Publications by authors named "Erika Ramsdale"

29 Publications

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Research priorities to address polypharmacy in older adults with cancer.

J Geriatr Oncol 2021 Feb 12. Epub 2021 Feb 12.

Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA, USA; Sidney Kimmel Cancer Center, Jefferson Health, Philadelphia, PA, USA.

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.
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http://dx.doi.org/10.1016/j.jgo.2021.01.009DOI Listing
February 2021

Association of Polypharmacy and Potentially Inappropriate Medications With Physical Functional Impairments in Older Adults With Cancer.

J Natl Compr Canc Netw 2021 Jan 22:1-8. Epub 2021 Jan 22.

1James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York.

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.
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http://dx.doi.org/10.6004/jnccn.2020.7628DOI Listing
January 2021

Patient and caregiver agreement on prognosis estimates for older adults with advanced cancer.

Cancer 2020 Jan 9;127(1):149-159. Epub 2020 Oct 9.

Division of Hematology/Oncology, Department of Medicine, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, New York.

Background: Disagreements between patients and caregivers about treatment benefits, care decisions, and patients' health are associated with increased patient depression as well as increased caregiver anxiety, distress, depression, and burden. Understanding the factors associated with disagreement may inform interventions to improve the aforementioned outcomes.

Methods: For this analysis, baseline data were obtained from a cluster-randomized geriatric assessment trial that recruited patients aged ≥70 years who had incurable cancer from community oncology practices (University of Rochester Cancer Center 13070; Supriya G. Mohile, principal investigator). Patient and caregiver dyads were asked to estimate the patient's prognosis. Response options were 0 to 6 months, 7 to 12 months, 1 to 2 years, 2 to 5 years, and >5 years. The dependent variable was categorized as exact agreement (reference), patient-reported longer estimate, or caregiver-reported longer estimate. The authors used generalized estimating equations with multinomial distribution to examine the factors associated with patient-caregiver prognostic estimates. Independent variables were selected using the purposeful selection method.

Results: Among 354 dyads (89% of screened patients were enrolled), 26% and 22% of patients and caregivers, respectively, reported a longer estimate. Compared with dyads that were in agreement, patients were more likely to report a longer estimate when they screened positive for polypharmacy (β = 0.81; P = .001), and caregivers reported greater distress (β = 0.12; P = .03). Compared with dyads that were in agreement, caregivers were more likely to report a longer estimate when patients screened positive for polypharmacy (β = 0.82; P = .005) and had lower perceived self-efficacy in interacting with physicians (β = -0.10; P = .008).

Conclusions: Several patient and caregiver factors were associated with patient-caregiver disagreement about prognostic estimates. Future studies should examine the effects of prognostic disagreement on patient and caregiver outcomes.
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http://dx.doi.org/10.1002/cncr.33259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736110PMC
January 2020

Older adults with cancer and their caregivers - current landscape and future directions for clinical care.

Nat Rev Clin Oncol 2020 12 2;17(12):742-755. Epub 2020 Sep 2.

University of Rochester Medical Center, Wilmot Cancer Institute, Department of Haematology/Oncology, Rochester, NY, USA.

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 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 the 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 the current guidelines as well as investigational studies underway to improve the outcomes of these patients.
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http://dx.doi.org/10.1038/s41571-020-0421-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851836PMC
December 2020

Speeding the dissemination and implementation of geriatric assessment: What we can learn from the business world.

J Geriatr Oncol 2020 09 24;11(7):1170-1174. Epub 2020 Mar 24.

James P Wilmot Cancer Institute, University of Rochester, School of Medicine and Dentistry, Rochester, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jgo.2020.03.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7502467PMC
September 2020

Associations of Polypharmacy and Inappropriate Medications with Adverse Outcomes in Older Adults with Cancer: A Systematic Review and Meta-Analysis.

Oncologist 2020 01 30;25(1):e94-e108. Epub 2019 Sep 30.

James P. Wilmot Cancer Center, University of Rochester Medical Center, Rochester, New York, USA.

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.
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http://dx.doi.org/10.1634/theoncologist.2019-0406DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964156PMC
January 2020

Deliberate Indifference: Inadequate Health Care in U.S. Prisons.

Ann Intern Med 2019 Apr 2;170(8):563-564. Epub 2019 Apr 2.

