Assessing frailty in older Indian patients before cancer treatment: Comparative analysis of three scales and their implications for overall survival.

INTRODUCTION: Frailty, characterized by ageing-related vulnerability, influences outcomes in older adults. Our study aimed to investigate the relationship between frailty and clinical outcomes in older Indian patients with cancer. MATERIALS AND METHODS: Our observational single-centre study, conducted at Tata Memorial Hospital from February 2020 to July 2022, enrolled participants aged 60 years and above with cancer. Frailty was assessed using the Clinical Frailty Scale (CFS), G8, and Vulnerable Elders Survey (VES)-13. The primary objective was to explore the correlation between baseline frailty and overall survival. Statistical analyses include Kaplan-Meier, Cox proportional hazards, and Harrell's C test. RESULTS: A total of 1,177 patients (median age 68, 76.9% male) were evaluated in the geriatric oncology clinic. Common malignancies included lung (40.0%), gastrointestinal (35.8%), urological (11.9%), and head and neck (9.0%), with 56.5% having metastatic disease. Using CFS, G8, and VES-13 scales, 28.5%, 86.4%, and 38.0% were identified as frail, respectively. Median follow-up was 11.6 months, with 43.3% deaths. Patients fit on CFS (CFS 1-2) had a median survival of 28.02 months, pre-frail (CFS 3-4) 13.24 months, and frail (CFS ≥5) 7.79 months (p < 0.001). Abnormal G8 (≤14) and VES-13 (≥3) were associated with significantly lower median survival (p < 0.001). Multivariate analysis confirmed CFS's predictive power for mortality (p < 0.001), with hazard ratios [HRs] for pre-frail at 1.61(95% confidence interval [CI] 1.25 to 2.06) and frail at 2.31 (95%CI 1.74 to 3.05). G8 ≤ 14 had HR 2.00 (95%CI 1.42 to 2.83), and abnormal VES-13 had HR 1.36 (95%CI 1.11-1.67). In the likelihood ratio test, CFS significantly improved the model fit (p < 0.001). Harrell's C index for survival prediction was 0.62 for CFS, 0.54 for G8, and 0.58 for VES-13. DISCUSSION: In conclusion, our study highlights varying frailty prevalence and prognostic implications in older Indian patients with cancer, emphasizing the need for personalized care in oncology for this aging population. We would recommend using CFS as a tool to screen for frailty for older Indian patients with cancer.

Performance of potentially inappropriate medications assessment tools in older Indian patients with cancer.

BACKGROUND: Polypharmacy and potentially inappropriate medication (PIM) use are common problems in older adults. Safe prescription practices are a necessity. The tools employed for the identification of PIM sometimes do not concur with each other. METHODS: A retrospective analysis of patients ≥60 years who visited the Geriatric Oncology Clinic of the Tata Memorial Hospital, Mumbai, India from 2018 to 2021 was performed. Beer's-2015, STOPP/START criteria v2, PRISCUS-2010, Fit fOR The Aged (FORTA)-2018, and the EU(7)-PIM list-2015 were the tools used to assess PIM. Every patient was assigned a standardized PIM value (SPV) for each scale, which represented the ratio of the number of PIMs identified by a given scale to the total number of medications taken. The median SPV of all five tools was considered the reference standard for each patient. Bland-Altman plots were utilized to determine agreement between each scale and the reference. Association between baseline variables and PIM use was determined using multiple logistic regression analysis. RESULTS: Of the 467 patients included in this analysis, there were 372 (79.66%) males and 95 (20.34%) females with an average age of 70 ± 5.91 years. The EU(7)-PIM list was found to have the highest level of agreement given by a bias estimate of 0.010, the lowest compared to any other scale. The 95% CI of the bias was in the narrow range of -0.001 to 0.022, demonstrating the precision of the estimate. In comparison, the bias (95%) CI of Beer's criteria, STOPP/START criteria, PRISCUS list, and FORTA list were -0.039 (-0.053 to -0.025), 0.076 (0.060 to 0.092), 0.035 (0.021 to 0.049), and -0.148 (-0.165 to -0.130), respectively. Patients on polypharmacy had significantly higher PIM use compared to those without (OR = 1.47 (1.33-1.63), p = <0.001). CONCLUSIONS: The EU(7)-PIM list was found to have the least bias and hence can be considered the most reliable among all other tools studied.

The current status of geriatric oncology in India.

Geriatric oncology in India is relatively new. The number of older persons with cancer is increasing exponentially; at our institution, 34% of patients registered are 60 years and over. Apart from the Tata Memorial Hospital in Mumbai, there are currently no other Indian centers that have a dedicated geriatric oncology unit. Geriatric assessments (GAs) are done sporadically, and older patients with cancer are usually assessed and treated based on clinical judgement. Challenges to increasing the uptake of GA include a lack of training/time/interest or knowledge of the importance of the GA. Other challenges include a lack of trained personnel with expertise in geriatric oncology, and a paucity of research studies that seek to advance the outcomes in older Indian patients with cancer. We anticipate that over the next 10 years, along with the inevitable increase in the number of older persons with cancer in India, there will be a commensurate increase in the number of skilled personnel to care for them. Key goals for the future include increased research output, increased number of dedicated geriatric oncology units across the country, India-specific geriatric oncology guidelines, geriatric oncology training programs, and a focus on collaborative work across India and with global partners. In this narrative review, we provide a broad overview of the status of geriatric oncology in India, along with a description of the work done at our center. We hope to spark interest and provide inspiration to readers to consider developing geriatric oncology services in other settings.

