Aging Resilience Evaluation Research Articles

Skeletal muscle density performance for screening frailty in older adults with cancer and the impact of diabetes: The CARE Registry

IntroductionSkeletal muscle density (SMD) measurements from imaging scans identify myosteatosis and could screen patients for geriatric assessment. We assessed SMD performance as a screening tool to identify older adults with cancer likely to be frail and who could benefit from in-depth assessment; we compared performance by sex and diabetes status. Materials and MethodsWe analyzed patients in the Cancer & Aging Resilience Evaluation (CARE) Registry. Frailty and diabetes were captured using a patient-reported geriatric assessment (CARE tool). Frailty was defined using CARE frailty index (CARE-FI) based on principles of deficit accumulation. SMD was calculated from computed tomography scans (L3 vertebrae). Analyses were conducted by sex and diabetes status. Scatterplots and linear regression described crude associations between SMD and frailty score. Classification performance (frail vs. non-frail) was analyzed with (1) area under the receiver operating characteristic curves (AUC) and confidence intervals (CIs); and (2) sensitivity/specificity for sex-specific SMD quartile cut-offs (Q1, median, Q3). Performance was compared between patients with and without diabetes using differences and estimated CIs (2000 bootstrap replicates). We additionally calculated positive and negative likelihood ratios (LR+, LR-). ResultsThe analytic cohort included 872 patients (39% female, median age 68 years, 27% with diabetes) with predominately stage III/IV gastrointestinal cancer; >60% planning to initiate first-line chemotherapy. SMD was negatively associated with frailty score; models were best fit in male patients with diabetes. AUC estimates for female (range: 0.58–0.62) and male (0.58–0.68) patients were low. Q3 cut-offs had high sensitivity (range: 0.76–0.89), but poor specificity (0.25–0.34). Diabetes did not impact estimates for female patients. Male patients with diabetes had greater sensitivity estimates compared to those without (sensitivity differences: 0.23 [0.07, 0.38], 0.08 [−0.07, 0.24], and 0.11 [0.00, 0.22] for Q1, median, Q3, respectively). LR estimates were most notable for male patients with diabetes (LR+ = 2.92, Q1 cut-off; LR- = 0.46, Q3 cut-off). DiscussionUsing SMD alone to screen older patients for geriatric assessment requires improvement. High-sensitivity cut-off points could miss 11–24% of patients with frailty, and many non-frail patients may be flagged. Screening with SMD is practical but work is needed to understand clinical andresource impacts of different cut-off points. Future research should evaluate performance with additional clinical data and in subgroups.

Intrinsic capacity and survival among older adults with gastrointestinal malignancies: The Cancer and Aging Resilience Evaluation registry.

Intrinsic capacity (IC) was introduced by the World Health Organization (WHO) as a marker of healthy aging, and is defined as the combination of an individual's physical, mental, and psychological capacities. This study aimed to assess IC via a patient-reported geriatric assessment (GA) and evaluate its association with survival among older adults with gastrointestinal (GI) malignancies. Data were used from a single-institution prospective registry of older adults undergoing GA before cancer therapy. Key domains of IC (vitality, locomotion, and sensory [hearing and visual], psychological, and cognitive capacities) were captured via GA, and each was given a score of 0 or 1 (0,impaired) to compute the total IC score (range, 0-6, where 6indicatesno impairment and ≤5indicatesimpairment in ≥1 domains). A frailty index (FI) was measured via the deficit accumulation method. Cox regression models and Kaplan-Meier curves were used to examine the impact of IC impairment on survival. The study included 665 patients; the median age was 68 years, 57.4% were men, and 72.9% were White. The median IC score was 4, and 79.3% of participants showed impairment in ≥1 domains of IC. Most commonly impaired domains were locomotion (48.7%) and vitality (43.9%). IC was inversely associated with FI (Spearman coefficient, -0.75; p<.001). IC impairment was associated with inferior overall survival (score, 4-5: adjusted hazard ratio [aHR], 1.7; 95% CI, 1.11-2.48; score, 2-3: aHR, 1.9; 95% CI, 1.30-2.85; score, 0-1: aHR, 1.9; 95% CI, 1.11-2.48). IC impairment is associated with frailty and reduced overall survival in older patients with GI malignancies. GA can be used to screen for IC impairment as recommended by the WHO. The World Health Organization introduced intrinsic capacity as a marker of healthy aging. Intrinsic capacity is the combination of an individual's physical, mental, and psychological capacities. It contains six key domains: vitality, locomotion, and sensory (hearing and visual), psychological, and cognitive capacities. Older adults with cancer are susceptible to a decrease in intrinsic capacity as a result of cancer and the aging process. In this study, we aimed to assess the intrinsic capacity for patients with gastrointestinal cancer and also identify whether there exists any association of intrinsic capacity with overall survival. We identified that approximately 80% of this population had one or more impaired domains, and more intrinsic capacity impairment was associated with reduced overall survival.

The “Get Moving Trial”: A phase I/II RCT of home-based (P)rehabilitation ((P)REHAB) with ExerciseRx in muscle-invasive bladder cancer (MIBC)—Study protocol for a randomized controlled trial.

