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Introduction: Differences in symptom distress among older (age 65-74) and very old (age 75+) patients with cancer, compared to younger patients, remain to be well explored. These differences are important to understand given the heterogeneity of older populations and may have implications for age-appropriate symptom detection and management., Materials and Methods: We examined routinely collected Edmonton Symptom Assessment System Revised (ESAS-r) scores from 9,143 patients age 40+ initiating chemotherapy for solid malignancies at a single academic cancer centre, between September 2011 and May 2019. We used multivariable logistic regression models to determine associations between the most common symptoms and age group (ages 40-64, 65-74, 75-84, and 85+), cancer site, clinical stage, sex, and income levels. We focused our findings on patients with the five most common cancers, breast (n = 1,532), prostate (n = 923), lung (n = 889), pancreatic (n = 429), and colorectal (n = 368), prior to receiving treatment., Results: Within our sample, 58.0% were age 40-64, 27.3% age 65-74, 11.8% age 75-84, and 2.9% age 85+. Among the nine symptoms in the ESAS-r (anxiety, depression, tiredness, wellbeing, nausea, pain, drowsiness, appetite, and shortness of breath), the most common symptoms overall were anxiety (moderate-severe scores [ESAS-r 4 or higher] were reported by 33.8% of patients), lack of well-being (38.3%), and tiredness (38.3%). Older age was associated with lower odds of moderate/severe anxiety (odds ratio [OR] 0.81, 95% confidence interval [CI] 0.73-0.90 for age 65-74; OR 0.81, 95%CI 0.70-0.93 for age 75-84; OR 0.62, 95%CI 0.47-0.82 for age 85+; referent is 40-64-year-olds for all analyses), and increased odds of tiredness (OR 1.00, 95%CI 0.90-1.11 for age 65-74; OR 1.19, 95%CI 1.04-1.37 for age 75-84; and OR 1.34, 95%CI 1.04-1.72 for age 85+). Advanced stage, female sex, and lower income levels were associated with higher odds of moderate/severe tiredness, anxiety, and lack of well-being in adjusted models. Patients with pancreatic and lung cancers reported worse scores for these three symptoms than patients with other cancers., Discussion: Older age was associated with differences in symptom experiences such as increased tiredness and reduced anxiety. Supportive care interventions and future research should focus on addressing these symptoms to improve patient quality of life., Competing Interests: Declaration of Competing Interest The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Study Objective: Instrumental activities of daily living (IADLs) are essential to patient function and quality of life after surgery. In older surgical patients, the incidence of preoperative IADL dependence has not been well characterized in the literature. This systematic review and meta-analysis aimed to determine the pooled incidence of preoperative IADL dependence and the associated adverse outcomes in the older surgical population., Design: Systematic review and meta-analysis., Setting: MEDLINE, MEDLINE Epub Ahead of Print and In-Process, In-Data-Review & Other Non-Indexed Citations, Embase/Embase Classic, Cochrane CENTRAL, and Cochrane Database of Systematic Reviews, ClinicalTrials.Gov, the WHO ICTRP (International Clinical Trials Registry Platform) were searched for relevant articles from 1969 to April 2022., Patients: Patients aged ≥60 years old undergoing surgery with preoperative IADL assessed by the Lawton IADL Scale., Interventions: Preoperative assessment., Measurement: The primary outcome was the pooled incidence of preoperative IADL dependency. Additional outcomes included post-operative mortality, postoperative