Clinical judgment versus geriatric assessment for frailty in older patients with cancer

Differences in preoperative frailty assessment of surgical candidates by sex, age, and race

Introduction

Surgical decision-making often relies on a surgeon's subjective assessment of a patient's frailty status to undergo surgery. Certain patient demographics can influence subjective judgment when compared to validated objective assessments. In this study, we explore the relationship between subjective and objective frailty assessments according to patient age, sex, and race.

Methods

Patients were prospectively enrolled in urology, general surgery, and surgical oncology clinics. Using a visual analog scale (0-100), operating surgeons independently rated the patient's frailty status. Objective frailty was classified using the Fried Frailty Criteria ranging from 0 to 5. Multivariable proportional odds models were conducted to examine the potential association of factors with objective frailty, according to surgeon frailty rating. Subgroup analysis according to patient sex, race, and age was also performed.

Results

Seven male surgeons assessed 203 patients preoperatively with a median age of 65. A majority of patients were male (61 %), white (67 %), and 60 % and 40 % underwent urologic and general surgery/surgical oncology procedures respectively. Increased subjective surgeon rating (OR 1.69; p < 0.001) was significantly associated with the presence of objective frailty. On subgroup analysis, a higher magnitude of such association was observed more in females (OR 1.86; p = 0.0007), non-white (OR 1.84; p = 0.0019), and older (>60, OR 1.75; p = 0.0001) patients, compared to male (OR 1.45; p = 0.0243), non-white (OR 1.48; p = 0.0109) and patients under 60 (OR 1.47; p = 0.0823).

Conclusion

The surgeon's subjective assessment of frailty demonstrated tendencies to rate older, female, and non-white patients as frail; however, differences in patient sex, age, and race were not statistically significant.

New treatment opportunities for older patients with acute myeloid leukemia and the increasing importance of frailty assessment - An oncogeriatric perspective

With the introduction of targeted chemotherapy drugs, a new age of treatment for acute myeloid leukemia (AML) has begun. The promotion of the azacitidine+venetoclax combination regimen to first line of treatment in patients deemed ineligible for intensive chemotherapy marks the first of many novel combination regimens becoming part of national treatment guidelines. We review recent phase II and III clinical trials and conclude that these novel regimens offer significant increases in response rates, remission rates, and overall survival. The incidence of adverse events, the accrued time toxicity, and the healthcare costs, however, are increasing as well. Compared with clinical trials, older patients in the real world frequently present with an inferior baseline health status, which is associated with an increased risk of experiencing side effects. The key to reaping the maximum benefit of the new agents and their combination regimens therefore lies in sufficient attention being given to a patients' preexisting comorbidities, potential frailty, and quality of life. A systematic collaboration between hemato-oncologists and geriatricians can be a potent first step towards addressing the increased treatment intensity patients with AML experience under the novel regimens. In this narrative review article we provide an overview of recent and ongoing clinical trials, highlight encountered adverse events, discuss frailty assessment options, and outline an oncogeriatic care path for older patients with AML.

Development of a Machine Learning-Based Model to Predict Timed-Up-and-Go Test in Older Adults

INTRODUCTION

The measurement of physical frailty in elderly patients with orthopedic impairments remains a challenge due to its subjectivity, unreliability, time-consuming nature, and limited applicability to uninjured individuals. Our study aims to address this gap by developing objective, multifactorial machine models that do not rely on mobility data and subsequently validating their predictive capacity concerning the Timed-up-and-Go test (TUG test) in orthogeriatric patients.

METHODS

We utilized 67 multifactorial non-mobility parameters in a pre-processing phase, employing six feature selection algorithms. Subsequently, these parameters were used to train four distinct machine learning algorithms, including a generalized linear model, a support vector machine, a random forest algorithm, and an extreme gradient boost algorithm. The primary goal was to predict the time required for the TUG test without relying on mobility data.

