Is Frailty Associated With Worse Outcomes After Head and Neck Surgery? A Narrative Review

Abstract

Objective: Frailty has emerged as an important determinant of many health outcomes across various surgical specialties. We examined the published literature reporting on frailty as a predictor of perioperative outcomes in head and neck cancer (HNC) surgery.Study Design: Narrative review with limited electronic database search and cross-referencing of included studies. Methods: PubMed was searched from inception until June 2019 to capture studies evaluating an association between frailty and perioperative outcomes among patients undergoing HNC surgery. Primary outcomes included mortality and morbidity, whereas secondary outcomes included in-hospital cost, length of stay, readmission, and discharge disposition.Results: We identified nine series examining frailty as a predictor of outcomes in HNC. The majority of studies (77%) identified patients using a large population-based database such as the National Surgical Quality Improvement Project or National Inpatient Sample. Frailty measures applied in the HNC surgery literature include the modified frailty index, Groningen Frailty Indicator, and John Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. Most studies demonstrated a significant association between frailty and perioperative outcomes, including mortality, perioperative complications, and Clavien-Dindo grade IV complications. Furthermore, frailty was associated with greater length of hospital stay, readmission rate, and likelihood of discharge to short-term or skilled nursing facilities.Conclusion: The current literature demonstrates the utility of frailty as a predictor of perioperative mortality and morbidity. Further research is needed to develop frailty screening measures in order to risk-stratify patients and optimize modifiable factors preoperatively.

Longitudinal Assessment of Frailty and Quality of Life in Patients Undergoing Head and Neck Surgery

“…Frailty is predictive of post-operative complications, mortality, longer hospital LOS, greater cost, and non-home discharge. 1,4,17 Frail patients in this study had a significantly longer hospital LOS compared to non-frail and prefrail patients. Identifying frailty prior to surgery is important for appropriate pre-operative counseling, initiation of supportive services that may improve outcomes, and selection of appropriate treatment.…”

“…Frailty, a state of increased vulnerability to stressors independent of age and characterized by decreased physiologic reserve and strength, 1 is an important concept in geriatric oncology. 2 Frailty appears to be more prevalent in head and neck cancer (HNC) patients compared to other solid malignancies, 3 and recognition that frail patients have unique vulnerabilities and challenges is increasing in HNC surgery.…”

“…physiologic age) can predict adverse post-operative outcomes following surgery independent of age and comorbidities. 1,[4][5][6][7][8] In a systematic review of 23 studies, frailty had a much stronger relationship with post-operative outcomes of mortality and length of stay than age. In fact, in many studies, age was not a significant predictor once frailty was adjusted for.…”

Utility of Frailty Screening Tools in Older Surgical Patients

“…38) Frailty identified using the modified frailty index and GFI was also consistently associated with poor outcomes in terms of length of stay, mortality, com-plications, and discharge to residential care for head and neck surgery. 39) Retrospective analyses of prospective databases of elective spine surgery also confirmed positive correlations between frailty and mortality, postoperative complications, and length of stay. While the modified frailty index was recommended, the researchers suggested the use of more comprehensive frailty indices specific for spinal surgery, such as the Adult Spinal Deformity frailty index, and consideration of adding clinical, radiographic, and laboratory measures to improve outcome predictions.…”

“… 38 ) Frailty identified using the modified frailty index and GFI was also consistently associated with poor outcomes in terms of length of stay, mortality, complications, and discharge to residential care for head and neck surgery. 39 )…”