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MULTICOMPONENT EXERCISE PROGRAM IN OLDER ADULTS WITH LUNG CANCER DURING ADJUVANT/PALLIATIVE TREATMENT: A SECONDARY ANALYSIS OF AN INTERVENTION STUDY

 

N. Martínez-Velilla1,2,3, M.L. Saez de Asteasu1,2, R. Ramírez-Vélez1, I.D. Rosero1, A. Cedeño-Veloz1,3, I. Morilla1,4, R.V. García1,4, F. Zambom-Ferraresi1,2, A. García-Hermoso1,5, M. Izquierdo1,2

1. Navarrabiomed, Complejo Hospitalario de Navarra (CHN)-Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain; 2. CIBER of Frailty and Healthy Aging (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain; 3. Department of Geriatric Medicine, Complejo Hospitalario de Navarra, Irunlarrea 3, Pamplona, Spain; 4. Department of Medical Oncology, Complejo Hospitalario de Navarra, Pamplona, Spain; 5. Laboratorio de Ciencias de la Actividad Física, el Deporte y la Salud, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, USACH, Santiago, Chile.
Corresponding author: Mikel Izquierdo, PhD, Department of Health Sciences, Public University of Navarra, Av. De Barañain s/n 31008 Pamplona (Navarra) Spain, Tel + 34 948 417876, mikel.izquierdo@gmail.com

J Frailty Aging 2021;in press
Published online February 7, 2021, http://dx.doi.org/10.14283/jfa.2021.2

 


Abstract

Background: Lung cancer is the second most prevalent common cancer in the world and predominantly affects older adults. This study aimed to examine the impact of an exercise programme in the use of health resources in older adults and to assess their changes in frailty status. Design: This is a secondary analysis of a quasi-experimental study with a non-randomized control group. Setting: Oncogeriatrics Unit of the Complejo Hospitalario de Navarra, Spain. Participants: Newly diagnosed patients with NSCLC stage I–IV. Intervention: Multicomponent exercise programme that combined resistance, endurance, balance and flexibility exercises. Each session lasted 45–50 minutes, and the exercise protocol was performed twice a week over 10 weeks. Measurements: Mortality, readmissions and Visits to the Emergency Department. Change in frailty status according to Fried, VES-13 and G-8 scales. Results: 26 patients completed the 10-weeks intervention (IG). Mean age in the control group (CG) was 74.5 (3.6 SD) vs 79 (3 SD) in the IG, and 78,9% were male in the IG vs 71,4% in the CG. No major adverse events or health-related issues attributable to the testing or training sessions were noted. Significant between-group differences were obtained on visits to the emergency department during the year post-intervention (4 vs 1; p:0.034). No differences were found in mortality rate and readmissions, where an increasing trend was observed in the CG compared with the IG in the latter (2 vs 0; p 0.092). Fried scale was the unique indicator that seemed to be able to detect changes in frailty status after the intervention. Conclusions: A multicomponent exercise training programme seems to reduce the number of visits to the emergency department at one-year post-intervention in older adults with NSCLC during adjuvant therapy or palliative treatment, and is able to modify the frailty status when measured with the Fried scale.

Key words: Lung cancer, frailty, exercise, health-care resources.


 

