Dr. Niegisch says that it is important to weigh age-related mortality to cancer related morbidity and mortality, as well as to identify patients having high risk of perioperative complications. The Charlson Comorbidity index (CCI) has been used for decades and predicts 10-year overall survival. A patient with 0 points has a 98% 10-year survival, while on the other extreme, patients with ≥7 points has a 0% 10-year survival. However, using CCI Dr. Niegisch cautions that age may overrule the impact of comorbidities and may not be the best tool. The Adult Comorbidity Evaluation (ACE) 27 score evaluates 9 organ systems, presence of malignancy, substance abuse and obesity, grading these conditions as none (0), mild (1), moderate (2), or severe (3) and assigns a final score. The benefit of ACE is that it is independent of age but is much more complex than CCI. Given that elderly patients with bladder cancer will have high comorbidity scores, these metrics are not great for the radical cystectomy population.
When assessing perioperative outcomes and the impact of comorbidities, both the ASA score, Elixhauser index and ECOG performance status all outperform CCI. Specifically, ASA score independently predicts post-operative complications and mortality (ASA 3 – 5x higher than ASA 1). However, most elderly patients are ASA 3 thereby already have a much higher risk according to Dr. Niegisch. Frailty has recently been touted as an appropriate measure for these elderly at-risk patients. Frailty is a common clinical syndrome in older adults that carries an increased risk of poor health outcomes including falls, incident disability, hospitalization and mortality. In a recent study, a modified frailty index (mFI) was defined in prior studies with 11 variables based on mapping the Canadian Study of Health and Aging Frailty Index to the National Surgical Quality Improvement Program comorbidities and activities of daily livings [1]. Among 2,679 cystectomy patients identified, 843 (31%) of patients had an mFI of 0, 1176 (44%) had an mFI of 1, 555 (21%) had an mFI of 2, and 105 (4%) had an mFI≥3. When stratified at a cutoff of mFI≥2, the overall complication rate was not different (61.7% vs. 58.3%, p = 0.1), but the mFI2 or greater group had a significantly higher rate of Clavien grade 4 or 5 complications (14.6% vs. 8.3%, p<0.001) and overall mortality rate (3.5% vs. 1.8%, P = 0.01) in the 30-day postoperative period. Thus, frailty impacts perioperative outcomes independent of comorbidities.
Nutritional deficiency has also been associated with perioperative mortality and overall survival in the bladder cancer population. Similarly, sarcopenia is predictive of OS and CSS for patients undergoing radical cystectomy, in addition to predicting postoperative complications.
Although the role of prehabilitation is unclear, there are many factors to consider when deciding on the appropriate elderly patient to subject to a radical cystectomy:
Dr. Niegisch concluded with several take home points:
- Comorbidities, frailty, nutrition deficiencies, and sarcopenia do have a significant impact on postoperative outcomes
- Preoperative assessment of these factors is crucial but complex
- A single test will not work and multidisciplinary/geriatric assessment would be optimal
- A pragmatic approach is to assess long-term prognosis with CCI or ACE 27, and perioperative risk with ASA score
Presented by: Guenter Niegisch, Heinrich-Heine-University, Dusseldorf, Germany
References:
1. Chappidi MR, Kates, M, Patel HD, et al. Frailty as a marker of adverse outcomes in patients with bladder cancer undergoing radical cystectomy. Urol Oncol 2016;34(6):256.e1-6.
Written by: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, twitter: @zklaassen_md at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark