UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl) UvA-DARE (Digital Academic Repository) Decision making in geriatric oncology Hamaker, M.E. Link to publication Citation for published version (APA): Hamaker, M. E. (2012). Decision making in geriatric oncology. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. Download date: 17 Feb 2021
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UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)
UvA-DARE (Digital Academic Repository)
Decision making in geriatric oncology
Hamaker, M.E.
Link to publication
Citation for published version (APA):Hamaker, M. E. (2012). Decision making in geriatric oncology.
General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).
Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, statingyour reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Askthe Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,The Netherlands. You will be contacted as soon as possible.
51%/97%. However, even in case of the highest sensitivity, the negative predictive value
was only 60%.
Conclusion: G8 and TRST demonstrated the highest sensitivity for frailty, but had a poor
specificity and negative predictive value. These findings suggest that for now, it may be
beneficial for all older cancer patients to receive a complete geriatric assessment as the
currently available frailty screening tools have insufficient discriminative power in
selecting patients for further assessment.
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Frailty screening tools in geriatric oncology
Introduction Although malignant tumours occur at all ages, cancer disproportionately strikes individuals
aged 65 years and older,1 and the number of elderly cancer patients will increase
substantially in the coming decades as a result of increasing life expectancy and ageing of
the population. Cancer specialists are faced with the challenge of determining the optimal
treatment for these patients, with their heterogeneity in comorbidity, physical reserve,
disability and geriatric conditions.
For this purpose, two concepts of geriatric medicine are being incorporated in geriatric
oncology: the concept of frailty and the comprehensive geriatric assessment. Frailty is
considered as a state of decreased physiological reserves, arising from cumulative deficits
in multiple physiological systems, resulting in a diminished resistance to stressors.2,3 As
cancer and its treatment both form significant stressors, requiring patients to encroach on
their reserves, the concept of frailty appears particularly relevant for older cancer
patients. As yet, there is no consensus on its operationalization. The original definition of
frailty as formulated by Fried et al. focuses primarily on physical weakness and wasting,
but many other definitions and criteria have been postulated, incorporating different
aspects of ageing that contribute to diminishing reserves.4‐6
In geriatric oncology, the comprehensive geriatric assessment (CGA) is used to detect
disabilities and geriatric conditions that potentially contribute to frailty. A CGA is a
systematic procedure used to objectively appraise the health status of older people,
focusing on somatic, functional and psychosocial domains,7 and its value in geriatric
medicine has been proven extensively.8 However, as a CGA is time‐consuming, research is
now focusing on screening tools to separate fit older cancer patients that are able to
receive standard cancer treatment based upon the complete treatment schedule, from
vulnerable patients that should subsequently receive a CGA to guide tailoring of their
treatment regimen.9
In this context, the sensitivity of a frailty screening tool is considered to be of prime
importance; this will allow the treating physician to trust that frail patients will correctly
be identified by the screening tool.10,11 However, to optimize the time‐saving potential of a
two‐stepped approach, a good specificity of the screening tool is also required to ensure
that the number of fit patients incorrectly identified as frail on the screening tool and thus
unnecessarily receive a CGA, will be limited. To determine which screening tool best
meets both criteria, we performed a systematic review to assess the sensitivity and
specificity of frailty screening tools in predicting the presence of impairments on a CGA.
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Methods
Search strategy and selection criteria Our aim was to identify cohort studies which investigated the association between an
established frailty screening tool and a more complete CGA in cancer patients,
independent of age, cancer type or stage of disease.
The following search was performed on December 28th 2011, in both Medline and
Embase: ((("Geriatric Assessment"[Mesh]) OR (gfi[tiab] OR groningen frailty index[tiab])
OR (tfi[tiab] OR tilburg frailty index[tiab]) OR (isar[tiab] OR identification seniors at
risk[tiab]) OR (G8[tiab]) OR (fried[tiab]) OR (barber[tiab]) OR (edmonton[tiab]) OR
(saop[tiab] OR senior adult oncology program[tiab]) OR (triage risk screening tool[tiab])
OR (runciman rowland questionnaires[tiab]) OR (ves 13 OR vulnerable elderly survey[tiab])
OR (abbreviated comprehensive geriatric assessment[tiab] OR acga[tiab]) OR (geriatric
assessment*[tiab])) OR ((screening tool*[tiab]) AND (elderl*[tiab] OR geriatri*[tiab] OR old
age[tiab]))) AND (("Neoplasms"[Mesh]) OR (neoplasm*[tiab] OR cancer*[tiab] OR
tumour[tiab] OR tumours[tiab] OR tumor[tiab] OR tumors[tiab] OR oncolog*[tiab] OR
malignan*[tiab])).
No language limits or date ranges were applied.
In addition, conference abstracts of the scientific meetings from 2007‐2011 of the
American Society of Clinical Oncology (ASCO), European Society of Medical Oncology
(ESMO), International Society of Geriatric Oncology (SIOG), American Geriatric Society
(AGS) and European Geriatric Medicine Society (EUGMS) were hand‐searched for studies
on CGA in cancer patients to identify additional eligible studies.
We defined a frailty screening tool as a tool designed to assess the concept of frailty,
irrespective of the population or purpose for which this tool is intended. A CGA was
defined as an assessment using validated assessment tools investigating at least three of
the following domains: cognitive function, mood/depression, nutritional status, activities
of daily living (ADL), instrumental activities of daily living (IADL), comorbidity,
polypharmacy, mobility/falls, and/or social support. Studies were not eligible for inclusion
in this review if the study cohort included non‐cancer patients. We also excluded studies if
the CGA was only performed in a subgroup of patients selected by the outcome of the
frailty screening tool(s). For studies which included more than one screening tool,
eligibility was assessed separately for each tool.
The titles and abstracts of all studies retrieved by the searches were assessed by one
reviewer (MH) to determine which warrant further examination. All potentially relevant
articles were subsequently screened as full text by two authors (MH and JJ). If only an
abstract was available, an effort was made to find the final report of the study by
searching Embase and Medline using the names of first, second and/or final authors as
186
Frailty screening tools in geriatric oncology
well as key words from the title. Also, in case of insufficient data in the original
manuscript, the authors were contacted for additional information, for example on the
ols used in the geriatric assessment or the cut‐off value of the screening tool. to
Data extraction Data regarding study design and results were independently extracted by two
investigators (MH and JJ) for each eligible study. Items that were extracted are the type of
study, study setting, study population (cancer type, cancer stage, cancer treatment, the
timing of screening), the frailty screening tools used including cut‐off values, the content
of the CGA and the assessment tools used, as well as the outcomes in terms of association
etween frailty screening tool and CGA. b
Quality assessment The methodological quality of each of the studies was also assessed independently by two
reviewers (MH and JJ), using the QUADAS‐2 tool (Quality Assessment of Studies of
Diagnostic Accuracy included in Systematic reviews, Appendix 1) as developed and revised
by Whiting et al.12,13 Disagreements among the reviewers were discussed during a
consensus meeting and in case of persisting disagreement, the assistance of a third
reviewer (BvM) was enlisted.
To address the suitability of the CGA to detect frailty, we used the definition formulated
by the International Society of Geriatric Oncology, which states that at minimum, a CGA
for older cancer patients should include assessment of functional status, cognition and
ood.7 m
Data synthesis and analysis We summarized the study results to describe our main outcomes of interest. If necessary,
sensitivity, specificity, positive and negative predictive values were calculated based on
the results listed in the publication, or – in case of insufficient published information – on
additional data obtained from the authors.
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Chapter 12
Table 1: Studies on the association between frailty assessment and comprehensive geriatric assessment
Publication Patients
Author
Publication year
Abstract(A) or full
text (F)
Setting/departm
ent
Study population
Number of patients
% m
ale
Median age
in years
(range)
Baitar14‐16
2011 A Unclear Various cancer types 135 ? 77 (66‐97)
Kellen17 2010 F Medical
oncology/ general practice
Various cancer types, irrespective of stage of disease or treatment
113 60% 77 (SD 4)
Kenis18 2009 A Medical
oncology Newly diagnosed cancer or progressive disease, during admission
140 ? 76.5 (SD 5.1)
Kenis19 2011 A Medical
oncology Various cancer types, patients considered for start of chemotherapy
843 37% 76.9 (SD 5.1)
Kristjansson20 2008 A Surgery Pre‐operative patients with
colorectal cancer considered for surgery
74 46% 80 (71‐94)
Luciani21 2010 F Medical
oncology Various cancer types, prior to start first‐line chemotherapy
419 55% 76 (70‐97)
Mohile22,23
2007 F Medical oncology
Prostate cancer patients receiving hormonal treatment
50 100% 78 (70‐92)
Molina‐Garrido
24‐26
2010 F Medical oncology
Early stage breast cancer prior to start chemotherapy
41 0% 74.5 (SD 5.1)
Molina‐Garrido
27
2011 A Medical oncology
Unclear 58 ? Not stated
Monfardini28 2010 A Medical
oncology Patients with breast cancer newly referred to medical oncologist
150 ? 76 (70‐94)
Owusu29 2010 F Medical
oncology Various cancer types, first visit to outpatient clinic with newly diagnosed cancer
