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ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 6  |  Page : 1023-1026

Agreement analysis between three different short geriatric screening scales in patients undergoing chemotherapy for solid tumors


1 Department of Medical Oncology, Tata Memorial Hospital, Mumbai, Maharashtra, India
2 Division of Clinical Research and Biostatistics, Malabar Cancer Centre, Kerala, India

Date of Web Publication13-Dec-2017

Correspondence Address:
Dr. Kumar Prabhash
Department of Medical Oncology, Tata Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.179062

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 > Abstract 

Background: Comprehensive geriatric assessment (CGA) in routine practice is not logistically feasible. Short geriatric screening tools are available for selecting patients for CGA. However none of them is validated in India. In this analysis we aim to compare the level of agreement between three commonly used short screening tools (Flemish version of TRST (fTRST), G8 and VES-13.
Methods: Patients ≥65 years with a solid tumor malignancy undergoing cancer directed treatment were interviewed between March 2013 to July 2014. Geriatric screening with G8, fTRST and VES-13 tools was performed in these patients. G8 score ≤14, fTRST score ≥1 and VES-13 score ≥3 were taken as indicators for the presence of a high risk geriatric profile respectively. R version 3.1.2 was used for analysis. Cohen kappa agreement statistics was used to compare the agreement between the 3 tools. p value of 0.05 was taken as significant.
Results: The kappa statistics value for agreement between G8 score and fTRST, between VES-13 and fTRST and between VES-13 and G8 were 0.12 (P = 0.04), 0.16 (P = 0.07) and 0.05 (P = 0.45) respectively. It was found that maximum agreement was observed for VES-13 and fTRST. The agreement value of VES-13 and fTRST observed was 59.44 %(39.63% for high risk profile and 19.81% for low risk profile). The agreement value of G-8 and fTRST was 39.62% (2.83% only for high risk profile and 36.79% for low risk profile). The lowest agreement was between G8 and VES-13, 35.84% (7.54% for high risk detection and 28.30% for low risk detection).
Conclusion: There was poor agreement (in view of kappa value been below 0.2) between the 3 short geriatric screening tools. Research needs to be directed to compare the agreement level between these 3 scales and CGA, so that the appropriate short screening tool can be selected for routine use.

Keywords: Agreement, geriatric, oncology, screening, short fratility scales


How to cite this article:
Joshi A, Tandon N, Patil VM, Noronha V, Gupta S, Bhattacharjee A, Prabhash K. Agreement analysis between three different short geriatric screening scales in patients undergoing chemotherapy for solid tumors. J Can Res Ther 2017;13:1023-6

How to cite this URL:
Joshi A, Tandon N, Patil VM, Noronha V, Gupta S, Bhattacharjee A, Prabhash K. Agreement analysis between three different short geriatric screening scales in patients undergoing chemotherapy for solid tumors. J Can Res Ther [serial online] 2017 [cited 2019 Jun 20];13:1023-6. Available from: http://www.cancerjournal.net/text.asp?2017/13/6/1023/179062


 > Introduction Top


The management of cancer in geriatric population poses a big challenge.[1] Commonly, the clinical trials either do not enroll geriatric patients in their studies or this age group is not well represented in their patient population. Hence, the applicability of the results of these clinical studies in geriatric population is questionable.[2] A complex interplay between a lot of factors including multiple comorbidities, polypharmacy, frail health, lack of social and economic support, and compromised organ functions makes the management of geriatric cancers very difficult.[1],[3],[4] As the delivery of the standard chemotherapy regimens become difficult due to the above-mentioned factors, the physicians often resort to offering nonstandard treatment in the aged patients.[5],[6]

Comprehensive geriatric assessment (CGA) is a multidimensional, interdisciplinary diagnostic process focused on determining a frail aged person's medical, psychological, and functional capability in order to develop a coordinated and integrated plan for the treatment and long-term follow-up. Though CGA enables appropriate selection of patients for cancer-directed treatment, however doing the same in routine clinical practice is cumbersome because it takes 35 min on an average to complete CGA evaluation of a single patient.[7] Short geriatric screening tools are available for identifying geriatric cancer patients who would benefit from CGA.[8],[9]

We aim to develop a comprehensive geriatric clinic at our cancer hospital. As a part of this goal, we performed geriatric screening by three short commonly used geriatric screening tools; G-8 score, Flemish version of the Triage Risk Screening Tool (fTRST) and vulnerable elders survey-13 (VES-13) score and did an analysis to compare the agreement level between these three.


