODS

Patients aged 70+ recruited in the prospective ELCAPA cohort were analyzed. A total of 837 patients with data on toxicities had received chemotherapy without other systemic treatment and were included between 2015 and 2022. To adjust for any imbalances in the distribution of covariates between patients receiving single-agent chemotherapy vs combination chemotherapy, we applied overlap weighting (a propensity-score-based technique). We used multinomial logistic regression.

RESULTS

Median (interquartile range) age was 81 (77-84). Forty-one percent experienced moderate toxicity, and 33% experienced severe toxicity. Hematologic toxicities accounted for 53% of severe toxicities and 66% of moderate toxicities. Age <80 years, cancer type, metastatic status, Eastern Cooperative Oncology Group performance status (ECOG-PS) >1, no cognitive impairment were associated with combination chemotherapy decision. In a univariate analysis with overlap weighting, no factors were associated with moderate toxicity. Hemoglobin < 10 g/dL and a CIRS-G score >12 were associated with severe toxicity. In a multivariate analysis, only hemoglobin < 10 g/dL was independently associated with severe toxicity, adjusted OR 2.96 (95% CI, 1.20-7.29).

CONCLUSION

By addressing indication bias for combination chemotherapy decision, only anemia and not cancer type, combination chemotherapy was predicting for severe chemotherapy-related toxicity in older patients with cancer. We did not find any predictors of moderate chemotherapy-related toxicity.

Developing a National Study That Integrates the Geriatric Assessment into the Care of Older Patients with Myeloid Malignancies

PURPOSE OF REVIEW

To highlight the priorities in geriatric assessment research in myeloid malignancies and discuss design considerations necessary to ensure research is patient-centric, generalizeable, and high quality.

RECENT FINDINGS

Older adults with myeloid malignancies including those who are perceived to have excellent performance status have multiple functional impairments. These impairments are associated with early mortality. Older adults have different functional trajectories through the course of treatment; this will be further investigated in our ongoing multicenter study. In a single-center study, we have demonstrated the use of geriatric assessment to guide treatment is feasible. Key priorities include designing a multicenter validation study to confirm the role of geriatric assessment in determining treatment tolerance and survival. Such a study should include core geriatric assessment measures and should enroll diverse patient population across various practices. Conducting such a study is necessary to advance patient care and trial design, and to open venues to conduct studies to confirm the role of geriatric assessment in treatment selection.

Function, cognition, and quality of life among older adults with lung cancer who live alone: A prospective cohort study

INTRODUCTION

Among older adults without cancer, living alone is associated with poor health outcomes. However, among older adults with non-small cell lung cancer (NSCLC) who live alone, data on function, cognition, and quality of life (QOL) during systemic treatment remain limited.

MATERIALS AND METHODS

We enrolled adults aged ≥65 with advanced NSCLC starting a new chemotherapy, immunotherapy, and/or targeted therapy regimen with non-curative intent. Patients completed geriatric assessments including instrumental activities of daily living (IADL), Montreal Cognitive Assessment, and QOL pretreatment and at 1, 2, 4, and 6 months, or until treatment discontinuation, whichever occurred earlier. We categorized change in IADL, cognition, and QOL as stable/improved, declined with recovery, or declined without recovery using clinically meaningful definitions of change. We used multinomial logistic regression to compare change between patients who lived alone versus with others.

RESULTS

Among 149 patients, median age was 73; 21% lived alone. Pretreatment IADL, cognition, and QOL scores were similar between older adults who lived alone versus with others. During NSCLC treatment, older adults who lived alone had similar trajectories of function (52% functional decline vs 38%), cognition (43% cognitive decline vs 50%), and QOL (45% QOL decline vs 44%) compared with those who lived with others. In unadjusted analyses, patients who lived alone were more likely to develop functional decline with recovery (reference category: stable/improved function) than those who lived with others (relative risk ratio 4.07, 95% CI 1.14-14.6, p = 0.03). However, this association was not observed after adjusting for age, race, prior NSCLC treatment, current treatment group, and pretreatment geriatric assessment differences. There were no differences in cognitive or QOL trajectories in unadjusted or adjusted analyses.