117 18% 72 (IQR 69‐80)
Pottel30‐32
2011 F Radiotherapy Head and neck cancer patients prior to start radiotherapy
51 84% 72 (65‐86)
Soubeyran33 2008 A Medical
oncology Various cancer types, prior to start of first‐line chemotherapy
364 59% 77 (70‐99)
Soubeyran34,3
5
2011 A Medical oncology
Unclear 1425 30% 78.2 (70‐98)
* A more detailed overview of the content of the geriatric assessment can be found in Appendix 3
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Frailty screening tools in geriatric oncology
Table 1: Studies on the association between frailty assessment and comprehensive geriatric assessment
Screening tool Geriatric assessment (CGA)*
Frailty screening
tool used (cut‐off)
Cognition
Mood
ADL
IADL
Nutritional status
Social support
Comorbidity
Polypharmacy
Mobility/falls
Cut‐off value for
frailty on CGA (nr of
impairm
ents unless
otherw
ise stated)
GFI (4+) G8 (≤14)
+ + + + + + + + 2+
aCGA (1+)** VES13 (3+) GFI (4+)
+ + + + Cognitive impairment or 2+ more other impairments
GFI (4+) G8 (≤14) TRST (1+/2+)
+ + + + + + 2+
TRST (1+) G8 (≤14)
+ + + + + + + + 2+
Fried (3+)
+ + + + + + 1+
VES‐13 (3+)
+ + + + + + 1+
VES‐13 (3+)
+ + + + + + 2+
VES‐13 (3+) Barber (1+)
+ + + + + + + 2+
Fried (3+) VES‐13 (3+)
+ + + + + + + 2+
VES‐13 (3+)
+ + + + + + ADL‐dependent, 3+ comorbidities or 1+ severe comorbidities
VES‐13 (3+)
+ + + + + + + + 2+
G8 (≤14) VES‐13 (3+)
+ + + + + + 2+
G8 (≤14)
+ + + + + + + 1+
G8 (≤14) VES‐13 (3+)
+ + + + + + + 1+
** In the original aCGA publications, screening yielded subscores per domain but not an overall score. This cut‐off value in this study was defined by its researchers, based on the aggregated results of the subscores. GFI Groningen Frailty Index, G8 Geriatric 8, aCGA abbreviated comprehensive geriatric assessment, VES13 Vulnerable Elders’ Survey‐13, TRST Triage risk screening tool, (I)ADL instrumental activities of daily living
189
Chapter 12
Results
Characteristics of included studies The literature search yielded 3943 citations (1769 from Medline and 2174 from Embase)
and an additional 497 studies on geriatric assessment in cancer patients were identified in
conference abstracts. For one of the identified abstracts, the full text publication came out
after the search date; however, as this contained additional, useful information, we
included this manuscript as well. After exclusion of 1279 duplicates and 3139 studies for
other reasons (Appendix 2), a total of 22 publications from 14 studies were included in this
review.14‐35
The characteristics of these 14 studies are summarized in Table 1. The first publication is in
2007 but most were published in the past two years.14‐35 For seven studies, full text
reports were available,17,21‐26,29‐32 but for the seven remaining studies, conference
abstracts were the only publications.14‐16,18‐20,27,28,33‐35 Median sample size was 117 patients
(range 41‐1425). Median age of included patients ranged from 72 to 80 years.14‐35 All but
two studies20,30‐32 were performed in the medical oncology department. Half of the studies
included patients with various cancer types17‐19,21,27,29,33 while two did not elaborate on the
type of patients that were included,27,34,35 the other five studies focused on one cancer
type only (two on breast cancer,24‐26,28 and one each on prostate cancer,22,23 colorectal
cancer20 and head and neck cancer30‐32).
Seven different frailty screening tools were assessed: Vulnerable elders survey‐135 was the
most frequently examined (VES‐13, 9 studies) followed by the Geriatric 836 (G8, six
* no overall scoring of aCGA is available; subscores for each geriatric domain are calculated. GFI Groningen Frailty Index, G8 Geriatric 8, VES‐13 Vulnerable elders’ survey‐13, aCGA abbreviated comprehensive geriatric assessment, TRST triage risk screening tool; (I)ADL (instrumental) activities of daily living
in eight studies.14‐16,18,19,22‐27,29‐32 The remaining two studies applied other definitions,
assigning different weights to the various assessed conditions (Table 1).17,28
Study populations showed a wide variation in the prevalence of frailty as diagnosed by the
CGA; a median of 68% of patients was considered frail (range 28‐94%, Table 3).14‐35 This
wide range cannot be explained solely by differences in the cut‐off used for the definition
of frailty on CGA, as in studies using the cut‐off of 1+ prevalence of frailty ranged from 28
to 80%20‐22,33‐35 while in studies using a cut‐off of 2+, the range was 43% to 88%.14‐16,18,19,22‐
27,29‐32 According to frailty screening tools, the median prevalence of frailty was 49% (range
12‐83%).14‐35
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Chapter 12
Quality assessment Results of the quality assessment can be found in Figure 1. Reviewer agreement was over
95% for all aspects. For patient selection, the risk of bias was generally considered low,
and little concerns existed about the applicability of selection criteria. Due to the lack of
information on the independent scoring of the frailty screening tool and the CGA, the risk
of bias was frequently unclear for both the index test as well as the reference test.
