Preoperative Frailty Assessment Research Articles

Preoperative rehabilitation optimization for spinal surgery: a narrative review of assessment, interventions, and feasibility.

Postoperative physical therapy (PT) is a cornerstone of orthopedic and musculoskeletal rehabilitation, proven to provide various positive clinical benefits. However, there is a paucity of literature evaluating the utility of preoperative rehabilitation specific to spine surgery. Thus, this review article aims to provide an overview of previously published studies discussing the efficacy of preoperative rehabilitation programs and its role in spinal surgery. Special emphasis was given to preoperative frailty assessments, physical performance tests, interventional strategies, feasibility, and future directions. We performed a literature review using PubMed, Google Scholar, EMBASE, and PubMed Central (PMC) using directed search terms. Articles that examined preoperative rehabilitation in adult spine surgery were compiled for this review. Prehabilitation programs focused on exercise, flexibility, and behavioral modifications have been shown to significantly improve pain levels and functional strength assessments in patients undergoing elective spine surgery. In addition, studies suggest that these programs may also decrease hospital stays, return to work time, and overall direct health care expenditure costs. Screening tools such as the FRAIL scale can be used to assess frailty while physical function tests like the timed-up-and go (TUGT), 5 repetition sit-to-stand test (5R-STST), and hand grip strength (HGS) can help identify patients who would most benefit from prehabilitation. This review illustrates that prehabilitation programs have the potential to increase quality of life, improve physical function and activity levels, and decrease pain, hospital stays, return to work time, and overall direct costs. However, there is a paucity of literature in this field that requires further study and investigation.

Differences in preoperative frailty assessment of surgical candidates by sex, age, and race

IntroductionSurgical decision-making often relies on a surgeon's subjective assessment of a patient's frailty status to undergo surgery. Certain patient demographics can influence subjective judgment when compared to validated objective assessments. In this study, we explore the relationship between subjective and objective frailty assessments according to patient age, sex, and race. MethodsPatients were prospectively enrolled in urology, general surgery, and surgical oncology clinics. Using a visual analog scale (0−100), operating surgeons independently rated the patient's frailty status. Objective frailty was classified using the Fried Frailty Criteria ranging from 0 to 5. Multivariable proportional odds models were conducted to examine the potential association of factors with objective frailty, according to surgeon frailty rating. Subgroup analysis according to patient sex, race, and age was also performed. ResultsSeven male surgeons assessed 203 patients preoperatively with a median age of 65. A majority of patients were male (61 %), white (67 %), and 60 % and 40 % underwent urologic and general surgery/surgical oncology procedures respectively. Increased subjective surgeon rating (OR 1.69; p < 0.001) was significantly associated with the presence of objective frailty. On subgroup analysis, a higher magnitude of such association was observed more in females (OR 1.86; p = 0.0007), non-white (OR 1.84; p = 0.0019), and older (>60, OR 1.75; p = 0.0001) patients, compared to male (OR 1.45; p = 0.0243), non-white (OR 1.48; p = 0.0109) and patients under 60 (OR 1.47; p = 0.0823). ConclusionThe surgeon's subjective assessment of frailty demonstrated tendencies to rate older, female, and non-white patients as frail; however, differences in patient sex, age, and race were not statistically significant.

The Preoperative Assessment of Frailty in the Setting of Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review

The Preoperative Assessment of Frailty in the Setting of Transcatheter Aortic Valve Implantation (TAVI): A Systematic Review

Preoperative frailty assessment with ultrasound in elderly patients scheduled for total knee arthroplasty.