TPS706 Background: Patients with MIBC often have a high burden of frailty, sarcopenia, mobility impairment, and multimorbidity, each of which is associated with reduced treatment tolerability. Prehabilitation programs are designed to improve functional capability prior to treatment to mitigate functional decline and optimize outcomes. Barriers to widespread adoption include cost, time, intensity of in-person interventions, and overly restrictive inclusion criteria which would exclude most patients with MIBC. Here, we describe a randomized controlled trial to evaluate the feasibility, usability, and impact of a pragmatic (P)REHAB exercise intervention delivered via the ExerciseRx app in participants with MIBC undergoing neoadjuvant chemotherapy (NAC) followed by radical cystectomy (RC). The primary objectives are to evaluate the (P)REHAB intervention vs. standard care (SC) to quantify the efficacy of the intervention to 1) improve or maintain physical function in patients with MIBC undergoing NAC followed by RC, and 2) globally characterize the impact of the (P)REHAB intervention with respect to patient-reported feasibility and acceptability, health-related quality of life, body-composition, frailty, treatment-associated and clinical outcomes. Methods: We will recruit and randomize 102 patients in a 1:1 ratio to the (P)REHAB or SC arms. The (P)REHAB arm will be prescribed a personalized, home exercise program (~20-minutes, 4x weekly) via the ExerciseRx app, during NAC, prior to RC and for 90-days post-RC as well as graded progression in step count. SC participants will receive printed guideline-based recommendations for physical activity during standard perioperative care. ExerciseRx comprises of 1) a provider dashboard integrated into the electronic health record for prescribing exercises and monitoring patient progress, and 2) a patient app, that administers exercise plans and tracks exercise repetitions using sensors in commodity smart devices. Step count in the (P)REHAB and SC arm will be tracked with Fitbit trackers. In the (P)REHAB arm, step count data from the Fitbit will be reviewable in the ExerciseRx provider dashboard and patient app. Eligibility criteria: English-speaking adults (&gt;18 years) with AJCC pT2-4 N0-1 M0 MIBC planning to undergo NAC followed by RC who are willing and able to participate in the trial. Primary outcome: Change in the Short Physical Performance Battery. Secondary outcomes: FitBit-assessed step count and sedentary time, ExerciseRx adherence and usability, patient-reported quality of life (EORTC-QLQ-C30, -BLM30), change in body composition (fat-mass, fat-free mass), frailty (Cancer and Aging Resilience Evaluation), treatment-associated adverse events between baseline and following NAC, and 3 months following RC. Trial enrollment will commence 10/2023. Clinical trial information: NCT06040762 .

Geriatric Assessment Impairment Profiles and Mortality in Older Adults With Gastrointestinal Cancers: Latent Class Analysis of the CARE Registry.

Many older adults with cancer have ≥2 impairments on geriatric assessment, which affects present and future frailty status, treatment tolerability, and outcomes. Our objective was to identify and describe distinct geriatric assessment impairment classes using latent class analysis (LCA) in older patients with gastrointestinal malignancies and assess 1-year mortality. We used the Cancer & Aging Resilience Evaluation (CARE) Study, a registry of older adults (≥60 years) at University of Alabama at Birmingham. The analytic cohort included patients with gastrointestinal malignancies who completed a self-administered geriatric assessment (CARE tool) before chemotherapy and had ≥1 geriatric assessment impairment. Thirteen geriatric assessment impairments were used as indicators in LCA. Resultant classes were described, mortality was estimated, and risk contrasts (differences and hazard ratios) were calculated with 95% confidence intervals. For comparison, estimates were provided for frailty categories (robust, prefrail, and frail) determined from 44 items in the CARE tool. Stratified analyses included high-risk (pancreatic, hepatobiliary, and esophageal) versus low-risk gastrointestinal cancers, and stage (IV vs I-III). Six geriatric assessment impairment classes were identified: Mild impairment (LC1); Social support impairment (LC2); Weight loss alone (LC3); Impaired, low anxiety/depression (LC4); Impaired with anxiety/depression (LC5); and Global impairment (LC6). One-year mortality was 14%, 22%, 29%, 34%, 50%, and 50% for LC1-LC6, respectively. For frailty categories, estimates ranged from 18% (robust) to 40% (frail). In stratified analyses, LC4-LC6 consistently had higher mortality estimates compared to LC1. The 6 geriatric assessment impairment classes showed a wider spread of mortality estimates compared to frailty categories and could be used to identify vulnerable patients and to plan interventions.

The association between food access and frailty among older adults with gastrointestinal malignancies-The CARE Registry.

Food access is associated with higher gastrointestinal (GI) cancer mortality; however, its association with frailty, which is a predictor of premature mortality among older adults with cancer, is less understood. The authors included 880 adults aged 60 years and older who were recently diagnosed with GI cancers and were undergoing self-reported geriatric assessment at their first prechemotherapy visit to the University of Alabama at Birmingham oncology clinic. Food access was measured using the 2019 US Department of Agriculture Economic Research Service designation low-income, low-access (LILA), classifying census tracts based on income and/or access to food stores at various distances. The primary outcome was frailty on the CARE (Cancer and Aging Resilience Evaluation) Frailty Index, a composite of the proportion of impaired geriatric assessment measures. The authors examined the LILA-frailty association with modified Poisson regression accounting for census-tract clustering. The median patient age was 69 years, 58.1% were men, 22.5% were non-Hispanic Black, 29.2% had colorectal cancer, 28.0% had pancreatic cancer, 70.1% presented with stage III/IV disease, and 34.9% were frail. A higher proportion in LILA areas were non-Hispanic Black (44.1% vs. 10.8%; p<.001) and had less education (high school or less: 48.1% vs. 37.9%; p=.020). Adjusting for age, race and ethnicity, sex, cancer type and stage, and education, an LILA designation was associated with 58% greater odds of worsening frailty status (95% confidence interval, 1.18-2.12). An analysis of LILA subcategories revealed that associations were maintained across all LILA measures. Poor food access was associated with a greater risk of frailty among newly diagnosed older adults with GI cancers before they received systemic treatment. Intervening on local food access, particularly in LILA areas, may be a target for improving rates of frailty and promoting health equity in this population.

Exploring Symptom Burden, Treatment Bother, Physical Function, and Quality of Life By Frailty Status in Patients with Multiple Myeloma

