Community Oncologists' Decision-Making for Treatment of Older Patients With Cancer

Association of oxaliplatin-containing adjuvant duration with post-treatment fall-related injury and fracture in patients with stage III colon cancer: a population-based retrospective cohort study

PURPOSE

Oxaliplatin-containing adjuvant chemotherapy yields a significant survival benefit in stage III colon cancer and is the standard of care. Simultaneously, it causes dose-dependent peripheral neuropathy that may increase the risk of fall-related injury (FRI) such as fracture and laceration. Because these events carry significant morbidity and the global burden of colon cancer is on the rise, we examined the association between treatment with a full versus shortened course of adjuvant chemotherapy and post-treatment FRI and fracture.

METHODS

In this overlap propensity score weighted, retrospective cohort study, we included patients aged ≥ 18 years with resected stage III colon cancer diagnosed 2007-2019 and treated with oxaliplatin-containing adjuvant chemotherapy (oxaliplatin plus a fluoropyrimidine; capecitabine [CAPOX] or 5-fluorouracil and leucovorin [FOLFOX]). Propensity score methods facilitate the separation of design from analysis and comparison of baseline characteristics across the weighted groups. Treatment groups were defined as 50% (4 cycles CAPOX/6 cycles FOLFOX) and > 85% (7-8 cycles CAPOX/11-12 cycles FOLFOX) of a maximal course of adjuvant chemotherapy to approximate the treatment durations received in the IDEA collaboration. The main outcomes were time to any FRI and time to fracture. We determined the subdistribution hazard ratios (sHR) estimating the association between FRI/fracture and treatment group, accounting for the competing risk of death.

RESULTS

We included 3,461 patients; 473 (13.7%) received 50% and 2,988 (86.3%) received > 85% of a maximal course of adjuvant therapy. For post-treatment FRI, median follow-up was 4.6 years and total follow-up was 17,968 person-years. There were 508 FRI, 301 fractures, and 692 deaths. Treatment with > 85% of a maximal course of therapy conferred a sHR of 0.84 (95% CI 0.62-1.13) for post-treatment FRI and a sHR of 0.72 (95% CI 0.49-1.06) for post-treatment fracture.

CONCLUSION

For patients with stage III colon cancer undergoing treatment with oxaliplatin-containing adjuvant chemotherapy, any potential neuropathy associated with longer durations of treatment was not found to result in greater rates of FRI and fracture. Within the limits of this retrospective study, our findings suggest concern about FRI, while mechanistically plausible, ought not to determine treatment duration.

A Survey of the Turkish Oncology Group (TOG): Are the Oncologists Trained for Decision Making on Geriatric Cancer Patients?

INTRODUCTION

Most newly diagnosed cancers occur in older adults, and it is important to understand a patient's underlying health status when making treatment decisions. Therefore, clinicians need enhanced competencies and skills to effectively care for this population. However, most clinicians receive minimal to no training in geriatrics. This study aims to evaluate the education and training levels in geriatric oncology among Turkish physicians and to understand the factors influencing oncologists' treatment decisions for geriatric cancer patients.

MATERIALS AND METHODS

A 24-question survey was prepared to obtain the participating physicians' demographic information, as well as to inquire whether they had received training during their medical education and residency on how to approach geriatric patients, in what process(es) they had received the training, whether they were currently treating geriatric patients, what they focused on when evaluating geriatric patients, and what they thought about their training and preparedness for approaching geriatric patients. The questionnaire was sent online to radiation and medical oncologists, and the link was published on the Turkish Society of Radiation Oncology and the Turkish Society of Medical Oncology websites.

RESULTS

Two hundred and three physicians participated in the survey, 131 of whom were women. The median age was 41.66 years (24-69 years). One hundred and fifty-six physicians (76.1%) received specialty education at the university hospital. One hundred and three of them were radiation oncologists, and 80 were medical oncologists. Of the physicians, 19.7% received education in geriatrics before they specialized in oncology, and 6.9% said they were educated after specialization. When determining suitability for radiotherapy, 10.7% of radiation oncologists said that they use geriatric assessment tools. Similarly, 13.8% of medical oncologists claimed that they used geriatric assessment tools in determining suitability for chemotherapy. Of the physicians, 177 (86.3%) thought that geriatric evaluation could independently increase patient survival rate. Furthermore, patient cognitive status, functional status, physiological age, polypharmacy, geriatric specialist recommendations, inpatient services, patient relatives, and similar factors were found to be useful in treatment decisions. Finally, 92.7% of the participants believed that receiving education would have changed their perspectives on treating geriatric patients.

CONCLUSION

Our results provide perspectives on developing knowledge on and skills in geriatric training among oncologists. Learning new approaches is necessary for oncologists who more frequently confront geriatric patients with cancer.

Geriatric Oncology: A 5-Year Strategic Plan

The increasing rate of the older adult population across the world over the next 20 years along with significant developments in the treatment of oncology will require a more granular understanding of the older adult population with cancer. The ASCO Geriatric Oncology Community of Practice (COP) herein provides an outline for the field along three fundamental pillars: education, research, and implementation, inspired by ASCO's 5-Year Strategic Plan. Fundamental to improving the understanding of geriatric oncology is research that intentionally includes older adults with clinically meaningful data supported by grants across all career stages. The increased knowledge base that is developed should be conveyed among health care providers through core competencies for trainees and continuing education for practicing oncologists. ASCO's infrastructure can serve as a resource for fellowship programs interested in acquiring geriatric oncology content and provide recommendations on developing training pathways for fellows interested in pursuing formalized training in geriatrics. Incorporating geriatric oncology into everyday practice is challenging as each clinical setting has unique operational workflows with barriers that limit implementation of valuable geriatric tools such as Geriatric Assessment. Partnerships among experts in quality improvement from the ASCO Geriatric Oncology COP, the Cancer and Aging Research Group, and ASCO's Quality Training Program can provide one such venue for implementation of geriatric oncology through a structured support mechanism. The field of geriatric oncology must continue to find innovative strategies using existing resources and partnerships to address the pressing needs of the older adult population with cancer to improve patient outcomes.

Disparities in care of older adults of color with cancer: A narrative review

This review describes the barriers and challenges faced by older adults of color with cancer and highlights methods to improve their overall care. In the next decade, cancer incidence rates are expected to increase in the United States for people aged ≥65 years. A large proportion will be older adults of color who often have worse outcomes than older White patients. Many issues contribute to racial disparities in older adults, including biological factors and social determinants of health (SDOH) related to healthcare access, socioeconomic concerns, systemic racism, mistrust, and the neighborhood where a person lives. These disparities are exacerbated by age-related challenges often experienced by older adults, such as decreased functional status, impaired cognition, high rates of comorbidities and polypharmacy, poor nutrition, and limited social support. Additionally, underrepresentation of both patients of color and older adults in cancer clinical research results in a lack of adequate data to guide the management of these patients. Use of geriatric assessments (GA) can aid providers in uncovering age-related concerns and personalizing interventions for older patients. Research demonstrates the ability of GA-directed care to result in fewer treatment-related toxicities and improved quality of life, thus supporting the routine incorporation of validated GA into these patients' care. GA can be enhanced by including evaluation of SDOH, which can help healthcare providers understand and address the needs of older adults of color with cancer who face disparities related to their age and race.

Determinants of Bone-Modifying Agent Prescribing for Metastatic Castration-Resistant Prostate Cancer in a National Health Care Delivery System

PURPOSE

Despite guidelines recommending bone-modifying agents (BMAs) to decrease skeletal-related events (SREs) in men with metastatic castration-resistant prostate cancer (mCRPC), BMAs are underutilized. In this retrospective cohort study, we report the factors associated with BMA use in a national health care delivery system.

METHODS

We used the Veterans Affairs Corporate Data Warehouse to identify men with mCRPC between 2010 and 2017. BMA prescribing frequency was evaluated, and the association between patient- and disease-specific factors with BMA use was assessed using multivariable logistic regression.

