JO U R N A L OF GE RI A TR IC O N COL O G Y 5 (2 0 1 4) 8 –10
Available online at www.sciencedirect.com
ScienceDirect
Editorial
Getting beyond screening for frailty in older patients with cancer☆ Gretchen Kimmicka,⁎, Heidi Whiteb a
Women's Cancer Program, Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA Internal Medicine, Geriatrics, Duke University Medical Center, Durham, NC 27710, USA
b
AR TIC LE I N FO
ABS TR ACT
Article history: Received 23 October 2013 Accepted 18 November 2013 Available online 21 December 2013
Prevention, detection and management of geriatric syndromes and frailty, or risk factors for these, are the cornerstones of Geriatrics and Geriatric Oncology. In older patients, functional level varies widely — from robust and able to tolerate cancer treatment, to frail and unable to tolerate even minor interventions without life-threatening consequences. At either end of the spectrum, treatment decisions are clear, but the identification of persons at risk for functional decline and frailty, where interventions or treatment modifications are needed, is where geriatrics is going to make the biggest impact on oncology. The concept of a Comprehensive Geriatric Assessment (CGA) includes a multidisciplinary assessment to detect geriatric syndromes and frailty and, most importantly, to determine when interventions are needed. This methodology has been successfully applied to patients with cancer, but is not necessary in all and, because it is time-intensive, is not feasible in most clinical settings. Brief tools to screen for frailty in patients with
☆ See accompanying article by Liuu et al. "Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: The ELCAPA-02 study" and Spyropoulou et al. "Completion of radiotherapy is associated with the Vulnerable Elders Survey-13 score in elderly patients with cancer". ⁎ Corresponding author at: DUMC Box 3204, 10 Bryan-Searle Drive, Seeley G. Mudd Bldg, Duke University Medical Center, Durham, NC 27710. E-mail address: [email protected] (G. Kimmick). 1879-4068/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jgo.2013.11.002
cancer and questionnaires to identify those at risk of toxicity are being studied.1–4 Several well studied tools that screen for vulnerability are available and have been applied in patients with cancer.5–7 Among these, the Vulnerable Elders Survey (VES-13) is recommended by the National Comprehensive Cancer Network (NCCN) (NCCN Senior Adult Oncology guidelines, www.nccn. org). There are also screening tools specifically developed for use in older patients with cancer, such the French G-8 questionnaire.8 Until now, the literature primarily contains reports describing the accuracy of these tools compared to a CGA in patients with cancer. In this volume of The Journal of Geriatric Oncology, there are two reports that advance our knowledge with respect to brief geriatric assessments and their accuracy in older patients with specific cancer types9 and the ability to predict completion of therapy.10 The ability of the VES-13 to identify patients at risk for not completing a planned radiation therapy (RT) course was studied by Dr. Kardamakis and colleagues. In their study of 238 patients older than 75 years with a wide variety of solid tumors, split pretty evenly between curative and palliative intent RT, and a few hematologic malignancies, the VES-13 predicted completion of RT, though with more acceptable sensitivity and specificity at a higher cut-off score >7, than the usual cut-off score of ≥3 for vulnerability. In this study, the VES-13 score predicted RT completion, independent of other factors including sex, comorbidities, whether RT was curative or palliative, and side effects. As the authors point out, knowledge of a higher
EDI TOR IA L
risk for not completing RT will be important in developing multidisciplinary supportive care. In a retrospective fashion, using data from the Elderly Cancer Patient (ELCAPA) study in France, Dr. Liuu and colleagues identified variability in the accuracy of the G-8 to identify frailty across tumor sites, stage of disease, and performance status. The ELCAPA study included a CGA, from which the G-8 scores were derived. The current report included 518 patients, age 70 and older, with solid tumors including breast, colorectal, urinary tract, upper GI and liver, prostate, and other sites. Stage was metastatic in approximately half of the cases. G-8 had particularly low sensitivity in prostate cancer and specificity in colorectal cancer. Liuu et al. speculate as to the reasons for the G-8 performing differently for different