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© 2002 American Society for Clinical Oncology Comprehensive Assessment of the Elderly Cancer Patient: The Feasibility of Self-Report MethodologyByFrom the Department of Radiation Oncology, Department of Medicine, Divisions of Medical Oncology and Geriatrics, School of Nursing, and Center for the Study of Aging and Human Development, Duke University Medical Center; Department of Radiation Oncology and Geriatric Research Education and Clinical Center, Veterans Affairs Medical Center; and Institute on Care at the End of Life, Duke University, Durham, NC. Address reprint requests to Sally Sockwell Ingram, MD, Box 3085, Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710; email: ingram{at}radonc.duke.edu
PURPOSE: Comprehensive geriatric assessment (CGA) has aided the medical community greatly in understanding the quality-of-life issues and functional needs of older patients. With its professional team assessment approach, however, CGA may be time consuming and costly. The goal of the present study was to assess the ability of cancer patients to complete a self-administered CGA and then to characterize cancer patients across multiple domains and age groups. PATIENTS AND METHODS: Two hundred sixty-six male outpatient oncology patients at the Durham Veterans Affairs Medical Center were asked to fill out a survey assessing 10 domains (demographics, comorbid conditions, activities of daily living, functional status, pain, financial well being, social support, emotional state, spiritual well-being, and quality of life). RESULTS: Seventy-six percent of the patients who received their surveys and kept their appointments returned the assessment tool. Older oncology patients had significantly less education (P < .0001), income (P = .05), frequent exercise (P = .01), and chance of being disease free (P = .003) than younger patients. Other findings in older patients were a higher rate of marriage (P = .02), more difficulty in taking medications (P = .05), and less cigarette (P = .03) and alcohol (P = .03) use. Members of all age cohorts reported a sense of social support, with younger patients deriving this more from family and friends than older patients, and older patients deriving social support more from membership in religious communities than younger patients. No differences were found across age groups for number and impact of comorbid illnesses, number of medications, basic and instrumental activities of daily living, pain, overall health rating, financial adequacy, anxiety, depression, and quality of life. CONCLUSION: CGA can be conducted in an outpatient cancer community using a self-report format. Despite the fact that this population varied demographically across age groups and is limited to veterans, this study demonstrated remarkable similarities between younger and older cancer patients in terms of functional status, health states, and quality of life.
SIX OF EVERY 10 cancer cases in the United States are detected in persons older than 64 years of age, a group that will represent 20% of the population in the United States by the year 2050.1 Appropriate assessment of geriatric cancer patients thus is becoming increasingly important. How can they effectively and efficiently be assessed in the outpatient clinic setting? During the last 15 years, geriatricians have developed and validated an approach to care for the elderly called comprehensive geriatric assessment (CGA). CGA measures topics pertinent to seniors, such as comorbid illnesses, living circumstances, social support systems, polypharmacy, and functional, mental, and nutritional states. Balducci and Extermann2 reported the use of CGA to evaluate patients in their Senior Adult Oncology Program. In one cohort of community-dwelling older cancer patients, they discovered that 72% were deficient in one or more instrumental activities of daily living (IADLs), such as dialing the phone or cooking a meal. Nineteen percent were malnourished, and 22% had memory disorders. This information, revealed by CGA, likely would have been missed otherwise. Furthermore, in a meta-analysis of controlled trials of CGA use, Stuck et al3 showed CGA management programs to have significant effects on reducing mortality, increasing physical and cognitive function, and preserving the living location of seniors. CGA can take up to 1.5 hours and is generally carried out in person by trained professionals. Often patients are assessed longitudinally and also with self-administered questionnaires.4,5 This team approach is labor intensive and expensive. A self-administered instrument that is comprehensive yet patient-friendly might offer significant advantages for the collection of such data. With a goal of ultimately improving care for older cancer populations, we attempted to assess the ability of cancer patients to complete a comprehensive assessment tool in their own homes and return the surveys during follow-up clinic appointments. An additional goal was to profile this geriatric cancer population.
