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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.

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.

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.

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

Key Objective: What do we know about cancer treatment tolerability in older adults and where are the gaps? Knowledge generated: While there is strong evidence that geriatric assessment findings can be helpful in predicting treatment tolerability in older adults with cancer, more research is needed on treatment tolerability assessment, monitoring, and mitigation efforts for older adults during and after completion of treatment. A model is proposed to guide research efforts and clinical care that incorporates multiple tolerability aspects and highlights the patient’s experience and functional status as important endpoints. Relevance: Incorporating patient reported outcomes, functional evaluation, as well as adverse event data provides a more comprehensive and accurate understanding of treatment tolerability in older adults.

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.

Polypharmacy poses a significant public health problem that disproportionately affects older adults (≥65 years) since this population represents the largest consumers of medications. Clinicians caring for older adults with cancer must rely on evidence to understand polypharmacy and its implications, not only to communicate with patients and other healthcare providers, but also because of the significant interplay between polypharmacy, cancer, cancer-related treatment, and clinical outcomes. Interest in polypharmacy is rising because of its prevalence, the origins and facilitating factors behind it, and the direct and indirect clinical outcomes associated with it. The growing body of publications focused on polypharmacy in older adults with cancer demonstrates that this is a significant area of research; however, limited evidence exists to guide medication use (e.g., prescribing, administration) in this population. Currently, research priorities aimed at polypharmacy in the field of geriatric oncology lack clarity. We identified current gaps in the literature in order to establish research priorities for polypharmacy in older adults with cancer. The five research priorities—Polypharmacy Methodology and Definitions, Suboptimal Medication Use, Comorbidities and Geriatric Syndromes, Underrepresented Groups, and Polypharmacy Interventions—highlight critical areas for future research to improve outcomes for older adults with cancer.

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.

12010 Background: Despite high prevalence of functional status (FS) and physical performance (PP) impairments among older adults with cancer, standardized assessments and interventions are not routinely used in oncology care. This study characterized how oncologist knowledge of Geriatric Assessment (GA) results influenced conversations and GA-guided recommendations addressing FS and PP concerns. Methods: Data were from a NCORP funded (UG1CA189961) nationwide cluster randomized controlled trial (ClinicalTrials.gov: NCT02107443; PI: Mohile), with inclusion criteria: age ≥70, stage III/IV solid tumor or lymphoma with palliative treatment intent, and ≥1 GA domain impairment. All subjects underwent baseline GA including standardized FS ([instrumental] activities of daily living) and PP (Timed Up and Go, Short Physical Performance Battery, Older Americans Resources and Services Physical Health scale, falls in past 6 months) measures. Oncologists in Intervention arm practices received full GA results and validated recommendations for each patient, while those in the usual care (UC) arm were only notified of depression or severe cognitive impairment. One clinical encounter per patient within 4 weeks of GA was audio-recorded, transcribed and blind coded using a priori content-analysis scheme to categorize conversations and oncologist response (dismissed, acknowledged, or addressed with recommendation) by GA domain. Frequencies, raw and adjusted (for site using generalized linear mixed models) proportions were compared using the Chi square test. Results: 541 patients (mean age: 77, range 70-96) were included. More FS and PP conversations occurred in Intervention (PP=532, FS=164) than UC (PP=183, FS=87) arm (p

UNLABELLED : Inappropriate medication use and polypharmacy are extremely common among older adults. Numerous studies have discussed the importance of a comprehensive medication assessment in the general geriatric population. However, only a handful of studies have evaluated inappropriate medication use in the geriatric oncology patient. Almost a dozen medication screening tools exist for the older adult. Each available tool has the potential to improve aspects of the care of older cancer patients, but no single tool has been developed for this population. We extensively reviewed the literature (MEDLINE, PubMed) to evaluate and summarize the most relevant medication screening tools for older patients with cancer. Findings of this review support the use of several screening tools concurrently for the elderly patient with cancer. A deprescribing tool should be developed and included in a comprehensive geriatric oncology assessment. Finally, prospective studies are needed to evaluate such a tool to determine its feasibility and impact in older patients with cancer. IMPLICATIONS FOR PRACTICE The prevalence of polypharmacy increases with advancing age. Older adults are more susceptible to adverse effects of medications. "Prescribing cascades" are common, whereas "deprescribing" remains uncommon; thus, older patients tend to accumulate medications over time. Older patients with cancer are at high risk for adverse drug events, in part because of the complexity and intensity of cancer treatment. Additionally, a cancer diagnosis often alters assessments of life expectancy, clinical status, and competing risk. Screening for polypharmacy and potentially inappropriate medications could reduce the risk for adverse drug events, enhance quality of life, and reduce health care spending for older cancer patients.

