Preoperative glucose in surgical oncology patient is not associated with postoperative outcomes after adjustment for frailty.

BACKGROUND: Observational studies have shown associations between even small elevations in preoperative glucose and poorer outcomes, including increased length of stay (LOS) and higher mortality. This has led to calls for aggressive glycemic control in the preoperative period, including delay of treatment until glucose is reduced. However, it is not known whether there is a direct causal effect of blood glucose or whether adverse outcomes result from overall poorer health in patients with higher glucose. METHODS: Analysis was performed using a retrospective database of patients aged 65 and older who underwent cancer surgery. The last measured preoperative glucose was the exposure variable. The primary outcome was extended LOS (>4 days). Secondary outcomes included mortality, acute kidney injury (AKI), major postoperative complications during the admission period, and readmission within 30 days. The primary analysis was a logistic regression with prespecified covariates: age, sex, surgical service, and the Memorial Sloan Kettering-Frailty Index. In an exploratory analysis, lasso regression was used to select covariates from a list of 4160 candidate variables. RESULTS: This study included 3796 patients with a median preoperative glucose of 104 mg/dL (interquartile range: 93-125). Higher preoperative glucose was univariately associated with increased odds of LOS > 4 days (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.22-1.73), with similar results for AKI, readmission, and mortality. Adjustment for confounders eliminated these associations for LOS (OR: 0.97 [95% CI: 0.80-1.18]) and attenuated all other glucose-outcome associations. Lasso regression gave comparable results to the primary analysis. Using the upper bound of the respective 95% confidence interval, we estimated that, at best, successful reduction of elevated preoperative glucose would reduce the risk of LOS > 4 days, 30-day major complication, and 30-day mortality by 4%, 0.5%, and 1.3%, respectively. CONCLUSIONS: Poor outcomes following cancer surgery in older adults with elevated glucose are most likely related to poorer overall health in these patients rather than a direct causal effect of glucose. Aggressive glycemic management in the preoperative period has very limited potential benefits and is therefore unwarranted.

Real-world Impact of Age at Diagnosis on Treatment Patterns and Survival Outcomes of Patients with Metastatic Pancreatic Ductal Adenocarcinoma.

BACKGROUND: Sixty-eight percent of patients with pancreatic ductal adenocarcinoma (PDAC) are 65 years and older. Older adults are under-represented in clinical trials and their care is complicated with multiple age-related conditions. Research suggests that older patients can experience meaningful responses to treatment for PDAC. The objective of this study was to evaluate the characteristics, rate of treatment, and survival outcomes of patients with metastatic PDAC (mPDAC) based on age at diagnosis. MATERIALS AND METHODS: Data were extracted for patients diagnosed with mPDAC between January 1, 2015, and March 31, 2020, from the Flatiron Health database. Patients were stratified into 3 age groups: <70 years old, 70-79 years, and ≥80 years. The proportion of patients who received first-line therapy, the types of regimens received in the metastatic setting, overall survival (OS) from the start of treatment were evaluated. RESULTS: Of the 8382 patients included, 71.3% (n = 5973) received treatment. Among patients who received treatment 55.5% (n = 3313) were aged <70 years at diagnosis, 33.0% (n = 1972) were 70-79 years, and 11.5% (n = 688) were ≥80 years. Patients ≥80 years of age were more likely to receive gemcitabine monotherapy and less likely to receive FOLFIRINOX. Among first-line treated patients, median OS significantly decreased with age. However, when comparing patients treated with the same first-line regimen, no significant differences in median OS were observed by age. CONCLUSIONS: This study highlights that older adults with mPDAC can benefit substantially by receiving appropriate levels of treatment.

Differences in urban and suburban/rural settings regarding care provision and barriers of cancer care for older adults during COVID-19.

PURPOSE: Care for older adults with cancer became more challenging during the COVID-19 pandemic, particularly in urban hotspots. This study examined the potential differences in healthcare providers' provision of as well as barriers to cancer care for older adults with cancer between urban and suburban/rural settings. METHODS: Members of the Advocacy Committee of the Cancer and Aging Research Group, with the Association of Community Cancer Centers, surveyed multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Respondents were recruited through organizational listservs, email blasts, and social media messages. Descriptive statistics and chi-square tests were used. RESULTS: Complete data was available from 271 respondents (urban (n = 144), suburban/rural (n = 127)). Most respondents were social workers (42, 44%) or medical doctors/advanced practice providers (34, 13%) in urban and suburban/rural settings, respectively. Twenty-four percent and 32.4% of urban-based providers reported "strongly considering" treatment delays among adults aged 76-85 and > 85, respectively, compared to 13% and 15.4% of suburban/rural providers (Ps = 0.048, 0.013). More urban-based providers reported they were inclined to prioritize treatment for younger adults over older adults than suburban/rural providers (10.4% vs. 3.1%, p = 0.04) during the pandemic. The top concerns reported were similar between the groups and related to patient safety, treatment delays, personal safety, and healthcare provider mental health. CONCLUSION: These findings demonstrate location-based differences in providers' attitudes regarding care provision for older adults with cancer during the COVID-19 pandemic.