Introduction

Lung cancer is the second most prevalent common cancer in the world and predominantly affects older adults; 50% of the diagnoses are in patients aged 70 or older, and about 14% in over 80 years old (1, 2). Overall, the survival rate at 5 years is lower in the very old, and patients aged 80 years or older are less likely to receive local therapy than younger patients (2). Additionally, the incidence and mortality from lung cancer have decreased among individuals aged 50 years and younger but have increased among those aged 70 years and older (3). However, geriatric patients may be undertreated, and are routinely underrepresented on clinical trials for many reasons including frailty, doubts about the usefulness of therapy, or lower patient willingness to pursue aggressive therapy (4, 5).
The standard-of-care therapy for patients with stage III Non-small cell lung cancer (NSCLC) is concurrent chemotherapy and radiotherapy (CRT), but there is a lack of data regarding the use of CRT in octogenarians and nonagenarians. The goal for the treatment of patients with stage IV NSCLC is palliation, both through improvement in their quality of life (QOL) and in prolongation of survival. Few comparative studies have been conducted that are limited to older patients, and even in very recent research of older adults with NSCLC, the cut-off age was 65 or 70 years (6), and in some studies, even 62.7% of patients aged ≥80 years with stage III NSCLC received no cancer-directed care (7). Patient selection is a key factor in order to administer some treatments in older adults because they are more likely to have a poor performance status with comorbidities, which can lead to little benefit (8).
There is a growing interest in non-invasive interventions for patients with lung cancer, with the goal of maximising physical performance. Physical exercise can be beneficial at any stage of the disease through increasing strength, endurance and decreasing emotional issues (9). Multicomponent exercise programmes have demonstrated to be well tolerated and safe in patients with lung cancer, but there is still a paucity of data to draw conclusive and precise exercise guidelines. A recent Cochrane review failed to establish any conclusive evidence regarding efficiency of exercise training on physical fitness in patients with advanced lung cancer (10–12), and there is little information on what kind of benefits an exercise intervention can provide in the use of health-related resources or the impact on the ability to reverse frailty in the older population. To date, the clinical effectiveness of physical exercise in advanced cancer remains inconclusive.
This study aimed to examine the impact of this exercise programme in the use of health resources and its ability to reduce the number of visits to an emergency department at one-year post-intervention and to assess the changes in frailty status.

 

Methods

Study design, setting and ethical considerations

This is a secondary analysis of a non-randomised, opportunistic control, longitudinal trial designed to examine the effects of a multicomponent exercise programme on surrogate measures of health status in patients with lung cancer in real-world settings (12). Patients were treated at the Oncogeriatrics Unit of the Complejo Hospitalario de Navarra (CHN), Pamplona, Spain. The study ran from May 2018 to November 2019 and was approved by the CHN Research Ethics Committee (25 April, 2018, reference number Pyto2018/5#214) according to the World Medical Association Declaration of Helsinki Declaration.

Patient population

Newly diagnosed patients with NSCLC stage I–IV (TNM classification) were enrolled after histologically confirmation and screening for eligibility by their oncologist. The study included an initial exam at the first visit (baseline) and a final exam after 10-weeks. The inclusion criteria were: aged 70 years or older, have a diagnosis of confirmed lung cancer, with a life expectancy exceeding 3 months (prognosis), with multimorbidity, a Barthel score ≥60 points, and to be able to communicate and collaborate with the research team. Exclusion criteria were clinically unstable patients defined medically as having received active treatment (chemotherapy or radiotherapy) before inclusion in the study, moderate–severe cognitive impairment considered as a score ≥5 in the Reisberg Global Deterioration Scale, and contraindications to exercise or already engaged in high levels of physical training.

Outcome assessment

The primary outcomes of this study were mortality rate, readmissions and visits to the emergency department during the year after the intervention. The secondary outcomes were the changes in the level of frailty measured with G8 (14, 15), Vulnerable Elders Survey-13 (VES-13) (16, 17) and Fried scales (17). The G8 is an eight-item screening tool, developed for older cancer patients. The tool covers multiple domains usually assessed by the geriatrician when performing the geriatric assessment. A score of ≤14 is considered abnormal. The VES-13 is a 13-item self-administered tool, developed for identifying older people at increased risk of health deterioration in the community. A score of ≥3 identifies individuals as “vulnerable”, which is defined as an increased risk of functional decline or death over 2 years. The Fried Frailty Criteria includes five items: weight loss, handgrip strength, gait speed, exhaustion and physical performance and a score of ≥3 indicates “frailty”.
Members of the research team were able to access the medical records of each patient. The same assessments were repeated at 10-weeks after intervention or usual care, and we checked the medical records in order to assess the mortality, number of readmissions and visits to the emergency department during the year posterior to the intervention.

Intervention

The intervention is described elsewhere (12). Briefly, the control group (CG) did not perform any kind of supervised physical exercises/activities during the intervention period but received habitual outpatient care, including comprehensive geriatric assessment and physical rehabilitation when needed.
The intervention group (IG) received a multicomponent exercise programme that combined resistance, endurance, balance and flexibility exercises. Each session lasted 45–50 minutes, and the exercise protocol was performed twice a week over 10 weeks (Table 1). EGYM Smart strength machines (eGym® GmbH, München, Germany) were used for both resistance training and maximum strength measurements of the lower and upper extremity muscles. Muscle power training including motivational gamification and maximum acceleration of constant weight from 30% to 60% of the maximun strength measurements were used during training (Explonic eGym® intelligent training program). The exercise programme was individualised and included measurements of vital signs at the beginning and end of each session. Patients were advised to carry out the «Vivifrail» programme (18) at home during the entire study period. The control group received the usual medical treatment and was advised to continue their usual activities without restriction in physical activity throughout the study period.

