Quality indicators for evaluating cancer care in low-income and middle-income country settings: a multinational modified Delphi study.

This Policy Review sourced opinions from experts in cancer care across low-income and middle-income countries (LMICs) to build consensus around high-priority measures of care quality. A comprehensive list of quality indicators in medical, radiation, and surgical oncology was identified from systematic literature reviews. A modified Delphi study consisting of three 90-min workshops and two international electronic surveys integrating a global range of key clinical, policy, and research leaders was used to derive consensus on cancer quality indicators that would be both feasible to collect and were high priority for cancer care systems in LMICs. Workshop participants narrowed the list of 216 quality indicators from the literature review to 34 for inclusion in the subsequent surveys. Experts' responses to the surveys showed consensus around nine high-priority quality indicators for measuring the quality of hospital-based cancer care in LMICs. These quality indicators focus on important processes of care delivery from accurate diagnosis (eg, histologic diagnosis via biopsy and TNM staging) to adequate, timely, and appropriate treatment (eg, completion of radiotherapy and appropriate surgical intervention). The core indicators selected could be used to implement systems of feedback and quality improvement.

Concanamycin A counteracts HIV-1 Nef to enhance immune clearance of infected primary cells by cytotoxic T lymphocytes.

Nef is an HIV-encoded accessory protein that enhances pathogenicity by down-regulating major histocompatibility class I (MHC-I) expression to evade killing by cytotoxic T lymphocytes (CTLs). A potent Nef inhibitor that restores MHC-I is needed to promote immune-mediated clearance of HIV-infected cells. We discovered that the plecomacrolide family of natural products restored MHC-I to the surface of Nef-expressing primary cells with variable potency. Concanamycin A (CMA) counteracted Nef at subnanomolar concentrations that did not interfere with lysosomal acidification or degradation and were nontoxic in primary cell cultures. CMA specifically reversed Nef-mediated down-regulation of MHC-I, but not CD4, and cells treated with CMA showed reduced formation of the Nef:MHC-I:AP-1 complex required for MHC-I down-regulation. CMA restored expression of diverse allotypes of MHC-I in Nef-expressing cells and inhibited Nef alleles from divergent clades of HIV and simian immunodeficiency virus, including from primary patient isolates. Lastly, we found that restoration of MHC-I in HIV-infected cells was accompanied by enhanced CTL-mediated clearance of infected cells comparable to genetic deletion of Nef. Thus, we propose CMA as a lead compound for therapeutic inhibition of Nef to enhance immune-mediated clearance of HIV-infected cells.

A comparative evaluation of telehealth and direct assessment when screening for spasticity in residents of two long-term care facilities.

OBJECTIVE: To evaluate the performance of telehealth as a screening tool for spasticity compared to direct patient assessment in the long-term care setting. DESIGN: Cross-sectional, observational study. SETTING: Two long-term care facilities: a 140-bed veterans' home and a 44-bed state home for individuals with intellectual and developmental disabilities. SUBJECTS: Sixty-one adult residents of two long-term care facilities (aged 70.1 ± 16.2 years) were included in this analysis. Spasticity was identified in 43% of subjects (Modified Ashworth Scale rating mode = 2). Contributing diagnoses included traumatic brain injury, spinal cord injury, birth trauma, stroke, cerebral palsy, and multiple sclerosis. MAIN MEASURES: Movement disorders neurologists conducted in-person examinations to determine whether spasticity was present (reference standard) and also evaluated subjects with spasticity using the Modified Ashworth Scale. Telehealth screening examinations, facilitated by a bedside nurse, were conducted remotely by two teleneurologists using a three-question screening tool. Telehealth screening determinations of spasticity were compared to the reference standard determination to calculate sensitivity, specificity, and the area under the curve (AUC) in receiver operating characteristics. Teleneurologist agreement was evaluated using Cohen's kappa. RESULTS: Teleneurologist 1 had a specificity of 89% and sensitivity of 65% to identify the likely presence of spasticity (n = 61; AUC = 0.770). Teleneurologist 2 showed 100% specificity and 82% sensitivity (n = 16; AUC = 0.909). There was almost perfect agreement between the two examiners at 94% (kappa = 0.875, 95% CI: 0.640-1.000). CONCLUSION: Telehealth may provide a useful, efficient method of identifying residents of long-term care facilities that likely need referral for spasticity evaluation.

