Search

The population of older adults with cancer in the United States is rapidly increasing, which will have a substantial impact on the oncology and public health workforces across the cancer continuum, from prevention to end of life. Unfortunately, inequities in existing social structures that cause increased psychosocial stressors have led to disparities in the incidence of cancer and the morbidity and mortality of cancer for individuals from marginalized backgrounds. It is imperative that older adults, especially those from historically marginalized backgrounds, be adequately represented in all stages of cancer research to address health inequities. Continued efforts and progress toward achieving social justice and health equity require a deeper commitment to and better understanding of the impact of social determinants of health within the cancer domain. Undoubtedly, a more holistic and integrated view that extends beyond the biologic and genetic factors of health must be adopted for health entities to recognize the critical role of environmental, behavioral, and social determinants in cancer health disparities. Against this backdrop, this paper uses a life course approach to present a multifactorial framework for understanding and addressing cancer disparities in an effort to advance social justice and health equity for racially and ethnically diverse older adults.

Despite recent advances in cancer, racial disparities in treatment outcomes persist, and their mechanisms are still not fully understood. The objective of this study was to examine racial differences in frailty and geriatric assessment impairments in an unselected cohort of older adults with newly diagnosed gastrointestinal (GI) malignancies.This study used data from the Cancer and Aging Resilience Evaluation Registry, a prospective cohort study that enrolled older adults (≥60 years) with GI malignancies who were presenting for their initial consultation. Participants who had a geriatric assessment completed before chemotherapy initiation and self-reported as either White or Black were included. Frailty was defined with a frailty index based on the deficit accumulation method. The differences in the prevalence and adjusted odds ratios for frailty and geriatric assessment impairments between Black and White participants were examined.Of the 710 eligible patients who were seen, 553 consented with sufficient data for analyses. The mean age at enrollment was 70 ± 7.1 years, 58% were male, and 23% were Black. Primary cancer diagnoses included colorectal cancer (32%), pancreatic cancer (27%), and hepatobiliary cancer (18%). Black participants were more likely to be frail (50.0% vs 32.7%; P.001) and report limitations in activities of daily living (27.3% vs 14.1%; P = .001), instrumental activities of daily living (64.8% vs 47.3%; P = .002), and walking 1 block (62.5% vs 48.2%; P = .004). These associations persisted even after adjustments for age, sex, education, cancer type, cancer stage, and comorbidity.Black participants were frailer and reported more limitations in function in comparison with White participants. These findings may partially explain disparities in cancer outcomes and warrant further examination.

Objectives Oncologists estimate patients' prognosis to guide care. Evidence suggests oncologists tend to overestimate life expectancy, which can lead to care with questionable benefits. Information obtained from geriatric assessment may improve prognostication for older adults. In this study, we created a geriatric assessment-based prognostic model for older adults with advanced cancer and compared its performance to alternative models. Materials and methods We conducted a secondary analysis of a trial (URCC 13070; PI: Mohile) capturing geriatric assessment and vital status up to one year for adults age ≥ 70 years with advanced cancer. Oncologists estimated life expectancy as 0–6 months, 7–12 months, and > 1 year. Three statistical models were developed: (1) a model including age, sex, cancer type, and stage (basic model), (2) basic model + Karnofsky Performance Status (≤50, 60–70, and 80+) (KPS model), and (3) basic model +16 binary indicators of geriatric assessment impairments (GA model). Cox regression was used to model one-year survival; c-indices and time-dependent c-statistics assessed model discrimination and stratified survival curves assessed model calibration. Results We included 484 participants; mean age was 75; 48% had gastrointestinal or lung cancer. Overall, 43% of patients died within one year. Oncologists classified prognosis accurately for 55% of patients, overestimated for 35%, and underestimated for 10%. C-indices were 0.61 (basic model), 0.62 (KPS model), and 0.63 (GA model). The GA model was well-calibrated. Conclusions The GA model showed moderate discrimination for survival, similar to alternative models, but calibration was improved. Further research is needed to optimize geriatric assessment-based prognostic models for use in older adults with advanced cancer.

BackgroundAging-related deficits that eventually manifest as frailty may be associated with poor emotional health in older patients with advanced cancer. This study aimed to examine the relationship between frailty and emotional health in this population.MethodsThis was a secondary analysis of baseline data from a nationwide cluster randomized trial. Patients were aged ≥70 years with incurable stage III/IV solid tumors or lymphomas, had ≥1 geriatric assessment (GA) domain impairment, and had completed the Geriatric Depression Scale, Generalized Anxiety Disorder-7, and Distress Thermometer. Frailty was assessed using a Deficit Accumulation Index (DAI; range 0–1) based on GA, which did not include emotional health variables (depression and anxiety), and participants were stratified into robust, prefrail, and frail categories. Multivariate logistic regression models examined the association of frailty with emotional health outcomes. Adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were reported.ResultsFive hundred forty-one patients were included (mean age: 77 years; 70–96). DAI ranged from 0.04 to 0.94; 27% of patients were classified as robust, 42% prefrail, and 31% frail. Compared with robust patients, frail patients had an increased risk of screening positive for depression (aOR = 12.8; 95% CI = 6.1–27.0), anxiety (aOR = 6.6; 95% CI = 2.2–19.7), and emotional distress (aOR = 4.62; 95% CI = 2.9–8.3). Prefrail compared with robust patients also had an increased risk of screening positive for depression (aOR = 2.22; 95% CI = 1.0–4.8) and distress (aOR = 1.71; 95% CI = 1.0–2.8).ConclusionIn older patients with advanced cancer, frailty is associated with poorer emotional health, which indicates a need for an integrated care approach to treating these patients.Implications for PracticeA relationship exists between frailty and poor emotional health in older adults with advanced cancer. Identifying areas of frailty can prompt screening for emotional health and guide delivery of appropriate interventions. Alternatively, attention to emotional health may also improve frailty.

Background: Polypharmacy and potentially inappropriate medications (PIMs) are prevalent in older adults with cancer, but their associations with physical function are not often studied. This study examined the associations of polypharmacy and PIMs with physical function in older adults with cancer, and determined the optimal cutoff value for the number of medications most strongly associated with physical functional impairment. Methods: This cross-sectional analysis used baseline data from a randomized study enrolling patients aged ≥70 years with advanced cancer starting a new systemic cancer treatment. We categorized PIM using 2015 American Geriatrics Society Beers Criteria. Three validated physical function measures were used to assess patient-reported impairments: activities of daily living (ADL) scale, instrumental activities of daily living (IADL) scale, and the Older Americans Resources and Services Physical Health (OARS PH) survey. Optimal cutoff value for number of medications was determined by the Youden index. Separate multivariate logistic regressions were then performed to examine associations of polypharmacy and PIMs with physical function measures. Results: Among 439 patients (mean age, 76.9 years), the Youden index identified ≥8 medications as the optimal cutoff value for polypharmacy; 43% were taking ≥8 medications and 62% were taking ≥1 PIMs. On multivariate analysis, taking ≥8 medications was associated with impairment in ADL (adjusted odds ratio [aOR], 1.64; 95% CI, 1.01–2.58) and OARS PH (aOR, 1.73; 95% CI, 1.01–2.98). PIMs were associated with impairments in IADL (aOR, 1.72; 95% CI, 1.09–2.73) and OARS PH (aOR, 1.97; 95% CI, 1.15–3.37). A cutoff of 5 medications was not associated with any of the physical function measures. Conclusions: Physical function, an important component of outcomes for older adults with cancer, is cross-sectionally associated with polypharmacy (defined as ≥8 medications) and with PIMs. Future studies should evaluate the association of polypharmacy with functional outcomes in this population in a longitudinal fashion.

