Urologic Oncology: Seminars and Original Investigations
Seminars ArticleAssessments of frailty in bladder cancer
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
References (73)
Immunological alterations in frail older adults: A cross sectional study
Exp Gerontol
(2018)- et al.
Frailty biomarkers in humans and rodents: Current approaches and future advances
Mech Ageing Dev
(2019) Frailty in elderly people
Lancet
(2013)Frailty syndrome and pre-operative risk evaluation: A systematic review
Arch Gerontol Geriatr
(2015)Simple frailty score predicts postoperative complications across surgical specialties
Am J Surg
(2013)A modified frailty index to assess morbidity and mortality after lobectomy
J Surg Res
(2013)- et al.
Cognitive frailty in geriatrics
Clin Geriatr Med.
(2018) Cognitive frailty as a predictor of dementia among older adults: A systematic review and meta-analysis
Arch Gerontol Geriatr.
(2020)Frailty index predicts severe complications in gynecologic oncology patients
Gynecol Oncol
(2015)Frailty as a predictor of complications after radical cystectomy: A prospective study of various preoperative assessments
Urol Oncol
(2019)
Discriminative ability of commonly used indexes to predict adverse outcomes after radical cystectomy: comparison of demographic data, American society of anesthesiologists, modified charlson comorbidity index, and modified frailty index
Clin Genitourin Cancer
Fit for surgery? Perspectives on preoperative exercise testing and training
Br J Anaesth
Perioperative cardiopulmonary exercise testing (CPET): consensus clinical guidelines on indications, organization, conduct, and physiological interpretation
Br J Anaesth
Sarcopenia
Lancet
Imaging of sarcopenia
Eur J Radiol
Development of a valid and reliable malnutrition screening tool for adult acute hospital patients
Nutrition
Immunological pathogenesis of main age-related diseases and frailty: Role of immunosenescence
European Geriatric Medicine
Frailty in older adults: evidence for a phenotype
J Gerontol A Biol Sci Med Sci
Frailty in the older surgical patient: a review
Age Ageing
Frailty and elderly in urology: Is there an impact on post-operative complications?
Cent European J Urol
Preoperative frailty predicts postoperative complications and mortality in urology patients
World J Urol
Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy
Urol Oncol
Systematic review and meta-analysis of the association between frailty and outcome in surgical patients
Ann R Coll Surg Engl
Preserved physical fitness is associated with lower 1-year mortality in frail elderly patients with a severe comorbidity burden
Clin Interv Aging
Frailty in surgical patients
Int J Colorectal Dis
Mitochondrial function is impaired in the skeletal muscle of pre-frail elderly
Sci Rep
How clinical practitioners assess frailty in their daily practice: An international survey
Aging Clin Exp Res
A 5-item frailty index based on NSQIP data correlates with outcomes following paraesophageal hernia repair
Surg Endosc
Instruments for the detection of frailty syndrome in older adults: A systematic review
PLoS One
Development and initial validation of the risk analysis index for measuring frailty in surgical populations
JAMA Surg
Validation of a frailty index in patients undergoing curative surgery for urologic malignancy and comparison with other risk stratification tools
Urol Oncol
Association of the modified frailty index with 30-day surgical readmission
JAMA Surg
Canadian study of health and aging clinical frailty scale: does it predict adverse outcomes among geriatric trauma patients?
J Am Coll Surg
A global clinical measure of fitness and frailty in elderly people
CMAJ
Reversible cognitive frailty, dementia, and all-cause mortality. The Italian longitudinal study on aging
J Am Med Direc Assoc
Cognitive frailty and incidence of dementia in older persons
J Prev Alzheimer Dis
Cited by (17)
11-item modified frailty index and outcomes after radical cystectomy
2023, Journal of Geriatric OncologyDynamic alterations of immunosenescence-related genes in older women with breast cancer receiving chemotherapy: A prospective study
2022, Translational OncologyCitation Excerpt :Obviously conclusive data are yet to be obtained in order to identify patients who would truly benefit from this strategy before putting it into clinical practice. Clinical frailty is a state of decreased physiological reserves and vulnerability to external stressors that is frequent in older individuals with cancer [27–29] and can be assessed by geriatric assessment (GA). Our study revealed that CD69 conversely correlated with multiple CGA scales, reflecting the lower CD69 is, the healthier patients will be.
Future Perspectives on Prehabilitation Interventions in Cancer Surgery
2022, Seminars in Oncology NursingCitation Excerpt :These vulnerable patients could benefit from prehabilitation to modify or optimize these clinical and physiologic impairments before surgery. Patients’ physiologic fitness using the Fried Frailty Criteria or the measurement of the psoas muscle volume to assess frailty preoperatively have shown to optimally predict adverse outcomes in prospective cohort studies.46 Clearly frail, elderly patients are at increased risk of negative outcomes, compared with younger, nonfrail patients.57
From fast-track to enhanced recovery after surgery in radical cystectomy pathways: A nursing perspective
2022, Asia-Pacific Journal of Oncology NursingCitation Excerpt :There is emerging awareness of the aging, comorbid frail population, which describes the RC population.42,43 Frailty is a multidimensional and dynamic age-related condition characterized by declining functioning across multiple physiological and psycho-social factors, accompanied by an elevated vulnerability to stressors.44,45 Frailty in RC Patients are significantly associated with mortality46 and surgical cancer treatment is a stressor adding further risk of deterioration of health status to the inherent risk of negative health care outcomes among frail elderly.
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