We conducted a cross-sectional multicenter study in 9 Moroccan public, civil and military medical oncology departments (Fig. 1: Moroccan Departments of Medical Oncology included in the study). The enrollment lasted 4 months from June 15th to October 15th, 2015. A specific questionnaire was developed.
Inclusion criteria: The study aimed to include all patients aged 65 years or older diagnosed with solid cancer. Every eligible patient who presented to the department for a scheduled consultation, chemotherapy session or emergency was asked to be included in the study. Hospitalized patients were also eligible.
The study was conducted only in medical oncology departments. Thus, it will not be representative of Moroccan epidemiology. Patients with localized head and neck, lung and cervical cancers are treated in radiotherapy departments, so they were not included.
All included patients signed an informed consent.
Exclusion criteria: Patients with a performance status of 4.
We developed a questionnaire of 4 sections: socio-demographic and economic data, clinical data, vulnerability and quality of life assessment. Medical data were filled in by investigators from patient medical records. Other sections were filled in by the patients. For illiterate patients, investigators asked them the questions and filled their responses in the questionnaire. The questionnaire was administered once for each patient included, and it took between 15 and 30 minutes. The treatment plan was not reviewed after the patient was included in the study.
Socio-demographic and economic data:
This section explored patient demographic and social information including age, sex, living conditions (urban, rural, alone, with spouse, with children, with brother/sister, in an institution), religion, civil status, number of children, level of education, source of financial income (personal pension, spouse pension, aid from children, still working), monthly income and health care coverage.
The education level of the patients was divided into illiterate and who had mosque, elementary, high school or university education. Mosque education consists of learning Arabic, the Quran and religion sciences. It has represented the main method of education for Moroccans for centuries.
Regarding income, we referred to the classification made by the government, and we have adapted it to the income ranges reported by the patients to be more representative of the poor. According to High Commission for Planning, the middle class has an income between 2,800 dirhams (252 euros) and 6760 dh per month (610 Euros) 5. We used the following ranges:
-<1,500 dh per month (136 Euros)
-1,500-3,000 dh per month (136–273 Euros)
-3,000–5,000 dh per month (273–455 Euros)
-5,000–8,000 dh per month (455–728 Euros)
->8,000 dh per month (728 Euros)
In the Moroccan context, it is usual for the family to ask the doctor to hide the diagnosis of cancer from the patient14, so we included this question in the questionnaire.
This section also included information about toxic habits: smoking, alcoholism and medicinal plant consumption.
To explore comorbidities, we looked for the most frequent ones. The age-adjusted Charlson Comorbidity Index aaCCI was also calculated15. We explored falls by asking patients and cancer data from medical reports.
In the vulnerability section, we used the G8 screening tool16.
The activities of daily living (ADL) were evaluated through the EORTC QLQ-C30 questionnaire by exploring the role, physical, cognitive and emotional function scores. In addition, we asked for each daily habit separately. We explored the degree of dependency for toileting, bathing, dressing, eating, and walking indoors and outdoors.
We included also religious practice as its represents an indispensable daily activity and can be good indicator of the vulnerability level of the patients. Ablutions and prayer are practiced five times a day at specific times. Ablution is mandatory before each prayer. Fit people do wet ablutions by washing their hands, forearms, face and feet one to three times each. If tired, they only use purified sand or dust to wipe their face and hands, which is considered dry ablution. Each prayer can take between 5 and 10 minutes according to the number of units. Every unit consists of reciting Quran verses of followed by movements including (in this order) bowing low with hands on knees, standing, prostration, sitting, prostration and standing up while reciting well-defined prayers. There are one to four units in each prayer. Unfit people can pray sitting or lying as normal prayer requires a certain level of physical condition; thus, they do not make these movements, and they only recite the Quran and prayers. Ramadan fasting is the third pillar of Islam. It consists of abstinence from food, drink and sexual activity from dawn to sunset during one month each year. Tired people or the elderly may not fast if their health will be compromised. In addition to Ramadan, very fit people can do optional fasting as much as they want, such as one day per month or two per week and/or during some religious holidays.
To assess the quality of life, we used the Moroccan validated version of the EORTC QLQ C30 questionnaire (Version 3.0)17, which includes five functional scales (physical, role, cognitive, emotional, and social), three symptom scales (fatigue, pain, and nausea and vomiting), six single items (dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties) and a global health and quality-of-life scale.
Score calculations were made according to the scoring recommendation18.
The statistical analysis was performed using SPSS 13.0. We used a Chi2 test to compare the qualitative variables and Student’s t-test or the Mann-Whitney U test to compare quantitative variables. The difference between subgroups was considered significant when the p-value was less than 0.05.
We explored the entire population included. Then, we made comparisons according to age (65–70 years old vs ≥ 71 years old), sex and G8 score. The study was approved by the ethical committee of the University of Medicine and Pharmacy of Rabat.