Pilot Randomized Trial of a Transdisciplinary Geriatric and Palliative Care Intervention for Older Adults With Cancer

Restricted access

Background: Oncologists often struggle with managing the unique care needs of older adults with cancer. This study sought to determine the feasibility of delivering a transdisciplinary intervention targeting the geriatric-specific (physical function and comorbidity) and palliative care (symptoms and prognostic understanding) needs of older adults with advanced cancer. Methods: Patients aged ≥65 years with incurable gastrointestinal or lung cancer were randomly assigned to a transdisciplinary intervention or usual care. Those in the intervention arm received 2 visits with a geriatrician, who addressed patients’ palliative care needs and conducted a geriatric assessment. We predefined the intervention as feasible if >70% of eligible patients enrolled in the study and >75% of eligible patients completed study visits and surveys. At baseline and week 12, we assessed patients’ quality of life (QoL), symptoms, and communication confidence. We calculated mean change scores in outcomes and estimated intervention effect sizes (ES; Cohen’s d) for changes from baseline to week 12, with 0.2 indicating a small effect, 0.5 a medium effect, and 0.8 a large effect. Results: From February 2017 through June 2018, we randomized 62 patients (55.9% enrollment rate [most common reason for refusal was feeling too ill]; median age, 72.3 years; cancer types: 56.5% gastrointestinal, 43.5% lung). Among intervention patients, 82.1% attended the first visit and 79.6% attended both. Overall, 89.7% completed all study surveys. Compared with usual care, intervention patients had less QoL decrement (–0.77 vs –3.84; ES = 0.21), reduced number of moderate/severe symptoms (–0.69 vs +1.04; ES = 0.58), and improved communication confidence (+1.06 vs –0.80; ES = 0.38). Conclusions: In this pilot trial, enrollment exceeded 55%, and >75% of enrollees completed all study visits and surveys. The transdisciplinary intervention targeting older patients’ unique care needs showed encouraging ES estimates for enhancing patients’ QoL, symptom burden, and communication confidence.

Submitted August 24, 2019; accepted for publication December 4, 2019.

Previous presentation: Presented in abstract form at the 2019 ASCO Annual Meeting; May 31–June 4, 2019; Chicago, Illinois (J Clin Oncol 2019;37[Suppl]:Abstract 11549).

Author contributions: All authors made substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data. All were involved in drafting the article or revising it critically for important intellectual content. All provided final approval of the manuscript and agree to be accountable for all aspects of the work.

Disclosures: Dr. Greer has disclosed that he recieves grant/research support from and is a consultant for Gaido Health/BCG Digital Ventures. The remaining authors have disclosed that they have not received any financial consideration from any person or organization to support the preparation, analysis, results, or discussion of this article.

Funding: Dr. Temel has disclosed funding from NCI (K24 CA181253). Dr. Nipp has disclosed funding from NIH/National Institute on Aging (R03AG053314).

Correspondence: Ryan D. Nipp, MD, MPH, Department of Medicine, Division of Hematology and Oncology, Massachusetts General Hospital Cancer Center, 55 Fruit Street, Yawkey 7B, Boston, MA 02114. Email: rnipp@mgh.harvard.edu
  • 1.

    Yancik R. Population aging and cancer: a cross-national concern. Cancer J 2005;11:437441.

  • 2.

    Patel SS, Nelson R, Sanchez J, . Elderly patients with colon cancer have unique tumor characteristics and poor survival. Cancer 2013;119:739747.

  • 3.

    Neugut AI, Matasar M, Wang X, . Duration of adjuvant chemotherapy for colon cancer and survival among the elderly. J Clin Oncol 2006;24:23682375.

  • 4.

    Sargent DJ, Goldberg RM, Jacobson SD, . A pooled analysis of adjuvant chemotherapy for resected colon cancer in elderly patients. N Engl J Med 2001;345:10911097.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5.

    Mor V, Allen S, Malin M. The psychosocial impact of cancer on older versus younger patients and their families. Cancer 1994;74(7 Suppl):21182127.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Nipp RD, Greer JA, El-Jawahri A, . Coping and prognostic awareness in patients with advanced cancer. J Clin Oncol 2017;35:25512557.

  • 7.

    Cheung WY, Le LW, Gagliese L, . Age and gender differences in symptom intensity and symptom clusters among patients with metastatic cancer. Support Care Cancer 2011;19:417423.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Linden W, Vodermaier A, Mackenzie R, . Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age. J Affect Disord 2012;141:343351.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    Derks MG, de Glas NA, Bastiaannet E, . Physical functioning in older patients with breast cancer: a prospective cohort study in the TEAM trial. Oncologist 2016;21:946953.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 10.

    Brighi N, Balducci L, Biasco G. Cancer in the elderly: is it time for palliative care in geriatric oncology? J Geriatr Oncol 2014;5:197203.

  • 11.

