VOLUME 25 䡠 NUMBER 14
JOURNAL OF CLINICAL ONCOLOGY
From the Department of Medicine,
University of Chicago, Chicago, IL; and
the Departments of Medicine and
Epidemiology, Columbia University
Medical Center, New York, NY.
Submitted December 6, 2006; accepted
February 20, 2007.
Supported by the American Society of
Clinical Oncology (ASCO) -Hartford
Fellowship Training Program in Geriatric
Oncology (M.B.R.), the ASCO Young
Investigator Award (S.G.M.), Hartford
Centers of Excellence (S.G.M.), the
University of Chicago Cancer Research
Center Women’s Board (M.B.R.), the
Illinois Department of Public Health
Penny Severns Breast Cancer Research
Fund (M.B.R.).
Presented in part in lecture format at
the University of Chicago Section of
Oncology Fellows’ Intensive course,
Chicago, IL, July 25, 2006; the Univer-
sity of Louisville, Department of Medi-
cine, Louisville, KY, September 5, 2005;
St Louis University Geriatrics Grand
Rounds, St Louis, MO, October 9,
2004; and the University of Chicago
Conference on Geriatric Oncology,
Chicago, IL, October 5, 2002.
Authors’ disclosures of potential con-
flicts of interest and author contribu-
tions are found at the end of this
article.
Address reprint requests to Miriam B.
Rodin, MD, PhD, The University of
Chicago, MC 6098, 5849 S Maryland
W-700, Chicago, IL 60637; e-mail:
mrodin@medicine.bsd.uchicago.edu.
© 2007 by American Society of Clinical
Oncology
0732-183X/07/2514-1936/$20.00
DOI: 10.1200/JCO.2006.10.2954
1936
Information downloaded from jco.ascopubs.org and provided by at UNIV OF PITTSBURGH, HSLS on October 16, 2013
Copyright © 2007 American Society of Clinical Oncology. All rights reserved.
䡠 MAY 10 2007
R E V I E W A R T I C L E
A Practical Approach to Geriatric Assessment in Oncology
Miriam B. Rodin and Supriya G. Mohile
A B S T R A C T
More than half of new cancers are diagnosed in elderly patients, but data from randomized clinical
trials do not represent the elderly population. Comprehensive geriatric assessment (CGA) can
contribute valuable information to oncologists for risk stratification of elderly cancer patients.
Functional impairments, frailty markers, cognitive impairments, and physical disabilities increase
the risk for adverse outcomes during cancer treatment. Evidence is accumulating that selected
elderly cancer patients benefit from CGA and geriatric interventions. However, perceived barriers
to CGA include time, familiarity, cost, and lack of a well-defined procedure to interpret and apply
the information. We present a model for rapid selection of elderly who would benefit from CGA
using screening tools such as the Vulnerable Elders-13 Survey. We also define important geriatric
functional risk factors, including mobility limitation, frailty, and dementia, and demonstrate how
brief screening tests can make use of data realistically available to clinical oncologists to determine
a stage of aging. Summary tables and a decision tree demonstrate how these data can be
compiled to determine the risk for toxicities and to anticipate ancillary support needs.
J Clin Oncol 25:1936-1944. © 2007 by American Society of Clinical Oncology
pitalization and transitions between independence
INTRODUCTION
and dependence.20,21
More than half of new cancers occur in the elderly.1 The importance of merging geriatric perspec-
Until recently, elderly patients have been under- tives into oncology has been well stated by Balducci
represented in the large cooperative trials.2-4 This and Beghe,12 Extermann,22 Repetto et al,23 and
has limited oncologists’ ability to extrapolate others.24-26 The hope is that geriatric assessments
from trials to practice. Consequently, clinical un- will improve treatment tolerance through individu-
certainty about treatment for older cancer pa- alized treatment planning. Descriptive studies of ge-
tients can result in suboptimal or overly toxic riatric syndromes and disability among elderly
cancer patients have shown that unrecognized geri-
treatment. Reanalysis of large trials has shown
atric problems occur commonly.27 In some case se-
that selected elderly benefit from standard ther-
ries, the prevalence is unexpectedly high.28 In others,
apy for the common tumors including colon,
due to referral bias, the prevalence is unexpectedly as
lung, breast, and non-Hodgkin’s lymphoma.5-11
low compared with elderly noncancer patients.29
How to extrapolate these results to clinical prac-
Several studies now report that geriatric measures
tice is not clear. Just as the stage of the disease and predict treatment tolerance.29-33 Pilot research sug-
tumor response must be assessed, oncologists gests that geriatric tools can be interpolated into
need to learn how to stage the functional age and oncology practice.27,34,35
anticipate the functional response to treatment.12
Geriatricians have validated standardized tools
for clinical staging of functional aging as distinct WHAT IS GERIATRIC ASSESSMENT?
from chronologic age.13 Much as an oncologist
would stage the tumor, the size and spread of dis- The assessment tools described in the geriatric
ease, and its projected biologic behavior, geriatri- oncology literature are often referred to as com-
cians look for signs of accelerated aging that increase prehensive geriatric assessment (CGA). The mul-
vulnerability to disablement and mortality.14 These tidimensional CGA includes a compilation of
tools have shown strong prognostic power to iden- reliable and valid tools to assess geriatric domains
tify high-risk elderly in the community,15-17 hospi- such as comorbidity, functional status, physical
tal,18 and nursing home.19 In the course of this work, performance, cognitive status, psychological sta-
core constructs evolved that stratify elderly by vul- tus, nutritional status, medication review, and so-
nerability to well-defined outcomes including hos- cial support. Although not all-inclusive, Table 1
from 130.49.198.5
 Geriatric Assessment

