Discordance Between Physical Vulnerability Assessed by G8 and Social Support Structure in Relation to Unplanned Outpatient Visits Among Older Adults With Cancer

Discordance Between Physical Vulnerability Assessed by G8 and Social Support Structure in Relation to Unplanned Outpatient Visits Among Older Adults With Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Discordance Between Physical Vulnerability Assessed by G8 and Social Support Structure in Relation to Unplanned Outpatient Visits Among Older Adults With Cancer Naomi Fukuzaki, Yukie Hisayama, Sakiko Aso, Nao Kawamura, Tomomi Suzuki, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8451734/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Social support is a domain of geriatric assessment, yet its relationship with physical vulnerability and outcomes remains unclear. We estimated the 6-month incidence of unplanned hospital visits among older outpatients with cancer and examined discordance between physical vulnerability and social support structure. Methods This retrospective study included outpatients aged 65–97 years receiving nurse-led decision-making support at a cancer center in Japan. Patients were classified into four support types by key-person relationship and cohabitation status. Physical vulnerability was assessed using the G8 screening tool. The primary outcome was 6-month unplanned hospital visits; secondary outcomes included falls, emergency hospitalization, delirium, and follow-up telephone consultations. Results Among 439 patients (median age, 78 years), 316 (72.0%) had low G8 scores (≤ 14). Patients with limited cohabitation support, particularly those living alone or with distant adult children, had relatively high G8 scores, indicating preserved physical function. Unplanned outpatient visits occurred most frequently among patients cohabiting with an older family member (30.8%), followed by socially isolated patients (15.7%) ( P = 0.010). Emergency hospitalization and telephone consultations rates did not differ by support types. Falls were more common in patients with low G8 scores, whereas unplanned visits were not associated with G8 status. Conclusion Unplanned hospital visits among older outpatients with cancer reflect a discordance between physical vulnerability and social support structure. Despite physical robustness among socially isolated patients, unplanned visits were more frequent among those living with families. Assessing social support structures alongside frailty may help nurses identify patients needing guidance for timely help-seeking. Aged Neoplasms Social Support Geriatric Assessment Outpatients Hospitalization 1. Introduction With the increasing number of older adults diagnosed with cancer, the American Society of Clinical Oncology (ASCO) emphasizes the importance of evaluating not only disease-related factors but also age-related vulnerabilities—such as functional, cognitive, nutritional, and social domains—through geriatric assessment ( 1 , 2 ). Among these domains, social support plays a critical role in treatment adherence, shared decision-making, and the overall well-being of older patients receiving cancer therapy. Insufficient or fragile social support has been associated with worse health outcomes in cancer populations, including lower treatment completion, poorer quality of life, including lower treatment completion, poorer quality of life, and shorter survival ( 3 – 6 ). In older adults with cancer, diminished social resources have been linked to emotional distress, as well as to higher risks of unplanned healthcare use and mortality ( 7 , 8 ). Nevertheless, most existing studies have focused on the presence or quantity of social support, rather than the structure of support networks, -specifically, the attributes of key persons (e.g., spouse, child, and sibling) and cohabitation status. Few studies have examined how the combination of physical vulnerability such as the Geriatric 8 (G8) score ( 9 ) and social support structure jointly affects nursing-related outcomes, including falls, unplanned visits, or telephone consultations. This study used clinical records in which certified nurse specialists (CNSs) provided decision-making support and performed G8 screening during treatment planning. The target population comprised older patients with cancer whose key person did not cohabit with them, as identified during the initial assessment of their family composition. The aims of this study were: ( 1 ) to estimate the incidence of unplanned outpatient visits within six months among older outpatients with cancer; and ( 2 ) to descriptively examine nursing-related outcomes across support types, focusing on the discordance between physical vulnerability assessed by the G8 screening tool and social support structure. 2. Methods 2.1 Setting and sample 2.1.1 Nursing certification system in Japan In Japan, there are two national certification systems for advanced nursing practice: the CNS and certified nurse (CN), both accredited by the Japanese Nursing Association.( 10 ) While CNSs are internationally comparable to advanced practice nurses, CNs are certified experts who provide direct, specialized care and technical guidance in specific clinical areas. Oncology CNs primarily focus on providing direct patient care and technical guidance in their specialized areas such as breast cancer nursing, palliative care, chemotherapy, or radiation therapy, enabling more tailored and effective patient support. 2.1.2 Study setting and participants This retrospective study was conducted at a specialized cancer hospital located in a regional city in Japan. The facility had a total of 615 beds, including 50 beds in a dedicated palliative care unit, and employed 630 nurses. Among them, 17 were CNSs, and 51 were CNs. At the Patient and Family Support Center, CNSs and CNs primarily focus on decision-making support and symptom management for outpatients. Interventions were initiated based at the request of outpatient nurses or, physicians, or directly by patients and their families. Four CNSs and 11 CNs were involved in the G8 screening and decision-making support for older adults. Among these, two CNSs and two CNs were assigned exclusively to this role, whereas the others served concurrently with other clinical duties. 2.2 Data collection For patients aged 65 years or older who did not cohabit with a key person, CNSs or CNs attended medical consultations during the treatment decision-making process to provide decision-making support. The G8 screening tool was not administered as a paper-based questionnaire. Instead, CNSs and CNs verified each G8 item using information from electronic medical records and brief interviews with the patient, as basic clinical information, such as age, medication use, and body mass index, was recorded during the initial nursing interview. A cutoff score of 14 points was applied to classify patients into low (≤ 14) and high (> 14) G8 groups, in accordance with previous validation studies ( 9 ). In October 2024, based on insights from cases collected between May and September, intervention criteria were refined to identify older adults who might require more proactive support during treatment decision-making. After this refinement, the intervention was provided to the following patients: ( 1 ) Patients aged 70 years or older who were not living with a key person. ( 2 ) Patients aged 70 years who were seen in internal medicine, and ( 3 ) All patients aged 85 years. 2.3 Measures 2.3.1 Patient characteristics and clinical variables The following variables were extracted from electronic medical records and nursing documentation: patient characteristics (age, sex, medical history, living arrangement, attributes of the key person [e.g., spouse, child, or other family member], and the key person’s age); and disease-related characteristics (cancer type, clinical department, initial treatment plan, and Eastern Cooperative Oncology Group Performance Status [ECOG PS] at baseline). Geriatric assessment variables were obtained using the G8 screening tool, and the total G8 score was used for descriptive analyses and patient classification. In this study, the term “key person” referred to the individual identified as the primary surrogate decision-maker during the initial nursing assessment. This role was distinct from that of other family members or supporters who might assist with daily care. Therefore, cohabitation with a spouse or other family member did not necessarily indicate cohabitation with a key person. Based on our previous findings that a lack of cohabitation with a key person was associated with poorer understanding of illness, this study focused on patients who did not live with their key person. 