Dyspnea is a common and distressing symptom for oncology patients.However, dyspnea is not well-characterized and often underestimated by clinicians. This systematic review summarizes the prevalence, ...intensity, distress, and impact of dyspnea in oncology patients and identifies research gaps.
A search of all of the relevant databases was done from 2009 to May 2022. A qualitative synthesis of the extant literature was performed using established guidelines.
One hundred-seventeen studies met inclusion criteria. Weighted grand mean prevalence of dyspnea in patients with advanced cancer was 58.0%. Intensity of dyspnea was most common dimension evaluated, followed by the impact and distress. Depression and anxiety were the most common symptoms that co-occurred with dyspnea.
Numerous methodologic challenges were evident across studies. Future studies need to use valid and reliable measures; evaluate the impact of dyspnea; and determine biomarkers for dyspnea.
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•Over 50% of patients with advanced cancer experience dyspnea.•Intensity of dyspnea was the most common dimension evaluated.•Occurrence of cardiopulmonary comorbidities is a significant risk factor for dyspnea.•Functional exercise capacity was the most common measure used to evaluate the impact of dyspnea.•Depression and anxiety were the most common symptoms that co-occurred with dyspnea.
Because comorbidity affects cancer treatment outcomes, guidelines recommend considering comorbidity when making treatment decisions in older patients with lung cancer. Yet, it is unclear whether ...treatment is targeted to healthier older adults who might reasonably benefit.
Receipt of first-line guideline-recommended treatment was assessed for 20,511 veterans age ≥ 65 years with non-small-cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry from 2003 to 2008. Patients were stratified by age (65 to 74, 75 to 84, ≥ 85 years), Charlson comorbidity index score (0, 1 to 3, ≥ 4), and American Joint Committee on Cancer stage (I to II, IIIA to IIIB, IIIB with malignant effusion to IV). Comorbidity and patient characteristics were obtained from VA claims and registry data. Multivariate analysis identified predictors of receipt of guideline-recommended treatment.
In all, 51% of patients with local, 35% with regional, and 27% with metastatic disease received guideline-recommended treatment. Treatment rates decreased more with advancing age than with worsening comorbidity for all stages, such that older patients with no comorbidity had lower rates than younger patients with severe comorbidity. For example, 50% of patients with local disease age 75 to 84 years with no comorbidity received surgery compared with 57% of patients age 65 to 74 years with severe comorbidity (P < .001). In multivariate analysis, age and histology remained strong negative predictors of treatment for all stages, whereas comorbidity and nonclinical factors had a minor effect.
Advancing age is a much stronger negative predictor of treatment receipt among older veterans with NSCLC than comorbidity. Individualized decisions that go beyond age and include comorbidity are needed to better target NSCLC treatments to older patients who may reasonably benefit.
This Provisional Clinical Opinion update presents a clinically pragmatic approach to hepatitis B virus (HBV) screening and management.
All patients anticipating systemic anticancer therapy should be ...tested for HBV by 3 tests-hepatitis B surface antigen (HBsAg), hepatitis B core antibody (anti-HBc) total immunoglobulin (Ig) or IgG, and antibody to hepatitis B surface antigen-but anticancer therapy should not be delayed. Findings of chronic HBV (HBsAg-positive) or past HBV (HBsAg-negative and anti-HBc-positive) infection require HBV reactivation risk assessment.Patients with chronic HBV receiving any systemic anticancer therapy should receive antiviral prophylactic therapy through and for minimum 12 months following anticancer therapy. Hormonal therapy alone should not pose a substantial risk of HBV reactivation in patients with chronic HBV receiving hormonal therapy alone; these patients may follow noncancer HBV monitoring and treatment guidance. Coordination of care with a clinician experienced in HBV management is recommended for patients with chronic HBV to determine HBV monitoring and long-term antiviral therapy after completion of anticancer therapy.Patients with past HBV infection undergoing anticancer therapies associated with a high risk of HBV reactivation, such as anti-CD20 monoclonal antibodies or stem-cell transplantation, should receive antiviral prophylaxis during and for minimum 12 months after anticancer therapy completion, with individualized management thereafter. Careful monitoring may be an alternative if patients and providers can adhere to frequent, consistent follow-up so antiviral therapy may begin at the earliest sign of reactivation. Patients with past HBV undergoing other systemic anticancer therapies not clearly associated with a high risk of HBV reactivation should be monitored with HBsAg and alanine aminotransferase during cancer treatment; antiviral therapy should commence if HBV reactivation occurs.Additional information is available at www.asco.org/supportive-care-guidelines.
Patients with lung cancer who undergo chemotherapy (CTX) experience multiple symptoms. Evaluation of how these symptoms cluster together and how these symptom clusters change over time are salient ...questions in symptom clusters research.
The purposes of this analysis, in a sample of patients with lung cancer (n = 145) who were receiving CTX, were to 1) evaluate for differences in the number and types of symptom clusters at three time points (i.e., before their next cycle of CTX, the week after CTX, and two weeks after CTX) using ratings of symptom occurrence and severity and 2) evaluate for changes in these symptom clusters over time.
At each assessment, a modified version of the Memorial Symptom Assessment Scale was used to assess the occurrence and severity of 38 symptoms. Exploratory factor analyses were used to extract the symptom clusters.
Across the two symptom dimensions (i.e., occurrence and severity) and the three assessments, six distinct symptom clusters were identified; however, only three of these clusters (i.e., lung cancer specific, psychological, nutritional) were relatively stable across both dimensions and across time. Two additional clusters varied by time but not by symptom dimension (i.e., epithelial/gastrointestinal and epithelial). A sickness behavior cluster was identified at each assessment with the exception of the week before CTX using only the severity dimension.
