Jamie N. Bakkum-Gamez, MD
The invited discussant of the studies, Jamie N. Bakkum-Gamez, MD, Professor of Obstetrics and Gynecology and Co-Lead of the Women’s Cancer Program at Mayo Clinic Cancer Center, Rochester, Minnesota, first reminded attendees of the scope of the problem: an estimated 40% or so of women slated for surgery for ovarian cancer can be classified as frail. This problem will only worsen as the population ages, she said.
“Frailty syndrome” has been established as a medical syndrome with multiple causes and contributors. It is characterized by diminished strength and endurance and reduced physiologic function, all of which increase one’s vulnerability to developing increased dependency and death.
Formal Assessment Tools
“Sometimes it’s quite clear, and sometimes it’s not,” therefore, formal assessments are important, Dr. Bakkum-Gamez noted. Instruments vary between those that are simple to use in the clinic and others that are complex algorithms fitting for research.
The 10-item Modified Frailty Index used in the study by Handley et al can be quickly applied in the clinical setting to calculate the degree of frailty.1 The Johns Hopkins Adjusted Clinical Groups frailty-defining indicator in the study by Nakhla et al is a curated analytic system developed by statisticians, economists, and providers that uses existing data to predict outcomes.2
“Theseapproaches are clearly diverse to the same question, and they both shed light on the impact of frailty syndrome,” Dr. Bakkum-Gamez said. Using these tools, the researchers were able to quantify the problem: frail patients had a doubling in complications and a tripling in the risk of dying postoperatively, among other adverse outcomes.
“But additionally and critically,” she added, although these and other instruments may identify individuals with frailty syndrome, they are less useful in informing clinical practice and identifying interventions. Better assessment tools—validated and standardized across practices—and effective interventions are needed for this unique patient population, she said.
Prioritizing the Patient’s Voice
“In ovarian cancer, we are in this as a team, and that includes the patient,” she emphasized. “As we navigate the much-needed novel ways to treat this medical syndrome, it’s imperative to listen to the voice of [patients]…to understand their support system going into discussions about surgery (and oncology care in general), and [to use] objective data to guide individualized management.”
“Sometimes shared decision-making means deciding not to operate,” Dr. Bakkum-Gamez added. “This is among the hardest decisions for a surgeon. We know when we make the wrong decision in operating—if the patient experiences a life-shortening complication—but it’s less clear to know if we make the wrong decision by not operating.”
DISCLOSURE: Dr. Bakkum-Gamez reported no conflicts of interest.
