EUROPEAN JOURNAL OF CANCER 4 6 ( 2 0 1 0 ) 1 0 1 9 –1 0 2 5

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journal homepage: www.ejconline.com

Review

Questionnaires and instruments for a multidimensional

assessment of the older cancer patient: What clinicians
need to know?
a,* a,b
A.G. Pallis , U. Wedding , D. Lacombe a, P. Soubeyran a,c
, H. Wildiers a,d

a
European Organization for Research and Treatment of Cancer, Elderly Task Force, EORTC Headquarters,
Avenue E. Mounierlaan, 83/11, B-1200 Brussels, Belgium
b
Univerity of Jena, Department of Haematology, Oncology and Palliative Care, Erlanger Allee 101, D - 07747 Jena, Germany
c
Institut Bergonié, Comprehensive Cancer Center, Bordeaux
d
Department of General Medical Oncology, University Hospitals Leuven, Belgium

A R T I C L E I N F O A B S T R A C T

Article history: Due to the ageing of the population in the Western world, a significant increase in the num-
Received 20 October 2009 ber of older patients diagnosed with neoplastic diseases is observed. Hence, there is an
Received in revised form 22 emerging need for tools to efficiently evaluate older patients’ functional and global status.
December 2009 These tools can allow treating oncologists to better select patients, to propose treatment
Accepted 6 January 2010 modifications, implement supportive measures and develop interventions to decrease
the risk of toxicity and in general better tailor the treatment plan on an individual level.
Currently significant uncertainty exists about the optimal tools and strategy for geriatric
Keywords: assessment, but on the other hand there is more than enough evidence that (some form
Older of) geriatric assessment detects many previously unrecognised problems, and allows direc-
Geriatric oncology ted intervention which can improve outcome and compliance of proposed treatments. In
Comprehensive geriatric the present paper, we discuss the most commonly used and studied tools for the assess-
assessment ment of functional status of older cancer patients.
Functional status  2010 Elsevier Ltd. All rights reserved.
Comorbidity
Cognition
Psychological status
Nutritional status

1. Introduction Western countries’ population, the number of older patients

with cancer is expected to increase within the coming
Cancer accounts for more deaths than heart diseases in the decades.2
Western world.1 More than 60% of diagnosed cancer cases Amongst older cancer patients of the same chronological
and more than 50% of cancer mortality are observed in people age there is a wide heterogeneity in physical and psychological
older than 60 years of age.1 Furthermore, due to ageing of the functioning. Ageing is a highly individualised process and all

* Corresponding author: Address: EORTC Headquarters, EORTC-ETF, Avenue E. Mounierlaan, 83/11, B-1200 Brussels, Belgium. Tel.: +32 (0)
2 774 10 62; fax: +32 (0) 2 774 35 45.
E-mail address: [email protected] (A.G. Pallis).
0959-8049/$ - see front matter  2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ejca.2010.01.006
1020 EUROPEAN JOURNAL OF CANCER 4 6 ( 2 0 1 0 ) 1 0 1 9 –1 0 2 5