BACKGROUND: Little is known about how older adults (OA) with advanced cancer interact with social network members (NM), and the nature of communication. This qualitative study aimed to characterize the processes by which OAs with cancer engage with NMs regarding their illness. METHODS: OAs 65+ with advanced cancer and considering treatment (n=29) and NMs (n=18) underwent semi-structured interviews asking 1) about their illness understanding; 2) to identify NMs with whom OAs discuss health-related matters; and 3) to describe the content, process, and impact of those illness-related conversations. Three coders analyzed transcribed interviews. Codes were categorized and emergent themes were identified to generate hypotheses. RESULTS: OAs seek NMs with medical backgrounds for cancer-related information and NMs with personal experience of a serious illness for emotional support. Patients characterize geographical location, frequency of communication, and length of NM relationship as factors that influence the nature of support the NM provides. Additionally, differences emerged between OA and NM perspectives on the depth of conversations and decision-making. CONCLUSIONS: A better characterization of how OAs’ seek and share information and support may improve medical communication, disease understanding, and support goals-concordant care. PRACTICAL IMPLICATIONS: Findings support more strategic involvement of key NMs in cancer-related conversations.

Despite substantial improvements in the outcomes of patients with cancer over the past two decades, older adults (aged ≥65 years) with cancer are a rapidly increasing population and continue to have worse outcomes than their younger counterparts. Managing cancer in this population can be challenging because of competing health-related and ageing-related conditions that can influence treatment decision-making and affect outcomes. Geriatric screening tools and comprehensive geriatric assessment can help to identify patients who are most at risk of poor outcomes from cancer treatment and to better allocate treatment for these patients. The use of evidence-based management strategies to optimize geriatric conditions can improve communication and satisfaction between physicians, patients and caregivers as well as clinical outcomes in this population. Clinical trials are currently underway to further determine the effect of geriatric assessment combined with management interventions on cancer outcomes, as well as the predictive value of geriatric assessment in context of treatment with contemporary systemic therapies, such as immunotherapies and targeted therapies. In this Review, we summarize the unique challenges of treating older adults with cancer and describe current guidelines as well as investigational studies underway to improve the outcomes of these patients.

PURPOSE: Chronic inflammation is a significant physiologic feature of frailty; however, its role and clinical utility in cancer-related frailty remains unknown. We sought to determine if pre-chemotherapy inflammation is predictive of frailty after chemotherapy in patients with breast cancer. METHODS: Female patients (N=144; age ≥50) with stage I-III breast cancer scheduled to receive chemotherapy and age-matched non-cancer controls (N=142) were included in this secondary analysis and assessed pre- and post-chemotherapy. Controls were assessed at equivalent time-points. Frailty was assessed using a modified Fried’s score (0-4) using self-reported measures of weakness, exhaustion, walking speed, and physical activity. Serum levels of interleukin (IL) 6, and soluble tumor necrosis factor-alpha (sTNFR) I and II were measured. Associations between pre-chemotherapy cytokine and receptors level (median as cutoff) and post-chemotherapy frailty were evaluated using T-tests. RESULTS: Pre-chemotherapy, patients with breast cancer were more frail than non-cancer controls (mean score: 1.17 vs 0.65; p

This letter to the editor responds to comments on an article that reported on the prevalence of frailty, anxiety, depression, and distress and the relationships between frailty and emotional health in older patients with advanced cancer.

BACKGROUND A geriatric assessment (GA) intervention improves communication about aging-related concerns, but its effect on communication in patients with various levels of frailty is unknown. METHODS This was a secondary analysis of a nationwide trial of patients aged ≥70 years with incurable cancer and impairment on 1 or more GA domains (ClinicalTrials.gov Identifier NCT02107443; principal investigator Supriya G. Mohile). Practice sites were randomized to either the GA-intervention or usual care. Frailty was assessed with a deficit accumulation index (range, 0-1), and patients were stratified as robust (0 to

BACKGROUND Older patients with advanced cancer who are 100% certain they will be cured pose unique challenges for clinical decision making, but to the authors' knowledge, the prevalence and correlates of absolute certainty about curability (ACC) are unknown. METHODS Cross-sectional data were collected in a geriatric assessment trial. ACC was assessed by asking patients, "What do you believe are the chances that your cancer will go away and never come back with treatment?" Response options were 100% (coded as ACC), >50%, 50/50

PURPOSE: Older patients with advanced cancer often have comorbidities that can worsen their cancer and treatment outcomes. We assessed how a geriatric assessment (GA)–guided intervention can guide conversations about comorbidities among patients, oncologists, and caregivers. METHODS: This secondary analysis arose from a nationwide, multisite cluster-randomized trial (ClinicalTrials.gov identifier: NCT02107443 ). Eligible patients were ≥ 70 years, had advanced cancer (solid tumors or lymphoma), and had impairment in at least one GA domain (not including polypharmacy). Oncology practices (n = 30) were randomly assigned to usual care or intervention. All patients completed a GA; in the intervention arm, a GA summary with recommendations was provided to their oncologist. Patients completed an Older Americans Resources and Services Comorbidity questionnaire at screening. The clinical encounter following GA was audio-recorded, transcribed, and coded for topics related to comorbidities. Linear mixed models examined the effect of the intervention on the outcomes adjusting for practice site as a random effect. RESULTS: Patients (N = 541) were 76.6 ± 5.2 years old; 94.6% of patients had at least one comorbidity with an average of 3.2 ± 1.9. The intervention increased the average number of conversations regarding comorbidities per patient from 0.52 to 0.99 ( P < .01). Moreover, there were a greater number of concerns acknowledged (0.52 v 0.32; P = .03) and there was a 2.4-times higher odds of having comorbidity concerns addressed via referral, handout, or other modes (95% CI, 1.3 to 4.3; P = .004). Most oncologists in the intervention arm (76%) discussed comorbidities in light of the treatment plan, and 41% tailored treatment plans. CONCLUSION: Providing oncologists with a GA-guided intervention enhanced communication regarding comorbidities.

