Cross-cultural Adaptation and Validation of the Geriatric 8 Screening Tool in Chinese Older Inpatients with Cancer

doi:10.21203/rs.3.rs-2008360/v1

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Cross-cultural Adaptation and Validation of the Geriatric 8 Screening Tool in Chinese Older Inpatients with Cancer

https://doi.org/10.21203/rs.3.rs-2008360/v1

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Background: Frailty is emerging as an important determinant of human health. The Geriatric 8 (G8) questionnaire, originally produced in English, is a common frailty screening tool designed specifically for older cancer patients. However, this tool has not yet been applied in China, partly due to a lack of a Chinese version. Therefore, this study aimed to translate the original G8 questionnaire into Chinese and validate its psychometric properties in Chinese older inpatients with cancer.

Methods: The Chinese version of the G8 (C-G8) questionnaire was generated using Brislin’s model of translation. The psychometric properties of the C-G8, including content validity, known-group divergent validity, convergent validity, internal consistency, test-retest reliability, and inter-rater reliability, were all examined.

Results: A total of 296 eligible subjects were consecutively enrolled in this cross-sectional study. The content validity index of the C-G8 were 0.8~1 at the item level and 0.975 at the scale level, respectively. The C-G8 identified more frail individuals among these older participants (>75 years) compared to their younger counterparts (65~75 years) (frailty prevalence: 87.1% vs. 70.9%, P=0.010). In addition, the convergent validity of the C-G8 was tested by correlating it with the FRAIL scale (r=-0.592, P<0.001), indicating a moderate correlation between these two instruments in screening frailty. Nevertheless, the C-G8 had a lower internal consistency (Cronbach’s α coefficient=0.501) but higher test-retest reliability and inter-rater reliability (intraclass correlation coefficient=0.913 and 0.993, respectively, P<0.001).

Conclusion: The C-G8 questionnaire was demonstrated to have acceptable validity and reliability and hence could be applied to Chinese older cancer patients.

Frailty

Geriatric 8

Cancer

Reliability

Validity

Cross-cultural adaptation

Cancer is the leading cause of death and a major obstacle to increasing life expectancy in the world [1]. According to Global Cancer Statistics 2020 [1], there are approximately 19.3 million new cancer cases and 10 million cancer deaths worldwide in 2020, and the global cancer burden is expected to reach 28.4 million in 2040, with a rise of 47% from 2020. Although malignancies would occur in people of all ages, more than two-thirds of new cancer cases are diagnosed among those adults aged 60 years and older [2]. With the increasing aging of the population, the cancer burden is anticipated to become heavier among the elderly. This inevitably poses a challenge for cancer specialists to determine the optimal therapeutic regimen for those older patients, a heterogeneous population in terms of comorbidity, disability, physical reserve, and geriatric conditions [3].

In an attempt to provide guidance for treatment decisions, two features of geriatrics, namely frailty and the comprehensive geriatric assessment (CGA), are being incorporated into geriatric oncology [3]. As one of the most severe global public health challenges, frailty has been regarded as a complex and age-related clinical condition characterized by decreased function across multiple physiological systems, which would induce increased susceptibility to stressors [4]. As is reported in several studies, frailty is significantly associated with a higher risk of chemotherapy intolerance [5], postoperative complications, mortality [6], and poor prognosis [7] among older patients with cancer. The CGA is an established tool used in geriatric medicine to identify unmet needs for intervention [8] and focuses on the medical, psychosocial, and functional domains of older patients [9] in order to develop a coordinated plan and maximize health promotion. In geriatric oncology, the CGA can be performed to detect disabilities and geriatric conditions that can conduce to frailty [3]. However, it is often time-consuming and impractical to perform a CGA in the ward with limited resources. Currently, there is no global standard assessment instrument for frailty [10]. Of note, research has focused on frailty screening methods to identify fit or frail older patients who are suitable to receive standard therapeutic regimens or to undergo a CGA to guide the tailoring of their treatment regimens [3].