RESULTS

Among 3,980 men identified with mCRPC (mean age 73.5 years, 29% Black), 47% received a BMA; median time to BMA from start of mCRPC treatment was 102 days. Factors associated with BMA use included previous BMA use (adjusted odds ratio [aOR], 7.81 [95% CI, 6.48 to 9.47]), diagnosis code for bone metastases (aOR, 1.26 [95% CI, 1.08 to 1.46]), and concomitant corticosteroid use (aOR, 1.53 [95% CI, 1.29 to 1.82]). Decreased BMA use was associated with advancing age (aOR, 0.85 per 10 years [95% CI, 0.78 to 0.92]), Charlson comorbidity index ≥2 (aOR, 0.76 [95% CI, 0.63 to 0.93]), Black race (aOR, 0.83 [95% CI, 0.70 to 0.98]), and decreased estimated glomerular filtration rate (eGFR; aOR, 0.19 [95% CI, 0.11 to 0.32] for eGFR 0-29 mL/minutes; aOR, 0.76 [95% CI, 0.64 to 0.91] for 30-59 mL/minutes).

CONCLUSION

Patients who are older, Black, or have more comorbidities are less likely to receive guideline concordant care to prevent SREs. These observations highlight the unique challenges of caring for patients with mCRPC and the need for future studies to increase BMA use in these populations.

Implementation of the Web-Enabled Cancer & Aging Resilience Evaluation (WeCARE) in an outpatient oncology setting

INTRODUCTION

Although geriatric assessments (GAs) are recommended for use in older adults with cancer, their integration into oncology practice remain suboptimal. Here, we report our experience integrating web-enabled GA (WeCARE) into oncology practice as an augmented delivery method and provider interface format to overcome implementation barriers.

MATERIALS AND METHODS

Older patients (≥60 years) with a gastro-intestinal (GI) malignancy presenting for an initial visit to medical oncology clinic at a single institution between December 7, 2021 and October 10, 2022 were contacted by staff two days in advance of their visits and sent a link to the WeCARE GA, rather than the paper version used previously. Results were directly embedded into the medical record. We describe our initial implementation outcomes and the results of a provider usability survey.

RESULTS

Of 266 eligible patients, 221 (83.1%) were successfully contacted by telephone and 200 (75.2%) completed the WeCARE prior to their appointment. More than one phone call was required to make contact for 35.7% of patients, with a mean duration of phone conversation of 2.8 min. Most patients preferred email delivery to text (63% vs 31%); 4.5% were unable to access surveys due to inadequate technology, and 25.7% brought up additional logistical concerns. Among GI oncology providers surveyed, all six found the WeCARE tool and dashboard acceptable, appropriate, and feasible. However, only a third of providers often or always used the dashboard to inform treatment decisions and guide interventions.

DISCUSSION

With nearly three-quarters of patients completing the WeCARE prior to their visits with minimal staff support and time required, this method of administration may be a viable format to overcome barriers to GA implementation. Additional work is needed to integrate the results meaningfully into clinical practice.

Modifiable fall risk factors among older adults with advanced cancer: Secondary analysis of a cluster-randomized clinical trial

INTRODUCTION

Older adults with cancer have unique fall risk factors related to their disease and treatment such as polypharmacy and neurotoxic treatments. In this secondary analysis, we identified modifiable risk factors associated with future falls among older adults with advanced cancers.

MATERIALS AND METHODS

Data were from the COACH study (ClinicalTrials.gov: NCT02107443; PI: Mohile). Patients were age ≥ 70, had stage III/IV solid tumor or lymphoma, ≥1 geriatric assessment impairment, and were receiving palliative intent treatment. Falls were self-reported at baseline (in the past six months), four to six weeks, three months, and six months. We generated inverse probability weights to account for mortality-related loss to follow-up and applied these in generalized linear mixed models to estimate incidence rate ratios.

RESULTS

Of 541 patients (mean age: 77, standard deviation [SD]: 5.27), 140 (26%) reported prior falls at baseline, and 467 (86%) had falls data for ≥1 follow-up timepoint. Of those, 103 (22%) reported at least one fall during the follow-up period, and 112 (24%) had incomplete follow-up due to death. In fully adjusted models, prior falls and impaired Timed Up and Go score were associated with higher incidence of falls over 6 months.

DISCUSSION

We identified several potentially modifiable fall risk factors in older adults with advanced cancers. Future studies should consider ways to integrate fall risk assessment into ongoing cancer care and intervene to reduce falls in this population.

Geriatric Oncology as an Unmet Workforce Training Need in the United Kingdom-A Narrative Review by the British Oncology Network for Undergraduate Societies (BONUS) and the International Society of Geriatric Oncology (SIOG) UK Country Group

Cancer is a disease associated with ageing. Managing cancer in older adults may prove challenging owing to pre-existing frailty, comorbidity, and wider holistic needs, as well as the unclear benefits and harms of standard treatment options. With the ongoing advances in oncology and the increasing complexity of treating older adults with cancer, the geriatric oncology field must be a priority for healthcare systems in education, research, and clinical practice. However, geriatric oncology is currently not formally taught in undergraduate education or postgraduate training programmes in the United Kingdom (UK). In this commentary, we outline the landscape of geriatric oncology undergraduate education and postgraduate training for UK doctors. We highlight current challenges and opportunities and provide practical recommendations for better preparing the medical workforce to meet the needs of the growing population of older adults with cancer. This includes key outcomes to be considered for inclusion within undergraduate and postgraduate curricula.

Factors associated with the evaluation of geriatric assessment (GA) domains by oncology specialists in Mexico

The use of geriatric assessment (GA) by oncology specialists in Mexico is low. We aimed to explore factors associated with the evaluation of individual GA domains by Mexican oncology specialists. We performed an exploratory analysis of a sequential explanatory mixed-methods study consisting of an online cross-sectional survey of Mexican oncology specialists and follow-up interviews on the use of GA in cancer care. For each GA domain, we performed multivariable logistic regression analyses with the frequency of evaluation of the domains as the dependent variable (dichotomised as never/rarely/sometimes versus most of the time/always). A p-value <0.05 was considered significant. Qualitative data from the interviews were analysed inductively. Of 196 respondents, 62% were male, 50% were surgical oncologists, 51% took care of >10 patients per day and 61.7% had access to a geriatrician. Self-perceived confidence in managing common geriatric conditions was associated with the evaluation of specific GA domains. For instance, self-perceived confidence in managing dementia (OR 2.72; 95% CI 1.42-5.51, p = 0.008) was associated with cognition evaluation, while for evaluation of falls, self-perceived confidence in evaluation of falls (OR 6.31; 95% CI 3.19-12.46, p < 0.001) was significantly associated. Follow-up interviews showed quality and appropriateness of evaluations may not be ideal: in many cases, physicians do not use guideline-recommended tools. For example, evaluation of cognition is commonly performed through non-validated methods which may miss the detection of patients with an impairment in this domain, partly due to limitations in knowledge and time to use recommended tools. In conclusion, self-perceived confidence in evaluating and managing common situations in older adults was associated with the evaluation of GA domains as part of everyday practice in a sample of oncology specialists in Mexico. This analysis supports the use of educational interventions to boost knowledge and confidence regarding the proper use of validated GA tools among oncology specialists.

Narrative Review of Multidisciplinary Management of Central Nervous Involvement in Patients with HER2-Positive Metastatic Breast Cancer: Focus on Elderly Patients

The tumor biology of human epidermal growth factor receptor 2 (HER2)-positive breast cancer (BC) promotes the development of central nervous system (CNS) metastases, with 25% of patients with HER2-positive BC developing CNS metastases. Furthermore, the incidence of HER2-positive BC brain metastases has increased in the last decades, likely because of the improved survival with targeted therapies and better detection methods. Brain metastases are detrimental to quality of life and survival and represent a challenging clinical problem, particularly in elderly women, who comprise a substantial proportion of patients diagnosed with BC and often have comorbidities or an age-related decline in organ function. Treatment options for patients with BC brain metastases include surgical resection, whole-brain radiation therapy, stereotactic radiosurgery, chemotherapy, and targeted agents. Ideally, local and systemic treatment decisions should be made by a multidisciplinary team, with input from several specialties, based on an individualized prognostic classification. In elderly patients with BC, additional age-associated conditions, such as geriatric syndromes or comorbidities, and the physiologic changes associated with aging, may impact their ability to tolerate cancer therapy and should be considered in the treatment decision-making process. This review describes the treatment options for elderly patients with HER2-positive BC and brain metastases, focusing on the importance of multidisciplinary management, the different points of view from the distinct disciplines, and the role of oncogeriatric and palliative care in this vulnerable patient group.

Frailty and medical financial hardship among older adults with cancer in the United States

Background

Little is known about the association between frailty level and medical financial hardship among older adults with cancer. This study aims to describe the prevalence of frailty and to identify its association with medical financial hardship among older cancer survivors in the United States.