Frailty, a decline in physical and cognitive reserve capacity, renders patients susceptible to various stressors and has been linked to adverse outcomes and increased healthcare utilization. This study aimed to determine whether ultrasound measurements of the rectus abdominis (RA) and biceps brachii (BB) could predict frailty in patients scheduled for total knee arthroplasty. Frailty was assessed using the Clinical Frailty Scale in adults aged ≥60 years. Ultrasound measurements of the rectus abdominis, BB, and quadriceps femoris muscles, along with thigh circumference measurements, were obtained before surgery. The predictive ability of the unadjusted and BMI- and body surface area (BSA)-adjusted measurements were evaluated using receiver operating characteristic curve analysis and area under the curve (AUC) values. Postoperative outcomes, such as admission to the intensive care unit or skilled nursing facility, delirium, falls, re-hospitalization, and 30-day mortality were recorded. We analyzed data from 148 patients. BB thickness provided a fair prediction of frailty. Average measurements of both BB adjusted for BMI (0.708, 95% CI 0.602-0.814; P<0.001), and BSA (0.708, 95% CI 0.598-0.817; P<0.001) had the highest AUC values. RA muscle measurements could not discriminate frailty. The BMI-adjusted measurements for: right quadriceps femoris thickness (AUC 0.614, 95% CI 0.503-0.725; P=0.044), left thigh circumference (AUC 0.648, 95% CI 0.528-0.769; P=0.016), and average thigh circumference (AUC 0.630, 95% CI 0.511-0.750; P=0.033) had statistically significant but poor AUC values. Preoperative ultrasound measurements of the bilateral BB can fairly predict frailty in patients scheduled for total knee arthroplasty.

Association of preoperative frailty with the risk of postoperative delirium in older patients undergoing hip fracture surgery: a prospective cohort study

ObjectiveThis study aimed to explore the correlation between preoperative frailty and the risk of postoperative delirium (POD) in older patients undergoing hip fracture surgery.MethodsIn total, 148 patients with hip fractures who were admitted to Tsinghua Changgung Hospital (Beijing, China) between January 2022 and January 2023 were involved in this study. Preoperative frailty scales were assessed, of which the CAM scale was postoperatively administered every morning and evening on days 1, 2, 3, 5, and 7. Binary logistic regression analysis was conducted to determine the correlation between preoperative frailty and the risk of POD.ResultsAmong 148 older patients with hip fractures, 71 (48.0%) were identified as preoperative frail and 77 (52.0%) as non-frail. The overall incidence of POD on day 7 was 24.3% (36/148), and preoperative frailty was associated with a significantly higher risk of POD compared with non-frailty (42.3% vs. 7.8%, P < 0.001). The binary logistic regression analysis revealed that preoperative frailty was noted as an independent risk factor for the risk of POD in older patients undergoing hip fracture surgery (P = 0.002).ConclusionPreoperative frailty increased the risk of POD in older patients undergoing hip fracture surgery.DiscussionPreoperative assessment of frailty in geriatric hip surgery can timely identify potential risks and provide interventions targeting frailty factors to reduce the incidence of POD in older patients undergoing hip fracture surgery. The findings suggested that preoperative frailty could increase the risk of POD in older patients undergoing hip fracture surgery. Further research is necessary to determine whether perioperative interventions aimed at enhancing frailty can mitigate the risk of POD and improve prognosis in older patients undergoing hip fracture surgery.

ASO Author Reflections: Preoperative Frailty and Nutritional Assessment of Patients Undergoing Oncologic Resections.

ASO Author Reflections: Preoperative Frailty and Nutritional Assessment of Patients Undergoing Oncologic Resections.

Preoperative Frailty and Malnutrition in Surgical Oncology Patients Predicts Higher Postoperative Adverse Events and Worse Survival: Results of a Blinded, Prospective Trial.

Frailty, a multidimensional state leading to reduced physiologic reserve, is associated with worse postoperative outcomes. Despite the availability of various frailty tools, surgeons often make subjective assessments of patients' ability to tolerate surgery. The Risk Analysis Index (RAI) is a validated preoperative frailty assessment tool that has not been studied in cancer patients with plans for curative-intent surgery. In this prospective, surgeon-blinded study, patients who had abdominal malignancy with plans for resection underwent preoperative frailty assessment with the RAI and nutrition assessment by measurement of albumin, prealbumin, and C-reactive protein (CRP). Postoperative outcomes and survival were assessed. The study included 220 patients, 158 (72%) of whom were considered frail (RAI ≥21). Frail patients were more likely to be readmitted within 30 and 90 days, (16% vs. 3% [P = 0.006] and 16% vs. 5% [P = 0.025], respectively). Patients with abnormal CRP, prealbumin, and albumin experienced higher rates of unplanned intensive care unit admission (CRP [27% vs. 8%; P < 0.001], albumin [30% vs. 10%; P < 0.001], prealbumin [29% vs. 9%; P < 0.001]) and increased postoperative mortality at 90 and 180 days. Survival was similar for frail and non-frail patients. In the multivariate analysis, frailty remained an independent risk factor for readmission (hazard ratio, 5.58; 95% confidence interval, 1.39-22.15; P = 0.015). In the post hoc analysis using the pre-cancer RAI score, the postoperative outcomes did not differ between the frail and non-frail patients. In conjunction with preoperative markers of nutrition, the RAI may be used to identify patients who may benefit from additional preoperative risk stratification and increased postoperative follow-up evaluation.

