Telemedicine in geriatric oncology - lessons learned from the COVID-19 experience

PURPOSE OF REVIEW

Telemedicine quickly became integrated into healthcare caused by the Coronavirus 19 (COVID-19) pandemic. Rapid use of telemedicine into healthcare systems was supported by the World Health Organization and other prominent national organizations to reduce transmission of the virus while continuing to provide access to care. In this review, we explored the effect of this swift change in care and its impact on older adults with cancer.

RECENT FINDINGS

Older adults are susceptible to the COVID-19 virus caused by various risk factors, such as comorbidity, frailty, decreased immunity, and cancer increases vulnerability to infection, hospitalization, and mortality. We found three major themes emerged in the literature published in the past 18 months, including access to care, telemedicine modes of communication, and the use of technology by older adults with cancer. These findings have brought insight into issues regarding healthcare disparities.

SUMMARY

The utilization of telemedicine by older adults with cancer has potential future benefits with the integration of technology preparation prior to the patient's initial visit and addressing known health disparities. The hybrid model of care provides in-person and or remote access to clinicians which may allow older adults with cancer the flexibility needed to obtain quality cancer care.

Healthcare providers' experiences of continuing care for older adults with cancer during the COVID-19 pandemic

PURPOSE

The COVID-19 pandemic has caused great strain on older adults with cancer and their healthcare providers. This study explored healthcare providers' reported changes in cancer care, clinical barriers to care, patient questions, and the overall experiences of caring for older adults with cancer during the COVID-19 crisis.

METHODS

The Advocacy Committee of the Cancer and Aging Research Group and the Association of Community Cancer Centers developed a survey for healthcare providers of adults with cancer, inquiring about their experiences during the pandemic. Responses from the survey's four open-ended items were analyzed by four independent coders for identification of common themes using deductive and inductive methods.

RESULTS

Participants (n = 137) represented a variety of demographic and clinical experiences. Six overall themes emerged, including (1) telehealth use, (2) concerns for patient mental health, (3) patient physical and social isolation, (4) patient fear of contracting COVID-19, (5) continued disruptions to cancer care, and (6) patients seeking guidance, particularly regarding COVID-19 vaccination. Questions fielded by providers focused on the COVID-19 vaccination's safety and efficacy during older adults' cancer treatment.

CONCLUSIONS

Additional resources (e.g., technology support, established care guidelines, and sufficient staffing) are needed to support older adults with cancer and healthcare providers during the pandemic. Future research should explore universally effective in-person and virtual treatment strategies for older adults with cancer.

IMPLICATIONS FOR CANCER SURVIVORS

Persistence of telehealth barriers, particularly a lack of infrastructure to support telehealth visits, social isolation, and restrictive visitor policies as a result of COVID-19, negatively impacted the mental health of older adults with cancer.

Outcome prioritization and preferences among older adults with cancer starting chemotherapy in a randomized clinical trial

INTRODUCTION

Older adults with cancer facing competing treatments must prioritize between various outcomes. This study assessed health outcome prioritization among older adults with cancer starting chemotherapy.

METHODS

Secondary analysis of a randomized trial addressing vulnerabilities in older adults with cancer. Patients completed three validated outcome prioritization tools: 1) Health Outcomes Tool: prioritizes outcomes (survival, independence, symptoms) using a visual analog scale; 2) Now vs. Later Tool: rates the importance of quality of life at three times-today versus 1 or 5 years in the future; and 3) Attitude Scale: rates agreement with outcome-related statements. The authors measured the proportion of patients prioritizing various outcomes and evaluated their characteristics.

RESULTS

A total of 219 patients (median [range] age 71 [65-88], 68% with metastatic disease) were included. On the Health Outcomes Tool, 60.7% prioritized survival over other outcomes. Having localized disease was associated with choosing survival as top priority. On the Now vs. Later Tool, 50% gave equal importance to current versus future quality of life. On the Attitude Scale, 53.4% disagreed with the statement "the most important thing to me is living as long as I can, no matter what my quality of life is"; and 82.2% agreed with the statement "it is more important to me to maintain my thinking ability than to live as long as possible".