Teleneurology service provided via tablet technology: 3-year outcomes and physician satisfaction.

INTRODUCTION: This study aimed to demonstrate that teleneurology consultations conducted via tablet technology are an efficient and cost-effective means of managing acute neurologic emergencies at community-based hospitals and that utilizing such technology yields high community physician satisfaction. METHOD: During a 39-month period, Vanderbilt University Medical Center in Tennessee USA, provided teleneurology services to 10 community-based hospitals that lacked adequate neurology coverage. Hospitalists at one community-based hospital were not comfortable treating any patient with a neurologic symptom, resulting in 100% of those patients being transferred. This facility now retains more than 60% of neurology patients. For less than US$1200, these hospitals were able to meet the only capital expenditure required to launch this service: the purchase of handheld tablet computers. Real-time teleneurology consultations were conducted via tablet using two-way video conferencing, radiologic image sharing, and medical record documentation. Community physicians were regularly surveyed to assess satisfaction. RESULTS: From February 2014 to May 2017, 3626 teleneurology consultations were conducted. Community physicians, in partnership with neurologists, successfully managed 87% of patients at the community-based hospital. Only 13% of patients required transfer to another facility for a higher level of care. The most common diagnoses included stroke (34%), seizure (11%), and headache/migraine (6%). The average time for the neurologist to answer a request for consultation page and connect with the community physician was 10.6 minutes. Ninety-one percent of community physicians were satisfied or somewhat satisfied with the overall service. CONCLUSION: In the assessment of neurology patients, tablets are a more cost-effective alternative to traditional telehealth technologies. The devices promote efficiency in consultations through ease of use and low transfer rates, and survey results indicate community physician satisfaction.

Risk-conscious correction of batch effects: maximising information extraction from high-throughput genomic datasets.

BACKGROUND: Batch effects are a persistent and pervasive form of measurement noise which undermine the scientific utility of high-throughput genomic datasets. At their most benign, they reduce the power of statistical tests resulting in actual effects going unidentified. At their worst, they constitute confounds and render datasets useless. Attempting to remove batch effects will result in some of the biologically meaningful component of the measurement (i.e. signal) being lost. We present and benchmark a novel technique, called Harman. Harman maximises the removal of batch noise with the constraint that the risk of also losing biologically meaningful component of the measurement is kept to a fraction which is set by the user. RESULTS: Analyses of three independent publically available datasets reveal that Harman removes more batch noise and preserves more signal at the same time, than the current leading technique. Results also show that Harman is able to identify and remove batch effects no matter what their relative size compared to other sources of variation in the dataset. Of particular advantage for meta-analyses and data integration is Harman's superior consistency in achieving comparable noise suppression - signal preservation trade-offs across multiple datasets, with differing number of treatments, replicates and processing batches. CONCLUSION: Harman's ability to better remove batch noise, and better preserve biologically meaningful signal simultaneously within a single study, and maintain the user-set trade-off between batch noise rejection and signal preservation across different studies makes it an effective alternative method to deal with batch effects in high-throughput genomic datasets. Harman is flexible in terms of the data types it can process. It is available publically as an R package ( https://bioconductor.org/packages/release/bioc/html/Harman.html ), as well as a compiled Matlab package ( http://www.bioinformatics.csiro.au/harman/ ) which does not require a Matlab license to run.

Long-term exposure to commercially available sunscreens containing nanoparticles of TiO2 and ZnO revealed no biological impact in a hairless mouse model.

BACKGROUND: The application of sunscreen is a critical component of a sun-safe strategy, however the possibility of unexpected, adverse outcomes resulting from long-term use of sunscreens containing nanoparticles of titanium dioxide (TiO2) and zinc oxide (ZnO) has not yet been examined. Here, immune-competent hairless mice were exposed over a 36-week period to weekly topical applications of sunscreens containing nanoparticles of ZnO or TiO2, or no metal oxide nanoparticles, with or without subsequent exposure to ultraviolet radiation (UVR). Control groups received no sunscreen applications, with or without UVR. RESULTS: Mice exposed to UVR in the absence of sunscreen developed statistically significant incidences of histologically-diagnosed malignant and benign skin neoplasms, whereas no statistically significant adverse biological outcomes were found in mice treated with the sunscreens containing ZnO or TiO2 nanoparticles. Elevated levels of Ti were detected in the livers of mice treated with sunscreen containing TiO2 nanoparticles compared to untreated control, but total Zn concentrations did not significantly alter in any major organs except for the skin of mice treated with ZnO sunscreen. Exposure to UVR did not have a significant impact on examined tissue concentrations of Zn or Ti. Few to no transcriptional changes were found in ZnO or TiO2-treated groups, but mice treated with the sunscreen containing only organic filters showed substantial gene disregulation. CONCLUSIONS: Taken together with previous work, this long-term study provided no basis to avoid the use of sunscreens containing metal oxide nanoparticles.

