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available at www.sciencedirect.com
journal homepage: www.europeanurology.com/eufocus

Review – Aging Male

Comprehensive Geriatric Assessment in the Older Adult with

Cancer: A Review

Catalina Hernandez Torres a, Tina Hsu a,b,*

a
University of Ottawa, Ottawa, Canada; b Division of Medical Oncology, The Ottawa Hospital Cancer Centre, Ottawa, Canada

Article info Abstract

Article history: Context: The number of older adults with cancer is expected to increase rapidly in the
Accepted October 21, 2017 upcoming decades. Aging is heterogeneous and chronological age is often not reflective
of biological age. A comprehensive geriatric assessment (CGA) is an in-depth assessment
Associate Editor: of multiple domains of health that results in better assessment of a patient’s overall
Christian Gratzke health and fitness and allows directed intervention to improve patient outcomes.
Objective: To review the value of CGA for older adults with cancer, CGA composition and
tools that can be utilized, and the feasibility of including CGA in oncologic practice.
Keywords: Evidence acquisition: The currently available evidence on CGA for older adults with
Comprehensive geriatric cancer was reviewed.
Evidence synthesis: A CGA can highlight unidentified health problems and identify
assessment
patients at higher risk of mortality, functional decline, surgical complications, chemo-
Older adults therapy intolerance, and chemotherapy toxicity. It has been shown that CGA is feasible in
Geriatric screening tools the oncology clinic, but geriatric screening tools may be useful to specifically identify
Cancer patients who would benefit from a full CGA.
Conclusions: CGA is feasible and can identify patients at higher risk of adverse events
such as mortality, functional decline, surgical complications, and chemotherapy toxicity.
Clinicians should consider incorporating CGA when assessing and caring for older adults
with cancer.
Patient summary: In this report, we review the benefits of a comprehensive geriatric
assessment (CGA), a detailed in-depth assessment that identifies health problems not
typically identified during routine assessments, for older adults with cancer. We
describe the different domains of the CGA and suggest tools to utilize, as well as ways
to incorporate CGA into the cancer care setting.
© 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. Ottawa Hospital Cancer Centre, 501 Smyth Road, Ottawa K1H 8L6, Canada.
Tel.: +1 613 7377700; Fax: +1 613 2473511.
E-mail address: thsu@toh.on.ca (T. Hsu).

