Incorporating Life Expectancy Research Articles

Tackling Guideline Non-concordance: Primary Care Barriers to Incorporating Life Expectancy into Lung Cancer Screening Decision-Making-A Qualitative Study.

Primary care providers (PCPs) are often the first point of contact for discussing lung cancer screening (LCS) with patients. While guidelines recommend against screening people with limited life expectancy (LLE) who are less likely to benefit, these patients are regularly referred for LCS. We sought to understand barriers PCPs face to incorporating life expectancy into LCS decision-making for patients who otherwise meet eligibility criteria, and how a hypothetical point-of-care tool could support patient selection. Qualitative study based on semi-structured telephone interviews. Thirty-one PCPs who refer patients for LCS, from six Veterans Health Administration facilities. We thematically analyzed interviews to understand how PCPs incorporated life expectancy into LCS decision-making and PCPs' receptivity to a point-of-care tool to support patient selection. Final themes were organized according to the Cabana et al. framework Why Don't Physicians Follow Clinical Practice Guidelines, capturing the influence of clinician knowledge, attitudes, and behavior on LCS appropriateness determinations. PCP referrals to LCS for patients with LLE were influenced by limited knowledge of the life expectancy threshold at which patients are less likely to benefit from LCS, discomfort estimating life expectancy, fear of missing cancer at the point of early detection, and prioritization of factors such as quality of life, patient values, clinician-patient relationship, and family support. PCPs were receptive to a decision support tool to inform and communicate LCS appropriateness decisions if easy to use and integrated into clinical workflows. Our study suggests knowledge gaps and attitudes may drive decisions to offer screening despite LLE, a behavior counter to guideline recommendations. Integrating a LCS decision support tool that incorporates life expectancy within the electronic medical record and existing clinical workflows may be one acceptable solution to improve guideline concordance and increase confidence in selecting high benefit patients for LCS.

The non-consumptive economic value of wildlife: the case of three cetacean species

The conservation of wildlife is one of the most pressing issues in the current times, but wildlife conservation economic values have often been largely ignored due to an absence of market prices, as setting an economic value on biodiversity or whole ecosystems can be challenging. Nevertheless, valuing wildlife can be of great significance to improve decision-making in the conservation field, as it can provide a complementary perspective based on economic principles. Whale-watching provides an opportunity for the economic valuation of wildlife. Specifically, it offers a framework in which the economic revenue allows the economic valuation of the targeted cetaceans to be estimated through the direct and indirect expenditure of the tourists who purchase whale-watching tours. Here, we performed an economic analysis based on population abundances of the three main species targeted by the whale-watching companies in the Strait of Gibraltar (Spain): long-finned pilot whales (Globicephala melas), common dolphins (Delphinus delphis) and killer whales (Orcinus orca). These species generated a total annual income of €4,089,056, €1,876,833, and €505,389, respectively, and each individual would generate an average of €14,048, €951, and €36,099 each year, respectively. Incorporating life expectancy, this corresponded to a total population value of €112,426,185, €16,685,147, and €19,171,107, respectively, over their lifetime. These values provide an idea of the potential contribution of cetaceans to the local economy but only represent their non-consumptive value based on tourism. Our results reinforce the idea that a sustainable, high-quality whale-watching culture, under ACCOBAMS High-Quality Whale-Watching requirements, should be promoted to ensure a sustainable industry, stable economic income and the viability of cetacean populations in the Strait of Gibraltar.

Perceived Barriers Among Clinicians and Older Adults Aged 65 and Older Regarding Use of Life Expectancy to Inform Cancer Screening: A Narrative Review and Comparison.

While cancer screening guidelines increasingly recommend incorporating life expectancy estimates to inform screening decisions for older adults, little is known about how this happens in practice. This review summarizes current knowledge about primary care clinician and older adult (65+) perspectives about use of life expectancy to guide cancer screening decisions. Clinicians report operational barriers, uncertainty, and hesitation around use of life expectancy in screening decisions. They recognize it may help them more accurately weigh benefits and harms but are unsure how to estimate life expectancy for individual patients. Older adults face conceptual barriers and are generally unconvinced of the benefits of considering their life expectancy when making screening decisions. Life expectancy will always be a difficult topic for clinicians and patients, but there are advantages to incorporating it in cancer screening decisions. We highlight key takeaways from both clinician and older adult perspectives to guide future research.

