Impact of geriatric assessment (GA) based frailty index (CARE-Frailty Index) on mortality and treatment-related toxicity among older adults with gastrointestinal (GI) malignancies

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Background: Older adults with cancer are at increased risk of treatment-related toxicity and mortality. A comprehensive geriatric assessment (GA) may uncover aging associated vulnerability and identify those at greatest risk of adverse outcomes. We studied the association between a novel frailty index and treatment-related morbidity and mortality among older adults with GI malignancies. Methods: Older adults (≥60y) referred for initial consultation at the UAB GI oncology clinic between 9/2017 to 12/2020 were enrolled in a prospective Cancer and Aging Resilience Evaluation (CARE) registry. All participants underwent a patient-reported GA at baseline as previously described (Williams et al J Geriat Oncol 2020). Using this information, we constructed a 44-item frailty index using a deficit accumulation approach. Vital status was acquired by linking with death records and chart review. In a subgroup of patients continuing care at UAB, we collected information on toxicity for the first 6 months of treatment via chart review using CTCAE v5.0. We used Kaplan Meier Methods and log-rank test to compare survival distributions, and a multivariate cox regression to adjust for potential confounders. We compared the toxicity rates across frailty subgroups using risk ratio (RR) calculated from general linear models. Results: Of 765 consecutive older adults referred to GI oncology clinic, 590 (77%) had available data to measure frailty index. Median age at enrollment was 68y; with 59% males and 72% White. Common cancer types included colorectal (30%) and pancreatic cancer (26%); mostly with advanced stage disease (stage III 28%; IV 46%). Overall, 168 (28%) were characterized as pre-frail and 230 (39.3%) as frail. As compared to non-frail, those who were frail were more likely to be Black (33% vs 20%; p < 0.01) and have pancreatic cancer (33.6% vs 21.8%; p < 0.01). Over a median follow up of 22 months, 212 (36%) patients had died. The 2y overall survival among non-frail, pre-frail and frail patients was 71%, 63% and 51%, respectively (log rank p value < 0.001). In a multivariate cox regression, as compared to non-frail patients, frailty was associated with worse OS (HR 1.75; 95% CI 1.13-2.70; p = 0.01) after adjusting for age, sex, race, cancer stage, cancer type, line of therapy and performance status. In a subset of 168 patients with available data, baseline frailty was associated with increased risk of ≥grade 3 non-hematologic toxicity (RR 2.23; 95% CI 1.27-3.92; p < 0.01) but not ≥grade 3 hematologic toxicity (RR 1.03; 95% CI 0.67-1.58; p = 0.90) as compared to non-frail patients Conclusions: The CARE-Frailty Index is a novel frailty index built on the principle of deficit accumulation using a patient-reported GA, and appears to be a robust predictor of survival and may predict treatment related toxicity among older adults with GI malignancies.

Geriatric assessment (GA) predictors of 1y mortality in older adults with gastrointestinal (GI) malignancies: Results from the CARE study

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Background: Chronologic age is an imperfect predictor of morbidity and mortality in older patients with newly-diagnosed GI malignancies. Identifying patients with GI malignancies that are at increased risk of mortality within the 1st year remains challenging given no prior studies have focused on this population, yet is critical to developing personalized treatment plans. To fill this gap, we examined predictors of 1y mortality using variables from a patient-reported GA in a prospective cohort of older adults with GI malignancies. Methods: Cancer and Aging Resilience Evaluation (CARE) is a prospective registry of older adults (≥60y) with cancer seen at UAB (J Geri Onc 2019; PMID 31005648). Patients with GI malignancies with GA completed within the timeframe of 3 mo. before and up to 6 mo. after diagnosis were included. Vital status (up to 12/7/2019) was ascertained by linking participants to LexisNexis. Multivariable Cox regression analysis was used to estimate associations between GA variables and 1y mortality, adjusting for age at cancer diagnosis, race, cancer stage (IV vs. I-III), cancer group (high risk: pancreatic, hepatobiliary, esophageal vs. low risk: colorectal, GIST, neuroendocrine, etc.), and planned chemotherapy (yes/no). Results: A total of 356 participants met eligibility criteria. Mean age at enrollment was 70y; 56.4% were females; 25% black; 47.1% had high-risk cancers. In unadjusted analysis, high-risk cancers, cancer stage, malnutrition, impaired performance status, limitations in social activities, impaired instrumental activities of daily living (IADL), physical health, mental health, anxiety, and ≥3 comorbidities were associated with higher 1y mortality. Our base model (demographic and clinical variables) demonstrated good discrimination (c statistic 0.758), but was improved with the addition of all significant GA variables (c-statistic 0.810). Fatigue and malnutrition were identified as the strongest predictors among the GA variables, and a model adding those to the base model retained high discrimination (c-statistic 0.804). The estimated 1yr survival was 53.1% for those with both fatigue and malnutrition compared to 88.1% in those with neither. Conclusions: Among older adults with GI malignancies, malnutrition and fatigue were the strongest GA predictors of 1yr mortality after adjusting for age and clinical factors. These findings provide evidence for developing targeted interventions in older patients with newly-diagnosed GI malignancies to reduce 1y mortality.