Older adults with advanced cancer are at a high risk for treatment toxic effects. Geriatric assessment evaluates ageing-related domains and guides management. We examined whether a geriatric assessment intervention can reduce serious toxic effects in older patients with advanced cancer who are receiving high risk treatment (eg, chemotherapy).In this cluster-randomised trial, we enrolled patients aged 70 years and older with incurable solid tumours or lymphoma and at least one impaired geriatric assessment domain who were starting a new treatment regimen. 40 community oncology practice clusters across the USA were randomly assigned (1:1) to the intervention (oncologists received a tailored geriatric assessment summary and management recommendations) or usual care (no geriatric assessment summary or management recommendations were provided to oncologists) by means of a computer-generated randomisation table. The primary outcome was the proportion of patients who had any grade 3-5 toxic effect (based on National Cancer Institute Common Terminology Criteria for Adverse Events version 4) over 3 months. Practice staff prospectively captured toxic effects. Masked oncology clinicians reviewed medical records to verify. The study was registered with ClinicalTrials.gov, NCT02054741.Between July 29, 2014, and March 13, 2019, we enrolled 718 patients. Patients had a mean age of 77·2 years (SD 5·4) and 311 (43%) of 718 participants were female. The mean number of geriatric assessment domain impairments was 4·5 (SD 1·6) and was not significantly different between the study groups. More patients in intervention group compared with the usual care group were Black versus other races (40 [11%] of 349 patients vs 12 [3%] of 369 patients; p0·0001) and had previous chemotherapy (104 [30%] of 349 patients vs 81 [22%] of 369 patients; p=0·016). A lower proportion of patients in the intervention group had grade 3-5 toxic effects (177 [51%] of 349 patients) compared with the usual care group (263 [71%] of 369 patients; relative risk [RR] 0·74 (95% CI 0·64-0·86; p=0·0001). Patients in the intervention group had fewer falls over 3 months (35 [12%] of 298 patients vs 68 [21%] of 329 patients; adjusted RR 0·58, 95% CI 0·40-0·84; p=0·0035) and had more medications discontinued (mean adjusted difference 0·14, 95% CI 0·03-0·25; p=0·015).A geriatric assessment intervention for older patients with advanced cancer reduced serious toxic effects from cancer treatment. Geriatric assessment with management should be integrated into the clinical care of older patients with advanced cancer and ageing-related conditions.National Cancer Institute.

Objectives Rural-urban disparities in the experiences of caregivers of older adults with advanced cancer may exist. This study examined factors associated with caregiver mastery and burden and explored whether rural-urban disparities in caregiver outcomes differed by education. Materials and methods Longitudinal data (baseline, 4–6 weeks, and 3 months) on caregivers of older adults (≥ 70) with advanced cancer were obtained from a multicenter geriatric assessment (GA) trial ( ClinicalTrials.gov : NCT02107443 ). Rurality was determined based on 2010 Rural-Urban Commuting Area codes. Caregivers' education was categorized as ≥ some college vs ≤ high school. Caregiver outcomes included Ryff Environmental Mastery (scored 7–35) and Caregiver Reaction Assessment (including self-esteem, disrupted schedules, financial problems, lack of social support, and health problems; each scored 1–5). Separate linear mixed models with interaction term of education and rurality were performed. Results Of 414 caregivers, 64 (15.5%) were from rural areas and 263 (63.5%) completed ≥ some college. Rurality was significantly associated with more disrupted schedules (β = 0.21), financial problems (β = 0.17), and lack of social support (β = 0.11). A significant interaction between education and rurality was found, with rurality associated with lower mastery (β = −1.27) and more disrupted schedule (β = 0.25), financial problems (β = 0.33), and lack of social support (β = 0.32) among caregivers with education ≤ high school. Conclusion Our study identifies subgroups of caregivers who are vulnerable to caregiving burden, specifically those from rural areas and with lower education. Multifaceted interventions are needed to improve caregivers' competency and reduce caregiving burden.

Cancer-related fatigue (CRF) is among the most commonly reported side effects experienced by cancer patients and survivors. Approximately one-third of women with breast cancer continue to suffer from CRF, even years after the completion of treatment. The causal mechanisms of CRF are not fully understood. However, numerous studies have demonstrated that systemic inflammation is associated with CRF. Hypothalamic-pituitary-adrenal (HPA) dysregulation, endocrine dysfunction, and sleep disturbance have also been proposed as contributing factors to CRF. Due to the high prevalence of CRF, the American Society of Clinical Oncology (ASCO) recommends that oncologists routinely and systematically screen for CRF throughout the cancer trajectory and provide prompt and specific treatments. Patients with CRF should be evaluated for treatable contributing factors (e.g., anemia, hypothyroidism), and, if found, their treatment plan should address those factors. CRF treatments include non-pharmacologic and pharmacologic therapies. Non-pharmacologic therapies such as physical activity, mind-body interventions, and psychosocial therapies have demonstrated promising efficacy and should be considered in the initial management of CRF. In this chapter, we explained the definition, prevalence, and impact of CRF and reviewed possible mechanisms associated with CRF. We also provide an algorithm based on clinical guidelines developed by the National Comprehensive Cancer Network (NCCN), the ASCO, the Pan-Canadian Practice Guideline Committee, and the Oncology Nursing Society to guide oncologists and other health professionals in screening, assessing, and prescribing treatments of CRF in breast cancer survivors.

Background Adult cancer survivors (ACS) are at increased risk for developing various comorbid conditions and having poor health-related quality of life (HRQOL) when compared to adults with no history of cancer. The effect of social and emotional support on HRQOL among ACS is not fully elucidated. The purpose of this study was to understand the role of social and emotional support on HRQOL in ACS and to examine if the association between social and emotional support and HRQOL is modified by gender, time since cancer diagnosis, or marital status. Methods Data for this study were obtained from the 2009 Behavioral Risk Factor Surveillance System. Statistical analysis was based on ACS with complete data (n = 23,939) on all variables considered. Multivariable logistic regression models were used to model the association between social and emotional support and indicators of HRQOL (i.e., general health, physical health, mental health, and activity limitation). To examine if gender, marital status, or the number of years since cancer diagnosis modify the association, separate stratified analyses were conducted. Results When compared to ACS who reported that they Rarely/Never received social and emotional support, those who reported that they Always received were 32 % less likely to report Fair/Poor General health, 23 % less likely to report frequent unhealthy days of Physical health, 73 % less likely to report frequent unhealthy days of Mental health and 38 % less likely to report frequent unhealthy days of Activity limitation. Social and emotional support was positively associated with all four domains of HRQOL among ACS who were female, unmarried, or greater than 5 years since cancer diagnosis, while this positive association was evident only with one or two domains of HRQOL among their corresponding counterparts (i.e., male, married, less than 5 years since diagnosis). Conclusions Social and emotional support is an important factor directly related to a better HRQOL, but it is modified by gender, marital status, and time since diagnosis. Findings from this study should inform health care providers about the importance of a support system for ACS in improving their overall quality of life.

