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Introduction: Older adults with cancer have unique fall risk factors related to their disease and treatment such as polypharmacy and neurotoxic treatments. In this secondary analysis, we identified modifiable risk factors associated with future falls among older adults with advanced cancers., Materials and Methods: Data were from the COACH study (ClinicalTrials.gov: NCT02107443; PI: Mohile). Patients were age ≥ 70, had stage III/IV solid tumor or lymphoma, ≥1 geriatric assessment impairment, and were receiving palliative intent treatment. Falls were self-reported at baseline (in the past six months), four to six weeks, three months, and six months. We generated inverse probability weights to account for mortality-related loss to follow-up and applied these in generalized linear mixed models to estimate incidence rate ratios., Results: Of 541 patients (mean age: 77, standard deviation [SD]: 5.27), 140 (26%) reported prior falls at baseline, and 467 (86%) had falls data for ≥1 follow-up timepoint. Of those, 103 (22%) reported at least one fall during the follow-up period, and 112 (24%) had incomplete follow-up due to death. In fully adjusted models, prior falls and impaired Timed Up and Go score were associated with higher incidence of falls over 6 months., Discussion: We identified several potentially modifiable fall risk factors in older adults with advanced cancers. Future studies should consider ways to integrate fall risk assessment into ongoing cancer care and intervene to reduce falls in this population., Competing Interests: Declaration of Competing Interest Dr. Loh has served as a consultant to Pfizer and Seattle Genetics and has received honoraria from Pfizer. Dr. Ramsdale has received honoraria from Flatiron Health. Dr. Wildes reports receiving consulting fees from Carevive Systems, Sanofi, and Pfizer., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: Functional outcomes during non-small cell lung cancer (NSCLC) treatment are critically important to older adults. Yet, data on physical function and which measures best capture functional change remain limited., Materials and Methods: This multisite, mixed methods cohort study recruited adults ≥65 years with advanced NSCLC starting systemic treatment (i.e., chemotherapy, immunotherapy, and/or targeted therapy) with non-curative intent. Participants underwent serial geriatric assessments prior to starting treatment and at one, two, four, and six months, which included the Karnofsky Performance Scale (KPS, range: 0-100%), instrumental activities of daily living (IADL, range: 0-14), European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Physical Functioning subscale (EORTC QLQ-C30 PF, range: 0-100), and Life-Space Assessment (LSA, range: 0-120). For all measures, higher scores represent better functioning. In a qualitative substudy, 20 patients completed semi-structured interviews prior to starting treatment and at two and six months to explore how treatment affected their daily functioning. We created joint displays for each interview participant that integrated their longitudinal KPS, IADL, EORTC QLQ-C30 PF, and LSA scores with patient quotes describing their function., Results: Among 87 patients, median age was 73 years (range 65-96). Mean pretreatment KPS score was 79% (standard deviation [SD] 13), EORTC QLQ-C30 PF was 69 (SD 23), and LSA was 67 (SD 28); median IADL was 13 (interquartile range [IQR] 10-14). At two months after treatment initiation, 70% of patients experienced functional decline on at least one measure, with only 13% of these patients recovering at six months. At two and six months, decline in LSA was the most common (48% and 35%, respectively). Joint displays revealed heterogeneity in how well each quantitative measure of physical function captured the qualitative patient experience., Discussion: Functional decline during NSCLC treatment is common among older adults. LSA is a useful measure to detect subtle functional decline that may be missed by other measures. Given heterogeneity in how well each quantitative measure captures changes in physical function, there is value to including more than one functional measure in geriatric oncology research studies., Competing Interests: Declaration of Competing Interest KPL and MLW reported conflicts of interest outside of the submitted work: KPL has served as a consultant for Pfizer and Seattle Genetics and has received speaker fees from Pfizer. MLW reported that an immediate family member is an employee of Genentech with stock ownership. MLW receives royalties from UpToDate. The remaining authors have no conflicts to report., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Competing Interests: Declaration of Competing Interest No authors declare any competing interests.

Introduction: Caregiver-oncologist concordance regarding the patient's prognosis is associated with worse caregiver outcomes (e.g., depressive symptoms), but mechanisms underpinning these associations are unclear. We explored whether caregiving esteem mediates these associations., Methods: At enrollment, caregivers and oncologists used a 5-point ordinal scale to estimate patient survival; identical responses were considered concordant. At 4-6 weeks, caregivers completed an assessment of the extent to which caregiving imparts self-esteem (Caregiver Reaction Assessment self-esteem subscale; range 0-5; higher score indicates greater esteem). They also completed Patient Health Questionnaire-2 (PHQ-2) for depressive symptoms, Distress Thermometer, and 12-Item Short Form Survey for quality of life (QoL). Mediation analysis with bootstrapping (PROCESS macro by Hayes) was used to estimate the extent to which caregiving mediated the effects of prognostic concordance on caregiver outcomes through caregiving esteem., Results: Prognostic concordance occurred in 28% the caregiver-oncologist dyads; 85% of the discordance were due to caregivers estimating a longer patient's survival. At 4-6 weeks, mean caregiving esteem score was 4.4 (range 1.5-5.0). Lower caregiving esteem mediated the associations of concordance with higher PHQ-2 [indirect effect = 0.12; 95% Confidence Interval (CI) 0.03, 0.27], greater distress (indirect effect =0.25; 95% CI 0.08, 0.48), and poorer QoL (indirect effect = -1.50; 95% CI -3.06, -0.41). Caregiving esteem partially mediated 39%, 64%, and 48% of the associations between caregiver-oncologist concordance and PHQ-2, distress, and SF-12, respectively., Conclusions: Caregiver-oncologist concordance was associated with lower caregiving esteem. Lower caregiving esteem mediated the negative relationship between caregiver-oncologist concordance and caregiver outcomes., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Shared decision making (SDM) is especially important for older adults with cancer given the risks of over- and undertreatment, uncertainty regarding benefits/harms worsened by research underrepresentation, and individual preferences. We aimed to adapt the Best Case/Worst Case (BC/WC) communication tool, which improves SDM in geriatric surgery, to geriatric oncology., Methods: We conducted focus groups with 40 stakeholders (fourteen older adults with lung cancer, twelve caregivers, fourteen medical oncologists) to elicit perspectives on using the BC/WC tool for geriatric oncology and to identify components needing refinement. During each focus group, participants viewed a BC/WC demonstration video and answered questions modified from the Decision Aid Acceptability Scale. We analyzed transcripts using deductive and inductive thematic analyses., Discussion: Participants believed that the BC/WC tool could help patients understand their cancer care choices, explore tradeoffs and picture potential outcomes, and deliberate about decisions based on their goals, preferences, and values. Oncologists also reported the tool could guide conversations to address points that may frequently be skipped (e.g., alternative options, treatment goals). Participant preferences varied widely regarding discussion of the worst-case scenario and desire for statistical information., Conclusion: The BC/WC tool is a promising strategy that may improve SDM in geriatric oncology and patient understanding of alternative options and treatment goals. Based on participant input, adaptations will include framing cancer care as a series of decisions, eliciting patient preferences and asking permission before offering the worst-case scenario, and selection of the two most relevant options to present if multiple exist., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