Methods

The National Health Interview Survey (NHIS; 2019-2020) was used to identify older cancer survivors (n = 3,919). Both the five-item (Fatigue, Resistance, Ambulation, Illnesses, and Low weight-for-height) FRAIL and the three-domain (Material, Psychological, and Behavioral) medical financial hardship questions were constructed based on the NHIS questionnaire. Multivariable logistic models were used to identify the frailty level associated with financial hardship and its intensity.

Results

A total of 1,583 (40.3%) older individuals with cancer were robust, 1,421 (35.9%) were pre-frail, and 915 (23.8%) were frail. Compared with robust cancer survivors in adjusted analyses, frail cancer survivors were more likely to report issues with material domain (odds ratio (OR) = 3.19, 95%CI: 2.16-4.69; p < 0.001), psychological domain (OR = 1.47, 95%CI: 1.15-1.88; p < 0.001), or behavioral domain (ORs ranged from 2.19 to 2.90, all with p < 0.050), and greater intensities of financial hardship.

Conclusion

Both pre-frail and frailty statuses are common in the elderly cancer survivor population, and frail cancer survivors are vulnerable to three-domain financial hardships as compared with robust cancer survivors. Ongoing attention to frailty highlights the healthy aging of older survivors, and efforts to targeted interventions should address geriatric vulnerabilities during cancer survivorship.

Geriatric assessment and the variance of treatment recommendations in geriatric patients with gastrointestinal cancer-a study in AIO oncologists

BACKGROUND

Geriatric assessment (GA) is recommended to detect vulnerabilities for elderly cancer patients. To assess whether results of GA actually influence the treatment recommendations, we conducted a case vignette-based study in medical oncologists.

MATERIALS AND METHODS

Seventy oncologists gave their medical treatment recommendations for a maximum of 4 out of 10 gastrointestinal cancer patients in three steps: (i) based on tumor findings alone to simulate the guideline recommendation for a '50-year-old standard patient without comorbidities'; (ii) for the same situation in elderly patients (median age 77.5 years) according to the comorbidities, laboratory values and a short video simulating the clinical consultation; and (iii) after the results of a full GA including interpretation aid [Barthel Index, Cumulative Illness Rating Scale (CIRS), Geriatric 8 (G8), Geriatric Depression Scale (GDS), Mini Mental Status Examination (MMSE), Mini-Nutritional Assessment (MNA), Timed Get Up and Go (TGUG), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-30 (EORTC QLQ-C30), stair climb test].

RESULTS

Data on 164 treatment recommendations were analyzed. The recommendations had a significantly higher variance for elderly patients than for 'standard' patients (944 versus 602, P < 0.0001) indicating a lower agreement between oncologists. Knowledge on GA had marginal influence on the treatment recommendation or its variance (944 versus 940, P = 0.92). There was no statistically significant influence of the working place or the years of experience in oncology on the variance of recommendations. The geriatric tools were rated approximately two times higher as being 'meaningful' (53%) and 'useful for the presented cases' (49%) than they were 'used in clinical practice' (19%). The most commonly used geriatric tool in patient care was the MNA (30%).

CONCLUSIONS

The higher variance of treatment recommendations indicates that it is less likely for elderly patients to get the optimal recommendation. Although the proposed therapeutic regimen varied higher in elderly patients and the oncologists rated the GA results as 'useful', the GA results did not influence the individual recommendations or its variance. Continuing education on GA and research on implementation into clinical practice are needed.

The perspectives of 606 US dermatologists on active surveillance for low-risk basal cell carcinoma

In this survey study of over 600 US dermatologists, identical clinical scenarios (10mm primary asymptomatic BCC) were presented except for randomly varied patient characteristics including age, life expectancy, and tumor location. Most dermatologists (62%) recommended active surveillance for patients with advanced age (91 years) and a 1-year life expectancy. The odds ratio for choosing active surveillance was 20.31 (95% CI 14.10-35.30) comparing a patient with a 1-year life expectancy to a healthy patient.

Cancer care for people with dementia: Literature overview and recommendations for practice and research

As many countries experience population aging, patients with cancer are becoming older and have more preexisting comorbidities, which include prevalent, age-related, chronic conditions such as dementia. People living with dementia (PLWD) are vulnerable to health disparities, and dementia has high potential to complicate and adversely affect care and outcomes across the cancer trajectory. This report offers an overview of dementia and its prevalence among patients with cancer and a summary of the research literature examining cancer care for PLWD. The reviewed research indicates that PLWD are more likely to have cancer diagnosed at an advanced stage, receive no or less extensive cancer treatment, and have poorer survival after a cancer diagnosis. These cancer disparities do not necessarily signify inappropriately later diagnosis or lower treatment of people with dementia as a group, and they are arguably less feasible and appropriate targets for care optimization. The reviewed research indicates that PLWD also have an increased risk of cancer-related emergency presentations, lower quality processes of cancer-related decision making, accessibility-related barriers to cancer investigations and treatment, higher experienced treatment burden and higher caregiver burden for families, and undertreated cancer-related pain. The authors propose that optimal cancer care for PLWD should focus on proactively minimizing these risk areas and thus must be highly person-centered, with holistic decision making, individualized reasonable adjustments to practice, and strong inclusion and support of family carers. Comprehensive recommendations are made for clinical practice and future research to help clinicians and providers deliver best and equitable cancer care for PLWD and their families.

Longitudinal Analysis of Patient-Reported Cognitive Function in Multiple Myeloma

BACKGROUND

Cancer-related cognitive impairment (CRCI) has been largely unstudied in patients with multiple myeloma (MM). This study describes patient-reported cognition over time and patient factors associated with adverse cognitive outcomes in MM.

METHODS

Participants enrolled in a registry in which they completed a geriatric assessment at study entry, and 3 & 6 months after entry. Cognitive function was assessed using the EORTC QLQ-C30 Cognitive Function subscale, with CRCI defined as scores < 75. Generalized estimating equation (GEE) models were used to fit longitudinal models to investigate differences by group and differences in changes over time by group, with adjustment for time since diagnosis.

RESULTS

One hundred and four adults with MM had mean age of 67 years and 30% identified as Black. Patient-reported CRCI was present in 18% of participants at enrollment, 21% at 3 months, and 30% at 6 months. Worse cognitive function was reported in those with impairments in physical function (P = .002), IADLs (P = .02), and performance status (P = .04), as well as in those who were prefrail/frail (P = .02) and depressed (P = .049). Greater cognitive decline over time was observed in patients without CRCI at enrollment (P < .0001) and those with lower levels of education (P = .04).

CONCLUSION

This is one of the first studies to describe longitudinal changes in patient-reported cognition in patients with MM. Several potentially intervenable factors, including physical function impairment and depression, were associated with worse cognition at study entry, but only baseline CRCI status and education level were predictive of future decline.

Patterns of care amongst older adults diagnosed with locally advanced esophageal cancer: A cohort study

INTRODUCTION

Since the early 2010s, neoadjuvant chemoradiation followed by esophagectomy (trimodal therapy) has been a recommended treatment for patients diagnosed with locally advanced esophageal cancer. However, it may also add treatment-related toxicity, particularly for older adults with significant comorbidity and frailty burdens. We examined contemporary patterns of care in older adults, which have not been well characterized.

MATERIALS AND METHODS

We used the Surveillance Epidemiology and End Results-Medicare database to identify a cohort of US adults aged 66 years and older diagnosed with incident locally advanced esophageal cancer between 2004 and 2017. Calendar year age-standardized percentages of treatment receipt were calculated. Joinpoint regression was used to detect temporal trends in treatment receipt. Descriptive associations between patient factors and treatment were assessed. Trend analyses quantified how the percentage of trimodal and definitive chemoradiation (no surgery) patients receiving cisplatin-based, carboplatin-based, and other chemotherapy regimens evolved over time.

RESULTS

In total, 4332 adults aged ≥66 years with locally advanced esophageal cancer were included. The age-standardized percentage of patients receiving trimodal therapy increased from 16.7% in 2004 to 26.1% in 2017 (annual percent change = 3.5%; 95% confidence interval [CI], 0.7%-6.4%) in adenocarcinomas and from 7.3% in 2004 to 9.1% in 2017 (annual percent change = 0.4%; 95% CI, -4.1%-5.1%) in squamous cell carcinomas. By 2017, definitive chemoradiation became the most frequently used treatment modality for adenocarcinomas (49.8%; 95% CI, 43.5-56.0) and squamous cell carcinomas (59.5%; 95% CI, 50.8-68.2). Patients with higher comorbidity and frailty burdens were less likely to be treated with trimodal therapy. Amongst patients receiving chemoradiation as part of their treatment, a large and swift channeling away from cisplatin and towards carboplatin-based regimens was observed.

