Frailty and cancer: Implications for oncology surgery, medical oncology, and radiation oncology

Gait Speed as a Measure of Frailty and Outcomes After Lung Resection

BACKGROUND

As a powerful, objective marker of frailty, 4-m gait speed (4MGS) can predict morbidity and mortality in various populations including cardiac surgery and oncology patients. Its role in thoracic surgery is understudied. This study aimed to evaluate associations between preoperative 4MGS and outcomes after pulmonary resection.

METHODS

A cohort study analyzed patients undergoing pulmonary resections at a high-volume surgical center from January 2021 to October 2023. Preoperative 4MGS was prospectively collected by medical assistants as part of routine vital sign assessments in clinic. Uni- and multivariable analyses were performed to evaluate the associations of preoperative 4MGS with postoperative length of stay, adverse events, and discharge disposition, controlling for lung function (FEV1), extent of resection, comorbidity, and other covariates.

RESULTS

Overall, 401 patients were included (median age, 69 years; interquartile range, 61-75 years): 123 (31%) lobectomy and 278 (69%) sublobar resection patients. After controlling for covariates, each decrease of 0.1 m/s in 4MGS was associated with average longer length of stay (beta, 0.12; 95% confidence interval [CI], 0.01-0.23) and increased odds of adverse events (odds ratio [OR], 1.10; 95% CI 1.00-1.25). These associations were largely maintained when analyses were repeated within the lobar and sublobar cohorts. Among the sublobar resections, decreases in 0.1 m/s of 4MGS was associated with increased odds of discharge to home requiring home services or to a rehabilitation facility (OR, 1.10; 95% CI 1.00-1.22).

CONCLUSIONS

Preoperative 4MGS is independently associated with important surgical outcomes after lung resection. The 4MGS marker can complement other preoperative measures used to risk-stratify patients undergoing lung resection.

Lecanemab for early Alzheimer's disease: Appropriate use recommendations from the French federation of memory clinics

Lecanemab, a monoclonal antibody targeting β-amyloid protofibrils, has shown promising results in a Phase III clinical trial for the treatment of early stages of Alzheimer's disease (AD) and has been approved by the European Medicines Agency. An Early Market Authorization could be submitted to the French regulatory agencies, potentially allowing for the drug's use in clinical practice in France in 2025. To guide French clinicians in administering lecanemab in a standardized way, the French Federation of Memory Clinics has developed appropriate use recommendations for lecanemab that highlight relevant questions established to ensure an optimal risk-benefit ratio. The recommendations emphasize that lecanemab treatment requires a comprehensive individualized evaluation of the risk-benefit ratio, which should occur in multidisciplinary meetings. When approved, the guidelines support the use of blood biomarkers, proposing specific cutoffs for patients eligible for lecanemab under restricted conditions. In addition to the European Medicines Agency restrictions in patients on anticoagulants, and APOE4 homozygotes, the guidelines recommend against lecanemab treatment for patients with high amyloid-related hemorrhagic risk such as probable cerebral amyloid angiopathy (Boston criteria v1.5) until further data become available. Additionally, we recommend that MRI monitoring be started before the third infusion to account for early Amyloid Related Imaging Abnormalities (ARIA) occurring on lecanemab. It is recommended to establish a specific clinical care pathway with protocols for patients with ARIA, with trained physicians and radiologists with expertise in neurological emergency and intensive care. Finally, a discontinuation protocol based on dementia severity assessment after 18 months of lecanemab treatment is suggested. Access to lecanemab requires a personalized biological and genetic diagnosis of AD, which is currently not necessary in most cases. Therefore, the healthcare system must rapidly adjust to new diagnostic procedures and treatment delivery to ensure equal access for all individuals.

A predictive model for neoadjuvant therapy response in breast cancer

Neoadjuvant therapy is a standard treatment for breast cancer, but its effectiveness varies among patients. This highlights the importance of developing accurate predictive models. Our study uses metabolomics and machine learning to predict the response to neoadjuvant therapy in breast cancer patients.

OBJECTIVE

To develop and validate predictive models using machine learning and circulating metabolites for forecasting responses to neoadjuvant therapy among breast cancer patients, enhancing personalized treatment strategies.

METHODS

Based on pathological analysis after neoadjuvant chemotherapy and surgery, this retrospective study analyzed 30 young women breast cancer patients from a single institution, categorized as responders or non-responders. Utilizing liquid chromatography-tandem mass spectrometry, we investigated the plasma metabolome, explicitly targeting 40 metabolites, to identify relevant biomarkers linked to therapy response, using machine learning to generate a predictive model and validate the results.

RESULTS

Eighteen significant biomarkers were identified, including specific acylcarnitines and amino acids. The most effective predictive model demonstrated a remarkable accuracy of 90.7% and an Area Under the Curve (AUC) of 0.999 at 95% confidence, illustrating its potential utility as a web-based application for future patient management. This model's reliability underscores the significant role of circulating metabolites in predicting therapy outcomes.

CONCLUSION

Our study's findings highlight the crucial role of metabolomics in advancing personalized medicine for breast cancer treatment by effectively identifying metabolite biomarkers correlated with neoadjuvant therapy response. This approach signifies a critical step towards tailoring treatment plans based on individual metabolic profiles, ultimately improving patient outcomes in breast cancer care.

Describing the outcomes of frail patients undergoing treatment with systemic therapies for acute myeloid leukaemia: A systematic review

INTRODUCTION

Acute myeloid leukaemia (AML) is a disease of the older person. Due to the demands of intensive chemotherapy, there is a significant risk of over or undertreatment, leading to either iatrogenic harm or missed windows of opportunity for remission or cure. Better tools to aid clinical decision making and risk stratify patients are needed. We aimed to investigate the association between frailty and the treatment and disease-related outcomes of adults receiving systemic therapy for AML.

MATERIALS AND METHODS

A systematic search of PubMed, EMBASE, CINAHL, and Web of Science databases was undertaken for studies assessing frailty (defined as multi-dimensional assessment evaluating two or more geriatric relevant domains or usage of a validated geriatric assessment screening tool) in the setting of adults undergoing systemic therapy for AML.

RESULTS

We identified 6,644 publications, 16 of which met inclusion criteria for extraction. The most commonly described outcomes were overall survival (OS) (n = 12), mortality (n = 8), response rate (n = 6), and high grade toxicity (n = 5). Eleven studies correlated frailty with treatment outcomes: frailty was predictive of lower OS (n = 5), higher mortality (n = 3), and more high grade toxicity (n = 1). OS in particular retained this relationship when controlling for variables such as molecular markers and performance status. Significant heterogeneity in outcome reporting and frailty assessment precluded meta-analysis. Included studies were generally of moderate quality.

DISCUSSION

Frailty was predictive of poorer outcomes in patients with AML distinct from and complimentary to traditional disease prognostic schema. Routine implementation of frailty assessment could represent an important tool to risk stratify patients and improve clinical decision making.

The association between social vulnerability index and survival in older adults with gastrointestinal cancers - The CARE Registry

INTRODUCTION

Older adults represent a majority of gastrointestinal (GI) cancer cases. Social determinants of health, such as neighborhood-level social vulnerability index (SVI), are associated with frailty, a predictor of mortality. The association between social vulnerability and survival is understudied.

MATERIALS AND METHODS

We evaluated 876 adults ≥60y with GI cancer enrolled in the Cancer & Aging Resilience Evaluation (CARE) Registry prior to chemotherapy. Exposure was the Center for Disease Control and Prevention's SVI in tertiles. SVI ranks census tracts between 0th and 100th percentile for lowest and highest vulnerability, respectively. Outcome was survival (enrollment to end of follow-up). Associations between SVI and survival were estimated using Cox proportional hazards models.

RESULTS

Median age of patients was 69y, 58 % were male, 22 % were non-Hispanic Black, 30 % had colorectal, 29 % had pancreatic cancer, and 70 % had stage III/IV disease. About 44 % of participants died in median 17 months follow-up. Frailty status differed by SVI tertile (tertile 1: 26.8 %; tertile 2: 34.3 %; tertile 3: 43.4 %, p-value: <0.001). Adjusting for age, sex, and cancer type/stage, those living in neighborhoods in the highest SVI tertile had 6 % higher hazard of death (95 % confidence interval [CI]: 0.8, 1.4) and in the second-highest tertile had 8 % higher hazard of death (95 % CI: 0.9, 1.4) compared to those in the lowest tertile. This association may be driven by the SVI housing characteristics theme [tertile 2: hazard ratio (HR) 1.40 (95 % CI: 1.09, 1.79); tertile 3: HR 1.20 (95 % CI: 0.93, 1.55)].

DISCUSSION

We did not find a statistically significant association between SVI and survival among older adults with GI cancers. Prior evidence of associations between SVI and overall area-level mortality may not reflect individual-level mortality specific to older adults. Prior evidence of associations between SVI and individual-level frailty among older adults with GI cancers suggests SVI may confer greater risk on development of frailty, which could indirectly impact survival. SVI of at-risk areas may need consideration when designing solutions to improve frailty among older adults with GI cancers, which could have a subsequent positive impact on mortality.

Effectiveness of exercise interventions on functional outcomes in frail adults with a previous or current diagnosis of cancer: a systematic review and meta-analysis

PURPOSE

Exercise improves functional outcomes in individuals with frailty and individuals with cancer, but it is unknown how exercise impacts function in individuals with both cancer and frailty. This systematic review aimed to determine if adults with cancer who are frail and participate in an exercise program have better functional outcomes compared to those who do not.

METHODS

Five databases (OVID Medline, Embase, CINAHL, EMCARE, and Ageline) were searched from inception to March 2024 for RCTs that investigated the impact of exercise on functional outcomes in individuals with cancer who are frail and ≥ 18 years. Title/abstract, full text review, and data extraction were done in duplicate. Cochrane ROB2 was used to assess risk of bias and GRADE for certainty of results.