James Wilmot Cancer Center, University of Rochester, Rochester, New York (E.R.).

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http://dx.doi.org/10.7326/M17-3154DOI Listing
April 2019

Association Between Symptom Burden and Physical Function in Older Patients with Cancer.

J Am Geriatr Soc 2019 05 8;67(5):998-1004. Epub 2019 Mar 8.

James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, New York.

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 <.01) when compared with those in the bottom quartile (N = 81; CSI score: 2 ± 2). With each unit increase in CSI score, the odds of having IADL impairment, physical activity limitations, falls, and SPPB scores of 9 or less increased by 4.8%, 4.4%, 2.9%, and 2.5%, respectively (P < .05 for all results).

Conclusions: In older patients with cancer, higher symptom burden is associated with functional impairment. Future studies are warranted to evaluate if improved symptom management can improve function in older cancer patients. J Am Geriatr Soc 67:998-1004, 2019.
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http://dx.doi.org/10.1111/jgs.15864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851835PMC
May 2019

Novel mHealth App to Deliver Geriatric Assessment-Driven Interventions for Older Adults With Cancer: Pilot Feasibility and Usability Study.

JMIR Cancer 2018 Oct 29;4(2):e10296. Epub 2018 Oct 29.

Division of Hematology/Oncology, James P Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States.

Background: Older 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.

Objective: We 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.

Methods: In 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.

Results: A 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.

Conclusions: TouchStream 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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http://dx.doi.org/10.2196/10296DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6234352PMC
October 2018

Characterizing cancer cachexia in the geriatric oncology population.

J Geriatr Oncol 2019 05 5;10(3):415-419. Epub 2018 Sep 5.

Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, United States; University of Rochester NCI Community Oncology Research Program (UR NCORP), Rochester, NY, United States.

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.
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http://dx.doi.org/10.1016/j.jgo.2018.08.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6401352PMC
May 2019

Pharmacist-led medication assessment and deprescribing intervention for older adults with cancer and polypharmacy: a pilot study.

Support Care Cancer 2018 Dec 4;26(12):4105-4113. Epub 2018 Jun 4.

Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, NY, USA.

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 $4282.27 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.
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http://dx.doi.org/10.1007/s00520-018-4281-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6204077PMC
December 2018

Geriatric assessment-driven polypharmacy discussions between oncologists, older patients, and their caregivers.

J Geriatr Oncol 2018 09 9;9(5):534-539. Epub 2018 Mar 9.

James Wilmot Cancer Center, University of Rochester, Rochester, NY, United States.

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.
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http://dx.doi.org/10.1016/j.jgo.2018.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6113101PMC
September 2018

Using Information Technology in the Assessment and Monitoring of Geriatric Oncology Patients.

Curr Oncol Rep 2018 03 6;20(3):25. Epub 2018 Mar 6.

James P Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, 601 Elmwood Avenue, Box 704, Rochester, NY, 14642, USA.

Purpose Of Review: 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.

Recent Findings: 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.
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http://dx.doi.org/10.1007/s11912-018-0672-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5878089PMC
March 2018

Providing Optimal Multidisciplinary Care to Older Patients With Cancer.

J Oncol Pract 2017 02;13(2):105-106

University of Rochester, James P. Wilmot Cancer Institute, Rochester, NY.

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http://dx.doi.org/10.1200/JOP.2016.019695DOI Listing
February 2017

Improving Quality and Value of Cancer Care for Older Adults.

Am Soc Clin Oncol Educ Book 2017 ;37:383-393

From the University of Rochester Medical Center, Rochester, NY; The Sidney Kimmel Cancer Center at Thomas Jefferson University, Philadelphia, PA; University of California, Los Angeles, Los Angeles, CA; Cancer and Aging Research Group, Rhinebeck, NY.

