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Table of Contents
LETTER TO EDITOR
Year : 2020  |  Volume : 3  |  Issue : 1  |  Page : 151-153

Authors' response to Vora and Rajpurohit


Department of Medical Oncology, Tata Memorial Center, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Date of Submission20-Jan-2020
Date of Acceptance20-Jan-2020
Date of Web Publication24-Feb-2020

Correspondence Address:
Kumar Prabhash
Department of Medical Oncology, Tata Memorial Center, Tata Memorial Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/CRST.CRST_32_20

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How to cite this article:
Noronha V, Joshi A, Patil VM, Prabhash K. Authors' response to Vora and Rajpurohit. Cancer Res Stat Treat 2020;3:151-3

How to cite this URL:
Noronha V, Joshi A, Patil VM, Prabhash K. Authors' response to Vora and Rajpurohit. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Apr 10];3:151-3. Available from: http://www.crstonline.com/text.asp?2020/3/1/151/279109



We thank Rajpurohit[1] and Vora[2] for their interest in our survey on the practice of geriatric assessment in older Indian patients with cancer[3] and the accompanying editorial.[4]

Dr. Rajpurohit has raised a very pertinent question about the age cutoff for geriatrics in India. As per the Indian Income Tax Act (1961), a senior citizen is defined as a person who is at least 60 years old.[5] As per the report by the Central Statistics Office of the Government of India entitled 'Elderly in India-2016,' during the period from 2009 to 2013, the life expectancy at birth was 65.8 years for men and 69.3 years for women. The average remaining length of life at age 60 years was 18 years (16.9 years in men and 19 years in women). Old age was, therefore, defined as 60 years and older.[6] Most developed countries use an age cutoff of 65 years and older, whereas in many developing countries, the age cutoff used is 60+ years. This brings us to the fundamental question of how we define old age. Although ageing is a physiological process and differs between individuals, the accepted societal definition is roughly the same as the retirement age in that population. In Africa, the age cutoff chosen was 50 years,[7] whereas in Japan, old age has been defined as 75 years and older.[8] Various other authors have also used the 60 years and over age cutoff for geriatric patients in India.[9],[10],[11],[12],[13],[14]

We agree with Dr. Rajpurohit's point on the need to modify the cognition assessment tools to consider illiterate patients. In our experience as well, the short geriatric cognition screening tools such as the mini-Cog test and the Blessed Orientation-Memory-Concentration Test are not appropriate for our patients, given the relatively high proportion of illiteracy and ethnic-cultural issues. To assess cognition in our geriatric oncology patients, we use the full version of the Mini-Mental Status Examination (MMSE) in literate patients and the Hindi version of the MMSE developed by Ganguli et al. for illiterate patients.[15]

Dr. Vora has rightly stated that the use of comprehensive geriatric assessment (CGA) tools has not been shown to affect survival. However, there are multiple other proven benefits of a CGA including identifying and treating problems that were not identified either on the initial evaluation or during follow-up, estimating the risk of toxicity from chemotherapy, predicting the likelihood of chemotherapy completion, predicting the risk of functional decline during treatment, overall improvement in quality of life (QOL),[16] and patient and caregiver satisfaction and communication.[17]

Dr. Vora questions whether it is possible that an older but physically fit patient may not require a CGA at all. We would like to reiterate that indeed every older patient would benefit from a CGA. The beauty of a CGA is that it evaluates the individual holistically and identifies vulnerabilities that may not be apparent during the routine clinical evaluation yet are extremely important and impact on QOL and toxicity/tolerance to therapy. These domains include cognition, nutrition, emotional well-being, comorbidities, socioeconomic issues, and polypharmacy/the use of potentially inappropriate medications, rather than only an assessment of physical function and falls which would be expected to be normal in this fit older patient.

Dr. Vora suggests that geriatric oncology should be a subspecialty of each individual tumor type or disease management group, rather than a superspecialty on its own. We totally agree that the oncology field is moving toward specialization for each of the disease types. We also agree that every oncologist requires the skills to take care of the older patient. However, there are certain common issues in geriatric oncology that occur across all the disease subtypes; these issues become more apparent with ageing and therefore are common problems and can be dealt with by a geriatric oncologist. The 'geriatric syndromes' consist of various conditions such as cognitive impairment, delirium, incontinence, falls, malnutrition, insomnia, fatigue, sensory impairments, gait disturbances, dizziness, depression, and pressure ulcers. These are relatively common in older adults and are not restricted to one particular organ system. Moreover, as of now, given the time constraints of doing a full CGA, and the lack of awareness of the need for a CGA, we firmly believe that geriatric oncology as a branch will help advance the care of our older patients with cancer. This view has been echoed by other authors as well.[18]

Dr. Vora has stated that we lack insights into the difference in the behavior of cancer in an older patient versus a younger one. Specifically, he has asked whether EGFR exon 19 deletion in a patient with non-small cell lung cancer confers the same predictions/prognostications in an 80-year old as compared to a 60-year old. Serendipitously, the original article and the accompanying editorial in the geriatric oncology section of the current issue of the journal answer this very question and we direct Dr. Vora to these articles.[19],[20]

