Is partial nephrectomy safe and effective in the setting of frail comorbid patients affected by renal cell carcinoma? Insights from the RECORD 2 multicentre prospective study

Frailty and Renal Cell Carcinoma: Integration of Comprehensive Geriatric Assessment into Shared Decision-making

CONTEXT

Frailty, a geriatric syndrome characterized by decreased resilience and physiological reserve, impacts the prognosis and management of older adults significantly, particularly in the context of surgical and oncological care.

OBJECTIVE

To provide an overview of frailty assessment in the management of older patients with a renal mass/renal cell carcinoma (RCC), focusing on its implications for diagnostic workup, treatment decisions, and clinical outcomes.

EVIDENCE ACQUISITION

A narrative review of the literature was conducted, focusing on frailty definitions, assessment tools, and their application in geriatric oncology, applied to the field of RCC. Relevant studies addressing the prognostic value of frailty, its impact on treatment outcomes, and potential interventions were summarized.

EVIDENCE SYNTHESIS

Frailty is a poor prognostic factor and can influence decision-making in the management of both localized and metastatic RCC. Screening tools such as the Geriatric Screening Tool 8 (G8) and the Mini-COG test can aid clinicians to select older patients (ie, aged ≥65 yr) for a further comprehensive geriatric assessment (CGA) performed by dedicated geriatricians. The CGA provides insights to risk stratify patients and guide subsequent treatment pathways. As such, the involvement of geriatricians in multidisciplinary tumor boards emerges as an essential priority to address the complex needs of frail patients and optimize clinical outcomes. Herein, we propose a dedicated care pathway as a first key step to implement frailty assessment in clinical practice and research for RCC.

CONCLUSIONS

Frailty has emerged as a crucial factor influencing the management and outcomes of older patients with RCC. Involvement of geriatricians in diagnostic and therapeutic pathways represents a pragmatic approach to screen and assess frailty, fostering individualized treatment decisions according to holistic patient risk stratification.

PATIENT SUMMARY

Frailty, a decline in resilience and physiological reserve, influences treatment decisions and outcomes in elderly patients with renal cell carcinoma, guiding personalized care. In this review, we focused on pragmatic strategies to screen patients with a renal mass suspected for renal cell carcinoma, who are older than 65 yr, for frailty and on personalized management algorithms integrating geriatric input beyond patient- and tumor-related factors.

Multiple factors influence decision making for the surgical treatment in patients with renal cell carcinoma

BACKGROUND

Surgical strategy in renal cell carcinoma (RCC) is considered based on the renal function. Partial nephrectomy (PN) preserves kidney function better than radical nephrectomy (RN), lowering risk of chronic kidney disease (CKD). The aim was to evaluate whether renal function and other clinical variables were important for surgical treatment selection.

METHODS

Patients with RCC, surgically treated between 1994 and 2018 were included. There were 663 patients in all stages, 265 women and 398 men, mean age 66 years.

CLINICAL DATA

estimated glomerular filtration rate (eGFR), WHO performance status (WHO-PS), Charlson comorbidity index (CCI), surgery, T-stage, M-stage, RCC type, tumor size, age, and gender were extracted from the medical records. Statistical analysis included Mann-Whitney U, X2-test, and logistic regression analysis.

RESULTS

Of 663 patients, 455 were treated with RN and 208 with PN. In all patients, preoperative eGFR was significantly higher in PN (80.8) than in RN (77.1, p = 0.015). Using logistic regression tumor size (odds ratio [OR]: 0.96; 95% confidence interval [CI]: 0.95-0.98, T-stage (OR: 0.46; 95% CI: 0.33-0.65), WHO-PS (OR: 0.39; 95% CI: 0.04-0.57), and CCI (OR: 1.23; 95% CI: 1.05-1.44), associated to treatment selection, while eGFR, M-stage, age, and gender did not. In cTa subgroup, eGFR was also higher in PN (84.6) than in RN (75.0, p = 0.007). Using logistic regression, tumor size (OR: 0.93; 95% CI: 0.83-0.98) and WHO-PS (OR: 0.36; 95% CI: 0.20-0.66) associated to treatment selection, while eGFR, CCI, age, and gender did not.