RESULTS

Eleven RCTs with 1419 participants were included in this review. Meta-analysis did not find a significant difference between intervention and control groups for submaximal walking tests (95% CI 0.24 (- 0.05-0.53), Short Physical Performance Battery (95% CI - 0.50 (- 1.15-0.15)), and grip strength (95% CI 1.83 (- 0.75 to 4.41). However, positive trends emerged for those participating in exercise programs related to submaximal walking test, grip strength, sit to stand, SPPB, and TUG scores.

CONCLUSION

There are few RCTs investigating exercise in this population, with high heterogeneity of existing interventions. This leads to low certainty in the results of the current study.

IMPLICATIONS FOR CANCER SURVIVORSHIP

Cancer survivors and patients need to be screened for frailty and be engaged in appropriate exercise. Further work should be done investigating appropriate parameters of exercise interventions for this population.

The Role of Palliative Care in the Management of Patients with Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver, and 85% to 90% of cases of HCC occur in patients with underlying liver disease. This makes it a complex illness to treat, because disease burden occurs not only from the cancer, but also potential decompensation of the underlying liver disease. Palliative care is multifaceted care that addresses physical, spiritual, and psychosocial needs of patients and can provide support for their caregivers. It can help in advance care planning and hospice support. Early integration of palliative care can improve patient qualify of life and patient/caregiver satisfaction.

Individual Rumination in Adult Cancer Care: A Concept Analysis

OBJECTIVE

To conceptualize rumination in adult cancer care.

METHODS

Walker and Avant's concept analysis method was used to examine rumination in adults with cancer. A systematic search was conducted across psychology, nursing, medicine, and public health disciplines in PsycINFO, PubMed, Web of Science, CINAHL, and Scopus databases from their inception to April 2024. Additional records were identified by manually searching reference lists of relevant studies.

RESULTS

Analysis of 50 articles identified rumination's three defining attributes (intrusions, brooding, instrumentality), antecedents (cancer-related adversity, pre-existing susceptibilities), and consequences (psychophysiological functioning impairments, long-term adaptation). Key features included trait-state duality, internal variability, external cyclicality, and high emotional correlation.

CONCLUSIONS

This concept analysis establishes a preliminary conceptual model of rumination in adult cancer care, integrating its attributes, antecedents, and consequences. The model offers insights into rumination mechanisms, highlighting its complexity and variability, and may inform the development of targeted interventions and theoretical development for cancer population. Further research is needed to validate the model and explore its clinical applications.

IMPLICATIONS FOR NURSING PRACTICE

Understanding rumination in adult cancer care helps nurses identify and support at-risk patients. By recognizing key signs, nurses can implement targeted interventions to improve patients' emotional and psychological well-being, ultimately enhancing their long-term adaptation and quality of life.

Frailty and Renal Cell Carcinoma: Integration of Comprehensive Geriatric Assessment into Shared Decision-making

CONTEXT

Frailty, a geriatric syndrome characterized by decreased resilience and physiological reserve, impacts the prognosis and management of older adults significantly, particularly in the context of surgical and oncological care.

OBJECTIVE

To provide an overview of frailty assessment in the management of older patients with a renal mass/renal cell carcinoma (RCC), focusing on its implications for diagnostic workup, treatment decisions, and clinical outcomes.

EVIDENCE ACQUISITION

A narrative review of the literature was conducted, focusing on frailty definitions, assessment tools, and their application in geriatric oncology, applied to the field of RCC. Relevant studies addressing the prognostic value of frailty, its impact on treatment outcomes, and potential interventions were summarized.

EVIDENCE SYNTHESIS

Frailty is a poor prognostic factor and can influence decision-making in the management of both localized and metastatic RCC. Screening tools such as the Geriatric Screening Tool 8 (G8) and the Mini-COG test can aid clinicians to select older patients (ie, aged ≥65 yr) for a further comprehensive geriatric assessment (CGA) performed by dedicated geriatricians. The CGA provides insights to risk stratify patients and guide subsequent treatment pathways. As such, the involvement of geriatricians in multidisciplinary tumor boards emerges as an essential priority to address the complex needs of frail patients and optimize clinical outcomes. Herein, we propose a dedicated care pathway as a first key step to implement frailty assessment in clinical practice and research for RCC.

CONCLUSIONS

Frailty has emerged as a crucial factor influencing the management and outcomes of older patients with RCC. Involvement of geriatricians in diagnostic and therapeutic pathways represents a pragmatic approach to screen and assess frailty, fostering individualized treatment decisions according to holistic patient risk stratification.

PATIENT SUMMARY

Frailty, a decline in resilience and physiological reserve, influences treatment decisions and outcomes in elderly patients with renal cell carcinoma, guiding personalized care. In this review, we focused on pragmatic strategies to screen patients with a renal mass suspected for renal cell carcinoma, who are older than 65 yr, for frailty and on personalized management algorithms integrating geriatric input beyond patient- and tumor-related factors.

Inequalities in quality metrics for colorectal cancer surgery in older adults: A retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program registry

BACKGROUND

With a growing proportion of patients undergoing surgery for colorectal cancer being older adults, it is unknown whether traditional quality metrics are achieved as often compared with younger adults. This work was done with a view to understand tailoring needs of quality metrics for older adults with colorectal cancer.

METHODS

This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program registry to identify adults (≥18 years) between 2016 and 2021 who underwent elective colorectal cancer surgery for nonmetastatic cancer. older adults was defined as adults ≥65 years. The association between older adults and attainment of consensus quality metrics were evaluated using multivariable logistic regression adjusting for patient, cancer, and treatment factors.

RESULTS

Of 46,159 patients undergoing elective colon cancer resection, 18,592 (40.3%) were older adults. Being an older adult was independently associated with a 14% reduction in odds of harvest of ≥12 nodes and 4.3 times increase in odds of 30-day mortality. Of 9,106 patients undergoing elective rectal cancer resection 5,143 (56.5%) were older adults. Being an older adult was independently associated with a 19% reduction in odds of harvest of ≥12 nodes, 2.3 times increase in odds of 30-day mortality and a 44% reduction in odds of receiving neoadjuvant radiation. Findings were robust to sensitivity analyses of alternate methods of handling missing data and alternate analytic approaches.

CONCLUSION

Given unique needs of the older adult population, interpretation of disparities in quality metrics is challenging because of an inability to differentiate between patient factors, tailored care, or bias. Monitoring and reporting of quality metrics for older adults need to be re-evaluated with consideration to stratification, unique benchmarks, and older adult-specific quality metrics.

Emerging advances in drug delivery systems (DDSs) for optimizing cancer complications

The management and treatment of tumor complications pose continuous challenges due to the inherent complexity. However, the advent of drug delivery systems (DDSs) brings promising opportunities to address the tumor complications using innovative technological approaches. This review focuses on common oncological complications, including cancer thrombosis, malignant serous effusion, tumor-associated infections, cancer pain, and treatment-related complications. Emphasis was placed on the application and potential of DDSs in mitigating and treating these tumor complications, and we delved into the underlying mechanisms of common cancer-associated complications, discussed the limitations of conventional treatments, and outlined the current status and potential development of DDSs for various complications in this review. Moreover, we have discussed the existing challenges in DDSs research, underscoring the need for addressing issues related to biocompatibility and targeting of DDSs, optimizing drug delivery routes, and enhancing delivery efficiency and precision. In conclusion, DDSs offer promising avenues for treating cancer complications, offering the potential for the development of more effective and safer drug delivery strategies, thereby improving the quality of life and survival rates of cancer patients.

Navigating Emergency Management of Cancer Patients: A Retrospective Study on First-Time, End-Stage, and Other Established Diagnoses in a High Turnover Emergency County Hospital

Background and Objectives: The incidence and prevalence of cancers are increasing worldwide, with special emphasis placed on prevention, early detection, and the development of new therapeutic strategies that strongly impact patient outcomes. Limited data are available about emergency care's role in treating patients with cancer. This study aims to determine the burden of end-stage and first-time diagnosis of cancer on emergency care in a high-turnover emergency care center. Materials and Methods: A retrospective observational study was conducted to identify patients requesting emergent aid for cancer-related symptoms in the Emergency Department of "St. Spiridon" Hospital from Iasi (Romania) between 1 October 2022 and 30 September 2023. The proportion and demographic characteristics of end-stage patients and those who received a first-time diagnosis during the emergency visit were evaluated. Risk analysis was performed to understand these patients' care needs (such as medical care, surgical care, specialty consults, intensive care, ward admission, and other hospital transfers) and immediate care outcomes (such as in-hospital mortality and home discharge). Results: 2318 patients with cancer requested emergent care (patient presentation rate of 3.08%), of which 444 (19.15%) were diagnosed for the first time, and 616 (26.57%) were at the end-stage. First-time diagnosed patients had a significantly different distribution of cancer types (p < 0.001), were more likely to need any form of medical care, to require a specialty consultation, or to be admitted to a ward (OR 2.65, 95% CI: 2.12-3.32; p < 0.001; OR 3.28, 95% CI: 2.48-4.35, p < 0.001; OR 2.09, 95% CI: 1.70-2.59; p < 0.001, respectively) but were less severe, while end-stage patients were more likely to address repeatedly to the emergency room (OR 1.86, 95% CI: 1.32-2.59; p = 0.001) and had higher odds of needing intensive care, assisted ventilation and death (OR-4.63, 95% CI: 1.10-19.45, p = 0.04; OR 2.59, 95% CI: 1.57-4.28; p < 0.001, and OR 4.06, 95% CI: 1.73-9.54; p = 0.001, respectively). Conclusions: The emergency department often carries the weight of diagnosing patients with cancer and treating patients with end-stage disease. These data highlight the importance of prehospital care, particularly for cancer screening and palliative care, and the importance of fostering multidisciplinary collaboration in the emergency room with oncologists, geriatricians, and palliative care specialists to improve patient outcomes.