DISCUSSION

In practice, definitive chemoradiation is the most commonly received treatment by older adults with locally advanced esophageal cancer. Four out of five older adults do not receive trimodal therapy, some of whom are potentially undertreated.

Communication About Fall Risk in Community Oncology Practice: The Role of Geriatric Assessment

PURPOSE

Falls are a modifiable source of morbidity for older adults with cancer, yet are underassessed in oncology practice. In this secondary analysis of a nationwide cluster-randomized controlled trial, we examined characteristics associated with patient-oncologist conversations about falls, and whether oncologist knowledge of geriatric assessment (GA) resulted in more conversations.

METHODS

Eligible patients (ClinicalTrials.gov identifier: NCT02107443) were age ≥ 70 years, had stage III/IV solid tumor or lymphoma, were being treated with noncurative treatment intent, and ≥ 1 GA domain impairment. Patients in both arms underwent GA. At practices randomly assigned to the intervention arm, oncologists were provided a GA summary with management recommendations. In both arms, patients had one clinical encounter audio-recorded, transcribed, and coded to categorize whether a conversation about falls occurred. Generalized linear mixed models adjusted for arm, practice site, and other important covariates were used to generate proportions and odds ratios (ORs) from the full sample.

RESULTS

Of 541 patients (intervention N = 293 and usual care N = 248, mean age: 77 years, standard deviation: 5.3), 528 had evaluable audio recordings. More patients had conversations about falls in the intervention versus usual care arm (61.3% v 10.3%, P < .001). Controlling for the intervention and practice site, history of falls (OR, 2.1; 95% CI, 1.3 to 3.6; P = .005) and impaired physical performance (OR, 4.7; 95% CI, 1.7 to 12.8; P = .002) were significantly associated with patient-oncologist conversations about falls.

CONCLUSION

GA intervention increased conversations about falls. History of falls and impaired physical performance were associated with patient-oncologist conversations about falls in community oncology practice.

Frailty and its association with health-related quality of life among older cancer patients: an evidence-based study from China

Background

There is limited information about the population characteristics and adverse health outcomes of older cancer patients in China. This study aimed to describe the prevalence of frailty and examine the association between frailty and health-related quality of life (HRQoL) among older cancer patients.

Methods

This was a cross-sectional study involving older patients diagnosed with cancer in two tertiary hospitals in Shandong Province, China. Frailty was assessed using Geriatric 8 (G-8). HRQoL was measured using the five-level EuroQol-5-dimension (EQ-5D-5L) questionnaire. The Tobit regression model and logistic regression model was used to identify the relationship between frailty and HRQoL.

Results

Of the 229 older patients, 175 (76.4%) were frail. Frail patients had lower EQ-5D-5L utility scores than those who were non-frail (0.830 vs. 0.889; P = 0.004). After adjustments for sociodemographic and cancer-related variables, frailty was statistically associated with worse health-related quality of life (OR = 6.024; P = 0.001).

Conclusion

Frailty was associated with deteriorated HRQoL in older patients with cancer. Early frailty screening and preventive interventions are essential for improving quality of life through decision-making or pretreatment optimization in geriatric oncology.

The majority of cancer cases and cancer mortality occur in older adults. Aging is a heterogenic process, which results in great diversity in older cancer patients concerning physical, psychological, and social status. There is limited information about the population characteristics and adverse health outcomes of older cancer patients in China, and the magnitude of this problem is unclear, creating challenges in understanding health disparities in geriatric cancer care. In this study, we have described the prevalence of frailty and explored the relationship between frailty and health-related quality of life (HRQoL). This study demonstrated that frailty, not being currently married, advanced cancer stage, and cancer site were significant factors influencing the lower HRQoL. Furthermore, frail individuals had a higher probability belonging to the lowest HRQoL quartile group. This study is considered as the first step in highlighting the importance of staging the aging and assessing quality of life among older cancer patients in China.

Association between cognitive impairment and oral anticancer agent use in older patients with metastatic renal cell carcinoma

BACKGROUND

Kidney cancer is the fastest-growing cancer diagnosis in the developed world. About 16% of new cases are stage IV, which has a low five-year survival rate. Many patients with metastatic renal cell carcinoma (mRCC) are older and may have mild cognitive impairment or dementia (MCI/D). Given prior reports of patients with dementia initiating less cancer therapy and the importance of oral anticancer agents (OAAs) in mRCC treatment, we investigated the prevalence of preexisting MCI/D in patients with mRCC and their OAA use.

METHODS

SEER-Medicare patients were analyzed who were ≥65 years, diagnosed with mRCC between 2007 and 2015, and had Medicare part D coverage. Patterns and predictors of (a) OAA utilization within the 12 months following mRCC diagnosis and (b) adherence (percent of days covered [PDC] ≥ 80%) during the first 90 days following treatment initiation were assessed.

RESULTS

Of the 2792 eligible patients, 268 had preexisting MCI/D, and 907 initiated OAA treatment within 12 months of mRCC diagnosis. Patients with preexisting MCI/D were less likely to begin an OAA than those without MCI/D (fully-adjusted HR 0.53, 95% CI 0.38-0.76). Among OAA initiators, a preexisting MCI/D diagnosis did not alter the likelihood that a person would be adherent (adjusted RR 0.84, 95% CI 0.55-1.28).

CONCLUSIONS

Patients with preexisting MCI/D were half as likely to start an OAA during the year following mRCC diagnosis than patients without comorbid MCI/D. The 90-day adherence of OAA initiators was not significantly different between those with and without preexisting MCI/D. In light of this, clinicians should assess mRCC patients for cognitive impairment and take steps to optimize OAA utilization by those with MCI/D.

Protocol paper: Multi-site, cluster-randomized clinical trial for optimizing functional outcomes of older cancer survivors after chemotherapy

BACKGROUND

Cancer survivors over the age of 65 have unique needs due to the higher prevalence of functional and cognitive impairment, comorbidities, geriatric syndromes, and greater need for social support after chemotherapy. In this study, we will evaluate whether a Geriatric Evaluation and Management-Survivorship (GEMS) intervention improves functional outcomes important to older cancer survivors following chemotherapy.

METHODS

A cluster-randomized trial will be conducted in approximately 30 community oncology practices affiliated with the University of Rochester Cancer Center (URCC) National Cancer Institute Community Oncology Research Program (NCORP) Research Base. Participating sites will be randomized to the GEMS intervention, which includes Advanced Practice Practitioner (APP)-directed geriatric evaluation and management (GEM), and Survivorship Health Education (SHE) that is combined with Exercise for Cancer Patients (EXCAP©®), or usual care. Cancer survivors will be recruited from community oncology practices (of participating oncology physicians and APPs) after the enrolled clinicians have consented and completed a baseline survey. We will enroll 780 cancer survivors aged 65 years and older who have completed curative-intent chemotherapy for a solid tumor malignancy within four weeks of study enrollment. Cancer survivors will be asked to choose one caregiver to also participate for a total up to 780 caregivers. The primary aim is to compare the effectiveness of GEMS for improving patient-reported physical function at six months. The secondary aim is to compare effectiveness of GEMS for improving patient-reported cognitive function at six months. Tertiary aims include comparing the effectiveness of GEMS for improving: 1) Patient-reported physical function at twelve months; 2) objectively assessed physical function at six and twelve months; and 3) patient-reported cognitive function at twelve months and objectively assessed cognitive function at six and twelve months. Exploratory health care aims include: 1) Survivor satisfaction with care, 2) APP communication with primary care physicians (PCPs), 3) completion of referral appointments, and 4) hospitalizations at six and twelve months. Exploratory caregiver aims include: 1) Caregiver distress; 2) caregiver quality of life; 3) caregiver burden; and 4) satisfaction with patient care at six and twelve months.

DISCUSSION

If successful, GEMS would be an option for a standardized APP-led survivorship care intervention.

TRIAL REGISTRATION

ClinicalTrials.govNCT05006482, registered on August 9, 2021.

Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies

We conducted a randomized controlled trial in older adults with hematologic malignancies to determine the impact of geriatrician consultation embedded in our oncology clinic alongside standard care. From February 2015 to May 2018, transplant-ineligible patients aged ≥75 years who presented for initial consultation for lymphoma, leukemia, or multiple myeloma at Dana-Farber Cancer Institute (Boston, MA, USA) were eligible. Pre-frail and frail patients, classified based on phenotypic and deficit-accumulation approaches, were randomized to receive either standard oncologic care with or without consultation with a geriatrician. The primary outcome was 1-year overall survival. Secondary outcomes included unplanned care utilization within 6 months of follow-up and documented end-of-life (EOL) goals-of-care discussions. Clinicians were surveyed as to their impressions of geriatric consultation. One hundred sixty patients were randomized to either geriatric consultation plus standard care (n=60) or standard care alone (n=100). The median age of the patients was 80.4 years (standard deviation = 4.2). Of those randomized to geriatric consultation, 48 (80%) completed at least one visit with a geriatrician. Consultation did not improve survival at 1 year compared to standard care (difference: 2.9%, 95% confidence interval: -9.5% to 15.2%, P=0.65), and did not significantly reduce the incidence of emergency department visits, hospital admissions, or days in hospital. Consultation did improve the odds of having EOL goals-of-care discussions (odds ratio = 3.12, 95% confidence interval: 1.03 to 9.41) and was valued by surveyed hematologic-oncology clinicians, with 62.9%-88.2% of them rating consultation as useful in the management of several geriatric domains.

Barriers and Facilitators for the Implementation of Geriatric Oncology Principles in Mexico: A Mixed-Methods Study

There is limited information regarding the use of the geriatric assessment (GA) for older adults with cancer in developing countries. We aimed to describe geriatric oncology practice among Mexican oncology professionals and to identify barriers and facilitators for the implementation of GA into the routine care of older adults with cancer in Mexico.

Routine use of geriatric oncology principles in Mexico is limited by insufficient personnel and knowledge.

Life expectancy in older adults with advanced cancer: Evaluation of a geriatric assessment-based prognostic model

OBJECTIVES

Oncologists estimate patients' prognosis to guide care. Evidence suggests oncologists tend to overestimate life expectancy, which can lead to care with questionable benefits. Information obtained from geriatric assessment may improve prognostication for older adults. In this study, we created a geriatric assessment-based prognostic model for older adults with advanced cancer and compared its performance to alternative models.

MATERIALS AND METHODS

We conducted a secondary analysis of a trial (URCC 13070; PI: Mohile) capturing geriatric assessment and vital status up to one year for adults age ≥ 70 years with advanced cancer. Oncologists estimated life expectancy as 0-6 months, 7-12 months, and > 1 year. Three statistical models were developed: (1) a model including age, sex, cancer type, and stage (basic model), (2) basic model + Karnofsky Performance Status (≤50, 60-70, and 80+) (KPS model), and (3) basic model +16 binary indicators of geriatric assessment impairments (GA model). Cox regression was used to model one-year survival; c-indices and time-dependent c-statistics assessed model discrimination and stratified survival curves assessed model calibration.

RESULTS

We included 484 participants; mean age was 75; 48% had gastrointestinal or lung cancer. Overall, 43% of patients died within one year. Oncologists classified prognosis accurately for 55% of patients, overestimated for 35%, and underestimated for 10%. C-indices were 0.61 (basic model), 0.62 (KPS model), and 0.63 (GA model). The GA model was well-calibrated.

CONCLUSIONS

The GA model showed moderate discrimination for survival, similar to alternative models, but calibration was improved. Further research is needed to optimize geriatric assessment-based prognostic models for use in older adults with advanced cancer.

Association of Oncologist-Patient Communication With Functional Status and Physical Performance in Older Adults: A Secondary Analysis of a Cluster Randomized Clinical Trial

IMPORTANCE

The functional status and physical performance of older adults with cancer are underassessed and undertreated despite the high prevalence of impaired functional status and physical performance in this population and their associations with chemotherapy-induced toxic effects and mortality.

OBJECTIVE

To examine the association between providing oncologists with a geriatric assessment (GA) summary with recommendations and having oncologist-patient conversations about functional and physical performance.

DESIGN, SETTING, AND PARTICIPANTS

Data for this secondary analysis were collected from October 29, 2014, to April 28, 2017, for a national cluster randomized clinical trial conducted by the University of Rochester Cancer Center National Cancer Institute Community Oncology Research Program evaluating the effect of a GA intervention on patient satisfaction with communication about aging-related concerns. There were 17 practice clusters in the intervention group and 14 in the usual care group. All 541 participants underwent a GA including standardized functional and physical performance measures and had 1 clinical encounter audio-recorded, transcribed, and blindly coded to categorize conversations by GA domain. Participants were aged 70 years or older, with a stage III or IV solid tumor or lymphoma with palliative treatment intent, and impairment in 1 or more GA domain. Statistical analysis was performed from August 18, 2020, to January 10, 2022.

INTERVENTIONS

Oncologist practices randomized to the intervention received a GA summary and validated recommendations for each patient prior to the audio-recorded clinical encounter.

MAIN OUTCOMES AND MEASURES

The primary analysis of this clinical trial assessed the effect of the intervention on patient satisfaction with oncologist communication about aging-related concerns. This secondary analysis assessed the post hoc hypothesis that the intervention would be associated with an increase in the proportion of patients having conversations with their oncologists and receiving oncologist recommendations specific to functional and physical performance concerns.

RESULTS

A total of 541 patients (276 men [51%]; mean [SD] age, 77.5 [5.2] years [range, 70-96 years]) were analyzed at baseline. Excluding 13 patients without audio recordings, 86% of patients (95% CI, 78%-91%) in the intervention group vs 59% of patients (95% CI, 47%-69%; P < .001) receiving usual care had conversations about functional or physical performance. Conversations were more frequently initiated by oncologists in the intervention group (84%; 95% CI, 77%-90%) than oncologists in the usual care group (58%; 95% CI, 45%-70%; P < .001). Oncologists in the intervention group were more likely to address patients' concerns (43%; 95% CI, 33%-53%) than oncologists in the usual care group (17%; 95% CI, 10%-26%; P < .001).

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a cluster randomized clinical trial, providing oncologists with a GA summary was associated with an increase in the number of oncologist-patient conversations about functional and physical performance-related concerns with recommendations to address these concerns. These findings support the use of the GA summary and recommendations as important tools in caring for older adults with advanced cancer and functional or physical impairments.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02107443.

Impact of the Cancer and Aging Research Group score and treatment intensity on survival and toxicity outcomes in older adults with advanced noncolorectal gastrointestinal cancers

BACKGROUND

Little is known regarding the predictive value of the Cancer and Aging Research Group (CARG) score, a validated chemotherapy toxicity prediction tool for older adults with cancer, for survival outcomes.

METHODS

This was a prospective observational study of patients ≥65 years old receiving first-line chemotherapy for advanced noncolorectal gastrointestinal cancer for which combination chemotherapy is the standard of care. Overall survival (OS), time to treatment failure (TTF), which was defined as the time from the start of first-line chemotherapy to the discontinuation of first-line chemotherapy for any reason, and toxicity were compared in 4 groups of patients: 1) non-high-risk (nHR) CARG score (<10) and standard-intensity therapy (ST), 2) nHR score and reduced-intensity therapy (RT), 3) high-risk (HR) CARG score (≥10) and ST, and 4) HR score and RT.

RESULTS

Fifty patients (median age, 71 years) were enrolled. The median OS in months was 19.7 in nHR/ST (n = 19) group, 12.7 in nHR/RT (n = 9) group, 4.5 in HR/ST (n = 12) group, and 3.9 in HR/RT (n = 10) group (log-rank test, P = .005). The median TTF in months was 9.1 in nHR/ST group, 2.5 in nHR/RT group, 2.3 in HR/ST group, and 3.0 in HR/RT group (log-rank test, P = .04). The CARG-score category was prognostic of OS (HR, 3.04; 95% confidence interval [CI], 1.59-5.83, P = .001) and TTF (HR, 2.60; 95% CI, 1.31-5.20, P = .007). The incidence of grade 3-5 toxicity was 68% in nHR/ST group, 33% in nHR/RT group, 92% in HR/ST group, and 70% in HR/RT group (Fisher exact test, P = .048).

CONCLUSIONS

Risk-adapted chemotherapy based on the CARG-score may improve treatment outcomes.

OUP accepted manuscript

Background

Methods

Results

Conclusions

Evaluation of geriatric assessment and management on the toxic effects of cancer treatment (GAP70+): a cluster-randomised study

BACKGROUND

Older adults with advanced cancer are at a high risk for treatment toxic effects. Geriatric assessment evaluates ageing-related domains and guides management. We examined whether a geriatric assessment intervention can reduce serious toxic effects in older patients with advanced cancer who are receiving high risk treatment (eg, chemotherapy).