Hospitalized Women's Perspective on Willingness-to-Screen for Cancers in Relation to Life Expectancy.

Objective: Life expectancy is an important tool for physicians and patients to determine when medical services for disease prevention should be rendered. Since patients’ preference is an important predictor for cancer screening compliance, incorporating life expectancy with cancer screening preferences becomes essential. The purpose of the study is to explore the mean life expectancy duration that hospitalized women expect in order to undergo cancer screening tests.Methods: A cross-sectional bedside survey including the contingent valuation method was used to assess the mean life expectancy among 475 cancer-free hospitalized women aged 50-75 years, which justified their willingness to undergo cancer screening tests. The probit and logistic regression models were used for the analysis in October 2021.Results: A total of 74% of women were willing to undergo cancer screening if the mean life expectancy was 24.3 months (SE = 12.8, p = 0.058). After adjustment for sociodemographic and clinical covariates, hospitalized women were willing to undergo cancer screening if the mean life expectancy was 26.6 months (SE = 13.3, p = 0.045). Race (African American and others vs Caucasians, OR = 2.34, 95% CI: 1.43-3.81) and annual household income <$20,000 (OR = 1.71, 95% CI: 1.02-2.86) were associated with the willingness to undergo cancer screening among hospitalized women.Conclusion: The study’s findings suggest that hospitalized women value the prospect of cancer screening tests, given the mean life expectancy of approximately 27 months. Therefore, offering screening tests to nonadherent hospitalized women with a mean life expectancy of 2¼ years, especially to those at high risk for developing cancer, with low income, or women of color, may improve adherence to cancer screening recommendations.

Patient-Reported Factors Associated With Older Adults’ Cancer Screening Decision-making

Decisions for older adults (aged ≥65 years) and their clinicians about whether to continue to screen for cancer are not easy. Many older adults who are frail or have limited life expectancy or comorbidities continue to be screened for cancer despite guidelines suggesting they should not; furthermore, many older adults have limited knowledge of the potential harms of continuing to be screened. To summarize the patient-reported factors associated with older adults' decisions regarding screening for breast, prostate, colorectal, and cervical cancer. Studies were identified by searching databases from January 2000 to June 2020 and were independently assessed for inclusion by 2 authors. Data extraction and risk of bias assessment were independently conducted by 2 authors, and then all decisions were cross-checked and discussed where necessary. Data analysis was performed from September to December 2020. The search yielded 2475 records, of which 21 unique studies were included. Nine studies were quantitative, 8 were qualitative, and 4 used mixed method designs. Of the 21 studies, 17 were conducted in the US, and 10 of 21 assessed breast cancer screening decisions only. Factors associated with decision-making were synthesized into 5 categories: demographic, health and clinical, psychological, physician, and social and system. Commonly identified factors associated with the decision to undergo screening included personal or family history of cancer, positive screening attitudes, routine or habit, to gain knowledge, friends, and a physician's recommendation. Factors associated with the decision to forgo screening included being older, negative screening attitudes, and desire not to know about cancer. Some factors had varying associations, including insurance coverage, living in a nursing home, prior screening experience, health problems, limited life expectancy, perceived cancer risk, risks of screening, family, and a physician's recommendation to stop. Although guidelines suggest incorporating life expectancy and health status to inform older adults' cancer screening decisions, older adults' ingrained beliefs about screening may run counter to these concepts. Communication strategies are needed that support older adults to make informed cancer screening decisions by addressing underlying screening beliefs in context with their perceived and actual risk of developing cancer.

A risk-based framework for assessing real-time lung cancer screening eligibility that incorporates life expectancy and past screening findings.