delirium [POD], functional status improvement, and discharge disposition., Main Results: Twenty-one studies (n = 5690) were included. In non-cardiac surgeries, the pooled incidence of preoperative IADL dependence was 37% (95% CI: 26.0%, 48.0%) among 2909 patients. Within cardiac surgeries, the pooled incidence of preoperative IADL dependence was 53% (95% CI: 24.0%, 82.0%) among 1074 patients. Preoperative IADL dependence was associated with an increased risk of postoperative delirium than those without IADL dependence (44.9% vs 24.4, OR 2.26; 95% CI: 1.42, 3.59; I 2 : 0%; P = 0.0005)., Conclusions: There is a high incidence of IADL dependence in older surgical patients undergoing non-cardiac and cardiac surgery. Preoperative IADL dependence was associated with a two-fold risk of postoperative delirium. Further work is needed to determine the feasibility of using the IADL scale preoperatively as a predictive tool for postoperative adverse outcomes., Competing Interests: Declaration of Competing Interest Frances Chung: Reports research support from the Ontario Ministry of Health Innovation Fund, ResMed Foundation, University Health Network Foundation, Up-to-date royalties, consultant to Takeda Pharma, STOP-Bang proprietary to University Health Network. Jean Wong: Reports research support from the Ontario Ministry of Health and Long-term Care and Merck Inc. Dr. Jean Wong is supported by a Merit Award from the University of Toronto, Department of Anesthesiology and Pain Medicine., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Older adults represent a large segment of the oncology population, however, they remain underrepresented in clinical research. Treatment of older adults is often extrapolated using data from younger and fitter patients, which may not be appropriate. Furthermore the implications of toxicity from treatment can be greater for this population. Predicting toxicity from treatment and its effect on quality of life and functional status for older adults therefore is important., Materials and Methods: We analyzed data from a clinical trial of geriatric assessment and management for Canadian elders with cancer (5C study). We assessed whether the baseline Cancer and Aging Research Group (CARG) toxicity score, G8 score, and Eastern Cooperative Oncology Group (ECOG) performance predicted grade 3-5 toxicity using logistic regression and pattern mixture models. We also assessed the impact of toxicity on quality of life and functional decline. Patients were followed for six months., Results: Three hundred sixteen patients were included. Mean age was 76 years old and 40% of patients were female. One hundred nineteen patients (38%) experienced at least one grade 3-5 toxicity. Neither the CARG toxicity score, G8, or ECOG were predictive of grade 3-5 toxicity. Patients who experienced grade 3-5 toxicity were more likely to have functional impairments over time (odds ratio 3.71, p = 0.03). However, they maintained their quality of life., Discussion: In this secondary analysis of a randomized controlled trial of geriatric assessment and management we did not find any predictors of grade 3-5 toxicity. Patients who did experience toxicity were more likely to report functional decline over time. Older adults who do experience treatment related toxicity may benefit from increased supports., Clinical Trial Information: NCT0315467., Competing Interests: Declaration of Competing Interest Tina Hsu reports receiving honoraria from Pfizer, Knight Therapeutics, Eisai, Ipsen, Mylan, and Apobiologix. Fay Strohschein reports receiving a financial award from the Canadian Association of Nurses in Oncology funded by Pfizer., (Copyright © 2023. Published by Elsevier Ltd.)