the changes involved in this process cannot be predicted just fered only best supportive care or only single-agent palliative
on the basis of chronological age. In routine clinical practice, chemotherapy, while for the second category of patients,
the main characteristic of older cancer patients is heterogene- which is the biggest and the most challenging, individualised
ity. Some patients will tolerate chemotherapy as well as their approaches and specific clinical trials are recommended.20
younger counterparts, while others will experience severe tox- However, it should be noted that there are no prospective ran-
icity, requiring treatment reduction, treatment delay or perma- domised trials demonstrating a survival or QoL benefit for CGA
nent discontinuation, and others might be in a situation, where use in older cancer patients. The purpose of the present paper
the best treatment option is not to treat them with chemother- is to present the essential components of CGA, and to describe
apy. Thus, a major issue confronted by oncologists treating old- the most commonly used and studied tools to perform CGA.
er cancer patients is how to effectively select patients suitable
for chemotherapy at all, and if yes, whether to treat with stan-
dard protocols (standard dose and interval) or with adapted 2. Functional status
regimens. As a consequence, it is clear that there is an emerg-
ing need for developing tools to better evaluate a patient’s ‘bio- It has been reported that cancer has a negative impact on pa-
logical’ or ‘functional age’ rather than chronological age. tients’ functional status.21 In oncology, assessment of func-
Geriatric assessment is a well-established comprehensive tional status is based on the evaluation of Performance
approach for the evaluation of the older patient.3 It includes Status (PS), either measured via Karnofsky-performance Sta-
the evaluation of several domains: functionality, mobility/risk tus (KPS),22 or Eastern-Cooperative-Oncology-Group (ECOG) –
of falls, cognition, depression, comorbidity, polypharmacy, PS23 or WHO-PS while in the geriatrics, assessment of func-
social situation and geriatric syndromes. The value of this tional status includes evaluation of the patient’s ability to per-
assessment for the geriatric patient has been demonstrated form activities of daily life (ADL) and instrumental activities
by several studies. A meta-analysis of 28 controlled trials of daily life (IADL).24 ADL include activities that are essential
which demonstrated that Comprehensive Geriatric Assess- for a patient to maintain independence in the home and in-
ment (CGA) if linked to geriatric interventions reduced early clude ability to bath and feed one’s self, dress, maintain con-
re-hospitalisation and mortality in older patients through tinence, use toilet and transfer. The basic scale used for ADL
early identification and treatment of problems.4 assessment is the Katz scale25 or the Barthel scale.26 This
Geriatricians, more than oncologists, are focused on the scale is a good prognostic factor for one-year mortality follow-
patient’s ability of self care. They want to know the risk of ing hospital admission.27 Another study revealed functional
early re-hospitalisation, the area and need for support, when status as a stronger predictor of length of stay, mortality,
patients return to their home after hospitalisation for acute and nursing home placement than principal admitting diag-
medical problems or the need of institutionalised care, e.g. nosis.28 ADL dependence is less strongly associated with out-
nursing homes. Based on the data generated in CGA, they come in the studies of older cancer patients, probably due to
make decisions on treatment and intervention. the low proportion of older cancer patients with ADL depen-
The information oncologists want to receive from CGA is dence participating to oncology clinical trials.29 Additionally,
different. They want to know, whether the newly diagnosed older cancer survivors are more likely to report ADL depen-
cancer disease is limiting life expectancy of the patient or dence.30 IADL are more advanced self-care activities that in-
whether other comorbid diseases are determining the progno- clude the ability to prepare meals, do housework, use
sis quad vitam. They want to know, whether the patient will telephone, take medications, manage one’s finances and use
experience major symptoms of the disease, causing deteriora- transportation means.31 In cancer patients, IADL dependence
tion of his health-related quality of life. Finally they want to has been associated with poorer survival in patients with lung
know, whether the patient will tolerate treatment (chemother- cancer 12 and in patients with acute myeloid leukaemia,32 risk
apy, radiotherapy, surgery or multimodal treatment) without of chemotherapy toxicity in patients with ovarian cancer10
major toxicity and deterioration of health-related quality of and postoperative complications.14
life, and without inducing treatment-related mortality. Discordance between direct functional assessment and
Specifically for cancer patients CGA has proven to be feasi- questionnaire-based assessment has been reported.33 For
ble5,6 and the information obtained is additional to just chro- that reason, some tools for direct functional assessment were
nological age and Performance Status (PS).7 Additionally it constructed. Commonly used tools include the ‘Timed Up and
detects more older cancer patients as being unfit for chemo- Go’ tool (measures speed during several functional manoeu-
therapy than physicians’ judgement.8 Several studies have vres, which include standing up, walking, turning and sitting
proven its value as a predictive tool for changes of quality of down),34 the ‘6-min walk test’, which has been proposed as a
life (QoL),9 severe toxicity10, early termination of treat- single measurement tool of functional status for older pa-
ment,11,12 postoperative morbidity13,14 and survival.10 Results tients35 and the Tinetti test which has been widely used in
of CGA changed treatment plans in a group of patients with the elderly to assess mobility, balance and gait.36 ADL and
breast cancer.15,16 According to CGA results, the patients are IADL dependence were associated with poorer survival in a
categorised into three groups for treatment decisions; (a) fit prospective study including oncological patients aged
patients, (b) vulnerable patients and (c) frail patients. Patients 70 years and older presented by Honecker and colleagues dur-
in the first group are good candidates for almost every form of ing previous ASCO meeting37 and in haematological patients
cancer treatment as they tolerate anti-cancer treatment as aged 70 years and older presented by Wedding et al. during
well as their younger counterparts with similar outcomes in previous ASH meeting.38 Frequently used tools for assess-
terms of survival.17–19 Patients in the last group are usually of- ment of functional status are presented in Table 1.
 EUROPEAN JOURNAL OF CANCER 4 6 ( 2 0 1 0 ) 1 0 1 9 –1 0 2 5 1021

