In the JournalsPerspective

Functional impairment linked to higher mortality among older adults with hematologic malignancies

Clark DuMontier, MD

Older adults with hematologic malignancies who require assistance with at least one basic or instrumental daily living activity have a higher risk for mortality than those who require no assistance, according to research published in Journal of the American Geriatrics Society.

Overall, more than a quarter (26.7%) of the 464 patients studied reported at least one dependency for instrumental activities of daily living (iADLs) and 11.4% reported at least one dependency for basic activities of daily living (ADLs).

“Older adults make up the majority of patients with blood cancers, yet they make up the minority of patients studied in clinical trials,” Clark DuMontier, MD, clinical fellow in medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, told HemOnc Today.

“This lack of representation in research has led to a lack of knowledge regarding whether treatments studied in younger, fitter populations will benefit the older, more frail populations who are treated in clinic,” he said. “We sought to determine whether dependency in functioning revealed a higher risk for death and hospitalizations in older adults with leukemia, lymphoma and multiple myeloma.”

The prospective cohort study by DuMontier and colleagues included 464 patients aged 75 years and older (mean age, 79.7 years; 65.3% men) with blood cancers such as leukemia, lymphoma, myelodysplastic syndrome and multiple myeloma who had an initial consultation at Dana-Farber Cancer Institute between Feb. 1, 2015, and Nov. 15, 2017. About 38% of patients had an aggressive hematologic malignancy and 45% had at least one previous line of therapy.

Study participants underwent a geriatric assessment on the day of study enrollment. ADLs assessed included patient-reported abilities in bathing, dressing, transferring, eating, grooming and toilet use, whereas iADLs included patient-reported ability to shop, prepare meals, do housework, take medications and conduct finances.

Researchers investigated associations between dependencies in iADLs and ADLs and mortality, as well as ED visits and unplanned hospitalizations.

Mean follow-up was 13.8 months.

On univariable analyses, patients who reported at least one ADL dependency (HR = 1.83; 95%

CI, 1.12-3) or iADL dependency HR = 2.46; 95% CI, 1.68-3.59) had increased risk for death.

However, on multivariable analyses adjusted for age, comorbidity, cancer aggressiveness and treatment intensity, only iADL dependency maintained the association (HR = 2.34; 95% CI, 1.46-3.74).

Patients with at least one iADL dependency also had higher odds of ED visits (OR = 2.76; 95% CI, 1.3-5.84) and unplanned hospitalizations (OR = 2.89; 95% CI, 1.37-6.09).

DuMontier and colleagues also tested interactions between iADL dependency and cancer aggressiveness that showed a significant impact on survival (P < .05). Patients with an iADL dependency and aggressive cancer had significantly shorter median survival than those with aggressive cancer who were iADL independent (10 months vs. > 34 months).

Patients with both aggressive cancer and iADL dependency also had a threefold higher hazard for death (HR = 3.61; 95% CI, 1.83-7.13) than those with aggressive cancer who were iADL independent.

“The association was strongest for those with the most advanced blood cancers, suggesting that higher-order functioning is critical to surviving aggressive leukemia, lymphoma and myeloma,” DuMontier said.

Cognitive impairment or social desirability bias may have led to under- or overreporting of patients’ functional status, the investigators noted. Another study limitation included its potential limited applicability because of its single-center nature.

Given the results of their study, DuMontier and colleagues affirmed the utility of recent ASCO guidelines that recommend geriatric assessments to identify older adults with cancer who have increased risk for mortality and adverse outcomes.

“Functional assessment should be incorporated into routine clinical practice for older adults with blood cancers,” DuMontier told HemOnc Today. “Detecting dependency in functioning not only identifies older patients vulnerable to worse outcomes, but also reveals areas in their health that can potentially be optimized. Functional assessment and interventions, alongside blood cancer treatments, could improve outcomes for older adults — including prolonging life, remaining out of the hospital, and continuing their ability to live in the community while undergoing cancer treatment.” – by Drew Amorosi

For more information:

Clark DuMontier, MD, can be reached at Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215; email: cdumontier@partners.org.

Additional reference:

Mohile SG, et al. J Clin Oncol. 2018;doi:10.1200/JCO.2018.78.8687.

Disclosure: The study was funded by the Murphy Family Fund to Dana-Farber Cancer Institute. The authors report no relevant financial disclosures.

Clark DuMontier, MD

Older adults with hematologic malignancies who require assistance with at least one basic or instrumental daily living activity have a higher risk for mortality than those who require no assistance, according to research published in Journal of the American Geriatrics Society.

Overall, more than a quarter (26.7%) of the 464 patients studied reported at least one dependency for instrumental activities of daily living (iADLs) and 11.4% reported at least one dependency for basic activities of daily living (ADLs).

“Older adults make up the majority of patients with blood cancers, yet they make up the minority of patients studied in clinical trials,” Clark DuMontier, MD, clinical fellow in medicine at Beth Israel Deaconess Medical Center and Harvard Medical School, told HemOnc Today.

“This lack of representation in research has led to a lack of knowledge regarding whether treatments studied in younger, fitter populations will benefit the older, more frail populations who are treated in clinic,” he said. “We sought to determine whether dependency in functioning revealed a higher risk for death and hospitalizations in older adults with leukemia, lymphoma and multiple myeloma.”

