The Prognostic Value of Comprehensive Geriatric Assessment on the Management of Older Patients With Small Cell Lung Cancer

The Prognostic Value of Comprehensive Geriatric Assessment on the Management of Older Patients With Small Cell Lung Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Prognostic Value of Comprehensive Geriatric Assessment on the Management of Older Patients With Small Cell Lung Cancer You Jin Chun, Kwang Joon Kim, Ji Yeon Lee, Ji Won Choi, Tae Hee Kim, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1252460/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The prognostic value of a comprehensive geriatric assessment (CGA) for the management of older cancer patients remains to be established. This study investigated the association of each CGA variable with overall survival (OS) in older small cell lung cancer (SCLC) patients. Methods A retrospective cohort enrolled 21 older SCLC patients over 65 years from March 2018 to 2019 at the Yonsei Cancer Center. The CGA was performed before treatment and included the following instruments: Frailty, a circumference of arm/calf, body mass index (BMI), sarcopenia (e.g., Timed Up and Go test [TUG], grip strength), comorbidity, polypharmacy, function, nutrition, depression, and cognitive function. The correlations of oncological and geriatric variables with OS were determined. The log-rank test and a Cox model were used for the analysis. Prognostic factors of OS were examined by using the Kaplan-Meier method. Results The median age was 75 years (range 67-85). All patients had the Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2. The median survival was 9.93 months (1.53-36.30). Among CGA parameters, activities of daily living (ADL) and nutritional status had significant differences in OS in univariate analysis. In multivariate analysis, only nutritional status was independently associated with survival (HR 0.17 [95% CI 0.05-0.57]). Median OS for low nutritional status was 5.63 months and the normal nutrition group was 15.5 months ( p = .004 ). Conclusions Geriatric assessment detects more information than routine oncological evaluation alone, such as ECOG PS. Pre-treatment nutritional status measured by CGA appears to be a predictor of OS in older SCLC patients. A prospective study with larger sample size is desirable in the future. Geriatric Assessment Nutritional status Small Cell Lung Cancer Frail Elderly Prognosis Survival Figures Figure 1 Background As life expectancy increases, the number of older cancer patients is also expected to gradually increase. Lung cancer, in particular, is the leading cause of cancer-related deaths in the older population. Small cell lung cancer (SCLC) is a neuroendocrine tumor, accounting for approximately 15% of all lung cancers[ 1 ]. Unlike the recent development of a various treatment that immunotherapy or target therapy for non-small cell lung cancer (NSCLC), it is true that there is no significant change in treatment for SCLC. Moreover, the median age at diagnosis of SCLC is over 65 years old, which is a cancer that mainly occurs in smokers and older populations. Although chemotherapy and radiation therapy for SCLC is very burdensome for older patients, older patients with SCLC are underestimated when making treatment decisions in the clinical setting. Specialized assessment of overall health status and full support and management for the older SCLC patients is very important. This is a different concept from palliative care and requires an independent approach by geriatric professionals. Older cancer patients are a very heterogeneous group of patients in terms of geriatric syndromes including decreased physiological reserves, comorbidities, cognitive impairment, and disability. Older age negatively affects treatment tolerance, which in turn affects the prognosis. Therefore, a comprehensive approach to older cancer patients is essential. Several studies have investigated the effects of comprehensive geriatric assessment (CGA) on overall survival (OS), in-hospital mortality, hospitalization, adverse events, quality of life, and treatment allocation, suggesting that the CGA more accurately determine the health status of older cancer patients compared to the Eastern Cooperative Oncology Group performance status (ECOG PS) which is commonly used function measuring score in the current clinical setting[ 2 , 3 ]. In other words, successful treatment of older cancer patients requires overall management of physical, cognitive, emotional, nutritional status, and medication history. For this reason, a formal geriatric assessment has been developed for older adults[ 4 – 6 ]. However, studies specifically examining the relationship between CGA and OS in older SCLC patients are lacking. Therefore, this study aimed to estimate the prognostic role of various CGA domains on OS in older patients with SCLC. This will enable appropriate predictions and interventions to determine whether to treat chemotherapy and manage it during chemotherapy in older SCLC patients. Methods Patients This retrospective cohort study enrolled 291 patients aged over 65 years diagnosed with cancer at Yonsei Cancer Center between March 2018 and March 2019. Patients who were not available to receive CGA or aged under 65 years were excluded. Of these, 21 patients were diagnosed with SCLC and completed CGA before treatment. Their survival was followed until August 2021. Apart from the CGA, ECOG PS was also measured. We aim to analyze the CGA domain associated with OS in older SCLC patients. Informed consent was waived by the Institutional Review Board of Yonsei University’s Health System in the ethics approval and consent to participate for this study as all the data was obtained from medical records (IRB number: 4-2021-1348). Statistical analysis The Cox regression test was used for univariate and multivariate analyses using the Cox proportional hazards model to evaluate the prognostic value of CGA domains. The log-rank test was used to evaluate survival differences between the groups according to CGA scores. Cumulative survival rates were calculated by the Kaplan-Meier method. Confidence intervals at the 95 % level [95% CI] were calculated, and statistical significance was considered with P -values less than 0.05 . All analyses were performed using SPSS for Windows, version 25 (SPSS Inc, Chicago, IL). Comprehensive geriatric assessment All participants underwent the CGA by trained geriatric nurses before the starting of chemotherapy. The CGA consisted of the following domains: basic items, physical activity, functional status, frailty, nutritional status, cognition, and depression. Basic items consisted of medical history including comorbidity, medications being taken, Timed Up and Go test (TUG test), grip strength, and lifestyle habits such as smoking. Comorbidity was evaluated by Charlson’s comorbidity index (CCI)[4], summing up the data regarding myocardial infarction, congestive heart failure, peripheral vascular disease, cerebral vascular disease, dementia, chronic pulmonary disease, rheumatologic disease, peptic ulcer disease, mild liver disease, diabetes, and so on. Since we only enrolled the SCLC patients, all patients scored 6 points in CCI, and 9 points were set as cut-offs for analysis[4]. The number of medications was analyzed by dividing 5 drugs as a cut-off value[7]. The clinical significance of sarcopenia is increasingly recognized as a component of cancer cachexia syndrome, and with this increasing awareness, a recent international consensus has established sarcopenia as the major diagnostic criterion for cancer cachexia[8]. Therefore, we included circumference of arm and calf[9], TUG test, and grip strength in the CGA parameters to evaluate sarcopenia. Circumference