|GERIATRIC ONCOLOGY SECTION
|Year : 2020 | Volume
| Issue : 2 | Page : 208-217
Initial experience of a geriatric oncology clinic in a tertiary cancer center in India
Vanita Noronha1, Anant Ramaswamy1, Ratan Dhekle2, Vikas Talreja1, Vikram Gota3, Kalpita Gawit3, Manjunath Krishnamurthy3, Vijay Maruti Patil1, Amit Joshi1, Nandini Menon1, Akhil Kapoor1, Anbarasan Sekar1, Darshit Shah1, Vikas Ostwal1, Shripad Banavali1, Kumar Prabhash1
1 Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
2 Utsaah Foundation, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
3 Department of Clinical Pharmacology, ACTREC, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||04-Apr-2020|
|Date of Decision||20-Apr-2020|
|Date of Acceptance||08-May-2020|
|Date of Web Publication||19-Jun-2020|
Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai - 400 012, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Little is known about the comprehensive geriatric assessment (CGA) profile of Indian patients. We aimed to describe the CGA results of the Indian geriatric oncology patients and identify the incidence of polypharmacy.
Methods: The study is a retrospective analysis of the data collected in the geriatric oncology clinic at Tata Memorial Hospital, a tertiary cancer hospital in India. Patients aged 60 years and over with malignancy were evaluated. The baseline social, demographic, and disease details were recorded. All patients underwent a CGA, in which the domains of nutrition, function and falls, psychological status, cognition, comorbidities, social support, fatigue, and polypharmacy were evaluated using various validated tools. Life expectancy and the risk of toxicity from chemotherapy were calculated. Based on the results of the CGA, the patients were referred to various specialists and advised methods to address any identified vulnerabilities. The study was approved by the Institutional Review Board, which granted a waiver of the requirement for written informed consent.
Results: A total of 251 patients were assessed between June 2018 and March 2020. All patients had solid tumor malignancies, commonly lung (41%) and gastrointestinal (28%). Fifty-nine percent of the patients were planned for palliative intent therapy. The median age was 70 years (range, 60–100). The median number of caregivers was 4 (interquartile range [IQR], 3–6). The median body mass index (BMI) was 21.9 kg/m2 (IQR, 18.9–24.2). The BMI of 109 patients (44%) was < 21 kg/m2. Seventy-eight percent of the patients had comorbidities, commonly hypertension (45%), diabetes (26%), and heart disease (17%). The median number of medications was 5 (IQR, 2–7), and 51% of the patients were on were on 5 or more medications. Only 4 patients (2%) scored normally in all the geriatric domains tested. Abnormalities were noted in the domains of comorbidities (79%), fatigue (77%), nutrition (65%), function and falls (52%), psychological status (32%), and cognition (18%). Seventy percent of the patients had an estimated >51% risk of developing Grade 3 or higher toxicity if treated with full-dose combination chemotherapy.
Conclusion: Ninety-eight percent of the Indian geriatric oncology patients had vulnerabilities in at least one geriatric domain. Polypharmacy was noted in more than 50% of the patients. There was an over 50% predicted risk of severe toxicity from combination chemotherapy in at least two out of every three patients.
Keywords: Comprehensive geriatric assessment, elderly, geriatric, India, LMIC, older
|How to cite this article:|
Noronha V, Ramaswamy A, Dhekle R, Talreja V, Gota V, Gawit K, Krishnamurthy M, Patil VM, Joshi A, Menon N, Kapoor A, Sekar A, Shah D, Ostwal V, Banavali S, Prabhash K. Initial experience of a geriatric oncology clinic in a tertiary cancer center in India. Cancer Res Stat Treat 2020;3:208-17
|How to cite this URL:|
Noronha V, Ramaswamy A, Dhekle R, Talreja V, Gota V, Gawit K, Krishnamurthy M, Patil VM, Joshi A, Menon N, Kapoor A, Sekar A, Shah D, Ostwal V, Banavali S, Prabhash K. Initial experience of a geriatric oncology clinic in a tertiary cancer center in India. Cancer Res Stat Treat [serial online] 2020 [cited 2020 Jul 14];3:208-17. Available from: http://www.crstonline.com/text.asp?2020/3/2/208/287200
| Introduction|| |
Advancing age is a risk factor for the development of malignancy, with persons aged over 65 years accounting for 60% of the newly diagnosed malignancies and 70% of all cancer deaths. The common malignancies include cancers of the breast, lung, prostate, cervix, esophagus, and ovary. It has been predicted that in 2026, in India, in the population aged 60 years and over, there will be approximately 4,50,000 men and 3,70,000 women with cancer.