Study Population Cancer patients were identified from outpatient medical oncology and radiation oncology clinics at the Durham Veterans Affairs Medical Center (DVAMC) in North Carolina for inclusion in this quality-improvement project. Patients were accrued from November 1999 through April 2000. A total of 266 consecutive patients had initial consultations or follow-up appointments scheduled during this time. A letter of introduction to the study and a copy of the survey were mailed to each patient 2 weeks before his or her scheduled appointment. Patients were asked to complete the survey and return all materials to clinic staff during the upcoming visit. No additional help in filling out questionnaires was provided. The information was to be reviewed by the clinicians and used as needed in patient management.
Components of the Assessment Tool
Statistical Methods
Of the 266 patients to whom surveys were given, 171 returned them. However, 15 patients who returned their surveys were found ineligible because they lacked a cancer diagnosis. Forty-five patients neither returned the questionnaire nor appeared for their appointments. Of the remaining 206 patients, 50 patients kept their clinic appointments but failed to return the questionnaires. Therefore, two response rates were observed. The absolute survey response rate to the initial mailing with no additional follow-up was 171 (64%) of 266. For patients who actually attended clinic with a cancer diagnosis, the response rate was 156 (76%) of 206. Because of the constraints of this quality-enhancement effort, surveys from patients who did not keep their appointments or from those who did not bring the survey with them were not pursued further. Reasons for nonparticipation were not elicited. Patient characteristics are listed in Table 1. The respondents to this survey all were male. The mean age was 68 years and the mean educational level was the 11th grade. Sixty-four percent of respondents were married; twenty-two percent lived alone. Slightly more than half of the patients (52%) lived on annual incomes near the poverty level, with 27% having no health insurance besides veterans benefits. Characteristics differed significantly across age categories. Older patients were more likely to be married (P = .02), with a 48% marriage rate in patients younger than 65 years, a 73% rate in patients 65 to 74 years, and a 68% rate in patients older than 74 years. Older respondents also had significantly fewer years of schooling (P < .0001) than the younger cohort. The middle-age cohort was significantly more likely to make more than $18,000 per year compared with respondents aged younger than 66 years or older than 74 years (P = .05). Fewer patients in the oldest group tended to smoke cigarettes (P = .03) and consume alcohol (P = .03). There was no difference in the percentage of people living alone across different age groups.
Tumor characteristics are presented in Table 2. Prostate cancer was the most common diagnosis (47% of all cases), followed by neoplasms of the head and neck (19%) and lung (12%). Mean time since diagnosis was 3.3 years, with average cancer stage II at initial diagnosis. At the time of the study visit, 82% of the patients were thought to have no evidence of active disease. Older patients were more likely to have active disease than were younger respondents (P = .003). The younger respondents received a greater number of treatments before this evaluation (P = .01).
Table 3 lists the results of seven areas of health and functional status assessed. Respondents took an average of five medications daily. Although there was no difference in medication use across different age groups, there was a trend toward significantly greater difficulty taking medications in the oldest patient cohort (P = .05). The mean number of comorbid conditions per patient was five, with these conditions having a moderate impact on daily life (mean, 12; range, zero to 39). Again, there was no significant difference in either the number or impact of comorbid conditions across age groups. The mean ADL score was 59 (range, 0 to 100), and the mean IADL score was 9.3 (range, 7 to 21). Sixty-nine percent of patients were dependent in at least one ADL, whereas 58% were dependent in one or more IADL. These data indicate substantial difficulty in the performance of both basic ADL and IADL. A high level of daily exercise, equivalent to walking a mile without resting three times per week or more or participating in aerobic exercise 3 times per week or more, was reported by 45% of the patients in this survey. There was a statistically significant difference regarding vigorous exercise. Fewer older patients (aged > 74 years) performed this high level of exercise weekly than did younger patients (P = .01). When asked about the worst pain experienced in the previous week, the mean score for all respondents was 4.2 (scale, 0 to 10), with no age difference noted. Finally, 76% of patients reported their health to be fair or poor. When asked about health changes over the previous year, one third reported that their health had declined, whereas 16% reported better overall health. Health perception, as measured with these two parameters, did not show any age differentiation.