Current lung cancer risk-based screening approaches use a single risk-threshold, disregard life-expectancy, and ignore past screening findings. We address these limitations with a comprehensive analytical framework, the individualized lung cancer screening decision (ENGAGE) tool that aims to optimize lung cancer screening for US ever-smokers under dynamic risk assessment by incorporating life expectancy and past screening findings over time. ENGAGE employs a partially observable Markov decision process framework that integrates published risk prediction and disease progression models, to dynamically assess the trade-off between the expected health benefits and harms associated with screening. ENGAGE evaluates lung cancer risk annually and provides real-time screening eligibility that maximizes the expected quality-adjusted life-years (QALYs) of ever-smokers. We compare ENGAGE against the 2013 U.S. Preventive Services Task Force (USPSTF) lung cancer screening guideline and single-threshold risk-based screening paradigms. Compared with the 2013 USPSTF guidelines, ENGAGE expands screening coverage among ever-smokers (ENGAGE: 78%, USPSTF: 61%), while reducing the number of screening examinations per person (ENGAGE:10.43, USPSTF:12.07, P<.001), yields higher effectiveness in terms of increased lung cancer-specific mortality reduction (ENGAGE: 19%, USPSTF: 15%, P<.001) and improves screening efficiency (ENGAGE: 696, USPSTF: 819 screens per death avoided, P<.001). When compared against a single-threshold risk-based screening strategy, ENGAGE increases QALY requiring 30% fewer screens per death avoided (ENGAGE: 696, single-threshold: 889, P<.001), and reduces false positives by 40%. ENGAGE provides a comprehensive framework for dynamic risk-based assessment of lung cancer screening eligibility by incorporating life expectancy and past screening findings that can serve to guide future policies on the effectiveness and efficiency of screening. A novel decision-analytical screening framework was developed for lung cancer, the individualized lung cancer screening decision (ENGAGE) tool to provide personalized screening schedules for ever-smokers. ENGAGE captures the dynamic nature of lung cancer risk and incorporates life expectancy into the screening decision-making process. ENGAGE integrates past screening findings and changes in smoking behavior of individuals and provides informed screening decisions that outperform existing screening guidelines and single-threshold risk-based screening approaches. A personalized lung cancer screening program facilitated by a tool such as ENGAGE could enhance the efficiency of lung cancer screening.

A Novel Curriculum on Using Life Expectancy to Inform Cancer Screening in Older Adults.

Many older adults with limited life expectancy still receive cancer screening. One potential contributor is that primary care providers (PCP) are not trained to incorporate life expectancy in cancer screening recommendations. We describe the development and evaluation of a novel curriculum to address this need. We developed and implemented a web-based learning module within a large Maryland group practice with PCPs for older adults. We assessed attitude, knowledge, self-efficacy, and self-reported behavior outcomes before the module, immediately after completing the module, and 6 months afterwards. Of 172 PCPs who were invited, 86 (50%) completed the module and of these, 50 (58.1%) completed the 6-months follow up survey. Immediately after the module, there was a significant increase in perceived importance of life expectancy (increase of 0.50 point on 10-point scale, 95% confidence intervals (CI) = 0.27-0.73), confidence in predicting life expectancy (increase of 2.32 points on 10-point scale, 95% CI = 1.95-2.70) and confidence in discussion screening cessation (increase of 1.69 points on 10-point scale, 95% CI = 1.37-2.02). Knowledge in patient-preferred communication strategies improved from 55% correct response to 97% (P < .001). However, most of these improvements dissipated by 6 months and there was no change in self-reported behavior at 6 months compared to baseline (P = .34). Although the module resulted in significant short-term improvement in attitude, knowledge, and self-efficacy, the changes were not sustained over time. Educational interventions such as this can be coupled with ongoing reinforcing strategies and/or decision support interventions to improve cancer-screening practices in older adults.