Managing an older patient with cancer can be challenging. These patients are often frail, have comorbidities, are on multiple medications, and may have social, economic, and psychological problems. Many times, older patients with cancer are not considered for a curative treatment approach, despite the tumor being amenable to radical treatment, just by virtue of their age. When these patients are treated with chemotherapy, radiation, and/or surgery, they may experience more toxicity and higher chance of morbidity and mortality. Some fit older patients may be denied aggressive therapy for fear of excessive morbidity, whereas some frail older patients may receive therapy that is overly aggressive, leading to morbidity. Therefore, striking the right balance is challenging. Many of the landmark clinical trials have excluded geriatric oncology patients, making evidence-based management decisions in this patient population even more difficult.
Patil et al. reported that of the 761 patients with solid tumors aged over 70 years and treated over a 2-year period at a rural cancer center in South India, 46% were treated with curative intent therapy. However, most of the patients did not receive multimodality therapy, and only 6% received chemotherapy. They proposed the establishment of a dedicated geriatric oncology clinic, to help better care for the needs of this group of patients.
The American Society of Clinical Oncology (ASCO) recommends that all geriatric oncology patients should undergo a comprehensive geriatric assessment (CGA) of various domains, including social support, physical function/falls, cognition, nutrition, medications, comorbid medical disorders, and depression. However, this recommendation has not been universally followed, because of the comprehensiveness of the assessment and the length of time required to complete it. We established a geriatric oncology outpatient clinic at our center to better care for our older patients with cancer. We describe our findings and the lessons learned.
| Methods|| |
General study methodology
This is a retrospective analysis of a prospectively collected database. The geriatric oncology clinic was started on June 15, 2018, and was held once a week in the Outpatient Department of Medical Oncology of the Tata Memorial Center, a tertiary care oncology hospital in Mumbai, India. Patients underwent a CGA, and the information was prospectively entered into a Microsoft Excel sheet. The Institutional Ethics Committee (IEC-III) granted approval for the study, along with permission for a waiver of the requirement for written informed consent for the retrospective portion (project – 900596). This manuscript includes the details from the retrospective part of the study. The study was conducted according to the ethical guidelines outlined in the Declaration of Helsinki, good clinical practice guidelines, and the Indian Council for Medical Research.
We initially evaluated patients aged 65 years or older, based on the global geriatric definition. In August 2019, we modified our age criterion to include patients aged 60 years or older, to align with Indian guidelines., Patients evaluated had a diagnosis of malignancy and were either being planned for systemic therapy or had recently been started on therapy, since one of the goals of the geriatric assessment was to help the treating oncologist to decide the plan and aggressiveness of systemic therapy. Patients or caregivers who refused to undergo the CGA and patients who were completely disabled (Eastern Cooperative Oncology Group [ECOG], performance status [PS] 4) were excluded from the study.
The process of geriatric assessment
The assessment was carried out by a medical oncologist and, based on availability, a clinical pharmacologist and a volunteer. Patients were explained the need for a CGA and were asked if they were willing to proceed. We followed the ASCO and the International Society of Geriatric Oncology guidelines for the CGA., Patients were interviewed and asked to fill out various questionnaires (help was provided by the oncologist or the volunteer, if necessary). Demographic, disease-related, and treatment-related information were obtained from the electronic medical records. The height, weight, and mid-arm and mid-thigh circumferences were measured, and Timed-Up-and-Go was checked in the clinic room. No additional testing, either blood tests or imaging, was done.
The details of the results of the CGA were made available to the patients' treating oncologists through a note in the patients' hospital files and the electronic medical records, along with recommendations for possible interventions to tackle the vulnerabilities in the non-oncologic areas identified through the CGA. In patients who were noted to have deficits in functions or a history of falls, a referral was made to the physiotherapy and occupational therapy department. Similarly, patients with deficits in nutrition or depression and/or anxiety were referred to the dietitian and/or to the psychiatrist/counselor, respectively. No change in oncologic management of the patient was made. The time taken for the assessment was recorded, however, this did not include the time spent by the patient filling out the self-administered questionnaires.
