Role of Frailty and Comorbidity in Determination of Operability for Patients With Oral and Oropharyngeal Squamous Cell Carcinoma
- 4 Downloads
Purpose of Review
To review the role of frailty and comorbidities in determining operability and associated outcomes in patients with oral and oropharyngeal squamous cell carcinoma.
Frailty and comorbidity have been linked to multiple adverse outcome measures including risk of mortality, surgical complications, length of stay, intensity of care needs, discharge disposition, risk of readmission, and cost of healthcare delivery. There are diverse objective and validated measures of comorbidity and frailty. Addition of comorbidity and objective frailty measurements has been demonstrated to improve predictive power of nomograms and clinical staging systems for patients with oral and oropharyngeal squamous cell carcinoma. The use of predictive tools that assess frailty may contribute to shared decision making, realistic expectations, and facilitation of appropriate level of care. While emerging literature supports the role of prehabilitation, there is paucity of data in support of such interventions for patients afflicted by oral and oropharyngeal cancer.
Frailty assesses operability beyond anatomic resectability and incorporates key determinants of physical, nutritional, and cognitive well-being. Objective measurements of frailty predict meaningful outcomes following surgery for cancers of the oral cavity and oropharynx. This paper suggests that clinicians should objectively and routinely assess frailty, which may facilitate patient counseling, improved risk stratification, informed decision making, and further research to elucidate relationship of frailty with outcomes in head and neck specific populations.
KeywordsFrailty Outcomes Comorbidity Head and neck cancer Oral cancer Oropharyngeal cancer
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance
- 1.He W, Goodkind D, Kowal PR. An aging world: 2015. 2016. https://www.census.gov/library/publications/2016/demo/P95-16-1.html. Accessed 15 June 2018.
- 7.Argiris A, Brockstein BE, Haraf DJ, Stenson KM, Mittal BB, Kies MS, et al. Competing causes of death and second primary tumors in patients with locoregionally advanced head and neck cancer treated with chemoradiotherapy. Clin Cancer Res. 2004;10:1956–62. https://doi.org/10.1158/1078-0432.CCR-03-1077.CrossRefGoogle Scholar
- 8.Beynon RA, Lang S, Schimansky S, Penfold CM, Waylen A, Thomas SJ, et al. Tobacco smoking and alcohol drinking at diagnosis of head and neck cancer and all-cause mortality: results from head and neck 5000, a prospective observational cohort of people with head and neck cancer. Int J Cancer. 2018;143:1114–27. https://doi.org/10.1002/ijc.31416.CrossRefGoogle Scholar
- 11.Dahlstrom KR, Bell D, Hanby D, Li G, Wang L-E, Wei Q, et al. Socioeconomic characteristics of patients with oropharyngeal carcinoma according to tumor HPV status, patient smoking status, and sexual behavior. Oral Oncol. 2015;51:832–8. https://doi.org/10.1016/j.oraloncology.2015.06.005.CrossRefGoogle Scholar
- 12.Noone AM, Howlader N, Krapcho M, Miller D, Brest A, Yu M, Ruhl J, Tatalovich Z, Mariotto A, Lewis DR, Chen HS, Feuer EJ, Cronin KA. SEER cancer statistics review, 1975-2015, National Cancer Institute. Bethesda, MD, https://seer.cancer.gov/csr/1975_2015/, based on November 2017 SEER data submission, posted to the SEER web site, April 2018.
- 18.Podsiadlo D, Richardson S. The timed “Up & Go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–8. https://doi.org/10.1111/j.1532-5415.1991.tb01616.x.CrossRefGoogle Scholar
- 21.Erichsen JE. Causes of death after operations. In: The science and art of surgery, being a treatise on surgical injuries, diseases, and operations, 2nd ed. September 1856.Google Scholar
- 27.ACS Risk Calculator—Home Page. https://riskcalculator.facs.org/RiskCalculator/. Accessed 17 Jun 2018.
