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original articles combination also affect the same fraction fa of the cells. If the sum of these two fractional terms is equal to 1, additivity is indicated. If the CI value is <1, synergy is indicated, and if the CI value is >1, antagonism is indicated. The above relationships can be portrayed graphically by a normalized isobologram. In these plots, the ratio of dose of drug needed to affect a fraction x when used in combination relative to when it is used alone is plotted (for different values of x) for drug 1 (vertical axis) against drug 2 (horizontal axis, Annals of Oncology Figure 2C). If the combination data points fall on the curve, an additive effect is indicated. If the combination data points fall on the lower left or on the upper right, synergism or antagonism is indicated, respectively. Note that one difference between the two methods of analysis is that the isobologram analysis of Steel and Peckham [3] defines an envelope of additivity, but the median effect method of Chou [2] defines only a single condition of additivity. Annals of Oncology 23: 2166–2172, 2012 doi:10.1093/annonc/mdr587 Published online 16 January 2012 Screening older cancer patients: first evaluation of the G-8 geriatric screening tool C. A. Bellera1,2*, M. Rainfray3,4, S. Mathoulin-Pélissier1,2,5, C. Mertens4,6, F. Delva1, M. Fonck6 & P. L. Soubeyran6 1 Clinical Research and Clinical Epidemiology Unit, Institut Bergonié, Regional Comprehensive Cancer Centre, Bordeaux; 2INSERM CIC-EC7, ISPED, Bordeaux University, Bordeaux; 3SFR Public Health, Bordeaux University, Bordeaux; 4Department of Clinical Gerontology, Bordeaux University Hospital, Bordeaux; 5INSERM U897 Epidemiology and Biostatistics, ISPED, Bordeaux University, Bordeaux; 6Department of Medical Oncology, Institut Bergonié, Regional Comprehensive Cancer Centre, Bordeaux, France Received 14 September 2011; revised 18 November 2011; accepted 21 November 2011 Background: Development of a geriatric screening tool is necessary to identify elderly cancer patients who would benefit from comprehensive geriatric assessment (CGA). We develop and evaluate the G-8 screening tool against various reference tests. Patients and methods: Analyses were based on 364 cancer patients aged >70 years scheduled to receive first-line chemotherapy included in a multicenter prospective study. The G-8 consists of seven items from the Mini Nutritional Assessment (MNA) questionnaire and age. Our primary reference test is based on a set of seven CGA scales: Activities Daily Living (ADL), Instrumental ADL, MNA, Mini–Mental State Exam, Geriatric Depression Scale, Cumulative Illness Rating Scale-Geriatrics, and Timed Get Up and Go. We considered the presence of at least one questionnaire with an impaired score as an abnormal reference exam. Additional reference exams are also discussed. Results: The prevalence of being at risk varied from 60% to 94% according to the various definitions of the reference test. When considering the primary reference test, a cut-off value of 14 for the G-8 tool provided a good sensitivity estimate (85%) without deteriorating the specificity excessively (65%). Conclusion: The G-8 shows good screening properties for identifying elderly cancer patients who could benefit from CGA. Key words: cancer, elderly, screening, sensitivity and specificity introduction The comprehensive geriatric assessment (CGA) is a multidisciplinary evaluation of an older individual’s functional, psychological and nutritional statuses, cognition, social support, and comorbidity. This assessment can detect geriatric *Correspondence to: Dr C. A. Bellera, Clinical Research and Clinical Epidemiology Unit, Institut Bergonié, Regional Comprehensive Cancer Center, 229 Cours de l’Argonne, 33076 Bordeaux, France. Tel: +33-5-56-33-04-95; Fax: +33-5-56-33-04-85; E-mail: [email protected] problems and potentially improves survival, physical, and cognitive state of patients as well as increases an elderly person’s chances of staying at home longer [1–4]. With regard to elderly cancer patients, CGA components have been shown to be prognostic factors of survival (such as functional status and quality of life) and even associated with changes in cancer treatment (such as functional status and malnutrition) [5–7]. Although randomized controlled trials evaluating the impact of CGA-based interventions in older cancer patients to provide definite evidence on its efficacy to improve survival are still rare, existing literature provides growing evidence that © The Author 2012. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: [email protected] original articles Annals of Oncology CGA can predict morbidity and mortality in older cancer patients [8]. Since 2005, the application of the CGA for cancer patients >70 has been recommended by the International Society of Geriatric Oncology [9]. However, its systematic application to this population does not seem essential as many patients can be treated according to the standard treatment protocol without major modification [10–12]. Similar findings have been derived from the general population as improved outcomes are observed in unfit patients, suggesting that healthy older people should be excluded of the process [4]. The current challenge at hand is to identify individuals for whom the CGA would be the most beneficial, justifying the need for a validated screening instrument. Several screening methods to identify frail patients are available [13–17]. They usually have to be administered by clinical personnel [13–15, 17]. In addition, most have been validated in the clinical geriatric context but not with cancer patients and thus do not necessarily take into account the side-effects of cancer treatment. The Vulnerable Elders Survey (VES-13), a selfadministered questionnaire, is one such tool that has been developed based on a large population of 6000 patients aged over 65 years [18]. It has since been evaluated in cancer patients by several studies but sample sizes are limited with heterogeneous cancer populations. Importantly, this tool has been evaluated against various reference exams [19–23] leading to different estimates of its screening performances, as highlighted in an recent editorial [24]. Current work on geriatric screening tools raises two issues. First, the development of a screening tool is necessary to individualize older cancer patients who would benefit from a CGA. This approach offers advantages both for the rationalization of the use of medical resources for the health care system and also to spare the patient from unnecessary clinical and biological examinations. In addition, from a methodological point of view, the reference exam to which the screening tool will be compared needs to be defined with rigor [25]. We propose to address these two issues. Using data collected previously in a multicenter study focusing on a cohort of elderly cancer patients, we carried out a series of analyses to finalize the choice of a high-performing screening tool. Specifically, for the development of this screening test, we wish to ensure that none of the ‘at risk’ patients will be missed, thus prioritizing sensitivity over specificity. methods patients Our research was elaborated based on a regional multicenter prospective study funded by a 2003 French clinical research program (NCT00210249 [26]). The primary objective of this study was to assess the role of the CGA in the management of elderly patients treated for a cancer with chemotherapy. Patients aged >70 years (no upper age limit) scheduled to receive first-line chemotherapy for various types of cancer [colon, pancreas, stomach, ovary, bladder, prostate, lung cancer, non-Hodgkin’s lymphoma (NHL), or cancer of unknown primary origin] were eligible for inclusion. Breast cancer patients were not included as very few elderly patients receive first-line chemotherapy. Patients with known central nervous system Volume 23 | No. 8 | August 2012 metastases were excluded. The protocol was approved by institutional review boards and ethics committees and was conducted in accordance with the Declaration of Helsinki, Good Clinical Practices, and local ethical and legal requirements. All patients provided written informed consent for their participation. baseline assessment The geriatric evaluation consultation was carried out after an initial specialized oncology consultation. This evaluation assessed the patient’s comorbidities, cognitive functions, mood disorders, nutritional and functional status, disabilities as well as the main geriatric syndromes, and the current medication of the elderly patient. The patient was seen by the clinical research nurse for the following questionnaires and scales: Instrumental (IADL) and Activities in Daily Living (ADL) questionnaires, the Geriatric Depression Scale (GDS-15), and a quality of life selfquestionnaire (QLQ-C30). The geriatrician was responsible for completing the Cumulative Illness Rating Scale for Geriatrics (CIRS-G), the Mini– Mental Status Exam (MMSE), and the Mini