2.3.2 Support type classification Patients were classified into four support types based on the relationship with their key person and cohabitation status, using demographic information recorded at the initial outpatient visit. Adult children were analyzed as a distinct category, as they frequently play a central role in parental medical decision-making in Japan, regardless of cohabitation status. The support types are defined as follows. 1) Co-residing family–key type: Patients living with a key person who was a spouse, parent, sibling, or partner (i.e., a cohabiting family member other than an adult child). 2) Distant-child type: Patients whose key person was an adult child living separately. 3) Cohabiting-child type: Patients whose key person was an adult child living with them. 4) Isolated type: Patients with no identified key person, those supported only by friends or others, or those whose key family person lived separately (including a non-cohabiting spouse, parent, or partner). 2.3.3 Outcomes Outcomes were assessed six months after the initial outpatient visit. The primary outcome was the occurrence of at least one unplanned hospital visit during the follow-up period. Secondary outcomes included falls, emergency hospitalization, delirium, and telephone consultations. All outcomes were extracted from electronic medical records and coded as binary variables (present vs absent), indicating whether each event occurred at least once during the six-month follow-up period. In the outpatient setting, unplanned hospital visits were typically preceded by telephone consultations. When patients or family members reported new or worsening symptoms, nurses conducted telephone triage, assessed the situation, and communicated relevant information to the attending or on-call physician. An unplanned hospital visit was defined as an in-person outpatient visit arranged outside a scheduled appointment, initiated following the joint clinical judgment by a nurse and physician that face-to-face evaluation was necessary. Delirium was identified based on the hospital’s standardized nursing delirium assessment, which is modeled on the core elements of the Confusion Assessment Method (CAM)( 11 )—acute onset or fluctuation, inattention, disorganized thinking, and altered level of consciousness. Registered ward nurses routinely perform this structured assessment in clinical practice, and delirium was coded only when these criteria were documented. 2.4 Statistical analysis Descriptive statistics were used to summarize the patient characteristics, disease-related factors, and clinical outcomes. Categorical variables are presented as frequencies and percentages. Associations between categorical variables were examined using the chi-squared test or Fisher’s exact test, as appropriate. Because this study was exploratory in nature, adjustments for multiple comparisons were not applied. All statistical tests were two-sided, and P < 0.05 was considered statistically significant. Because this study was exploratory in nature, analyses were primarily descriptive, and no multivariable adjustment was performed. Data analyses were performed using IBM SPSS version 29.0 (IBM Corp., Armonk, NY, USA). 2.5 Ethical considerations This study was approved by the Clinical Research Ethics Review Committee of our institution. Owing to the retrospective nature of this study, the ethics committee waived the requirement for informed consent. 3. Results 3.1 Participant characteristics A total of 2,120 patients aged ≥ 65 years had their first outpatient visit between May and September 2024. Among them, 303 patients who did not live with a key person received the intervention. After refinement of intervention criteria in October 2024, 293 patients aged ≥ 70 years without a cohabiting key person, 147 patients aged ≥ 70 years seen in internal medicine, and 158 patients aged ≥ 85 years were newly identified as requiring decision-making support. Of these, 125, 65, and 63 patients, respectively, received the intervention. During this period, 414 patients were excluded: 129 due to scheduling difficulties; 102 with benign disease; 98 who returned to the referring hospital; 12 referred to palliative care; 58 who were hospitalized; and 15 for other reasons. A total of 556 patients underwent intervention between May 2024 and January 2025. Complete data were available for 481 patients. After excluding 42 patients with benign conditions, 439 patients were included in the final analysis. Table 1 summarizes the patient characteristics. The median age was 78 years (range, 65–97 years), and 55.4% of patients were male. Regarding living arrangements, 211 (48.1%) patients lived with others, 209 (47.6%) lived alone, and 19 (4.3%) lived in a facility. Ninety patients (20.5%) lived with a key person, whereas 347 (79.0%) did not. Initial cancer treatments varied, with surgery being the most common (35.5%), followed by chemotherapy (targeted/immunotherapy) (17.1%), palliative care pathways (11.8%), radiation therapy (8.7%), and endoscopic submucosal dissection (7.7%). Table 1 Baseline characteristics of the study participants (n = 439) Characteristics n (%) or Median (Range) Age, median (range) 78 (65–97) Sex Male/Female 243 (55.4) / 196 (44.6) Cancer type Lung cancer 104 (23.7) Colorectal cancer 61 (13.9) Hepato-biliary-pancreatic cancer 52 (11.8) Cancer stage Stage 0/Stage I 15 (3.4)/119 (27.1) Stage II/Stage III/Stage IV 63 (14.1)/68 (15.5)/105 (23.9) Unknown/hematologic or sarcoma 69 (15.7) Initial cancer treatment Surgery 156 (35.5%) Chemotherapy /targeted / immunotherapy 75 (17.1%) Palliative care 52 (11.8%) Radiation therapy 38 (8.7%) Endoscopic submucosal dissection 34 (7.7%) Performance status (PS) 0 / 1 / 2 195 (44.4)/174 (39.6)/50 (11.4) 3 / 4 / Missing 16 (3.6)/3(0.07)/1 Living arrangement Living with others 211 (48.1) Living alone 209 (47.6) Residing in a facility 19 (4.3) Cohabitation with a key person Yes 90 (20.5) No 347 (79.0) Treatment intent Curative 258 (58.6) Disease-control/palliative chemotherapy 119 (26.4) Best supportive care/Missing 60 (13.7)/5(1.1) 3.2 G8 screening results Among the 439 patients, the median G8 score was 13.0 (range, 4.5–17.0). A total of 316 patients (72.0%) had a G8 score ≤ 14, indicating vulnerability, whereas 123 patients (28.0%) had a G8 score > 14. 3.2.1 G8 classification and support type Among the 439 participants included in the final analysis, support types were distributed as follows: 58 patients (13.2%) were categorized as Type 1 (co-residing family–key), 216 (49.2%) as Type 2 (distant-child), 37 (8.4%) as Type 3 (cohabiting-child), and 128 (29.2%) as Type 4 (isolated type) (Table 2 ). Table 2 Distribution of G8 scores by support type (n = 439) Support type Total G8 ≤ 14 (Low) G8 > 14 (High) G8 median Type 1: Co-residing family–key 58 47 (81.0%) 11 (19.0%) 13 (6‒17) Type 2: Distant-child 216 158 (73.1%) 58 (26.9%) 13 (4.5‒17) Type 3: Cohabiting-child 37 34 (91.9%) 3 (8.1%) 13 (6‒17) Type 4: Isolated type 128 77 (60.2%) 51 (39.8%) 14 (6‒17) Overall comparison: χ²(3) = 18.65, P < 0.001 Pairwise comparisons (Fisher’s exact test, unadjusted): 1 vs. 2 = ns 1 vs. 3 = ns 1 vs. 4 = P < 0.05 2 vs. 3 = P < 0.05 2 vs. 4 = P < 0.05 3 vs. 4 = P < 0.001 The distribution of G8 scores differed significantly across support types (χ²( 3 ) = 18.65, P < 0.001). The proportion of patients with low G8 scores (≤ 14) was highest in Type 3 (91.9%) and Type 1 (81.0%), followed by Type 2 (73.1%), and lowest in Type 4 (60.2%). Pairwise comparisons using Fisher’s exact test showed significant differences between Type 1 and 4 ( P < 0.05), Type 2 and 3 ( P < 0.05), Type 2 and Type 4 ( P < 0.05), and Types 3 and 4 ( P < 0.001), whereas no significant differences were observed between Types 1 and 2 or between Types 1 and 3. 