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

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

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 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.

Older adults with cancer have complex medical needs and often experience higher rates of treatment-related toxicities compared to their younger counterparts. The advent of health information technologies can address multiple gaps in the care of this population. We review the role of existing and emerging technologies in facilitating the use of comprehensive geriatric assessment (CGA) in routine clinics, promoting symptom reporting, and monitoring medication adherence. Increasingly, studies demonstrate the feasibility of implementing electronic CGA in routine oncology practices. Evidence also suggests that electronic symptom reporting can improve outcomes in patients with cancer. In addition, technology devices can be used to promote adherence to cancer therapy. There are many opportunities for information technology to be integrated into the management and treatment of older adults with cancer. However, further evaluation of these technologies is needed to ensure that they meet the needs of the targeted end users.

The aims of this study were to compare the application of three geriatric medication screening tools to the Beers Criteria alone for potentially inappropriate medication quantification and to determine feasibility of a pharmacist-led polypharmacy assessment in a geriatric oncology clinic. Adult patients with cancer aged 65 and older underwent a comprehensive geriatric assessment. A polypharmacy assessment was completed by a pharmacist and included a review of all drug therapies. Potentially inappropriate medications were screened using the Beers Criteria, Screening Tool to Alert doctors to Right Treatment/Screening Tool of Older Persons’ Prescriptions, and the Medication Appropriateness Index. Deprescribing occurred after discussion with the pharmacist, geriatric oncologist, patient, and caregiver. Data were collected for 26 patients. The mean number of medications was 12. The Beers Criteria alone identified 38 potentially inappropriate medications compared to 119 potentially inappropriate medications with the three-tool assessment; a mean of 5 potentially inappropriate medications were identified per patient. After the application of the three-tool assessment, 73% of potentially inappropriate medications identified were deprescribed, resulting in a mean of 3 medications deprescribed per patient. Approximately two thirds of patients reported a reduction in symptoms after the deprescribing intervention. Healthcare expenditures of $4282.27 per patient were potentially avoided as a result of deprescribing. Our three-tool assessment identified three times more potentially inappropriate medications than the Beers Criteria alone. Pharmacist-led deprescribing interventions are feasible and may lead to improved patient outcomes and cost savings. This three-tool assessment process should be incorporated into interdisciplinary assessments of older patients with cancer and validated in future studies.

Incarcerated persons have a constitutionally protected right to adequate health care. However, there is a growing epidemic of inadequate health care in U.S. prisons. The authors discuss the medical...

Older adults with chronic diseases are often excluded from study populations, so EBM guidelines often do not apply to them.

We investigated a recent (January 1999 to December 2009) cohort of 95 elderly Hodgkin lymphoma subjects. At diagnosis, median age was 67 years (range, 60-89 years), whereas 61% had significant comorbidity, 26% were unfit, 17% had a geriatric syndrome, and 13% had loss of activities of daily living. Overall response rate to therapy was 85%, whereas incidence of bleomycin lung toxicity was 32% (with associated mortality rate, 25%). With 66-month median follow-up, 2-year and 5-year overall survival were 73% and 58%, respectively (advanced-stage, 63% and 46%, respectively). Most International Prognostic Score factors were not prognostic on univariate analyses, whereas Cox multivariate regression identified 2 risk factors associated with inferior overall survival: (1) age more than 70 years (2.24; 95% CI, 1.16-4.33, P = .02) and (2) loss of activities of daily living (2.71; 95% CI, 1.07-6.84, P = .04). Furthermore, a novel survival model based on number of these risk factors (0, 1, or 2) showed differential 2-year OS of 83%, 70%, and 13%, respectively (P < .0001) and 5-year OS of 73%, 51%, and 0%, respectively (P < .0001).