Nutritional Assessment (MNA) as well as for performing the ‘Timed Get Up and Go’ (GUG) evaluation. As necessary, the oncologist scheduled interventions with various health care practitioners (social worker, nutritionist, physiotherapist, team of psychologists, and/or psychiatrist) as well as any necessary supplementary examinations such as extra blood analyses. Geriatric assessment data were blinded to the physician. These questionnaires and scales have been validated including cut-off values for defining abnormal test results. The domain covered by each of these questionnaires, the range of their respective scores, as well as cut-off values for defining abnormal scores are summarized in Table 1. reference exam In order to evaluate a screening tool, a clear definition of the reference exam must first be provided. No recognized definition for such reference tool is available in the literature [24]. We retained a set of seven validated questionnaires (ADL, IADL, MMSE, GDS-15, MNA, CIRS-G, and GUG), which are routinely used and often considered as components of the CGA [8]. Similarly, a clear definition of what constitutes an abnormal reference should be provided. We considered the presence of at least one questionnaire with an impaired score as an abnormal reference exam. As exploratory analyses, we also investigated five additional reference exams. We considered using at least two abnormal scores based on the aforementioned set of seven questionnaires. Next, we considered leaving out either the ADL or the IADL and using at least one or two questionnaires with an impaired score. proposition of a screening tool We chose to assess the G-8 screening tool consisting of eight items: a selection of seven items from the MNA questionnaire as well as an indication of age. As such, the G-8 tool shares common questions with the MNA short form, although the latter was not specifically developed for cancer patients [37]. Items selected from the MNA questionnaire included questions relating to nutritional status [food intake (MNA item A), weight loss (item B), body mass index (item F)], motor skills (item C), psychological status (item E), number of medications (item H), and selfperception of health (item P). Age was considered in three categories (<80, 80–85, and >85) as it is typically included in frailty criteria [14, 18]. We maintained the same scores as those used in the original MNA questionnaire and used a score of 0 (>85) to 2 (<80) for age. Overall, the G-8 score ranged from 0 (heavily impaired) to 17 (not at all impaired). The G-8 questionnaire is provided in Table A1. The choice of the items that constituted the G-8 was driven by earlier findings. Following a preliminary analysis [26], we investigated factors doi:10.1093/annonc/mdr587 | original articles Annals of Oncology Table 1. CGA questionnaires: reference values, cut-off values, and proportions of subjects with abnormal scores in a series of 364 subjects Description of the questionnaire Questionnaire Reference ADL IADL MMSE Katz 1963 [27] Lawton 1969 [28] Folstein 1975 [29] GDS-15 Sheikh 1986 [30], Yesavage 1988 [31] Guigoz 1994 [32] MNA GUG CIRS-G Mathias 1986 [33], Podsiadlo 1991 [34] Linn 1968 [35], Miller 1991 [36] Number of subjects with an abnormal score Across all patients From subset of 339 patients (# abnormal scores with all seven assessments /# available) (%) available (%) Domain Score range Abnormal score if Autonomy Autonomy Cognitive functions Mood functions Nutritional status Mobility 0–6 0–8 0–30 ADL ≤5 IADL ≤7 MMSE ≤23 66/353 (19%) 257/353 (73%) 70/351 (20%) 57 (17%) 244 (72%) 59 (17%) 0–15 GDS-15 ≥6 155/342 (45%) 153 (45%) 0–30 MNA ≤23.5 231/353 (65%) 218 (64%) 0–∞ ≥20 seconds 88/353 (25%) 79 (23%) 99/364 (27%) 131 (39%) Comorbidity Up to 14 At least one comorbidities comorbidity grade 3/4 ADL, Activities of Daily Living; CGA, comprehensive geriatric assessment; CIRS-G, Cumulative Illness Rating Scale for Geriatrics; GDS-15, Geriatric Depression Scale 15; GUG, Get Up and Go; IADL, Instrumental Activities Of Daily Living; MMSE, Mini–Mental State Exam; MNA, Mini Nutritional Assessment. associated with early death risk (death within 6 months of treatment initiation). Advanced disease stage, male gender, low MNA score, and impaired GUG were significantly and independently associated with early death risk. These preliminary results highlighted the value of the MNA score when evaluating elderly cancer patients as compared with other test scores specific to other domains. These results appear coherent as the content