NCCN Policy Summit: Cancer Across Geography.

Geographic location of a patient directly impacts access to care, including preventive screenings and early detection. Although there is a higher prevalence of the most common cancers in urban areas, mortality rates are higher in rural communities. Notably, indigenous communities residing on tribal lands often experience heightened access issues and environmental exposure to known and probable human carcinogens. The burdens associated with a cancer diagnosis can be exacerbated by various barriers to accessing quality care; however, there are emerging best practices to overcome these barriers. Understanding the interplay between geography and a patient's access to cancer care services is crucial for addressing existing disparities and ensuring equitable health care provision across regions. By leveraging innovative policy and practice solutions, communities can begin to close care gaps and establish bidirectional trust between patients and providers across the care continuum, which is necessary to enact meaningful reforms. To advance the conversation on geographic disparities and strategies that mitigate associated barriers to care, NCCN hosted the Policy Summit "Cancer Across Geography" on June 15, 2023, at the National Press Club in Washington, DC. Through keynote addresses and multistakeholder panel discussions, this hybrid event explored care imbalances across geography, recent policy and technology advancements, and current challenges associated with cancer care. This created a forum for a diverse group of attendees to thoughtfully discuss policies and practices to advance high-quality, effective, efficient, equitable, and accessible cancer care for all. Speakers and attendees featured multidisciplinary clinicians, epidemiologists, community oncologists, researchers, payers, patient advocates, industry, providers, policymakers, and leaders representing underserved communities, among others.

NCCN Policy Summit: Reducing the Cancer Burden Through Prevention and Early Detection.

Cancer prevention, screening, and early detection play an integral role in cancer incidence and outcomes. It is estimated that 30% to 50% of cancers worldwide are preventable, and it is well established that early detection of many cancers is associated with improved treatment outcomes. A recent NCCN Policy Summit: Reducing the Cancer Burden Through Prevention and Early Detection brought together healthcare providers, payers, policymakers, patient advocates, industry representatives, and technology representatives to explore challenges, triumphs, and outstanding questions surrounding current practices. Keynotes were delivered by Dr. Lisa Richardson, Director of the Division of Cancer Prevention and Control within the CDC, and Dr. Danielle Carnival, White House Cancer Moonshot Coordinator. Dr. Richardson focused on the field of public health, translating its utility in preventing and diagnosing cancer in the United States, while Dr. Carnival discussed ambitious goals by the Cancer Moonshot in reducing the cancer burden. Panelists highlighted characteristics of high-impact prevention and early detection programs, including how genetic testing has impacted this space. Existing programs are often challenged due to limitations in data, as well as financial, structural, and social barriers to motivating individuals to act on recommendations. Despite these barriers, we can learn from highly successful programs and should apply proven attributes, such as community engagement, more broadly.

NCCN Policy Summit: Cancer Care in the Workplace: Building a 21st Century Workplace for Patients, Survivors, and Caretakers.

Survival rates for people with cancer and quality of life for survivors have increased significantly as a result of innovations in cancer treatment, improvements in early detection, and improved healthcare access. In the United States, 1 in 2 men and 1 in 3 women will be diagnosed with cancer in their lifetime. As more cancer survivors and patients remain in the workforce, employers must evaluate how they can adjust workplace policies to meet employee and business needs. Unfortunately, many people still encounter barriers to remaining in the workplace following a cancer diagnosis for themselves or a loved one. In an effort to explore the impacts of contemporary employment policies on patients with cancer, cancer survivors, and caregivers, NCCN hosted the Policy Summit "Cancer Care in the Workplace: Building a 21st Century Workplace for Cancer Patients, Survivors, and Caretakers" on June 17, 2022. This hybrid event, through keynotes and multistakeholder panel discussions, explored issues regarding employer benefit design, policy solutions, current best and promising practices for return to work, and how these issues impact treatment, survivorship, and caregiving in the cancer community.

Risk of falling for people with venous leg ulcers: a literature review.

