Older patients with acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) experience intense inpatient healthcare at the end-of-life (EOL) . Early advance care planning (ACP) may improve care at EOL for patients with AML and MDS. The Serious Illness Care Program (SICP) is a multicomponent, communication intervention developed to improve conversations about values for patients with serious illnesses. The SICP has been shown to improve the quality and frequency of ACP discussions. We adapted the SICP for delivery via telehealth to older patients with AML and MDS. We conducted a single-center qualitative study of 45 participants (25 clinicians, 15 older patients with AML and MDS, and 5 caregivers). Participants, whether clinicians, patients, or caregivers, agreed that the SICP would help older patients with AML and MDS to share their personal values with their care team. Four qualitative themes emerged from our data: 1) Serious illness conversations can be conducted via telehealth, 2) Older patients have limited experience using technology but are willing and able to learn, 3) Patients feel that serious illness conversations will help them understand their AML or MDS diagnosis and prognosis better, and 4) Serious illness conversations should be common and routine, not extra-ordinary. The adapted SICP may provide older patients with AML and MDS an opportunity to share what matters most to them with their care team and may assist oncologists in aligning patient care with patient values. The adapted SICP is the subject of an ongoing single-arm pilot study at the Wilmot Cancer Institute.
Many older patients with myeloid neoplasms experience treatment-related toxicities. We previously demonstrated that a home-based, progressive aerobic walking and resistance exercise program (EXCAP©®) improved physical and psychological outcomes in patients with cancer. However, older patients have more difficulty adhering to exercise than younger patients. Reasons may include low motivation, difficulty with transportation, and limited access to exercise professionals. To improve exercise adherence, we integrated a mobile app with EXCAP©® (GO-EXCAP) and assessed its feasibility and usability in a single-arm pilot study among older patients with myeloid neoplasms undergoing outpatient chemotherapy. GO-EXCAP intervention lasts for 2 cycles of treatment. Primary feasibility metric wasdata reporting on the app. Usability was evaluated via the system usability scale (SUS). Patients were interviewed at mid- and post-intervention to elicit their feedback, and deductive thematic analysis was applied to the transcripts. Twenty-five patients (mean age: 72 years) were recruited. Recruitment and retention rates were 64% and 88%, respectively. Eighty-two percent (18/22) entered some exercise data on the app at least half of the study days excluding hospitalization (a priori we considered 70% as feasible). Averaged daily steps were 2,848 and 3,184 at baseline and post-intervention, respectively. Patients also performed resistance exercises 26.2 minutes/day, 2.9 days/week at low intensity (rate of perceived exertion 3.8/10). Usability was above average (SUS 70.3). In qualitative analyses, three themes were identified including positive experience with the intervention, social interactions, and flexibility. The GO-EXCAP intervention is feasible and usable for older patients with myeloid neoplasms undergoing outpatient chemotherapy. This trial is registered at www.clinicaltrials.gov as NCT04035499.
IMPORTANCE A poor prognostic understanding regarding curability is associated with lower odds of hospice use among patients with cancer. However, the association between poor prognostic understanding or prognostic discordance and health care use among older adults with advanced incurable cancers is not well characterized. OBJECTIVE To evaluate the association of poor prognostic understanding and patient-oncologist prognostic discordance with hospitalization and hospice use among older adults with advanced cancers.
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 <0.2), prefrail (0.2 to <0.35), or frail (≥0.35). The clinic visit after the GA‐intervention was audio‐recorded, transcribed, and coded to evaluate the number and quality of conversations about aging‐related concerns. Linear mixed models examined differences in the number and quality of conversations within and between arms. All P values were 2‐sided. Results Patients (n = 541) were classified as robust (27%), prefrail (42%), or frail (31%). In the usual care arm, frail patients (vs robust ones) engaged in more aging‐related conversations (adjusted mean difference, 1.73; 95% confidence interval [CI], 0.59‐2.87), conversations of higher quality (difference, 1.12; 95% CI, 0.24‐2.0), and more discussions about evidence‐based recommendations (difference, 0.71; 95% CI, 0.04‐1.38; all P values ≤ .01). Similarly, in the GA intervention arm, frail patients (vs robust ones) engaged in more aging‐related conversations (difference, 2.49; 95% CI, 1.51‐3.47), conversations of higher quality (difference, 1.31; 95% CI, 0.56‐2.06), and more discussions about evidence‐based recommendations (difference, 0.87; 95% CI, 0.32‐1.42; all P values ≤ .01). Furthermore, the GA‐intervention significantly improved the number and quality of conversations in all patients: robust, prefrail, and frail (all P values ≤ .01). Conclusions Patients with higher degrees of frailty and those exposed to the GA‐intervention had more and higher quality conversations about aging‐related concerns with oncologists. Lay Summary 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. This study conducted a secondary analysis of a nationwide trial of patients aged ≥70 years with incurable cancer and 1 or more GA domain impairments. Patients were stratified as robust, prefrail, or frail. The number and quality of conversations about aging‐related concerns that occurred during the clinic visit after the GA‐intervention were determined. Patients with higher degrees of frailty and those in the GA intervention arm had more and higher quality conversations about aging‐related concerns with oncologists.
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