tumor types; we would like to add to that speculation. The G-8 screening tool may be more ‘accurate’ in some tumors than others, based on the demographic risk factors for the cancer, such as sex and race, or it may be a reflection of the geriatric syndromes represented in the G-8 tool, which include food intake, weight loss, body mass index, mobility, presence and severity of dementia, complexity of medications, self-perceived health status, and age. In fact, incidence of certain geriatric syndromes varies by race, which is also a risk factor for prostate cancer; multiple comorbidities, frailty, disability, and malnutrition are more common in black than in white patients.11 An interaction between risk of death in the presence of geriatric syndromes and age is also noted; in the presence of geriatric syndromes, the risk of death is significantly higher in the young-old (age 65–74), but persons aged 90 and older are not significantly affected by this risk.11,12 Differential age distribution among the cancer types, therefore, may be a confounder. Syndromes are also not independent; definitions and prevalence estimates overlap substantially. Less inclusive definitions have lower prevalence, but tend to be better predictors of outcomes. In essence, other factors which influence variation in the occurrence of geriatric syndromes may relate to the predominance of specific geriatric syndromes and the sensitivity of the G-8 screening tool that could not be fully accounted for or controlled in this relatively small cohort. We also speculate that screener sensitivity could be improved by screening at multiple points in time, including during the evaluation and treatment process. Screener sensitivity could also be improved as the programs of care are developed and implemented to go beyond initial screening, with additional issues being detected without relying upon a time consuming CGA. Translational research is needed to apply geriatric assessment screening tools within a framework that promotes the appropriate application of professional services that will enhance outcomes and cancer care experiences for older adults. Gero-focused nurses, physical therapists, nutritionists, psychologists, pharmacists, social workers and geriatricians can provide treatments and education that are likely to improve the experience and outcomes of cancer care. We need to determine how to mobilize these services in an efficient and cost-effective manner so that a geriatric assessment becomes the backbone of a cancer care process that enhances outcomes. Current research indicates that specialized, organized and coordinated geriatric care in the hospital setting improves outcomes such as being alive and in their own home up to one year after the event.13 Similarly, gero-oncology specific research needs to focus on how, where, when and how much care is needed to
9
improve outcomes. At this time descriptions of outcomes of coordinated geriatrics care for patients with cancer are practically nonexistent. Although it is informative to know that the VES-13 predicts radiation treatment completion, the next step is to determine if geriatric management resulting from VES-13 screening improves radiation treatment completion. Optimal treatment of the older adult patient who has cancer starts with careful delineation of goals through conversation. The treatment plan should be comprehensive and address cancer-specific treatment, symptom-specific treatment, supportive treatment modalities, and end-of-life care.14 This ideal definition of gero-focused oncology care is supported by geriatric assessment screening tools which are a necessary component in comprehensive person-centered cancer care for older adults. These tools help identify robust older adults who are likely to benefit from standard full dose treatment regimens, in addition to identifying those at risk for poorer outcomes. Newer tools are being crafted that incorporate usual measures of therapy toxicity in conjunction with geriatric assessment measures to answer specific questions regarding the likelihood of therapy toxicity in older adults. But the value of CGA and GA screening goes far beyond decision support. The primary value of a geriatric assessment comes from the adoption of geriatric management. Developing and testing these models need our research attention.
Disclosures and Conflicts of Interest Dr. Kimmick serves as a consultant for Astra Zeneca, Novartis, and Pfizer. She has received honoraria from the France Foundation, ASCO, and Astra Zeneca and research funding from Astra Zeneca and Roche.