Table 1. Comprehensive Geriatric Assessment Measures

Time Cutoff Point
Required for Adverse
Geriatric Domain Measure No. of Items Administration (min) Score Range Outcomesⴱ
Function Activities of daily living36 8 Self- or interviewer 5-10 0-16 ⱕ 14
administered
Instrumental activities of 7 Self- or interviewer 5-10 0-14 ⱕ 12
daily living37 administered
Objective physical performance Short Physical Performance 4 separate physical Administered by a member 5-10 0-12 ⬍9
Battery17 performance of the assessment team
tests
Timed Up and Go38 Get up from a chair Administered by a member 5 Time (seconds) ⬎ 8.5 sec
and walk 8 feet of the assessment team
and back
Comorbidity Cancer and Leukemia Group 18 Self- or interviewer 15 0-54 ⬎ 10
B adaptation of Charlson administered
Comorbidity Score35
Cumulative Illness Rating 13 Self- or administered 10 0-52 ⱖ5
Scale in Geriatrics39
Nutrition Mini Nutritional 6 Interviewer administered ⬍5 0-12 ⱕ 11
Assessment40
Social support RAND medical social 5 Self-administered ⬍5 0-5 ⬍4
support scale27
Cognition Short Portable Mental 10 Interviewer administered ⬍5 0-10 ⬎3
Status Questionnaire41
Blessed Orientation 6 Interviewer administered ⬍5 0-28 ⬎ 10
Memory42
Folstein Mini Mental State 7 Interviewer Administered 5-10 0-30 ⬍ 24
Examination43
Depression Geriatric Depression Scale44 15 Self-administered ⬍5 0-15 ⱖ5
Beck Depression Scale45 21 Self-administered 10 0-63 ⱖ 13
ⴱ
Prospectively associated with an increase in disability, mortality, or adverse outcomes in previous studies.

