Assessing frailty in older Indian patients before cancer treatment: Comparative analysis of three scales and their implications for overall survival

INTRODUCTION

Frailty, characterized by ageing-related vulnerability, influences outcomes in older adults. Our study aimed to investigate the relationship between frailty and clinical outcomes in older Indian patients with cancer.

MATERIALS AND METHODS

Our observational single-centre study, conducted at Tata Memorial Hospital from February 2020 to July 2022, enrolled participants aged 60 years and above with cancer. Frailty was assessed using the Clinical Frailty Scale (CFS), G8, and Vulnerable Elders Survey (VES)-13. The primary objective was to explore the correlation between baseline frailty and overall survival. Statistical analyses include Kaplan-Meier, Cox proportional hazards, and Harrell's C test.

RESULTS

A total of 1,177 patients (median age 68, 76.9% male) were evaluated in the geriatric oncology clinic. Common malignancies included lung (40.0%), gastrointestinal (35.8%), urological (11.9%), and head and neck (9.0%), with 56.5% having metastatic disease. Using CFS, G8, and VES-13 scales, 28.5%, 86.4%, and 38.0% were identified as frail, respectively. Median follow-up was 11.6 months, with 43.3% deaths. Patients fit on CFS (CFS 1-2) had a median survival of 28.02 months, pre-frail (CFS 3-4) 13.24 months, and frail (CFS ≥5) 7.79 months (p < 0.001). Abnormal G8 (≤14) and VES-13 (≥3) were associated with significantly lower median survival (p < 0.001). Multivariate analysis confirmed CFS's predictive power for mortality (p < 0.001), with hazard ratios [HRs] for pre-frail at 1.61(95% confidence interval [CI] 1.25 to 2.06) and frail at 2.31 (95%CI 1.74 to 3.05). G8 ≤ 14 had HR 2.00 (95%CI 1.42 to 2.83), and abnormal VES-13 had HR 1.36 (95%CI 1.11-1.67). In the likelihood ratio test, CFS significantly improved the model fit (p < 0.001). Harrell's C index for survival prediction was 0.62 for CFS, 0.54 for G8, and 0.58 for VES-13.

DISCUSSION

In conclusion, our study highlights varying frailty prevalence and prognostic implications in older Indian patients with cancer, emphasizing the need for personalized care in oncology for this aging population. We would recommend using CFS as a tool to screen for frailty for older Indian patients with cancer.

Performance of potentially inappropriate medications assessment tools in older Indian patients with cancer

BACKGROUND

Polypharmacy and potentially inappropriate medication (PIM) use are common problems in older adults. Safe prescription practices are a necessity. The tools employed for the identification of PIM sometimes do not concur with each other.

METHODS

A retrospective analysis of patients ≥60 years who visited the Geriatric Oncology Clinic of the Tata Memorial Hospital, Mumbai, India from 2018 to 2021 was performed. Beer's-2015, STOPP/START criteria v2, PRISCUS-2010, Fit fOR The Aged (FORTA)-2018, and the EU(7)-PIM list-2015 were the tools used to assess PIM. Every patient was assigned a standardized PIM value (SPV) for each scale, which represented the ratio of the number of PIMs identified by a given scale to the total number of medications taken. The median SPV of all five tools was considered the reference standard for each patient. Bland-Altman plots were utilized to determine agreement between each scale and the reference. Association between baseline variables and PIM use was determined using multiple logistic regression analysis.

RESULTS

Of the 467 patients included in this analysis, there were 372 (79.66%) males and 95 (20.34%) females with an average age of 70 ± 5.91 years. The EU(7)-PIM list was found to have the highest level of agreement given by a bias estimate of 0.010, the lowest compared to any other scale. The 95% CI of the bias was in the narrow range of -0.001 to 0.022, demonstrating the precision of the estimate. In comparison, the bias (95%) CI of Beer's criteria, STOPP/START criteria, PRISCUS list, and FORTA list were -0.039 (-0.053 to -0.025), 0.076 (0.060 to 0.092), 0.035 (0.021 to 0.049), and -0.148 (-0.165 to -0.130), respectively. Patients on polypharmacy had significantly higher PIM use compared to those without (OR = 1.47 (1.33-1.63), p = <0.001).