CONCLUSION

Although survival was the top priority for most participants, some older individuals with cancer prioritize other outcomes, such as cognition and function. Clinicians should elicit patient-defined priorities and include them in decision-making.

Healthcare providers' attitudes towards delay in cancer treatment during COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic has created unprecedented obstacles leading to delays in treatment for older adults with cancer. Due to limited resources at the height of the pandemic, healthcare providers were constantly faced with ethical dilemmas regarding postponing or rescheduling care for their patients.

MATERIALS AND METHODS

Two survey-based studies were conducted at different time-points during the pandemic looking at factors affecting oncology care providers' attitudes towards delay in treatment for older adults with cancer. Eligible participants were recruited by email sent through professional organizations' listservs, email blasts, and social media. Change in provider attitude over time was analyzed by comparing responses from the 2020 and 2021 surveys. Data analysis included descriptive statistics and chi-squares.

RESULTS

In 2020, 17.5% of respondents were strongly considering/considering postponing cancer treatment for younger patients (age 30 and below), while 46.2% were considering delaying treatment for patients aged >85. These responses were in stark contrast to the results of the 2021 survey, where only 1.4% of respondents strongly considered postponing treatment for younger patients, and 13.5% for patients aged >85.

DISCUSSION

All recommendations to postpone treatment for older adults with cancer must be made after mutual discussion with the patient. Throughout the COVID-19 pandemic, oncology care providers had to consider multiple factors while treating patients, frequently making most decisions without appropriate institutional support.

Impact of the Cancer and Aging Research Group (CARG) chemotherapy toxicity (tox) risk score on the benefit of a geriatric assessment–driven intervention (GAIN) among older adults with cancer

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Background: The CARG tox score can predict risk of chemotherapy-related tox in older adults with cancer. GAIN can reduce tox vs standard of care (SOC) among these patients (pts); GAIN’s impact across CARG risk groups is unknown. Methods: A secondary analysis of the GAIN randomized clinical trial (NCT02517034) of pts aged ≥65 (solid tumor diagnosis, starting a new chemotherapy) was performed. Pts were randomized 2:1 to receive GAIN vs SOC and were categorized into low (0-5), medium (6-9), and high (10-20) risk groups according to CARG score. The primary outcome was incidence of grade 3-5 tox. Chi-square/Fisher’s exact tests were used to compare outcomes (GAIN vs SOC, stratified by risk groups). Log-rank tests were used to compare 1-year survival across risk groups. Results: This analysis included 600 pts: 26.5% low risk, 45.2% medium risk, 28.3% high risk. Table shows pt/treatment characteristics. For pts with low/medium risk scores, GAIN demonstrated a 14.0% (95% CI 4.1%-23.9%) reduction in tox vs SOC (p = 0.006). No significant reduction in tox was observed among pts with high risk scores (p = 0.86). One-year survival (GAIN vs SOC) for each risk group was 73.6% vs 67.4% (low risk), 68.5% vs 64.5% (medium risk), and 57.3% vs 61.7% (high risk), respectively (log-rank p = 0.10). Conclusions: Older adults with low/medium, but not high, CARG risk scores benefit from GAIN. Additional strategies may be needed to improve outcomes for pts with high CARG risk scores. Clinical trial information: NCT02517034. [Table: see text]

Geriatric Assessment-Driven Intervention (GAIN) on Chemotherapy-Related Toxic Effects in Older Adults With Cancer: A Randomized Clinical Trial

Importance

Although geriatric assessment-driven intervention improves patient-centered outcomes, its influence on chemotherapy-related toxic effects remains unknown.

Objective

To assess whether specific geriatric assessment-driven intervention (GAIN) can reduce chemotherapy-related toxic effects in older adults with cancer.

Design, Setting, and Participants

A randomized clinical trial enrolled 613 participants from a National Cancer Institute-designated cancer center between 2015 and 2019. Patients were 65 years and older with a solid malignant neoplasm, were starting a new chemotherapy regimen, and completed a geriatric assessment. Patients were followed up until chemotherapy completion or 6 months after initiation, whichever occurred first. Data analysis was done by intention-to-treat principle.