Use of self-rated health to identify frailty and predict mortality in older adults with cancer. Results from the care study

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Background: Poor self-rated health (SRH) is a known predictor of mortality in the general adult population, but little is known about its use in older adults with cancer. The purpose of this study was to examine the association and ability of SRH to identify frail older adults and assess its ability to predict mortality in older adults with cancer. Methods: Using participants from the Cancer & Aging Resilience Evaluation (CARE) Registry who had undergone a geriatric assessment, we examined SRH using a single-item from the Patient-Reported Outcomes Measurement Information System (PROMIS) global health scale. SRH scores were dichotomized into Poor (poor and fair) and Good (good, very good, and excellent). Multivariable logistic regression analyses were used to examine associations between SRH and frailty (based on frailty index) and specific geriatric impairments adjusting for age, sex, comorbidity, cancer type and stage. Finally, the impact of SRH on all-cause mortality was assessed with a multivariable cox regression model. Results: A total of 708 participants with malignancy were included, median age was 68y, 41.5% male, and 74.6% White. Colorectal cancer was the most common cancer (27.1%) and 48.2% of the participants had Stage IV disease. Poor SRH was reported by 42% of participants and was associated with significantly higher odds of frailty (adjusted Odds Ratio [aOR] = 21.8; 95%CI 13.7-34.8). Similarly, poor SRH was independently associated with higher odds of impairments in Activities of Daily Living (ADL) (aOR = 5.6, 95%CI, 3.6-8.9), independent ADL (aOR = 8.4, 95%CI, 5.8-12.4), cognition (aOR = 4.6, 95%CI 2.3-9.3), malnutrition (aOR = 4.5, 95%CI 3.2-6.4), falls (aOR = 3.6, 95%CI 2.4-5.4), anxiety (aOR = 4.6, 95%CI 2.9-7.3), and depression (aOR = 5.4, 95%CI 3.0-9.7). The SRH demonstrated high sensitivity (84.3%) and specificity (78.4%) for identifying frailty, with a positive predictive value of 67% and negative predictive value of 90.6%. The 1y survival rate in those with Poor SRH was significantly worse (64.7% vs 84.3%, log rank p value < 0.001). In a multivariate cox regression analysis, poor SRH remained an independent predictor of worse survival (adjusted Hazard Ratio 2.29 [1.6-3.2], p< 0.01) after adjusting for age, sex, race, cancer type, stage, comorbidity, and planned treatment. Conclusions: Poor SRH is highly associated with frailty and could be a simple tool to identify frail older patients with cancer at risk for adverse events and increased mortality.

Association between chronological age and geriatric assessment (GA) to identify deficits in elderly adults with cancer: Findings from the Care Registry

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Background: Although ASCO and NCCN guidelines recommend that adults with cancer diagnosed at age ≥65y undergo a GA, the association between chronologic age and GA identified deficits remains understudied, and thus, the appropriate age cut-off for employing GA in clinical settings remains unknown. We addressed this gap by examining the association between chronologic age and GA deficits in older adults with cancer. Methods: The Cancer and Aging Resilience Evaluation (CARE) is an ongoing prospective registry of older adults (≥60y) with cancer at a single site. Eligible patients underwent a patient-reported GA adapted from the Cancer and Aging Research Group. The association between age categories (10y increments) and presence of GA deficits was tested using chi-squared tests of trend. Linear association between age and GA deficits was examined using Pearson correlation. Results: The median age at enrollment was 70y (60-96) for 08 participants; 58% were male. Most common cancer types were colorectal (27%), pancreatic (17%), and hepatobiliary (12%). No significant correlation was found between chronologic age and the number of GA deficits (r = 0.03). There was no association between the youngest (60-70y) vs. the oldest age groups (≥80y) with respect to the prevalence of GA deficits: frailty (33% vs. 33%, p= 0.97); impairment of activities of daily living (ADL) (20% vs. 16%, p= 0.7);impairment of instrumental ADL (50% vs 60%, p= 0.3); malnutrition (42% vs. 33%, p =0.4), cognitive impairment (8% vs. 6%, p= 0.6), falls (19% vs. 30%, p 0.1), anxiety (19% vs. 11%, p= 0.1) and depression (13.4% vs. 13.7%, p= 0.2) (Table). Prevalence of 3+ comorbidities was higher in the older patients (45% vs. 59%, p= 0.03). Conclusions: In our cohort of older adults with mostly gastrointestinal malignancies, age was not associated with GA identified deficits and the prevalence of most impairments was similar across age-groups. The use of chronologic age alone to identify which patients may benefit from GA is problematic, and adults 60yrs and above, or perhaps even younger, may derive benefits from a GA. [Table: see text]