RESULTS

The random forest algorithm yielded the most accurate estimations of the TUG test time. The best-performing algorithm demonstrated a mean absolute error of 2.7 s, while the worst-performing algorithm exhibited an error of 7.8 s. The methodology used for variable selection appeared to exert minimal influence on the overall performance. It is essential to highlight that all the employed algorithms tended to overestimate the time for quick patients and underestimate it for slower patients.

CONCLUSION

Our findings demonstrate the feasibility of predicting the TUG test time using a machine learning model that does not depend on mobility data. This establishes a basis for identifying patients at risk automatically and objectively assessing the physical capacity of currently immobilized patients. Such advancements could significantly contribute to enhancing patient care and treatment planning in orthogeriatric settings.

Chemotherapy-Related Toxic Effects and Quality of Life and Physical Functioning in Older Patients

Importance

Although older patients are at increased risk of developing grade 3 or higher chemotherapy-related toxic effects, no studies, to our knowledge, have focused on the association between toxic effects and quality of life (QOL) and physical functioning.

Objective

To investigate the association between grade 3 or higher chemotherapy-related toxic effects and QOL and physical functioning over time in older patients.

Design, Setting, and Participants

In this prospective, multicenter cohort study, patients aged 70 years or older who were scheduled to receive chemotherapy with curative or palliative intent and a geriatric assessment were included. Patients were treated with chemotherapy between December 2015 and December 2021. Quality of life and physical functioning were analyzed at baseline and after 6 months and 12 months.

Exposures

Common Terminology Criteria for Adverse Events grade 3 or higher chemotherapy-related toxic effects.

Main Outcomes and Measures

The main outcome was a composite end point, defined as a decline in QOL and/or physical functioning or mortality at 6 months and 12 months after chemotherapy initiation. Associations between toxic effects and the composite end point were analyzed with multivariable logistic regression models.

Results

Of the 276 patients, the median age was 74 years (IQR, 72-77 years), 177 (64%) were male, 196 (71%) received chemotherapy with curative intent, and 157 (57%) had gastrointestinal cancers. Among the total patients, 145 (53%) had deficits in 2 or more of the 4 domains of the geriatric assessment and were classified as frail. Grade 3 or higher toxic effects were observed in 94 patients (65%) with frailty and 66 (50%) of those without frailty (P = .01). Decline in QOL and/or physical functioning or death was observed in 76% of patients with frailty and in 64% to 68% of those without frailty. Among patients with frailty, grade 3 or higher toxic effects were associated with the composite end point at 6 months (odds ratio [OR], 2.62; 95% CI, 1.14-6.05) but not at 12 months (OR, 1.09; 95% CI, 0.45-2.64) and were associated with mortality at 12 months (OR, 3.54; 95% CI, 1.50-8.33). Toxic effects were not associated with the composite end point in patients without frailty (6 months: OR, 0.76; 95% CI, 0.36-1.64; 12 months: OR, 1.06; 95% CI, 0.46-2.43).

Conclusions and Relevance

In this prospective cohort study of 276 patients aged 70 or older who were treated with chemotherapy, patients with frailty had more grade 3 or higher toxic effects than those without frailty, and the occurrence of toxic effects was associated with a decline in QOL and/or physical functioning or mortality after 1 year. Toxic effects were not associated with poor outcomes in patients without frailty. Pretreatment frailty screening and individualized treatment adaptions could prevent a treatment-related decline of remaining health.

Clinical decision-making in older patients with cancer: a cross-sectional single-centre study to assess the impact of clinical judgement and patient preferences

OBJECTIVE

The heterogeneity in the population of older patients with cancer makes clinical decision-making difficult. We investigated the agreement between the G8 score and clinical judgment in frailty assessments, determined the impact of a life-expectancy calculator, and explored patient and caregiver preferences towards the treatment goal.

METHODS

Patients aged ≥75 years in need of new oncological treatment were prospectively enrolled between June 2020 and February 2021. Frailty was estimated by the oncologist and caregiver and compared to the G8 estimation. We examined whether the oncologist changed the fit/frail estimation based on life expectancy calculated using the ePrognosis tool. The main treatment goals, either longevity or quality of life (QoL), from the patient's and caregiver's perspective were noted and compared.