 > Methods Top


Patient selection

Patients aged more than or equal to 65 years with a solid tumor malignancy that required them to undergo cancer-directed treatment were interviewed from March 2013 to July 2014 prior to the initiation of their therapy. It was decided beforehand that the result of the assessment will not bear any implications on the patient's treatment. These patients were treated in accordance with institutional guidelines.

Geriatric screening

All selected patients underwent geriatric screening three brief functionality-based screening tools:

  1. G-8 score [10],[11]

    The G-8 scale is a screening tool that includes seven items from the Mini Nutritional Assessment and an age-related item. The total score can range from 0 to 17. The questionnaire is depicted in [Table 1]
    Table 1: G 8 questionnaire

    Click here to view


    • A G-8 ≤14 indicates the presence of a geriatric risk profile
  2. fTRST [12]

    The fTRST is a simple five-item screening tool, and the total score can range from 0 to 6. It has been elaborated in [Table 2]
    Table 2: Flemish version of the Triage Risk Screening Tool (fTRST)

    Click here to view


    • A score of ≥2 indicates high risk patients within the geriatric population. However, a score of more than or equal to one is considered as a high geriatric risk profile within oncologic population
  3. VES-13[13]

    The VES-13 scale is a self-administered survey that consists of one item for age and additional 12 items that assess self-related health, functional capacity, and physical performance.

    • A VES-13 score more than or equal to three indicated the presence of a geriatric risk profile.


Statistical analysis

R version 3.1.2 was used for analysis (R: A Language and Environment for Statistical Computing, Vienna, Austria). Cohen kappa agreement statistics was used to compare the agreement between the three tools. A P value of 0.05 was taken as significant. The interpretation of kappa value for the level of agreement was done as per the below-mentioned table.[14]


 > Results Top


A total of 106 patients aged more than 65 years who came to our institute with a histologically confirmed solid malignancy were included from March 2013 to July 2014. All the 106 patients were able to complete the questionnaire satisfactorily, and hence, geriatric screening was feasible in 100% of patients.

Baseline characteristics

The mean age of the patients was 70.2 years with a range from 65 to 88 years. About 70% of the patients were males and the rest were females. Forty nine percent of these patients had comorbidities. The most common comorbidities were hypertension in 30% of the patients and diabetes in 18% of the patients. Others had ischemic heart disease (n = 5), bronchial asthma (n = 2), chronic obstructive pulmonary disease (n = 2), hypothyroidism (n = 1), psychiatric illness (n = 1), and past history of pulmonary tuberculosis (n = 3).

The patients had carcinoma of lung (n = 78), head and neck (n = 5), esophagus (n = 6), breast (n = 5), and prostate (n = 12) cancer. Eighty eight out of the 106 patients (83.01%) were metastatic. The patients were administered chemotherapy or targeted therapy with curative intent in 19% and palliative intent in rest of the patients.

Outcomes

Geriatric risk was present in 99 patients (93.3%) according to G-8 score, 71 patients (66.9%) according to fTRST score and 58 patients (54.7%) according to VES-13 score.

The kappa statistics value for agreement between G-8 score and fTRST was 0.12 with a P value of 0.04. Similarly, the kappa statistics value for agreement between VES-13 and fTRST was found to be 0.16 (P = 0.07) and between VES-13 and G-8 was 0.05 (P = 0.45). The value of kappa and the level of agreement according to the same have been depicted in [Table 3]. The distribution of risk stratification according to each scale is shown in [Table 4].
Table 3: The value of kappa and agreement level

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Table 4: The agreement test statistics results to compare the agreement between tests score to detect the high risk and low risk individuals through Kappa statistics and P value

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It was observed that the maximum agreement existed between VES-13 and fTRST to detect the high risk and low risk individuals. The agreement value of VES-13 and fTRST observed was 59.44% (39.63% for high risk detection and 19.81% for low risk detection). The agreement measurement of G-8 and fTRST was predicted to be 39.62% (2.83% only for high risk detection and 36.79% for low risk detection). The lowest agreement was found between G-8 and VES-13 scores and was predicted to be 35.84% (7.54% for high risk detection and 28.30% for low risk detection).