Table 1
Multi-component exercise program

Abbreviations: HR: Heart Rate; RM: Repetition Maximum.

 

Statistical analyses

All analyses were performed by a researcher who was not involved in the study’s participant assessments and interventions. The statistical data analysis was performed with the commercial software SPSS Statistics version 25.0 (IBM Corp., Chicago, IL, USA). The Shapiro–Wilk test was used to determine whether parametric tests were appropriate, and the normality of data was checked graphically. In the present study, descriptive data, including frequencies for categorical variables and means and standard deviation (SD) for continuous variables, were reported. Baseline differences and use of health resources (readmission and visits to the emergency department) were analysed using the chi-squared test and Mann–Whitney U test for nominal data and the Kruskal–Wallis test for ordinal data. A significance level of 5% (p <0.05) was adopted for all statistical analyses.

 

Results

Characteristics of participants

Of the 42 volunteers, 34 attended the oncologic and geriatric clinics screening. Of these, 26 completed the 10-weeks intervention. Two patients from the IG did not complete the programme due to death or oesophagal surgery. Data from the 19 remaining patients from the IG were analysed. A total of 6 of the 13 CG subjects dropped out of the study and did not take the final exam due to the progression of the disease (n = 3) or death (n = 3). Data from the 7 remaining CG participants were analysed. A total of 19 participants (4 females, 15 males) were eligible for analysis in the IG and 7 participants (2 females, 5 males) in the CG (Figure 1). All subjects in the IG completed at least 86% of the planned training sessions. No major adverse events or health-related issues attributable to the testing or training sessions were noted.
Table 2 displays the baseline characteristics by group. No significant differences were found between the two groups, except for age. Patients in the IG had a mean (SD) age of 74.5 (3.6) years, range 70–81 years (78.9% males) and BMI 26.8 (4.5) kg/m2. In total, 41% underwent surgery, and 78.9% received adjuvant chemotherapy alone or in combination with other therapies. Participants in the CG had a mean (SD) age of 79.0 (3.0) years, range 75–83 years (71.4% males), and BMI 25.5 (2.5) kg/m2. Within this group, 14% were submitted to surgery, and 85.7% were receiving adjuvant chemotherapy alone or in combination with other therapies.

Figure 1
CONSORT Flow Diagram – modified for non-randomized
trial design

Table 2
Baseline characteristics of the participants

Abbreviations: BMI, body mass index; COPD, chronic obstructive pulmonary disease; TNM, tumor node metastasis; VATS, video-assisted thoracic surgery; VES-13, Vulnerable Elders Survey-13. aData are reported as mean ± standard deviation or number (%).

 

Mortality, readmissions and Visits to the Emergency Department

Significant between-group differences were obtained on visits to the emergency department during the year post-intervention (4 vs 1; p:0.034). Furthermore, no differences were found in mortality rate and readmissions, where an increasing trend was observed in the CG compared with the IG in the latter (2 vs 0; p 0.092) (Table 3).

Table 3
Mortality rate, readmissions and visits to the Emergency Department at one year post-intervention

Abbreviations: ED, Emergency Department; IQR, interquartile range.

 

Change in frailty status according to Fried, VES-13 and G-8

Although no significant between-group differences were obtained on frailty status changes assessed with the G-8, VES-13 and Fried scale, the unique indicator that seems to be able to detect changes in frailty status is the Fried Index after the intervention (Table 4).

Table 4
Changes in frailty status according to G-8, VES-13
and Frailty Index after the intervention

Abbreviations: VES, Vulnerable Elders Survey.

