Frailty screening methods for predicting outcome of a comprehensive geriatric assessment in elderly patients with cancer: a systematic review

Summary

Comprehensive geriatric assessment (CGA) is done to detect vulnerability in elderly patients with cancer so that treatment can be adjusted accordingly; however, this process is time-consuming and pre-screening is often used to identify fit patients who are able to receive standard treatment versus those in whom a full CGA should be done. We aimed to assess which of the frailty screening methods available show the best sensitivity and specificity for predicting the presence of impairments on CGA in elderly patients with cancer. We did a systematic search of Medline and Embase, and a hand-search of conference abstracts, for studies on the association between frailty screening outcome and results of CGA in elderly patients with cancer. Our search identified 4440 reports, of which 22 publications from 14 studies, were included in this Review. Seven different frailty screening methods were assessed. The median sensitivity and specificity of each screening method for predicting frailty on CGA were as follows: Vulnerable Elders Survey-13 (VES-13), 68% and 78%; Geriatric 8 (G8), 87% and 61%; Triage Risk Screening Tool (TRST 1+; patient considered frail if one or more impairments present), 92% and 47%, Groningen Frailty Index (GFI) 57% and 86%, Fried frailty criteria 31% and 91%, Barber 59% and 79%, and abbreviated CGA (aCGA) 51% and 97%. However, even in case of the highest sensitivity, the negative predictive value was only roughly 60%. G8 and TRST 1+ had the highest sensitivity for frailty, but both had poor specificity and negative predictive value. These findings suggest that, for now, it might be beneficial for all elderly patients with cancer to receive a complete geriatric assessment, since available frailty screening methods have insufficient discriminative power to select patients for further assessment.

Introduction

Although malignant tumours can occur in people of all ages, cancer disproportionately affects those aged 65 years and older,¹ and the number of elderly patients with cancer will increase substantially in the coming decades as a result of increasing life expectancy and population ageing. A challenge for cancer specialists is to determine the optimum treatment for elderly patients—a heterogeneous population with regard to comorbidity, physical reserves, disability, and geriatric conditions.

To help guide treatment decisions, two features of geriatric medicine are being incorporated in geriatric oncology: the concept of frailty and the comprehensive geriatric assessment (CGA). Frailty is considered to be a state of decreased physiological reserves, arising from cumulative deficits in several physiological systems and resulting in a diminished resistance to stressors.2, 3 Cancer and treatment are substantial stressors that diminish physiological reserves, so the concept of frailty is particularly relevant for older patients with cancer. As yet, there is no consensus on the definition and measurement of frailty. The original definition of frailty, formulated by Fried and colleagues,⁴ focused on physical weakness and wasting, but many other definitions and criteria have been postulated, incorporating different aspects of ageing that contribute to diminished physiological reserves.5, 6

In geriatric oncology, a CGA is done to detect disabilities and geriatric conditions that can contribute to frailty. A CGA is a systematic procedure that objectively appraises the health status of elderly people, focusing on somatic, functional, and psychosocial domains,⁷ with proven value in geriatric medicine.⁸ However, because a CGA is time-consuming, research is focusing on screening methods to identify fit elderly patients who are able to receive standard cancer treatment based on the complete treatment schedule, and vulnerable patients who should subsequently receive a CGA to guide tailoring of their treatment regimen.⁹

High sensitivity is crucial for a frailty screening method, to ensure that frail patients will correctly be identified by the approach.10, 11 However, to optimise the time-saving potential of a two-stepped approach, a high specificity is also required, to limit the number of fit patients who are incorrectly identified as frail and who unnecessarily receive a CGA. We did a systematic review to assess the sensitivity and specificity of frailty screening methods for predicting the presence of impairments on a CGA.