Mackenzi Pergolotti

Geriatric Assessment-Identified Deficits in Older Cancer Patients With Normal Performance Status

BACKGROUND We investigated whether a brief geriatric assessment (GA) would identify important patient deficits that could affect treatment tolerance and care outcomes within a sample of older cancer patients rated as functionally normal (80%-100%) on the Karnofsky performance status (KPS) scale. METHODS Cancer patients aged ≥65 years were assessed using a brief GA that included both professionally and patient-scored KPS and measures of comorbidity, polypharmacy, cognition, function, nutrition, and psychosocial status. Data were analyzed using descriptive statistics and multivariable logistic regression. RESULTS The sample included 984 patients: mean age was 73 years (range: 65-99 years), 74% were female, and 89% were white. GA was conducted before (23%), during (41%), or after (36%) treatment. Overall, 54% had a breast cancer diagnosis (n = 528), and 46% (n = 456) had cancers at other sites. Moreover, 81% of participants (n = 796) had both professionally and self-rated KPS ≥80, defined as functionally normal, and those patients are the focus of analysis. In this subsample, 550 (69%) had at least 1 GA-identified deficit, 222 (28%) had 1 deficit, 140 (18%) had 2 deficits, and 188 (24%) had ≥3 deficits. Specifically, 43% reported taking ≥9 medications daily, 28% had decreased social activity, 25% had ≥4 comorbidities, 23% had ≥1 impairment in instrumental activities of daily living, 18% had a Timed Up and Go time ≥14 seconds, 18% had ≥5% unintentional weight loss, and 12% had a Mental Health Index score ≤76. CONCLUSION Within this sample of older cancer patients who were rated as functionally normal by KPS, GA identified important deficits that could affect treatment tolerance and outcomes.

The Prevalence of Potentially Modifiable Functional Deficits and the Subsequent Use of Occupational and Physical Therapy by Older Adults with Cancer

BACKGROUND Occupational and physical therapy (OT/PT) services seek to reduce morbidity, mortality, and improve the quality of life of individuals; however, little is known about the needs and use of OT/PT for older adults with cancer. The goal of this study was to describe the functional deficits and their associations with other factors, and to examine the use of OT/PT after a noted functional deficit. MATERIALS AND METHODS This study analyzed data from an institution-based registry that included geriatric assessments of older adults with cancer linked to billing claims data. Logistic regression was used to model predictors of functional deficits. Use of OT/PT was determined and validated with medical chart review. RESULTS 529 patients with cancer, a median age of 71, 78% were female, 87% Caucasian, 57% married, 53% post-secondary education, and 63% with breast cancer were included. In a multivariable model, the odds of having any functional deficits increased with age [5 year OR: 1.31, 95% CI: (1.10, 1.57)] were higher for those with a high school diploma versus those with advanced degrees [OR: 1.66, 95% CI: (1.00, 2.77)] and were higher for patients with comorbidities [OR: 1.15, 95% CI: (1.10, 1.21)]. Of patients with functional deficits only 9% (10/111) received OT/PT within 12 months of a noted deficit. DISCUSSION The odds of having any potentially modifiable functional deficit were higher in patients with increasing age, comorbid conditions, and with less than a college degree. Few were referred for OT/PT services suggesting major underutilization of these potentially beneficial services.

Physical activity communication between oncology providers and patients with early-stage breast, colon, or prostate cancer.

National guidelines recommend that patients with a cancer diagnosis engage in regular physical activity to reduce cancer‐related fatigue, maintain quality of life and physical function, and improve overall prognosis and survival. This study investigates oncology provider communications about physical activity during routine clinic visits with patients with early‐stage breast, colon, or prostate cancer.

Occupational Therapy for Adults With Cancer: Why It Matters

Adult cancer survivors are significantly more likely to report being in fair or poor health, have comorbidities, one or more limitations in activities of daily living, and poorer functional status when compared with similar age adults without a cancer diagnosis. Occupational therapy is specifically designed to evaluate and treat functional deficits, yet it remains underused in cancer care.