Depression among older adults with gastrointestinal (GI) malignancies: Results from the Cancer and Aging Resilience Evaluation (CARE) registry

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Background: Depression among older adults with cancer is often under recognized and under treated. This study characterizes the burden of depression in older adults with GI malignancies and its relationship with geriatric assessment (GA) impairments, health-related quality of life (HRQOL), and healthcare utilization. Methods: Since September 2017, patients ≥60 years in GI oncology clinics at UAB were asked to complete a CARE GA questionnaire. We examined depression using the Patient-Reported Outcomes Measurement Information System (PROMIS) Depression 4 item short form; moderate/severe (mod/sev) depression was defined by a T-score ≥60. GA impairments, HRQOL (PROMIS Global-10), and healthcare utilization were compared between those with and without mod/sev depression using a Chi-squared or t-test. Results: A total of 462 enrolled; mean age was 69 (range 60-96), majority white (72%), males (52%), and with advanced stage (III/IV, 69.1%). Most common cancers were colorectal (36%), pancreatic (23%), or hepatobiliary (15%). Overall, 55 patients reported mild depressive symptoms (12%) and 60 (13%) were found to have mod/sev depression. Depressed participants did not differ in demographics or GI cancer type/stage. Those reporting mod/sev depression were more likely to report falls (44 v 19%, p<.001), impaired performance status (63 v 27%, p<.001), dependence in activities of daily living (ADL; 45 v 14%, p<.001), dependence in instrumental ADL (84 v 45%, p<.001), cognitive dysfunction (40 v 5%, p<.001), financial distress (37 v 23%, p=.03), anxiety (76 v 10%, p<.001), fatigue (88 v 54%, p<.001), and pain (70 v 32%, p<.001). Depressed patients reported lower physical (32 v 45%, p<.001) and mental (36 v 50%, p<.001) HRQOL sub-scores, as well as more emergency room visits (67 v 49%, p=.009), but no difference in hospitalizations. Conclusions: More than one out of eight older adults with a GI malignancy reported mod/sev depression, which was associated with impairment in several geriatric domains and overall quality of life. As depression is a pleiotropic yet treatable comorbidity, oncologists should prioritize its screening and treatment.

Integrating geriatric assessment into routine gastrointestinal (GI) consultation: The Cancer and Aging Resilience Evaluation (CARE)

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Background: Integrating Geriatric Assessment (GA) in the management of older adults with cancer is recommended, yet rarely practiced in routine oncologic care. In this report, we describe the feasibility of integrating the routine incorporation of GA in the management of older adults with GI malignancies and characterize GA impairments. Methods: CARE was adapted from the Cancer and Aging Research Group GA with modifications to create a completely patient-reported version. The CARE assesses self-reported functional status, physical function, nutrition, social support, anxiety/depression, cognitive function, comorbidities, and social activities. Patients ≥ 60yo referred for consultation to the GI Oncology clinic were asked to complete the CARE (paper/pencil) on their first visit. The completed CARE was collected during nurse triage and submitted to the clinical team prior to the physician encounter. Feasibility was defined as completion of the CARE by ≥ 80% of eligible patients during the initial consultation. Results: Between September 2017 and August 2018, 199 eligible new patients attended the GI Oncology Clinic, 192 (96.5%) were approached, and 181 (90.4%) completed the CARE. Most patients (79.6%) felt the length of time to complete was appropriate (median time of 10 minutes [IQR 10-15 minutes]). The mean age was 70y (range 60-96), 54.3% were male, and 75.1% were non-Hispanic white. Common tumor types included colon (27.8%), pancreatic (21.2%), and rectal (10.2%) cancer; predominately advanced stage diseases (stage III: 26.9%; stage IV: 40.0%). GA impairments were prevalent: 48.6% reported dependence in Instrumental Activities of Daily Living, 18.0% reported dependence in Activities of Daily Living, 22.5% reported ≥ 1 fall, 29.4% reported a performance status ≥ 2, 51.3% were limited in walking one block, 75.7% reported polypharmacy (≥ 4 medications), and 84.3% had ≥ 1 comorbidity. Conclusions: Performing a GA in the routine care of older adults with GI malignancies is feasible, and GA impairments are common among older adults with GI malignancies. A fully patient-reported GA such as the CARE may facilitate broader incorporation of GA in the routine clinic work flow.