DISCUSSION

Approximately half of older adults with advanced NSCLC who lived alone were able to maintain their function, cognition, and QOL during NSCLC treatment, which was similar to older adults who lived with others. Many older adults with advanced NSCLC who live alone can receive systemic treatment with individualized supportive care.

Malnutrition risk screening in adult oncology outpatients: An ASPEN systematic review and clinical recommendations

BACKGROUND

Malnutrition screening is not widely practiced in outpatient cancer centers. This review aims to determine the validity of malnutrition screening tools and provide recommendations for clinical use.

METHODS

Studies identified by a systematic review assessed the general validity of screening tools in adult oncology outpatients from five databases through 2022. The American Society for Parenteral and Enteral Nutrition (ASPEN) convened a working group of members from the Academy of Nutrition and Dietetics, Academy of Oncology Nurse and Patient Navigators, American Cancer Society, American Society for Clinical Oncology, American Society for Nutrition, American Society for Radiation Oncology, Association of Cancer Care Centers, and Oncology Nursing Society to answer the following questions: (1) should clinicians screen for malnutrition, (2) which malnutrition screening tools are recommended, and (3) what are the clinical applications for malnutrition risk screening in adult oncology outpatients?

RESULTS

Twenty of 738 studies met the criteria and were reviewed. Six screening tools with specific cut-points demonstrated validity and are recommended, including the Mini Nutritional Assessment (≤23.5), Malnutrition Screening Tool (MST; MST ≥ 2 and patient-led MST ≥ 2), Malnutrition Universal Screening Tool (MUST; MUST ≥ 1 and MUST ≥ 2), Nutrition Risk Screening-2002 (NRS-2002; NRS-2002 ≥ 2 and NRS-2002 ≥ 3), NUTRISCORE ≥ 5, and Patient-Generated Subjective Global Assessment Short Form (PG-SGA SF; PG-SGA SF ≥ 7 and PG-SGA SF ≥ 8).

CONCLUSION

Six screening tools are valid for malnutrition risk identification in oncology ambulatory settings and recommended before treatment initiation and regularly thereafter, depending on treatment course. Research is needed to understand to what extent early diagnosis and management of malnutrition improves the clinical care of oncology patients.

[Oncogeriatric pathway in oncology support care day hospital and link with the palliative pathway]

The discovery of a cancer for which there is no immediate curative option is a frequent occurrence in the elderly. This article describes two well-identified pathways coordinated by advanced practice nurses at our facility: the oncogeriatric pathway and the early palliative pathway, as well as the link between these pathways.

Breaking down frailty: Assessing vulnerability in acute myeloid leukemia

Acute myeloid leukemia (AML) is a disease primarily affecting older adults. However, not all patients at older ages are suitable for curative treatment with intensive chemotherapy due to "frailty" demonstrated by their functional status, physiologic reserve, and vulnerability to disease and treatment morbidity. Lack of consensus exists on how to select older, less fit patients most appropriate for standard intensive chemotherapy (IC), hypomethylating agents (HMA) with venetoclax, or less intensive regimens. A total of 37 studies of frailty assessments and composite indices in AML show heterogeneous results regarding the ability of frailty and Comprehensive Geriatric Assessment (CGA) measures to predict treatment outcomes. CGA, Geriatric 8 (G8) risk score, and hematopoietic cell transplant comorbidity index (HCT-CI) show association with prognosis, and should be validated in larger therapeutic trials. Studies of biomarkers, like albumin and C-reactive protein, and patient-reported outcomes demonstrate the potential to enhance information gained from rigorous geriatric assessment.