Diagnosis of Respiratory Sarcopenia for Stratifying Postoperative Risk in Non-Small Cell Lung Cancer

Importance

Physical biomarkers for stratifying patients with lung cancer into subtypes suggestive of outcomes are underexplored.

Objective

To investigate the clinical utility of respiratory sarcopenia for optimizing postoperative risk stratification in patients with non-small cell lung cancer (NSCLC).

Design, Setting, and Participants

This retrospective cohort study reviewed consecutive patients undergoing lobectomy and mediastinal lymph node dissection for NSCLC at 2 institutions in Tokyo, Japan, between 2009 and 2018. Eligible patients underwent electronic computed tomography image analysis. Follow-up began at the date of surgery and continued until death, the last contact, or March 2022. Data analysis was performed from April 2022 to March 2023.

Main Outcomes and Measures

Respiratory sarcopenia was identified by poor respiratory strength (peak expiratory flow rate) and was confirmed by a low pectoralis muscle index (PMI; pectoralis muscle area/body mass index). Patients with poor peak expiratory flow rate but normal PMI received a diagnosis of pre-respiratory sarcopenia. Short-term and long-term postoperative outcomes were compared among patients with a normal status, pre-respiratory sarcopenia, and respiratory sarcopenia. Group differences were analyzed using the Kruskal-Wallis test and Pearson χ2 test for continuous and categorical data, respectively. Survival differences were compared using the log-rank test. Univariable and multivariable analyses were conducted using the Cox proportional hazards model.

Results

Of a total of 1016 patients, 806 (497 men [61.7%]; median [IQR] age, 69 [64-76] years) were eligible for electronic computed tomography image analysis. The median (IQR) duration of follow-up for survival was 5.2 (3.6-6.4) years. Respiratory strength was more closely correlated with PMI than pectoralis muscle radiodensity (Pearson r2, 0.58 vs 0.29). Respiratory strength and PMI declined with aging simultaneously (both P for trend < .001). Pre-respiratory sarcopenia was present in 177 patients (22.0%), and respiratory sarcopenia was present in 130 patients (16.1%). The risk of postoperative complications escalated from 82 patients (16.4%) with normal status to 39 patients (22.0%) with pre-respiratory sarcopenia to 39 patients (30.0%) with respiratory sarcopenia (P for trend < .001), as did the risk of delayed recovery after surgery (P for trend < .001). Compared with patients with normal status or pre-respiratory sarcopenia, patients with respiratory sarcopenia exhibited worse 5-year overall survival (438 patients [87.2%] vs 133 patients [72.9%] vs 85 patients [62.5%]; P for trend < .001). Multivariable analysis identified respiratory sarcopenia as a factor independently associated with increased risk of mortality (hazard ratio, 1.83; 95% CI, 1.15-2.89; P = .01) after adjustment for sex, age, smoking status, performance status, chronic heart disease, forced expiratory volume in 1 second, diffusing capacity for carbon monoxide, C-reactive protein, albumin, carcinoembryonic antigen, histology, and pathologic stage.

Conclusions and Relevance

This study identified individuals at higher risk of poor outcomes by screening and staging respiratory sarcopenia. The early diagnosis of respiratory sarcopenia could optimize management strategies and facilitate longitudinal care in patients with NSCLC.

Progress in lung cancer study coupled with cognitive frailty in elderly individuals

Cognitive frailty is increasingly prevalent among elderly patients, heightening the risks of dementia, disability, and mortality. This demographic also faces a rising incidence of lung cancer, and cognitive frailty complicates rehabilitation efforts. Research on cognitive frailty in elderly lung cancer patients is still emerging. This review examines the definition and assessment of cognitive frailty, its the current prevalence in this population, and nursing management strategies. While tools for assessing cognitive frailty are not standardized, the incidence remains high, leading to adverse health outcomes. Comprehensive interventions for elderly lung cancer patients with cognitive frailty are insufficient, highlighting the need for more effective strategies to mitigate this issue. The goal is to enhance both research and clinical practices in identifying and diagnosing cognitive frailty in this vulnerable population.

Prognostic value of electronic health records-based frailty measures for all-cause mortality in older patients with non-small cell lung cancer

INTRODUCTION

Frailty screening is important to guide treatment decisions for older patients with non-small cell lung cancer (NSCLC). However, the performance of frailty measures (FMs) remains unclear. This study aimed to evaluate the prognostic value of FMs based on electronic health records (EHR) data in clinical settings for all-cause mortality in older patients with NSCLC.

MATERIALS AND METHODS

We retrospectively analyzed 4253 patients aged ≥65 years, newly diagnosed with NSCLC (2007-2018) using EHR data from the National Cancer Center, Korea. Frailty was measured by either laboratory tests (frailty index based on routine laboratory tests [FI-Lab]), comorbidities and performance status (electronic Frailty index [eFI]), or both (combined frailty index [FI-combined]). Patients were categorized as frail or non-frail. Cox proportional hazards models and C-index were used to estimate the predictive ability of FMs for all-cause mortality in 1 year, 3 years, and 5 years post-diagnosis, adjusting for age, sex, and SEER stage.

RESULTS

EHR-based FMs could enhance the prognostic ability to predict the survival of older patients with NSCLC. In the total population, FI-Lab showed the largest predictive value, especially for 1-year mortality with an adjusted hazard ratio for frail vs. non-frail groups of 2.25 (95 % CI 2.02-2.51) and C-index of 0.74 compared to 0.72 in the base model (p-value<0.001). FI-Lab could improve the prognostic ability for 1-year mortality in patients with regional and distant SEER stages and those receiving systemic therapy, whereas FI-combined could improve the prediction of 3-year and 5-year mortality in patients with localized disease and receiving surgery.

DISCUSSION

Easy-to-use FMs derived from EHR data can enhance the prediction of all-cause mortality in older patients with NSCLC. Oncologists can utilize comprehensive FMs comprising comorbidities, functional status, and subclinical tests or FI-Lab, depending on the patient's medical condition, to facilitate shared cancer care planning.

Common comorbidity indices fail to predict short-term postoperative outcomes following male urethroplasty

PURPOSE

To evaluate whether commonly used comorbidity indices [Charlson Comorbidity Index (CCI), Van Walraven Index (VWI), and modified frailty index (mFI)] predict postoperative readmissions and complications after urethroplasty.

METHODS

Patients undergoing urethroplasty for urethral stricture from the State Inpatient Database and State Ambulatory Surgery and Services Database for Florida (2010-2015) and California (2010-2011) were identified. We calculated CCI, VWI, and mFI scores for each patient. We extracted the following adverse outcomes: 30 day ER services, 30 day inpatient readmissions, and 90 day Clavien-Dindo III-V complications. We constructed receiver operating characteristic (ROC) curves and compared area under the curve (AUC), using the VWI as the reference index.

RESULTS

We identified 908 urethroplasty patients. Among these patients, 11.5% (n = 104) of patients had a complication, with 4.8% (n = 44) specifically having 30-day ER services, 6.2% (n = 56) having 30 day readmissions, and 9.0% (n = 82) having 90-day Clavien-Dindo III-V complications. ROC curves demonstrated poor predictive performances for all four indices as no index achieved an AUC > 0.70. The indices performed similarly poorly but the mFI-DX was particularly poor at predicting 90 day Clavien-Dindo III-V complications (AUC = 0.49; 95% CI 0.43-0.55; p < 0.01).

CONCLUSIONS

The CCI, VWI, and mFI have poor ability to identify patients who had an adverse event after urethroplasty. Our results support the need for a urology-specific comorbidity index to better identify at-risk patients undergoing urethroplasty.

Association of preoperative frailty with short- and long-term outcomes after hepatic resection for elderly patients with hepatocellular carcinoma: multicentre analysis

BACKGROUND

The growing demand for surgical resection in elderly patients with hepatocellular carcinoma highlights the need to understand the impact of preoperative frailty on surgical outcomes. The aim of this multicentre cohort study was to investigate the association between frailty and short- and long-term outcomes after hepatic resection among elderly patients with hepatocellular carcinoma.

METHODS

A multicentre analysis was conducted on elderly patients with hepatocellular carcinoma (aged greater than or equal to 70 years) who underwent curative-intent resection at ten Chinese hospitals from 2012 to 2021. Frailty was assessed using the Clinical Frailty Scale (with frailty defined as a Clinical Frailty Scale score greater than or equal to 5). The primary outcomes were overall survival and recurrence-free survival; secondary outcomes encompassed postoperative 30-day morbidity and mortality, and 90-day mortality. The outcomes between patients with and without preoperative frailty were compared.

RESULTS

Of the 488 elderly patients, 148 (30.3%) were considered frail. Frail patients experienced significantly higher 30-day morbidity (68.9% (102 of 148) versus 43.2% (147 of 340)), 30-day mortality (4.1% (6 of 148) versus 0.6% (2 of 340)), and 90-day mortality (6.1% (9 of 148) versus 0.9% (3 of 340)) compared with non-frail patients (all P < 0.010). During a median follow-up of 37.7 (interquartile range 20.4-57.8) months, frail patients demonstrated significantly worse median overall survival (41.6 (95% c.i. 32.0 to 51.2) versus 69.7 (95% c.i. 55.6 to 83.8) months) and recurrence-free survival (27.6 (95% c.i. 23.1 to 32.1) versus 42.7 (95% c.i. 34.6 to 50.8) months) compared with non-frail patients (both P < 0.010). Multivariable Cox regression analysis revealed frailty as an independent risk factor for decreased overall survival (HR 1.61; P = 0.001) and decreased recurrence-free survival (HR 1.32; P = 0.028).

