==== Front Cancer Med Cancer Med 10.1002/(ISSN)2045-7634 CAM4 Cancer Medicine 2045-7634 John Wiley and Sons Inc. Hoboken 37245226 10.1002/cam4.6038 CAM46038 CAM4-2023-02-0815.R1 Research Article RESEARCH ARTICLES Cancer Prevention Association of unmet basic resource needs with frailty and quality of life among older adults with cancer—Results from the CARE registry Williams et al. Williams Grant R. https://orcid.org/0000-0003-4294-5232 1 2 grwilliams@uabmc.edu Fowler Mackenzie 1 Giri Smith https://orcid.org/0000-0002-1827-5032 1 2 Dai Chen 1 Harmon Christian 1 Al‐Obaidi Mustafa 1 Stephenson Coryn 3 Bona Kira 4 Landier Wendy 1 2 Bhatia Smita https://orcid.org/0000-0002-7755-5683 1 2 Wolfson Julie 1 2 1 Institute for Cancer Outcomes & Survivorship University of Alabama Birmingham Alabama USA 2 O'Neal Comprehensive Cancer Center University of Alabama Birmingham Alabama USA 3 University of Missouri Columbia Missouri USA 4 Division of Population Sciences Dana‐Farber Cancer Institute Boston Massachusetts USA * Correspondence Grant R. Williams, Divisions of Hematology/Oncology & Gerontology, Geriatrics, and Palliative Care, Institute for Cancer Outcomes and Survivorship, O'Neal Comprehensive Cancer Center at UAB, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder 500, Birmingham, AL 35233, USA. Email: grwilliams@uabmc.edu 28 5 2023 6 2023 12 12 10.1002/cam4.v12.12 1384613855 11 4 2023 20 2 2023 23 4 2023 © 2023 The Authors. Cancer Medicine published by John Wiley & Sons Ltd. https://creativecommons.org/licenses/by/4.0/ This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Abstract Background Basic resource needs related to transportation, housing, food, and medications are important social determinants of health and modifiable indicators of poverty, but their role in modifying the risk of frailty and health‐related quality of life (HRQoL) remains unknown. The goal of our study was to examine the prevalence of unmet basic needs and their association with frailty and HRQoL in a cohort of older adults with cancer. Methods The CARE registry prospectively enrolls older adults (≥60 years) with cancer. Assessments of transportation, housing, and material hardship were added to the CARE tool in 8/2020. The 44‐item CARE Frailty Index was used to define frailty, and subdomains of physical and mental HRQoL were assessed using the PROMIS® 10‐global. Multivariable analysis examined the association between unmet needs with frailty and HRQoL subdomains, adjusting for covariates. Results The cohort included 494 participants. Median age of 69 years, 63.6% were male and 20.2% were Non‐Hispanic (NH) Black. Unmet basic needs were reported in 17.8% (transportation 11.5%, housing 2.8%, and material hardship 7.5%). Those with unmet needs were more often NH Black (33.0% vs. 17.8%, p = 0.006) and less educated ( 75 years. 20 For this study, we included the subset of participants recruited between August 2020 and April 2022 that completed the social determinants of health section. This study was approved by the Institutional Review Board at University of Alabama at Birmingham (IRB‐300000092) and performed in accordance with the ethical standards of the 1964 Declaration of Helsinki and its later amendments. 2.2 Study measures 2.2.1 Basic resource needs Social determinants of health measures embedded within the CARE tool assessed basic needs as outlined here: (1) Health‐related transportation insecurity was measured using two previously published items: 21 How much trouble is it for you to get transportation to your doctor? [dichotomized as some trouble/a lot of trouble versus a little trouble/no trouble]; Have you ever missed a doctor's appointment because of transportation issues? [yes/no]. Patients were classified as having unmet transportation needs if they identified trouble in either of these questions. (2) Housing insecurity was assessed using two items adapted from the Protocol for Responding to and Assessing Patients Assets, Risks and Experiences (PRAPARE) instrument developed by the National Association of Community Health Centers. 22 The first inquired about the participant's current housing situation [I have housing; I do not have housing (staying with others, in a hotel, in a shelter, living outside on the street, on a beach, in a car, or in a park)] and the second asked whether participants were worried about losing their housing [yes/no]. 23 Patients were classified as having unmet housing needs if they responded I do not have housing or had concerns about losing their housing. (3) Material hardship (security of food, utilities, and medications/medical care) was assessed using a single item adapted from the PRAPARE instrument: In the past year, have you or any family members you live with been unable to get any of the following when it was really needed? [a list of yes/no items was provided: food, utilities, medicine or any healthcare (medical, dental, mental health, vision), phone, clothing, child care, or other]. 