summarizes tools commonly implemented within the CGA to
evaluate geriatric domains. Scores on these tools have been linked
prospectively with adverse outcomes in the elderly. The tools elicit
self-reported tasks required for self-care or activities of daily living
(ADLs) such as bathing, dressing, eating, using the toilet, and trans-
ferring between bed and chair.36 The instrumental ADLs (IADLs) are
tasks required for living independently in the community, which
include the ability to walk outside the home, climb steps, shop, prepare
meals, pay bills, do laundry, use transportation, and take medications
correctly.37 The CGA also includes screens for dementia,41-43,46 de-
pression,44,45 and other geriatric syndromes including falls, frailty,
incontinence, poor appetite, and delirium.47 In a geriatric center,
assessments include directly observed physical performance.48 CGA
detects unsuspected conditions in more than 50% of patients older
than 65 years that may affect their ability to complete cancer treat-
ment.22,23,34 Extermann et al49 demonstrated that comorbidity and
functional status were independent in cancer patients, consistent with
geriatric cross-sectional and prospective studies demonstrating that
functional status, comorbidity, and frailty are distinct entities.50 A
recent report identified that geriatric syndromes are common among
oncology patients.47
IS GERIATRIC ASSESSMENT EFFECTIVE?
In geriatrics, the term CGA does not designate a set of questionnaires
administered to patients, but the entire process of multidisciplinary
interpretation of the results. Systematic reviews of trials of geriatric
assessment have shown effectiveness provided the interventions are
implemented.51-54 The benefits to patients may include prolongation
of life, prevention of hospitalization or admission to nursing homes,52
prevention of geriatric syndromes,53,54 recognition of cognitive defi-
cits,52 and improvement of subjective well-being.51 One large ran-
domized controlled trial subgroup analysis showed better results for
elderly cancer patients than other elderly medical patients.55
In oncology, CGA could assist decision making (ie, balance the
durable benefit against likely life expectancy). CGA is used to follow
changes in performance status, and to identify patients for interven-
tion that would improve fitness for treatment. It is not useful or
efficient to complete a CGA on every patient older than age 65 years,
and there are few well-defined procedures for oncologists to select
patients for CGA or how to interpret the results. Oncologists ask how
CGA improves on the simple Karnofsky performance scale and East-
ern Cooperative Oncology Group performance score (ECOG-
PS),56,57 and how to abbreviate the CGA without losing predictive
power.27,34,35,58 Unless CGA is viewed as necessary and convenient,
applications will probably be limited to specialty programs and clinical
trials. This review is neither systematic nor structured. We defer to the
complete expert reviews compiled by other authorities. In this review,
we offer a practical approach to staging the aging and suggest how
selected geriatric tools that might be used in clinical oncology practice.
STAGING THE AGING
Geriatricians make rough distinctions by decades of age, but within a
decade of age, there is considerable diversity in life expectancy, abil-
ity to live independently, and burden of chronic disease. Functional

