The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: scoring and interpretation

The SAKK cancer-specific geriatric assessment (C-SGA): a pilot study of a brief tool for clinical decision-making in older cancer patients

Background

Recommendations from international task forces on geriatric assessment emphasize the need for research including validation of cancer-specific geriatric assessment (C-SGA) tools in oncological settings. This study was to evaluate the feasibility of the SAKK Cancer-Specific Geriatric Assessment (C-SGA) in clinical practice.

Methods

A cross sectional study of cancer patients ≥65 years old (N = 51) with pathologically confirmed cancer presenting for initiation of chemotherapy treatment (07/01/2009-03/31/2011) at two oncology departments in Swiss canton hospitals: Kantonsspital Graubünden (KSGR N = 25), Kantonsspital St. Gallen (KSSG N = 26). Data was collected using three instruments, the SAKK C-SGA plus physician and patient evaluation forms. The SAKK C-SGA includes six measures covering five geriatric assessment domains (comorbidity, function, psychosocial, nutrition, cognition) using a mix of medical record abstraction (MRA) and patient interview. Five individual domains and one overall SAKK C-SGA score were calculated and dichotomized as below/above literature-based cut-offs. The SAKK C-SGA was evaluated by: patient and physician estimated time to complete, ease of completing, and difficult or unanswered questions.

Results

Time to complete the patient questionnaire was considered acceptable by almost all (≥96%) patients and physicians. Patients reported slightly shorter times to complete the questionnaire than physicians (17.33 ± 7.34 vs. 20.59 ± 6.53 minutes, p = 0.02). Both groups rated the patient questionnaire as easy/fairly easy to complete (91% vs. 84% respectively, p = 0.14) with few difficult or unanswered questions. The MRA took on average 8.32 ± 4.72 minutes to complete. Physicians (100%) considered time to complete MRA acceptable, 96% rated it as easy/fairly easy to complete. Individual study site populations differed on health-related characteristics (excellent/good physician-rated general health KSGR 71% vs. KSSG 32%, p = 0.007). The overall mean C-SGA score was 2.4 ± 1.12. Patients at KSGR had lower C-SGA scores (2.00 ± 1.19 vs. 2.81 ± 0.90, p = 0.009) and a smaller proportion (28% vs.65%, p = 0.008) was above the C-SGA cut-off score compared to KSSG.

Conclusions

These results suggest the SAKK C-SGA is a feasible practical tool for use in clinical practice. It demonstrated discriminative ability based on objective geriatric assessment measures, but additional investigations on use for clinical decision-making are warranted. The SAKK C-SGA also provides important usable domain information for intervention to optimize outcomes in older cancer patients.

Experience of multidisciplinary assessment of elderly patients with cancer in a French general hospital during 1 year: a new model care study

OBJECTIVES

Our main aim was to describe and explore a multidisciplinary approach to the management of elderly patients with cancer, who constitute a heterogeneous population.

MATERIALS AND METHODS

This descriptive study was performed between October 2009 and September 2010. Patients with cancer ≥ 70 years of age were included. Some underwent a simplified multidimensional geriatric assessment with a Charlson score administered by an oncologist, and the evaluation was submitted to a geriatrician who decided whether or not a complete a comprehensive geriatric assessment (CGA) (n=54) should be done. Another group of patients directly underwent a CGA (n=49), and a few patients included in a specific trial underwent a geriatric assessment (n=8). Each patient was classified as fit, vulnerable, or frail by a multidisciplinary team.

RESULTS

111 patients were included (median age: 81 years [range: 65-96]; 60 males). The most frequent types of cancer were lung (n=29), gastrointestinal (n=20) and head and neck (n=14). Median Charlson score was 2.1 [range: 0-9]. Standard therapy was given to 37/41 (90%) fit, 19/41 (42%) vulnerable, and 6/29 (21%) frail patients. Thirteen frail patients received best supportive care. A social worker was mobilized for 2/41 (5%) fit, 14/41 (34%) vulnerable, and 11/29 (38%) frail patients.

CONCLUSIONS

Our study outlines the possibilities of cooperation between geriatricians and oncologists in a general hospital. This collaboration could modify therapeutic schedules especially in frail and vulnerable patients.

Declining functional status in older women with a history of breast cancer: implications for women's health nurses

Older breast cancer survivors are at risk for a decline in functional status, which is associated with increased risk for disability, increased health care costs and increased risk of nursing home placement. The comprehensive geriatric assessment is a useful tool for identifying women with a history of breast cancer who are at increased risk for decline in functional status. Use of the comprehensive geriatric assessment will allow nurses to identify functional care needs and develop care plans and interventions that are aimed at maintenance of functional status.