Introduction: Evidence-based guidelines for patients with Multiple Myeloma (MM) acknowledge the importance of frailty status when deciding on treatment. Frailty status may also influence patient outcomes throughout cancer treatment. Electronic Patient Reported Outcomes (ePROs) effectively capture the real-world patient experience as it relates to frailty status and health outcomes. Using ePROs, this study explored symptom burden, symptom bother, physical function, and quality of life across fit, intermediate, and frail patients with MM. Methods: All consenting adult patients with a MM diagnosis and current evidence of treatment were enrolled in the Carevive PROmPT® remote symptom monitoring platform between September 1, 2020 and March 10, 2023. Demographic and clinical characteristics were captured at baseline, including age, sex, race, frailty status, comorbidities, and social determinants of health. Classification of a patient's frailty status (fit, intermediate, or frail) involved triangulating data from three separate sources: Carevive's electronic Geriatric Assessment (eGA), the Cancer and Aging Resilience Evaluation (CARE) geriatric survey, and self-reported activity level. Validated psychometric tools were also used weekly to capture each outcome of interest, including symptoms (PRO-CTCAE), treatment bother (FACT-GP5), physical function (PROMIS-4a) and quality of life (EORTC QLQ #29-30). All results were stratified by frailty status. Results: A total of 151 patients were included in analysis. The median age was 66 (range 20-87), more than half were male (56%), the majority were white (75%), and most had at least one comorbidity (56%). The median follow time was 12 weeks (range 1-57). Frailty status was successfully classified for 147 (97%) patients and 99% of patients with 12+ weeks of follow up; among those classified, 93 (63%) were fit, 42 (29%) were intermediate, and 12 (8%) were frail. Across all patients, the most frequently reported symptoms were general pain (23% across all patient-weeks), numbness and tingling (23% across all patient-weeks), and fatigue (21% across all patient-weeks) (See Figure). Symptom burden was considerably lower for fit (16%) and intermediate (16%) patients at the start of their treatment compared to frail patients (25%). However, all patients had a consistent reduction in symptom burden over time (Fit - Week 1: 16%, Week 12: 5%; Intermediate - Week 1: 16%, Week 12: 6%; Frail - Week 1: 25%, Week 12: 6%). Physical function exhibited no change across 12 weeks. However, the non-static levels were consistently highest for fit patients, followed by intermediate patients, and then frail patients. On average, physical function was two-fold higher for fit patients compared to frail patients. Treatment bother and quality of life were comparable over time across all levels of frailty. However, on average, frail patients began treatment at a lower level of quality of life. Conclusions: This study illustrates the feasibility of using remote symptom monitoring for gathering data on frailty status, symptom burden, treatment bother, physical function, and quality of life for patients with MM. Findings suggest there may be functional differences in the overall patient experience at different levels of frailty. This further supports the importance of using frailty status in oncology care, especially to identify actionable risk factors for poor health outcomes during cancer treatment.

Exploring Symptom Burden, Treatment Bother, Physical Function, and Quality of Life By Frailty Status in Patients with Acute Myeloid Leukemia

Introduction: Evidence-based guidelines for patients with Acute Myeloid Leukemia (AML) acknowledge the importance of frailty status when deciding on treatment. Frailty status may also influence patient outcomes throughout cancer treatment. Electronic Patient Reported Outcomes (ePROs) effectively capture the real-world patient experience as it relates to frailty status and health outcomes. Using ePROs, this study explored symptom burden, treatment bother, physical function, and quality of life across fit, intermediate, and frail patients with AML . Methods: All consenting adult patients with an AML diagnosis and current evidence of treatment were enrolled in the Carevive PROmPT® remote symptom monitoring platform between September 1, 2020 and March 10, 2023. Demographic and clinical characteristics were captured at baseline, including age, sex, race, frailty status, comorbidities, and social determinants of health. Classification of a patient's frailty status (fit, intermediate, or frail) involved triangulating data from three separate sources: Carevive's electronic Geriatric Assessment (eGA), the Cancer and Aging Resilience Evaluation (CARE) geriatric survey, and self-reported activity level. Validated psychometric tools were also used weekly to capture each outcome of interest, including symptoms (PRO-CTCAE), treatment bother (FACT-GP5), physical function (PROMIS-4a) and quality of life (EORTC QLQ #29-30). All results were stratified by frailty status. Results: A total of 124 patients were included in the analysis. The median age of patients was 66 (range 21-88), half were male (50%), a majority were white (76%), and most had at least one comorbidity (69%). The median follow up time was 12 weeks (range 1-89). Frailty status was successfully classified for 117 (94%) patients and 98% of patients with 12+ weeks of follow up; among those classified, 38 (32%) were fit, 63 (54%) were intermediate, and 16 (14%) were frail. Across all patients, the most frequently reported symptoms were fatigue (23% across all patient-weeks), decreased appetite (18% across all patient-weeks), and general pain (18% across all patient-weeks) (See Figure). Symptom burden was considerably lower for fit patients at the start of their treatment (12%) compared to intermediate (18%) and frail (20%) patients. Fit patients also had a consistent reduction in symptom burden over time (Week 1: 11%; Week 12: 4%), as did intermediate patients (Week 1: 20%; Week 12: 11%). However, frail patients had intermittent spikes of symptom burden across the same time period (Week 5: 17%, Week 11: 17%). Treatment bother, physical function, and quality of life were comparable between fit and intermediate patients but consistently worse for frail patients. Conclusions: This study illustrates the feasibility of using remote symptom monitoring for gathering data on frailty status, symptom burden, treatment bother, physical function, and quality of life for patients with AML. Findings suggest there may be functional differences in the overall patient experience at different levels of frailty. This further supports the importance of using frailty status in oncology care, especially to identify actionable risk factors for poor health outcomes during cancer treatment.

Health Outcome Preferences Among Older Adults with Multiple Myeloma Undergoing Systemic Therapy