Objectives Polypharmacy (PP) and potentially inappropriate medications (PIM) are common in older adults with cancer, increasing the risk of adverse outcomes. Approaches to identifying and addressing PP/PIM are needed. Materials and Methods Patients ≥70 years with advanced cancer were enrolled in this cluster-randomized study. All underwent geriatric assessment (GA), and oncologists randomized to the intervention arm received GA-driven recommendations; no information was provided to oncologists at usual care sites. For patients with PP (≥5 medications or ≥1 high-risk medication), clinic visits with treating oncologists were audiorecorded and transcribed, and discussions regarding PP/PIM identified. Quality of provider response was coded as dismissed, mentioned, acknowledged, or addressed. Results Forty patient transcripts were analyzed (20 per arm). More discussions occurred in the intervention group (n = 81) versus the usual care group (n = 51). More concerns per patient were brought up in the intervention group (4.1 vs. 2.6, p = 0.07). Physician-initiated discussions were higher in the intervention group (73% vs. 49%, p = 0.006). More PP concerns were “addressed” in the intervention group (59% vs. 45%, p = 0.1). Oncology supportive care medication concerns were more often addressed in the usual care group (58% vs. 18%, p = 0.008), but medication management concerns were addressed more commonly in the intervention group (38% vs. 79%, p = 0.003). Conclusion In this secondary analysis, a GA-driven intervention increased PP discussions, particularly about total number of medications and medication management. PP/PIM concerns were more commonly addressed in the intervention group, except for the subset of conversations about supportive care medications.

Objectives Older self-perceived age is associated with poor health and higher healthcare utilization in the geriatric population. We evaluated the associations of self-perceived age with geriatric assessment (GA) domain impairments in older adults with cancer. Methods This was a secondary analysis of baseline data from a GA cluster-randomized trial (URCC 13070; PI: Mohile). We included patients aged ≥70 with incurable stage III/IV solid tumor or lymphoma considering or receiving treatment and had ≥1 GA domain impairment other than polypharmacy. Multivariate analyses were used to evaluate the associations of age difference between chronological and self-perceived age (categorized into “feeling younger than chronological age” vs. “feeling the same or older than their chronological age”) with GA domain impairments. Results We included 533 patients; mean age was 76.6 (SD 5.2). On multivariate analyses, compared to those who felt younger than their chronological age, those who felt the same or older were more likely to have impairments in physical performance [Adjusted Odds Ratio (AOR) 5.42, 95% Confidence Interval (CI) 1.69–17.40)], functional status (AOR 2.31, 95% CI 1.73–3.07), comorbidity (AOR 1.62, 95% CI 1.20–2.19), psychological health (AOR 2.62, 95% CI 1.85–3.73), and nutrition (AOR 1.65, 95% CI 1.20–2.28). They were also more likely to screen positively for polypharmacy (AOR 1.86, 95% CI 1.30–2.65). Conclusions Older adults with cancer who felt the same or older than their chronological age were more likely to have GA domain impairments. Further studies are needed to better understand the relationships between self-perceived age, aging-related conditions, and outcomes in this population.

OBJECTIVES To evaluate the relationships between aging-related domains captured by geriatric assessment (GA) for older patients with advanced cancer and caregivers' emotional health and quality of life (QOL). DESIGN In this cross sectional study of baseline data from a nationwide investigation of older patients and their caregivers, patients completed a GA that included validated tests to evaluate eight domains of health (eg, function, cognition). SETTING Thirty-one community oncology practices throughout the United States. PARTICIPANTS Enrolled patients were aged 70 and older, had one or more GA domain impaired, and had an incurable solid tumor malignancy or lymphoma. Each could choose one caregiver to enroll. MEASUREMENTS Caregivers completed the Generalized Anxiety Disorder-7, Distress Thermometer, Patient Health Questionnaire-2 (depression), and Short Form Health Survey-12 (SF-12 for QOL). Separate multivariate linear or logistic regression models were used to examine the association of the number and type of patient GA impairments with caregiver outcomes, controlling for patient and caregiver covariates. RESULTS A total of 541 patients were enrolled, 414 with a caregiver. Almost half (43.5%) of the caregivers screened positive for distress, 24.4% for anxiety, and 18.9% for depression. Higher numbers of patient GA domain impairments were associated with caregiver depression (adjusted odds ratio [aOR] = 1.29; P

Active patient partner engagement with SCOREboard – a diverse group of older patients with cancer, caregivers of older patients with cancer, survivors, and patient advocates – to conduct the largest randomized geriatric assessment clinical trial to date, has been shown to be feasible and resulted in tangible and invaluable benefits for both the research team and patient partners alike. Actively engaging patient partners should be an essential component in the development, conduct, and completion of all clinical research.

OBJECTIVES: Cancer-related fatigue is characterized by an overwhelming sense of tiredness that cannot be relieved by sleep or rest; it often persists for years into survivorship. Maintaining appropriate nutritional status is critical during cancer treatment, though few studies have assessed relationships between diet quality and cancer-related fatigue. Herein, we aimed to investigate the association between serum lycopene, a proxy for diet quality, and fatigue in a large representative sample of the US population. METHODS: Data were obtained from the 2005–2006 NHANES dataset. Serum total lycopene was quantified from fasting blood samples and used as a continuous variable. Patient-reported fatigue was assessed from a question on the validated Patient Health Questionnaire-9: “Over the last 2 weeks, how often have you been bothered by… feeling tired or having little energy?”; fatigue was categorized as no fatigue (0), low fatigue (1), or moderate-severe fatigue (2–3). Multinomial regression models were applied to assess the association between serum lycopene and fatigue while controlling for age, race/ethnicity, and body mass index. Results are reported as odds ratios (OR) and 95% confidence intervals (CIs) for having low or moderate-severe vs. no fatigue for a 10-μg/dL increase in serum lycopene for all participants and those with a previous cancer diagnosis. RESULTS: Participants (n = 4091) were 48.3 ± 18.7 years old, 52% female, and 51.7% non-Hispanic White; 329 had a prior cancer diagnosis. A self-reported cancer diagnosis was associated with a 31.8% greater odds of having moderate-severe vs. no fatigue (OR = 1.32, 95% CI = 1.12–1.55) and a 6.8% greater odds of having low fatigue (OR = 1.07, 95% CI = 0.93–1.22). A 10-μg/dl increase in serum lycopene concentrations was associated with a 5.3% lower odds of moderate-severe vs. no fatigue (OR = 0.95, 95% CI = 0.90–0.99) and a similar odds of low fatigue (OR = 1.01, 95% CI = 0.97–1.04). These associations were similar for patients who had had a cancer diagnosis. CONCLUSIONS: Higher levels of serum lycopene were associated with lower odds of moderate-severe. Dietary interventions should be further explored for their associations with cancer-related fatigue among patients with cancer and cancer survivors. FUNDING SOURCES: National Cancer Institute.