METHODS

In this cluster-randomised trial, we enrolled patients aged 70 years and older with incurable solid tumours or lymphoma and at least one impaired geriatric assessment domain who were starting a new treatment regimen. 40 community oncology practice clusters across the USA were randomly assigned (1:1) to the intervention (oncologists received a tailored geriatric assessment summary and management recommendations) or usual care (no geriatric assessment summary or management recommendations were provided to oncologists) by means of a computer-generated randomisation table. The primary outcome was the proportion of patients who had any grade 3-5 toxic effect (based on National Cancer Institute Common Terminology Criteria for Adverse Events version 4) over 3 months. Practice staff prospectively captured toxic effects. Masked oncology clinicians reviewed medical records to verify. The study was registered with ClinicalTrials.gov, NCT02054741.

FINDINGS

Between July 29, 2014, and March 13, 2019, we enrolled 718 patients. Patients had a mean age of 77·2 years (SD 5·4) and 311 (43%) of 718 participants were female. The mean number of geriatric assessment domain impairments was 4·5 (SD 1·6) and was not significantly different between the study groups. More patients in intervention group compared with the usual care group were Black versus other races (40 [11%] of 349 patients vs 12 [3%] of 369 patients; p<0·0001) and had previous chemotherapy (104 [30%] of 349 patients vs 81 [22%] of 369 patients; p=0·016). A lower proportion of patients in the intervention group had grade 3-5 toxic effects (177 [51%] of 349 patients) compared with the usual care group (263 [71%] of 369 patients; relative risk [RR] 0·74 (95% CI 0·64-0·86; p=0·0001). Patients in the intervention group had fewer falls over 3 months (35 [12%] of 298 patients vs 68 [21%] of 329 patients; adjusted RR 0·58, 95% CI 0·40-0·84; p=0·0035) and had more medications discontinued (mean adjusted difference 0·14, 95% CI 0·03-0·25; p=0·015).

INTERPRETATION

A geriatric assessment intervention for older patients with advanced cancer reduced serious toxic effects from cancer treatment. Geriatric assessment with management should be integrated into the clinical care of older patients with advanced cancer and ageing-related conditions.

FUNDING

National Cancer Institute.

Older cancer survivors living with financial hardship in China: A qualitative study of family perspectives

OBJECTIVE

Financial hardship among older cancer survivors has not been well-studied, despite its debilitating effects on their health and well-being. The purpose of this study was to describe the lived experiences of Chinese older cancer survivors who have experienced financial hardship following a cancer diagnosis.

METHODS

A qualitative study was conducted. Data was collected using in-depth interviews with 21 older cancer survivors (aged ≥ 60) with financial hardship and 20 family caregivers in Shandong Province, China between August 2020 and January 2021. Data were analyzed using Colaizzi's phenomenological method.

RESULTS

Four main themes emerged: (1) older survivors have insufficient ability to address cancer-related costs; (2) financial transfers from adult children to older parents became prevalent after a cancer diagnosis; (3) cancer-related financial worries and stress extended into children's families; (4) coping and adjustment strategies were used by the extended family. Traditional Confucian culture and the Chinese health care system considerably impacted the interpretation of financial hardship.

CONCLUSION

Both older cancer survivors and their adult children experienced financial distress impacted by filial piety in China. Strategies adapted to Confucian family values and the health care system are needed to address cancer-related financial hardships.

Dosing Schedules of Gemcitabine and nab-Paclitaxel for Older Adults With Metastatic Pancreatic Cancer

Background

Gemcitabine and nab-paclitaxel (GA) is a first-line treatment for patients with metastatic pancreatic cancer (mPDAC). The traditional dosing schedule of GA is days 1, 8, and 15 of a 28-day cycle. Frequently, older adults are given a modified dosing schedule using 2 doses per cycle because of toxicity. We retrospectively analyzed treatment patterns and outcomes of older adults with mPDAC given these 2 dosing schedules.

Methods

Patients 65 years or older with mPDAC treated with GA in a nationwide real-world database between January 1, 2014, and May 31, 2019, were included. Demographic, disease, and treatment information were collected. Patients were grouped by dosing at treatment initiation (traditional vs modified dosing schedules). Endpoints were time on treatment (TOT) and overall survival (OS) in patients receiving at least 2 cycles. All statistical tests were 2-sided.

Results

1317 patients were included (traditional dosing schedule: n = 842; modified dosing schedule: n = 475). Median age at diagnosis was 72 and 73 years for traditional and modified dosing schedules, respectively (P < .001), but sex, race, and performance status were not statistically significantly different. The median TOT and OS were better for the traditional vs modified dosing schedule (unadjusted median TOT, first-line = 4.18 vs 3.26 mo, P =.04; OS = 9.44 vs 7.63 mo, P =.003).

Conclusion

In this real-world cohort, treatment of older mPDAC patients with a modified dosing schedule of GA resulted in shorter TOT and worse OS vs a traditional dosing schedule. With the caveats of potential confounding that exist in a nonrandomized retrospective database, these results suggest that dose intensity may be important, and prospective studies are necessary to ensure we treat our patients most effectively.

Prevalence of and factors associated with treatment modification at first cycle in older adults with advanced cancer receiving palliative treatment

INTRODUCTION

Treatment toxicities are common in older adults with cancer and consequently, treatment modifications are sometimes considered. We evaluated the prevalence and factors associated with treatment modifications at the first cycle in older patients receiving palliative systemic treatment.

METHODS

Patients (n = 369) from the GAP 70+ Trial (NCT02054741; PI: Mohile) usual care arm were included. Enrolled patients were aged 70+ with advanced cancer and ≥ 1 Geriatric Assessment (GA) domain impairment. Treatment modification was defined as any change from National Comprehensive Cancer Network guidelines or published clinical trials. Baseline variables included: 1) sociodemographic factors; 2) clinical variables; 3) GA domains; and 4) physician beliefs about life expectancy. Bivariate analyses and multivariable cluster-weighted generalized estimating equation model were conducted to assess the association of baseline variables with cycle 1 treatment modifications.

RESULTS

Mean age was 77.2 years (range: 70-94); 62% had lung or gastrointestinal cancers, and 35% had treatment modifications at cycle 1. Increasing age by one year (odds ratio (OR) 1.1, 95% confidence interval [CI] 1.0-1.2), receipt of ≥second line of chemotherapy (OR 1.8, CI 1.1-3.0), functional impairment (OR 1.6, CI 1.1-2.3) and income ≤$50,000 (OR 1.7, CI 1.1-2.4) were independently associated with a higher likelihood of cycle 1 treatment modification.

CONCLUSION

Treatment modifications occurred in 35% of older adults with advanced cancer at cycle 1. Increasing age, receipt of ≥second line of chemotherapy, functional impairment, and lower income were independently associated with treatment modifications. These findings emphasize the need for evidence-based regimens in older adults with cancer and GA impairments.

Prognostic value of disease risk score versus gait speed in older adults with lymphoma

Measures of physical function predict survival in older patients with lymphoma but their prognostic ability has not been compared to disease-specific risk scores. We prospectively recruited patients ≥75 years with lymphoma. Patients underwent a frailty screen including 4-m gait speed. Disease-specific risk scores were obtained retrospectively. Among 168 patients, there was no association between disease-specific risk score and survival. Conversely, faster gait speed was significantly associated with survival in the entire cohort (HR = 0.16; 95%CI, 0.06-0.42; p = 0.0003) indicating a HR of 0.63 for an increase in gait speed of 0.25 m/s. When gait speed was added to the DLBCL IPI and FLIPI separately, it was significantly associated with OS (p = 0.004 for DLBCL, p = 0.03 for FLIPI) which increased its predictive power. Our study of older lymphoma patients demonstrates gait speed may improve outcome prediction beyond standard prognostic scores.

