Seminars Article
Assessments of frailty in bladder cancer

https://doi.org/10.1016/j.urolonc.2020.04.036Get rights and content

Highlights

  • Frailty is increasingly common in bladder cancer, and associated with a spectrum of poor outcomes after radical cystectomy.

  • No universally agreed upon screening or diagnostic tool for frailty exists, but the 11-item modified Frailty Index is the most studied in radical cystectomy patients.

  • The gold standard frailty assessment is multidisciplinary care and a Comprehensive Geriatric Assessment performed by a geriatrician, but this is not universally available.

Abstract

Background and Aims

The incidence of frailty is increasing as the population ages, which has important clinical implications given the associations between frailty and poor outcomes in the bladder cancer population. Due to a multi-organ system decline and decreased physiologic reserve, frail patients are vulnerable to stressors of disease and have poorer mortality and morbidity rates than their nonfrail peers. The association between frailty and poor outcomes has been documented across multiple populations, including radical cystectomy, creating a need for frailty assessments to be used preoperatively for risk stratification. We aim to provide a review of the common frailty assessments and their relevance to radical cystectomy patients.

Findings

A variety of assessments for frailty exist, from short screening items to comprehensive geriatric assessments. The syndrome spans multiple organ systems, as do the potential diagnostic instruments. Some instruments are less practical for use in clinical practice by urologists, such as the Canadian Study of Health and Aging Frailty Index and Comprehensive Geriatric Assessment. The tool most studied in radical cystectomy is the modified Frailty Index, associated with high grade complications and 30-days mortality. Frailty often coexists with malnutrition and sarcopenia, stressing the importance of screening for and addressing these syndromes to improve patient's perioperative outcomes.

Conclusions

There is no universally agreed upon frailty assessment, but the most studied in radical cystectomy is the modified Frailty Index, providing valuable data with which to counsel patients preoperatively. Alterations in immune phenotypes provide potential future diagnostic biomarkers for frailty.

Introduction

Frailty is the phenotype of declining physiologic function and loss of functional reserve across organ systems, leading to vulnerability against disease and death [1], [2], [3], [4]. The number of elderly patients undergoing surgical procedures is increasing at an even faster rate than the general population's aging due to advances in anesthesia and perioperative medicine, leading to increasing prevalence of frailty in surgical patients [5]. Frailty has been reported in 7 to 10% of community dwelling adults older than 65 [1] and 21.8% of urologic patients above 70 [6]. Across multiple methods of defining frailty, it is linked to increased ICU stay, hospitalization, readmission, and mortality rates [4], [5], [6]. Specific to radical cystectomy, frailty rates are associated with higher complications and mortality [7], [8]. Due to the increasing likelihood of frailty pre- and post-operatively; there is a need for accurate identification of frailty to inform risk assessment and shared decision making [9,10]. Unfortunately, frailty screening tools are rarely used in urologic practice, in part due to the lack of consensus on an optimal tool for radical cystectomy patients.

Section snippets

Functional assessment of frailty

There is no consensus on how to define frailty clinically and despite an abundance of tools, scales, and instruments there is no standard method for screening frailty in routine clinical practice [11]. Furthermore, frailty is a dynamic condition; patents may move between robust, prefrail and frail states throughout their clinical course. Approaches are varied and range from prospective assessments involving physical assessment alongside clinical history, to techniques relying entirely on

Comprehensive geriatric assessments

CGA is a process for developing the plan of care for frail older adults with complex health problems and needs using interprofessional teams to address not only pertinent medical conditions, but their psychological status and functional abilities within social and environmental contexts [36]. Older adults often have subtle and sometimes difficult to elicit patient factors that are best identified with targeted assessments obtained from specialized health providers in geriatrics, geriatric

Sarcopenia and imaging techinques in frailty

Physical deconditioning, including reduced aerobic fitness, is a significant driver of adverse outcomes after urologic surgery and should form part of the assessment process [43]. Cardiopulmonary exercise testing is the gold standard assessment for aerobic fitness, highly predictive of outcome after urological surgery and may be used not only to aid in risk assessment and diagnosis of comorbidity but in prescription and evaluation of physical prehabilitation [44].

Impaired aerobic fitness

Nutritional assessments: Identification of malnourished bladder cancer patients

Unrecognized malnutrition may among the most pressing “silent epidemic's” facing cancer patients today. Although it is well known that >30% of hospitalized patients is malnourished at admission [54], older data estimates only 3% are recognized and diagnosed, and even fewer are treated [55]. This is tragic as mortality is 5 times greater for patients diagnosed with malnutrition versus well-nourished patients [55]. Further, patients with preexisting malnutrition and/or weight loss have a 2- to

Inflammatory biomarkers/markers of immune activation

Inflammation is widely considered to be a cause of frailty and the increased susceptibility to chronic morbidity, disability, and death that often coexists with frailty [2,63,64]. Immune dysfunction from lifelong chronic inflammatory state is a predisposing factor for many age-related chronic illnesses seen in frailty including atherosclerosis, diabetes, dementia, cancers, Parkinson's, and osteoporosis [1,2,64,65]. Multiple cross-sectional studies describe elevated immune and inflammatory

Conclusions

In summary, frailty is a multidimensional state of loss of physiologic reserves that result in a decreased ability to withstand physiological stressors. Preoperative interventions (including physical and nutritional prehabilitation) aimed at improving outcomes after urological cancer surgery, are especially important for frail patients. Measurement tools and diagnostic biomarkers need therefore not only to be sensitive and specific at detecting frailty, but also time-efficient, and employ

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    Funding: DCG is supported by the Urology Care Foundation Residency Research Award

    Relevant Disclosures: PEW: Has received grant funding related to surgical nutrition from NIH, Abbott, Baxter, Fresenius, and Takeda. Dr. Wischmeyer has served as a consultant to Abbott, Fresenius, Baxter, Cardinal Health Nutricia, and Takeda for surgical nutrition research. Dr. Wischmeyer has received unrestricted gift donation for surgical research from Musclesound. Dr. Wischmeyer has received honoraria or travel expenses for lectures on improving nutrition care in surgery from Abbott, Baxter and Nutricia.

    SRM: US Highbush Blueberry Council - research funding, Dairy Management, Inc - research funding, Aurora Health - honoraria

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