of this questionnaire includes items not only related to the nutritional status of the patient but also items oriented toward the exploration of cognitive or mood troubles as well as disabilities or comorbidities that are present in geriatric questionnaires of the CGA. We thus expected items of the G-8 to be strongly correlated with scores of geriatric questionnaires. Although in brief, items of the G-8 tend to cover domains usually addressed by the CGA. As such, we anticipated strong associations. statistical analyses Qualitative variables were described using counts and proportions. Quantitative continuous variables were described using means and standard deviations for normal data or medians and ranges otherwise. Associations between qualitative variables were tested using the chi-square test or the Fisher’s exact test depending on the sample sizes. Performance of the G-8 tool was evaluated using sensitivity (Se), specificity (Sp), receiver operating curve (ROC), and area under the ROC curve (AUC). Confidence intervals (95% CI) are reported. results baseline patient characteristics and geriatric evaluations Between September 2002 and September 2005, 364 patients were included across 12 regional centers (Table 2). Median age was 77 years (70–99 years) with slightly more males (59%). The main cancer types and locations were lymphomas (30%), cancer of the colon (28%), stomach (10%), lung (10%), pancreas (6%), prostate (6%), bladder (5%), and ovary (4%). | Bellera et al. Table 2. Baseline characteristics of the patients Characteristics N (%) Sex Male Female Age (years) <80 80–85 (inclusive) >85 ECOG performance status 0–1 2–4 Cancer site Non-Hodgkin’s lymphoma Colon Stomach Lung Pancreas Prostate Bladder Ovary Unknown primary Disease stage—solid tumors M0 M1 MX Disease stage—non-Hodgkin’s lymphoma aaIPI 0–1 aaIPI 2–3 214 (59%) 150 (41%) 247 (68%) 89 (24%) 28 (8%) 261 (76%) 83 (24%) 110 (30%) 101 (28%) 37 (10%) 37 (10%) 23 (6%) 20 (6%) 18 (5%) 14 (4%) 4 (1%) 62 (24%) 134 (53%) 58 (23%) 59 (54%) 51 (46%) aaIPI, age-adjusted International Prognostic Index; ECOG, Eastern Cooperative Oncology Group. Most of the solid tumors were of advanced stage (53%). Almost half of the NHL patients were of International Prognostic Index (IPI) stage 2–3 (46%). Across all tumor types, Volume 23 | No. 8 | August 2012 original articles Annals of Oncology Table 3. Proportion of patients with an abnormal Reference exam and performance of the G-8 screening tool according to six definitions of the reference exam Reference exam Subjects with an abnormal reference exam N (total = 339) % Seven questionnaires: ADL, IADL, MMSE, GDS-15, MNA, GUG, and CIRS-G At least one impaired score 319 (94%) At least two impaired scores 259 (76%) Six questionnaires: IADL, MMSE, GDS-15, MNA, GUG, and CIRS-G At least one impaired score 319 (94%) At least two impaired scores 257 (76%) Six questionnaires: ADL, MMSE, GDS-15, MNA, GUG, and CIRS-G At least one impaired score 290 (86%) At least two impaired scores 205 (60%) Se (95% CI) Sp (95% CI) AUC (95% CI) 85% (81% to 89%) 92% (88% to 95%) 65% (41% to 85%) 0·48 (0·37–0·60) 87% (82% to 92%) 85% (80% to 89%) 85% (81% to 89%) 92% (88% to 95%) 65% (41% to 85%) 47% (36% to 58%) 87% (82% to 92%) 85% (80% to 89%) 89% (85% to 93%) 0·97 (93% to 99%) 60% (45% to 74%) 39% (31% to 48%) 90% (86% to 93%) 84% (80% to 88%) For the performance of the G-8 questionnaire, sensitivity (Se), specificity (Sp), and area under the ROC curve (AUC) with 95% confidence intervals (95% CIs) are presented assuming a cut-off value of 14 (≤14 versus >14). ADL, Activities of Daily Living; CIRS-G, Cumulative Illness Rating Scale for Geriatrics; GDS-15, Geriatric Depression Scale 15; GUG, Get Up and Go; IADL, Instrumental Activities of Daily Living; MNA, Mini Nutritional Assessment; MMSE, Mini–Mental State Examination. the advanced stages (M1/MX or IPI 2–3) represented the majority of inclusions (67%). The seven evaluations were available for 339 patients (93%). Complete assessment was significantly more often available for subjects with localized disease (97% for localized versus 90% for advanced disease), men (95% for men versus 90% for women), and for patients with better performance status [98% for Eastern Cooperative Oncology Group (ECOG) 0–1 versus 85% for ECOG 2–4]. Patients who completed the assessment were also significantly younger (mean age 77·5 versus 82·2). The questionnaire with the lowest completion rate was the MMSE (92%) while the CIRS-G was available for all patients. Among the patients who completed