Introduction: Multiple Myeloma (MM) is the second most common hematologic malignancy in the US; over half of patients are ≥70y at diagnosis. Prior studies have shown that treatment preferences of older adults with cancer vary based on burden/intensity of current treatment and its impact on functional and cognitive well-being in addition to anticipated survival. However, no such studies exist among older adults with MM. We sought to understand health outcome preferences in a cohort of older adults with MM. Methods: Using the Cancer and Aging Resilience Evaluation in Hematologic Malignancies Registry (NCT05556928), a single institution prospective observational study of older adults with hematologic malignancies undergoing systemic therapy, we identified patients diagnosed with multiple myeloma at age ≥50y who had undergone a geriatric assessment (GA) within 30 days of initiating a new line of therapy (1 st to 5 th line).Treatment preference was assessed using a 9-item health outcome preference attitude scale (Case et al Patient Educ Couns 2013), rating self-reported agreement with statements related to health outcomes on a Likert scale. Frailty was assessed using a deficit accumulation method as previously described (Giri S et al J Am Geriatr Soc 2023) We measured the proportion of patients reporting other outcomes being “as important” or “more important” than survival and compared the response between younger (&amp;lt;70y) and older (≥70y) adults. Subsequently, we built proportional odds models to study the factors associated with a greater prioritization of outcomes other than survival. All p values were two sided and the level of significance was chosen at 0.05. Results: Of the 228 patients initiating a new line of therapy between 01/2022 to 4/2023, 104 (47%) underwent treatment preference assessment. The median age at enrollment was 65y with 33% ≥70y; 62% were males, 57% whites; 19% had ISS stage 3 disease; 28% were frail on the CARE frailty index. In the younger (age &amp;lt;70y) vs older (age ≥70y) patients, 32% vs 77% agreed/strongly agreed with: “I would rather live a shorter life than lose my ability to take care of myself”; and 54% vs 79% agreed/strongly agreed with: “It is more important to me to maintain my thinking ability than to live as long as possible”. In multivariable models, age but not frailty, sex, race or disease stage were associated with health outcome prioritization other than survival. Each 1y increase in age was associated with and 8% (Odds Ratio 1.08; 95% CI 1.03-1.13; p value=0.001) and 4% (OR 1.04; 95% CI 1.0-1.09; p value=0.04) increased odds of rating functional independence and cognition respectively as more important than survival. Conclusions: Three out of four older adults (age&amp;gt;70y) with MM rated other outcomes (particularly physical function and cognitive ability) as being more important than survival. Eliciting which outcomes are the most important for older patients can help define treatment goals and improve shared decision-making. Further, interventions focusing on preserving physical and cognitive function need to be tested in this population.

Implementation of the Web-Enabled Cancer & Aging Resilience Evaluation (WeCARE) in an outpatient oncology setting

IntroductionAlthough geriatric assessments (GAs) are recommended for use in older adults with cancer, their integration into oncology practice remain suboptimal. Here, we report our experience integrating web-enabled GA (WeCARE) into oncology practice as an augmented delivery method and provider interface format to overcome implementation barriers. Materials and MethodsOlder patients (≥60 years) with a gastro-intestinal (GI) malignancy presenting for an initial visit to medical oncology clinic at a single institution between December 7, 2021 and October 10, 2022 were contacted by staff two days in advance of their visits and sent a link to the WeCARE GA, rather than the paper version used previously. Results were directly embedded into the medical record. We describe our initial implementation outcomes and the results of a provider usability survey. ResultsOf 266 eligible patients, 221 (83.1%) were successfully contacted by telephone and 200 (75.2%) completed the WeCARE prior to their appointment. More than one phone call was required to make contact for 35.7% of patients, with a mean duration of phone conversation of 2.8 min. Most patients preferred email delivery to text (63% vs 31%); 4.5% were unable to access surveys due to inadequate technology, and 25.7% brought up additional logistical concerns. Among GI oncology providers surveyed, all six found the WeCARE tool and dashboard acceptable, appropriate, and feasible. However, only a third of providers often or always used the dashboard to inform treatment decisions and guide interventions. DiscussionWith nearly three-quarters of patients completing the WeCARE prior to their visits with minimal staff support and time required, this method of administration may be a viable format to overcome barriers to GA implementation. Additional work is needed to integrate the results meaningfully into clinical practice.

The association of the comorbidity polypharmacy score (CPS) with functional limitations, frailty, and mortality in older adults with gastrointestinal malignancies.

12036 Background: Older adults share a growing burden of cancer morbidity and mortality. The presence of comorbid medical conditions and polypharmacy may present significant challenges to cancer management for older adults. Although geriatric assessment (GA) is recommended to personalize treatment for older adults with cancer, it remains underutilized in routine oncology practice, and how best to measure comorbidity and polypharmacy remain unknown. The Comorbidity Polypharmacy Score (CPS), which is the sum of the number of comorbid medical conditions and medications for a patient, has been validated in other medical fields. Here we review the association of CPS with key outcomes among older adults with gastrointestinal (GI) malignancy. Methods: The Cancer and Aging Resilience Evaluation (CARE) tool is a brief, patient-completed GA developed for older adults with cancer at the University of Alabama at Birmingham (UAB). For patients enrolled in the CARE registry, diagnosed with a new GI malignancy between September 2017 and April 2021, we calculated a CPS based upon the number of patient-reported medical comorbid conditions and daily medications. Patients were separated into two groups, those with CPS ≥ 15, or high-risk, and those with CPS &lt; 15. Multivariable analyses were adjusted for age, sex, race, cancer type, and cancer stage, and were performed to examine the potential association between high-risk CPS and falls, functional limitations, frailty, and mortality. Results: 548 patients were included in this study with a mean age of 69.7 years; 44.9% female and 23.9% Black. Common GI malignancies included colorectal (30.8%), pancreatic (25.5%), hepatobiliary (17.7%), and gastroesophageal (10.8%). Patients with CPS ≥ 15 were more likely to report falls (adjusted odds ratio [aOR] 3.39, 95% CI 1.91-6.02), dependence in activities of daily living (ADL) (aOR 3.07, 95% CI 1.67-5.66) and instrumental ADL (aOR 3.81, 95% CI 2.02-7.20), and have frailty (aOR 5.17, 95% CI 2.84-9.39). There was not a statistically significant association with either six-month or twelve-month survival. Conclusions: CPS was associated with falls, functional limitations, and frailty, but not survival, among older adults with GI malignancies. This association highlights the potential role of CPS as an efficient screening tool for older adults with cancer who would benefit from more comprehensive comorbidity and medication review.

Racial Differences in Aging-Related Deficits Among Older Adults With Colorectal Cancer.