1. Introduction upcoming decades, which will have a major impact on

cancer care.
By 2030, there will be 1 billion older adults globally [1]. This Aging is a complex process and chronological age is often
is concerning as cancer is strongly associated with aging and not reflective of biological age. Older adults with cancer
59% of cancers diagnosed in Europe already occur in present a set of unique challenges, including age-related
patients aged 65 yr [2]. This will result in significant physiological changes such as organ decline, comorbidities,
growth in the number of older adults with cancer in the and functional deterioration. Cancer itself adds another
https://doi.org/10.1016/j.euf.2017.10.010
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layer of complexity to the aging process as older adults with
cancer are more likely to have impairments in their ability
to care for themselves, poorer self-rated health, and more
geriatric syndromes, such as cognitive impairments and
falls [3,4].
A comprehensive geriatric assessment (CGA) can help to
better assess a patient’s biological age. A CGA is an in-depth
multidimensional evaluation of a patient’s health used to
identify changes that are potentially treatable to improve
patient outcomes [5]. CGA provides a framework for an
individualized and integrated treatment plan and provides
physicians with important information to optimize a
patient’s treatment and follow-up plan [6]. In this review,
we describe the components of CGA and how it adds value
to standard oncologic care. In addition, we review screening
tools available to help select patients who would benefit
from a CGA and discuss how to interpret and utilize results.
2. Evidence acquisition
The currently available evidence on CGA for older adults
with cancer was reviewed.
3. Evidence synthesis
3.1. CGA domains
A CGA comprises the following domains: functional status,
comorbidity, polypharmacy, cognition, psychological sta-
tus, social support, and nutritional status (Table 1).
3.1.1. Functional status
Function is important in oncology as it often determines a
patient’s fitness for treatment and strongly influences treat-
ment recommendations. In oncology, functional status is
most commonly measured using the Eastern Cooperative
Oncology Group (ECOG) performance status (PS) or Kar-
nofsky performance status (KPS). However, both of these
can be imprecise measures of patient function. Although
80% of older cancer patients have an ECOG PS of 0–1 (fully
active with no restrictions or mild restrictions for strenuous
tasks), up to 50% of these patients require assistance with
their instrumental activities of daily living (IADLs) [7].
IADLs are the activities that allow a person to live inde-
pendently and include meal preparation, shopping, clean-
ing, laundry, transportation, taking medications, managing
finances, and using the telephone. Activities of daily living
(ADLS) are the activities needed to care for oneself including
walking and transferring positions, dressing, bathing, toi-
leting, and feeding oneself. The Katz and Lawton instru-
ments are the tools most widely utilized to measure ADLS
and IADLS, respectively. The Katz ADL subscale consists of
six questions rated on a 3-point Likert scale, and the Lawton
IADL subscale consist of eight questions rated on a 3-point
Likert scale [8,9].
Functional status can also be measured objectively. The
timed up and go (TUG) test, which consists of a person rising
from a chair, walking 3 m, turning around, walking back to
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Cancer: A Review. Eur Urol Focus (2018), https://doi.org/10.1016/j.euf.2017.10.010
the chair, and sitting down, is a common measure of gait
speed and balance [10]. The TUG time has been associated
with adverse health events, including postoperative com-
plications in older patients undergoing cancer surgery [11]
and higher mortality in cancer patients receiving chemo-
therapy [12]. In addition to helping in initial treatment
decisions and predicting treatment outcomes, monitoring
functional status is also important because some treat-
ments such as androgen deprivation therapy (ADT) can
adversely impact physical function. One study revealed
slower TUG times and poorer self-rated physical function
over 36 months in men with nonmetastatic prostate cancer
receiving continuous ADT [13].
3.1.2. Comorbidities
Several instruments are available to measure comorbidities
(Table 1). The Charlson Comorbidity Index (CCI) is an instru-
ment derived from medical patients admitted to hospital
and measures the presence of 19 comorbidities, with higher
scores predicting worse 1-yr mortality [14]. Limitations of
the CCI are that most patients referred to oncologists are
reasonably fit and the median CCI in outpatients is 0, with
few patients scoring above 3 [15]. An update of the CCI
resulted in the removal of five comorbidities, a decrease in
the weighting for three comorbidities, and an increase in
the weight for four comorbidities [16].
Several other tools for measuring comorbidity have been
evaluated in cancer patients. The Cumulative Illness Rating
Scale-Geriatrics (CIRS-G) assesses for comorbid conditions
in 14 organ systems and classifies them by severity on a
scale from 0 to 4 (none to severe/life-threatening)
[17]. CIRS-G is more sensitive than the CCI, but requires
more training to administer [18]. Some studies report the
number of grade 3 and 4 comorbid conditions, although this
approach has lower inter-rater reliability [15]. The Adults
Comorbidity Evaluation-27 (ACE-27) index is another com-
monly used tool which was specifically developed to assess
comorbidities in cancer patients (Table 1) [19].
The original CCI is the most widely used to measure
comorbidity in oncology and has been recommended by
expert consensus as a preferred tool to assess comorbidities
[20]. Clinicians are encouraged to use the instrument best
suited to their clinical practice.
3.1.3. Polypharmacy
Polypharmacy, defined as the use of four or more medica-
tions, is common in older adults and increases the risk of
adverse drug interaction and decreases compliance with
medications [21]. In addition to the number of medications,
a review is important to identify any potentially inappro-
priate medications that might place the patient at higher
risk of adverse events. Screening tools to assess for poly-
pharmacy include the Medication Appropriateness Index,
the Screening Tool of Older Persons’ Prescriptions (STOPP),
and the Screening Tool to Alert doctors to Right Treatment
(START) (Table 1) [22]. A thorough evaluation for drug
interactions, especially with newly prescribed cancer ther-
apies, is important, and consultation with a pharmacist can
be helpful. Assessing patient compliance with medications
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Table 1 – Comprehensive geriatric assessment tools and suggested interventions.