3.2.1 G8 classification and support type Among the 439 participants included in the final analysis, support type was classified as follows: 58 patients (13.2%) were categorized as Type 1 (co-residing family-key), 216 (49.2%) as Type 2 (distant-child), 37 (8.4%) as Type 3 (cohabiting-child), and 128 (29.2%) as Type 4 (isolated type) (Table 2 ). Pairwise comparisons using Fisher’s exact test showed that Type 4 had a significantly higher proportion of patients with high G8 scores (> 14), whereas Type 3 had the highest proportion of patients with low G8 scores (≤ 14). In contrast, the co-residing family–key type (Type 1) showed a mixed distribution of G8 scores and did not differ significantly from either Type 2 or Type 3. 3.3 Outcomes at six months During the 6-month follow-up, 68 of the 439 patients (15.5%) experienced at least one unplanned hospital visit. Falls occurred in 41 patients (9.2%), and telephone consultations were conducted for 198 patients (44.2%). Emergency hospitalization was required for 43 patients (9.8%), and delirium was observed in 8 patients (1.8%). Comparisons by G8 scores revealed that falls were significantly more frequent in the low G8 group (10.1% vs. 3.3%; P = 0.018). No significant differences were observed in telephone consultations (37.4% vs. 39.6%; P = 0.677), unplanned visits (10.6% vs. 17.4%; P = 0.075), emergency hospitalizations (11.4% vs. 5.5%; P = 0.715), or delirium (0.8% vs. 2.8%; P = 0.295). 3.4 Factors associated with outcomes As shown in Table 3 , unplanned outpatient visits differed significantly across support types (P = 0.010), with the highest rate observed in Type 1 (co-residing family–key). Table 3 Six-month clinical outcomes across the four support types (n = 439) Outcome Type 1: Co-residing family–key n = 58 n (%) Type 2: Distant-child n = 216 n (%) Type 3: Cohabiting-child n = 37 n (%) Type 4: Isolated n = 128 n (%) P value Unplanned outpatient visit 16 (30.8%) 26 (12.0%) 5 (13.5%) 21 (15.7%) 0.010 Delirium 0 (0.0%) 4 (1.9%) 1 (2.7%) 5 (3.7%) 0.442 Falls 7 (13.5%) 17 (7.9%) 4 (10.8%) 8 (6.0%) 0.367 Telephone consultation 26 (50.0%) 86 (39.8%) 13 (35.1%) 46 (34.3%) 0.244 Emergency hospitalization 10 (17.2%) 16 (7.4%) 4 (10.8%) 13 (10.2%) 0.165 No significant differences were found across support types for delirium (P = 0.442), falls (P = 0.367), telephone consultations (P = 0.244), or emergency hospitalizations (P = 0.165). 4. Discussion In the present study, we observed that unplanned outpatient visits were more frequent among patients in the co-residing family–key (Type 1) and isolated (Type 4) groups. As emergency hospitalization and telephone contact rates did not differ across support types, these visits may be influenced by the timing of decisions about when to seek medical attention and whether patients have someone with whom to share their symptoms. Older adults with limited practical or emotional support have been reported to face difficulties in timely help-seeking ( 12 , 13 ). In our study, patients without readily available support (Types 2 and 4) had relatively high G8 scores, indicating preserved physical and cognitive function. This finding is consistent with evidence that living alone does not necessarily correspond to poorer function among older adults with cancer ( 14 ), In contrast, studies in older populations have reported that living alone is a risk factor for frailty( 15 ). Collectively, these findings suggest that differences in unplanned visits are driven not by physical vulnerability but by variation in symptom appraisal and help-seeking behaviors shaped by the social context in which patients interpret and act on symptom changes. Because many support-limited older adults in this study had relatively high G8 scores, some may have had sufficient capacity to engage in structured follow-up. Simple strategies, such as nurse-initiated telephone check-ins or brief technology-assisted symptom checklists, could help clarify when medical attention should be sought and reduce delays in help-seeking. Future studies should incorporate measures of formal caregiving and community-based resources to better distinguish social isolation from functional support availability. This study has several limitations. First, this study was conducted at a single regional cancer center using a retrospective design, which may limit the generalizability of the findings. Second, institutional criteria for nurse-led supportive care interventions were revised during the study. Although consistent outcome definitions were applied, changes in clinical practice patterns over time may have influenced patient identification and introduced a selection bias. Third, support types were assessed only at baseline, and changes in caregiving arrangements, availability of support, or use of formal caregiving resources—such as home-visit nursing services, care managers, or community-based support—were not captured. Even among older adults living alone, access to such resources may substantially influence symptom interpretation and help-seeking behavior, potentially reducing unplanned outpatient visits. The absence of these data limits our ability to fully characterize the functional support available to patients and should be considered when interpreting the findings. Fourth, the G8 screening tool was administered by nurses using electronic medical record data and brief interviews rather than a self-administered questionnaire. Although this approach reflects routine clinical practice, measurement variability cannot be fully excluded. Finally, because this study was exploratory, the analyses were primarily descriptive and unadjusted. Potential confounding factors related to cancer type, treatment, disease severity, and performance status were not fully controlled for, and some outcomes, such as delirium, occurred infrequently. Therefore, the findings should be interpreted as hypothesis-generating rather than confirmatory. 5. Conclusion This study demonstrates a clear discordance between physical vulnerability assessed by the G8 screening tool and social support structure in relation to unplanned outpatient visits among older adults with cancer. In this exploratory study of older outpatients with cancer, unplanned hospital visits within six months differed by social support structure rather than by physical vulnerability assessed using the G8 screening tool. Higher rates of unplanned visits were observed among patients living with an older family member and those who were socially isolated, despite similar rates of emergency hospitalization and telephone consultations across support types. These findings suggest that unplanned visits may reflect differences in symptom appraisal and help-seeking behaviors shaped by social context. Assessing key person relationships and cohabitation status may help nurses identify patients who require clearer guidance on when to seek medical attention. Nurse-led follow-up strategies may be particularly beneficial for older patients whose social support structures complicate timely decision-making. Declarations Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing Interests The authors declare that they have no competing interests to declare that are relevant to the content of this article. Ethics Approval This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of Shizuoka Cancer Center (approval no. J2024-150-2025-1-2). Informed Consent The ethics committee waived the requirement for informed consent owing to the retrospective nature of the study and the use of anonymized data. Author Contributions NF conceived and designed the study, collected data, performed data analysis, and drafted the manuscript. SA contributed to study conception, data collection, and manuscript drafting. YH, NK, TS, and YW collected the data and supported data verification. KN supervised the study and provided a critical review of the manuscript. All authors reviewed and approved the final manuscript. Acknowledgments The authors would like to thank the outpatient nursing team for their cooperation during data collection. Part of this study was presented as a poster at the 63rd Annual Meeting of the Japan Society of Clinical Oncology, Yokohama, Japan, in 2025, where it received the Medical Staff Award. We would like to thank Editage (www.editage.jp) for English language editing. Data availability The data that support the findings of this study are available from the corresponding author upon reasonable request. Due to privacy and ethical restrictions, the data are not publicly available. References Mohile SG, Dale W, Somerfield MR et al (2018) Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. 