On the need for comprehensive assessment of impact of comorbidity in elderly patients with head and neck cancer

Measurement of Sarcopenia in Head and Neck Cancer Patients and Its Association With Frailty

In head and neck cancer (HNC) there is a need for more personalized treatment based on risk assessment for treatment related adverse events (i.e. toxicities and complications), expected survival and quality of life. Sarcopenia, defined as a condition characterized by loss of skeletal muscle mass and function, can predict adverse outcomes in HNC patients. A review of the literature on the measurement of sarcopenia in head and neck cancer patients and its association with frailty was performed. Skeletal muscle mass (SMM) measurement only is often used to determine if sarcopenia is present or not. SMM is most often assessed by measuring skeletal muscle cross-sectional area on CT or MRI at the level of the third lumbar vertebra. As abdominal scans are not always available in HNC patients, measurement of SMM at the third cervical vertebra has been developed and is frequently used. Frailty is often defined as an age-related cumulative decline across multiple physiologic systems, with impaired homeostatic reserve and a reduced capacity of the organism to withstand stress, leading to increased risk of adverse health outcomes. There is no international standard measure of frailty and there are multiple measures of frailty. Both sarcopenia and frailty can predict adverse outcomes and can be used to identify vulnerable patients, select treatment options, adjust treatments, improve patient counselling, improve preoperative nutritional status and anticipate early on complications, length of hospital stay and discharge. Depending on the definitions used for sarcopenia and frailty, there is more or less overlap between both conditions. However, it has yet to be determined if sarcopenia and frailty can be used interchangeably or that they have additional value and should be used in combination to optimize individualized treatment in HNC patients.

Comparison of preoperative assessment tools in older patients undergoing cancer surgery: A prospective study

INTRODUCTION

Surgery in older adults with cancer is complex due to multiple age related confounding factors. There are many scoring systems available for preoperative risk stratifications of older patients. Currently very few prospective studies comparing the various commonly used scales are available. This is the first study which compares the established preoperative risk assessment tools of Eastern Cooperative Oncology Group Performance Scale (ECOG) and American Society of Anaesthesiologists Physical Status Scale (ASA) with frailty scores of Modified Frailty Index (MFI) and Clinical Frailty Scale (CFS).

MATERIAL AND METHODS

This is a prospective observational study of older patients with cancer who underwent oncosurgery in a tertiary cancer centre during the one-year study period. Patients were scored on the CFS, MFI, ASA and ECOG scales. All patients were followed up for 30 days immediately following surgery and their post operative complications were documented. Univariate and multivariate analyses were done and a p value of ≤0.05 was considered statistically significant.

RESULTS

Of the 820 patients studied, 15.6% had prolonged hospital stay, 9.1% had 30-day morbidity, 0.7% had readmission, and mortality was 1.1%. High-risk scores on the ASA and CFS were significantly associated with prolonged postoperative stay, readmission, morbidity, and mortality (p < 0.05). High-risk scores on the ECOG was significantly associated with prolonged hospital stay (p = 0.027), 30-day morbidity (p = 0.003), and mortality (p = 0.001), but not with readmission. There was no significant association between MFI score and the postoperative variables studied (p > 0.05). On multivariate analysis, morbidity was significantly associated only with male gender (p = 0.015), higher cancer stage (p = 0.005), higher ASA score (p = 0.029), and prolonged hospital stay (p = 0.001). Mortality was significantly associated only with emergency surgery (p = 0.012) and prolonged hospital stay (p = 0.004), and prolonged hospital stay was significantly associated with advanced cancer stage (p = 0.001) and emergency surgery (p = 0.02).

CONCLUSIONS

In older patients undergoing cancer surgery, ASA and CFS are predictors of prolonged postoperative stay, morbidity, mortality, and readmission. A high-risk ECOG score is predictive of prolonged post operative stay, 30-day morbidity, and mortality, but not of readmission. Score on MFI is not a predictor of postoperative outcomes. Newer predictive tools which include cancer- specific factors are required for better management of these patients.

Evaluation of the Braden scale in predicting surgical outcomes in older patients undergoing major head and neck surgery

BACKGROUND

Being able to predict negative postoperative outcomes is important for helping select patients for treatment as well for informed decision-making by patients. Frailty measures are often time and resource intensive to use as screening measures, whereas the Braden scale, a commonly used measure to assess patients at risk of developing pressure ulcers after surgery, may be a potential tool to predict postoperative complication rates and longer length of stay (LOS) in patients undergoing major head and neck cancer surgery.

METHODS

A retrospective analysis of Braden scale scores was performed on a prospectively collected cohort of patients undergoing major head and neck surgery recruited between December 2011 and April 2014. The association of Braden scale score with the primary outcomes of complications and LOS was analyzed using logistic regression and linear regression models on univariate analysis (UVA), respectively. Multivariate analysis (MVA) was performed based on a backward stepwise selection algorithm.

RESULTS

There were 232 patients with a mean (SD) Braden scale score of 14.9 (2.8) with a range from 9 to 23. The Braden scale (β = -.07 per point; 95% CI -0.09, -0.04, P < .001) was an independent predictor of increased LOS on UVA, but not on MVA when adjusted for other variables. For overall complications, as well as type of complication, the Braden scale score was not a significant predictor of complications on either UVA or MVA.

CONCLUSION

In the sample population, the Braden scale did not demonstrate an ability to predict negative outcomes in head and neck surgery patients.