REFERENCES
1. Hamaker ME, Jonker JM, de Rooij SE, et al. Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review. Lancet Oncol 2012;13:e437–e444. 2. Puts MT, Hardt J, Monette J, et al. Use of geriatric assessment for older adults in the oncology setting: a systematic review. J Natl Cancer Inst 2012;104:1133–1163. 3. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective 500 patient multicenter study. J Clin Oncol 2010;28 [abstr 9001]. 4. Extermann M, Boler I, Reich R, et al. The Chemotherapy Risk Assessment Scale for High-age Patients (CRASH) score: design and validation. J Clin Oncol 2010;28 [abstr 9000]. 5. Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001;49:1691–1699. 6. Luciani A, Ascione G, Bertuzzi C, et al. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable elders survey-13. J Clin Oncol 2010;28: 2046–2050. 7. Kenis C, Schuermans H, Van Custem E, et al. Screening for a geriatric risk profile in older cancer patients: a comparative study of the predictive validity of three screening tools. Crit Rev Oncol Hematol 2009;72:22 [Suppl.].
10
EDI TOR IAL
8. Soubeyran P, Bellera C, Goyard J, et al. Validation of the G8 screening tool in geriatric oncology: The ONCODAGE project. J Clin Oncol 2011;29:550S. 9. Liuu E, Canouï-Poitrine F, Tournigand C, et al: Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: The ELCAPA-02 study. J Geriatr Oncol. 10. Spyropoulou D, Pallis AG, Leotsinidis M, et al: Completion of radiotherapy is associated with the Vulnerable Elders Survey-13 score in elderly patients with cancer. J Geriatr Oncol.
11. Kane RL, Shamliyan T, Talley K, et al. The association between geriatric syndromes and survival. J Am Geriatr Soc 2012;60: 896–904. 12. Kane RL, Talley KMC, et al. Common Syndromes in Older Adults Related to Primary and Secondary Prevention. Rockville (MD); 2011. 13. Ellis G, Whitehead MA, O'Neill D, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011:CD006211. 14. White HK, Cohen HJ. The older cancer patient. Nurs Clin North Am 2008;43:307–322.
Available online at www.sciencedirect.com
ScienceDirect
Editorial
Getting beyond screening for frailty in older patients with cancer☆ Gretchen Kimmicka,⁎, Heidi Whiteb a
Women's Cancer Program, Duke Cancer Institute, Duke University Medical Center, Durham, NC 27710, USA Internal Medicine, Geriatrics, Duke University Medical Center, Durham, NC 27710, USA
b
AR TIC LE I N FO
ABS TR ACT
Article history: Received 23 October 2013 Accepted 18 November 2013 Available online 21 December 2013
Prevention, detection and management of geriatric syndromes and frailty, or risk factors for these, are the cornerstones of Geriatrics and Geriatric Oncology. In older patients, functional level varies widely — from robust and able to tolerate cancer treatment, to frail and unable to tolerate even minor interventions without life-threatening consequences. At either end of the spectrum, treatment decisions are clear, but the identification of persons at risk for functional decline and frailty, where interventions or treatment modifications are needed, is where geriatrics is going to make the biggest impact on oncology. The concept of a Comprehensive Geriatric Assessment (CGA) includes a multidisciplinary assessment to detect geriatric syndromes and frailty and, most importantly, to determine when interventions are needed. This methodology has been successfully applied to patients with cancer, but is not necessary in all and, because it is time-intensive, is not feasible in most clinical settings. Brief tools to screen for frailty in patients with
☆ See accompanying article by Liuu et al. "Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: The ELCAPA-02 study" and Spyropoulou et al. "Completion of radiotherapy is associated with the Vulnerable Elders Survey-13 score in elderly patients with cancer". ⁎ Corresponding author at: DUMC Box 3204, 10 Bryan-Searle Drive, Seeley G. Mudd Bldg, Duke University Medical Center, Durham, NC 27710. E-mail address: [email protected] (G. Kimmick). 1879-4068/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.jgo.2013.11.002
cancer and questionnaires to identify those at risk of toxicity are being studied.1–4 Several well studied tools that screen for vulnerability are available and have been applied in patients with cancer.5–7 Among these, the Vulnerable Elders Survey (VES-13) is recommended by the National Comprehensive Cancer Network (NCCN) (NCCN Senior Adult Oncology guidelines, www.nccn. org). There are also screening tools specifically developed for use in older patients with cancer, such the French G-8 questionnaire.8 Until now, the literature primarily contains reports describing the accuracy of these tools compared to a CGA in patients with cancer. In this volume of The Journal of Geriatric Oncology, there are two reports that advance our knowledge with respect to brief geriatric assessments and their accuracy in older patients with specific cancer types9 and the ability to predict completion of therapy.10 The ability of the VES-13 to identify patients at risk for not completing a planned radiation therapy (RT) course was studied by Dr. Kardamakis and colleagues. In their study of 238 patients older than 75 years with a wide variety of solid tumors, split pretty evenly between curative and palliative intent RT, and a few hematologic malignancies, the VES-13 predicted completion of RT, though with more acceptable sensitivity and specificity at a higher cut-off score >7, than the usual cut-off score of ≥3 for vulnerability. In this study, the VES-13 score predicted RT completion, independent of other factors including sex, comorbidities, whether RT was curative or palliative, and side effects. As the authors point out, knowledge of a higher
