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18]
Review Developing a comprehensive cancer specific geriatric
Article assessment tool
Rao S, Salins N, Deodhar J, Muckaden M
Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
Correspondence to: Dr. Naveen Salins, E‑mail: naveensalins@gmail.com

Abstract
BACKGROUND: Population aging is one of the most distinctive demographic events of this century. United Nations projections suggest that the
number of older persons is expected to increase by more than double from 841 million in 2013 to >2 billion by 2050. It is estimated that 60% of the
elderly patients may be affected by cancer and may present in the advanced stage. The aim of this paper was to develop a brief cancer‑specific
comprehensive geriatric assessment tool for use in a geriatric population with advanced cancer that would identify the various medical, psychosocial,
and functional issues in the older person. METHODS: Literature on assessment of geriatric needs in an oncology setting was reviewed such that
validated tools on specific domains were identified and utilized. The domains addressed were socioeconomic, physical symptoms, comorbidity,
functional status, psychological status, social support, cognition, nutritional status and spiritual issues. Validated tools identified were Kuppuswamy
scale (socioeconomic), Edmonton Symptom Assessment Scale (Physical symptoms) and SAKK cancer‑specific geriatric assessment tool, which
included six standard geriatric measures covering five geriatric domains (comorbidity, functional status, psychological status, social support,
cognition, nutritional status). The individual measures were brief, reliable, and valid and could be administered by the interviewer. CONCLUSION: The
tool was developed for use under the geriatric palliative care project of the department of palliative medicine at Tata Memorial Hospital, Mumbai.
We plan to test the feasibility of the tool in our palliative care set‑up, conduct a needs assessment study and based on the needs assessment
outcome institute a comprehensive geriatric palliative care project and reassess outcomes.
Key Words: Advanced cancer, geriatric assessment tool, palliative care

Introduction financial, environmental and spiritual that affect their global

United Nations projections suggest that the number of
older persons is expected to increase by more than double
from 841 million in 2013 to >2 billion by 2050. India has
about 100 million elderly at present, and this is expected to
increase to 324 million by 2050, constituting 20% of the
total population.[1] Cancer is 11 times more likely to develop
in people over 65 years as compared to their younger
counterparts.[2] In the United States, 60% of all cancers
and approximately 70% of cancer‑related deaths[3] occur
in those 65 years or older. Based on an Indian Council of
Medical Research population‑based cancer registry report the
prevalence of cancer patients in India above the age of 60
is estimated to reach >1 million by 2021.[4] Government
of India adopted the “National Policy on Older Persons”
in January 1999 defining senior citizen or elderly as a
person who is of age 60 or above. Thus for the purpose
of this paper the age 60 years or above will be considered
as elderly.
Elderly patients needing palliative care services present
with unique concerns and the traditional assessment and
management guidelines fail to address their complex needs.
The aim of this paper was to develop a brief cancer‑specific
comprehensive geriatric assessment tool for use in geriatric
population in an advanced cancer care set‑up that would
identify the various medical, psychosocial, and functional
issues in the older person.
Background and Rationale
Review of literature in geriatrics and oncology indicate
that the elderly patients have multiple issues involving
various domains that is, physical, cognitive, affective, social,
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health.
Pain occurs in nearly all patients with advanced cancer[5]
and is twofold higher in those over the age of 60 or
above. [6,7] Elderly patients in addition have chronic
nonmalignant pain that predate cancer. Expression of
pain in the elderly patients may be atypical and presence
of cognitive impairment, delirium and dementia create
barriers in effective pain assessment. [8] Misconceptions
about cancer and aging process as well as cultural aversion
to narcotics, concerns about side effects and fear of
addiction to opioids [9] further impede effective pain
management. Besides pain, a high prevalence of symptoms
such as fatigue (up to 70% of elderly patients),[10] loss
of appetite and depression has been reported in elderly
patients with advanced cancer. Unrelieved or sub‑optimally
treated symptoms have a serious effect on the quality
of life of the elderly [11] resulting in depression, social
isolation, and immobility.[12] The elderly population have
multiple comorbidities that affect the outcomes in patients
with cancer [13,14] and in Indian elderly population an
added burden of communicable diseases compound this
problem. [15] In addition, the elderly patients are at an
increased risk of drug‑drug and drug‑disease interactions.[16]
Frailty,[17] functional status[18] and malnutrition[19] are crucial
factors that need to be taken into consideration in the
care of older adults as it is a strong predictor of negative
outcomes including disability, institutionalization, and
mortality. A study conducted in a tertiary care hospital
in India identified poor nutritional status among elderly
cancer patients.[20] The prevalence of depression in cancer
ranges from 17% to 25%[21] and has been correlated with
decreased quality of life and is a significant predictor of
mortality. [22] Suicide is another major concern in older
adults almost twice as likely as the younger populations.[23]
Cognitive impairments, delirium and dementia have been
identified as independent prognostic indicators of survival[24]
in patients with cancer. Lower socioeconomic status has an
adverse effect on survival due its effect on nutrition, social
support, and lack of access to better disease modifying
options. In India problems of the elderly patients are
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Rao, et al.: Cancer-specific geriatric assessment tool