12017 Background: Patients commonly experience impaired sleep throughout cancer treatment and for years into survivorship. Impaired sleep may mediate other cancer-related symptoms and can lead to the inability to complete daily activities and lower quality of life. More effective non-pharmacological treatment options for impaired sleep are needed. We conducted a nationwide, multicenter, phase III randomized controlled trial (RCT) comparing the effects of yoga (Yoga for Cancer Survivors; YOCAS), cognitive behavioral therapy for insomnia (CBT-I), and a behavioral placebo on impaired sleep in cancer survivors. Methods: This RCT was conducted via the URCC NCORP Research Base. Participants were cancer survivors 2-60 months post-treatment with insomnia. They were randomized to 1) YOCAS (75-min session biweekly for 4 wks), 2) CBT-I (90-min session weekly for 8 wks), and 3) behavioral placebo (survivorship health education per ASCO guidelines; 75-min session biweekly for 4 wks). Sleep efficiency, sleep duration, wake after sleep onset (WASO), and sleep latency were assessed via actigraphy at baseline and post-intervention. Actigraphs were worn on the non-dominant wrist 24 hours a day for 7 days. Linear mixed models were used to assess intervention effects on sleep outcomes. Results: 740 survivors were enrolled (93% female, mean age 56±11 years, 73% breast cancer). Results revealed significant group differences among survivors in the 3 arms in sleep efficiency, sleep duration, and WASO (all p0.05). YOCAS and CBT-I subjects maintained sleep efficiency (mean change= -0.8% and -0.03%, respectively, all p>0.05) while behavioral placebo subjects significantly reduced sleep efficiency (mean change= -3.4%, p0.05) while CBT-I and behavioral placebo subjects significantly reduced sleep duration (mean change= -20.3 minutes and -26.6 minutes, respectively, all p

12049 Background: Prior studies suggest that social support plays a role in disease understanding of older patients with advanced cancer. In this study, we examined the association of quantity and quality of social support with belief in curability among older patients with advanced incurable cancer. Methods: We performed a secondary analysis of a cluster-randomized geriatric assessment trial (URCC 13070: PI Mohile) that recruited older adults (≥70) with advanced incurable cancer and caregivers. At enrollment, patients completed the Older Americans Resources and Services (OARS) Medical Social Support form to measure both quantity (number of close friends and relatives) and quality of social support. Quality of social support was measured using twelve questions, each ranged from 1 (none of the time) to 5 (all of the time). Higher cumulative scores indicated greater quality of support. For beliefs in curability, patients were asked, “What do you believe are the chances that your cancer will go away and never come back with treatment?” Responses were 0%, 50%, and 100%. Ordinal logistic regression was used to investigate the association of social support with beliefs in curability, adjusting for adjusting for age, gender, education, race, number of Geriatric Assessment (GA) impairments, cancer type, and locality (rural versus urban). Results: We included 347 patients; mean age was 76.4 years, 91% were white, 52% were male, 46% had household income

12114 Background: In a nationwide prospective study, we found that patients with breast cancer had greater perceived cognitive impairment (PCI) before and after chemotherapy compared to controls without cancer. To gain further insight into the role that inflammation plays in cognitive function, we evaluated relationships between immune cell counts and lymphocyte:monocyte ratio with PCI at pre- and post- chemotherapy. Methods: Data were collected as part of longitudinal cohort study conducted through the National Cancer Institute Community Oncology Research Program network (NCT01382082). Self-reported PCI was scored at pre-chemotherapy (0-7 days before first chemotherapy) and post-chemotherapy (0-30 days after last chemotherapy) from the PCI sub-scale of the Functional Assessment of Cancer Therapy: Cognitive Function (possible score range 0-72). Immune cell counts were measured by complete blood count with differential at pre- and post- chemotherapy. Lymphocyte:monocyte ratio (LMR) was calculated. Separate linear regression models evaluated the association of immune cell counts and LMR with 1) pre-chemotherapy PCI and 2) post-chemotherapy PCI. Models were adjusted for age, cognitive reserve (reading score), anxiety, and depression. Results: PCI and immune cell data were available for 544 patients at pre-chemotherapy and 532 at post-chemotherapy. Subjects had a mean age of 53.1 (SD=10.8). At pre-chemotherapy, higher basophil count and higher LMR were significantly associated with worse PCI (β=5.73, SE=2.37, p

12109 Background: Cancer-related fatigue is a common, debilitating condition that can persist for months or years after cancer treatment. Time-restricted eating has been shown to improve circadian rhythm and strengthen rest and activity patterns, and therefore could help reduce persistent fatigue. Herein, we evaluated the feasibility of recruiting cancer survivors to a two-week, single-arm, time-restricted eating intervention with a 10-h eating window, assessed safety of the intervention, monitored adherence, and obtained initial estimates of within-group change in patient-reported fatigue. Methods: We recruited adults 4-60 months post-cancer treatment who had a fatigue level ≥3 on a scale from 0-10 and who did not already consume food within a 10-h window. Participants were asked to consume all food and beverages within a self-selected 10-h eating window for 14 days; water was allowed at all times. Participants completed a daily diary indicating when they began and stopped eating each day. To assess fatigue, participants completed the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) and the Brief Fatigue Inventory (BFI) at pre- and post-intervention. We report mean±standard deviation and used a t-test to assess differences in pre- vs. post-intervention scores. Results: A total of 21 participants consented (20 breast cancer, 1 prostate cancer; 20 female; age 57.7±11.4 years; 1.6±1.1 years post-primary treatment). The study was feasible: 19/21 (90.5%) completed pre- and post-intervention assessments and daily diaries. It was also safe: there were two mild adverse events—one unlikely (insomnia) and one possibly related to the intervention (acute headache) and no severe adverse events. Most of the participants adhered to the intervention; 14/19 (73.7%) ate all of their food within a 10-h window at least 80% of the days, and 16/19 (84.2%) reported an average eating window ≤10 h. Fatigue scores improved a clinically meaningful degree for FACIT-F total score, FACIT-F fatigue subscale, and the BFI total score from pre- to post-intervention per established cutoffs (Table). Conclusions: Cancer survivors were willing and able to adhere to a two-week time-restricted eating intervention, and the intervention was safe. Also, fatigue was reduced with moderate to large effect sizes after two weeks of time-restricted eating. Based on our results, a follow-up randomized controlled trial to investigate time-restricted eating to alleviate cancer-related fatigue among cancer survivors is indicated. Funding: NIH/NCI UG1CA189961, T32CA102618. Clinical trial information: NCT04243512. [Table: see text]

562 Background: Chemotherapy adversely affects the immune system and physical function. Inflammation is independently associated with functional decline. Compared to the individual cytokines [e.g., interleukin-6 (IL-6)], the pro-inflammatory index, IL-6/IL-10 ratio, is a better predictor of poor outcomes and mortality in many diseases. Other markers of inflammation such as soluble tumor necrosis factor (sTNFR) I, and sTNFRII have also been shown to be predictive of poor outcomes. We have previously reported a significant increase in sTNFRI/II with chemotherapy in patients with breast cancer. However, it is not yet understood if chemotherapy-related changes to inflammatory makers is associated with physical function after treatment. In this study, we assessed the relationship between changes of pro-inflammatory markers during chemotherapy with physical function after completing chemotherapy. Methods: This was a secondary analysis of a large nationwide cohort study in women with stage I-III breast cancer (NCT01382082). Serum levels of IL6, IL10, sTNFRI, and sTNFRII were measured ≤7 days before chemotherapy (T1) and ≤1 month after chemotherapy (T2), and the IL6/IL10 ratio was calculated. Absolute changes (T2-T1) of sTNFR-I and sTNFRII (reported in pg/mL) and the IL6/IL10 ratio were calculated. Physical function was measured by the Functional Assessment of Cancer Therapy: General – physical well being (FACT-PWB) at T1 and T2 and contains 7-items, each using a 5-point rating scale ranging from 0 (Not at all) to 4 (Very much), with a total score ranging from 0-28; higher scores represent higher physical function. ANOVA was used to compare means of FACT-PWD scores and mean changes of pro-inflammatory markers. Multivariate linear regressions were used to determine if increased pro-inflammatory markers were associated with lower FACT-PWD at T2, controlling for baseline FACT-PWD, age, race, education, and marital status. Results: We included 580 patients (mean age=53 years, range 22-81). Physical function significantly and clinically declined from T1-T2 (mean=22.2, SE=0.23 vs mean=19.4, SE=0.25; p