Variation in the content of the CGA resulted in some concerns about the applicability of
study results and may also have introduced risk of bias. Flow and timing of the studies
yielded few concerns. Full results of the quality assessment can be found in Appendix 1b.
Figure 1: Quality assessment of included studies, using the QUADAS‐2 assessment tool (Appendix 1a).
13 The
complete assessments per study can be found in Appendix 1b.
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Frailty screening tools in geriatric oncology
Frailty screening tools vs. comprehensive geriatric assessment Table 3 gives an overview of the sensitivity and specificity of the frailty screening tools
compared to frailty as detected by CGA, while Figure 2 demonstrates the relationship
between sensitivity and false‐positives per screening tool. For the VES‐13, sensitivity
ranged from 39% to 88% with a median of 68%.17,21‐32,34,35 Thus, a median of 32% of frail
patients were not recognized as frail by the VES‐13. The specificity was better, ranging
from 62% to 100%, with a median of 78%. Thus, the VES‐13 yielded 22% false‐positives.
For the G8, the sensitivity ranged from 77% to 92%, with a median of 87% but the
specificity ranged from 39% to 75%, with a median of 61%.14‐16,18,19,30‐35 The TRST (using a
cut‐off of 1+) showed a sensitivity of 91% with a specificity of between 43 and 50%.18,19
For the GFI, sensitivity ranged from 39% to 62%, and the specificity was between 69% and
87%.14‐18 For the Fried frailty criteria, the sensitivity was between 25% and 37%, with a
specificity of 86% to 96%.20,27
Table 3: Sensitivity and specificity of frailty screening tools for outcome of (summarized) comprehensive geriatric assessment (CGA)
Interestingly, as the prevalence of frailty in most study populations was high, even the
screening tools with the highest sensitivity to frailty still yielded negative predictive values
of around 60% (Table 3). This means that four out of every ten patients considered fit
fter frailty screening, will be diagnosed as frail after CGA. a
Frailty screening tools vs. individual geriatric conditions Although frailty screening tools are generally used to predict overall frailty, a few studies
have addressed the association between these tools and individual geriatric conditions
(Table 4); four studies addressed the latter association for VES‐13,17,22,23,29‐32 while one
study each looked at aCGA,17 GFI17 and G8.30‐32 Comparison of results is compromised,
however, by the different methods of presentation of the data.
Overall, VES‐13 appears to be most strongly associated with ADL and IADL functioning
(area under the curve (AUC) between 0.81 and 0.91, sensitivity between 67% and 83% and
specificity between 61% and 89%.)17,22,23,29‐32 Association between VES‐13 and cognitive
disorders, impaired mobility and malnutrition was fair (AUC 0.79‐0.81, 0.78‐0.87 and 0.78
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Frailty screening tools in geriatric oncology
Table 4: Association between screening tools and individual geriatric domains
aCGA abbreviated comprehensive geriatric assessment, G8 Geriatric 8, GFI Groningen frailty index, VES‐13 Vulnerable Elders Survey‐13; AUC area under the curve
respectively) 22,23,29‐32 G8 showed a strong association with malnutrition (AUC 0.95), but
was of lesser value for predicting the presence of other geriatric conditions. 30‐32 aCGA
showed a strong association with ADL and IADL impairment (sensitivity 97% and 92%,
specificity 47% and 69% respectively), but the sensitivity for cognitive dysfunction or
depressive symptoms was low (23% and 69% respectively). 17 GFI demonstrated poor
sensitivity for functional impairment (ADL impairment 47%, IADL impairment 39%) but
asonable specificity (76% and 86% respectively). 17 re
Discussion A useful frailty screening tool in geriatric oncology should have a high sensitivity, thus
allowing the assessor to trust that those patients deemed fit actually are fit, and a
sufficient specificity so that the time‐consuming process of a full CGA is optimally
utilized.10,11,39 In this systematic review on the discriminative power of frailty screening
tools for outcome of full CGA, we found that those tools with the highest sensitivity lacked
specificity and vice versa. In addition, even for the screening tools with the highest
sensitivity, the negative predictive value (i.e. the proportion of patients considered fit on
the screening tool that were also considered fit after full CGA) was around 63%, meaning
over a third of patients were unjustly considered fit after frailty screening.