Screening elderly cancer patients for disabilities: evaluation of study of osteoporotic fractures (SOF) index and comprehensive geriatric assessment (CGA)

BACKGROUND

Comprehensive geriatric assessment (CGA) is a multidimensional tool aimed at detecting multiple age-related problems; the study of osteoporotic fractures (SOF) index is a 3-item instrument designed to measure frailty and pre-frailty status. The aim of this prospective cohort study was to evaluate the accuracy of the SOF index and CGA in predicting the disability status in elderly cancer patients.

PATIENTS AND METHODS

Patients aged ≥ 70 years with a confirmed diagnosis of a solid or hematologic tumor underwent both CGA and SOF assessment. The sensitivity and specificity of SOF in determining the presence of frailty were analyzed using the CGA as the reference standard. The diagnostic accuracy of SOF < 80% was considered not acceptable.

RESULTS

The study involved 400 patients aged ≥ 70 years (median age 77.2, range 70-97).The SOF and CGA classified, respectively, 33.2% and 31.8% of patients as fit, 67.8% and 68.2% as unfit. The SOF showed a sensibility and a specificity of 89.0 [95% confidence interval (CI) 84.7-92.5] and 81.1 (73.2-87.5) with an accuracy of 86.5 (82.8-89.7). The negative predictive value (NPV) was 103/133, i.e. 77.4% (95% CI 69.4-84.2).

CONCLUSIONS

As the SOF proved to reach the end-point of our study, we support its use as a means of screening elderly cancer patients in everyday clinical practice.

Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review

Comprehensive geriatric assessment (CGA) is done to detect vulnerability in elderly patients with cancer so that treatment can be adjusted accordingly; however, this process is time-consuming and pre-screening is often used to identify fit patients who are able to receive standard treatment versus those in whom a full CGA should be done. We aimed to assess which of the frailty screening methods available show the best sensitivity and specificity for predicting the presence of impairments on CGA in elderly patients with cancer. We did a systematic search of Medline and Embase, and a hand-search of conference abstracts, for studies on the association between frailty screening outcome and results of CGA in elderly patients with cancer. Our search identified 4440 reports, of which 22 publications from 14 studies, were included in this Review. Seven different frailty screening methods were assessed. The median sensitivity and specificity of each screening method for predicting frailty on CGA were as follows: Vulnerable Elders Survey-13 (VES-13), 68% and 78%; Geriatric 8 (G8), 87% and 61%; Triage Risk Screening Tool (TRST 1+; patient considered frail if one or more impairments present), 92% and 47%, Groningen Frailty Index (GFI) 57% and 86%, Fried frailty criteria 31% and 91%, Barber 59% and 79%, and abbreviated CGA (aCGA) 51% and 97%. However, even in case of the highest sensitivity, the negative predictive value was only roughly 60%. G8 and TRST 1+ had the highest sensitivity for frailty, but both had poor specificity and negative predictive value. These findings suggest that, for now, it might be beneficial for all elderly patients with cancer to receive a complete geriatric assessment, since available frailty screening methods have insufficient discriminative power to select patients for further assessment.

[Standardized geriatric assessment or comprehensive gerontological assessment: where do we stand?]

The concept of comprehensive gerontological assessment is a foundation of modern geriatrics. Our focus was to try to clarify the underlying concepts, assess the level of evidence and clarify the issues still under debate. The concept implies the definition of an interdisciplinary process for a multidimensional assessment in order to produce a coordinated plan. The central notion is that the systematization of this multidimensionality and interdisciplinarity needs the establishment of dedicated process (meeting tools, clinical information system, etc.). Following dimensions should be covered: health, social, economic, environmental and psychological. Any assessment process that could lead to forgetting one of its dimensions cannot be viewed as a comprehensive gerontological assessment. The level of evidence is higher in hospital acute inpatient unit but it is still low in all other areas of health care but the scattered data in the literature argues for qualitative benefits (improved quality of care or quality of life). The questions that remain are numerous including the choice of strategy for initial evaluation (maximum versus minimum; from the outset by many professionals versus graduated based on the minimum initial evaluation), the choice of tool, the optimal location, the required intensity of monitoring and the ideal target population.

