Pragmatic geriatric assessment for cancer patients in Brazil
Dr Antonio Fabiano Ferreira Filho - Oncosinos, Novo Hamburgo, Brazil
First of all, all these geriatric evaluations, they are very critical to the better treatment of our older cancer patients. But, unfortunately, the education of oncologists in Brazil at this moment does not place a strong emphasis on the particularities of these patients. So there is a lot of work to be done in the process of education of new oncologists, this is one thing, so that the majority of them will understand the need for these evaluations because it is still widespread that clinical examination can, by itself, detect some fragilities of older patients, older cancer patients, which is not the case. We need more refined tools to do this detection.
Besides education issues there is always this idea that these evaluations take a lot of time, human resources. So there is a need to, while at the same time maintaining efficacy of these evaluations, they should be somehow simplified so that these evaluations, these critical evaluations, can be more of widespread use and to the benefit of as more patients as possible.
What was the aim of the assessment?
The aim of this pragmatic geriatric assessment, it was an idea that… it’s a bit strange but it came up from an idea of design, from Scandinavian design that very nice things, very functional things, very beautiful things, pieces of design, they should be that everyone can afford them and can benefit from them. And when you look at Scandinavian designs, all these pieces of design, they are functional, they are simple and they are beautiful. They are cool, let’s put it like this.
So I tried to, in our centre, Oncosinos, we tried to create a tool that could be very efficient. In this we had also this idea of the Pareto principle that most of the consequences come from very little of cause. So if we could go to the core of the problem we could achieve much more pieces of information. So we wanted a tool that could be efficient, functional, simple and that could be easy to use. That was the main idea, that it was to simplify and to make the possibility of these geriatric assessments to be more used widespread in the world.
What results were obtained from the assessment?
The first thing that is very important is that we evaluated 71 patients in our institute from age 60 to older but the majority of them were more than 65 years old. All kinds of tumours were evaluated and the median age was 73 years old, so it was quite an older population. What is very interesting is that the time to perform these evaluations, all these evaluations, was a median of 9.5 minutes, less than ten minutes. What we found was that we evaluated basically a measure of vitality, a measure of functional reserve, which is gait speed and with a threshold of 1 metre per second. In this regard we found that 40% of patients were pre-fragile and about 20% of patients were fragile. So only 40% of our population was what we can call fit or non-fragile which fits very well with the most widespread screening evaluation used in Europe and the US which is the G8 score. So we used the gait speed as a pre-screening evaluation like the G8. That was the main idea.
With this we can evaluate the notes that 60% of our population is pre-fragile or fragile. So with the difference with the G8 score, the G8 score takes about 4-5 minutes, that’s okay, but it’s a screening test. So we thought that we’d substitute the G8 for the gait screen. We have a wonderful paper by Frederic Pamoukdjian, from the Department of Geriatric Oncology in Bobigny, France from 2017 who showed that the gait speed correlates quite well in the sensitivity and, even better, specificity than the G8. So we asked the patient to walk, it takes one minute, we have the gait speed and instead of sending or not the patient to a geriatric evaluation, we are already in front of the patient quite happy to take this opportunity. So we decided to evaluate with four more domains which is nutrition, with a minimal nutritional evaluation; polypharmacy, which is a widespread problem in the older geriatric population, you can adjust treatment and take out some medications which are not needed; risk of depression, which is also about 25% of patients, worldwide cancer patients, have depression so we can detect it very fast with five small questions, it’s the Geriatric Depression Scale 5; and on the end we added cognition evaluation by the Mini-Cog exam which takes three minutes. So we evaluate nutrition, polypharmacy, risk of depression and cognitive cognition and all this, we do this in a median of less than ten minutes in general.
So what we found in our analysis of 71 patients, we found that the median time to perform our pragmatic geriatric evaluation was 9.5 minutes; it varies from 5 minutes to 16 but a median of 9.5. 40% of our patients were pre-fragile, 20% of patients fragile. We have 51% of patients taking more than three medications so we can adjust. For instance, some patients take two kinds of benzodiazepines, you can take one, of course. The risk of nutritional risk was 60% of the patients; risk of depression 25% and the cognitive risk 40% of patients. So in general in these 71 patients we found 126 instances where you can make medical interventions before the treatment as a kind of prehabilitation and not to rehabilitate. You prehabilitate the patient to the treatment, you adjust the treatment with these pieces of information. So in 71 patients we found the very first beneficent 126 instances where we could intervene medically.
How will results from this assessment impact geriatric oncology in Brazil?
That’s a very good question. There are already some centres in Brazil which are planning to use our pragmatic geriatric evaluation, one of them in the north of Brazil which is it’s the biggest oncology centre in Fortaleza in a state called Ceará. Of course, the work continues in Oncosinos and also in the Federal University.
Your interview in ecancer will help a lot to disseminate this message. This pragmatic geriatric evaluation is very important, not only to developing countries but even to more developed countries because it can be performed very fast, gives lots of pieces of information and it can be done very simply by, for instance, a trained nurse.
In the meantime we created a website called oncosenior.com in which these tests are already available, open source, to all physicians, to all medical students, to all medical workers, physiotherapists, for instance, also can perform these tests, so that it can be available and widespread to as many people as possible to enhance the treatment, for better treatment of senior cancer patients, for older cancer patients. So that’s how we are working on this aspect.
It is already in Portuguese, in English and in French and soon to be in German, Spanish and Russian also so that hopefully a patient in India or in Moscow or, I don’t know, the South of France, they can also benefit from this too.
Is there anything you’d like to add?
Yes, there is something I would like to add. That besides the benefit for the patients themselves, which is very clear, there is also the potential that this tool can help with the economy of millions of dollars each year in the world. Because the use of this tool gives the physician pieces of information that will allow him or her to better design the treatment for the particular patient. So this means better results with less complications, less hospitalisations, less long hospitalisations, which at the end of the day increase the costs for all players – hospitals, insurance companies and for us as a society as a whole. So it has the potential to economise millions of dollars in a very simple way.