Preoperative assessment using the five-factor modified frailty index: A call for standardized preoperative assessment and prehabilitation services in gynecologic oncology


      • The 5 factor mFI is a simple tool for perioperative assessment of frailty in gynecologic cancer patients.
      • Older age, African American race, laparoscopic surgery and obesity are associated with higher mFI score.
      • Patients with higher 5-factor mFI score account for the majority of readmissions and 30-day complications.



      To evaluate if the 5-factor modified frailty index (mFI) is associated with postoperative complications, readmissions or non-home discharge in gynecologic cancer patients undergoing surgery.


      Patients with a diagnosis of gynecologic cancer (cervical, uterine, or ovarian cancer) who underwent surgery between 2014 and 2018 were identified through the National Surgical Quality Improvement Program (NSQIP) database. The 5-factor mFI was applied and patients classified into 6 categories (mFI groups 0,1,2, 3, 4 and 5). The incidence of 30-day complications, readmissions and non-home discharge was evaluated. Multivariable logistic regression models were used to determine the association between mFI category and readmissions/ complications. Adjusted probabilities of events were calculated based on patient characteristics.


      At total of 31,181 gynecologic cancer cases were included in the analysis: N = 2968 (9.4%) cervical, N = 20,862 (66.4%) uterine, and N = 7351 (23.4%) ovarian cancers. Of all patients, 46.1% were in category 0, 36.5% category 1, and 1% category 3–5. Factors associated with increased mFI included older age, African American race, laparoscopic surgery and obesity. A significant dose-response relationship between higher mFI and readmission and 30-day complications was noted on adjusted multivariable analysis (adjusted OR 2.37 (1.65–3.45) and 2.10 (1.59–2.75) for readmissions and complications, respectively, in mFI category 3–5). These associations were consistent within each cancer type.


      The 5-factor mFI universally predicts postoperative readmissions, 30-day complications and non-home discharge in patients with gynecologic cancer. Incorporation of mFI into routine preoperative assessment can identify patients for non-surgical treatments, prehabiliatation and short term home assessments.