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Chapter 12
Given the content of the frailty screening tools and the population and purpose for which
they were developed (Table 2), the lack of sensitivity of some of these screening tools
when used to predict outcome of CGA is hardly surprising. For example, the VES‐135 and
Fried frailty criteria6 focus strongly on functional status (Table 2). Therefore, it is not
surprising that these tools are not very successful in identifying impairments in other
geriatric domains. For other screening tools, such as the GFI, the lack of discriminative
power could be explained by the fact that they were designed to diagnose frailty in a
different patient population than that in which it is being used in geriatric oncology (Table
2). In fact, most of the screening tools that are being used in geriatric oncology were not
designed or validated for this particular setting; only the G8 and aCGA developed
specifically for use in older cancer patients. As the aCGA was designed to identify which
individual geriatric domains require further assessment, the lack of sensitivity for overall
frailty (median 51%) as well as for two of the four individual domains for which it was
designed (Table 4) is disappointing. Ultimately, the G8 and the TRST ‐ developed to assess
functional impairment in older patients admitted to the emergency department37 – had
the highest sensitivity for frailty on CGA (87 and 91% respectively) but both lacked
specificity (61% and 45% respectively).
Thus, no screening tool currently used in geriatric oncology combined adequate sensitivity
and specificity. In addition, for tools with the highest sensitivity, the percentage of
patients diagnosed as frail after screening was around 70%, and – based on the negative
predictive value of these tools – one‐third of the remaining 30% was incorrectly diagnosed
as fit. Considering these findings, the question rises whether there is any benefit in a two‐
stepped approach in which a CGA is preceded by a screening tool. The time‐saving
potential of this approach will be limited if the prevalence of frailty is high, and potentially
does not outweigh the risk of incorrectly identifying patients as fit and delivering care‐as‐
usual where a more cautious approach would have been better.
Another aspect for which the use of a screening tool prior to CGA could be beneficial is to
identify which geriatric domains require further assessment; this could save time by
allowing the CGA to be limited to those domains only. Several studies in this review
addressed this issue (Table 4); however, the available data are limited. In addition, these
studies examined the association between the entire screening tool and a specific geriatric
domain while it would be more useful to assess the sensitivity of each individual screening
question for the presence or absence of the specific geriatric conditions that the question
inquires after. This aspect warrants further exploration in future research.
This systematic review provides a valuable overview of all currently available evidence on
the use of frailty screening tools in geriatric oncology but it also has several limitations.
First of all, we limited our search to studies performed in older cancer patients, thus
excluding available evidence from other patient populations. However, the prevalence of
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Frailty screening tools in geriatric oncology
geriatric conditions and frailty will differ greatly in various contexts and the discriminative
power of frailty screening tools should therefore be assessed in the context that it will be
used in. Another limitation of this review is that no full text reports have been published
for half of the included studies, and we had to rely on conference abstracts as the only
source of information on the execution and results of the study. In particular, this limited
our ability to analyse the predictive value of the frailty screening tools for individual
domains. Moreover, the content of the CGA differed considerably between studies, as did
the cut‐off value that was used to define frailty. The definition of frailty that is used will
influence the prevalence of frailty in a study population and similarly the sensitivity and
specificity of screening tools in predicting that frailty. This lack of golden standard for
assess frailty assessment decreased the comparability of study results and subsequently
hampered the execution of a formal meta‐analysis, thus leaving uncertainty about the
relative quality of the different screening tools for detecting frailty in older cancer
patients. In 2005, the International Society of Geriatric Oncology recommended that, at
minimum, frailty assessment for older cancer patients should include an evaluation of
functional status, cognition and mood.39 In wake of growing evidence that geriatric
conditions, such as nutritional status, polypharmacy, comorbidity and social support may
also be significant for older cancer patients, perhaps an update of these recommendations
should be undertaken. Moreover a consensus in the scales to use, including their cut‐off
values, would result in greater uniformity in clinical practice and research, and allow for
better comparison between studies and patient populations.
