bluuebunny/crossref_metadata_2025_split huggingface dataset:
Improving person-centered communication of goals, proxy, and advance directives in older patients with advanced cancer: Secondary analysis from a University of Rochester NCI Community Oncology Research Program (NCORP) cluster randomized controlled trial (CRCT).
Authors: Flannery Marie Anne , Culakova Eva , Loh Kah Poh , Epstein Ronald M. , Kamen Charles Stewart , Obrecht Spencer , Melnyk Nataliya , Whitehead Mary I. , Geer Jodi , Giguere Jeffrey K. , Mustian Karen Michelle , Duberstein Paul , Dale William , Mohile Supriya Gupta 
Published: March 2020

11523 Background: Quality person-centered care relies on effective communication between the clinical team and the patient/caregiver eliciting goals and discussing wishes. In a PCORI- and NCI-funded CRCT, we found that providing community-based oncologists with geriatric assessment-guided recommendations led to more and higher quality discussions of age-related issues for older patients with advanced cancer. In this secondary analysis, we assessed whether specific recommendations to oncologists to discuss patient goals, proxy and advance directives resulted in increased communication about these topics. Methods: Patients aged 70+ with advanced solid tumors or lymphoma and at least one impaired geriatric domain (e.g., function, cognition) were enrolled (URCC 13070; PI: Mohile). Oncology practices were randomized to the intervention (oncologists received recommendations to elicit goals and discuss wishes) or usual care. The clinic visit after the oncologist received recommendations was recorded and transcribed; two blinded coders evaluated the transcripts for discussion of the specific topic areas recommended in the intervention. Between arm differences were compared using generalized linear models controlling for practice cluster. Results: From 2014-17, 528 patients (284 intervention) provided transcripts from 31 practices (mean age = 77, range 70-96 years; 49% female; mixed cancer diagnoses). Topics related to patient goals, proxy and advance directive wishes were more often discussed in the intervention arm (goals of care preferences: 9 vs 2%, p = .02, treatment goals: 35 vs 20%. p = .04, elicit caregiver input: 28 vs 3%. p < .01, assess values and goals: 25 vs 7%, p = .07, health care proxy: 40 vs 1%, p = .004, advance directive: 25 vs 1%, p = .002). Conclusions: In this community-based study of older adults providing recommendations to oncologists to discuss specific topics resulted in increased person-centered discussions with patients and caregivers about goals, proxy and advance directive wishes. However, the content areas were discussed in less than half of all visits. Clinical trial information: NCT02107443.
Accelerated sarcopenia and outcomes in older adults with cancer: The Health ABC Study.
Authors: Williams Grant Richard , Chen Yanjun , Kenzik Kelly , McDonald Andrew Michael , Shachar Shlomit S. , Klepin Heidi D. , Kritchevsky Stephen , Bhatia Smita 
Published: March 2020

11526 Background: Progressive loss of muscle mass and strength (sarcopenia) is a well-known phenomenon of aging; however, little is known about the contribution of a cancer diagnosis to sarcopenia and its subsequent impact on disability. Using a prospective cohort of older adults from pre- to post-cancer diagnosis and a similarly-followed non-cancer cohort, we examined the trajectory of sarcopenia measures and their association with overall survival (OS) and major disability among those with cancer. Methods: The Health, Aging, and Body Composition (Health ABC) Study is a prospective longitudinal study where 3,075 community-dwelling older adults (70-79y) underwent 6 annual assessments of body composition and were followed for development of sentinel events (cancer, disability, death). Appendicular lean mass (ALM [kg]) was a sum of DXA-based lean tissue of all extremities. Hand grip strength (HGS [kg]) was averaged from 2 trials per hand. Gait speed (GS) was evaluated over a 20m course. We used linear mixed effect models to compare the change in ALM, HGS, and GS between individuals who subsequently developed cancer and those who did not, adjusting for age, race, gender, enrollment site. Among patients with cancer, we used multivariable cox regression for time from cancer diagnosis to mortality and major disability (cane/walker, inability to walk 0.25 mile/climb 10 steps, assistance with activities of daily living) treating sarcopenia measures as time-varying covariates. Results: Mean age at enrollment was 75y; 52% female; 42% black; 515 new cancers (prostate: 23%, colorectal: 15%, lung: 13%, breast: 11%). Compared with non-cancer controls, we found significantly steeper declines in HGS ( p= 0.03) and GS ( p< 0.001), and a trend in ALM ( p= 0.07) prior to cancer diagnosis; and a significantly steeper decline in ALM ( p< 0.001), but no difference in HGS ( p= 0.6) or GS ( p= 0.4) after cancer diagnosis. Slow GS was associated with a 44% increase in mortality ( p= 0.02) and a 70% increase in disability ( p= 0.02), but not ALM or HGS. Conclusions: Accelerated loss in sarcopenia measures both prior to and after a cancer diagnosis, and association with disability and mortality in older adults with cancer, present opportunities for targeted interventions.
Age disparities among cancer clinical trial participants: The role of industry sponsorship.
Authors: Ludmir Ethan B. , Mainwaring Walker , Miller Austin B. , Lin Timothy , Jethanandani Amit , Espinoza Andres F. , Fuller Clifton David 
Published: March 2020