We entered the patients' demographic details (age, gender, education, address, marital status, living situation, number of caregivers, profession, smoking history, and ECOG PS) and disease-related features (primary tumor, stage, intent of therapy, and therapy planned). We documented the medications that the patients were taking, both prescription and over-the-counter, including the use of alternative medicines (ayurvedic/homeopathic/naturopathic/others) and the use of potentially inappropriate medicines as per Beers criteria. Polypharmacy was defined as taking 5 or more medications. Not all domains were assessed in all patients. Our understanding of the process of a CGA evolved with time, and we added/changed the assessments. We scored the patients using the G8 questionnaire, Vulnerable Elders Survey-13, and the Triage Risk Screening Tool  in an attempt to assess whether these screening tools could reliably predict a deficit in the CGA in our Indian patients. The various domains checked and the tools used along with the range of normal and abnormal values are detailed in [Table 1].
|Table 1: Details of the scoring system for the various domains tested as part of the comprehensive geriatric assessment for patients assessed in the geriatric oncology clinic at Tata Memorial Center, Mumbai, India: The tests used, the range of possible scores, and the values considered abnormal are enumerated|
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Chemotherapy risk assessment
We used the online CARG tool to assess the chemotherapy toxicity risk.,
Determination of noncancer life expectancy
We used the ePrognosis online tool to calculate the Lee and the Schonberg indices for each patient. This manuscript does not include the details of the individual patients' life expectancies.
Quality of life
From July 2019 onward, we requested patients to fill out quality of life (QoL) forms (European Organization for Research and Treatment of Cancer QLQ-C30, v. 3.0). The QLQ-C30 questionnaire comprises thirty questions, including five multi-item functioning scales (physical, role, social, emotional, and cognitive functioning), nine symptom scales (pain, fatigue, nausea/vomiting, constipation, sleep, appetite, dyspnea, and financial impact), and two items that measure the overall health/QoL. From January 2020, we requested caregivers to fill out the caregiver burden scale (originally developed by the Frontotemporal Lobar Degeneration Association), which is a 22-item questionnaire that assesses the experience of burden of a caregiver while caring for a sick individual. This manuscript does not contain the QoL data or the caregiver burden data.
Patients were asked whether they had been advised and had received pneumococcal and influenza vaccines in the last 1 year, and if not, they were advised to do so.
The data analysis was performed using the SPSS software, version 20 (IBM SPSS Statistics for Windows, Version 20.0. IBM Corp., Armonk, NY, USA). Demographics, clinical details, and deficits in the various domains were presented with descriptive statistics, using absolute numbers, simple percentages, median, range, and interquartile range (IQR). If even a single test was used to assess a particular domain, then that domain was considered to have been tested in that patient. To calculate the proportion of patients who had a deficit in a particular domain, the denominator was all the patients in whom that domain was tested.
| Results|| |
Between June 2018 and March 2020, 251 patients were assessed in the geriatric oncology clinic. The patient flow and the various domains tested are depicted in [Figure 1]. The median time taken for the CGA was 50 min (IQR, 40–61).
|Figure 1: The flow of patients who were evaluated in the geriatric clinic between June 2018 and March 2020, including the various domains tested and the number of patients the domains were tested in. PS: Performance status, as measured by the Eastern Cooperative Oncology Group Scale; ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living; TUG: Timed-Up-and-Go test; CCI: Charlson Comorbidity Index; CIRS-G: Cumulative Illness Rating Scale-Geriatric; GDS: Geriatric Depression Scale; GAD-7: Generalized Anxiety Disorder; MMSE: Mini-Mental Status Examination; ESAS: Edmonton Symptom Assessment Scale; BMI: Body mass index; MNA: Mini Nutritional Assessment; G8: Geriatric 8 Health Status Screening Tool; VES-13: Vulnerable Elders Survey-13; TRST: Triage Risk Screening Tool|
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The median age was 70 (range, 60–100); 62 (25%) were farmers. All patients were living with family. Pertinent demographic and disease-related details are provided in [Table 2].
|Table 2: The demographic, disease-related, and treatment-related details of the patients evaluated in the geriatric oncology clinic|
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The median number of medications taken was 5 (IQR, 2–7). Nineteen patients (8%) were taking no medications; polypharmacy was noted in 127 patients (51%), and 23% of the patients reported the use of alternative medications (ayurvedic [15%], homeopathic [5%], and naturopathic [2%]).