Ultimately, establishing whether a patient is fit or frail is not a goal in itself, but a method
for optimizing and tailoring oncologic and non‐oncologic treatment in elderly cancer
patients. Therefore, future research should focus on a more elaborate exploration of the
value of frailty and individual geriatric conditions for predicting and improving clinical
utcomes such as quality of life, survival, treatment tolerance and functional decline. o
In conclusion, although the Geriatric 8 and Triage Risk Screening Tool demonstrated the
best sensitivity for frailty on full CGA in older cancer patients, they had a poor specificity
and negative predictive value. Perhaps it will be possible to develop targeted screening
tools with better sensitivity and specificity once the relative importance of individual
geriatric domains and the benefit of appropriate interventions and follow‐up are fully
elucidated in this patient population. Until such a time, it may be beneficial for all older
patients to receive a complete geriatric assessment, since the two‐stepped approach –
using frailty screening tools to select patients for CGA – has insufficient discriminative
power.
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Chapter 12
Appendix 1a: Quality Assessment of studies of Diagnostic Accuracy included in Systematic reviews‐2 (QUADAS‐
2) tool12,13
Domain 1: Patient Selection Risk of Bias: Could the selection of patients have introduced bias? 1: Was a consecutive or random sample of patients enrolled? 2: Was a case–control design avoided? 3: Did the study avoid inappropriate exclusions? Applicability: Are there concerns that the included patients and setting do not match the review question? Domain 2: Index Test Risk of Bias: Could the conduct or interpretation of the index test have introduced bias?
1: Were the index test results interpreted without knowledge of the results of the reference standard?
2: If a threshold was used, was it prespecified? Applicability: Are there concerns that the index test, its conduct, or its interpretation differ from the review question? Domain 3: Reference Standard Risk of Bias: Could the reference standard, its conduct, or its interpretation have introduced bias? 1: Is the reference standard likely to correctly classify the target condition?
For this purpose, we used the definition formulated by the International Society of Geriatric Oncology, which states that at minimum, a CGA for older cancer patients should include assessment of functional status, cognition and mood.
40 2: Were the reference standard results interpreted without knowledge of the results of the index test?
Applicability: Are there concerns that the target condition as defined by the reference standard does not match the research question? Domain 4: Flow and Timing Risk of Bias: Could the patient flow have introduced bias? 1: Was there an appropriate interval between the index test and reference standard? 2: Did all patients receive the same reference standard? 3: Were all patients included in the analysis?
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Frailty screening tools in geriatric oncology
Appendix 1b: Overview of quality assessment according to the QUADAS‐2 tool per study
Exclusion n= 3139 Not original research n= 747 Not oncology n= 444 No comprehensive geriatric assessment (CGA) n= 1340 No screening tool n= 566 No association screening tool with CGA n= 22 Non‐cancer patients included n= 8 CGA not performed in all patients n= 3 Substantial overlap with another publication n= 2 Insufficient data for analysis n= 5 Retrospective tool development n= 2
Inclusion: 22 publications from 14 studies
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Chapter 12
Appendix 3: Complete overview of comprehensive geriatric assessment per study
Author
Frailty screening tool
used (cut‐off)
Cognition
Mood
ADL
IADL
Nutrition
Mobility/falls
Social
Comorbidity
Polypharmacy
Others
Baitar (2011)
14‐16
GFI (4+) G8 (≤14)
MMSE GDS Katz Lawton TUG MOS‐ SSS
Charlson
Kellen (2010)
17
aCGA (1+) VES13 (3+) GFI (4+)
MMSE GDS Barthel Lawton
Kenis (2009)
18
GFI (4+) G8 (≤14) TRST (1+/2+)
MMSE GDS Katz + + CIRS‐G + Age
Kenis (2011)
19
TRST (1+) G8 (≤14)
MMSE GDS Katz Lawton MNA Fall history
Charlson + Fatigue (Mob‐T)
Kristjansson (2008)
20
Fried (3+) MMSE GDS Barthel MNA CIRS‐G +
Luciani (2010)
21
VES‐3 (3+) MMSE Katz Lawton MNA CIRS‐G + Social status
Mohile (2007)
22,23
VES‐3 (3+) SPMSQ, Pfeiffer
Katz Lawton MOS‐SSS
Charlson + SPPB
