Healthcare providers' experiences of continuing care for older adults with cancer during the COVID-19 pandemic.

PURPOSE: The COVID-19 pandemic has caused great strain on older adults with cancer and their healthcare providers. This study explored healthcare providers' reported changes in cancer care, clinical barriers to care, patient questions, and the overall experiences of caring for older adults with cancer during the COVID-19 crisis. METHODS: The Advocacy Committee of the Cancer and Aging Research Group and the Association of Community Cancer Centers developed a survey for healthcare providers of adults with cancer, inquiring about their experiences during the pandemic. Responses from the survey's four open-ended items were analyzed by four independent coders for identification of common themes using deductive and inductive methods. RESULTS: Participants (n = 137) represented a variety of demographic and clinical experiences. Six overall themes emerged, including (1) telehealth use, (2) concerns for patient mental health, (3) patient physical and social isolation, (4) patient fear of contracting COVID-19, (5) continued disruptions to cancer care, and (6) patients seeking guidance, particularly regarding COVID-19 vaccination. Questions fielded by providers focused on the COVID-19 vaccination's safety and efficacy during older adults' cancer treatment. CONCLUSIONS: Additional resources (e.g., technology support, established care guidelines, and sufficient staffing) are needed to support older adults with cancer and healthcare providers during the pandemic. Future research should explore universally effective in-person and virtual treatment strategies for older adults with cancer. IMPLICATIONS FOR CANCER SURVIVORS: Persistence of telehealth barriers, particularly a lack of infrastructure to support telehealth visits, social isolation, and restrictive visitor policies as a result of COVID-19, negatively impacted the mental health of older adults with cancer.

Pooled analysis of first-line treatment with targeted agents in patients with chronic lymphocytic leukemia aged 80 years and older.

Patients aged 80 years and older make up a fifth of patients with CLL but are underrepresented in clinical trials. We analyzed the outcomes of these patients treated with targeted agents in the front-line setting in six trials of the German CLL Study Group. Targeted agents included venetoclax, ibrutinib, and idelalisib, mainly used in combination with anti-CD20 antibodies. Among 716 patients, 33 matched the selection criteria (5%). Of those, the majority had relevant comorbidity, organ dysfunctions, and/or high-/very high-risk disease. The overall response rate was 73%. The median progression-free survival was 49.2 months compared with those not reached in younger patients. There were 11 documented deaths of which two were deemed related to therapy. Additional results including 40 patients treated with BTK-inhibitors from the GCLLSG registry suggest that treatment with targeted agents is feasible and effective. Dedicated studies are warranted for this particular subgroup of patients.

Differences in urban and suburban/rural settings regarding care provision and barriers of cancer care for older adults during COVID-19.

PURPOSE: Care for older adults with cancer became more challenging during the COVID-19 pandemic, particularly in urban hotspots. This study examined the potential differences in healthcare providers' provision of as well as barriers to cancer care for older adults with cancer between urban and suburban/rural settings. METHODS: Members of the Advocacy Committee of the Cancer and Aging Research Group, with the Association of Community Cancer Centers, surveyed multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Respondents were recruited through organizational listservs, email blasts, and social media messages. Descriptive statistics and chi-square tests were used. RESULTS: Complete data was available from 271 respondents (urban (n = 144), suburban/rural (n = 127)). Most respondents were social workers (42, 44%) or medical doctors/advanced practice providers (34, 13%) in urban and suburban/rural settings, respectively. Twenty-four percent and 32.4% of urban-based providers reported "strongly considering" treatment delays among adults aged 76-85 and > 85, respectively, compared to 13% and 15.4% of suburban/rural providers (Ps = 0.048, 0.013). More urban-based providers reported they were inclined to prioritize treatment for younger adults over older adults than suburban/rural providers (10.4% vs. 3.1%, p = 0.04) during the pandemic. The top concerns reported were similar between the groups and related to patient safety, treatment delays, personal safety, and healthcare provider mental health. CONCLUSION: These findings demonstrate location-based differences in providers' attitudes regarding care provision for older adults with cancer during the COVID-19 pandemic.

Development and implementation of an interdisciplinary telemedicine clinic for older patients with cancer-Preliminary data.