Introduction: Geriatric assessment (GA) provides information on key health domains of older adults and is recommended to help inform cancer treatment decisions and cancer care. However, GA is not feasible in many health institutions due to lack of geriatric staff and/or resources. To increase accessibility to GA and improve treatment decision making for older adults with cancer (≥65 years), we developed a self-reported, electronic geriatric assessment tool: Comprehensive Assessment for My Plan (CHAMP)., Materials and Methods: Older adults with cancer were invited to join user-centered design sessions to develop the layout and content of the tool. Subsequently, they participated in usability testing to test the usability of the tool (ease of use, acceptability, etc.). Design sessions were also conducted with oncology clinicians (oncologists and nurses) to develop the tool's clinician interface. GA assessment questions and GA recommendations were guided by a systematic review and Delphi expert panel., Results: A total of seventeen older adults participated in the study. Participants were mainly males (82.4%) and 75% were aged 75 years and older. Nine oncology clinicians participated in design sessions. Older adults and clinicians agreed that the tool was user-friendly. Domains in the final CHAMP tool (with questions and recommendations) included functional status, falls risk, cognitive impairment, nutrition, medication review, social supports, depression, substance use disorder, and miscellaneous items., Discussion: CHAMP was designed for use by older adults and oncologists and may enhance access to GA for older adults with cancer. The next phase of the CHAMP study will involve field validation in oncology clinics., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Purpose: Clinical judgement may not be sufficient to detect relevant problems in older cancer patients. We investigated what Geriatric Assessment tools (GA) are used by Canadian radiation oncologists (CROs) to treat non-metastatic prostate cancer patients aged 80 years and older., Methods: A 27-item cross-sectional survey was developed with input from a multidisciplinary team and distributed electronically to Genitourinary (GU) CROs via LimeSurvey. Survey contents included: demographics, treatment choice based on components of GA, and how GA tools are used in clinic. Descriptive statistics were used to analyze multiple-choice data, with Open-ended question being coded and analyzed for emerging themes., Results: 154 GU CRO's were contacted, 44 responded (29%). Active surveillance was the choice of therapy in older low risk prostate cancer patients regardless of factors used in a GA assessment (97%). Results in intermediate and high-risk older prostate cancer patients were more heterogenous. Functional status and comorbidities were the most important factor in the decision-making-process (94%, 91%). Sixty-six percent of CROs did not use any GA tools; yet 77% felt comfortable to very comfortable treating older patients. Eighty-eight percent felt there were some to very few guidelines in helping them to treat older patients. Barriers to using GA included lack of knowledge, time, support, and resources., Conclusions: GAs are not commonly utilized by CROs. Majority of CROs felt comfortable treating older patients with prostate cancer, regardless of guidelines/evidence in this population. This may have negative implications on patient care. CROs are however open to referring patients for a formal GA., (Copyright © 2019. Published by Elsevier Ltd.)

Nutritional issues among older adults with cancer are an understudied area of research despite significant prognostic implications for treatment side effects, cancer-specific mortality, and overall survival. In May of 2015, the National Cancer Institute and the National Institute on Aging co-sponsored a conference focused on future directions in geriatric oncology research. Nutritional research among older adults with cancer was highlighted as a major area of concern as most nutritional cancer research has been conducted among younger adults, with limited evidence to guide the care of nutritional issues among older adults with cancer. Cancer diagnoses among older adults are increasing, and the care of the older adult with cancer is complicated due to multimorbidity, heterogeneous functional status, polypharmacy, deficits in cognitive and mental health, and several other non-cancer factors. Due to this complexity, nutritional needs are dynamic, multifaceted, and dependent on the clinical scenario. This manuscript outlines the proceedings of this conference including knowledge gaps and recommendations for future nutritional research among older adults with cancer. Three common clinical scenarios encountered by oncologists include (1) weight loss during anti-cancer therapy, (2) malnutrition during advanced disease, and (3) obesity during survivorship. In this manuscript, we provide a brief overview of relevant cancer literature within these three areas, knowledge gaps that exist, and recommendations for future research., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The breast cancer incidence in low and middle income countries (LMCs) is increasing globally, and patient outcomes are generally worse in these nations compared to high income countries (HICs). This is partly due to resource constraints associated with