Life Expectancy and Treatment Patterns in Elderly Patients With Low-Risk Papillary Thyroid Cancer: A Population-Based Analysis

ObjectiveGuidelines endorse active surveillance for low-risk papillary thyroid carcinoma (PTC), but this is not commonly utilized. Those with limited life expectancy due to age and comorbidity may be best suited for active surveillance given their higher likelihood of other-cause mortality compared to disease-specific mortality. MethodsSurveillance, epidemiology, and end results-Medicare was queried for patients >65 years with T1, N0, M0 PTC who received surgery. We evaluated the overall survival, disease-specific survival (DSS), and survival based on tumor size and extent of surgery (hemi- vs total thyroidectomy). We created a competing risk model to identify the cumulative incidence of other-cause mortality to define patient groups with life expectancies of less than 10 and 15 years. ResultsA total of 3280 patients were included. The 20-year overall survival and DSS were 38.2% and 98.5%, respectively. DSS was comparable between patients based on tumor size and surgery. The cancer cohort had better survival compared to matched controls (P < .001). Life expectancy was less than 15 years for any patient aged >80 years regardless of Charlson comorbidity score (CCS ≥ 0) and any patient aged >70 years with CCS ≥ 1. Life expectancy was less than 10 years for any patient a >80 years with CCS ≥ 1 and aged >70 years with CCS ≥ 3. ConclusionOlder patients with comorbidities have limited life expectancies but excellent DSS from low-risk PTC. Incorporating life expectancy into management decisions and guidelines would likely promote selection of less aggressive management for populations that are most suited for this approach.

Lifetime risk of primary shoulder arthroplasty over a decade: a population-level analysis

Purpose: Lifetime risk estimates can serve as a marker for disease burden in a population and enable health funders and the health workforce to plan for healthcare demand. While the lifetime risk of hip and knee arthroplasty have previously been estimated at national levels, this approach has not yet been applied to shoulder arthroplasty. This study aimed to quantify the lifetime risk of primary shoulder arthroplasty in Australia, and examine changes in lifetime risk over a ten-year period. Methods: De-identified individual-level data on all primary partial shoulder arthroplasty (PSA) and total shoulder arthroplasty (TSA) procedures performed in Australia from 1 January 2008 to 31 December 2017 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). The AOANJRR has a near-complete capture rate (>98.8%) of all hip, knee and shoulder arthroplasties performed in Australia, and registry data are validated against state-level health department data using a sequential multi-level matching process. The full collection of AOANJRR national shoulder arthroplasty data commenced in 2008. Population data and life tables (incorporating life expectancy and all-cause mortality) were obtained from the Australian Bureau of Statistics. The lifetime risk of primary PSA and primary TSA was calculated for each year from 2008-2017 using AOANJRR data, population data and life tables data, according to a standardised formula. Separate calculations were undertaken for males and females. Results: From 2008 to 2017, a total of 38,868 primary shoulder arthroplasties were performed. Of these, 5,979 (15%) were PSA procedures and the majority (N=32,889, 85%) were TSA procedures. Glenohumeral osteoarthritis was the most common reason for both PSA (53% in 2017) and TSA (57% in 2017). The lifetime risk of PSA decreased significantly for both sexes over time. For males, lifetime risk decreased from 0.25% (95% CI 0.22% to 0.28%) in 2008 to 0.11% (95% CI 0.09% to 0.13%) in 2017. For females, lifetime risk decreased from 0.55% (95% CI 0.51% to 0.60%) to 0.11% (95% CI 0.09% to 0.13%). In contrast, there was a significant increase in the lifetime risk of TSA. For males, this tripled from 0.54% (95% CI 0.49% to 0.58%) in 2008 to 1.68% (95% CI 1.60% to 1.76%) in 2017. For females, lifetime risk more than doubled from 0.99% (95% CI 0.92% to 1.05%) to 2.77% (95% CI 2.67% to 2.88%). Conclusions: Compared to declining PSA trends, there was substantial growth in TSA use over a decade. To put these findings in context, the lifetime risk of TSA in Australia increased to 1 in 60 for males and 1 in 40 for females by the end of 2017. The steep increase in lifetime risk of TSA over time probably relates to addressing previously unmet need for surgery, given the increasing availability of skilled surgeons trained to perform the procedure and advances in prosthesis design and materials. Greater awareness among patients and health professionals of successful outcomes following TSA may have also contributed to the observed growth. These data improve our understanding of the rising national burden of primary TSA, and can assist in planning to meet future surgical demand. The methods used for this study can also be re-applied in future years for ongoing population-level surveillance and to facilitate a planned international comparison.