Considering the domains of function and falls, cognition, nutrition, psychological status (depression/anxiety), fatigue, social support, comorbidities, and polypharmacy, only 4 patients (2%) had no deficits in any domain. The median number of abnormal domains was 3 (IQR, 2–4). The details of the results of testing in the various geriatric domains are given in [Table 3]. Of the 37 patients who had an ECOG PS of 0, 9 patients (24%) had deficits in the function domain, while 59 of the 128 (46%) PS 1 patients, 39 of the 54 (72%) PS 2 patients, and 22 of the 27 (81%) PS 3 patients had deficits in the function and falls domain. Of the 84 patients in whom the use (or the lack thereof) of a walking assist device (e.g., walking stick and walker) was documented, only 7 of the 35 patients (20%) with an abnormality in the physical function/fall domain were using one; none of the 42 patients who tested normal in the function/fall domain reported the use of a walking assist device.
|Table 3: The results of testing the various geriatric domains in 251 patients evaluated at our geriatric oncology clinic in Mumbai, India|
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Chemotherapy risk assessment
CARG risk assessment was calculated in 248 (99%) patients. The median CARG risk score was 8 (IQR, 6–10). A score of 8 corresponds to a 59% predicted risk of Grade 3 or higher toxicities from a standard dose combination chemotherapy regimen. Similarly, scores of 6 and 10 correspond to estimated risk levels of 44% and 72%, respectively. Only 20 patients (8%) had a CARG risk score of 4, corresponding to a 30% risk. A total of 173 patients (70%) had a score of 7 or more, which corresponds to an estimated risk level of at least 51%.
Of the 30 patients in whom the status for pneumococcal and influenza vaccines was assessed, only 1 patient (3%) had been advised and had received these two vaccines in the last 12 months. This patient had been advised vaccination in the medical oncology clinic at TMH, not his primary care giver.
| Discussion|| |
Only 2% of the patients evaluated in our geriatric oncology clinic had a normal CGA. The commonly deranged CGA domains included comorbidities (79%), fatigue (77%), and nutrition (65%), followed by function and falls (52%), psychological status (32%), and cognition (18%). Polypharmacy was seen in over half of the patients. In 70% of the patients, there was an estimated risk of at least 51% for developing Grade 3 or higher toxicity from full-dose combination chemotherapy. Before assessment in the geriatric oncology clinic, none of the vulnerabilities identified in the CGA had been addressed, other than nutrition in some of the patients. Only 20% of the patients who had a deficit in function and falls had been recommended the use of a walking assist device, and 97% of the patients had not received the recommended vaccines against influenza and pneumococcus. Our study underlines the need for a CGA in all older Indian patients with cancer to identify and treat vulnerabilities in the non-oncologic domains.
In a large multicentric study by Kenis et al., undertaken in 1967 patients in ten Belgian hospitals, 71% of the patients had an abnormal G8 screening test, which led to a CGA. The CGA revealed that 66% of the patients had an abnormal Instrumental Activities of Daily Living (IADL) score, 57% had an abnormal Activities of Daily Living (ADL) score, 38% had a history of falls, 68% were at risk for malnutrition, 15% were malnourished, and 61% were at risk for depression. Thus, it appears that worldwide, geriatric patients have multiple deficits in the CGA. There is practically no literature on the comprehensive geriatric profile in Indian patients with cancer. In a study on 70 geriatric patients (general medicine non-oncology patients) in rural Bangalore, the authors reported that 31% of the patients were at risk for falls, 14% had cognitive impairment, 17% had depression, and 13% patients had a body mass index <18.5 kg/m 2. To the best of our knowledge, the only data (reported in abstract form) on the CGA profile in Indian geriatric oncology patients have been reported by Vora et al. in 46 patients; they reported that an abbreviated CGA took 20–30 min to administer, and 54% of the patients had impairment in ADL/IADL and 47% had 2 or more comorbidities. Approximately 20% of the patients who had severe impairment in one or more domains had been considered fit for chemotherapy by the treating oncologist before the geriatric assessment.
None of our patients were vulnerable in the social support domain. Our center being a referral hospital for patients from all over India, only 30% of our patients were local to Mumbai, and the remainder faced varying degrees of logistic and social issues while staying in Mumbai, away from home. However, no patient lived alone or in an assisted living facility or nursing home. All patients lived at home, with family. Perhaps because of extensive social support and being surrounded by family members, falls had occurred only in 13% of the patients, whereas 52% had functional deficits and were at risk of falls.
We had earlier conducted a survey to assess the knowledge and application of the principles of geriatric oncology in India. We found that although 99% of the oncologists polled cared for geriatric patients in their regular practice and 87% of the oncologists cared for ten or more older patients with cancer each week, 36% were not aware of the ASCO guidelines for geriatric oncology. About 70% of the oncologists reported that they assessed their older patients with cancer informally, based on their judgment, without the use of any validated assessment tools. Only 9% reported that they always performed a multidimensional geriatric assessment using validated tools. The proportion of patients with cancer aged over 65 years in the United States of America is 54%, similar to India, where 56% of the patients with cancer are aged over 60 years. As per our hospital-based cancer registry, 82208 patients with cancer were registered at Tata Memorial Hospital during the study period. Of these, 23894 patients (29%) were aged over 60 years. There were 15020 (62.9%) male and 8874 (37.1%) female patients, resulting in a male: female ratio of 1.7:1. Thus, the proportion of older patients with cancer who actually sought treatment was low, and of these, just about 1% were referred to our geriatric oncology clinic for evaluation, and that too, only patients with solid tumors. To the best of our knowledge, ours is the only geriatric oncology clinic in India. Thus, there is an urgent need to raise awareness and provide education regarding the need and methodology of a CGA in India.