CONCLUSION

Tumor size, CCI scores, T-stage, and WHO-PS, all had an impact on the surgical strategy for all RCC patients. In patients with T1a RCC, tumor size and WHO-PS associated independently with treatment decision. After adjusted analysis, renal function lost its independent association with the treatment strategy in RCC patients.

Is It Time to Integrate Frailty Assessment in Onconephrology?

Simple Summary

There are an increasing number of older people living with kidney cancer and/or cancer and kidney disease worldwide, sparking a wider discussion on the impact of frailty and the clinical significance of conducting frailty assessments for this patient population. We provide an update on the current evidence related to frailty assessment in onconephrology and identify areas where further research efforts are anticipated to address knowledge gaps within this topic.

Abstract

Onconephrology has emerged as a novel sub-specialty of nephrology dedicated to the intersection between the kidney and cancer. This intersection is broad and includes a number of important areas of focus, including concurrent chronic kidney disease (CKD) and cancer, acute kidney complications of cancer, and cancer-treatment-induced nephrotoxicity. The importance of onconephrology is even more evident when considering the global growth in the population of older adults, many of whom are living with some degree of frailty. Furthermore, a considerable proportion of older adults have CKD (some of whom eventually progress to kidney failure) and are at high risk of developing solid tumour and hematologic malignancies. Specific to kidney disease, the association between frailty status and kidney disease has been explored in depth, and tools to capture frailty can be used to guide the management and prognostication of older adults living with kidney failure. Whilst there is emerging data regarding the assessment and impact of frailty in onconephrology, there remains a relative paucity of knowledge within this topic. In this article, we evaluate the definition and operationalization of frailty and discuss the significance of frailty within onconephrology. We review evidence on current approaches to assessing frailty in onconephrology and discuss potential developments and future directions regarding the utilization of frailty in this patient population. A greater awareness of the intersections and interactions between frailty and onconephrology and further efforts to integrate frailty assessment in onconephrology to optimize the delivery of realistic and goal-directed management strategies for patients is needed.

Robotic-assisted radical prostatectomy is pushing the boundaries: a national survey of frailty using the national surgical quality improvement program

Background

Robotic-assisted radical prostatectomy (RARP) has been found to be comparable and, in some cases, favorable to open surgical approaches, while being used in a frailer population.

Objectives

We aimed to illustrate the trend in population frailty and compare morbidity and mortality postoperatively in patients who underwent RARP.

Design and Methods

The National Surgical Quality Improvement Program data set was used to select patients who underwent RARP between the years 2011-2019. Age, frailty indicators, surgical characteristics, and perioperative morbidity and mortality were compared between the years 2011-2019 using the chi-square test (χ²) for categorical variables and the one-way analysis of variance (ANOVA) for continuous variables.

Results

Our patient population consisted of 66,683 patients who underwent RARP. There was an increase in mean age and frailty indicated by an increase in 5-item frailty score ⩾2, metabolic syndrome index = 3, and American Society of Anesthesiologists' (ASA) class ⩾3 between the years 2011-2019 (p < 0.001). Whereas the rate of mortality and morbidity, indicated by postoperative Clavien-Dindo grade ⩾4 and major morbidity, remained the same over the same period (p > 0.264). Furthermore, operative time and length of stay decreased over the same period (p < 0.001).

Conclusion

RARP is being performed on more frail patients, with no added morbidity or mortality.

Utility of the Age Discrepancy between Frailty-Based Biological Age and Expected Life Age in Patients with Urological Cancers

Background: The estimation of biological age is challenging in patients with cancers. We aimed to investigate frailty-based biological ages using frailty-discriminant scores (FDS) and examined the effect of biological-expected life age discrepancy on the prognosis of patients with urological cancers. Methods: We retrospectively evaluated frailty in 1035 patients having urological cancers. Their frailty-based biological age was then defined by the FDS, which is a comprehensive frailty assessment tool, using 1790 noncancer individuals as controls. An expected life age (=chronological age + life expectancy) was subsequently calculated using the 2019 life expectancy table. The primary outcome was the estimation of the biological-expected life age discrepancy between the frailty-based biological age and expected life age in patients with urological cancers. Secondary outcomes were the evaluation of the effect of the biological-expected life age discrepancy on overall survival. Results: We included 405, 466, and 164 patients diagnosed with prostate cancer, urothelial carcinoma, and renal cell carcinoma, respectively. The median chronological age, life expectancy, and estimated frailty-based biological age were 71, 17, and 83 years, respectively. The biological-expected life age discrepancy in any urological cancers, localized diseases, and metastatic diseases was −4.8, −6.3, and +0.15 years, respectively. The biological-expected life age discrepancy of >5 years was significantly associated with poor overall survival. Conclusions: The biological-expected life age discrepancy between frailty-based biological age and expected life age may be helpful in understanding the role of frailty and patient/doctor conversation.