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., Competing Interests: Declaration of Competing Interest Dr. Lund's spouse is a paid employee of GlaxoSmithKline and owns stock in the company. Dr. Loh reports being paid as a consultant to Pfizer and Seattle Genetics., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Increasing numbers of older adults undergo allogeneic stem cell transplantation (SCT) as the only chance of meaningful survival for hematologic malignancies. However, toxicities in vulnerable patients may offset the benefits of SCT. Frailty and abnormal geriatric assessment (GA) prior to SCT have been associated with decreased overall survival in persons aged 60 and older. The purpose of this pilot study was to determine the prevalence of baseline GA deficits and frailty, the prevalence of frailty or death at three and six months after allogeneic SCT, and associations between baseline assessments and the presence of frailty or death post-SCT., Methods: We enrolled 50 patients aged 60 years and older and completed a baseline GA including comorbidity, polypharmacy, nutrition, physical performance, functional status, social support, depression and anxiety, and cognition. Frailty was defined as three or more abnormalities of gait speed, grip strength, weight loss, physical activity, and exhaustion, and was assessed at baseline, three months, and six months after SCT. A composite outcome of frailty or death at three months and six months was analyzed., Results: Frailty was present in 11/50 (22%) of patients at baseline. Ten patients did not complete three- month follow-up, and twelve patients did not complete six-month follow-up. Of those with follow-up data, 22 patients (55%) were frail or deceased three months after SCT, and 27 patients (71%) were frail or deceased six months after SCT. Frailty at baseline was not significantly associated with frailty or death at three or six months after SCT. However, the study's small enrollment limits conclusions on these associations., Conclusion: GA deficits and frailty are prevalent in older adult SCT recipients at baseline and after transplant. Future studies should aim for larger enrollment in order to validate associations between these deficits and outcomes, especially survival, functional status, and quality of life following SCT., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest in relationship to the work presented in this manuscript. Preliminary results from this study were presented at the International Society of Geriatric Oncology (SIOG) annual meeting in Paris, France, in 2012. The baseline results from this study were reported in the Journal of Geriatric Oncology. This study was used in partial fulfillment of the requirements of a Masters of Science in Epidemiology., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: 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)., Methods: 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., Findings: 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; p<0·0001) 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)., Interpretation: 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., Funding: National Cancer Institute., Competing Interests: Declaration of interests KPL reports consultant fees from Pfizer and Seattle Genetics and honoraria from Pfizer. RFD received honoraria for consulting from Exelixis. TW reports research funding from Janssen and consultant fees from Seattle Genetics and Carevive. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Treatment toxicities are common in older adults with cancer and consequently, treatment modifications are sometimes considered. We evaluated the prevalence and factors associated with treatment modifications at the first cycle in older patients receiving palliative systemic treatment., Methods: Patients (n = 369) from the GAP 70+ Trial (NCT02054741; PI: Mohile) usual care arm were included. Enrolled patients were aged 70+ with advanced cancer and ≥ 1 Geriatric Assessment (GA) domain impairment. Treatment modification was defined as any change from National Comprehensive Cancer Network guidelines or published clinical trials. Baseline variables included: 1) sociodemographic factors; 2) clinical variables; 3) GA domains; and 4) physician beliefs about life expectancy. Bivariate analyses and multivariable cluster-weighted generalized estimating equation model were conducted to assess the association of baseline variables with cycle 1 treatment modifications., Results: Mean age was 77.2 years (range: 70-94); 62% had lung or gastrointestinal cancers, and 35% had treatment modifications at cycle 1. Increasing age by one year (odds ratio (OR) 1.1, 95% confidence interval [CI] 1.0-1.2), receipt of ≥second line of chemotherapy (OR 1.8, CI 1.1-3.0), functional impairment (OR 1.6, CI 1.1-2.3) and income ≤$50,000 (OR 1.7, CI 1.1-2.4) were independently associated with a higher likelihood of cycle 1 treatment modification., Conclusion: Treatment modifications occurred in 35% of older adults with advanced cancer at cycle 1. Increasing age, receipt of ≥second line of chemotherapy, functional impairment, and lower income were independently associated with treatment modifications. These findings emphasize the need for evidence-based regimens in older adults with cancer and GA impairments., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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., Competing Interests: Declaration of Competing Interest Dr. Kah Poh Loh serves as a consultant to Pfizer and Seattle Genetics. Dr. Allison Magnuson reports an honorarium for an educational lecture provided at the American Society of Radiation Oncology 2020 Annual meeting. All other authors have no relevant conflicts of interest to report., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Older patients with myeloid neoplasms (MN) receiving outpatient chemotherapy are at risk of experiencing treatment-related toxicities such as functional decline. A mobile health (mHealth) exercise intervention may ameliorate these toxicities. This qualitative study aimed to inform the design of a mHealth exercise intervention for this population., Methods: This was a qualitative study of thirteen patients aged ≥60 years receiving hypomethylating agents for MN. EXCAP©® is a home-based walking and progressive resistance exercise program. We combined EXCAP©® with a mobile app; the combination (GO-EXCAP Mobile App) has not been previously tested. A brief verbal description about the intervention was provided to the participants but they did not perform it. Participants were interviewed and inductive thematic analysis was used to analyze the data., Results: Mean age was 71.6 (SD 8.5). Three themes were identified: 1) Perceptions of the intervention feasibility, 2) Ways to leverage the app to deliver the exercise intervention, and 3) Personalized exercise goals. Walking and resistance exercises were perceived to be feasible. Patients were comfortable initiating the intervention in cycle 2 of chemotherapy, with exercise increments occurring from week 2-4 of the cycle. Ways to leverage the app to deliver EXCAP©® include 1) Video feature for exercise demonstration and interactions, and 2) Exercise data and symptom surveys to be communicated to the exercise physiologist and primary oncology team. Preservation of existing function and activity was an important goal to participants., Conclusions: Our findings provide insights about the preferences of older adults with MN for a mHealth exercise intervention., Competing Interests: Declaration of Competing Interest Dr. Loh serves as a consultant to Pfizer and Seattle Genetics. Dr. Mohile received research funding from Carevive for other projects. All other authors have no relevant conflicts of interest to report., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