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J Health Commun 20:328–342. https://doi.org/10.1080/10810730.2014.965369 Singhal S, Walter LC, Smith AK et al (2024) Function, cognition, and quality of life among older adults with lung cancer who live alone: a prospective cohort study. J Geriatr Oncol 15:102068. https://doi.org/10.1016/j.jgo.2024.102068 Jiang Y, Wu W, Liu H, Zhou Q, Xi H (2025) Association between living alone and frailty and its gender disparity: a multicenter cross-sectional study in Chinese older adults undergoing hospitalisation. BMC Public Health 25:2738. https://doi.org/10.1186/s12889-025-24133-w Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 23 Mar, 2026 Reviews received at journal 09 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers invited by journal 30 Jan, 2026 Editor assigned by journal 30 Jan, 2026 Submission checks completed at journal 11 Jan, 2026 First submitted to journal 25 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8451734","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":583113010,"identity":"33a0601e-d9e6-4b6f-8b0d-895bca78049c","order_by":0,"name":"Naomi Fukuzaki","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3ElEQVRIiWNgGAWjYJCCDwwHgCQPY+MDIJUAxXgB4wyolmYDUrUwsEkQo5zBnP0AYzPPmcP2/D2H2yp/1NjlmTcwPHuAT4tlTwJQy43DzBJnG9tu8xxLLpY5wJBugE+LwYEE9sc8Hw6zMZxnbLvN2HAgcQYDQ5oEXi3nHwBt+XCYRx6opfAnUVpuQBwmYQB0GAMvcVoeNjbOOZNuYHjmYLM00C+JM5gJ+eV88sGGN8es7eXOpD/8CAyxxBnsPWkP8GkBRksDmgAzTxp+HVgA+zGStYyCUTAKRsGwBgBe50+MFnhjigAAAABJRU5ErkJggg==","orcid":"","institution":"Shizuoka Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Naomi","middleName":"","lastName":"Fukuzaki","suffix":""},{"id":583113016,"identity":"ad2f37a5-cdcf-4ccc-a4d3-ed88083618fc","order_by":1,"name":"Yukie Hisayama","email":"","orcid":"","institution":"Shizuoka Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Yukie","middleName":"","lastName":"Hisayama","suffix":""},{"id":583113018,"identity":"5f6caa39-1eb5-4c82-bbf0-65f494490b56","order_by":2,"name":"Sakiko Aso","email":"","orcid":"","institution":"Shizuoka Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Sakiko","middleName":"","lastName":"Aso","suffix":""},{"id":583113020,"identity":"88089bd0-1171-4cc2-8c92-1600a2d32a33","order_by":3,"name":"Nao Kawamura","email":"","orcid":"","institution":"Shizuoka Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Nao","middleName":"","lastName":"Kawamura","suffix":""},{"id":583113022,"identity":"a9cbc2b2-d556-48f3-b987-5bfef2e52f57","order_by":4,"name":"Tomomi Suzuki","email":"","orcid":"","institution":"Shizuoka Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Tomomi","middleName":"","lastName":"Suzuki","suffix":""},{"id":583113023,"identity":"d56e033f-5816-4ef4-b55c-38dcba340557","order_by":5,"name":"Yumi Watanabe","email":"","orcid":"","institution":"Shizuoka Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Yumi","middleName":"","lastName":"Watanabe","suffix":""},{"id":583113024,"identity":"58ac04c4-aa0c-4eb0-825a-84f56be749fd","order_by":6,"name":"Kazuko Nakajima","email":"","orcid":"","institution":"Shizuoka Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Kazuko","middleName":"","lastName":"Nakajima","suffix":""}],"badges":[],"createdAt":"2025-12-26 03:23:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8451734/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8451734/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":101880419,"identity":"5af3930f-0704-4f75-8966-7ea924a58937","added_by":"auto","created_at":"2026-02-04 15:00:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":948615,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8451734/v1/97bd2f55-fd20-4cb6-955f-c34d7c9e1c36.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Discordance Between Physical Vulnerability Assessed by G8 and Social Support Structure in Relation to Unplanned Outpatient Visits Among Older Adults With Cancer","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eWith the increasing number of older adults diagnosed with cancer, the American Society of Clinical Oncology (ASCO) emphasizes the importance of evaluating not only disease-related factors but also age-related vulnerabilities\u0026mdash;such as functional, cognitive, nutritional, and social domains\u0026mdash;through geriatric assessment (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Among these domains, social support plays a critical role in treatment adherence, shared decision-making, and the overall well-being of older patients receiving cancer therapy. Insufficient or fragile social support has been associated with worse health outcomes in cancer populations, including lower treatment completion, poorer quality of life, including lower treatment completion, poorer quality of life, and shorter survival (\u003cspan additionalcitationids=\"CR4 CR5\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In older adults with cancer, diminished social resources have been linked to emotional distress, as well as to higher risks of unplanned healthcare use and mortality (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNevertheless, most existing studies have focused on the presence or quantity of social support, rather than the structure of support networks, -specifically, the attributes of key persons (e.g., spouse, child, and sibling) and cohabitation status. Few studies have examined how the combination of physical vulnerability such as the Geriatric 8 (G8) score (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and social support structure jointly affects nursing-related outcomes, including falls, unplanned visits, or telephone consultations.\u003c/p\u003e \u003cp\u003eThis study used clinical records in which certified nurse specialists (CNSs) provided decision-making support and performed G8 screening during treatment planning. The target population comprised older patients with cancer whose key person did not cohabit with them, as identified during the initial assessment of their family composition.\u003c/p\u003e \u003cp\u003eThe aims of this study were: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) to estimate the incidence of unplanned outpatient visits within six months among older outpatients with cancer; and (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) to descriptively examine nursing-related outcomes across support types, focusing on the discordance between physical vulnerability assessed by the G8 screening tool and social support structure.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Setting and sample\u003c/h2\u003e \u003cdiv id=\"Sec4\" class=\"Section3\"\u003e \u003ch2\u003e2.1.1 Nursing certification system in Japan\u003c/h2\u003e \u003cp\u003eIn Japan, there are two national certification systems for advanced nursing practice: the CNS and certified nurse (CN), both accredited by the Japanese Nursing Association.(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) While CNSs are internationally comparable to advanced practice nurses, CNs are certified experts who provide direct, specialized care and technical guidance in specific clinical areas. Oncology CNs primarily focus on providing direct patient care and technical guidance in their specialized areas such as breast cancer nursing, palliative care, chemotherapy, or radiation therapy, enabling more tailored and effective patient support.