RESULTS

Forty-nine patients were included in the analysis. Comparison of the oncologist's and the caregiver's frailty estimation with the G8 assessment showed agreement and a Kappa coefficient of 58.3% (0.231) and 60% (0.255), respectively. The ePrognosis score and the odds of change in the frailty estimation by the oncologist showed no correlation. Regarding preferences, 28 (57.1%) and 17 (34.7%) patients and eighteen (47.3%) and seventeen (44.7%) caregivers chose longevity and QoL, respectively. The observed agreement and Kappa coefficient were 78.8% and 0.578.

CONCLUSION

Compared to the G8 assessment, frailty was underestimated by both oncologists and caregivers. Most of the patients chose longevity over QoL, and the preferences between the patient and the caregiver matched in the majority of cases.

The Geriatric G8 Score Is Associated with Survival Outcomes in Older Patients with Advanced Prostate Cancer in the ADHERE Prospective Study of the Meet-URO Network

Introduction: Androgen receptor pathway inhibitors (ARPIs) have been increasingly offered to older patients with prostate cancer (PC). However, prognostic factors relevant to their outcome with ARPIs are still little investigated. Methods and Materials: The Meet-URO network ADHERE was a prospective multicentre observational cohort study evaluating and monitoring adherence to ARPIs metastatic castrate-resistant PC (mCRPC) patients aged ≥70. Cox regression univariable and multivariable analyses for radiographic progression-free (rPFS) and overall survival (OS) were performed. Unsupervised median values and literature-based thresholds where available were used as cut-offs for quantitative variables. Results: Overall, 234 patients were enrolled with a median age of 78 years (73-82); 86 were treated with abiraterone (ABI) and 148 with enzalutamide (ENZ). With a median follow-up of 15.4 months (mo.), the median rPFS was 26.0 mo. (95% CI, 22.8-29.3) and OS 48.8 mo. (95% CI, 36.8-60.8). At the MVA, independent prognostic factors for both worse rPFS and OS were Geriatric G8 assessment ≤ 14 (p < 0.001 and p = 0.004) and PSA decline ≥50% (p < 0.001 for both); time to castration resistance ≥ 31 mo. and setting of treatment (i.e., post-ABI/ENZ) for rPFS only (p < 0.001 and p = 0.01, respectively); age ≥78 years for OS only (p = 0.008). Conclusions: Baseline G8 screening is recommended for mCRPC patients aged ≥70 to optimise ARPIs in vulnerable individuals, including early introduction of palliative care.

The Clinical Utility of Systemic Immune-Inflammation Index Supporting Charlson Comorbidity Index and CAPRA-S Score in Determining Survival after Radical Prostatectomy-A Single Centre Study

The selection of candidates for the curative treatment of PCa requires a careful assessment of life expectancy. Recently, blood-count inflammatory markers have been introduced as prognosticators of oncological and non-oncological outcomes in different settings. This retrospective, monocentric study included 421 patients treated with radical prostatectomy (RP) for nonmetastatic PCa and aimed at determining the utility of a preoperative SII (neutrophil count × platelet count/lymphocyte count) in predicting survival after RP. Patients with high SIIs (≥900) presented significantly shorter survival (p = 0.02) and high SIIs constituted an independent predictor of overall survival [HR 2.54 (95%CI 1.24−5.21); p = 0.01] when adjusted for high (≥6) age-adjusted CCI (ACCI) [HR 2.75 (95%CI 1.27−5.95); p = 0.01] and high (≥6) CAPRA-S [HR 2.65 (95%CI 1.32−5.31); p = 0.006]. Patients with high scores (ACCI and/or CAPRA-S) and high SIIs were at the highest risk of death (p < 0.0001) with approximately a one-year survival loss during the first seven years after surgery. In subgroup of high CAPRA-S (≥6), patients with high ACCIs and high SIIs were at the highest risk of death (p <0.0001). Our study introduces the SII as a straightforward marker of mortality after RP that can be helpful in pre- and postoperative decision-making.

