Who Will Care for the Caregivers? Increased Needs When Caring for Frail Older Adults With Cancer

As the number of older adults with cancer increases, the number of caregivers for these patients is also increasing. A 2015 report estimated that 2.4 million Americans provide unpaid care to an adult aged 50 years or older with cancer. Cancer caregivers are more likely to report a higher burden of care compared to those caring for noncancer patients, and caregiving can impact caregivers’ emotional and physical health. However, little is known about how increasing aging-related impairments in this vulnerable population impact caregiver health and quality of life (QOL). The study by Kehoe et al in this issue sought to evaluate the relationships between geriatric assessment (GA) impairments in older adults with cancer and their caregivers’ QOL, physical health, and emotional health. Kehoe et al conducted a cross-sectional study using baseline data from older adults with advanced cancer and their caregivers from 31 community oncology practice clusters enrolled in the Improving Communication in Older Cancer Patients and Their Caregivers (COACH) study. The COACH study is a cluster-randomized trial evaluating if GAguided recommendations improve communication between patients, caregivers, and oncologists. Eligible patients were aged 70 years or older, had an advanced solid tumor or lymphoma, were considering or receiving cancer treatment, and had one or more GA domain impairment at enrollment. Caregiver QOL, physical health, and emotional health were assessed with the Short Form Health Survey-12 (SF-12), Patient Health Questionnaire-2 (depression), and Generalized Anxiety Disorder seven-item scale. In total, 414 patients were enrolled with a caregiver. The authors found that a higher number of patient GA domain impairments was associated with worse caregiver QOL (regression coefficient β = −1.14; P < .001), caregiver physical health (β = −1.24; P < .001), and caregiver depression (adjusted odds ratio = 1.29; P < .001). Patient functional impairment was associated with lower caregiver QOL, and patient nutritional impairment was associated with caregiver depression. As the authors note, this study’s cross-sectional design precludes conclusions about causality and the direction of the associations. Nonetheless, the findings are hypothesis generating and reveal important areas of cancer caregivers’ health that require further evaluation. In addition, the study sample consisted of patients and caregivers enrolled in a clinical trial and, thus, may not be representative of the general older population with cancer. However, the trial recruited from community oncology sites rather than academic cancer centers, which increases the generalizability of the results. This study adds to a small number of prior studies that examined associations between patient GA results and caregiver outcomes. Rajasekaran et al evaluated 244 patients, aged 70 years or older, with a new diagnosis of cancer and assessed caregiver burden with the Zarit Burden Interview. While multiple GA measures were associated with higher caregiver burden in unadjusted analysis, only Eastern Cooperative Oncology Group (ECOG) performance status of 3 to 4 and hemoglobin less than 12 g/dL were associated with higher caregiver burden after adjustment for confounders. In another study, Hsu et al evaluated 100 cancer patients, aged 65 years or older, with caregiver-reported GA measures (except cognition) and caregiver burden, as assessed by the Caregiver Strain Index. In a multivariable analysis, caregiver employment and patient instrumental activities of daily living (IADLs) impairment were associated with higher caregiver burden. Last, Germain et al conducted a prospective observational study of 98 patients, aged 70 years or older, and evaluated caregiver burden (Zarit Burden Interview) and QOL (SF-12) at the time of geriatric oncology consultation, 3 months, and 6 months. In a multivariable analysis over 6 months, caregiver age younger than 70 years, lower caregiver burden, and patient independence in activities of daily living (ADLs) were associated with better caregiver QOL on the emotional domain. Overall, these studies support the finding that worse patient functional status (from global performance status by ECOG to functional status by ADLs/IADLs) is associated with higher caregiver burden. The study by Kehoe et al identified additional associations with poor caregiver outcomes (eg, impaired patient nutrition and caregiver depression), likely due to the larger sample size, resulting in greater power to detect smaller associations. In addition, Kehoe et al captured a frailer population with more advanced disease due to the inclusion criteria of advanced cancer and one or more GA impairments at enrollment, which were not required in the other studies. Last, Kehoe et al assessed outcomes beyond caregiver burden, including QOL, physical health, and emotional health. The main novel finding of this DOI: 10.1111/jgs.15863