of arm and calf means the amount of muscle mass. Since muscle mass itself may not indicate reliable muscle function, we further measured the TUG test and grip strength. In the TUGtest, the patient was observed and timed while standing up from the chair, walking three meters, turns walking back, and sitting down again[10]. Patients who were able to complete the task in less than 12.6 seconds were considered to have good mobility. The cut-off value of hand grip strength was based on the consensus of the Asian Working Group for Sarcopenia (AWGS): 26.0 kg for male and 18.0 kg for female patients, respectively[11]. Additionally, body mass index (BMI) was also measured. Level of Frailty was assessed by the FRAIL scale, which was translated into Korean from Morley et al.’s FRAIL scale[12]. This self-reported five-item tool includes fatigue (F), resistance (R), ambulation (A), illnesses (I), and loss of weight (L). The total score (0-5) can be categorized into three: robust (0), pre-frail (1-2), frail (3-5). Functional statuswas evaluated by assessing Activities of Daily Living (ADL)[13] and Korean Instrumental Activities of Daily Living (IADL)[14]. Six items of ADL included dressing, eating, walking on a corridor, toilet use, bathing, fecal and urinary continence. Older adults with at least one dependency in ADL category were considered as ADL dependent. IADL included eight items which were shopping, housekeeping, ability to handle finances, ability to prepare food, traveling via car or public transportation, doing laundry, ability to use the telephone, and medication use. Older adults with at least one dependency in IADL category were assessed as IADL dependent. Nutritional status was assessed by the short version of the Mini Nutritional Assessment (MNA)[15]. It consists of 6 questions: decreased food intake, weight change, exercise capacity, medical history, cognitive impairment, and BMI. The MNA score (range 0-14) of over 12 was evaluated as normal nutritional status, a score of 8-11 as a risk of malnutrition, and a score of 0-7 as a stage of malnutrition. Cognitive function was assessed using the Korean version of the Mini-Mental Status Examination for Dementia Screening (MMSE-DS). This 30-item tool indicated decrease in cognitive capacity with lower score[16]. A score below 17 denotes impairment, a score from 17 to 24 denotes mild impairment, and a score of 25 or more denotes normal in cognitive capacity[17]. The Korean version Short Form of the Geriatric Depression Scale (GDSSF-K) was used to assess depression. This 15-item tool (range 0-15) indicated the risk of depression when the score is more than five points[18]. Results Patients Characteristics Of the 21 older SCLC patients, 20 were males, and 1 was female ( Table 1 ). The median age of the patients was 75 years old (range, 67-85). Nineteen patients were initially at the extensive stage; 2 patients were at the limited stage. Of the 21 patients, 20 (95.24%) patients had ECOG PS 0 or 1. Treatment of SCLC was classified as combined chemoradiation (sequential or concurrent), chemotherapy alone, and best supportive care. The recommended chemotherapy for SCLC in this study was carboplatin-etoposide. Nine patients underwent combined chemoradiation therapy including radiation to the lung, and only one of them received radiation to the metastatic lesion of the pelvic bone. Nine patients received chemotherapy alone, one patient was not treated due to spondylitis and the other patient was due to a urinary tract infection. Only one patient received prophylactic cranial irradiation (PCI). Six patients with brain metastases underwent the whole brain radiation therapy, and 15 patients were without brain metastases. The median OS was 9.3 months (1.53-36.30 months) ( Table 1 ). Table 1 Characteristics of Patients N % Age at CGA Median, year (Range) 75 (67-85) Gender Male 20 Female 1 Treatment Combined chemoradiation (sequential or concurrent) 9 42.86% Chemotherapy alone 9 42.86% Best supportive care 2 9.52% Follow up loss 1 4.76% ECOG PS 0 12 57.14% 1 8 38.10% 2 1 4.76% Stage Extensive 19 90.48% Limited 2 9.52% PCI Done 1 Brain metastases Yes* 6 28.57% No 15 71.43% OS Median, month (Range) 9.33 (1.53-36.30) *All patients with brain metastases received whole brain radiation therapy. N , Number of included patients; ECOG PS , the Eastern Cooperative Oncology Group performance status; PCI , prophylactic cranial irradiation; OS , Overall survival Baseline Cga Results Results regarding the relationship between the CGA domains and OS are summarized in Table 2 . In univariate analysis, the level of frailty did not affect OS. The median arm circumference of the patients was 24 cm and the median calf circumference was 30.5 cm, which also did not affect OS. Seven patients with BMI over 25 kg/m 2 were defined as obese, 6 patients with BMI over 23 kg/m 2 were overweight, and 8 patients with BMI less than 23 kg/m 2 . Differences by BMI were also insignificant. There were 8 patients with normal TUG, 5 patients with prolonged TUG, and 8 patients who did not perform the test. TUG also did not affect OS. A minimum score of 6 points on CCI was the baseline score for patients diagnosed with SCLC, and 10 patients with a total score of over 9 points, including other chronic diseases, did not affect OS. Ten patients were taking more than 5 drugs, and this also did not affect OS. There were 6 patients with current smokers, 14 patients with ex-smokers, and 1 patient with never-smoker. Smoking history did not affect OS. Eleven patients with a depression-related GDS score of over 5 and 11 patients with IADL dependency were measured, but none of them significantly affected OS. The MMSE defined cognitive impairment based on a score of less than 24, with only 1 patient scoring less than 24 and all other patients being normal. Therefore, MMSE did not affect survival. Finally, in univariate analysis, ADL and nutritional status significantly affected the survival of SCLC patients ( p = 0.017, p = 0.025 , respectively). There were 7 patients with ADL dependency, 11 patients with normal nutritional status with an MNA score of over 12, 8 patients with 8-11 points, and 2 patients with 0-7 points. It showed that the better the nutritional status, the longer the survival. In multivariate analysis, adjusted for sex and age, only nutritional status had a significant effect on OS. Those with an MNA score of over 12 had significantly longer survival than those with an MNA score of less than 12 (median survival 5.63 vs 15.50, p = 0.004 , HR 0.17 [95% CI 0.05-0.57]) (Figure 1). Table 2 Domains explored by comprehensive geriatric assessment Univariate analysis Multivariate analysis p value Exp(B) 95% CI p value Exp(B) 95% CI Frail 0-2 14 0.437 1.51 0.54-4.24 3-5 7 Circumference of arm (cm) median 24 0.400 0.91 0.74-1.13 range 21-28.5 Circumference of calf (cm) median 30.5 0.909 0.99 0.84-1.17 range 26.5-38.8 BMI < 23 kg/m 2 8 0.146 0.85 0.68-1.06 ≥ 23 kg/m 2 6 ≥ 25 kg/m 2 7 TUG (Second) normal 8 0.507 0.66 0.20-2.24 Higher (≥12.6s) 5 not done 8 Grip strength (kg) normal 13 0.694 0.82 0.29-2.26 low(<26kg in men; <18kg in women) 8 CCI < 9 11 0.456 1.46 0.54-3.93 ≥ 9 10 Drug ≥ 5 11 0.875 1.08 0.40-2.93 < 5 10 Smoking never-smoker 1 ex-smoker 14 0.273 0.30 0.04-2.59 current-smoker 6 0.545 0.50 0.06-4.65 MNA ≥12 11 0.025 0.30 0.11-0.86 0.004 0.17 0.05-0.57 8-11 8 0-7 2 GDS ≥ 5 11 0.619 0.76 0.26-2.21 < 5 9 Unknown 1 ADL Impaired 7 0.017 3.78 1.27-11.22 IADL Impaired 11 0.458 1.46 0.54-3.94 MMSE < 24 1 0.100 0.13 0.01-1.48 ≥ 24 16 unknown 4 BMI , Body Mass Index; TUG , Timed Up and Go test; CCI , Charlson Comorbidity Index; MNA , Mini Nutritional Assessment; GDS , Geriatric Depression Scale; ADL , activities of Daily Living; IADL , Instrumental Activities of