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 Rodin and Mohile
status can change catastrophically in the face of acute illness.59 Table 2
lists the estimated average remaining life expectancy (RLE) in quartiles
of longevity by age and health status.60 RLE is often underestimated.
The CGA provides data to assist classification of a patient as upper,
middle, or lowest quartile.
COMORBIDITY
Multiple comorbidities are common in elderly cancer patients and can
affect cancer stage at presentation and survival.61-69 Any new comor-
bidity, such as cancer, will increase functional demands on an older
person.61 The Charlson Comorbidity Index provides a summary score
of burden of illness.70 It has predictive value for cancer treatment
tolerance49,62-64 and cancer survival.65-67,69 Satariano et al67 and others
have shown how competing mortality of comorbid disease is directly
related to cancer-related life expectancy,71 and the impact of comor-
bidity on RLE has been factored into cancer screening and treatment
decision models.71-74 Furthermore, it is likely that elderly with multi-
ple comorbidities are taking more than five prescription drugs, in-
creasing the likelihood of interaction with chemotherapy agents.27,75
FRAILTY
Frailty is the extreme phenotype of aging.50 Even in the absence of
disease, aging results in progressive loss of organ reserve and the extra
capacity needed to maintain physiologic homeostasis under stress.
Normal aging is characterized by blunted response to stressors.76 An
example of this phenomenon is the onset of congestive failure in the
absence of clinical heart disease from anemia and sepsis. A trained
elderly athlete has less heart rate variability and ventricular compliance
compared with a young athlete. Loss of lung elasticity and chest wall
mobility increases the work of breathing, so an elder may not meet the
demands of acidosis, hypoxia, and exercise. Under stress of disease,
drugs, and fatigue, hospitalized elderly may develop delirium, an acute
failure of brain function, and be unable to communicate, follow in-
structions, or perform ADLs.18
Frail elderly are weak and slow. The clinical criteria for frailty
were set out by Fried et al15,50 and adapted by a National Institutes of
Aging and American Geriatrics Society expert consensus in 2004, as
shown in Appendix 1 (online only).21,77 At this conference, frailty was
defined as a clinical syndrome and as an encompassing conceptualiza-
tion of diverse “vulnerabilities, weaknesses, instabilities, and limita-
tions.” Suggestions for future research included the development of a
standardized definition for a clinical phenotype of frailty, determina-
Table 2. Remaining LE in Years by Age, Sex, and Quartile of LE
Remaining LE at Age (years)
70 75
Sex L M H L M H
Men 6.7 12.4 18 4.9 9.3 14.2
Women 9.5 15.7 21.3 6.8 11.9 17
NOTE. Adapted from Walter et al.60
Abbreviations: LE, life expectancy; L, low quartile of LE; M, middle quartile of LE; H, high quartile of LE.
1938
tion of causes of frailty and specific impairments, creation of collabo-
rative networks to study frailty, and descriptive studies of the
interaction of frailty with cancer and its treatment. The John Hartford
Foundation will sponsor a collaborative Cancer and Aging research
conference chaired by Arti Hurria, MD, from City of Hope Cancer
Center (Duarte, CA) to explore these ideas.
Although additional data for the utility of frailty screening in
cancer is forthcoming, several leading experts have encouraged the use
of the criteria suggested by Fried et al15,50 for frailty (derived from the
Cardiovascular Health Study) in evaluating older patients with cancer.
The criteria were included in the National Comprehensive Cancer
Network’s guide to cancer treatment for senior adults. The frailty
index includes five physical features or criteria and stratifies the aged
into nonfrail, prefrail, and frail. Frailty is diagnosed if three or more
criteria are present. Prefrailty is defined as the presence of one or two
criteria. Up to 40% of persons older than age 80 are frail.78 In two
community cohorts of women age 70 to 79 years, 33% to 45% were
nonfrail, 55% to 44% were prefrail, and the remaining 11% were
frail.79 Obesity can mask frailty if clinicians only use weight loss or
underweight as criteria. However, even among obese women, the
index identified prefrailty and frailty based on exhaustion, slow gait,
and low levels of activity.80 Oncologists recognize frailty in the appear-
ance of cancer cachexia. Ferrucci et al78 have reviewed and summa-
rized what is known about the overlap of cancer cachexia, fatigue, and
theagingfrailphenotype.Theyhypothesizedthatrigorouschemother-
apy, like illness, is essentially a test of physiologic reserve.
In addition to the five index features, noncancer frailty shares
biomarkers associated with advanced cancer including low hemoglo-
bin, cholesterol, and albumin, which are correlated with poor physical
performance, reduced muscle strength, and higher mortality in
cancer-free elderly.81-86 Frailty markers describe a low-grade proin-
flammatory state of aging characterized by higher levels C-reactive
protein and interleukin-6.87 In a large population, Ferrucci et al87
found that levels of inflammatory markers increased significantly with
age. Others have shown increased levels of proinflammatory biomar-
kers to be associated with disabling illnesses such as cardiovascular
disease, dementia, and osteoporosis, low body weight, anorexia, aber-
rations of glucose metabolism, and protein synthesis.77,87 The physical
characteristics of frailty overlap those of advanced cancer. Treatment
of cancer (eg, androgen ablation for prostate cancer) causes anemia,
sarcopenia, and potentially cognitive impairment. Despite the obvi-
ous benefits, we do not know how significantly androgen ablation
affects already frail older men. Advances in research on primary
frailty and cancer-related cachexia may lead to new treatments for
primary and cancer-associated frailty. The value of serial assessments
80 85 90
L M H L M H L M H
3.3 6.7 10.8 2.2 4.7 7.9 1.5 3.2 5.8
4.6 8.6 13 2.9 5.9 7.9 1.8 3.9 6.8
JOURNAL OF CLINICAL ONCOLOGY
 Geriatric Assessment