Trajectory Analysis of Health Care Utilization Before and After Major Surgery.

To characterize patterns of health care utilization before and after surgery and determine any association with preoperative frailty. Frail patients experience worse postoperative outcomes and increased costs during the surgical encounter. Evidence is comparatively lacking for the longer-term effects of frailty on postoperative health care utilization. Retrospective, longitudinal cohort analysis of adult patients undergoing any elective surgical procedure after preoperative frailty assessment with the Risk Analysis Index from February 2016 to December 2020 at a large integrated health care delivery and financing system. Group-based trajectory modeling of claims data estimated distinct clusters of patients with discrete utilization trajectories. Multivariable regression predicted membership in trajectories of interest using preoperative characteristics, including frailty. Among 29,067 surgical encounters, 4 distinct utilization trajectories emerged in longitudinal data from the 12 months before and after surgery. All cases exhibited a surge in utilization during the surgical month, after which most patients returned to "low" [25,473 (87.6%)], "medium" [1403 (4.8%)], or "high" [528 (1.8%)] baseline utilization states established before surgery. The fourth trajectory identified 1663 (5.7%) cases where surgery occasioned a transition from "low" utilization before surgery to "high" utilization afterward. Risk Analysis Index score alone did not effectively predict membership in this transition group, but a multivariable model with other preoperative variables was effective ( c = 0.859, max rescaled R2 = 0.264). Surgery occasions the transition from low to high health care utilization for a substantial subgroup of surgical patients. Multivariable modeling may effectively discriminate this utilization trajectory, suggesting an opportunity to tailor care processes for these patients.

Impact of Frailty and Sarcopenia on Short- and Long-Term Outcomes in Elderly Patients Undergoing Radical Gastrectomy for Gastric Cancer.

The impact of frailty and sarcopenia in patients with gastric cancer is unclear. This study aimed to comprehensively examine the impact of frailty and sarcopenia on the short- and long-term outcomes in elderly patients undergoing radical gastrectomy for gastric cancer. We retrospectively assessed 246 patients aged ≥ 65years who underwent radical gastrectomy. Frailty and sarcopenia were assessed using the modified frailty index (mFI) and psoas muscle mass index (PMI), respectively. There were 30 (12.2%) and 60 (24.4%) patients with High-mFI and Low-PMI, respectively. As the age increased, both sexes showed significant correlations with PMI and mFI (r = - 0.238, 0.322, P = 0.003 and 0.002, respectively). High-mFI and Low-PMI did not affect the short-term outcomes. However, High-mFI was an independent risk factor for non-home discharge (P = 0.004) and was a significant predictor of 3- and 5-year overall survival (OS) (HR = 2.76 and 2.26; P = 0.002 and 0.005, respectively) and 1-, 3- and 5-year non-cancer-specific survival (non-CSS) (HR = 4.88, 8.05, and 4.01; P = 0.017, < 0.001, < 0.001, respectively). Low-PMI was a significant predictor of only 5-year OS (HR = 2.03, P = 0.003) and non-CSS (HR = 2.10, P = 0.020). Frailty is significant predictor of non-home discharge and 1-, 3-, 5-year OS and 3- and 5-year non-CSS. Sarcopenia is a significant predictor of 5-year OS and non-CSS. Preoperative assessment of both frailty and sarcopenia can help surgeons to select adequate treatment strategies for the elderly population.

RAI-measured frailty predicts non-home discharge following metastatic brain tumor resection: national inpatient sample analysis of 20,185 patients.