Findings provide insights into the most common symptom clusters in patients with lung cancer undergoing CTX. Most common symptoms within each cluster appear to be relatively stable across the two dimensions, as well as across time.
Older patients with poor prognosis cancers have complex needs that can benefit from geriatrics and palliative care principles. Because they are not routinely assessed, the prevalence of preexisting ...geriatric and palliative conditions in this population is unknown.
We used the nationally representative Health and Retirement Study (HRS) linked with Medicare claims (1998-2016) to identify adults aged ≥65 years diagnosed with poor prognosis cancers (cancers with a median survival ≤1 year). Using the HRS interview before the first Medicare cancer claim, we used survey-weighted descriptive statistics and modified Poisson regression analysis to examine the prevalence of the following clinically significant conditions: functional impairment, difficulty with mobility, falls and injurious falls, social support, cognition, advance care planning, use of pain or sleep medications, and presence of pain or breathlessness.
Of 2105 participants (mean age 76, 53% women, 34% lung cancer, 21% gastrointestinal cancer), the median survival was 9.6 months. Approximately 65% had difficulty climbing stairs (95% CI 63%-67%), 49% had no advance directive (95% CI 45%-54%), 35% lived alone (95% CI 33%-37%), 36% fell in the last 2 years (95% CI 34%-38%), and 32% rated their memory as poor (95% CI 29%-34%). After adjusting for gender, cancer type, and HRS survey time before the first Medicare claim for a poor prognosis cancer, functional impairment and falls were highest among adults aged 85+. Adults aged 65-74 years were less likely to have an advance directive. After adjusting for age, cancer type, and HRS survey time, women had a higher rate of pain and physical impairment. In exploratory analyses, race and socioeconomic status predicted difficulty with mobility and instrumental activities of daily living, living alone, and advance directive completion.
Due to a high prevalence across multiple domains, all older adults with poor prognosis cancers should be assessed for geriatric and palliative care conditions.
An academic career in aging research is filled with the incredible highs of important discoveries that improve the lives of older adults and repeated lows when papers and grants are rejected or ...studies are negative. To normalize the experience of setbacks and failures in aging research, we invited three senior investigators to share their journeys of persistence and resilience as they have navigated their research careers. This career development symposium was presented at the 2021 Annual Scientific Meeting of the American Geriatrics Society, which was held virtually. We aimed to connect researchers in aging, especially trainees and junior investigators, through personal stories of persistence and shared strategies to build resilience and respond to setbacks with a growth mindset.
Cancer survival has improved since the 1990s, but to different extents across age groups, with a disadvantage for older adults. We aimed to quantify age-related differences in relative survival ...(RS-1-year and 1-year conditioning on surviving 1 year) for 10 common cancer types by stage at diagnosis. We used data from 18 United States Surveillance Epidemiology and End Results cancer registries and included cancers diagnosed in 2012 to 2016 followed until December 31, 2017. We estimated absolute differences in RS between the 50 to 64 age group and the 75 to 84 age group. The smallest differences were observed for prostate and breast cancers (1.8%-points 95% confidence interval (CI): 1.5-2.1 and 1.9%-points 95% CI: 1.5-2.3, respectively). The largest was for ovarian cancer (27%-points, 95% CI: 24-29). For other cancers, differences ranged between 7 (95% CI: 5-9, esophagus) and 18%-points (95% CI: 17-19, pancreas). Except for pancreatic cancer, cancer type and stage combinations with very high (>95%) or very low (<40%) 1-year RS tended to have smaller age-related differences in survival than those with mid-range prognoses. Age-related differences in 1-year survival conditioning on having survived 1-year were small for most cancer and stage combinations. The broad variation in survival differences by age across cancer types and stages, especially in the first year, age-related differences in survival are likely influenced by amenability to treatment. Future work to measure the extent of age-related differences that are avoidable, and identify how to narrow the survival gap, may have most benefit by prioritizing cancers with relatively large age-related differences in survival (eg, stomach, esophagus, liver and pancreas).
Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy.
To characterize comorbidity and life expectancy in older veterans with ...incidental, symptom-detected, or screen-detected nodules in 2008-09 compared to 2013-14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008-09 subgroup.
Retrospective cohort study.
Urban Veterans Affairs Medical Center.
243 veterans age ≥65 with newly diagnosed pulmonary nodules in 2008-09 (followed for four years through 2012 or 2013) and 446 older veterans diagnosed in 2013-14.
The primary outcome was receipt of any follow-up nodule imaging and/or biopsy within four years after nodule diagnosis. Primary predictor variables included age, Charlson-Deyo Comorbidity Index (CCI), and life expectancy. Favorable life expectancy was defined as age 65-74 with CCI 0 while limited life expectancy was defined as age ≥85 with CCI ≥1 or age ≥65 with CCI ≥4. Interaction by nodule size was also examined.
From 2008-09 to 2013-14, the number of older veterans diagnosed with new pulmonary nodules almost doubled, including among those with severe comorbidity and limited life expectancy. Overall among the 2008-09 subgroup, receipt of nodule follow-up decreased with increasing comorbidity (CCI ≥4 versus 0: adjusted RR 0.61, 95% CI 0.39-0.95) with a trend towards decreased follow-up among those with limited life expectancy (adjusted RR 0.69, 95% CI 0.48-1.01). However, we detected an interaction effect with nodule size such that comorbidity and life expectancy were associated with decreased follow-up only among those with nodules ≤6 mm.
We found some individualization of pulmonary nodule follow-up according to comorbidity and life expectancy in older veterans with smaller nodules only. As increased imaging detects nodules in sicker patients, guidelines need to be more explicit about how to best incorporate comorbidity and life expectancy to maximize benefits and minimize harms for patients with nodules of all sizes.
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