Summary Data on outcome, prognostic factors, and treatment for very elderly nonHodgkin lymphomas (NHL) is sparse. We conducted a multicentre retrospective analysis of NHL patients ‡80 years (at diagnosis) treated between 1999 and 2009. Detailed characteristics were obtained including geriatric syndromes, activities of daily living (ADLs), and co-morbidities using the Cumulative Illness Rating Scale-Geriatrics (CIRS-G). We identified 303 patients: 170 aggressive NHL (84% B cell/16% T cell) and 133 indolent NHL (82% B cell/18% T cell). Median age was 84 years (80‐95). A geriatric syndrome was present in 26% of patients, 18% had ‡1 grade 4 CIRS-G, and 14% had loss of ADLs. At 49-month median follow-up, 4-year progressionfree (PFS) and overall survival (OS) for aggressive NHLs were 31% and 44% respectively (stage I/II: PFS 53% and OS 66%; stage III/IV: PFS 20% and OS 32%; P

Lymphoma comprises two groups of diseases: Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Within both subsets are numerous variations with distinct biologic, molecular, and cytogenetic characteristics. The World Health Organization (WHO) classification of NHL, for example, now identifies several dozen broad entities and nearly 60 unique clinicopathologic subtypes. In addition to pathologic heterogeneity, there is clinical diversity within lymphomas, with some patients achieving cure, others having prolonged disease stabilization, and still others experiencing a rapidly fulminant decline and death. It is increasingly appreciated that both clinical and biological features strongly influence outcome. Practical implementation of a personalized approach to treatment is urgently needed, but efforts thus far have focused primarily on prognostication, with much less emphasis on determining therapeutic options. Nevertheless, better prognostic tools will facilitate the design of "risk-stratified" trials that will ultimately benefit patients. Thus far, the development of personalized treatment in lymphomas clusters into several broad approaches: refinement of clinical prognostic models for better risk stratification, use of high-throughput technology to identify biologic subtypes within pathologically similar diseases, "response-adapted" changes in therapy via imaging with [(18)F]fluoro-2-deoxy-d-glucose positron emission tomography (FDG-PET), and anti-idiotype vaccines. An important unmet need is the implementation of these tools into treatment choices for individual patients, and this is the focus of intense ongoing research.

Effective collaboration among healthcare providers is an essential component of high-quality patient care. Interprofessional education is foundational to ensuring that students are prepared to engage in optimal collaboration once they enter clinical practice particularly in the care of complex geriatric patients undergoing surgery.To enhance interprofessional education between nursing students and medical students in a clinical environment, we modeled the desired behavior and skills needed for interprofessional preoperative geriatric assessment for students, then provided an opportunity for students to practice skills in nurse/physician pairs on standardized patients. This experience culminated with students performing skills independently in a clinic setting.Nine nursing students and six medical students completed the pilot project. At baseline and after the final clinic visit we administered a ten question geriatric assessment test. Post-test scores (M=90.33, SD=11.09) were significantly higher than pre-test scores (M=72.33, SD=12.66, t(14)=-4.50, p0.001. Nursing student post-test scores improved a mean of 22.0 points and medical students a mean of 11.7 points over pre-test scores. Analysis of observational notes provided evidence of interprofessional education skills in the themes of shared problem solving, conflict resolution, recognition of patient needs, shared decision making, knowledge and development of one's professional role, communication, transfer of interprofessional learning, and identification of learning needs.Having nursing and medical students "learn about, from and with each other" while conducting a preoperative geriatric assessment offered a unique collaborative educational experience for students that better prepares them to integrate into interdisciplinary clinic teams.

