Association Between Frailty and Time Alive and At Home After Cancer Surgery Among Older Adults: A Population-Based Analysis

Abstract

Background: Although frailty is known to impact short-term postoperative outcomes, its long-term impact is unknown. This study examined the association between frailty and remaining alive and at home after cancer surgery among older adults. Methods: Adults aged ≥70 years undergoing cancer resection were included in this population-based retrospective cohort study using linked administrative datasets in Ontario, Canada. The probability of remaining alive and at home in the 5 years after cancer resection was evaluated using Kaplan-Meier methods. Extended Cox regression with time-varying effects examined the association between frailty and remaining alive and at home. Results: Of 82,037 patients, 6,443 (7.9%) had preoperative frailty. With median follow-up of 47 months (interquartile range, 23–81 months), patients with frailty had a significantly lower probability of remaining alive and at home 5 years after cancer surgery compared with those without frailty (39.1% [95% CI, 37.8%–40.4%] vs 62.5% [95% CI, 62.1%–63.9%]). After adjusting for age, sex, rural living, material deprivation, immigration status, cancer type, surgical procedure intensity, year of surgery, and receipt of perioperative therapy, frailty remained associated with increased hazards of not remaining alive and at home. This increase was highest 31 to 90 days after surgery (hazard ratio [HR], 2.00 [95% CI, 1.78–2.24]) and remained significantly elevated beyond 1 year after surgery (HR, 1.56 [95% CI, 1.48–1.64]). This pattern was observed across cancer sites, including those requiring low-intensity surgery (breast and melanoma). Conclusions: Preoperative frailty was independently associated with a decreased probability of remaining alive and at home after cancer surgery among older adults. This relationship persisted over time for all cancer types beyond short-term mortality and the initial postoperative period. Frailty assessment may be useful for all candidates for cancer surgery, and these data can be used when counseling, selecting, and preparing patients for surgery.

The impact of unexpected intensive care unit admission after cancer surgery on long-term symptom burden among older adults: a population-based longitudinal analysis

“…The results of this study cannot be used in isolation and should be combined with all the data available to clinicians when discussing transfer to ICU and implementation of aggressive life-prolonging measures. Indeed, one in five older adults admitted to the ICU after cancer surgery will die in hospital with key patient groups, such as those with baseline frailty being at higher risk for poor outcomes [ 8 , 62 ]. However, the ability to accurately determine which patients will survive their hospitalization at the time of ICU admission remains challenging and there may be discrepancies in perceived outcomes between the surgical and ICU teams, patients, and families [ 63 – 65 ].…”

Frailty After Cancer Surgery Among Older Adults: A Geriatric Oncology Perspective

“…The study by Hallet et al 5 clearly showed the importance of considering frailty as an important factor in evaluating older adults before oncologic surgery. However, we need to keep in mind that the surgery itself may not contribute as much as frailty to the long-term outcomes.…”

“…The study by Hallet et al 5 has the potential of stimulating further studies that could prospectively evaluate this important long-term outcome with a more thorough geriatric assessment before oncologic surgery and more detailed capture of functional outcomes after surgery. For example, in a prospective study published in 2020 that involved 229 patients before an elective surgery for solid tumors, of those alive at 1 year, 26% were institutionalized, and by 2 years, almost half of the entire cohort (46%) were institutionalized or had died.…”

“…Referring patients to a prehabilitation program and using a standardized early recovery after surgery protocol have been found beneficial for multiple postoperative outcomes. Studies like the one by Hallet et al 5 remind us of the importance of shared decision-making for older adults considering surgery in their cancer journey and how important it is to screen them for frailty to positively affect their outcomes.…”

“…The article by Hallet et al 5 in this issue of the journal is a retrospective populationbased study in Ontario, Canada, evaluating the association between frailty and remaining alive and at home after cancer surgery among older adults. Among 82,037 patients included, 7.9% were considered frail using the Johns Hopkins Adjusted Clinical Groups frailty marker.…”