INTRODUCTION: Little is known about the risk of falling for people with venous leg ulcers (VLUs), and this subject has not been considered in UK populations. Many problems associated with living with VLUs are also known risk factors for sustaining a fall. This literature review considered the question: 'Do community-dwelling older adults with VLUs have different outcomes in physical function measures used to assess the risk of falling compared with those without VLUs?' METHOD: A review of quantitative literature relating to measures of physical function in people with and without VLUs was undertaken, the development of which was guided by the PRISMA guidelines. FINDINGS: People with VLUs have poorer scores in measures of physical function than in people without. Reliability of studies included in the review was hampered by small sample sizes and threats to internal validity and generalisability. CONCLUSIONS: People with VLUs may be at a greater risk of falling owing to limitations in balance and mobility. Improving physical function may result in ulcer healing and better quality of life. Reducing falls risk may also lead to improved patient safety and enhanced care outcomes. Further research is needed to better understand the problem.

The Association of Specific Executive Functions and Falls Risk in People with Mild Cognitive Impairment and Early-Stage Dementia.

BACKGROUND/AIMS: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk. METHODS: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. RESULTS: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. CONCLUSION: The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response.

Promoting Activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED): randomised controlled trial.

OBJECTIVE: To determine the effectiveness of an exercise and functional activity therapy intervention in adults with early dementia or mild cognitive impairment compared with usual care. DESIGN: Randomised controlled trial. SETTING: Participants' homes and communities at five sites in the United Kingdom. PARTICIPANTS: 365 adults with early dementia or mild cognitive impairment who were living at home, and family members or carers. INTERVENTION: The intervention, Promoting activity, Independence, and Stability in Early Dementia and mild cognitive impairment (PrAISED), was a specially designed, dementia specific, rehabilitation programme focusing on strength, balance, physical activity, and performance of activities of daily living, which was tailored and progressive and addressed risk and the psychological needs of people with dementia. Up to 50 therapy sessions were provided over 12 months. The control group received usual care plus a falls risk assessment. Procedures were adapted during the covid-19 pandemic. MAIN OUTCOME MEASURES: The primary outcome was score on the carer (informant) reported disability assessment for dementia scale 12 months after randomisation. Secondary outcomes were self-reported activities of daily living, physical activity, quality of life, balance, functional mobility, fear of falling, frailty, cognition, mood, carer strain, service use at 12 months, and falls between months 4 and 15. RESULTS: 365 patient participants were randomised, 183 to intervention and 182 to control. The median age of participants was 80 years (range 65-95), median Montreal cognitive assessment score was 20 out of 30 (range 13-26), and 58% (n=210) were men. Intervention participants received a median of 31 therapy sessions (interquartile range 22-40) and reported completing a mean 121 minutes of PrAISED exercise each week. Primary outcome data were available for 149 intervention and 141 control participants. Scores on the disability assessment for dementia scale did not differ between groups: adjusted mean difference -1.3, 95% confidence interval -5.2 to 2.6; Cohen's d effect size -0.06, 95% confidence interval -0.26 to 0.15; P=0.51). Upper 95% confidence intervals excluded small to moderate effects on any of the range of outcome measures. Between months 4 and 15 the intervention group experienced 79 falls and the control group 200 falls (adjusted incidence rate ratio 0.78, 95% confidence interval 0.5 to 1.3; P=0.3). CONCLUSION: The intensive PrAISED programme of exercise and functional activity training did not improve activities of daily living, physical activity, or quality of life; reduce falls; or improve any other secondary health status outcomes, despite good uptake. Future research should consider alternative approaches to maintaining ability and wellbeing in people with dementia. TRIAL REGISTRATION: ISRCTN Registry ISRCTN15320670.

The relationships between muscle strength, biomechanical functional moments and health-related quality of life in non-elite older adults.