 

Discussion

The main finding of this study was that supervised multicomponent exercise training can be beneficial for patients with lung cancer, by decreasing the number of visits to the emergency department. Previously, we showed that a multicomponent exercise programme in older patients with NSCLC under adjuvant therapy or palliative treatment positively affected measures of functional performance and quality of life (i.e., pain symptoms and dyspnea) (12), but this secondary analysis goes a step further, and analyses additional outcomes that may help when making decisions in relation to the use of healthcare resources.
Non-oncologic causes of readmission and death predominate in the first 90 days after pneumonectomy, after which oncologic causes prevail (19). Most previous studies have been related to readmissions after pulmonary resection (21, 22), but there is hardly any data on the influence of exercise programmes on the number of visits to the emergency department or on the influence of frailty in the use of health resources in cancer patients (17, 23). Older adults have been traditionally excluded from clinical trials, and clinical data obtained in a younger population cannot be automatically extrapolated to older patients with lung cancer (23). Older patients have more comorbidities and tend to tolerate aggressive chemotherapy and radiotherapy worse than younger patients. Much of the data available currently is based on retrospective studies of trials that included patients with good performance status and patients of all ages. Nonetheless, retrospective analyses of ordinary trials without age-specific entry criteria are potentially biased by the intrinsic selection that governs enrollment. In the present study, we did not find differences in the mortality rate, but this factor is very difficult to modify, especially in an older population as complex and frail as the one that participated in the study. However, we found that the IG had a non-significant lower number of readmissions (p = 0.09) and a lower number of visits to the emergency department (p = 0.034) at one-year post-intervention, which had at least a moderate impact on aspects related to the quality of life and use of health resources.
Chronological age alone should not be the only factor in the cancer treatment plan. Other factors should be taken into account and frailty assessment in older patients with primary lung cancer is increasingly being recognised as a very important tool (24), and it could be used even to prevent under- or overtreatment (25). In fact, a comprehensive geriatric assessment should be used together with an evaluation of the toxicity profile of each drug to guide the choice of the best treatment (26).
There is a big dilemma regarding the scales and the models to select the patients who most benefit of specific oncogeriatric approaches (15). Some studies suggest the VES-13 scale or G-8 scale, nevertheless, the only scale in our study that identified a possible reversal of the frailty status was the Fried Index. This could be because physical exercise modifies more parameters that are taken into account in Fried model of frailty (physical activity, grip strength and gait speed) compared to the G8 model (which has a vague and generic question about mobility), or the VES-13 (which has questions related more to basic activity rather than functional capacity). This has implications for future studies and helps to clarify which indices we should use in this population sector. In our study, a supervised exercise training programme was able to reverse frailty in 21.1% of patients (vs 0% in CG) using the Fried scale. This scale includes many functional aspects such as handgrip strength and gait velocity that could benefit from a physical exercise programme in comparison with G-8 and VES-13 scales.
The management of the older person with cancer should be based on the risk/benefit assessment, and in the multidisciplinary interventions (medical, psychological and social) it may improve the tolerance of the treatments (27). Exercise should be part of this multidisciplinary approach because it provides physiological and psychological benefits for cancer survivors Cancer rehabilitation as a part of clinical management is still underutilised, but older adults with lung cancer would welcome a proactive intervention. There are some barriers due to the psychosocial impact of diagnosis and the effects of cancer treatment, but the intervention must be tailored to individual need and address physical limitations, psychological and social welfare in addition to physical activity and nutritional advice (28). In this regard, the present study shows that these kind of programmes are feasible and may improve the quality of life of older patients with NSCLC.
This study had several limitations that should be considered. The most important was that the number of participants in our study was relatively small, but there are not many related studies with more patients, and so more extensive multicentre studies are encouraged to reinforce our findings. However, our study based on a supervised and individualized multicomponent physical exercise intervention including muscle power training and motivational gamification was beneficial and safe for patients with advanced NSCLC, under adjuvant therapy or palliative treatment. To our knowledge, none of the previous studies that have evaluated physical training in older adults with lung cancer reported serious adverse events, which is consistent with the findings of our study. We believe that the present study represents an important addition to the current body of knowledge on the safety of exercise interventions, particularly in the elderly with NSCLC under adjuvant therapy or palliative treatment. Well-designed randomized clinical trials should be performed to corroborate the current findings, with a larger sample size to detect a significant difference in the components studied.
In conclusion, a multicomponent exercise training programme seems to reduce the number of visits to the emergency department at one-year post-intervention in older adults with NSCLC during adjuvant therapy or palliative treatment for their disease, and is able to modify the frailty status measured with the Fried scale.