Examining Older Adults’ Attitudes and Perceptions of Cancer Screening and Overscreening: A Qualitative Study

Introduction/Objectives:Screening guidelines for breast, cervical, and colorectal cancer (CRC) are less clear for older adults due to the potential harms that may result from screening. Understanding older adults’ attitudes and perceptions, especially racial/ethnic minority and underserved adults, of cancer screening can help health care providers determine how best to communicate with older adults about cancer screening and screening cessation. The objective of this study was to determine how older adults primarily from minority/underserved backgrounds perceive cancer screening and overscreening.Methods:Four focus groups (n = 39) were conducted with adults (>=65 years of age) in 3 community settings in south-central Pennsylvania. Two focus groups were conducted in Spanish and translated to English upon transcription. Focus group data was managed and analyzed using QSR NVivo 12. Inductive thematic analysis was used to analyze the data where themes emerged following the coding process.Results:The focus group participants had an average age of 74 years and were primarily female (74%) and Hispanic (69%), with 69% reporting having less than a high school degree. Four key themes were identified from the focus groups: (1) importance of tailored and targeted education/information; (2) impact of physician/patient communication; (3) impact of barriers and facilitators to screening on cancer screening cessation; and (4) awareness of importance of screening. Participants were more likely to be agreeable to screening cessation if they received specific information regarding their health status and previous medical history from their physician as to why screening should be stopped and told by their physician that the screening decision is up to them.Conclusions:Older adults prefer individualized information from their physician in order to justify screening cessation but are against incorporating life expectancy into the discussion. Future research should focus on developing interventions to test the effectiveness of culturally tailored screening cessation messages for older adults.

The Uptake and Efficacy of Neoadjuvant Therapy in Older Adults with Locally Advanced Esophogastric Cancer.

Data on Neo+/- adjuvant treatment in older patients with cancer is sparse. The management of locally advanced esophagogastric cancer (LAEC) in older patients was evaluated to determine treatment modalities and identify factors associated with survival. Patients diagnosed with LAEC (stage II or III) over 5 years were identified from the National Cancer Registry of Ireland. Treatment was classified as "best supportive care (BSC)," "surgery only," "neo/adjuvant treatment," and "chemo/radiation alone."Survival was assessed. Univariate and multivariate analysis (MVA) of clinicopathological factors and treatment was conducted. Forty-six percent (n = 580) of the 1251 patients were ≥ 70 years, 11% (n = 134) received BSC, 23% (n = 288) surgery only, 31% (n = 390) had chemo/radiation alone, and 35% (n = 439) had neo/adjuvant treatment. Forty-six percent, 10%, and 0% of patients < 75, ≥ 75, and ≥ 80 years of age, respectively, received neoadjuvant treatment. Age was associated with treatment received (p < 0.001). Older patients were less likely to receive neo/adjuvant treatment, surgery, and any treatment. Median survival (OS) decreased with age (< 70 years: 23 months; 70-74: 19 months; 75-79: 13 months; ≥ 80 years: 10 months). In MVA, older age, smoking, later stage, and higher grade were significantly associated with a higher risk of death. Patients receiving neo/adjuvant treatment had lower risk of death than any other treatment group regardless of age. Older patients were less likely to receive treatment for LAEC than younger patients. Patients aged ≥ 70 years benefit from neo/adjuvant treatment. Prospective clinical trials focusing on older patients and incorporating life expectancy, comorbidities, and geriatric assessment are needed to guide treatment.

Treatment approaches and survival outcomes of older patients with locally advanced esophageal cancer (LAEC) in Ireland.

