Transplantation and Cellular Therapy for Older Adults-The MSK Approach.

PURPOSE OF REVIEW: Hematologic malignances more commonly affect older individuals and often present with advanced, higher risk disease than younger patients. Allogeneic and autologous hematopoietic cell transplantation is well-established treatment modalities with curative potential following either frontline treatments for these diseases or salvage therapy in the relapsed or refractory setting. More recently, novel cellular immunotherapy such as chimeric antigen receptor T-cell therapy has been shown to lead to high response rate and durable remission in many patients with advanced blood cancers. RECENT FINDINGS: Given unique characteristics of older patients, how best to deliver these higher-intensity and time sensitive treatment modalities for them remains challenging. Moreover, their short-term and potential long-term impact on their functional status, cognitive status, and quality of life may be significant considerations for many older patients. All these issues contributed to the lack of access and significant underutilization of these potential curative treatment strategies. In this review, we present up to date evidence to support potential benefits of transplantation and cellular therapy for older adults, their steady improving outcomes, and most importantly, highlight the use of geriatric assessment to help select appropriate older patients and optimize them prior to and following transplantation and cellular therapy. We specifically describe our approach at Memorial Sloan Kettering Cancer Center and encouraging early results from its implementation.

Geriatric Communication Skills Training Program for Oncology Healthcare Providers: a Secondary Analysis of Patient and Caregiver Outcomes.

Geriatric cancer patients and their caregivers have unique needs that make it difficult for their healthcare providers (HCPs) to effectively communicate with them. As ineffective communication can lead to negative health outcomes, it is important that oncology HCPs receive specialized training on communication with older adult patients and their caregivers. We conducted a small pilot study examining audio recordings of clinical encounters between HCPs and older adult cancer patients/caregivers and questionnaires completed by the patients and their caregivers before and after the HCPs participated in a geriatric communication skills training program. Eleven HCPs completed the 6-h Geriatric Comskil Training. Two clinic consultations with unique geriatric patients (n = 44) and their caregivers (n = 29) were recorded before and after training and coded for HCPs' use of communication skills. Patients and caregivers also completed surveys measuring their satisfaction with HCP communication and perceived empathy. Analysis of the audio recordings revealed that HCPs did not increase their use of communication skills after training. Although our sample was too small to detect statistical significance, measures of effect size showed trending improvements in patients' and caregivers' perceptions of HCPs' empathy and satisfaction with their communication after training. Our findings build on previous studies evaluating the feasibility and effectiveness of the Geriatric Comskil Training in real world setting and indicate that the training may have improved HCPs' communication with older adult patients and their caregivers even if their use of their observable communication skills did not change.

Preoperative frailty predicts postoperative falls in older patients with cancer.

INTRODUCTION: Patient falls in the hospital lead to adverse outcomes and impaired quality of life. Older adults with cancer who are frail may be at heightened risk of falls in the postoperative period. We sought to evaluate the association between degree of preoperative frailty and risk of inpatient postoperative falls and other outcomes among older adults with cancer. MATERIALS AND METHODS: We identified 7,661 patients aged 65 years or older who underwent elective cancer surgery from 2014 to 2020, had a hospital stay of ≥1 day, and had Memorial Sloan Kettering-Frailty Index (MSK-FI) data to allow assessment of frailty. Univariable logistic regression analysis was performed to evaluate the association between frailty and falls. Multivariable logistic regression analysis was performed to evaluate the composite outcome of 30-day readmission or 90-day death, with frailty, falls, and the interaction between frailty and falls as predictors; the analysis was adjusted for age, sex, race, and preoperative albumin level. RESULTS: In total, 7,661 patients were included in the analysis. Seventy-one (0.9%) had a fall, of whom eight (11%) were readmitted to the hospital within 30 days and seven (10%) died within 90 days. Higher MSK-FI score was associated with higher risk of falls (odds ratio [OR], 1.40 [95% confidence interval [CI], 1.21-1.59]). The risk of falls for a patient with an MSK-FI score of 1 was 0.6%, compared with 1.7% for a patient with an MSK-FI score of 4. Poor outcome was associated with frailty (OR, 1.07 [95% CI, 1.02-1.13]) but not with falls (OR, 1.17 [95% CI, 0.57-2.22]). DISCUSSION: Preoperative frailty is associated with risk of inpatient postoperative falls and with other adverse outcomes after surgery among older adults with cancer. Screening for frailty in the preoperative setting would enable healthcare institutions to implement interventions aimed at reducing the incidence of inpatient postoperative falls to reduce fall-related adverse events.