all seven evaluations, the ADL questionnaire had the highest number of ‘normal’ nonimpaired scores (83%) compared with 28%, 36%, and 55% for the IADL, MNA, and GDS-15, respectively. These distributions of scores were similar when we considered the global population (Table 1). reference exams and rules When the seven questionnaires were considered, 94% of the population presented with at least one impaired score and 76% presented with two or more impaired scores. Proportions of subjects with an abnormal reference exam are presented in Table 3 using other rules. performance of the screening tool As expected, items of the G-8 screening tool showed strong associations with at least one of the geriatric evaluations (Table 4). Approximately 82% of the population presented an impaired G-8 score. When considering an impaired reference standard as at least one impaired score, the sensitivity and specificity estimates were close, whether the reference standard included all seven questionnaires, excluded the ADL, or excluded the IADL. Similar results apply when considering an impaired reference standard as two impaired scores, although the specificity fell drastically Volume 23 | No. 8 | August 2012 (down to 45%) for relatively smaller gains in sensitivity. The resulting ROC curves for the G-8 against the various reference exams were very similar, leading to comparable AUC estimates. We show the ROC curve representing the G-8 screening tool against the reference exam consisting of the seven questionnaires (Figure 1). When retaining the seven questionnaires as part of the reference exam, the ROC curves suggested that cut-off values ∼14 would provide good sensitivity estimates, of at least 80%, without deteriorating the specificity excessively (not <60%). discussion Based on a multicenter cohort study, we carried out the first evaluation of the G-8 screening tool for geriatric oncology. We also discussed the definition of the reference exam it should be compared with. The G-8 tool incorporating elements of the MNA questionnaire and age is thus proposed with the selected items covering multiple domains usually assessed by the geriatrician when performing the CGA: disability, nutrition, cognition, depression, and comorbidities. As in the MNA questionnaire, items specific on mood or cognition disorders, dependence, and comorbidities are highly subjective, and as such cannot be considered as a valuable evaluation of these domains, but rather global and/or subjective assessments. Moreover, it should be acknowledged that the G-8 tool is not aimed at replacing the expertise of geriatricians for the diagnosis of frailty. Rather, it should be used as a screening tool to identify patients in need for a further assessment and appropriate care. Selection of the optimal cut-off value of the screening tool should rely on the desired properties of the tool under development. Because of the duality between sensitivity and specificity, both parameters cannot be simultaneously maximized. When developing a screening test, we wish to ensure that none of the at risk patients will be missed. Thus the sensitivity should be prioritized over the specificity. Our doi:10.1093/annonc/mdr587 | original articles Annals of Oncology Table 4. Exploratory tests for associations between individual items of the G-8 tool and components of the CGA Associations investigated between MNA items and score (normal/impaired) of common CGA componentsa P value for the test statistics for the associationb Association between MNA item ‘food intake’ and ADL 0·06 IADL <0·001 MNA <0·001 Association between MNA item ‘weight loss’ and ADL 0·02 IADL 0·39 MNA <0·001 Association between MNA item ‘mobility’ and ADL <0·001 IADL 0·001 GUG <0·001 Association between MNA item ‘neuropsychological problems’ and MMSE <0·001 GDS-15 <0·001 Association between MNA item ‘body mass index’ and ADL 0·63 IADL 0·31 MNA <0·001 Association between MNA item ‘more than three prescribed medications’ and CIRS-G 0·003 Association between G-8 item ‘self-perception of health’ and ADL <0·001 IADL 0·001 GDS-15 <0·001 CIRS-G 0.79 P values for the tests of association are reported based on the 339 patients with the complete set of questionnaires for the CGA. a CGA components are analyzed as binary variables (normal versus impaired score). b Chi-square test or Fisher’s exact test, depending on the sample size. ADL, Activities of Daily Living; CGA, comprehensive geriatric assessment; CIRS-G, Cumulative Illness Rating Scale for Geriatrics; GDS-15, Geriatric Depression