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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bone Health Considerations in Breast Cancer

OBJECTIVES

The treatment of breast cancer requires the use of multiple modalities to achieve local control of disease and to prevent distant recurrence. Among patients whose tumors are hormone-receptor positive, endocrine therapy for up to 10 years in the adjuvant setting can be an important component of such therapy, but it is not without adverse events. Ovarian suppression or estrogen restriction can have a rapid and clinically significant detrimental effect on bone mineral density, leading to potential osteoporotic fracture. This article reviews the major causes of breast cancer treatment-induced bone loss and pharmacologic and nonpharmacologic management strategies to maintain bone health in this population.

DATA SOURCES

PubMed and international clinical practice guidelines were used.

CONCLUSION

A holistic, long-term approach is needed to identify and offer early intervention to patients at high-risk of significant bone density loss. A combination of routine screening, use of oral or intravenous bone-modifying agents, oral supplementation of calcium and vitamin D, and physical activity, including weight-bearing exercise, are required to maintain adequate bone health during treatment for breast cancer.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses are well-situated in the primary and survivorship care teams for patients with breast cancer to provide proactive education on the need to assess and actively manage bone health. Nonpharmacologic interventions such as dietary supplementation and physical activity are essential to health promotion and are within the nursing scope of practice to emphasize with this patient population.

Perceived End-of-Life Educational Needs by Clinical Trials Nurses at a Comprehensive Cancer Center

Objective

Determine palliative care end-of-life (EOL) educational needs among clinical trials nurses (CTNs) at an urban comprehensive cancer center.

Methods

The End-Of-Life Professional Caregiver Survey (EPCS) was used to determine the EOL educational needs of CTNs and collect demographics on years of experience, education, past EOL-specific training, and possession of their own advanced directive. The “Surprise Question” was also asked to explore the percent of patients on clinical trials who may be nearing EOL.

Results

Twenty-nine CTNs completed the survey. Mean years of experience as an RN and CTN was 10.45 and 2.5, respectively. 79% and 17% held a bachelors or master's degree, respectively. Twenty-seven percent reported previous End-of-Life Nursing Education Consortium (ELNEC) or similar training and 20% stated they had their own advanced directive. Mean total score for the EPCS was 94.83, with subscale means of 42.41 for the Patient and Family Centered Communication (PFCC), 26.9 for Cultural and Ethical Values (CEV), and 25.52 for the Effective Care Delivery (ECD). Highest scoring items included confidence in communicating with colleagues about EOL care, being present with dying patients, and recognizing patients who are appropriate for hospice referral. Lowest scoring items included participating in code status discussions, resolving ethical issues and family conflicts at EOL, and addressing requests for assisted suicide. Responses to the Surprise Question indicated that 27.5% of the CTNs would not be surprised if half or more of their patients died within the next 12 months.

Conclusions

Many patients with cancer on clinical trials may be nearing EOL. CTNs perceive the need for education to increase confidence in handling difficult communication.

A Retrospective, Cross-Sectional Study of Self-Reported Physical Activity and Depression Among Breast, Gynecologic, and Thoracic Cancer Survivors

OBJECTIVES

To describe cancer survivors' self-reported frequency and intensity of physical activity and depression.

SAMPLE & SETTING

1,412 breast (n = 375), gynecologic (n = 369), and thoracic (n = 668) cancer survivors at an urban comprehensive cancer center between July 2017 and December 2018.

METHODS & VARIABLES

Attainment of recommended physical activity was assessed using the Godin-Shepard Leisure-Time Physical Activity Questionnaire, and depression was assessed using the Patient Health Questionnaire (PHQ)-2 or PHQ-9. Abstracted characteristics, including age, sex, race, years since diagnosis, pain, body mass index, smoking, and marital and employment status, were also assessed.

RESULTS

872 patients were insufficiently active, and 105 patients reported some level of depression. Breast cancer survivors were significantly more likely to attain recommended activity levels than gynecologic or thoracic survivors. There was no intergroup difference in the incidence or severity of depression.

IMPLICATIONS FOR NURSING

Nurses working with survivors should assess physical activity and support patients to meet weekly exercise duration and intensity recommendations.