further compounded by factors like lack of social security Measurements

and inadequate facilities for health care, rehabilitation, and
recreation.[25] Major proportion of the elderly patients are
out of workforce and partially or totally dependent on
others.[26] Social isolation is also an independent predictor
of mortality in the geriatric population.[27]
An audit conducted as part of a geriatric palliative care
project over 6 months (October 2013–March 2014) by
the Department of Palliative Medicine, Tata Memorial
Hospital, India indicate that nearly 40% of all patients
with advanced cancer referred to palliative care services
were aged 60 years or above. The most common physical
symptoms reported were pain (74%), fatigue (90%), loss
of appetite (75%) and anxiety (45%) as reported on the
Edmonton Symptom Assessment Scale. About 68% of
the elderly patients complained of mobility impairment
with 58% having an Eastern Cooperative Oncology
Group‑Performance Status of 2 or 3. However, no details
regarding patient’s baseline level of functioning that is,
ability to complete Activities of Daily Living (ADLs) and
instrumental activities of daily living (IADLs) were available.
Cognitive impairment, perceived social support, presence
of psychological and spiritual concerns, nutritional status
were not being assessed adequately in a busy palliative care
outpatient set‑up highlighting the need for a comprehensive
geriatric assessment.
A meta‑analysis of 28 controlled trials of comprehensive
geriatric assessment demonstrated that geriatric
assessments if linked with geriatric interventions reduce
re-hospitalizations and mortality in older patients through
early identification and treatment of problems, [28] reduce
functional decline and improve mental health outcomes.[29]
However, these tools are time‑consuming and impractical
for use in a busy palliative care setting. [30] Our goal was
to develop a brief and comprehensive assessment tool that
could be used in the geriatric population in an advanced
cancer care and palliative care setting, which would include
all the essential domains evaluated by geriatricians and
oncologists as independent predictors of mortality and
morbidity in older patients. Following are the validated
tools used in of the geriatric population addressing the
above‑mentioned domains.
Modified Kuppuswamy’s Socioeconomic Status
Scale (2013)
Kuppuswamy’s scale is widely used to measure the
socioeconomic status of an individual in an urban Indian
community based on three variables namely education
level of head of family (HOF), occupation of HOF and
income per month. It is an important tool in hospital and
community‑based research in India, which was originally
proposed in 1976. Socioeconomic status on this study was
scored using the updated version of the scale.[40]
Edmonton symptom assessment system
This tool is designed to assist in the assessment of nine
symptoms common in cancer patients: Pain, tiredness,
nausea, loss of appetite, shortness of breath, drowsiness,
depression, anxiety, best wellbeing and others. It is the
patient’s opinion of the severity of the symptom and the
gold standard for symptom assessment.
Charlson comorbidity index
Charlson comorbidity index (CCI) assesses comorbidity level
by taking into account both the number and severity of
19 pre‑defined comorbid conditions. The CCI was further
adapted to account for increasing age by adding one point
to the CCI score for each decade of life over the age of 50.
Hall (William H Hall, 2004) et  al. have created a Microsoft
Excel Macro to calculate CCI to facilitate its correct and
uniform use in medical research that was used to assess
comorbidity in this study. Has good reliability, excellent
correlation with mortality and progression‑free survival
outcomes, and is easily modifiable particularly to account
for the effect of age.[41]
Vulnerable elders survey‑13
Vulnerable elders survey (VES‑13) is a validated
tool used to assess the risk of health deterioration in
community‑dwelling older adults by considering a number
of factors including disabilities, age, self‑reported health
status, and functional limitations. The VES‑13 correlates
with the Comprehensive Geriatric Assessment with a
value of 0.4 and with ADL/IADL scales with a value of
0.5 showing it as a valid tool. Internal consistency for the

