“Celebrating Resilience”: A review of abstracts on functional resilience at the International Society of Geriatric Oncology 2022 annual meeting

1. Introduction

The International Society of Geriatric Oncology (SIOG) 2022 Annual Meeting in Geneva, Switzerland focused on the theme of “celebrating resilience,” including resilience of geriatric oncology as a field, resilience in the workplace, and functional resilience of older adults with cancer. SIOG 2022 featured research from 44 countries with 60 talks, 13 oral abstract presentations, and 226 posters. [1] In this report, we highlight studies presented that focused on functional resilience among older adults with cancer.

Functional resilience refers to older adults’ ability to maintain their functional status over time or to recover from events that cause functional decline or disability. [2,3] Functional status is important because it reflects older adults’ ability to conduct their day-to-day activities, such as eating or drinking (i.e., activities of daily living) [4], managing their medications (i.e., instrumental activities of daily living) [5], and mobility. Functional resilience research complements but is uniquely different from frailty. [6] Because cancer-directed therapies can impact functional trajectories longitudinally, [7,8] maximizing resilience in older adults can allow for recovery of function after treatment. [9]

Our objective is to provide a broad overview of functional resilience research presented at SIOG 2022 (Table 1). We discuss how to measure functional resilience, how functional resilience research is incorporated across different cancer-directed therapies and diseases, and how specific interventions can improve functional resilience. These findings can help optimize the management and recovery from cancer-directed treatment of older adults with cancer.

Table 1.

Selected functional resilience research presented at the SIOG annual meeting 2022.