Electronic Rapid Fitness Assessment Identifies Factors Associated with Adverse Early Postoperative Outcomes following Radical Cystectomy.

PURPOSE: Frailty is associated with adverse outcomes following radical cystectomy. Prospective tools to identify factors affecting outcomes are needed. We describe a novel electronic rapid fitness assessment to evaluate geriatric patients undergoing radical cystectomy. MATERIALS AND METHODS: Before undergoing radical cystectomy between February 2015 and February 2018, 80 patients older than age 75 years completed the electronic rapid fitness assessment and were perioperatively comanaged by the Geriatrics Service. Physical function and cognitive function over 12 domains were evaluated and an accumulated geriatric deficit score was compiled. Hospital length of stay, discharge disposition, unplanned intensive care unit admissions, urgent care visits, readmissions, complications and deaths were assessed. RESULTS: A total of 65 patients who underwent radical cystectomy for bladder cancer without concomitant procedures completed the assessment. Median age was 80 (77, 84) years and 52 (80%) were male. A higher proportion of patients with intensive care unit admission, urgent care visit and major complications had impairments identified within electronic rapid fitness assessment domains, including Timed Up and Go. Readmission rates were similar between patients with or without deficits identified. Higher accumulated geriatric deficit score was significantly associated with intensive care unit admission (p=0.035), death within 90 days (p=0.037) and discharge to other than home (p=0.0002). CONCLUSIONS: We demonstrated the feasibility of assessing fitness in patients older than 75 years undergoing radical cystectomy using a novel electronic fitness tool. Physical limitations and overall impairment corresponded to higher intensive care unit admission rates and adverse postoperative outcomes. Larger studies in less resourced environments are required to validate these findings.

Assessment of Frailty Can Guide Decision Making for Utilization of Sentinel Lymph Node Biopsy in Patients with Thick Melanoma.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is often omitted in selected patients with advanced primary melanoma, although the justification/criteria for omission have been debated. OBJECTIVE: We sought to determine whether assessment of frailty could serve as an objective marker to guide selection for SLNB in patients with advanced primary melanoma. METHODS: Patients presenting with clinical stage IIC (ulcerated, > 4 mm Breslow thickness) cutaneous melanoma from January 1999 through June 2019 were included. Frailty was assessed using the Memorial Sloan Kettering Frailty Index (MSK FI), a composite score of functional status and medical comorbidities. Five-year melanoma-specific survival (MSS) and overall survival (OS) were estimated using Cox regression, and predictors of OS were identified using competing risk models. RESULTS: MSS did not differ between patients who did (n = 451) or did not undergo SLNB (n = 179) [63.2% vs. 65.0%, p = 0.14]; however, omission of SLNB was associated with decreased 5-year OS (29% vs. 44%, p < 0.001). In a multivariable competing risk model, selection for SLNB omission was an independent predictor of death from non-melanoma causes (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.2-2.3, p < 0.001). After incorporation of the MSK FI score into the multivariable model in this subset, MSK FI (HR 2.4, 95% CI 1.5-4.1, p < 0.001), but not SLNB omission, was an independent predictor of poorer OS. CONCLUSION: We observed worse OS in patients with thick melanoma selected not to undergo SLNB, which was attributed to death due to non-melanoma causes. Formal assessment of frailty may provide an objective prognostic measure to guide selective use of SLNB in these patients.

Frailty based on the memorial Sloan Kettering Frailty Index is associated with surgical decision making, clinical trial participation, and overall survival among older women with ovarian cancer.

