Comprehensive geriatric assessment in older patients with cancer: an external validation of the multidimensional prognostic index in a French prospective cohort study

How comprehensive is our comprehensive geriatric assessment in clinical practice? An Irish perspective

PURPOSE

Comprehensive geriatric assessment (CGA) is the cornerstone of high-quality care for older adults. There is no current gold standard to guide what should be included as the baseline measure for CGAs. We examined what metrics are being captured in CGA baseline assessments completed by community based integrated care teams in Ireland.

METHODS

CGA's care pathways in Ireland are usually initiated with a written document that establish patients baseline in various assessment areas. These documents were the focus of this study. We completed a cross-sectional study of the components captured in CGA baseline assessments completed in a community setting. We contacted operational leads in each of the community health organisations in Ireland and requested a copy of their current initial baseline screening document for CGA.

RESULTS

We reviewed 16 individual CGA baseline documents for analysis in this study. Common assessment areas in all documents included frailty (with the Rockwood Clinical frailty scale used in 94%, n = 15), cognition (4AT-56% of CGAs, MMSE-25%, MOCA-25%, AMTS-19%, AD8-19%, Addenbrookes-13%, 6CIT-13%, mini cog-6%), mobility (100%, n = 16), falls (100%, n = 16), continence (100% n = 16), nutrition (100% n = 16). Mood (94%, n = 15), pain (44%, n = 7), bone health (63%, n = 10), sleep (62%, n = 10) and skin integrity (56%, n = 9). Formal functional assessment was completed in 94% (n = 15) of CGAs with the Barthel index being the tool most used 81% (n = 13). Half of the CGAs included a section describing carer strain (50%, n = 8). The majority of CGAs included a patient centred question which was some variation of 'what matters most to me' (75% n = 11). 87.5% of assessments included a care plan summary (n = 14).

CONCLUSIONS

This report highlights that the core tenets of CGA are being assessed across different community based initial CGA screening instruments. There was significant variability in the discussion of challenging topics such as carer strain and social well-being. Our results should prompt a discussion about whether a minimum dataset should be developed for inclusion in nationwide initial baseline CGA document, aiming to improve standardisation of assessments, which will impact areas highlighted for intervention and ultimately guide population health policy.

Comprehensive geriatric assessment to predict adverse events in elderly patients undergoing posterior lumbar fusion surgery

PURPOSE

Although comprehensive geriatric assessment (CGA) has been used widely, its impact on adverse events in elderly patients has not been fully examined. The present study aimed to investigate the relationships between subcomponents of CGA and adverse events (AEs) in elderly patients undergoing posterior lumbar fusion surgery.

METHODS

A total of 242 eligible elderly patients enrolled. Our CGA included activities of daily living, instrumental activities of daily living, nutritional status, cardiac function, pulmonary function, renal function, frailty, cognition, anxiety, depression, delirium, chronic pain score, comorbidity and polypharmacy. Comprehensive complication index was used to summarize postoperative complications and its severity. Logistic regression was performed to determine the relationships between subcomponents of a CGA and postoperative AEs.

RESULTS

Present study found that female were more vulnerable to have AEs. Postoperative major AEs were associated with delirium (odds ratio (OR): 4.302, 95% confidence interval (CI) 1.720-10.761, p = 0.002), nutritional status (OR: 3.030, 95%CI 1.218-7.541, p = 0.017), cognitive impairment (OR: 4.122, 95%CI 1.179-14.407, p = 0.027), Charlson comorbidity index (CCI) (OR: 4.800, 95%CI 1.852-12.440, p = 0.001) and severe dependent (OR: 3.772, 95%CI 1.116-9.841, p = 0.007). Further analysis showed that delirium (OR: 2.824, 95%CI 1.068-7.467, p = 0.036) and CCI (OR: 3.221, 95%CI 1.184-8.766, p = 0.022) were independently related to major AEs.

CONCLUSIONS

These results indicate that preoperative screening preoperative delirium, cognitive, nutrition and CCI are essential to prevent postoperative major AEs of the surgical elderly.

Comprehensive Geriatric Assessment for Older Women with Early-Stage (Non-Metastatic) Breast Cancer-An Updated Systematic Review of the Literature

BACKGROUND

A previous systematic review by our team (2012) undertook comprehensive geriatric assessment (CGA) in breast cancer and concluded there was not sufficient evidence to instate CGA as mandatory practice. SIOG/EUSOMA guidelines published in 2021 advocate the use of CGA in breast cancer patients. The aim is to perform an updated systematic review of the literature.

METHODS

A systematic review of studies published between 2012 and 2022 that assessed the use of CGA in breast cancer was performed on Cochrane, PubMed and Embase.

RESULTS

A total of 18 articles including 4734 patients with breast cancer were identified. The studies covered four themes for use of CGA in breast cancer: (1) to determine factors influencing survival (2) as an adjunct to treatment decision-making (3) to measure quality of life, and (4) to determine which tools should be included. There was evidence to support the use of CGA in themes 1-3; however, it is uncertain which assessment tools are best to use (theme 4).

CONCLUSIONS

CGA can be used to determine factors affecting survival and quality of life in breast cancer patients and can therefore be used to aid treatment decision-making. Further work is required to determine gold standard CGA.

Validation of the Onco-MPI in predicting short-term mortality in older Indian patients with cancer

INTRODUCTION

The number of older patients with cancer is increasing exponentially worldwide, and a similar trend has also been noted in India. The Multidimensional Prognostic Index (MPI) strongly correlates the presence of individual comorbidities with mortality, and the Onco-MPI prognosticates patients accurately for overall mortality. However, limited studies have evaluated this index in patient populations beyond Italy. We evaluated the performance of the Onco-MPI index in predicting mortality in older Indian patients with cancer.