Daily Living; MMSE , Mini-Mental State Exam Discussion CGA has important prognostic information. This can be helpful to predict survival and life expectancy in older people, which is crucial for oncologists to know when to make treatment decisions. CGA in older cancer patients indicates previously unknown geriatric problems in many patients (up to 50%) and may alter treatment decisions in 10-20% of patients[ 19 ]. Among the domains of CGA, limitations in cognition, nutrition, function, and comorbidities have been shown to be important factors in diminishing OS in older cancer patients in several studies[ 20 – 22 ]. It has also been shown that specialized geriatric intervention for older cancer patients significantly improved OS and facilitated a return to their own home compared to conventional care. We recommend some form of geriatric assessment, such as CGA, in all older cancer patients for whom to make important treatment decisions, and our study began on this basis. We analyzed retrospectively enrolled data to investigate the prognostic significance of the CGA domain and identified that low MNA scores and impaired ADL were significant indicators of poor OS in patients with SCLC. In multivariate analysis, only malnutrition, independent of PS, was associated with poor OS. Our results are consistent with previous studies examining CGA parameters associated with changes in cancer treatment. In cancer treatment, malnutrition is known as a practical parameter to consider, as it is associated with therapeutic toxicity and mortality[ 23 ]. In several studies, a low BMI of less than 21 kg/m 2 was related to a modification of the cancer treatment regimen[ 24 ]. According to another study, malnutrition as assessed by MNA, BMI, weight loss, and low serum albumin was also related to changes in cancer treatment, mostly a decrease in treatment intensity[ 25 ]. In comparative studies of biochemical markers, anthropometric measures, and the MNA, the MNA was found to be strongly correlated with baseline weight loss in cancer patients and was recommended as a nutritional assessment tool. This suggests that early intervention and treatment of malnutrition in older cancer patients might be particularly important for improving OS. Malnutrition screening in older cancer patients enables preventive actions early stage of malnutrition in their cancer treatment[ 26 ]. Nutritional supplementation may be beneficial for older patients. A meta-analysis of 55 clinical trials showed the benefit of oral supplementations on OS in older patients. They reported that malnourished older patients benefit from oral supplementations when taking oral supplementation compared to patients not taking it (OR 0.66 [95% CI 0.49-0.90]) with reduced mortality[ 27 ]. In line with our findings, it appears that malnourished older cancer patients might also be able to improve their OS with oral supplementation, which requires further research. A recent meta-analysis study has been reported that sarcopenia affects the survival rate of lung cancer patients[ 28 ], but our study did not show a significant difference. While most of these studies performed survival analysis by measuring muscle size via Computer Tomography (CT), our study analyzed survival by assessing muscle function (i.e., TUG and grip strength). There are some studies on the effect of muscle function assessment on survival, but it is still insufficient[ 29 ]. In addition to sarcopenia, there are studies on the effects of ADL and IADL assessment on survival, but data are still lacking. In our study, the ADL dependency was found to affect survival in a univariate analysis. In other words, CGA has the potential to be a useful evaluation tool to predict the prognosis for older cancer patients in various aspects. However, it is not easy to apply CGA to clinical practice. Implementation of CGA in various clinical environments can pose significant challenges due to the lack of specific information about CGA tools. For example, what is the exact question for a particular geriatric assessment tool, what cutoff scores are used within a particular scale, how the results should be interpreted, and whether this scale has been validated in oncology. To overcome these limitations, the National Comprehensive Cancer Network (NCCN), the European Organization for Research and Treatment of Cancer (EORTC), and the International Society of Geriatric Oncology (SIOG) guidelines are proposing a ‘two-step’ approach with screening tools for early risk detection. Through the G8 questionnaire[ 30 ], the presence of risk factors is initially screened to select older cancer patients in need of geriatric assessment, and CGA and geriatric interventions are performed. The G8 questionnaire is currently known as one of the best screening tools to identify older cancer patients due to its high sensitivity and independent 1-year survival rate. Our study has several limitations to be noted. First, it was conducted at a single institution with a relatively small sample size of 21 patients. Also, since only patients suitable for chemotherapy were initially enrolled, there is a possibility that only patients with relatively good cognitive function or performance status were selected. Therefore, the interpretation of our results should be cautious, and a prospective study with larger sample size is desirable in the future. Despite the above limitations, this is an important study to suggest the prognostic implications of CGA in older patients with SCLC. Conclusions Geriatric assessment detects more information than routine oncological evaluation alone, such as ECOG PS. Pre-treatment nutritional status measured by CGA appears to be a predictor of OS in older SCLC patients. Further studies are required to verify the prospective role of CGA on older cancer patients. Abbreviations ADL: Activities of Daily Living BMI: Body Mass Index CCI: Charlson Comorbidity Index CGA: Comprehensive Geriatric Assessment ECOG PS: Eastern Cooperative Oncology Group performance status EORTC: European Organization for Research and Treatment of Cancer GDSSF-K: Korean version Short Form of the Geriatric Depression Scale HR: Hazard Ratio IADL: Instrumental Activities of Daily Living MMSE: Mini-Mental State Exam MNA: Mini Nutritional Assessment NCCN: National Comprehensive Cancer Network NSCLC: Non-Small Cell Lung Cancer OS: Overall Survival PCI: Prophylactic Cranial Irradiation SCLC: Small Cell Lung Cancer SIOG: International Society of Geriatric Oncology TUG: Timed Up and Go test Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Board of Yonsei University’s Health System (IRB number: 4-2021-1348) and adhered to the tenets of the Declaration of Helsinki. Informed consent was waived by the IRB of Yonsei University’s Health System for this study as all the data was obtained from medical records. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available due to the ethics approval for this study. However, the data are available from the corresponding author on reasonable request. Competing interests The authors have no competing interests do declare. Funding This work was supported by the Research Program funded by the Korea Disease Control and Prevention Agency (2019-ER6302-02) and IITP grant funded by the Korea government (MSIT) (No.2017-0-01779, XAI). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Acknowledgements We would like to thank the Division of medical oncology for assistance with patient enrollment. Authors’ Contributions YJC, KJK, COK, and MHH were involved in the study design. JYL, JWC, THK did data collection. HRK, BCC, and MHH helped on recruiting participants. YJC and JYL did data analysis. YJC did manuscript writing. KJK, COK and MHH supervised the study and performed significant editing of the manuscript. All authors have read and approved the final manuscript. References SEER Cancer Statistics Review, 1975- 2016 , based on November 2018 SEER data submission , posted to the SEER web site , April 2019 . [ https://seer.cancer.gov/csr/1975 2016/] LeCaer H, Barlesi F, Corre R, Jullian H, Bota S, Falchero L, Vergnenegre A, Dujon C, Delhoume JY, Chouaid C et al : A multicentre phase II randomised trial of weekly docetaxel / gemcitabine followed by erlotinib on progression , vs the reverse sequence , in elderly patients with advanced non small - cell lung cancer selected with a comprehensive geriatric assessment ( the GFPC 0504 study ). 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1252460","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":80064283,"identity":"0715e3f3-6096-4ae2-8955-365d464b589b","order_by":0,"name":"You Jin Chun","email":"","orcid":"","institution":"Severance Executive Healthcare Clinic, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"You","middleName":"Jin","lastName":"Chun","suffix":""},{"id":80064284,"identity":"875783ac-7e92-439c-8944-7fc1485a9054","order_by":1,"name":"Kwang Joon Kim","email":"","orcid":"","institution":"Divison of Geriatrics, Department of Internal medicine, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kwang","middleName":"Joon","lastName":"Kim","suffix":""},{"id":80064285,"identity":"2272fbdd-f5bb-4253-976b-2a1835f62d46","order_by":2,"name":"Ji Yeon Lee","email":"","orcid":"","institution":"Yonsei University College of Nursing","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ji","middleName":"Yeon","lastName":"Lee","suffix":""},{"id":80064286,"identity":"73649eea-be08-4cff-afe1-4cf012a03ecd","order_by":3,"name":"Ji Won Choi","email":"","orcid":"","institution":"Divison of Geriatrics, Department of Internal medicine, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ji","middleName":"Won","lastName":"Choi","suffix":""},{"id":80064287,"identity":"eed23322-d513-45e8-b7aa-d9bc0bbb3af5","order_by":4,"name":"Tae Hee Kim","email":"","orcid":"","institution":"Divison of Geriatrics, Department of Internal medicine, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Tae","middleName":"Hee","lastName":"Kim","suffix":""},{"id":80064288,"identity":"35d9bba6-909b-4974-81e1-1da8cf0b2e1b","order_by":5,"name":"Hye Ryun Kim","email":"","orcid":"","institution":"Divison of Oncology, Department of Internal medicine, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hye","middleName":"Ryun","lastName":"Kim","suffix":""},{"id":80064289,"identity":"6f3648ce-587b-42ac-9950-3e6f6a81e5e8","order_by":6,"name":"Byoung Chul Cho","email":"","orcid":"","institution":"Divison of Oncology, Department of Internal medicine, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Byoung","middleName":"Chul","lastName":"Cho","suffix":""},{"id":80064290,"identity":"09472072-1ecd-4bf2-81a4-43add693d608","order_by":7,"name":"Min Hee Hong","email":"","orcid":"","institution":"Divison of Oncology, Department of Internal medicine, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Min","middleName":"Hee","lastName":"Hong","suffix":""},{"id":80064291,"identity":"461c196d-bfb8-4446-a99d-ae5d65d10a49","order_by":8,"name":"Chang Oh Kim","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAoklEQVRIiWNgGAWjYBAC/vYe4888FQwMBkRrkThzJuHwnDOkaDGIyDlw+G8bSVokchsO5847nLid/wDjhx/EaclnOJy77XDizhkJzJI9JGnZcIOBQZp4h/HOAWo5f4D5N3FaQN7nbQBqOZDARpwt4EDmOZZuvOFGYpslUX6BRGWNteyG84cP3yAqxKCgGYgZG0jQwMBQR5LqUTAKRsEoGGEAAPlmPLOj69RKAAAAAElFTkSuQmCC","orcid":"","institution":"Divison of Geriatrics, Department of Internal medicine, Yonsei University College of Medicine, Severance Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Chang","middleName":"Oh","lastName":"Kim","suffix":""}],"badges":[],"createdAt":"2022-01-12 06:14:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1252460/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1252460/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":17810525,"identity":"7d266f58-316a-4c28-8f60-267add60e2ad","added_by":"auto","created_at":"2022-01-31 16:22:01","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23386,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverall survival according to nutritional status\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe Mini Nutritional Assessment (MNA) is one of the domains of comprehensive geriatric assessment (CGA). The overall survival (OS) was longer in older small cell lung cancer (SCLC) patients with normal nutritional status or at risk of undernutrition compared to patients with malnutrition (median survival 15.50 vs 5.63, \u003cem\u003ep = 0.004\u003c/em\u003e, HR 0.17 [95% CI 0.05-0.57]).\u003c/p\u003e","description":"","filename":"Fig01.png","url":"https://assets-eu.researchsquare.com/files/rs-1252460/v1/aa31eb6044550bc2bfd4560b.png"},{"id":20791636,"identity":"00dc44f0-ad00-4fdd-90fd-b8053879a80f","added_by":"auto","created_at":"2022-04-26 17:29:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1109639,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1252460/v1/2cce18dd-aa99-4c8a-96c4-9dd5241483c8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Prognostic Value of Comprehensive Geriatric Assessment on the Management of Older Patients With Small Cell Lung Cancer\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eAs life expectancy increases, the number of older cancer patients is also expected to gradually increase. Lung cancer, in particular, is the leading cause of cancer-related deaths in the older population. Small cell lung cancer (SCLC) is a neuroendocrine tumor, accounting for approximately 15% of all lung cancers[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Unlike the recent development of a various treatment that immunotherapy or target therapy for non-small cell lung cancer (NSCLC), it is true that there is no significant change in treatment for SCLC. Moreover, the median age at diagnosis of SCLC is over 65 years old, which is a cancer that mainly occurs in smokers and older populations. Although chemotherapy and radiation therapy for SCLC is very burdensome for older patients, older patients with SCLC are underestimated when making treatment decisions in the clinical setting. Specialized assessment of overall health status and full support and management for the older SCLC patients is very important. This is a different concept from palliative care and requires an independent approach by geriatric professionals.\u003c/p\u003e \u003cp\u003eOlder cancer patients are a very heterogeneous group of patients in terms of geriatric syndromes including decreased physiological reserves, comorbidities, cognitive impairment, and disability. Older age negatively affects treatment tolerance, which in turn affects the prognosis. Therefore, a comprehensive approach to older cancer patients is essential. Several studies have investigated the effects of comprehensive geriatric assessment (CGA) on overall survival (OS), in-hospital mortality, hospitalization, adverse events, quality of life, and treatment allocation, suggesting that the CGA more accurately determine the health status of older cancer patients compared to the Eastern Cooperative Oncology Group performance status (ECOG PS) which is commonly used function measuring score in the current clinical setting[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In other words, successful treatment of older cancer patients requires overall management of physical, cognitive, emotional, nutritional status, and medication history. For this reason, a formal geriatric assessment has been developed for older adults[\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, studies specifically examining the relationship between CGA and OS in older SCLC patients are lacking. Therefore, this study aimed to estimate the prognostic role of various CGA domains on OS in older patients with SCLC. This will enable appropriate predictions and interventions to determine whether to treat chemotherapy and manage it during chemotherapy in older SCLC patients.