e23034 Background: Neo+/- adjuvant treatment data in older patients with cancer is sparse due to exclusion of this population from clinical trials. We evaluated the management of locally advanced esophagogastric cancer (LAEC) in older Irish patients to determine treatment modalities utilized and identify factors associated with survival. Methods: Patients diagnosed with LAEC (stage II or III) over a 5 year period (2007-2011)were identified from the National Cancer Registry of Ireland. Follow-up was till end 2014.Demographic characteristicswere assessed. Treatment was classified as “best supportive care (BSC)”, “surgery only”, “neo/adjuvant treatment” and “chemo/radiation alone” (ie chemo, radiotherapy or chemoradiotherapy alone in the absence of surgery).Survival was estimated by Kaplan-Meier estimates and Cox models. Clinicopathologic factors and treatment type found to be significant in univariate analysis were included in a multivariate analysis (MVA). Results: 46%(n = 580) of the 1,251 patients were ≥70yrs, 62% had stage III disease and 51% had gastric cancer. 11% (n = 134) received BSC, 23% (n = 288) had surgery only, 31%(n = 390) had chemo/radiation alone, 35% (n = 439) had neo/adjuvant treatment. 20% (n = 39) of patients ≥75yrs had neoadjuvant treatment compared to 46% &lt; 75 yrs. No patient ≥80yrs received neo/adjuvant treatment. With increasing age patients were less likely to receive neo/adjuvant treatment (p &lt; 0.001), less likely to receive surgery (p &lt; 0.001) and less likely to receive any treatment (p &lt; 0.001).Median survival(OS) decreased with age (&lt; 70yrs: 23months; 70-74: 19months; 75-79:13months; ≥80 years:10 months). In MVA, older age, smoking, later stage, higher grade were significantly associated with a higher risk of death.Including an interaction between treatment and age, patients receiving adjuvant or neoadjuvant treatment had lower risk of death than any other treatment group regardless of age. Conclusions: Older patients were less likely to receive any treatment for LAEC than younger patients. Patients ≥70 years benefit from neo/adjuvant treatment, however,these patients are often excluded based on age. Prospective clinical trials focusing on elderly patients and incorporating life expectancy, comorbidities and geriatric assessment are needed to best guide treatment.

Colorectal Cancer Screening and Surveillance Colonoscopy in Older Adults.

The purpose of this chapter is to highlight current recommendations regarding colorectal cancer (CRC) screening and post-polypectomy surveillance colonoscopy in older adults and to review the available literature in order to help inform decision-making in this age group. Age is a risk factor for CRC; however, older adults with a history of prior screening are at lower risk for CRC compared to those who have never been screened. Decision-making for CRC screening and post-polypectomy surveillance colonoscopy in older adults is complex and several factors including age, screening history, comorbidities, functional status, bowel preparation, prior experiences, preferences, and barriers need to be considered when weighing risks and benefits. Recent guidelines have started to incorporate life expectancy and prior screening history into their recommendations; however, how to incorporate these factors into actual clinical practice is less clear. There are limited data on the relative benefits of screening and surveillance in older adults and therefore, at this time, decision-making should be individualized and incorporate patient preferences in addition to medical factors.

Screening mammography use in older women according to health status: a systematic review and meta-analysis.

BackgroundThe extent to which screening mammography (SM) recommendations in older women incorporate life expectancy factors is not well established.ObjectiveThe objective of this review was to evaluate evidence on SM utilization in older women by life expectancy factors.Data sourcesWe searched Medline, Embase and Web of Science from January 1991 to March 2016.Study selectionWe included studies examining SM utilization in women ages ≥65 years that measured life expectancy using comorbidity, functional limitations or health or prognostic status.Data extraction and synthesisORs and 95% CIs were extracted and grouped by life expectancy category. Findings were aggregated into pooled ORs and 95% CIs and meta-analyzed by life expectancy category.Main outcomes and measuresThe primary outcome was SM utilization within the last 5 years. Life expectancy factors included number of comorbidities, Charlson Comorbidity Index (CCI), activities of daily living, instrumental activities of daily living, self-reported health status and 5-year prognostic indices.ResultsOf 2,606 potential titles, we identified 25 meeting the inclusion criteria (comorbidity: eight studies, functional status: 11 studies and health/prognostic status: 13 studies). Women with higher CCI scores had decreased SM utilization (pooled OR: 0.75, 95% CI: 0.67–0.85), but increased absolute number of comorbidities were weakly associated with increased SM utilization (pooled OR: 1.17, 95% CI: 1.00–1.36). Women with more functional limitations had lower SM use odds than women with no limitations (pooled OR: 0.72, 95% CI: 0.62–0.83). Screening utilization odds were lower among women with poor vs excellent health (pooled OR: 0.85, 95% CI: 0.74–0.96).ConclusionGreater CCI score, functional limitations and lower perceived health were associated with decreased SM use, whereas higher absolute number of comorbidities was associated with increased SM use. SM guidelines should consider these factors to improve assessments of potential benefits and harms in older women.

