Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools

Abstract

Objective To retrospectively validate and compare a modified frailty index predicting adverse outcomes to other risk stratification tools among patients undergoing urologic oncological surgeries. Materials and Methods The American College of Surgeons National Surgical Quality Improvement Program was queried from 2005–2013 to identify patients undergoing cystectomy, prostatectomy, nephrectomy, and nephroureterectomy. Using the Canadian Study of Health & Aging Frailty Index, 11 variables were matched to the database; 4 were also added due to their relevance in oncology patients. The incidence of mortality, Clavien-Dindo IV complications, and adverse events were assessed with patients grouped according to their modified frailty index score. Results A total of 41,681 cases of patients were identified undergoing surgery for presumed urological malignancy. Patients with a high frailty index score of >0.20 had a 3.70 odds of a Clavien-Dindo IV event (CI: 2.865–4.788, p<0.0005) and a 5.95 odds of 30-day mortality (CI: 3.72–9.51, p<0.0005) in comparison to non-frail patients after adjusting for race, gender, age, smoking history and procedure. Using C-statistics to compare the sensitivity and specificity of the predictive ability of different models per risk stratification tool and Akaiki Information Criteria to assess for the fit of the models with the data, the modified frailty index was comparable or superior to the Charlson Comorbidity Index but inferior to the American Society of Anesthesiologists Risk Class in predicting 30-day mortality or Clavien-Dindo IV events. When the modified frailty index was augmented with the American Society of Anesthesiologists Risk Class, the new index was superior in all regards in comparison to risk stratification tools. Conclusion Existing risk stratification tools may be improved by incorporating variables in our 15 point modified frailty index as well as other factors such as walking speed, exhaustion, and sarcopenia to fully assess frailty. This is relevant in diseases like kidney and prostate cancer, where surveillance and other non-surgical interventions exist as alternatives to a potentially complicated surgery. In these scenarios, our modified frailty index augmented by the American Society of Anesthesiologists Risk Class may help inform which patients do not benefit from surgery although this index needs prospective validation.

Validating the predictors of outcomes after radical cystectomy for bladder cancer

“…Also using the NSQIP, Lascano et al performed a similar analysis of several urologic surgeries, including RC and reported that a high mFI score was associated with severe complications and 30‐day mortality after adjustment for a limited number of patient variables. It is noteworthy that, although the mFI outperformed the CCI, its performance was inferior to that of the simple ASA classification . Most recently, Sathianathen et al reported on a simplified Frailty Index among older patients (aged ≥65 years) who were undergoing RC.…”

Initial Evaluation of [18F]DCFPyL for Prostate-Specific Membrane Antigen (PSMA)-Targeted PET Imaging of Prostate Cancer

“…Regardless, there are notable limitations and caveats in the results presented by Suskind et al [1] that are as important to appreciate as its strengths. Although multiple frailty assessment tools exist [4,6], including the NSQIP-FI used in this study, their clinical use may be limited by the time needed to complete them; as such, simplified tools (such as walking speed or hand-grip strength) that have recently been shown to be equally effective as full frailty assessment [5] may be more germane to a busy clinical setting. The ACS-NSQIP website also offers an online risk calculator (http:// riskcalculator.facs.org/), which takes into account multiple variables, and can quantify the likelihood of postoperative mortality, overall-and organ-specific morbidity.…”

“…The ACS-NSQIP website also offers an online risk calculator (http:// riskcalculator.facs.org/), which takes into account multiple variables, and can quantify the likelihood of postoperative mortality, overall-and organ-specific morbidity. Second, the authors grouped complications as 'major' or 'minor' in their current study [1]: it may be more prudent to discuss complications according to the Clavien-Dindo system as has been done elsewhere in the context of urological oncology patients [6], which may be a more standardised approach to grading the severity of complications and their downstream management. Third, while it is plausible that frail patients are likely to have inferior perioperative outcomes, in general, there is a relative paucity of high-level evidence on specific interventions or techniques that can mitigate this risk, both in the elective and emergent surgery settings.…”

The importance of frailty: Know thy patient

“… that are as important to appreciate as its strengths. Although multiple frailty assessment tools exist , including the NSQIP‐FI used in this study, their clinical use may be limited by the time needed to complete them; as such, simplified tools (such as walking speed or hand‐grip strength) that have recently been shown to be equally effective as full frailty assessment may be more germane to a busy clinical setting. The ACS‐NSQIP website also offers an online risk calculator (http://riskcalculator.facs.org/), which takes into account multiple variables, and can quantify the likelihood of postoperative mortality, overall‐ and organ‐specific morbidity.…”

“…The ACS‐NSQIP website also offers an online risk calculator (http://riskcalculator.facs.org/), which takes into account multiple variables, and can quantify the likelihood of postoperative mortality, overall‐ and organ‐specific morbidity. Second, the authors grouped complications as ‘major’ or ‘minor’ in their current study : it may be more prudent to discuss complications according to the Clavien–Dindo system as has been done elsewhere in the context of urological oncology patients , which may be a more standardised approach to grading the severity of complications and their downstream management. Third, while it is plausible that frail patients are likely to have inferior perioperative outcomes, in general, there is a relative paucity of high‐level evidence on specific interventions or techniques that can mitigate this risk, both in the elective and emergent surgery settings.…”