Scale; GUG, Get Up and Go; IADL, Instrumental Activities of Daily Living; MNA, Mini Nutritional Assessment; MMSE, Mini–Mental State Examination. analysis suggested that a threshold value at 14 (≤14 versus >14) would provide good sensitivity estimates for the G-8 of at least 80%, without deteriorating the specificity under 60%. As recently acknowledged by Molina-Garrido et al. [24], currently, there is no one standard model of CGA accepted in the scientific community. A standard model composed of validated scales that would enable standardization of studies and results is needed. Our selection of seven tests and questionnaires that have been individually validated in geriatric oncology is thus coherent and sensible. Depending on our definition of being at risk, the prevalence varied between 60% and 94%. Although these estimates could appear high, it should be noted that our target population included first-line chemotherapy elderly patients and as such a large proportion of advanced disease (about two-thirds in our | Bellera et al. Figure 1. Receiver operating curve (sensitivity versus 1-specificity) for the G-8 screening tool against the reference exam consisting of seven comprehensive geriatric assessment questionnaires (at least one abnormal score versus none). sample). We expect that a general population of elderly cancer patients will involve a smaller proportion of advanced disease leading to lower estimates of at risk subjects. We defined being at risk as having at least one or two areas of impairments when assessing the multiple dimensions of the physical and psychological conditions of the older cancer patient. We preferred the threshold of one abnormal questionnaire since our objective is to be sensitive in the detection of oncological frailty. Still, this choice may be debatable since patients with only one abnormal questionnaire do not necessarily need the intervention of a geriatrician in all cases. The simultaneous inclusion of the ADL and IADL can also be discussed. Indeed, one could at first argue that both focus on the patient’s autonomy and as such could be redundant. However, the two scales do not address the same stage of independence with IADL referring to skills required to maintain usual activities in the community (ability to shop, managing money, etc.), which are affected earlier than the skills encompassed by the ADL that are required to maintain very basic home activities (ability to bath, dress, etc.). It is therefore expected that skills impaired on ADL will be observed in the later stage of disability and should be identified relatively easily. On the other hand, impaired IADL skills are probably more subtle to identify during a standard consultation. Identifying and observing abnormal IADL can be considered as an early stage of disability. Furthermore, four questions of the IADL questionnaire have been shown to be highly correlated with cognitive deficiencies [38]. Given the high prevalence of cognitive impairment in the elderly [39], impairment on the IADL scale should thus be accounted for. Finally, concerning the IADL, Lawton [28] originally suggested that certain activities such as shopping, preparing meals, and housework were gender-based and thus less representative for males so should only be evaluated for female patients. While this issue was also recently debated in the context of geriatric screening tools [40], this distinction did not appear relevant in Volume 23 | No. 8 | August 2012 original articles Annals of Oncology our dataset. Indeed, we applied both approaches when performing our analysis but did not notice any gender-based differences in terms of prevalence of subjects with an abnormal IADL score (data not shown). As of today, there is no clear definition of what should constitute the reference exam when evaluating a screening tool aimed at detecting old cancer patients in need for a CGA. The existing literature focusing on the validation of the VES-13 questionnaire is an illustration of this issue since it has been compared with very various reference exams [19–22]. Impairment on the CGA was defined either as meeting the cutoff scores for impairment on two of seven individual tests within the CGA [19] (including ADL, IADL, Charlson index, and other usual tests) or as at least two abnormal scores of another set of seven questionnaires [21] or as having impairment in two or more domains (ADL and IADL), or being cognitively impaired (MMS ≤24) [20]. With regard to the only large study available, the reference exam is not systematically