The value of geriatric assessments in predicting treatment tolerance and all-cause mortality in older patients with cancer

BACKGROUND

Awareness of the use of geriatric assessments for older patients with cancer is increasing. The aim of this review is to summarize all available evidence on the association between geriatric assessments and relevant oncologic outcomes.

METHOD

A systematic search was conducted in Medline and Embase of studies on geriatric assessment in oncology, focusing on the association between baseline assessment and outcome.

RESULTS

The literature search identified 2008 reports; 51 publications from 37 studies were selected for inclusion in the review. The quality of studies was heterogeneous and generally poor. A median of five geriatric conditions were assessed per study (interquartile range: 4-8). Little consistency was found in the results of the studies. Furthermore, different tools appear to be predictive depending on the outcome measure: frailty, nutritional status, and comorbidity assessed by the Cumulative Illness Rating Scale for Geriatrics were predictive for all-cause mortality; frailty was predictive for toxicity of chemotherapy; cognitive impairment and activities of daily living impairment were predictive for chemotherapy completion; and instrumental activities of daily living impairment was predictive for perioperative complications.

CONCLUSION

Although various geriatric conditions appear to be of some value in predicting outcome in elderly patients with cancer, the results are too inconsistent to guide treatment decisions. Further research is needed to elucidate the role of geriatric assessments in the oncologic decision-making process for these patients.

Use of geriatric assessment for older adults in the oncology setting: a systematic review

BACKGROUND

Geriatric assessment is a multidisciplinary diagnostic process that evaluates the older adult's medical, psychological, social, and functional capacity. No systematic review of the use of geriatric assessment in oncology has been conducted. The goals of this systematic review were: 1) to provide an overview of all geriatric assessment instruments used in the oncology setting; 2) to examine the feasibility and psychometric properties of those instruments; and 3) to systematically evaluate the effectiveness of geriatric assessment in predicting or modifying outcomes (including the impact on treatment decision making, toxicity of treatment, and mortality).

METHODS

We searched Medline, Embase, Psychinfo, Cinahl, and the Cochrane Library for articles published in English, French, Dutch, or German between January 1, 1996, and November 16, 2010, reporting on cross-sectional, longitudinal, interventional, or observational studies that assessed the feasibility or effectiveness of geriatric assessment instruments. The quality of articles was evaluated using relevant quality assessment frameworks.

RESULTS

We identified 83 articles that reported on 73 studies. The quality of most studies was poor to moderate. Eleven studies examined psychometric properties or diagnostic accuracy of the geriatric assessment instruments used. The assessment generally took 10-45 min. Geriatric assessment was most often completed to describe a patient's health and functional status. Specific domains of geriatric assessment were associated with treatment toxicity in 6 of 9 studies and with mortality in 8 of 16 studies. Of the four studies that examined the impact of geriatric assessment on the cancer treatment decision, two found that geriatric assessment impacted 40%-50% of treatment decisions.

CONCLUSION

Geriatric assessment in the oncology setting is feasible, and some domains are associated with adverse outcomes. However, there is limited evidence that geriatric assessment impacted treatment decision making. Further research examining the effectiveness of geriatric assessment on treatment decisions and outcomes is needed.

Cancer in the elderly in an equatorial area: French Guiana

Little information is available on the management of cancer in equatorial areas, and specifically the management of elderly cancer patients. We have retrospectively reviewed the clinical files of 71 patients older than 70 years with cancer who were treated in the Cayenne Hospital in French Guiana. The population is that of an equatorial country with the health organization of a European country. We found that oncogeriatric evaluation was feasible but is far from being routinely used. The selection of screening tools of frailty is likely to be useful in making decisions for these patients. However, specific problems are emerging: cultural mediation; low income; illegal immigrants; comorbidities; specific tropical diseases; and the incidence of HIV, human T-lymphotropic virus Type 1 and hepatitis infections. This led us to expand the study to the whole cancer patient population and to implement specific information in the database used for follow-up. These preliminary observations should be relevant for other countries.

Two sides of the medallion: poor treatment tolerance but better survival by standard chemotherapy in elderly patients with advanced-stage diffuse large B-cell lymphoma

BACKGROUND

We investigated treatment of unselected elderly patients with diffuse large B-cell lymphoma (DLBCL) and its subsequent impact on treatment tolerance and survival.