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.1.2 Study setting and participants\u003c/h2\u003e \u003cp\u003e This retrospective study was conducted at a specialized cancer hospital located in a regional city in Japan. The facility had a total of 615 beds, including 50 beds in a dedicated palliative care unit, and employed 630 nurses. Among them, 17 were CNSs, and 51 were CNs. At the Patient and Family Support Center, CNSs and CNs primarily focus on decision-making support and symptom management for outpatients. Interventions were initiated based at the request of outpatient nurses or, physicians, or directly by patients and their families. Four CNSs and 11 CNs were involved in the G8 screening and decision-making support for older adults. Among these, two CNSs and two CNs were assigned exclusively to this role, whereas the others served concurrently with other clinical duties.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Data collection\u003c/h2\u003e \u003cp\u003eFor patients aged 65 years or older who did not cohabit with a key person, CNSs or CNs attended medical consultations during the treatment decision-making process to provide decision-making support. The G8 screening tool was not administered as a paper-based questionnaire. Instead, CNSs and CNs verified each G8 item using information from electronic medical records and brief interviews with the patient, as basic clinical information, such as age, medication use, and body mass index, was recorded during the initial nursing interview. A cutoff score of 14 points was applied to classify patients into low (\u0026le;\u0026thinsp;14) and high (\u0026gt;\u0026thinsp;14) G8 groups, in accordance with previous validation studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn October 2024, based on insights from cases collected between May and September, intervention criteria were refined to identify older adults who might require more proactive support during treatment decision-making. After this refinement, the intervention was provided to the following patients:\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) Patients aged 70 years or older who were not living with a key person.\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) Patients aged 70 years who were seen in internal medicine, and\u003c/p\u003e \u003cp\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) All patients aged 85 years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Measures\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.3.1 Patient characteristics and clinical variables\u003c/h2\u003e \u003cp\u003eThe following variables were extracted from electronic medical records and nursing documentation: patient characteristics (age, sex, medical history, living arrangement, attributes of the key person [e.g., spouse, child, or other family member], and the key person\u0026rsquo;s age); and disease-related characteristics (cancer type, clinical department, initial treatment plan, and Eastern Cooperative Oncology Group Performance Status [ECOG PS] at baseline). Geriatric assessment variables were obtained using the G8 screening tool, and the total G8 score was used for descriptive analyses and patient classification.\u003c/p\u003e \u003cp\u003eIn this study, the term \u0026ldquo;key person\u0026rdquo; referred to the individual identified as the primary surrogate decision-maker during the initial nursing assessment. This role was distinct from that of other family members or supporters who might assist with daily care. Therefore, cohabitation with a spouse or other family member did not necessarily indicate cohabitation with a key person.\u003c/p\u003e \u003cp\u003eBased on our previous findings that a lack of cohabitation with a key person was associated with poorer understanding of illness, this study focused on patients who did not live with their key person.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.3.2 Support type classification\u003c/h2\u003e \u003cp\u003ePatients were classified into four support types based on the relationship with their key person and cohabitation status, using demographic information recorded at the initial outpatient visit. Adult children were analyzed as a distinct category, as they frequently play a central role in parental medical decision-making in Japan, regardless of cohabitation status. The support types are defined as follows.\u003c/p\u003e \u003cp\u003e1) Co-residing family\u0026ndash;key type: Patients living with a key person who was a spouse, parent, sibling, or partner (i.e., a cohabiting family member other than an adult child).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003e2) Distant-child type: Patients whose key person was an adult child living separately.\u003c/h3\u003e\n\n\u003ch3\u003e3) Cohabiting-child type: Patients whose key person was an adult child living with them.\u003c/h3\u003e\n\u003cp\u003e4) Isolated type: Patients with no identified key person, those supported only by friends or others, or those whose key family person lived separately (including a non-cohabiting spouse, parent, or partner).\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003cdiv class=\"Heading\"\u003e2.3.3 Outcomes\u003c/div\u003e \u003cp\u003eOutcomes were assessed six months after the initial outpatient visit. The primary outcome was the occurrence of at least one unplanned hospital visit during the follow-up period. Secondary outcomes included falls, emergency hospitalization, delirium, and telephone consultations.\u003c/p\u003e \u003cp\u003eAll outcomes were extracted from electronic medical records and coded as binary variables (present vs absent), indicating whether each event occurred at least once during the six-month follow-up period.\u003c/p\u003e \u003cp\u003eIn the outpatient setting, unplanned hospital visits were typically preceded by telephone consultations. When patients or family members reported new or worsening symptoms, nurses conducted telephone triage, assessed the situation, and communicated relevant information to the attending or on-call physician. An unplanned hospital visit was defined as an in-person outpatient visit arranged outside a scheduled appointment, initiated following the joint clinical judgment by a nurse and physician that face-to-face evaluation was necessary.\u003c/p\u003e \u003cp\u003eDelirium was identified based on the hospital\u0026rsquo;s standardized nursing delirium assessment, which is modeled on the core elements of the Confusion Assessment Method (CAM)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u0026mdash;acute onset or fluctuation, inattention, disorganized thinking, and altered level of consciousness. Registered ward nurses routinely perform this structured assessment in clinical practice, and delirium was coded only when these criteria were documented.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize the patient characteristics, disease-related factors, and clinical outcomes. Categorical variables are presented as frequencies and percentages. Associations between categorical variables were examined using the chi-squared test or Fisher\u0026rsquo;s exact test, as appropriate. Because this study was exploratory in nature, adjustments for multiple comparisons were not applied. All statistical tests were two-sided, and \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Because this study was exploratory in nature, analyses were primarily descriptive, and no multivariable adjustment was performed. Data analyses were performed using IBM SPSS version 29.0 (IBM Corp., Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Ethical considerations\u003c/h2\u003e \u003cp\u003e This study was approved by the Clinical Research Ethics Review Committee of our institution. Owing to the retrospective nature of this study, the ethics committee waived the requirement for informed consent.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Participant characteristics\u003c/h2\u003e \u003cp\u003eA total of 2,120 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;65 years had their first outpatient visit between May and September 2024. Among them, 303 patients who did not live with a key person received the intervention.