Dizziness and impaired walking balance in aging patients during chemotherapy

INTRODUCTION

Older adults are at risk of adverse effects during chemotherapy including nausea and fatigue, but many also suffer from dizziness and peripheral neuropathy. This may lead to balance and walking impairments and increased risk of falls and affect health-related quality of life. Moreover, these symptoms are often underreported with inadequate awareness among health professionals leading to deficient focus on the need for targeted assessment and rehabilitation. We aimed to examine the prevalence of dizziness, impaired walking balance, and neuropathy and falls in older adults ≥65 years with gastrointestinal cancer receiving chemotherapy and the associations between these symptoms. Further, we aimed to examine the quantity of patients reporting these symptoms to the oncologist.

MATERIALS AND METHODS

This is a cross-sectional study among patients ≥65 years with gastrointestinal cancers who have completed three or more series of chemotherapy. The prevalence of dizziness, impaired walking balance, neuropathy, and reporting of these adverse effects was examined through structured questionnaires.

RESULTS

Of two hundred patients (57 % male, mean age 74.4 years) the prevalence of dizziness was 54 % and the prevalence of patients experiencing impaired walking balance was 48 %. Symptoms of neuropathy was present in 32 % of patients and 11 % experienced falls during chemotherapy. Symptoms of neuropathy was associated with experiencing dizziness: odds ratio (OR) 1.98 (95 % confidence interval [CI]: 1.06; 3.71) and impaired balance: OR 3.61 (95 % CI: 1.87; 6.96). Less than half the patients (48 %) told the oncologist about these symptoms.

DISCUSSION

Dizziness and impaired walking balance during chemotherapy are underreported yet profound symptoms among older patients with cancer. Dizziness and impaired balance should be systematically assessed during chemotherapy among older patients.

Geriatric assessment for the practicing clinician: The why, what, and how

Older adults with cancer heterogeneously experience health care, treatment, and symptoms. Geriatric assessment (GA) offers a comprehensive evaluation of an older individual's health status and can predict cancer-related outcomes in individuals with solid tumors and those with hematologic malignancies. In the last decade, randomized controlled trials have demonstrated the benefits of GA and GA management (GAM), which uses GA information to provide tailored intervention strategies to address GA impairments (e.g., implementing physical therapy for impaired physical function). Multiple phase 3 clinical trials in older adults with solid tumors and hematologic malignancies have demonstrated that GAM improves treatment completion, quality of life, communication, and advance care planning while reducing treatment-related toxicity, falls, and polypharmacy. Nonetheless, implementation and uptake of GAM remain challenging. Various strategies have been proposed, including the use of GA screening tools, to identify patients most likely to benefit from GAM, the systematic engagement of the oncology workforce in the delivery of GAM, and the integration of technologies like telemedicine and mobile health to enhance the availability of GA and GAM interventions. Health inequities in minoritized groups persist, and systematic GA implementation has the potential to capture social determinants of health that are relevant to equitable care. Caregivers play an important role in cancer care and experience burden themselves. GA can guide dyadic supportive care interventions, ultimately helping both patients and caregivers achieve optimal health.

Molecular signaling and clinical implications in the human aging-cancer cycle

It is well documented that aging is associated with cancer, and likewise, cancer survivors display accelerated aging. As the number of aging individuals and cancer survivors continues to grow, it raises additional concerns across society. Therefore, unraveling the molecular mechanisms of aging in tissues is essential to developing effective therapies to fight the aging and cancer diseases in cancer survivors and cancer patients. Indeed, cellular senescence is a critical response, or a natural barrier to suppress the transition of normal cells into cancer cells, however, hypoxia which is physiologically required to maintain the stem cell niche, is increased by aging and inhibits senescence in tissues. Interestingly, oxygen restriction or hypoxia increases longevity and slows the aging process in humans, but hypoxia can also drive angiogenesis to facilitate cancer progression. In addition, cancer treatment is considered as one of the major reasons that drive cellular senescence, subsequently followed by accelerated aging. Several clinical trials have recently evaluated inhibitors to eliminate senescent cells. However, some mechanisms of aging typically can also retard cancer cell growth and progression, which might require careful strategy for better clinical outcomes. Here we describe the molecular regulation of aging and cancer in crosstalk with DNA damage and hypoxia signaling pathways in cancer patients and cancer survivors. We also update several therapeutic strategies that might be critical in reversing the cancer treatment-associated aging process.