Domain Assessment tool Description Abnormal score Suggested intervention

(range) [42,43]

Functional Katz Activities of Daily Living [9]

6-item tool to assess basic activities of daily living 5 (0–6) Physical therapy and
status Lawton Instrumental Activities of
8-item tool to assess activities of daily living needed 7 (0–8) occupational therapy referral;
Daily Living [8] to live independently home safety evaluation;
Timed up and go test [10] Time it takes a patient to stand up from a chair >12 s institute home health care;
(without using their arms), walk 3 metres, turn evaluate fall risk; promote
around, and return to the chair and sit down exercise
Comorbidities Charlson Comorbidity Index [14] Assess for presence of 19 comorbid conditions 1 Informed discussion about
weighted for severity prognosis and treatment
Charlson Comorbidity Index Assess for presence of 12 comorbidities 1 options; referral to specialist.
(updated index) [16]
Cumulative Illness Rating Scale 14-item tool; score based on severity of each (0–56)
for Geriatrics (CIRS-G) [44] comorbid condition, graded from 0 to 4
Adults Comorbidity Evaluation- 27-item; score based on severity of each comorbid Overall comorbidity
27 (ACE-27) [19] condition, graded from 0–3 score ranges from 0
(none) to 3 (severe)
Polypharmacy Screening Tool of Older Persons’ 65 indicators for potentially inappropriate NA Discontinue unnecessary
Prescriptions (STOPP) [22] prescribing, including drug-drug and drug-disease medications; avoid potentially
interactions, therapeutic duplication, and drugs that inappropriate medications;
increase the risks of geriatric syndromes consult pharmacist for
Screening Tool to Alert doctors to 22 evidence-based indicators to identify prescribing NA medication review and
Right Treatment (START) [22] omissions in older people reconciliation
Beer’s criteria [45] Identifies potentially inappropriate medications that NA
should be avoided if possible in older adults
Cognition Mini Mental Status examination 11-item test that includes registration, attention and 23 (0–30) Send for formal cognitive
(MMSE) [34] calculation, recall, language, and orientation testing; delirium prevention;
Montreal Cognitive Assessment 12-item test of cognitive function; assesses short <26 (0–30) assess capacity and ability to
(MOCA) [35] term memory, visuospatial awareness, executive consent to treatment; involve
function, attention, and orientation. caregiver and identify health
Mini-Cog [36] Cognitive screen that includes a recall test and clock <3 (0–5) care proxy
drawing
Blessed Orientation Memory 6-item tool that tests orientation, attention and >10 (0–12)
Concentration test [37] memory
Psychological Geriatric Depression Scale [25] 15-item self-assessment with yes/no questions used >5 (0–15) Counseling, referral to
status to identify older patients at risk of depression psychiatry and/or psychology;
Hospital Anxiety and Depression 14-item self-assessment of anxiety (7 items) and >8 (0–21) for consider medications to treat
Scale [46] depression (7 items) depression and anxiety or depression; referral
anxiety subscales to support programs; spiritual
care
Social support Social history Assess social support and living condition NA Transportation assistance;
Medical Outcomes Survey social 19-item tool involving 4 social domains: emotional Lower scores worse home health care; home safety
support survey [27] support, tangible support, affectionate support, and (0–100) evaluation; support groups;
medical outcomes referral to social work
Nutrition Mini Nutritional Assessment [40] 6-item tool to identify patients at risk of <24 (0–30) Dietician consult, specific
malnutrition dietary recommendations, oral
care, and supplemental
nutrition

NA = not applicable.