Study	N	Population	Findings
Bluethmann et al. [8]	403	Women with breast cancer	At three months, chemotherapy and age were independently associated with decreased physical performance as measured by the Short Physical Performance Battery score.
Banwait et al. [10]	69	Adults (>65 years) with hepatobiliary and pancreatic cancers	There was an association between worsening frailty (measured by the geriatric assessment and 5-item frail scale) and decreased overall survival.
Gregorio et al. [12]	17	Trainees, attendings, and advanced practice providers (APPs)	A multidisciplinary needs assessment of clinicians revealed that lack of knowledge (for attending physicians and APPs) and lack of time (for trainees) were the greatest limitations to performing a geriatric assessment.
Thibaud et al. [16]	115	Adults (>65 years) with hematologic malignancies referred for chemotherapy	The HEMA-4 score can predict survival among older adults with hematologic malignancies by identifying three prognostic groups: frail, fit, and vulnerable.
Jensen-Battaglia et al. [17]	12	Adults (>60 years) with acute myeloid leukemia (AML)	Oncologists, patients, and caregivers referenced physical function in their discussion of AML treatment decisions.
Steer et al. [18]	18	Adults (>70 years) with cancer and a G8 score < 14	Addition of PhotoVoice discussion of patient-derived photographs to the electronic Rapid Functional Assessment tool (eRFA) was feasible and can enhance supportive care. Limitations include time constraints.
Loh et al. [19]	179	Adults (aged 70–79 years) cancer in the Health ABC study with a new cancer diagnosis, IL6 levels, and > 3 post-diagnosis longitudinal functional measures	IL-6 levels were associated with functional trajectories and differed by race. Higher log IL-6 levels were associated with being in the low stable and decline group in White compared to Black patients.
Van der Hulst et al. [20]	146	Adults (> 70 years) receiving elective surgery for nonmetastatic colorectal cancer	There was no sustained postoperative deterioration in daily functioning and quality of life at 12 months in frail and non-frail patients.
Gonzalez Senac et al. [21]	95	Adults (> 74 years) admitted for elective colorectal surgery	Frail older patients admitted for elective colorectal surgery had more respiratory complications and kidney injury after surgery.
Gonzalez Senac et al. [23]	73	Adults (>74 years) admitted for elective colorectal cancer surgery	In-hospital functional decline after colorectal surgery is associated with older age, frailty, systemic and severe complications, and longer hospital stay.
Hoffmann et al. [24]	1257	Adults (>65 years) with cancer who were hospitalized after surgery	Impaired sensorium is associated with an increased risk of postoperative delirium.
Vonnes et al. [26]	530	Adults with cancer undergoing radiotherapy	Timed Up and Go can identify increased risk for deconditioning in patients receiving radiotherapy.
Trevino et al. [27]	29 dyads	Adults (>65 years) with cancer and caregiver dyads	When compared to usual care, Managing Anxiety from Cancer (a seven-session cognitive-behavioral therapy intervention) resulted in a greater reduction in anxiety.
Presley et al. [28]	18	Adults (>60 years) with advanced lung cancer receiving treatment	A novel physical therapy and progressive muscle relaxation intervention with longitudinal gut microbiome biospecimen collection and activity tracking was feasible in older adults with advanced lung cancer.
Mauer et al. [34]	Target goal 80–100	Adults (>60 years) with breast cancer	This pilot trial will assess the feasibility and acceptability to integrate pre-treatment clonal hematopoiesis of indeterminate potential (CHIP) diagnostics into the routine care of patients with breast cancer.
Soo et al. [35]	154	Adults (>70 years) with solid cancer or diffuse large B-cell lymphoma initiating systemic cancer-directed treatment	When compared to usual care, comprehensive geriatric assessment (via geriatrician co-management integrated with oncology care) led to better quality of life and healthcare delivery in older adults receiving cancer-directed treatment.
Harmon et al. [36]	120	Adults (>60 years) with gastrointestinal cancers	>75% of new patients completed the geriatric assessment prior to their appointment using the web-enabled cancer and aging resilience evaluation (WeCARE).
Lopez de San Vicente Hernandez et al. [37]	18	Adults (>70 years) with cancer	In a prospective pilot study, a multicomponent exercise intervention was associated with improved physical performance, quality of life, cognitive function, and fatigue reduction.
Murphy et al. [38]	45	Adults (>70 years) being treated for breast cancer and managed by occupational therapy (OT)	OT can address a wide range of needs for patients, including 1:1 OT sessions, physiotherapy sessions, equipment provision, social services referral, and lymphedema management.
Jethwa et al. [39]	28	Adults (>70 years) being treated for breast cancer and managed by physiotherapy (PT)	Functional impairment and sarcopenia are common issues. PT helps address musculoskeletal issues, balance, gait, and exercise in the setting of bone metastases.
Pattwell et al. [40]	15	Adults (> 70 years) being treated for breast cancer and managed by a dietician	Dietary interventions are diverse, including nutritional support advice, oral nutritional supplements, caregiver involvement, meal preparation support, healthy eating advice, oral care counseling, and weight management discussions.
Korc-Grodzicki et al. [41]	113	Healthcare providers	Participants in the Geriatric Oncology: Cognition and Communication (2-day virtual meeting) training reported improved knowledge about caring for older patients with cancer.
Anand et al. [42]	704	Adults (> 70 years) receiving cancer treatment and with >1 geriatric domain impairment from the GAP70+ (NCT02054741) trial	Patients living with a spouse or adult children had increased odds of robust instrumental social support. This suggests that living arrangement is associated with instrumental social support.
Mills et al. [43]	21 dyads	Older adults with multiple myeloma (MM) and caregiver dyads	The COVID-19 restrictions led to a loss of social support that is associated with the dyad’s ability to cope with MM. Dyadic interventions are needed to provide alternate physical and social activity opportunities.

2. Measuring Functional Resilience

Fundamental to studying resilience is measuring it, and there were several abstracts that demonstrated how to use a geriatric assessment (GA) to measure resiliency. Banwait et al. conducted a retrospective analysis of adults age ≥ 65 years with hepatobiliary and pancreatic cancers, finding that GA identified impairments across multiple geriatric domains. [10] Furthermore, a frailty screen classified the majority of patients as prefrail and frail, despite 78% of patients carrying a “healthy” ECOG performance status of 0–1. [10] This work provides another example demonstrating that GA and screens based on the geriatric construct of frailty—which conceptually is related to functional resilience—are superior at identifying the aging-related vulnerabilities that may threaten the ability of an older patient to adapt to the stressors of cancer and cancer treatment. [11] Gregorio et al. administered a needs assessment of GA at an academic U.S. Veterans Affairs Hospital-based medical oncology clinic. [12] Gregorio’s study highlighted that innovative strategies are needed to overcome the time and knowledge barriers that limit more widespread implementation of GA and thus screening for resilience. [13] Thibaud and colleagues explored the validity of the HEMA-4 score, [14] which consists of GA components of mini-mental status exam <27 points, ≥2 comorbidities as measured by Charlson Comorbidity Score, [15] albumin <35 g/l, and C-reactive protein >10 mg/l. [16] In a multicenter prospective cohort study for older patients with hematologic malignancies who were intended to receive chemotherapy, HEMA-4 reliably predicted the overall survival by three prognostic groups: frail patients with very poor outcomes, vulnerable patients who should be further investigated by a GA, and fit patients with excellent one-year survival. [16] In addition, Jensen-Battaglia et al. used qualitative analysis of patients, oncologist, and caregiver conversations on treatment decisions in acute myeloid leukemia to show that physical function as a marker of resilience was raised by all three parties, demonstrating its importance. [17]