of biomarkers to monitor disease progression, such as cancer, has not talization. Thus, assessment tools should be chosen that reliably iden-
been well studied. tify elderly who are vulnerable for developing functional impairments.
The patients in the middle ranges of RLE in Table 2, with no dominant
life-limiting comorbidity, and who are neither exceptionally healthy
FUNCTIONAL ASSESSMENT
nor frail, are likely to benefit from tools designed to elicit risk for
disability as opposed to preexisting disability. In an office setting,
Ferrucci et al78 observed that common geriatric assessment tools are impaired IADL may be less apparent than ADL dependency. Any
sensitive indicators of the pace of late life decline, chiefly progressive IADL difficulty has also been shown to predict increased all-cause
loss of mobility and ADL. Several widely used quality-of-life tools mortality.95 Multiple IADL impairments suggest that the presence of
query functional status, but in a general way. These include (among ADL impairment is highly likely.
others) the European Organization for Research and Treatment of
Cancer Quality of Life C30,88 the Medical Outcomes Study–Short
DIRECTLY OBSERVED PERFORMANCE
Form 36-item questionnaire,89 and the cancer-specific Functional
Assessment of Cancer Treatment series of questionnaires.90 The geri-
atric forms for ADL36 and IADL37 differ in that they ask for specific Geriatricians watch how patients walk. What may seem effortless is
task performance (ie, “Do you bathe with or without assistance?”). We a complex and risky task for frail elderly. Changes in mobility are
know little about the course of ADL and IADL difficulties experienced associated with progressive loss of other functions.88 Four simple
during cancer treatment. Positive results of several intervention stud- maneuvers have been standardized: walking a short course (4 m
ies suggest that the elderly do experience functional decline during [approximately 15 ft]) marked on the floor with tape “at your usual
treatment and benefit from specific interventions.91,92 As listed in speed,” rising from a straight chair five times “quick as you can,”
Table 3, the presence of even one ADL impairment increases the risk of and standing still with heel to toe and on one leg for 10 seconds
adverse outcomes for hospitalized elderly. Extermann93 showed that each. The Short Physical Performance Battery is scored 0 to 12.
most components of the multifaceted CGA have been associated with This brief test predicted adverse outcomes of mortality and func-
cancer treatment toxicity and mortality. tional (ADL/IADL) decline at 1 and 4 years.96 Directly observed
The risk of functional decline should be assessed proactively measures of gait are a source of data to confirm self-reported
rather than reactively. IADL/ADL can be scored as any difficulty (1) function and have shown fine discriminatory power in the inter-
versus no difficulty (0); however, research has identified important mediate range of scores.48 As many as 10% of elderly with no ADL
distinctions between any and no difficulty. The elderly may not notice or IADL impairment, patients who would generally be considered
increased effort needed to perform a task because they “take it slow- ECOG-PS 0 to 1, perform poorly on timed tests of basic mobility.97
er.”92 The gradations from “no difficulty” to “a little difficulty”, “a lot Finally, these measures are highly associated with risk of falling in
of difficulty,” or “only with help” portend different levels of risk as general geriatric populations.53 Risk of falls and sequelae of falls
indicated in the Vulnerable Elder’s Survey-13 (VES-13)94 scoring have not been well reported in the oncology literature.
guide shown in Appendix 2.16 Items on this screening tool were asso-
ciated with an increased risk of health deterioration in a large popula-
SYNDROMES: DEMENTIA, DEPRESSION, AND DELIRIUM
tion of elderly Medicare beneficiaries. Many elderly patients in
treatment for cancer are not apparently frail, and screening for the
presence or absence of impairment will miss the vulnerable group for A geriatric medical history asks about the geriatric syndromes; these
whom extra compensation explains their independence and for are easily recognized clinical presentations of multifactorial etiology.
whom the extra stress of treatment may result in a preventable hospi- They are increasingly recognized among oncology inpatients.47 For
our purposes, the critical syndromes within oncology are dementia,
delirium, depression, and falls. We have briefly discussed dementia as
a comorbidity, and have related falls to directly observed walking.
Table 3. Mortality Impact of Selected Geriatric Functional Impairments Dementia is characterized by an insidious, progressive loss of
2-Year Mortality (%)
thinking abilities, including one or more functions of memory, recall
and recognition for verbal and visual information, judgment, lan-
Impairment Impairment
Functional Domain Prevalence Present Absent guage fluency, and problem solving.69,98 Dementia is predominantly a
Physical impairment
disease of the elderly, as is cancer. Approximately 6% to 10% of people
Any ADL 39 51 32 65 years or older suffer from some form of dementia and the preva-
Any IADL 65 48 23 lence increases to 25% to 48% in the population older than 80 years of
Mobility 1 29 38 28 age.99 In a large meta-analysis, risk for moderate dementia increased
2⫹ 36 51 28 from 2.4 per 1,000 person-years in persons age 65 to 69 years to 27.5
Cognitive impairment per 1,000 person-years in persons age 85 to 89 years.100 As listed in
Baseline delirium 5 50 39
Table 4, the relative risk for mortality for elderly persons with pneu-
MMSE ⬍ 20 32 57 31
Dementia 17 74 31
monia or hip fracture was higher if severe dementia was present.101
Overall, a diagnosis of dementia portends increased mortality, per-
NOTE. Adapted from Inouye et al.18
Abbreviations: ADL, activities of daily living; IADL, instrumental activities of
haps by as much as 150% during 5 years.102 Therefore, the presence of
daily living; MMSE, Mini Mental State Examination. dementia alone or with other comorbidities has significant impact on
RLE. A full diagnostic work-up may or may not be needed or desired,