Older adults' perspectives on incorporating life expectancy in cancer screening.

6588Background: Professional societies recommend that a patient’s life expectancy be incorporated in cancer screening as the benefits of screening may take years to accrue but the harms may be more...

Adjuvant treatment for older women with invasive breast cancer.

Older women experience a large share of breast cancer incidence and death. With the projected rise in the number of older cancer patients, adjuvant chemo-, radiation and endocrine therapy management will become a key component of breast cancer treatment in older women. Many factors influence adjuvant treatment decisions including patient preferences, life expectancy and tumor biology. Geriatric assessment predicts important outcomes, identifies key deficits, and can aid in the decision making process. This review utilizes clinical vignettes to illustrate core principles in adjuvant management of breast cancer in older women and suggests an approach incorporating life expectancy and geriatric assessment.

Individualizing Life Expectancy Estimates for Older Adults Using the Gompertz Law of Human Mortality

BackgroundGuidelines recommend incorporating life expectancy (LE) into clinical decision-making for preventive interventions such as cancer screening. Previous research focused on mortality risk (e.g. 28% at 4 years) which is more difficult to interpret than LE (e.g. 7.3 years) for both patients and clinicians. Our objective was to utilize the Gompertz Law of Human Mortality which states that mortality risk doubles in a fixed time interval to transform the Lee mortality index into a LE calculator.MethodsWe examined community-dwelling older adults age 50 and over enrolled in the nationally representative 1998 wave of the Health and Retirement Study or HRS (response rate 81%), dividing study respondents into development (n = 11701) and validation (n = 8009) cohorts. In the development cohort, we fit proportional hazards Gompertz survival functions for each of the risk groups defined by the Lee mortality index. We validated our LE estimates by comparing our predicted LE with observed survival in the HRS validation cohort and an external validation cohort from the 2004 wave of the English Longitudinal Study on Ageing or ELSA (n = 7042).ResultsThe ELSA cohort had a lower 8-year mortality risk (14%) compared to our HRS development (23%) and validation cohorts (25%). Our model had good discrimination in the validation cohorts (Harrell’s c 0.78 in HRS and 0.80 in the ELSA). Our predicted LE’s were similar to observed survival in the HRS validation cohort without evidence of miscalibration (Hosmer-Lemeshow, p = 0.2 at 8 years). However, our predicted LE’s were longer than observed survival in the ELSA cohort with evidence of miscalibration (Hosmer-Lemeshow, p<0.001 at 8 years) reflecting the lower mortality rate in ELSA.ConclusionWe transformed a previously validated mortality index into a LE calculator that incorporated patient-level risk factors. Our LE calculator may help clinicians determine which preventive interventions are most appropriate for older US adults.

How Radiation Oncologists Evaluate and Incorporate Life Expectancy Estimates Into the Treatment of Palliative Cancer Patients: A Survey-Based Study

We surveyed how radiation oncologists think about and incorporate a palliative cancer patient's life expectancy (LE) into their treatment recommendations. A 41-item survey was e-mailed to 113 radiation oncology attending physicians and residents at radiation oncology centers within the Boston area. Physicians estimated how frequently they assessed the LE of their palliative cancer patients and rated the importance of 18 factors in formulating LE estimates. For 3 common palliative case scenarios, physicians estimated LE and reported whether they had an LE threshold below which they would modify their treatment recommendation. LE estimates were considered accurate when within the 95% confidence interval of median survival estimates from an established prognostic model. Among 92 respondents (81%), the majority were male (62%), from an academic practice (75%), and an attending physician (70%). Physicians reported assessing LE in 91% of their evaluations and most frequently rated performance status (92%), overall metastatic burden (90%), presence of central nervous system metastases (75%), and primary cancer site (73%) as "very important" in assessing LE. Across the 3 cases, most (88%-97%) had LE thresholds that would alter treatment recommendations. Overall, physicians' LE estimates were 22% accurate with 67% over the range predicted by the prognostic model. Physicians often incorporate LE estimates into palliative cancer care and identify important prognostic factors. Most have LE thresholds that guide their treatment recommendations. However, physicians overestimated patient survival times in most cases. Future studies focused on improving LE assessment are needed.