Associations of quality of social support and accurate beliefs about curability among older adults with advanced cancer

INTRODUCTION

Supporting older adults with advanced cancer to better understand their disease and its prognosis is important for shared decision-making. Social support is a potentially modifiable factor that may influence disease understanding. In this study, we examined the associations of quantity and quality of social support with patients' beliefs about the curability of their advanced cancer.

MATERIALS AND METHODS

We performed a secondary analysis of a cluster-randomized trial that recruited older adults aged ≥70 with advanced incurable cancer. At enrollment, patients completed the Older Americans Resources and Services (OARS) Medical Social Support form that measures both quantity (number of close friends and relatives) and quality of social support. Quality of social support was measured using 12 questions in instrumental and emotional support, each ranging from 1 (none of the time) to 5 (all of the time). Higher cumulative scores indicated greater quality of support. For beliefs about curability, patients were asked, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Responses were 0 %, <50 %, 50/50, >50 %, and 100 %. Ordinal logistic regression was used to investigate the association of quantity and quality of social support with beliefs about curability, adjusting for potential confounders.

RESULTS

We included 347 patients; mean age was 76.4 years and 91 % were white. Quantity of social support was not associated with belief in curability [adjusted odds ratio (AOR) 1.03, 95 % confidence interval (CI) (0.92, 1.16)]. For every unit increase in the quality of social support (OARS Medical Social Support score), the odds of believing in curability decreased by 26.7 % [AOR 0.73, 95 % CI (0.56, 0.97)].

DISCUSSION

Our study demonstrated that the quality, but not the quantity, of social support was associated with patients' beliefs about curability. These findings suggest that bolstering social support may directly enhance disease understanding. This insight informs supportive care interventions that specifically address disease comprehension among patients.

A novel scoring system proposal to guide surgical treatment indications for high grade gliomas in elderly patients: DAK-75

High-grade gliomas are the most prevalent neurooncological desease in adults, their incidence increases with age, peaking in the seventh decade. This paper aims to address how to select patients for surgical resection by identifying pre-surgical predictors of 12-month mortality in newly diagnosed HGG patients aged ≥ 75 years. A prognostic score will be proposed to guide surgical decisions based on expected survival. Retrospective observational single-center cohort study was carried out at the "Città della Salute e della Scienza-Molinette" University Hospital in Turin, Italy. All consecutive patients aged ≥ 75 years newly diagnosed with HGG were included, regardless of whether they underwent surgical resection. Clinical, radiological, histological and molecular data were collected.Variables potentially available at the time of diagnosis were considered to develop a multivariable logistic regression predictive model, with 12-months overall survival as the dependent variable. 102 patients aged 75 years or older received a new diagnosis of high-grade glioma, of whom 68 underwent surgical resection. Patients undergoing surgery were slightly younger (76.9 vs 79.0 years, p = 0.007) and had better performance status (median KPS 80 vs 70). Most tumors undergoing surgery were localized in cortical or subcortical non-motor areas (p < 0.001) and less frequently deep-seated (p = 0.023) or multifocal (p < 0.001). A predictive model, the DAK-75 score, was developed: the AUROC of the final model was 0.822 (95% CI 0.741-0.902). The score includes clinical presentation, tumor location, and KPS, ranging from 0 to 20, categorizing risk scores into low-risk and high-risk groups (< or > 8). Higher scores corresponded to fewer surgical patients and higher one-year mortality rates (92.2% vs 47.1%, p < 0.001). DAK-75 score may represent a valuable tool in the decision-making process for neurosurgical intervention in elderly patients diagnosed with HGG. Further studies are needed to externally and prospectively validate the scoring system.

