Clinical impact of evaluation of frailty in endoscopic submucosal dissection for early gastric cancer in elderly patients

Risk factors for preoperative frailty in older patients with gastric cancer: a systematic review and meta-analysis

PURPOSE

To summarize the available evidence on risk factors for preoperative frailty in older gastric cancer patients.

METHODS

We comprehensively searched the CNKI, Wanfang, VIP, CBM, PubMed, Embase, The Cochrane Library, Web of Science, and CINAHL databases for preoperative articles on risk factors for frailty in older gastric cancer patients. The search was conducted from the time of construction of the library to January 27, 2024, with no language restrictions. The quality of the included studies was rated by the Newcastle-Ottawa Scale and the Agency for Healthcare Research and Quality tool.

RESULTS

A total of 20 studies were included, including 16 cohort studies and 4 cross-sectional studies, with a total sample size of 51,717 individuals. The results of the meta-analysis showed that age, albumin, hemoglobin, cancer stage III-IV, Charlson Comorbidity Index score ≥ 3, Eastern Cooperative Oncology Group score > 2, American Society of Anesthesiologists score > 2, smoking, nutritional risk, high school degree or above, and sleep disorders are the main influencing factors for the occurrence of preoperative frailty in older gastric cancer patients. Among them, high school degree or above was a protective factor.

CONCLUSIONS

Our study provides valid evidence of risk factors for preoperative frailty in older patients with gastric cancer and informs clinical healthcare professionals to make targeted interventions.

How can we approach preoperative frailty and related factors in patients with cancer? A scoping review

AIM

To identify factors related to preoperative frailty in patients with cancer and map the tools that measure frailty.

DESIGN

A Scoping review.

METHODS

This scoping review based on Arksey and O'Malley's framework. Articles from CINAHL, PubMed, EMBASE, and PsycINFO databases published between January 2011 and April 2021. The searched keywords were concepts related to 'cancer', 'frailty' and 'measurement'.

RESULTS

While 728 records were initially identified, 24 studies were eventually selected. Research on frailty was actively conducted between 2020 and 2021. Factors related to preoperative frailty were age (22.9%), sex (11.4%), body mass index (11.4%) and physical status indicators (54.3%). The most common result of preoperative frailty was postoperative complications (35.0%). 24 instruments were used to measure frailty.

IMPLICATIONS FOR PATIENT CARE

Selecting an appropriate preoperative frailty screening tool can help improve patient postoperative treatment outcomes.

IMPACT

There are many instruments for assessing preoperative frailty, each evaluating a multi-dimensional feature. We identified the frailty screening tools used today, organized the factors that affect frailty, and explored the impact of frailty. Identifying and organizing frailty measurement tools will enable appropriate evaluation.

REPORTING METHOD

PRISMA-ScR.

PATIENT CONTRIBUTION

No patient or public contribution.

Relation between frailty and adverse outcomes in elderly patients with gastric cancer: a scoping review

Background

Playing an exemplary role, frailty have crucial effect on the preoperative evaluation of elderly patients. Previous studies have shown that frailty is associated with complications and mortality in patients with gastric cancer (GC). However, with the development of the concept of "patient-centered", the range of health-related outcomes is broad. The differences in relation between frailty and various adverse outcomes will be further explored.

Method

The PubMed, Embase, Web of Science, Cochrane Library, China National Knowledge Infrastructure, Wan Fang, and Chinese Biomedical Literature databases were searched for keywords, including frailty (such as frail) and gastric cancer (such as stomach neoplasms or stomach cancer or gastrectomy or gastric surgery). The search period is until August 2023. The included studies were observational or cohort studies with postoperative related adverse outcomes as primary or secondary outcome measures. Valid assessment tools were used. The Quality Assessment Tool for Observational Cohort and Cross-sectional Studies was used to assess methodological quality in the included literature.

Result

Fifteen studies were included, including 4 cross-sectional studies, 8 retrospective cohort studies, and 3 prospective cohort studies. Among them, 6 studies were rated as "Good" and 9 studies were rated as "Fair," indicating that the quality of the literature was high. Then, 10 frailty assessment tools were summarized and classified into two broad categories in accordance with frailty models. Results of the included studies indicated that frailty in elderly patients with GC was associated with postoperative complications, mortality, hospital days, readmissions, quality of life, non-home discharge, and admission to the intensive care unit.