Table 1: Cancer‑specific geriatric assessment tool

Domain Measures Number How administered Scores and
of items cut‑offs
Socioeconomic Kuppuswamy scale[31] 3 MRA 3-29
Physical symptoms Edmonton symptom assessment scale[32] 9 MRA 0-10
Spiritual Two question model 2 Interviewer administered
SAKK C‑SGA (5 domains, 6 measures) developed by the swiss group for clinical cancer researcha
Comorbidity Age‑adjusted Charlson Comorbidity index[33] 18 MRA 0-43; ≥4
Functional status Vulnerable elders survey‑13[34] 12 Self‑report or interviewer administered 0-10; ≥3
Number of falls since the last 6 months[35]b 1 Interviewer administered
Psychosocial Geriatric depression scale 5‑item short form[36] 5 Self‑report or interviewer 0-5; ≥2
Modified medical outcomes study social support survey[37] 8 Interviewer administered 0-14; ≤2.5
Nutrition Mini nutritional assessment[38] 3 Interviewer administered and MRA 0-14; ≤11
Cognition Mini‑Cog[39] 3 Interviewer administered 0-5; ≥3
a
Permission was obtained from the authors for the use of this tool in our setting; bNot included in SAKK C‑SGA. MRA=Medical record abstraction; SAKK C‑SGA=SAKK
cancer‑specific geriatric assessment. Items 1,2, and 3 in Table 1 are additions made to SAKK C‑SGA tool to suit the palliative care population in India