Precision Oncology in Older Cancer Patients: A Single-Center Experience

In the last two decades, next-generation sequencing (NGS) has facilitated enormous progress in cancer medicine, in both diagnosis and treatment. However, the usefulness of NGS in older cancer patients is unclear. To determine the role of NGS in older cancer patients, we retrospectively assessed demographic, clinicopathologic, and disease-specific data from 100 randomly selected cancer patients (any subtype/stage) who underwent NGS testing in 2020 at our institution and compared the treatment outcomes (progression-free survival [PFS] and overall survival [OS]) in the younger and older patient cohorts (A [n = 34] and B [n = 66]: age < 70 and ≥70 years, respectively). Overall, 27% had targetable mutations, and 8% received NGS-determined targeted therapy (45% and 19% of patients with a targetable mutation in cohorts A and B, respectively; p = 0.2), of whom 38% (3% of the whole cohort) benefited from the therapy (PFS > 6 months). The median OS (from diagnosis) was 192 and 197 weeks in cohorts A and B, respectively (p = 0.08). This pilot study revealed no significant age-stratified difference in the diagnostic approach and treatment strategy. A small, but relevant, proportion of the cohort (3%) benefited from NGS-determined treatment. Nevertheless, older cancer patients with targetable mutations less frequently received targetable therapies.

Development and Implementation of a Geriatric Oncology Interdisciplinary Case-Based Educational Intervention for Cancer Care Providers

PURPOSE

To develop and implement a continuing professional development (CPD) activity focused on geriatric assessment (GA) in oncology for oncologists and geriatricians. We evaluated the impact of this activity on knowledge, skills, and performance regarding GA in oncology, as well as its feasibility and acceptability.

METHODS

We included teams composed of an oncologist and a geriatrician working in Mexico. Curriculum content was selected from geriatric oncology guidelines. We used Project Extension for Community Healthcare Outcome (ECHO)'s model to create a 12-week online course. A one-group pretest post-test quasi-experimental design was used to evaluate the intervention's effectiveness. At baseline, participants answered a multiple-choice knowledge assessment, a survey on self-perceived competence in GA, and an adaptation of the Association for Community Cancer Centers Geriatric Oncology Gap Assessment Tool, evaluating self-perceived performance in conducting geriatric interventions. These assessments and a satisfaction questionnaire were also completed postintervention. Baseline and postintervention scores were compared using paired t-tests.

RESULTS

We included 40 participants (20 oncologists and 20 geriatricians). Median attendance was 10 sessions (range 2-12). Thirty-eight participants completed the satisfaction questionnaire, with a median score of 10/10 (range 8-10). The mean baseline and postintervention knowledge scores were 59.5 ± 12.8 and 74.4 ± 9.7, respectively (P < .001, effect size 1.14). The mean baseline and postintervention competence scores were 6.42 ± 2.5 and 9.02 ± 0.8, respectively (P < .001, effect size 1.03). The mean baseline and postintervention performance scores were 2.58 ± 0.65 and 3.29 ± 0.5, respectively (P < .001, effect size 1.64).

CONCLUSION

A CPD activity for oncologists and geriatricians on the basis of the Project ECHO model was feasible and acceptable, leading to increased knowledge, competence, and performance in geriatric oncology. This could represent a novel method for increasing the geriatric competence of the cancer care workforce in Latin America and globally.

The association between social vulnerability and geriatric assessment impairments among older adults with gastrointestinal cancers-The CARE Registry

BACKGROUND

Older adults comprise the majority of patients with gastrointestinal (GI) cancer. Geriatric assessments (GAs) are recommended for older adults with cancer in part to detect aging-related impairments (e.g., frailty) associated with early mortality. Social factors like social vulnerability may also influence aging-related impairments. However, the association between social vulnerability and aging outcomes among older adults with cancer is understudied.