BACKGROUND: Frailty assessment is an important marker of the older adult's fitness for cancer treatment independent of age. Pretreatment geriatric assessment (GA) is associated with improved mortality and morbidity outcomes but must occur in a time sensitive manner to be useful for cancer treatment decision making. Unfortunately, time, resources and other constraints make GA difficult to perform in busy oncology clinics. We developed the Cancer and Aging Interdisciplinary Team (CAIT) clinic model to provide timely GA and treatment recommendations independent of patient's physical location. METHODS: The interdisciplinary CAIT clinic model was developed utilizing the surge in telemedicine during the COVID-19 pandemic. The core team consists of the patient's oncologist, geriatrician, registered nurse, pharmacist, and registered dietitian. The clinic's format is flexible, and the various assessments can be asynchronous. Patients choose the service method-in person, remotely, or hybrid. Based on GA outcomes, the geriatrician provides recommendations and arrange interventions. An assessment summary including life expectancy estimates and chemotoxicity risk calculator scores is conveyed to and discussed with the treating oncologist. Physician and patient satisfaction were assessed. RESULTS: Between May 2021 and June 2022, 50 patients from multiple physical locations were evaluated in the CAIT clinic. Sixty-eight percent was 80 years of age or older (range 67-99). All the evaluations were hybrid. The median days between receiving a referral and having the appointment was 8. GA detected multiple unidentified impairments. About half of the patients (52%) went on to receive chemotherapy (24% standard dose, 28% with dose modifications). The rest received radiation (20%), immune (12%) or hormonal (4%) therapies, 2% underwent surgery, 2% chose alternative medicine, 8% were placed under observation, and 6% enrolled in hospice care. Feedback was extremely positive. CONCLUSIONS: The successful development of the CAIT clinic model provides strong support for the potential dissemination across services and institutions.

Adapting an Evidence-Based Exercise and Education Program for Older Breast Cancer Survivors for the REJOIN Trial.

Physical activity (PA) promotes survival and mitigates symptoms in older breast cancer survivors (BCS), especially to reduce joint pain associated with adjuvant hormonal treatment. The purpose is to describe the adaptation process for an evidence-based exercise and education curriculum (i.e., Fit & Strong!) to support older BCS participating in the Using Exercise to Relieve Joint Pain and Improve Aromatase Inhibitor Adherence in Older Breast Cancer Survivors trial. We reviewed all educational materials with scientific/clinical experts to identify necessary content changes. Next, we conducted semistructured phone interviews with BCS to review all educational materials and conducted a real-time pretest for the trial. Overall, BCS found the adapted materials and experience acceptable (mean score of 9.2/10 for satisfaction). Content changes included simplifying exercise instructions, prioritizing content related to the trial goals, and updating photographs. Because of COVID, the pretest was conducted via Zoom. Our multistep adaptation process provided an acceptable intervention to meet the needs of older BCS. Lessons learned will be applied to the forthcoming pilot trial.

Healthcare providers' attitudes towards delay in cancer treatment during COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic has created unprecedented obstacles leading to delays in treatment for older adults with cancer. Due to limited resources at the height of the pandemic, healthcare providers were constantly faced with ethical dilemmas regarding postponing or rescheduling care for their patients. MATERIALS AND METHODS: Two survey-based studies were conducted at different time-points during the pandemic looking at factors affecting oncology care providers' attitudes towards delay in treatment for older adults with cancer. Eligible participants were recruited by email sent through professional organizations' listservs, email blasts, and social media. Change in provider attitude over time was analyzed by comparing responses from the 2020 and 2021 surveys. Data analysis included descriptive statistics and chi-squares. RESULTS: In 2020, 17.5% of respondents were strongly considering/considering postponing cancer treatment for younger patients (age 30 and below), while 46.2% were considering delaying treatment for patients aged >85. These responses were in stark contrast to the results of the 2021 survey, where only 1.4% of respondents strongly considered postponing treatment for younger patients, and 13.5% for patients aged >85. DISCUSSION: All recommendations to postpone treatment for older adults with cancer must be made after mutual discussion with the patient. Throughout the COVID-19 pandemic, oncology care providers had to consider multiple factors while treating patients, frequently making most decisions without appropriate institutional support.

Remaining Agile in the COVID-19 pandemic healthcare landscape - How we adopted a hybrid telemedicine Geriatric Oncology care model in an academic tertiary cancer center.

INTRODUCTION: The COVID-19 pandemic has impacted healthcare on an unprecedented scale, with healthcare resources being channeled into managing the devastating effects of the outbreak. Healthcare provision for vulnerable older adults has also been affected by lockdowns and suspension of selected medical services worldwide. In our tertiary cancer center, the National University Cancer Institute, Singapore (NCIS), our Geriatric Oncology (GO) service for older adults with cancer was halted for five months. In this paper, we describe the adoption of a hybrid telemedicine model by our GO service to continue care provision for older adults in the midst of the pandemic. MATERIALS AND METHODS: Comprehensive geriatric assessments (CGA) were done via telemedicine and virtual multidisciplinary discussions were held prior to the patients' clinic visits. A hybrid telemedicine consultation allowed geriatricians and oncologists, segregated in different sites during the pandemic, to provide a hybrid physical and video geriatric oncology consultation. Scheduled phone follow ups by GO nurses helped to monitor patients for treatment-related toxicities and geriatric syndromes. RESULTS: Two hundred fifty patients were enrolled in the program from July 2020 to August 2021. All were assessed with a CGA, with 240 receiving interventions in the one-stop clinic. The average amount of time spent per visit was shortened from four hours to two and a half hours with an average of three interventions on the same day, versus one previously. Of the patients who received interventions, 84.8% were satisfied with the hybrid telemedicine model and 80.8% of them had reported a maintained or improved quality of life after being enrolled in the program. DISCUSSION: Telemedicine has been widely adopted during the pandemic, but older adults with limited digital literacy may find it a challenge. Our hybrid telemedicine model has allowed us to continue to provide cancer care, identify issues brought about by social isolation, and render timely assistance. It has become imperative to adapt, prepare and plan for the challenges we may face amid the ongoing COVID-19 pandemic and similar future outbreaks. Only by doing so can we remain agile and resilient, to continue providing quality care to our older patients with cancer.