\u003c/p\u003e \u003cp\u003eAfter refinement of intervention criteria in October 2024, 293 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;70 years without a cohabiting key person, 147 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;70 years seen in internal medicine, and 158 patients aged\u0026thinsp;\u0026ge;\u0026thinsp;85 years were newly identified as requiring decision-making support. Of these, 125, 65, and 63 patients, respectively, received the intervention.\u003c/p\u003e \u003cp\u003eDuring this period, 414 patients were excluded: 129 due to scheduling difficulties; 102 with benign disease; 98 who returned to the referring hospital; 12 referred to palliative care; 58 who were hospitalized; and 15 for other reasons.\u003c/p\u003e \u003cp\u003eA total of 556 patients underwent intervention between May 2024 and January 2025. Complete data were available for 481 patients. After excluding 42 patients with benign conditions, 439 patients were included in the final analysis.\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the patient characteristics. The median age was 78 years (range, 65\u0026ndash;97 years), and 55.4% of patients were male. Regarding living arrangements, 211 (48.1%) patients lived with others, 209 (47.6%) lived alone, and 19 (4.3%) lived in a facility. Ninety patients (20.5%) lived with a key person, whereas 347 (79.0%) did not. Initial cancer treatments varied, with surgery being the most common (35.5%), followed by chemotherapy (targeted/immunotherapy) (17.1%), palliative care pathways (11.8%), radiation therapy (8.7%), and endoscopic submucosal dissection (7.7%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study participants (n\u0026thinsp;=\u0026thinsp;439)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%) or Median (Range)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, median (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (65\u0026ndash;97)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale/Female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e243 (55.4) / 196 (44.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (23.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eColorectal cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (13.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepato-biliary-pancreatic cancer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (11.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCancer stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage 0/Stage I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (3.4)/119 (27.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStage II/Stage III/Stage IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (14.1)/68 (15.5)/105 (23.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown/hematologic or sarcoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (15.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial cancer treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156 (35.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy /targeted / immunotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (17.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePalliative care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiation therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (8.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEndoscopic submucosal dissection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (7.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePerformance status (PS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e0 / 1 / 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e195 (44.4)/174 (39.6)/50 (11.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3 / 4 / Missing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (3.6)/3(0.07)/1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving arrangement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving with others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211 (48.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLiving alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e209 (47.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResiding in a facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCohabitation with a key person\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90 (20.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e347 (79.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment intent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e258 (58.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease-control/palliative chemotherapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (26.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBest supportive care/Missing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (13.7)/5(1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e3.2 G8 screening results\u003c/h2\u003e \u003cp\u003eAmong the 439 patients, the median G8 score was 13.0 (range, 4.5\u0026ndash;17.0).\u003c/p\u003e \u003cp\u003eA total of 316 patients (72.0%) had a G8 score\u0026thinsp;\u0026le;\u0026thinsp;14, indicating vulnerability, whereas 123 patients (28.0%) had a G8 score\u0026thinsp;\u0026gt;\u0026thinsp;14.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 G8 classification and support type\u003c/h2\u003e \u003cp\u003eAmong the 439 participants included in the final analysis, support types were distributed as follows: 58 patients (13.2%) were categorized as Type 1 (co-residing family\u0026ndash;key), 216 (49.2%) as Type 2 (distant-child), 37 (8.4%) as Type 3 (cohabiting-child), and 128 (29.2%) as Type 4 (isolated type) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of G8 scores by support type (n\u0026thinsp;=\u0026thinsp;439)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSupport type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eG8\u0026thinsp;\u0026le;\u0026thinsp;14 (Low)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eG8\u0026thinsp;\u0026gt;\u0026thinsp;14 (High)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eG8 median\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 1: Co-residing family\u0026ndash;key\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (81.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11 (19.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e(6‒17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 2: Distant-child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e158 (73.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58 (26.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e(4.5‒17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 3: Cohabiting-child\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (91.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (8.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e(6‒17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 4: Isolated type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e77 (60.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003cp\u003e(6‒17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003cstrong\u003eOverall comparison:\u003c/strong\u003e \u0026chi;\u0026sup2;(3) = 18.65, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePairwise comparisons (Fisher\u0026rsquo;s exact test, unadjusted):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 vs. 2 = ns\u003c/p\u003e\n\u003cp\u003e1 vs. 3 = ns\u003c/p\u003e\n\u003cp\u003e1 vs. 4 = \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05\u003c/p\u003e\n\u003cp\u003e2 vs. 3 = \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05\u003c/p\u003e\n\u003cp\u003e2 vs. 4 = \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05\u003c/p\u003e\n\u003cp\u003e3 vs. 4 = \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001\u003c/p\u003e\n\u003cp\u003eThe distribution of G8 scores differed significantly across support types (χ\u0026sup2;(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u0026thinsp;=\u0026thinsp;18.65, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The proportion of patients with low G8 scores (\u0026le;\u0026thinsp;14) was highest in Type 3 (91.9%) and Type 1 (81.0%), followed by Type 2 (73.1%), and lowest in Type 4 (60.2%).