10559 Background: Lung cancer is the leading cause of cancer death in the U.S, accounting for about 25% of all cancer mortality. The U.S Preventive Services Task Force has recommended annual screening for lung cancer using low-dose computed tomography (LDCT) scanning for individuals at higher risk (aged 55-80 years with a >30 pack-year smoking history). Early detection using LDCT scanning reduces lung cancer specific mortality by 20%. Despite its efficacy, the uptake of annual lung cancer screening among high-risk individuals remains low ( < 18%). The purpose of this study was to identify factors associated with the uptake of lung cancer screening in high-risk individuals in the U.S population. Methods: Data for this study were obtained from the 2017-2019 Behavioral Risk Factor Surveillance System (BRFSS), a population-based survey conducted annually by the Centers for Disease Control and Prevention (CDC) in collaboration with health departments in all 50 states, Washington, DC, and the U.S territories. We restricted our sample to high-risk individuals aged 55-80 years with a >30 pack-year smoking history. Only subjects with complete data on all predictor variables (age, gender, race/ethnicity, marital status, education, income, insurance, COPD, current smoking status, primary care provider) and the outcome variable (uptake of lung cancer screening) (n = 11, 714) were included in the final analysis. Chi-square tests were used to compare the uptake of lung cancer screening by demographic and socioeconomic factors. Multivariable logistic regression models were used to model the association between the predictors and the outcome variable. Results: Individuals with no health insurance (OR: 0.64; 95%CI: 0.46-0.90), no primary healthcare provider (OR: 0.40; 95%CI: 0.31-0.52), no chronic obstructive pulmonary disease (COPD) (OR: 0.35; 95%CI: 0.31-0.0.40) and who were females (OR: 0.86; 95%CI: 0.76-0.96) were less likely to participate in annual lung cancer screening. Individuals aged 65–69 years (OR: 1.65; 95%CI: 1.38-1.97), 70–74 years (OR: 1.77; 95%CI: 1.46-2.14) or 75–80 years (OR: 1.42; 95%CI: 1.16-1.76) were more likely to receive annual lung cancer screening compared with those aged 55-59 years. Race/ethnicity, level of education, level of income, marital status, and current smoking status had no significant association with the uptake of annual lung cancer screening. Conclusions: Our study identifies factors associated with lower uptake of annual lung cancer screening (no health insurance coverage, no primary healthcare provider, no COPD, and female gender). The findings from this study have important implications for the design of more effective interventions to target specific subgroups for the uptake of annual lung cancer screening.

138 Background: GA evaluates aging-related domains (e.g., function) known to be associated with cancer treatment toxicity. We found that providing a GA summary with management recommendations to oncologists reduces clinician-rated toxicity in older patients with advanced cancer receiving high risk treatment (presented at ASCO2020). Herein, we report on the effects of the GA intervention on symptomatic toxicities measured by Patient-Reported Outcomes Common Terminology Criteria for Adverse Events [PRO-CTCAE]. Methods: In the national cluster randomized clinical trial eligible patients (n=718) had age>70, advanced solid tumors or lymphoma, 1+ GA impairment, and were initiating a new treatment regimen with high risk of toxicity. Severity grade of 24 PRO-CTCAE items was collected on a 0-4 scale at enrollment, 4-6 weeks, 3, and 6 months. Of 24 items, 11 (e.g. fatigue, dyspnea) were classified as core (Reeve 2014). Baseline adjusted method (Basch 2016) was used to determine symptomatic toxicities: if the severity of any item increased after baseline to grade 2 or higher, the patient was classified as experiencing grade ≥2 event (similarly for grade ≥ 3 events). The effects of GA intervention on symptomatic toxicities were assessed using generalized linear mixed model (GLMM) with random effect for the practice cluster. Results: Mean age was 77 years (range 70-96); 43% female, 87% white; 34% had gastrointestinal and 25% had lung cancer; 27% received prior chemotherapy. 710 patients provided PRO-CTCAE data (366 usual care, 344 intervention), 85.6% reported grade ≥2 and 49.4% grade ≥3 events at baseline. After baseline, compared to usual care, patients in the GA intervention arm reported fewer grade ≥2 overall symptomatic toxicities (76.5% vs. 84.7%) and fewer core symptomatic toxicities (grade ≥2: 71.8% vs. 82.0%; grade ≥3: 46.2% vs. 53.6%). Specifically, less dyspnea and less fatigue was reported in GA-arm (Table). Conclusions: GA intervention resulted in fewer symptomatic toxicities as evaluated by PRO-CTCAE. Clinical trial information: NCT02054741 . [Table: see text]

33 Background: GA evaluates aging-related domains (e.g., function) known to be associated with cancer treatment toxicity. We found that providing a GA summary with management recommendations to oncologists reduces clinician-rated toxicity in older patients (pts) with advanced cancer receiving high risk treatment (presented @ASCO2020). Herein, we report secondary outcomes on the effects of the GA intervention on aging-related outcomes. Methods: Pts aged ≥ 70 with incurable solid tumors or lymphoma and ≥ 1 impaired GA domain starting a new treatment regimen were enrolled. Community oncology practices were randomized to intervention (oncologists received GA summary/recommendations) or usual care (none given). Secondary analyses examined effects of the intervention on functional outcomes (patient-reported falls, instrumental activities of daily living (IADL), short physical performance battery (SPPB), geriatric depression scale (GDS), and medications [total and prescription]). Outcomes were analyzed using linear mixed effects model, logistic or Poisson regression adjusted for baseline values, time, and site effects as appropriate. Results: From 2013-19, 718 pts were enrolled from 41 practices. Age (mean 77 yrs), sex (43% women), number of impaired GA domains (median 4/8), and treatment type (chemotherapy 88%) were not different by arm. More pts in intervention were black (12% vs 3%, p

12040 Background: Older patients with advanced cancer often have comorbidities that increase the risk of toxicity from neoplastic therapy but are not always considered in treatment planning. We assessed the utility of a geriatric assessment (GA) intervention to increase the number and quality of discussions about comorbidities among oncologists, older patients, and caregivers. Methods: This multi-site trial enrolled patients who were ≥70 years, had advanced solid tumors or lymphoma, had ≥1 GA impairment, and who were considering or receiving cancer treatment. All patients received the GA and completed an Older Americans Resources and Services Comorbidity survey, which evaluated 15 conditions and interference with activities (clinical impairment = ≥3 comorbidities or ≥1 highly interfering). Oncology practices were randomized to intervention (GA with a summary with management recommendations provided to oncologists) or usual care (GA only). The clinic visit after GA was audio-recorded, transcribed, and coded for GA topics including comorbidity. Generalized linear mixed models adjusting for site (random effect) were used to assess the effect of the intervention. Results: Patients (n=527 evaluable, 76.6±5.2 years, 49% female) and oncologists (n=131, 63 in intervention) were enrolled from 31 sites. In total, 94.5% of patients had ≥1 comorbidity with an average of 3.2±1.9; 64% were clinically impaired by comorbidity (p=0.76 between arms). The intervention arm had twice the number of conversations about comorbidities (1.02 vs. 0.52 conversations per patient, difference 0.50, 95% CI 0.18-0.81, p=0.004) and conversations were more likely to be initiated by the oncologist (p