11527 Background: Randomized controlled trials (RCTs) in oncology, which often establish the standard of care for cancer patients, do not necessarily enroll trial participants representative of the broader patient population. We sought to characterize age disparities for cancer patients enrolled on RCTs, and asked whether certain trial-related factors (such as industry sponsorship) predispose trials to larger age disparities between trial enrollees and the general population. Methods: All phase 3 RCTs in clinical oncology with results available were identified through ClinicalTrials.gov. Only randomized multi-arm trials assessing a therapeutic intervention for cancer patients were included. The scope of trials was limited to breast, colorectal, lung, and prostate disease sites. Trial participant median ages were compared to national SEER data for population median ages by disease site. Results: Three-hundred and two trials met inclusion criteria. For all trials, the trial median age was an average 6.23 years younger than the population median age (95% CI: -5.55 to -6.91 years, p < 0.001). Trials with industry sponsorship had significantly younger trial patient populations compared with non-industry-sponsored trials (mean difference from population -6.57 vs -4.48 years, p = 0.02). Younger patients were enrolled on trials evaluating targeted agents (p = 0.04), superiority-design trials (p = 0.02), and trials utilizing a surrogate primary endpoint (p = 0.03). By disease site, lung cancer trials enrolled the youngest patients relative to the population median (-8.98 years), followed by breast (-7.76 years), colorectal (-6.96 years), and prostate (+2.66 years, p < 0.001). Conclusions: Industry-funded clinical trials are associated with larger age disparities among trial participants; we believe this represents a novel finding both in clinical oncology and academic medicine more broadly. Underrepresentation of older patients on RCTs has major ramifications for the generalizability of results as well as equity of access to care; future efforts to address trial participant age disparities may focus on those trials at greatest risk for disparities based on the identified risk factors, including industry sponsorship.
Cumulative burden of new-onset chronic health conditions (CHCs) among older cancer survivors.
Authors: Kenzik Kelly , Williams Grant R. , Bhakta Nickhill , Robison Leslie L. , Bhatia Smita 
Published: March 2020