\u003c/p\u003e \u003cp\u003ePairwise comparisons using Fisher\u0026rsquo;s exact test showed significant differences between Type 1 and 4 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), Type 2 and 3 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), Type 2 and Type 4 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and Types 3 and 4 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas no significant differences were observed between Types 1 and 2 or between Types 1 and 3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e3.2.1 G8 classification and support type\u003c/h2\u003e \u003cp\u003eAmong the 439 participants included in the final analysis, support type was classified as follows: 58 patients (13.2%) were categorized as Type 1 (co-residing family-key), 216 (49.2%) as Type 2 (distant-child), 37 (8.4%) as Type 3 (cohabiting-child), and 128 (29.2%) as Type 4 (isolated type) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePairwise comparisons using Fisher\u0026rsquo;s exact test showed that Type 4 had a significantly higher proportion of patients with high G8 scores (\u0026gt;\u0026thinsp;14), whereas Type 3 had the highest proportion of patients with low G8 scores (\u0026le;\u0026thinsp;14). In contrast, the co-residing family\u0026ndash;key type (Type 1) showed a mixed distribution of G8 scores and did not differ significantly from either Type 2 or Type 3.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Outcomes at six months\u003c/h2\u003e \u003cp\u003eDuring the 6-month follow-up, 68 of the 439 patients (15.5%) experienced at least one unplanned hospital visit. Falls occurred in 41 patients (9.2%), and telephone consultations were conducted for 198 patients (44.2%). Emergency hospitalization was required for 43 patients (9.8%), and delirium was observed in 8 patients (1.8%).\u003c/p\u003e \u003cp\u003eComparisons by G8 scores revealed that falls were significantly more frequent in the low G8 group (10.1% vs. 3.3%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.018). No significant differences were observed in telephone consultations (37.4% vs. 39.6%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.677), unplanned visits (10.6% vs. 17.4%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.075), emergency hospitalizations (11.4% vs. 5.5%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.715), or delirium (0.8% vs. 2.8%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.295).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Factors associated with outcomes\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, unplanned outpatient visits differed significantly across support types (P\u0026thinsp;=\u0026thinsp;0.010), with the highest rate observed in Type 1 (co-residing family\u0026ndash;key).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSix-month clinical outcomes across the four support types (n\u0026thinsp;=\u0026thinsp;439)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOutcome\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType 1:\u003c/p\u003e \u003cp\u003eCo-residing family\u0026ndash;key\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;58\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eType 2: Distant-child\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;216\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eType 3: Cohabiting-child\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;37\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eType 4: Isolated\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;128\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnplanned outpatient visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(30.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e(12.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e(15.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.010\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelirium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(1.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(2.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(3.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.442\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFalls\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e(13.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e(7.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e(6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.367\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTelephone\u003c/p\u003e \u003cp\u003econsultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e(50.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e86\u003c/p\u003e \u003cp\u003e(39.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e(35.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003cp\u003e(34.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.244\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency hospitalization\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e(17.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(7.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(10.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003cp\u003e(10.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNo significant differences were found across support types for delirium (P\u0026thinsp;=\u0026thinsp;0.442), falls (P\u0026thinsp;=\u0026thinsp;0.367), telephone consultations (P\u0026thinsp;=\u0026thinsp;0.244), or emergency hospitalizations (P\u0026thinsp;=\u0026thinsp;0.165).\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn the present study, we observed that unplanned outpatient visits were more frequent among patients in the co-residing family\u0026ndash;key (Type 1) and isolated (Type 4) groups. As emergency hospitalization and telephone contact rates did not differ across support types, these visits may be influenced by the timing of decisions about when to seek medical attention and whether patients have someone with whom to share their symptoms.\u003c/p\u003e \u003cp\u003eOlder adults with limited practical or emotional support have been reported to face difficulties in timely help-seeking (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In our study, patients without readily available support (Types 2 and 4) had relatively high G8 scores, indicating preserved physical and cognitive function. This finding is consistent with evidence that living alone does not necessarily correspond to poorer function among older adults with cancer (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), In contrast, studies in older populations have reported that living alone is a risk factor for frailty(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCollectively, these findings suggest that differences in unplanned visits are driven not by physical vulnerability but by variation in symptom appraisal and help-seeking behaviors shaped by the social context in which patients interpret and act on symptom changes.\u003c/p\u003e \u003cp\u003eBecause many support-limited older adults in this study had relatively high G8 scores, some may have had sufficient capacity to engage in structured follow-up. Simple strategies, such as nurse-initiated telephone check-ins or brief technology-assisted symptom checklists, could help clarify when medical attention should be sought and reduce delays in help-seeking. Future studies should incorporate measures of formal caregiving and community-based resources to better distinguish social isolation from functional support availability.