Hypofractionated Radiotherapy in Head and Neck Cancer Elderly Patients: A Feasibility and Safety Systematic Review for the Clinician.

OBJECTIVE: Radiotherapy (RT) in the head and neck (H&N) site are undoubtedly the most challenging treatments for patients. Older and frail patients are not always able to tolerate it, and there are still no clear guidelines on the type of treatments to be preferred for them. The recommendations for Risk-Adapted H&N Cancer Radiation Therapy during the coronavirus disease 2019 (COVID-19) pandemic provided by the ASTRO-ESTRO consensus statement achieved a strong agreement about hypofractionated RT (HFRT). A systematic literature review was conducted in order to evaluate the feasibility and safety of HFRT for older patients affected by H&N malignancies. MATERIALS AND METHODS: A systematic database search was performed on PubMed and Embase according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Original studies, case series, and case reports describing the use of HFRT (with at least 2.2 Gy fractions) in patients with mean age ≥65 years were included. The analysis was based on the type of study, number of patients, mean age, tumor site, histology, performance status (PS), RT details, concomitant chemotherapy (CT), and described clinical outcomes. All the reported doses have been calculated in equivalent dose in 2 Gy fractions (EQD2) and biologically effective dose (BED) using α/ß = 10 Gy or α/ß = 12 Gy. RESULTS: We selected 17 papers that met the inclusion criteria and divided them in 4 categories: 6 articles analyze HFRT performed twice daily in repeated cycles, 3 once a day in repeated cycles, 4 in alternative days, and the last 4 in consecutive days. CONCLUSION: HFRT seems to be a good treatment with an acceptable prolonged disease control. In older patients fit for radical treatments, a 55 Gy in 20 fractions regimen can be proposed as a valid alternative to the standard fractionated RT, but there are a multitude of hypofractionated regimens, ranging from single fraction, quad shot, and 1-, 2-, 3-, 4-, and 5-week schedules that all may be appropriate. The correct regimen for a patient depends on many factors, and it represents the result of a more specific and complex decision.

Spreading geriatric oncology culture through professional caregivers: Results of a French massive open online course (MOOC).

Geriatric oncology is based on the synergy between several professionals whose common goal is to improve care for older patients with cancer. This requires sharing a common core of knowledge to facilitate collaboration between them. To date, training in geriatric oncology has been limited in scope and difficult to access for caregivers, particularly nurses and healthcare aides. To meet this need, a massive open online course (MOOC), in geriatric oncology has been developed in France. This kind of course aims to provide simultaneous access for a large number of participants and to foster communication with the pedagogical team through discussion forums. The first session of the MOOC, which has been set up in the Occitania region of France, went online nationwide from March 6 to June 23, 2020. Despite the SARS CoV-2 global health crisis, 1020 people subscribed to the first session and 417 (40.9%) were certified at the end of the course. Most are nurses (35.2%) and work outside Occitania (56.3%). A survey revealed a high satisfaction level regarding relevance of lessons (97.9%), pedagogical quality of teaching team (97.9%), knowledge acquisition (93.6%), meeting learners' needs (90.4%) and practical value of the course (88.3%). This preliminary experience demonstrates the ability of this MOOC to spread the culture of geriatric oncology and the educational potential of this new type of online training.

Goals of care conversations and telemedicine.

Rapid expansion of telemedicine is one of the transformative healthcare consequences of the COVID pandemic. As a result, telemedicine has allowed clinicians to address the needs of older adults with cancer, who faced the highest risks from COVID, while maintaining safety at home. In light of the COVID experience, which is an important source of learning, this article provides guidance on approaches to enhance telemedicine-enabled supportive care for the geriatric cancer patient.

Survey of cancer care providers' attitude toward care for older adults with cancer during the COVID-19 pandemic.