CONCLUSION

Frailty is significantly associated with adverse short-term and long-term outcomes after resection in elderly patients with hepatocellular carcinoma. The findings suggest that frailty assessment should be incorporated into perioperative and postoperative evaluation for elderly patients undergoing hepatocellular carcinoma resection.

Frailty transitions and associated factors in older cancer survivors in the USA: using a multi-state modeling

PURPOSE

Frailty is a major concern in the aging cancer population. It can progress to severe frailty or death or improve to pre-frail or non-frail states. However, frailty transitions in older cancer survivors are not well understood. This study aimed to explore frailty transitions and associated factors in older cancer survivors.

METHODS

We analyzed data from the National Health and Aging Trends Study (NHATS) in 2017-2022, focusing on older adults aged ≥ 65 who have been diagnosed with cancer. Frailty was assessed annually using the Fried Frailty Phenotype. Multi-state Markov models were used to explore transitions between frailty states (non-frail, pre-frail, frail, and death) and examine the association with sociodemographic factors, comorbidities, and inflammatory biomarkers (IL-6 and CRP).

RESULTS

Among 1219 survivors, 25.27% were non-frail, 52.34% pre-frail, and 22.40% frail at baseline. Over 5 years, there were 1396 transitions: 950 (68.05%) progressed or deceased, and 446 (31.95%) reversed. Pre-frail individuals transitioned to frailty slightly more than they reversed to non-frailty (0.25 vs. 0.21). Frail individuals were more likely to decease than to reverse (0.30 vs. 0.28). Factors associated with frailty progression included older age, lower education, more comorbidities, and higher IL-6 and CRP levels. Being female and obese were protective against the frailty-to-death transition.

CONCLUSIONS

The results showed dynamic frailty transitions in older cancer survivors and identified key sociodemographic and physiological factors.

IMPLICATIONS FOR CANCER SURVIVORS

These findings can guide targeted interventions, highlighting the importance of early identification and tailored approaches to prevent frailty progression in older cancer survivors.

Development and validation of the Taiwan Cancer Frailty Tool for older patients with cancer: A prospective longitudinal study

INTRODUCTION

The increasing occurrence of cancer in Taiwan's older population highlights the need for a culturally attuned frailty assessment tool. This study aimed to develop and validate a frailty screening instrument specifically designed for older Taiwanese patients with cancer to predict survival outcomes.

MATERIALS AND METHODS

Patients aged ≥65 years newly diagnosed with cancer before treatment initiation at three Hospitals in Taiwan were prospectively included from July 2018 to December 2020 to participate in the study. Participants were randomly divided into development and validation groups with a 3:1 ratio. Key variables from the comprehensive geriatric assessment (CGA) were selected to create the Taiwan Cancer Frailty Tool (TCFT). The ability of the TCFT to evaluate frailty and predict survival outcomes was tested.

RESULTS

Overall, 692 patients were included over the recruitment period, with 519 and 173 in the development and validation cohorts, respectively. The TCFT was developed based on five multivariate analysis factors from the CGA (weight loss, restricted mobility/transfer, falls, impaired cognitive function, and polypharmacy), scoring each factor binary with a maximum score of five. The areas under the receiver operating characteristic curve for the TCFT in predicting frailty were 0.79 (95 % confidence interval [CI]: 0.75-0.83) and 0.86 (95 % CI: 0.80-0.91) in the development and validation groups, respectively, compared with the CGA as the gold standard. Higher TCFT scores correlated with shorter survival (hazard ratio [HR]: 2.39-6.99 and 10.2-88.3) in the development and validation groups, respectively, (p < 0.001).

DISCUSSION

Our study suggests that the TCFT effectively predicts frailty and survival among older Taiwanese patients with cancer, proving to be a culturally sensitive screening tool. Future studies should target a wider application and validation across diverse clinical settings.

Frailty: An Underappreciated Risk Factor for IBD Complications

PURPOSE OF REVIEW

The prevalence of IBD in older adults is rapidly growing. Older adults with IBD are underrepresented in research and clinical trials and yet at great risk for adverse events. Therefore, understanding advanced aged associated constructs in older adults can be critical to improving the management of older adults with IBD.

RECENT FINDINGS

In this review, we present recent studies on frailty in IBD. We identify 4 major themes in the literature: studies that describe frailty in patients with IBD, studies that report on consequences of frailty, studies of frailty as a risk stratification modality, and studies of frailty as an exposure and outcome. In reviewing the literature, we discuss the heterogeneity that exists and outline future directions to ensure appropriate applications for frailty in the field of IBD.

Racial Disparities in Patients with Metastatic Tumors of the Spine: A Systematic Review

OBJECTIVE

Disparities in access and delivery of care have been shown to disproportionately affect certain racial groups. Studies have been conducted to assess these disparities within the spinal metastasis population, but the extent of their effects in the setting of other socioeconomic measures remains unclear. The purpose of this study was to perform a systematic review to understand the effect of racial disparities on outcomes in patients with metastatic spine disease.

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed, where a comprehensive online search was performed using Pubmed, Medline, Web of Science, Cochrane, Embase, and Science Direct using MeSH terms related to metastatic spine tumor surgery and racial disparities up to February 2023. Two independent reviewers screened and analyzed articles to include studies assessing the following primary outcomes: clinical presentation, treatment type, postoperative complications, readmission, reoperation, survival and/or mortality, length of hospital stay, discharge disposition, and advance care planning.

RESULTS

A total of 13 studies were included in final analysis; 12 were retrospective cohort studies (Level of evidence III) and 1 was a prospective study (Level of evidence II). Postoperative complications were the most studied outcome in 46% of studies (6 of 13), followed by survival in 31% (4 of 13), and treatment type also in 31% (4 of 13). Overall, race was found to be significantly associated with at least one evaluated outcome in 69% of studies (9 of 13). Racial disparities were found in the incidence of cord compression, non-routine discharge, and treatment type in patients with metastatic spine disease. No differences were found on rates of post-operative ambulation, advance care planning, readmission, or survival; inconsistent results were seen for postoperative complications and length of stay. Nine studies (69%) included at least one other measure of socioeconomic status in multivariate analysis, with the two most common being insurance type and income.

CONCLUSIONS

Although some studies suggest race to be associated with presenting characteristics, treatment type and outcome of patients with spinal metastases, there was significant variability in the inclusion of measures of socioeconomic status in study analyses. As such, the association between race and outcomes in oncologic spine surgery remains unclear.

Frailty as a predictor of adverse outcomes in patients with hepatectomy - the importance of design studies to improve frailty: A systematic review and meta-analysis of 128 868 patients

BACKGROUND

Frailty has been associated with increased mortality among patients with surgery. However, evidence about the frailty prevalence and outcomes in frail populations with hepatectomy is inconsistent and has not been clarified. The purpose of this study was to quantitatively synthesize the prevalence of frailty and the role of frailty on mortality in patients with hepatectomy.

METHODS

Embase, PubMed, Scopus, and Web of Science were searched for eligible studies that explored the prevalence and impact of frailty in hepatectomy from inception until January 24, 2024. The pooled prevalence of frailty and odds ratio (OR) corresponding 95% confidence intervals (CI) in mortality and major complications estimates were analyzed.

RESULTS

A total of 26 studies containing 128 868 patients with hepatectomy were included. The prevalence of frailty in hepatectomy was 23% (95% CI: 17-28; p = .000). Frailty was associated with an increased odds ratio for mortality (adjusted OR = 3.06; 95% CI: 1.85-5.04; p = .000). Furthermore, frailty was significantly associated with an increased odds ratio for major complications (adjusted OR = 3.20; 95% CI: 2.04-5.04; p < .01).

CONCLUSION

The prevalence of frailty in patients with hepatectomy is prevalent, which has a significant adverse impact on the outcomes of patients with hepatectomy. These findings highlight the importance of frailty assessment in this population, which may provide prognostic details.

Preoperative geriatric assessment to predict functional outcome after major urologic operations: Results from a multicenter study

INTRODUCTION

Major urological tumor surgery entails a severe risk of unexpected adverse events, persistent functional deterioration, and death in older patients. The Erlangen Index (EI) geriatric assessment tool has previously been shown to predict incomplete functional recovery following major urological tumor surgery in an elderly patient collective. We prospectively evaluated assessment tools including EI in a multicenter setting.

MATERIALS AND METHODS

A total of 340 patients over the age of 65 were assessed prospectively before and after cystectomy, prostatectomy, or renal tumor surgery at three academic centers in Germany and Austria. Endpoints were long-term functional deterioration (Activities of daily living (ADL) measured by Barthel-Index) at day 30 and day 180, and mortality at day 180.

RESULTS

In this study 58 (17.0 %) patients underwent cystectomy, 140 (41.2 %) prostatectomy and 142 (41.8 %) a kidney tumor operation. Mean age was 74.8 years. ADL impairment as a measure of incomplete recovery at day 30 and 180 after surgery were recorded in 47.6 % and 37.4 % of cases, respectively. The EI showed good sensitivity for mortality at day 180 (reference cohort: 85 %, validation center 1: 100 %, validation center 2: 50 %) and for ADL impairment at day 180 (reference cohort 75.4 %, validation center 1 72.3 %, validation center 2 83.3 %).

CONCLUSION

Elderly patients with a poor performance status have a high risk of persistent functional deterioration. Data from this multicenter external validation trial confirms the EI as an accurate and reliable tool to identify patients with high risk of mortality or persistent postoperative functional impairment.