Context: Older adults with advanced cancer face uncertainty related to their disease and treatment., Objectives: To evaluate the associations of uncertainty with psychological health and quality of life (QoL) in older adults with advanced cancer., Methods: Secondary cross-sectional analysis of baseline data from a national clustered geriatric assessment trial. Patients 70 years and older with advanced cancer considering a new line of chemotherapy were recruited. We measured uncertainty using the modified nine-item Mishel Uncertainty in Illness Scale. Dependent variables included anxiety (Generalized Anxiety Disorder-7), depression (Generalized Depression Scale-15), distress (distress thermometer), QoL (Functional Assessment of Cancer Therapy-General), and emotional well-being (Functional Assessment of Cancer Therapy-General subscale). We used multivariate linear regression analyses to evaluate the association of uncertainty with each dependent variable. We conducted a partial least squares analysis with a variable importance in projection (VIP) plot to assess the contribution of individual variables to the model. Variables with a VIP <0.8 were considered less influential., Results: We included 527 patients (median age 76 years; range 70-96). In multivariate analyses, higher levels of uncertainty were significantly associated with greater anxiety (β = 0.11; SE = 0.04), depression (β = 0.09; SE = 0.02), distress (β = 0.12; SE = 0.02), as well as lower QoL (β = -1.08; SE = 0.11) and emotional well-being (β = -0.29; SE = 0.03); the effect sizes were considered small. Uncertainty items related to disease and treatment were most strongly associated with psychological health and QoL scores (all VIP >0.8)., Conclusion: Uncertainty among older patients with advanced cancer is associated with worse psychological health and QoL. Tailored uncertainty management strategies are warranted., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of Competing Interest Dr. Loh has served as a consultant to Pfizer and Seattle Genetics. All other authors have declared no conflicts of interest.

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., Competing Interests: Declaration of Competing Interest Dr. Loh has served as a consultant to Pfizer and Seattle Genetics. All other authors have declared no conflicts of interest., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Context: Discordance in prognostic understanding between caregivers of adults with advanced cancer and the oncologist may shape caregivers' views of the oncologist and bereavement outcomes., Objectives: We examined prospective associations of caregiver-oncologist discordance with caregiver-oncologist therapeutic alliance and caregiver anxiety after patient death., Methods: We conducted a secondary analysis of data collected in a cluster randomized controlled trial from August 2012 to June 2014 in Western New York and California. At enrollment, caregivers and oncologists used a seven-point scale to rate their beliefs about the patient's curability and living two years or more: 100%, about 90%, about 75%, about 50 of 50, about 25%, about 10%, and 0%. Discordance was defined as a difference of two points or more. Outcomes at seven months after patient death included caregiver-oncologist therapeutic alliance (The Human Connection scale, modified into five items) and caregiver anxiety (Generalized Anxiety Disorder-7). We conducted multivariable linear regression models to assess the independent associations of discordance with alliance and anxiety., Results: We included 97 caregivers (mean age 63) and 38 oncologists; 41% of caregiver-oncologist dyads had discordant beliefs about the patient's curability, and 63% of caregiver-oncologist dyads had discordant beliefs about living two years or more. On multivariate analysis, discordance in beliefs about curability was associated with lower anxiety (β = -2.20; SE 0.77; P = 0.005). Discordance in beliefs about length of life was associated with a weaker alliance (β = -5.87; SE = 2.56; P = 0.02)., Conclusion: A better understanding of how caregivers understand and come to terms with poor prognoses will guide interventions to improve cancer care delivery and outcomes of cancer treatment., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Context: There has been surprisingly little attention to conceptual and methodological issues that influence the measurement of discretionary utilization at the end of life (DIAL), an indicator of quality care., Objective: The objectives of this study were to examine how DIALs have been operationally defined and identify areas where evidence is biased or inadequate to inform practice., Methods: We conducted a scoping review of the English language literature published from 1/1/04 to 6/30/17. Articles were eligible if they reported data on ≥2 DIALs within 100 days of the deaths of adults aged ≥18 years. We explored the influence of research design on how researchers measure DIALs and whether they examine demographic correlates of DIALs. Other potential biases and influences were explored., Results: We extracted data from 254 articles published in 79 journals covering research conducted in 29 countries, mostly focused on cancer care (69.1%). More than 100 DIALs have been examined. Relatively crude, simple variables (e.g., intensive care unit admissions [56.9% of studies], chemotherapy [50.8%], palliative care [40.0%]) have been studied more frequently than complex variables (e.g., burdensome transitions; 7.3%). We found considerable variation in the assessment of DIALs, illustrating the role of research design, professional norms and disciplinary habit. Variables are typically chosen with little input from the public (including patients or caregivers) and clinicians. Fewer than half of the studies examined age (44.6%), gender (37.3%), race (26.5%), or socioeconomic (18.5%) correlates of DIALs., Conclusion: Unwarranted variation in DIAL assessments raises difficult questions concerning how DIALs are defined, by whom, and why. We recommend several strategies for improving DIAL assessments. Improved metrics could be used by the public, patients, caregivers, clinicians, researchers, hospitals, health systems, payers, governments, and others to evaluate and improve end-of-life care., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Oncologists can be one of the major barriers to older adult's participation in research. Multiple studies have described academic clinicians' concerns for not enrolling older adults onto trials. Although the majority of older adults receive their cancer care in the community, few studies have examined the unique challenges that community oncologists face and how they differ from oncologist-related barriers in academia., Methods: Semi-structured interviews were conducted by telephone or face-to-face with 44 medical oncologists (24 academic-based and 20 community-based) at City of Hope from March to June 2018. Interviews explored oncologists' perceptions of barriers to clinical trial enrollment of older adults with cancer. Data were analyzed using qualitative content analysis., Results: Of the 44 participants, 36% were women and 68% were in practice for >10 years. Among the entire sample, stringent eligibility criteria (n = 20) and oncologist concerns for treatment toxicities (n = 15) were the most commonly cited barriers. Compared to academic oncologists, community