Geriatric Oncology Cognition and Communication (Geri-Onc CC): An interactive training for healthcare professionals.

INTRODUCTION: The number of older adults with cancer continues to increase. Many national and international organizations have called for the development of training opportunities for healthcare professionals (HCPs) to meet the unique needs of older adults with cancer and their families. MATERIALS AND METHODS: We developed and implemented the Geriatric Oncology Cognition and Communication (Geri-Onc CC) training program for HCPs of all disciplines. This program included a two-day, intensive didactic and experiential training followed by six bi-monthly booster videoconference calls. We describe the format and content of this training, the preliminary results of program evaluation, as well as changes in knowledge, self-efficacy, and attitudes toward older adults pre- to post-training. RESULTS: We describe data from the first six cohorts of HCPs who attended the training (n = 113). Participants rated the training highly favorably and reported that it met their training goals Mean = 4.8 (1-5 Scale). They also demonstrated a significant increase in their knowledge about geriatric oncology [(Pre-Mean = 6.2, standard deviation [SD] = 1.7; Post-Mean 6.8, SD = 1.6), p = 0.03] and self-efficacy in their ability to utilize the knowledge and skills they learned in the course [(Pre-Mean = 3.3, SD = 0.7; Post-Mean 4.5, SD = 0.4), p < 0.001]. There were no significant changes in attitudes toward older adults (p > 0.05), which were already very positive before the training. DISCUSSION: There is a strong need for training in geriatric oncology. We have demonstrated that implementing this training was feasible, highly regarded, and positively impacted knowledge and self-efficacy regarding utilization of the knowledge and skills learned in the training.

Development and implementation of an interdisciplinary telemedicine clinic for older patients with cancer-Preliminary data.

BACKGROUND: Frailty assessment is an important marker of the older adult's fitness for cancer treatment independent of age. Pretreatment geriatric assessment (GA) is associated with improved mortality and morbidity outcomes but must occur in a time sensitive manner to be useful for cancer treatment decision making. Unfortunately, time, resources and other constraints make GA difficult to perform in busy oncology clinics. We developed the Cancer and Aging Interdisciplinary Team (CAIT) clinic model to provide timely GA and treatment recommendations independent of patient's physical location. METHODS: The interdisciplinary CAIT clinic model was developed utilizing the surge in telemedicine during the COVID-19 pandemic. The core team consists of the patient's oncologist, geriatrician, registered nurse, pharmacist, and registered dietitian. The clinic's format is flexible, and the various assessments can be asynchronous. Patients choose the service method-in person, remotely, or hybrid. Based on GA outcomes, the geriatrician provides recommendations and arrange interventions. An assessment summary including life expectancy estimates and chemotoxicity risk calculator scores is conveyed to and discussed with the treating oncologist. Physician and patient satisfaction were assessed. RESULTS: Between May 2021 and June 2022, 50 patients from multiple physical locations were evaluated in the CAIT clinic. Sixty-eight percent was 80 years of age or older (range 67-99). All the evaluations were hybrid. The median days between receiving a referral and having the appointment was 8. GA detected multiple unidentified impairments. About half of the patients (52%) went on to receive chemotherapy (24% standard dose, 28% with dose modifications). The rest received radiation (20%), immune (12%) or hormonal (4%) therapies, 2% underwent surgery, 2% chose alternative medicine, 8% were placed under observation, and 6% enrolled in hospice care. Feedback was extremely positive. CONCLUSIONS: The successful development of the CAIT clinic model provides strong support for the potential dissemination across services and institutions.