The Geriatric 8 (G8) questionnaire is a common frailty screening tool designed specifically for older patients with cancer [3] and administered by healthcare professionals in clinical practice [11]. The G8 questionnaire, developed by Bellera et al. [12], was first applied to frailty screening in 364 older patients with cancer, and presented good sensitivity (85%, 95%CI: 81%-89%) and acceptable specificity (65%, 95%CI: 41%-85%) [13] at a threshold of 14 points when using the CGA as a reference standard. As per previous studies, the G8 has been verified to have a strong prognostic value for functional decline [14], overall survival [15, 16], and complications [17] among older patients with cancer. Recently, Cavusoglu et al. [18] revealed that the Turkish version of the G8 (T-G8) was a valid and reliable tool for older patients without malignancy in geriatric outpatient clinics, with a strong agreement between the T-G8 and CGA in the validity (kappa = 0.630, P < 0.001) and high inter-rater and intra-rater agreement in the reliability (kappa = 0.886 and 0.875, P < 0.001, respectively). Nevertheless, it is still necessary to conduct further investigations to explore the application of the T-G8 in older cancer patients, especially the psychometric properties of the T-G8 measured in this population. In addition, Yuk et al. [19] translated the G8 into Korean and validated its effectiveness in Korean patients over 70 years old scheduled for cancer surgery. Their findings suggested that the Korean version of the G8 (K-G8) was meaningful and significantly correlated with some evaluation indicators, including patients’ age, comorbidity, and performance status. However, the reliability and validity of the K-G8 needs to be further investigated.

To the best of our knowledge, the G8 questionnaire is a practical and useful tool for screening frailty among older patients with cancer. However, its application in the Chinese population is limited partly due to a lack of a Chinese version. Therefore, the aim of this study was to translate and culturally adapt the G8 questionnaire into Chinese through an internationally accepted methodology for Chinese older inpatients with cancer. Moreover, the validity and reliability of the Chinese version of the G8 (C-G8) in this population would also be verified.

Study design and participants

This study incorporated a cross-sectional descriptive design and was conducted at six hospitals (The First Affiliated Hospital of Anhui Medical University, The First Affiliated Hospital of Anhui Medical University North District, The First Affiliated Hospital of Bengbu Medical College, The First Affiliated Hospital of Soochow University, Affiliated Hospital of Jiangnan University, and Henan Provincial People’s Hospital) in Anhui, Jiangsu, and Henan provinces, China from Jan. 2021 to Jun. 2022. All patients were consecutively enrolled if they met the following criteria: 1) ≥ 65 years old; 2) with histologically-confirmed any types of cancer; 3) before any treatments or between any two steps of treatment sequence such as chemotherapy, radiotherapy, and surgery; and 4) signed the written informed consents. The exclusion criteria were as follows: 1) diagnosed with cancer cachexia [20]; 2) with obvious difficulties in communication such as lisping and decreased hearing; and 3) incomplete questionnaire filling.

Ethical considerations

Ethical approval

was obtained from the Clinical Medical Research Ethics Committee of the First Affiliated Hospital of Anhui Medical University (No. Quick-PJ2022-04-65) and other five hospitals. This study conformed to the standards of the Declaration of Helsinki.

G8 questionnaire

The G8 questionnaire, an 8-item physician screening frailty tool based on the Mini-Nutritional Assessment (MNA) [21], includes food intake, weight loss, body mass index (BMI), mobility, neuropsychological status (depression and dementia), number of medications, self-perception of health, and chronological age [12]. According to Bellera et al. [12], the seven items of the G8 from the original 18-item MNA remained the same scores as those used in the original MNA questionnaire. Meanwhile, the patient’s age is assigned a score of 0 (> 85 years old) to 2 (< 80 years old). The total score of the G8 ranges from 0 to 17, and lower scores indicate a higher risk of frailty. The patients with a score ≤ 14 would be considered potentially frail in geriatric oncology [11]. The qualified research nurses assessed the frailty status of patients at their first visit in the ward.

