Rev. Bras. Hematol. Hemoter. vol.37 número4

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rev bras hematol hemoter. 2015;37(4):259–262

w w w . r b h h . o r g

Revista

Brasileira

de

Hematologia

e

Hemoterapia

Brazilian

Journal

of

Hematology

and

Hemotherapy

Case

Report

Limitations

of

performance

status

assessment

in

elderly

with

acute

myeloid

leukemia

Ana

Lúcia

Ippolito

Carbonell

∗

_,

_Maria

_de

_Lourdes

_Chauffaille

UniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil

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Articlehistory:

Received23October2014 Accepted25December2014 Availableonline14April2015

Introduction

Elderlypatientspresentclinicalandfunctionalheterogeneity. Thusthechronologicalage(60yearsandolder)alonedoesnot characterizethisgroupofindividualscorrectly.Performance statusscalessuchastheKarnofskyPerformanceScale(KPS)1 or EasternCooperative Oncologic Group Scale(ECOG),2 _are usedbyhematologistsindecisionmakingforelderlypatients withcancer. Good performance statusis defined asa KPS equaltoorgreaterthan80%oranECOGlessthan2.These scoresareoneofthecriteriautilizedtochoosethetreatment strategy for elderly patients with acute myeloid leukemia (AML). AMLis morefrequentin the aged. Consideringthe highriskoftoxicityduringAMLtreatmentinelderlypatients, manyresearchershaverecommendedtheapplicationof geri-atricinstruments atbaselineand inthefollowup ofthese individuals. The objective of this paper is to improve the understandingofhowgeriatricapproachesmay benefitthe performancestatusassessmentofelderlypatientswithAML.

∗ _{Corresponding}_author_at_:_Rua_Diogo_de_Faria,_824,_04034-000_São_Paulo,_SP,_Brazil. E-mailaddress:acarbone@uol.com.br(A.L.I.Carbonell).

Twocases,asclinicalchallenges,areusedtoexemplifythis clinicalcontext.

Clinical

challenges

Case1–Patient1:75-year-oldmanwithdenovoAML,normal karyotype,KPSof90%andECOGof1

Case2– Patient 2:65-year-old womanwithde novo AML, normalkaryotype,KPSof80%andECOGof1

Question:Howdogeriatricinstrumentsimprovethe char-acterizationofthesepatients?(Table1).

Brief

considerations

about

performance

status

and

functional

status

Performancestatus–assessedbyKPSand/orbyECOG(Table2) – is the traditional method applied by hematologists to

http://dx.doi.org/10.1016/j.bjhh.2015.03.007

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revbrashematolhemoter.2015;37(4):259–262

Table1–Hematologicdataofclinicalchallengepatients.

Patient1 Patient2

Age(years) 75 65

Gender Male Female

Diagnosis DenovoAML DenovoAML Marrowblasts(%) 38 47

Hemoglobin(g/dL) 10.7 8.9 Whitebloodcellcount(×103/␮L) 3400 2870

Plateletcount(×103/␮L) 92 50

AML:acutemyeloidleukemia.

evaluatethedisease/treatmentimpactontheelderlypatient’s abilitytocareforthemselvesandtowork.

Theseinstruments are notbasedon asystematic

ques-tionnaire. The scores are obtained based on a general

impression of the clinician about the patient’s symptoms

and the patient’s autonomy to care for themself and to

work.Onedisadvantageofthis methodisthe lackof defi-nitionstospecificallycharacterize thescorelevels ofthese scales.3

Functionalstatusisthelevelofautonomythatan individ-ualhasindailyactivities.TheActivityDailyLivingScale(ADL)4 and InstrumentalActivity OfDaily Living Scale(IADL)5 _are complementarytoolswidelyvalidatedtomeasurefunctional status.

ADLwasvalidatedbyKatzinchronicallyillpatientsandis composedofsixquestionsaboutspecificanduniversaltasks.4 IADLwasdelineatedbyLawtonandisascalewithnine ques-tionswiththreepossibleanswers:able,ablewithhelpand

unable.Itreferstotheautonomyinactivitiesthataremore influencedbyculturalcontext(Table2).

In1995,Moretal.6_evaluated_the_validity_of_KPS_by_showing theautonomyindailylivingactivitiesforeachKPSassessed in685patientswithadvancedcanceronapplyingtheKPSand ADL.Theyshowedthattheautonomyofthesepatientswas lowerastheirKPSscoredecreased.

KPS,ECOG,ADLandIADLrefertothesameconstruct,i.e., tothesameabstracttheoreticalconcept.DifferenttoKPSand ECOG,ADLandIADLemployasequenceofspecificquestions. Thepossibleanswerstoeachquestionaregraduatedintwo (ableorunable)orinthree(able,ablewithhelp,andunable) levels.Theseinstrumentshighlightimprovementsor impair-mentsinfunctionalityduringthefollowupofthepatient.

AsshowninTable2,thecorrelationbetweenthesescores suggests thatpatientswithpoorKPShavelosttheir auton-omyintheIADL5_and_are_at_risk_of_dependence_in_basic_ADL.4 However,individualswithgoodKPSprobablyhavepreserved autonomyintheADLdimensionbutmayevolvewithsome IADLdependence.

LoosingautonomyinADLandhavingpoorscoresinKPS (≤80%)orECOG(>1)areofprognosticvalue.3,7

However,despitetheprognosticvalueofperformance sta-tus,elderlypatientswithgoodKPScouldbeathighriskto succumb duringtheinductionphaseofAMLtreatmentfor reasons notrelated tothe disease.This eventhasjustified someresearcherstoapplyinggeriatricapproachesinelderly patientswithAML.Thegoldstandardmethodforevaluating olderpatientsisComprehensiveGeriatricAssessment(CGA). CGAisamultidisciplinaryandtime-consumingapproach that includes functional, cognitive, psychological status, comorbidity, nutritional, polypharmacy and social support

Table2–Correlationsbetweenperformanceandfunctionalscales.

