Comparison of two frailty screening tools in older women with early breast cancer
Introduction
Over 25% of centenarians are autonomous in all 6 basic activities of daily living. However, for a large majority of older adults, the gradual deterioration in physical and functional status that occurs with aging may decrease independence and can result in premature death.
In Spanish populations, frail elderly individuals account for between 10% and 20% of patients over 65 years of age [1] and up to 46% of patients over 85 years of age [2], although these values are highly dependent on the criteria used to define frailty and the type of community being studied.
The term “frailty” is highly controversial. The concept is used in a broad sense to describe a state of high vulnerability to adverse health events [3]. The term was often used in medical literature in the 1980s, but its meaning is not well defined. The term frailty has the following connotations: being dependent on others, having substantial risk for developing or currently having multiple health problems, gradually losing “functional reserve”, having chronic diseases that are both medically and psychosocially complex and having “atypical” forms of disease presentation. This population could benefit from specialized geriatric programs. It is highly debated and not decided whether frailty is reversible.
Several studies have shown that frailty has serious prognostic implications, which are reflected by the higher incidence of disability, the higher rate of hospitalization and the greater number of prescription drugs used. Together, these prognostic factors result in the imposition of higher financial and caregiving burdens [4], [5].
To date, there is a lack of consensus concerning the definition of this concept among the elderly. For some authors, the coexistence of certain clinical conditions is the hallmark of frailty, while for others, it is the lack of independence in activities of daily living and the need for institutional care that define the term. Fried et al. hypothesized that frailty is a wasting syndrome characterized by weakness, lack of strength, low energy, physical sluggishness and a low activity level. In this work, the authors reported that the presence of these factors predict an early death [6]. Fried et al. developed an operational definition of frailty based on the presence of at least 3 of 5 criteria: unintentional weight loss (more than 4.5 kg), exhaustion weakness (≤20th percentile by force dynamometer), low physical activity (≤20th percentile in kcal/week adjusted for gender) and slowness (≤20th percentile in the time taken to walk 5 m). In this study, the cumulative mortality rates at 3 years were 3% and 18% in groups of patients without and with frailty, respectively. Further, the deterioration in ability to perform activities of daily living (ADL) 7 years after initial assessment were 23% and 63% and the rates of emergence of first decline at 3 years were 15% and 28%, respectively.
Recently, members of the Study of Osteoporotic Fractures Research Group have attempted to determine whether the CHS index devised by Fried and used thus far to define the syndrome of frailty in the elderly, could be replaced by a simple index with comparable predictive value, the SOF (Study of Osteoporotic Fractures). The SOF consists of only 3 components: intentional or unintentional weight loss of 5% or more, ability to lift oneself from a chair 5 times without using one's arms, and self-reported reduced energy level (answer to the question “Do you feel energetic?”). Older women who do not exhibit any of these 3 components are described as “not fragile”, those exhibiting 1 component are described as “pre-frail”, and those exhibiting all 3 components are considered “fragile”. The study concluded that the SOF index, which is a simplified method for determining frailty in the elderly due to its use of only three components, predicted the risk of falls, disability, fractures and death with the same efficiency as the CHS index, which is a more complex index using five components [7].
In oncology, many treatments are aimed at improving survival, autonomy and quality of life for patients, without a curative intent. Such treatments must be chosen appropriately, as their therapeutic indices (i.e., the window wherein people benefit without experiencing unacceptable side effects) may be low. Recently, research in oncology has begun to elucidate the factors that influence the ability of one's body to return to a state of homeostasis after the stress of chemotherapy treatment or aggressive surgical intervention [8].
Although there is no clear universal definition of frailty [9], [10], [11], [12], it is generally thought that the inability to engage independently in basic activities of daily living, which include bathing, continence, feeding, transferring, toileting and dressing is synonymous with frailty [13]. Indeed, research in this population suggests that loss of independent functioning in these areas signals the inability to accommodate circumstances that involve stress, even mild stress [13]. Dependence in instrumental activities of daily living, or core activities, is associated with increased mortality [14]. In addition, dependence on some instrumental activities predicts the development of dementia [15] and an increased risk of toxicity associated with chemotherapy [11].
From the literature on frailty, two points are evident. First, while frailty results in a dramatic change in functional status, this change progresses in a chronic fashion. Second, the median survival of a fragile patient is decreased by 2 years [16]. Frail elderly cancer patients need effective palliation, which may include low-dose chemotherapy [13].
Given the ambiguity of the definition of frailty, many have proposed a set of scales and screening items that aim to achieve a better definition and more accurately quantify this syndrome. In addition, because a full Comprehensive Geriatric Assessment (CGA) is time consuming, these screening tests permit the identification of patients who may benefit from a full CGA. It is unclear which index yields the best definition of the term ‘frailty’ and hence is preferable for use in research.