FRAIL scale

The FRAIL scale was used to evaluate the convergent validity of the C-G8. It consists of the following five domains: fatigue, resistance, ambulation, illnesses, and weight loss [22]. Patients would be scored 1 for each of these five deficits, and the total score of the FRAIL ranges from 0 to 5 [23], with higher scores indicating more severe frailty. Patients could be classified as robust health (0 points), pre-frail (1–2 points), or frail (3–5 points) [24]. The FRAIL scale was primarily based on the patients’ self-report at their first visit in the ward.

Translation and cultural adaptation

In this study, the practice to translate the original G8 questionnaire into Chinese had been authorized by Prof. Bellera. The translation and cross-cultural adaptation of the original version of the G8 questionnaire into Chinese were performed based on the established guidelines and methods that had been published elsewhere [25–27].

Firstly, two bilingual native Chinese speakers independently forward-translated the original G8 questionnaire into Chinese. Among them, one translator was a professor from the field of geriatric nursing and familiar with the terminology and content of the G8 questionnaire. The other translator was an English lecturer at a university with a Ph.D. in linguistics and no medical background. Then, the forward-translations were reconciliated by a third bilingual and bicultural independent translator, who was not involved in the forward translation process, to compare the two C-G8 versions regarding the discrepancies of words, sentences, and meanings and finalize the C-G8 after comprehensive discussions.

Secondly, the C-G8 was independently back-translated by two professors who had lived in English-speaking countries for at least 10 years. Among them, one professor specialized in public health and the other one in English education. Of note, both of them were completely blind to the original version of the G8. Then, the research team members reviewed the back-translations in respect of the comparability of meaning with the target language and the clarity of words, and finalized the back-translated G8.

Thirdly, an expert committee (including a geriatrician, geriatric nursing expert, public health nutritionist, methodologist, and language specialists) carefully compared and discussed the translated, back-translated, and original versions of the G8. In addition, a monolingual expert in biobehavioral nursing and health informatics was invited to compare the differences between the back-translated and original versions through emails. The feedback indicated that no major differences were found between the back-translated and original versions. The expert committee checked the document and confirmed that the preliminary C-G8 achieved conceptual, semantic, and idiomatic equivalence.

A pretest of twenty older inpatients with cancer was performed by ten clinical nurses through the preliminary C-G8. The research purpose was also explained to clinical nurses in detail. The feedback was received from these nurses through face-to-face interviews to identify whether they could understand the meaning and clarity of each question and answer in the preliminary C-G8. No major changes were made to the C-G8, and healthcare professionals could complete the C-G8 within 3 minutes. The items of the C-G8 in the final version were modified relative to the preliminary version, as presented in Appendix A. Lastly, the final C-G8 was obtained (including Chinese version and English version), as shown in Appendix B.

Psychometric evaluation

Validity

To determine the content validity of the C-G8, the content validity index (CVI) was applied to assess the responses from a panel of five geriatric experts regarding each item of the C-G8 for content equivalence. The CVI of the C-G8 at the item level (I-CVI) and that at the scale level (S-CVI) were calculated respectively. The known-group divergent validity of the C-G8 was evaluated by age based on the previous study [28]. The convergent validity of the C-G8 was determined through its correlation with the FRAIL scale [22].

Reliability

The Cronbach’s α coefficient [29] and item-total correlations [30] were calculated to evaluate the internal consistency of the C-G8. To evaluate its reproducibility, test-retest reliability was assessed in a convenient sample of 37 participants at an interval of 7–14 days [31]. Besides, an additional 19 participants were screened independently by two qualified researchers in two sequential sessions to determine the inter-rater reliability of the C-G8.