Preoperative risk stratification for patients undergoing metastatic brain tumor resection (MBTR) is based on established tumor-, patient-, and disease-specific risk factors for outcome prognostication. Frailty, or decreased baseline physiologic reserve, is a demonstrated independent risk factor for adverse outcomes following MBTR. The present study sought to assess the impact of frailty, measured by the Risk Analysis Index (RAI), on MBTR outcomes. All MBTR were queried from the National Inpatient Sample (NIS) from 2019 to 2020 using diagnosis and procedural codes. The relationship between preoperative RAI frailty score and our primary outcome - non-home discharge (NHD) - and secondary outcomes - complication rates, extended length of stay (eLOS), and mortality - were analyzed via univariate and multivariable analyses. Discriminatory accuracy was tested by computation of concordance statistics in area under the receiver operating characteristic (AUROC) curve analysis. There were 20,185 MBTR patients from the NIS database from 2019 to 2020. Each patient's frailty status was stratified by RAI score: 0-20 (robust): 34%, 21-30 (normal): 35.1%, 31-40 (very frail): 13.9%, 41+ (severely frail): 16.8%. Compared to robust patients, severely frail patients demonstrated increased complication rates (12.2% vs. 6.8%, p < 0.001), eLOS (37.6% vs. 13.2%, p < 0.001), NHD (52.0% vs. 20.6%, p < 0.001), and mortality (9.9% vs. 4.1%, p < 0.001). AUROC curve analysis demonstrated good discriminatory accuracy of RAI-measured frailty in predicting NHD after MBTR (C-statistic = 0.67). Increasing RAI-measured frailty status is significantly associated with increased complication rates, eLOS, NHD, and mortality following MBTR. Preoperative frailty assessment using the RAI may aid in preoperative surgical planning and risk stratification for patient selection.

Predictors of postoperative urinary tract infection following holmium laser enucleation of the prostate.

Storage urinary symptoms and urinary tract infection (UTI) are among the most common complications following holmium laser enucleation of the prostate (HoLEP). We aimed to study the incidence and risk factors for storage urinary symptoms and early UTI following HoLEP. A prospectively maintained database was reviewed for patients who underwent HoLEP over a five-year period at a single tertiary center. Patient demographics, preoperative, operative, and postoperative characteristics, as well as infection rates, were obtained and analyzed using the appropriate statistical methods. Of a total 514 patients who underwent HoLEP, 473 patients with complete followup data were included. Mean (± standard deviation) age and median (interquartile range) prostate volume were 72±9.1 years and 89 (68-126) g, respectively. Preoperative positive urine culture and urine retention were seen in 28.5% (n=135) and 23.46 % (n=111) of patients, respectively. At six-week followup, irritative urinary symptoms were seen in 32.3% (n=153) of patients, while 13.5% (n= 64) of patients had positive urine culture. Bivariate and multivariate analysis showed that factors associated with significant higher rate of postoperative UTI at six weeks were high body mass index (BMI) (p= 0.023), weak grip strength within preoperative frailty assessment (p=0.042), positive preoperative urine culture (p=0.025), and postoperative incontinence (p=0.002). Storage urinary symptoms are common complaints post-HoLEP; however, it may be caused by an inflammatory rather than infective process in a significant percentage of patients. Possible predictors of UTI after HoLEP are high BMI, preoperative positive urine culture, higher frailty scale, and postoperative urinary incontinence.

Adverse effects of frailty on the outcomes of surgery for degenerative cervical myelopathy: results from a prospective multicenter international data set of 757 patients.