Despite the known influences of both race- and aging-related factors in colorectal cancer outcomes and mortality, limited literature is available on the intersection between race and aging-related impairments. To explore racial differences in frailty and geriatric deficit subdomains among patients with colorectal cancer. Retrospective study using data from the Cancer and Aging Resilience Evaluation registry. A comprehensive cancer center in the Deep South. Older adults (aged ≥60 years) with colorectal cancer. Measure of frailty and geriatric assessment subdomains of physical function, functional status, cognitive complaints, psychological function, and health-related quality of life. Black patients lived in areas with a higher social vulnerability index compared to White patients (0.69 vs 0.49; p < 0.01) and had limited social support more often (54.5% vs 34.9%; p = 0.01). After adjustment for age, cancer stage, comorbidities, and social vulnerability index, Black patients were found to have a higher rate of frailty than White patients (adjusted OR 3.77; 95% CI, 1.76-8.18; p = 0.01). In addition, Black patients had more physical limitations (walking 1 block: adjusted OR 1.93; 95% CI, 1.02-3.69; p = 0.04), functional limitations (activities of daily living: adjusted OR 3.21; 95% CI, 1.42-7.24; p = 0.01), and deficits in health-related quality of life (poor global self-reported health: adjusted OR 2.45; 95% CI, 1.23-5.13; p = 0.01). Similar findings were shown after stratification by stage I to III vs IV. Retrospective study at a single institution. Among older patients with colorectal cancer, Black patients were more likely to be frail than White patients, with deficits observed specifically in physical function, functional status, and health-related quality of life. Geriatric assessment may provide an important tool in addressing racial inequities in colorectal cancer. ANTECEDENTES: A pesar de las influencias conocidas de los factores relacionados con la raza y el envejecimiento en los resultados y la mortalidad del cáncer colorectal, hay muy poca literatura sobre la intersección entre los impedimentos relacionados con la raza y el envejecimiento.OBJETIVO: El objetivo era explorar las diferencias raciales en los subdominios de fragilidad y déficit geriátrico entre los pacientes con cáncer colorectal.DISEÑO: Estudio retrospectivo utilizando datos del registro Cancer and Aging Resilience Evaluation.AJUSTES: Un centro oncológico integral en el Sur Profundo.PACIENTES: Adultos mayores (≥60 años) con cáncer colorrectal de raza Negra o Blanca.PRINCIPALES MEDIDAS DE RESULTADO: Medida compuesta de fragilidad y subdominios de evaluación geriátrica de función física, estado funcional, quejas cognitivas, función psicológica y calidad de vida relacionada con la salud.RESULTADOS: De los 304 pacientes incluidos, el 21,7% (n = 66) eran negros y la edad media era de 69 años. Los pacientes negros vivían en áreas con un índice de vulnerabilidad social (SVI) más alto en comparación con los pacientes blancos (SVI 0,69 vs 0,49; p < 0,01) y con mayor frecuencia tenían apoyo social limitado (54,5% vs 34,9%; p = 0,01). Después de ajustar por edad, estadio del cáncer, comorbilidades y SVI, los pacientes de raza negra tenían una mayor tasa de fragilidad en comparación con los pacientes de raza blanca (ORa 3,77, IC del 95%: 1,76-8,18; p = 0,01). Además, los pacientes negros tenían más limitaciones físicas (caminar 1 cuadra: ORa 1,93, IC 95% 1,02-3,69; p = 0,04), limitaciones funcionales (actividades de la vida diaria: ORa 3,21, IC 95% 1,42-7,24; p = 0,01 ) y déficits en la calidad de vida relacionada con la salud (mala salud global autoinformada: ORa 2,45, IC 95% 1,23-5,13; p = 0,01). Las quejas cognitivas y las funciones psicológicas no difirieron según la raza (p > 0,05). Se mostraron hallazgos similares después de la estratificación por estadio I-III frente a IV.LIMITACIONES: Estudio retrospectivo en una sola institución.CONCLUSIONES: Entre los pacientes mayores con cáncer colorrectal, los pacientes negros tenían más probabilidades que los pacientes blancos de ser frágiles, observándose déficits específicamente en la función física, el estado funcional y la calidad de vida relacionada con la salud. La evaluación geriátrica puede proporcionar una herramienta importante para abordar las desigualdades raciales en el cáncer colorrectal.

Rural-urban disparities in mortality and geriatric assessment among older adults with cancer: The cancer & aging resilience evaluation (CARE) registry

IntroductionRural-urban disparities persist in cancer mortality, despite improvement in cancer screening and treatment. Although older adults represent the majority of cancer cases and are over-represented in rural areas, few studies have explored rural-urban disparities in mortality and age-related impairments among older adults with cancer. Materials and MethodsWe included 962 newly-diagnosed older adults (≥60 years) with cancer who underwent geriatric assessment (GA) at their first pre-chemotherapy visit to an academic medical center in the Southeastern United States. We used Rural-Urban Commuting Area (RUCA) codes to classify residence at time of diagnosis into urban and rural areas. We used one-year survival and pre-treatment frailty as outcomes. We used Cox proportional hazards regression to evaluate the association between residence and one-year mortality, and logistic regression to evaluate the association between residence and pre-treatment frailty. All tests were two-sided. ResultsMedian age at GA was 68.0 (interquartile rage [IQR]: 64.0, 74.0) years; most had colorectal cancer (24.3%) with advanced stage (III/IV 73.2%) disease. Overall, 11.4% resided in rural and 88.6% in urban areas. Rural areas had a higher proportion of White and less educated participants. After adjustment for age, sex, race, education, employment status, and cancer type/stage, rural residence was associated with higher hazard of one-year mortality (hazard ratio [HR] = 1.78, 95% confidence interval [CI] = 1.23, 2.57) compared to urban residence. Frailty was an effect modifier of this association (HROverall = 1.83, 95% CI = 1.27, 2.57; HRFrail = 2.05, 95% CI = 1.23, 3.41; HRNot Frail = 1.55, 95% CI = 0.90, 2.68). DiscussionAmong older adults with newly diagnosed cancer, rural residence was associated with reduced one-year survival, particularly among frail older adults. The rural-urban disparities observed in the current study may be due to frailty in conjunction with disparities in social determinants of health across rural and urban areas. Future studies should focus on understanding and intervening on underlying causes of these disparities.

The association of the CARE Frailty Index with survival among older adults with pancreatic cancer.