implementing recommended breast cancer therapies. Clinical practice guideline (CPG) adherence can improve breast cancer outcomes, however, many CPGs are created in HICs, and include costly recommendations that may not be feasible in LMCs. In addition, the quality of CPGs can be variable. The aim of this study was to perform a systematic review of CPGs on early breast cancer systemic therapy with potential international impact, to evaluate their content, quality, and resource sensitivity. A MEDLINE and gray literature search was completed for English language CPGs published between 2005 and 2010, and then updated to July 2014. Extracted guidelines were evaluated using the AGREE 2 instrument. Guidelines were specifically analyzed for resource sensitivity. Most of the extracted CPGs had similar recommendations with regards to systemic therapy. However, only one, the Breast Health Global Initiative, made recommendations with consideration of different global resources. Overall, the CPGs were of variable quality, and most scored poorly in the quality domain evaluating implementation barriers such as resources. Published CPGs for early breast cancer are created in HICs, have similar recommendations, and are generally resource-insensitive. Given the visibility and influence of these CPGs on LMCs, efforts to create higher quality, resource-sensitive guidelines with less redundancy are needed., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Intensive chemotherapy (IC) used to treat acute myeloid leukemia (AML) is associated with toxicity, particularly in older adults. Emerging data suggest that baseline quality of life (QOL) and physical function may predict outcomes in oncology, although data in AML are limited. We investigated the association between baseline QOL and physical function with short-term treatment outcomes in adults and elderly AML patients., Materials and Methods: We conducted a prospective, longitudinal study of adults (age 18+) AML patients undergoing IC. Before starting IC, patients completed the European Organisation for the Research and Treatment of Cancer (EORTC) 30-item questionnaire (QLQ-C30) and Functional Assessment of Cancer Therapy Fatigue subscale (FACT-Fatigue) in addition to physical function tests (grip strength, timed chair stands, 2-min walk test). Outcomes included 60-day mortality, intensive care unit (ICU) admission and achievement of complete remission (CR). Logistic regression was carried out to evaluate each outcome., Results: Of the 239 patients (median age 57.5 years), 56.7% were male and median Charlson comorbidity score was 0. Sixty-day mortality, ICU admission and CR occurred in 9 (3.7%), 15 (6.3%) and 167 (69.9%) patients, respectively. Using univariate regression, neither QOL nor physical function at presentation was predictive of 60-day mortality (all P > 0.05), whereas ICU admission (P < 0.001) and remission status at 30 days (P = 0.007) were. Fatigue (P = 0.004) and role functioning (P = 0.003) were predictors of ICU admission; QOL and physical function were not. A higher Charlson score predicted ICU admission (P = 0.01) and remission status (P = 0.002). The cytogenetic risk group was associated with achievement of CR (P = 0.02); QOL and physical function were not (all P > 0.05). Findings were similar when patients age 60+ were examined. Relationships between fatigue and role functioning with ICU admission deserve further exploration., Conclusions: Baseline QOL and physical function tests in this prospective study were not associated with short-term mortality, ICU admission or achievement of CR after the first cycle of chemotherapy.

Background: Cancer is a disease that mostly affects older adults. Treatment adherence is crucial to obtain optimal outcomes such as cure or improvement in quality of life. Older adults have numerous comorbidites as well as cognitive and sensory impairments that may affect adherence. The aim of this systematic review was to examine factors that influence adherence to cancer treatment in older adults with cancer., Patients and Methods: Systematic review of the literature published between inception of the databases and February 2013. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of cancer treatment adherence were included. Data sources included MEDLINE, EMBASE, PsychINFO, Cumulative Index to Nursing and Allied Health (CINAHL), Web of Science, ASSIA, Ageline, Allied and Complementary Medicine (AMED), SocAbstracts and the Cochrane Library. Two reviewers reviewed abstracts and abstracted data using standardized forms. Study quality was assessed using the Mixed Methods Appraisal Tool 2011., Results: Twenty-two manuscripts were identified reporting on 18 unique studies. The quality of most studies was good. Most studies focused on women with breast cancer and adherence to adjuvant hormonal therapy. More than half of the studies used data from administrative or clinical databases or chart reviews. The adherence rate varied from 52% to 100%. Only one qualitative study asked older adults about reasons for non-adherence. Factors associated with non-adherence varied widely across studies., Conclusion: Non-adherence was common across studies but little is known about the factors influencing non-adherence. More research is needed to investigate why older adults choose to adhere or not adhere to their treatment regimens taking into account their multimorbidity.