oncologists more often cited patient attitudes, beliefs, and understanding (n = 9 vs. n = 2) and caregiver burden (n = 6 vs. n = 0). In contrast, compared to community oncologists, academic oncologists more often cited oncologist bias (n = 10 vs. n = 3) and insufficient time/support (n = 4 vs. n = 1)., Conclusions: Differences in perceptions among academic and community oncologists about trials suggest that barriers are multifaceted, complex, and vary by practice setting. Interventions to increase trial accrual among older adults with cancer may benefit from being tailored to address the unique barriers of different practice settings., Competing Interests: Declaration of Competing Interest None reported., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: Cognitive impairment (CI) increases chemotherapy toxicity risk with need to understand this association utilizing publicly available short screening tools. We evaluated this utilizing a lower threshold on a short screening tool in older adults with cancer., Materials and Methods: We analyzed data from the Cancer and Aging Research Group (CARG) Chemotherapy Toxicity Risk tool (CARG score) development and validation cohorts (n = 703), which recruited adults age ≥ 65 with cancer from academic centers. Cognition was evaluated with the Blessed Orientation-Memory-Concentration test (BOMC). Patients with BOMC score ≥ 11 were excluded. Utilizing cut-points for older adults, we considered moderate BOMC scores (5-10) as potential CI. Logistic regression was used for analysis., Results: Patient baseline characteristics included: mean age 73; 85% white; 63% college or higher education; 250 (36%) potential CI; 385 (55%) severe toxicity. Patients with potential CI were more likely non-white (p ≤ 0.01) and to have high school or lower education (p ≤ 0.01) and high CARG score (p = 0.04). Potential CI was associated with increased severe toxicity risk (OR = 1.54, p ≤ 0.01). After adjusting for CARG score, this association became nonsignificant (OR = 1.35; p = 0.08). Among patients with lower education (n = 258; 36.7%), potential CI remained associated with severe toxicity, even after adjusting for CARG score (OR = 1.87, p = 0.03)., Conclusions: Our findings suggest potential cognitive impairment, defined by BOMC score 5-10, in older adults with cancer and lower education is associated with increased severe toxicity risk. Future studies are needed to validate these findings. Healthcare providers should consider cognitive testing before treatment for these vulnerable patients., Competing Interests: Declaration of Competing Interest None to disclose., (Copyright © 2019. Published by Elsevier Ltd.)

Context: Although patient and physician characteristics are thought to be predictive of discretionary interventions at the end of life (EoL), few studies have data on both parties., Objective: To test the hypothesis that patient preferences and physician attitudes are both independently associated with discretionary interventions at the EoL., Methods: We report secondary analyses of data collected prospectively from physicians (n = 38) and patients with advanced cancer (n = 265) in the Values and Options in Cancer Care study. Predictor variables were patient attitudes toward EoL care and physician-reported comfort with medical paternalism, assessed indirectly using a modified version of the Control Preference Scale. We explored whether the magnitude of the physician variable was influenced by the inclusion of particular patient treatment-preference variables (i.e., effect modification). Outcomes were a chemotherapy use score (≤14 days before death [scored 2], 15-31 days before death [scored 1], and >31 days [scored 0]) and an emergency department visit/inpatient admission score (two or more admissions in the last 31 days [scored 2], one admission [1], and 0 admissions [0]) in the last month of life., Results: Chemotherapy scores were nearly 0.25 points higher if patients expressed a preference for experimental treatments with unknown benefit at study entry (0.238 points, 95% CI = 0.047-0.429) or reported an unfavorable attitude toward palliative care (0.247 points, 95% CI = 0.047-0.450). A two-standard deviation difference in physician comfort with medical paternalism corresponded to standardized effects of 0.35 (95% CI = 0.03-0.66) for chemotherapy and 0.33 (95% CI = 0.04-0.61) for emergency department visits/inpatient admissions. There was no evidence of effect modification., Conclusion: Patient treatment preferences and physician attitudes are independently associated with higher levels of treatment intensity before death. Greater research, clinical, and policy attention to patient treatment preferences and physician comfort with medical paternalism might lead to improvements in care of patients with advanced disease., (Copyright © 2019 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Cancer cachexia, characterized by weight loss and sarcopenia, leads to a decline in physical function and is associated with poorer survival. Cancer cachexia remains poorly described in older adults with cancer. This study aims to characterize cancer cachexia in older adults by assessing its prevalence utilizing standard definitions and evaluating associations with components of the geriatric assessment (GA) and survival., Materials and Methods: Patients with cancer older than 65 years of age who underwent a GA and had baseline CT imaging were eligible in this cross-sectional study. Cancer cachexia was defined by the international consensus definition reported in 2011. Sarcopenia was measured using cross-sectional imaging and utilizing sex-specific cut-offs. Associations between cachexia, sarcopenia, and weight loss with survival and GA domains were explored., Results: Mean age of 100 subjects was 79.9 years (66-95) and 65% met criteria for cancer cachexia. Cachexia was associated with impairment in instrumental activities of daily living (IADL) (p = .017); no significant association was found between sarcopenia or weight loss and IADL impairment. Cachexia was significantly associated with poorer survival (median 1.0 vs 2.1 years, p = .011)., Conclusions: Cancer cachexia as defined by the international consensus definition is prevalent in older adults with cancer and is associated with functional impairment and decreased survival. Larger prospective studies are needed to further describe cancer cachexia in this population., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: Older patients with advanced cancer often have age-related health issues (e.g., memory impairment) that influence their cancer treatment decisions. Communication about these age-related concerns can potentially lead to further assessment and subsequent clinical interventions to improve treatment decision-making and patients' quality of life. Yet, little is known about the communication of age-related concerns between oncologists, patients, and caregivers., Materials and Methods: This study is a secondary analysis of data from the Values and Options in Cancer Care (VOICE) study. Audio-recorded and transcribed outpatient clinical oncology encounters with 37 patients with advanced cancer ≥60 years of age were content-analyzed. Two trained coders used a structured coding scheme based on pre-specified geriatric assessment (GA) domains to examine the transcripts for the frequency and quality of communication about age-related concerns. Atlas.ti version 6 was used for all analyses., Results: The median age of the patients was 66 years (range = 60-90 years); patients were mostly female (26/37), married (22/37), and White (36/37). Out of 37 audio-recorded visits, 31 had at least one mention of an age-related concern with a total of 70 mentions. Oncologists initiated communication about age-related concerns half of the time (53%). When age-related concerns were mentioned, half of the time (50%) the oncologist did not implement further evidence-based interventions