Immune-Related Adverse Events in the Older Adult with Cancer Receiving Immune Checkpoint Inhibitor Therapy

Objective:

Older adults with cancer (OAC) may be at elevated risk for immune-related adverse events (irAEs) during immune checkpoint inhibitor (ICI) therapy due to the normal organ function changes of aging, as well as related to a higher prevalence of comorbid conditions compared to younger patients. The importance of high-quality nursing care cannot be overstated for this population, including proactive symptom assessment, management, and coordination of care. The purpose of this paper is to describe the unique challenges faced by OAC receiving ICI drugs.

Methods:

We present both a case study and the results of a single-institution retrospective study from a large, urban US National Cancer Institute– designated comprehensive cancer center. The retrospective study examined the frequency and intensity of irAEs experienced by patients aged 75 years or older who received ICI therapy between January 2016 and December 2018 for melanoma.

Results:

We reviewed the records of 38 OAC (age range 75–92 years) with locally advanced or metastatic melanoma who received pembrolizumab, nivolumab and/or ipilimumab. Median length of therapy was 7.4 months, and median time to onset of irAEs was 81 days. Approximately half (47%) of the patients experienced Grade 1–3 irAEs, and discontinued therapy related to inability to tolerate the ICI more frequently than was reported in clinical trials (24%).

Conclusions:

OAC who receive ICI therapy frequently experience irAEs that may result in treatment interruption, discontinuation or long-lasting toxicity. Nurses are well positioned to provide support to this vulnerable population.

A Model for Building Research Capacity and Infrastructure in Oncology: A Nursing Research Fellowship

OBJECTIVE

This article describes how one comprehensive cancer center in the Northeast United States reorganized their nursing research fellowship (NRF) with the goals of engaging nurses in research processes, developing a culture of inquiry, building nursing research capacity, and sustaining infrastructures for facilitating high-quality, nurse-led oncology research studies.

METHODS

The basis for the curriculum, course work, and research practicum is derived from academic courses taught at the undergraduate, graduate, and doctoral levels. Evidence from the current literature, expertise of nurse-scientists, and feedback from former fellows provided the background for a fellowship model that included: (1) amending curriculum timeframes; (2) incorporating protected time; (3) improving access to resources; (4) enhancing the protection, data sharing, and accessibility of data; and (5) involving nurse-scientists as mentors and facilitators of research processes. These factors were incorporated over 3 years. Metrics included individual class and overall course evaluations and ongoing assessments.

RESULTS

In three cohorts from 2016 to 2019, a total of 21 nurses were accepted, and 18 (86%) nurses completed the NRF. In cohort 1 through cohort 3, 17 fellows presented their research findings internally, and a total of nine projects were presented at external forums. There were seven fellows whose manuscript submissions resulted in 21 journal publications. Of the 18 fellows, 15 (83%) conducted institutional review board-approved studies and three (17%) fellows developed studies involving one concept analysis and two systematic reviews.

CONCLUSIONS

Utilizing technology, the fellowship improved access beyond the classroom setting. Improved application processes, the inclusion of protected time for nurses, and mentoring from nurse-scientists demonstrate a commitment to fostering a culture supporting new knowledge and innovation for improving patient care.

Financial Support Models: A Case for Use of Financial Navigators in the Oncology Setting

BACKGROUND

Financial toxicity causes significant psychological and practical distress for patients and can affect their ability and willingness to undertake optimal treatment. Although different models of financial support are typically available to patients undergoing cancer treatments, not all models can offer equal amounts of support and effective solutions, particularly to those patients at the highest levels of risk for this toxicity.

OBJECTIVES

This article discusses the two most prevalent models available to healthcare institutions to provide financial support (financial counseling and financial advocacy) and makes recommendations for implementation of a more comprehensive, proactive financial navigation model.

METHODS

This article reviews current and emerging financial support models.

FINDINGS

Financial toxicity is on the rise, and the financial navigation model shows promise in decreasing the number of patients experiencing financial hardship.

Financial Support Models: A Case for Use of Financial Navigators in the Oncology Setting

BACKGROUND

Financial toxicity causes significant psychological and practical distress for patients and can affect their ability and willingness to undertake optimal treatment. Although different models of financial support are typically available to patients undergoing cancer treatments, not all models can offer equal amounts of support and effective solutions, particularly to those patients at the highest levels of risk for this toxicity.

OBJECTIVES

This article discusses the two most prevalent models available to healthcare institutions to provide financial support (financial counseling and financial advocacy) and makes recommendations for implementation of a more comprehensive, proactive financial navigation model.

METHODS

This article reviews current and emerging financial support models.

FINDINGS

Financial toxicity is on the rise, and the financial navigation model shows promise in decreasing the number of patients experiencing financial hardship.