Statistical analysis

Continuous variables were expressed as mean ± standard deviation (SD), and categorical variables were reported as frequency numbers (percentages). To evaluate the content validity of the C-G8, the relevant criteria were as follows [27]: 1 = not relevant; 2 = unable to assess relevance; 3 = relevant, but needs minor alteration; 4 = very relevant and succinct. The CVI was calculated as the percentage of items with a rating of 3 or 4 [32]. The known-group divergent validity based on age was determined using the Chi-squared test. Besides, the convergent validity was assessed through the Spearman correlation [33] between the total score of the C-G8 and the total score of the FRAIL scale. The absolute magnitude of the correlation coefficients related to Spearman analysis was as follows [34]: <0.1, negligible; 0.1–0.39, weak; 0.4–0.69, moderate; 0.7–0.89, strong; 0.9-1.0, very strong. In addition, the internal consistency was evaluated using Cronbach’s α coefficient. Spearman correlation coefficients were calculated between the score of each item and the total score of all items in the C-G8. The test-retest reliability and inter-rater reliability were assessed by calculating the intraclass correlation coefficient (ICC) [31, 35]. The values of Cronbach’s α coefficient and ICC greater than 0.7 were considered to have good internal consistency and test-retest/inter-rater reliability, respectively [31]. All data analyses were performed with IBM SPSS 26.0 software package (Armonk, NY, USA). The significance level was set at P value (two-tailed) < 0.05.

All participants’ characteristics

Overall, a total of 303 (100%) participants consecutively participated in this study from Jan. 2021 to Jun. 2022. Of the subjects, 7 (2.3%) were excluded for incomplete questionnaire filling. Therefore, 296 (97.7%) eligible participants were included in the final analysis.

The age of the participants ranged from 65 to 91 years old, with a mean age of 72 (± 5) years old. Among them, 55.1% were male and the mean BMI of the total participants was 22.36 (± 3.80). Most were married (93.9%), received elementary school or below (63.5%), and did not exercise regularly (70.3%). The majority had no history of smoking/drinking (64.2%/67.9%) and no tumor metastasis (63.5%). The included subjects were primarily diagnosed with gastric cancer (28.0%) and colorectal cancer (26.0%).

The total mean score of the FRAIL was 1.62 (± 1.34), and 46.6% were judged to be pre-frail and 27.4% were frail. Meanwhile, the prevalence of frailty was 74.3% using the C-G8. Further details about the characteristics of all participants were shown in Table 1.

Table 1

All participants’ characteristics (N = 296).
Variables	N or Mean ± SD	%
Age	72 ± 5	—
Sex
Male	163	55.1
Female	133	44.9
BMI	22.36 ± 3.80	—
Marriage
Married	278	93.9
Unmarried/Widowed/Divorced	18	6.1
Educational background
Elementary school or below	188	63.5
Middle school	69	23.3
High school or above	34	11.5
Not available	5	1.7
Smoking history
Yes	106	35.8
No	190	64.2
Drinking history
Yes	95	32.1
No	201	67.9
Doing regular exercise
Yes	84	28.4
No	208	70.3
Not available	4	1.4
Types of cancer
Gastric	83	28.0
Esophageal	9	3.0
Colorectal	77	26.0
Liver	24	8.1
Pancreas	9	3.0
Lung	23	7.8
Breast	10	3.4
Endometrial	14	4.7
Ovarian	28	9.5
Cervical	19	6.4
Tumor metastasis
Yes	94	31.8
No	188	63.5
Not available	14	4.7
FRAIL
Total mean score	1.62 ± 1.34	—
Robust 0	77	26.0
Prefrail 1–2	138	46.6
Frail 3–5	81	27.4
C-G8
Total mean score	12.26 ± 2.83	—
Normal > 14	76	25.7
Abnormal ≤ 14	220	74.3

The prevalence of frailty in older inpatients with different types of cancer

According to the C-G8, the prevalence of frailty in all older cancer patients was 74.3%, with the highest prevalence observed in esophageal cancer and pancreas cancer (88.9%) and the lowest prevalence in cervical cancer (47.4%), as listed in Table 2. While based on the FRAIL scale, the prevalence of frailty in all older cancer patients was 74.0%, with the highest prevalence observed in pancreas cancer (100.0%) and the lowest prevalence in breast cancer (30.0%).