to address the age-related concern (e.g., conduct a cognitive screen for a memory concern)., Conclusion: Interventions are needed to improve the frequency and quality of the communication about age-related concerns to improve the care of older adults with cancer., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Objectives: Sleep disturbance is prevalent and often coexists with depression, fatigue, and pain in the cancer population. The aim of this study was to describe the prevalence of sleep disturbance with co-existing depression, fatigue, and pain in older patients with cancer. We also examined the associations of several socio-demographic and clinical variables with sleep disturbance., Methods: This cross-sectional study consisted of 389 older patients with solid and hematologic malignancies who were referred to the Specialized Oncology Care & Research in the Elderly (SOCARE) clinics at the Universities of Rochester and Chicago between May 2011 and October 2015 and completed a sleep and geriatric assessment (that inquires about fatigue, pain, and depression). Multivariate logistic regression was used to identify variables associated with sleep disturbance., Results: The prevalence of sleep disturbance was 40%. Of those with sleep disturbance (n = 154), 84% also had at least one of the other three symptoms (25% had one symptom, 38% had two symptoms, and 21% had three symptoms). Sleep disturbance was more likely to be reported in those with comorbidities (45% vs. 28%, P = 0.002), depression (49% vs. 36%, P = 0.015), fatigue (49% vs. 23%, P < 0.001), and pain (45% vs. 31%, P = 0.010). On multivariable analysis, only fatigue (adjusted odds ratio (AOR) 1.90, 95% CI 1.10-3.30, P = 0.020) was independently associated with sleep disturbance., Conclusions: Sleep disturbance is prevalent and often co-occurs with depression, fatigue, or pain in older patients with cancer. Fatigue was significantly associated with sleep disturbance and future studies should explore interventions that target sleep disturbance and fatigue., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: To evaluate the association between renal function (RF) and chemotherapy-related toxicity (CRT) in older adults with cancer and to compare the effect of different RF formulas and body weight measurements on this association., Methods: This is a secondary analysis of data from a prospective multicenter study of patients ≥ age 65 who were starting a new chemotherapy regimen. RF was estimated with 4 formulas (modified Jelliffe [Jelliffe], Cockcroft-Gault [CG], Wright, and Modification of Diet in Renal Disease [MDRD]), using actual, ideal and adjusted body weights for 492 patients. The association between baseline RF and grade 3-5 CRT was evaluated by unconditional logistic regression., Results: As a continuous variable, decreased creatinine clearance (CrCl) calculated by CG with actual body weight was associated with increased odds of CRT (OR 1.12, P<0.01; 95% CI 1.04-1.20) indicating that on average for every 10mL/min decrease in CrCl the odds of CRT increased by 12%. Very low RF (in the lowest 10%) with all formulas (CG, Jelliffe, Wright and MDRD) was associated with increased odds for CRT. This association is independent of the type of chemotherapy received (those requiring dose adjustment for renal function vs not). Neither primary dose reduction nor chemotherapy duration was associated with CRT. Serum creatinine alone was not associated with increased odds of CRT (OR 0.67, P=0.15)., Conclusions: Decreased RF is associated with increased odds of CRT and should be considered when assessing risk of CRT in older adults with cancer. Serum creatinine alone is not adequate for risk assessment., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: Older men with a prostate cancer (PCa) diagnosis face competing mortality risks. Little is known about the prevalence of vulnerability and predictors of mortality in this population compared to men without a PCa diagnosis. We examined the predictive utility of the Vulnerable Elders Survey (VES-13) for mortality in older men with a PCa diagnosis as compared to controls., Materials and Methods: Men aged ≥65years from an urban geriatrics clinic completed the VES-13 between 2003 and 2008. Each patient with a PCa diagnosis was matched by age to five controls, resulting in 59 patients with a PCa diagnosis and 318 controls. Cox proportional hazard models were used to determine the association of a PCa diagnosis and vulnerability on the VES-13 with mortality., Results and Conclusions: The mean age for men with a PCa diagnosis and controls was 77.9years and 76.1years, respectively. Of those with a PCa diagnosis, 74.6% had no active disease or a rising PSA only. Regardless of PCa diagnosis, vulnerable individuals on the VES-13 were more likely to die during the study period (VES-13≥3: HR=4.46, p<0.01; VES13≥6: HR=3.77, p<0.01). Men with a PCa diagnosis were not more likely to die compared to age-matched controls (VES-13≥3: HR=1.14, p=0.59; VES13≥6: HR=1.06, p=0.83). Vulnerability for men with a PCa diagnosis was more predictive of mortality. Therefore, the assessment of vulnerability is important for establishing goals of care., Competing Interests: AND CONFLICT OF INTEREST STATEMENTS The authors have no conflicts of interest to disclose., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Polypharmacy is a highly prevalent problem in older persons, and is challenging to assess and improve due to variations in definitions of the problem and the heterogeneous methods of medication review and reduction. The purpose of this review is to summarize evidence regarding the prevalence and impact of polypharmacy in geriatric oncology patients and to provide recommendations for assessment and management. Polypharmacy has somewhat variably been incorporated into geriatric assessment studies in geriatric oncology, and polypharmacy has not been consistently evaluated as a predictor of negative outcomes in patients with cancer. Once screened, interventions for polypharmacy are even more uncertain. There is a great need to create standardized interventions to improve polypharmacy in geriatrics, and particularly in geriatric oncology. The process of deprescribing is aimed at reducing medications for which real or potential harm outweighs benefit, and there are numerous methods to determine which medications are candidates for deprescribing. However, deprescribing approaches have not been evaluated in older patients with cancer. Ultimately, methods to identify polypharmacy will need to be clearly defined and validated, and interventions to improve medication use will need to be based on clearly defined and standardized methods., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Older adults with cancer represent a complex patient population. Geriatric assessment (GA) is recommended to evaluate the medical and supportive care needs of this group. "GA with management" is a term encompassing the resultant medical decisions and interventions implemented in response to vulnerabilities identified on GA. In older, non-cancer patients, GA with management has been shown to improve a variety of outcomes, such as reducing functional decline and health care utilization. However, the role of GA with management in the older adult with cancer is less well established. Rigorous clinical trials of GA with management are necessary to develop an evidence base and support its use in the routine oncology care of older adults. At the recent U-13 conference, "Design and Implementation of Intervention Studies to Improve or Maintain Quality of Survivorship in Older and/or Frail Adults with Cancer," a session was dedicated to developing research priorities in GA with management. Here we summarize identified knowledge gaps in GA with management studies for older patients with cancer and propose areas for future research., (Copyright © 2016. 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.)

