Almost 60% of all cancer cases occur in patients ≥65 years of age and an increase of 70% is expected in the next 30 years [GLOBOCAN, 2012]. Worldwide, there is about 2.26 million newly diagnosed female breast cancer cases in 2020, accounting for almost 1 in 4 cancer cases among women [GLOBOCAN, 2020]. In Mexico, 15.5% of patients over 65 years of age were estimated in a cohort of more than 5,400 women with breast cancer (Cabrera-Galeana, et al. 2018).
Despite the increasing incidence of cancer in the geriatric population, there is few evidences to guide oncological treatment decisions in this age group (Hurria, et al. 2014). This is reflected in an over-treatment of less fit patients, and under-treatment for those in good conditions to carry out a complete oncological management. The chronological age as well as the functional status based on the Karnofsky Performance Status or the ECOG (Eastern Cooperative Oncology Group) scale are still used for treatment decision-making (Soto-Pérez de Celis, et al. 2018).
Comprehensive Geriatric Assessment (CGA)
The CGA is a functional and physiological evaluation of the geriatric patient. It involves: functional status, psychological problems, polypharmacy, comorbidities, nutrition, social support and cognitive deficit (Hamaker, et al. 2012). Interventions derived from CGA have been shown to have an impact in reducing mortality, improving functional status and reducing hospital admissions in cancer patients (Hamaker, et al. 2012, Kenis, et al. 2013, Poh-Loh, et al. 2018, Stuck, et al. 1993, Cohen, et al. 2002). The CGA identifies up to 70% of unknown geriatric problems not detected in routine practice and leads to changes in planned oncology management in up to 50% of patients (Hamaker, et al. 2014, Decoster, et al. 2013, Yokom 2010, Caillet 2014).
Despite the usefulness of CGA, it is not routinely performed in the general oncology consultation, due to the time required and the need for a geriatrician, so its routine application is not feasible (Hernández 2017, Extermann, et al. 2005).
Geriatric Screening Tools
G8 (Table 1) is a geriatric screening tool designed to identify elderly cancer patients who benefit from a CGA. It detects frailty with a sensitivity of 85% and specificity of 64% (vanWalree, et al. 2019), so it is currently recommended by the guidelines of the Society of Oncology Geriatric (SIOG) (Decoster, et al. 2015). G8 involves 8 questions that assess: nutritional status, mobility, psychological status, polypharmacy, self-perception of health status and age; it takes about 4.4 minutes to perform and stratifies the patients according to their score in: >14: healthy patient, who does not warrant any intervention and can receive conventional oncology treatment; and ≤14: vulnerable / fragile patient requiring a CGA (Ferrat, et al. 2017, Hamaker, et al. 2017).
Table 1
G8 Geriatric Screening Tool
|
Items
|
Possible responses (score)
|
A
|
Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing, or swallowing difficulties?
|
0 = severe decrease in food intake
|
1 = moderate decrease in food intake
|
2 = no decrease in food intake
|
B
|
Weight loss during the last 3 months?
|
0 = weight loss > 3 kg
|
1 = does not know
|
2 = weight loss between 1 and 3 kg
|
3 = no weight loss
|
C
|
Mobility?
|
0 = bed or chair bound
|
1 = able to get out of bed/chair but does not go out
|
2 = goes out
|
D
|
Neuropsychological problems?
|
0 = severe dementia or depression
|
1 = mild dementia
|
2 = no psychological problems
|
E
|
BMI (weight in kg)/(height in m2)
|
0 = BMI < 19
|
1 = BMI 19 to < 21
|
2 = BMI 21 to < 23
|
3 = BMI ≥ 23
|
F
|
Takes more than three prescription drugs per day?
|
0 = yes
|
1 = no
|
G
|
In comparison with other people of the same age, how does the patient consider his/her health status?
|
0.0 = not as good
|
0.5 = does not know
|
1.0 = as good
|
2.0 = better
|
H
|
Age
|
0 = > 85
|
1 = 80 – 85
|
2 = < 80
|
|
Total score
|
0 – 17
|
BMI: body mass index
|
Abnormal results on G8 have been shown to be associated with a negative impact on functional status and reduced survival (Aaldriks, et al. 2013, Bellera, et al. 2012, Saliba, et al. 2001, Baitar, et al. 2013, Kenis, et al. 2014, Kellen, et al. 2010). It is estimated that between 20 to 50% of the screened population will have a G8 with fragility criteria. Therefore, geriatric screening should be carried out in order to discriminate frail patients and those who can tolerate any conventional cancer treatment regardless of their chronological age (Takahashi, et al. 2017, Martínez-Tapia, et al. 2016, Bellera 2017).
The National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology Guidelines for Geriatric Oncology (ASCO), and the International Society of Geriatric Oncology (SIOG), recommends to perform a CGA in patients ≥65 years receiving chemotherapy and they include G8 as part of the tools to be used for the evaluation of patient mortality prediction (Extermann, et al. 2005, VanderWalde, et al. 2016, Supriya, et al. 2018). So recently, the Mexican Consensus on Diagnosis and Treatment of Breast Cancer, recommends performing G8 as part of the evaluation for all the geriatric patients since 2019 (Consenso Mexicano sobre el Diagnóstico y Tratamiento del Cáncer Mamario 2021).