LipiD-QuanT: a novel method to quantify lipid accumulation in live cells.

Lipid droplets (LDs) are the main storage organelles for triglycerides. Elucidation of lipid accumulation mechanisms and metabolism are essential to understand obesity and associated diseases. Adipogenesis has been well studied in murine 3T3-L1 and human Simpson-Golabi-Behmel syndrome (SGBS) preadipocyte cell lines. However, most techniques for measuring LD accumulation are either not quantitative or can be destructive to samples. Here, we describe a novel, label-free LD quantification technique (LipiD-QuanT) to monitor lipid dynamics based on automated image analysis of phase contrast microscopy images acquired during in vitro human adipogenesis. We have applied LipiD-QuanT to measure LD accumulation during differentiation of SGBS cells. We demonstrate that LipiD-QuanT is a robust, nondestructive, time- and cost-effective method compared with other triglyceride accumulation assays based on enzymatic digest or lipophilic staining. Further, we applied LipiD-QuanT to measure the effect of four potential pro- or antiobesogenic substances: DHA, rosiglitazone, elevated levels of D-glucose, and zinc oxide nanoparticles. Our results revealed that 2 µmol/l rosiglitazone treatment during adipogenesis reduced lipid production and caused a negative shift in LD diameter size distribution, but the other treatments showed no effect under the conditions used here.

Impact of Medical Oncology-Focused Quality Programs on Cancer Care Around the World.

Quality cancer care is efficient, accessible, coordinated, and evidence-based. Recognizing the necessary key components, development of pathways and guidelines to incorporate these key domains, and finally respectful adaptation to cultural differences can ensure that cancer care globally is of the highest quality. This quality care should be judged not only on how it optimizes health outcomes for patients, but also its impact on the care providers and the global community.

Quality indicators in surgical oncology: systematic review of measures used to compare quality across hospitals.

BACKGROUND: Measurement and reporting of quality indicators at the hospital level has been shown to improve outcomes and support patient choice. Although there are many studies validating individual quality indicators, there has been no systematic approach to understanding what quality indicators exist for surgical oncology and no standardization for their use. The aim of this study was to review quality indicators used to assess variation in quality in surgical oncology care across hospitals or regions. It also sought to describe the aims of these studies and what, if any, feedback was offered to the analysed groups. METHODS: A literature search was performed to identify studies published between 1 January 2000 and 23 October 2023 that applied surgical quality indicators to detect variation in cancer care at the hospital or regional level. RESULTS: A total of 89 studies assessed 91 unique quality indicators that fell into the following Donabedian domains: process indicators (58; 64%); outcome indicators (26; 29%); structure indicators (6; 7%); and structure and outcome indicators (1; 1%). Purposes of evaluating variation included: identifying outliers (43; 48%); comparing centres with a benchmark (14; 16%); and supplying evidence of practice variation (29; 33%). Only 23 studies (26%) reported providing the results of their analyses back to those supplying data. CONCLUSION: Comparisons of quality in surgical oncology within and among hospitals and regions have been undertaken in high-income countries. Quality indicators tended to be process measures and reporting focused on identifying outlying hospitals. Few studies offered feedback to data suppliers.

Surface coatings of ZnO nanoparticles mitigate differentially a host of transcriptional, protein and signalling responses in primary human olfactory cells.