PATIENTS AND METHODS

Data from all 419 advanced-stage DLBCL patients, aged 75 or older and newly diagnosed between 1997 and 2004, were included from five regional population-based cancer registries in The Netherlands. Subsequent data on comorbidity, performance status, treatment, motives for adaptations or refraining from chemotherapy and toxic effects was collected from the medical records. Follow-up was completed until 1st January 2009.

RESULTS

Only 46% of patients received the standard therapy [aggressive chemotherapy with cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP)-like chemotherapy]. Motives for withholding chemotherapy were refusal by patient/family, poor performance status or estimated short life expectancy. Of all patients receiving CHOP-like chemotherapy, only 56% could complete at least six cycles. Grade 3 or 4 toxicity occurred in 67% of patients receiving standard therapy. The independent effect of therapy on survival remained after correction for the age-adjusted International Prognostic Index.

CONCLUSIONS

Standard therapy was applied less often in elderly patients with a subsequent independent negative impact on survival. Furthermore, high toxicity rate and the impossibility of the majority of patients to complete treatment were seen. This implies that better treatment strategies should be devised including a proper selection of senior patients for this aggressive chemotherapy.

Cancer surgery in the elderly

The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.

Study protocol of KLIMOP: a cohort study on the wellbeing of older cancer patients in Belgium and the Netherlands

Background

Cancer is mainly a disease of older patients. In older cancer patients, additional endpoints such as quality of survival and daily functioning might be considered equally relevant as overall or disease free survival. However, these factors have been understudied using prospective designs focussing on older cancer patients. Therefore, this study will focus on the impact of cancer, ageing, and their interaction on the long-term wellbeing of older cancer patients.

Methods/Design

This study is an observational cohort study. We aim to recruit 720 cancer patients above 70 years with a new diagnosis of breast, prostate, lung or gastrointestinal cancer and two control groups: one control group of 720 patients above 70 years without a previous diagnosis of cancer and one control group of 720 cancer patients between 50 - 69 years newly diagnosed with breast, prostate, lung or gastrointestinal cancer. Data collection will take place at inclusion, after six months, after one year and every subsequent year until death or end of the study. Data will be collected through personal interviews (consisting of socio-demographic information, general health information, a comprehensive geriatric assessment, quality of life, health locus of control and a loneliness scale), a handgrip test, assessment of medical records, two buccal swabs and a blood sample from cancer patients (at baseline). As an annex study, caregivers of the participants will be recruited as well. Data collection for caregivers will consist of a self-administered questionnaire examining depression, coping, and burden.

Discussion

This extensive data collection will increase insight on how wellbeing of older cancer patients is affected by cancer (diagnosis and treatment), ageing, and their interaction. Results may provide new insights, which might contribute to the improvement of care for older cancer patients.

[Geriatric assessment contribution to treatment decision-making in thoracic oncology]

BACKGROUND

Lung cancer is a frequently occurring disease among elderly people. The objective of this study was to search for a relationship between multimodal geriatric assessment and a decision-making in the treatment of patients with this condition.

METHODS

Forty-nine elderly patients (aged 70 years and over) diagnosed with a primary lung cancer underwent a geriatric assessment before decision for treatment was made in a multidisciplinary meeting. We described the impact of the geriatric assessment on the management decisions made.

RESULTS

Almost half of treatment (44.9%) decisions were modified by the geriatric assessment. For patients with so called "pre-frailty" according to Balducci's criteria, 60% of treatment decisions were modified by the results of geriatric assessment (use of only one chemotherapeutic drug, dose disease or best supportive care). For this group of patients, Folstein MMSE and IADL were predictive of change in decision-making, with the threshold estimated to be 26 points. Only the MMSE was significantly associated with the medical decision in multivariate analysis.

CONCLUSION

Geriatric assessment should be integrated into treatment decision-making for patients with primary lung cancer aged more than 70 years, particularly those where frailty is a concern. Folstein's MMSE was predictive in our study for changes in decision-making.

Examining five- and ten-year survival in older women with breast cancer using cancer-specific geriatric assessment

PURPOSE

To examine five- and ten-year survival based on cancer-specific geriatric assessment (C-SGA) in older women with early stage breast cancer.

METHODS

We evaluated 660 women ≥65-years old diagnosed with stage I-IIIA primary breast cancer and attending physician permission to contact in four geographic regions in the United States of America (USA). Data were collected over ten-years of follow-up from consenting women's medical records, telephone interviews, National Death Index and Social Security Death Index. C-SGA was described by four domains using six measures: socio-demographic (financial resources); clinical (comorbidity, obesity); function (physical function limitations); and psychosocial (general mental health, social support). Survival from all-cause and breast-cancer-specific mortality and receipt of guideline-recommended therapy was assessed for different groups of subjects with C-SGA domain deficits (cut-off ≥3 deficits).