The goal of this study was to determine the effect of the degree of frailty on long-term neurological and functional outcomes after surgery for degenerative cervical myelopathy (DCM). A combined database of patients enrolled in the Cervical Spondylotic Myelopathy-North America and Cervical Spondylotic Myelopathy-International prospective international multicenter observational studies who underwent surgery for DCM was used as the source data. All patients underwent baseline and follow-up assessment at 2 years after surgery for functional, disability, and quality of life measurements (modified Japanese Orthopaedic Association [mJOA] scale, Neck Disability Index, SF-36 physical and mental component summary scores). Patients were separated into 4 groups according to their baseline modified frailty index 5-point scale score: not frail, pre-frail, frail, and severely frail. Differences among groups were analyzed at baseline and at 2 years after surgery, including change in scores (delta values) and the odds ratio of achieving the minimum clinically important difference (MCID) through univariate and multivariable logistic regression adjusting for age, approach, number of levels treated, and sex. A total of 757 patients (63% male) with a mean age of 56 (95% CI 55.5-57.2) years were included: 470 patients underwent an anterior approach, 310 had a posterior approach, and 23 had a combined anterior/posterior approach. A total of 50% (n = 378) of patients were classified as not frail, with 33% (n = 250) pre-frail, 13% (n = 101) frail, and 4% (n = 28) severely frail. The baseline mJOA score was significantly lower with increasing frailty (14.00 [95% CI 13.75-14.19] for not frail vs 9.71 [95% CI 9.01-10.42] for severely frail patients; p < 0.05), but the change at 2 years was not significantly different among all groups (2.43 [95% CI 2.16-2.71] for not frail vs 2.56 [95% CI 1.10-4.02] for severely frail). The SF-36 delta values were also not different among groups, but significantly worse at baseline with increasing frailty. The odds ratio of achieving MCID for mJOA was significantly higher in the not frail group (1.89 [95% CI 1.36-2.61]; p < 0.05) compared to the other frailty cohorts, which remained after adjusting for age, approach, levels treated, and sex. The odds ratio of achieving MCID for the SF-36 domains was similar among all frailty groups. Increasing frailty is associated with worse baseline functional and quality of life measures in patients undergoing surgery for DCM. Frailty does not affect the magnitude of improvement in outcome measures after surgery, but reduces the chance of achieving the MCID for functional impairment significantly. Preoperative frailty assessment can therefore help guide clinicians in managing expectations after surgery for DCM. Potentially modifiable factors should be optimized in frail patients preoperatively to enhance functional outcomes.

Clinical Frailty Scale as a predictor of adverse outcomes following aortic valve replacement: a systematic review and meta-analysis

ObjectivesAssessment of frailty prior to aortic valve intervention is recommended in European and North American valvular heart disease guidelines. However, there is a lack of consensus on how it is...

Functional outcome and frailty in colorectal surgery patients.

Frailty is a recognized risk and predictor of poor health outcomes in older patients undergoing surgery. A significant proportion of elderly patients undergoing colorectal cancer-related surgery are nevertheless not routinely assessed for frailty in current clinical practice in Australia. We examined the preoperative use of the Clinical Frailty Scale (CFS) to predict post-operative functional outcomes in geriatric patients undergoing colorectal cancer surgery. This retrospective observational cohort study included elderly colorectal cancer patients (n = 227) who underwent elective major colorectal surgery from 2016 to 2020 at Nepean Hospital, Australia. CFS was calculated retrospectively from medical records and the relationship between CFS and functional outcome factors was analysed. Frail patients (n = 111) had a significant postoperative functional decline as demonstrated by discharge to supported care (57% vs. 0.9%), Barthel Index change (P<0.05) and inability to self-manage stoma (P<0.05) compared to non-frail patients (n = 116). Multivariate analysis with adjustment for age, comorbidities as measured by Charlson Comorbidities Index (CCI), and cognitive impairment, demonstrated frailty was the most significant independent predictor of discharge to supported care (OR 109.3). Cognitive impairment and an increased CCI were also found to be important predictors. Preoperative frailty is significantly associated with postoperative functional decline and postoperative adverse outcomes, highlighting the potential utility of CFS in preoperative frailty assessment.

Impact of preoperative frailty on the surgical and survival outcomes in older patients with solid cancer after elective abdominal surgery

Frailty is common in older patients with cancer; however, its clinical impact on the survival outcomes has seldom been examined in these patients. This study aimed to investigate the association of frailty with the survival outcomes and surgical complications in older patients with cancer after elective abdominal surgery in Taiwan. We prospectively enrolled 345 consecutive patients aged ≥65 years with newly diagnosed cancer who underwent elective abdominal surgery between 2016 and 2018. They were allocated into the fit, pre-frail, and frail groups according to comprehensive geriatric assessment (CGA) findings. The fit, pre-frail, and frail groups comprised 62 (18.0%), 181 (52.5%), and 102 (29.5%) patients, respectively. After a median follow-up of 48 (interquartile range, 40-53) months, the mortality rates were 12.9%, 31.5%, and 43.1%, respectively. The adjusted hazard ratio was 1.57 (95% confidence interval [CI], 0.73-3.39; p=0.25) and 2.87 (95% CI, 1.10-5.35; p=0.028) when the pre-frail and frail groups were compared with the fit group, respectively. The frail group had a significantly increased risk for a prolonged hospital stay (adjusted odds ratio, 2.22; 95% CI, 1.05-4.69; p=0.022) compared with the fit group. Pretreatment frailty was significantly associated with worse survival outcomes and more surgical complications, with prolonged hospital stay, in the older patients with cancer after elective abdominal surgery. Preoperative frailty assessment can assist physicians in identifying patients at a high risk for surgical complications and predicting the survival outcomes of older patients with cancer.