It Is Time to Ask About Financial Toxicity

Increasing attention in the oncology community has turned to the problem of financial toxicity, a term coined to reflect the significant negative impact that high medical costs combined with income interruption during treatment may cause. Numerous studies have described how widespread the problem is, affecting as many as 73% of patients with cancer, and its association with negative outcomes, such as decreased health-related quality of life, unplanned and unwanted lifestyle changes because of lack of funds, and intentional nonadherence to planned therapy in an attempt to decrease out-of-pocket costs. Several articles describe brief screening tools, such as the Distress Thermometer, and psychometrically tested assessment instruments, like the Comprehensive Score for Financial Toxicity, that are potentially suitable to incorporate into routine clinical practice. However, there are very few tested interventions for financial toxicity, despite the recognized need for evidence-based practice in this area.

Rigor and Reproducibility: A Systematic Review of Salivary Cortisol Sampling and Reporting Parameters Used in Cancer Survivorship Research

Salivary cortisol is a commonly used biomarker in cancer survivorship research; however, variations in sampling protocols and parameter reporting limit comparisons across studies. Standardized practices to provide rigor and reproducibility of diurnal salivary cortisol sampling and reporting are not well established. Previous systematic reviews examining relationships between diurnal salivary cortisol and clinical outcomes have resulted in mixed findings. It remains unclear which sampling protocols and reporting parameters offer the greatest utility for clinical research. This review examines diurnal salivary cortisol sampling protocols and reporting parameters to evaluate whether a standardized approach is recommended. A comprehensive search of intervention studies among adult cancer survivors including diurnal salivary cortisol resulted in 30 articles for review. Sampling protocols ranged from 1 to 4 days with the majority of studies sampling cortisol for 2 days. Sampling instances ranged from 2 to 7 times per day, with the majority collecting at 4 time points per day. Diurnal cortisol slope and cortisol awakening response (CAR) were the most commonly reported parameters associated with clinical outcomes. Flattened cortisol slopes, blunted CARs, and elevated evening cortisol concentrations were associated with poorer psychosocial and physiological outcomes. Based on our review, we propose that a rigorous, standardized diurnal salivary cortisol sampling protocol should include sampling at key diurnal times across ≥3 consecutive days to report diurnal cortisol parameters (i.e., CAR and slope) and objective measures of participant protocol adherence. Diminishing budgetary resources and efforts to minimize participant burden dictate the importance of standardized cortisol sampling protocols and reporting parameters.

Speed of Adoption of Immune Checkpoint Inhibitors of Programmed Cell Death 1 Protein and Comparison of Patient Ages in Clinical Practice vs Pivotal Clinical Trials

Importance

The US Food and Drug Administration (FDA) is increasing its pace of approvals for novel cancer therapeutics, including for immune checkpoint inhibitors of programmed cell death 1 protein (anti-PD-1 agents). However, little is known about how quickly anti-PD-1 agents agents reach eligible patients in practice or whether such patients differ from those studied in clinical trials that lead to FDA approval (pivotal clinical trials).

Objectives

To assess the speed with which anti-PD-1 agents agents reached eligible patients in practice and to compare the ages of patients treated in clinical practice with the ages of those treated in pivotal clinical trials.

Design, Setting, and Participants

This retrospective cohort study, performed from January 1, 2011, through August 31, 2016, included patients from the Flatiron Health Network who were eligible for anti-PD-1 agents treatment of selected cancer types, which included melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC).

Main Outcomes and Measures

Cumulative proportions of eligible patients receiving anti-PD-1 agents treatment and their age distributions.

Results

The study identified 3089 patients who were eligible for anti-PD-1 agents treatment (median age, 66 [interquartile range, 56-75] years for patients with melanoma, 66 [interquartile range, 58-72] years for patients with RCC, and 67 [interquartile range, 59-74] years for patients with NSCLC; 1742 male [56.4%] and 1347 [43.6%] female; 2066 [66.9%] white). Of these patients, 2123 (68.7%) received anti-PD-1 agents treatment, including 439 eligible patients with melanoma (79.1%), 1417 eligible patients with NSCLC (65.6%), and 267 eligible patients with RCC (71.2%). Within 4 months after FDA approval, greater than 60% of eligible patients in each cohort had received anti-PD-1 agents treatment. Overall, similar proportions of older and younger patients received anti-PD-1 agents treatment during the first 9 months after FDA approval. However, there were significant differences in age between clinical trial participants and patients receiving anti-PD-1 agents treatment in clinical practice, with more patients being older than 65 years in clinical practice (range, 327 of 1365 [60.6%] to 46 of 72 [63.9%]) than in pivotal clinical trials (range, 38 of 120 [31.7%] to 223 of 544 [41.0%]; all P < .001).