Comparison of Modified Frailty Index, Clinical Frailty Scale, ECOG Score, and ASA PS Score in Predicting Postoperative Outcomes in Cancer Surgery: A Prospective Study

Multiple pre-operative risk assessment scores are available for risk stratification of cancer patients undergoing surgery. This is the first study comparing commonly used preoperative risk assessment tools of Eastern Cooperative Oncology Group Performance Scale (ECOG) and American Society of Anaesthesiologists Physical Status Scale (ASA PS) with frailty scores of Modified Frailty Index (MFI) and Clinical Frailty Scale (CFS). This is a prospective observational study of adult cancer patients undergoing oncosurgery in a tertiary cancer center over one year. Pre-operative risk stratification was done using CFS, MFI, ASA PS, and ECOG scales. All patients were followed up postoperatively for 30 days, and complications were documented. Univariate and multivariate analyses were performed. p value of ≤0.05 was considered significant. Of the 4107 patients studied, 12.6% had prolonged hospitalization, 6.1% had morbidity, 0.9% had readmission, and mortality was 0.6%. ASA PS, ECOG, and CFS were significantly associated with prolonged hospitalization, morbidity, and mortality. MFI was significantly associated with prolonged hospitalization and morbidity. No score could predict readmission. On multivariate analysis, morbidity and readmission were significantly associated with neoadjuvant therapy (p=0.001), mortality with emergency surgery (p=0.001), and prolonged hospitalization with stage III and IV cancer (p=0.001). In adult patients undergoing oncosurgery, ASA PS, ECOG, and CFS are predictors of prolonged hospitalization, morbidity, and mortality. MFI is predictive of prolonged hospitalization and morbidity. None of the studied pre-operative risk scores predict readmission. Newer predictive tools with cancer-specific factors are required for better risk stratification of cancer patients undergoing surgery.

Association of Limited Health Literacy With Frailty, Health-Related Quality of Life, and Health Care Utilization Among Older Adults With Cancer: The Cancer and Aging Resilience Evaluation Registry

PURPOSE

Limited health literacy-ability to obtain, process, and understand health information-can hinder communication, access to medical treatment, and identification and management of comorbidities. Older adults have high rates of poor health literacy, but its role in aging-related outcomes among older adults with cancer is understudied.

METHODS

We included 876 older adults age 60 years and older with cancer from the Cancer and Aging Resilience Evaluation Registry completing self-reported geriatric assessment, including health literacy, at first visit to medical oncology. The exposure was limited health literacy. Outcomes were frailty, physical/mental health-related quality of life (HRQOL), and health care utilization. We used modified Poisson regression to examine the association of exposure on outcomes adjusting for age, race-ethnicity, sex, and cancer type/stage.

RESULTS

Median age at enrollment was 68; 57.8% were male; 20.2% were non-Hispanic Black. The most prevalent cancers were advanced-stage (46.8% stage IV) colorectal (26.9%) and pancreatic (19.0%). Those with limited health literacy were older (70 v 68 years; P < .001), male (63.0% v 55.1%; P = .026), non-Hispanic Black (28.8% v 16.1%; P < .001), ≤high school educated (62.3% v 28.1%; P < .001), and retired/disabled (86.3% v 71.2%; P < .001). In multivariable analysis, limited health literacy was associated with higher prevalence of frailty (prevalence ratio [PR], 2.64 [95% CI, 2.15 to 3.26]), impaired physical (PR, 1.90 [95% CI, 1.59 to 2.27]) and mental (PR, 2.08 [95% CI, 1.76 to 2.47]) HRQOL, and hospitalization in the last year (PR, 1.28 [95% CI, 1.10 to 1.48]) versus adequate health literacy.

CONCLUSION

Older adults with cancer and limited health literacy had higher adjusted prevalence of frailty, impaired physical and mental HRQOL, and recent hospitalization. Interventions to address limited health literacy should be explored in this vulnerable and growing cancer population.

Surgical Oncology Care for Patients With Frailty-Is the Juice Worth the Squeeze?

This Viewpoint describes how frailty assessments should be incorporated into surgical oncology decision-making for older adults with head and neck cancer.

Prediction of moderate and severe toxicities of chemotherapy in older patients with cancer: a propensity weighted analysis of ELCAPA cohort

BACKGROUND

Currently available predictive models for chemotherapy-related toxicity are not sufficiently discriminative in older patients with cancer and do not consider moderate toxicities. The purpose of this study was to identify factors associated with moderate and severe chemotherapy toxicities in older patients with cancer.

MATERIALS AND METHODS

Patients aged 70+ recruited in the prospective ELCAPA cohort were analyzed. A total of 837 patients with data on toxicities had received chemotherapy without other systemic treatment and were included between 2015 and 2022. To adjust for any imbalances in the distribution of covariates between patients receiving single-agent chemotherapy vs combination chemotherapy, we applied overlap weighting (a propensity-score-based technique). We used multinomial logistic regression.

RESULTS

Median (interquartile range) age was 81 (77-84). Forty-one percent experienced moderate toxicity, and 33% experienced severe toxicity. Hematologic toxicities accounted for 53% of severe toxicities and 66% of moderate toxicities. Age <80 years, cancer type, metastatic status, Eastern Cooperative Oncology Group performance status (ECOG-PS) >1, no cognitive impairment were associated with combination chemotherapy decision. In a univariate analysis with overlap weighting, no factors were associated with moderate toxicity. Hemoglobin < 10 g/dL and a CIRS-G score >12 were associated with severe toxicity. In a multivariate analysis, only hemoglobin < 10 g/dL was independently associated with severe toxicity, adjusted OR 2.96 (95% CI, 1.20-7.29).

CONCLUSION

By addressing indication bias for combination chemotherapy decision, only anemia and not cancer type, combination chemotherapy was predicting for severe chemotherapy-related toxicity in older patients with cancer. We did not find any predictors of moderate chemotherapy-related toxicity.

Frailty in patients with ovarian cancer and the role of healthcare access, race, and ethnicity

OBJECTIVE

Ovarian cancer has poor 5-year survival, particularly among non-Hispanic (NH) Black patients. Efforts to identify patients at high-risk of functional limitations and frailty may improve outcomes. In this study, we examined how healthcare access (HCA) and race/ethnicity relate to frailty among patients with ovarian cancer.

METHODS

We identified Hispanic, NH Black, and NH White patients diagnosed at ages ≥6 5 years with ovarian cancer between 2009 and 2015 using SEER-Medicare. Log-binomial regression was used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the association between HCA and race/ethnicity with pre- or post-diagnosis frailty, adjusting for age and comorbidities.

RESULTS

A total of 6041 patients with ovarian cancer were included, including 91.8% NH White, 6.6% NH Black, and 1.7% Hispanic. Pre-diagnosis, 14.7% of patients were defined as frail (NH White: 14.3%; NH Black: 17.9%; Hispanic: 20.8%). Post-diagnosis, frailty prevalence increased to 58.8% (NH White: 58.2%; NH Black: 65.2%; Hispanic: 70.2%). No statistically significant associations were observed between race/ethnicity and pre- or post-diagnosis frailty in fully adjusted models. After adjustment for patient characteristics and healthcare accessibility and availability, higher healthcare affordability was associated with a decreased prevalence of pre-diagnosis frailty (PR: 0.91, 95% CI: 0.8 5, 0.98).

CONCLUSIONS

Patients with ovarian cancer have a high prevalence of frailty after diagnosis, particularly NH Black and Hispanic patients. Improving healthcare affordability may prevent or help manage frailty in Medicare patients, improve receipt of cancer treatment, and increase cancer survival.

Breaking down frailty: Assessing vulnerability in acute myeloid leukemia

Acute myeloid leukemia (AML) is a disease primarily affecting older adults. However, not all patients at older ages are suitable for curative treatment with intensive chemotherapy due to "frailty" demonstrated by their functional status, physiologic reserve, and vulnerability to disease and treatment morbidity. Lack of consensus exists on how to select older, less fit patients most appropriate for standard intensive chemotherapy (IC), hypomethylating agents (HMA) with venetoclax, or less intensive regimens. A total of 37 studies of frailty assessments and composite indices in AML show heterogeneous results regarding the ability of frailty and Comprehensive Geriatric Assessment (CGA) measures to predict treatment outcomes. CGA, Geriatric 8 (G8) risk score, and hematopoietic cell transplant comorbidity index (HCT-CI) show association with prognosis, and should be validated in larger therapeutic trials. Studies of biomarkers, like albumin and C-reactive protein, and patient-reported outcomes demonstrate the potential to enhance information gained from rigorous geriatric assessment.

Effect of Frailty on Postoperative Outcomes Following Major Abdominal Surgeries: A Prospective Observational Study

Background

Frailty poses unique challenges for patients undergoing major cancer surgeries due to their extreme vulnerability to physiological stressors and can be an important factor in determining postoperative outcomes.

Aims and objective

The objective of the study was to determine the incidence of frailty in patients undergoing major abdominal cancer surgeries and identify the risk factors predicting poor outcomes.

Materials and methods

This was a prospective observational study conducted following institutional ethics approval and CTRI registration. We included 308 adult patients who underwent major abdominal cancer surgeries over two years. The preoperative frailty score was calculated using the 11-point modified frailty index score (mFI scale). Patients with a mFI score ≥ 3 points were considered frail. Clinical outcomes such as postoperative complications (Clavien-Dindo grades III and IV), surgical site infections, need for vasopressors, mechanical ventilation, acute kidney injury (AKI), length of ICU and hospital stay, and mortality at 30 days were recorded.

Results

The overall incidence of frailty according to the mFI scale was 8.1%. Age and higher American Society of Anesthesiology (ASA) status were significantly associated with frailty (OR -1.073, p < 0.001, and OR -10.220, p < 0.001) respectively. Frailty was an independent predictor of major postoperative complications (OR -8.147, 95%; CI -2.524-26.292, p < 0.001). Frailty was also significantly associated with an increased duration of mechanical ventilation and length of stay (p < 0.001).