 

Funding: M.I. is funded in part by a research grant PI17/01814 from the Ministerio de Economía, Industria, y Competitividad (ISCIII, FEDER). R.R.-V. is funded in part by a Postdoctotal fellowship grant ID 420/2019 of the Universidad Pública de Navarra, Spain. N.M.-V. is funded in part by a research grant from Gobierno de Navarra: «Project prevención de deterioro funcional del anciano frágil con cáncer de pulmón mediante un programa de ejercicio tras valoración geriátrica integral” (Expediente 43/18), promovido por el Departamento de Salud.
Acknowledgments: We thank Fundacion Miguel Servet (Navarrabiomed) for its support during the implementation of the study, as well as Fundacion Caja Navarra and Fundacion La Caixa. Finally, we thank our patients and their families for their confidence in the research team.
Conflicts of Interest: The authors declare no conflicts of interest.
Ethical Standards: The study was approved by the CHN Research Ethics Committee (25 April, 2018, reference number Pyto2018/5#214) according to the World Medical Association Declaration of Helsinki Declaration.

 

References

1. Casaluce F, Sgambato A, Maione P, Spagnuolo A, Gridelli C. Lung cancer, elderly and immune checkpoint inhibitors. J Thorac Dis. 2018;10(1):S1474-S1481. doi:10.21037/jtd.2018.05.90.
2. Owonikoko TK, Ragin CC, Belani CP, et al. Lung cancer in elderly patients: An analysis of the surveillance, epidemiology, and end results database. J Clin Oncol. 2007;25(35):5570-5577. doi:10.1200/JCO.2007.12.5435.
3. Wingo PA, Cardinez CJ, Landis SH, et al. Long-term trends in cancer mortality in the United States, 1930-1998. Cancer. 2003;97(12 SUPPL.):3133-3275. doi:10.1002/cncr.11380.
4. Hutchins LF, Unger JM, Crowley JJ, Coltman C. A. J, Albain KS. Underrepresentation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med. 1999;341(27):2061-2067. doi:10.1056/NEJM199912303412706.
5. Sacher AG, Le LW, Leighl NB, Coate LE. Elderly patients with advanced NSCLC in phase III clinical trials: Are the elderly excluded from practice-changing trials in advanced NSCLC? J Thorac Oncol. 2013;8(3):366-368. doi:10.1097/JTO.0b013e31827e2145.
6. Carmichael JA, Wing-San Mak D, O’Brien M. A review of recent advances in the treatment of elderly and poor performance NSCLC. Cancers (Basel). 2018;10(7). doi:10.3390/cancers10070236.
7. Cassidy RJ, Zhang X, Switchenko JM, et al. Health care disparities among octogenarians and nonagenarians with stage III lung cancer. Cancer. 2018;124(4):775-784. doi:10.1002/cncr.31077.
8. Takigawa N, Ochi N, Nakagawa N, et al. Do elderly lung cancer patients aged ≥75 years benefit from immune checkpoint inhibitors? Cancers (Basel). 2020;12(7):1-12. doi:10.3390/cancers12071995.
9. Michaels C. The importance of exercise in lung cancer treatment. Transl Lung Cancer Res. 2016;5(3):235-238. doi:10.21037/tlcr.2016.03.02.
10. Peddle-McIntyre CJ, Singh F, Thomas R, Newton RU, Galvao DA, Cavalheri V. Exercise training for advanced lung cancer. Cochrane Database Syst Rev. 2019;2019(2). doi:10.1002/14651858.CD012685.pub2.
11. Rosero ID, Ramírez-Vélez R, Lucia A, et al. Systematic review and meta-analysis of randomized, controlled trials on preoperative physical exercise interventions in patients with non-small-cell lung cancer. Cancers (Basel). 2019;11(7). doi:10.3390/cancers11070944.
12. Rosero ID, Ramírez-Vélez R, Martínez-Velilla N, Cedeño-Veloz BA, Morilla I, Izquierdo M. Effects of a Multicomponent Exercise Program in Older Adults with Non-Small-Cell Lung Cancer during Adjuvant/Palliative Treatment: An Intervention Study. J Clin Med. 2020;9(3):862. doi:10.3390/jcm9030862.