    Blank TO, Bellizzi KM. A gerontologic perspective on cancer and aging. Cancer 2008;112(11 Suppl):25692576.

  • 12.

    Mohile SG, Velarde C, Hurria A, . Geriatric assessment-guided care processes for older adults: a Delphi consensus of geriatric oncology experts. J Natl Compr Canc Netw 2015;13:11201130.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13.

    Dotan E, Walter LC, Baumgartner J, . NCCN Clinical Practice Guidelines in Oncology: Older Adult Oncology. Version 1.2019. Accessed August 24, 2019. To view the most recent version, visit NCCN.org.

  • 14.

    Mohile SG, Dale W, Somerfield MR, . Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 2018;36:23262347.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15.

    Temel JS, Greer JA, Muzikansky A, . Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733742.

  • 16.

    Zimmermann C, Swami N, Krzyzanowska M, . Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet 2014;383:17211730.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 17.

    Temel JS, Greer JA, El-Jawahri A, . Effects of early integrated palliative care in patients with lung and GI cancer: a randomized clinical trial. J Clin Oncol 2017;35:834841.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18.

    Nipp RD, El-Jawahri A, Traeger L, . Differential effects of early palliative care based on the age and sex of patients with advanced cancer from a randomized controlled trial. Palliat Med 2018;32:757766.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19.

    Nipp RD, Greer JA, El-Jawahri A, . Age and gender moderate the impact of early palliative care in metastatic non-small cell lung cancer. Oncologist 2016;21:119126.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Stuck AE, Siu AL, Wieland GD, . Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342:10321036.

  • 21.

    Mohile S, Dale W, Magnuson A, . Research priorities in geriatric oncology for 2013 and beyond. Cancer Forum 2013;37:216221.

  • 22.

    Dankwa-Mullan I, Rhee KB, Stoff DM, . Moving toward paradigm-shifting research in health disparities through translational, transformational, and transdisciplinary approaches. Am J Public Health 2010;100(Suppl 1):S1924.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23.

    Bruera E, Kuehn N, Miller MJ, . The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 1991;7:69.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Kroenke K, Spitzer RL, Williams JB, . An ultra-brief screening scale for anxiety and depression: the PHQ-4. Psychosomatics 2009;50:613621.

  • 25.

    Ferguson M, Capra S, Bauer J, . Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999;15:458464.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Saliba D, Elliott M, Rubenstein LZ, . The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001;49:16911699.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Overcash J, Extermann M, Parr J, . Validity and reliability of the FACT-G scale for use in the older person with cancer. Am J Clin Oncol 2001;24:591596.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Nipp RD, El-Jawahri A, Moran SM, . The relationship between physical and psychological symptoms and health care utilization in hospitalized patients with advanced cancer. Cancer 2017;123:47204727.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Nipp RD, El-Jawahri A, D’Arpino SM, . Symptoms of posttraumatic stress disorder among hospitalized patients with cancer. Cancer 2018;124:34453453.

  • 30.

    D’Ath P, Katona P, Mullan E, . Screening, detection and management of depression in elderly primary care attenders. I: the acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions. Fam Pract 1994;11:260266.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Stewart AL, Kamberg C. Physical functioning measures. In: Stewart AL, Ware JE Jr, eds. Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham, NC: Duke University Press; 1992:86101.

    • Search Google Scholar
    • Export Citation
  • 32.

    Fillenbaum GG, Smyer MA. The development, validity, and reliability of the OARS Multidimensional Functional Assessment Questionnaire. J Gerontol 1981;36:428434.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33.

    Maly RC, Frank JC, Marshall GN, . Perceived efficacy in patient-physician interactions (PEPPI): validation of an instrument in older persons. J Am Geriatr Soc 1998;46:889894.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Broadbent E, Petrie KJ, Main J, . The brief illness perception questionnaire. J Psychosom Res 2006;60:631637.

  • 35.

    Cohen J. A power primer. Psychol Bull 1992;112:155159.

  • 36.

    Pandya C, Magnuson A, Flannery M, . Association between symptom burden and physical function in older patients with cancer. J Am Geriatr Soc 2019;67:9981004.

  • 37.

    Demark-Wahnefried W, Clipp EC, Morey MC, . Lifestyle intervention development study to improve physical function in older adults with cancer: outcomes from Project LEAD. J Clin Oncol 2006;24:34653473.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38.

    Oldervoll LM, Loge JH, Lydersen S, . Physical exercise for cancer patients with advanced disease: a randomized controlled trial. Oncologist 2011;16:16491657.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Horgan AM, Leighl NB, Coate L, . Impact and feasibility of a comprehensive geriatric assessment in the oncology setting: a pilot study. Am J Clin Oncol 2012;35:322328.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40.

    Nipp RD, Yao N, Lowenstein LM, . Pragmatic study designs for older adults with cancer: report from the U13 conference. J Geriatr Oncol 2016;7:234241.

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 587 587 377
PDF Downloads 235 235 182
EPUB Downloads 0 0 0