Use of a simplified geriatric evaluation in thoracic oncology
Introduction
In 2005, life-expectancy in metropolitan France was 83.7 years in females and 76.8 years in males, and this continues to increase [1]; at 75 years of age, life-expectancy is a further 13.2 years in females and 10.4 years in males. Approximately 25% of individuals aged 80 years will become centenarians. Epidemiological data indicate that in 2005 in France, 30% of cancers and 48% of deaths attributable to cancer occurred after the age of 75 years. According to the Institut de Veille Sanitaire, there were 30,651 cases of bronchial cancer in the general population in France in 2005, of which 7545 (24.6%) occurred in elderly patients aged ≥75 years. During the same year, there were 26,624 deaths attributable to bronchial cancer in the general population, of which 8753 (32.8%) were in patients aged 75 years or above [2].
The management of elderly patients with cancer may be complicated by various factors. Physiological modifications linked to age and co-morbidities can modify the presentation of some cancers, and affect tolerance to surgical, interventional, pharmacological or radiotherapy-based anti-cancer treatments. These considerations have led to the suggestion that geriatric evaluation may aid in the decision-making process relating to the management of elderly patients.
The Comprehensive Geriatric Assessment (CGA) is a reproducible procedure which enables the systematic collection of medical, psychological and social information on a patient [3], [4], [5]. Its main objective is to help establish a program of care in order to optimize treatment and subsequent management. The CGA includes an evaluation of cognitive function, state of mind, nutritional status, autonomy, and iatrogenic risk. It also includes an analysis of associated co-morbidities and of the patient's social situation [3], [4], [5]. Geriatric evaluation also permits the evaluation of factors of frailty which would make anti-cancer treatment, particularly chemotherapy, hazardous, non-effective or even deleterious in terms of survival or quality of life, and also provides information on whether a patient is likely to refuse specific treatment, motivated uniquely by age. Balducci and Extermann proposed an algorithm using data provided by geriatric evaluation to classify elderly patients with cancer into three main groups [6]. Group 1 included patients in good general state, termed “harmonious”, who did not have any serious or non-stabilized co-morbidity, and who presented with normal autonomy. Group 2 included patients termed “intermediate”. These patients were autonomous, but had significant co-morbidities; the desired benefit of using aggressive treatment such as surgery or chemotherapy for the tumor was not clearly defined. Finally, group 3 included patients termed “frail”, who had severe co-morbidities and a loss of autonomy or independence, and for whom aggressive treatment did not appear to be indicated. Geriatric evaluation therefore has the main objective of identifying factors of frailty that would make surgery, radiotherapy or chemotherapy difficult or, in contrast, acceptable for a given patient in the framework of personalized care. The decision to start a specific treatment should take into account the desired survival compared to the survival of a patient without neoplasia, while respecting the patient's quality of life, the possibility of toxic effects of the drugs used, and the possible deterioration of co-morbidities of the patient.
However, the CGA described in the literature is a long process which is not specifically targeted at neoplastic pathologies. In order to improve the management of elderly patients with bronchial cancer, we have developed a simplified geriatric evaluation (SGE), which is adapted to cancer and is quicker to perform than the CGA. This assessment enables a quick response to the increasing demands of clinical services. This report describes the SGE and its use in patients with thoracic cancer.
Section snippets
Material and methods
This was a retrospective study to describe the use of SGE in the management of patients with thoracic cancer treated at a specialized center. SGE was carried out by an interventional geriatric team (IGT) consisting of a geriatrician, a nurse and an ergotherapist.
Results
Between 2005 and 2007, 365 patients were admitted to our center for treatment of bronchial cancer. Fifty-seven of these patients, aged ≥75 years, underwent SGE (15.6%). The mean age of the 57 patients was 80.8 years, and more than one-third were female. Non-small cell bronchial cancer was the most prevalent histological type identified (89.5%). The characteristics of these patients are summarized in Table 2.
The results of SGE are shown in Table 3. All patients except two lived in their own home
Discussion
This study describes the feasibility and usefulness of SGE in thoracic oncology. The data shows that SGE provides complementary information to the simple determination of performance status. Overall, there seems to be a correlation between the SGE-based classification and the performance status. For instance, none of the patients in group 1 were classified as performance status 3 or 4, as compared to 12.5% of patients in group 2+, 66.6% of patients in group 2− and 80.0% of patients in group 3.
Conflict of interest
None declared.
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