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Purpose 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. Methods 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. Results 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 $4,282.27 per patient were potentially avoided as a result of deprescribing. Conclusions 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.

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). (Blood. 2012; 119(3):692-695)

Background Polypharmacy (PP) and potentially inappropriate medications (PIM) are highly prevalent in older adults with cancer. This study systematically reviews the associations of PP and/or PIM with outcomes and, through a meta‐analysis, obtains estimates of postoperative outcomes associated with PP in this population. Materials and Methods We searched PubMed, Embase, Web of Science, and Cochrane Register of Clinical Trials using standardized terms for concepts of PP, PIM, and cancer. Eligible studies included cohort studies, cross‐sectional studies, meta‐analyses, and clinical trials which examined outcomes associated with PP and/or PIM and included older adults with cancer. A random effects model included studies in which definitions of PP were consistent to examine the association of PP with postoperative complications. Results Forty‐seven articles met the inclusion criteria. PP was defined as five or more medications in 57% of the studies. Commonly examined outcomes included chemotherapy toxicities, postoperative complications, functional decline, hospitalization, and overall survival. PP was associated with chemotherapy toxicities (4/9 studies), falls (3/3 studies), functional decline (3/3 studies), and overall survival (2/11 studies). A meta‐analysis of four studies indicated an association between PP (≥5 medications) and postoperative complications (overall odds ratio, 1.3; 95% confidence interval [1.3–2.8]). PIM was associated with adverse outcomes in 3 of 11 studies. Conclusion PP is associated with postoperative complications, chemotherapy toxicities, and physical and functional decline. Only three studies showed an association between PIM and outcomes. However, because of inconsistent definitions, heterogeneous populations, and variable study designs, these associations should be further investigated in prospective studies. Implications for Practice Polypharmacy and potentially inappropriate medications (PIM) are prevalent in older adults with cancer. This systematic review summarizes the associations of polypharmacy and PIM with health outcomes in older patients with cancer. Polypharmacy and PIM have been associated with postoperative complications, frailty, falls, medication nonadherence, chemotherapy toxicity, and mortality. These findings emphasize the prognostic importance of careful medication review and identification of PIM by oncology teams. They also underscore the need to develop and test interventions to address polypharmacy and PIM in older patients with cancer, with the goal of improving outcomes in these patients.

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<0.01), had GI cancer (38% vs 31%, p<0.01), and had prior chemotherapy (31% vs 23%, p=0.02). Pts in intervention experienced a lower proportion of grade 3-5 toxicity (175/349; 50%) than pts in usual care (262/369; 71%). The relative risk (RR: intervention vs usual care) of grade 3-5 toxicity was 0.74 (95% CI: 0.63-0.87; p=0.0002); the difference was mostly driven by non-heme toxicities (RR 0.73; 95% CI: 0.53-1.0, p<0.05). OS was not significantly different (71% vs 74%, p=0.3). More pts in intervention received reduced intensity treatment at cycle 1 (49% vs 35%, RR 0.81, p=0.01). Dose modifications due to toxicity were lower in intervention (42% vs 58%, p<0.0001), but results were not significant after controlling for practice (RR 0.85; 95% CI: 0.67-1.08, p=0.2). Conclusions: Providing GA information to oncologists reduces the proportion of older pts who experience grade 3-5 toxicity from high-risk palliative cancer treatment, without compromising OS. Reduced treatment intensity at cycle 1 may explain these results. Funding: R01CA177592, U01CA233167, UG1CA189961. Clinical trial information: NCT02054741 .

Summary Data on outcome, prognostic factors, and treatment for very elderly non‐Hodgkin 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 progression‐free (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 < 0·0001 and 0·0002, respectively). Four‐year PFS and OS for indolent NHL were 44% and 66% respectively, regardless of stage. Multivariate regression analysis identified two key factors that predicted inferior PFS and OS for both NHL groups: lack of CR and loss of ADLs. Prospective studies for very elderly NHL that incorporate geriatric tools, especially ADLs, are warranted.

BackgroundOlder patients with cancer are at an increased risk of adverse outcomes. A geriatric assessment (GA) is a compilation of reliable and validated tools to assess domains that are predictors of morbidity and mortality, and it can be used to guide interventions. However, the implementation of GA and GA-driven interventions is low due to resource and time limitations. GA-driven interventions delivered through a mobile app may support the complex needs of older patients with cancer and their caregivers.ObjectiveWe aimed to evaluate the feasibility and usability of a novel app (TouchStream) and to identify barriers to its use. As an exploratory aim, we gathered preliminary data on symptom burden, health care utilization, and satisfaction.MethodsIn a single-site pilot study, we included patients aged ≥65 years undergoing treatment for systemic cancer and their caregivers. TouchStream consists of a mobile app and a Web portal. Patients underwent a GA at baseline with the study team (on paper), and the results were used to guide interventions delivered through the app. A tablet preloaded with the app was provided for use at home for 4 weeks. Feasibility metrics included usability (system usability scale of >68 is considered above average), recruitment, retention (number of subjects consented who completed postintervention assessments), and percentage of days subjects used the app. For the last 8 patients, we assessed their symptom burden (severity and interference with 17-items scored from 0-10 where a higher score indicates worse symptoms) using a clinical symptom inventory, health care utilization from the electronic medical records, and satisfaction (6 items scored on a 5-point Likert Scale for both patients and caregivers where a higher score indicates higher satisfaction) using a modified satisfaction survey. Barriers to use were elicited through interviews.ResultsA total of 18 patients (mean age 76.8, range 68-87) and 13 caregivers (mean age 69.8, range 38-81) completed the baseline assessment. Recruitment and retention rates were 67% and 80%, respectively. The mean SUS score was 74.0 for patients and 72.2 for caregivers. Mean percentage of days the TouchStream app was used was 78.7%. Mean symptom severity and interference scores were 1.6 and 2.8 at preintervention, and 0.9 and 1.5 at postintervention, respectively. There was a total of 27 clinic calls during the intervention period and 15 during the postintervention period (week 5-8). One patient was hospitalized during the intervention period (week 1-4) and two patients during the postintervention period (week 5-8). Mean satisfaction scores of patients and caregivers with the mobile app were 20.4 and 23.4, respectively. Barriers fell into 3 themes: general experience, design, and functionality.ConclusionsTouchStream is feasible and usable for older patients on cancer treatment and their caregivers. Future studies should evaluate the effects of the TouchStream on symptoms and health care utilization in a randomized fashion.

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