Abstract
This letter to the editor responds to comments on an article that reported on the prevalence of frailty, anxiety, depression, and distress and the relationships between frailty and emotional health in older patients with advanced cancer.
We would like to thank Drs. Chen and Yang for their critical review1 of our article that reported the prevalence of frailty, anxiety, depression, and distress and the relationships between frailty and emotional health.2 We conducted a secondary cross-sectional analysis of baseline data from the COACH study, a national cluster randomized controlled trial evaluating the effect of a standardized geriatric assessment (GA) with GA-guided recommendations on communication between older patients with advanced and incurable solid tumors or lymphomas, their oncologists, and their caregivers (University of Rochester Cancer Center [URCC] 13070; ClinicalTrials.gov identifier NCT02107443).3 The study was conducted within the URCC National Cancer Institute Community Oncology Research Program (NCORP) and enrolled patients from 31 community oncology practice sites between October 2014 and April 2017.3 In the primary study, eligible patients (1) were aged ≥70 years, (2) had a diagnosis of stage III/IV solid tumor or lymphoma that was considered by their treating oncologists to be incurable, (3) were considering or receiving any type of cancer treatment (of any line), and (4) were found to have an impairment in at least one GA domain (excluding polypharmacy).3 For this cross-sectional analysis, we included all older patients with advanced cancer with available data at the study entry. The participant flow of the parent COACH study, including reasons for exclusion was previously reported in the primary paper.3 Given that our study focused on all patients with available baseline data, there was no loss to-follow up.
We agree that prognosis is an important factor in emotional health. Given the inclusion criteria of the primary study (incurable cancer with at least one GA impairment), participants enrolled onto this study had poor prognosis. Other secondary analyses of this data have also been conducted, looking specifically at the prognosis of patients in this study, and confirmed patients’ poor prognosis. A study by Loh et al examined oncologists’ prognostic understanding of patients enrolled onto the COACH study.4 Oncologists were asked, “Considering the patient’s health and the patient’s underlying medical conditions, what would you estimate the patient’s overall life expectancy to be?” Response options were 6 months or less, 7 to 12 months, 1 to 2 years, 2 to 5 years, and more than 5 years. Loh et al reported that only 10% of oncologists reported that patients’ life expectancy was more than 5 years. Oncologists were also asked, “What do you believe are the chances the cancer will go away and never come back with treatment?” Response options were 100%, more than 50%, 50%, less than 50%, 0%, or uncertain. Only 1% of oncologists thought that the cancers were curable, again showing the poor prognosis of patients on the study. However, it has been well established that oncologists tend to overestimate their patient’s life expectancy in advanced cancer settings.5-8 Further work in this same sample of patients by Lund et al examined the life expectancy in older adults with advanced cancer through the evaluation of a GA-based prognostic model.9 To conduct the analysis Lund et al obtained patients’ vital status and date of death or end of follow-up data from the study forms, and this was subsequently verified by the patients’ community oncology practice. As part of the COACH study, survival was only assessed up to 1 year following enrollment onto the study. The investigators found that 43% of patients enrolled in the COACH study died within 1 year following enrollment onto the study.
Given the overall poor prognosis of individuals enrolled onto this study and given the inclusion criteria, we believe that there is limited effect of varying prognosis of these older patients with advanced cancer on the emotional health outcomes. Future studies examining the effect of frailty and emotional health should prospectively evaluate the effect of prognosis on emotional health in patients with varying life expectancies from cancer.
Contributor Information
Nikesha Gilmore, Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA.
Eva Culakova, Department of Surgery, Division of Supportive Care in Cancer, University of Rochester Medical Center, Rochester, NY, USA.
Supriya Mohile, Wilmot Cancer Institute, University of Rochester Medical Center, Rochester, NY, USA.
Conflict of Interest
The authors indicated no financial relationships.
References
- 1. Chen ZX, Yang T.. Comment on: The relationship between frailty and emotional health in older patients with advanced cancer. Oncologist. 2021;27:e819. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Gilmore N, Kehoe L, Bauer J, et al. The relationship between frailty and emotional health in older patients with advanced cancer. Oncologist 2021;26(12):e2181-e2191. 10.1002/onco.13975 . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Mohile SG, Epstein RM, Hurria A, et al. Communication with older patients with cancer using geriatric assessment: A cluster-randomized clinical trial from the National Cancer Institute Community Oncology Research Program. JAMA Oncol. 2020;6(2):196-204. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Loh KP, Seplaki CL, Sanapala C, et al. Association of prognostic understanding with health care use among older adults with advanced cancer: A secondary analysis of a cluster randomized clinical trial. JAMA Network Open. 2022;5(2):e220018. 10.1001/jamanetworkopen.2022.0018 . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Glare P, Virik K, Jones M, et al. A systematic review of physicians’ survival predictions in terminally ill cancer patients. BMJ. 2003;327(7408):195-198. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Thai V, Ghosh S, Tarumi Y, et al. Clinical prediction survival of advanced cancer patients by palliative care: A multi-site study. Int J Palliat Nurs. 2016;22(8):380-387. 10.12968/ijpn.2016.22.8.380 . [DOI] [PubMed] [Google Scholar]
- 7. Gramling R, Gajary-Coots E, Cimino J, et al. Palliative care clinician overestimation of survival in advanced cancer: Disparities and association with end-of-life care. J Pain Symptom Manag. 2019;57(2):233-240. [DOI] [PubMed] [Google Scholar]
- 8. Christakis NA, Lamont EB.. Extent and determinants of error in physicians’ prognoses in terminally ill patients: Prospective cohort study. West J Med. 2000;172(5):310-313. 10.1136/ewjm.172.5.310 . [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Lund JL, Duberstein PR, Loh KP, et al. Life expectancy in older adults with advanced cancer: Evaluation of a geriatric assessment-based prognostic model. J Geriatr Oncol. 2022;13(2):176-181. [DOI] [PMC free article] [PubMed] [Google Scholar]