METHODS

The authors included 908 older adults aged 60 years and older who were recently diagnosed with GI cancer undergoing GA at their first prechemotherapy visit to the University of Alabama at Birmingham oncology clinic. The primary exposure of interest was the social vulnerability index (SVI). Outcomes were frailty (frail vs. robust/prefrail) and total number of GA impairments (range, 0-13). The authors examined the association between SVI and outcomes using Poisson regression with robust variance estimation and generalized estimating equations.

RESULTS

The median age at GA was 69 years (interquartile range, 64-75 years), 58.2% of patients were male, 22.6% were non-Hispanic Black, 29.1% had colorectal cancer, 28.2% had pancreatic cancer, and 70.3% had stage III/IV disease. Adjusting for age, sex, cancer type, and disease stage, each decile increase in the SVI was associated with an 8% higher prevalence of frailty (prevalence ratio, 1.08; 95% confidence interval, 1.05-1.11) and a 4% higher average count of total GA impairments (risk ratio, 1.04; 95% confidence interval, 1.02-1.06). The results were attenuated after further adjustment for race and education.

CONCLUSIONS

Greater social vulnerability was associated with a higher prevalence of frailty and an increasing average number of GA impairments among older adults with GI cancers before systemic treatment. Intervening on social vulnerability may be a target for improving the risk of frailty and GA impairments, but associations of race and education should be further evaluated.

Immunotherapy in Patients with Advanced Non-Small-Cell Lung Cancer Under-Represented by Clinical Trials

Since the initial US FDA approval of an immune checkpoint inhibitor (ICI) for the treatment of non-oncogene-driven non-small-cell lung cancer (NSCLC) nine years ago, this therapeutic strategy has been cemented as a crucial component of treatment for most of these patients. However, there is a clear efficacy-effectiveness gap whereby patients in the 'real world' seem to have more modest clinical outcomes compared to those enrolled in landmark clinical trials. This gap may be driven by the under-representation of important patient populations, including populations defined by clinical or molecular characteristics. In this review, we summarize the data outlining the evidence of ICIs in patients with poor Eastern Cooperative Oncology Group performance status (ECOG PS), underlying autoimmune disease (AID), older age, active brain metastases (BMs), and molecular aberrations such as EGFR mutations, ALK fusions, BRAF mutations and ROS1 fusions.

Roadmap to a Global Template for Implementation of Ototoxicity Management for Cancer Treatment

Ototoxicity is among the adverse events related to cancer treatment that can have far-reaching consequences and negative impacts on quality-of-life for cancer patients and survivors of all ages. Ototoxicity management (OtoM) comprises the prevention, diagnosis, monitoring, and treatment, including rehabilitation and therapeutic intervention, of individuals who experience hearing loss, tinnitus, or balance/vestibular difficulties following exposures to ototoxic agents, including platinum chemotherapy (cisplatin, carboplatin) and cranial radiation. Despite the well-established physical, socioeconomic, and psychological consequences of hearing and balance dysfunction, there are no widely adopted standards for clinical management of cancer treatment-related ototoxicity. Consensus recommendations and a roadmap are needed to guide development of effective and feasible OtoM programs, direct research efforts, address the needs of caregivers and patients at all stages of cancer care and survivorship. Here we review current evidence and propose near-term to longer-term goals to advance OtoM in five strategic areas: (1) beneficiary awareness, empowerment, and engagement, (2) workforce enhancement, (3) program development, (4) policy, funding, and sustainability, and (5) research and evaluation. The goal is to identify needs and establish a roadmap to guide worldwide adoption of standardized OtoM for cancer treatment and improved outcomes for patients and survivors.

Adverse drug reactions and drug-related problems with supportive care medications among the oncological population

AIM

The current study emphasizes the impact of adverse drug reactions (ADRs) and Drug-Related Problems (DRPs) caused by supportive care medications administered with chemotherapy.