549 Background: Chemotherapy adversely affects physical function. While many patients recover after treatment (i.e. are resilient), some are unable to return to their pre-treatment function (i.e. are non-resilient). Since immune dysfunction may play a role in functional decline, we assessed the relationship of pre-chemotherapy immune cell profiles with functional decline and resilience in women with breast cancer receiving chemotherapy. Methods: This study was based on a large nationwide cohort study in women with stage I-III breast cancer. Physical function was measured by the Functional Assessment of Cancer Therapy: General – Physical subscale (FACT-PWB) ≤7 days before chemotherapy (T1), ≤1 month after chemotherapy (T2), and 6 months after T2 (T3). Functional decline at T2 and T3 was defined as > 1 point decrease (clinically meaningful difference) in FACT-PWD score from T1. Patients were considered non-resilient if they had T2 functional decline and did not return to within 1 point of their baseline FACT-PWB score by T3. Immune cell counts, neutrophil:lymphocyte ratio (NLR), and lymphocyte:monocyte ratio (LMR) were obtained at T1. Multivariate logistic regressions were used to determine whether immune cell counts and ratios were associated with functional decline and being non-resilient controlling for baseline FACT-PWD, age, race, education, and marital status. Results: One-third of patients (178/529; mean age 53, range 22-81) had functional decline from T1-T3. Of the 59% (n = 310) of patients with functional decline at T2, 50% (n = 147) did not recover by T3 (i.e. were non-resilient). Patients with a low ( < median) NLR at T1 were twice as likely to have functional decline by T3 than those with a high (≥ median) NLR [Adjusted Odds Ratio (AOR) 1.8, 95% CI: 1.2-2.8, p < 0.01]. Similarly, in patients with functional decline at T2, those with a low NLR at T1 were twice as likely to be non-resilient than those with high NLR (AOR: 1.9, 95% CI: 1.1-3.2, p = 0.01). Conversely, patients with high T1 lymphocytes were twice as likely to be non-resilient than those with low lymphocytes (AOR: 1.8, 95% CI: 1.1-3.1, p = 0.02). Conclusions: One-third of women with breast cancer have clinically meaningful, persistent functional decline six months after completing chemotherapy. Higher pre-chemotherapy lymphocytes and lower NLR may be useful to identify which women are at increased risk of functional decline and reduced ability to regain baseline physical function. These findings can inform interventions to ameliorate this decline.

12009 Background: GA evaluates aging-related domains (e.g., function) known to be associated with cancer treatment toxicity. In this CRCT, we evaluated if providing a GA summary with management recommendations to oncologists can reduce toxicity in older patients (pts) with advanced cancer receiving chemotherapy and/or other agents with a high reported prevalence of grade 3-5 toxicity. Methods: Pts aged > 70 with incurable solid tumors or lymphoma and > 1 impaired GA domain starting a new treatment regimen were enrolled. Community oncology practices were randomized to intervention (oncologists received GA summary/recommendations for impairments) or usual care (none given). The primary outcome was proportion of pts who experienced any grade 3-5 toxicity (CTCAE v.4) within 3 months. Practice staff prospectively captured toxicities; blinded oncology clinicians reviewed medical records to verify. Secondary outcomes included 6 month overall survival (OS) and treatment intensity (standard vs reduced). Outcomes were analyzed using generalized linear mixed/Cox models with Arm as a fixed effect, controlling for practice. Results: From 2013-19, 718 pts were enrolled from 41 practices. Age (mean 77 yrs), sex (43% women), number of impaired GA domains (median 4/8), and treatment type (chemotherapy 88%) were not different by Arm. More pts in intervention were Black (12% vs 3%, p

12070 Background: Cognitive impairment is a prevalent side effect of chemotherapy. We have previously shown that chemotherapy treatment is associated with worse performance on the Rapid Visual Processing test (RVP), an objective measure of sustained attention, over time compared to non-cancer controls. Better understanding of the biologic mechanisms underlying cognitive impairment in cancer patients is needed. The pro-inflammatory cytokine tumor necrosis factor alpha (TNFα) has been implicated in increasing blood brain barrier (BBB) permeability, which in turn is associated with cognitive impairment. This study assessed the relationships of TNFα and S100β, a biomarker of BBB permeability, to each other and to RVP performance over time. Methods: We analyzed a subset of participants (n = 89 patients, n = 52 controls, mean age = 60) from a prospective longitudinal study of women with breast cancer receiving chemotherapy and non-cancer controls. TNFα and S100β were measured in serum pre-chemotherapy (T1, ≤7 days before first treatment) and post-chemotherapy (T2, ≤1 month after last treatment) and at corresponding times for controls. Sustained attention was assessed by total correct rejections on the RVP test at T1 and T2. Separate linear regression models including all participants were used to relate 1) baseline TNFα and S100β levels to change in RVP performance over time, 2) change in TNFα and S100β to change in RVP performance over time, and 3) change in TNFα to change in S100β. Models were adjusted for age. 4) T-tests were used to compare the TNFα and S100β change scores (T1 to T2) of patients vs controls. Results: Greater increase (T1 to T2) in the pro-inflammatory cytokine TNFα was associated with worse cognition, measured by performance on RVP over time (p = 0.02). Higher baseline S100β, a biomarker of BBB permeability, was associated with worse performance on RVP over time (p = 0.09). Increase in TNFα was associated with increase in S100β (p = 0.11). S100β increased from T1 to T2 in patients relative to controls (p = 0.09). Conclusions: These results suggest that higher TNFα may be related to increases in blood brain barrier permeability and worse cognition. Future studies will further define the link between inflammation, blood brain barrier permeability and chemotherapy-related cognitive decline, with the goal of informing the development of new interventions. Funding: R01CA231014, T32CA102618, DP2CA195765, UG1CA189961.

