Can we estimate the risk of chemotherapy toxicity in Indian geriatric patient population and utility of CRASH (chemotherapy risk assessment scale for high age patients) score?

Abstract

Background: Aging is heterogeneous and elderly population is diverse in health status and functional reserve. Cancer is a disease of aging, with the majority falling in age group above 65 years. The management of cancer in older aged person has many facets.The standard oncology evaluation cannot recognize those with likelihood of toxicity due to treatment. We need objective and measurable factors for decision making. This study was undertaken to predict severe chemotherapy toxicity using CRASH (the Chemotherapy Risk Assessment Scale for High-Age Patients) score. Methods: The study was conducted in the Department of Medical Oncology at Dr. B. L. Kapur Hospital, Pusa Road, New Delhi. It was a prospective observational cohort study conducted from October 2014-2016 including 100 patients. Patients with age ≥ 65 years with malignancy who were planned to be treated with a new course of cytotoxic chemotherapy were enrolled. The study commenced upon obtaining the necessary clearance from the hospital ethics. CRASH score was calculated and patient stratified in 4 categories i.e low (0- 3), Int (intermediate) -low (4-6), Int-high (7-9) and high (greater than 9). Toxicity was graded as per CTCAE Adverse events criteria Version 4.0. Patients developing Grade 3/4/5 non-hematologic or grade 4/5 hematologic toxicity was taken as development of severe toxicity. Results: Out of 100 patients, 64 (64%) were able to complete their prescribed treatment. Three fourth of the patients had ECOG PS less or equal to 2 (76 out of 100). Forty-four percent patients (44 patients) of our study cohort experienced Grade 4 hematologic (H) or Grade 3/4 non-hematologic toxicity (NH). Highest score in each category (Heme/nonheme/ CRASH) predicts nearly 100% toxicity risk. At a critical value of CRASH ≥ 6.5, the sensitivity is calculated as 100% while specificity is 89.09%. The accuracy of prediction is 93.88%. The median time taken to develop toxicity was 39.5 days. Conclusions: CRASH score utilizes clinical assessment and basic laboratory values. Yet it accurately predicts severe chemotherapy toxicity above a critical value of 6.5. Based on above study, first 30 days are crucial as 45% of patients experienced toxicity in this time frame. With the help of these clinical predictive markers, care of elderly will be optimized. (Table Presented) .