International Survey on Frailty Assessment in Patients with Cancer

Background

Frailty negatively affects the outcomes of patients with cancer, and its assessment might vary widely in the real world. The objective of this study was to explore awareness and use of frailty screening tools among the ONCOassist healthcare professionals (HCPs) users.

Materials and Methods

We sent 2 emails with a cross-sectional 15-item survey in a 3-week interval between April and May 2021. Differences in the awareness and use of tools according to respondents’ continents, country income, and job types were investigated.

Results

Seven hundred thirty-seven HCPs from 91 countries (81% physicians, 13% nurses, and 5% other HCPs) completed the survey. Three hundred and eighty-five (52%) reported assessing all or the majority of their patients; 518 (70%) at baseline and before starting a new treatment. Three hundred and four (43%) HCPs were aware of performance status (PS) scores only, 309 (42%) age/frailty/comorbidity (AFC) screening, and 102 (14%) chemotoxicity predictive tools. Five hundred and thirty-seven (73%) reported using tools; 423 (57%) just PS, 237 (32%) AFC, and 60 (8%) chemotoxicity ones. Reasons for tools non-use (485 responders) were awareness (70%), time constraints (28%), and uselessness (2%). There were significant differences in awareness and use of screening tools among different continents, country income, job types, and medical specialties (P < .001 for all comparisons).

Conclusion

Among selected oncology HCPs, there is still a worldwide lack of knowledge and usage of frailty screening tools, which may differ according to their geography, country income, and education. Targeted initiatives to raise awareness and education are needed to implement frailty assessment in managing patients with cancer.

The Prognostic Accuracy of Clinical Judgment Versus a Validated Frailty Screening Instrument in Older Patients at the Emergency Department: Findings of the AmsterGEM Study

STUDY OBJECTIVE

To compare the prognostic accuracy of clinical judgment for frailty in older patients at the emergency department with a validated screening instrument and patient-perceived frailty.

METHODS

A prospective cohort study in patients 70 years of age and older in 2 Dutch EDs with a follow-up of 3 months. A dichotomous question was asked to the physician and patient: "Do you consider the patient / yourself to be frail?" The Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) was used as a validated screening instrument. The primary composite outcome consisted of either functional decline, institutionalization, or mortality.

RESULTS

A total of 736 patients were included. The physician identified 59% as frail, compared with 49% by ISAR-HP and 43% by patients themselves. The level of agreement was fair (Fleiss Kappa, 0.31). After 3 months, 31% of the patients experienced at least 1 adverse health outcome. The sensitivity was 79% for the physician, 72% for ISAR-HP, 61% for the patient, and 48% for all 3 combined. The specificity was 50% for the physician, 63% for ISAR-HP, 66% for the patient, and 85% for all 3 positive. The highest positive likelihood ratio was 3.03 (physician, ISAR-HP, patient combined), and the lowest negative likelihood ratio was 0.42 (physician). The areas under the receiver operating curves were all poor: 0.68 at best for ISAR-HP.

CONCLUSION

Clinical judgment for frailty showed fair agreement with a validated screening instrument and patient-perceived frailty. All 3 instruments have poor prognostic accuracy, which does not improve when combined. These findings illustrate the limited prognostic value of clinical judgment as a frailty screener in older patients at the ED.

Thoracic surgery with geriatric assessment and collaboration can prepare frail older adults for lung cancer surgery

BACKGROUND AND OBJECTIVES

We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients.

METHODS

Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA > 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 < FI-CGA < 0.4. A qualitative analysis of geriatric interventions was performed.

RESULTS

Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18).

CONCLUSION

Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.

International efforts in geriatric radiation oncology

INTRODUCTION

Geriatric assessment (GA) has been recommended to form part of treatment decision making for older adults with cancer. However despite consensus guidelines from various organizations, GA does not appear to be a part of routine practice in radiation oncology. The aim of the current study was to explore the implementation of GA in radiation oncology.