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Rao, et al.: Cancer-specific geriatric assessment tool
VES‑13 in a study by Luciani et  al. found a Cronbach’s
alpha of 0.9 when compared against Comprehensive
Geriatric Assessment (CGA). Sensitivity was reported to be
87% and specificity of 62% versus CGA and 90% and 70%
versus ADL/IADL.
Number of falls in the last 6 months
Older patients are at a risk of falls due to mobility, balance,
and gait impairments. Patients with cancer are at a greater
risk for pathologic fracture or hemorrhage.
Geriatric depression scale‑5
The Geriatric depression scale (GDS) was specifically
developed for use with older people, 60 years and above,
as a basic screening measure for depression. Holy and
colleagues selected 5 items that had the strongest correlation
with a clinical diagnosis of depression and developed
the GDS‑5 for use in faster paced settings. Sensitivity of
GDS‑5 ranges from 89% to 98% and specificity ranges
from 73% to 85% (Rinaldi et  al. 2003; Weeks et  al. 2003).
Reliability coefficient was 0.84, and interrater reliability was
0.88 (Rinaldi et  al. 2003).
The Modified Medical Outcomes Study Social Support
Survey
To reduce respondent burden the original 19‑item Medical
Outcomes Study Social Support Survey[42] was shorted to
an 8‑item version named modified Medical Outcomes Study
Social Support Survey (mMOS‑SS). [43,44] The mMOS‑SS
has two subscales covering two domains (emotional
and instrumental (tangible) social support). Moser et  al.
demonstrated that the mMOS‑SS demonstrated good
internal reliability, consistent factor structure, good
convergent, divergent and discriminate validity. It’s a reliable
and valid tool to measure social support especially in the
geriatric context.
The Mini‑Cog
This is a simple screening tool developed in 2000 to
detect cognitive impairment quickly in older adults. It
comprises of 3‑item recall test and clock drawing test,
which allows clinicians to quickly assess numerous cognitive
domains and provides a visible record of both normal and
impaired performance that can be tracked over time. In
the original validation article, with a sample of culturally
diverse, community‑dwelling persons, 50% of whom had
dementia, the Mini‑Cog demonstrated a sensitivity of 99%
and specificity of 96%, compared with Mini Mental State
Examination (91% and 92% respectively). [45] A score of
3–5 out of 5 is a negative screen for dementia (Borson
et  al., 2006), but a score of 0–2 out of 5 may increase
detection of mild cognitive impairment (McCarten et  al.,
2012). The Mini‑Cog is not strongly influenced by
education, culture, or language, and it was perceived as less
stressful to the patient than other longer mental status tests.
Mini‑Nutritional assessment Short Form
The Mini‑Nutritional assessment (MNA) ‑ Short Form is
a quick screening version of the original MNA used to
identify older adults at risk for malnourishment early so that
nutritional intervention can be initiated. The sensitivity has
been reported as 97.9% and specificity 100% for predicting
96
under‑nutrition, diagnostic accuracy 98.7%, reliability not
reported.
Spiritual status
We screened the spiritual concerns using the two‑question
model developed by Fitchett and Risk. The two questions
included:
• Is spirituality or religion important to you
• Are your spiritual resources working for you?
Conclusion
Geriatric patients with advanced cancer present with a
unique set of needs and challenges and the prevailing
adult palliative care needs assessment model fails to
recognize these distinctive domains. Any assessment that
does not address the special needs of the elderly would
be incomplete and inappropriate. An effective geriatric
palliative care program should evaluate the physiologic,
functional, and health‑related quality of life of the patient;
aid in formulating appropriate treatment and management
strategies; monitor the clinical and functional outcomes; and
in addition aid in identifying patient and caregiver treatment
preferences.
Department of Palliative Medicine at Tata Memorial
Hospital, Mumbai, developed this tool, as an attempt to
bridge gaps in needs assessment such that it will positively
improve geriatric palliative care services and thereby improve
outcomes. We plan to assess the feasibility of the tool,
validate it in regional language, conduct a needs assessment
study, and based on the needs assessment outcomes, institute
a comprehensive geriatric palliative care package and reassess
outcomes of intervention.
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Letter to the Editor
Proximal type of epithelioid sarcoma of back with
metastasis to humerus at presentation: Indicating
aggressive behavior
Sir,
Epithelioid sarcoma (ES), first described by Enzinger, is an
uncommon soft tissue sarcoma seen in the distal extremities
of young adults.[1] It is usually a slow‑growing tumor with
tendency to recur locally and metastasize, which has been
documented in 40‑45% cases. [2] This case is uncommon
on account of ES presenting as fracture humerus due to
metastasis, which prompted us to report this case.
A 67‑year‑old female presented with pain and swelling in
the left arm since 15 days and swelling on lower back.
On general examination, the patient was moderately built
with good general health. Local examination revealed that
there was tenderness and swelling at the upper end of left
humerus. Radiological examination revealed pathological
fracture of upper end of left humerus. Subcutaneous
swelling was evident in the left lower back region,
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How to cite this article: Rao S, Salins N, Deodhar J,
Muckaden M. Developing a comprehensive cancer specific geriatric
assessment tool. Indian J Cancer 2015;52:94-7.
Source of Support: Nil, Conflict of Interest: None declared.
measuring 4.1 × 4.0 × 3.3 cm. On elucidating details of
history, patient revealed that back swelling was 3 months
prior to swelling at the upper end of humerus. Routine
hematological and biochemical parameters including renal
and liver function tests were within normal limit.
Incisional bone biopsy of the humerus lesion and excision
biopsy of the back mass with wide margins was carried
out. The soft tissue mass was well‑circumscribed, firm, and
grey‑white. On cut surface, it was tan‑colored, solid, with
areas of hemorrhage. Both the biopsies showed similar
histopathological and immunohistochemical (IHC) features:
The tumor tissue was composed of round to polygonal cells
arranged in sheets, separated by irregular fibrous septae. The
cells had intense eosinophilic cytoplasm and pleomorphic
nuclei with prominent eosinophilic nucleoli. Some of the
cells showed rhabdoid appearance [Figures 1 and 2]. IHC
staining showed reactivity for cytokeratin (CK), vimentin,
and epithelial membrane antigen (EMA) [Figure 3]. Desmin
was focally positive, mainly in the rhabdoid‑appearing
97