Validation of the Onco-MPI in predicting short-term mortality in older Indian patients with cancer.

INTRODUCTION: The number of older patients with cancer is increasing exponentially worldwide, and a similar trend has also been noted in India. The Multidimensional Prognostic Index (MPI) strongly correlates the presence of individual comorbidities with mortality, and the Onco-MPI prognosticates patients accurately for overall mortality. However, limited studies have evaluated this index in patient populations beyond Italy. We evaluated the performance of the Onco-MPI index in predicting mortality in older Indian patients with cancer. MATERIALS AND METHODS: This observational study was conducted between October 2019 and November 2021 in the Geriatric Oncology Clinic at Tata Memorial Hospital in Mumbai, India. The data of patients aged ≥60 years with solid tumors who underwent a comprehensive geriatric assessment was analysed. The study's primary aim was to calculate the Onco-MPI for patients in the study and correlate it with one-year mortality. RESULTS: A total of 576 patients aged ≥60 years were included in the study. The median age (range) of the population was 68 (60-90) years, and 429 (74.5%) were male. After a median follow-up of 19.2 months, 366 (63.7%) patients had died. The proportion of patients classified as low risk (0-0.46), moderate risk (0.47-0.63) and high risk (0.64-1.0) were 38% (219 patients), 37% (211 patients) and 25% (145 patients), respectively. There was a significant difference in one-year mortality rates between the low-risk patients compared to medium and high-risk patients (40.6% vs 53.1% vs 71.7%; p < 0.001). DISCUSSION: The current study validates the Onco-MPI as a predictive tool for estimating short-term mortality in older Indian patients with cancer. Further prospective studies need to build on this index to obtain a score with greater discrimination in the Indian population.

The prevalence of cognitive impairment in older Indian persons with cancer and brain metastases.

Background: Older patients with cancer are more vulnerable to the effects of cognitive impairment affecting their functional status, quality of life, compliance to treatment and ultimately survival. Cancer-related cognitive impairment may be due to the cancer itself or due to the treatment of cancer. There are no data regarding the prevalence of cognitive impairment in older persons with cancer and brain metastasis. Methods: This retrospective analysis was conducted on a prospectively collected data set of patients who attended the geriatric oncology clinic at a tertiary care comprehensive cancer centre in India from June 2018 to July 2021. Patients aged 60 years and above with malignancy were included. Cognition was assessed with the mini-mental status examination (MMSE); the Hindi MMSE was used for illiterate patients. A score of ≤23 on the MMSE was considered abnormal. Correlation between the presence of cognitive impairment and brain metastasis was tested using the chi-square test. Results: A total of 597 patients were included, of which 462 (77.4%) were male. The median age was 69 years (range: 60-100 years). All patients had solid tumours; 244 (40.9%) had lung, 189 (31.7%) had gastrointestinal and 75 (12.6%) had head and neck malignancies. Forty-one (6.9%) patients had brain metastases, of which 10 (24.4%) had solitary, 30 (73.2%) had multiple lesions and 1 (2.4%) had leptomeningeal metastases. Cognitive impairment was noted in 11 (26.8%) of the 41 patients with brain metastases and 91 (16.4%) of the 556 patients without brain metastases. There was no significant correlation between the presence of brain metastases and cognitive impairment, p = 0.086. Conclusion: Older persons with cancer and brain metastases were not found to have a higher occurrence of cognitive impairment than those without brain metastases in this study. The next step is to understand whether older persons with brain metastases are at a higher risk for cognitive decline as a result of therapeutic interventions such as cranial radiotherapy and chemotherapy.

Caregiver burden in older Indian patients with cancer- Experience from a tertiary care center.

INTRODUCTION: Most of the long-term care for older adults with chronic or debilitating illnesses is provided by unpaid family members or informal caregivers. There is limited information on caregiver burden among caregivers of older patients with cancer in India. Hence, we assessed the prevalence and severity of caregiver burden among caregivers of older Indian patients with cancer. MATERIALS AND METHODS: This was an observational study conducted at the geriatric oncology clinic at Tata Memorial Centre, Mumbai, India. Caregivers of patients aged 60 years and over with a diagnosis of cancer were assessed for caregiver burden using the Zarit Burden Interview. Descriptive statistics were used for demographic and clinical variables. Factors impacting caregiver burden were analyzed using multiple linear regression analysis. RESULTS: Caregiver burden was assessed among 127 caregivers of older Indian patients with cancer. The median patient age was 69 years (range 60-90). Most patients were men (75.6%). There were 33 female caregivers (26%), and 94 male caregivers (74%). The median caregiver burden score was 12 (IQR 6-20). Caregiver burden was "little/none" in 97 (76.4%), "mild-moderate" in 25 (19.7%), "moderate-severe" in four (3.1%) and "severe" in one (0.8%) of the caregivers assessed. On multivariate analysis, factors that significantly impacted caregiver burden scores were the presence of psychological issues in the patient and the caregiver's educational level. DISCUSSION: Caregiver burden was low among caregivers of older Indian patients with cancer seen at a single center. Caregivers of patients with psychological disorders, and those who had less schooling reported higher caregiver burden.