There were also innovative GA delivery platforms and biomarkers that were studied. One example of innovative GA delivery was shared by Steer et al., who studied the implementation of photographs and photovoice discussion in addition to an electronic GA (via the electronic Rapid Functional Assessment tool [eRFA]) in an older cohort. [18] Rather than simply filling out questionnaires, patient-provided photographs of important aspects of their aging and what matters most in their lives may provide “snapshots” into key elements of resilience, representing a novel screening tool. [18] Finally, Loh et al. studied an emerging biomarker of aging in the inflammatory cytokine interleukin-6, finding it to be associated with functional trajectories and decline in gait speed in the years following a new diagnosis of cancer. [19] Moreover, these associations were different in White versus Black patients. [19] These findings highlight the possibility of a laboratory test to complement the geriatric assessment in identifying older patients with cancer at risk of mobility and functional decline. [19] Their work emphasizes the need to not only identify novel markers of frailty and resiliency, but also to investigate whether race and other social constructs modify the predictive relationships these markers have with their studied outcomes.

3. Cancer Treatment-Specific Considerations

3.1. Surgery

Functional resilience plays an important role in the surgical care of geriatric oncology patients as it affects both recovery potential and post-operative complications. A key consideration for choosing the right patient for surgical intervention is considering frailty and functional resilience. Based on a study of 146 participants age > 70 years undergoing elective surgery for non-metastatic colorectal cancer, frail participants experienced worsened post-operative morbidity, functional status, and quality of life. [20] These findings were similar to preliminary results from a prospective observational study of patients age > 74 years who underwent elective colorectal surgery. [21] Frailty per the Fried Criteria [22] was associated with more severe post-operative complications, specifically respiratory or renal failure, and admission to the intensive care unit. [21] The same authors, Gonzalez Senac et al., evaluated in-hospital functional decline in adults >74 years who underwent elective colorectal surgery, and they found that in-hospital functional decline was associated with increased age, frailty, and post-operative complications. [23] In Hoffmann et al.’s study of 1257 older adults who underwent surgery, preoperative frailty in patients with intact sensorium was associated with a higher likelihood of postoperative delirium. [24] There was no significant association with preoperative frailty on postoperative delirium in people with an impaired sensorium. [24] Nevertheless, age and frailty alone should not preclude frail older adults from receiving surgical care. While surgery may impose a significant risk of complications and functional decline, the rates of worsened functional status were not sustained at 12 months. [20]

3.2. Radiation

Falls are a common problem during cancer therapies and fall prevention is a key area for continued research to promote functional resiliency. [25] Vonnes et al. screened patients weekly with Timed Up and Go test (TUG) to identify patients at risk for falls and to further initiate referrals to rehabilitation services. [26] Patients undergoing radiation therapy for neurological or thoracic cancers had the slowest TUG score. Patients demonstrated high satisfaction with rehabilitation referrals. Therefore, serial assessment of fall risks with appropriate referrals to rehabilitation or physical therapy might provide an efficient strategy to mitigate falls, promote resiliency, and decrease the risk of functional decline. [26]

3.3. Supportive Care

The inclusion of supportive care services and interdisciplinary healthcare personnel promotes functional resilience in older adults with cancer and their caregivers. In a pilot randomized controlled trial of a dyadic intervention for older adults with cancer and their caregivers, a psychotherapy intervention delivered by licensed social workers significantly reduced anxiety in older adults with cancer and their caregivers. [27] There are also ongoing studies that prospectively assess resiliency using novel associations, such as assessing the gut microbiome in adults aged >60 years with advanced lung cancer who participated in a novel virtual health physical therapy and progressive muscle relaxation intervention during active treatment. [28] Evaluating and implementing supportive care interventions are an underutilized approach to maintaining functional resiliency, particularly among older adults with advanced cancers.