METHOD

This is a longitudinal observational study carried out at the Ramaiah Medical College Hospital in Bengaluru, Karnataka, India, at the Department of Oncology. The data was recorded using a specifically created data collecting form. Based on the PCNE (Pharmaceutical Care Network Europe), DRPs are identified. The WHO probability scale, Modified Hartwig and Siegel for ADR severity assessment, Naranjo's algorithm for causality assessment, Rawlins and Thompson for predictability assessment, and Modified Shumock and Thornton for preventability assessment were all utilized. The OncPal guideline was considered in terms of the precision of supportive care medications regarding the reduction of ADRs in cancer patients.

RESULT

We enrolled 302 patients,166 (55%) female and 136 (45%) male (SD 14.378) (mean 49.97), patients with one comorbidity 59(19.6%) and multimorbidity (two or more) 45(14.9%), the DRPs identified were found to be 153 (50.6%); only P2 (safeties of drug therapy PCNE) were considered in this study. ADRs which are identified 175(57.9%) contributed/caused by the supportive care medications. WHO probability scale: 97 (32.1%) possible and 60 (19.9%) unlikely; Naranjo's algorithm: 97 (32.1%) unlikely and 69 (22.8%) possible; ADR severity assessment scale (Modified Hartwig and Siegel): 95 (31.5%) mild and 63 (20.9%) moderates; Rawlins and Thompson for determining predictability of an ADR: 33 (10.9%) predictable and 137 (45.5%) non-predictable; and Modified Shumock and Thornton for determining preventability of an ADR: 81 (26.8%) probably preventable and 90 (29.8%) non-preventable. The statistical comparison through preforming t-test and measuring Chi-Square between group with ADRs and without ADRs shows in some variables, significantly (Alcohol consumption status, P = .019) and Easter Cooperative Oncology Group (ECOG) performance status P < 0.001.

CONCLUSION

Comprehensive assessment of supportive medications in cancer patients would enhance the patient management and therapeutic outcome. The potential adverse drug reactions (ADRs) caused by supportive care medications can contribute to longer hospital stays and interact with the systemic anti-cancer treatment. The health care professionals should be informed to monitor the patients clinically administered with supportive medications.

Impact of a multimodal effort re-education programme on functionality, physical performance, and functional capacity in cancer patients with dyspnoea: a randomised experimental study

BACKGROUND

In recent years, there has been a significant increase in the survival rates of cancer patients. However, this has also led to an increase in side effects, such as dyspnoea, which can negatively impact of patients. We propose a programme for re-educating effort. The main objective is to test the effectiveness of this programme in improving respiratory symptoms and functionality in cancer patients.

METHODOLOGY

Experimental, prospective, longitudinal, randomised study with a parallel fixed-assignment scheme (CG-IG). The patients were selected from the Medical Oncology Service of the University Hospital Complex of Salamanca (CAUSA), Spain. Two parallel intervention programmes were designed for the two study groups (Conventional Clinical Practice-Effort Re-education Programme). Primary variables: dyspnoea (MRC), functionality (Barthel); secondary variables: physical performance (SPPB) and functional capacity (ECOG) and the socio-demographic variables (age, sex, anatomopathological diagnosis, and number of treatment lines).

RESULTS

The study sample consisted of 182 patients, with 12 excluded, resulting in a final sample size of n = 170. Sex distribution (CG: 52.9% male and 47.1% female; IG: 49.4% male and 50.6% female). The primary oncological diagnosis was lung cancer, and the most frequent tumour stages were III and IV. Statistically significant differences were found between the IG and CG scores (p < 0.001, d = 0.887, 95% CI) and between the IG and CG scores (p = 0.004, d = 0.358, 95% CI), indicating that the IG performed better.

CONCLUSION

The results of this study support the beneficial effects of an exercise re-education programme, carried out by an interdisciplinary team in improving the autonomy of oncology patients with dyspnoea.

TRIAL REGISTRATION

The clinical trial was registered in ClinicalTrials.gov (NCT04186754). (03 September 2019).