In Reply to the Comment on "The Relationship Between Frailty and Emotional Health in Older Patients With Advanced Cancer".

We would like to thank Drs. Chen and Yang for their critical review[1] 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.