The effect of frailty on the quality of life and lower urinary symptoms following robot-assisted radical prostatectomy: A longitudinal analysis (FRARP-QL Study)

Association between Geriatric 8 frailty and health-related quality of life in older patients with cancer (PROGNOSIS-G8): a Danish single-centre, prospective cohort study

BACKGROUND

Health-related quality of life (HRQoL) is highly valued among older adults with cancer. The Geriatric 8 screening tool identifies individuals with frailty, but its association with HRQoL remains sparsely investigated. Herein, we evaluate whether Geriatric 8 frailty is associated with short-term and long-term HRQoL in older patients with cancer.

METHODS

In this Danish single-centre, prospective cohort study, patients aged 70 years and older, referred to oncological assessment for solid cancers, were screened with the Geriatric 8. Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) Quality-of-Life Core 30 (QLQ-C30) and Elderly 14 (ELD14) questionnaires at baseline, 3 months, 6 months, 9 months, and 12 months. Patient characteristics were obtained from medical records. Differences in mean global health status and QoL (GHS), measured using the two seven-point Likert scale questions from the EORTC QLQ-C30 regarding overall health and QoL during the past week, between patients with frailty (defined as a Geriatric 8 score of ≤14) and without frailty within 12 months were the primary outcome. Secondary outcomes were differences in the mean EORTC Summary Score comprised of all questions from the QLQ-C30 except for those included in the GHS and a question concerning financial difficulties, and five functional (physical, role, and social functioning, maintaining purpose, and family support from the EORTC QLQ-C30 and the EORTC-QLQ-ELD14), and five symptom scales (fatigue, pain, mobility, future worries, and burden of illness from the EORTC-QLQ-C30 and the EORTC-QLQ-ELD14). Analyses were done using linear mixed models. All primary and secondary outcomes were adjusted for gender, treatment intent, and cancer type and the primary outcome was also assessed by means of a responder analysis.

FINDINGS

Between June 1, 2020 and Oct 15, 2021, 1398 eligible patients were screened with the Geriatric 8 (908 [65%] with frailty and 490 [35%] without frailty) and provided medical record data. Of these patients, 707 (51%) also provided HRQoL data (437 [62%] with frailty and 270 [38%] without frailty). When adjusted, patients with frailty had poorer GHS (-15·1, 95% CI -18·5 to -11·6; p<0·0001) at baseline and throughout follow-up (3 months -7·4, -11·0 to -3·7, p=0·0001; 6 months -11·7, -15·5 to -7·9, p<0·0001; 9 months -10·4, -14·3 to -6·5, p<0·0001; 12 months -10·4, -14·6 to -6·2, p<0·0001) compared to patients without frailty. Adjusted summary scores were also poorer for patients with frailty (-9·9, 95% CI -12·1 to -7·6; p<0·0001) compared to patients without frailty at baseline and throughout follow-up (3 months -8·2, -10·5 to -5·8, p=0·0001; 6 months -9·0, -11·4 to -6·6, p<0·0001; 9 months -9·2, -11·7 to -6·8, p<0·0001; 12 months -8·9, -11·5 to -6·3, p<0·0001). Patients with frailty had significantly worse physical and role functioning, mobility, and fatigue outcomes, with no differences in family support within 12 months, at all timepoints.

INTERPRETATION

Older patients with cancer and frailty have significantly poorer HRQoL than those without frailty within the 12 months following an oncology referral. Thus, by identifying and treating frailty, we can ultimately improve patient HRQoL.

FUNDING

The Danish Cancer Society, Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, University of Southern Denmark, Dagmar Marshalls Fond, and Agnes and Poul Friis Fond.

The significance of G8 and other geriatric assessments in urologic cancer management: A comprehensive review

In urologic oncology, which often involves older patients, it is important to consider how to manage their care appropriately. Geriatric assessment (GA) is a method that can address the specific needs of older cancer patients. The GA encompasses various assessment domains, but these domains exhibit variations across the literature. Some of the common items include functional ability, nutrition, comorbidities, cognitive ability, psychosocial disorders, polypharmacy, social and financial support, falls/imbalance, and vision/hearing. Despite the diversity of domains, there is limited consensus on reliable measurement methods. This review discusses the role of GA in managing urologic cancer in unique scenarios, such as those necessitating temporary or permanent urinary catheters or stomas due to urinary diversion. A comprehensive GA is time and human-resource-intensive in real-world clinical practice. Hence, simpler tools such as the Geriatric-8 (G8), capable of identifying high-risk patients requiring a detailed GA, are also under investigation in various contexts. Therefore, we conducted a systematic literature review on the G8. Our findings indicate that patients with low G8 scores encounter difficulties with stoma self-care after urinary diversion and have higher risks of urinary tract infections and ileus after radical cystectomy. The utilization of G8 as a screening tool for urologic cancer patients may facilitate the delivery of appropriate and personalized treatment and care.