How Radiation Oncologists Evaluate and Incorporate Life Expectancy Estimates Into the Palliative Treatment of Cancer Patients: A Survey-Based Study

Purpose/Objective(s): Fatigue is frequently experienced in patients with brain metastases (BM) and can impair quality of life (QOL). The purpose of this study is to examine the change in fatigue scores over time in patients receiving whole brain radiation therapy (WBRT) with different assessment tools. Materials/Methods: QOL scores were prospectively collected in patients with BM treated with WBRT. Items relating to fatigue in the Edmonton Symptom Assessment System (ESAS), Brain Symptom and Impact Questionnaire (BASIQ), Spitzer Questionnaire, European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire (EORTC QLQ-C30), EORTC brain module (EORTC QLQ-BN20+2), EORTC QLQ-C15-PAL, and Functional Assessment of Cancer Therapy General (FACT-G) were included this study. Questionnaires were organized and analyzed based on scales used: 0-10, 1-4, and 0-4 at baseline, 1, 2 and 3 months follow-up. The Wilcoxon Signed Rank test was used to determine whether fatigue scores changed over time compared to baseline prior to WBRT. Results: Three hundred seventy-one patients with follow-up data were available for analysis. Three hundred nine patients completed at least one follow-up using a questionnaire with a scale of 1-4 (Spitzer, PAL15, BN20+2, QLQ-C30) and 0-4 (FACT-G). The median KPS was 80 and median age was 64 years. There was significant fatigue score increases at months 1 and 2 compared to baseline fatigue score (p < 0.0001, p Z 0.0008), respectively. No significant increase (p Z 0.13) was detected at month 3. There was an increase in fatigue score in patients without dexamethasone (Dx) at month 1 (p Z 0.015) but no differences were observed in subsequent follow-ups. Sixty-two patients completed at least one follow-up using a questionnaire with a scale of 0-10 (ESAS, BASIQ). The median KPS was 70 and median age was 64 years. There was fatigue score increases at month 1 compared to baseline (p Z 0.009). Other two months had no significant changes. There was no difference on fatigue changes between patients with and without Dx treatment (p Z 0.2). Conclusions: There was an increase in fatigue in the first two months following WBRT, but no difference in fatigue scores between patients treated with and without Dx in majority of patients. Fatigue is an important symptom outcome that needs to be addressed in patients treated with WBRT. Author Disclosure: L. Khan: None. M. Tsao: None. N. Pulenzas: None. L. Zhang: None. N. Thavarajah: None. B. Lechner: None. E. Barnes: None. C. Danjoux: None. E. Chow: None.

Prognostic Indices for Older Adults

To better target services to those who may benefit, many guidelines recommend incorporating life expectancy into clinical decisions. To assess the quality and limitations of prognostic indices for mortality in older adults through systematic review. We searched MEDLINE, EMBASE, Cochrane, and Google Scholar from their inception through November 2011. We included indices if they were validated and predicted absolute risk of mortality in patients whose average age was 60 years or older. We excluded indices that estimated intensive care unit, disease-specific, or in-hospital mortality. For each prognostic index, we extracted data on clinical setting, potential for bias, generalizability, and accuracy. We reviewed 21,593 titles to identify 16 indices that predict risk of mortality from 6 months to 5 years for older adults in a variety of clinical settings: the community (6 indices), nursing home (2 indices), and hospital (8 indices). At least 1 measure of transportability (the index is accurate in more than 1 population) was tested for all but 3 indices. By our measures, no study was free from potential bias. Although 13 indices had C statistics of 0.70 or greater, none of the indices had C statistics of 0.90 or greater. Only 2 indices were independently validated by investigators who were not involved in the index's development. We identified several indices for predicting overall mortality in different patient groups; future studies need to independently test their accuracy in heterogeneous populations and their ability to improve clinical outcomes before their widespread use can be recommended.