Frailty Index for Prediction of Surgical Outcome in Ovarian Cancer: Results of a Prospective Study [Editorial Material]

Surgical complete tumor resection is the strongest prognostic factor for patients with ovarian cancer; however, frailty is common among this population, which raises concerns for surgical outcomes and recovery. Alternative therapies such as neoadjuvant therapy are available, and identification of the frail patient can assist with identification of the appropriate treatment. Frailty index is a deficit accumulation model that uses symptoms, signs, current disease status, and disabilities in activities of daily life to evaluate frailty. Very few prospective studies have evaluated frailty index among a population of patients with ovarian cancer. This prospective study aimed to evaluate the frailty index as a predictor of surgical outcomes among patients with ovarian cancer. Patients older than 18 years with histologically confirmed or strongly suspected ovarian cancer and a surgery with an expected minimal duration of 60 minutes were included. Recruitment occurred between October 2015 and January 2017. Validated questionnaires and screening tools were used to assess the medical, physical, cognitive, and psychological state of each patient prior to surgery. Frailty index was calculated based on previously published studies, with a cutoff calculated by performing receiver operating characteristic curve analyses to differentiate women with severe complications from those without. Further receiver operating characteristic analyses were used to evaluate predictive outcomes of continuous variables, and a multivariable Cox proportional hazards model was used to obtain independent risk factors for overall survival. Postoperative complications were graded using validated Clavien-Dindo criteria. A 3-month follow-up call was conducted to record late postoperative complications following discharge and follow-up for overall mortality continued until September 2020. A total of 144 patients undergoing surgery for ovarian cancer were included in this analysis, with 27 (19%) experiencing severe postoperative complications and 3 (2%) dying within 30 days of surgery. The overall prevalence of frailty defined by a frailty index >0.26 and frailty index >0.15 was 33% and 74%, respectively. Frailty index >0.26 (odds ratio [OR], 3.64; 95% confidence interval [CI], 1.34-9.85; P = 0.01), Eastern Cooperative Oncology Group performance status >1 (OR, 6.33; 95% CI, 1.31-30.51; P = 0.02), recurrent surgery (OR, 3.05; 95% CI, 0.98-9.47; P = 0.05), and high surgical complexity score (OR, 8.86; 95% CI, 1.88-47.76; P = 0.006) were significant predictors of severe postoperative complications. Patients with frailty index <0.15 had a mean survival of 54 months, whereas those with <0.15 frailty index had a mean survival of 34 months (P = 0.02). Frailty index >0.15 (hazard ratio [HR], 1.87; 95% CI, 1.01-3.47; P = 0.048), residual tumor <1 cm (HR, 2.75; 95% CI, 1.53-4.99; P = 0.001), residual tumor >1 cm (HR, 5.00; 95% CI, 2.74-9.13; P < 0.001), and albumin <35.5 g/dL (HR, 1.92; 95% CI, 1.08-3.43; P = 0.03) were significant parameters for reduced overall survival. This study demonstrates a robust association between frailty index and major postoperative complications and overall survival among women with ovarian cancer. Frailty index and also surgical complexity score, ECOG performance status >1, and recurrent surgery were predictors of postoperative complications, whereas frailty index, tumor residual sizes, and albumin levels were predictors of overall survivalYYYYY.