is essential. Use of blister packs can improve medication
compliance.
3.1.4. Psychological and social support
Depression is common in older patients with cancer.
Depressive spectrum disorders have been found to be as
high as 58% in patients older than 60 years [23]. In patients
with cancer, depression is associated with more rapid
symptom progression and greater pain, and is an indepen-
dent predictor of early death in patients with advanced
cancer [24]. A tool commonly used to assess for depression
is the Geriatric Depression Scale (GDS). The short-version
GDS is a validated tool consisting of 15 yes/no questions and
can be completed by most patients in 5–7 min. A score >5 is
associated with a possible diagnosis of depression [25].
Caregivers provide both physical and emotional support
to cancer patients, especially in older adults, who are more
likely to be frail. The availability of adequate social sup-
ports is an important consideration when deciding about
treatments, as they may influence a patient’s ability to
attend appointments and comply with recommended
treatments. Lack of social support has been identified as
a significant predictor of mortality in older adults [26]. The
Medical Outcomes Survey (MOS) is a commonly used
social support survey that consists of four social domains:
emotional support, tangible support, affectionate support,
and medical outcomes. It is a self-administered survey
comprising 19 questions rated on a 5-point Likert scale
(range 0-100, with higher scores indicating more social
support) [27].

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3.1.5. Cognition
Subtle changes in cognition, such as a decline in memory
and processing speed, are normal with aging [28]. Never-
theless, cognitive abnormalities are common and found in
up to 50% of patients with cancer in screening cognitive
examinations [7]. These findings have important implica-
tions for oncologic care decisions, including informed
consent, compliance with treatment, and the safety of
treatment delivery. For instance, an older adult with cogni-
tive impairment may not recognize signs of toxicity requir-
ing medical care. For this reason, the International Society of
Geriatric Oncology (SIOG) recommends that all patients
aged 70 yr with prostate cancer be screened for cognition
[29]. This is also a reasonable strategy to consider for older
adults with other cancers before any discussion of treat-
ment options. It is important to note, however, that the
presence of a cognitive impairment does not necessarily
mean that the patient is incapable of consent, so a patient’s
capacity to understand a decision, appreciate implications
for themselves, make a choice, and express a rationale for a
decision should be assessed.
It is also important to assess cognition because treat-
ments, particularly systemic therapies, can be associated
with worsening cognitive function. A recent meta-analysis
suggested a moderate to large decline (effect size 0.67) in
visuomotor skills compared to noncancer control subject
after 6–12 mo of ADT [30]. However, a more recent study
suggested that long-term ADT had no adverse effects on
cognition over 36 mo [31]. No changes in other cognition
domains (attention, memory, executive function, language,
and visuospatial awareness) were noted. Although chemo-
therapy-associated changes in cognition are commonly
reported by patients, the exact prevalence varies signifi-
cantly by cancer type, follow-up duration, and the battery of
cognitive tests used, and most studies to date have been in
patients with breast cancer [32]. This issue is further com-
plicated by the natural declines in cognition, specifically
attention and memory, that occur with aging. A recent
prospective study found no decline in cognition in older
cancer survivors (mean age 76 yr) who received chemo-
therapy [33].
Several tools are available for screening for cognitive
impairment. The Mini Mental Status examination (MMSE)