11528 Background: In the US there are an estimated 11 million survivors of cancer diagnosed at ≥65y of age. Description of the morbidity in these survivors has been limited to single complications or to prevalence of comorbidities. The cumulative burden of CHCs remains unstudied, and is critically needed to inform healthcare delivery in this burgeoning population. Methods: Using SEER-Medicare, we identified 300,082 patients with breast (34%), prostate (33%), colorectal (16%), non-small cell lung (NSCLC 10%) or non-Hodgkin lymphoma (NHL 7%) diagnosed between 2000 and 2011 at age > 65y (mean age at diagnosis: 75y; 47% males, 88% non-Hispanic whites). An age-, race-, and sex-similar non-cancer cohort (n = 97,842) was assembled. New-onset non-malignant health conditions (n = 109) were consolidated into 10 organ-specific CHCs. Inpatient CHC visits were used to describe severe CHCs. The cumulative incidence (CI) and cumulative burden (CB) of CHCs was described up to 10y from cancer diagnosis and by attained age – up to six months prior to death or until 12/31/2013. Subsequent malignant neoplasms (SMNs) were described 10y from primary cancer diagnosis. Results: The 10y CI of any CHC and severe CHC was 98% (95%CI 98-99%) and 73% (72-73%) in cancer patients and 92% (91-92%) and 55% (54-55%) in non-cancer controls (hazard ratio [HR10y]: 1.65, 95%CI 1.64-1.66). Cardiovascular conditions were the largest contributor to severe non-malignant CHCs (10y CI: 49%-69%). Prostate cancer survivors had the highest 10y CI for SMNs (19.4%). The CI for severe CHCs was 44% by age 80y and 85% by age 90y, compared to 34% and 54% in controls (p < 0.001). The 10y CB of CHCs was highest among NSCLC (42 CHCs/survivor) and NHL (41 CHCs/survivor) survivors; in comparison, the 10y CB was 31 CHCs/individual in controls. Colorectal cancer survivors had greatest overall burden at age 80y (27 CHCs/survivor) and 90y (36 CHCs/survivor), compared to 13 and 16 CHCs/individual in controls. Conclusions: The cumulative burden of new-onset multimorbidity among older cancer survivors is substantially greater than that of their non-cancer counterparts, providing quantifiable evidence that survivor-adapted healthcare management policies and risk-based interventions are needed.
Early mortality after resection of locally advanced rectal cancer in elderly United States patients.
Authors: Sineshaw Helmneh M. , Yabroff K Robin , Tsikitis Vassiliki Liana , Jemal Ahmedin , Mitin Timur 
Published: March 2020

11529 Background: Early mortality after resection of locally advanced rectal cancer in patients age 75 and older has not been studied in the United States. This information could inform clinical decision-making for patients who achieve complete clinical response after neoadjuvant therapy and consider watchful waiting versus surgical resection. Methods: Using the National Cancer Data Base, we identified patients age 75 years and older who underwent surgery for clinical stage II or III rectal cancer between 2004-2015. We performed multivariable logistic regression analyses to assess associations between patient and facility characteristics and 30-day, 90-day, and 6-month mortality. Results: Among 11,326 patients, 94% underwent resection and the remaining 6% underwent local excision. Overall early mortality rates after surgery were 4%, 7.6% and 11% for 30-day, 90-day and six-month, respectably. Six-month mortality varied by age subgroup (8% in 75-79 years old to 17.7% in 85 years and older), and comorbidity score (9.5% for comorbidity score = 0 to 18.5% for comorbidity score ≥ 2). Between 2004 and 2015, six-month mortality declined significantly from 11.9% in 2004-2007 to 9.8% in 2012-2015 ( P trend = 0.0029), with the decline larger among patients age 85 years and older (from 19.4% in 2004-2007 to 15.3% in 2012-2015, P trend = 0.0377). In the multivariable analysis, older age, higher comorbidity score, and lower facility case volume were significantly associated with higher odds of six-month mortality. Patients treated at National Cancer Institute (NCI) designated centers had 32% lower odds of six-month mortality compared with those treated at non-NCI designated teaching/research centers. Conclusions: Post-operative six-month mortality among patients age 75 years and older with locally advanced rectal cancer in the US declined steadily over the past decade. Older age, high comorbidity score, and low facility case volume were associated with higher six-month mortality after surgery. Additional efforts are needed to guide elderly patients and their physicians in discussing treatment options for locally advanced rectal cancer.
Unraveling the high cost of end-of-life care: An oncology care model experience.
Authors: Hoverman J. Russell , Taniguchi Cynthia B. , Hayes Jad , Eagye Kathryn , Mann B. Brooke , Neubauer Marcus A. 
Published: March 2020