Interventions

Patients were randomized (2:1) to either the GAIN (intervention) or standard of care (SOC) arm. In the GAIN arm, a geriatrics-trained multidisciplinary team composed of an oncologist, nurse practitioner, social worker, physical/occupation therapist, nutritionist, and pharmacist reviewed geriatric assessment results and implemented interventions based on prespecified thresholds built into the geriatric assessment's domains. In the SOC arm, geriatric assessment results were sent to treating oncologists for consideration.

Main Outcomes and Measures

The primary outcome was incidence of grade 3 or higher chemotherapy-related toxic effects (graded using National Cancer Institute Common Terminology Criteria for Adverse Events, version 4.0). Secondary outcomes included advance directive completion, emergency department visits, unplanned hospitalizations, average length of stay, unplanned hospital readmissions, chemotherapy dose modifications, and early discontinuation. Overall survival analysis was performed up to 12 months after chemotherapy initiation.

Results

Among the 605 eligible participants for analysis, median (range) age was 71 (65-91) years, 357 (59.0%) were women, and 432 (71.4%) had stage IV disease. Cancer types included gastrointestinal (202 [33.4%]), breast (136 [22.5%]), lung (97 [16.0%]), genitourinary (91 [15.0%]), gynecologic (54 [8.9%]), and other (25 [4.1%]). Incidence of grade 3 or higher chemotherapy-related toxic effects was 50.5% (95% CI, 45.6% to 55.4%) in the GAIN arm and 60.6% (95% CI, 53.9% to 67.3%) in the SOC arm, resulting in a significant 10.1% reduction (95% CI, -1.5 to -18.2%; P = .02). A significant absolute increase in advance directive completion of 28.4% with GAIN vs 13.3% with SOC (P < .001) was observed. No significant differences were observed in emergency department visits, unplanned hospitalizations, average length of stay, unplanned readmissions, chemotherapy dose modifications or discontinuations, or overall survival.

Conclusions and Relevance

In this randomized clinical trial, integration of multidisciplinary GAIN significantly reduced grade 3 or higher chemotherapy-related toxic effects in older adults with cancer. Implementation of GAIN into oncology clinical practice should be considered among older adults receiving chemotherapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT02517034.

Synthesis of highly fluorescent y-enyne dendrimers with four and six arms

A first generation of dendrimeric Y-enynes with extended flexible chains was synthesized using Sonogashira coupling. Dendrimers 9 and 10 are highly fluorescent in the solid state and in solution.

Macroscopic chirality of a liquid crystal from nonchiral molecules

The transfer of chirality from nonchiral polymer networks to the racemic B2 phase of nonchiral banana-shaped molecules is demonstrated. This corresponds to the transfer of chirality from an achiral material to another achiral material. There are two levels of chirality transfers. (a) On a microscopic level the presence of a polymer network (chiral or nonchiral) favors a chiral state over a thermodynamically stable racemic state due to the inversion symmetry breaking at the polymer-liquid crystal interfaces. (b) A macroscopically chiral (enantimerically enriched) sample can be produced if the polymer network has a helical structure, and/or contains chemically chiral groups. The chirality transfer can be locally suppressed by exposing the liquid crystal to a strong electric field treatment.

Optical studies of the liquid crystal B2 phase formed by banana-shaped molecules

Null-transmission ellipsometry and depolarized light microscopy have been performed on free-standing films of three achiral banana-shaped compounds in the B2 phase. Our results support a two-layer unit cell previously proposed to explain the observed antiferroelectricity in thin films and bulk samples. We have studied thicker films than previously reported and have found no deviations in the film structure from the earlier findings. Moreover, we can determine the layer spacing, the molecular tilt from the layer normal, and the three principal indices of refraction in the molecular reference frame.

Estimation of potential lifetime cancer risks for trihalomethanes from consuming chlorinated drinking water in Taiwan

Data on concentrations of trihalomethanes (THMs) in raw and chlorinated water collected from three water treatment plants in Taiwan and estimates of the lifetime cancer risk for THMs from drinking water, using age-adjusted factors and volatilization terms, are presented. Data on THM levels in drinking water were obtained from the annual reports of the Environmental Protection Administration (EPA) of Taiwan. The methodology for estimation of lifetime cancer risks was taken from the USEPA. Chloroform was the major species of THMs, especially in the water plant of south Taiwan. Chloroform contributed the majority of the lifetime cancer risks (range: 87.5-92.5%) of total risks from the three water supply areas. All lifetime cancer risks for CHCl(3), CHBrCl(2), CHBr2Cl, and CHBr3 from consuming tap water in the three water supply areas were higher than 10(-6). The sum of lifetime cancer risks for CHCl(3), CHBrCl(3), CHBr2Cl, and CHBr3 was highest (total risk for total THMs<1.94x10(-4)) for tap water from south Taiwan.