ECOG KPS IADL

Goodperformance 0–1 Normalactivity 80–100% Abletocarryon normalactivityand towork Phonecalls? Locomotion? Shopping? Makingmeals? Housekeeping? Housework? Carewithclothes? Takingmedicines? Managingmoney? Isindependence ininstrumental activities preserved? ADL

Poorperformance 2 Inbed<50% ofnormal daytime

50–70% Unabletowork;able toliveathomeand careformost personalneeds Bathing? Dressing? Toilet? Transference? Continence? Feeding?

Isindependencein basicactivities preserved?

3–5 Inbed>50% ofnormal daytime

0–40% Unabletocarefor self;requires equivalentof institutionalor hospitalcare

KPS:Karnofskyperformancescale;ECOG:EasternCooperativeOncologyGroupscale;IADL:instrumentalactivitiesofdailyliving;ADL:basic activitiesofdailyliving;Goodperformance:KPS≥80%andECOG<2;Independence:nodependenceinADLandIADL;Dependence:needhelp

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Table3–Functionalassessmentandcomorbidityscores ofclinicalchallengepatients.

Patient1 Patient2

Age(years) 75 65

Gender Male Female

KPS/ECOG 90%/1 80%/1 ADL/IADL Independent Dependenta

HCT-CI 0 3b

KPS: Karnofsky performance scale; ECOG: eastern cooperative oncologic group scale; ADL: activities of daily living scale; IADL:instrumental activities ofdaily livingscale;Independent: no dependence in daily activities; HCT-CI: hematopoietic cell transplantation-comorbidityindex.

a _Patient₂_needed_help_to_take_{medications/locomotion}_and_she

hadurinaryincontinence.

b _Patient₂_had_{insulin-dependent}_diabetes_mellitus_and_serum

cre-atinineequalto2.6mg/dL.

assessments.Overthelast20 years,CGAhasbeen applied intheoncogeriatricfieldandhasaggregatedimportantdata forthetherapeuticmanagementofthisgroupofindividuals. ItisnotablethattheADLandIADLaretoolswidelyusedfor thefunctionalstatusassessmentincludedinCGA.8

In2006,Weddingetal.9_demonstrated_the_benefit_of_adding theIADLtotheKPSinthefunctionalassessmentofelderly patientswithAML.Sincethen,severalotherresearchershave studied the impact of geriatric parameters in the survival andthe qualityoflifeofolderpatientswithhematological malignancies.10

Agingisassociatedwithahighincidenceofcomorbidities thathaveasignificantimpactonsurvivalandon complica-tionsoftreatment.11 _{Comorbidities}_are_morbid_entities_that havealreadybeendiagnosedatthetimeofthediagnosisof theindexdisease,hereAML,orthatarediagnosedduringthe patientfollowup.

Extermannet al.11 _studied_the _tools_used _for comorbid-ityscoringinelderlypatientswithcancer.Theyshowedthat comorbidity scores increase with advancing age and that thesescoresarecorrelatedwithmortalitybutnotassociated tofunctionalstatus.11 _In_conclusion,_comorbidity_and func-tionalityareindependentvariablesandshouldbemeasured separatelyinolderpatientswithcancer.

Recently,hematologistsdevelopeddiseasespecific instru-mentsthatmeasurethe impactofcomorbiditiesonelderly individualswithAML,myelodysplasticsyndromesandthose submittedto hematopoieticstem cell transplantation. Sor-roretal.developedtheHematopoieticCell Transplantation ComorbidityIndex (HCT-CI)12 _which _has_already _been vali-datedinpatientswithAML.

Whathappenedtothepatient’sassessmentwiththe aggre-gationofsomegeriatricscales? Table3showstheresultof functionalandcomorbidityassessmentofthetworeported cases.

Clinical

challenges

follow-up

Patient1wassubmittedtothestandardtreatmentwithfull dosesoftheAMLinductionprotocol andoneconsolidation

phase.Afterconsolidation,heevolvedwithsepsisand pro-longedneutropenicperiod.Sixmonthsafterthediagnosisof AML,hewasaliveandwithoutevidenceofdisease.

Patient2wassubmittedtoexclusivepalliativecare, accord-ingtoherandherfamily’swishesandconsideringtheimpact ofhercomorbidity scoreand herdependence accordingto ADL/IADL.ShediedofAMLfourmonthsafterdiagnosis.

Consideringthesetwopatients,bothwithgoodKPS,Patient 1 wasten years older than Patient 2. Despite this,he had greaterautonomyandalowercomorbidityscorethat delin-eated aclinical context more favorableto AML treatment. Moreover,theaggregationofgeriatrictoolsaddedinformation aboutPatient2thatidentifiedherfunctionaland comorbidity-relatedrisks.Theseinstrumentsprovidedspecificinformation forthemanagementofherfinalphaseoflife.

Inconclusion,ADLand IADLimprovedthesensitivityof the functional assessment of these elderly patients. They added importantinformationaboutPatient 2thatchanged herperformancescorefrom‘good’to‘goodbutdependent’. Furthermore,theHCT-CIscorepredictedtheimpactof comor-bidities onhersurvival.TheapplicationsofADL,IADLand HCT-CIimprovetheassessmentofelderlypatientswith hema-tologicalmalignances.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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