title: Predicting the risk of chemotherapy toxicity in older patients: the Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score.
abstract: BACKGROUND
  Tools are lacking to assess the individual risk of severe toxicity from chemotherapy. Such tools would be especially useful for older patients, who vary considerably in terms of health status and functional reserve.
  
  
  METHODS
  The authors conducted a prospective, multicentric study of patients aged ≥70 years who were starting chemotherapy. Grade 4 hematologic (H) or grade 3/4 nonhematologic (NH) toxicity according to version 3.0 of the Common Terminology Criteria for Adverse Events was defined as severe. Twenty-four parameters were assessed. Toxicity of the regimen (Chemotox) was adjusted using an index to estimate the average per-patient risk of chemotherapy toxicity (the MAX2 index). In total, 562 patients were accrued, and 518 patients were evaluable and were split randomly (2:1 ratio) into a derivation cohort and a validation cohort.
  
  
  RESULTS
  Severe toxicity was observed in 64% of patients. The Chemotherapy Risk Assessment Scale for High-Age Patients (CRASH) score was constructed along 2 subscores: H toxicity and NH toxicity. Predictors of H toxicity were lymphocytes, aspartate aminotransferase level, Instrumental Activities of Daily Living score, lactate dehydrogenase level, diastolic blood pressure, and Chemotox. The best model included the 4 latter predictors (risk categories: low, 7%; medium-low, 23%; medium-high, 54%; and high, 100%, respectively; P(trend) < .001). Predictors of NH toxicity were hemoglobin, creatinine clearance, albumin, self-rated health, Eastern Cooperative Oncology Group performance, Mini-Mental Status score, Mini-Nutritional Assessment score, and Chemotox. The 4 latter predictors provided the best model (risk categories: 33%, 46%, 67%, and 93%, respectively; P(trend) < .001). The combined risk categories were 50%, 58%, 77%, and 79%, respectively; P(trend) < .001). Bootstrap internal validation and independent sample validation demonstrated stable risk categorization and P(trend) < .001.
  
  
  CONCLUSIONS
  The CRASH score distinguished several risk levels of severe toxicity. The split score discriminated better than the combined score. To the authors' knowledge, this is the first score systematically integrating both chemotherapy and patient risk for older patients and has a potential for future clinical application.
authors.affiliation: Senior Adult Oncology Program, Moffitt Cancer Center, University of South Florida, Tampa, Florida 33612, USA. martine.extermann@moffitt.org
authors.forename: Martine
authors.initials: M
authors.lastname: Extermann
authors.forename: Ivette
authors.initials: I
authors.lastname: Boler
authors.forename: Richard R
authors.initials: RR
authors.lastname: Reich
authors.forename: Gary H
authors.initials: GH
authors.lastname: Lyman
authors.forename: Richard H
authors.initials: RH
authors.lastname: Brown
authors.forename: Joseph
authors.initials: J
authors.lastname: DeFelice
authors.forename: Richard M
authors.initials: RM
authors.lastname: Levine
authors.forename: Eric T
authors.initials: ET
authors.lastname: Lubiner
authors.forename: Pablo
authors.initials: P
authors.lastname: Reyes
authors.forename: Frederic J
authors.initials: FJ
authors.lastname: Schreiber
authors.forename: Lodovico
authors.initials: L
authors.lastname: Balducci
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000970:Antineoplastic Agents / Q000009:adverse effects*; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000009:adverse effects*; D005260:Female; D006801:Humans; D008297:Male; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods*
chemical_list: D000970:Antineoplastic Agents