Of the screening tests currently in use, the Vulnerable Elderly Survey (VES-13), the Timed Up and Go Test, the 7-item physical performance test and the Barber Questionnaire are the most widely used. The VES-13 assesses age, functional status and activity. If the score is equal to or greater than 3, there is an increased risk of functional impairment and the patient would likely benefit from the implementation of a full CGA [17]. The VES-13 is a self-administered survey consisting of 1 item relating to age and 12 additional items relating to self-perception of health status, functional ability and physical fitness [17], [18]. The test “Timed Up and Go” consists of measuring the time required for an elderly person to get up, take a few steps, turn around and sit down again. The CGA is applied for patients who require more than 10 s to perform the exercise, use their arms to get up or make a wrong turn [19], [20]. Of all of the described instruments, the Barber Questionnaire was created in England in the early 1980s, initially as a postal questionnaire, with the intent to identify elderly persons at risk for dependence [21], [22]. Other authors have subsequently modified the questionnaire with regard to both the content and the route of administration. It is currently the most widely used questionnaire in Spain for the identification of at-risk elderly [23]. It consists of 9 questions. The result is considered positive if a patient answers yes to one or more of the questions. The questionnaire is often used as a screen (by questionnaire) that identifies people at risk or as a further evaluation in order to inform intervention efforts. Its major applications are in the elderly.
Section snippets
Study population
In this cross-sectional, observational study in design, women greater than 65 years of age with early breast cancer, were eligible. Patients were enrolled from January 1, 2007, to December 31, 2007, at the University General Hospital in Elche prior to commencement of chemotherapy. Patients were enrolled in a consecutive manner.
Inclusion criteria (patients must meet all criteria)
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Age greater than 65 years.
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Not admitted to the hospital at the time of enrollment.
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New diagnosis of non-metastatic breast cancer that was histologically confirmed in the
Characteristics of patients enrolled in the study
The group consisted of 41 patients, all of whom were female. The average age at diagnosis was 74.5 years, with a range of 66.5–87.5 years. Half of the population was between 75.32 and 82.18 years of age. The majority of the patients (78%) were over 70 years of age.
Of the sample, 78% were married and 17.2% were widowed. Regarding education, 68.3% did not surpass elementary educational level, only one of them had a school diploma and there were nobody with university studies (Table 2).
Descriptive study of tumor characteristics and treatment
The most
Discussion
The elderly are a heterogeneous group. The spectrum of impairment can range from those who are independent to those who have a moderate risk of health deterioration (vulnerable) to those at risk of functional impairment or death (fragile) [17], [38]. The frail elderly and those at greatest risk of frailty have reduced functionality and physiologic reserve, which lead to an increased likelihood of progressive deterioration, loss of function and adverse health events.
In a recent study that
Conclusions
The usefulness of the Barber Questionnaire to screen the elderly population for risk has been questioned. Few studies have analyzed the validity of frailty screens [21], [22], [57]. Only two have been assessed in the Spanish population [23], [58] and none of them have been validated for populations with cancer.
From the results of our study, the Barber Questionnaire does not seem to be useful in identifying frailty in women over 65 years of age with non-metastatic breast cancer before
Conflict of interest
The authors declare that they have no conflicts of interest.
Reviewers
Miriam B. Rodin, MD, PhD, The University of Chicago, Section of Geriatrics, MC 6098, 5841 S Maryland Ave W-700, Chicago, IL 60637, United States.
Catherine Terret, MD, PhD, Centre Léon Bérard, Department of Medical Oncology, 28, rue Laënnec, F-69373 Lyon cedex 08, France.
Martine Extermann, MD, PhD, H Lee Moffitt Cancer Center USF, 12902 Magnolia Drive, Tampa, FL 33612, United States.
M.J. Molina-Garrido studied medicine at the University of Murcia and received her medical degree in 2001. She is a Specialist in Medical Oncology and also holds a Diploma in Geriatry in the Autonoma University of Barcelona. She is going to complete a Master in Geriatry and Gerontology in the University of Barcelona. In 2006 she finished her training as an Oncologist (General University Hospital in Elche, Alicante) and now concentrates on geriatric assessment and frailty in elderly cancer
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Cited by (0)
M.J. Molina-Garrido studied medicine at the University of Murcia and received her medical degree in 2001. She is a Specialist in Medical Oncology and also holds a Diploma in Geriatry in the Autonoma University of Barcelona. She is going to complete a Master in Geriatry and Gerontology in the University of Barcelona. In 2006 she finished her training as an Oncologist (General University Hospital in Elche, Alicante) and now concentrates on geriatric assessment and frailty in elderly cancer patients. She is the main author of many abstracts in national, international and mundial congresses about Geriatric Oncology.
C. Guillen-Ponce studied medicine at the Autonoma University of Madrid and received her medical degree in 1999. She is a Specialist in Medical Oncology and holds a Diploma in Geriatry in the Autonoma University of Barcelona. She is completing now a Master in Geriatry and Gerontology in the University of Barcelona. In 2004, she finished her training as an Oncologist (University Hospital Ramón y Cajal in Madrid). In 2005 she was appointed Director of the Division of Genetic Counselling in General University Hospital in Elche with special responsibilities for research. Her clinical interests include treatment and prevention of cancer and she has participated in many international clinical trials in cancer and several studies about elderly cancer patients.