SUO 2017: Objective Measures of Frailty as Predictors of Postoperative Complications After Radical Cystectomy

Washington, DC ( Radical cystectomy (RC) for muscle-invasive bladder cancer (MIBC) remains a highly morbid procedure with significant recovery time. However, as many bladder cancer patients are elderly to begin with, the compounded effect has significant implications on outcomes.

While prior studies have established an association between various nomograms and indices with perioperative risk, the authors of this abstract specifically focus on validated frailty indices, including Clinical Epidemiological Survey for Depression (CES-D), Charlson Comorbidity Index (CCI), Katz Index of Independence in Activities of Daily Living (Katz ADL), Karnofsky Performance Scale (KPS), and Eastern Cooperative Oncology Group (ECOG) performance status, as well as usual clinical markers such as preoperative grip strength, gait speed, weight loss of ≥10 pounds in the past year, exhaustion, and low physical activity. This was completed in a prospective manner in patients older than 65 undergoing RC at a single institution.

They enrolled 91 patients over a 2-year period (mean age 74.7). Of these, 68 (74.7%) patients had at least one postoperative complication within 90-days with no difference in age (p=0.8) – though this is higher than reported series for all RC patients, already hinting at the effect of age 

67.0% of patients underwent open radical cystectomy, with no difference in complication rates between open and robotic (p=0.08). 

While gait speed (p<0.001), CCI (p<0.02), physical activity (p<0.02), and weight loss (p<0.03) were significantly associated with 90-day complications on univariate analysis assessing 90-day postoperative complication rates, on multivariable analysis, only physical activity level (OR 0.73, CI 0.53-0.94, p<0.04) and CCI (OR 3.36, CI 1.14-10.56, p<0.04) were associated with increased risk of 90-day complications (controlling for pathologic stage, urinary diversion, blood transfusions, and age). Grip strength and subjective assessment tools (CES-D, Katz ADL, KPS, ECOG) were not associated with 90-day postoperative complications (p>0.05). Interestingly, this is different than prior studies, but perhaps accounting for these in a MV model negated their effect. 

Based on this, the authors note that overall objective measures of frailty, such as preoperative physical activity level or CCI, may be better predictors of postoperative complications than subjective assessments, such as ECOG status. These measures may be useful for identifying older patients at increased risk for complications after radical cystectomy who may need higher acuity care in the perioperative period.

Limitations / Discussion Points:

1. Single-institution analysis – limitations as expected with a single-institution analysis. Who was completing the subjective assessment? Was there concordance? 
2. Sample size - Is the number of patients sufficient to discriminate the effect?

Presented by: Madeleine L. Burg 

Co-Authors: Thomas G. Clifford , Soroush T. Bazargani , Jie Cai , Anne K. Schuckman , Hooman Djaladat and Siamak Daneshmand
Affiliation: USC/Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA

Written by: Thenappan Chandrasekar, MD, Clinical Fellow, University of Toronto, twitter: @tchandra_uromd at the 18th Annual Meeting of the Society of Urologic Oncology, November 20-December 1, 2017 – Washington, DC