11534 Background: Simply put, cancer care in the last 30 days of life (30DAY) is often aggressive and expensive without best meeting the wishes and needs of patients and caregivers. In this study, we evaluated total and 30DAY cost data for patients who died while enrolled from July 1, 2016 to June 30, 2017 in the Oncology Care Model (OCM), a Medicare (CMS) program initiated by the Center for Medicare and Medicaid Innovation. Methods: CMS provided claims data on 16 OCM-participating US Oncology Network practices. We measured 30DAY OCM episode expenditures (“EXP30”) for n = 5017 deceased patients, as well as patient demographics, clinical outcomes (hospital, ICU, and ER visits) and 30DAY treatments . The population was divided into two cohorts: those with ≥ 3 days of hospice care (“HC”) and those without (“NOHC”). EXP30 was compared between HC and NOHC at the univariate level using Wilcoxon Rank-sums; categorical variables were compared using Chi-squared tests. Multivariate regression was used to determine the effect of HC on EXP30 adjusted for demographic and disease factors. Results: HC had mean EXP30 reduction of $7,192 vs. NOHC [95%CI -$7,628, -$6,730] adjusted for demographics and disease. HC had lower rates of death in hospital (0.03% vs. 43.3%, p < .0001). Mean expense by days before death: NOHC values 0-30 days = $20,701; 31-60 days = $12,962; 61-90 days = $9,952 and HC values 0-30 days = $10,877; 31-60 days = $10,376; 61-90 days = $9,064. Conclusions: All categories of care except HC are associated with significantly higher cost in the last 30 days of life. The dramatic and steep trajectory in the last 30 days suggests high expense but also loss of choices as to how best to live the end of one’s life. The results will be updated as new data become available. [Table: see text]
Palliative Prognostic Index application at an inpatient palliative care service from a Brazilian tertiary Hospital: A prospective observational study.
Authors: Branco Tiago Pugliese , dos Santos Tavares Alze Pereira , Braz Mariana Sarkis , Monteiro Mariana Ribeiro , Kinupe Abrahao Ana Beatriz , A. F. de Menezes Thiago , Paparelli Carolina , Kishimoto Carolina Sassaki , M. F. Medeiros Helena , Ebina Karen , R. B. Cabral Luciana , Fernandes Maria Clara , Cortizo Silvia , Borges Fabiola , Nagashima Simone , Aguiar Pedro Nazareth 
Published: March 2020

11537 Background: Palliative Care Index (PPI) has been proposed to improve the accuracy of survival prediction for advanced cancer patients. The aim of this study is to investigate the feasibility and real-world prognosis survival of oncology inpatients from a Brazilian tertiary hospital using PPI. Methods: Hospitalized advanced cancer patients who have been referred to the Palliative Care Team were enrolled from May 2011 to December 2018. The PPI was collected within 24 hours of the referral by the palliative care physician. Primary endpoint was median overall survival (OS), estimated with the use of the Kaplan–Meier method, in three groups: PPI < 4.0; 4.0 ≤ PPI > 6.0 and PPI ≥ 6.0. Secondary endpoints were OS rate at 3-week for patients with PPI ≥ 6.0, and the most accurate PPI value to predict 6 and 3-week survival, calculated by ROC curve. Results: Total of 1.381 patients were included in this cohort with a median age of 68-year-old, and 51.3% of females. The most frequent primary cancer sites were lung/chest (17,2%), colorectal (14,3%), breast (11,2%), and biliopancreatic (10,9%). Among 454 patients with PPI < 4.0, median OS was 44 days (95% CI: 35,5-52,4); 20 days (95% CI: 15,4-24,5) for 260 patients with 4.0≤ PPI < 6.0 and 8 days (95% CI: 7-8,9) between 655 patients with PPI ≥ 6. Differences in OS among the groups adjusted for primary site, age and gender were significant (p < 0,001). OS rate at 3 weeks for PPI≥ 6.0 was 28.1% (OR 5,39 p < 0.001). PPI value of < 5,5 best predicted 6-week OS (79% sensibility, 55% specificity, AUC 0,714) and the PPI value of ≥ 5,5 predicted 3-week OS (67% sensibility, 73% specificity, AUC 0,753). Conclusions: PPI is feasible and suitable for routine clinical practice to predict survival among Brazilian patients with advanced cancer. In our study, PPI 5.5 seems to be the most accurate value to predict survival within 3 weeks.
Predictive value of an electronic frailty index (FI) in U.S. Veterans with newly diagnosed non-small cell lung cancer (NSCLC).
Authors: Sheikh Ayesha Rizwan , Cheng David , Fillmore Nathanael , Do Nhan , Brophy Mary T. , Tuck David P. 
Published: March 2020