Table 2

Frailty prevalence in older inpatients with different types of cancer (N = 296).
Types of cancer	FRAIL [N (%)]			C-G8 [N (%)]
Types of cancer	Robust 0	Prefrail 1–2	Frail 3–5	Normal > 14	Abnormal ≤ 14
Gastric	16 (19.3)	50 (60.2)	17 (20.5)	16 (19.3)	67 (80.7)
Esophageal	3 (33.3)	5 (55.6)	1 (11.1)	1 (11.1)	8 (88.9)
Colorectal	21 (27.3)	36 (46.8)	20 (26.0)	16 (20.8)	61 (79.2)
Liver	7 (29.2)	6 (25.0)	11 (45.8)	6 (25.0)	18 (75.0)
Pancreas	0 (0.0)	4 (44.4)	5 (55.6)	1 (11.1)	8 (88.9)
Lung	8 (34.8)	8 (34.8)	7 (30.4)	9 (39.1)	14 (60.9)
Breast	7 (70.0)	2 (20.0)	1 (10.0)	3 (30.0)	7 (70.0)
Endometrial	4 (28.6)	8 (57.1)	2 (14.3)	6 (42.9)	8 (57.1)
Ovarian	5 (17.9)	13 (46.4)	10 (35.7)	8 (28.6)	20 (71.4)
Cervical	6 (31.6)	6 (31.6)	7 (36.8)	10 (52.6)	9 (47.4)

Validity analysis

Content validity

The CVI of the C-G8 was achieved and evaluated by five experts from the field of geriatrics, geriatric nursing, cancer nursing, and public health nutrition. The I-CVI of all items in the C-G8 ranged from 0.8 to 1. Accordingly, the S-CVI of all items in the C-G8 was 0.975.

Known-group divergent validity

Table 3 presented the known-group divergent validity of the C-G8 based on age. According to the C-G8, the prevalence of frailty was significantly higher in older cancer patients (> 75 years, 87.1%) compared to their younger counterparts (65 ~ 75 years, 70.9%), P = 0.010.

Table 3

Known-group divergent validity of the C-G8 questionnaire based on age (N = 296).
	Age		χ²	P value
	65–75 years (N = 234)	> 75 years (N = 62)	χ²	P value
C-G8 [N (%)]			6.704	0.010
>14	68 (29.1)	8 (12.9)
≤14	166 (70.9)	54 (87.1)

Convergent validity

The convergent validity of the C-G8 was tested by correlating it with the FRAIL scale (r=-0.592, P < 0.001), indicating a moderate correlation between these two instruments in screening frailty among these older cancer patients.

Reliability analysis

Table 4 displayed the item-total correlations of the C-G8 questionnaire. All 8 items of the C-G8 were significantly and positively correlated to the total score of the C-G8 (r = 0.191 ~ 0.719, P < 0.01), with the strong correlation observed in weight loss (r = 0.719, P < 0.001) and the weak correlation observed in age (r = 0.191, P = 0.001). The internal consistency of the C-G8 based on the Cronbach’s α coefficient presented a value of 0.501. Additionally, the ICC of the test-retest reliability at an interval of 7–14 days was 0.913 (95%CI: 0.838–0.954, P < 0.001) and that of the inter-rater reliability was 0.993 (95%CI: 0.981–0.997, P < 0.001).