Hence, it can be concluded that there is a significant agreement between geriatric risk scoring by VES-13 and fTRST scales to detect patients with high or low risk.


 > Discussion Top


In this analysis, we found that geriatric screening in cancer patients is feasible by a brief and simple questionnaire and has a significant impact on the detection of unknown geriatric problems which have a strong prognostic value for functional decline. However, there is only a slight agreement level between these three short screening scales. All these three scales were developed separately, and each one of them can be used independently for selecting patients for CGA.[10],[11],[12],[13] We have not done CGA in these patients and hence a comparison of these scales with CGA is not possible in this study. Our aim was to detect the level of agreement between these three tools and select one of them for screening patients for CGA. It was planned that if the agreement level was substantial, then the decision would be made on the basis of time utilized to complete the evaluation for a single patient. In that scenario, we would have opted for fTRST as the time for completion is below a minute in most of the patients.

All the three geriatric screening tools used in the study take into account different domains to calculate a score which denotes a high risk profile. The G-8 score is oriented to screening of age and nutritional status.[10],[11] The fTRST encompasses social and neurocognitive impairment apart from taking recent hospitalization and polypharmacy into account.[12] The VES-13 is associated with age and self-perception of health status, functional ability, and physical fitness.[13] Therefore, the difference in the domain screened may be responsible for the discrepancy in the geriatric high risk profile.

Soubeyran et al. also compared the diagnostic accuracy of the G-8 and VES-13 in a prospective cohort study of 1674 cancer patients accrued before treatment in 23 health care facilities.

G-8 and VES-13 showed a high risk profile in 68.4%, and 60.2% of the patients, respectively. Mean time to complete G-8 or VES-13 was about 5 min. G-8 appeared more sensitive (76.5% vs. 68.7%, P = 0.0046) whereas VES-13 was more specific (74.3% vs. 64.4%, P < 0.0001). Abnormal G-8 score (hazard ratio = 2.72) was found to be an independent prognostic factor of 1-year survival. Hence, the authors concluded that G-8 questionnaire is currently one of the best screening tools available to identify older cancer patients requiring comprehensive assessment.[15]

India is a developing country with a fast growing geriatric population.[1],[4] The unavailability of a unit dedicated to geriatrics has hampered the growth of geriatric oncology in India.[4] To the best of our knowledge, none of the government tertiary care centers in India have a geriatric unit.[6] This is reflected in the management of the old patients. In a tertiary cancer center from North India, it was seen that only 43% of aged patients received treatment.[5] Even worse situation prevails in cancer centers located in rural India where only 8% of the aged patients received palliative chemotherapy in a dedicated cancer center in rural South India (personal communication with Dr. Patil). In a survey reported [16] by Arora et al., only 50% of potentially curable patients received standard of care. Ninety two respondents felt that evidence based recommendations are lacking for elderly patients.[6] In an effort for doing a feasibility study for doing CGA in a private set up, Vora et al. reported that it required 6 h on an average to complete CGA in a single patient during their initial experience. Later, they used an abbreviated version of CGA, which took around 20–30 min per patient.[17] Interestingly, in this study, it was found that 20% of patients who had impairment in CGA were deemed fit for chemotherapy by the medical oncologist.[17]

We are in the process of developing a geriatric cancer clinic in our hospital. In our early phase, we plan to do CGA only in those elderly patients who would have a high risk profile on short screening tools. In a bid to decide which one to use we had performed this study. However, as there was only slight agreement among the three commonly used scales, the internationally accepted geriatric screening tools should be validated in India for ruling a high risk profile.


 > Conclusion Top


Geriatric screening in cancer patients is feasible by a brief and simple questionnaire and has a significant impact on the detection of unknown geriatric problems which have a strong prognostic value for functional decline. However, there is poor agreement (in view of kappa value being below 0.2) between the three short geriatric screening tools; G-8, fTRST and VES-13. Research needs to be directed to compare the agreement level between these three scales and CGA, so that the appropriate short screening tool can be selected for routine use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Mohile SG, Bylow K, Dale W, Dignam J, Martin K, Petrylak DP, et al. A pilot study of the vulnerable elder's survey-13 compared with the comprehensive geriatric assessment for identifying disability in older patients with prostate cancer who receive androgen ablation. Cancer 2007;109:802-10.  Back to cited text no. 13
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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