|MUSINGS: GERIATRIC ONCOLOGY
|Year : 2020 | Volume
| Issue : 4 | Page : 808-813
Ethnocultural inequity in the geriatric assessment
Vanita Noronha, Anant Ramaswamy, Shripad Banavali, Shreya Gattani, Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
|Date of Submission||16-Nov-2020|
|Date of Decision||23-Nov-2020|
|Date of Acceptance||23-Nov-2020|
|Date of Web Publication||25-Dec-2020|
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Noronha V, Ramaswamy A, Banavali S, Gattani S, Prabhash K. Ethnocultural inequity in the geriatric assessment. Cancer Res Stat Treat 2020;3:808-13
|How to cite this URL:|
Noronha V, Ramaswamy A, Banavali S, Gattani S, Prabhash K. Ethnocultural inequity in the geriatric assessment. Cancer Res Stat Treat [serial online] 2020 [cited 2021 May 6];3:808-13. Available from: https://www.crstonline.com/text.asp?2020/3/4/808/305012
Our genotype as Homo sapiens binds us by a common thread. Living in communities and adaptation have led to the dominance of our species. Different groups of people have established various common practices and traditions, which make for striking differences. A case study of this phenomenon is the way we say hello. The appropriate greeting would be a handshake in America, a bow in Japan, a nose bump in Oman, a kiss in France, sticking-out the tongue in Thailand and “Namaste” (folded hands) in India, now popularized in the socially distanced COVID era. Taking a step further, the entire way of life is different if you compare an executive in New York (USA) to a farmer in a tribal village in Odisha (India).
The cornerstone of assessing an older patient with cancer involves a geriatric assessment (GA) to evaluate for the presence of various vulnerabilities in the domains of function and falls, cognition, nutrition, psychology, social support, and comorbidities. It also involves assessment for the presence of various geriatric syndromes, estimation of non-cancer life expectancy, and chemotherapy toxicity risk assessment. The GA has been developed in a predominantly western urban cohort of patients. We established the geriatric oncology clinic at the Tata Memorial Center (Mumbai, India) in June 2018, and over the past 2 years, we have discovered that there are multiple aspects of the GA that are culturally inappropriate for our Indian patients. Acknowledging and understanding these differences are the first steps towards adapting the GA for our patients. We will describe some of these differences in this article and attempt to find possible solutions [Table 1].
|Table 1: Various aspects of the geriatric assessment that are culturally inappropriate for our older Indian patients with cancer and the possible solutions|
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| How Old is Old?|| |
The basic building block of geriatric oncology is the establishment of the age cut-off beyond which a person is considered “old.” The International Society of Geriatric Oncology (SIOG) defines this age as 70 years, while the American Society of Clinical Oncology (ASCO) recommendations are for persons aged 65 years and older. When we first started our geriatric oncology clinic, we followed the ASCO guidelines, and accordingly evaluated patients aged 65 years and older. We gradually realized that the age cut-off varies across cultures and is affected by several factors including the life expectancy in the population and the age at retirement. Life expectancy varies widely across cultures: The current life expectancy in Hong Kong and Japan is 85 years; in the USA, it is 79 years; and in the Central African Republic, it is 54 years. India lies somewhere in between, with an average life expectancy of 70.4 years, with 71.8 years for women and 69.2 years for men. In Japan, the age cut off for the geriatric population is 75 years, while in India, according to the “National Policy on Older Persons” established by the Government of India, a senior citizen or an older person is defined as anyone who is 60 years or older. We therefore changed the age cut-off of our geriatric oncology clinic to 60 years. Even though using a lower age cut-off is simple to follow for most of the GA (we just applied the tools for evaluation of the patients, regardless of their age), it raises questions regarding the aspects within the tools that are specific to a particular age, for example, the Beer's criteria established by the American Geriatric Society to evaluate the use of potentially inappropriate medications in older adults specifies an age threshold (≥70 years) above which the use of drugs like aspirin for primary cardiac prevention is inappropriate and that direct oral anticoagulants such as dabigatran and rivaroxaban are to be used cautiously (>75 years). The Triage Risk Screening tool is to be used in persons aged 75 years and older, while screening tools like the G8 and VES both have points assigned for age., The Cancer and Aging Research Group chemotherapy risk tool also factors in the age of the patient. As these scales were developed in populations in which the geriatric age cut-off is 5 years more than ours, should there be some sort of an adjustment or age-weighted factor to level the playing field? Another issue to be considered is that of the immigrants. What should the approach be to those who were born and went to school in a low- or middle-income country like India and then moved to a high-income country for additional education or work? What geriatric age cut-off should be used for them?