Feasibility of a Geriatric Oncology Longitudinal End to End (GOLDEN) Program in a Tertiary Cancer Center in Singapore.

INTRODUCTION: In the National University Cancer Institute, Singapore (NCIS), 2 pilot programs providing (i) surgical prehabilitation before cancer surgery and (ii) geriatric oncology support for older adults planned for chemotherapy and/or radiotherapy were merged to form the Geriatric Oncology Longitudinal End to eNd (GOLDEN) program in 2019 to support patients from the time of their cancer diagnosis, through their treatment process, to cancer survivorship. METHODS AND MATERIALS: Older adults aged ≥65 years were enrolled in either surgical prehabilitation, the geriatric medical oncology (GO) arm, or both. All patients undergo a geriatric assessment. We assessed if patients had a change in treatment plans based on GOLDEN recommendations, and the impact on patient related outcomes. RESULTS: There were 777 patients enrolled in the GOLDEN program over 2 years; 569 (73%) were enrolled in surgical prehabilitation, 308 (40%) were enrolled in the GO arm, with 100 (12.8%) enrolled in both. 56.9% were females. Median age was 73. Lower gastrointestinal (51.2%) and hepatobiliary cancers (24.1%) were the most common cancer types. 43.4% were pre-frail and 11.7% were frail. Of the 308 patients in the GO arm, 86.0% had geriatric syndromes, while 60.7% had a change in their treatment plans based on GOLDEN recommendations. 31.5% reported an improved global health status, while 38.3% maintained their global health status. 226 (73%) responded that they had benefited from the GOLDEN. CONCLUSION: More than half of the population was either pre-frail or frail. Amongst those in the GO arm, the majority had geriatric syndromes and had a change in their treatment plans based on GOLDEN recommendations. Majority reported either improvement or maintenance in global health status, with most feeling they have benefited from the program. Further evaluation of the longitudinal geriatric hematology-oncology program for cancer-related outcomes and sustainability should be carried out.

The association between perioperative frailty and ability to complete a web-based geriatric assessment among older adults with cancer.

INTRODUCTION: The aim of this study was to assess the degree to which patient frailty is associated with both need for assistance and time required to complete the eRFA, a web-based GA tool. MATERIALS AND METHODS: We retrospectively identified patients who underwent surgery for cancer from 2015 to 2020, had a hospital length of stay ≥1 day, and completed the eRFA before surgery. Frailty was assessed using two methods: the MSK-FI (score 0-11) and the AGD (score 0-13). Time to complete the eRFA was automatically recorded by a web-based tool; assistance with eRFA completion was self-reported by the patient. RESULTS: In total, 3456 patients were included (median age, 78 years). Overall, 58% of surveys were completed without assistance, 30% were completed with assistance, and 12% were completed by someone other than the patient. Younger age (median age: without assistance, 77 years; with assistance, 80 years; completed by someone else, 80 years) and lower frailty score (median AGD: 4, 6, and 8, respectively; median MSK-FI: 2, 3, and 3, respectively) were associated with independency (all p < 0.001). Higher frailty score was associated with longer time to complete the eRFA (all nonlinear association p < 0.001). CONCLUSION: Frail patients are more likely to benefit from completion of GA to determine appropriate treatment. Given that not all cancer patients have a caregiver who can assist completing a digital questionnaire, innovative solutions are needed to help frail patients complete the eRFA without assistance.

Remaining Agile in the COVID-19 pandemic healthcare landscape - How we adopted a hybrid telemedicine Geriatric Oncology care model in an academic tertiary cancer center.