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 Rodin and Mohile

functional capacity, and physical status. In the national sample of

Table 4. Impact of Dementia on Mortality for Elderly Hospitalized for Hip
Fracture and Pneumonia
elders from the Medicare Current Beneficiary Survey, a score of ⱖ 3
identified 32% of individuals as vulnerable. This identified group had
Risk Factor Hazard Ratio 95% CI
more than four times the risk of death or functional decline during 2
Pneumonia patients (n ⫽ 119) years when compared with elders scoring less than 3. Higher scores
Dementia 4.6 1.8 to 11.8
predict an increasing risk for functional decline and/or death107—an
Higher pneumonia severity score 3.1 1.1 to 8.9
Older age 1.1 0.98 to 1.1
important consideration for balancing best survival benefit of aggres-
Hip fracture patients (n ⫽ 97) sive cancer treatment against a realistic estimate of RLE. The clinical
Dementia 5.8 1.7 to 20.4 utility of the VES-13 was demonstrated during a short time period of 8
Higher Charlson comorbidity 1.4 1.1 to 1.8 to 11 months. The risk of functional decline or death increased with
score
each increase of 1 point along the entire scale 0 to 10.107
ADL impairment walk/transfer 3.4 1.3 to 8.9
Nursing home resident 1.5 0.5 to 4.5
The VES-13 is included in the National Cancer Comprehensive
Older age 1.0 0.9 to 1.1 Network (NCCN) practice guidelines for senior adults and has been
used in oncology to help with patient selection, risk stratification, and
NOTE. Adapted from Morrsion et al.101
Abbreviation: ADL, activities of daily living. toxicity evaluation.108,109 We performed a pilot study of the VES-13 in
our genitourinary oncology clinics.27 We selected the VES-13 because
it has been validated on a representative community-dwelling elderly
population.16 Using a nine-component CGA as the gold standard,34
but the oncologist is obligated to determine whether a patient can the VES-13 accurately identified elderly men with prostate cancer who
follow directions to self-manage drugs and symptoms, and is able to were at risk by CGA, which we defined as having impairments in two
make informed decisions about treatment. Clinical suspicion of de- or more domains. We use it routinely in our geriatrics clinics to
mentia is not sensitive. Physicians frequently miss the diagnosis if prescreen new patients on the telephone, to estimate the amount of
severe short-term memory loss is not prominent.103 Brief cognitive staff and room time they will need.110 The tool is scored on a contin-
screening tools include the Blessed Dementia Rating Scale,42 Mini- uum of 0 to 10. It is administered by telephone in less than 5 minutes
Mental State Examination,43 Mini-Cog,46 and Short Portable Mental or completed by the receptionist when the patient registers.
Status Questionnaire.41 An abnormal screen for cognitive impairment We agree with Overcash et al that all patients older than age 70
does not diagnose dementia. The purpose of screening is to assess years should be prescreened for vulnerability before treatment is de-
cognitive capacity and to stratify risk. cided, or even before invasive staging.58 We also agree with the NCCN
Delirium is an acute disturbance of attention and arousal that is guidelines that every elderly patient does not need a CGA.111 The
marked by fluctuation during the course of a day. Delirium can be NCCN guideline suggests that the criteria by Fried et al15 for frailty
agitated or hypoactive. Speech is incoherent or rambling. Delirium has from the Cardiovascular Health Study or the VES-1316 could be used
been shown repeatedly to be a poor prognostic factor for survival to screen for geriatric impairment. There are few data to support
among hospitalized elderly. Inouye et al104 validated a simple bedside specific recommendations for screening tools or suggestions about
scale, the Confusion Assessment Measure. Thus far, delirium has been how the evaluations ought to be sequenced. Comparison trials of
poorly documented in the oncology literature, but the combination of different models of CGA may suggest strategies for different institu-
drugs, fevers, sepsis, anemia, fatigue, pain, and electrolyte imbalances tional environments, patient types, or tumor types. When we evalu-
make it a common occurrence.104,105 Depression is poorly recognized ated the VES-13 as a prescreen in our prostate cancer clinics, we
by oncologists, although it has been associated with poorer survival.106 discovered that more than half of the men scored 3 or more.27 Exam-
Beyond a sensitive inquiry, there are a number of short validated ining only the men younger than age 85 who scored 3 or more, the
depression scales including the Beck Depression Inventory45 and the VES-13 accurately identified men with geriatric impairments in one or
Geriatric Depression Scale.44 more domains of the CGA. We have on-site and off-site geriatric
referral clinics for oncology consultation. If geriatric consultation is
not available, a prescreen VES score of 3 or more places more burden
WHO SHOULD RECEIVE A CGA?
on oncologists to look for syndromes, functional impairment, cogni-
tive impairment, fall risk, and frailty. We suggest the following strategy
Despite recent studies demonstrating the feasibility of CGA in to gather the data by integrating routine clinical observations with
oncology,27,34,35 its adoption as standard of care has been slow due standardized geriatric assessments.
to the lack of resources and difficulties with interpretation of In general, experts in the field suggest that all patients 70 years
results or implementation of interventions in specialty oncology and older should undergo some form of geriatric assessment. The
clinic settings. Oncologists have speculated about the practicality VES-13 and/or criteria by Fried et al15 for frailty may serve as useful
of a long battery of questionnaires. A short, reliable assessment that tools to assess patients quickly and efficiently within a busy oncology
fits into the flow of a busy oncology clinic is needed. Shorter clinic. For example, all patients who score 3 on the VES-13 or who are
versions based on the established tools have been offered.34,58 The not plainly agile and fit should also be assessed formally for mobility
brief CGA uses responses to impairment screening questions to with timed 4-m gait speed and assessments of rising from a straight
motivate more extensive data gathering. chair.17,112 The standard timed values are listed in Table 5. In our
One tool that may prove practical for screening in oncology is the experience, this procedure takes less than 1 minute, including instruc-
VES-13.16 The VES-13 is a self-administered survey that consists of tions to patients. Gait speed is incorporated into the frailty index. All
one question for age and 12 items that assess self-reported health, patients age 70 years and older should have a baseline cognitive

