BOSTON – The VA’s Frailty Index (VA-FI) was created to identify patients at high risk of unfavorable outcomes. A new study sought to determine how it works with older patients with non-small cell lung cancer (NSCLC).
Researchers from Massachusetts General Hospital, Harvard Medicine School, the VA Boston Healthcare System and colleges pointed out that veterans with NSCLC are a heterogeneous population and their levels of frailty range widely.
For the report in Cancer Medicine, researchers identified NSCLC patients 65 and older and diagnosed in 2002-2017, using the VA Central Cancer Registry. The studying calculated VA-FI by incorporating administrative codes from VA electronic health records data linked with Medicare and Medicaid data.
The study team looked at the associations between the VA-FI and times of mortality, hospitalization, and emergency room (ER) visits, while also evaluating the change in discrimination and calibration of reference prognostic models after adding VA-FI.
Ultimately, the study identified a cohort of 42,204 older NSCLC VA patients, with 55.5% of them classified as frail (VA-FI >0.2).
“After adjustment, there was a strong association between VA-FI and the risk of mortality (HR = 1.23 for an increase of four deficits or, equivalently, an increase of 0.129 on VA-FI, p < 0.001), hospitalization (HR = 1.16 for four deficits, p < 0.001), and ER visit (HR = 1.18 for four deficits, p < 0.001),” the authors wrote. “Adding VA-FI to baseline prognostic models led to statistically significant improvements in time-dependent area under curves and did not have a strong impact on calibration.”
The study determined that older NSCLC patients with higher VA-FI have notably increased risks of mortality, hospitalizations, and ER visits following diagnosis, concluding, “An electronic frailty index can serve as an accessible tool to identify patients with vulnerabilities to inform clinical care and research.”
As to why the study team assessed NSCLC patients, the authors pointed out that the most common lung cancer has a median age at diagnosis of 70 years and disproportionately affects older patients; those patients have varying functional status, cognitive impairment, and comorbid conditions.
“ Limited evidence is available for guiding care and treatment of older cancer patients due to their under-representation in clinical trials,” researchers advised. “Traditional assessments such as those based on chronological age and performance status may not account for the full range of vulnerabilities experienced by older patients with cancer. In the absence of assessments reflective of their full vulnerabilities, frail patients may be at risk of overtreatment with intensive therapies and fit older patients may be at risk of undertreatment with milder, less efficacious therapies.”
The authors recounted how current guidelines have recommended the adoption of geriatric assessments in older adults with cancer to help address the gap, although that hasn’t occurred because of limitations in time, resources, and geriatrics expertise.
In addition, the study noted that electronic frailty indices have been developed recently to assess physiologic vulnerability based on the cumulative number of health deficits ascertained through electronic health record (EHR) and administrative data.
“Electronic indices cannot fully capture elements of a geriatric assessment (e.g. gait speed),” they pointed out. “However, as these electronic indices depend only on data collected during routine care, they can be automatically computed and implemented at scale. This can facilitate automated screening of vulnerable patients for clinical care, and also retrospective identification of frail patients for research when alternative measures are not widely or consistently recorded.”
- Cheng D, Dumontier C, Sheikh AR, La J, Brophy MT, Do NV, Driver JA, Tuck DP, Fillmore NR. Prognostic value of the veterans affairs frailty index in older patients with non-small cell lung cancer. Cancer Med. 2022 Mar 26. doi: 10.1002/cam4.4658. Epub ahead of print. PMID: 35338613.