Background: Our previous systematic review of geriatric assessment (GA) in oncology included a literature search up to November 2010. However, the quickly evolving field warranted an update. Aims of this review: (i) provide an overview of all GA instruments developed and/or in use in the oncology setting; (ii) evaluate effectiveness of GA in predicting/modifying outcomes (e.g. treatment decision impact, treatment toxicity, mortality, use of care)., Materials and Methods: Systematic review of literature published between November 2010 and 10 August 2012. English, Dutch, French and German-language articles reporting cross-sectional or longitudinal, intervention or observational studies of GA instruments were included., Data Sources: MEDLINE, EMBASE, PsycINFO, CINAHL and Cochrane Library. Two researchers independently reviewed abstracts, abstracted data and assessed the quality using standardized forms. A meta-analysis method of combining proportions was used for the outcome impact of GA on treatment modification with studies included in this update combined with those included in our previous systematic review on the use of GA., Results: Thirty-five manuscripts reporting 34 studies were identified. Quality of most studies was moderate to good. Eighteen studies were prospective, 11 cross-sectional and 5 retrospective. Three studies examined treatment decision-making impact and found decisions changed for fewer than half of assessed patients (weighted percent modification is 23.2% with 95% confidence interval (20.3% to 26.1%). Seven studies reported conflicting findings regarding predictive ability of GA for treatment toxicity/complications. Eleven studies examined GA predictions of mortality, and reported that instrumental activities of daily living, poor performance status and more numerous GA deficits were associated with increased mortality risk. Other outcomes could not be meta-analyzed., Conclusion: Consistent with our previous review, several domains of GA are associated with adverse outcomes. However, further research examining effectiveness of GA on treatment decisions and oncologic outcomes is needed.

Background: The objective was to compare 5-year overall survival (OS) between adolescent and young adult (AYA) patients (age 15-19) with acute lymphoblastic leukemia (ALL) treated at a pediatric versus an adult center., Patients and Methods: This was a population-based analysis using administrative data of Ontario ALL AYA patients diagnosed between 1986-2009. We calculated predicted survival proportions (PSPs) and 95% confidence intervals (CI). We also surveyed sites to determine whether pediatric or adult-based protocols were used in each period., Results: Overall, 290 patients between 15-19 years of age were diagnosed with ALL during the study period; 144 patients (49.7%) were treated at an adult center. When adjusted for gender, age, income quintile and time period, AYA patients treated at a pediatric center did not have a significantly different PSP (0.65, 95% CI: 0.56-0.75) in comparison to those treated at an adult center (0.62, 95% CI 0.52-0.73; P = 0.87). Most AYA patients treated at adult centers received pediatric protocols in the recent periods., Conclusions: Using population-based data, AYA ALL patients had similar outcomes whether treated at a pediatric or an adult center. Early introduction of aggressive treatment protocols in adult centers may have negated differences in outcomes among AYA patients by site of care.

Background: In some centers, outpatient management for cancer patients with low-risk febrile neutropenia (FN) has been implemented into routine clinical practice. Our objective was to evaluate the current level of evidence before supporting widespread adoption of outpatient management for this population., Methods: We systematically reviewed randomized controlled trials evaluating efficacy and safety of outpatient management of FN., Results: From 1448 reviewed articles, 14 studies were included for meta-analysis. (i) Inpatient versus outpatient setting (6 studies) was not significantly associated with treatment failure [risk ratio 0.81; 95% confidence interval (CI) 0.55-1.19; P = 0.28]. Death occurred in 13 of 742 FN episodes with no difference between the two groups (risk ratio 1.11; 95% CI 0.41-3.05; P = 0.83). (ii) Outpatient oral versus outpatient parenteral antibiotics (8 studies) were similarly efficacious with no association between route of drug administration and treatment failure (risk ratio 0.93; 95% CI 0.65-1.32; P = 0.67). No death occurred in 857 FN episodes., Conclusion: Based on the current literature, outpatient treatment of FN is a safe and efficacious alternative to inpatient management. Variation between studies in terms of time to discharge, choice of antibiotic class, and age of study population may limit the interpretation of the data.