Table 4

Item-total score correlations in the C-G8 questionnaire (N = 296).
C-G8 items	Correlation coefficients	P value
1. Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing, or swallowing difficulties?	0.632	< 0.001^**
2. Weight loss during the last 3 months?	0.719	< 0.001^**
3. Mobility?	0.442	< 0.001^**
4. Neuropsychological problems?	0.196	0.001^**
5. BMI? (Weight in kg) / (Height in m²)	0.619	< 0.001^**
6. Takes more than three prescription drugs per day?	0.198	0.001^**
7. In comparison with other people of the same age, how does the patient consider his/her health status?	0.434	< 0.001^**
8. Age	0.191	0.001^**
Note: ^**P < 0.01. Spearman correlation coefficients were calculated between the score of each item and the total score of all items in the C-G8 questionnaire.

Compared with Western countries, the research on frailty started at a later stage in China, with its focus placed on older residents in communities [36]. Although some frailty screening instruments have been developed or cross-culturally adapted for community individuals, they may not be applicable for older patients with cancer. Therefore, there is an urgent demand for useful, practical, and simple frailty screening tools that can be specifically applied to assess the frailty status of these patients. Currently, this is the first study to culturally adapt and validate the psychometric properties of the G8 in China. In this study, the translation and back-translation of the original G8 questionnaire into Chinese was conducted with the assistance of Brislin’s model of translation [37], and the C-G8 achieved conceptual, semantic, and idiomatic equivalence to the original instrument. Besides, it was simple to understand and implement the C-G8 by clinical professionals. It presented favorable content validity, known-group divergent validity, and convergent validity. However, it had a lower internal consistency but higher test-retest reliability and inter-rater reliability.

It was feasible for clinical professionals to use the C-G8 to assess the frailty status among Chinese older inpatients with cancer. In this study, the prevalence of frailty was 74.3% with the C-G8 and 74.0% (pre-frail and frail) with the FRAIL, which was similar to the results of previous studies [38, 39]. Since frailty is increasingly common in older cancer patients, it has been regarded as an important predictor of postoperative complications, disease progression, chemotherapy intolerance, and death [9]. Thus, the healthcare service for older cancer patients should be improved through the involvement of geriatricians whenever possible to provide guidance for the care of those with frailty, including pre-treatment optimization of cancer and multidisciplinary decision-making based on an individual balance between risks and benefits [5].

Content validity refers to the degree to which the elements of an assessment instrument are relevant to and representative of the targeted construct for a particular purpose, and it is considered the most important aspect of a measure of a theoretical construct [40]. In this study, five experts evaluated the content validity of the C-G8 on eight items, and they made slight modifications to the C-G8 to make it more cross-culturally adaptable for Chinese individuals. The I-CVI and S-CVI values of the C-G8 were 0.8 ~ 1 and 0.975, respectively, indicating that the C-G8 had good content validity based on the evaluation criteria of the previous study [41].

In terms of the known-group divergent validity, the C-G8 was effective in identifying more frail individuals among these older participants compared to their younger counterparts (87.1% vs. 70.9%, P = 0.010). As per previous studies, older age was associated with higher levels of frailty among community-dwelling adults aged ≥ 65 years old [42, 43]. It has been well established that the biological changes associated with aging are risk factors for frailty [44]. As mentioned before, frailty can be regarded as a multisystemic aging syndrome with decreased physiological and functional reserve, where the biological changes of aging can be seen in most tissues and organs and are the pathogenic mechanism for frailty [45]. As a result, frailty would increase with older age [45]. For cancer patients, both cancer itself and therapies, can be significant additional stressors that would pose challenges for the patients’ physiologic reserve; therefore, the prevalence of frailty is especially high among older cancer patients [9]. In this study, the prevalence of frailty in patients with different cancers ranged from 47.4–88.9%, with the highest prevalence observed in esophageal cancer and pancreas cancer and the lowest prevalence in cervical cancer based on the C-G8. In general, patients with digestive system cancer (e.g., esophageal cancer, pancreas cancer) were more likely to have difficulty in absorbing and digesting nutrients than those with cervical cancer, thus leading to the occurrence of malnutrition and weight loss. One explainable reason might be that the seven items of the G8 are derived from the MNA questionnaire, which focuses on the assessment of nutrition. However, it is required to generalize these findings with caution because of the unequal sample size at baseline for these different types of cancer. Given this fact, the prevalence of frailty was not compared between the younger and the older groups of patients with different types of cancer. Consequently, further attempts to compare the frailty prevalence in cancer patients with different age groups in large sample size are needed.