- 30.Habbous S, Chu KP, Harland LTG, la Delfa A, Fadhel E, Sun B, et al. Validation of a one-page patient-reported Charlson comorbidity index questionnaire for upper aerodigestive tract cancer patients. Oral Oncol. 2013;49:407–12. https://doi.org/10.1016/j.oraloncology.2012.11.010.CrossRefGoogle Scholar
- 31.Karnofsky DA, Abelmann WH, Craver LF, Burchenal JH. Karnofsky Palliative Performance Scale. PsycTESTS Dataset. 1948. https://doi.org/10.1037/t60198-000.
- 37.Paleri V, Wight RG, Silver CE, Haigentz M Jr, Takes RP, Bradley PJ, et al. Comorbidity in head and neck cancer: a critical appraisal and recommendations for practice. Oral Oncol. 2010;46:712–9. https://doi.org/10.1016/j.oraloncology.2010.07.008.CrossRefGoogle Scholar
- 38.•Nieman CL, Pitman KT, Tufaro AP, Eisele DW, Frick KD, Gourin CG. The effect of frailty on short-term outcomes after head and neck cancer surgery. Laryngoscope. 2018;128:102–10. https://doi.org/10.1002/lary.26735 This is a retrospective review which assesses frailty, utilizing the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator, in a large national database of head and neck cancer patients. The authors show that 7.4% of the patients are frail, and frailty is associated with discharge disposition, in-hospital death, complications, length of stay, and cost. CrossRefGoogle Scholar
- 40.Abt NB, Richmon JD, Koch WM, Eisele DW, Agrawal N. Assessment of the predictive value of the modified frailty index for Clavien-Dindo grade IV critical care complications in major head and neck cancer operations. JAMA Otolaryngol Head Neck Surg. 2016;142:658–64. https://doi.org/10.1001/jamaoto.2016.0707.CrossRefGoogle Scholar
- 41.Chen MM, Orosco RK, Harris JP, Porter JB, Rosenthal EL, Hara W, et al. Predictors of readmissions after head and neck cancer surgery: a national perspective. Oral Oncol. 2017;71:106–12. https://doi.org/10.1016/j.oraloncology.2017.06.010.CrossRefGoogle Scholar
- 44.•Wachal B, Johnson M, Burchell A, Sayles H, Rieke K, Lindau R, et al. Association of modified frailty index score with perioperative risk for patients undergoing total laryngectomy. JAMA Otolaryngol Head Neck Surg. 2017;143:818–23. https://doi.org/10.1001/jamaoto.2017.0412 This is a retrospective study of NSQIP data for patients who underwent total laryngectomy. The index utilized was the modified frailty index. An MFI score of 3 or higher had a higher rate of complications, and frail status was predictive of length of stay and discharge disposition. Interestingly, most patients (84.3%) had an MFI of 2 or less, suggesting that many frail patients are being selected against laryngectomy. CrossRefGoogle Scholar
- 46.• Adams P, Ghanem T, Stachler R, Hall F, Velanovich V, Rubinfeld I. Frailty as a predictor of morbidity and mortality in inpatient head and neck surgery. JAMA Otolaryngol Head Neck Surg. 2013;139:783–9. https://doi.org/10.1001/jamaoto.2013.3969 This is a retrospective study using the NSQIP database evaluating the impact of frailty on morbidity and mortality of head and neck cancer patients. Patients with an mFI of 4 out of 11 or higher had an increase in mortality from 0.2 to 11.9%. Similarly, complications were also shown to increase with increasing frail score. This study thereby provides more data regarding the impact of frailty on morbidity and mortality. CrossRefGoogle Scholar
- 49.Chen J-H, Yen Y-C, Yang H-C, Liu SH, Yuan SP, Wu LL, et al. Curative-intent aggressive treatment improves survival in elderly patients with locally advanced head and neck squamous cell carcinoma and high comorbidity index. Medicine. 2016;95:e3268. https://doi.org/10.1097/MD.0000000000003268.CrossRefGoogle Scholar