A randomized controlled trial of outpatient CAncer REhabilitation for older adults: The CARE Program

BACKGROUND Large numbers of older adults (aged 65years or older) are surviving cancer; however, many survivors report decreased quality of life (QOL) and limitations in activities of daily living (ADL) and instrumental activities of daily living (IADL) both during and after treatment [1-3]. Occupational and physical therapy (OT/PT) are services focused on improving functional status and QOL that are largely unexplored and underutilized in cancer survivorship care [4,5]. METHODS/DESIGN This is a randomized, single-blind, two-arm, single institution pilot study. Eighty-two patients will be recruited from a university-affiliated outpatient oncology clinic. Inclusion criteria include the following: aged 65years or older, diagnosis of cancer within 5years, English speaking, has at least one functional deficit, and able to safely participate in an outpatient rehabilitation program. Exclusion criteria are: currently receiving rehabilitation or eligible for hospice. Consented patients will be randomized into two groups: (1) the CARE (CAncer REhabilitation) Program consisting of outpatient OT/PT and (2) standard of care. PRIMARY OUTCOME change in Nottingham Extended Activities of Daily Living (NEADL) scores from baseline to 3months between CARE and control. DISCUSSION This study is one of the first RCTs aimed at examining the effect of OT/PT in older adults with cancer. If positive, findings from this study will suggest the potential for outpatient OT/PT to improve the functional ability and QOL of older adults with cancer.

Skeletal muscle measures and physical function in older adults with cancer: sarcopenia or myopenia?

Background Skeletal muscle loss, commonly known as sarcopenia, is highly prevalent in older adults and linked with adverse outcomes in cancer, yet the definition and role of sarcopenia remains uncertain. The aim of this study was to examine the association of Computerized Tomography (CT) assessed skeletal muscle measures with physical function in older adults with cancer. Results CTs for 185 patients were available. Median age 73 (IQR 68–76) and 56.5% female. After controlling for sex and BMI, we found no evidence that SMI was associated with physical function impairments. Both SMD and SMG were associated physical function impairments and higher values were associated with decreased limitations in instrumental activities of daily living (RR 0.84 [CI 0.73–0.96] and 0.94 [CI 0.89–0.99], respectively), climbing stairs (RR 0.84 [CI 0.76–0.94] and 0.91 [CI 0.87–0.96]), walking 1 block (RR 0.77 [CI 0.67–0.90] and 0.91 [CI 0.85–0.97]), and prolonged Timed Up and Go (RR 0.83 [CI 0.75–0.92] and 0.92 [CI 0.88–0.96]). Materials and Methods Using the Carolina Senior Registry, we identified patients with CT imaging performed within 60 days +/− of baseline geriatric assessment (GA). Skeletal muscle area and density (SMD) were analyzed from L3 lumbar segments. Muscle area and height (m2) were used to calculate skeletal muscle index (SMI). Skeletal Muscle Gauge (SMG) was created by multiplying SMI x SMD. Conclusions Skeletal muscle mass as assessed from CT imaging was not associated with physical function impairments. Skeletal muscle radiodensity was more associated with physical function and may aid in identifying older adults at risk for functional impairments.

Activities, function, and health-related quality of life (HRQOL) of older adults with cancer

OBJECTIVE This study aims to (1) describe the activities, function, and health-related quality of life (HRQOL) of a large sample of older adults (age ≥65) with cancer, (2) identify the associations with demographics, cancer type, comorbid conditions, and ability to participate in activities and functional status. MATERIALS AND METHODS The Health Registry/Cancer Survivorship Cohort is an institutional database designed to aid cancer survivorship research. The registry includes three measures of patient-reported HRQOL: FACT-G and PROMIS® Global measures for physical and mental health. Other measures included in the registry are cancer type, date from diagnosis, number of comorbid conditions and specific conditions and their limitations in daily activity, and self-reported daily activity/function. RESULTS Our sample consists of 768 older adults with cancer, mean age 72years, 60% female, and 90% White. Mean scores for HRQOL: FACT-G (85, range: 25-108), PROMIS-physical (48, range: 16-67) and, PROMIS-mental (51, range: 21-67). In multivariable models, Black race, one or more comorbid conditions, and Gastrointestinal cancer (p<.05), and patient- reported decreased levels of activities/function were all independently associated with poor HRQOL (p<.0001). CONCLUSIONS Older Black adults with cancer, those that have high comorbidity burden, with gastrointestinal cancers and those that report decreased ability to participate in daily activities/function reported poorer HRQOL. As geriatric oncology moves towards trying to identify who may need supportive services, this study demonstrated that a one question patient-reported level of activities and functional ability were independently associated with physical, mental, and cancer-specific HRQOL.