3.4. Chemotherapy in Hematologic Malignancies

Within the session “Survivorship and Resilience in Hematologic Malignancies,” there were discussions on how to manage resilience for patients receiving chemotherapy. For older adults with multiple myeloma and chronic lymphocytic leukemia, a GA had been used to inform treatment decisions and guide supportive care interventions. [29,30] As hematological diseases can significantly contribute to frailty (e.g., by debilitating pathological fractures or uncontrolled pain) it is of utmost importance to understand how cancer treatments and effective supportive care measures can potentially reverse frailty and promote resilience.

Managing comorbidities is also a key component to preserving functional resilience during chemotherapy. Cardiovascular comorbidities are frequent in older patients with lymphoma, and many common treatment protocols include cardiotoxic drugs, such as anthracyclines or Bruton’s tyrosine kinase inhibitors. [31] Thus, stringent cardiovascular prevention is a key strategy to maintaining functional resilience. This cardiovascular risk is further underlined by the high prevalence of clonal hematopoiesis of indeterminate potential (CHIP) after cytotoxic chemotherapies, which is related to an increased risk for cardiovascular events [32] and can eventually potentiate cardiovascular sequelae after anthracycline-containing therapies. [33] Therefore, survivorship care might be adapted according to the CHIP status of older adults. For example, an ongoing trial that implements CHIP diagnostics into routine care of breast cancer patients was introduced. [34]

4. Improving Functional Resilience

Improving functional resilience relies on a multidisciplinary, multimodal approach which starts with a GA. In a multicenter, open-label, pragmatic randomized controlled trial in Australia of participants >70 years old, the incorporation of GA and co-management by a geriatrician has been shown to improve functionality, reduce unplanned hospital admissions, and prevent early discontinuation of planned treatment. [35] This ultimately leads to better quality of life and healthcare delivery among older adults. [35] Unfortunately, the GA remains underutilized. To address potential barriers, a web-based GA tool (i.e., Web-Enabled Cancer & Aging Resilience Evaluation, also known as WeCARE) has been trialed at the outpatient oncology practice at the University of Alabama at Birmingham, where the patients were given a pragmatic GA questionnaire via a link through text or email. [36] More than 75% of patients were able to complete this questionnaire prior to coming to their appointment, demonstrating the feasibility of online tools to reduce common barriers to GA implementation. [36]

Once the assessment has been completed, physicians can target identified areas of vulnerability. In a prospective pilot study carried out in two Spanish hospitals, an 8-week multicomponent exercise intervention involving balance, aerobic, and resistance training improved physical performance, fatigue, cognitive function, and quality of life during the intervention. [37] At the 1-week follow-up visit, physical performance and cognitive function continued to be improved. [37] This indicates that ongoing participation in a monitored exercise program may lead to consistent improvement in functionality. [37] The Royal Marsden Senior Adult Oncology Programme (SAOP) conducted a prospective study evaluating occupational therapy for adults aged >70 years with breast cancer who were receiving systemic cancer-directed therapy, which addressed a diverse range of needs for patients. [38] In this same population, the Royal Marsden SAOP also found that physical therapy addressed critical issues, such as functional impairment, sarcopenia, and musculoskeletal issues. [39]

In addition to exercise interventions, other interventions are being integrated to improve functional resilience, such as nutritional interventions, [40] training to improve communication about cognitive impairment, [41] and social support interventions. [42,43] For example, in the Royal Marsden SAOP experience, older adults with cancer receiving systemic anticancer therapy were managed with dietary interventions that included nutritional support advice, an oral nutritional supplement, and caregiver involvement. [40] Therefore, the care team for a geriatric oncology patient should be multidisciplinary in nature, consisting of oncologists, geriatricians, physical therapists, occupational therapists, pharmacists, and social workers. Together, the team could assess and address functional status, physical disability, medication interactions, cognitive decline, mood disturbances, socioeconomic burden, and goals of care.

5. Conclusion

Optimizing functional resilience is critical to improving outcomes for older adults with cancer. A thorough assessment and understanding of functional trajectories and resilience can guide cancer-directed treatment and decision-making, ensuring that older adults are neither undertreated or overtreated for their cancer. [2] Interventions that focus on improving functional resilience can help older adults improve during and after treatment and maintain their quality of life. The studies in this report provide a deeper and broader understanding of functional resilience to better inform the care of older adults with cancer.