The concepts of quality and value have become ubiquitous in discussions about health care, including cancer care. Despite their prominence, these concepts remain difficult to encapsulate, with multiple definitions and frameworks emerging over the past few decades. Defining quality and value for the care of older adults with cancer can be particularly challenging. Older adults are heterogeneous and often excluded from clinical trials, severely limiting generalizable data for this population. Moreover, many frameworks for quality and value focus on traditional outcomes of survival and toxicity and neglect goals that may be more meaningful for older adults, such as quality of life and functional independence. A history of quality and value standards and an evaluation of some currently available standards and frameworks elucidate the potential gaps in application to older adults with cancer. However, narrowing the focus to processes of care presents several opportunities for improving the care of older adults with cancer now, even while further work is ongoing to evaluate outcomes and efficiency. New models of care, including the patient-centered medical home, as well as new associated bundled payment models, would be advantageous for older adults with cancer, facilitating collaboration, communication, and patient-centeredness and minimizing the fragmentation that impairs the current provision of cancer care. Advances in information technology support the foundation for these models of care; these technologies facilitate communication, increase available data, support shared decision making, and increase access to multidisciplinary specialty care. Further work will be needed to define and to continue to tailor processes of care to achieve relevant outcomes for older patients with cancer to fulfill the promise of quality and value of care for this vulnerable and growing population.
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http://dx.doi.org/10.1200/EDBK_175442DOI Listing
December 2017

Current debate in the oncologic management of rectal cancer.

World J Gastrointest Oncol 2016 Oct;8(10):715-724

Trish Millard, Paul R Kunk, Erika Ramsdale, Division of Hematology-Oncology, Department of Medicine, University of Virginia Health System, Charlottesville, VA 22908, United States.

Despite the considerable amount of research in the field, the management of locally advanced rectal cancer remains a subject to debate. To date, effective treatment centers on surgical resection with the standard approach of total mesorectal resection. Radiation therapy and chemotherapy have been incorporated in order to decrease local and systemic recurrence. While it is accepted that a multimodality treatment regimen is indicated, there remains significant debate for how best to accomplish this in regards to order, dosing, and choice of agents. Preoperative radiation is the standard of care, yet remains debated with the option for chemoradiation, short course radiation, and even ongoing studies looking at the possibility of leaving radiation out altogether. Chemotherapy was traditionally incorporated in the adjuvant setting, but recent reports suggest the possibility of improved efficacy and tolerance when given upfront. In this review, the major studies in the management of locally advanced rectal cancer will be discussed. In addition, future directions will be considered such as the role of immunotherapy and ongoing trials looking at timing of chemotherapy, inclusion of radiation, and non-operative management.
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http://dx.doi.org/10.4251/wjgo.v8.i10.715DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5064049PMC
October 2016

A Comprehensive Look at Polypharmacy and Medication Screening Tools for the Older Cancer Patient.

Oncologist 2016 06 5;21(6):723-30. Epub 2016 May 5.

Division of Hematology/Oncology, University of Virginia Health System, Charlottesville, Virginia, USA.

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.
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http://dx.doi.org/10.1634/theoncologist.2015-0492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4912369PMC
June 2016

Interprofessional training enhances collaboration between nursing and medical students: A pilot study.

Nurse Educ Today 2016 May 4;40:33-8. Epub 2016 Feb 4.

Department of Medicine, Emily Couric Cancer Center, Charlottesville, VA 22903, United States. Electronic address:

Background: 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.

Study Design: 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.

Results: 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, p<0.001. 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.

Conclusions: 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.
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http://dx.doi.org/10.1016/j.nedt.2016.01.024DOI Listing
May 2016

Treatment of leptomeningeal carcinomatosis: current challenges and future opportunities.

J Clin Neurosci 2015 Apr 9;22(4):632-7. Epub 2015 Feb 9.

University of Chicago, Department of Neurology, 5841 S. Maryland Avenue, MC 2030, Chicago, IL 60637, USA. Electronic address:

Leptomeningeal metastasis (LM) in breast cancer patients confers a uniformly poor prognosis and decreased quality of life. Treatment options are limited and often ineffective, due in large part to limitations imposed by the blood-brain barrier and the very aggressive nature of this disease. The majority of studies investigating the treatment of LM are not specific to site of origin. Conducting randomized, disease-specific clinical trials in LM is challenging, and much clinical outcomes data are based on case reports or retrospective case series. Multiple studies have suggested that chemo-radiotherapy is superior to either chemotherapy or radiation therapy alone. Attempts to overcome current obstacles in the treatment of breast cancer LM hold promise for the future. We review the epidemiology, diagnosis, and prognosis of LM in breast cancer, and discuss the treatment options currently available as well as those under investigation.
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http://dx.doi.org/10.1016/j.jocn.2014.10.022DOI Listing
April 2015

The Vulnerable Elders Survey-13 predicts mortality in older adults with later-stage colorectal cancer receiving chemotherapy: a prospective pilot study.