BACKGROUND: Inhaled nanoparticles have been reported in some instances to translocate from the nostril to the olfactory bulb in exposed rats. In close proximity to the olfactory bulb is the olfactory mucosa, within which resides a niche of multipotent cells. Cells isolated from this area may provide a relevant in vitro system to investigate potential effects of workplace exposure to inhaled zinc oxide nanoparticles. METHODS: Four types of commercially-available zinc oxide (ZnO) nanoparticles, two coated and two uncoated, were examined for their effects on primary human cells cultured from the olfactory mucosa. Human olfactory neurosphere-derived (hONS) cells from healthy adult donors were analyzed for modulation of cytokine levels, activation of intracellular signalling pathways, changes in gene-expression patterns across the whole genome, and compromised cellular function over a 24 h period following exposure to the nanoparticles suspended in cell culture medium. RESULTS: ZnO nanoparticle toxicity in hONS cells was mediated through a battery of mechanisms largely related to cell stress, inflammatory response and apoptosis, but not activation of mechanisms that repair damaged DNA. Surface coatings on the ZnO nanoparticles mitigated these cellular responses to varying degrees. CONCLUSIONS: The results indicate that care should be taken in the workplace to minimize generation of, and exposure to, aerosols of uncoated ZnO nanoparticles, given the adverse responses reported here using multipotent cells derived from the olfactory mucosa.

Improving access to imaging availability in otology clinic.

RATIONALE: Radiologic imaging is an essential component in the workup of many patients with neuro-otologic conditions. However, patients often present for consultation with a neurotologist without the imaging that they have already undergone as part of their workup by a referring clinician. This disconnect causes frustration for clinicians and possible delays in care for patients. Anecdotally, clinicians felt that patients who had contact with clinic coordinators before their appointment were more likely to have their prior imaging available for review at the time of their initial consultation. AIMS AND OBJECTIVES: We aimed to increase the rate at which new patients brought their prior imaging to their initial consultation to at least 80% by improving previsit communication with patients and referring providers. METHODS: Key stakeholders identified pain points in the flow of information from patients' outside facility workups. We then used the Plan-Do-Study-Act quality improvement framework to develop, implement and iterate on two interventions intended to improve communication with patients, referring clinics and outside imaging centres. Chart review was used to assess the proportion of patients with imaging available for review at the time of initial consultation and a short satisfaction survey was sent to attending neurotologists in the pre and postintervention periods. RESULTS: Before any interventions, 56.5% of typical new patients who reported having prior imaging had that imaging available for review at the time of their initial consultation. Following our interventions, this percentage increased to 73.5% and then 80.9% of new patients, respectively. Additionally, physicians reported improved satisfaction in several areas and spent less time reviewing imaging outside of clinic visits after our interventions. CONCLUSIONS: Improved communication and tracking of image receipt in clinics receiving many referrals saves physicians' time, reduces frustration and cuts down on the overall administrative burden following patients' appointments.

Quality indicators for systemic anticancer therapy services: a systematic review of metrics used to compare quality across healthcare facilities.

PURPOSE: The number of systemic anticancer therapy (SACT) regimens has expanded rapidly over the last decade. There is a need to ensure quality of SACT delivery across cancer services and systems in different resource settings to reduce morbidity, mortality, and detrimental economic impact at individual and systems level. Existing literature on SACT focuses on treatment efficacy with few studies on quality or how SACT is delivered within routine care in comparison to radiation and surgical oncology. METHODS: Systematic review was conducted following PRISMA guidelines. EMBASE and MEDLINE were searched and handsearching was undertaken to identify literature on existing quality indicators (QIs) that detect meaningful variations in the quality of SACT delivery across different healthcare facilities, regions, or countries. Data extraction was undertaken by two independent reviewers. RESULTS: This review identified 63 distinct QIs from 15 papers. The majority were process QIs (n = 55, 87.3%) relating to appropriateness of treatment and guideline adherence (n = 28, 44.4%). There were few outcome QIs (n = 7, 11.1%) and only one structural QI (n = 1, 1.6%). Included studies solely focused on breast, colorectal, lung, and skin cancer. All but one studies were conducted in high-income countries. CONCLUSIONS: The results of this review highlight a significant lack of research on SACT QIs particularly those appropriate for resource-constrained settings in low- and middle-income countries. This review should form the basis for future work in transforming performance measurement of SACT provision, through context-specific QI SACT development, validation, and implementation.

Septal Perforation Repair Using a Temporoparietal Fascia and Polydioxanone Plate Construct: A Multi-Institutional Analysis.