OBJECTIVE: to investigate the association between muscle strength, biomechanical functional moments during everyday tasks and health-related quality of life (HRQoL) in older adults. METHODS: eighty-four healthy adults aged 60-88 years were tested. A torque dynamometer was utilised to measure muscle moments at the knee and hip joints. Functional assessment involved three-dimensional biomechanical analysis of gait, chair rise and sit-down, stair ascent and descent using an 8-camera VICON® system with Kistler force plates. HRQoL was assessed using the Short Form-36 (SF-36) questionnaire. RESULTS: Spearman's correlation coefficient showed significant correlation (P < 0.001) between isometric strength and functional moments (r = 0.24-0.67). Muscle strength was significantly correlated with SF-36 scores, including physical functioning, bodily pain, vitality, social functioning and role emotional scores. Knee flexion moment was correlated with role physical, vitality, social functioning, role emotional, mental health and mental component scores (r = 0.24-0.40). CONCLUSION: loss of muscle strength is associated with poorer functional ability and both are associated with reduced HRQoL. The reduction in HRQoL is considerable in the physical functioning domain. Cause and effect was not established but studies need to be undertaken to evaluate the benefits of strength training, functional activity training or increased participation in life.

The prevalence of sarcopenia in fallers and those at risk of falls in a secondary care falls unit as measured by bio-impedance analysis.

OBJECTIVES: Sarcopenia is characterised by loss of skeletal muscle mass and strength with adverse outcomes: physical disability, poor quality of life and death. Low muscle mass and strength are risk factors for falls, although there are few data available on the prevalence of sarcopenia in fallers. This study aimed to determine prevalence of sarcopenia in older people referred to a falls clinic. METHODS: Consecutive patients referred to a secondary care falls unit were recruited. Sarcopenia was diagnosed using the European Working Group on Sarcopenia definition (low muscle mass and function) and cut-off points. Bio-impedance measured appendicular skeletal muscle mass. Gait speed and grip strength were functional measures. RESULTS: Fifty-eight patients were recruited. Mean (SD) grip strength for women and men respectively were 17.9 (4.9) and 29.9(8.7) kg, mean (SD) gait speeds were 0.61(0.18) and 0.72 (0.4) m/s, mean (SD) appendicular skeletal muscle index in women and men were 6.98(1.0) and 7.85 (1.0) kg/m2 (p=0.018). Prevalence of sarcopenia was 9.8% (95% CI=1.6%-18%). CONCLUSIONS: Sarcopenia, as measured by bio-impedance is not uncommon in older people accessing a secondary care falls clinic. Bio-impedance was simple to perform, although further validation against gold standard methods is needed. As nutritional and exercise interventions for sarcopenia are available, simple methods for diagnosing sarcopenia in fallers should be considered.

The effect of visual biofeedback on balance in elderly population: a systematic review.

BACKGROUND: Balance is commonly affected by multiple factors, especially among the elderly population. Visual biofeedback (VBF) is an intervention tool that can be used in balance rehabilitation. AIM: This study aimed to systematically review randomized controlled trials that examine whether VBF training is effective in improving balance in an elderly population. DATA SOURCES: Three databases were searched: CIAHL, EMBASE, and MEDLINE. The searches were limited to the period from 2010 to 2016. ELIGIBILITY CRITERIA: Healthy adults, aged ≥65 years, with no specific disorders were included. Interventions were any VBF intervention with the aim of improving balance and were compared to no intervention, traditional exercises, placebo, or standard care. The outcome measures were balance as measured by any validated outcome measure. STUDIES APPRAISAL METHOD: The Physiotherapy Evidence Database quality assessment tool and The Cochrane Collaboration tool for assessing risk of bias were used by two independent authors (HA and FM) in order to appraise the included studies. RESULTS: The database search resulted in 879 articles, of which five papers were included. VBF was compared to no intervention, a placebo, and traditional exercise. The total number of participants in all the five included studies was 181, with a mean age of 74.3 years (standard deviation 6.7). Two studies were rated as high-quality studies, and three were rated as fair quality. CONCLUSION: Engaging elderly people living in the community in VBF training was found to be effective and could improve their balance ability. However, the variation between studies in methodology, intervention protocol, and outcomes utilized made it difficult to inform a definitive statement regarding the potential application of VBF for balance training with the elderly. Furthermore, high-quality randomized control trials are required. The systematic review level of evidence is moderate, and the strength of recommendation is that VBF is likely to be beneficial.