Overview of clinical management for older patients with renal cell carcinoma

The rapidly increasing pool of older patients being diagnosed with and surviving their cancer is creating many challenges. Regarding localized renal cell carcinoma, surgery is considered as gold standard treatment options even in older men, whereas active surveillance and ablation therapy are alternative options for a proportion of these patients. With regard to advanced disease, anti-vascular endothelial growth factor tyrosine kinase inhibitors (VEGFR-TKI) and immune check point inhibitor are standard treatment modalities, although treatment choice from multiple regimens and prevention of adverse events need to be considered. Better assessment techniques, such as comprehensive geriatric assessment to meet the unique needs of older patients, are a central focus in the delivery of high-quality geriatric oncology care. Through this process, shared decision-making should be adopted in clinical care to achieve optimal goals of care that reflect patient and caregiver hopes, needs and preferences. It is necessary to continue investigating oncological outcomes and complications associated with treatment in this population to ensure appropriate cancer care. In this narrative review, we completed a literature review of the various treatments for renal cell carcinoma in older patients that aimed to identify the current evidence related to the full range of the treatments including active surveillance, surgery, ablation therapy and systemic therapy. Prospectively designed studies and studies regarding geriatric assessment were preferentially added as references. Our goals were to summarize the real-world evidence and provide a decision framework that guides better cancer practices for older patients with renal cell carcinoma.

Impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for renal cancer: a systematic review

BACKGROUND

Frailty has been recognized as a major risk factor for adverse perioperative and oncological outcomes in patients with genitourinary malignancies. Yet, the evidence supporting such an association in patients with renal cell carcinoma (RCC) is still sparse. Herein we provide an updated comprehensive overview of the impact of frailty on perioperative and oncologic outcomes in patients undergoing surgery or ablation for RCC.

EVIDENCE ACQUISITION

A systematic review of the English-language literature was conducted using the MEDLINE (Via PubMed), Web of Science and the Cochrane Library databases according to the principles highlighted by the EAU Guidelines Office and the PRISMA statement recommendations. The review protocol was registered on PROSPERO (CRD42021242516). The overall quality of evidence was assessed according to GRADE recommendations.

EVIDENCE SYNTHESIS

Overall, 18 studies were included in the qualitative analysis. Most of these were retrospective single-centre series including patients undergoing surgery for non-metastatic RCC. The overall quality of evidence was low. A variety of measures were used for frailty assessment, including the Canadian Study of Health and Aging Frailty Index, the five-item frailty index, the Modified Rockwood's Clinical Frailty Scale Score, the Hopkins Frailty score, the Groningen Frailty Index, and the Geriatric nutritional risk index. Sarcopenia was defined based on the Lumbar skeletal muscle mass at cross-sectional imaging, the skeletal muscle index, the total psoas area, or the psoas muscle index. Overall, available studies point to frailty and sarcopenia as potential independent risk factors for worse perioperative and oncological outcomes after surgery or ablation for different RCC stages. Increased patient's frailty was indeed associated with higher risk of perioperative complications, healthcare resources utilization, readmission rates and longer hospitalization periods, as well as potentially lower cancer specific or overall survival.

CONCLUSIONS

Frailty has been consistently associated with worse outcomes after surgery for RCC, reinforcing the value of preoperative frailty assessment in carefully selected patients. Given the low quality of the available evidence (especially in the setting of tumour ablation), prospective studies are needed to standardize frailty assessments and to identify patients who are expected to benefit most from preoperative geriatric evaluation, aiming to optimize decision-making and postoperative outcomes in patients with RCC.