Conclusions and Relevance

Anti-PD-1 agents rapidly reached patients in clinical practice, and patients treated in clinical practice differed significantly from patients treated in pivotal clinical trials. Future actions are needed to ensure that rapid adoption occurs on the basis of representative trial evidence.

Financial Toxicity: Management as an Adverse Effect of Cancer Treatment

Along with many physical and emotional adverse effects associated with cancer therapy, attention has been directed to defining and identifying interventions to manage financial strain that can occur because of high medical payments and reduced income from employment interruption. Nurses can support patients and families by encouraging open communication during shared treatment decision making and throughout the cancer experience.
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Predictors of Unplanned Hospitalizations in Patients With Nonmetastatic Lung Cancer During Chemotherapy

PURPOSE/OBJECTIVES

To determine predictors of unplanned hospitalizations in patients with lung cancer to receive chemotherapy in the outpatient setting and examine the potential financial burden of these events.
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DESIGN

Retrospective, longitudinal cohort study.
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SETTING

The National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.
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SAMPLE

Of 104,388 incident cases of lung cancer diagnosed from 2005-2009, 2,457 cases of patients with lung cancer who received outpatient chemotherapy were identified. Patients were aged 66 years or older at diagnosis, had uninterrupted Medicare Part A and B coverage with no health maintenance organization enrollment, and received IV chemotherapy at least once.
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METHODS

Generalized estimating equations was used.
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MAIN RESEARCH VARIABLES

Patient age, sex, race, marital status, degree of residential urbanization, median income, education level, stage, receipt of radiation therapy, and comorbidities.
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FINDINGS

Younger age, non-White race, lower education, higher income, receipt of radiation therapy, and lack of preexisting comorbidity were significant predictors of the likelihood of an initial unplanned hospitalization for lung cancer. Non-White race, receipt of radiation therapy, and comorbidity were factors associated with an increased number of hospitalizations. 
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CONCLUSIONS

Unplanned hospitalizations are frequent, disruptive, and costly. This article defines areas for further exploration to identify patients at high risk for unexpected complications. 
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IMPLICATIONS FOR NURSING

This article represents a foundation for development of risk models to enable nursing evaluation of patient risk for chemotherapy treatment interruption and unplanned hospitalization.

The Rise of Big Data in Oncology

OBJECTIVES

To describe big data and data science in the context of oncology nursing care.

DATA SOURCES

Peer-reviewed and lay publications.

CONCLUSION

The rapid expansion of real-world evidence from sources such as the electronic health record, genomic sequencing, administrative claims and other data sources has outstripped the ability of clinicians and researchers to manually review and analyze it. To promote high-quality, high-value cancer care, big data platforms must be constructed from standardized data sources to support extraction of meaningful, comparable insights.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must advocate for the use of standardized vocabularies and common data elements that represent terms and concepts that are meaningful to patient care.

Primer in Genetics and Genomics, Article 6: Basics of Epigenetic Control

The epigenome is a collection of chemical compounds that attach to and overlay the DNA sequence to direct gene expression. Epigenetic marks do not alter DNA sequence but instead allow or silence gene activity and the subsequent production of proteins that guide the growth and development of an organism, direct and maintain cell identity, and allow for the production of primordial germ cells (PGCs; ova and spermatozoa). The three main epigenetic marks are (1) histone modification, (2) DNA methylation, and (3) noncoding RNA, and each works in a different way to regulate gene expression. This article reviews these concepts and discusses their role in normal functions such as X-chromosome inactivation, epigenetic reprogramming during embryonic development and PGC production, and the clinical example of the imprinting disorders Angelman and Prader-Willi syndromes.