Anthracycline-based chemotherapy (ABC) is the most effective therapy for diffuse large B-cell lymphoma (DLBCL). The addition of rituximab to ABC in controlled trials has demonstrated superior survival, yet ABC is inconsistently utilized in elderly patients, and little is known about the penetrance or impact of rituximab with other treatments. We analyzed the treatment and survival patterns of 7559 patients with DLBCL over age 66 diagnosed from 1992 to 2002 using a linked Surveillance, Epidemiology and End Results (SEER)–Medicare database. Rituximab use was first detected in 1999 and by 2002 was incorporated in 79% of ABC-treated patients and 71% of patients treated with non-anthracycline chemotherapy, but only 12% of patients not receiving cytotoxic chemotherapy. ABC rates remained constant across time as did rates of no therapy, which were highest among the very old. Rituximab-associated survival improvements were seen among elderly treated with or without anthracyclines. Patients treated with rituximab but not anthracyclines had comparable survival to those treated with anthracycline but not rituximab.

The study analyzed outcomes of a consecutive case series of 37 patients with peripheral T-cell non-Hodgkin lymphoma, from related and unrelated donors, using allogeneic hematopoietic cell transplantation (allo-HCT), between the years 2000 and 2007. All patients were pretreated; the majority had either relapsed or progressive disease (n=25, 68%), 13 had cutaneous histologies (CTCL), and all were ineligible for autologous transplant. Fully ablative conditioning regimens were used in 13 patients while 24 patients underwent reduced intensity conditioning (RIC). At five years the overall survival (OS) and progression-free survival (PFS) probabilities were 52.2% and 46.5%, respectively. At the time of analysis, 9 (24.3%) patients had either relapsed (n=6) or progressed (n=3) post allo-HCT. The cumulative incidences of relapse/progression and non-relapse mortality at 5 years were 24.3% and 28.9%. No statistically significant variables for survival or relapse were discovered by univariate Cox-regression analysis of disease and patient characteristics; differences between CTCL and other histologies were not significant. The median follow-up of 64.0 months (range: 16.4–100.4) indicates a mature data-set with probable cure in the survivors. The relapse/progression curves reached and maintained plateaus after 1 year post-transplant, demonstrating that long-term disease control is possible after allo-HCT in PTCL patients with advanced disease.

Abstract 3668 Background: The prevalence of NHL in patients (pts) ≥ 80 years has recently tripled; however, data on prognostic factors and treatment for this very elderly population is sparse. Methods: A multicenter retrospective analysis of NHL pts ≥80 years diagnosed between (1999–2009) was completed. Detailed characteristics obtained include geriatric syndromes (GS), activities of daily living (ADLs), and co-morbidities using the Cumulative Illness Rating Scale-Geriatrics (CIRS-G). Further, univariate associations with survival were determined, while a multivariate Cox regression proportional hazards model was performed. Results: We identified 303 pts: 170 aggressive NHL (84% B-cell and 16% T-cell) and 133 indolent NHL (82% B-cell and 18% T-cell). Median age was 84 years (range 80–95). Poor performance status (PS), high LDH, and extranodal disease were more common in aggressive vs. indolent NHLs (P=0.004, 0.005, and 0.002, respectively). Furthermore, aggressive NHL pts presented more frequently with advanced stage and higher relative prognostic scores (P=0.0002 and 0.003 respectively). Loss of any ADL was more frequent in aggressive histology (P=0.002). Diffuse large B-cell NHL was the most common histology overall, while follicular lymphoma was the most diagnosed indolent NHL. At least one GS was present in 80 pts (26%) with dementia being most common (26%). Loss of at least one ADL was seen in 14%, while 30% of pts were considered “non-fit” at diagnosis. Of available treatment data in aggressive B-NHL, 62% received rituximab (R)-containing regimen and 18% received chemotherapy without R. Those with aggressive T-cell NHL were treated with systemic therapy in 74%, topical in 15%, radiation in 4%, and no therapy in 7%. Indolent B-cell NHL had observation in 38% for a median of 26 months, R alone in 21%, R plus chemotherapy in 15%, radiation alone in 7%, and chemotherapy alone in 9%. Cutaneous T-cell pts received topical therapies in 42%, systemic therapy in 29%, and radiation alone in 17%. At 49-month median follow-up, 4-year progression-free (PFS) and overall survival (OS) for aggressive NHL were 31% and 44%, respectively (stage I/II: PFS 53% and OS 66%; stage III/IV: PFS 20% and OS 32%; p Conclusion: To our knowledge, this represents the largest analysis of very elderly NHL reported to date. We identified that loss of ADL's and lack of CR to initial treatment were robust predictors of survival in very elderly NHL, irrespective of histology, and they superseded the prognostic value of either PS or age. Geriatric assessments, including ADLs, are powerful predictors of outcome in very elderly NHL and should be prospectively studied. Disclosures: No relevant conflicts of interest to declare.