1940 JOURNAL OF CLINICAL ONCOLOGY

 Geriatric Assessment

ancillary services. However important it is to remember that abnormal

Table 5. Scoring Observed Physical Performance
scores on these tools deserve a response, it has not been established
4-m Walk (m/sec) 5 Chair Standsⴱ (seconds) how specific data about functional deficits should influence cancer
Score “At Your Usual Speed” “As Quickly As You Can”
decision making. The limited data that are available suggest that inter-
0† Unable ⬎ 60 or unable
ventions addressing geriatric deficits in cancer patients will improve
1 ⬍ 0.42 ⬎ 16.7-60
2 0.43-0.59 13.7-16.69
outcomes. For the most part, any elder who screens as vulnerable or
3 0.60-0.77 11.2-13.69 impaired on these tools deserves a multidimensional assessment by
4‡ ⬎ 0.77 ⬍ 11.2 practitioners who are experienced with interpreting and implement-
NOTE. Adapted from Guralnik et al.17
ing interventions. Thus, we believe that vulnerable elders will receive
ⴱ
Time it takes for patient to rise from a straight chair five times. the best quality medical care within a collaborative and multidisci-
†Lowest quartile.
‡Highest quartile.
plinary environment that uses the experience of oncology, geriatrics,
social work, psychiatry, neurology, rehabilitation, and other fields
with expertise in age-related illnesses.
In summary, we have briefly reviewed several different measure-
screening using any of the short forms. Patients understand that it ment approaches to CGA in the elderly. The assessments include
is important for their oncologist to be assured that their instruc- questionnaires, screening tools, open-ended questions, and struc-
tions can be followed. Comorbidity, polypharmacy, weight loss, tured collation of routine clinical data and observations of physical
body mass index, and subjective reports of fatigue, weakness, and performance. Several of the geriatric syndromes require no technical
exhaustion (all or most days of the last week) are nearly always expertise on the part of the physician, just the awareness to document
obtained. Three of these items contribute to the frailty index. The markers of frailty, cognitive impairment, and disability, and to refer
ECOG-PS does indicate levels of energy expenditure, adding the appropriately. Table 6 summarizes how scores on the VES-13, frailty,
fifth criterion if the suggested scale is not available. One question physical performance, dementia, and syndromes can be used to strat-
about falls or near falls (any in the last month) should be asked. For ify elderly patients as healthy, at average risk; vulnerable, at moderately
hospitalized elderly oncology patients, many nursing protocols increased risk; or frail, at extreme risk. Figure 1 presents a schematic
include mandatory documentation of delirium and ADL status. decision tree for the sequence of evaluations and the treatment mod-
These should be recorded in the problem list. For an outpatient ifications indicated by the results of screening and CGA. Appendix A3
with a VES-13 score of 3 or more, the social history should inquire (online only) presents case examples of assessments and interventions
explicitly about the identity, proximity, and availability of assis- generated by the CGA approach we have described.
tance with ADL and IADL. The standardized tools we suggest include directly observed
Using the tools and scoring methods we have presented, the physical performance, VES-13, cognitive screening, and targeted
oncology record will contain much of the documentation for geriatric questions about syndromes as geriatric measures. The remainder
risk stratification. Screening tools to identify vulnerable and frail el- of the data needed to stratify elderly to stage their aging are derived
derly adults within oncology may be useful for prognostication and to from routine clinical history and examination, such as comorbid-
indicate which patients would benefit from referral to geriatrics or to ity and polypharmacy. The utility of prescreening with the VES-13

