Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy

Abstract

Objective To investigate the modified frailty index (mFI) as a pre-operative predictor of post-operative complications following radical cystectomy in bladder cancer patients. Materials and Methods Patients undergoing radical cystectomy (RC) were identified from the National Surgical Quality Improvement Program (NSQIP) participant use files (2011-2013). The mFI was defined in prior studies with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index to NSQIP comorbidities and activities of daily living (ADL)s. Modified frailty index groups were determined by the number of risk factors per patient (0, 1, 2, ≥3). Univariate, χ2, independent sample t-test, and logistic regression analyses were performed when appropriate. A sensitivity analysis was performed to determine the mFI value at which Clavien 4 and 5 complications would reach significance. Results Of the 2679 cystectomy patients identified, 31% percent of patients had a mFI of 0, 44% had a mFI of 1, 21% had a mFI of 2, and 4% had a mFI ≥ 3. Overall, 59% of patients experienced a Clavien complication. When stratified at a cutoff of mFI >=2, the overall complication rate was not different (61.7% vs. 58.3%, p=0.1319), but the mFI2 or greater group had a significantly higher rate of Clavien grade 4 or 5 complications (14.6% vs. 8.3%, p<0.001) and overall mortality rate (3.5% vs. 1.8%, p=0.0128) in the 30-day post-operative period. The multivariate logistic regression model showed independent predictors of Clavien grade 4 or 5 complications were age >80 years old (OR, 1.58 [1.11-2.27]), mFI2 (odds ratio [OR], 1.84 [1.28-2.64]), and mFI3 (OR, 2.58 [1.47-4.55]). Conclusions Among patients undergoing radical cystectomy, the mFI can identify those patients at greatest risk for severe complications and mortality. Given that bladder cancer is increasing in prevalence particularly among the elderly, pre-operative risk stratification is crucial to inform decision making about surgical candidacy.

Feasibility and outcomes of selective tetramodal bladder‐preservation therapy in elderly patients with muscle‐invasive bladder cancer

“…Frailty has been proposed as a more accurate predictor of postoperative complication than chronological age in various fields of surgery . Among the frailty indices proposed for perioperative risk stratification, the mFI has been identified as a stronger predictor of severe complications after RC than age and is useful for preoperative risk stratification, particularly in younger patients . In the present study, 20% of patients diagnosed with frailty showed equivalent complete response, protocol completion and survival rates after TeMT to those who were not diagnosed with frailty.…”

“…Frailty was further evaluated using the mFI, a simplified version of the original 70‐item Canadian Study of Health and Aging Frailty Index containing 11 preoperative variables, including functional health status and specific comorbidities of interest. This index was initially developed to predict complications in patients with colectomy; subsequently, it was shown to be a predictor of complications after RC . The mFI scores were retrospectively obtained from patients’ medical records at the time of protocol enrollment, and categorized into low (0 or 1) and high (>2) mFI.…”

“…In addition to chronological age, clinical features reflecting biological age have been used to identify patients unfit for RC. Frailty, defined as a syndrome of physiological decline with increased vulnerability to adverse health outcomes, is a predictor of worse postoperative outcomes after RC . Sarcopenia, defined as the degenerative loss of skeletal muscle mass, is another predictor of postoperative complication after RC .…”

The LACE Score as a Tool to Identify Radical Cystectomy Patients at Increased Risk of 90-Day Readmission and Mortality

“…A recent study by Chappidi et al [16] used the modified frailty index (mFI) to identify high-risk patients for 30-day complications and mortality. The mFI is an 11 variable score consisting of medical comorbidities, very similar in concept to the CCI, although including different medical conditions as covariates.…”

Enhanced recovery after urologic surgery—Current applications and future directions

“…Furthermore, bladder cancer disproportionately impacts an older population in whom medical comorbidities are common . Due to procedural complexity and necessary application within a comparatively fragile population, perioperative morbidity following radical cystectomy is high with complications reported in 28‐64% of patients . Length of stay following the procedure is often in the range of 10 days and highly dependent on occurrence of complications and return of bowel function .…”