Table 1 – Instruments used for functional assessment. Table 2 – Tools used for comorbidity assessment in older
cancer patients.
Scale
Scale
Activities of
Daily Life (ADL) – ability to bath Charlson Comorbidity A weighted index that takes
(Katz scale25) Index (CCI)50 into account the number and
– feed one’s self the seriousness of comorbid
disease; a score > 5 is
– dress considered high and is
usually associated with poor
– maintain continence prognosis
Cumulative Illness Rating Classifies comorbidities by
– use toilet Scale-Geriatric (CIRS-G)51 organ systems (13 or 14
according to the version) and
– transfer grades each condition from 0
Instrumental (no problem) to 4 (severely
Activities of – prepare meals incapacitating or life-
Daily Life (IADL)31 threatening condition)
– do housework The Adult Comorbidity Measures the severity of
Evaluation (ACE-27)41 comorbidity based on 26
– use telephone disease systems; each
condition is graded with a 3-
– take medications category severity system
(mild, moderate, severe)
– manage one’s finances and

– use transportation means

nitive disturbances do influence the way of diagnosis and the
‘Timed Up Measures speed during several
and Go’34 functional manoeuvres, treatment of older patients with cancer.56,57 Old patients with
which include standing up, walking, cancer of large intestine and dementia had fewer chances to
turning and sitting down have a histological confirmation of their disease, to have cura-
‘6-min walk test’35 Measures the distance walked during tive surgical therapy and they were less likely to receive adju-
a 6-min time period vant treatment.56 Similarly old patients with breast cancer
and Alzheimer’s disease were less likely to be given curative
3. Comorbidity surgery and to receive chemotherapy and radiation,57 while
moreover their survival was considerably shorter.58 Further-
Comorbidity is a frequent problem in older cancer patients more, the presence of dementia is associated with the nega-
and is a competing source for mortality in older cancer pa- tive impact on survival.59,60
tients.6 These comorbid medical conditions may often lead Cognitive function has obviously significant impact on the
to death from causes other than cancer, thus nullifying any patient’s compliance with treatment. Patients with memory
possible benefit of treatment. Comorbidity has a negative im- impairment will have problems to understand and follow
pact on survival in cancer patients11,39–45 and on treatment treatment instructions.
tolerance,46,47 although this observation has not been con- Several tools have been developed for the assessment of
firmed by other studies.48 De Groot and colleagues reported dementia (Table 3). These include the Mini Mental State
in a systematic review 13 different methods to evaluate Examination,61 the Blessed Dementia Rating Scale,62 the
comorbidity,49 but usually the number and the severity of Short Portable Mental Status Questionnaire63 and the Demen-
comorbid diseases are evaluated with questionnaires such tia Detection Test.64 Other screening cognitive tools are the
as Charlson Comorbidity Index (CCI),50 the Cumulative Illness Mini-Cog instrument65 and the ‘Clock Drawing Test’.66 All
Rating Scale-Geriatric (CIRS-G)51 and the Adult Comorbidity these tools are screening tools and an abnormal test does
Evaluation (ACE-27)41 (Table 2). Furthermore, comorbid dis- not diagnose dementia, but requires further evaluation. Fur-
eases also lead to polypharmacy and increased use of medica- ther studies are required for defining the most optimal scale
tions which can lead to drug-drug interactions and increased for a particular patient and a particular end-point (e.g. sur-
treatment-related toxicity in the older cancer patients.52,53 vival, toxicity, quality of life).
Most guidelines for drug treatment of chronic diseases in old-
er patients do not reflect how to prioritise treatment in the 5. Psychological status
situation of multiple chronic diseases.54
Another important issue when evaluating an older cancer pa-
4. Cognition tient is the presence or not of depression. Up to 50% of older
patients have been found to have some depressive symp-
Dementia is characterised by a progressive loss of thinking toms7,16 and the depression has been associated with poorer
operations, such as loss of memory, the function of retraction survival.67 In a similar way, symptoms of depression were
and recognition for verbal and optical information and lan- associated with poorer progression-free survival, overall sur-
guage fluency.55 Two big epidemiologic studies prove that cog- vival and toxicity in older women with ovarian cancer treated
1022 EUROPEAN JOURNAL OF CANCER 4 6 ( 2 0 1 0 ) 1 0 1 9 –1 0 2 5