Can modified frailty index predict postoperative complication after lung cancer surgery?

The impact of the modified frailty index (mFI) on postoperative complications after lung cancer surgery was investigated. Patients who underwent lung cancer surgery in 2017 were included. 30-day postoperative mortality and morbidity were evaluated according to their Clavien-Dindo classification. mFI values are presented as the sum of values of 11 included items. Logistic regression was used to assess the effect of mFI on postoperative severe complication incidence. Among 190 patients considered, severe postoperative complications (Grade 3 or more) were observed in 30 (16%). No patients died within 30days of surgery. The incidence of severe complications was 3.6% in patients with mFI of 0, 16.2% in patients with mFI of 1, 23.4% in patients with mFI of 2, and 31.6% in patients with mFI of 3 or more, and was correlated with the grade of mFI. Univariate and multivariate analyses showed that the high mFI was significantly predictive of postoperative complications. Frail patients of mFI ≥ 2 were at 3.0-fold greater risk of severe complications than non-frail patients of mFI 0 or 1. mFI was associated with morbidity after lung cancer surgery. Preoperative frailty assessment and appropriate intervention to frail patients would be required to improve postoperative outcomes.

ASO Author Reflections: Preoperative Frailty Assessment Predicts Postoperative Adverse Outcomes in Elderly Lung Cancer Patients: A Retrospective Cohort Study.

ASO Author Reflections: Preoperative Frailty Assessment Predicts Postoperative Adverse Outcomes in Elderly Lung Cancer Patients: A Retrospective Cohort Study.

Preoperative Frailty Assessment Predicts Postoperative Mortality, Delirium and Pneumonia in Elderly Lung Cancer Patients: A Retrospective Cohort Study.

The purpose of this study was to investigate the predictive value of the 5-factor modified frailty index (mFI-5) for postoperative mortality, delirium and pneumonia in patients over 65 years of age undergoing elective lung cancer surgery. Data were collected from a single-center retrospective cohort study conducted in a general tertiary hospital from January 2017 to August 2019. In total, the study included 1372 elderly patients aged over 65 who underwent elective lung cancer surgery. They were divided into frail group (mFI-5, 2-5), prefrail group (mFI-5, 1) and robust group (mFI-5, 0) on the basis of mFI-5 classification. The primary outcome was postoperative 1-year all-cause mortality. Secondary outcomes were postoperative pneumonia and postoperative delirium. Frailty group had the highest incidence of postoperative delirium (frailty 31.2% versus prefrailty 1.6% versus robust 1.5%, p < 0.001), postoperative pneumonia (frailty 23.5% versus prefrailty 7.2% versus robust 7.7%, p < 0.001), and postoperative 1-year mortality (frailty 7.0% versus prefrailty 2.2% versus robust 1.9%. p < 0.001). Frail patients have significantly longer length of hospitalization than those in the robust group and prefrail patients (p < 0.001). Multivariate analysis showed a clear link between frailty and increased risk of postoperative delirium (aOR 2.775, 95% CI 1.776-5.417, p < 0.001), postoperative pneumonia (aOR 3.291, 95% CI 2.169-4.993, p < 0.001) and postoperative 1-year mortality (aOR 3.364, 95% CI, 1.516-7.464, p = 0.003). mFI-5 has potential clinical utility in predicting postoperative death, delirium and pneumonia incidence in elderly patients undergoing radical lung cancer surgery. Frailty screening of patients (mFI-5) may provide benefits in risk stratification, targeted intervention efforts, and assist physicians in clinical decision-making.

The FARGO study: Frailty assessment for risk prediction in gynecologic oncology.