Results from the five instruments used to assess quality of life are shown in Table 4. The mean global EORTC-QLQ score was 51 (range, 0 to 100), reflecting compromised quality of life in these cancer patients. Yet there were no differences across age groups globally or in each subscale of the EORTC (symptoms, physical functioning, financial impact, role functioning, emotional functioning, or social functioning). On evaluation of emotional state, 32% of the respondents screened positive for anxiety and 26% screened positive for depression. Again, no significant differences or trends were seen across age groups. The mean financial well-being scores were 6.0, 6.1, and 6.1 (range, 3 to 9) for age groups younger than 65 years, 65 to 74 years, and older than 74 years. This indicates a similar level of financial difficulty for all patients despite the fact that respondents older than 75 years had a significantly lower income than the others (P = .05). In this study, information on perceived social support was derived from two measures, the MOS9 and the SOBI.11 The MOS measures perceived support from family and friends. The SOBI measures perceived support related to being part of a religious community. Although respondents younger than 75 years had the highest MOS scores, older patients scored significantly higher in social support on the SOBI (P = .03).
This report demonstrates the feasibility of obtaining comprehensive assessment information using a mailed, self-administered instrument from elderly cancer patients who attend an oncology clinic. Both the absolute survey response rate (64%) and the clinic attendee response rate (76%) are comparable to the literature on mailed survey responses. Smith et al16 used a self-administered survey to assess quality of life in 2,234 men treated for prostate cancer. All surveys were mailed, and 74% were returned. Langendijk et al17 evaluated quality of life longitudinally in patients with non–small-cell lung cancer. After the initial in-clinic evaluation, 79% of the nondeceased patients responded to mailed follow-up surveys. The response rates reported here are particularly encouraging given that the mean educational level of our patients was the 11th grade, 22% of patients lived alone, and 52% of patients lived with annual household incomes of less than $18,000. Furthermore, patients received only one mailing of the explanation letter and 24-page survey. The letter simply requested that the form be filled out and brought back to the clinic. No attempts at collecting additional information were made. Higher response rates would likely be obtained with some follow-up prompting. A characteristic aspect of the patients reported here is that they are veterans. Patients served by the veterans health-care system typically are sicker, poorer, and less well educated than patients served outside the system.18-21 Our patients were similar to other comprehensively assessed veterans populations. For example, 72% of the patients in this study received no more than a high school diploma, similar to that of a New England veteran population of 1,667 patients, in which Kazis et al21 reported 58% of patients to have no more than 12 years of education. Similarly, 52% of our patients were living on less than $18,000 annually. In the study by Kazis et al, 52% of the population was living on less than $20,000 per year. Our patients reported 5.4 comorbid illnesses each, similar to the 5.8 comorbid conditions reported by patients in the study by Kazis et al. The percentage of patients in our study who were married increased significantly by age. Specifically, 48% of our respondents younger than 65 years were married, 73% of those aged 65 to 74 years were married, and 68% of those older than 74 years were married. Kazis et al demonstrated the same increase by age, with 42% of patients older than 50 years, 54% of patients 50 to 64 years, and 65% of patients older than 65 years being married. This suggests, at the very least, that these study results may generalize well to gero-oncology patients throughout the 173 facilities in the Veterans Affairs hospital system. The information gathered here also characterizes this population as comparable to other nonveteran geriatric oncology cohorts. Information about comprehensive assessment in oncology patients is available from three groups, Extermann and Aapro4 in Florida, Monfardini et al22 in Italy, and Velikova et al23 in New Mexico. In each case, assessments were administered by trained health professionals based in centers dedicated to geriatric oncology. Despite the difference in information gathering techniques, the samples are remarkably similar. Cancer types among males in these studies were comparable, with prostate, lung, and head and neck cancers most common. The incidence of depression also was similar across the study groups. In the present study, 26% of the participants screened positive for major depressive symptoms with the Hospital Anxiety and Depression Scale inventory. Velikova et al24 found 24% of their patients to be depressed using the Geriatric Depression Scale, a figure nearly identical to the 26% incidence of positive screens reported by Extermann and Aapro4 using the Geriatric Depression Scale. Dependence in ADLs