It took us a median of 50 min to complete the physician-administered portion of the geriatric evaluation, chemotherapy risk assessment, and evaluation of life expectancy, excluding the time required for completion of the self-administered questionnaires and the Mini Nutritional Assessment (MNA), that was done by a trained volunteer. We attempted to check whether the use of screening tools could be predictive of the need for a CGA in our patients. However, since 98% of the patients had hitherto unsuspected vulnerabilities detected on the CGA, there will probably not be much benefit of performing the screening tests; rather, the various geriatric domains should be directly tested in older Indian patients with cancer. A CGA may not be feasible in a busy practice or in a resource-limited crowded academic center, and this reiterates the need for a dedicated geriatric oncology clinic set-up.
While testing the various geriatric domains, we faced some difficulties as the tools have been developed for a Western cohort of patients, and we found some portions culturally inappropriate for our patients. About 18% of our patients were illiterate and 35% had not completed school. To assess cognition, we were unable to use the short cognitive screening tools such as the Mini-Cog test  and Blessed Orientation-Memory-Concentration test, as many of the patients did not know how to read or how to draw time on a clock face, and many patients did not know the exact time or the months of the year as per the Gregorian calendar. We, therefore, used the Mini-Mental State Examination (MMSE) tool in all patients, even though this required more time. We were initially unable to assess cognition in many of these patients as the MMSE required the ability to read and write. We subsequently started using the Hindi version of the MMSE, described by Ganguli et al. for use in illiterate patients  which helped solve the problem. In terms of assessing the IADLs, many of our rural patients had never owned a telephone and therefore did not use one; this did not reflect a deficit in their IADL, but rather a way of life that was different from that of many patients in a developed country. Similarly, as part of the MNA, the markers for protein consumption include at least one serving of dairy products per day, two or more servings of legumes or eggs per day, or meat/fish/poultry every day. Approximately 38% of Indians are vegetarian, and <30% of Indians eat meat/fish/poultry regularly, making the results of the MNA difficult to interpret in the Indian patients.
Our study provides the first data on the comprehensive geriatric profile of Indian patients with cancer. We used multiple validated tools to assess each domain. All the data were prospectively entered and retrospectively analyzed. The limitations of our study include the lack of longitudinal data – each patient was only seen once for the initial CGA and then was referred back to the primary treating oncologist. The QoL data have not been reported, since numbers were small. The cohort of patients may not have been completely representative of the general Indian geriatric oncology patient population. Our cohort included solid tumor patients, reflecting the disease management groups of the two main oncologists who ran the geriatric oncology clinic. Several E-mail and verbal communications were made to the entire department of medical oncology regarding the existence of the geriatric oncology clinic; however, most of the patients assessed in the geriatric oncology clinic came from our own oncology clinics, somewhat reflecting the lack of awareness of the need for a geriatric assessment, even in a tertiary academic oncology center.
| Conclusions|| |
About 98% of Indian geriatric oncology patients had deficits in at least one domain on a CGA. The commonly deranged domains included comorbidities (79%), fatigue (77%), and nutrition (65%). Polypharmacy was noted in 51% of the patients, and 70% of the patients had at least a 51% predicted risk of Grade 3 or higher toxicities if treated with standard-dose combination chemotherapy. We have a long way to go before CGA is accepted by our medical oncology community as a prerequisite for properly planning the treatment in the geriatric oncology patients in our country.
Financial support and sponsorship
Conflicts of interest
- Dr. Vanita Noronha has received research funding from Amgen, Sanofi India Ltd., Dr. Reddy's Laboratories Inc., Intas Pharmaceuticals, and AstraZeneca Pharma India Ltd. (all research grants paid to the institution)
- Dr. Kumar Prabhash has received research funding from Dr. Reddy's Laboratories Inc., Fresenius Kabi India Pvt. Ltd., Alkem Laboratories, Natco Pharma Ltd., BDR Pharmaceuticals Intl. Pvt. Ltd, and Roche Holding AG (all research grants paid to the institution).
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[Table 1], [Table 2], [Table 3]