Table 3 – Tools for assessment of cognitive status. Table 4 – The Geriatric Depression Scale.
Scale Geriatric Depression Scale (GDS)

Mini Mental State Questions are grouped into seven Evaluation of risk of depression. Several versions
Examination61 categories, each representing a available (GDS 30, 15, 4 item)
different cognitive domain or Interpretation of results:
function (orientation to time, Scoring system for the GDS 15-item
orientation to place, repetition of
words, attention, calculation, – Range 0–15
recall of words, language and
visual construction). It has a – Interpretation scores
maximum score of 30 points. • 0–5: no depression
(Patients with scores lower than • 6–15: possible depression
23 points are considered as
dementia suspects).
Blessed Dementia It assesses patient’s changes in
Rating Scale62 three domains: in performance of
day-to-day activities, in habits
and in personality, interests, drive Table 5 – Nutrition assessment.
One point is scored for each Mini-Nutritional Assessment Questionnaire
question with higher scores
representing more severe Exists in 2 parts: a screening part and a more
problem. A score of 15 or higher extensive part in case screening were positive.
represents a moderate to severe
functional impairment – Scoring for the screening part:
Short Portable 10-Item questionnaire that
Mental Status assesses orientation, memory, – Range 0–14
Questionnaire63 attention, calculation and
language – Interpretation score
Mini-Cog Combination of two simple
instrument65 cognitive tasks (three-item word – 12 or more: no risk
memory and clock drawing)
– 11 or less: risk of malnutrition
Scoring for the global score:
(1) Degree score < 17: malnourished
with platinum-based regimens,10 while in patients with colo-
(2) Degrees score > 17 and 6 23,5: at risk of malnutrition
rectal cancer the depression was associated with higher 30-d (3) Degrees score P 24: well-nourished,
postoperative morbidity.14 Additionally, depression has an with a maximum of 30 points
impact on the treatment administered to patients. A large
study of 24,696 older breast cancer patients in the Surveil-
lance, Epidemiology and End Results (SEER)–Medicare data- patients to identify risk of malnutrition has been recom-
base (ages 67–90 years) revealed that less-than-definitive mended by many national, international and specialist organ-
treatment was offered to women with a recent diagnosis of isations.78 The most commonly used screening tool for
depression and these women also experienced worse sur- nutritional status is the Mini-Nutritional Assessment (MNA)
vival.68 The most widely used tools for depression assessment questionnaire; it is a non-invasive and validated question-
in the older cancer patients are the Geriatric Depression Scale naire to evaluate nutritional status in elderly people (Table 5),
(GDS)69 (Table 4) and the Beck Depression Inventory (BDI)70 classified in three groups: malnourished, at risk of malnutri-
and for demented patients the Cornell Scale for Depression tion and well-nourished.79
(CSDD).71
7. Two-step approach for geriatric assessment
6. Nutritional status (selection of patients with screening test)