Molina‐ Garrido (2010)
24‐26
VES‐3 (3+) Barber (1+)
Pfeiffer Barthel Lawton NSI Gijon Charlson +
Molina‐ Garrido (2011)
27
Fried (3+) VES‐13 (3+)
Pfeiffer Barthel Lawton NSI Gijon Charlson +
Monfardini (2010)
28
VES‐3 (3+)
MMSE GDS Katz Lawton CIRS‐G +
Owusu (2010)
29
VES‐3 (3+)
MMSE GDS Katz Lawton TUG, fall history
MOS‐SSS
Charlson + Visual/hearing impairment
Pottel (2011)
30‐32
G8 (≤14) VES‐3 (3+)
MMSE GDS Katz Lawton MNA Tinetti CIRS‐G
Soubeyran (2008)
33
G8 (≤14) MMSE GDS Katz Lawton MNA TUG CIRS‐G Quality of life (QLQ‐C30)
Soubeyran (2011)
34,35
G8 (≤14) VES‐3 (3+)
MMSE GDS Katz Lawton MNA TUG CIRS‐G
GFI Groningen Frailty Index, G8 Geriatric 8, VES‐13 Vulnerable elders survey‐13, aCGA abbreviated comprehensive geriatric assessment, TRST triage risk screening tool + assessed without the use of a specific assessment tool (I)ADL instrumental activities of daily living, MMSE mini mental state examination, SPMSQ short portable mental status questionnaire, GDS geriatric depression scale, MNA mini nutritional assessment, NSI nutrition screening initiative TUG Timed up and go, MOS‐SSS medical outcomes study – social support survey CIRS‐G cumulative illness rating scale‐geriatric, SPPB short physical performance battery QLQ‐C30 quality of life questionnaire
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References 1. Muss HB. Cancer in the elderly: a societal perspective from the United States. Clin Oncol (R Coll Radiol )
2009;21:92‐98. 2. Ferrucci L, Guralnik JM, Studenski S et al. Designing randomized, controlled trials aimed at preventing or
delaying functional decline and disability in frail, older persons: a consensus report. J Am Geriatr Soc 2004;52:625‐634.
3. Rockwood K, Mitnitski A. Frailty defined by deficit accumulation and geriatric medicine defined by frailty. Clin Geriatr Med 2011;27:17‐26.
4. Slaets JP. Vulnerability in the elderly: frailty. Med Clin North Am 2006;90:593‐601. 5. Saliba D, Orlando M, Wenger NS et al. Identifying a short functional disability screen for older persons. J
Gerontol A Biol Sci Med Sci 2000;55:M750‐M756. 6. Fried LP, Tangen CM, Walston J et al. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci
Med Sci 2001;56:M146‐M156. 7. Extermann M, Aapro M, Bernabei R et al. Use of comprehensive geriatric assessment in older cancer
patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005;55:241‐252.
8. Ellis G, Whitehead MA, O'Neill D et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev 2011;7:CD006211.
9. Maas HA, Janssen‐Heijnen ML, Olde Rikkert MG, Machteld Wymenga AN. Comprehensive geriatric assessment and its clinical impact in oncology. Eur J Cancer 2007;43:2161‐2169.
10. Molina‐Garrido MJ, Guillen‐Ponce C. Overvaluation of the vulnerable elders survey‐13 as a screening tool for vulnerability. J Clin Oncol 2011;29:3201‐3202.
11. Falci C, Brunello A, Monfardini S. Detecting functional impairment in older patients with cancer: is vulnerable elders survey‐13 the right prescreening tool? An open question. J Clin Oncol 2010;28:e665‐e666.
12. Whiting P, Rutjes AW, Reitsma JB et al. The development of QUADAS: a tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25.
13. Whiting PF, Rutjes AW, Westwood ME et al l. QUADAS‐2: a revised tool for the quality assessment of diagnostic accuracy studies. Ann Intern Med 2011;155:529‐536.
14. Baitar A, Van Fraeyenhove F, Galdermans D et al. Evaluation of the groningen frailty indicator as a screening tool for frailty in older cancer patients (PTS). European Journal of Cancer 2011:46:S282.
15. Baitar A, Vandebroek A, De DE et al. Evaluation of the g8 questionnaire as a screening tool for frailty in older cancer patients (PTS). European Journal of Cancer 2011;47:S275.
16. Schrijvers D, Baitar A, de Vos M et al P. Evaluation of the Groningen Frailty Index as a screening tool in elderly patients (PTS): an interim analysis. Annals of Oncology 2010;21(Suppl 8):556PD.
17. Kellen E, Bulens P, Deckx L et al. Identifying an accurate pre‐screening tool in geriatric oncology. Crit Rev Oncol Hematol 2010;75:243‐248.
18. Kenis C, Schuermans H, van Cutsem 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(suppl 1):S22.
19. Kenis C, Decoster L, Vanpuyvelde K et al l. Comparison of two screening tols in older cancer patients. J Geriatr Oncol 2011;2(suppl 1):S39.
20. Kristjansson SR, Jordhoy MS, Nesbakken A, Wyller TB. A comparison of two methods to measuring frailty in elderly patients with colorectal cancer. Crit Rev Oncol Hematol 2008;68(suppl1):S30.
