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Novel frailty index predicts short-term outcomes after esophagectomy in elderly patients with esophageal cancer
Background
Despite advances in perioperative care, esophageal cancer patients undergoing esophagectomy have a high risk of postoperative major morbidity and death. We sought to determine the association between frailty defined by a novel scoring system and short-term outcomes of elderly patients.
Methods
We identified 467 esophageal cancer patients older than 65 years who underwent esophagectomy between 01/2011 and 03/2021. Frailty was assessed using a novel validated institutional frailty score, a composite score of functional status and 10 medical comorbidities. We excluded 10 patients without available functional component and 10 without available ECOG performance status, a covariate included in our multivariable models, leaving 447 patients for final analysis. Associations between frailty and short-term outcomes—90-day mortality, 30-day major complication, readmission within 30-days of discharge, discharge to a facility—were assessed using multivariable logistic regression models for each of the outcomes separately, with continuous frailty score as the predictor, and adjusted for age and ECOG performance status.
Results
Patients had a median age of 71 years, were predominantly male (81%) and white (88%), underwent neoadjuvant therapy (81%), Ivor Lewis esophagectomy (86%), and minimally invasive surgery (55%). The 30-day and 90-day mortality rate was 2.2% and 4.9%, respectively. One hundred thirty-eight patients (31%) had a major complication (≥ grade 3), 78 (18%) were readmitted, and 31 (7.2%) were discharged to another facility. Among patients with 90-days of follow-up, 137 had major complications within 30-days of surgery, of whom 19 died within 90 days of surgery, yielding a failure to rescue rate of 14% (95% CI 8.8%-21%). Preoperative frailty predicted increased risk of 30-day major complications (OR 1.23, 95%CI 1.08-1.41, p=0.002), of hospital readmissions (OR 1.32, 95%CI 1.14-1.54, p < 0.001), and discharge to a facility (OR 1.86, 95%CI 1.49-2.37, p < 0.001). However, no association between preoperative frailty and 90-day mortality was found.
Conclusions
Frailty assessed by our novel frailty assessment is associated with increased risk of 30-day major complications, hospital readmissions, and discharge to a facility, but not with 90-day mortality. Incorporating frailty assessment in presurgical evaluation identifies a subgroup of patients at major risk for morbidity for which pre-abilitation measures or aggressive perioperative interventions should be tailored to improve outcomes.
Legal entity responsible for the study
The author.
Funding
This work was supported, in part, by the National Institutes of Health/National Cancer Institute Cancer Center Support Grant P30 CA008748.
Disclosures
Y. Janjigian: Advisory / Consultancy: Bristol-Myers Squibb, Merck Serono, RGENIX, Eli Lilly, Daiichi-Sankyo, Pfizer, Bayer, Imugene, Merck, Zymeworks, Seagen, Basilea Pharmaceutica, AstraZeneca, Michael J. Hennessy Associates, Paradigm Medical Communications; Research grant / Funding (institution): NCI, Department of Defense, Cycle for Survival, Fred's Team, RGENIX, Bayer, Genetech/Roche, Bristol-Myers Squibb, Eli Lilly, Merck; Shareholder / Stockholder / Stock options: RGENIX. D. Jones: Advisory / Consultancy: AstraZeneca, Merck. D. Molena: Advisory / Consultancy: AstraZeneca, BMS, Johnson and Johnson. All other authors have declared no conflicts of interest.