Table 6. Stages of Aging With Associated Measures

ACOVE Stage
Measure Healthy/Usual Vulnerable Frail

VES-13 score 0-2 3-6 7⫹

Walking speed, m/sec ⬎ 0.77 ⬍ 0.42
Chair stand timeⴱ, seconds ⬍ 11.2 Unable, ⬎ 60
Frailty score 0 1-2 3-5
Syndromes 0 1 2⫹
Remaining life expectancy High Middle Low
Common CGA measures with suggested cutoffs,† factoring
in performance status and life-limiting comorbidity
ADLs 0 1 2⫹
Instrumental ADLs 0 1 2⫹
Mini Mental State Examination ⬎ 26 23-26 ⬍ 23
Short Portable Mental Status Questionnaire 0 1 2⫹
Geriatric Depression Scale 0 5 6⫹
Polypharmacy (No. of medications per day) ⬍5 5-8 9⫹
Comorbidity None limiting Slight Severe

Abbreviations: ACOVE, Assessing Care of Vulnerable Elders; VES, Vulnerable Elder’s Survey; CGA, comprehensive geriatric assessment; ADLs, activities of
daily living.
ⴱ
Time it takes for patient to rise from a straight chair five times.
†Adapted from Hurria et al34 and Mohile et al.27

www.jco.org 1941
 Rodin and Mohile

Age > 70

VES-13 < 3 VES-13 ≥ 3 Obvious frail

Gait
Fig 1. Screening elderly cancer patients for
Cognition CGA CGA comprehensive geriatric assessment (CGA).
Syndromes
VES-13, Vulnerable Elder’s Survey-13.

Negative: Positive: Negative: Positive:

Frail
no CGA refer for CGA usual care vulnerable

Negative: Negative: Dose reduction

Healthy
treatment limited treatment limited implement geriatric Palliative care
usual care
by comorbidities by comorbidities intervention

and observing mobility is that clear cutoff values have been estab-
lished. For the source ADL/IADL tools, which are presented for
comparison in the lower part of Table 6, cutoffs are not standardized
in the research literature, but can be adjusted in various ways to suit the
analytic purpose. The values entered in Table 6 are derived from
sources that in our judgment address the needs of oncology pa-
tients.27,34,58 Patients who do not score impairments on any of the
suggested screens (syndromes [delirium, falls, frailty], cognition, VES-
13, and observed performance) probably do not need referral for CGA
with interventions unless additional observations suggest otherwise.
Patients who score in the vulnerable category may benefit from a
CGA. We agree with Balducci et al113 that frail and ADL-impaired
patients should be considered for symptomatic palliation in consulta-
tion with a geriatric medicine consultant. We anticipate that future
research will determine the usefulness of our suggested approach for
selecting elderly oncology patients for usual oncology care or CGA and
geriatric consultation.
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS
OF INTEREST
The authors indicated no potential conflicts of interest.
AUTHOR CONTRIBUTIONS
Conception and design: Miriam B. Rodin, Supriya G. Mohile
Financial support: Miriam B. Rodin, Supriya G. Mohile
Administrative support: Miriam B. Rodin, Supriya G. Mohile
Provision of study materials or patients: Miriam B. Rodin, Supriya G.
Mohile
Collection and assembly of data: Miriam B. Rodin, Supriya G.
Mohile
Data analysis and interpretation: Miriam B. Rodin, Supriya G.
Mohile
Manuscript writing: Miriam B. Rodin, Supriya G. Mohile
Final approval of manuscript: Miriam B. Rodin, Supriya G. Mohile

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