MATERIALS AND METHODS

This observational study was conducted between October 2019 and November 2021 in the Geriatric Oncology Clinic at Tata Memorial Hospital in Mumbai, India. The data of patients aged ≥60 years with solid tumors who underwent a comprehensive geriatric assessment was analysed. The study's primary aim was to calculate the Onco-MPI for patients in the study and correlate it with one-year mortality.

RESULTS

A total of 576 patients aged ≥60 years were included in the study. The median age (range) of the population was 68 (60-90) years, and 429 (74.5%) were male. After a median follow-up of 19.2 months, 366 (63.7%) patients had died. The proportion of patients classified as low risk (0-0.46), moderate risk (0.47-0.63) and high risk (0.64-1.0) were 38% (219 patients), 37% (211 patients) and 25% (145 patients), respectively. There was a significant difference in one-year mortality rates between the low-risk patients compared to medium and high-risk patients (40.6% vs 53.1% vs 71.7%; p < 0.001).

DISCUSSION

The current study validates the Onco-MPI as a predictive tool for estimating short-term mortality in older Indian patients with cancer. Further prospective studies need to build on this index to obtain a score with greater discrimination in the Indian population.

Non-metastatic castration-resistant prostate cancer: management recommendations

INTRODUCTION AND OBJECTIVE

Survival and quality of life (QoL) of patients with non-metastatic castration-resistant prostate cancer (nmCRPC) deteriorate significantly when they develop metastases. New generation antiandrogens (apalutamide, enzalutamide and darolutamide) can prolong metastasis-free survival (MFS) and overall survival (OS) in these patients, maintaining their QoL.

MATERIAL AND METHODS

After the performance of a systematic review of the literature, a scientific committee reached a consensus on simple and practical recommendations to consolidate and improve the management of patients with nmCRPC in urology consultations.

RESULTS

Recommendations are made on the frequency of PSA determination and imaging tests in patients with nmCRPC. The importance of co-morbidities in patients with nmCRPC is also highlighted, and recommendations are also made on functional and QoL assessment that can be carried out during urology consultations. The efficacy, safety, and effects on QoL of new generation antiandrogens are reviewed.

CONCLUSIONS

To evaluate treatment of patients with nmCRPC, it is necessary to consider co-morbidities and QoL, in addition to age. New generation antiandrogens are a safe and effective treatment option for patients with nmCRPC. The recommendations of this review can be helpful in optimizing the management of nmCRPC patients in urology consultations.

The Multidimensional Prognostic Index as a Measure of Frailty in Elderly Patients with Head and Neck Cancer

Purpose

The multidimensional prognostic index (MPI) is a prognostic model derived from the comprehensive geriatric assessment (CGA) which can predict 1-year mortality risk in elderly individuals. We hypothesized that the MPI also reflects the degree of frailty and thus will correlate with established measures of frailty. Therefore, the aim of this study is to explore whether the MPI-score is a measure of frailty in older head and neck cancer patients and is associated with several physical functioning measurements.

Patients and Methods

From November 2019 to July 2020, a prospective cohort study enrolled patients with head and neck cancer aged ≥70 years, and patients <70 years with an abnormal G8 score. The MPI-score ranged from 0 to 1 and was categorized in MPI-stage 1 (≤0.33, non-frail); MPI-stage 2 (0.34-0.66, mildly frail), and MPI-stage 3 (≥0.67, severe frail). Pearson's correlation coefficient and multivariable linear regression were used to study the association between MPI-score and the physical functioning measurements handgrip strength, gait speed, and the timed up and go test (TUGT).

Results

A total of 163 patients were included. One hundred four (63.8%) patients were categorized as non-frail according MPI-stage 1, and 59 (36.2%) patients as mildly or severe frail (n=55 MPI-stage 2; n=4 MPI-stage 3, respectively). A higher MPI-score was significantly associated with lower hand grip strength (B -0.49 [95% CI -0.71; -0.28] p<0.001), lower gait speed (B -0.41 [95% CI -0.55; -0.25] p<0.001), and a slower TUGT (B 0.53 [95% CI 0.66; 0.85] p<0.001).

Conclusion

Almost one-third of the included patients with head and neck cancer was mild or severe frail. A higher MPI-score, indicating higher degree of frailty, was associated with worse physical performance by lower handgrip strength, gait speed, and a slower TUGT. Thus, the MPI reflects the degree of frailty.

Nutritional Assessment in Older Adults : MNA® 25 years of a Screening Tool and a Reference Standard for Care and Research; What Next?

A tool to assess nutritional status in older persons was really needed. It took 5 years to design the MNA® (Mini Nutrition Assessment) tool, complete the first validations studies both in Europe and in the U.S. and to publish it. After the full MNA®, the MNA® short form and the self-MNA® have been validated. As well as Chinese and other national MNA® forms. Now more than 2000 clinical research have used the MNA® all over the world from community care to hospital. At least 22 Expert groups included the MNA® in new clinical practice guidelines, national or international registries. The MNA® is presently included in almost all geriatric and nutrition textbook and part of the teaching program for medicine and other health care professional worldwide. The urgent need is to target the frail older adults more likely to have weight loss and poor appetite and to prevent frailty and weight loss in the robust. We present in this paper the review of 25 years of clinical research and practice using the MNA® worldwide.