In the general geriatric population, low Body Mass Index (BMI) A major concern is the feasibility of implementing CGA in
is associated with an increased risk of mortality.72,73 Nutrition every day’s clinical practice. The CGA approach combines a
is a major issue in cancer patients and nutritional decline in variety of assessments and questionnaires and it is a time
these patients may result from both disease course and its and man-power-consuming procedure, not reimbursed by
treatment.74 Malnutrition in cancer has a negative prognosis, health systems, explaining why it is often not used in routine
and it has an impact on both response to anti-cancer treat- clinical practice. Because of these difficulties in the use of
ment and patient overall survival and influences Health-Re- CGA in every day’s clinical practice, several shorter screening
lated Quality of Life (HRQoL).75 Nutritional status is a tools have been developed. These screening tools are used to
predictor of long-term survival in non-small cell lung cancer select patients with impairment who need further multidisci-
(NSCLC) patients treated with lobectomy,76 while nutrition plinary evaluation. However, none of these screening tools
intervention has been shown to improve outcomes in NSCLC has been prospectively validated using full-CGA as gold-
patients treated with chemotherapy.77 Routine screening of standard.
 EUROPEAN JOURNAL OF CANCER 4 6 ( 2 0 1 0 ) 1 0 1 9 –1 0 2 5 1023

In routine clinical practice, it is probably much more cost- workshop was held under the auspices of EORTC with the
effective and practical to use a simple screening test in all participation of 23 oncology and ageing specialists through-
cancer patients aged 70 years or more. This allows to identify out Europe, and five representatives from EORTC. Main topics
the proportion of patients who are fit and where complete discussed were blockage for clinical trial development in old-
CGA would not identify relevant age-related problems. This er patients, clinical trials end-points and geriatric assess-
allows focusing the efforts on the smaller group (those with ment. There was a consensus for use of a minimal dataset
a positive screening) where the yield of geriatric assessment data collection in the older with the use of G8, IADL, social sit-
will be much larger. uation and Charlson Comorbidity Index. Several groups are
The vulnerable elders survey-13 (VES-13) is a self-adminis- addressing these issues in clinical trials and a uniform ap-
tered questionnaire that consists of 12 items for functional proach should be implemented across different institutions
capacity, physical status and patient’s perception of his that will allow a common language and reproducible assess-
health and one question for age.80 In a pilot study, VES-13 ments in various settings.
accurately identified elderly prostate cancer patients who
were defined as having impairment by CGA. Conflict of interest statement
The G8 questionnaire is a very simple screening tool,
which includes seven Mini-Nutritional Assessment items None declared.
and age (<80, 80–85, >85), for a total score ranging from 0 (poor
score) to 17 (good score).81 In an exploratory study of 364 can-
cer patients older than 70, with a cut-off score of 14, G8 had
Acknowledgements
90% sensitivity and 60% specificity. This cut-off is now pro-
spectively being validated in a large Nation-wide French study
This publication has been supported by a fellowship (AGP)
(Oncodage).
provided by ‘Fonds Cancer (FOCA)’ from Belgium.
Overcash and colleagues developed an abbreviated CGA
with only 15 items.82 These 15 items include three questions
about ADLs, four questions about IADLs, four questions from
R E F E R E N C E S
the MMSE and four questions from the GDS. Correlations ran-
ged from 0.84 to 0.96 for the entire CGA and the abbreviated
CGA. Röhrig and colleagues confirmed the same items of
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