[34] is an 11-item screening test assessing orientation,
immediate and delayed recall, attention, and language. It
is one of the screening tests most commonly used and can
be easily performed in clinic. The Montreal Cognitive
Assessment is more sensitive and specific than the MMSE
and better at detecting subtle cognitive deficits [35]. Other
shorter screening tests include the Mini-Cog [36], which
consists of a three-word recall and a clock drawing test. The
Blessed Orientation Memory Concentration test [37] is a
six-item tool that tests orientation, attention, and memory.
Patients who screen positive on the screening test should be
further evaluated for dementia.
3.1.6. Nutrition
Poor nutritional status has been described in up to 44% of
patients with cancer [38]. Weight loss is a well-described
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prognostic factor for mortality in cancer patients [39] and
malnutrition has been correlated with longer hospital
stay [38].
The Mini-Nutritional Assessment is a validated tool to
identify older adults at risk of malnutrition [40] and com-
prises six questions (intake, weight loss, mobility, body
mass index, psychological stress), with a lower score indi-
cating poorer nutrition. Low scores have been associated
with lower chemotherapy tolerance and higher mortality in
patients on palliative chemotherapy [41]. Patients who are
malnourished should be referred to a dietician for nutrition
intervention, which may help improve patient outcomes.
3.2. CGA benefits
CGA has been widely used in the assessment of older adults
and is the cornerstone of geriatric medicine. Meta-analyses
have shown that CGA-driven interventions in the general
geriatric population reduce mortality [5,47], maintain phys-
ical function [47,48], and reduce the likelihood of nursing
home admission [5,47].
In oncology, CGA has been shown to be beneficial in
many ways. In up to 70% of older patients, CGA can reveal
problems otherwise not identified through a traditional
oncologic assessment [49,50]. Abnormalities on a CGA,
including malnutrition [12,41] and slow walk speed [12],
have been associated with a higher risk of mortality, while
depression and needing help with IADLS are associated with
a higher likelihood of functional decline [51]. Lastly, tools
that incorporate CGA components to assess the risk of
severe toxicity have been developed, including the Cancer
and Aging Research Group chemotoxicity calculator [52]
and the Chemotherapy Risk Assessment Scale for High Age
Patients [53], both of which are readily available online
(Table 2). Furthermore, interventions directed at CGA-iden-
tified problems have been associated with a higher likeli-
hood of completing cancer treatments compared to stan-
dard oncologic care [54].
Nevertheless, the ability of a CGA to influence cancer
treatment decisions and outcomes in cancer patients has
yet to be firmly established. Studies on the influence of a
CGA on oncologic decisions have shown mixed results.
Some studies have shown that the result of a CGA impacts
the treatment plan in 20.8–49% of patients, while others
suggest that the CGA results rarely or never influenced
oncologic management [55]. There are several ongoing
randomized studies globally exploring the impact of CGA
on oncologic outcomes (eg, NCT02812992, NCT02785887,
and NCT02025062).
3.2.1. CGA benefits in surgery
Older adults are increasingly presenting for surgical evalu-
ation: 65% of patients undergoing urologic procedures are
aged 65 yr [56]. Age alone is not a reliable marker of
surgical risk [57] and the traditional surgical assessment
may not accurately identify those patients at higher risk of
postoperative complications (POCs). Accurate identification
of operative risk is important to inform older adults about
the risks and benefits of surgery so that they can make an
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Table 2 – Chemotherapy toxicity prediction tools for older adults.