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003ePatients\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective cohort study enrolled 291 patients aged over 65 years diagnosed with cancer at Yonsei Cancer Center between March 2018 and March 2019. Patients who were not available to receive CGA or aged under 65 years were excluded. Of these, 21 patients were diagnosed with SCLC and completed CGA before treatment. Their survival was followed until August 2021. Apart from the CGA, ECOG PS was also measured. We aim to analyze the CGA domain associated with OS in older SCLC patients. Informed consent was waived by the Institutional Review Board of Yonsei University\u0026rsquo;s Health System in the ethics approval and consent to participate for this study as all the data was obtained from medical records (IRB number: 4-2021-1348).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Cox regression test was used for univariate and multivariate analyses using the Cox proportional hazards model to evaluate the prognostic value of CGA domains. The log-rank test was used to evaluate survival differences between the groups according to CGA scores. Cumulative survival rates were calculated by the Kaplan-Meier method. Confidence intervals at the 95 % level [95% CI] were calculated, and statistical significance was considered with \u003cem\u003eP\u003c/em\u003e-values less than \u003cem\u003e0.05\u003c/em\u003e. All analyses were performed using SPSS for Windows, version 25 (SPSS Inc, Chicago, IL).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComprehensive geriatric assessment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll participants underwent the CGA by trained geriatric nurses before the starting of chemotherapy. The CGA consisted of the following domains: basic items, physical activity, functional status, frailty, nutritional status, cognition, and depression. Basic items consisted of medical history including comorbidity, medications being taken, Timed Up and Go test (TUG test), grip strength, and lifestyle habits such as smoking. Comorbidity was evaluated by Charlson\u0026rsquo;s comorbidity index (CCI)[4], summing up the data regarding myocardial infarction, congestive heart failure, peripheral vascular disease, cerebral vascular disease, dementia, chronic pulmonary disease, rheumatologic disease, peptic ulcer disease, mild liver disease, diabetes, and so on. Since we only enrolled the SCLC patients, all patients scored 6 points in CCI, and 9 points were set as cut-offs for analysis[4].\u0026nbsp;The number of medications was analyzed by dividing 5 drugs as a cut-off value[7].\u0026nbsp;The clinical significance of sarcopenia is increasingly recognized as a component of cancer cachexia syndrome, and with this increasing awareness, a recent international consensus has established sarcopenia as the major diagnostic criterion for cancer cachexia[8]. Therefore, we included circumference of arm and calf[9], TUG test, and grip strength in the CGA parameters to evaluate sarcopenia. Circumference of arm and calf means the amount of muscle mass. Since muscle mass itself may not indicate reliable muscle function, we further measured the TUG test and grip strength. In the TUGtest, the patient was observed and timed while standing up from the chair, walking three meters, turns walking back, and sitting down again[10]. Patients who were able to complete the task in less than 12.6 seconds were considered to have good mobility. The cut-off value of hand grip strength was based on the consensus of the Asian Working Group for Sarcopenia (AWGS): 26.0 kg for male and 18.0 kg for female patients, respectively[11]. Additionally, body mass index (BMI) was also measured. Level of Frailty was assessed by the FRAIL scale, which was translated into Korean from Morley et al.\u0026rsquo;s FRAIL scale[12]. This self-reported five-item tool includes fatigue (F), resistance (R), ambulation (A), illnesses (I), and loss of weight (L). The total score (0-5) can be categorized into three: robust (0), pre-frail (1-2), frail (3-5). Functional statuswas evaluated by assessing Activities of Daily Living (ADL)[13] and Korean Instrumental Activities of Daily Living (IADL)[14]. Six items of ADL included dressing, eating, walking on a corridor, toilet use, bathing, fecal and urinary continence. Older adults with at least one dependency in ADL category were considered as ADL dependent. IADL included eight items which were shopping, housekeeping, ability to handle finances, ability to prepare food, traveling via car or public transportation, doing laundry, ability to use the telephone, and medication use. Older adults with at least one dependency in IADL category were assessed as IADL dependent. Nutritional status was assessed by the short version of the Mini Nutritional Assessment (MNA)[15]. It consists of 6 questions: decreased food intake, weight change, exercise capacity, medical history, cognitive impairment, and BMI. The MNA score (range 0-14) of over 12 was evaluated as normal nutritional status, a score of 8-11 as a risk of malnutrition, and a score of 0-7 as a stage of malnutrition. Cognitive function was assessed using the Korean version of the Mini-Mental Status Examination for Dementia Screening (MMSE-DS). This 30-item tool indicated decrease in cognitive capacity with lower score[16]. A score below 17 denotes impairment, a score from 17 to 24 denotes \u0026nbsp;mild impairment, and a score of 25 or more denotes normal in cognitive capacity[17]. The Korean version Short Form of the Geriatric Depression Scale (GDSSF-K) was used to assess depression. This 15-item tool (range 0-15) indicated the risk of depression when the score is more than five points[18].\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003ePatients Characteristics\u003c/h2\u003e \u003cp\u003eOf the 21 older SCLC patients, 20 were males, and 1 was female \u003cb\u003e(\u003c/b\u003eTable \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e The median age of the patients was 75 years old (range, 67-85). Nineteen patients were initially at the extensive stage; 2 patients were at the limited stage. Of the 21 patients, 20 (95.24%) patients had ECOG PS 0 or 1. Treatment of SCLC was classified as combined chemoradiation (sequential or concurrent), chemotherapy alone, and best supportive care. The recommended chemotherapy for SCLC in this study was carboplatin-etoposide. Nine patients underwent combined chemoradiation therapy including radiation to the lung, and only one of them received radiation to the metastatic lesion of the pelvic bone. Nine patients received chemotherapy alone, one patient was not treated due to spondylitis and the other patient was due to a urinary tract infection. Only one patient received prophylactic cranial irradiation (PCI). Six patients with brain metastases underwent the whole brain radiation therapy, and 15 patients were without brain metastases. The median OS was 9.3 months (1.53-36.30 months) \u003cb\u003e(\u003c/b\u003eTable \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge at CGA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian, year (Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75 (67-85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined chemoradiation (sequential or concurrent)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChemotherapy alone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e42.86%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBest supportive care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.52%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFollow up loss\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.76%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eECOG PS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e57.14%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e38.10%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4.76%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eStage\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExtensive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90.48%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLimited\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9.52%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eBrain metastases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.57%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71.43%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian, month (Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.33 (1.53-36.