OBJECTIVES: To determine whether the Memorial Sloan Kettering Frailty Index (MSK-FI) is associated with decision-making in older women surgically treated for advanced-stage ovarian cancer. METHODS: We retrospectively applied the MSK-FI to women ≥70 years with newly diagnosed advanced-stage ovarian cancer surgically treated at our institution from 01/2001-05/2017. MSK-FI components, including 10 comorbidities and functional assessment, were extracted from medical records. The MSK-FI ranges from 0 to 11, with higher scores indicating greater frailty. The primary outcome was the association between frailty and rate of primary debulking surgery (PDS), for which a multivariable logistic regression was used, adjusted for stage and histology. RESULTS: We identified 430 women treated with PDS (n = 231, 54%) or neoadjuvant chemotherapy/interval debulking (n = 199, 46%) with complete data. MSK-FI score distribution was: "0", 95 patients (22%); "1", 172 (40%); "2", 89 (21%); and "3+", 74 (17%). More-frail patients were less likely to have undergone PDS (OR for a unit increase of MSK-FI: 0.64; 95%CI, 0.53-0.77; p < 0.0001). Grade 3+ complications and unintended intensive care admission occurred in 40 (9%) and 38 (9%) women, respectively, but were not associated with frailty (OR 1.21; 95%CI, 0.96-1.52; p = 0.11). More-frail patients were more likely to delay postoperative chemotherapy (non-linear association p = 0.009) and less likely to enroll in research (OR 0.84; 95%CI, 0.70-1.00; p = 0.049). Greater frailty was associated with poorer overall survival (HR 1.16; 95%CI, 1.05-1.30; p = 0.005). CONCLUSIONS: Frailty, as calculated by the MSK-FI, is strongly associated with treatment approach in older women with advanced ovarian cancer, suggesting objective or subjective correlates of the MSK-FI influence decision-making.

Is screening for psychosocial risk factors associated with mental health care in older adults with cancer undergoing surgery?

BACKGROUND: Surgery is a notable stressor for older adults with cancer, who often are medically and psychosocially complex. The current study examined rates of preoperative psychosocial risk factors in older adults with cancer who were undergoing elective surgery and the relationship between these risk factors and the provision of mental health services during the postoperative hospitalization. METHODS: A total of 1211 patients aged ≥75 years who were referred to the geriatrics service at a comprehensive cancer center were enrolled. Patients underwent elective surgery with a length of stay of ≥3 days and were followed for at least 30 days after surgery. A comprehensive geriatric assessment was administered as part of routine preoperative care. Bivariate relationships between demographic and surgical characteristics and the preoperative comprehensive geriatric assessment and the receipt of mental health services during the postoperative hospitalization period were examined. Characteristics with bivariate relationships that were significant at the level of P < .10 were entered into a multivariable regression predicting postoperative mental health service use. RESULTS: Approximately one-fifth of the total sample (20.6%) received postoperative mental health services. In multivariable analyses, high distress (P = .007) and poor social support (P = .02) were found to be associated with a greater likelihood of the receipt of mental health services. Of those patients with high distress and poor social support, only approximately one-quarter (24.6%-25.5%) received mental health care. CONCLUSIONS: Distressed older adults and those with low levels of support preoperatively were found to be more likely to receive mental health services after surgery. Nevertheless, less than one-third of these patients received inpatient postoperative mental health care, indicating that barriers to translating screening into the provision of psychosocial services remain.

Geriatric co-management leads to safely performed cytoreductive surgery in older women with advanced stage ovarian cancer treated at a tertiary care cancer center.

OBJECTIVE: To assess fitness and outcomes in older women undergoing cytoreductive surgery for advanced ovarian cancer (OC). METHODS: A prospective study of OC patients referred to Geriatrics Clinic for preoperative evaluation. All completed the electronic Rapid Fitness Assessment (eRFA) and were followed by Geriatrics Service during inpatient postoperative course, co-managed by Surgical Service. Outcomes were 30-day Intensive Care Unit (ICU) admission, emergency room (ER) visit, readmission, mortality, adverse surgical events. Descriptive statistics were used. RESULTS: Forty-two women (median age 79, range 74-88), 38 with newly diagnosed advanced OC, 4 with recurrent OC, underwent cytoreductive surgery between 5/2015 and 1/2018. Preoperative age-related impairments per eRFA: high level of distress (71%), functional dependency (59%), limited social activity (59%), depression (57%), slow Time Up and Go (54%), Karnofsky Performance Score (KPS) ≤ 80 (41%), poor social support (43%), polypharmacy (35%), weight loss>10 lbs. (25%), fall history (244%), cognitive impairment (13%). Median number of comorbid conditions = 3. Among 38 newly diagnosed women, 26 (68%) had stage IIIC, 11 (29%) stage IV. Sixteen (42%) underwent primary debulking surgery, 22 (58%) neoadjuvant chemotherapy followed by interval debulking surgery. Median duration of surgery = 245.5 min (range 95-621); median hospital length of stay = 6 days (range 0-22). Optimal debulking rate = 97%, complete gross resection rate = 63%. One patient was admitted to ICU, 26% had 30-day ER visit, 10% were readmitted. Any complication, minor complication, major complication occurred in 58%, 55%, 8%, respectively. Median time from surgery to postoperative chemotherapy = 34.5 days (range 19-66). Median follow-up = 15.7 months (range 3.7-38.0), 12-month survival = 93.3%. There was no 180-day mortality. CONCLUSION: Cytoreductive surgery among older women with advanced OC and frailty can be performed safely in a tertiary care center with preoperative/postoperative geriatric and surgical co-management.