G8 and VES-13 as screening tools for geriatric assessment and predictors of survival in older Indian patients with cancer.

BACKGROUND: Geriatric 8 (G8) and Vulnerable Elders Survey-13 (VES-13) are quick and easy-to-use screening tools, developed and validated in older patients living in North America and Europe for predicting abnormalities in the subsequent geriatric assessment. The applicability of these screening tools in older Indian patients with cancer is not known. METHODS: An observational study in 308 Indian patients with cancer aged ≥60 years, who were evaluated in the Geriatric Oncology clinic at the Tata Memorial Hospital, Mumbai, India, between June 2018 and November 2020. Patients underwent the G8 and VES-13 screening tools followed by a geriatric assessment. The objectives were to determine the diagnostic accuracy of the G8/VES-13 screening tools to detect an abnormal geriatric assessment, to determine their association with the Eastern Cooperative Oncology Group (ECOG) performance status (PS)/Cancer Aging and Research Group (CARG) scores, to determine the optimal cut-off value on the G8 scale for older Indian patients with cancer, and to determine whether an abnormal G8/VES-13 score was associated with shorter survival. We also aimed to assess the utility of combining the G8 and VES-13 scores to predict for an abnormal geriatric assessment and poorer survival. RESULTS: The sensitivity and specificity of the G8 (cut-off, ≤14) score were 84.4% and 17.6%, respectively, whereas those for the VES-13 score (≥3) were 34.9% and 82.4%, respectively. The appropriate abnormal G8 cut-off score was noted to be 12. Abnormal G8 (≤14) and VES-13 scores were not associated with an abnormal subsequent geriatric assessment [p = 0.736 (G8)], while abnormal G8 (≤14) scores did not predict for worse survival outcomes. Lowering the cut-off of the G8 score to <12 and/or combining an abnormal G8 (<12) with the VES-13 score were found to be associated with an abnormal subsequent geriatric assessment [p < 0.001 (G8), p < 0.001(G8 + VES-13)] and predicted for worse survival. CONCLUSIONS: An abnormal G8 cut-off score < 12 is therefore appropriate in older Indian patients with cancer. G8 < 12 predicts for the presence of non-oncological vulnerabilities and shorter survival. Lowering the cutoff of G8 to 12translated to a 35% reduction in the number of patients undergoing a complete geriatric assessment. Combined with VES-13, the G8 can be reliably used to identify those patients who would benefit the most from a geriatric assessment and help in optimal resource utilization especially in busy Indian centers.

Comparison of the Performance of APACHE II, SOFA, and mNUTRIC Scoring Systems in Critically Ill Patients: A 2-year Cross-sectional Study.

AIMS AND OBJECTIVES: Different severity scores are being used to assess outcomes in intensive care unit, but variable data had been reported so far per their performance. Main objective of this study is to compare performance of acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), and modified nutrition risk in critically ill (mNUTRIC) scoring systems regarding the outcomes in the form of morbidity and mortality in medical intensive care unit (MICU) at rural tertiary-care health center. MATERIALS AND METHODS: In this cross-sectional study, 1,990 patients older than 18 years admitted in the ICU were enrolled. Age, gender, diagnosis, intubation, comorbidities, APACHE II, SOFA scores, m NUTRIC score, MICU stays in days, and need of mechanical ventilation were noted. RESULTS: When we compared different score with mortality, APACHE-II was having sensitivity of 89.9% and specificity of 97.6%; SOFA had 90.1% sensitivity and 96.6% specificity; while mNUTRIC score had 97.2% sensitivity and 74.0% specificity. APACHE-II score had sensitivity of 93.4%, SOFA had 90.5%, and mNUTRIC score 92.3% with low specificity of 76.5% in predicting requirement of mechanical ventilation. mNUTRIC score and ICU length of stay showed moderate positive correlation (p value = <0.001). CONCLUSION: All the three scores were comparable in sensitivity and specificity in predicting outcomes in the form of mortality, need of mechanical ventilation, and length of ICU stays. mNUTRIC score was more sensitive than others, and as it was based on nutritional status, hence more weightage should be given on this score. HOW TO CITE THIS ARTICLE: Kumar S, Gattani SC, Baheti AH, Dubey A. Comparison of the Performance of APACHE II, SOFA, and mNUTRIC Scoring Systems in Critically Ill Patients: A 2-year Cross-sectional Study. Indian J Crit Care Med 2020;24(11):1057-1061.