Conclusion

This scoping review concludes that high levels of preoperative frailty increase the risk of adverse outcomes in elderly patients with GC. Frailty will be widely used in the future clinical evaluation of elderly gastric cancer patients, precise risk stratification should be implemented for patients, and frailty management should be implemented well to reduce the occurrence of adverse treatment outcomes.

Prevalence and unfavorable outcome of frailty in older adults with gastric cancer: a systematic review and meta-analysis

BACKGROUND AND AIM

Previous studies reported inconsistent results on the prevalence and prognostic implications of frailty among older adults with gastric cancer. This systematic review synthesized available literature pertaining on this topic to establish the prevalence and unfavorable outcomes of frailty in older adults with gastric cancer.

METHODS

A comprehensive search was conducted across multiple English databases including PubMed, Cochrane Library, CINAHL, Embase, and Web of Science as well as Chinese databases, namely, CNKI, Wan Fang, and CBM, from inception to July 4, 2023, to identify potential studies. Data related to the incidence of frailty and its unfavorable outcomes in older adults with gastric cancer were extracted. RevMan5.3 and R 4.2.2 were used to evaluate pooled prevalence, hazard ratios (HR), and 95% confidence interval (CI).

RESULTS

This review comprehensively selected 13 studies, comprising 9 cohort studies and 4 cross-sectional studies, on 44,117 older adults diagnosed with gastric cancer. The incidence of frailty among older adults with gastric cancer ranged from 10 to 71%. The pooled prevalence of frailty was 29% (95% CI 0.21-0.39). Frailty was found to be associated with an elevated risk of postoperative complications (HR = 1.99, 95% CI 1.45-2.73), prolonged postoperative hospital stay (HR = 2.68, 95% CI 2.38-3.02), likelihood of readmission (HR = 3.28, 95% CI 1.77-6.08), and an increased mortality risk (HR = 1.60, 95% CI 1.36-1.90).

CONCLUSIONS

Frailty was associated with a poor prognosis in older adults with gastric cancer. Clinical medical staff should focus on the frailty of older adults with gastric cancer, conduct large-scale, multicenter, and prospective studies and early screening of patients, and provide guidance for the implementation of prevention and treatment strategies.

Frailty and long-term survival of patients with gastric cancer: a meta-analysis

Background

The relationship between frailty and the long-term clinical outcome of gastric cancer (GC) patients has not yet been established, although frailty is associated with a poor short-term outcome. The impact of frailty on long-term survival of GC patients was investigated through a systematic review and meta-analysis.

Methods

Observational studies with longitudinal follow-ups for a minimum of one year were identified through a search of the PubMed, Embase, Cochrane Library, and Web of Science databases, in accordance with the objective of the meta-analysis. Combining the findings was achieved using a random-effects model, which accounted for inter-study heterogeneity.

Results

Ten datasets from nine cohort studies were included, which involved 7613 patients with GC. A total of 2074 patients (27.2%) were with frailty at baseline, and the mean follow-up duration was 48.1 months. A pooled analysis of the results showed that frailty was linked to a poor long-term overall survival in GC patients (risk ratio [RR]: 1.65, 95% confidence interval [CI]: 1.27 to 2.13, p < 0.001; I2 = 80%). Sensitivity analysis showed consistent results in older patients (≥ 65 years, RR: 1.51, p = 0.002) and the oldest old (≥ 80 years, RR: 1.41, p = 0.01). In addition, frailty was also associated with poor long-term progression-free survival (RR: 1.65, 95% CI: 1.39 to 1.96, p < 0.001; I2 = 0%) and disease-specific survival (RR: 1.71, 95% CI: 1.23 to 2.37, p = 0.001; I2 = 4%).

Conclusion

Frailty is associated with poor long-term survival of patients with GC.