- 51.Corrêa GTB, Bandeira GA, Cavalcanti BG, Santos FBG, Rodrigues Neto JFR, Guimarães ALS, et al. Analysis of ECOG performance status in head and neck squamous cell carcinoma patients: association with sociodemographical and clinical factors, and overall survival. Support Care Cancer. 2012;20:2679–85. https://doi.org/10.1007/s00520-012-1386-y.CrossRefGoogle Scholar
- 58.Amin MB, Edge S, Greene FL, et al. AJCC cancer staging manual. Berlin: Springer; 2016.Google Scholar
- 62.Panwar A, Wang F, Lindau R, et al. Prediction of discharge destination following laryngectomy. Unpublished results, personal communication, 6/20/2018. 2018.Google Scholar
- 65.Borggreven PA, Verdonck-de Leeuw IM, Muller MJ, Heiligers MLCH, de Bree R, Aaronson NK, et al. Quality of life and functional status in patients with cancer of the oral cavity and oropharynx: pretreatment values of a prospective study. Eur Arch Otorhinolaryngol. 2007;264:651–7. https://doi.org/10.1007/s00405-007-0249-5.CrossRefGoogle Scholar
- 68.Maggiore R, Zumsteg ZS, BrintzenhofeSzoc K, Trevino KM, Gajra A, Korc-Grodzicki B, et al. The older adult with locoregionally advanced head and neck squamous cell carcinoma: knowledge gaps and future direction in assessment and treatment. Int J Radiat Oncol Biol Phys. 2017;98:868–83. https://doi.org/10.1016/j.ijrobp.2017.02.022.CrossRefGoogle Scholar
- 73.Gillis C, Buhler K, Bresee L, Carli F, Gramlich L, Culos-Reed N, et al. Effects of nutritional prehabilitation, with and without exercise, on outcomes of patients who undergo colorectal surgery: a systematic review and meta-analysis. Gastroenterology. 2018;155:391–410.e4. https://doi.org/10.1053/j.gastro.2018.05.012.CrossRefGoogle Scholar
- 74.Boujibar F, Bonnevie T, Debeaumont D, Bubenheim M, Cuvellier A, Peillon C, et al. Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: a cohort study. J Thorac Dis. 2018;10:2240–8. https://doi.org/10.21037/jtd.2018.03.161.CrossRefGoogle Scholar
- 75.VanderWalde NA, Deal AM, Comitz E, Stravers L, Muss H, Reeve BB, et al. Geriatric assessment as a predictor of tolerance, quality of life, and outcomes in older patients with head and neck cancers and lung cancers receiving radiation therapy. Int J Radiat Oncol Biol Phys. 2017;98:850–7. https://doi.org/10.1016/j.ijrobp.2016.11.048.CrossRefGoogle Scholar
- 76.Pottel L, Lycke M, Boterberg T, Pottel H, Goethals L, Duprez F, et al. Serial comprehensive geriatric assessment in elderly head and neck cancer patients undergoing curative radiotherapy identifies evolution of multidimensional health problems and is indicative of quality of life. Eur J Cancer Care. 2014;23:401–12. https://doi.org/10.1111/ecc.12179.CrossRefGoogle Scholar
- 79.• Brugel L, Laurent M, Caillet P, Radenne A, Durand-Zaleski I, Martin M, et al. Impact of comprehensive geriatric assessment on survival, function, and nutritional status in elderly patients with head and neck cancer: protocol for a multicentre randomised controlled trial (EGeSOR). BMC Cancer. 2014;14:427. https://doi.org/10.1186/1471-2407-14-427 This is a large randomized trial of patients 70 years of age or older which is still collecting data. Once the results are out, this can provide much-needed high quality evidence on the benefit of a comprehensive geriatric assessment, involvement of a geriatrician on the team, and selection of who may benefit. CrossRefGoogle Scholar