RESULTS

The proportion of women with ≥3 C-SGA deficits surviving ten-years was consistently statistically significantly lower (all-cause 26% versus 46% and breast-cancer-specific 76% versus 89%, p≤0.04). The proportion significantly decreased as number of C-SGA deficits increased (linear trend p<0.0001). Receipt of guideline-recommended therapy decreased with age but not consistently by number of C-SGA deficits. The all-cause and breast-cancer-specific death rate at five- and ten-years was consistently approximately two times higher in women with ≥3 C-SGA deficits even when fully adjusted for confounding factors (HR(5-yrAllCauseFullyAdjusted)=1.87 [1.36-2.57], HR(10-yrAllCauseFullyAdjusted)=1.74 [1.35-2.15], HR(5-yrBreastCancerFullyAdjusted)=1.95 [1.18-3.20], HR(10-yrBreastCancerFullyAdjusted)=1.99 [1.21-3.28]).

CONCLUSION

Regardless of age and stage of disease, C-SGA predicts five- and ten-year all-cause and breast-cancer-specific survival in older women. Hence, C-SGA may provide an effective strategy to guide treatment decision-making and to identify risk factors for intervention.

Geriatric oncology: an overview of progresses and challenges

Thanks to the global improvement of health care and living conditions, the world population is aging. Already, in developed countries half of the cancers occur in patients aged 70 and older. In booming Asian nations, such as South Korea, the aging trend is particularly striking, and therefore geriatric oncology is rapidly coming at the foreground of oncology practice. As older patients have a very variable health status, the need for proper integration of an oncologic and a geriatric approach has become increasingly clear. The last two decades have seen the development of geriatric oncology programs and research, which we review here. An increasing amount of data is making clear that a geriatric assessment identifies many problems in older people with cancer, adds prognostic information, and might improve the outcomes of these patients. The near future will likely deliver the following: Operationalization of geriatric assessment into assessment and decision tools, as well as multidisciplinary interventions, in oncology; cooperation of aging and cancer research in the understanding of cancer biology, aging physiology, pharmacology of anticancer drugs; improved clinical study designs; development of geriatric oncology programs, and screening tools accessible to the private practitioner.

Detecting Disabilities in Older Patients With Cancer: Comparison Between Comprehensive Geriatric Assessment and Vulnerable Elders Survey-13

Purpose

Comprehensive geriatric assessment (CGA) is a multidimensional method used by geriatricians and oncologists to detect and evaluate multiple age-related problems and to plan and coordinate interventions. Because its main drawback is the time required, efforts have been made to evaluate screening instruments suitable for preliminarily assessing elderly patients. The main aim of this study was to establish the accuracy of the Vulnerable Elders Survey-13 (VES-13) in predicting the presence of abnormalities revealed by CGA.

Patients and Methods

Patients age ≥ 70 years with a histologically or cytologically confirmed diagnosis of a solid or hematologic tumor underwent both CGA and a VES-13 assessment, and the reliability and validity of VES-13 were analyzed.

Results

Fifty-three percent of the 419 elderly patients with cancer (mean age, 76.8 years) were vulnerable on VES-13; the rates of disabilities on CGA and activities of daily living (ADLs)/instrumental activities of daily living (IADLs) scales were 30% and 25%, respectively. The sensitivity and specificity of VES-13 were 87% and 62%, respectively, versus CGA and 90% and 70%, respectively, versus ADL/IADL scales.

Conclusions

On the basis of our data, VES-13 is highly predictive of impaired functional status and can thus be considered a useful preliminary means of assessing older patients with cancer before undertaking a full CGA.

Geriatric assessment in oncology practice

There is no standard tool for assessing the "functional age" of an older adult with cancer, although it is widely recognized that chronological age does not capture the heterogeneous physiological and functional status of older adults. Integrating a "geriatric assessment" into oncology research and clinical practice would help fill this void. Geriatric assessment covers factors that predict morbidity and mortality in older adults, including functional status, comorbidity, cognition, psychological state, nutritional status, and social support. This assessment provides a broader overall understanding of individual characteristics that affect life expectancy. In addition, this assessment identifies areas of vulnerability in older adults for which further evaluation or intervention is indicated. This article will address the utility of a geriatric assessment in oncology practice, review data that attest to the benefits of the assessment, and issue a call for further research into how this assessment can be integrated into oncology care. Doing so will help develop targeted interventions and optimize cancer outcomes in this rapidly growing population.