21. Luciani A, Ascione G, Bertuzzi C et al l. Detecting disabilities in older patients with cancer: comparison between comprehensive geriatric assessment and vulnerable elders survey‐13. J Clin Oncol 2010;28:2046‐2050.
22. Mohile SG, Bylow K, Stadler WW, Rodin M. A pilot study of the Vulnerable Elders Survey (VES‐13) as compared to Comprehensive Geriatric Assessment (CGA) to examine geriaric domains in elder prostate cancer patients at risk for decline. J Clin Oncol 2006;24(suppl):8539.
23. Mohile SG, Bylow K, Dale W et al. A pilot study of the vulnerable elders survey‐13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007;109:802‐810.
24. Molina‐Garrido MJ, Guillen‐Ponce C. Comparison of two frailty screening tools in older women with early breast cancer. Crit Rev Oncol Hematol 2011;79:51‐64.
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25. Molina‐Garrido M, Guillen‐Ponce C, Santiago J et al. Barber test as a screening tool in multidimensional geriatric evaluation in elderly women with early breast cancer. J Clin Oncol 2009;155:e20645.
26. Molina‐Garrido MJ, Guillen‐Ponce C, Guirado‐Risueno M et al Usefulness of the Barber test is compared with the comprehensive geriatric assessment for identifying disability in outpatients older than 65 years with breast cancer who receive chemotherapy. Crit Rev Oncol Hematol 2008;68(suppl2):S33.
27. Molina‐Garrido M, Guillen‐Ponce C, Munoz M et al. A comparison of the fried criteria and the VES‐13 questionnaire as screening instruments for frail elderly patients diagnosed with cancer. European Geriatric Medicine 2011;2(suppl 1):S34.
28. Monfardini S, Basso U, Fiduccia P et al. Can the short screening test Vulnerable Elders Survey 13 (VES‐13) substitute for the time‐consuming comprehensive geriatric assessment (CGA) to identify vulnerable/frail elderly breast cancer patients? Journal of Clinical Oncology 2010;28.
29. Owusu C, Koroukian SM, Schluchter M et al. Screening older cancer patients for a Comprehensive Geriatric Assessment: A comparison of three instruments. J Geriatr Oncol 2011;28:121‐129.
30. Pottel L, Boterberg T, Pottel H et al. Determination of an adequate screening tool for identification of vulnerable elderly head and neck cancer patients treated with radio(chemo)therapy. J Clin Oncol 2011;di:10.1016/j/jgo.2011.11.006.
31. Debruyne PR, Boterberg T, Pottel H et al. Can the Vulnerable Elders Survey‐13 and/or the G8 adequatley identify elderly patients with head and neck cancer in need of a comprehensive geriatric assessment? J Clin Oncol 2011:e19670.
32. Pottel L, Boterberg T, Pottel H et al l. Could the combined test "VES‐13 + (max‐G8) represent an interesting alternative screening tool for identification of potential vulnerable elderly head and neck cancer patients? J Geriatr Oncol 2011;2(suppl1):S21.
33. Soubeyran P, Bellera CA, Gregoire F et al. Validation of a screening test for elderly patients in oncology. J Clin Oncol 2008;26(15S):20568.
34. Soubeyran P, Bellera C, Goyard J et al. Validation of the G8 geriatric screening tool for elderly cancer patients and comparions with the VES‐13: final results of the ONCODAGE project. J Geriatr Oncol 2011;2(S1):S17.
35. 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(15S):9001.
36. Bellera C, Rainfray M, Mathoulin‐Pelissier S, Soubeyran I. Validation of a screening tool in geriatric oncology: the Oncodage project. Crit Rev Oncol Hematol 2008;68(suppl):O2.
37. Meldon SW, Mion LC, Palmer RM et al. A brief risk‐stratification tool to predict repeat emergency department visits and hospitalizations in older patients discharged from the emergency department. Acad Emerg Med 2003;10:224‐232.
38. Overcash JA, Beckstead J, Moody L et al. The abbreviated comprehensive geriatric assessment (aCGA) for use in the older cancer patient as a prescreen: scoring and interpretation. Crit Rev Oncol Hematol 2006;59:205‐210.
39. Extermann M, Aapro M, Bernabei R et al. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005;55:241‐252.
40. Extermann M, Aapro M, Bernabei R et al. Use of comprehensive geriatric assessment in older cancer patients: recommendations from the task force on CGA of the International Society of Geriatric Oncology (SIOG). Crit Rev Oncol Hematol 2005;55:241‐252.