13. Soubeyran P, Bellera C, Goyard J, et al. Screening for Vulnerability in Older Cancer Patients: The ONCODAGE Prospective Multicenter Cohort Study. PLoS One. 2014;9(12):e115060. doi:10.1371/journal.pone.0115060.
14. Bellera CA, Rainfray M, Mathoulin-Pélissier S, et al. Screening older cancer patients: First evaluation of the G-8 geriatric screening tool. Ann Oncol. 2012;23(8):2166-2172. doi:10.1093/annonc/mdr587.
15. Decoster L, Van Puyvelde K, Mohile S, et al. Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†. Ann Oncol. 2015;26(2):288-300. doi:10.1093/annonc/mdu210.
16. Saliba D, Elliott M, Rubenstein LZ, et al. The vulnerable elders survey: A tool for identifying vulnerable older people in the community. J Am Geriatr Soc. 2001;49(12):1691-1699. doi:10.1046/j.1532-5415.2001.49281.x.
17. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001;56(3):M146-56. https://www.ncbi.nlm.nih.gov/pubmed/11253156.
18. Izquierdo M, Casas-Herrero A, Zambom-Ferraresi F, Martínez-Velilla N, Alonso-Bouzón C, Rodriguez-Mañas L. Multicomponent physical exercise program vivifrail. A practical guide for prescribing a Multicomponent Physical training program to prevent weakness and falls in people over 70 [Internet]. 2017 [cited 2019 Aug 4]. Available from: http://vivifrail.com/wp-content/uploads/2019/11/VIVIFRAIL-ENG-Interactivo.pdf
19. Jones GD, Tan KS, Caso R, et al. Time-varying analysis of readmission and mortality during the first year after pneumonectomy. In: Journal of Thoracic and Cardiovascular Surgery. Vol 160. Mosby Inc.; 2020:247-255.e5. doi:10.1016/j.jtcvs.2020.02.086.
20. Handy JR, Child AI, Grunkemeier GL, et al. Hospital readmission after pulmonary resection: Prevalence, patterns, and predisposing characteristics. Ann Thorac Surg. 2001;72(6):1855-1860. doi:10.1016/S0003-4975(01)03247-7.
21. Hu Y, McMurry TL, Isbell JM, Stukenborg GJ, Kozower BD. Readmission after lung cancer resection is associated with a 6-fold increase in 90-day postoperative mortality. J Thorac Cardiovasc Surg. 2014;148(5):2261-2267.e1. doi:10.1016/j.jtcvs.2014.04.026.
22. Min L, Yoon W, Mariano J, et al. The vulnerable elders-13 survey predicts 5-year functional decline and mortality outcomes in older ambulatory care patients. J Am Geriatr Soc. 2009;57(11):2070-2076. doi:10.1111/j.1532-5415.2009.02497.x.
23. Ludmir EB, Subbiah IM, Mainwaring W, et al. Decreasing incidence of upper age restriction enrollment criteria among cancer clinical trials. J Geriatr Oncol. 2020;11(3):451-454. doi:10.1016/j.jgo.2019.11.001.
24. Wang Y, Zhang R, Shen Y, Su L, Dong B, Hao Q. Prediction of chemotherapy adverse reactions and mortality in older patients with primary lung cancer through frailty index based on routine laboratory data. Clin Interv Aging. 2019;14:1187-1197. doi:10.2147/CIA.S201873.
25. Tsubata Y, Shiratsuki Y, Okuno T, et al. Prospective clinical trial evaluating vulnerability and chemotherapy risk using geriatric assessment tools in older patients with lung cancer. Geriatr Gerontol Int. 2019;19(11):1108-1111. doi:10.1111/ggi.13781.
26. Gridelli C, Aapro M, Ardizzoni A, et al. Treatment of advanced non-small-cell lung cancer in the elderly: Results of an International Expert Panel. J Clin Oncol. 2005;23(13):3125-3137. doi:10.1200/JCO.2005.00.224.
27. Balducci L, Extermann M. Management of Cancer in the Older Person: A Practical Approach. Oncologist. 2000;5(3):224-237. doi:10.1634/theoncologist.5-3-224.
28. Swan F, Chen H, Forbes CC, Johnson MJ, Lind M. CANcer BEhavioural nutrition and exercise feasibility trial (CanBenefit); phase I qualitative interview findings. J Geriatr Oncol. 2020. doi:10.1016/j.jgo.2020.09.026.