The Impact of Dementia on Cancer Treatment Decision-Making, Cancer Treatment, and Mortality: A Mixed Studies Review

Dementia and cancer occur commonly in older adults. Yet, little is known about the effect of dementia on cancer treatment and outcomes in patients diagnosed with cancer, and no guidelines exist. We performed a mixed studies review to assess the current knowledge and gaps on the impact of dementia on cancer treatment decision-making, cancer treatment, and mortality. A search in PubMed, Medline, and PsycINFO identified 55 studies on older adults with a dementia diagnosis before a cancer diagnosis and/or comorbid cancer and dementia published in English from January 2004 to February 2020. We described variability using range in quantitative estimates, ie, odds ratios (ORs), hazard ratios (HRs), and risk ratios (RR) when appropriate and performed narrative review of qualitative data. Patients with dementia were more likely to receive no curative treatment (including hospice or palliative care) (OR, HR, and RR range = 0.40-4.4, n = 8), while less likely to receive chemotherapy (OR and HR range = 0.11-0.68, n = 8), radiation (OR range = 0.24-0.56, n = 2), and surgery (OR range = 0.30-1.3, n = 4). Older adults with cancer and dementia had higher mortality than those with cancer alone (HR and OR range = 0.92-5.8, n = 33). Summarized findings from qualitative studies consistently revealed that clinicians, caregivers, and patients tended to prefer less aggressive care and gave higher priority to quality of life over life expectancy for those with dementia. Current practices in treatment-decision making for patients with both cancer and dementia are inconsistent. There is an urgent need for treatment guidelines for this growing patient population that considers patient and caregiver perspectives.

MacKenzie A, Soto-Perez-de-Celis E, Maggiore RJ, Merrill JK, Katta S, Smith KT, Klepin HD. How Is Geriatric Assessment Used in Clinical Practice for Older Adults With Cancer? A Survey of Cancer Providers by the American Society of Clinical Oncology

PURPOSE

For patients with cancer who are older than 65 years, the 2018 ASCO Guideline recommends geriatric assessment (GA) be performed. However, there are limited data on providers' practices using GA. Therefore, ASCO's Geriatric Oncology Task Force conducted a survey of providers to assess practice patterns and barriers to GA.

METHODS

Cancer providers treating adult patients including those ≥ 65 years completed an online survey. Questions included those asking about awareness of ASCO's Geriatric Oncology Guideline (2018), use of validated GA tools, and perceived barriers to using GA. Descriptive statistics and statistical comparisons between those aware of the Guideline and those who were not were conducted. Statistical significance was set at P < .05.

RESULTS

Participants (N = 1,277) responded between April 5 and June 5, 2019. Approximately half (53%) reported awareness of the Guideline. The most frequently used GA tools, among those aware of the Guideline and those who were not, assessed functional status (69% v 50%; P < .001) and falls (62% v 45%; P < .001). Remaining tools were used < 50% of the time, including tools assessing weight loss, comorbidities, cognition, life expectancy, chemotherapy toxicity, mood, and noncancer mortality risk. GA use was two to four times higher among those who are aware of the Guideline. The most frequent barriers for those who reported being Guideline aware were lack of resources, specifically time (81.7%) and staff (77.0%). In comparison, those who were unaware of the Guideline most often reported the following barriers: lack of knowledge or training (78.4%), lack of awareness about tools (75.2%), and uncertainty about use of tools (75.0%).

CONCLUSION

Among providers caring for older adults, 52% were aware of the ASCO Guideline. Some domains were assessed frequently (eg, function, falls), whereas other domains were assessed rarely (eg, mood, cognition). Guideline awareness was associated with two to four times increased use of GA and differing perceived barriers. Interventions facilitating Guideline-consistent implementation will require various strategies to change behavior.

Gait speed, survival, and recommended treatment intensity in older adults with blood cancer requiring treatment

BACKGROUND

Brief measures of physical function such as gait speed may be useful to optimize treatment intensity for older adults who have blood cancer; however, little is known about whether such assessments are already captured within oncologists' "gestalt" assessments.

METHODS

Gait speed was assessed in 782 patients ≥75 years of age who had blood cancer, with results reported to providers after treatment decisions were made; 408 patients required treatment when different intensities were available per National Comprehensive Cancer Network (NCCN) guidelines. We performed structured abstractions of treatment intensity recommendations into standard intensity, reduced intensity, or supportive care, based on NCCN guidelines. We modeled gait speed and survival using Cox regression and performed ordinal logistic regression to assess predictors of NCCN-based categorizations of oncologists' treatment intensity recommendations, including gait speed.

RESULTS

The median survival by gait speed category was 10.8 months (<0.4 m/s), 18.6 months (0.4-0.6 m/s), 34.0 months (0.6-0.8 m/s), and unreached (>0.8 m/s). Univariable hazard ratios (HRs) for death increased for each lower category compared with ≥0.8 m/s (0.6-0.8 m/s: HR, 1.76; 0.4-0.6 m/s: HR, 2.30; <0.4 m/s: HR, 3.31). Gait speed predicted survival in multivariable Cox regression (all P < .05). In multivariable models including age, sex, and Eastern Cooperative Oncology Group performance status, gait speed did not predict oncologists' recommended treatment intensity (all P > .05) and did not add to a base model predicting recommended treatment intensity.

CONCLUSION

In older adults with blood cancer who presented for treatment, gait speed predicted survival but not treatment intensity recommendation. Incorporating gait speed into decision making may improve optimal treatment selection.

Treatment decision-making in acute myeloid leukemia: a qualitative study of older adults and community oncologists

Little is known about the characteristics of patients, physicians, and organizations that influence treatment decisions in older patients with AML. We conducted qualitative interviews with community oncologists and older patients with AML to elicit factors that influence their treatment decision-making. Recruitment was done via purposive sampling and continued until theoretical saturation was reached, resulting in the inclusion of 15 patients and 15 oncologists. Participants' responses were analyzed using directed content analysis. Oncologists and patients considered comorbidities, functional status, emotional health, cognition, and social factors when deciding treatment; most oncologists evaluated these using clinical gestalt. Sixty-seven percent of patients perceived that treatment was their only option and that they had not been offered a choice. In conclusion, treatment decision-making is complex and influenced by patient-related factors. These factors can be assessed as part of a geriatric assessment which can help oncologists better determine fitness and guide treatment decision-making.

Older adult participation in cancer clinical trials: A systematic review of barriers and interventions

Cancer is a disease of aging and, as the world's population ages, the number of older persons with cancer is increasing and will make up a growing share of the oncology population in virtually every country. Despite this, older patients remain vastly underrepresented in research that sets the standards for cancer treatments. Consequently, most of what we know about cancer therapeutics is based on clinical trials conducted in younger, healthier patients, and effective strategies to improve clinical trial participation of older adults with cancer remain sparse. For this systematic review, the authors evaluated published studies regarding barriers to participation and interventions to improve participation of older adults in cancer trials. The quality of the available evidence was low and, despite a literature describing multifaceted barriers, only one intervention study aimed to increase enrollment of older adults in trials. The findings starkly amplify the paucity of evidence-based, effective strategies to improve participation of this underrepresented population in cancer trials. Within these limitations, the authors provide their opinion on how the current cancer research infrastructure must be modified to accommodate the needs of older patients. Several underused solutions are offered to expand clinical trials to include older adults with cancer. However, as currently constructed, these recommendations alone will not solve the evidence gap in geriatric oncology, and efforts are needed to meet older and frail adults where they are by expanding clinical trials designed specifically for this population and leveraging real-world data.

Assessment of Financial Toxicity Among Older Adults With Advanced Cancer

Importance

Financial toxicity (FT), unintended and unanticipated financial burden experienced by cancer patients undergoing cancer care, is associated with negative consequences and increased risk of mortality. Older patients (≥70 years) with cancer are at risk for FT, yet data are limited on FT and whether oncologists discuss FT with their patients.

Objective

To examine the prevalence of FT in older adults with advanced cancer, its association with health-related quality of life (HRQoL), and cost conversations between oncologists and patients.

Design, Setting, and Participants

This cross-sectional secondary analysis was performed on baseline data from the Improving Communication in Older Cancer Patients and Their Caregivers study, a cluster randomized trial from 31 community oncology practices across the US that was conducted from October 29, 2014, to April 28, 2017. Participants included 536 patients with advanced cancer who answered 3 questions regarding financial toxicity. Data were analyzed from September 1, 2019, to May 1, 2020.

Exposure

Older patients undergoing cancer care treatments.

Main Outcomes and Measures

The main outcome looked at FT and its association with HRQoL. Three questions were used to identify patients 70 years or older experiencing FT. Multivariable linear regression models were used to assess the independent associations of FT with HRQoL. A single audio-recorded clinic transcript was analyzed within 4 weeks of enrollment for patients with FT. The framework method was used to identify frequency and themes related to cost conversations.