Convergent validity refers to the demonstration of substantial and significant correlations between different instruments designed to assess a common construct, and it is a basic requirement for the validity of any psychological test [46]. The FRAIL scale, with its focus on the patient’s fatigue, resistance, ambulation, illnesses, and weight loss domains, was an efficient and cost-effective way to screen those patients with frailty from large groups [9]. It has been recommended by the International Academy on Nutrition and Aging (IANA) for use in clinical practice, and is being increasingly used in the Asia-Pacific region, as reported by the Asia-Pacific Clinical Practice Guidelines for the Management of Frailty in 2017 [47]. Recently, the FRAIL scale has been validated to display acceptable validity and reliability in Chinese older adults [28]; therefore, it was applied to measure the convergent validity of the C-G8 in the current study. As it can be seen, there was a moderate correlation between the C-G8 and the FRAIL scale (r=-0.592, P < 0.001) among Chinese older cancer patients. Besides, there was also a moderate agreement between the C-G8 and the FRAIL in measuring frailty (data not shown, Kappa = 0.462, 95% CI: 0.3464–0.5776, P < 0.001). Both instruments found a similar prevalence of frailty in this population (~ 74.3%, ~ 74.0%). Nevertheless, it is still required to conduct further clinical studies to explore the convergent validity between the G8 questionnaire and the FRAIL scale or other research standard frailty measures.

The Cronbach’s α coefficient of the C-G8 was 0.501, which suggested a relatively lower internal consistency of the C-G8 based on the previous criteria [31]. It could be explained by several lower item-total correlations of the C-G8 in this study, including neuropsychological disorders, number of medications, and age (r = 0.191 ~ 0.198, P = 0.001). Of note, most of the subjects enrolled in this study had no neuropsychological disorders (94.9%), and they also had a predominance of age younger than 80 years old (90.5%). Moreover, most of them took less than three prescription drugs per day (78.0%). Based on these facts, the scores of these three items might not correlate well with the total score of all items. Further, one item regarding self-perception of health had an unequal difference score (e.g., 0, 0.5, 1, and 2), and the other one (number of medications) had a dichotomous response, and these might result in a lower discrimination capacity than an ordinal response [28]. It should be noted that the current weight of patients can be measured, while the two items in the C-G8 regarding the patients’ nutritional status and weight loss in the past three months were obtained through their self-reports, and this recall bias may have affected the internal consistency [29]. Although Bellera et al.[12] showed that the original G8 had good sensitivity and acceptable specificity when using the CGA as a reference standard in screening frail older cancer patients, the internal consistency of the original G8 was not provided. The ICC of the test-retest reliability at an interval of 7–14 days was 0.913, which suggested that the stability of the C-G8 was satisfactory over time based on the criteria of Terwee et al [31]. Apart from this, the inter-rater reliability of the C-G8 was 0.993, indicating that the measurement could be repeated by other trained researchers if necessary.

Some inevitable limitations in this study need to be highlighted. Firstly, the treatment progression of all patients should remain as homogeneous as possible, which could minimize the influence of confounding factors on assessing their frail status during the assessment with the C-G8. Secondly, the predictive performance of the C-G8 for clinical outcomes when using the CGA as a reference in this population should be investigated in future studies. Thirdly, the generalization of these findings may be limited by the unrepresentative samples, for instance, the proportion of patients with gastric cancer and colorectal cancer in this study is relatively higher than other types of cancer.