Background: Nasal septal perforations (NSPs) are notoriously difficult to fix and closure can paradoxically lead to worsening of symptoms, prompting numerous techniques for repair including temporoparietal fascia (TPF)-polydioxanone (PDS) plate interposition grafting. Objectives: To compare rates of NSP closure with TPF-PDS interposition grafting among a variety of institutions with diverse environmental influences and patient-specific factors. Methods: Retrospective review of patients undergoing TPF-PDS interposition grafting at seven different U.S. institutions over 5 years. Outcomes include closure rate, self-reported symptom improvement, change in Nasal Obstruction Symptomatic Evaluation (NOSE) score, and postoperative complications. Results: Sixty-two patients (39 female) with a mean age of 41.5 years were included. Most common perforation location was anterior (53%), and average size was 1.70 cm2. NSP closure with symptomatic improvement was achieved in 95% of participants. Postoperative NOSE scores decreased on average by 42 points. Residual crusting occurred in 29% of patients, independent of external factors. Conclusions: TPF-PDS interposition grafting is highly effective for NSP repair in a wide variety of settings, and NOSE scores correspond well with patient-reported outcomes.

Racial and Ethnic Disparities in Colorectal Cancer Screening and Outcomes.

Colorectal cancer (CRC) incidence and mortality vary by race and ethnicity in the United States, with the highest burden of disease among Black and American Indian/Alaska Native individuals. There are multiple contributors to these disparities, including lifestyle and environmental risk factors that result from adverse social determinants of health and are more prevalent in minority and medically underserved communities. In addition, participation in CRC screening, which is demonstrated to reduce CRC-related mortality, is lower in all racial/ethnic minority groups than for White individuals. Evidence-based efforts to reduce CRC disparities aim to increase screening uptake via multicomponent and culturally tailored interventions.

Knowledge and attitudes of lower Michigan primary care physicians towards dietary interventions: A cross-sectional survey.

Background: Dietary interventions are first-line therapies for the prevention and management of many chronic diseases, yet primary care physicians prescribe these interventions infrequently. Objectives: This study investigates primary care physicians' current knowledge and opinions regarding the delivery of dietary interventions. This work aims to identify modifiable barriers to prescribing dietary interventions to prevent and treat diet-related diseases. Methods: We designed and fielded an anonymous, cross-sectional survey of faculty and resident physicians across the Internal Medicine, Family Medicine, and Pediatrics departments in three academic and community hospitals in lower Michigan. Data were collected between January 15 and April 15, 2019. Self-rated knowledge and attitudes were measured on a 5-point Likert scale. Objective scores were calculated for each question as percentage answered correctly among all respondents. Objective knowledge scores were compared based on participants' years in practice. Results: Response rate was 23% (356 responses). The sample was 62.3% female and 75.3% non-Hispanic White, and 56.7% were age 40 or younger. Average objective knowledge score was 70.3% (±17.2) correct. Mean self-rated knowledge score was 2.51 (±0.96) on a scale of 1(Poor) - 5(Excellent). Overall agreement with a statement of importance of dietary interventions was 3.99 (±0.40) on a scale of 1 (strongly disagree) to 5 (strongly agree). A majority (91.7%) of respondents indicated they would like more opportunities to learn about the evidence supporting dietary interventions. Conclusions: Physicians desire to incorporate dietary interventions into their practice. Findings encourage the development of educational strategies to support dietary intervention use among primary care physicians.

Comparative Analysis of Recidivism After Endoscopic and Microscopic-Based Cholesteatoma Resection.

OBJECTIVES: 1) To analyze outcomes of cholesteatoma resection utilizing postauricular microscopic and endoscopic ear surgery (EES) approaches.2) To analyze predictors of residual and recurrent cholesteatoma. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Three hundred seventy-five adult and pediatric patients with cholesteatoma (2012-2017). INTERVENTIONS: Patients underwent surgical resection of cholesteatoma with EES (n = 122) and microscopic (n = 253) approach. MAIN OUTCOME MEASURES: Residual cholesteatoma, recurrent cholesteatoma, second-look procedures. RESULTS: The endoscopic cohort included significantly more pediatric cases (p = 0.0008). There was no difference in laterality, gender distribution, congenital or acquired cholesteatoma, and revision cases between the cohorts. Out of 122 EES cases, 16 (13%) developed residual disease and 9 (7%) developed recurrent disease. Of 253 microscopic cases 16 (6%) developed residual disease while 11 (4%) developed recurrent disease. Second look procedures were more commonly used in EES cohort (50 vs 18%). Single predictor analysis revealed 12 predictors for residual disease and 5 for recurrent disease. Multivariable model identified pediatric case distribution and higher disease stage to be significant predictors for both residual (p = 0.04, 0.007) and recurrent disease (p = 0.02, 0.01). EES approach was associated with a weak significance for residual disease (p = 0.049) but not recurrent disease (p = 0.34). CONCLUSIONS: EES approach for cholesteatoma resection seems to perform similarly to microscopic approach with no difference in rates of recurrent disease. However, it is associated with a higher rate of residual disease; this may be a reflection of a greater rate of second look procedures done in this group.