clearly defined [22]. The experience of the evaluation of the VES-13 highlights the importance of properly defining the reference exam. This first evaluation has some limits. One could argue that the social environment and biological variables were not considered in the screening tool. While potentially informative, some sociocultural variables were collected through a questionnaire developed for the purpose of the ongoing study. It was not validated previously, and we thus considered that it should not be considered part of the reference exam. Although some biological variables can be associated with chemotherapy-related toxicity, their evaluation is often part of the routine oncological assessment and as such cannot be considered as a component of the CGA. Finally, the QLQ-C30 questionnaire provided valuable information but unlike other questionnaires, it is not a usual component of the geriatric evaluation. Given the design of the study, reproducibility of the G-8 could not be evaluated and should be addressed in a future study. Similarly, it would be of particular interest to confirm these preliminary findings in a larger population allowing us to address a broader range of treatments (chemotherapy, surgery, and radiotherapy) or cancer types (e.g. by including breast cancers) through subgroup analyses. Finally, the VES-13 was not initially included in our study and as such could not be assessed. Although the lack of a common reference tool makes the comparison of screening tools particularly complex, these preliminary results are promising. When compared with a reference exam defined as the set of seven geriatric evaluations (ADL, IADL, MNA, MMSE, GDS-15, CIRS-G, and GUG), this first evaluation suggests good screening classification properties for the G-8 tool for use in geriatric oncology. We believe its excellent sensitivity and reasonable specificity as well as the ease of administration make the G-8 a promising screening tool, which now requires validation in a larger-scale prospective study. acknowledgements The authors thank Pippa McKelvie-Sebileau from Institut Bergonié for medical writing assistance, the research nurses, and geriatricians from all participating institutions: Centre Volume 23 | No. 8 | August 2012 Hospitalier Universitaire (CHU) Bordeaux, Centre Hospitalier Général (CHG) Agen, CHG Libourne, CHG Agen, CHG Mont de Marsan, CHG Villeneuve sur Lot, Francheville Polyclinique Périgueux, CHG Pau, CHG Bayonne, CHG Périgueux, and CHG Le Bouscat. The authors also thank the reviewers for their helpful comments. funding French Ministry of Health (Programme Hospitalier de Recherche Clinique C2003CTT); Ligue Nationale Contre le Cancer; and Sanofi-Aventis, Amgen, Chugaï, and Bristol-Myers Squibb, pharmaceutical companies. disclosure The authors declare no conflict of interest. references 1. Ellis G, Whitehead MA, Robinson D et al. Comprehensive geriatric assessment for older adults admitted to hospital: meta-analysis of randomised controlled trials. BMJ 2011; 343: d6553. 2. Huss A, Stuck AE, Rubenstein LZ et al. Multidimensional preventive home visit programs for community-dwelling older adults: a systematic review and metaanalysis of randomized controlled trials. J Gerontol A Biol Sci Med Sci 2008; 63: 298–307. 3. Rubenstein LZ, Josephson KR, Wieland GD et al. Effectiveness of a geriatric evaluation unit. A randomized clinical trial. N Engl J Med 1984; 311: 1664–1670. 4. Stuck AE, Siu AL, Wieland GD et al. 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The G-8 questionnaire Items Possible responses (score) A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing, or swallowing difficulties? B Weight loss during the last 3 months? C Mobility? E Neuropsychological problems? F BMI? (weight in kg)/(height in m2) H Takes more than three prescription drugs per day? P In comparison with other people of the same age, how does the patient consider his/her health status? Age Total score 0 = severe decrease in food intake 1 = moderate decrease in food intake 2 = no decrease in food intake 0 = weight loss >3 kg 1 = does not know 2 = weight loss between 1 and 3 kg 3 = no weight loss 0 = bed or chair bound 1 = able to get out of bed/ chair but does not go out 2 = goes out 0 = severe dementia or depression 1 = mild dementia 2 = no psychological problems 0 = BMI <19 1 = BMI 19 to <21 2 = BMI 21 to <23 3 = BMI ≥23 0 = yes 1 = no 0.0 = not as good 0.5 = does not know 1.0 = as good 2.0 = better 0: >85 1: 80–85 2: <80 0–17 BMI, body mass index. Volume 23 | No. 8 | August 2012