The prevalence and outcomes of frailty in older cancer patients: a systematic review
The prevalence and outcomes of frailty in older cancer patients: a systematic review
C. Handforth 1
A. Clegg 0
C. Young 1
S. Simpkins 0
M. T. Seymour 1
P. J. Selby 1
J. Young 0
0 Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust , Bradford , UK
1 St James' Institute of Oncology, Leeds Teaching Hospitals NHS Trust , Leeds
Background: Frailty is a state of vulnerability to poor resolution of homeostasis following a stressor event, such as chemotherapy or cancer surgery. Better knowledge of the epidemiology of frailty could help drive a global cancer care strategy for older people. The aim of this review was to establish the prevalence and outcomes of frailty and pre-frailty in older cancer patients. Methods: Observational studies that reported data on the prevalence and/or outcomes of frailty in older cancer patients with any stage of solid or haematological malignancy were considered. We searched Medline, CINAHL, Cochrane Library, EMBASE, Web of Science, Allied and Complementary medicine, Psychinfo and ProQuest (1 January 1996 to 30 June 2013). The primary outcomes were prevalence of frailty, treatment-related side-effects, unplanned hospitalization and mortality. Risk of bias was assessed using the Newcastle-Ottawa checklist. Results: Data from 20 studies evaluating 2916 participants are included. The median reported prevalence of frailty and pre-frailty was 42% (range 6%-86%) and 43% (range 13%-79%), respectively. A median of 32% (range 11%-78%) of patients were classified as fit. Frailty was independently associated with increased all-cause mortality [adjusted 5-year hazard ratio (HR) 1.87, 95% confidence interval (CI) 1.36-2.57]. There was evidence of increased risk of postoperative mortality for both frailty (adjusted 30-day HR 2.67, 95% CI 1.08-6.62) and pre-frailty (adjusted HR 2.33, 95% CI 1.204.52). Treatment complications were more frequent in those with frailty, including intolerance to cancer treatment (adjusted odds ratio 4.86, 95% CI 2.19-10.78) and postoperative complications (adjusted 30-day HR 3.19, 95% CI 1.68-6.04). Conclusions: More than half of older cancer patients have pre-frailty or frailty and these patients are at increased risk of chemotherapy intolerance, postoperative complications and mortality. The findings of this review support routine assessment of frailty in older cancer patients to guide treatment decisions, and the development of multidisciplinary geriatric oncology services.
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introduction
The ageing global population presents considerable challenges
for the planning and delivery of healthcare services
internationally. Cancer disproportionately affects older people, with more
than one-third of cancers diagnosed in those over the age of 70
[1]. Current UK projections indicate that by 2030, 76% of men
with cancer and 70% of women with cancer will be aged over 65
years [2]. An international strategy is required to address the
implications of population ageing for cancer care services [3].
Older cancer patients are often under-treated, are
underrepresented in clinical trials, and have poorer outcomes than
younger individuals [47]. Chronological age alone is a poor
predictor of cancer treatment tolerance [8] and the
heterogeneity of the older cancer patient population requires a carefully
tailored approach to care that considers individual frailty.
Frailty is a state of vulnerability to poor resolution of
homeostasis following a stressor event. It develops as a consequence of
cumulative decline across multiple physiological systems and
increases the risk of adverse outcomes [9]. In the general
population, 10% of people aged 65 and over have frailty, rising to
between 25% and 50% of those aged 85 and over [10]. Both
cancer and the systemic treatments offered by oncologists are
significant stressors that have the potential to challenge
physiological reserve. Better knowledge of the epidemiology of frailty
in older cancer patients is essential to drive a global strategy of
cancer care for older people. It will guide shared treatment
decisions based on an individualized balance of risk and benefit.
The phenotype model, cumulative deficit model and
comprehensive geriatric assessment (CGA) are the three most
evidence-based approaches to the identification of frailty. The
phenotype model identifies frailty on the basis of three or more
physical characteristics (unintentional weight loss, exhaustion,
low energy expenditure, slow gait speed and weak grip strength)
[11]. Those with one or two characteristics are categorized
as pre-frail. The cumulative deficit model defines frailty as the
cumulative effect of individual deficits, which are clinical signs,
symptoms, disease states, disabilities and abnormal laboratory
test results [12]. CGA is a multidimensional, multi-disciplinary
assessment process that relates directly to individualized
treatment plans [13]. It is rec (...truncated)