Geriatric assessment in oncology practice

There is no standard tool for assessing the "functional age" of an older adult with cancer, although it is widely recognized that chronological age does not capture the heterogeneous physiological and functional status of older adults. Integrating a "geriatric assessment" into oncology research and clinical practice would help fill this void. Geriatric assessment covers factors that predict morbidity and mortality in older adults, including functional status, comorbidity, cognition, psychological state, nutritional status, and social support. This assessment provides a broader overall understanding of individual characteristics that affect life expectancy. In addition, this assessment identifies areas of vulnerability in older adults for which further evaluation or intervention is indicated. This article will address the utility of a geriatric assessment in oncology practice, review data that attest to the benefits of the assessment, and issue a call for further research into how this assessment can be integrated into oncology care. Doing so will help develop targeted interventions and optimize cancer outcomes in this rapidly growing population.

Older breast cancer survivors: geriatric assessment domains are associated with poor tolerance of treatment adverse effects and predict mortality over 7 years of follow-up

PURPOSE

To evaluate geriatric assessment (GA) domains in relation to clinically important outcomes in older breast cancer survivors.

METHODS

Six hundred sixty women diagnosed with primary breast cancer in four US geographic regions (Los Angeles, CA; Minnesota; North Carolina; and Rhode Island) were selected with disease stage I to IIIA, age >or= 65 years at date of diagnosis, and permission from attending physician to contact. Data were collected over 7 years of follow-up from consenting patients' medical records, telephone interviews, physician questionnaires, and the National Death Index. Outcomes included self-reported treatment tolerance and all-cause mortality. Four GA domains were described by six individual measures, as follows: sociodemographic by adequate finances; clinical by Charlson comorbidity index (CCI) and body mass index; function by number of physical function limitations; and psychosocial by the five-item Mental Health Index (MHI5) and Medical Outcomes Study Social Support Survey (MOS-SSS). Associations were evaluated using t tests, chi(2) tests, and regression analyses.

RESULTS

In multivariable regression including age and stage, three measures from two domains (clinical and psychosocial) were associated with poor treatment tolerance; these were CCI >or= 1 (odds ratio [OR] = 2.49; 95% CI, 1.18 to 5.25), MHI5 score less than 80 (OR = 2.36; 95% CI, 1.15 to 4.86), and MOS-SSS score less than 80 (OR = 3.32; 95% CI, 1.44 to 7.66). Four measures representing all four GA domains predicted mortality; these were inadequate finances (hazard ratio [HR] = 1.89; 95% CI, 1.24 to 2.88; CCI >or= 1 (HR = 1.38; 95% CI, 1.01 to 1.88), functional limitation (HR = 1.40; 95% CI, 1.01 to 1.93), and MHI5 score less than 80 (HR = 1.34; 95% CI, 1.01 to 1.85). In addition, the proportion of women with these outcomes incrementally increased as the number of GA deficits increased.

CONCLUSION

This study provides longitudinal evidence that GA domains are associated with poor treatment tolerance and predict mortality at 7 years of follow-up, independent of age and stage of disease.

Physiological aging in older adults with cancer: implications for treatment decision making and toxicity management

Because the risk of cancer increases with age, the growth of the aging population will lead to a larger number of older adults with cancer. Standard cancer treatments can be safe and effective in older adults and result in improved survival and enhanced quality of life. Because physiological decline varies among older adults, cancer treatment requires an individualized approach. Consideration of physiological age, rather than chronological age alone, is required to guide treatment decision making and prevent and manage treatment toxicities and other complications. This article examines the impact of physiological aging on treatment decision making and toxicity management in older adults with cancer.

Comorbidity, disability and geriatric syndromes in elderly breast cancer survivors. Results of a single-center experience

Advancing age is a major risk factor for breast cancer. Long-term follow-up is recommended after diagnosis and treatment of early breast cancer. With older age, the risk of comorbid conditions and functional impairment increases. A useful tool in the management and follow-up of these elderly patients could be a comprehensive geriatric assessment (CGA).

PURPOSE

A descriptive, transversal study was carried out of the prevalence of other comorbidities and of the functional impairment in elderly patients on follow-up after curative treatment of early breast cancer.

PATIENTS

Women aged> or =70 at diagnosis; early breast cancer treated surgically. No disease recurrence allowed.