Estimation of metal and organochlorine pesticide exposures and potential health threat by consumption of oysters in Taiwan

Pollutant concentrations detected in oysters from 12 different culture areas of Taiwan (especially for the Hsiangshan area and the Machu Islands) from 1991-98 were evaluated to investigate potential carcinogenic (inorganic As and organochlorine pesticides) and non-carcinogenic (Cu, Zn, Cd and inorganic As) risk to the public from ingestion of the oysters. The highest geometric mean (GM) Cu and Zn concentrations of 1108 (range 113-2806) and 1567 (range 303-3593) microg/g dry weight were obtained in oysters from the Hsiangshan coastal area. The maximum GM Cd and As concentrations of 6.82 and 19.3 microg/g dry weight were found in oysters from the Machu Islands area. The p,p'-DDE values range from not detectable in Penghu Islands' oysters to 164 ng/g dry weight in Machu Islands' oysters. The highest tDDT (sum of p,p'-DDE, p,p'-DDD and p,p'-DDT) concentrations of 337 and 340 ng/g dry weight were found in oysters from Kimmen and Machu Islands, respectively. A calculated target hazard quotient (THQ; daily intake/reference dose) of 11.4 (based on 139 g oysters/day) for Cu caused by consuming oysters from the Hsiangshan area is higher than that from other areas (range 0.124-5.95). The highest average Cu intake from Hsiangshan's oysters for individuals is 11.4 times (i.e. THQ=11.4) more than that of reference dose (40 microg/kg/day). However, the maximum THQ values for Cd and As caused by consuming oysters collected from the Machu Islands were 5.57 and 2.63 for Cd and As, respectively. Generally, the results of THQ showed that if only the maximally exposed individuals were considered, the value of 65.4% for oyster was higher than 1.0 in comparison with reference dose. All cancer risk estimates for inorganic As from consuming oysters were higher than 10(-6) (range from 128x10(-6) to 509x10(-6) for maximally exposed individuals and range from 17.1x10(-6) to 68.0x10(-6) for typically exposed individuals, respectively); that is the risk of the lower end of the range of acceptable risk. The highest risk estimate for inorganic As was 509x10(-6) for consumption of oysters by Machu Islands' residents. The lifetime cancer risks of 19.0x10(-6) for tDDT by consuming oysters from the Machu Islands was higher than those from the Penghu Islands (0.37x10(-6)). Therefore, the sum of lifetime cancer risks for tDDT and inorganic As had the highest risks (total risk=528x10(-6)) of consuming oysters from the Machu Islands. Furthermore, a 10(-6) upper limit on lifetime risk as the health protection standard would require maximum oyster consumption rates of approximately 0.26 g/day.

Effects of low polymer content in a liquid-crystal microlens

A small number of bifunctional monomers are mixed with a nematic liquid crystal (LC) and cured with a distributed electric field, which is produced by a circular-hole-patterned electrode structure. A gradient type of lens, that is, a LC microlens, is investigated for various polymer concentrations. Addition of 3% polymer is enough to freeze the gradient-index properties of the structure in the form of a convex lens, and a polymer-stabilized LC microlens is demonstrated. Although a lower concentration of polymer cannot hold the distribution properties in a curing process, it can maintain the variable focus as a nematic material can. The polymer networks can also eliminate the disclination line that usually appears and causes the lens in this type of LC device to deteriorate.

Hemoglobin J-Korat in Thais

Hemoglobin J(Korat), a "fast" hemoglobin with an anomaly in its beta chain different from the anomalies previously reported, was the major hemoglobin component in the blood of nine subjects among 1923 Thais from northeastern Thailand. After hemoglobin E, J(Korat) is the second most frequent of the anomalous hemoglobins among Thais.