was prominent and also consistent with previous research. Fifty-eight percent of our population was dependent in one or more IADLs, as was 56% of the population in the study by Extermann and Aapro4 and 56% of the population in the study by Velikova et al.23 This information suggests that strong similarities exist across various oncology populations and that comprehensive assessment data can be adequately retrieved through a self-assessed format. CGA derives from the idea that older individuals may represent as unique a cohort of patients, as do children, for whom an entire discipline (pediatrics) exists. Data from early inpatient and outpatient geriatric evaluation and management programs show increases in functional status, health perception, and survival among elderly persons involved in such programs. A national, multisite trial of CGA and follow-up management was therefore started in 1995.24 Over 3.5 years, 1,388 patients were enrolled onto the study. Participants were randomized to receive either outpatient specialized geriatric care, inpatient geriatric specialty care, both, or neither (these patients received routine adult care without the CGA and management approach). Patients cared for by either the outpatient or inpatient geriatric specialty teams demonstrated a significantly higher quality of life than those cared for by nonspecialty clinics. Outpatient geriatric specialty care also resulted in significant decreases in patient fatigue, whereas inpatient CGA and management resulted in significant increases in patient physical function, basic ADLs, pain control, and energy level. Neither resulted in increased survival, however, compared with the patients who received routine adult care.24 Research to better define the dimensions and biologic parameters of frailty may allow better focus of such programs on issues of importance to the older cancer patient.25-27 There is no doubt that specialized geriatric evaluation and management will continue to evolve. The information gained is clearly helpful with individual patient care and to patient outcome. In this era of increasing cost control, however, it may not be possible to offer CGA with a personalized on-site specialty team. We were able to demonstrate that comprehensive data can be collected from self-report, even in low socioeconomic populations. It is for this reason that we recommend additional evaluation of self-assessment instruments. The collection of large amounts of data, which can then be verified by the health team, would seem to be an efficient approach to characterizing and treating this patient population. This may therefore be an effective mechanism for bringing the important methodology of geriatric assessment to the older population with cancer. Clinical trials will need to additionally define the actual impact of CGA on outcomes in elderly cancer patient populations.
R.E.M. and this project were supported by National Institutes of Health (NIH) grant no. 1K08AG/CA00915-01 and by a Young Investigator Grant from the NIH Claude D. Pepper Center of Excellence Research Core. P.H.S. is supported by a John A. Hartford Foundation geriatric oncology fellowship.
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Aaronson NK, Ahmedzai S, Bergman B, et al: The European Organization for Research and Treatment of Cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 85: 365-376, 1993 10. Fillenbaum GG, Smyer MA: The development, validity, and reliability of the OARS Multidimensional Functional Assessment Questionnaire. J Gerontol 36: 428-534, 1981 11. Reuben DB, Laliberte L, Hiris J, et al: A hierarchical exercise scale to measure function at the advanced activities of daily living (AADL) level. J Am Geriatr Soc 38: 855-861, 1990[Medline] 12. Duke Pain Initiative: Adult Pain Scales: Thermometer. Pain Management Reference Cards. Durham, NC, Duke University Medical Center, 1999 13. Sherbourne CD, Stewart AL: The MOS social support survey. Soc Sci Med 32: 705-714, 1991 14. Zigmond AS, Snaith RP: The hospital anxiety and depression scale. Acta Psychiatr Scand 67: 361-370, 1983[Medline] 15. Holland JC, Kash KM, Passik S, et al: A brief spiritual beliefs inventory for use in quality of life research in life-threatening illness. Psychooncology 7: 460-469, 1998[CrossRef][Medline] 16. Smith DS, Carvalhal GF, Schneider K, et al: Quality-of-life outcomes for men with prostate carcinoma detected by screening. Cancer 88: 1454-1463, 2000[CrossRef][Medline] 17. Langendijk JA, ten Velde GP, Aaronson NK, et al: Quality of life after palliative radiotherapy in non-small cell lung cancer: A prospective study. Int J Radiat Oncol Biol Phys 47: 149-155, 2000[CrossRef][Medline] 18. Knight SJ, Schmiel JS, Kuzel T, et al: Quality of life in metastatic prostate cancer among men of lower socioeconomic status: Feasibility and criterion related validity of three measures. J Urol 160: 1765-1769, 1998[CrossRef][Medline]
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Copyright © 2002 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2 analysis evaluated categorical variables, and Cochran-Armitage tests determined trends. For continuous variables, analysis of variance was used to examine differences between age groups and to determine linear trends. 