699 Background: Outcomes of older adults with pancreatic cancer are highly variable with increased susceptibility to chemotherapy toxicities and inferior survival compared to younger patients. Determining which older adults are at higher risk for adverse outcomes remains a clinical challenge. We evaluated the association of a novel patient-reported geriatric assessment (GA)-based frailty index with survival among older adults with pancreatic cancer. Methods: Older adults (≥60y) referred for initial consultation at the UAB GI oncology clinic were prospectively enrolled in the Cancer and Aging Resilience Evaluation (CARE) registry. All patients underwent a patient-reported GA capturing multiple aging-related domains of health. The 44-item CARE frailty index (CARE-FI) based on the principles of deficit accumulation was utilized to determine frailty. The primary outcome was overall survival (OS) from the time of GA. Kaplan Meier method was used to estimate OS and comparisons between groups were by log-rank. A multivariate Cox regression model adjusted for age, sex, race, and cancer stage. Results: A total 254 older adults with pancreatic cancer were included; median age 70y, 52.4% male, 77% non-Hispanic white and 43.4% with stage IV disease. Overall, 40.1% (n=102) were frail, 26.0% (n=66) pre-frail and 33.9% (n=86) robust. No significant clinico-demographic differences across the 3 frailty groups were found. Differences in OS over two-year period was observed across the three frailty groups by the KM method ( p=0.008). In multivariate cox regression, frail status was associated with an increased risk of mortality (HR 1.9 [95% CI 1.19 – 2.98]; p=0.01) compared to robust status after adjustment for aforementioned confounders. Conclusions: The CARE-FI is a novel frailty index built on the principles of deficit accumulation using a patient-reported GA and is independently associated with survival among older adults with pancreatic cancer.[Table: see text]

Prevalence and Impact of Potentially Inappropriate Medication Use on Post-Transplant Outcomes Among Older Adults with Plasma Cell Dyscrasias Receiving an Autologous Stem Cell Transplant

Background Polypharmacy and potentially inappropriate medication (PIM) use is a healthcare concern in older adults with cancer, predisposing them to multiple adverse outcomes. While there is no standard definition on the number of medications needed for polypharmacy, polypharmacy negatively impacts patient outcomes with an increase in adverse drug events, drug interactions, and hospitalizations. The prevalence and impact of PIM use on post-transplant outcomes among older adults with plasma cell dyscrasias (PCD) undergoing autologous stem-cell transplantation (ASCT) has not been adequately studied. Methods Using data from the Cancer and Aging Resilience Evaluation in Hematologic Malignancies (CARE-Heme) study, a single-center prospective observational registry of older adults with hematologic malignancies, we identified adults who were ≥50y at the time of referral to ASCT for plasma cell dyscrasia from January 2020 to March 2022. Eligible patients underwent a comprehensive geriatric assessment at the time of their pre-transplant visit along with a comprehensive review of their medication history by either a pharmacist, registered nurse, or physician. We defined polypharmacy as use of ≥5 medications and used the American Geriatrics Society (AGS) Beers 2019 criteria for assessment of PIM. The primary outcome was 30-day readmission following ASCT. Secondary outcomes included length of hospitalization during transplant, incident falls, and health related quality of life (HRQoL) (using PROMIS global 10 measure) at 90 days post-ASCT. Modified Poisson regression with robust variance estimator was used to compute adjusted relative risk of readmission and incident falls and multiple linear regression used to compute the adjusted mean difference of length of stay (LOS) and physical and mental HRQoL between those with one or more PIM use vs those without. All models were adjusted for age, sex, race (white vs other), comorbidity, frailty (using a 44-item deficit accumulation index) and melphalan dose. Results Of 112 adults enrolled in the registry, 101 proceeded with ASCT. The median age at transplant was 64 yrs (range 50-79); 59% were male and 58% were non-Hispanic white. The median number of medications was 9 (Interquartile range, IQR 6-12); 88% were taking ≥5 medications, whereas 57% were taking ≥9 medications. Overall, 38% (95% CI 28-48%) of the patients had evidence of at least one PIM (median 1, range 1-5). The prevalence of PIM was 26%, 43%, and 45% in the age groups 50-60 yrs, 60-70 yrs, and >70 yrs, respectively (Figure 1). The most prescribed PIM therapeutic category was anticholinergics (n = 15), non-cyclooxygenase selective oral NSAIDs (n= 10), skeletal muscle relaxants (n= 6), and central nervous system antidepressants (n = 6). Overall, 9% of patients were readmitted within 30 days whereas 16% of patients had falls within 90 days of ASCT. Patients with at least one PIM vs those without had an increased risk of readmission within 30 days (RR 6.07; 95%CI 1.01-36.7; p = 0.046). Furthermore, those with PIM vs without had a trend towards increased risk of falls (RR 2.13; 95%CI 0.86-5.32; p = 0.10) and worse physical (β -4.04; 95% CI -8.31-0.23; p = 0.06) and mental HRQoL (-3.65; 95% CI -7.61-0.31; p = 0.07) at 90 days. Meanwhile, there was no significant difference in the LOS index between the two groups (β 1.09; 95% CI -1.02-3.21; p = 0.30). (Table 1) Conclusion Our study showed a high prevalence of PIM use among older adults with PCD undergoing ASCT. Use of PIM was associated with a significantly increased risk of readmission and a trend towards increased risk of falls and worse HRQoL. Our findings are limited by our small sample size and need to be confirmed by larger studies that may pave the way for de-prescribing interventions to minimize PIM use in this population to improve post-transplantation outcomes of this vulnerable population. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Evaluating Concordance between International Myeloma Working Group (IMWG) and Simplified Frailty Index (SFI) Among Older Adults with Multiple Myeloma (MM)