\u003c/p\u003e \u003cp\u003eThis study has several limitations. First, this study was conducted at a single regional cancer center using a retrospective design, which may limit the generalizability of the findings. Second, institutional criteria for nurse-led supportive care interventions were revised during the study. Although consistent outcome definitions were applied, changes in clinical practice patterns over time may have influenced patient identification and introduced a selection bias. Third, support types were assessed only at baseline, and changes in caregiving arrangements, availability of support, or use of formal caregiving resources\u0026mdash;such as home-visit nursing services, care managers, or community-based support\u0026mdash;were not captured. Even among older adults living alone, access to such resources may substantially influence symptom interpretation and help-seeking behavior, potentially reducing unplanned outpatient visits. The absence of these data limits our ability to fully characterize the functional support available to patients and should be considered when interpreting the findings. Fourth, the G8 screening tool was administered by nurses using electronic medical record data and brief interviews rather than a self-administered questionnaire. Although this approach reflects routine clinical practice, measurement variability cannot be fully excluded. Finally, because this study was exploratory, the analyses were primarily descriptive and unadjusted. Potential confounding factors related to cancer type, treatment, disease severity, and performance status were not fully controlled for, and some outcomes, such as delirium, occurred infrequently. Therefore, the findings should be interpreted as hypothesis-generating rather than confirmatory.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThis study demonstrates a clear discordance between physical vulnerability assessed by the G8 screening tool and social support structure in relation to unplanned outpatient visits among older adults with cancer. In this exploratory study of older outpatients with cancer, unplanned hospital visits within six months differed by social support structure rather than by physical vulnerability assessed using the G8 screening tool. Higher rates of unplanned visits were observed among patients living with an older family member and those who were socially isolated, despite similar rates of emergency hospitalization and telephone consultations across support types. These findings suggest that unplanned visits may reflect differences in symptom appraisal and help-seeking behaviors shaped by social context. Assessing key person relationships and cohabitation status may help nurses identify patients who require clearer guidance on when to seek medical attention. Nurse-led follow-up strategies may be particularly beneficial for older patients whose social support structures complicate timely decision-making.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests to declare that are relevant to the content of this article.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eEthics Approval \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Institutional Review Board of Shizuoka Cancer Center (approval no. J2024-150-2025-1-2). \u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe ethics committee waived the requirement for informed consent owing to the retrospective nature of the study and the use of anonymized data.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNF conceived and designed the study, collected data, performed data analysis, and drafted the manuscript. \u003c/p\u003e\n\u003cp\u003eSA contributed to study conception, data collection, and manuscript drafting. \u003c/p\u003e\n\u003cp\u003eYH, NK, TS, and YW collected the data and supported data verification. \u003c/p\u003e\n\u003cp\u003eKN supervised the study and provided a critical review of the manuscript. \u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e \u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the outpatient nursing team for their cooperation during data collection. Part of this study was presented as a poster at the 63rd Annual Meeting of the Japan Society of Clinical Oncology, Yokohama, Japan, in 2025, where it received the Medical Staff Award. We would like to thank Editage (www.editage.jp) for English language editing.\u003c/p\u003e\n\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available from the corresponding author upon reasonable request. Due to privacy and ethical restrictions, the data are not publicly available.\u003c/p\u003e\n\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMohile SG, Dale W, Somerfield MR et al (2018) Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. 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BMC Public Health 25:2738. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-025-24133-w\u003c/span\u003e\u003cspan address=\"10.1186/s12889-025-24133-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Aged, Neoplasms, Social Support, Geriatric Assessment, Outpatients, Hospitalization","lastPublishedDoi":"10.21203/rs.3.rs-8451734/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8451734/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eSocial support is a domain of geriatric assessment, yet its relationship with physical vulnerability and outcomes remains unclear. We estimated the 6-month incidence of unplanned hospital visits among older outpatients with cancer and examined discordance between physical vulnerability and social support structure.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis retrospective study included outpatients aged 65\u0026ndash;97 years receiving nurse-led decision-making support at a cancer center in Japan. Patients were classified into four support types by key-person relationship and cohabitation status. Physical vulnerability was assessed using the G8 screening tool. The primary outcome was 6-month unplanned hospital visits; secondary outcomes included falls, emergency hospitalization, delirium, and follow-up telephone consultations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 439 patients (median age, 78 years), 316 (72.0%) had low G8 scores (\u0026le;\u0026thinsp;14). Patients with limited cohabitation support, particularly those living alone or with distant adult children, had relatively high G8 scores, indicating preserved physical function. Unplanned outpatient visits occurred most frequently among patients cohabiting with an older family member (30.8%), followed by socially isolated patients (15.7%) (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.010). Emergency hospitalization and telephone consultations rates did not differ by support types. Falls were more common in patients with low G8 scores, whereas unplanned visits were not associated with G8 status.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eUnplanned hospital visits among older outpatients with cancer reflect a discordance between physical vulnerability and social support structure. Despite physical robustness among socially isolated patients, unplanned visits were more frequent among those living with families. Assessing social support structures alongside frailty may help nurses identify patients needing guidance for timely help-seeking.\u003c/p\u003e","manuscriptTitle":"Discordance Between Physical Vulnerability Assessed by G8 and Social Support Structure in Relation to Unplanned Outpatient Visits Among Older Adults With Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-02 11:26:51","doi":"10.21203/rs.3.rs-8451734/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"124063589382093723768219769578860918949","date":"2026-03-24T02:04:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-09T06:17:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"138317207621431887274705270875263108498","date":"2026-02-02T04:55:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-30T14:25:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-30T14:24:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-12T01:54:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2025-12-26T03:05:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6d85c4fb-42ee-4fd8-9bc9-3468e9abe461","owner":[],"postedDate":"February 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-02T11:26:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-02 11:26:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8451734","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8451734","identity":"rs-8451734","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}