Abstract 2625 Purpose. Survival rates for eHL (most commonly defined as age over 60 years) are significantly and disproportionately inferior to those achieved in younger patients (pts). Reported 5-year event-free survival (EFS) rates for advanced-stage eHL have historically ranged from 30%–45% with 5-year overall survival (OS) rates of 40%–55%. Potential explanations for these discrepant inferior outcomes include co-morbidities precluding delivery of chemotherapy, treatment-related toxicities, and biology of disease. Data examining toxicity, survival, and prognostication for eHL in the modern era are lacking. Methods. We report a multicenter collaboration that retrospectively investigated a large cohort of eHL pts treated over a recent 12-year period (June 1999 December 2010). We examined clinical characteristics, treatment-related toxicities, and outcomes. Furthermore, comorbidities were assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G) scale. Patients were also classified as “fit” vs “not fit” (i.e., loss of activities of daily living (ADLs), >3 grade 3 CIRS-G, any grade 4, and/or presence of geriatric syndrome). Univariate associations with survival were determined, while a multivariate Cox proportional hazards model was completed. Additionally, a prognostic model was constructed by classification and regression tree (CART) analysis. Results. 113 eligible pts were identified, while 95 had full data and were analyzed. Among these 95 pts (58M:37F), median age was 67 years (range, 60–89), with 33% of pts ages 70–79 years, while 7% were 80–89 years. 27% of pts had a prior malignancy at a median of 8.4 years (range, 1–25 years) prior to HL diagnosis, for which most had received radiation. At HL diagnosis, there were presence of B symptoms in 54%, performance status 2–4 in 27%, 21% with history of coronary artery disease, and 16% had diabetes. In terms of functional status, 61% of pts had a CIRS-G grade 3 or 4 in at least 1 category, while 46% had a cumulative score >6. Further, 17% had presence of a geriatric syndrome, 26% were classified as 'not fit', and 13% had loss of ADLs at time of HL diagnosis. 25% of pts had bone marrow involvement, while 20% had other extranodal disease (most common: bone and lung). Altogether, 64% of pts had stage III/IV disease, of which 58% had an international prognostic score (IPS) of 4–7. HL histology was nodular sclerosis in 47%, mixed cellularity 31%, NOS 16%, lymphocyte predominant 5%, and lymphocyte depleted 1%. Primary treatment consisted of: ABVD-based (n=67), MOPP-based (n=6), BCVPP (n=6), ChlVPP (n=5), radiation alone (n=4), CHOP (n=3), hospice (n=2), BEACOPP (n=1), and watchful waiting (n=1). 78% of pts received granulocyte-colony stimulating factor (G-CSF) with therapy. The overall response rate (ORR) among treated pts was 85% (73% complete remission (CR) rate). In terms of toxicity, the incidence of bleomycin lung toxicity (BLT) was 32%, which had an associated mortality rate of 25%. Notably, the incidence of BLT was 37% vs 0% among pts who received G-CSF vs not, respectively (p=0.041). With a median follow-up of 66 months (6–154) months, the 5-year EFS and OS for all eHL pts were 44% and 58%, respectively (stage I/II: 61% and 79%; and stage III/IV: 36% and 46%; p=0.009 and p=0.001, respectively). Prognostic factors that predicted survival on univariate analysis are detailed in Table 1. On multivariate regression analysis, 2 factors were associated with inferior survival: 1) age ≥ 70 years (EFS: 1.76 (95%CI 0.98–3.16), p=0.06; and OS: 2.24 (95%CI 1.16–4.33), p=0.02) and 2) Loss of ADLs (EFS: 2.47 (95%CI 0.98–6.21), p=0.055; and OS: 2.71 (95%CI 1.07–6.84), p=0.04). Furthermore, a survival model by multivariate CART analysis, based on number of these 2 adverse factors (0, 1, 2), was formed: 5-year EFS 73%, 51%, 0%, respectively (p Conclusions. This large, retrospective multicenter analysis of eHL found a high ORR and CR rate, but poor long-term outcomes. As shown previously, a significant percentage of eHL pts suffered BLT, which was fatal in 25% and appeared strongly related to use of growth factors. Further, several geriatric specific variables, including loss of ADL's, was highly predictive of outcome and should be prospectively incorporated into clinical trials. Finally, we developed a new prognostic model for eHL that identifies pt populations with markedly divergent outcomes. Disclosures: No relevant conflicts of interest to declare.