Tool Predictive factors Links

CARG [52] Age 72 yr www.mycarg.org/Chemo_Toxicity_Calculator

Gastrointestinal or genitourinary cancer
Standard chemotherapy dosing
>1 chemotherapy drug
Anemia <11 g/dl
Creatinine clearance <34 ml/min (Jelliffe method)
Any fall in the past 6 months
Hearing, fair or worse
Limited in walking 1 block
Inability to take medications independently
Restriction in social activities because of physical/emotional health
CRASH [53] Hematologic risk factors https://moffitt.org/for-healthcare-providers/clinical-programs-and-services/
Diastolic blood pressure >72 mm Hg senior-adult-oncology-program/senior-adult-oncology-program-tools/
Lawton Instrumental Activities of Daily Living <26
Lactate dehydrogenase >0.74  upper limit of normal
MAX-2 score
Nonhematologic risk factors
Eastern Cooperative Oncology Group performance status (1+)
Mini Mental Status Examination <30
Mini Nutritional Assessment <28
MAX-2 score

CARG = Cancer and Aging Research Group; CRASH = Chemotherapy Risk Assessment Scale for High Age Patients; MAX-2 = index score for chemotherapy
toxicity.

informed decision. The American College of Surgeons
National Surgical Quality Improvement Program and the
American Geriatrics Society recommend a multidimen-
sional preoperative assessment of all older adults undergo-
ing surgery [58].
It has been shown that a CGA helps in predicting adverse
outcomes, including POCs, longer hospital stays, higher
readmission rates, and higher risk of being discharged to
a nursing home [59]. In particular, deficiencies in IADLs,
ADLs, fatigue, cognition, and frailty were associated with
POCs and discharge to a non-home institution [59]. The
PACE study is the largest prospective study of CGA before
elective oncologic surgery [60], in which 15% of patients had
genitourinary cancers. In this study, IADL dependence,
fatigue, and PS were associated with a 50% increase in
the relative risk for POCs and extended hospital stays
[60]. It is important to note that 61% and 65% of patients
with a normal PS or American Society of Anesthesiology
(ASA) score, respectively, had an abnormal CGA component,
highlighting the lack of sensitivity of PS and ASA in isolation
for risk stratification of older adults with cancer before
surgery. It has also been shown that a TUG time of >20 s
is an independent predictor of POCs (odds ratio 3.43) in
addition to the ASA score [11]. Unfortunately, no predictors
of early postoperative mortality have been identified in this
population. These findings suggest that a preoperative CGA
can identify patients at higher risk of POCs and should be
considered routinely in the surgical oncology setting. It is
still unclear whether pre-rehabilitation in patients identi-
fied as being frail can improve surgical outcomes, and
studies are ongoing [61].
Postoperative delirium is a serious complication of sur-
gery and is more common among older adults. It is associ-
ated with longer hospitalization and a higher likelihood of
readmission. Several studies suggest that 19–29% of older
adults undergoing oncologic surgery develop delirium
[62,63]. A large study of 416 patients aged 75 yr with
solid tumors (13% genitourinary cancers) who were evalu-
ated by a geriatrics team before surgery revealed that IADL
dependence, a history of falls, and a CCI of 3+ were associ-
ated with a higher risk of delirium [62].
Few studies have specifically studied outcomes in older
adults undergoing urologic oncologic procedures. One small
study of older adults undergoing radical cystectomy found
that older age and impaired preoperative cognition were
associated with a higher likelihood of delirium [63]. Another
study of older adults undergoing urologic surgery found
that older age, impaired cognition, dependence for IADLs,
and a history of delirium were predictive of postoperative
delirium [64]. Patients identified as being at high risk of
delirium should be monitored closely. In addition, preven-
tive measures including avoidance of precipitating drugs
(eg, anticholinergics and benzodiazepines), early ambula-
tion, minimization of lines, orientation, and adequate nutri-
tion should be instituted to prevent delirium [65].
Further data, in particular from randomized trials, are
required to validate the use of CGA or screening tools to
determine perioperative risk and impact on morbidity and
mortality among older adults with cancer. Practical and
short screening tools are needed in the surgical setting,
where a complete CGA may be challenging to complete.
Nevertheless, surgeons treating older adults should take
into account factors associated with fragility, such as comor-
bidities and cognitive status, when predicting outcomes
[57].
3.3. Who should undergo CGA
An age cutoff for routine referral for CGA is controversial
given the heterogeneity in the aging process. SIOG and the