12005 Background: Insomnia, a prevalent and troublesome side effect experienced by cancer survivors, significantly impairs recovery and survival. We conducted a nationwide, multicenter, phase III, blinded, randomized controlled trial testing whether 1) yoga is superior to survivorship health education (SHE) and 2) yoga is non-inferior to cognitive behavioral therapy for insomnia (CBT-I) for treating insomnia in survivors. Methods: The trial was conducted via the University of Rochester Cancer Center NCI Community Oncology Research Program (URCC NCORP) Research Base. Participants were cancer survivors between 2-60 months post adjuvant therapy, with insomnia, no metastatic disease, and no yoga participation during the previous 3 months. Survivors were randomized into 1) YOCAS yoga (2x/wk; 75 min/sess for 4 wks with pranayama, asana, and dhyana, N = 251), 2) CBT-I (1x/wk, 90 min/sess for 8 wks with sleep hygiene, stimulus control, sleep restriction, and cognitive therapy, N = 238), or 3) SHE (2x/wk; 75 min/sess for 4 wks with ASCO-recommended survivorship education, N = 251). Insomnia was assessed pre- and post-intervention via the Insomnia Severity Index. Results: 740 eligible cancer survivors were enrolled (93% female, mean age = 56 + 11, 75% breast cancer). ANCOVAs with baseline values as covariates revealed YOCAS is significantly better than SHE for treating insomnia at post-intervention (CS = change score; CS mean diff = -1.43, SE = 0.42, p < 0.01). Yoga participants demonstrated greater improvements in insomnia from pre- to post-intervention (CS = -3.61, SE = 0.30) compared to SHE participants (CS = -2.19, SE = 0.33, all p < 0.01). Intent-to-treat analyses of non-inferiority (non-inferiority margin set at 1.15 a priori) showed YOCAS is inferior to CBT-I (CS mean diff = 3.52, CI = 2.55 - 4.50, p < 0.01). However, analyses of non-inferiority using the optimal treatment effect in fully compliant survivors were inconclusive regarding whether YOCAS is non-inferior to CBT-I for treating insomnia (CS mean diff = 2.20, CI = 0.42 - 3.98, p = 0.09). Significantly more survivors withdrew from CBT-I and SHE due, in part, to disliking the interventions compared to YOCAS (30%, 25%, and 16%, respectively, p < 0.01). Conclusions: YOCAS yoga is better than SHE and results are inconclusive as to whether yoga is non-inferior to CBT-I for treating insomnia among survivors. Clinicians should consider prescribing YOCAS and CBT-I for survivors reporting insomnia. Funding: NCI UG1CA189961, R01CA181064, T32CA102618. Clinical trial information: NCT02613364 .

The esophagus and trachea arise from the dorsal and ventral aspects of the anterior foregut, respectively. Abnormal separation of the esophagus and trachea leads to the formation of the common birth defect esophageal atresia with/without tracheoesophageal fistula (EA/TEF). Although loss of multiple signaling molecules and transcription factors has been implicated in EA/TEF formation, the underlying cellular mechanisms remain unknown. Here, we combine Xenopus and mouse genetic models to identify the transcription factor Isl1 as a new player regulating trachea-esophageal separation. Significantly, we find that Isl1 orchestrates the separation process through modulating a specific epithelial progenitor cell population (Isl1+ Nkx2.1+ Sox2+) located at the dorsal-ventral boundary of the foregut. Our lineage tracing experiments show that this population contributes to both tracheal and esophageal epithelium. Moreover, Isl1 is required for the transcription of Nkx2.1 in this unique population. Finally, deletion of the chromosomal region spanning the ISL1 gene has been found in patients with abnormal trachea-esophageal separation. Our studies thus provide definitive evidence that ISL1 is a new player in the process of foregut morphogenesis, acting in a small progenitor population of boundary cells.

BACKGROUND. Ensuring older patients with advanced cancer and their oncologists have similar beliefs about curability is important. We investigated discordance in beliefs about curability in patient‐oncologist and caregiver‐oncologist dyads. MATERIALS AND METHODS. We used baseline data from a cluster randomized trial assessing whether geriatric assessment improves communication and quality of life in older patients with advanced cancer and their caregivers. Patients were aged ≥70 years with incurable cancer from community oncology practices. Patients, caregivers, and oncologists were asked: “What do you believe are the chances the cancer will go away and never come back with treatment?” Options were 100%, >50%, 50/50

OBJECTIVES To evaluate the independent association between symptom burden and physical function impairment in older adults with cancer. DESIGN Cross-sectional. SETTING Two university-based geriatric oncology clinics. PARTICIPANTS Patients with cancer aged 65 years or older who underwent evaluation with geriatric assessment (GA). MEASUREMENTS Symptom burden was measured as a summary score of severity ratings (range = 0-10) of 10 commonly reported symptoms using a Clinical Symptom Inventory (CSI). Functional impairment was defined as the presence of one or more impairments of instrumental activities of daily living (IADLs), any significant physical activity limitation on the Medical Outcomes Survey (MOS), one or more recent falls in the previous 6 months, or a Short Physical Performance Battery (SPPB) score of 9 or less. Multivariate analysis evaluated the association between symptom burden and physical function impairment, adjusting for other clinical and sociodemographic variables. RESULTS From 2011 to 2015, 359 patients with cancer and a median age of 81 years (range = 65-95 y) consented. The mean CSI score was 23.2 ± 20.5 with an observed range of 0 to 90. Patients in the highest quartile of symptom burden (N = 91; CSI score 52 ± 13) had a higher prevalence of IADL impairment (91% vs 51%), physical activity limitation (93% vs 65%), falls (55% vs 21%), and SPPB score of 9 or less (92% vs 69%) (all P values

OBJECTIVES To evaluate relationships between frailty and cognition longitudinally in adults 50 years and older with breast cancer receiving chemotherapy. DESIGN Secondary analysis of a prospective longitudinal observational study. SETTING University of Rochester NCI Community Oncology Research Program community oncology clinics. PARTICIPANTS Patients with breast cancer age 50 and older receiving adjuvant/neoadjuvant chemotherapy (n = 376) and age-matched controls without cancer (n = 234). MEASUREMENTS Frailty was assessed using a modified frailty score from self-reported assessments (weakness, exhaustion, physical activity, and gait speed). Cognition was assessed by patient report (Functional Assessment of Cancer Therapy-Cognition [FACT-Cog]) and objective measures. Frailty and cognition were measured at three time points (prechemotherapy [A1], postchemotherapy [A2], and 6 months postchemotherapy [A3]; similar time interval for controls). Linear regression models evaluated associations between frailty and cognition adjusting for covariates. RESULTS The average age was 59 years (standard deviation = 6.4 y). At baseline, patients with cancer had a higher mean frailty score (1.21 vs .73; P

Background: This study's objectives were to describe community oncologists' beliefs about and confidence with geriatric care and to determine whether geriatric-relevant information influences cancer treatment decisions. Methods: Community oncologists were recruited to participate in 2 multisite geriatric oncology trials. Participants shared their beliefs about and confidence in caring for older adults. They were also asked to make a first-line chemotherapy recommendation (combination vs single-agent vs no chemotherapy) for a hypothetical vignette of an older patient with advanced pancreatic cancer. Each oncologist received one randomly chosen vignette that varied on 3 variables: age (72/84 years), impaired function (yes/no), and cognitive impairment (yes/no). Other patient characteristics were held constant. Logistic regression models were used to identify associations between oncologist/vignette-patient characteristics and treatment decisions. Results: Oncologist response rate was 61% (n=305/498). Most oncologists agreed that "the care of older adults with cancer needs to be improved" (89%) and that "geriatrics training is essential" (72%). However