23 Patients were classified as having unmet material needs if they answered yes to any of the items. Patients were classified as having overall unmet basic resource needs if they had any unmet needs in one or more of the categories above (transportation, housing or material hardship). 2.2.2 Frailty Using the principles of deficit accumulation and following the procedures outlined by Searle et al., 24 we constructed the CARE Frailty Index. 25 Based on 44 identified health deficits from the CARE geriatric assessment tool, the CARE Frailty Index was calculated as the proportion of deficits for each patient (range 0–1). Participants were required to have nonmissing data for at least 30 items in order to compute a valid frailty score and were categorized as robust (0–0.2), prefrail (0.2–0.35), and frail (>0.35), as previously described. 24 Our team has previously shown that the CARE frailty index predicts functional decline, severe chemotherapy toxicities, and survival among older adults; 25 similarly constructed frailty indices have shown comparable results. 12 , 13 , 14 , 15 , 26 See Table S1 for a full list of the CARE frailty index items. 2.2.3 Health‐related quality of life The CARE tool assesses HRQoL using the National Institutes of Health Patient‐Reported Outcomes Measurement Information System® (PROMIS®) Global Health 10‐item short‐form. The PROMIS Global Health 10‐item scale includes separate scoring for physical and mental health subscales. 27 , 28 PROMIS measures have been tested in large samples of adults in the United States and item responses are converted to t‐scores with a standardized mean score of 50 and a standard deviation of 10. 30 The minimal clinically relevant difference for PROMIS ranges from 2 to 6 points, and a score of ≤40 (1 standard deviation) is considered impaired for the subscales. 29 Low physical and mental subdomains of HRQoL were defined as a t‐score of ≤40 (1 standard deviation). 2.2.4 Covariates Patients self‐reported information regarding race, ethnicity, education, marital status, and employment. Urban–rural status was obtained via patient‐reported ZIP code merged with Rural–Urban Commuting Area (RUCA) code data. Categorization B from the University of Washington School of Medicine was used to define urban, micropolitan, and rural status. 30 , 31 Urban and micropolitan were combined into one urban group due to similarity in outcomes between the two as discussed in a prior study. 32 Information regarding cancer stage, cancer type, and date of diagnosis were abstracted from the electronic medical record. 2.3 Statistical analyses Distribution‐appropriate bivariate statistical tests, namely chi‐squared test/Fisher's exact test for categorical variables, were used to compare patient characteristics and frailty categories between those with and without unmet basic resource needs. Logistic regression models were used to evaluate the association between unmet basic resource needs with frailty and physical and mental domains of HRQoL. An additional logistic regression model was used to assess predictors of unmet basic resource needs. Multivariable models were adjusted for potential confounders including age, sex, race/ethnicity, education, marital status, employment status, urban–rural status, cancer type, and cancer stage. All hypothesis testing was two‐sided and the level of significance was set at 0.05. All statistical analyses were conducted using SAS statistical software version 9.4 (SAS Institute Inc.). 3 RESULTS 3.1 Patients Between August 2020 and April 2022, a total of 494 older adults completed the CARE tool and the social determinants of health survey (see Figure S1 for consort diagram). Most participants were age 60–69 years (56.2%), male (63.6%), and non‐Hispanic White (75.1%) (Table 1). Most participants had a high school education or some college (52.9%), were married (57.6%), and were retired (62.1%). Most participants resided in urban (90.7%) versus rural areas (9.3%). Finally, participants had either colorectal cancer (33.1%), pancreatic (18.0%), hepatobiliary (12.0%), or other cancers (36.9%). The majority had advanced stage disease (stage III: 30.6%; stage IV: 44.5%). Overall, 29.0% of the cohort was frail (see Table S1 for prevalence of individual frailty item impairments); impaired physical HRQoL was observed in 36.2% and impaired mental HRQoL in 39.1%. Median time from cancer diagnosis to CARE tool completion was 35 days. TABLE 1 Participant characteristics. Variable Total Unmet need, 88 (17.8%) No unmet needs, 406 (82.2%) p‐value Age group 0.630 60–64 147 (29.9) 30 (34.1) 117 (29.0) 65–69 129 (26.3) 26 (29.6) 103 (25.6) 70–74 102 (20.8) 14 (15.9) 88 (21.8) 75–79 57 (11.6) 9 (10.2) 48 (11.9) 80+ 56 (11.4) 9 (10.2) 47 (11.7) Sex, male 314 (63.6) 52 (59.1) 262 (64.5) 0.336 Race/Ethnicity 0.021 Non‐Hispanic White 364 (75.1) 56 (64.4) 308 (77.4) Non‐Hispanic Black 98 (20.2) 27 (31.0) 71 (17.8) Other 23 (4.7) 4 (4.6) 19 (4.8) Education 0.023