Association of preoperative frailty and postoperative delirium in older cancer patients undergoing elective abdominal surgery: A prospective observational study in Taiwan

BACKGROUND

Postoperative delirium (POD) is a common surgical complication in elderly patients. As frailty is a relatively novel concept, its clinical significance for POD has seldom been examined. This study aimed to investigate the association between frailty and POD in aged cancer patients undergoing elective abdominal surgery in Taiwan.

METHODS

We prospectively enrolled 345 consecutive patients aged ≥65 years with newly diagnosed cancer who underwent elective abdominal surgery between 2016 and 2018. Frailty assessment was performed using the Comprehensive Geriatric Assessment (CGA). POD was assessed daily using the Confusion Assessment Method from postoperative day 1 until discharge. Patients were allocated into fit and frail groups.

RESULTS

POD occurred in 19 (5.5%) of 345 patients. POD incidence was 1.6%, 3.1%, 4.8%, 11.5%, and 10.0% in patients with 0, 1, 2, 3, and 4+ frail conditions, respectively, which presented a positive linear correlation among patients with an increased number of frail conditions and POD incidence. Based on CGA, 159 (46.1%) and 186 (53.9%) patients were allocated to fit and frail groups, respectively. POD incidence was 2.5% and 8.1% for the fit and frail groups, respectively. Frailty status was an independent risk factor for POD occurrence in multivariate analysis.

CONCLUSION

Our study identified frailty as an independent risk factor for POD in aged Taiwanese cancer patients undergoing elective abdominal surgery. Given the high prevalence of frailty among older cancer patients, preoperative assessment is important to identify high risk of POD and to improve the quality of postoperative care.

Cross-cultural adaptation and validation of the geriatric 8 screening tool in Chinese hospitalized older adults with cancer

OBJECTIVES

To translate, cross-culturally adapt, and validate the Geriatric 8 (G8) questionnaire in Chinese hospitalized older adults with cancer.

METHODS

The Chinese version of the G8 (C-G8) was produced following Brislin's guidelines. The psychometric properties of the C-G8 were evaluated among 296 eligible patients.

RESULTS

The content validity index of the C-G8 was 0.8∼1 at the item level and 0.975 at the scale level. The C-G8 identified more frail individuals among these older (>75 years) participants compared to their younger (65∼75 years) counterparts (frailty prevalence: 87.1% vs. 70.9%, P=0.010). The convergent validity of the C-G8 was tested by correlating it with the FRAIL scale (r=-0.592, P<0.001). The C-G8 had a lower internal consistency (Cronbach's α coefficient=0.501) but higher test-retest reliability and inter-rater reliability (intraclass correlation coefficient=0.913 and 0.993, respectively, P<0.001).

CONCLUSIONS

The C-G8 questionnaire presented acceptable validity and reliability and could be used in Chinese hospitalized older adults with cancer.

Impact of frailty on survival and readmission in patients with gastric cancer undergoing gastrectomy: A meta-analysis

Background

Frailty as a common geriatric syndrome can affect the clinical outcomes in patients with gastric cancer. However, the impact of frailty on survival and readmission patients with gastric cancer has not been well-characterised.

Objectives

To investigate the impact of frailty on survival and readmission in patients with gastric cancer undergoing gastrectomy by conducting a meta-analysis.

Methods

Eligible studies were identified by searching the PubMed, Web of Science, Cochrane Library, and Embase databases until 2 September 2022. Observational studies that evaluated the value of frailty in predicting adverse outcomes in gastric cancer patients undergoing gastrectomy were included. The outcomes of interest were overall survival, disease-specific survival (death from gastric cancer), and readmission. Adjusted hazard ratios (HR) with 95% confidence intervals (CI) were pooled to calculate the association of frailty with adverse outcomes.

Results

Eight studies reported on nine articles with 2,792 patients with gastric cancer were included. A fixed-effect meta-analysis indicated that frailty was associated with a reduced in-hospital overall survival (HR 2.08; 95% CI 1.46–2.95), long-term overall survival (HR 1.84; 95% CI 1.37–2.47), and disease-specific survival (HR 1.94; 95% CI 1.34–2.83). In addition, frailty was associated with increased risk of readmission within 1 year (HR 3.63; 95% CI 1.87–7.06).