Introduction: Despite significant advances in therapeutics, older adults with MM are at increased risk of treatment related toxicity and mortality. Frailty is an aging-associated state of cumulative decline in many physiological systems, resulting in diminished resistance to stressors, including cancer therapy. In 2015, the International Myeloma Working Group (IMWG) developed a geriatric assessment (GA) based frailty index (IMWG-FI) using age, comorbidities, and physical function (instrumental activities of daily living, IADL; activities of daily living, ADL) to predict risk of toxicity and mortality among older adults with MM (Palumbo, et al., Blood 2015). However, GA is not routinely incorporated in clinical practice and a simplified frailty index (SFI; Facon et al Leukemia 2020) has been proposed as an alternative to using ECOG performance status (ECOG PS) as a proxy for physical function (IADL/ADL). However, the concordance between IMWG-FI and SFI remains relatively unknown, as well as their predictive ability in clinical practice, particularly among patients with relapsed, refractory multiple myeloma (RR-MM). Our goal was to describe the prevalence of frailty using IMWG-FI and SFI as well as evaluate their concordance among patients with newly-diagnosed (ND) and RR-MM. Methods: The Cancer and Aging Resilience Evaluation in Hematologic Malignancies (CARE-Heme) Registry is an ongoing prospective registry enrolling adults ≥50 years of age with a diagnosis of a hematologic malignancy undergoing treatment at a single institution. For this analysis, we included patients ≥50yo with ND- or RR-MM initiating a new treatment regimen (ranging from first to sixth line of treatment). All of the patients included in this study underwent a comprehensive GA prior to beginning a new line of therapy or stem cell transplant. We abstracted physician reported ECOG PS and comorbidities by reviewing medical records. We calculated IMWG frailty score as well as SFI using published methods. Each patient was categorized into frail/non-frail using the IMWG frailty score (fit, intermediate-fit, frail; collapsing fit/intermediate fit into the non-frail category) and the simplified frailty score (non-frail, frail) using published cutoffs. We measured the agreement between the total frailty scores using Spearman Correlation Coefficient and the frail/non-frail categorization using the Kappa statistic. Relevant treatment outcomes including progression-free survival, overall survival, and grade 2-5 toxicities (both hematologic and non-hematologic) were recorded until disease progression, death, or 6 cycles of treatment were completed. Results: A total of 146 adults with MM (49 ND-MM, 51 pre-transplant, and 46 RR-MM) starting a new line of therapy or ASCT between 8/2020 to 1/2022 were included in this study. The median age was 62 (IQR 57-70) with 53% males and 36% blacks. Most patients had IgG isotype (64%) with International Staging System (ISS) stage III disease (38%) whereas 30% patients had high risk cytogenetics. The distribution by IWMG Frailty category was as follows: 43% fit, 32% intermediate-fit, and 25% frail. Using SFI, 32% of patients were characterized as frail and 68% were characterized as non-frail (Figure 1). Although, the frailty scores were well correlated with each other (Spearman rho 0.67, p value <.001), the agreement between SFI and IMWG-FI in terms of frailty categorization was moderate (Kappa statistic 0.50); 79% of patients were classified in the same frailty group, however about 21% of patients were characterized in different frailty categories using the two scales (Table 1). SFI over-estimated frailty in about 14% of patients. There was very little agreement between a patient-reported vs physician rated ECOG-PS (Kappa statistic 0.13). The discordance between the two FI worsened if a patient reported version of ECOG PS (Kappa statistic 0.30) was used. Conclusions: Among older adults with MM, the prevalence of frailty ranged 25% by IMWG-FI to 32% by SFI. There was only a modest agreement between SFI and IMWG FI, which was worse when using patient reported version of ECOG PS. Studies comparing outcomes across the two frailty indices should take into account the potential for misclassification bias. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Safety, Feasibility, and Efficacy of Upfront Daratumumab-Based Therapy in Blacks with Dysproteinemia

Background: Black patients (pts) with dysproteinemia are underrepresented in clinical trials included in new drug applications and biological license application submissions. Even after approval, access to novel therapies remains a challenge. Daratumumab (dara) is an anti-CD38 monoclonal antibody, which has revolutionized the care of patients with both multiple myeloma (MM) and light chain (AL) amyloidosis. The underrepresentation of black pts in clinical trials of dara in newly diagnosed patients with dysproteinemia raises concerns regarding the safety, tolerability and efficacy of dara in this population. We report the results from a cohort of pts treated with dara in the management of newly diagnosed MM (NDMM) and AL amyloidosis. Methods: The Cancer and Aging Resilience Evaluation in Hematologic Malignancies (CARE-Heme) registry is an ongoing prospective registry enrolling pts ≥50 years of age with a diagnosis of hematologic malignancy undergoing treatment at a single institution. For this analysis, we included pts with NDMM and AL amyloidosis treated with dara-based combination therapy between January 2020 and January 2022. We obtained baseline disease- and patient-related characteristics. Toxicity was evaluated by chart review up to the first 6 cycles and adverse events (AEs) were graded using Common Terminology Criteria for Adverse Events (CTCAE v5.0). For patients receiving >1 cycle, response assessment was ascertained using International Myeloma Working Group (IMWG) uniform response criteria. All patients were followed until progression, death or last follow up and progression-free survival (PFS) and overall survival (OS) were measured using Kaplan Meier methods. Health-related quality of life (HRQoL) was measured using Patient-Reported Outcomes Measurement Information System (PROMIS) global 10 and quantified using physical health (PH) and mental health (MH) t-scores at baseline and 3 month follow up. Variables were compared in each race by using independent and paired sample t-tests as appropriate. Results: Over the study period, 36 black pts (NDMM=32; AL=4) and 50 white pts (NDMM=44; AL=6) received upfront dara-based combination therapy. There were no differences in age or sex, IGH translocations, but there was a higher incidence of cytogenetic high-risk disease among the black pts in our cohort (p=0.02). Black pts presented with more advanced disease at the time of presentation - hypercalcemia 33% vs. 14%, p=0.04; renal dysfunction 56% vs. 28%, p=0.01; anemia 67% vs. 38%, p=0.01). Incidence of bone disease was similar between the groups (p=0.69) (Table 1) Among blacks, the most utilized regimen was DaraVRd (56%), DaraRd (17%), DaraKRd (11%) and DaraVCd (11%). While for the white pts, it was DaraVRd (52%), DaraRd (12%), DaraKRd (8%) and DaraVCd (22%). Blacks had a similar incidence of ≥grade 3 non-hematologic AEs (p=0.21), with fatigue, diarrhea and leg edema being the most common. There is a trend towards higher ≥grade 3 hematologic AEs which did not reach statistical significance (p=0.05). After 6 cycles of therapy, overall response rate was comparable (100% vs. 94%, p=0.81) among the two groups (≥VGPR 47% vs. 62%, p=0.36). With 18 month median follow up, there was no difference in median PFS and OS, both not reached (Figure 1). Complete quality of life (QoL) t-scores were available at baseline for 55 pts (20 blacks and 35 whites). The baseline PH and MH related QoL scores were comparable between whites and blacks (p= 0.51; p=0.58, respectively). From baseline to 3 months follow up, PH t-scores improved in both whites as well as blacks although the difference was not statistically significant. Meanwhile, MH t-scores remained largely unchanged from baseline to follow up in both groups. Conclusions: We report the largest cohort to date of black pts with dysproteinemia systematically treated with frontline dara. Our data shows the feasibility of this strategy in a single institution setting with comparable safety, efficacy and HRQoL with the use of upfront dara-based combinations in black and white pts. Our data supports comparable clinical outcomes among black pts when treated with novel therapeutic combinations despite a higher proportion of high risk cytogenetic abnormalities in our cohort without an increase in AEs. Minority representation in cancer clinical trials as well as access to approved novel therapies can significantly help mitigate disparities in outcomes. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Pain among older adults with gastrointestinal malignancies- results from the cancer and aging resilience evaluation (CARE) Registry.