| The Saas-Bahu Phenomenon|| |
The functional status of an older person is assessed using the instrumental activities of daily living (IADL) scale. IADL refer to the activities that a person needs to be able to perform to live independently in a society and include housekeeping, cooking, laundry, shopping, taking medicines, finances, transport, and using the telephone. Globally, the traditional male role in the society does not include the first three tasks, i.e., housekeeping, cooking, and laundry and therefore, the scoring system requires men to get only 5 points while the women need 8 points, to be labeled high-functioning and independent. In India, when a woman gets married, she traditionally moves in with the husband's family. She becomes the “bahu” (daughter-in-law), and the husband's mother becomes the “saas” (mother-in-law). The bahu then takes over the traditional female tasks in the family including housekeeping, cooking, and laundry. This led to several older Indian women not getting a full score on the IADL pro forma simply because they had a daughter-in-law to perform these tasks for them, despite the fact that they were probably high-functioning.
| The Use of the Telephone|| |
Although in modern India, mobile telephony has spread widely, particularly among the youth, the use of telephones was not widespread 30–40 years ago in the rural areas, which is when our current geriatric population was young. Thus, several of our patients were unable to use the telephone, and therefore, lost 1 point on the IADL scale. However, this also did not reflect impaired functioning or a problem with IADL, rather it reflected the rural way of life and the absence of the need for a telephone to function optimally.
| The Problems of Relocation|| |
In our geriatric oncology clinic, 70% of the patients evaluated were from outside the state of Maharashtra. This issue of relocation raised several problems in the GA. Take the example of Mr. P, a 63-year-old man whose home is in Bihar. He was diagnosed with locally advanced lung cancer. Mr. P's brother lives and works in Mumbai, so Mr. P decided to seek treatment at the Tata Memorial Hospital and to stay with his brother for the duration of his treatment. His initial workup took 6 weeks; he was then planned for induction chemotherapy and was referred to our geriatric clinic for baseline assessment. For over a month, he had not engaged in any shopping, housekeeping, meal preparation, or laundry and was transported to and from the hospital by his nephew. He would shop when he was in Bihar and took the public transport, but he also subsequently became fatigued due to the cancer, testing, and frequent hospital visits. Therefore, he was unsure whether he would be able to shop or travel independently if he were back home. He thus scored a 3 on the IADL scale, indicating a deficit in function. During his cognitive assessment with the mini-mental status examination (MMSE), he was unable to tell us which hospital floor he was on, since his nephew had been taking him to all his appointments and he had not really paid attention. Since coming to his brother's home, he had not kept track of the dates, and was unable to provide the day/date/month. He could not do a serial subtraction of 7's, but he appeared to be preoccupied during the evaluation. Mr. P's score of 21 on the MMSE indicated a cognitive deficit, but it was unclear whether this was a true deficit, or the result of the disorientation that inevitably accompanies relocation.
| The Illiteracy Problem|| |
About 18% of our patients were illiterate, 9% had received only primary school education, and for 37%, the highest level of education was 10th grade. Many of the patients were unable to draw a clock face and did not know the date on the Gregorian calendar. Thus, short cognitive screening tools like the Blessed Orientation Memory-Concentration (BOMC) and the Mini-Cog test were not useful., Therefore, we needed to perform the entire MMSE to assess cognition, even though this took a significantly longer time. For the illiterate patients, we attempted to use the Hindi version of the MMSE developed by Ganguli et al., however, this too required patients to know the day/date/month/year, the names of the days of the week, and drawing of a basic shape (square within a square), which was challenging for several patients. The orientation questions were geared toward a rural population and included questions regarding the name of the village, post office, village block, district, etc., which were irrelevant, and therefore, were not answered by those illiterate patients who lived in the less rural or more urban settings.
| Thin Body Habitus, Lack of Access to a Weighing Scale, and Vegetarianism|| |
When we first started performing the GA, we used unintentional weight loss and low body mass index (BMI) to evaluate for malnutrition. We soon discovered that many of our patients (21%) did not know their baseline weight since they did not have access to a weighing scale. Besides, many of the patients were thin; the median weight in our cohort was 57 kg (interquartile range [IQR], 49–64), with a median BMI of 21.9 kg/m2 (IQR, 18.9–24.2). We therefore started using the Mini Nutritional Assessment (MNA) scale to perform a more accurate nutritional evaluation. Unfortunately, the MNA also includes questions regarding weight loss and BMI as well as a question regarding protein intake including the consumption of milk products daily, two or more servings of legumes or eggs per week, and meat/fish/poultry daily. Approximately 40% of Indians are vegetarian and <30% eat meat/poultry/fish every day. Thus, the results of the MNA also possibly did not accurately describe the nutritional status of our patients.