Frailty index developed from a cancer-specific geriatric assessment and the association with mortality among older adults with cancer

Background: An objective measure is needed to identify frail older adults with cancer who are at increased risk for poor health outcomes. The primary objective of this study was to develop a frailty index from a cancer-specific geriatric assessment (GA) and evaluate its ability to predict all-cause mortality among older adults with cancer. Patients and Methods: Using a unique and novel data set that brings together GA data with cancer-specific and long-term mortality data, we developed the Carolina Frailty Index (CFI) from a cancer-specific GA based on the principles of deficit accumulation. CFI scores (range, 0-1) were categorized as robust (0-0.2), pre-frail (0.2-0.35), and frail (>0.35). The primary outcome for evaluating predictive validity was all-cause mortality. The Kaplan-Meier method and log-rank tests were used to compare survival between frailty groups, and Cox proportional hazards regression models were used to evaluate associations. Results: In our sample of 546 older adults with cancer, the median age was 72 years, 72% were women, 85% were white, and 47% had a breast cancer diagnosis. Overall, 58% of patients were robust, 24% were pre-frail, and 18% were frail. The estimated 5-year survival rate was 72% in robust patients, 58% in pre-frail patients, and 34% in frail patients (log-rank test, P<.0001). Frail patients had more than a 2-fold increased risk of all-cause mortality compared with robust patients (adjusted hazard ratio, 2.36; 95% CI, 1.51-3.68). Conclusions: The CFI was predictive of all-cause mortality in older adults with cancer, a finding that was independent of age, sex, cancer type and stage, and number of medical comorbidities. The CFI has the potential to become a tool that oncologists can use to objectively identify frailty in older adults with cancer.

The Effects of Exercise on Patient-Reported Outcomes and Performance-Based Physical Function in Adults With Acute Leukemia Undergoing Induction Therapy: Exercise and Quality of Life in Acute Leukemia (EQUAL)

Introduction. Fatigue is a distressing symptom for adults with acute leukemia, often impeding their ability to exercise. Objectives. 1) Examine effects of a 4-week mixed-modality supervised exercise program (4 times a week, twice a day) on fatigue in adults with acute leukemia undergoing induction chemotherapy. 2) Evaluate effects of exercise program on cognition, anxiety, depression, and sleep disturbance. 3) Evaluate effect of intervention on adherence to exercise. Methods. 17 adults (8 intervention, 9 control), aged 28-69 years, newly diagnosed with acute leukemia were recruited within 4 days of admission for induction treatment. Patient-reported outcomes (PROs) (fatigue, cognition, anxiety, depression, sleep disturbance, mental health, and physical health) and fitness performance-based measures (Timed Up and Go [TUG], Karnofsky Performance Status, and composite strength scoring) were assessed at baseline and at discharge. Changes in PRO and performance-based physical function measures from baseline to time of discharge were compared between groups using Wilcoxon Rank Sum tests. Results. With PROMIS (Patient-Reported Outcomes Measurement Information System) Fatigue, we found a median change in fatigue (−5.95) for the intervention group, which achieved a minimally important difference that is considered clinically relevant. Intervention group reduced their TUG performance by 1.73 seconds, whereas the control group remained fairly stable. A concerning finding was that cognition decreased for both groups during their hospitalization. 80% adherence of visits completed with a mean of 6 sessions attended per week. Conclusions. Our study provides information on the impact of exercise on symptomatology, with focus on fatigue and other psychosocial variables in acute leukemia.

Adjuvant treatment for older women with invasive breast cancer

Older women experience a large share of breast cancer incidence and death. With the projected rise in the number of older cancer patients, adjuvant chemo-, radiation and endocrine therapy management will become a key component of breast cancer treatment in older women. Many factors influence adjuvant treatment decisions including patient preferences, life expectancy and tumor biology. Geriatric assessment predicts important outcomes, identifies key deficits, and can aid in the decision making process. This review utilizes clinical vignettes to illustrate core principles in adjuvant management of breast cancer in older women and suggests an approach incorporating life expectancy and geriatric assessment.