The impact of pain on functional status and mental health among older adults with cancer is a relevant, yet understudied. We sought to identify the prevalence of pain at diagnosis in older adults with gastrointestinal (GI) malignancies and evaluate the association of pain with functional status limitations, cognition, and mental health. This prospective cross-sectional study included older adults (age ≥ 60) with GI cancers enrolled in the CARE Registry. Pain measured in numeric rating scale from 0 to 10. We utilized the literature based cutoff for moderate-severe as ≥ 4. Logistic regression used to assess differences in functional status, falls, cognitive complaints, and depression/anxiety associated with moderate/severe pain, adjusted for sex, race, education, ethnicity, marital status, cancer type/stage, and treatment phase. Our cohort included 714 older adults with an average mean age of 70years and 59% male. Common diagnoses included colorectal (27.9%) and pancreatic (18%). A total of 43.3% reported moderate/severe pain. After multivariate adjusting for covariates, participants with self-reported moderate/severe pain were more likely to report limitations in instrumental activities of daily living (adjusted odds ratio [aOR] 4.3 95% confidence interval [CI] 3.1-6.1, p < .001), limitation in activities of daily living (aOR 3.2 95% CI 2.0-5.1, p < .001), cognitive complaints (aOR 2.9 95% CI 1.4-6.0, p < .004), anxiety (aOR 2.2 95% CI 1.4-3.4, p < 0.01), and depression (aOR 3.7 95% CI 2.2-6.5, p < .001). Pain is common among older adults with GI cancers and is associated with functional status limitations, cognitive complaints, and depression/anxiety. Strategies to reduce pain and minimize its potential impact on function and mental health warrant future research.

SIOG2022-0050 - Implementation of the Web-Enabled Cancer & Aging Resilience Evaluation (WeCARE) in an Outpatient Oncology Setting

SIOG2022-0050 - Implementation of the Web-Enabled Cancer & Aging Resilience Evaluation (WeCARE) in an Outpatient Oncology Setting

Longitudinal changes in patient-reported cognitive complaints among older adults with gastrointestinal malignancies - results from the Cancer and Aging Resilience Evaluation (CARE) Registry.

Longitudinal change in patient-reported cognitive complaints (CC) in older adults with cancer is poorly understood. The purpose of this study was to evaluate early longitudinal CC and predictors among older adults with cancer. We examined early CC change on the PROMIS® Short Form4a Cognitive Function among adults ≥ 60years with GI cancer enrolled in the Cancer and Aging Resilience Evaluation (CARE) undergoing geriatric assessment (GA) at baseline and one 3-6-month follow-up. Multivariable linear regression examined associations of demographics, socioeconomics, GA domains, baseline cognitive score, and treatment toxicities on follow-up cognitive score. Bayesian analysis of covariance (ANCOVA) determined best fitting model. A total of 218 participants were included. The median follow-up was 3.7months, the mean age was 69.2 ± 7.1, and 57.3% were male. The most common cancer was colorectal (30.7%) with most stage III/IV (73.7%). About half (51.8%) had stable cognition baseline to follow-up (follow-up t-score ± 5 points of baseline), 20.6% improved (≥ 5 increase), and 27.5% declined (≥ 5 decrease). After adjustment, there were no significant baseline predictors of follow-up cognitive t-score. Baseline t-score was the best-fitting predictor of follow-up t-score. In this first study, examining early change in CC among older adults with cancer, ~ 28% exhibited cognitive decline. Baseline cognition is the most important early predictor of follow-up cognition. Longer follow-up is needed to identify long-term predictors of CC change in cancer survivors. Cognitive decline, even early, may occur in many older adults with cancer. Baseline and regular follow-up assessments of cognitive symptoms are an important component of survivorship care.

Differences in Pretreatment Frailty Across Gastrointestinal Cancers in Older Adults: Results From the Cancer and Aging Resilience Evaluation Registry.

Frailty predicts poor outcomes in older adults with cancer, but how it differs between different cancer types is unknown. We examined differences in pretreatment frailty between colorectal (CRC), pancreatic, and hepatobiliary cancers. We included older adults age 60 years or older with the above cancer types enrolled in the Cancer and Aging Resilience Evaluation registry. Frailty was defined using a 44-item Cancer and Aging Resilience Evaluation frailty index constructed on the basis of the principles of deficit accumulation (including several geriatric assessment impairments encompassing malnutrition, functional status, comorbidities, anxiety, depression, cognitive complaints, health-related quality of life, falls, ability to walk one block, interference in social activities, and polypharmacy). Multivariable logistic regression models were used to examine the adjusted odds ratio (aOR) of frailty between cancer types. A total of 505 patients were included (mean age 70 years, 59% male): 211 (41.8%) CRC, 178 (35.2%)pancreatic cancer, and 116 (23.0%) hepatobiliary cancer. Patients with pancreatic cancer had the highest prevalence of frailty (23.3% CRC, 40.6% pancreatic, 34.3% hepatobiliary; P = .001). Both pancreatic (aOR, 2.18; 95% CI, 1.38 to 3.45), and hepatobiliary cancer (aOR, 1.73; 95% CI, 1.03 to 2.93) were independently associated with higher odds of frailty relative to CRC. Frailty was driven by higher rates of malnutrition and instrumental activities of daily living impairments in patients with pancreatic cancer and higher number of comorbidities in patients with hepatobiliary cancer. Older adults with pancreatic and hepatobiliary cancers are at high-risk of pretreatment frailty. Early interventions to improve nutritional and functional status and optimization of comorbidities may help improve outcomes.