The prospective cohort study by DuMontier and colleagues included 464 patients aged 75 years and older (mean age, 79.7 years; 65.3% men) with blood cancers such as leukemia, lymphoma, myelodysplastic syndrome and multiple myeloma who had an initial consultation at Dana-Farber Cancer Institute between Feb. 1, 2015, and Nov. 15, 2017. About 38% of patients had an aggressive hematologic malignancy and 45% had at least one previous line of therapy.

Study participants underwent a geriatric assessment on the day of study enrollment. ADLs assessed included patient-reported abilities in bathing, dressing, transferring, eating, grooming and toilet use, whereas iADLs included patient-reported ability to shop, prepare meals, do housework, take medications and conduct finances.

Researchers investigated associations between dependencies in iADLs and ADLs and mortality, as well as ED visits and unplanned hospitalizations.

Mean follow-up was 13.8 months.

On univariable analyses, patients who reported at least one ADL dependency (HR = 1.83; 95%

CI, 1.12-3) or iADL dependency HR = 2.46; 95% CI, 1.68-3.59) had increased risk for death.

However, on multivariable analyses adjusted for age, comorbidity, cancer aggressiveness and treatment intensity, only iADL dependency maintained the association (HR = 2.34; 95% CI, 1.46-3.74).

Patients with at least one iADL dependency also had higher odds of ED visits (OR = 2.76; 95% CI, 1.3-5.84) and unplanned hospitalizations (OR = 2.89; 95% CI, 1.37-6.09).

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DuMontier and colleagues also tested interactions between iADL dependency and cancer aggressiveness that showed a significant impact on survival (P < .05). Patients with an iADL dependency and aggressive cancer had significantly shorter median survival than those with aggressive cancer who were iADL independent (10 months vs. > 34 months).

Patients with both aggressive cancer and iADL dependency also had a threefold higher hazard for death (HR = 3.61; 95% CI, 1.83-7.13) than those with aggressive cancer who were iADL independent.

“The association was strongest for those with the most advanced blood cancers, suggesting that higher-order functioning is critical to surviving aggressive leukemia, lymphoma and myeloma,” DuMontier said.

Cognitive impairment or social desirability bias may have led to under- or overreporting of patients’ functional status, the investigators noted. Another study limitation included its potential limited applicability because of its single-center nature.

Given the results of their study, DuMontier and colleagues affirmed the utility of recent ASCO guidelines that recommend geriatric assessments to identify older adults with cancer who have increased risk for mortality and adverse outcomes.

“Functional assessment should be incorporated into routine clinical practice for older adults with blood cancers,” DuMontier told HemOnc Today. “Detecting dependency in functioning not only identifies older patients vulnerable to worse outcomes, but also reveals areas in their health that can potentially be optimized. Functional assessment and interventions, alongside blood cancer treatments, could improve outcomes for older adults — including prolonging life, remaining out of the hospital, and continuing their ability to live in the community while undergoing cancer treatment.” – by Drew Amorosi

For more information:

Clark DuMontier, MD, can be reached at Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA 02215; email: cdumontier@partners.org.

Additional reference:

Mohile SG, et al. J Clin Oncol. 2018;doi:10.1200/JCO.2018.78.8687.

Disclosure: The study was funded by the Murphy Family Fund to Dana-Farber Cancer Institute. The authors report no relevant financial disclosures.

    Perspective
    William Dale

    William Dale

    DuMontier and colleagues asked whether functional assessment, a central aspect of geriatric assessment for older adults with cancer, was associated with important clinical outcomes for patients with hematologic malignancies. The answer is a resounding yes: over two times the likelihood of an ED visit, hospitalization or death.

    This is the latest evidence that functional status — in this case iADLs — is one of the most important predictors of poor outcomes in older adults with cancer. However, most of the previous evidence has been in patients with solid tumor malignancies. Given this fact, it is refreshing to see a large, prospective study on important clinical outcomes assessing age-associated problems for older adults with hematologic malignancies.

    Equally important, this practice aligns with recently published ASCO guidelines. These first-ever, evidence-based guidelines for the assessment of older adults with cancer are focused on patients with solid tumors who are considering the use of chemotherapy. One of the geriatric assessment tools with the greatest evidence supporting it is functional assessment using iADLs. This work shows how this measure also applies to older adults with hematologic malignancies. It is especially interesting that iADLs are so strongly associated with mortality.

    That finding for hematologic malignancies is both reassuring and concerning — reassuring because it confirms the importance of these measures for properly identifying high-risk older patients; concerning because such assessments are rarely done.

    Why aren’t functional assessments done more routinely in older patients with cancer? Because they have been viewed as overly cumbersome or time-consuming. However, compared with many other routine assessments for patients with cancer, they are much quicker and less resource-intensive.

    Given their value for risk stratification of patients, they are one of the best, most value-based assessments available and should be part of every new patient assessment when considering toxic therapies. The case for including these types of assessments for all patients with cancer over the age of 65 years is strong enough that it should be adopted as the standard of care.

    • William Dale, MD, PhD
    • City of Hope

    Disclosures: Dale reports no relevant financial disclosures.