Adoption of immunotherapy into real-world practice: Insights from the use of checkpoint inhibitors

e14583

Background: Cancer research has been criticized regarding the generalizability of trials to older persons, as well as the timeliness of the impact of new trials on real-world practice. Despite growing enthusiasm about programmed death 1 checkpoint inhibitors (anti-PD1s), little is known about the speed with which these drugs are adopted into real-world practice, or whether anti-PD1 treated patients in real-world practice are older than patients treated in trials. Methods: We used retrospective data from Flatiron Health’s electronic health record database, which includes 250 cancer clinics and 1.5 million patients with cancer. We identified patients diagnosed after January 1, 2011 who underwent systemic therapy for: advanced melanoma (n=1,670), advanced non-small cell lung cancer (aNSCLC; n=19,536), or metastatic renal cell carcinoma (mRCC; n=2,018). Then, we determined the proportion treated with anti-PD1s in the 2nd line or later following US Food and Drug Administration (FDA) approval. Therapy lines containing study drugs were excluded. Chi-square tests were used to compare age distributions of patients treated in real-world practice to patients treated in trials that support FDA approval. Results: At 6 months following FDA approval, 71.9% of patients with melanoma undergoing treatment were receiving anti-PD1s, versus 33.0% of patients with aNSCLC and 46.0% of patients with mRCC. Within 1 year, more than half of all treated patients with these 3 cancers were receiving anti-PD1s (71.0% in melanoma; 51.4% in aNSCLC; and 51.8% in mRCC). The median ages at first receipt of anti-PD1s were ≥65 years (65.1 years in melanoma; 67.9 years in aNSCLC; 66.0 years in mRCC). Anti-PD1 treated patients were significantly older in real-world practice than patients treated in trials (Table: all p<0.001). Conclusions: In a large national sample of patients with cancer, anti-PD1s were adopted rapidly into real-world practice. Compared to patients treated in real-world practice, older patients were underrepresented in clinical trials. [Table: see text]

Racial disparities in the use of programmed death-1 checkpoint inhibitors

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Background: There are concerns about racial disparities in access to trials of new cancer drugs, including the programmed death 1 checkpoint inhibitors (anti-PD1s). It is unknown whether these disparities extend to anti-PD1 treated patients in real-world practice. Methods: We used retrospective data from Flatiron Health’s electronic health record database, which includes more than 250 cancer clinics and 1.5 million patients with cancer. We identified patients diagnosed after January 1, 2011 who underwent systemic therapy for: advanced non-small cell lung cancer (aNSCLC; n = 13,473), metastatic renal cell carcinoma (mRCC; n = 1,537), and advanced melanoma (n = 1,221). Within each cohort, we identified treatment type (anti-PD1 versus non-anti-PD1). Therapy lines containing study drugs were excluded. We used logistic regressions to model the use of anti-PD1s by race, adjusting for factors such as age, sex, stage at diagnosis and line of therapy. Results: Of 16,231 patients in our sample, 4,643 (28.6%) were treated with anti-PD1s. Racial distributions differed for anti-PD1 treated patients compared to non-anti-PD1 treated patients in the aNSCLC cohort (Table: p < 0.01), but not in the mRCC cohort (p = 0.84) or the advanced melanoma cohort (p = 0.96). In bivariate analyses of patients with aNSCLC, anti-PD1 treatment was associated with other race, male sex, stage II at diagnosis, squamous histology, smoking history and line of therapy (all p < 0.05). Adjusted models showed there were no significant differences in likelihood of receiving anti-PD1s when comparing black and white patients undergoing systemic therapy for aNSCLC (aOR for black vs. white: 0.86, 95% CI 0.72-1.02), mRCC (aOR 0.90, 95% CI 0.53-1.49), or melanoma (aOR 2.02, 95% CI 0.42-14.59). Conclusions: Among patients undergoing systemic therapy in a large national network of cancer clinics, we found no significant racial disparities in the use of anti-PD1s. [Table: see text]

Behind the scenes of clinical research: from trial to triumph

The oncology field has seen its share of clinical advancements. Patients now may be able to receive therapies that are associated with less toxicity and are surviving their diseases for longer periods.

Non-Hodgkin's lymphoma

OBJECTIVES

To review the etiology, epidemiology, classification, diagnosis, staging, prognosis, treatment, and nursing implications of non-Hodgkin's lymphoma.

DATA SOURCES

Research studies, review articles, and book chapters pertaining to non-Hodgkin's lymphoma.

CONCLUSIONS

Non-Hodgkins's lymphomas are a heterogeneous group of lympho-proliferative disorders, increasing in frequency, for which therapy ranges from supportive to curative.

IMPLICATIONS FOR NURSING PRACTICE

An understanding of the variety of presentations and treatments of non-Hodgkin's lymphomas will enable the oncology nurse to assist patients and their families to cope with the disease, make treatment-related decisions, and optimize the patient's quality of life.