INTRODUCTION: The COVID-19 pandemic has impacted healthcare on an unprecedented scale, with healthcare resources being channeled into managing the devastating effects of the outbreak. Healthcare provision for vulnerable older adults has also been affected by lockdowns and suspension of selected medical services worldwide. In our tertiary cancer center, the National University Cancer Institute, Singapore (NCIS), our Geriatric Oncology (GO) service for older adults with cancer was halted for five months. In this paper, we describe the adoption of a hybrid telemedicine model by our GO service to continue care provision for older adults in the midst of the pandemic. MATERIALS AND METHODS: Comprehensive geriatric assessments (CGA) were done via telemedicine and virtual multidisciplinary discussions were held prior to the patients' clinic visits. A hybrid telemedicine consultation allowed geriatricians and oncologists, segregated in different sites during the pandemic, to provide a hybrid physical and video geriatric oncology consultation. Scheduled phone follow ups by GO nurses helped to monitor patients for treatment-related toxicities and geriatric syndromes. RESULTS: Two hundred fifty patients were enrolled in the program from July 2020 to August 2021. All were assessed with a CGA, with 240 receiving interventions in the one-stop clinic. The average amount of time spent per visit was shortened from four hours to two and a half hours with an average of three interventions on the same day, versus one previously. Of the patients who received interventions, 84.8% were satisfied with the hybrid telemedicine model and 80.8% of them had reported a maintained or improved quality of life after being enrolled in the program. DISCUSSION: Telemedicine has been widely adopted during the pandemic, but older adults with limited digital literacy may find it a challenge. Our hybrid telemedicine model has allowed us to continue to provide cancer care, identify issues brought about by social isolation, and render timely assistance. It has become imperative to adapt, prepare and plan for the challenges we may face amid the ongoing COVID-19 pandemic and similar future outbreaks. Only by doing so can we remain agile and resilient, to continue providing quality care to our older patients with cancer.

Feasibility of a geriatric comanagement (GERICO) pilot program for patients 75 and older undergoing radical cystectomy.

BACKGROUND: Retrospective studies have shown the beneficial impact of geriatric comanagement (GERICO) on perioperative outcomes of older adults with cancer. We prospectively assessed the feasibility of perioperative GERICO for older adults with bladder cancer undergoing radical cystectomy. METHODS: We conducted a pilot study wherein all patients 75 years and older undergoing radical cystectomy between October 2019 and November 2020 were referred to the Geriatric Service preoperatively. Feasibility was defined according to the percentage of patients who received preoperative evaluation by the Geriatrics Service, who were followed for more than 80% of their inpatient days and who had their surgery rescheduled for logistical reasons. Urology advanced practice provider (APP) satisfaction with the program was measured via an 11-item survey. RESULTS: Sixty-six eligible patients underwent radical cystectomy in the stated time frame; 59 (89%; 95% confidence interval [CI], 79-97%) were referred to the Geriatric Service for evaluation. The median age of patients who had geriatric comanagement was 79 years; 40 (68%) were male. Forty-one patients (69%) were visited on at least 80% of the days in which they were not in the intensive care unit. No surgeries were rescheduled for logistical reasons. Nine of the 12 urology APPs (75%) responded to the survey; all nine "somewhat" or "strongly" agreed with statements indicating satisfaction with the program. CONCLUSION: Despite the challenges of the COVID-19 pandemic, we showed that perioperative GERICO is feasible. Fully powered prospective randomized controlled trials should be conducted to assess GERICO's impact on perioperative outcomes of older adults with cancer.

Models of clinical care delivery for geriatric oncology in Canada and the United States: A survey of geriatric oncology care providers.