MATERIALS AND METHODS

This anonymous international survey investigated current use of GA in patients presenting for radiation therapy aged 65 years and over, in accordance with Checklist for Reporting Results of Internet E-Surveys (CHERRIES) guidelines. The survey was designed, using Qualitrics™, an online survey tool. It was distributed via SIOG, social media and radiation oncology professional organizations. Survey responses were analyzed using simple descriptive statistics. An additional analysis by creating a dichotomous variable based on awareness of major clinical practice guidelines and current use of GA.

RESULTS

Among 158 respondents, there was relatively low awareness of GA guidelines and low uptake of validated tools and processes. A minority of participants, only 16%, stated that they had a specialized geriatric oncology program in their institution. Approximately a third (34%) of respondents were unaware of any GA clinical practice guidelines. With regard to what way participants assess older patients differently to younger patients, 16% reported formally using specific validated tools, whereas 73% reported an informal assessment based on their own judgment, with 5% reporting no difference between younger and older patients. Regarding the use of validated screening tools for geriatric impairments, over half reported using none (57%). Regarding GA implementation, the main barriers highlighted included a lack of clinical/support staff, a lack of training, knowledge, understanding or experience about GA and a lack of time.

DISCUSSION

Relatively low awareness of guidelines and low uptake of formal GA tools and processes were found. The integration of GA principles into radiation oncology appears to be ad hoc and very much in its infancy. There is a clear need for increased interdisciplinary education and collaboration between the disciplines of radiation oncology and geriatric medicine.

Predictive Value of Geriatric Oncology Screening and Geriatric Assessment in Older Patients with Solid Cancers: Protocol for a Danish prospective cohort study (PROGNOSIS-G8)

INTRODUCTION

Older patients with cancer constitute a heterogeneous group with varying degrees of frailty; therefore, geriatric assessment with initial geriatric oncology screening is recommended. The Geriatric 8 (G8) and the modified Geriatric 8 (mG8) are promising screening tools with high accuracy and an association with survival. However, evidence is sparse regarding patient-centered outcomes. This protocol describes a study, which aims to address the predictive and prognostic value of the G8 and mG8, with quality of life (QoL) as the primary outcome.

MATERIALS AND METHODS

In this single-center prospective cohort study, patients, age ≥70 years with solid malignancies, will be screened with the G8 and mG8 prior to receiving 1st line antineoplastic treatment. Patients will contribute medical record data including; cancer type, Charlson comorbidity index score, performance status, and treatment intent, type, and dosage, at baseline. Patients will complete QoL questionnaires (EORTC QLQ-C30 and ELD-14) at baseline, 3, 6, 9, and 12-months follow-up. Two functional measurements (the 30-s chair stand test and the handgrip strength test) will be conducted at baseline to assess the added predictive and prognostic value. At 12 months follow-up, initially administered treatment and treatment adherence will be recorded and assessed with generalized linear models, while overall survival and cancer-specific survival will be assessed using survival analysis models with time-varying covariates. The relationship between frailty (G8 ≤ 14, mG8 ≥ 6) and QoL within 12 months will be examined using mixed regression models.

DISCUSSION

Geriatric oncology screening may identify a subgroup of older patients with frailty, at risk of experiencing diminishing QoL and poor treatment adherence. With the proposed screening program, patients who require treatment modification and additional support to maintain their QoL may be identified. It is our hope, that these insights may facilitate the formation of national guidelines for the treatment of older patients with cancer. Registration:NCT04644874.

[Why and how to assess older people with cancer?]

The older population accounts for almost 60% of new cancers. Their management is a public health problem and is complex. It raises different questions: Is the patient's prognosis linked to cancer or another pathology? The heterogeneity of this population emphasises the importance of the overall condition assessment, in particular to avoid over-treatment (or under-treatment), and to be able to identify frail or vulnerable elderly patients who are at risk of having more treatment toxicities. Through this article, we will recall the importance of geriatric in-depth evaluation (EGA) by detailing the different factors that impact the therapeutic decision, tolerance to treatments… This EGA is however time-consuming and not all patients can be evaluated. In order to identify the subjects covered by this EGA, screening scales have been developed. Finally, we will develop the place of research in oncogeriatric management.