|LETTER TO EDITOR
|Year : 2020 | Volume
| Issue : 3 | Page : 660-661
Author's reply to Kanesvaran et al. and Vora
Vanita Noronha, Anant Ramaswamy, Kumar Prabhash
Department of Medical Oncology, Tata Memorial Center, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||06-Aug-2020|
|Date of Decision||06-Aug-2020|
|Date of Acceptance||07-Aug-2020|
|Date of Web Publication||19-Sep-2020|
Department of Medical Oncology, Tata Memorial Center, Mumbai, Homi Bhabha National Institute, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Noronha V, Ramaswamy A, Prabhash K. Author's reply to Kanesvaran et al. and Vora. Cancer Res Stat Treat 2020;3:660-1
We thank Kanesvaran and Chowdhury and Vora for their insightful comments regarding our initial experience of establishing a geriatric oncology clinic at the Tata Memorial Hospital in Mumbai, India, and the accompanying editorial.
We agree with Kanesvaran and Chowdhury that we need to establish new culturally appropriate tools for the geriatric assessment, as it would be a valuable addition in the evaluation of older adults with cancer in other developing countries as well. We are working toward this.
The geriatric assessment takes time, and this limits its universal applicability. The burning need is to make the geriatric assessment quicker, so that it can be done rapidly and relatively easily in a busy clinic, which might help improve the uptake of geriatric assessment by the oncology community. The suggestion by Kanesvaran and Chowdhury of sending some of the geriatric assessment questions to the patients by E-mail is a good one. Another method that we are exploring is to give a printout of the geriatric tools, such as the Geriatric Depression Scale, to the patients while they are waiting for their appointment. We have observed that although a significant proportion of the patients are illiterate, they are often accompanied by younger, literate relatives who are willing and able to help them fill out these forms.
We agree to some extent with Dr. Vora regarding the need for taking a collateral history. We have incorporated the history of various geriatric syndromes such as insomnia and constipation in the geriatric assessment. We also inquired of the patients and their relatives regarding a history of neuropsychological problems, as this is one of the points from the G8 screening questionnaire. Regardless of whether the history indicated a memory problem, we administered the mini-mental status examination to all our older patients, as it is a good objective evaluation of cognition.
We agree with Dr. Vora that merely diagnosing the presence of non-oncologic vulnerabilities is not sufficient. Following the geriatric assessment, interventions must be carried out in the identified vulnerable domains. Our geriatric oncology patients are routinely referred to various specialists including physiotherapists, occupational therapists, dietitians, nutritionists, psychiatrists, counselors, social workers, and general physicians. We are hoping to one day establish a multidisciplinary geriatric oncology clinic incorporating all these specialists, so that it becomes a one-stop shop for our older patients with cancer. Currently, the clinic comprises clinical pharmacologists, physiotherapists and social workers, but we are gradually attempting to expand this to be able to provide integrated oncogeriatric care.
Dr. Vora's suggestion to incorporate the Cancer and Aging Research Group (CARG) risk assessment-tool-based chemotherapy dose reduction strategy is an excellent one, but we would like to point out an important caveat. The CARG chemotoxicity calculator has been developed in a cohort of American patients and needs to be validated in our Indian population. In 2019, Dr. Erin Moth reported that the CARG chemotoxicity risk calculator could not reliably predict severe toxicity from chemotherapy in Australian older patients with cancer (odds ratio: 1.04; 95% confidence interval: 0.92–1.18; P = 0.54, area under the receiver operating characteristic curve: 0.52). An ongoing study at the Tata Memorial Center (Mumbai, India) to evaluate the ability of the CARG chemotoxicity risk calculator to reliably predict the toxicity from chemotherapy in older Indian patients with cancer has just completed patient recruitment, and the results are awaited. Until we ascertain that it is reliable in the Indian setting, it may be premature to reduce the dose of chemotherapy based on this tool. For now, we calculate the expected chemotherapy toxicity for full-dose combination chemotherapy, reduced-dose combination chemotherapy, full-dose monotherapy, and reduced-dose monotherapy and provide these figures to the treating clinician who then makes the final decision regarding the dose of systemic therapy to be administered.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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