OBJECTIVES: Care for older adults with cancer became more challenging during the COVID-19 pandemic. We sought to examine cancer care providers' attitudes toward the barriers and facilitators related to the care for these patients during the pandemic. MATERIALS AND METHODS: Members of the Advocacy Committee of the Cancer and Aging Research Group, along with the Association of Community Cancer Centers, developed the survey distributed to multidisciplinary healthcare providers responsible for the direct care of patients with cancer. Participants were recruited by email sent through four professional organizations' listservs, email blasts, and messages through social media. RESULTS: Complete data was available from 274 respondents. Only 15.4% had access to written guidelines that specifically address the management of older adults with cancer during the COVID-19 pandemic. Age was ranked fifth as the reason for postponing treatment following comorbid conditions, cancer stage, frailty, and performance status. Barriers to the transition to telehealth were found at the patient-, healthcare worker-, and institutional-levels. Providers reported increased barriers in accessing basic needs among older adults with cancer. Most respondents agreed (86.3%) that decision making about Do Not Resuscitate orders should be the result of discussion with the patient and the healthcare proxy in all situations. The top five concerns reported were related to patient safety, treatment delays, healthcare worker mental health and burnout, and personal safety for family and self. CONCLUSION: These findings demand resources and support allocation for older adults with cancer and healthcare providers during the COVID-19 pandemic.

Experiences of healthcare providers of older adults with cancer during the COVID-19 pandemic.

OBJECTIVES: Care for older adults with cancer became more challenging during the COVID-19 pandemic. We sought to examine healthcare providers' clinical barriers, patient questions, and overall experiences related to care delivery for these patients during the pandemic. MATERIALS AND METHODS: Members of the Advocacy Committee of the Cancer and Aging Research Group along with the Association of Community Cancer Centers developed a 20-question survey for healthcare providers of older adults with cancer. Eligible participants were recruited by email sent through professional organizations' listservs, email blasts, and social media. This manuscript reports the qualitative data from the survey's three open-ended questions. Free text, open-ended survey items were analyzed by two independent coders for identification of common themes using NVivo software. Theme agreement was reached through consensus and count comparisons of participant responses were made. RESULTS: Healthcare system organizational challenges and meeting basic needs and support were commonly reported themes among respondents (n = 274). Barriers to care delivery included organizational challenges, patients' access to resources and support, concerns for patients' mental and physical health, and telehealth challenges. Respondents reported older adults were asking about their health and cancer care as well as access to basic needs and supports. Providers described worrying about patients' mental health, fear of personal safety, frustration in multi-level institutions, as well as experiencing positive leadership and communication. CONCLUSION: Providers are faced with balancing their concerns for personal and patient safety. These findings demand resources and support allocation for older adults with cancer and healthcare providers during the COVID-19 pandemic.

COVID-19 in Older Individuals with Cancer: Problem and Potential Solutions.

The ongoing coronavirus disease-2019 (COVID-19) pandemic has radically affected medical practice and healthcare delivery in the United States and beyond. Its impact on vulnerable populations especially older adults battling cancer is striking. Older adults with baseline immunosenescence compounded with multimorbidity and reduced physiological reserves are at even higher risk of succumbing to infection. When it comes to older adults with cancer mortality, it often multifactorial with modifiable risk factors. A specific approach with attention to advance care planning and how cancer care is delivered coupled with a comprehensive geriatric assessment may ultimately be the key to improve overall survival.

Adapting care for older cancer patients during the COVID-19 pandemic: Recommendations from the International Society of Geriatric Oncology (SIOG) COVID-19 Working Group.

The COVID-19 pandemic poses a barrier to equal and evidence-based management of cancer in older adults. The International Society of Geriatric Oncology (SIOG) formed a panel of experts to develop consensus recommendations on the implications of the pandemic on several aspects of cancer care in this age group including geriatric assessment (GA), surgery, radiotherapy, systemic treatment, palliative care and research. Age and cancer diagnosis are significant predictors of adverse outcomes of the COVID-19 infection. In this setting, GA is particularly valuable to drive decision-making. GA may aid estimating physiologic reserve and adaptive capability, assessing risk-benefits of either providing or temporarily withholding treatments, and determining patient preferences to help inform treatment decisions. In a resource-constrained setting, geriatric screening tools may be administered remotely to identify patients requiring comprehensive GA. Tele-health is also crucial to ensure adequate continuity of care and minimize the risk of infection exposure. In general, therapeutic decisions should favor the most effective and least invasive approach with the lowest risk of adverse outcomes. In selected cases, this might require deferring or omitting surgery, radiotherapy or systemic treatments especially where benefits are marginal and alternative safe therapeutic options are available. Ongoing research is necessary to expand knowledge of the management of cancer in older adults. However, the pandemic presents a significant barrier and efforts should be made to ensure equitable access to clinical trials and prospective data collection to elucidate the outcomes of COVID-19 in this population.