Conclusion

The modified frailty index (mFI) score remains a strong predictor of postoperative complications in patients undergoing major abdominal cancer surgeries and can help optimize risk factors to minimize complications.

How to cite this article

Joshi M, Bhoslae SJ, Pandhare J, Rathod R, Solanki SL, Kulkarni AP. Effect of Frailty on Postoperative Outcomes Following Major Abdominal Surgeries: A Prospective Observational Study. Indian J Crit Care Med 2024;28(11):1038-1043.

Is Cancer Associated With Frailty? Results From a Longitudinal Study of Old Danish Twins

BACKGROUND

Although age is an important risk factor for both cancer and frailty, it is unclear whether cancer itself increases the risk of frailty. We aimed to assess the association between cancer and frailty in a longitudinal cohort of older Danish twins, taking familial effect into account.

METHODS

Using the Danish Cancer Registry, cancer cases were identified among participants aged 70 and over in the Longitudinal Study of Aging Danish Twins (LSADT). Frailty was evaluated over 10 years of follow-up using the frailty index (FI) and defined as FI > 0.21. Stratified Cox regressions were performed on discordant twin pairs (pairs where one twin had incident cancer and the other was cancer-free) and on all LSADT individual twins (twin pairs and singletons) with no history of cancer.

RESULTS

Among the 72 discordant pairs (n = 144, median age at inclusion = 75) included in the study, the median FI at inclusion was 0.08 for both cancer twins and cancer-free co-twins. From the stratified Cox regression, twins with cancer had an increased hazard of developing frailty (hazard ratio [HR] = 3.67, 95% confidence interval [CI] = 1.02-13.14) compared with their cancer-free co-twins. The analyses on individual twins (n = 4 027) provided similar results, showing an increased hazard of frailty in individuals with cancer (HR = 2.57, 95% CI = 1.77-3.74) compared with those without cancer.

CONCLUSIONS

We showed a higher risk of becoming frail following a cancer diagnosis in both discordant twin pairs and individual twins. These findings support the importance of monitoring frailty in older adults with cancer through geriatric assessments and the implementation of frailty interventions.

Unveiling the intrinsic role of malnutrition in patients with Crohn's disease undergoing major surgery using entropy balancing weighting analysis

The negative role of malnutrition in patients with Crohn's disease is known; however, many coexisting disease-related factors could cause misinterpretation of the real culprit. This study aimed to describe the role of malnutrition using a novel methodology, entropy balancing. This was a retrospective analysis of consecutive patients undergoing elective major surgery for Crohn's disease, preoperatively screened following the European Society for Clinical Nutrition guidelines. Two-step entropy balancing was applied to the group of malnourished patients to obtain an equal cohort having a null or low risk of malnutrition. The first reweighting homogenised the cohorts for non-modifiable confounding factors. The second reweighting matched the two groups for modifiable nutritional factors, assuming successful treatment of malnutrition. The entropy balancing was evaluated using the d-value. Postoperative results are reported as mean difference or OR, with a 95 % CI. Of the 183 patients, 69 (37·7 %) were at moderate/high risk for malnutrition. The malnourished patients had lower BMI (d = 1·000), Hb (d = 0·715), serum albumin (d = 0·981), a higher lymphocyte count (d = 0·124), Charlson Comorbidity Index (d = 0·257), American Society of Anaesthesiologists (d = 0·327) and Harvey-Bradshaw scores (d = 0·696). Protective loop ileostomy was more frequently performed (d = 0·648) in the malnourished group. After the first reweighting, malnourished patients experienced a prolonged length of stay (mean difference = 1·9; 0·11, 3·71, days), higher overall complication rate (OR 4·42; 1·39, 13·97) and higher comprehensive complication index score (mean difference = 8·9; 2·2 15·7). After the second reweighting, the postoperative course of the two groups was comparable. Entropy balancing showed the independent role of preoperative malnutrition and the possible advantages obtainable from a pre-habilitation programme in Crohn's disease patients awaiting surgery.

Prehabilitation in Frail Octogenarian and Nonagenarian Patients in Colorectal Cancer Surgery: Short- and Medium-Term Outcomes

Background: There is still limited evidence on the results of prehabilitation in very old frail patients. The aim of this study is to analyze the outcomes and course of octogenarian and nonagenarian patients undergoing prehabilitation before surgery for colorectal cancer (CRC). Methods: a prospective study was conducted in a tertiary hospital from 2018 to 2022. All patients diagnosed with CRC over 80 years old and proposed for surgery were included. A comprehensive geriatric assessment (CGA) for frailty detection was performed, and the therapeutic decision was taken by the multidisciplinary tumor committee. Prehabilitation led by the geriatric team was performed. The rate of medical and surgical complications, hospital stay, in-hospital mortality, and first-year mortality were recorded. Results: CRC surgery was proposed in 184 patients >80 years. After a multidisciplinary decision, surgery was performed on 126 (68.5%) patients, of whom 12 (0.5%) were nonagenarians. Fifty percent of octogenarians and 86% of nonagenarians were frail. Prehabilitation consisted of the following: adapted physical exercise (100%); oral nutritional supplementation (73.8%); anemia treatment (59.5%); delirium prevention (5.6%); antidepressant treatment (15.9%); vitamin D supplementation (21.4%); and pharmacological deprescription (38.1%). The post-surgical complication rate was low (4.3% surgical and 29.4% medical complications), and in-hospital mortality was very low (3.2%). Nonagenarian patients had a higher rate of complications compared to octogenarians (OR 4.0 (95% CI 1.13-14.12))-mainly heart failure (OR 4.68 (95% CI 1.21-18.09))-but there were no differences in hospital stay or first-year mortality. Conclusions: prehabilitation in very old patients with CRC surgery is possible and provides good results.

Development and validation of a diagnostic nomogram for frailty in cancer patients

BACKGROUND

The presence of frailty decreases the overall survival of cancer patients. An accurate and operational diagnostic method is needed to help clinicians choose the most appropriate treatment to improve patient outcomes.

METHODS

Data were collected from 10 649 cancer patients who were prospectively enrolled in the Investigation on Nutritional Status and its Clinical Outcomes of Common Cancers (INSCOC) project in China from July 2013 to August 2022. The training cohort and validation cohort were randomly divided at a ratio of 7:3. The multivariable logistic regression analysis, multivariate Cox regression analyses, and the least absolute shrinkage and selection operator (LASSO) method were used to develop the nomogram. The concordance index and calibration curve were used to assess the diagnostic utility of the nomogram model.

RESULTS

The 10 risk factors associated with frailty in cancer patients were age, AJCC stage, liver cancer, hemoglobin, radiotherapy, surgery, hand grip strength (HGS), calf circumference (CC), PG-SGA score and QOL from the QLQ-C30. The diagnostic nomogram model achieved a good C index of 0.847 (95% CI, 0.832-0.862, P < 0.001) in the training cohort and 0.853 (95% CI, 0.83-0.876, P < 0.001) in the validation cohort. The prediction nomogram showed 1-, 3-, and 5-year mortality C indices in the training cohort of 0.708 (95% CI, 0.686-0.731), 0.655 (95% CI, 0.627-0.683), and 0.623 (95% CI, 0.568-0.678). The 1-, 3-, and 5-year C indices in the validation cohort were similarly 0.743 (95% CI, 0.711-0.777), 0.680 (95% CI, 0.639-0.722), and 0.629 (95% CI, 0.558-0.700). In addition, the calibration curves and decision curve analysis (DCA) were well-fitted for both the diagnostic model and prediction model.

CONCLUSIONS

The nomogram model provides an accurate method to diagnose frailty in cancer patients. Using this model could lead to the selection of more appropriate therapy and a better prognosis for cancer patients.

Underweight as a Risk Factor for Major Intra-abdominal Malignancy Surgeries

Purpose The relationship between body mass index (BMI) and postoperative outcomes for oncology surgeries among the Asian population remains controversial. A prevailing perception suggests that excess adiposity is associated with reduced cancer survival. However, several reports have shown that overweight or early obese states confer better survival outcomes. It is hypothesized that patients with better nutrition and surplus calories grant survival advantages to radical cancer treatment. The purpose of this study is to examine the relationship between BMI and postoperative 30-day and one-year mortality in the Asian population. Methods This retrospective review investigates the postoperative mortality, intensive care unit (ICU) admission, and length of hospital stay following major abdominal cancer surgeries within the Asian population. Patients were stratified into three groups based on their BMI: underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5-27.5 kg/m2), and obese (BMI > 27.5 kg/m2). Results A total of 646 patients were included in this study. At 30 days, the underweight group presents an 8% mortality compared to 1% and 3% mortality in the normal BMI and obese groups, respectively. At one year, the low BMI group presents a significant increase in mortality of 53% as opposed to the normal BMI and obese group with mortality rates of 14% and 12%, respectively (p < 0.001). There is a significant increase in the ICU admission rate in the underweight group (n = 13, 25%) compared to the normal BMI and obese groups (n = 26, 6%; n = 8, 6% p < 0.001). Similarly, the group with lower BMI was observed to require a longer hospital stay postoperatively (median (IQR) 11.0 (4.0-24.0)) compared to the normal (median (IQR) 4.0 (3.0-9.0)) and obese (median (IQR) 4.5 (3.0-8.0)) patients. Conclusion Concordant results were observed in the underweight patient group with increased one-year mortality, ICU admission rate, and hospital stay postoperatively. Low BMI presents as an independent risk factor for major radical surgeries.

Toxicity of Cancer Immunotherapies in Older Patients: Does Age Make a Difference?

