Does Frailty Predict for Complications After Bladder Cancer Surgery?

Measures of frailty and comorbidity failed to offer predictive information regarding postoperative complications in a study of patients with bladder cancer undergoing radical cystectomy. Better stratification accord remains an unmet need in the field.

“Despite significant refinements in surgical techniques, radical cystectomy remains a highly morbid operation, and greater than one-half of patients experience complications during their hospital stay and after discharge,” wrote study authors led by Yair Lotan, MD, of the University of Texas Southwestern Medical Center at Dallas. Earlier research has been done attempting to predict post–radical cystectomy outcomes using tools such as the American Society of Anesthesiologists (ASA) Physical Status Classification, the Charlson Comorbidity Index (CCI), and others.

More recently, there has been suggestion that measures of frailty might be correlated with post–radical cystectomy outcomes. The new study assessed whether the modified Frailty Index (mFI), as well as the CCI and ASA classifications, can predict complications following the operation. The results were published in Cancer.

The study included a total of 346 patients with bladder cancer who underwent radical cystectomy. The mean age in the study was 67.7 years, and 82.4% of the cohort were men. A total of 130 patients (37.6%) received neoadjuvant chemotherapy.

The mean mFI score was 1.4 (range, 0–6); the most common factors contributing to that score included hypertension (65.3%), diabetes (25.1%), chronic obstructive pulmonary disease (18.2%), and prior cardiac intervention or angina within the past month (12.1%). The mean CCI score was 1.4 (range, 0–6). There was a strong correlation between the mFI and CCI scores, but weak correlations between mFI and ASA class and between CCI and ASA class.

A total of 196 patients (56.6%) experienced a postoperative complication, and 19.4% had a major complication; 7 patients died within 1 month of surgery. There were no differences in complication rates based on mFI score, CCI score, or ASA class.

When mFI was simplified into a “low” and “high” score, this remained true. For example, 17.1% of “low” score patients had a major complication after radical cystectomy, compared with 22.7% of “high” score patients (P = .193).

Some specific complications did show correlations with the mFI score. For example, higher mFI grouping was significantly correlated with the length of hospital stay. All three of the classification methods were correlated with the cost of operation plus hospitalization. The rate of hospitalization, though, was no different based on mFI or the other scoring systems.

“Our attempt to validate the mFI failed to demonstrate its ability at stratifying patients with respect to postoperative complications or readmissions,” the authors concluded. “Furthermore, it did not demonstrate any added value over similarly poor performing, albeit well known, measures, such as ASA class and the CCI score. There is a need for the development of improved risk-assessment tools to predict postoperative outcomes after radical cystectomy.”

Matthew Mossanen, MD, an expert in bladder cancer at Brigham and Women’s Hospital in Boston who was not involved with the study, told Cancer Network that while it is somewhat surprising to see the frailty score fail to predict complications reliably, the difficulty in this field is well established. “It’s a unique operation with its own set of challenges,” he said. “Not only are we removing an organ, but we need to reconstruct the urinary system.”

While this study failed to show its primary endpoint, Mossanen said, “It is hard to imagine how a frail patient isn’t at higher risk for a complication after surgery. It might just be that it’s hard to really capture frailty.” As the authors also note, future research will perhaps need to focus on more specific measures that are relevant to the challenges of this operation. “The bottom line is that we’ve got to keep searching for better ways … to predict who is going to have a problem after cystectomy,” Mossanen said.