Frailty screening in dermato‐oncology practice: a modified Delphi study and a systematic review of the literature

Abstract

Background Appropriate management and prevention of both under-and overtreatment in older skin cancer patients can be challenging. It could be helpful to incorporate frailty screening in dermato-oncology care, since frailty is associated with adverse health outcomes. Objectives This study aimed to identify and prioritize the requirements a frailty screening tool (FST) should fulfil in dermato-oncology practice and to select the best existing FST(s) for this purpose. Methods A modified two-round Delphi procedure was performed among 50 Italian and Dutch specialists and patients to review and prioritize a list of potential FST requirements, using a 5-point Likert scale. Consensus was defined as a mean score of ≥4.0. A systematic literature search was performed to identify existing multidomain FSTs, which were then assessed on the requirements resulting from the modified Delphi procedure. Results Consensus was achieved on evaluation of comorbidities (4.3 AE 0.7), polypharmacy (4.0 AE 0.9) and cognition (4.1 AE 0.8). The FST should have appropriate measurement properties (4.0 AE 1.0), be quickly executed (4.2 AE 0.7), clinically relevant (4.3 AE 0.7), and both easily understandable (4.1 AE 1.2) and interpretable (4.3 AE 0.7). Of the 26 identified FSTs, four evaluated the content-related domains: the Geriatric-8 (G8), the modified Geriatric-8 (mG8), the Groningen Frailty Indicator (GFI) and the Senior Adult Oncology Program 2 (SAOP2) screening tool. Of these, the G8 was the most extensively studied FST, with the best psychometric properties and execution within 5 min. Conclusions The G8 appears the most suitable FST for assessing frailty in older adults with skin cancer, although clinical studies assessing its use in a dermato-oncology population are needed to further assess whether or not frailty in this particular patient group is associated with relevant outcomes (e.g. complications and mortality), as seen in previous studies in other medical fields.

Predictors of surgical treatment burden, outcomes, and overall survival in older adults with basal cell carcinoma: Results from the prospective, multicenter BATOA cohort

“…Nonetheless, as both comorbidities and iADL dependency are frailty related, frailty screening could aid in estimating patients' life expectancy in a more holistic approach, 23 although current experience in dermatology daily care is limited. 21,32 However, as chronological age was not identified as a significant predictor of treatment burden, complications, cosmetic result, or overall survival, physicians should refrain from making treatment decisions based solely on age, and preferably prioritize the consideration of frailty-related patient characteristics that could lead to adverse health outcomes. The combination of overall low treatment burden and high overall survival leads us to believe that the surgical treatment choices have been adequate in this part of the BATOA cohort.…”

Characteristics and management of skin cancers in very elderly patients: A real‐world challenge for clinicians

“…28 Even though it is an expression of population aging, chronological age itself does not define frailty, whose definition stems from a complex multidisciplinary evaluation. 29,30 Life expectancy is defined as the probable number of additional years that a person is expected to live while the expression "lag time to benefit" refers to the time between an intervention to the onset of improved health outcomes. 31,32 In this study, for the screening and global assessment of the elderly patient and to predict survival.…”

“…31,32 In this study, for the screening and global assessment of the elderly patient and to predict survival. 29,[34][35][36] Therefore, when facing skin cancer in very elderly patients, a patient-centred approach and shared decisionmaking are crucial to define patient's preferences and priorities when choosing the best treatment strategy. 31,37 No guidelines specifically address whether clinicians should treat nonfatal conditions in patients at the end of life and age per se is not considered as an absolute or relative contraindication to treatment.…”

Optimizing shared decision making in older adults with basal cell carcinoma: experiences from a specialized outpatient clinic

“…Longer time slots were available to provide more time for evaluation of patient‐related factors [e.g. frailty, including the ‘Geriatric‐8’ (G8) frailty screening tool], 3 , 4 treatment goals and a multidisciplinary approach (e.g. with radiotherapists, plastic surgeons, primary care physicians or nursing home specialists).…”

“… 8 Incorporation of integrated, holistic care is not always easy in daily practice, although the use of predictive instruments (e.g. the G8 or other frailty screening tools) 4 might assist in identifying patients in need of multidisciplinary approaches and/or more extensive counselling around BCC management.…”