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e \u003cp\u003e*All patients with brain metastases received whole brain radiation therapy.\u003c/p\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e, Number of included patients; \u003cem\u003eECOG PS\u003c/em\u003e, the Eastern Cooperative Oncology Group performance status; \u003cem\u003ePCI\u003c/em\u003e, prophylactic cranial irradiation; \u003cem\u003eOS\u003c/em\u003e, Overall survival\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline Cga Results\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResults regarding the relationship between the CGA domains and OS are summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In univariate analysis, the level of frailty did not affect OS. The median arm circumference of the patients was 24 cm and the median calf circumference was 30.5 cm, which also did not affect OS. Seven patients with BMI over 25 kg/m\u003csup\u003e2\u003c/sup\u003e were defined as obese, 6 patients with BMI over 23 kg/m\u003csup\u003e2\u003c/sup\u003e were overweight, and 8 patients with BMI less than 23 kg/m\u003csup\u003e2\u003c/sup\u003e. Differences by BMI were also insignificant. There were 8 patients with normal TUG, 5 patients with prolonged TUG, and 8 patients who did not perform the test. TUG also did not affect OS. A minimum score of 6 points on CCI was the baseline score for patients diagnosed with SCLC, and 10 patients with a total score of over 9 points, including other chronic diseases, did not affect OS. Ten patients were taking more than 5 drugs, and this also did not affect OS. There were 6 patients with current smokers, 14 patients with ex-smokers, and 1 patient with never-smoker. Smoking history did not affect OS. Eleven patients with a depression-related GDS score of over 5 and 11 patients with IADL dependency were measured, but none of them significantly affected OS. The MMSE defined cognitive impairment based on a score of less than 24, with only 1 patient scoring less than 24 and all other patients being normal. Therefore, MMSE did not affect survival. Finally, in univariate analysis, ADL and nutritional status significantly affected the survival of SCLC patients (\u003cem\u003ep = 0.017, p = 0.025\u003c/em\u003e, respectively). There were 7 patients with ADL dependency, 11 patients with normal nutritional status with an MNA score of over 12, 8 patients with 8-11 points, and 2 patients with 0-7 points. It showed that the better the nutritional status, the longer the survival. In multivariate analysis, adjusted for sex and age, only nutritional status had a significant effect on OS. Those with an MNA score of over 12 had significantly longer survival than those with an MNA score of less than 12 (median survival 5.63 vs 15.50, \u003cem\u003ep = 0.004\u003c/em\u003e, HR 0.17 [95% CI 0.05-0.57]) \u003cb\u003e(Figure 1).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDomains explored by comprehensive geriatric assessment\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"13\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c7\" namest=\"c4\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"6\" nameend=\"c13\" namest=\"c8\"\u003e \u003cp\u003eMultivariate analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003ep\u003c/span\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eExp(B)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003ep\u003c/span\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003eExp(B)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c13\" namest=\"c10\"\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eFrail\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.437\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.54-4.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3-5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCircumference of arm (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.400\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.74-1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003erange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21-28.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCircumference of calf (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.909\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.84-1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003erange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26.5-38.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt; 23 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.146\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.68-1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge; 23 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge; 25 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eTUG (Second)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.507\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.20-2.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigher\u003c/p\u003e \u003cp\u003e(\u0026ge;12.6s)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enot done\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGrip strength (kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enormal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.694\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.29-2.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003elow(\u0026lt;26kg in men; \u0026lt;18kg in women)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eCCI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt; 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.456\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.54-3.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge; 9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDrug\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.875\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.40-2.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSmoking\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003enever-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eex-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.273\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.04-2.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ecurrent-smoker\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.545\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.06-4.