BACKGROUND: Geriatric assessment (GA) can help improve patient care and outcomes. There are increasing numbers of centres in Canada and the United States (U.S.) which provide geriatric oncology services, but the distribution and structure of these clinics is unclear. This study sought to identify and describe outpatient geriatric oncology clinics in Canada and the U.S. MATERIALS AND METHODS: A 30-question survey was administered electronically to clinics identified by the authors, through a search of the internet and from members of geriatric oncology community of practices in Canada and the U.S. Additional clinics were identified via a snowball method. Descriptive statistics were used. An exploratory analysis of factors associated with higher volumes of patients seen was done using a two sample t-test and one-way Analysis of Variance (ANOVA) for categorical variables and simple linear regression for continuous variables. RESULTS: Nineteen clinics (5 in Canada, 14 in U.S.) responded. Median duration in operation was 5 years (range < 1 to 25 years). More than a third (36.8%) were run by a geriatric oncologist alone, 36.8% had input from both geriatrics and oncology, while 21.1% had access to only one of the disciplines. The majority of clinics had nursing, social work and pharmacy involvement, with fewer having physiotherapy and dieticians. Just over half (53%) had an age cut-off for referral to their clinic. Fitness for treatment was the most common reason for referral. Clinics saw a median of 188 consults per year (range 0-1000). Clinics which have been operating longer (p = 0.002), those that took less time to complete a GA (p = 0.03), and those in which individual components of the GA were assessed by each discipline, rather than by one point person (p = 0.02), saw more new consults annually. CONCLUSION: There has been a growth of geriatric oncology services in Canada and the U.S. within the last five years. The composition and structure of clinics varies widely though the majority have both geriatrics and oncology expertise. Support to build more geriatric oncology services is needed to reach more older adults with cancer. This study provides some insight into ways to structure these clinics.

Geriatrics communication skills training program for oncology healthcare providers to improve the management of care for older adults with cancer.

Objective: We evaluated the feasibility, acceptability, and preliminary efficacy of a novel intervention, the Geriatric Communication Skills Training Program (Geriatric Comskil Training) for multidisciplinary healthcare providers (HCPs). Methods: Three 2-h modules comprised the training: Geriatrics 101, Cognitive Syndromes, and Shared Decision-Making. Modules consisted of didactic knowledge, exemplary videos, and experiential learning role plays with standardized patients. We collected pre- and post-training data from 11 HCPs (module evaluations, self-efficacy, communication skills uptake in interaction with standardized patients, perceived ageism) and 44 patients (perceived HCP empathy, satisfaction with HCP communication). Results: HCPs rated all modules high, with over 90% agreement on all course evaluation items assessing involvement, critical thinking, and reflectiveness, and significant improvements in self-efficacy. HCPs demonstrated an uptake in communication skills from pre- to post-training in agenda setting and overall skill use and reported promising trends towards lower ageism scores (d = 0.58). Promising trends in patient-reported HCP empathy (d = 0.39) and satisfaction with communication (d = 0.29) emerged from pre- to post-training. Conclusion: Continued efforts are needed to strengthen HCP education related to geriatric communication across the cancer continuum. Innovation: The Geriatric Comskil Training demonstrated feasibility, acceptability, and increases in self-efficacy and communication skills uptake for HCPs.

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.

Association of frailty with 90-day postoperative mortality & geriatric comanagement among older adults with cancer.

INTRODUCTION: Geriatric medical comanagement of older surgical patients with cancer is associated with lower 90-day postoperative mortality. Here, we investigate the hypothesis that this association varies on the basis of the degree of a patient's frailty. METHODS: Frailty was assessed using the Memorial Sloan Kettering Frailty Index. Our hypothesis was evaluated using two approaches, both adjusted for age, sex, American Society of Anesthesiologists Physical Status, preoperative albumin, operating room duration, and estimated blood loss. A logistic regression was performed with 90-day mortality as the outcome and geriatric comanagement, continuous Memorial Sloan Kettering Frailty Index, and an interaction term between these two variables as the primary predictors. We then categorized frailty into four levels and, within each level, performed logistic regression with geriatric comanagement as the primary predictor and 90-day mortality as the outcome. Finally, we extracted the effect size and used a meta-analytic approach to test for heterogeneity. RESULTS: Of 1687 patients aged ≥75 years who underwent elective cancer surgery with a length of stay of ≥1 day, 931 (55%) received comanagement; 31 patients (3.3%) who received comanagement died within 90 days, compared with 72 (9.5%) who did not. Ninety-day mortality was not statistically significantly different by degree of frailty in either analysis (interaction P = 0.4; test of heterogeneity P = 0.8). CONCLUSION: Geriatric comanagement is valuable for all older surgical patients, not just the frail, and should be provided to as large a portion of the older surgical population as possible. Further research should examine predictors of response to geriatric comanagement.