EDI TOR IA L
risk for not completing RT will be important in developing multidisciplinary supportive care. In a retrospective fashion, using data from the Elderly Cancer Patient (ELCAPA) study in France, Dr. Liuu and colleagues identified variability in the accuracy of the G-8 to identify frailty across tumor sites, stage of disease, and performance status. The ELCAPA study included a CGA, from which the G-8 scores were derived. The current report included 518 patients, age 70 and older, with solid tumors including breast, colorectal, urinary tract, upper GI and liver, prostate, and other sites. Stage was metastatic in approximately half of the cases. G-8 had particularly low sensitivity in prostate cancer and specificity in colorectal cancer. Liuu et al. speculate as to the reasons for the G-8 performing differently for different tumor types; we would like to add to that speculation. The G-8 screening tool may be more ‘accurate’ in some tumors than others, based on the demographic risk factors for the cancer, such as sex and race, or it may be a reflection of the geriatric syndromes represented in the G-8 tool, which include food intake, weight loss, body mass index, mobility, presence and severity of dementia, complexity of medications, self-perceived health status, and age. In fact, incidence of certain geriatric syndromes varies by race, which is also a risk factor for prostate cancer; multiple comorbidities, frailty, disability, and malnutrition are more common in black than in white patients.11 An interaction between risk of death in the presence of geriatric syndromes and age is also noted; in the presence of geriatric syndromes, the risk of death is significantly higher in the young-old (age 65–74), but persons aged 90 and older are not significantly affected by this risk.11,12 Differential age distribution among the cancer types, therefore, may be a confounder. Syndromes are also not independent; definitions and prevalence estimates overlap substantially. Less inclusive definitions have lower prevalence, but tend to be better predictors of outcomes. In essence, other factors which influence variation in the occurrence of geriatric syndromes may relate to the predominance of specific geriatric syndromes and the sensitivity of the G-8 screening tool that could not be fully accounted for or controlled in this relatively small cohort. We also speculate that screener sensitivity could be improved by screening at multiple points in time, including during the evaluation and treatment process. Screener sensitivity could also be improved as the programs of care are developed and implemented to go beyond initial screening, with additional issues being detected without relying upon a time consuming CGA. Translational research is needed to apply geriatric assessment screening tools within a framework that promotes the appropriate application of professional services that will enhance outcomes and cancer care experiences for older adults. Gero-focused nurses, physical therapists, nutritionists, psychologists, pharmacists, social workers and geriatricians can provide treatments and education that are likely to improve the experience and outcomes of cancer care. We need to determine how to mobilize these services in an efficient and cost-effective manner so that a geriatric assessment becomes the backbone of a cancer care process that enhances outcomes. Current research indicates that specialized, organized and coordinated geriatric care in the hospital setting improves outcomes such as being alive and in their own home up to one year after the event.13 Similarly, gero-oncology specific research needs to focus on how, where, when and how much care is needed to
9
improve outcomes. At this time descriptions of outcomes of coordinated geriatrics care for patients with cancer are practically nonexistent. Although it is informative to know that the VES-13 predicts radiation treatment completion, the next step is to determine if geriatric management resulting from VES-13 screening improves radiation treatment completion. Optimal treatment of the older adult patient who has cancer starts with careful delineation of goals through conversation. The treatment plan should be comprehensive and address cancer-specific treatment, symptom-specific treatment, supportive treatment modalities, and end-of-life care.14 This ideal definition of gero-focused oncology care is supported by geriatric assessment screening tools which are a necessary component in comprehensive person-centered cancer care for older adults. These tools help identify robust older adults who are likely to benefit from standard full dose treatment regimens, in addition to identifying those at risk for poorer outcomes. Newer tools are being crafted that incorporate usual measures of therapy toxicity in conjunction with geriatric assessment measures to answer specific questions regarding the likelihood of therapy toxicity in older adults. But the value of CGA and GA screening goes far beyond decision support. The primary value of a geriatric assessment comes from the adoption of geriatric management. Developing and testing these models need our research attention.