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMNA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.025\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.11-0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003e0.004\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"4\" nameend=\"c13\" namest=\"c10\"\u003e \u003cp\u003e0.05-0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8-11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0-7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eGDS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.619\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.26-2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt; 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eADL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpaired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.017\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1.27-11.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIADL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eImpaired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.458\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.54-3.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMMSE\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt; 24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e0.100\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.01-1.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c11\" namest=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c13\" namest=\"c12\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge; 24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eunknown\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c12\" namest=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"13\" nameend=\"c13\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eBMI\u003c/em\u003e, Body Mass Index; \u003cem\u003eTUG\u003c/em\u003e, Timed Up and Go test; \u003cem\u003eCCI\u003c/em\u003e, Charlson Comorbidity Index; \u003cem\u003eMNA\u003c/em\u003e, Mini Nutritional Assessment; \u003cem\u003eGDS\u003c/em\u003e, Geriatric Depression Scale; \u003cem\u003eADL\u003c/em\u003e, activities of Daily Living; \u003cem\u003eIADL\u003c/em\u003e, Instrumental Activities of Daily Living; \u003cem\u003eMMSE\u003c/em\u003e, Mini-Mental State Exam\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCGA has important prognostic information. This can be helpful to predict survival and life expectancy in older people, which is crucial for oncologists to know when to make treatment decisions. CGA in older cancer patients indicates previously unknown geriatric problems in many patients (up to 50%) and may alter treatment decisions in 10-20% of patients[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Among the domains of CGA, limitations in cognition, nutrition, function, and comorbidities have been shown to be important factors in diminishing OS in older cancer patients in several studies[\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. It has also been shown that specialized geriatric intervention for older cancer patients significantly improved OS and facilitated a return to their own home compared to conventional care. We recommend some form of geriatric assessment, such as CGA, in all older cancer patients for whom to make important treatment decisions, and our study began on this basis.\u003c/p\u003e \u003cp\u003eWe analyzed retrospectively enrolled data to investigate the prognostic significance of the CGA domain and identified that low MNA scores and impaired ADL were significant indicators of poor OS in patients with SCLC. In multivariate analysis, only malnutrition, independent of PS, was associated with poor OS. Our results are consistent with previous studies examining CGA parameters associated with changes in cancer treatment. In cancer treatment, malnutrition is known as a practical parameter to consider, as it is associated with therapeutic toxicity and mortality[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In several studies, a low BMI of less than 21 kg/m\u003csup\u003e2\u003c/sup\u003e was related to a modification of the cancer treatment regimen[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. According to another study, malnutrition as assessed by MNA, BMI, weight loss, and low serum albumin was also related to changes in cancer treatment, mostly a decrease in treatment intensity[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In comparative studies of biochemical markers, anthropometric measures, and the MNA, the MNA was found to be strongly correlated with baseline weight loss in cancer patients and was recommended as a nutritional assessment tool. This suggests that early intervention and treatment of malnutrition in older cancer patients might be particularly important for improving OS. Malnutrition screening in older cancer patients enables preventive actions early stage of malnutrition in their cancer treatment[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Nutritional supplementation may be beneficial for older patients. A meta-analysis of 55 clinical trials showed the benefit of oral supplementations on OS in older patients. They reported that malnourished older patients benefit from oral supplementations when taking oral supplementation compared to patients not taking it (OR 0.66 [95% CI 0.49-0.90]) with reduced mortality[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In line with our findings, it appears that malnourished older cancer patients might also be able to improve their OS with oral supplementation, which requires further research.\u003c/p\u003e \u003cp\u003eA recent meta-analysis study has been reported that sarcopenia affects the survival rate of lung cancer patients[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], but our study did not show a significant difference. While most of these studies performed survival analysis by measuring muscle size via Computer Tomography (CT), our study analyzed survival by assessing muscle function (i.e., TUG and grip strength). There are some studies on the effect of muscle function assessment on survival, but it is still insufficient[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. In addition to sarcopenia, there are studies on the effects of ADL and IADL assessment on survival, but data are still lacking. In our study, the ADL dependency was found to affect survival in a univariate analysis. In other words, CGA has the potential to be a useful evaluation tool to predict the prognosis for older cancer patients in various aspects.\u003c/p\u003e \u003cp\u003eHowever, it is not easy to apply CGA to clinical practice. Implementation of CGA in various clinical environments can pose significant challenges due to the lack of specific information about CGA tools. For example, what is the exact question for a particular geriatric assessment tool, what cutoff scores are used within a particular scale, how the results should be interpreted, and whether this scale has been validated in oncology. To overcome these limitations, the National Comprehensive Cancer Network (NCCN), the European Organization for Research and Treatment of Cancer (EORTC), and the International Society of Geriatric Oncology (SIOG) guidelines are proposing a \u0026lsquo;two-step\u0026rsquo; approach with screening tools for early risk detection. Through the G8 questionnaire[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], the presence of risk factors is initially screened to select older cancer patients in need of geriatric assessment, and CGA and geriatric interventions are performed. The G8 questionnaire is currently known as one of the best screening tools to identify older cancer patients due to its high sensitivity and independent 1-year survival rate.