CONCLUSIONS

The EU(7)-PIM list was found to have the least bias and hence can be considered the most reliable among all other tools studied.

Correlation of the Geriatric Assessment with Overall Survival in Older Patients with Cancer

AIMS

Global guidelines recommend that all older patients with cancer receiving chemotherapy should undergo a geriatric assessment. However, utilisation of the geriatric assessment is often constrained by its time-intensive nature, which limits its adoption in settings with limited resources and high demand. There is a lack of evidence correlating the results of the geriatric assessment with survival from the Indian subcontinent. Therefore, the aims of the present study were to assess the impact of the geriatric assessment on survival in older Indian patients with cancer and to identify the factors associated with survival in these older patients.

MATERIALS AND METHODS

This was an observational study, conducted in the geriatric oncology clinic of the Tata Memorial Hospital (Mumbai, India). Patients aged 60 years and older with cancer who underwent a geriatric assessment were enrolled. We assessed the non-oncological geriatric domains of function and falls, nutrition, comorbidities, cognition, psychology, social support and medications. Patients exhibiting impairment in two or more domains were classified as frail.

RESULTS

Between June 2018 and January 2022, we enrolled 897 patients. The median age was 69 (interquartile range 65-73) years. The common malignancies were lung (40.5%), oesophagus (31.9%) and genitourinary (12.1%); 54.6% had metastatic disease. Based on the results of the geriatric assessment, 767 (85.4%) patients were frail. The estimated median overall survival in fit patients was 24.3 (95% confidence interval 18.2-not reached) months, compared with 11.2 (10.1-12.8) months in frail patients (hazard ratio 0.54; 95% confidence interval 0.41-0.72, P < 0.001). This difference in overall survival remained significant after adjusting for age, sex, primary tumour and metastatic status (hazard ratio 0.56; 95% confidence interval 0.41-0.74, P < 0.001). In the patients with a performance status of 0 or 1 (n = 454), 365 (80.4%) were frail; the median overall survival in the performance status 0-1 group was 33.0 months (95% confidence interval 24.31-not reached) in the fit group versus 14.4 months (95% confidence interval 12.25-18.73) in the frail patients (hazard ratio 0.50; 95% confidence interval 0.34-0.74, P = 0.001). In the multivariate analysis, the geriatric assessment domains that were predictive of survival were function (hazard ratio 0.68; 95% confidence interval 0.52-0.88; P = 0.003), nutrition (hazard ratio 0.64; 95% confidence interval 0.48-0.85, P = 0.002) and cognition (hazard ratio 0.67; 95% confidence interval 0.49-0.91, P = 0.011).

DISCUSSION

The geriatric assessment is a powerful prognostic tool for survival among older Indian patients with cancer. The geriatric assessment is prognostic even in the cohort of patients thought to be the fittest, i.e. performance status 0 and 1. Our study re-emphasises the critical importance of the geriatric assessment in all older patients planned for cancer-directed therapy.

The current status of geriatric oncology in India

Geriatric oncology in India is relatively new. The number of older persons with cancer is increasing exponentially; at our institution, 34% of patients registered are 60 years and over. Apart from the Tata Memorial Hospital in Mumbai, there are currently no other Indian centers that have a dedicated geriatric oncology unit. Geriatric assessments (GAs) are done sporadically, and older patients with cancer are usually assessed and treated based on clinical judgement. Challenges to increasing the uptake of GA include a lack of training/time/interest or knowledge of the importance of the GA. Other challenges include a lack of trained personnel with expertise in geriatric oncology, and a paucity of research studies that seek to advance the outcomes in older Indian patients with cancer. We anticipate that over the next 10 years, along with the inevitable increase in the number of older persons with cancer in India, there will be a commensurate increase in the number of skilled personnel to care for them. Key goals for the future include increased research output, increased number of dedicated geriatric oncology units across the country, India-specific geriatric oncology guidelines, geriatric oncology training programs, and a focus on collaborative work across India and with global partners. In this narrative review, we provide a broad overview of the status of geriatric oncology in India, along with a description of the work done at our center. We hope to spark interest and provide inspiration to readers to consider developing geriatric oncology services in other settings.