Financial distress amongst older adults with gastrointestinal (GI) malignancies

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Background: Many patients with cancer report financial distress (FD); however, the magnitude of FD in the growing number of older adults with cancer remains less clear, particularly in those with GI malignancies. The purpose of this study was to evaluate the proportion of older adults with GI malignancies reporting FD and to characterize geriatric assessment (GA) and cancer-related factors associated with FD. Methods: Older adults ( ≥ 60yrs) seen in the GI oncology clinic at the University of Alabama Birmingham (UAB) were asked to fill out a patient-reported GA, entitled the Cancer & Aging Resilience Evaluation (CARE), at their visit. The CARE includes questions pertaining to patient’s independence in Activities of Daily Living (ADLs), Instrumental Activities of Daily Living (IADLs), falls, physical function, polypharmacy, and comorbidity. A single item question regarding FD from the patient satisfaction questionnaire (PSQ-18) was included. FD was defined as agreement with the phrase “Do you have to pay for more medical care than you can afford.” Demographic and GA characteristics were compared between those with and without FD using Chi-square and t-tests. Results: 233 patients completed the CARE a median of 71 days after diagnosis. Median age 68y (60-96); 54.5% male and 76.0% non-Hispanic white. Most common cancer types included colorectal (39.1%) and pancreatic cancers (20.6%). A total of 62 patients (26.6%) had FD. Patients with FD were more likely to be younger (68.1 vs. 70.1y, p = 0.04), of black race (37.1% vs. 15.8%, p = 0.007), have low education ( ≤ high school: 74.2% vs. 59.6%, p = 0.02), have one or more falls (31.5% vs. 19.9%, p = 0.077), to be limited a lot in walking 1 block (54.4% vs. 27.4%, p = 0.0003), take more than 4 medications (88.3% vs. 70.8%, p = 0.007), to have more than one comorbid condition (93.1% vs. 82.6%, p = 0.052), to report impaired IADLs (61.3% vs. 43.9%, p = 0.055), and impaired ADL (27.4% vs. 14.6%, p = 0.069). No associations were found with GI cancer type or stage, marital status, time from diagnosis, or hearing/vision impairments. Conclusions: Over a quarter of the older adult population with GI malignancies report FD. Several GA and demographic factors were associated with FD that may help identify older patients at risk for FD.

A population-based multivariate analysis of the association of county demographic and medical system factors with per capita pediatric trauma death rates in North Carolina

OBJECTIVE

This study analyzed the association between demographic and medical system factors and the pediatric trauma death rate in North Carolina.

SUMMARY BACKGROUND DATA

Trauma is the leading cause of death in children. Various medical system factors have been suggested to reduce pediatric morbidity and mortality rates, but the association with these rates has not been tested.

METHODS

Data were obtained from the North Carolina medical examiner's database. The dependent variable was the county per capita pediatric trauma death rate. Twenty-one demographic and medical system measures were selected as independent variables.

RESULTS

Nine hundred forty-one pediatric trauma deaths from 1986 to 1989 were included in our sample. Multivariate analysis identified the variables most highly associated with the dependent variables. The presence of advanced life support (ALS) training was the only medical system factor associated significantly with pediatric trauma death rates. Trauma centers, emergency (911) telephone access, and other medical resource variables had no significant association.

CONCLUSIONS

The study confirms other reports showing that demographic factors have an important predictive association with the trauma death rate in children. Advanced life support was the only medical system resource associated significantly with pediatric trauma death rates. This study underlines the significance of pre-hospital care in the treatment of pediatric trauma.

The response of the rat liver to alterations in total portal blood flow

In attempting to isolate the various components involved in the stimulus induced by partial hepatectomy, the effect of sudden increased portal flow to the whole liver has been studied. The technique involved the construction of a portacaval anastomosis and after a week, reconstitution of the original portal vein, allowing resumption of portal blood flow. The effects of increased portal flow in this experiment were to induce hypertrophy of hepatocytes and a minor degree of DNA synthesis.