A new frailty index developed by clinicians from Memorial Sloan Kettering (MSK) Cancer Center, New York City, aligns well with the geriatric assessment but is easier to use and could be helpful for perioperative assessment of older surgical patients with cancer, the developers say.
"Older cancer patients are at higher risk for morbidity and mortality after surgery. However, among older cancer patients, some do well like younger patients, and some do very poorly despite being the same age as their peers. The difference lies in frailty," first author Armin Shahrokni, MD, MPH, of the MSK Geriatrics Service, told Medscape Medical News.
He and his colleagues describe the MSK–Frailty Index (MSK-FI) in an article published online May 10 in JAMA Network Open.
"MSK-FI is very easy to implement," Shahrokni said. The surgeon only needs to ask five simple questions related to activities of daily living. Information regarding the rest of the variables needed to calculate the MSK-FI score is retrieved from ICD9/10 codes submitted by the institution within the first 48 hours of hospital admission, he explained.
The researchers assessed the MSK-FI in 1137 cancer patients (median age, 80 years; 51% women) who were seen in the MSK geriatrics service for a preoperative evaluation for surgery that required a hospital stay.
The median MSK-FI score was higher in patients who were dependent for activities of daily living, experienced a fall in the past year, had poor Karnofsky performance status scores, slower gait speed, limited social activity, were taking five or more medications, or had four or more comorbid conditions compared with patients without impairments in those domains.
On multivariable analysis, each 1-point increase in MSK-FI score was associated with longer length of stay (0.58 day; P = .002) and higher likelihood of admission to the intensive care unit (odds ratio, 1.28; P = .02).
Each 1-point increase in MSK-FI score was also associated with a higher risk of dying within 1 year of surgery. The 1-year risk for death was 5% for patients with an MSK-FI score of 0 compared with nearly 20% for those whose score was 4 or higher (nonlinear association, P = .005). The association of MSK-FI with 1-year mortality persisted in sensitivity analyses that excluded patients with stage IV cancer or stage III/IV cancer.
"We also assessed the correlation between MSK-FI and the geriatric assessment (which is the gold standard of frailty) and found out that these two have strong correlation with each other," Shahrokni told Medscape Medical News.
The next steps in development, he said, include assessing the external validity of MSK-FI, especially in smaller hospitals and institutions with limited resources, and assessing the relationship between MSK-FI and surgical outcomes of a much more homogeneous group of patients (eg, pancreatic cancer patients). In addition, more specific data on healthcare processes (eg, time to and receipt of neoadjuvant or adjuvant treatment) are needed, he said.
The team is developing a very short frailty screening questionnaire based on geriatric assessment and the MSK-FI that can serve as a fast frailty screening tool during the preoperative period.
"Important Tools" for Clinicians
In a linked editorial, Elizabeth George, MD, and Shipra Arya, MD, of Stanford University Hospital and Clinics in California, note, "Regardless of the measure, frailty has been shown to be an independent risk factor of adverse outcomes across surgical specialties, and the MSK-FI is no different.
"A number of retrospective and prospective frailty screening tools have been developed during the past decade, and much work has been done to convince clinicians that patient frailty is predictive of adverse perioperative outcomes," they point out.
"The next frontier of frailty research lies within the realm of implementation science, as we endeavor to incorporate frailty screening into routine clinical practice and electronic medical records," they conclude.
"Until we make it easy for surgeons and ancillary health care professionals to adopt frailty screening into their clinical workflow, meaningful change in the care of high-risk patients will be hard to accomplish. We encourage future research to include real-world applications of preoperative frailty screening so that we might learn how to best implement these important tools," they conclude.
The research was supported by the Beatriz and Samuel Seaver Foundation and the Memorial Sloan Kettering Cancer and Aging Program and by a grant from the National Cancer Institute. The authors and editorialists have disclosed no relevant financial relationships.
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