TPS12137 Background: Little is known about how to best predict postoperative outcomes and chemotherapy tolerance in an increasingly aging and complex gynecologic oncology (GO) population. Frailty is a multidimensional age-related and disease-related state of vulnerability to stressors due to reduced capacity of different physiological systems. Resource limitations are a barrier to routine adoption of frailty assessments through comprehensive clinical evaluations in daily practice. This highlights the relevance of studying potential biomarkers of frailty, which could complement or replace clinical assessments. Frailty has been associated with worse perioperative and oncologic outcomes in many subspecialties, however the literature in patients with gynecologic malignancies is very limited. Methods: The FARGO study is a multi-centre prospective cohort study of 280 patients aged ≥55 years-old undergoing surgery, with or without chemotherapy for a suspected or confirmed gynecologic malignancy. Patient recruitment will occur over 13 months. The over-arching goal is to evaluate the predictive value of frailty assessments in predicting surgical and chemotherapy outcomes. The two primary objectives are: 1) To evaluate the predictive value of preoperative frailty assessment based on the Frailty Phenotype (FP), compared to a perioperative cardiovascular risk assessment, in predicting the composite of all-cause death or new disability at 6 months after surgery 2) To create of a biobank to explore possible biomarkers of frailty, including mitochondrial DNA levels. Secondary objectives include to evaluate the predictive value of clinical and biomarker frailty assessment for 30-day postoperative complications, for chemotherapy tolerance and 1-year recurrence-free survival. Patients will undergo frailty and cardiovascular risk assessment prior to surgery and/or neoadjuvant chemotherapy. A trained clinical research assistant will measure frailty based on the clinical frailty scale (CFS) and the FP. The cardiovascular risk calculation will be based on the preoperative Revised Cardiac Risk Index, age, and occurrence of myocardial injury after non-cardiac surgery (MINS). Research personnel blinded to the frailty and cardiovascular risk assessment will evaluate study outcomes including death, disability, and clinical events at 30 days, 6 months, and 12 months after surgery. Disability will be measured with the WHODAS 2.0 (World Health Organization Disability Assessment Schedule), a validated patient-reported outcome measure. Pre-specified blood biomarkers will be measured. Our study emphasizes patient-centered outcomes (i.e. loss of independence, short and long-term disability) and system-level outcomes. Our findings may have important implications to assist in risk stratification and planning for oncologic treatments and perioperative care needs. Clinical trial information: will be added later .

A Prospective Evaluation of Different Frailty Indices in Patients Undergoing Transurethral Resection of Bladder Tumor

BackgroundMost studies investigating the relationship between preoperative frailty and postoperative outcomes among bladder cancer patients only assess frailty retrospectively in patients who have undergone radical cystectomy. Transurethral resection of bladder tumor (TURBT) is a commonly performed procedure in outpatient settings for a large number of bladder cancer patients. The prevalence of frailty among bladder cancer patients and its impact on postoperative complications and mortality are not well studied. MethodsTo assess the prevalence of frailty among bladder cancer patients planned for TURBT at a tertiary cancer center using the modified frailty index (mFI) and Risk Analysis Index (RAI) and further assess the impact of these indices on 30-day postoperative complications and mortality rates. ResultsBetween May 2020 and March 2021, 343 consecutive patients were enrolled. The mean age of the cohort was 64.8 ± 13.1 years, 86.6% were male, and 82% had non–muscle-invasive bladder cancer (NMIBC). The majority of the cohort (92%) was found to have low American Society of Anesthesiologists (ASA) score class (I + II), while 35.3% were labeled as frail using mFI 2+, and 32.1% based on RAI (III, IV). The 30-day readmission, postoperative complications, and mortality rates in this cohort were 3.8%, 2.3%, and 6.6%, respectively. RAI was a better indicator of mortality compared to mFI. As such, patients with low RAI score (I, II) had 0.054 odds for 30-day mortality compared to the patients with high RAI score (III, IV) (OR 0.054; CI 95%, 0.004 to 0.784; P = 0.033).Conclusion Frailty, as measured by Risk Analysis Index, is an independent predictor of early mortality in patients undergoing TURBT. Preoperative frailty assessment may improve risk stratification and patient counseling prior to surgery.