Chemotherapy-related cognitive impairment (CRCI) can occur during or after chemotherapy and represents a concern for many patients with cancer. Among older patients with cancer, in whom there is little clinical trial evidence examining side effects like CRCI, many unanswered questions remain regarding risk for and resulting adverse outcomes from CRCI. Given the rising incidence of cancer with age, CRCI is of particular concern for older patients with cancer who receive treatment. Therefore, research related to CRCI in older patients with cancers is a high priority. In this manuscript, we discuss current gaps in research highlighting the lack of clinical studies of CRCI in older adults, the complex mechanisms of CRCI, and the challenges in measuring cognitive impairment in older patients with cancer. Although we focus on CRCI, we also discuss cognitive impairment related to cancer itself and other treatment modalities. We highlight several research priorities to improve the study of CRCI in older patients with cancer., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine the association between falls and health-related quality of life (HRQOL) in older cancer survivors., Materials and Methods: Using the 2006-2011 Surveillance, Epidemiology, and End Results cancer registry system and the Medicare Health Outcomes Survey (SEER-MHOS) linkage database, a cross-sectional analysis was performed including 17,958 older cancer survivors. Multivariable regression models were used to evaluate the association of falls with HRQOL measured by the physical component summary (PCS) and mental component summary (MCS) scores on the Veteran RAND 12-item health survey after controlling for demographic, health- and cancer-related factors. A longitudinal analysis using the analysis of covariance (ANCOVA) models was also conducted comparing changes in HRQOL of older cancer survivors who fell with HRQOL of older patients with cancer who did not fall., Results: In the cross-sectional analysis, 4524 (25%) cancer survivors who fell reported a significantly lower PCS (-2.18; SE=0.16) and MCS (2.00; SE=0.17) scores compared to those who did not (N=13,434). In the longitudinal analysis, after adjusting for baseline HRQOL scores and covariates, patients who fell reported a decline in mean HRQOL scores of both PCS (-1.54; SE=0.26) and MCS (-1.71; SE=0.27). Presence of depression, functional impairment and comorbidities was significantly associated with lower HRQOL scores., Conclusion: Falls are associated with lower HRQOL scores and are associated with a significant prospective decline in HRQOL in older cancer survivors. Further research is necessary to determine if assessment and intervention programs can help improve HRQOL by reducing the likelihood of falls., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Androgen deprivation therapy (ADT) can decrease the physical performance (PP) of older men with prostate cancer (PC)., Methods: We conducted a three-arm randomized pilot study (n=19) comparing a home-based walking and resistance intervention (EXCAP) and a technology-mediated walking and resistance intervention using Wii-Fit to a usual-care arm in men ≥70 years with PC receiving ADT. The intervention lasted for 6 weeks, with follow-up at 12 weeks. The primary pre-specified outcome was change in Short Physical Performance Battery (SPPB) score. Mixed effects regression models were used to assess change in outcomes over time., Results: Mean participant age was 70 years (range: 67-93). Eight patients were randomized to the Wii-Fit arm, 6 to the EXCAP arm, and 5 to the usual-care arm. SPPB scores remained nearly constant in the usual-care arm (β=-0.12; p=0.79), while individuals in the EXCAP arm had on average a 1.2 point increase at each follow-up (β=1.20; 95% CI: 0.36, 2.06). The Wii-fit arm had a non-significant increase in SPPB score over time relative to usual-care (β=0.32; 95% CI -0.43, 1.06; p=0.46). Individuals in the EXCAP arm had an increase in steps per day over time compared to the usual-care arm (p-value=0.006); the EXCAP arm had an increase of 2720 steps (95% CI: 1313, 4128) while the usual-care arm had an increase of 97 steps (95% CI: -1140, 1333). Participants in the Wii-Fit arm had an increase of 1020 steps (95% CI: -474, 1238, p=0.710). Other outcomes (i.e., handgrip strength, lean muscle mass, and chest press repetitions) were not statistically significant., Conclusions: A home-based aerobic and resistance exercise program, EXCAP, shows promise for improving PP in older men with PC on ADT., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: In older patients with cancer, we aimed to investigate associations between a patient-reported outcome measure for sarcopenia (SarcoPRO) and the Short Physical Performance Battery (SPPB), self-reported falls, and limitations in instrumental activities of daily living (IADLs)., Materials and Methods: Assessments were conducted as part of the initial evaluation of older, often frail, patients with cancer seen in the Specialized Oncology Care and Research in the Elderly (SOCARE) clinic. Univariate associations were evaluated using Spearman's correlation and Wilcoxon sign ranked tests. Logistic regressions were used to identify associations of clinical factors and SarcoPRO scores or SPPB scores with falls and IADL limitations., Results: In total, 174 older patients with cancer were evaluated. A moderate correlation was found between the SarcoPRO and the SPPB (ρ=0.62). After adjusting for multiple clinical factors, neither the SarcoPRO nor the SPPB were associated with falls. In contrast, both higher SarcoPRO (i.e., worse) and lower SPPB (i.e., worse) scores were associated with limitations in IADLs (odds ratio for one unit change in predictor: SarcoPRO: 1.06, p<0.0001; SPPB: 0.71, p=0.003, respectively). Models using the SarcoPRO and SPPB explained similar amounts of variability in association with IADL limitations (AUC: 0.88 vs. 0.87, respectively)., Conclusions: The SarcoPRO was moderately associated with the SPPB, an objective measure of physical performance, and was associated with limitations in IADLs. Thus, older patients with cancer who present with IADL limitations should be screened for sarcopenia. The SarcoPRO shows promise as a measure for screening as well as outcome assessment for research on sarcopenia., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Age-based reduction of chemotherapy dose with the first cycle (primary dose reduction, PDR) is not routinely guideline recommended. Few studies, however, have evaluated how frequently PDR is utilized in the treatment of older patients with cancer and which factors may be associated with this decision., Methods: We conducted a secondary analysis of a multi-institutional prospective cohort study of patients age ≥65 years treated with chemotherapy. The dose and regimen were at the discretion of the treating oncologist. The prevalence of PDR and its association with treatment intent (palliative vs. curative), tumor type, patient characteristics (sociodemographics and geriatric assessment variables), and chemotherapy-associated toxicity were evaluated., Results: Among 500 patients (mean age 73, range 65-91 years), 179 patients received curative intent chemotherapy and 321 patients received palliative intent chemotherapy, with PDR being more common in the latter sub-group (15% vs. 25%, p = 0.005). Increasing age was independently associated with PDR in both sub-groups. Comorbidity (prior cancer or liver/kidney disease) was independently associated with PDR in the palliative sub-group alone while Karnofsky Performance Status (KPS) was not associated with PDR in either subgroup. There was no significant difference in the rates of grades 3-5 toxicity, dose reductions, or delays with PDR. Patients in the palliative sub-group treated with PDR had higher rates of hospitalization compared to those treated with standard doses., Conclusion: PDR is more common in the palliative setting, but is also utilized among patients treated with curative intent. Factors associated with PDR include age and comorbid conditions, but not KPS., (Published by Elsevier Ltd.)

Objective: To determine how age may modulate the association of a history of cancer with a 12-month history of anxiety and depressive disorders., Methods: The authors used population-based, cross-sectional surveys, the Collaborative Psychiatric Epidemiology Surveys. These surveys were conducted in the United States in 2001-2003 and included 16,423 adult participants, of whom 702 reported a cancer history. The Composite International Diagnostic Interview evaluated the presence of a 12-month history of anxiety and depressive disorders., Results: Among those with a cancer history, older adults (≥60 years old) were less likely than younger adults (18-59 years old) to have a 12-month history of an anxiety or depressive disorder. Compared with their peers without cancer, younger adults with a cancer history had more anxiety (23.8% versus 13.9%) and depressive (16.0% versus 9.5%) disorders, whereas older adults with a cancer history had lower levels of anxiety (3.7% versus 6.3%) and depressive (1.9% versus 3.9%) disorders. In multivariable modeling, there was a statistically significant interaction between age group and cancer history, with the risk for anxiety and depressive disorders elevated in the younger age group with a cancer history (odds ratio: 5.84 and odds ratio: 6.13, respectively) but decreased in the older age group with a cancer history (odds ratio: 0.55 and odds ratio: 0.45, respectively)., Conclusion: The authors' findings suggest a considerable age-dependent variation with regard to anxiety and depressive disorders in adults with a cancer history. Investigation of the mechanisms contributing to this apparent age differential in risk could have important mental illness treatment implications in this population., (Copyright © 2014 American Association for Geriatric Psychiatry. Published by Elsevier Inc. All rights reserved.)

Objective: Older patients who receive hematopoietic cell transplantation (HCT) may be at risk for adverse outcomes due to age-related conditions or frailty. Geriatric assessment (GA) has been used to evaluate HCT candidates but can be time-consuming. We therefore sought to determine the predictive ability of two screening tools, the Vulnerable Elders Survey (VES-13) and the G8, for abnormal GA or frailty., Materials and Methods: We enrolled 50 allogeneic HCT candidates age ≥60 years. The GA included measures of medical, physical, functional, and social health. Frailty was defined as 3 or more abnormalities on grip strength, gait speed, weight loss, exhaustion, and activity. We associated baseline characteristics and abnormal GA or frailty. We determined the sensitivity and predictive ability of the VES-13 and G8 for GA and frailty., Results: Overall, 33 (66%) patients (mean age 65.4 years) had an abnormal GA, and 11 patients (22%) were frail. The G8 screening tool had a higher sensitivity for an abnormal GA (69.7%), and the VES-13 had a higher specificity (100%). Both tools had similar discriminatory ability., Conclusions: Older HCT candidates had a significant number of deficits on baseline GA and a high prevalence of frailty. Existing screening tools may not be able to replace a full GA., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Context: Hot flashes (HF) are a common distressing symptom in women with breast cancer (BC). Current pharmacologic options are moderately effective and are associated with bothersome side effects. Complementary and alternative medicine is commonly used by cancer patients. However, information on the association of hot flashes severity with such use and self-rated health is lacking., Objective: To examine the hot flashes severity in women with breast cancer and its association with complementary and alternative medicine use and self-rated health (SRH)., Design: Longitudinal multicenter study to assess information needs of cancer outpatients., Participants: Patients with a diagnosis of breast cancer who were scheduled to undergo chemotherapy and/or radiotherapy., Outcome Measures: Hot flashes severity (0 = not present and 10 = as bad as you can imagine), use of complementary and alternative medicine (yes/no), and self-rating of health (SRH) status post-treatment and six-months thereafter (1-5, higher score = better SRH)., Results: The majority of women with HF (mean age = 54.4 years) were Caucasian and married, with higher education, and 93% had received surgical treatment for BC. At the end of treatment, 79% women reported experiencing HF [mean severity = 5.87, standard deviation (SD) = 2.9]; significantly more severe HF were reported by younger women with poor SRH, poor performance status, and those reporting doing spiritual practices. At follow-up, 73% had HF (mean severity = 4.86, SD = 3.0), and more severe HF were reported by younger women with poor self-rated health who had undergone chemotherapy plus radiotherapy, used vitamins, and did not exercise., Conclusions: A high percentage of women experienced hot flashes at the end of treatment and at six-month follow-up. A significant association of hot flashes severity with spiritual practice, increased vitamin use, and reduced exercise emphasize the need for future studies to confirm the results. This can facilitate safe use of complementary and