In summary, the C-G8 questionnaire achieved conceptual, semantic, and idiomatic equivalence to the original instrument. It is a feasible and useful instrument that takes less than 3 minutes for healthcare professionals to perform frailty screening. Thus, it can be applied in clinical practice to guide cancer therapies among these Chinese older cancer inpatients with limited resources. The C-G8 was validated to have favorable content validity, known-group divergent validity, and convergent validity. However, it presented lower internal consistency but higher test-retest reliability and inter-rater reliability. Although the original G8 displayed good sensitivity and acceptable specificity when using the CGA as a reference standard, its other psychometric properties, such as reliability and known-group divergent validity were not provided. Moreover, it is still necessary to conduct multicenter studies to explore the psychometric properties of the G8 in other multiple languages.

The G8 is a practical and useful tool that allows healthcare professionals to perform frailty screening for older patients with cancer. The findings of this study provide the first cross-culturally translated and validated instrument for frailty screening among older inpatients with cancer in China. The application of the C-G8 may provide more in-depth insights into the frailty status among these older cancer patients, which may contribute to cancer treatment guidance in this population. Notably, a routine assessment of the frailty status of these patients in clinical practice may also help clinicians facilitate multidisciplinary decision-making, develop more individualized management strategies, and further provide optimized care for this population.

Funding

This study received no external funding.

Conflicts of interest

All authors have no conflict of interest and no financial associations to disclosure.

Data availability statement

The datasets used or analyzed during the current study are available from the corresponding author upon reasonable request.

Code availability

N/A.

Authors’ contributions

Study concepts and design: Qianqian Zhang, Li Wang, Biyue Hu, and Qilian Zhou;

Data acquisition: Shuping Zhang, Biyue Hu, Yuling Yang, Wanxia Wang, Tongtong Yin, and Shihui Yu;

Quality control of data and algorithms: Shuping Zhang, Biyue Hu, Yuling Yang, Wanxia Wang, Tongtong Yin, and Shihui Yu;

Data analysis and interpretation: Qianqian Zhang, Qilian Zhou, Qingfeng Li, and Yuxia Tang;

Statistical analysis: Qianqian Zhang, Shuping Zhang, Qingfeng Li, and Biyue Hu;

Manuscript preparation: Qianqian Zhang and Li Wang;

Manuscript editing: Qianqian Zhang and Li Wang;

Manuscript review: Li Wang, Qianqian Zhang, and Yuxia Tang.

Ethics approval

This study was approved by the Clinical Medical Research Ethics Committee of the First Affiliated Hospital of Anhui Medical University (No. Quick-PJ2022-04-65) and other five hospitals and complied with the Declaration of Helsinki.

Consent to participate

All participants were fully informed about the research purpose before they provided signed consent.

Consent for publication

All authors critically reviewed the manuscript and approved the final version submitted for publication.

Acknowledgements

We would like to express our great appreciation to the participants for their effort and time. We sincerely thank Prof. Bellera C.A. for authorizing us to translate the G8 questionnaire into Chinese. We are deeply grateful to all interpreters and experts for their help in translating and back-translating the G8 questionnaire. We also deeply thank Dr. Zaslavsky O. for comparing the differences between the back-translated and original versions.

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No competing interests reported.

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Cross-cultural Adaptation and Validation of the Geriatric 8 Screening Tool in Chinese Older Inpatients with Cancer

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Abstract

Introduction

Material And Methods

Study design and participants

Ethical considerations

G8 questionnaire

FRAIL scale

Translation and cultural adaptation

Psychometric evaluation

Validity

Reliability

Statistical analysis

Results

All participants’ characteristics

The prevalence of frailty in older inpatients with different types of cancer

Validity analysis

Content validity

Known-group divergent validity

Convergent validity

Reliability analysis

Discussion

Conclusion

Implications For Clinical Practice

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1