Effectiveness of surgery for adults with hallux valgus deformity: a systematic review.

BACKGROUND: Hallux valgus (HV) is a common foot deformity. In severe stages of this condition, surgery is often necessary. Currently, there is no systematic review comparing the effectiveness of surgery over conservative treatment. OBJECTIVES: The objective of this review was to establish the effectiveness of surgery compared to conservatory management for adults with HV. INCLUSION CRITERIA TYPES OF PARTICIPANTS: The current review included adults (18 years or over) with HV deformity, excluding adults with neurological problems causing foot deformities, for example, cerebral palsy, neuropathy, stroke and multiple sclerosis. TYPES OF INTERVENTIONS: The review included any type of HV surgery compared to no surgery, conservative treatment or different types of HV surgeries. OUTCOMES: The primary outcome was gait measurement, and secondary outcomes included quality of life, patient satisfaction, pain assessed using any validated assessment tool and adverse events. TYPES OF STUDIES: The review included randomized controlled trials. SEARCH STRATEGY: The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in 16 databases without language and date limitations. METHODOLOGICAL QUALITY: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments developed by the Joanna Briggs Institute (JBI). DATA EXTRACTION: Data were extracted from papers included in the review using the standardized data extraction tool developed by the JBI. DATA SYNTHESIS: Quantitative data were, where possible, pooled in statistical meta-analysis using RevMan5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). Effect sizes expressed as risk ratio (for categorical data) and mean differences (MD) or standardized MD (for continuous data) and their 95% confidence intervals were calculated for analysis. Where statistical pooling was not possible, the findings have been presented in narrative form. RESULTS: Searching identified 2412 citations. After removal of duplicates, paper retrieval and critical appraisal, 25 studies were included in the review. The included trials were of medium-to-poor quality.Twenty-four trials compared the effectiveness of different types of surgeries. Meta-analysis revealed no difference in level of pain between distal chevron-type osteotomy and other surgical procedures (standard mean difference [SMD] 0.02, 95% confidence interval [CI] -0.24 to 0.28). One single trial reported that distal chevron osteotomy is more effective than Lindgren osteotomy in terms of walking speed (MD -0.24, 95% CI -0.43 to -0.05).One medium quality trial assessed the effectiveness of HV surgery compared to conservative or no treatment. This trial showed that surgery, specifically distal chevron osteotomy of the first metatarsal, is a more effective procedure for pain compared to conservative treatment (MD -15.00, 95% CI -22.79 to -7.21) and also no treatment in the first year (MD -18.00, 95% CI -25.62 to -10.38). CONCLUSION: The current systematic review showed that differences between various types of surgical procedures, specifically osteotomies of the first metatarsal on clinical outcomes, are minimal. There is evidence from one study, that surgery, specifically distal chevron osteotomy of the first metatarsal is a more effective procedure than conservative or no treatment in reducing pain in the first year following surgery. However, this systematic review has identified that there is a lack of high-quality studies comparing similar types of HV treatments that assess the same outcomes.

Upper limb joint position sense during shoulder flexion in healthy individuals: a pilot study to develop a new assessment method.