Abstract 3124 Background: The incidence of NHL increases exponentially with rising age. The most rapidly growing segment of the population is persons > age 65 years, especially > age 80. As a percentage of US population, the age group >80 years has increased by >250% from 1960 to 2000. Furthermore, persons >80 years will more than double within 20 years. However, little data is available regarding the characteristics or outcomes of very elderly NHL patients (pts). Methods: We completed a multicenter retrospective analysis of very elderly NHL pts (=/> 80) diagnosed (dx) between 9/99-9/09 at 4 Chicago centers. Detailed pt and disease characteristics were collected including comorbidities, which were assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). Pts were also classified if they were “fit” (i.e., preserved activities of daily living (ADLs), Result: We identified 150 pts (F:M 1.14) with a median age of 84 years (80-96). 74 pts had aggressive NHL histology: DLBCL n=56 (systemic n=49, primary CNS n=5, gastric n=1, PEL n=1), T-cell n=11 (peripheral n=7, Sezary n=4) and MCL n=7. 76 pts had indolent NHL: follicular n=32, mycoses fungoides n=16, MZL n=17, CLL/SLL n=8 and lymphoplasmacytic n=4. Disease characteristics at dx included: B symptoms 20%, PS 2–3 18%, marrow involvement 35%, >1 extranodal 20%, elevated LDH 38%, anemia 41%, thrombocytopenia 16%, renal insufficiency 25%, and 36% had a history of coronary artery disease. Additionally, 28% had prior malignancy. Comorbidities were common; 77% of pts had a cumulative CIRS score >6, while 74% had a grade 3–4 CIRS-G in at least 1 category. Furthermore, 33% were classified as “not fit” at NHL dx, 12% had loss of ADLs, while 22% had a geriatric syndrome at time of NHL dx. 57% had stage III/IV disease. Pts with aggressive B cell histology received a rituximab (R)-containing regimen 85% of the time, while 84% of all aggressive NHL received at least one cycle with an anthracycline. Initial therapy for B cell indolent NHL were: observation (24%), R alone (35%), R-chemotherapy (CT) (31%), radiation (8%), and CT alone (2%). Among all pts, the overall response to first treatment was 68% (CR 49%). With 40-month median follow-up (1-120), 3-year EFS (event-free survival) and OS (overall survival) for all pts were 43.8% and 70.3%, respectively (stage I/II: EFS 49% and OS 81%; stage III/IV: EFS 42% and OS 65%; p=0.039 and p=0.09, respectively). Among aggressive NHL (n=74), 3-year EFS and OS were 55% and 64% (stage I/II: EFS 86% and OS 94%; stage III/IV: EFS 45% and OS 57%; p=0.0006 and p=0.03, respectively), while for indolent NHL (n=76), the 3-year EFS and OS were 34% and 77%, respectively (Figures 1–3). Prognostic factors predicting survival are shown in Table 1. In multivariate regression analyses, no response to initial therapy (i.e., SD/PD) predicted for significantly inferior EFS and OS (HR 5.45 [2.02-13.65], p=0.0007 and HR 6.88 [1.66-28.44], p=0.008, respectively). Conclusion: Long-term survival of very elderly NHL was feasible with 64% and 77% 3-year OS for aggressive and indolent histologies, respectively. However, comorbidities as well as a designation of “unfit” portended a significantly inferior outcome in univariate models. Primary resistance to initial therapy occurred in 32% of pts and also predicted for poor prognosis. Given the rising incidence and prevalence of very elderly NHL, prospective examination of this subset of pts is strongly warranted. Disclosures: No relevant conflicts of interest to declare.