Conclusions

Frailty was associated with a reduced overall survival and disease-specific survival and an increased risk of readmission in patients with gastric cancer undergoing gastrectomy. Frail status may play an important role in the risk stratification of gastric cancer after gastrectomy.

The Clinical Frailty Scale (CFS) employment in the frailty assessment of patients suffering from Non-Communicable Diseases (NCDs): A systematic review

Background

The Clinical Frailty Scale (CFS) is a well-established tool that has been widely employed to assess patients' frailty status and to predict clinical outcomes in the acute phase of a disease, but more information is needed to define the implications that this tool have when dealing with Non-Communicable Diseases (NCDs).

Methods

An electronic literature search was performed on PubMed, Scopus, EMBASE, Web of Science, and EBSCO databases to identify studies employing the CFS to assess frailty in patients with NCDs.

Findings

After database searching, article suitability evaluation, and studies' quality assessment, 43 studies were included in the systematic review. Researches were conducted mostly in Japan (37.5%), and half of the studies were focused on cardiovascular diseases (46.42%), followed by cancer (25.00%), and diabetes (10.71%). Simplicity (39.29%), efficacy (37.5%), and rapidity (16.07%) were the CFS characteristics mostly appreciated by the authors of the studies. The CFS-related results indicated that its scores were associated with patients' clinical outcomes (33.92%), with the presence of the disease (12.5%) and, with clinical decision making (10.71%). Furthermore, CFS resulted as a predictor of life expectancy in 23 studies (41.07%), clinical outcomes in 12 studies (21.43%), and hospital admissions/readmissions in 6 studies (10.71%).

Discussion

CFS was found to be a well-established and useful tool to assess frailty in NCDs, too. It resulted to be related to the most important disease-related clinical characteristics and, thus, it should be always considered as an important step in the multidisciplinary evaluation of frail and chronic patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.asp? PROSPERO 2021, ID: CRD42021224214.

Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

Predictors of early and late mortality after the treatment for early gastric cancers

OBJECTIVES

Although many patients with early gastric cancers (EGCs) die of non-gastric cancer-related causes, the association of the risk categories of lymph node metastasis (LNM) with all-cause mortality remains unclear. We aimed to clarify the predictors of early and late mortality, separately.

METHODS

Patients with endoscopic resection or gastrectomy for EGCs between 2003 and 2017 were retrospectively enrolled. We analyzed predictors for early and late mortality, including risk categories of LNM, treatment method, and nine non-cancer-related indices, separately, with a cut-off value of 3 years.

RESULTS

We enrolled 1439 patients with a median follow-up period of 79 months. The 5-year overall survival rate was 86.8%. In the multivariate Cox analysis, the most important predictors for early and late mortality were age ≥85 years (hazard ratio [HR] 2.88 and 4.54, respectively) and Eastern Cooperative Oncology Group Performance Status ≥2 (HR 3.00 and 4.19, respectively). Charlson comorbidity index ≥2 (HR 2.76 and 1.99, respectively), American Society of Anesthesiologists Physical Status ≥3 (HR 2.35 and 1.79, respectively), and C-reactive protein/albumin ratio ≥0.028 (HR 2.30 and 1.58, respectively) were also predictors for both early and late mortality. Male (HR 2.26), intermediate- (HR 2.12)/high-risk (HR 1.85) of LNM in eCura system, and sarcopenia evaluated by the psoas muscle mass index (HR 1.70) were predictors for early mortality.

CONCLUSION

The combined assessment of multiple predictors might help to predict early and/or late mortality in patients with EGCs. The eCura system was associated with early mortality.

Impact of frailty on the long-term outcomes of elderly patients with esophageal squamous cell carcinoma

OBJECTIVE

We aimed to clarify the association between frailty evaluated using the clinical frailty scale (CFS) and outcomes in elderly patients with esophageal squamous cell carcinoma.