J Am Geriatr Soc 2013 Nov;61(11):2043-4

Section of Hematology/Oncology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois; Geriatrics & Palliative Medicine, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.

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http://dx.doi.org/10.1111/jgs.12536DOI Listing
November 2013

Approach to the older patient with stage II/III colorectal cancer: who should get curative-intent therapy?

Am Soc Clin Oncol Educ Book 2013 :163-8

From the University of Chicago Medical Center, Department of Medicine, Section of Hematology/Oncology, Chicago, IL; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, Chapel Hill, NC.

The majority of new colorectal cancer diagnoses occur in adults 65 and older a rapidly growing segment of the U.S. population. Older adults are a markedly heterogeneous group, and although recent clinical trials in locally advanced colorectal cancer have incorporated limited numbers of older patients, the data can not be generalized to most older patients. In particular, patients who are not "fit"-those with poor functional reserve, major comorbidities, or who otherwise meet criteria for frailty or "prefrailty"-are poorly represented in published trials. Population-based data demonstrate that older adults are much less likely to be treated in the adjuvant or neoadjuvant settings for stage II/III colorectal cancer, but it is unclear what the basis should be for withholding potentially curative therapy. Age and Eastern Cooperative Oncology Group (ECOG) performance status (PS) are frequently used to determine eligibility for treatment, but data increasingly suggest these are inadequate; the emerging definition of a spectrum of "fit" to "frail" older patients may provide additional guidance. Available data suggest that fit older patients may benefit as much from curative-intent therapy as younger patients. For frail or vulnerable (prefrail) patients, on the other hand, the benefit must be carefully weighed against the risk of toxicity and competing risks from their comorbidities. Life expectancy and patient preferences should always be elucidated. Geriatrician comanagement may be helpful in determining priorities, providing a comprehensive assessment, and modifying competing risk factors. Even many vulnerable or frail patients can successfully complete (and derive benefit from) carefully considered treatment regimens.
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http://dx.doi.org/10.14694/EdBook_AM.2013.33.163DOI Listing
April 2016

Evidence-based guidelines and quality measures in the care of older adults.

Virtual Mentor 2013 Jan 1;15(1):51-5. Epub 2013 Jan 1.

University of Chicago, USA.

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http://dx.doi.org/10.1001/virtualmentor.2013.15.1.pfor1-1301DOI Listing
January 2013

A retrospective multicenter analysis of elderly Hodgkin lymphoma: outcomes and prognostic factors in the modern era.

Blood 2012 Jan 23;119(3):692-5. Epub 2011 Nov 23.

Division of Hematology/Oncology, University of Massachusetts Medical School, Worcester, 01655, USA.

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).
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http://dx.doi.org/10.1182/blood-2011-09-378414DOI Listing
January 2012

Analysis of very elderly (≥80 years) non-hodgkin lymphoma: impact of functional status and co-morbidities on outcome.

Br J Haematol 2012 Jan 16;156(2):196-204. Epub 2011 Nov 16.

Division of Hematology/Oncology, Advocate Lutheran General Hospital, 1700 Luther Lane, Park Ridge, IL, USA.

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.
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http://dx.doi.org/10.1111/j.1365-2141.2011.08934.xDOI Listing
January 2012

Old versus frail: why it matters in lymphoma.

Leuk Lymphoma 2011 Jun;52(6):938-40

Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL, USA.

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http://dx.doi.org/10.3109/10428194.2011.582657DOI Listing
June 2011

Allogeneic transplant for peripheral T-cell lymphoma: a sparkle of hope and many questions.

Leuk Lymphoma 2011 Aug;52(8):1415-7

Section of Hematology/Oncology, University of Chicago, Chicago, IL 60637, USA.

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http://dx.doi.org/10.3109/10428194.2011.573038DOI Listing
August 2011

Personalized treatment of lymphoma: promise and reality.

Semin Oncol 2011 Apr;38(2):225-35

Lymphoma Program, The University of Chicago, Chicago, IL 60637, USA.

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.
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http://dx.doi.org/10.1053/j.seminoncol.2011.01.008DOI Listing
April 2011