BACKGROUND: Altered shoulder joint position sense (JPS) following shoulder injury has been demonstrated in the literature and may increase the risk of injury. A JPS assessment targeting the shoulder will provide the clinician with an objective marker. The present study aimed to develop an assessment method of JPS using an active relocation test (ART). METHODS: In total, 40 healthy participants were recruited. A laser-pointer attached to the index finger during an ART allowed measurement (mm) of JPS by measuring the distance between the target and relocated position. Participants were blindfolded and stood an arm's length (approximately 1 m) away from the wall. Whilst keeping the wrist in neutral and elbow extended, the participant actively moved to the target position (90° glenohumeral flexion), held for 5 seconds, returned their arm to their side and actively returned to the target position. A mean was calculated from three trials to provide an ART score. RESULTS: The mean (SD) dominant and nondominant ART score was 89.2 (SD 35.5) mm (95% confidence interval = 77.87 mm to 100.5 mm) and 94.1 (34.5) mm (95% confidence interval = 83.1 mm to 105.2 mm), respectively. Arm dominance did not significantly affect ART scores. CONCLUSIONS: No significant difference was demonstrated between the dominant and nondominant arm using an ART assessing JPS acuity. Further studies are needed to establish inter-rater and intra-rater reliability.

Interventions incorporating physical and cognitive elements to reduce falls risk in cognitively impaired older adults: a systematic review.

BACKGROUND: Cognitive impairment is a risk factor for falls. Older adults with cognitive impairment (such as dementia) have an increased risk of falling compared with age-matched individuals without a cognitive impairment. To reduce falls in this population, interventions could theoretically target and train both physical and cognitive abilities. Combining and addressing cognitive components in falls rehabilitation is a novel and emerging area of healthcare. OBJECTIVES: The objective of this review was to identify the effectiveness of combined cognitive and physical interventions on the risk of falls in cognitively impaired older adults. INCLUSION CRITERIA TYPES OF PARTICIPANTS: Older persons who were 65 years or older and identified as having a cognitive impairment either through diagnosis or assessment of global cognition. TYPES OF INTERVENTION(S): Multifactorial or multiple interventions where physical and cognitive elements were combined was compared against standard care or a single element intervention. TYPES OF STUDIES: Randomized controlled trials (RCTs), controlled clinical trials and experimental studies in which randomization was used. OUTCOMES: Outcomes related to falls, including falls rate, specific falls risk measures (i.e. Physiological Profile Assessment) or related clinical outcome measures (i.e. Timed Up and Go test, Tinetti and gait speed). SEARCH STRATEGY: A three-step search strategy was utilized in this review, including search of electronic databases: CENTRAL, JBISRIR, MEDLINE, EMBASE, AMED, CINAHL and PsychINFO. Initial keywords used were dementia, cognitive impairment, memory loss, exercise, rehabilitation and accidental falls. Grey literature (Google Scholar) and trials registers (Current Controlled Trials) searches were also completed. METHODOLOGICAL QUALITY: The methodological quality of included studies was assessed using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) software. DATA EXTRACTION: Data was extracted from articles included in the review using the standardized data extraction tool from JBI-MAStARI. DATA SYNTHESIS: A quantitative meta-analysis was performed where possible. Otherwise, data synthesis was in the form of narrative review. Sub-group analysis according to level of cognitive impairment was completed where possible. RESULTS: Eight RCTs were included in this review; they evaluated the effectiveness of multicomponent exercise programs, including physical and cognitive activities, music-based group exercise and mind-body tai chi on falls related outcomes. Most of the studies were of good quality with an average quality score of 7.5. Four studies reported effectiveness based on the number of falls, half of which reported a significant difference between the groups, but pooling of results into meta-analysis was not possible because of differences in reporting of the outcome. Falls related outcomes that were combined in meta-analysis included balance (Berg balance scale), functional mobility (Timed Up and Go) and gait speed (m/s). There was a statistically significant improvement in balance and gait speed following the intervention; however, the studies were too heterogeneous to be included in the analysis from the functional mobility results. CONCLUSION: Overall, multicomponent interventions incorporating both physical and cognitive components demonstrated positive effects on balance, functional mobility and gait speed when compared with a control and had significantly better effect on balance and gait speed within mild cognitive impairment populations.

Understanding the theoretical underpinning of the exercise component in a fall prevention programme for older adults with mild dementia: a realist review protocol.