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National Comprehensive Cancer Network (NCCN) suggest
that a CGA be administered to all patients aged 70 yr
receiving treatment [66,67]. Similarly, several expert panels
suggest CGA as routine for patients aged 70–75 yr and older
[20,42]. Nevertheless, younger patients with age-related
health concerns should also be referred for CGA.
3.4. Feasibility of CGA and geriatric screening tools
CGA completion is feasible in the oncologic setting to assess
older adults seen in clinic. It was shown that a CGA con-
sisting of 14 validated measures, which can be predomi-
nantly self-administered, is feasible to administer in the
clinical setting to older adults with cancer [68]. The majority
(78%) of older patients were able to complete the geriatric
assessment without help and the average time to comple-
tion was 27 min (range 8–45). The CGA has been also used in
the Cancer and Leukemia Group B cooperative group setting
[69]. The self-completed portion of this CGA is available
online at the website www.mycarg.org, which summarizes
and provides interpretation for the data.
Despite this, CGA uptake has been low owing to concerns
about time and lack of resources, limiting its use in daily
practice. As a result, multiple screening tools have been
developed to help identify which patients are most likely to
have abnormal CGA findings and thus might benefit from a
referral (Table 3). Ideally, a screening tool has both high
sensitivity (to avoid missing patients who would benefit
from a CGA) and high specificity (to minimize patients
referred for CGA to those likely to benefit). A recent sys-
tematic review looking at seven geriatric screening tools
found that the Geriatric 8 (G8) and Triage Risk Screening
Tool 1+ were the most sensitive but had relatively low
specificity [70]. In North America, the Vulnerable Elders
Survey-13 is the preferred tool according to expert opinion,
while the G8 is more widely used in Europe [20,42]. SIOG
suggests that the G8 has been most rigorously tested and
has the highest sensitivity, but the choice of which specific
screening tool to utilize depends on familiarity with the tool
and its use and clinical context [66].
Table 3 – Geriatric screening tools.
Screening tool Sensitivity Specificity Items
(%) (%) (n)
Vulnerable Elders 68 78 13
Survey-13 [71]
Geriatric 8 [72] 87 61 8 Includes 7 items from the Mini Nutritional Assessment
Triage Risk Screening 92 47 5 Assesses cognitive impairment, presence of a caregiver,
Tool +1 [73]
Groningen Frailty 57 86 15
Index [74]
Fried frailty criteria 31 91 5 Frailty defined as >3 criteria: unintentional weight loss
[75]
Abbreviated CGA [76] 51 97 15
CGA = comprehensive geriatric assessment.
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Although screening tools do not replace a CGA, they can
help in selecting patients who will benefit from a formal
CGA and guided interventions [77]. However, in many
clinical settings, it is still not feasible to conduct a CGA,
even just in patients who screen positive on a geriatric
screening tool, because of limitations in timely access to
geriatricians. In this context, it is unclear whether screen-
ing of patients is beneficial. However, several studies have
found that that an abnormal result on a geriatric screening
tool can still be predictive of adverse outcomes, including
chemotherapy toxicity [78], functional decline [79], and
1-yr survival [80].
In the surgical setting, no screening tool has been shown
to predict postoperative complications, so a screening tool
should not be used in isolation to select patients for surgery.
SIOG guidelines suggest that the G8 be used as the initial
step in assessing older men with prostate cancer, and that
those with a normal G8 score be considered as fit and
suitable for treatment with standard therapies [81]. Those
with an abnormal G8 should be assessed for independence
for ADL, weight loss, and comorbidities using the CIRS-G.
Those who are dependent for more than one ADL, have
severe comorbidities, or who have >10% weight loss are
considered frail and should be treated symptomatically
with adapted treatments. Those in between should have
geriatric interventions to improve their health, and with
improvements can be considered for standard therapies.
3.5. Ongoing challenges and CGA limitations in the oncology
setting
Much research is still needed to further define the role of
CGA in oncologic assessment, decision-making, and follow-
up. Most studies of CGA have been conducted among older
patients with a variety of cancers. There are relatively few
studies of CGA and geriatric screening tools specifically in
genitourinary cancers and in the surgical setting, although
there is increasing recognition and interest in this area.
Further studies are needed to define how CGA findings
should direct oncologic decision-making, and data are
Description Time to Abnormal score
complete cutoff (range)
Includes age, physical status, functional capacity, and <10 min 3 (0–10)
self-rated health
<10 min 14 (0–17)
questionnaire plus age
2 min 1 (0–6)
difficulty with ambulation, recent hospitalization, and
polypharmacy
Assesses diminished abilities and resources in physical, N/A 4 (0–15)
cognitive, social, and psychological functioning
5 min 3
(10 lbs in past year), self-reported exhaustion,
weakness (grip strength), slow walking speed, and low
physical activity
Combines the items of the CGA that are most 4 min 1 (0–4)
predictive of the total rating score of each scale
EUF-402; No. of Pages 10

E U RO P E A N U RO L O GY F O C U S X X X ( 2 018 ) X X X– X X X 7

Fit
No Standard
abnormalities treatment

Standard oncologic assessment +

suggested minimum geriatric Interventions to
Vulnerable improve
assessment Independent ADL; reversible issues
Independence for ADL/IADL dependence for IADL Modiied
Fall history Weight loss 5–10% treatments
Comorbidities Poor social support Consider standard
Unintentional weight loss History of falls treatment if
Social supports improvements
Timed up and go test with interventions
Cognitive screen (eg, mini-Cog)