METHODS

CGA was conducted in an oncology unit using screening instruments (activities of daily living [ADL]; instrumental activities of daily living [IADL]; body mass index [BMI]; geriatric depression scale [GDS]). Cognitive status was reported by the patient. Comorbidity was classified using the Charlson score.

RESULTS

From January 2005 to June 2006 91 patients were seen. Mean age at surgery: 76 (70-92). Mean age at CGA: 80 (71-95). Aged population (almost 25% were more than 84 at the time of CGA). Median follow-up: 5 years (range 1-12). Good performance status (PS) in most (only 9% PS 2). Eighty-three percent were fully independent for ADL and 71% for IADL. IADL most affected was the ability to drive/use public transport. Twenty-eight percent had geriatric syndromes and 23% were classified as "frail". Increased age was associated with worsening PS (p=0.0001) and worsening function (ADL p<0.0001 and IADL p<0.0001). The study is remarkable for the high comorbidity index found in the elderly survivors. Median Charlson score was 2 (1-6). More than 75% of the series had a score >/=4. Cardiovascular disease (hypertension) was the most prevalent comorbid condition. As an effect of this, the majority of patients were polymedicated (75% took more than six drugs). Comorbidity was independent of functionality and age.

CONCLUSIONS

Older patients with early breast cancer on follow-up have a high prevalence of comorbidity. In our series, function and independence were maintained. A selection bias cannot be excluded, as the fitter patients are those who usually continue with the follow-up, while those frail patients who do not continue because of their functional impairment are usually lost.

Participation of older newly-diagnosed cancer patients in an observational prospective pilot study: an example of recruitment and retention

Background

There have been few prospective observational studies which recruited older newly-diagnosed cancer patients, and of these only some have reported information on the number needed to screen to recruit their study sample, and the number and reasons for refusal and drop-out. This paper reports on strategies to recruit older newly-diagnosed cancer patients prior to treatment into an observational prospective pilot study and to retain them during a six-month period.

Methods

Medical charts of all patients in the Segal Cancer Centre aged 65 and over were screened and evaluated for inclusion. Several strategies to facilitate recruitment and retention were implemented. Reasons for exclusion, refusal and loss to follow-up were recorded. Descriptive statistics were used to report the reasons for refusal and loss to follow-up. A non-response analysis using chi-square tests and t-tests was conducted to compare respondents to those who refused to participate and to compare those who completed the study to those who were lost to follow-up. A feedback form with open-ended questions was administered following the last interview to obtain patient's opinions on the length of the interviews and conduct of this pilot study.

Results

3060 medical charts were screened and 156 eligible patients were identified. Of these 112 patients participated for a response rate of 72%. Reasons for refusal were: feeling too anxious (40%), not interested (25%), no time (12.5%), too sick (5%) or too healthy (5%) or other reasons (5%). Ninety-one patients participated in the six-month follow-up (retention 81.3%), seven patients refused follow-up (6.2%) and fourteen patients died (12.5%) during the course of the study. The median time to conduct the baseline interview was 45 minutes and 57% of baseline interviews were conducted at home. Most patients enjoyed participation and only five felt that the interviews were too long.

Conclusion

It was feasible to recruit newly-diagnosed cancer patients prior to treatment although it required considerable time and effort. Once patients were included, the retention rate was high despite the fact that most were undergoing active cancer treatment.

Can we better manage Unfit older cancer patients?

The term Unfit refers to older cancer patients not amenable with standard treatment and needing therefore a modified or attenuated treatment or also not deserving an active therapeutic approach. To determine whether an old patient is Unfit a Multidimensional Geriatric Evaluation is needed, but to spare time, shortened tools of evaluation are now in a phase of development. Most of the available data on older cancer patients derive from clinical prospective studies carried out in a selected population, with the exclusion then of Unfit patients. The challenge of this special issue of CTR is that of providing a clinically useful information on the basis of the results of the available studies and expert opinion in the main tumor types.