Geriatric Assessment, Not ASA Physical Status, Is Associated With 6-Month Postoperative Survival in Patients With Cancer Aged ≥75 Years.

BACKGROUND: The American Society of Anesthesiologists physical status (ASA PS) classification system is the most common method of assessing preoperative functional status. Comprehensive geriatric assessment (CGA) has been proposed as a supplementary tool for preoperative assessment of older adults. The goal of this study was to assess the correlation between ASA classification and CGA deficits among oncogeriatric patients and to determine the association of each with 6-month survival. PATIENTS AND METHODS: Oncogeriatric patients (aged ≥75 years) who underwent preoperative CGA in an outpatient geriatric clinic at a single tertiary comprehensive cancer center were identified. All patients underwent surgery, with a hospital length of stay (LOS) ≥1 day and at least 6 months of follow-up. ASA classifications were obtained from preoperative anesthesiology notes. Preoperative CGA scores ranged from 0 to 13. Six-month survival was assessed using the Social Security Death Index. RESULTS: In total, 81 of the 980 patients (8.3%) included in the study cohort died within 6 months of surgery. Most patients were classified as ASA PS III (85.4%). The mean number of CGA deficits for patients with PS II was 4.03, PS III was 5.15, and PS IV was 6.95 (P<.001). ASA classification was significantly associated with age, preoperative albumin level, hospital LOS, and 30-day intensive care unit (ICU) admissions. On multivariable analysis, 6-month mortality was associated with number of CGA deficits (odds ratio [OR], 1.14 per each unit increase in CGA score; P=.01), 30-day ICU admissions (OR, 2.77; P=.003), hospital LOS (OR, 1.03; P=.02), and preoperative albumin level (OR, 0.36; P=.004). ASA classification was not associated with 6-month mortality. CONCLUSIONS: Number of CGA deficits was strongly associated with 6-month mortality; ASA classification was not. Preoperative CGA elicits critical information that can be used to enhance the prediction of postoperative outcomes among older patients with cancer.

Electronic Assessment of Physical Decline in Geriatric Cancer Patients.

PURPOSE OF REVIEW: The purpose of this review is to explore state-of-the-art remote monitoring and emerging new sensing technologies for in-home physical assessment and their application/potential in cancer care. In addition, we discuss the main functional and non-functional requirements and research challenges of employing such technologies in real-world settings. RECENT FINDINGS: With rapid growth in aging population, effective and efficient patient care has become an important topic. Advances in remote monitoring and in its forefront in-home physical assessment technologies play a fundamental role in reducing the cost and improving the quality of care by complementing the traditional in-clinic healthcare. However, there is a gap in medical research community regarding the applicability and potential outcomes of such systems. While some studies reported positive outcomes using remote assessment technologies, such as web/smart phone-based self-reports and wearable sensors, the cancer research community is still lacking far behind. Thorough investigation of more advanced technologies in cancer care is warranted.

Electronic Rapid Fitness Assessment: A Novel Tool for Preoperative Evaluation of the Geriatric Oncology Patient.

Background: The American College of Surgeons and American Geriatrics Society recommend performing a geriatric assessment (GA) in the preoperative evaluation of older patients. To address this, we developed an electronic GA, the Electronic Rapid Fitness Assessment (eRFA). We reviewed the feasibility and clinical utility of the eRFA in the preoperative evaluation of geriatric patients. Methods: We performed a retrospective review of our experience using the eRFA in the preoperative assessment of geriatric patients. The rate and time to completion of the eRFA were recorded. The first 50 patients who completed the assessment were asked additional questions to assess their satisfaction. Descriptive statistics of patient-reported geriatric-related data were used for analysis. Results: In 2015, 636 older patients with cancer (median age, 80 years) completed the eRFA during preoperative evaluation. The median time to completion was 11 minutes (95% CI, 11-12 minutes). Only 13% of patients needed someone else to complete the assessment for them. Of the first 50 patients, 88% (95% CI, 75%-95%) responded that answering questions using the eRFA was easy. Geriatric syndromes were commonly identified through the performance of the GA: 16% of patients had a positive screening for cognitive impairment, 22% (95% CI, 19%-26%) needed a cane to ambulate, and 26% (95% CI, 23%-30%) had fallen at least once during the previous year. Conclusions: Implementation of the eRFA was feasible. The eRFA identified relevant geriatric syndromes in the preoperative setting that, if addressed, could lead to improved outcomes.

