What is 'frailty' in elderly cancer patients?
Dr Muriel Rainfray - Bordeaux Hospital University Center, Bordeaux, France
First I have been speaking about what is frailty because it is of great interest for the oncologists to be able to see who is frail and who is not in patients over 75 years old, for instance. So frailty is a very debated concept in the geriatric world and I tried to explain what are the two main concepts about frailty.
How do you classify patients as frail or non-frail?
Sometimes you can see that, frailty is a sort of a less rapid movement, gait. Also you can see frailty with the specific screening tools which allow the oncologist to refer the patient to a geriatrician or not for a most important assessment that’s called a comprehensive geriatric assessment.
What can you tell us about these tools and screening for frailty?
The [?? 1:29] one is the VES-13, it’s an American tool validated by geriatricians in a rather broad population, non-specific cancer population but a rather broad population. The more recent one is a French one that we called G8 because there are eight questions and in five minutes you can have the answers. Then, if the score is above 14 the patient is quite well, not frail, you can go through normal standard treatment. But if the score is under 14 the patient may be frail and then could be addressed to a referral to a geriatrician for a more complete assessment. Some of the questions are, for instance, do you have anorexia? Have you a good appetite? Have you a good appetite? Are you able to move from your bed to walk outside, for instance? What do you think of your health status? Do you think you are well, you are fine, or do you think you are very tired and so? Do you have cognitive problems, memory complaints or depression? And what’s your class of age from 75-85?
How can the algorithm you create affect the therapies you choose?
It gives a score, OK? It gives a score and if the score is under 14 the patient may be referred to a geriatrician to have a more complete assessment: physical assessment, mental, cognitive assessment and such for depression. Frailty is one of numerous arguments to treat or not to treat or to give a standard treatment or an adapted treatment or a delayed treatment but it’s an important point. You have to take into consideration also the life expectancy of the patient.
What are the differences between a 60 year old and 90 year old patient?
The big difference is on the physical status of a person in 60s and in 90s years old because frailty appears mostly after 75 years old and in the population over 80 years old frailty is around 30% of people in great epidemiological studies, especially in women. And frailty is predictive for disabilities and death.
What should cancer doctors do to improve therapy for older and more frail patients?
The oncologists need to learn how to detect frailty with simple screening tools that we try to offer them and to validate in cancer patients. I think they could improve therapy being more careful for the potential complications the frail patients may have during the treatment. Geriatricians are able to, I would say, predict a lot of complications when they have evaluated the patient before the beginning of the treatment. For instance, I spoke today of delirium. Delirium is a very bad complication occurring after surgery, for instance. If the geriatrician has evaluated the patient before surgery he is able to see that patient will have delirium after surgery and the surgical team has to do that and that and not to do this and this.
How would you sum up what cancer clinicians should do to treat frail patients?
Oncologists must realise that old people are a very heterogeneous population which is very different from 60s to 90 years old or even centenarians, I spoke too this morning about centenarians. The second point is that they have to learn how to detect frailty in their old people with cancer and work with geriatricians to together have a better appreciation of the health status of the patient before doing a treatment.
Can these tools predict the efficacy and toxicities of treatments?
Until today these tools are not validated for predicting adverse events, for instance, during chemotherapy. They do not predict death or disabilities or adverse events during the treatment. So a lot of research done today about that but, for the moment, nothing has been validated.