For systemic therapy, consider: Frail

Geriatric screening tool Dependence for ADL
(eg, G8, VES-13) Severe comorbidities Consider
Moderate to severe supportive
cognitive impairment
care
TUG >20 s

Figure 1 – Suggested use of geriatric assessment in oncologic practice. ADL = Activities of Daily Living; IADL = Independent Activities of Daily Living;
G8 = Geriatric 8; VES-13 = Vulnerable Elders Survey-13.

needed to confirm that these changes result in better 4. Conclusions

patient outcomes.
Current research has focused on the value of a baseline
CGA on decision-making and patient outcomes. The role of
serial CGA in cancer care is unknown. There are few studies,
even in the general geriatric population, on using serial
CGA to monitor and tailor subsequent treatment. In oncol-
ogy, there are only a few studies looking at serial CGA, with
one small study showing that repeat CGA identified an
average of three new problems on follow-up CGAs carried
out over a period of 6 months and influenced oncologic
treatment in 36% of cases [82]. Further studies are required
to evaluate the value of serial measurement of CGA in
oncology.
3.6. Recommendations
Several international organizations, including the NCCN and
SIOG, agree that a CGA provides valuable information that can
help to individualize and improve treatment for older adults
with cancer [43,66]. The CGA does help to identify those
patients at risk of adverse outcomes, including poorer prog-
nosis, treatment toxicity, and functional decline. However,
more studies are needed to assess whether it can impact
treatment outcomes. A CGA has been shown to be feasible in
both the research and clinical setting. However, screening
tools, such as the G8 and VES-13 may help to further select
patients who will benefit from CGA. Randomized controlled
trials looking at the impact of CGA on cancer outcomes such as
disease-free survival and overall survival are ongoing.

At this time, we suggest that all patients aged 70 yr, as
well as those with age-related health concerns, have at
minimum an assessment of their ability to perform their
ADL/IADL, history of falls, comorbidities, unintentional
weight loss, and social supports (Fig. 1). They should also
have a cognitive screen and a TUG test. In patients being
considered for systemic therapy, the use of a geriatric
screening tool and/or chemotherapy toxicity predictor
may be most helpful for decision-making. The domains
and tools suggested are the components most likely to
predict adverse outcomes and influence decision-making
according to currently available studies and the most
feasible to implement. Patients who are considered fit
should receive standard oncologic treatment, while frail
patients should be treated with supportive care measures.
Those who are vulnerable should have interventions to
reverse potentially reversible health issues (Table 1). They
should receive modified oncologic treatment, although
standard treatment can be considered if patients improve
with intervention. These recommendations can be refined
as further data become available.
Author contributions: Tina Hsu had full access to all the data in the study
and takes responsibility for the integrity of the data and the accuracy of
the data analysis.
Study concept and design: Hernandez Torres, Hsu.
Acquisition of data: Hernandez Torres, Hsu.
Analysis and interpretation of data: Hernandez Torres, Hsu.
Drafting of the manuscript: Hernandez Torres, Hsu.
Critical revision of the manuscript for important intellectual content:
Hernandez Torres, Hsu.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: Hernandez Torres, Hsu.
Supervision: Hsu.
Other: None.
Financial disclosures: Tina Hsu certifies that all conflicts of interest,
including specific financial interests and relationships and affiliations
relevant to the subject matter or materials discussed in the manuscript
(eg, employment/affiliation, grants or funding, consultancies, honoraria,
stock ownership or options, expert testimony, royalties, or patents filed,
received, or pending), are the following: None.
Funding/Support and role of the sponsor: None.

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Cancer: A Review. Eur Urol Focus (2018), https://doi.org/10.1016/j.euf.2017.10.010
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8 E U R O P E A N U R O L O GY F O C U S X X X ( 2 0 18 ) X X X– X X X
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