The use of immunotherapy agents especially immune checkpoint inhibitors is growing, and toxicities known as immune-related adverse events affecting any organ system may develop as a consequence of the treatment. With an ageing population, a considerable number of patients who will receive these therapies will be older adults. However, older patients who have highly heterogenous clinical characteristics, age-related changes in the immune system, a higher prevalence of comorbidities and frailty have been poorly represented in clinical trials, leaving gaps in understanding the safety of immune checkpoint inhibitor agents in this subgroup. Therefore, the safety of immune checkpoint inhibitors is a primary point of consideration when treating older patients with cancer. The available evidence is conflicting, but it generally suggests that the incidence of immune-related adverse events is not necessarily higher in older patients, but it may have a different profile. It is important to also note that the management of immune-related adverse events can be a challenge in these patients, owing to the risks associated with the use of corticosteroids and a reduced physiological reserve. A comprehensive characterisation of immune ageing, potential biomarkers to predict immune-related adverse events, the use of measures for frailty, enrolling older patients with cancer to clinical trials and analysis of real-world data are necessary to improve the evidence-based decision making for immune checkpoint inhibitor treatment in a geriatric oncology population.

Multimorbidity and the risk of malnutrition, frailty and sarcopenia in adults with cancer in the UK Biobank

BACKGROUND

Malnutrition, sarcopenia and frailty are distinct, albeit interrelated, conditions associated with adverse outcomes in adults with cancer, but whether they relate to multimorbidity, which affects up to 90% of people with cancer, is unknown. This study investigated the relationship between multimorbidity with malnutrition, sarcopenia and frailty in adults with cancer from the UK Biobank.

METHODS

This was a cross-sectional study including 4122 adults with cancer (mean [SD] age 59.8 [7.1] years, 50.7% female). Malnutrition was determined using the Global Leadership Initiative on Malnutrition criteria. Probable sarcopenia and sarcopenia were defined using the European Working Group on Sarcopenia in Older People 2 criteria. (Pre-)frailty was determined using the Fried frailty criteria. Multimorbidity was defined as ≥2 long-term conditions with and without the cancer diagnosis included. Logistic regression models were fitted to estimate the odds ratios (ORs) of malnutrition, sarcopenia and frailty according to the presence of multimorbidity.

RESULTS

Genitourinary (28.9%) and breast (26.1%) cancers were the most common cancer diagnoses. The prevalence of malnutrition, (probable-)sarcopenia and (pre-)frailty was 11.1%, 6.9% and 51.2%, respectively. Of the 11.1% of participants with malnutrition, the majority (9%) also had (pre-)frailty, and 1.1% also had (probable-)sarcopenia. Of the 51.2% of participants with (pre-)frailty, 6.8% also had (probable-)sarcopenia. No participants had (probable-)sarcopenia alone, and 1.1% had malnutrition, (probable-)sarcopenia plus (pre-)frailty. In total, 33% and 65% of participants had multimorbidity, including and excluding the cancer diagnosis, respectively. The most common long-term conditions, excluding the cancer diagnosis, were hypertension (32.5%), painful conditions such as osteoarthritis or sciatica (17.6%) and asthma (10.4%). Overall, 80% of malnourished, 74% of (probable-)sarcopenia and 71.5% of (pre-)frail participants had multimorbidity. Participants with multimorbidity, including the cancer diagnosis, had higher odds of malnutrition (OR 1.72 [95% confidence interval, CI, 1.31-2.30; P < 0.0005]) and (pre-)frailty (OR 1.43 [95% CI 1.24-1.68; P < 0.0005]). The odds increased further in people with ≥2 long-term conditions in addition to their cancer diagnosis (malnutrition, OR 2.41 [95% CI 1.85-3.14; P < 0.0005]; (pre-)frailty, OR 2.03 [95% CI 1.73-2.38; P < 0.0005]). There was little evidence of an association of multimorbidity with sarcopenia.

CONCLUSIONS

In adults with cancer, multimorbidity was associated with increased odds of having malnutrition and (pre-)frailty but not (probable-)sarcopenia. This highlights that multimorbidity should be considered a risk factor for these conditions and evaluated during nutrition and functional screening and assessment to support risk stratification within clinical practice.

Evaluating the Survival Benefits of Perioperative Chemotherapy in Frail and Morbid Muscle-Invasive Bladder Cancer Patients

INTRODUCTION

Current guidelines endorse the use of perioperative chemotherapy (POC) in muscle-invasive bladder cancer (MIBC) to enhance the long-term overall survival (OS) compared to radical cystectomy (RC) alone. This study aims to assess the impact of POC on the OS in frail and morbid (F-M) patients undergoing RC.

METHODS

A retrospective multicenter study of 291 patients who underwent RC between 2015 and 2019 was performed. Patients with both a Charlson comorbidity index ≥ 4 and Modified Frailty Index ≥ 2 were classified as the F-M cohort. We compared the clinical and pathological characteristics and outcomes of the F-M patients who received POC to those who underwent RC alone. Univariable and multivariable analyses were performed to identify the predictors of the OS.

RESULTS

The F-M cohort included 102 patients. POC was administered to 44% of these patients: neoadjuvant (NAC) to 31%, adjuvant (AC) to 19%, and both to 6 (6%). The OS was significantly lower in the F-M cohort compared to in the healthier patients (median OS 42 months, p = 0.02). The F-M patients who received POC were younger, less morbid and had better renal function. Although POC was marginally associated with improved OS in the univariable analysis (p = 0.06), this was not significant in the multivariable analysis (p = 0.50). NAC was associated with improved OS in the univariable analysis (p = 0.004) but not after adjustment for competing factors (p = 1.00). AC was not associated with the OS.

CONCLUSIONS

POC does not improve the OS in F-M patients undergoing RC. Personalized treatment strategies and further prospective studies are needed to optimize care in this unique vulnerable population.

Role of frailty in predicting prognosis of older patients with lung cancer: An updated systematic review and meta-analysis

INTRODUCTION

Frailty is a syndrome affecting primarily older adults that can impact disease course, treatment, and outcomes in patients with lung cancer (LC). We systematically reviewed current data on the correlation between frailty and overall survival (OS), recurrence-free survival (RFS), and the risk of complications in older patients with LC.

MATERIALS AND METHODS

PubMed, EMBASE, and Scopus databases were searched for observational cohort, cross-sectional, and case-control studies involving participants aged 18 years or older diagnosed with LC. Eligible studies were required to perform frailty assessments and have non-frail participants as a comparator group. Random-effects models were used for analysis, and the reported effect sizes were represented as hazards ratio (HR) or odds ratios (OR) with associated 95% confidence intervals (CI).

RESULTS

Seventeen studies were included, most with a retrospective cohort design (n = 16) and patients with non-small cell lung carcinoma (NSCLC). Older patients with LC and frailty had lower OS (HR 1.70, 95% CI: 1.39, 2.07) and RFS (HR 2.50, 95% CI: 1.02, 6.12), compared to non-frail subjects. Frail subjects also had increased risk of complications (OR 1.89, 95% CI: 1.42, 2.53).

DISCUSSION

The observed association between frailty and OS, RFS, and an increased susceptibility to complications emphasizes the potential significance of frailty status as a substantial prognostic indicator. Our results underscore the vital role of including frailty assessment as an integral element within the management plan for patients dealing with lung cancer.

Prevalence and impact of frailty in patients undergoing colorectal cancer surgery: A systematic review and meta-analysis based on modified frailty index

Frailty has been linked to unfavorable postoperative outcomes in patients with colorectal cancer (CRC). However, the prevalence of frailty among CRC surgery patients and its association with mortality and postoperative complications, as evaluated by the modified frailty index (mFI), have not been thoroughly investigated and necessitate clarification. PubMed, Web of Science, Embase, and CBM databases were systematically searched for relevant studies (up to January 2024), and the pooled prevalence and odds ratio (OR) estimate were calculated. A total of 16 studies containing 245 747 patients undergoing CRC surgery were included. The prevalence of frailty among CRC surgery patients was 31% (95% confidence interval [CI] = 20%-42%; I2 = 100%, p < 0.001). In patients undergoing CRC surgery, frailty was associated with a higher incidence of postoperative complications (OR = 1.94; 95% CI = 1.47-2.56; I2 = 91.9%, p < 0.001), but it did not exhibit any significant correlation with the 30-day mortality (OR = 5.17; 95% CI = 0.39-68.64; I2 = 94.4%, p < 0.001). Frailty is common in CRC surgery and exerts a significant negative impact on the postoperative outcomes. Future research could explore the potential of the mFI to facilitate a more streamlined and precise quantification of frailty, thereby establishing a refined understanding of its correlation with surgery prognosis.

Unveiling the multi-dimensional frailty network among older cancer survivors in China: A network analysis study

INTRODUCTION

Frailty has a significant impact on the overall quality of life of older cancer survivors, but the relationships among frailty symptoms are not well understood. This study aims to explore the specific associations among multidimensional symptoms of frailty among older cancer survivors by employing network analysis to provide supportive evidence for targeted interventions in the future.

MATERIALS AND METHODS

Data were obtained by cluster sampling from three large Grade-A tertiary hospitals in Shandong Province, China, and collected through face-to-face interviews by trained investigators. We included patients who were diagnosed with a solid malignant tumor at the age of 60 years or older. Frailty indicators were measured by the Groningen Frailty Indicator (GFI) and analyzed primarily through network analysis, including network estimation, centrality, and stability analysis. The relative importance of a node in a network was tested by centrality analyses, and Spearman correlations were applied to estimate the relationships between symptom pairs (symptom score) and symptom clusters (standardized symptom score) in the symptom network. In terms of centrality, the indexes of strength, closeness, and betweenness were adopted to measure the importance of nodes.

