Journal of Cancer Research and Clinical Oncology · 12 authors, 5 centres
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This study of 153 women aged 60+ with endometrial cancer found that preoperative frailty assessments (G8, ECOG, CCI) significantly predicted perioperative complications, transfusions, and longer hospital stays, whereas age and BMI alone did not. Frail patients had 2-3 times higher complication rates. The findings suggest that routine frailty screening could identify high-risk patients who may benefit from prehabilitation programs.
**Background:** Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries, primarily affecting elderly women (median age at diagnosis 68 years). While chronological age and BMI are often used as prognostic factors, they may not capture the heterogeneity of aging. Frailty, a multidimensional syndrome of decreased homeostatic reserves, is increasingly recognized as a predictor of adverse surgical outcomes. This study evaluated five commonly used global health assessment tools to determine whether preoperative frailty status predicts perioperative outcomes better than age or BMI alone in elderly EC patients.
**Methods:** This retrospective cohort study included 153 consecutive women aged ≥60 years (median 71±7.4 years) with all stages of EC who underwent primary elective surgery at University Medical Center Mainz between January 2008 and December 2019. Preoperative frailty was assessed using five tools: G8 questionnaire (frail ≤14 points), ECOG performance status (frail ≥2), Charlson Comorbidity Index (CCI, frail =3), ASA Physical Status System (frail ≥3), and Lee-Schonberg prognostic index (frail: 4-year mortality ≥20%, i.e., Lee-Index ≥8 points). The G8 was determined retrospectively using age and Mini Nutritional Assessment; ECOG was assigned by the operating surgeon; CCI was based on ICD-10 codes; ASA PS was collected from anesthesia records; and the Lee-Index was modified to exclude cancer diagnosis. Primary outcomes were perioperative laboratory values (hemoglobin), transfusion rates, and postoperative in-hospital complications (classified by ICD-10 codes corresponding to NSQIP). Statistical analyses included chi-square tests and propensity score matching to adjust for age and BMI.
**Key Results:** Among 153 patients, 38.9% were frail by G8, 17.2% by ECOG (ECOG 2), 28.2% by CCI (CCI 3), 57.2% by ASA PS (ASA 3), and 34.2% by Lee-Index (20-<30% 4-year mortality). Frail patients had significantly higher rates of preoperative anemia (hemoglobin <10 g/dl): G8 frail 10.5% vs non-frail 2.2% (p=0.029); ECOG frail 14.3% vs non-frail 4.3% (p=0.025); CCI frail 11.4% vs non-frail 2.8% (p<0.001). Age and BMI alone showed no significant association with anemia (age p=0.252; BMI p=0.133). Perioperative transfusion rates were significantly higher in frail patients: G8 frail 25.9% vs non-frail 3.3% (p<0.001); ECOG frail 31.8% vs non-frail 8.5% (p=0.006); CCI frail 27.3% vs non-frail 6.5% (p<0.001). Age and BMI alone were not associated with transfusion rates (age p=0.242; BMI p=0.253). Postoperative complications were significantly more frequent in frail patients: G8 frail 20.7% vs non-frail 6.7% (p=0.028); ECOG frail 40.9% vs non-frail 2.8% (p=0.002); CCI frail 25.0% vs non-frail 7.4% (p=0.003). Age and BMI alone showed no significant association (age p=0.805; BMI p=0.731). Length of hospital stay ≥9 days was significantly associated with ECOG (frail 59.1% vs non-frail 25.4%, p=0.003) and CCI (frail 50.0% vs non-frail 31.2%, p=0.029), but not with G8 (p=0.125), age (p=0.110), or BMI (p=0.568). Propensity score matching confirmed that frailty (by G8, ECOG, CCI) remained a significant predictor of complications, with hazard ratios: G8 HR 2.12 (95% CI 0.012-0.313, p=0.034); CCI HR 2.6 (95% CI 0.064-0.459, p=0.009); ECOG HR 2.6 (95% CI 0.087-0.617, p=0.009). Age and BMI did not persist as significant predictors in matched groups.
**Clinical Implications:** This study demonstrates that preoperative frailty assessment using tools like G8, ECOG, and CCI significantly predicts perioperative anemia, transfusion needs, postoperative complications, and prolonged hospitalization in elderly EC patients, whereas age and BMI alone do not. The findings support incorporating standardized frailty screening into routine preoperative workup for older cancer patients. Identifying frail patients could enable targeted prehabilitation programs (nutrition counseling, physiotherapy) and individualized perioperative management to reduce morbidity. Limitations include the retrospective design, moderate sample size (n=153), and lack of validation for the most appropriate tool. Prospective studies are needed to establish standardized frailty assessment and intervention protocols.