Results

This study evaluated 536 patients 70 years or older with advanced cancer. Ninety-eight patients (18.3%) reported FT; mean (SD) age was 76.4 (5.4) years; 59 (60.2%) were female, 14 (14.3%) were Black/African American, 91 (92.9%) were not employed, and 29 (29.6%) had Medicare as their sole insurance coverage. On multivariate regression analyses, FT was associated with higher levels of depression (β = 0.81; 95% CI, 0.15-1.48), anxiety (β = 1.67; 95% CI, 0.74-2.61), and distress (β = 0.73; 95% CI, 0.08-1.39) and lower HRQoL (β = -5.30; 95% CI, -8.92 to -1.69). Among those who reported FT, 49% had a conversation with their health care professional about costs. Most conversations (79%) were initiated by oncologists or patients. Four themes were generated from cost conversations: statements regarding cost of care, ability to afford medical prescriptions, indirect consequences associated with inability to work and provide for family, and cost burden in nontreatment domains.

Conclusions and Relevance

In this study, among older adults with advanced cancer, FT is associated with worse HRQoL. Almost half of conversations among patients reporting FT demonstrated costs are being actively discussed. Resources and interventions are needed to manage FT.

Older adults with cancer and their caregivers - current landscape and future directions for clinical care

Despite substantial improvements in the outcomes of patients with cancer over the past two decades, older adults (aged ≥65 years) with cancer are a rapidly increasing population and continue to have worse outcomes than their younger counterparts. Managing cancer in this population can be challenging because of competing health and ageing-related conditions that can influence treatment decision-making and affect outcomes. Geriatric screening tools and comprehensive geriatric assessment can help to identify patients who are most at risk of poor outcomes from cancer treatment and to better allocate treatment for these patients. The use of evidence-based management strategies to optimize geriatric conditions can improve communication and satisfaction between physicians, patients and caregivers as well as clinical outcomes in this population. Clinical trials are currently underway to further determine the effect of geriatric assessment combined with management interventions on cancer outcomes as well as the predictive value of geriatric assessment in the context of treatment with contemporary systemic therapies such as immunotherapies and targeted therapies. In this Review, we summarize the unique challenges of treating older adults with cancer and describe the current guidelines as well as investigational studies underway to improve the outcomes of these patients.

Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review

PURPOSE

The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms.

METHODS

We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability.

RESULTS

Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%).

CONCLUSION

Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.

Management of Acute Myeloid Leukemia (AML) in Older Patients

PURPOSE OF REVIEW

The acute myeloid leukemia (AML) treatment landscape has rapidly evolved over the past few years. These changes have several implications for the care of older adults (≥ 60 years), who have inferior clinical outcomes. We review decision-making in older adults, focusing on patient- and disease-related factors. We then summarize current treatment options, including multiple recently approved therapies, based on hypothetical clinical scenarios.

RECENT FINDINGS

In lieu of using chronological age to determine fitness, we highlight the importance of standardized fitness assessments using geriatric assessments. Next, we review intensive and lower-intensity treatment options in the upfront setting. We focus on multiple newly approved medications, including venetoclax, midostaurin, CPX-351, gemtuzumab, glasdegib, enasidenib, and ivosidenib, and their specific indications. Lastly, we briefly discuss supportive care of older adults with AML. Outcomes of older adults with AML remain poor; fortunately, there are many new promising treatment options. Personalized treatment plans based on patient- and disease-specific factors are essential to the care of older adults with AML.

Embracing the complexity: Older adults with cancer-related cognitive decline-A Young International Society of Geriatric Oncology position paper

Cancer-related cognitive decline (CRCD) may have particularly significant consequences for older adults, impacting their functional and physical abilities, level of independence, ability to make decisions, treatment adherence, overall quality of life, and ultimately survival. In honor of Dr. Hurria's work we explore and examine multiple types of screening, assessment and non-pharmacologic treatments for CRCD. We then suggest future research and clinical practice questions to holistically appreciate the complexity of older adults with cancer's experiences and fully integrate the team-based approach to best serve this population.

Association between a cognitive screening test and severe chemotherapy toxicity in older adults with cancer

INTRODUCTION

Cognitive impairment (CI) increases chemotherapy toxicity risk with need to understand this association utilizing publicly available short screening tools. We evaluated this utilizing a lower threshold on a short screening tool in older adults with cancer.

MATERIALS AND METHODS

We analyzed data from the Cancer and Aging Research Group (CARG) Chemotherapy Toxicity Risk tool (CARG score) development and validation cohorts (n = 703), which recruited adults age ≥ 65 with cancer from academic centers. Cognition was evaluated with the Blessed Orientation-Memory-Concentration test (BOMC). Patients with BOMC score ≥ 11 were excluded. Utilizing cut-points for older adults, we considered moderate BOMC scores (5-10) as potential CI. Logistic regression was used for analysis.

RESULTS

Patient baseline characteristics included: mean age 73; 85% white; 63% college or higher education; 250 (36%) potential CI; 385 (55%) severe toxicity. Patients with potential CI were more likely non-white (p ≤ 0.01) and to have high school or lower education (p ≤ 0.01) and high CARG score (p = 0.04). Potential CI was associated with increased severe toxicity risk (OR = 1.54, p ≤ 0.01). After adjusting for CARG score, this association became nonsignificant (OR = 1.35; p = 0.08). Among patients with lower education (n = 258; 36.7%), potential CI remained associated with severe toxicity, even after adjusting for CARG score (OR = 1.87, p = 0.03).

CONCLUSIONS

Our findings suggest potential cognitive impairment, defined by BOMC score 5-10, in older adults with cancer and lower education is associated with increased severe toxicity risk. Future studies are needed to validate these findings. Healthcare providers should consider cognitive testing before treatment for these vulnerable patients.

Communication With Older Patients With Cancer Using Geriatric Assessment: A Cluster-Randomized Clinical Trial From the National Cancer Institute Community Oncology Research Program

Importance

Older patients with cancer and their caregivers worry about the effects of cancer treatment on aging-related domains (eg, function and cognition). Quality conversations with oncologists about aging-related concerns could improve patient-centered outcomes. A geriatric assessment (GA) can capture evidence-based aging-related conditions associated with poor clinical outcomes (eg, toxic effects) for older patients with cancer.

Objective

To determine whether providing a GA summary and GA-guided recommendations to oncologists can improve communication about aging-related concerns.

Design, Setting, and Participants

This cluster-randomized clinical trial enrolled 541 participants from 31 community oncology practices within the University of Rochester National Cancer Institute Community Oncology Research Program from October 29, 2014, to April 28, 2017. Patients were aged 70 years or older with an advanced solid malignant tumor or lymphoma who had at least 1 impaired GA domain; patients chose 1 caregiver to participate. The primary outcome was assessed on an intent-to-treat basis.

Interventions

Oncology practices were randomized to receive either a tailored GA summary with recommendations for each enrolled patient (intervention) or alerts only for patients meeting criteria for depression or cognitive impairment (usual care).

Main Outcomes and Measures

The predetermined primary outcome was patient satisfaction with communication about aging-related concerns (modified Health Care Climate Questionnaire [score range, 0-28; higher scores indicate greater satisfaction]), measured after the first oncology visit after the GA. Secondary outcomes included the number of aging-related concerns discussed during the visit (from content analysis of audiorecordings), quality of life (measured with the Functional Assessment of Cancer Therapy scale for patients and the 12-Item Short Form Health Survey for caregivers), and caregiver satisfaction with communication about aging-related patient concerns.

Results

A total of 541 eligible patients (264 women, 276 men, and 1 patient did not provide data; mean [SD] age, 76.6 [5.2] years) and 414 caregivers (310 women, 101 men, and 3 caregivers did not provide data; mean age, 66.5 [12.5] years) were enrolled. Patients in the intervention group were more satisfied after the visit with communication about aging-related concerns (difference in mean score, 1.09 points; 95% CI, 0.05-2.13 points; P = .04); satisfaction with communication about aging-related concerns remained higher in the intervention group over 6 months (difference in mean score, 1.10; 95% CI, 0.04-2.16; P = .04). There were more aging-related conversations in the intervention group's visits (difference, 3.59; 95% CI, 2.22-4.95; P < .001). Caregivers in the intervention group were more satisfied with communication after the visit (difference, 1.05; 95% CI, 0.12-1.98; P = .03). Quality of life outcomes did not differ between groups.

Conclusions and Relevance

Including GA in oncology clinical visits for older adults with advanced cancer improves patient-centered and caregiver-centered communication about aging-related concerns.

Trial Registration

ClinicalTrials.gov identifier: NCT02107443.