alternative medicine and favorable outcomes while managing cancer-related hot flashes., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: To examine using audio-recorded encounters the extent and process of companion participation when discussing treatment choices and prognosis in the context of a life-limiting cancer diagnosis., Methods: Qualitative analysis of transcribed outpatient visits between 17 oncologists, 49 patients with advanced cancer, and 34 companions., Results: 46 qualifying companion statements were collected from a total of 28 conversations about treatment choices or prognosis. We identified a range of companion positions, from "pseudo-surrogacy" (companion speaking as if the patient were not able to speak for himself), "hearsay", "conflation of thoughts", "co-experiencing", "observation as an outsider", and "facilitation". Statements made by companions were infrequently directly validated by the patient., Conclusion: Companions often spoke on behalf of patients during discussions of prognosis and treatment choices, even when the patient was present and capable of speaking on his or her own behalf., Practice Implications: The conversational role of companions as well as whether the physician checks with the patient can determine whether a companion facilitates or inhibits patient autonomy and involvement. Physicians can reduce ambiguity and encourage patient participation by being aware of when and how companions may speak on behalf of patients and by corroborating the companion's statement with the patient., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

BACKGROUND: Guidelines recommend informed decision-making regarding prostate specific antigen (PSA) screening for men with at least 10 years of remaining life expectancy (RLE). Comorbidity measures have been used to judge RLE in previous studies, but assessments based on other common RLE measures are unknown. We assessed whether screening rates varied based on four clinically relevant RLE measures, including comorbidities, in a nationally-representative, community-based sample. METHODS: Using the National Social Life, Health and Aging Project (NSHAP), we selected men over 65 without prostate cancer (n=709). They were stratified into three RLE categories (0-7 years, 8-12 years, and 13+ years) based on validated measures of comorbidities, self-rated health status, functional status, and physical performance. The independent relationship of each RLE measure and a combined measure to screening was determined using multivariable logistic regressions. RESULTS: Self-rated health (OR = 6.82; p < 0.01) most closely correlated with RLE-based screening, while the comorbidity index correlated the least (OR = 1.50; p = 0.09). The relationship of RLE to PSA screening significantly strengthened when controlling for the number of doctor visits, particularly for comorbidities (OR= 43.6; p < 0.001). Men who had consistent estimates of less than 7 years RLE by all four measures had an adjusted PSA screening rate of 43.3%. CONCLUSIONS: Regardless of the RLE measure used, men who were estimated to have limited RLE had significant PSA screening rates. However, different RLE measures have different correlations with PSA screening. Specific estimates of over-screening should therefore carefully consider the RLE measure used.

While the benefits of exercise for managing cancer-and treatment-related side effects has been shown among various populations of cancer survivors, a relative dearth of information exists among older cancer patients. OBJECTIVES: To determine the prevalence of exercise participation during and after primary cancer treatment in older (≥65 years) and the oldest (≥80 years) cancer patients and to examine the relationships between exercise, symptoms, and self-rated health (SRH). MATERIALS AND METHODS: 408 newly diagnosed older cancer patients (mean age=73, range=65-92) scheduled to receive chemotherapy and/or radiation therapy reported symptoms and SRH prior to, during, and 6 months after treatment, and exercise participation during and following treatment. RESULTS: Forty-six percent of older and 41% of the oldest patients reported exercising during treatment. Sixty percent of older and 68% of the oldest patients reported exercising in the 6 months thereafter. Older patients who exercised during treatment reported less shortness of breath and better SRH during treatment, and better SRH following treatment. The oldest patients who exercised during treatment reported less memory loss and better SRH during treatment and less fatigue and better SRH following treatment. The oldest patients who exercised following treatment reported less fatigue, skin problems, and total symptom burden following treatment. CONCLUSION: These data suggest a willingness of older cancer patients to attempt exercise during and after treatment. Exercise during these times is associated with less severe symptoms; further clinical research examining the efficacy of formal exercise interventions to reduce symptoms and improve SRH in older cancer patients is needed.

OBJECTIVES: To evaluate the relationship of age with symptoms and interference with daily function and QOL during RT. DESIGN: A prospective observational study. SETTING: A university-based radiation oncology department. PARTICIPANTS: 903 cancer patients who received radiation therapy (RT). The mean age was 61 yrs (18-92) and 41% were ≥ 65 yrs. MEASUREMENTS: A symptom inventory was administered pre- and post-RT. Patients rated 10 symptoms and their interference with daily function and QOL on a Likert scale from 0 (not present) to 10 (as bad as possible). A total symptom score was calculated by adding the ratings of individual symptoms. T-tests, Pearson correlation coefficients, and mixed modeling were used to investigate relationships between symptoms and their interference with daily function and QOL. RESULTS: For older and younger patients, the total symptom score worsened during RT (p's < .001). There were no differences in the change in total symptom burden and interference with QOL between older and younger patients during RT. After RT, although younger patients reported significantly worse pain (p = .03), nausea (p <.01), and sleep disturbance (p <.01), symptom interference with walking was more severe in older patients (p = .01). Mixed modeling showed that older age (p=<.001), time of survey (after RT, p<.001), and age*time interaction (p<.001) increased the likelihood of reporting that symptoms interfered with walking. CONCLUSION: The prevalence of symptoms was similar for older and younger patients during RT. Older patients are more likely to report that symptoms interfere with walking after RT.