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        • Clegg A.
        • Young J.
        • Iliffe S.
        • Rikkert M.O.
        • Rockwood K.
        Frailty in elderly people.
        Lancet. 2013; 381: 752-762
        • Cesari M.
        • Gambassi G.
        • Abellan van Kan G.
        • Vellas B.
        The frailty phenotype and the frailty index: different instruments for different purposes.
        Age Ageing. 2014; 43: 10-12
        • Makary M.A.
        • et al.
        Frailty as a predictor of surgical outcomes in older patients.
        J. Am. Coll. Surg. 2010; 210: 901-908
        • Kumar A.
        • et al.
        Inflammatory and nutritional serum markers as predictors of peri-operative morbidity and survival in ovarian cancer.
        Anticancer Res. 2017; 37: 3673-3677
        • Shinall M.C.
        • et al.
        Association of preoperative patient frailty and operative stress with postoperative mortality.
        JAMA Surg. 2020; 155e194620
        • Partridge J.S.L.
        • Harari D.
        • Dhesi J.K.
        Frailty in the older surgical patient: a review.
        Age Ageing. 2012; 41: 142-147
        • de Arruda F.N.
        • et al.
        Determinants of health-related quality of life in elderly ovarian cancer patients: the role of frailty and dependence.
        Gynecol. Oncol. 2019; 153: 610-615
        • Di Donato V.
        • et al.
        Preoperative frailty assessment in patients undergoing gynecologic oncology surgery: a systematic review.
        Gynecol. Oncol. 2021; 161: 11-19
        • Geessink N.
        • et al.
        Frailty and quality of life among older people with and without a cancer diagnosis: findings from TOPICS-MDS.
        PLoS One. 2017; 12e0189648
        • Wilkes J.G.
        • et al.
        Frailty cost: economic impact of frailty in the elective surgical patient.
        J. Am. Coll. Surg. 2019;
        • Decoster L.
        • et al.
        Screening tools for multidimensional health problems warranting a geriatric assessment in older cancer patients: an update on SIOG recommendations†.
        Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. 2015; 26: 288-300
        • Rockwood K.
        • Andrew M.
        • Mitnitski A.
        A comparison of two approaches to measuring frailty in elderly people.
        J. Gerontol. A Biol. Sci. Med. Sci. 2007; 62: 738-743
        • Hall D.E.
        • et al.
        Development and initial validation of the risk analysis index for measuring frailty in surgical populations.
        JAMA Surg. 2017; 152: 175-182
        • Wildiers H.
        • et al.
        International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer.
        J. Clin. Oncol. 2014; 32: 2595-2603
        • Subramaniam S.
        • Aalberg J.J.
        • Soriano R.P.
        • Divino C.M.
        New 5-factor modified frailty index using American College of Surgeons NSQIP data.
        J. Am. Coll. Surg. 2018; 226: 173-181.e8
        • Kumar A.
        • et al.
        Functional not chronologic age: frailty index predicts outcomes in advanced ovarian cancer.
        Gynecol. Oncol. 2017; 147: 104-109
        • Sia T.Y.
        • Wen T.
        • Cham S.
        • Friedman A.M.
        • Wright J.D.
        Effect of frailty on postoperative readmissions and cost of care for ovarian cancer.
        Gynecol. Oncol. 2020; 159: 426-433
        • Yao T.
        • et al.
        Frailty in ovarian cancer identified the need for increased postoperative care requirements following cytoreductive surgery.
        Gynecol. Oncol. 2019; 153: 68-73
        • Tewari K.S.
        • Java J.J.
        • Eskander R.N.
        • Monk B.J.
        • Burger R.A.
        Early initiation of chemotherapy following complete resection of advanced ovarian cancer associated with improved survival: NRG Oncology/Gynecologic Oncology Group study.
        Ann. Oncol. Off. J. Eur. Soc. Med. Oncol. 2016; 27: 114-121
        • Narasimhulu D.M.
        • et al.
        Frailty is a determinant of suboptimal chemotherapy in women with advanced ovarian cancer.
        Gynecol. Oncol. 2020; 158: 646-652
        • Adedayo P.
        • Resnick K.
        • Singh S.
        Preoperative frailty is a risk factor for non-home discharge in patients undergoing surgery for endometrial cancer.
        J. Geriatr. Oncol. 2018; 9: 513-515
        • Driver J.A.
        • Viswanathan A.N.
        Frailty measure is more predictive of outcomes after curative therapy for endometrial cancer than traditional risk factors in women 60 and older.
        Gynecol. Oncol. 2017; 145: 526-530
        • Mohile S.G.
        • et al.
        Practical assessment and Management of Vulnerabilities in older patients receiving chemotherapy: ASCO guideline for geriatric oncology.
        J. Clin. Oncol. 2018; 36: 2326-2347
        • Dale W.
        • et al.
        How is geriatric assessment used in clinical practice for older adults with Cancer? A survey of Cancer providers by the American Society of Clinical Oncology.
        JCO Oncol. Pract. 2021; 17: 336-344
        • Filippova O.T.
        • et al.
        Geriatric co-management leads to safely performed cytoreductive surgery in older women with advanced stage ovarian cancer treated at a tertiary care cancer center.
        Gynecol. Oncol. 2019; 154: 77-82
        • Carli F.
        • Brown R.
        • Kennepohl S.
        Prehabilitation to enhance postoperative recovery for an octogenarian following robotic-assisted hysterectomy with endometrial cancer.
        Can. J. Anaesth. 2012; 59: 779-784
        • Levett D.Z.H.
        • Edwards M.
        • Grocott M.
        • Mythen M.
        Preparing the patient for surgery to improve outcomes.
        Best Pract. Res. Clin. Anaesthesiol. 2016; 30: 145-157
        • Miralpeix E.
        • Mancebo G.
        • Gayete S.
        • Corcoy M.
        • Solé-Sedeño J.-M.
        Role and impact of multimodal prehabilitation for gynecologic oncology patients in an enhanced recovery after surgery (ERAS) program.
        Int. J. Gynecol. Cancer. 2019; 29: 1235-1243
        • Schneider S.
        • Armbrust R.
        • Spies C.
        • du Bois A.
        • Sehouli J.
        Prehabilitation programs and ERAS protocols in gynecological oncology: a comprehensive review.
        Arch. Gynecol. Obstet. 2020; 301: 315-326