Disclosures and Conflicts of Interest Dr. Kimmick serves as a consultant for Astra Zeneca, Novartis, and Pfizer. She has received honoraria from the France Foundation, ASCO, and Astra Zeneca and research funding from Astra Zeneca and Roche.
REFERENCES
1. Hamaker ME, Jonker JM, de Rooij SE, et al. Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review. Lancet Oncol 2012;13:e437–e444. 2. Puts MT, Hardt J, Monette J, et al. Use of geriatric assessment for older adults in the oncology setting: a systematic review. J Natl Cancer Inst 2012;104:1133–1163. 3. Hurria A, Togawa K, Mohile SG, et al. Predicting chemotherapy toxicity in older adults with cancer: a prospective 500 patient multicenter study. J Clin Oncol 2010;28 [abstr 9001]. 4. Extermann M, Boler I, Reich R, et al. The Chemotherapy Risk Assessment Scale for High-age Patients (CRASH) score: design and validation. J Clin Oncol 2010;28 [abstr 9000]. 5. Saliba D, Elliott M, Rubenstein LZ, et al. The Vulnerable Elders Survey: a tool for identifying vulnerable older people in the community. J Am Geriatr Soc 2001;49:1691–1699. 6. Luciani A, Ascione G, Bertuzzi C, et al. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable elders survey-13. J Clin Oncol 2010;28: 2046–2050. 7. Kenis C, Schuermans H, Van Custem E, et al. Screening for a geriatric risk profile in older cancer patients: a comparative study of the predictive validity of three screening tools. Crit Rev Oncol Hematol 2009;72:22 [Suppl.].
10
EDI TOR IAL
8. Soubeyran P, Bellera C, Goyard J, et al. Validation of the G8 screening tool in geriatric oncology: The ONCODAGE project. J Clin Oncol 2011;29:550S. 9. Liuu E, Canouï-Poitrine F, Tournigand C, et al: Accuracy of the G-8 geriatric-oncology screening tool for identifying vulnerable elderly patients with cancer according to tumour site: The ELCAPA-02 study. J Geriatr Oncol. 10. Spyropoulou D, Pallis AG, Leotsinidis M, et al: Completion of radiotherapy is associated with the Vulnerable Elders Survey-13 score in elderly patients with cancer. J Geriatr Oncol.
11. Kane RL, Shamliyan T, Talley K, et al. The association between geriatric syndromes and survival. J Am Geriatr Soc 2012;60: 896–904. 12. Kane RL, Talley KMC, et al. Common Syndromes in Older Adults Related to Primary and Secondary Prevention. Rockville (MD); 2011. 13. Ellis G, Whitehead MA, O'Neill D, et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011:CD006211. 14. White HK, Cohen HJ. The older cancer patient. Nurs Clin North Am 2008;43:307–322.
