Baseline Comprehensive Geriatric Assessment and Risk of Postoperative Morbidity and Mortality Among Older Adults Undergoing Radical Cystectomy
John Ernandez, BA1, Sumedh Kaul, MS2, Aaron Fleishman, MPH2, Ruslan Korets, MD3, Peter Chang, MD, MPH3, Andrew Wagner, MD3, Simon Kim, MD4, Joaquim Bellmunt, MD, PhD5, Nima Aghdam, MD6, Aria F. Olumi, MD3, Dae Kim, MD, MPH, ScD7, Ellen P. McCarthy, PhD, MPH7, Boris Gershman, MD3.
1Harvard Medical School, Cambridge, MA, USA, 2Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA, 3Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA, 4Division of Urology, University of Colorado Anschutz Medical Center, Aurora, CO, USA, 5Department of Medicine, Division of Medical Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA, 6Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA, USA, 7Marcus Institute for Aging Research, Hebrew SeniorLife; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
BACKGROUND: Clinical practice guidelines call for the use of comprehensive geriatric assessment (GA) in older adults to identify vulnerabilities in domains that may be optimized prior to treatment. However, the associations of individual GA domains with perioperative outcomes and survival after cancer surgery are understudied. The role of baseline GA is particularly relevant among bladder cancer (BC) patients undergoing radical cystectomy (RC) given the high morbidity of this surgery. We therefore developed a claims-based comprehensive geriatric assessment (cGA) for older adults undergoing RC and evaluated its associations with perioperative outcomes and survival.
METHODS: Using SEER-Medicare, we identified patients 66-89 years diagnosed from 2000 to 2017 with Tany Nany cM0 bladder cancer who underwent RC with Medicare fee-for-service enrollment. The cGA consisted of six domains, each assessed in a baseline period preceding RC: function, assessed by the claims-based frailty index (CFI), a validated deficit accumulation model of frailty; mobility, cognition, and depression, assessed from algorithms based on CMS Chronic Condition Warehouse methods; comorbidity, assessed using the Charlson comorbidity index (CCI); and nutritional deficiency. The associations between cGA domains and 90-day hospital readmission, 90-day ER utilization, healthy days at home, and all-cause mortality were evaluated using multivariable regression.
RESULTS: A total of 4,662 patients were included. Overall, 351 (8%) patients were frail (CFI ≥ 0.25) with 55 (1%) meeting criteria for activities-of-daily-living (ADL) dependence (CFI ≥ 0.35), and 1,864 (40%) patients with CCI ≥ 2. Baseline cGA domains were notable for hip fracture and/or mobility impairment in 95 (2%) patients, cognitive impairment in 214 (5%) patients, depression in 423 (9%) patients, and nutritional deficiency in 546 (12%) patients. Frail patients were significantly more likely to exhibit vulnerabilities in each cGA domain compared to pre-frail patients (CFI < 0.25). The associations of individual cGA domains and each outcome are summarized in Table 1. On multivariable analysis, ADL-dependence, depression, and CCI ≥ 1 were independently associated with increased risks of 90-day readmission and 90-day ER utilization. Deficiencies in all cGA domains, except hip fracture and/or mobility impairment, were associated independently with fewer healthy days at home. Baseline frailty (CFI ≥ 0.25), nutritional deficiency, and CCI ≥ 1 were also independently associated with worse mortality.
CONCLUSIONS: Among older adults with bladder cancer undergoing RC, baseline frailty, comorbidity, and depression were independently associated with worse perioperative outcomes, while frailty, comorbidity and nutritional deficiency were associated with worse survival. These observations support the utility of baseline cGA among older adults undergoing urologic cancer surgery, but also highlight the need for further study to better define the role of individual cGA domains in surgical patients. 
Back to 2023 Abstracts