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.

Caregiver burden in older Indian patients with cancer- Experience from a tertiary care center

INTRODUCTION

Most of the long-term care for older adults with chronic or debilitating illnesses is provided by unpaid family members or informal caregivers. There is limited information on caregiver burden among caregivers of older patients with cancer in India. Hence, we assessed the prevalence and severity of caregiver burden among caregivers of older Indian patients with cancer.

METHODS

This was an observational study conducted at the geriatric oncology clinic at Tata Memorial Centre, Mumbai, India. Caregivers of patients aged 60 years and over with a diagnosis of cancer were assessed for caregiver burden using the Zarit Burden Interview. Descriptive statistics were used for demographic and clinical variables. Factors impacting caregiver burden were analyzed using multiple linear regression analysis.

RESULTS

Caregiver burden was assessed among 127 caregivers of older Indian patients with cancer. The median patient age was 69 years (range 60-90). Most patients were men (75.6%). There were 33 female caregivers (26%), and 94 male caregivers (74%). The median caregiver burden score was 12 (IQR 6-20). Caregiver burden was "little/none" in 97 (76.4%), "mild-moderate" in 25 (19.7%), "moderate-severe" in four (3.1%) and "severe" in one (0.8%) of the caregivers assessed. On multivariate analysis, factors that significantly impacted caregiver burden scores were the presence of psychological issues in the patient and the caregiver's educational level.

CONCLUSION

Caregiver burden was low among caregivers of older Indian patients with cancer seen at a single center. Caregivers of patients with psychological disorders, and those who had less schooling reported higher caregiver burden.

Geriatric assessment as a predictor of survival among older Indian patients with cancer

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Background: ASCO guidelines recommend that geriatric assessment (GA) should be performed in all older adults with cancer. However, GA is labor- and time-intensive, hence the uptake is poor, especially in crowded resource poor-settings. There are no data correlating GA with overall survival (OS) outcomes from the Indian subcontinent. Methods: A prospective observational study in the geriatric oncology clinic of the Tata Memorial Hospital in Mumbai, India. Patients aged 60 years and above, with cancer who underwent a GA were enrolled. The domains assessed included: function (basic and instrumental activities of daily living, timed-up-and-go), nutrition (body mass index, unintentional weight loss, mini-nutritional assessment), comorbidities, cognition, psychological (depression, anxiety), social support, and medication (polypharmacy and potentially inappropriate medications). Patients with > 2 deranged GA domains were considered frail. Results: Between June 2018 and January 2022, 909 patients were enrolled. The median age was 69 (IQR, 60-88) years. Common malignancies included lung (40%), esophagus (21%) and head and neck (11%); 53% had metastatic disease. 80% had > 2 impaired domains in GA patients had vulnerabilities in a median of 3 (IQR, 0-5) domains. Median OS in fit patients based on the GA was 17.5 (95% CI, 13.9-21.0) months vs 12.1 (95% CI, 10.1-14.0) months in frail patients, (HR 0.66; 95% CI, 0.49-0.88, p = 0.005), which remained significant after adjusting for age, sex, and stage (HR, 0.71; 95% CI: 0.53-0.94, p = 0.021). In the multivariate analysis (Table), the domains that were predictive of survival were nutrition (HR: 0.65, 95% CI: 0.47-0.92, p = 0.014), cognition (HR: 0.65; 95% CI: 0.46-0.91, p = 0.012) and fatigue (HR: 0.74, 95% CI: 0.56-0.98, p = 0.038). Conclusions: In older Indian patients with cancer, GA is a powerful prognosticator of survival. In settings where a complete GA is not possible, nutrition, cognition, and fatigue should be the minimum domains assessed. Clinical trial information: CTRI/2020/04/024675. [Table: see text]

Prevalence and outcomes of frailty in older patients with cancer: A prospective study from geriatric oncology clinic