METHODS

We retrospectively included 67 patients (aged ≥ 75 years) diagnosed with esophageal squamous cell carcinoma (tumor depth ≥ m3) between 2011 and 2016. The patients were retrospectively evaluated and categorized according to their CFS scores (1-7) and divided into non-frailty (scores 1-2) and frailty groups (scores 3-7). Postoperative complications, 5 year survival rate, and prognostic risk factors were analyzed.

RESULTS

Significant differences in performance status, American Society of Anesthesiologists-Physical Status score, Charlson comorbidity index, and treatment type were observed between the two groups. Thirty-six patients underwent surgery, and morbidities with Clavien-Dindo grades ≥ II and ≥ IIIa were found in 72.2 and 47.2% of the patients, respectively. The remaining 31 patients underwent endoscopic resection and/or chemo (radio) therapy. The morbidity rate did not differ between the two groups. The 5 year survival rate was 75.3% overall and 92.7 and 60.8% in patients in the non-frailty and frailty groups, respectively (p = 0.007). Multivariate analysis revealed that frailty and cStage ≥ II were independent risk factors of overall survival (p = 0.005 and p = 0.013, respectively) and disease-specific survival (p = 0.048 and p = 0.027, respectively).

CONCLUSIONS

Frailty greatly impacts the prognosis of elderly patients with esophageal cancer, regardless of surgical or nonsurgical treatment. The CFS score could be a useful prognostic predictor.

Clinical Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients with Comorbidities

Purpose

As the rate of endoscopic resection for early gastric cancer (EGC) has increased in patients with comorbid diseases, it is necessary to elucidate the efficacy of endoscopic submucosal dissection (ESD) for EGC in patients with comorbidities. This study aimed to analyze the clinical outcomes of ESD for EGC in patients with comorbidities.

Materials and Methods

A total of 969 patients with 1,015 lesions who underwent ESD for EGC at Seoul National University Hospital between 2010 and 2014 were analyzed. The short- and long-term clinical outcomes were evaluated according to the comorbidity status.

Results

Comorbidities were observed in 558 patients (57.6%). The comorbidity group had a higher proportion of patients using antithrombotic agents (29.5% vs. 0.9%; P<0.0001). Although procedure-related complications (bleeding and perforation) were not significantly different between the two groups, the length of hospital stay was significantly longer (1.8 vs. 1.4 days, P=0.023), while survival was significantly shorter in the comorbidity group (5-year overall survival rate: 90.5% vs. 97.2%, P<0.0001; 5-year disease-specific survival rate: 97.9% vs. 100%, P=0.018; 5-year disease-free survival rate: 83.4% vs. 89.2%, P=0.007).

Conclusions

Gastric ESD can be performed in patients with comorbidities without increasing the risk of complications.

Effects of preoperative frailty on outcomes following surgery among patients with digestive system tumors: A systematic review and meta-analysis

BACKGROUND

Frailty is common in patients who undergo digestive system tumor surgery. This review aimed to explore the effects of preoperative frailty on multiple outcomes following surgery among patients with digestive system tumors.

METHODS

PubMed (Medline), Embase, Web of Science, and other databases were searched from the inception of each database to April 2021. Meta-analysis or qualitative synthesis was performed to examine the relationship between preoperative frailty and adverse postoperative outcomes.

RESULTS

A total of 29 studies encompassing 122,548 patients were included. Through meta-analysis, frailty was associated with an increased risk of total complications (risk ratio [RR] 1.44; 95 % confidence interval [CI] 1.39 to 1.50), major complications (RR 1.72; 95 % CI 1.51 to 1.95), 30-d mortality (RR 2.40; 95 % CI 2.14 to 2.70), and 5-year mortality (RR 1.74; 95 % CI 1.35 to 2.24). Through qualitative synthesis, compared with non-frail patients, two studies found that frail patients had a worse quality of life, and three studies reported that frail patients experienced greater rates of non-home discharge. However, two studies demonstrated inconsistent conclusions regarding the relationship between frailty and functional status.

CONCLUSIONS

Preoperative frailty was an important risk factor for multiple adverse postoperative outcomes of patients with digestive system tumors, including objective clinical outcomes and patient-centered outcomes. Future studies focusing on the effects of frailty on patient-centered outcomes such as quality of life and functional status are needed.