RESULTS

Five hundred and eight older cancer survivors were included, with an average age of 68.4 years (standard deviation [SD] = 5.4), and a higher proportion were male (n = 307[60.4%]). The prevalence of frailty among older cancer survivors was 58.9% (n = 299), with a mean GFI score of 4.46 (SD = 2.87). The strongest edge was between "dressing and undressing" and "going to the toilet" (r = 0.58). The nodes with the higher strength centrality were "going to the toilet" (rS=1.09), "walking around outside" (rS=0.97), and "part of social network" (rS=0.96); and the nodes with the higher closeness centrality were "mark physical fitness" (rC=0.005), "calm and relaxed" (rC=0.005), and "nervous or downhearted" (rC=0.005).

DISCUSSION

This study demonstrated that older cancer survivors in China have a high prevalence of frailty, with self-care and social participation-related symptoms playing a key role in the multidimensional network of frailty symptoms. Psychological symptoms can rapidly influence other symptoms within this network. Therefore, prioritizing psychological symptoms in the assessment of older adults with cancer is essential for effective frailty management.

Pre-emptive Laparoscopic Colostomy Creation in Obstructing Locally Advanced Rectal and Anal Cancer Does Not Delay the Starting of Oncological Treatments

BACKGROUND

Managing patients with obstructing rectal cancer is challenging due to the risks of gastrointestinal obstruction and perforation. This study evaluates the outcomes of pre-emptive laparoscopic colostomy creation in patients with locally advanced rectal and anal cancer to prevent symptoms and facilitate therapy initiation.

METHODS

This retrospective cohort study includes patients with locally advanced rectal or anal cancer assessed by our Colorectal Multidisciplinary Team from January 2017 to February 2024. Patients who underwent pre-emptive laparoscopic colostomy were compared to a control group of non-obstructing rectal cancer patients who started direct oncological treatment. The primary endpoint was the time from diagnosis to the initiation of oncological treatments. The secondary endpoints were the rate and timing of subsequent radical resection, surgical morbidity and hospital stay. A Weibull regression was used to evaluate the time differences between the groups.

RESULTS

There were 37 patients who received pre-emptive laparoscopic colostomy, compared to 207 control patients. The mean time from diagnosis to the start of neoadjuvant therapy was 38.3 ± 2.3 days. Despite higher rates of malnutrition and more advanced stages in the colostomy group, no significant differences were observed in the time to start therapy (p = 0.083) or time to radical resection (p = 0.187) between the groups. The laparoscopic procedure showed low rates of postoperative complications and acceptable lengths of stay.

DISCUSSION AND CONCLUSIONS

Pre-emptive laparoscopic colostomy is a feasible approach for managing obstructing rectal or anal cancer. Treatment timelines were not extended compared to timelines for non-obstructing cases, despite differences in nutritional status and staging. Further prospective studies with larger cohorts are needed to validate these findings and refine treatment protocols for obstructing gastrointestinal malignancies.

Comparative effectiveness of treatment approaches for early invasive breast cancer

BACKGROUND

Randomized controlled trials (RCTs) suggested breast conserving therapy (BCT) and mastectomy have similar survival for early-stage breast cancer, whereas observational studies reported survival advantage for BCT. We aimed to address biases in observational studies to compare the effect of BCT and mastectomy on survival.

METHODS

We emulated a target trial using institutional cancer registry. We included adult women diagnosed with early invasive first primary breast tumors ≤ 5 cm between July 2011 and December 2017. We used cloning, censoring, and weighting to estimate risk differences (RDs) and risk ratios (RRs) for all-cause mortality and recurrence or all-cause mortality between BCT and mastectomy (reference).

RESULTS

Our study population comprised 534 observations with breast cancer. Median age was 56 years and 65 % were racial/ethnic minorities. The 8-year RD was 1.5 % (95 % confidence limits [CL]: -7.0 %, 9.8 %) and RR was 1.1 (95 % CL: 0.57, 2.2) for all-cause mortality. Results for recurrence or mortality were similar.

CONCLUSIONS

Our results suggest that target trial emulation to mitigate selection and immortal-time biases in observational studies may generate estimates that are more compatible with RCTs when comparing the effects of BCT and mastectomy on survival. Studies with longer follow-up and more events are needed to confirm our findings.

Frailty and all-cause and cancer-related mortality in cancer patients: A prospective cohort study

PURPOSE

To evaluate the associations between frailty and all-cause and cancer-related mortality. Additionally, the objective is to compare the magnitude of these associations between older adults and younger adults.

METHODS

We gathered baseline data from NHANES (1999-2018) and developed a cumulative index consisting of 39 items to evaluate frailty. The National Death Index database was utilized to track the survival status of individuals. The Cox regression model was employed to estimate the associations between frailty status and all-cause and cancer-related mortality.

RESULTS

Ultimately, 3398 cancer patients were included in the analysis, comprising 910 younger adults and 2488 older adults. Compared to non-frail patients, the elevated all-cause and cancer-related mortality among pre-frail patients was not statistically significant (HRs = 1.312, 95%CI: 0.956-1.800, P = 0.092; HRs = 1.462, 0.811-2.635, P = 0.207). However, a significant elevation of both all-cause and cancer-related mortality risk was observed among frail patients (HRs = 2.213, 1.617-3.030, P < 0.001; HRs = 2.463, 95%CI = 1.370-4.429, P = 0.003). Frailty individuals demonstrated a more pronounced association with the prediction of all-cause mortality in younger (HRs = 2.230, 1.073-4.634, P = 0.032) than in older adults (HRs = 2.090, 1.475-2.960, P < 0.001). Sensitivity analysis consistently revealed robust results. RCS plots suggested a progressively escalating dose-response correlation between frailty and both all-cause and cancer-related mortality risk.

CONCLUSIONS

Pre-frailty did not result in an increase in mortality risks compared to non-frailty. However, frailty caused a higher all-cause and cancer-related mortality risk than non-frailty. Identifying those at risk and implementing targeted interventions may contribute to extending healthy life expectancy, regardless of age.

Association between Cognitive Function and Physical Function, Frailty, and Quality of Life in Older Breast Cancer Survivors

BACKGROUND

Older cancer survivors in general are at greater risk for cancer-related cognitive impairment (CRCI), yet few studies have explored its association with health outcomes. This study examined the association between subjective and objective measures of cognitive function and physical function, frailty, and quality of life (QoL) among older breast cancer survivors.

MATERIALS AND METHODS

Older breast cancer survivors who reported cognitive concerns completed surveys on patient-reported cognitive function, physical function, frailty, and QoL as well as objective tests of visuospatial working memory and sustained attention. Data were analyzed using descriptive statistics and separate linear regression models.

RESULTS

A total of 219 female breast cancer survivors completed the study. Perceived cognitive abilities were associated with better physical function, frailty, and QoL (p ≤ 0.001) while cognitive concerns were negatively related with these metrics (p ≤ 0.001). Poorer visuospatial working memory and sustained attention were linked to increased frailty (p ≤ 0.001-0.01), whereas poorer sustained attention was associated with poorer physical function (p < 0.01).

CONCLUSIONS

Older breast cancer survivors with perceived cognitive impairment and poorer cognitive performance reported poorer physical functioning, increased frailty, and poorer QoL. These findings underscore the importance of assessing cognitive concerns and their associated outcomes in older breast cancer survivors.

Bibliometric analysis of research trends in the relationship between frailty and neoplasms over the past decade

BACKGROUND

The relationship between frailty and neoplasms has attracted increasing attention from researchers in recent years. This study aims to identify current research hotspots and status in this field through bibliometric and visualization analysis.

METHODS

Literature on the relationship between frailty and neoplasms, meeting the inclusion criteria, was collected from the Core Collection. Bibliometric analysis and visualization were performed using WoS, VOSviewer, and CiteSpace.

RESULTS

Our study included 7410 documents on frailty and neoplasms, authored by 43,605 researchers from 9478 institutions across 115 countries, and published in 2067 journals. The USA emerged as the most productive and influential country in this field, with 3059 publications and 89,319 citations. The University of Texas MD Anderson Cancer Center and Mayo Clinic were recognized as the most productive institution and the institution with the highest citation count, respectively. The Journal of Geriatric Oncology was the leading publisher. Kirsten K Ness and James L Kirkland were identified as the most productive and most cited authors, respectively. Cluster analysis identified five key areas: body condition and nutrition, quality of life, frailty, mortality and care, and the elderly and frailty.

CONCLUSION

The relationship between frailty and neoplasms remains a contentious and frequently discussed topic. Our findings indicate that research primarily focuses on cancer, the elderly, clinical trials, adverse health outcomes, frailty assessment, and nutrition.

Immunotherapy and radiotherapy for older patients with invasive bladder cancer unfit for surgery or chemotherapy: practical proposal by the international geriatric radiotherapy group

The standard of care for non-metastatic muscle invasive bladder cancer is either radical cystectomy or bladder preservation therapy, which consists of maximal transurethral bladder resection of the tumor followed by concurrent chemoradiation with a cisplatin-based regimen. However, for older cancer patients who are too frail for surgical resection or have decreased renal function, radiotherapy alone may offer palliation. Recently, immunotherapy with immune checkpoint inhibitors (ICI) has emerged as a promising treatment when combined with radiotherapy due to the synergy of those two modalities. Transitional carcinoma of the bladder is traditionally a model for immunotherapy with an excellent response to Bacille Calmette-Guerin (BCG) in early disease stages, and with avelumab and atezolizumab for metastatic disease. Thus, we propose an algorithm combining immunotherapy and radiotherapy for older patients with locally advanced muscle-invasive bladder cancer who are not candidates for cisplatin-based chemotherapy and surgery.