Older People with Access to Hand-Held Devices: Who Are They?

INTRODUCTION: Multiple comorbid conditions among older patients require frequent physician office and emergency room visits, at times leading to hospitalization. In recent years, mobile health (m-health) systems utilizing hand-held devices (e.g., smartphones) have been developed, which could be used for health-related interventions. This study investigates sociodemographic and clinical characteristics of individuals who have or have not accessed Internet via hand-held devices. MATERIALS AND METHODS: Adults older than 65 years of age who participated in the Health Tracking survey of the Pew Internet and American Life Project in 2012 were included in the analysis. Data were analyzed for prevalence of Internet access via hand-held devices and differences in sociodemographic and clinical characteristics. Different online health information seeking behavior is also reported. RESULTS: In the weighted sample size of 3,116 responses, 472 (15.1%) had access to Internet via hand-held devices. Those with such an access were younger and had higher income and education and better overall quality of life and quality of life at the time of answering the survey. They were more likely to be female and married or living as married. Those with diabetes or significant change in physical condition in the prior year were less likely to have such an access. In the multivariate analysis, older or diabetic individuals had lower probability of such access. Higher likelihood of access was associated with higher income and education, being married, female gender, better quality of life, higher number of comorbid illnesses, and emergency room visit or hospital admission in the last 12 months. CONCLUSIONS: Investigators should pay attention to sociodemographic and clinical disparities of older adults to develop feasible m-health interventions.

Can the inpatient hospital setting be a golden opportunity to improve colon cancer screening rates in the United States?

BACKGROUND: Colorectal cancer is the third most common cancer in the United States. Despite efforts to increase colorectal cancer screening, the rate of compliance with the recommended screening remains relatively suboptimal according the American Cancer Society (53%). PURPOSE: To assess whether the time of hospitalization is a suitable opportunity for patients to receive counseling and for recruiting patients to undergo screening colonoscopy for colon cancer. METHOD: In 2009, we conducted a cross-sectional survey of hospitalized adults age 50 to 80 years in order to assess their responses on a modified version of the Health Information National Trends Survey. We conducted χ(2) analyses on these data to examine the differences in patients' knowledge of colorectal cancer screening and prior adherence to screening guidelines and to assess whether they would be willing to undergo a screening in the near future if prompted by their physicians. RESULTS: We enrolled a total of 332 participants to complete the study questionnaire. About 94% of the subjects had heard about colon cancer, and 83.4% had heard of any screening tests to detect colorectal cancer. About 66% of subjects reported the colonoscopy to be the most effective screening test for colon cancer. Approximately 55% of the total sample group adhered to recommended screening guidelines for colon cancer using the colonoscopy. CONCLUSIONS: The time of hospitalization is a potential "golden opportunity" to counsel patients and promote colon cancer screening.

Cognitive function and ability to complete a web-based geriatric assessment among older adults with cancer.

BACKGROUND: The purpose of this study was determined whether cognitive impairment is associated with time taken to complete the electronic rapid fitness assessment (eRFA). We hypothesized that taking more time to complete the eRFA will indicate worsened cognitive function. METHODS: We retrospectively identified patients who presented to the Memorial Sloan Kettering Cancer Center Geriatrics Service for preoperative evaluation and completed the eRFA as a part of their preoperative assessment from February 2015 to December 2020. Cognitive function was assessed using the Mini-Cog©, which is a screening test for cognitive function status. Patients in this study underwent elective surgery and had a hospital length of stay ≥1 day. Time to complete the eRFA was automatically recorded by a web-based tool; assistance with eRFA completion was self-reported by the patient. In total, 2599 patients were included, of which 2387 had available Mini-Cog© scores. RESULTS: Overall, 50% of surveys were completed without assistance, 37% were completed with assistance, and 13% were completed by somebody else; Mini-Cog© scores were lower, corresponding to worsened cognitive function status, in patients requiring assistance (median score respectively, 5 vs. 4 vs. 3; p-value <0.0001; rates of cognitive impairment 7.5%, 22%, and 38%). Among patients who completed the questionnaire independently, greater cognitive impairment was associated with longer time to complete the eRFA (change in score per 5 min = -0.09; 95% CI -0.14, -0.03; p = 0.002). CONCLUSIONS: We found evidence that requirement for assistance in completing web-based questionnaires, and time taken to complete a questionnaire, predict which patients benefit from more comprehensive cognitive function assessments. Future studies should further validate this finding in a more diverse population and establish optimal clinical pathways.

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.