This study demonstrated that the SAKK C-SGA is feasible and easy to implement in daily clinical practice. The overall time to complete was less than 30 minutes and considered acceptable by patient and physician alike. Importantly, most participants rated the SAKK C-SGA (patient questionnaire and MRA) as easy or fairly easy to complete. Only a small number of patients or physicians reported questions that were either difficult or unanswered. This likely reflects real-world patient-specific difficulties encountered in daily oncological practice as opposed to problems with the questions themselves. This is supported by the fact that all measures included in the SAKK C-SGA are widely used and previously validated. Plus there was no pattern to the individual questions that were reported as difficult or unanswered (e.g. only one question was mentioned twice, questions identified were not domain-specific).
These findings also suggest that the SAKK C-SGA was able to objectively discriminate older patients’ health. The difference in SAKK C-SGA scores between study sites mirrored differences in the site-specific patient characteristics. KSGR had an overall healthier population (as assessed by other health-related measures) with a higher proportion of patients being treated for curative intent than KSSG. Correspondingly, KSGR SAKK C-SGA scores were lower and a higher proportion was below the cut-off score (i.e. fit for standard treatment). In both sites more patients below the cut-off score had better physician-rated general health, a longer life expectancy as well as better WHO performance scores. Interestingly, in this population C-SGA scores were related to other health measures but not age, underscoring the potential advantage of C-SGA versus age-based decision-making. As expected (i.e. health-related measures were designed to assess unique health states) there was not complete overlap in how individual health-related measures and the SAKK C-SGA identified the patient population. This is similar to findings by other researchers who found physicians and C-SGA do not identify the same patient populations as fit/unfit for treatment and that C-SGA compares with but is not identical to assessments based other health-measures [36–40].
Although shorter screening tools exist and the SAKK C-SGA had high correlation with other simpler health-related measures (e.g. WHO performance score) it affords additional clinical benefit to patient and provider [4, 25, 40–44]. The time to complete though longer than a brief screen is suitable for pre-treatment or pre-trial oncological work-ups. The time to complete the SAKK C-SGA in daily oncological practice was similar to that of another C-SGA tool pilot tested in clinical trial settings . It also requires much less time and no referral for a full comprehensive geriatric assessment. This is particularly important since not all healthcare systems offer specialized geriatric care. Second, the SAKK C-SGA identifies individual domain deficits for intervention acknowledged within the C-SGA literature as having specific benefits in the care of older cancer patients [2, 16, 19, 45]. The problems identified can be addressed either within oncological practices and/or by referral depending on available resources and expertise. For example, engaging social workers, arranging transportation, or providing nutritional counseling before start of treatment could be arranged by staff handling cancer treatment, general practitioners, or referral to a geriatrician depending on individual patient needs and care situations.
The key advantage is that such interventions, regardless of where they are initiated, may mitigate an older patient’s risk for poor cancer treatment outcomes and increase their quality of life. A recent study in Spain showed that C-SGA detects more information than oncological evaluation alone . Another in Canada found that in 70% of their study patients C-SGA identified previously unidentified medical problems . In this Swiss population, over half of our patients were identified by the SAKK C-SGA as not a risk for poor outcomes (i.e. below cut-off/fit for standard treatment). Nevertheless, all but one of these patients had a deficit in at least one domain that otherwise may not have been identified by oncological evaluation alone or even a briefer C-SGA screen. Thus use of the SAKK C-SGA provides readily usable information that can improve outcomes for patients above or below the cut-off without delay (i.e. no additional assessment necessarily required). However, we did find that when dementia was present the SAKK C-SGA (like any geriatric assessment) was challenging to administer. In patients with dementia (especially advanced cases) decision-making regarding treating cancer is likely not be aided by objective C-SGA measurement. But instead will require a more complex individualized process between patient-physician-family/caregiver.
Other researchers in the field and SIOG have identified the need for shorter C-SGA tools applicable for busy clinical oncology settings . The SAKK C-SGA has several benefits directly addressing this need. First, assessment using the SAKK C-SGA requires much less time than a full geriatric assessment and does not require referral to a specialist or geriatrics training to administer. Second, using standard geriatric assessment tools in key domains the SAKK C-SGA maximizes information gathering and minimizes patient/physician burden. In fact, since the tool can be administered by any combination of patient (all but Mini-Cog), trained staff, or physician it is easily customized to the individual patient and clinical setting. Lastly, our findings suggest that use of the SAKK C-SGA is feasible in clinical practice and may be well suited to determine eligibility for clinical trials based on patient health instead of chronological age.
A major challenge of C-SGA is to find a balance between time to conduct and producing clinically useful information (i.e. identifying targets for intervention). The SAKK C-SGA is a step forward in this balancing act but can be further improved. This study used an electronic excel-based CCI calculator that made collecting comorbidity data and calculating CCI information easier, more accurate, and immediately available . Based on our positive experience with the excel-based CCI we decided that an electronic version of the SAKK C-SGA could offer similar advantages in clinical practice and clinical trials. An electronic SAKK C-SGA would make gathering data more efficient, produce real time results that can be immediately incorporated into treatment planning, and increase the likelihood of more widespread and uniform use. Development is underway and validation and feasibility studies are planned.
Several strengths and weaknesses of this study should be considered. The SAKK C-SGA was developed with input from geriatricians and oncologists specifically for use in busy oncological and clinical trial settings. The tool includes only standard psychometrically evaluated geriatric assessment measures covering previously identified key domains. The SAKK C-SGA is easy to score and available in multiple languages. However, the results of this study are based on a small number of patients in Switzerland. Thus generalizability of these findings to other clinical settings and other healthcare systems are limited. We did not require exact measurement of time to complete and assume that most patients/physicians estimated times. However, both the patient and physician estimates had similar standard deviations and the perception of time to complete (i.e. estimated time was acceptable to nearly all) is an important factor in willingness to adopt the tool. The SAKK C-SGA should be further tested in larger patient samples, a variety of settings, and over longer periods of time to include outcome data.