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Background: Frail older patients present with increased symptom burden, medical complexity and reduced tolerance to medical and surgical interventions. Data regarding the prevalence of frailty and its association with outcomes, such as overall survival, is limited from India. This study aimed to establish the prevalence of frailty and its association with overall survival (OS) in older patients with cancer. Methods: This was a prospective study conducted in geriatric oncology clinic of Tata memorial hospital (Mumbai India). Patients aged 60 years and above referred to the clinic were included. Frailty was identified using the Rockwoods Clinical frailty scale, and patients with a score of five or more were diagnosed as frail. Demographic details, type of cancer, stage and multi-domains geriatric assessment was done. Cancer and Ageing Research group online toxicity tool was used to assess the chemotherapy toxicity risk. A t-test or two-sample Wilcoxon rank-sum test was used to study the association between frailty status and non-categorical variables and the Pearson chi-squared test was used to measure the association between categorical variables. The Kaplan Meier survival estimation and the Cox proportional hazard model were used to perform the survival analysis. Results: Between June 2018 to January 2022, 909 patients were evaluated and 662 patients with clinical frailty score were included. The median age was 68 (60-86) years and 107 (16%) were above the age of 75 years. The most common malignancies were lung (39%), esophagus (21%) and head and neck (10%); 53% had metastatic disease. 192 (29%) were frail, and it prevalence increased with age. Frailty status was associated with poor OS (unadjusted HR: 2.512; 95% CI: 1.931-3.268). This association was significant even after adjusting for age, gender, BMI and stage of cancer (adjusted HR: 2.104; 95% CI: 1.598-2.770). Frailty was associated with comorbidities such as diabetes (32% vs 23%, p = 0.014), chronic obstructive pulmonary disease (13% vs 7%, p = 0.045) and cardiovascular disease (19% vs 12%, p = 0.017). Among the geriatric domains, frail patients had greater incidence of polypharmacy (52% vs 33%, p < 0.01), slower gait speed (53% vs 12%, p < 0.01), impaired cognition (25% vs 7%, p < 0.01), poor nutritional status (51% vs 17%, p < 0.001), depression (29% vs 8%, p < 0.01) and anxiety (14% vs 5%, p < 0.01). Conclusions: The prevalence of frailty among older cancer patients is high. It is associated with poor physical, cognitive and psychological resilience and is associated with poor overall survival. Our study supports the routine assessment of frailty in older patients with cancer to guide treatment decisions. Clinical trial information: CTRI/2020/04/024675.

The prevalence of cognitive impairment in older Indian persons with cancer and brain metastases

Background

Older patients with cancer are more vulnerable to the effects of cognitive impairment affecting their functional status, quality of life, compliance to treatment and ultimately survival. Cancer-related cognitive impairment may be due to the cancer itself or due to the treatment of cancer. There are no data regarding the prevalence of cognitive impairment in older persons with cancer and brain metastasis.

Methods

This retrospective analysis was conducted on a prospectively collected data set of patients who attended the geriatric oncology clinic at a tertiary care comprehensive cancer centre in India from June 2018 to July 2021. Patients aged 60 years and above with malignancy were included. Cognition was assessed with the mini-mental status examination (MMSE); the Hindi MMSE was used for illiterate patients. A score of ≤23 on the MMSE was considered abnormal. Correlation between the presence of cognitive impairment and brain metastasis was tested using the chi-square test.

Results

A total of 597 patients were included, of which 462 (77.4%) were male. The median age was 69 years (range: 60–100 years). All patients had solid tumours; 244 (40.9%) had lung, 189 (31.7%) had gastrointestinal and 75 (12.6%) had head and neck malignancies. Forty-one (6.9%) patients had brain metastases, of which 10 (24.4%) had solitary, 30 (73.2%) had multiple lesions and 1 (2.4%) had leptomeningeal metastases. Cognitive impairment was noted in 11 (26.8%) of the 41 patients with brain metastases and 91 (16.4%) of the 556 patients without brain metastases. There was no significant correlation between the presence of brain metastases and cognitive impairment, p = 0.086.

Conclusion

Older persons with cancer and brain metastases were not found to have a higher occurrence of cognitive impairment than those without brain metastases in this study. The next step is to understand whether older persons with brain metastases are at a higher risk for cognitive decline as a result of therapeutic interventions such as cranial radiotherapy and chemotherapy.