Durability and inflammogenic impact of carbon nanotubes compared with asbestos fibres.

BACKGROUND: It has been suggested that carbon nanotubes might conform to the fibre pathogenicity paradigm that explains the toxicities of asbestos and other fibres on a continuum based on length, aspect ratio and biopersistence. Some types of carbon nanotubes satisfy the first two aspects of the fibre paradigm but only recently has their biopersistence begun to be investigated. Biopersistence is complex and requires in vivo testing and analysis. However durability, the chemical mimicking of the process of fibre dissolution using in vitro treatment, is closely related to biopersistence and more readily determined. Here, we describe an experimental process to determine the durability of four types of carbon nanotubes in simulated biological fluid (Gambles solution), and their subsequent pathogenicity in vivo using a mouse model sensitive to inflammogenic effects of fibres. The in vitro and in vivo results were compared with well-characterised glass wool and asbestos fibre controls. RESULTS: After incubation for up to 24 weeks in Gambles solution, our control fibres were recovered at percentages consistent with their known in vitro durabilities and/or in vivo persistence, and three out of the four types of carbon nanotubes tested (single-walled (CNTSW) and multi-walled (CNTTANG2, CNTSPIN)) showed no, or minimal, loss of mass or change in fibre length or morphology when examined by electron microscopy. However, the fourth type [multi-walled (CNTLONG1)] lost 30% of its original mass within the first three weeks of incubation, after which there was no further loss. Electron microscopy of CNTLONG1 samples incubated for 10 weeks confirmed that the proportion of long fibres had decreased compared to samples briefly exposed to the Gambles solution. This loss of mass and fibre shortening was accompanied by a loss of pathogenicity when injected into the peritoneal cavities of C57Bl/6 mice compared to fibres incubated briefly. CNTSW did not elicit an inflammogenic effect in the peritoneal cavity assay used here. CONCLUSIONS: These results support the view that carbon nanotubes are generally durable but may be subject to bio-modification in a sample-specific manner. They also suggest that pristine carbon nanotubes, either individually or in rope-like aggregates of sufficient length and aspect ratio, can induce asbestos-like responses in mice, but that the effect may be mitigated for certain types that are less durable in biological systems. Results indicate that durable carbon nanotubes that are either short or form tightly bundled aggregates with no isolated long fibres are less inflammogenic in fibre-specific assays.

Patient-reported distress and age-related stress biomarkers among colorectal cancer patients.

OBJECTIVE: Distress among cancer patients has been broadly accepted as an important indicator of well-being but has not been well studied. We investigated patient characteristics associated with high distress levels as well as correlations among measures of patient-reported distress and "objective" stress-related biomarkers among colorectal cancer patients. METHODS: In total, 238 patients with colon or rectal cancer completed surveys including the Distress Thermometer, Problem List, and the Hospital Anxiety and Depression Scale. We abstracted demographic and clinical information from patient charts and determined salivary cortisol level and imaging-based sarcopenia. We evaluated associations between patient characteristics (demographics, clinical factors, and psychosocial and physical measures) and three outcomes (patient-reported distress, cortisol, and sarcopenia) with Spearman's rank correlations and multivariable linear regression. The potential moderating effect of age was separately investigated by including an interaction term in the regression models. RESULTS: Patient-reported distress was associated with gender (median: women 5.0, men 3.0, p < 0.001), partnered status (single 5.0, partnered 4.0, p = 0.018), and cancer type (rectal 5.0, colon 4.0, p = 0.026); these effects varied with patient age. Cortisol level was associated with "emotional problems" (ρ = 0.34, p = 0.030), anxiety (ρ = 0.46, p = 0.006), and depression (ρ = 0.54, p = 0.001) among younger patients. We found no significant associations between patient-reported distress, salivary cortisol, and sarcopenia. CONCLUSIONS: We found that young, single patients reported high levels of distress compared to other patient groups. Salivary cortisol may have limited value as a cancer-related stress biomarker among younger patients, based on association with some psychosocial measures. Stress biomarkers may not be more clinically useful than patient-reported measures in assessing distress among colorectal cancer patients.