Finally, we completely agree with Dr. Vora's statement that surveys are not solutions. However, surveys do serve an important purpose: they help measure the scope of the problem and may serve as roadmaps for the work ahead.[21] Recognizing the need for geriatric oncology assessment for our patients, we have started a dedicated geriatric oncology clinic at Tata Memorial Hospital (Mumbai, India), and we hope to answer a few of the questions that are facing the geriatric oncology community of India.[22]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Vora AD. The real issue with geriatric oncology. Cancer Res Stat Treat 2020;3:149-50.  Back to cited text no. 1
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2.
Rajpurohit A. Geriatric oncology in India: An unmet need. Cancer Res Stat Treat 2020;3:150-1.  Back to cited text no. 2
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Noronha V, Talreja V, Joshi A, Patil V, Prabhash K. Survey for geriatric assessment in practicing oncologists in India. Cancer Res Stat Treat 2019;2:232-6.  Back to cited text no. 3
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Available online from the Government of India Income Tax Department webpage at. Available from: https://www.incometaxindia.gov.in/Pages/faqs.aspx?k=FAQs+for+Senior+Citizens&c=17. [Last accessed on 2020 Jan 20].  Back to cited text no. 5
    
6.
Available from: http://mospi.nic.in/sites/default/files/publication_reports/ElderlyinIndia_2016.pdf. [Last accessed on 2020 Jan 20].  Back to cited text no. 6
    
7.
Available from: https://www.who.int/healthinfo/survey/ageingdefnolder/en/. [Last accessed on 2020 Jan 20].  Back to cited text no. 7
    
8.
Ouchi Y, Rakugi H, Arai H, Akishita M, Ito H, Toba K, et al. Redefining the elderly as aged 75 years and older: Proposal from the joint committee of Japan gerontological society and the Japan geriatrics society. Geriatr Gerontol Int 2017;17:1045-7.  Back to cited text no. 8
    
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Sneha SG, Simhadri K, Subeesh VK, Sneha SV. Predictors of adverse drug reactions in geriatric patients: An exploratory study among cancer patients. South Asian J Cancer 2019;8:130-3.  Back to cited text no. 9
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Shashidhar G, Sivaranjani K, Reddy Ammatalli NK. A study of comprehensive geriatric assessment in elderly patients in rural Bangalore. Int J Contemp Med Surg Radiol 2018;3:C17-20.  Back to cited text no. 10
    
11.
Rao S, Salins N, Deodhar J, Muckaden M. Developing a comprehensive cancer specific geriatric assessment tool. Indian J Cancer 2015;52:94-7.  Back to cited text no. 11
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Shet R, Shetty SR, MK Kumar MN, Yadav RD, SS. A study to evaluate the frequency and association of various mucosal conditions among geriatric patients. J Contemp Dent Pract 2013;14:904-10.  Back to cited text no. 12
    
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Yeole BB, Kurkure AP, Koyande SS. Geriatric cancers in India: An epidemiological and demographic overview. Asian Pac J Cancer Prev 2008;9:271-4.  Back to cited text no. 13
    
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Sarkar A, Shahi U. Assessment of cancer care in Indian elderly cancer patients: A single center study. South Asian J Cancer 2013;2:202-8.  Back to cited text no. 14
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15.
Ganguli M, Ratcliff G, Chandra V, Sharma S, Gilby J, Pandav R, et al. The hindi version of the MMSE: The development of a cognitive screening instrument for a largely illiterate rural elderly population in India. Int J Geriatr Psychiatr 1995;10:367-77.  Back to cited text no. 15
    
16.
Mohile SG, Dale W, Somerfield MR, Schonberg MA, Boyd CM, Burhenn PS, et al. Practical assessment and management of vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology. J Clin Oncol 2018;36:2326-47.  Back to cited text no. 16
    
17.
Mohile SG, Epstein RM, Hurria A, Heckler CE, Canin B, Culakova E, et al. Communication with older patients with cancer using geriatric assessment: A cluster-randomized clinical trial from the national cancer institute community oncology research program. JAMA Oncol 2019:1-9. doi: 10.1001/jamaoncol.2019.4728. [Epub ahead of print].  Back to cited text no. 17
    
18.
Vijaykumar DK, Anupama R, Gorasia TK, Beegum TR, Gangadharan P. Geriatric oncology: The need for a separate subspecialty. Indian J Med Paediatr Oncol 2012;33:134-6.  Back to cited text no. 18
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Kapoor A, Noronha V, Patil VM, Joshi A, Menon N, Chougule A, et al. The efficacy and safety of first-line therapy for the epidermal growth factor receptor mutant non-small-cell lung cancer in older versus younger patients: Pooled analysis of two randomized controlled trials. Cancer Res Stat Treat 2020;3:44-50.  Back to cited text no. 19
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Friedlaender A, Addeo A. Age is a fact and not an exclusion criterion in epidermal growth factor receptor treatment. Cancer Res Stat Treat 2020;3:85-6.  Back to cited text no. 20
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Noronha V. Making a case for cancer research in India. Cancer Res Stat Treat 2018;1:71-4.  Back to cited text no. 21
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22.
Noronha VM, Ramaswamy A, Talreja V, Patil V, Joshi A, Menon N, et al. The comprehensive geriatric profile of Indian oncology patients: Experience of a geriatric oncology clinic in a tertiary cancer center in India. J Geriatr Oncol 2019;10:S104.  Back to cited text no. 22
    




 

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