\u003c/p\u003e \u003cp\u003eOur study has several limitations to be noted. First, it was conducted at a single institution with a relatively small sample size of 21 patients. Also, since only patients suitable for chemotherapy were initially enrolled, there is a possibility that only patients with relatively good cognitive function or performance status were selected. Therefore, the interpretation of our results should be cautious, and a prospective study with larger sample size is desirable in the future. Despite the above limitations, this is an important study to suggest the prognostic implications of CGA in older patients with SCLC.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGeriatric assessment detects more information than routine oncological evaluation alone, such as ECOG PS. Pre-treatment nutritional status measured by CGA appears to be a predictor of OS in older SCLC patients. Further studies are required to verify the prospective role of CGA on older cancer patients.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eADL:\u003c/strong\u003e Activities of Daily Living\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMI:\u003c/strong\u003e Body Mass Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCCI:\u003c/strong\u003e Charlson Comorbidity Index\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCGA:\u003c/strong\u003e Comprehensive Geriatric Assessment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eECOG PS:\u003c/strong\u003e Eastern Cooperative Oncology Group performance status\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEORTC:\u003c/strong\u003e European Organization for Research and Treatment of Cancer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGDSSF-K:\u003c/strong\u003e Korean version Short Form of the Geriatric Depression Scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHR:\u003c/strong\u003e Hazard Ratio\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIADL:\u003c/strong\u003e Instrumental Activities of Daily Living\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMMSE:\u003c/strong\u003e Mini-Mental State Exam\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMNA:\u003c/strong\u003e Mini Nutritional Assessment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNCCN:\u003c/strong\u003e National Comprehensive Cancer Network\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNSCLC:\u003c/strong\u003e Non-Small Cell Lung Cancer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOS:\u003c/strong\u003e Overall Survival\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePCI:\u003c/strong\u003e Prophylactic Cranial Irradiation\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSCLC:\u003c/strong\u003e Small Cell Lung Cancer\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSIOG:\u003c/strong\u003e International Society of Geriatric Oncology\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTUG:\u003c/strong\u003e Timed Up and Go test\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Institutional Review Board of Yonsei University\u0026rsquo;s Health System (IRB number: 4-2021-1348) and adhered to the tenets of the Declaration of Helsinki. Informed consent was waived by the IRB of Yonsei University\u0026rsquo;s Health System for this study as all the data was obtained from medical records.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to the ethics approval for this study. However, the data are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests do declare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Research Program funded by the Korea Disease Control and Prevention Agency (2019-ER6302-02) and IITP grant funded by the Korea government (MSIT) (No.2017-0-01779, XAI). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank the Division of medical oncology for assistance with patient enrollment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYJC, KJK, COK, and MHH were involved in the study design. JYL, JWC, THK did data collection. HRK, BCC, and MHH helped on recruiting participants. YJC and JYL did data analysis. YJC did manuscript writing. KJK, COK and MHH supervised the study and performed significant editing of the manuscript. All authors have read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e\u003cb\u003eSEER\u003c/b\u003e Cancer Statistics Review, 1975-\u003cb\u003e2016\u003c/b\u003e, \u003cb\u003ebased on November 2018 SEER data submission\u003c/b\u003e, \u003cb\u003eposted to the SEER web site\u003c/b\u003e, \u003cb\u003eApril 2019\u003c/b\u003e. 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Support Care Cancer 2013, \u003cb\u003e21\u003c/b\u003e(12):3261\u0026ndash;3270.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoubeyran P, Fonck M, Blanc-Bisson C, Blanc J-F, Ceccaldi J, Mertens C, Imbert Y, Cany L, Vogt L, Dauba J \u003cem\u003eet al\u003c/em\u003e: \u003cb\u003ePredictors of Early Death Risk in Older Patients Treated With First-Line Chemotherapy for Cancer\u003c/b\u003e. Journal of Clinical Oncology 2012, \u003cb\u003e30\u003c/b\u003e(15):1829\u0026ndash;1834.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Geriatric Assessment, Nutritional status, Small Cell Lung Cancer, Frail Elderly, Prognosis, Survival","lastPublishedDoi":"10.21203/rs.3.rs-1252460/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1252460/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eThe prognostic value of a comprehensive geriatric assessment (CGA) for the management of older cancer patients remains to be established. This study investigated the association of each CGA variable with overall survival (OS) in older small cell lung cancer (SCLC) patients.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods \u003c/strong\u003eA retrospective cohort enrolled 21 older SCLC patients over 65 years from March 2018 to 2019 at the Yonsei Cancer Center. The CGA was performed before treatment and included the following instruments: Frailty, a circumference of arm/calf, body mass index (BMI), sarcopenia (e.g., Timed Up and Go test [TUG], grip strength), comorbidity, polypharmacy, function, nutrition, depression, and cognitive function. The correlations of oncological and geriatric variables with OS were determined. The log-rank test and a Cox model were used for the analysis. Prognostic factors of OS were examined by using the Kaplan-Meier method.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThe median age was 75 years (range 67-85). All patients had the Eastern Cooperative Oncology Group performance status (ECOG PS) 0-2. The median survival was 9.93 months (1.53-36.30). Among CGA parameters, activities of daily living (ADL) and nutritional status had significant differences in OS in univariate analysis. In multivariate analysis, only nutritional status was independently associated with survival (HR 0.17 [95% CI 0.05-0.57]). Median OS for low nutritional status was 5.63 months and the normal nutrition group was 15.5 months (\u003cem\u003ep = .004\u003c/em\u003e).\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions \u003c/strong\u003eGeriatric assessment detects more information than routine oncological evaluation alone, such as ECOG PS. Pre-treatment nutritional status measured by CGA appears to be a predictor of OS in older SCLC patients. A prospective study with larger sample size is desirable in the future.\u003c/p\u003e","manuscriptTitle":"The Prognostic Value of Comprehensive Geriatric Assessment on the Management of Older Patients With Small Cell Lung Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-01-31 16:21:59","doi":"10.21203/rs.3.rs-1252460/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5ec6b7f8-b48a-484f-8790-ec28dfb34cb0","owner":[],"postedDate":"January 31st, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-04-26T17:29:15+00:00","versionOfRecord":[],"versionCreatedAt":"2022-01-31 16:21:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1252460","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1252460","identity":"rs-1252460","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}