11545 Background: Frailty is a well-established predictor of survival, but assessing it in a real-world healthcare setting is often time-consuming and impractical. We sought to determine if a quantitative measure of frailty, computed automatically from electronic health records using the cumulative deficit model, also predicts overall survival in patients with NSCLC. Methods: We conducted a retrospective cohort study of Veterans identified to have NSCLC in the VA Precision Oncology Data Repository. Frailty was assessed using a previously validated FI, the Frailty Index for Veterans Affairs (VA-FI), consisting of 31 deficits. We categorized non-frail patients into non-frail (0-0.1) and pre-frail (0.1-0.2) groups, and frail patients into mild (0.2-0.3), moderate (0.3-0.4) and severe ( > 0.4) groups. Associations of frailty and survival were assessed using Kaplan-Meier estimates and Cox models. The added value of frailty status for predictive performance was quantified using the continuous net-reclassification index (NRI). Results: The cohort included 359 patients with NSCLC. The mean age was 66 years, and 96.1% were male, including 76.3% Caucasian and 16.2% African-American. The majority had an advanced stage cancer (15.9% and 44.3% with stages III and IV respectively) with minority falling into the early stage category (15.3% and 6.1% with stages I and II respectively). A substantial proportion of patients were identified to be frail (30%). The frailty categories differentiated survival profiles of patients with 2-year survival ranging from 0.41 for non-frail patients to 0.08 for the severely frail patients (log-rank p < 0.001). Frail patients exhibited significantly shorter survival than non-frail group even after adjusting for age, gender, and stage in a multivariate Cox model (hazard ratio 1.7, p < 0.001). Inclusion of frailty status in the Cox model significantly improved 2-year risk estimates of survival (NRI 0.35; 95% CI 0.27–0.47). Conclusions: Frailty as determined by VA-FI is a significant predictor of survival independent of stage and demographic factors among NSCLC patients in this VA cohort. VA-FI is an automated and a practically feasible tool to better estimate life expectancy and help individualize patient care.
Pilot randomized trial of a transdisciplinary geriatric intervention for older adults with cancer.
Authors: Kay Paul , El-Jawahri Areej , Fuh Charn-Xin , Temel Brandon , Landay Sophia , Lage Daniel , Franco-Garcia Esteban , Scott Erin , Stevens Erin , O'Malley Terrence , Mohile Supriya Gupta , Dale William , Traeger Lara , Jackson Vicki , Greer Joseph , Temel Jennifer S. , Nipp Ryan David 
Published: March 2020

11549 Background: Oncologists often struggle with managing the unique care needs of older adults with cancer. We sought to determine the feasibility of delivering a transdisciplinary geriatric intervention designed to address the geriatric (physical function & comorbidity) and palliative care (symptoms & prognostic understanding) needs of older adults with cancer. Methods: We randomly assigned patients age ≥65 with newly diagnosed incurable gastrointestinal (GI) or lung cancer to receive a transdisciplinary geriatric intervention or usual care. Intervention patients received two visits with a geriatrician who was trained to address patients’ palliative care needs in addition to conducting a geriatric assessment. We defined the intervention as feasible if > 70% of patients enrolled in the study and > 75% completed study visits and surveys. At baseline and week 12, we assessed patients’ quality of life (QOL, Functional Assessment of Cancer Therapy General), symptoms (Edmonton Symptom Assessment System), and communication confidence (Perceived Efficacy in Patient Physician Interactions). As this was a pilot study, we calculated mean change scores in outcomes and estimated intervention effect sizes (ES). Results: From 2/2017-6/2018, we randomized 62 patients (55.9% enrollment rate [most common reason for refusal was feeling too ill]; median age = 72.3 [range 65.2-91.8]; 45.2% female; cancer types: 56.5% GI, 43.5% lung). Among intervention patients, 82.1% attended the first visit and 76.2% attended both. Overall, 77.8% completed all study surveys. Compared to usual care, intervention patients had less decrement in QOL scores (-0.77 vs -3.84, ES = .21), greater reduction in the number of moderate/severe symptoms (-0.69 vs +1.04, ES = .58), and more improvement in communication confidence (+1.06 vs -0.80, ES = .38). Conclusions: In this trial of older adults with advanced cancer, more than half enrolled in the study and over 75% of those who enrolled completed all study visits and surveys. Our effect size estimates suggest that a transdisciplinary intervention targeting patients’ geriatric and palliative care needs may be a promising approach to improve patients’ QOL, symptom burden, and communication confidence. Clinical trial information: NCT02868112.