Surgical Tolerability and Frailty in Elderly Patients Undergoing Robot-Assisted Radical Prostatectomy: A Narrative Review

Simple Summary

Life expectancy in Western countries and East Asian countries has incremented over the past decades, resulting in a rapidly aging world, while in general, radical prostatectomy (RP) is not recommended in elderly men aged ≥75 years. Together with the evolving technique of robotic surgeries, surgical indications for RP should be reconsidered in ‘elderly’ and ‘frail’ men, since this procedure has now become one of the safest and most effective cancer treatments for prostate cancer. One important element to determine surgical indications is surgical tolerability. However, evidence is scarce regarding the surgical tolerability in elderly men undergoing robot-assisted radical prostatectomy (RARP). In this review, we focused on the surgical tolerability in ‘elderly’ and/or ‘frail’ men undergoing RARP, with the intent to provide up-to-date information on this matter and to support the decision making of therapeutic options in this spectrum of patients.

Abstract

Robot-assisted radical prostatectomy (RARP) has now become the gold standard treatment for localized prostate cancer. There are multiple elements in decision making for the treatment of prostate cancer. One of the important elements is life expectancy, which the current guidelines recommend as an indicator for choosing treatment options. However, determination of life expectancy can be complicated and difficult in some cases. In addition, surgical tolerability is also an important issue. Since frailty may be a major concern, it may be logical to use geriatric assessment tools to discriminate ‘surgically fit’ patients from unfit patients. Landmark studies show two valid models such as the phenotype model and the cumulative deficit model that allow for the diagnosis of frailty. Many studies have also developed geriatric screening tools such as VES-13 and G8. These tools may have the potential to directly sort out unfit patients for surgery preoperatively.

Improvement of quality of life and symptom burden after robot-assisted radical prostatectomy in patients with moderate to severe LUTS

The aim of this study was to assess clinically meaningful differences of preoperative lower urinary tract symptoms (LUTS) and quality of life (QoL) before and after robot-assisted radical prostatectomy (RARP). Therefore we identified 5506 RARP patients from 2007 to 2018 with completed International Prostate Symptom Score (IPSS) and -QoL questionnaires before and 12 months after RARP in our institution. Marked clinically important difference (MCID) was defined by using the strictest IPSS-difference of − 8 points. Multivariable logistic regression analyses (LRM) aimed to predict ∆IPSS ≤ − 8 and were restricted to RARP patients with preoperatively moderate (IPSS 8–19) vs. severe (IPSS 20–35) LUTS burden (n = 2305). Preoperative LUTS was categorized as moderate and severe in 37% (n = 2014) and 5.3% of the complete cohort (n = 291), respectively. Here, a postoperative ∆IPSS ≤ − 8, was reported in 38% vs. 90%. In LRM, younger age (OR 0.98, 95%CI 0.97–0.99; p = 0.007), lower BMI (OR 0.94, 95%CI 0.92–0.97; p < 0.001), higher preoperative LUTS burden (severe vs. moderate [REF.] OR 15.6, 95%CI 10.4–23.4; p < 0.001), greater prostate specimen weight (per 10 g, OR 1.12, 95%CI 1.07–1.16; p < 0.001) and the event of urinary continence recovery (OR 1.66 95%CI 1.25–2.21; p < 0.001) were independent predictors of a marked LUTS improvement after RARP. Less rigorous IPSS-difference of − 5 points yielded identical predictors. To sum up, in substantial proportions of patients with preoperative moderate or severe LUTS a marked improvement of LUTS and QoL can be expected at 12 months after RARP. LRM revealed greatest benefit in those patients with preoperatively greatest LUTS burden, prostate enlargement, lower BMI, younger age and the event of urinary continence recovery.