Prephase rituximab/prednisone therapy and aging-related, proinflammatory cytokine milieu in older, vulnerable patients with newly diagnosed diffuse large B-cell lymphoma.

Diffuse large B-cell lymphoma (DLBCL) predominantly affects older adults with suboptimal therapeutic outcomes due to increased treatment-related mortality and toxicities in vulnerable patients, clinically defined by geriatric impairments such as functional limitation, multimorbidity, or cognitive deficits. In this prospective pilot study, we evaluated a rituximab/prednisone prephase treatment strategy in 33 older, vulnerable patients with newly diagnosed DLBCL, defined by either age ≥70 years or age 60-70 years with Karnofsky performance scale (KPS) <80. A single dose of rituximab 375 mg/m2 between 3-10 days and oral prednisone for at least 5 days prior to the first dose of chemoimmunotherapy was administered. All patients completed prephase treatment and all but one commenced anthracycline-based chemoimmunotherapy. Only one early cycle death occurred. Toxicity events, defined by either unplanned hospitalization, unplanned dose reduction/delay, or chemotherapy discontinuation, occurred in 22 patients (67%). Sixteen patients (48%) experienced grade 3 or higher non-hematologic toxicities and/or grade 4 or higher hematologic toxicities. With a median follow-up of 4.4 years, both 5-year progression-free survival and overall survival were at 81% (95% confidence interval: 69-96). Importantly, we found that phenotypic impairments in basic and instrumental activities of daily living, physical function, mobility, KPS, and Cancer and Aging Research Group chemotherapy toxicity risk score were significantly associated with senescence-associated, proinflammatory cytokine milieu which was readily reversed with prephase treatment, potentially explaining its clinical effectiveness. Prephase therapy with rituximab/prednisone should be considered for all older, vulnerable DLBCL patients prior to curative intent, anthracycline-based chemoimmunotherapy. This trial was registered as clinicaltrials gov. Identifier: NCT89028394.

NCCN Guidelines® Insights: Older Adult Oncology, Version 1.2021.

The NCCN Guidelines for Older Adult Oncology address specific issues related to the management of cancer in older adults, including screening and comprehensive geriatric assessment (CGA), assessing the risks and benefits of treatment, preventing or decreasing complications from therapy, and managing patients deemed to be at high risk for treatment-related toxicity. CGA is a multidisciplinary, in-depth evaluation that assesses the objective health of the older adult while evaluating multiple domains, which may affect cancer prognosis and treatment choices. These NCCN Guidelines Insights focus on recent updates to the NCCN Guidelines providing specific practical framework for the use of CGA when evaluating older adults with cancer.

Updated recommendations regarding the management of older patients with breast cancer: a joint paper from the European Society of Breast Cancer Specialists (EUSOMA) and the International Society of Geriatric Oncology (SIOG).

Breast cancer is increasingly prevalent in older adults and is a substantial part of routine oncology practice. However, management of breast cancer in this population is challenging because the disease is highly heterogeneous and there is insufficient evidence specific to older adults. Decision making should not be driven by age alone but should involve geriatric assessments plus careful consideration of life expectancy, competing risks of mortality, and patient preferences. A multidisciplinary taskforce, including members of the European Society of Breast Cancer Specialists and International Society of Geriatric Oncology, gathered to expand and update the previous 2012 evidence-based recommendations for the management of breast cancer in older individuals with the endorsement of the European Cancer Organisation. These guidelines were expanded to include chemotherapy toxicity prediction calculators, cultural and social considerations, surveillance imaging, genetic screening, gene expression profiles, neoadjuvant systemic treatment options, bone-modifying drugs, targeted therapies, and supportive care. Recommendations on geriatric assessment, ductal carcinoma in situ, screening, primary endocrine therapy, surgery, radiotherapy, adjuvant systemic therapy, and secondary breast cancer were updated.