Page 55 - Risk quantification and modification in older patients with colorectal cancer

Risk stratification using ISAR-HP and G8 screening tools
Introduction
In the Netherlands, more than 13,000 patients are diagnosed with colorectal cancer every year.1 Colorectal cancer is predominantly a disease of the elderly as 60% of patients are over 70 years of age at time of diagnosis and the number of older patients in the next two decades is expected to increase by another 40%.2 Older patients are a heterogeneous group with a great variety in comorbidity, physiological reserves, geriatric impairments and functionality.3,4 As a result of these differences, benefit from treatment can differ and the elderly are at risk for adverse health outcomes after major stressors like emergency department visits, hospitalization, cancer and its treatment.5,6 Selecting optimal treatment for older patients is challenging as age, cognitive functioning, physical functioning and comorbidities are related to adverse outcomes and death.7-10 The International Society of Geriatric Oncology (SIOG) recommends assessment of patient’s physiological reserve using a geriatric assessment (GA).11 A GA can detect health issues and functional problems that are often missed in a regular oncological workup while they are associated with poor oncological outcomes.12 With an increasing number of older patients diagnosed with cancer, screening methods have been developed to identify those at risk for adverse health outcomes and who may benefit from a comprehensive geriatric evaluation and interventions. At present, several screening methods are proposed in the SIOG guideline to select patients for subsequent GA.13 The screening questionnaire Geriatric 8 (G8) proved to have the highest sensitivity compared to the TRST 1+, GFI and VES-13 screening tools14 Unfortunately, specificity and positive predictive value of the G8 are low, resulting in high numbers of unnecessary GA and low predictive value for outcomes. Therefore, a GA is still considered the golden standard for identifying frail patients and predicting adverse outcomes.14
In 2012 the Identification of Seniors At Risk-Hospitalized Patients (ISAR-HP) was developed to select patients that are at risk for functional decline both during and after hospital admission.15 It was validated in adults ≥65 years of age.15,16
From 2015 onward hospitals in the Netherlands are required by The Dutch Health Care Inspectorate to screen older colorectal cancer patients for vulnerability (patients with urgent or emergency surgery are excluded). Both the G8 and the ISAR-HP may be used for this purpose.17
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