Frail old patients as a target population for cancer trials

The recent distinction between co-morbidity and multi-morbidity well stresses the difficulty of managing old patients with cancer whose complexity is not captured by a list of diagnoses or biological burden alone. The most adequate answer found by oncologists and geriatricians was to work together for better evaluating the physiological age and body reserve of the patient. The gold standard tool to assess old patient with cancer is named Comprehensive Geriatric Assessment. Its systematic application needs geriatric competences and time. In this context, a great number of cancer patients are considered as "frail" because they have reduced available physiological reserves. They might not withstand stress when challenged. Oncologists and geriatricians have imagined an innovative process to change the screening procedure of these patients, determine the prognosis, adapt the treatment strategy, to increase the patient's survival and his/her quality of life. The internet website "www.clinicaltrials.com" only lists 8 studies focused on frail elders with cancer. Six of them are focused on specific cancers or specific treatments, one was applied to all kind of cancers and the last was an opinion overview from oncologists and geriatricians. The selection criteria of frail patients are very diverse and probably include cancer patients who are not comparable. It is now time to try to identify new practical, reliable and accurate tools to facilitate the inclusion of the same kind of patients suffering from the same kind of cancer to be able to give more appropriate care and at the same time to constitute a valuable data base. Existing tools are reviewed and analyzed.

Prediction of falls in older adults with cancer: a preliminary study

PURPOSE/OBJECTIVES

To determine the extent to which falls occur in older adult patients with cancer; to identify how falls relate to depression, age, functional status, and cognition; and to develop a model for predicting falls.

DESIGN

Descriptive, prospective, quantitative.

SETTING

Patients in the Senior Adult Oncology Program at the H. Lee Moffitt Cancer Center and Research Institute.

SAMPLE

165 patients aged 70 years or older with any diagnosis of cancer, treatment type, and stage.

METHODS

Data were collected during a one-time interview using a comprehensive geriatric assessment consisting of the Instrumental Activities of Daily Living (IADL) Scale, Activities of Daily Living (ADL) Scale, Geriatric Depression Scale, Mini-Mental State Examination, and a fall assessment.

MAIN RESEARCH VARIABLES

Falls, functional status, depression, cognition, age, and gender.

FINDINGS

IADL scores were found to be a predictor of falls while controlling for age and ADL status. An IADL score of 22 predicts a 21% risk of a fall. Fall risk increases to 81% at an IADL score of 9.

CONCLUSIONS

IADL score is a predictor of falls in this older adult population with cancer. ADL scores are not a predictor of falls when IADL is included in the model.

IMPLICATIONS FOR NURSING

Nurses must play a vital role in conducting fall screening and risk assessments for older adults with cancer.

A practical approach to geriatric assessment in oncology

More than half of new cancers are diagnosed in elderly patients, but data from randomized clinical trials do not represent the elderly population. Comprehensive geriatric assessment (CGA) can contribute valuable information to oncologists for risk stratification of elderly cancer patients. Functional impairments, frailty markers, cognitive impairments, and physical disabilities increase the risk for adverse outcomes during cancer treatment. Evidence is accumulating that selected elderly cancer patients benefit from CGA and geriatric interventions. However, perceived barriers to CGA include time, familiarity, cost, and lack of a well-defined procedure to interpret and apply the information. We present a model for rapid selection of elderly who would benefit from CGA using screening tools such as the Vulnerable Elders-13 Survey. We also define important geriatric functional risk factors, including mobility limitation, frailty, and dementia, and demonstrate how brief screening tests can make use of data realistically available to clinical oncologists to determine a stage of aging. Summary tables and a decision tree demonstrate how these data can be compiled to determine the risk for toxicities and to anticipate ancillary support needs.

Comprehensive geriatric assessment for older patients with cancer

PURPOSE

During the last decade, oncologists and geriatricians have begun to work together to integrate the principles of geriatrics into oncology care. The increasing use of a comprehensive geriatric assessment (CGA) is one example of this effort. A CGA includes an evaluation of an older individual's functional status, comorbid medical conditions, cognition, nutritional status, psychological state, and social support; and a review of the patient's medications. This article discusses recent advances on the use of a CGA in older patients with cancer.

METHODS

In this article, we provide an update on the studies that address the domains of a geriatric assessment applied to the oncology patient, review the results of the first studies evaluating the use of a CGA in developing interventions to improve the care of older adults with cancer, and discuss future research directions.

RESULTS

The evidence from recent studies demonstrates that a CGA can predict morbidity and mortality in older patients with cancer. Accumulating data show the benefits of incorporating a CGA in the evaluation of older patients with cancer. Prospective trials evaluating the utility of a CGA to guide interventions to improve the quality of cancer care in older adults are justified.

CONCLUSION

Growing evidence demonstrates that the variables examined in a CGA can predict morbidity and mortality in older patients with cancer, and uncover problems relevant to cancer care that would otherwise go unrecognized.