LACK OF A STRONG PRIMARY HEALTHCARE SYSTEM
The Cumulative Illness Rating Scale for Geriatrics or the simpler Charlson Comorbidity Index require the patient to have knowledge of their general medical illnesses., This presupposes two important points: First, that the patient has sought regular medical care prior to the GA, thus permitting a diagnosis of a chronic health condition to be made; and second, that the person knows the details of his/her prior diagnosis, workup, and therapy. Both these premises were violated in many of our patients. The World Health Organization recommends a doctor-to-patient ratio of 1:1000, while the actual ratio in India is roughly 1:2000. Our patients, especially the rural cohort, sought medical care on an as-needed basis for acute illnesses, rather than regular health maintenance visits. Some patients preferred faith healers and practitioners of alternative systems of medicine. Not a single patient evaluated in our geriatric clinic had received the influenza or pneumonia vaccines prior to coming to our hospital; yet 23% of our patients were receiving alternative medications. Even for the patients who had been diagnosed with a medical illness, many did not know the details of the diagnosis or the therapy received, since there is no uniform system of electronic medical records or digitization; medical files, if they exist at all, usually consist of a few loose papers on which some details have been illegibly scrawled.
| Issues with Evaluating Mental Health|| |
We assessed whether our patients were at risk for depression or anxiety by asking them to fill out the Geriatric Depression Scale-Short Form and the Generalized Anxiety Disorder-7 item scale., Given the stigma surrounding the issue of mental health as well as the fact that for our illiterate and semi-literate patients, the questions had to be asked and answered out loud, often in the presence of family members, it is not inconceivable that the answers to some of the questions such as, “Do you think it is wonderful to be alive now?” and “Are you bothered by being so restless that it's hard to sit still?” may not have been completely accurate.
| Social Issues and the Joint Family Construct|| |
A traditional Indian joint family includes other family members in addition to those in the nuclear family who stay together. Approximately 37% of Indians live in extended families, and the proportion has been increasing recently., This is a boon for our geriatric patients. All our patients lived with their family or caregivers; thus, their social support network was strong. None of the patients lived in assisted living facilities or nursing homes. Thus, most of the questions on the OARS Medical Social Support scale like whether they had someone to take them to the doctor, or to do their chores or cooking, or to talk to, or give advice were redundant. However, the fact that most of the questions on the social support questionnaire were irrelevant argues for the need for a different tool. The issue that cropped up with patients living in extended families included the loss of autonomy in decision-making, as there were more stakeholders involved. Our patients did have numerous other issues which required the assistance of a social worker, like arrangement for a low-cost stay in Mumbai, transportation, financial assistance from various charitable organizations, arrangement for medications, etc. There were three patients (1%) evaluated in our clinic who were living on the footpath as they could not afford any accommodation in Mumbai. These are the issues that would need to be incorporated in an appropriate social questionnaire for our Indian older patients with cancer.
| Fatigue and Mobility|| |
We used the Mobility scales (tiredness and with help) to assess functional mobility and fatigue. These scales assess the ability of a person to transfer, walk indoors, go outdoors, climb stairs, and walk outside in good and bad weather. However, the portion of the questionnaire regarding mobility in bad weather caused confusion in our patients, since the weather in Mumbai is essentially warm throughout the year, with practically no variation, and has hardly anything that could be termed “bad weather.”
| Life Expectancy|| |
To assess the life expectancy, we used the ePrognosis website, calculating the Lee and Schonberg indices. Both the indices have been developed in community-living adults in the United States. We chose these scales as they provide the risk of mortality at 5 and 10 years, and an estimation of the life expectancy at a shorter time interval (5 years) was considered valuable in patients with cancer. However, considering the significant difference between the life expectancy of Indians and Americans, this is perhaps not an appropriate scale to use. The Suemoto scale for life expectancy has been developed and validated in 5 cohorts of community dwelling adults in 16 countries, including England, America, Mexico, Latin America (Sao Paulo, Brazil), and Europe. However, the Suemoto scale provides only the 10-year mortality risk, which is quite hard to interpret in our patients with cancer. To the best of our knowledge, there is no life expectancy scale that has been developed for Indian patients with cancer.
Thus, multiple parts of the GA were culturally inappropriate and could simply not be analyzed or led to erroneous or unreliable results. Dr. Soto Pérez de Celis in his recent editorial, “Global geriatric oncology: One size does not fit all,” stated, “Copying and pasting models from high-resource settings to regions, countries, or practices with limited resources is a recipe for failure.” What we need is to develop an India-specific GA tool to assess the unique problems of our patients. The first step toward this is recognition of the problem and the particular areas that need to be changed, which we have attempted to outline above. Banerjee et al. have taken the initial steps to formulate a culturally appropriate tool for Indian patients with cancer, however, this also incorporates several points like the use of the telephone, the BMI, ability to do shopping/housework, drawing geometric shapes, etc., which may be difficult for some of our patients.
Ultimately, optimal patient care can come only from an individualized treatment plan, and this applies perfectly to performing a GA in the Indian older patients with cancer.
The American screenwriter, Robert Alan had said, “Cultural differences should not separate us from each other, but rather cultural diversity brings a collective strength that can benefit all of humanity.” By reconciling the cultural differences and establishing a GA that is directed at Indian patients with cancer, we hope to harness this collective strength and benefit all of geriatric oncology.
Financial support and sponsorship
Conflicts of interest
Outside of the current work, the authors report the following 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)
- Dr. Shreya Gattani reports no conflicts of interest
- Dr. Anant Ramaswamy reports no conflicts of interest
- Dr. Shripad Banavali reports no conflicts of interest.
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