BACKGROUND: Older adults with mild dementia are at an increased risk of falls. Preventing those at risk from falling requires complex interventions involving patient-tailored strength- and balance-challenging exercises, home hazard assessment, visual impairment correction, medical assessment and multifactorial combinations. Evidence for these interventions in older adults with mild cognitive problems is sparse and not as conclusive as the evidence for the general community-dwelling older population. The objectives of this realist review are (i) to identify the underlying programme theory of strength and balance exercise interventions targeted at those individuals that have been identified as falling and who have a mild dementia and (ii) to explore how and why that intervention reduces falls in that population, particularly in the context of a community setting. This protocol will explain the rationale for using a realist review approach and outline the method. METHODS: A realist review is a methodology that extends the scope of a traditional narrative or systematic evidence review. Increasingly used in the evaluation of complex interventions, a realist enquiry can look at the wider context of the intervention, seeking more to explain than judge if the intervention is effective by investigating why, what the underlying mechanism is and the necessary conditions for success. In this review, key rough programme theories were articulated and defined through discussion with a stakeholder group. The six rough programme theories outlined within this protocol will be tested against the literature found using the described comprehensive search strategy. The process of data extraction, appraisal and synthesis is outlined and will lead to the production of an explanatory programme theory. DISCUSSION: As far as the authors are aware, this is the first realist literature review within fall prevention research and adds to the growing use of this methodology within healthcare. This synthesis of evidence will provide a valuable addition to the evidence base surrounding the exercise component of a fall intervention programme for older adults with mild dementia and will ultimately provide clinically relevant recommendations for improving the care of people with dementia. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015030169.

The biomechanical functional demand placed on knee and hip muscles of older adults during stair ascent and descent.

Age-related decline in physical capabilities may lead to older adults experiencing difficulty in performing everyday activities due to high demands placed on the muscles of their lower extremity. This study aimed to determine the biomechanical functional demand in terms of joint moments and maximal muscle capabilities at the knee and hip joints while older adults performed stair ascent (SA) and stair descent (SD). Eighty-four healthy older adults aged 60-88 years were tested. A torque dynamometer attached to a purpose-built plinth was utilized to measure muscle moments at the knee and hip joints. Participants also underwent full body 3-D biomechanical assessment of stair ascent and descent using an 8-camera VICON system (120Hz) with 3 Kistler force plates. Stair negotiation required knee extensor moments in excess of the maximum isometric muscle strength available (SA 103%, SD 120%). For the hip, the levels of demand were high, but were slightly lower than those of the knee joint. Stair negotiation placed a high level of demand on the knee extensors with demand in SA reaching maximal isometric capacity and demand in SD exceeding maximal isometric capacity. The levels of demand leave little reserve capacity for the older adult to draw on in unexpected situations or circumstances.

A new method of using heart rate to represent energy expenditure: the Total Heart Beat Index.

OBJECTIVES: To develop a new method of representing energy expenditure using heart rate and to determine its reproducibility compared with the criterion standard of oxygen cost. DESIGN: Repeated-measures design. SETTING: University gait analysis laboratory and gymnasium at 2 spinal injury units. PARTICIPANTS: Twenty unimpaired adults and 17 subjects with spinal cord injury (SCI). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Heart rate and oxygen consumption were measured on 20 unimpaired adults walking under controlled steady-state and nonsteady-state conditions. New methods of estimating energy expenditure by using heart rate were compared with oxygen consumption, oxygen cost, and Physiological Cost Index (PCI). Nine subjects with SCI, walking with and without functional electric stimulation, were assessed to determine use of these new measures with this group. Sensitivity to change of the new measurement techniques was investigated in 10 subjects with SCI, comparing wheelchair pushing to walking. RESULTS: The Total Heart Beat Index (THBI) was developed as a new index, calculated by dividing the total heartbeats during activity by distance traveled. High repeatability was found under steady-state and nonsteady-state conditions (intraclass correlation coefficients,.893-.995). Sensitivity to change in activity level was also shown. CONCLUSIONS: The THBI is a simple parameter to calculate from continuous heart rate data and provides a reproducible alternative to gas analysis and the PCI.