LEVEL OF EVIDENCE

Level 2b individual cohort study.

The impact of comorbidity on overall survival in elderly nasopharyngeal carcinoma patients: a National Cancer Data Base analysis

The number of elderly patients with cancer is increasing. Medical comorbidities are more common in this population. Little is known regarding the prognostic relevance of comorbidities in elderly patients with nasopharyngeal carcinoma (NPC). Using the National Cancer Data Base (NCDB), we queried patients age >65 years diagnosed with NPC and treated with definitive radiation between 2004 and 2012 to examine the association between comorbidity and survival outcomes. Comorbidity was assessed with the Charlson Comorbidity Index (CCI). The influence of comorbidity on overall survival (OS) was evaluated. Cox proportional hazards model was used to study the impact of comorbidity on OS. A total of 1137 patients met the specified criteria. Median follow-up was 61.2 months. Five-year OS was 50.4%. Comorbidities were present in 22.4% of patients, with 17.6% of patients having a CCI score of 1% and 4.8% having a CCI score of ≥2. Patients with a CCI score of 0 had significantly higher 5-year OS than patients with a CCI score of 1 or ≥2 (53.1% vs. 42.2% vs. 32.9%, P < 0.001). In multivariate analysis, CCI was a statistically significant independent prognostic factor for the risk of death of all causes for patients with a CCI score of 1 (hazard ratio [HR]: 1.242; 95% confidence interval [CI]: 1.002-1.539) or CCI score of ≥2 (HR: 1.625; 95% CI: 1.157-2.283) when compared to patients with a CCI score of 0. Comorbidity as measured by CCI is a strong independent prognostic factor for OS in elderly patients with NPC and lends support to the inclusion of comorbidity assessment due to its prognostic value when treating elderly patients with NPC.

Hyperglycemia and risk of adverse outcomes following microvascular reconstruction of oncologic head and neck defects

INTRODUCTION

Our aim is to examine the correlation between perioperative hyperglycemia and post-operative outcomes following microvascular reconstruction of head and neck defects.

PATIENTS AND METHODS

Retrospective review of a prospectively collected database of 350 consecutive patients who underwent microvascular reconstruction of malignant head and neck defects over a 2 year period. The relationship between perioperative hyperglycemia (≥ 180 mg/dL) and the incidence of the following complications was evaluated: flap loss, flap-related complications and surgical site infections (SSI). Sub-group analysis based on timing of hyperglycemia was also performed.

RESULTS

We identified 313 patients (89.4%) in the normoglycemic group and 37 patients (10.6%) in the hyperglycemic group. Baseline demographics, tumor stage, operative variable were comparable. There were no significant differences in flap-related complications and overall mortality. SSI were significantly higher in the hyperglycemic cohort (48% vs. 28%, p = 0.01). On multivariate analysis, hyperglycemia [OR 2.07; 95% CI, 1.87-4.89], perioperative insulin administration [OR 4.805; 95% CI, 2.18-10.60], prolonged operative time [OR 1.003; 95% CI, 1.002-1.025] and higher Charlson co-morbidity indices [II: OR 2.286 & III: OR 2.284] were independent predictors of SSI. On sub-group analysis, only patients with early (POD 1) post-operative hyperglycemia had a significant OR for SSI (OR 1.88; 95% CI, 1.07-3.29).

CONCLUSION

Our findings suggest that perioperative hyperglycemia, specifically during the first 24 h post-operatively, is associated with SSI in microvascular head and neck reconstruction. This association highlights the need for strict screening of head and neck patients for hyperglycemia especially in the immediate post-operative period.

Treatment in elderly patients with head and neck cancer : A challenging dilemma

Despite the increasing number of elderly patients requiring treatment for head and neck cancer, there is insufficient available evidence about the oncological results of treatment and its tolerability in such patients. Owing to comorbidities, elderly patients often need complex evaluation and pretreatment management, which often results in their exclusion from clinical trials. The question of which patients constitute the highest-risk groups regarding treatment-related morbidity and mortality, and who can tolerate and benefit from aggressive treatment, has not been adequately studied. Biologic rather than chronologic age should be a more important factor in treatment protocols. Age-specific prospective clinical studies are needed on the treatment of head and neck cancer in elderly patients.

Use of the frailty index in evaluating the prognosis of older people in Beijing: A cohort study with an 8-year follow-up

OBJECTIVE

Frailty is a significant healthcare challenge in China. However, the relationship between frailty and the prognosis of older people in China remains unclear. The present study aimed to evaluate the prevalence of frailty and determine if the frailty index, a comprehensive geriatric assessment, was associated with the prognosis of older people in a Chinese population.

METHODS

Data were drawn from the Beijing Longitudinal Study of Aging, a representative cohort study with an 8-year follow-up. Evaluations based on the use of the frailty index were performed in a cohort of 1808 people aged 60 years and over residing in Beijing urban and rural areas. The initial survey was conducted in 2004, with follow-up surveys at 3, 5, and 8 years. Mortality data for all individuals were collected and analyzed.

RESULTS

The frailty index and the age of individuals showed the same trend, with a higher frailty index expected as age increased. Respondents with the same frailty index level differed across factors such as sex and location. Male individuals, rural dwellers, and older individuals showed higher frailty rates than female individuals, urban dwellers, and younger individuals.

CONCLUSIONS

Frailty is a condition associated with problems across multiple physiological systems. The frailty index increases with age, and may be a significant tool for evaluation of the prognosis of older people in China.