Identifying the frail kidney cancer patient

Identifying the frail kidney cancer patient

The first day of EMUC18 came to a close with a session on kidney cancer, specifically on the frailty of renal cancer patients. Dr. Umberto Capitanio (Milan, IT) gave a talk on the definitions of frailty, and the ways that the treating urologist could identify their patients as such.

Dr. Capitanio was upfront about his inexperience on the subject: “I am not a geriatrician but a urologist. Before preparing this presentation, I was not used to assessing the frailty of patients. This is my take, as a urologist, on why frailty is an important factor in RCC, and how it ought to impact our decision-making.”

A small audience survey revealed that a majority had some idea of the definition of frailty, but did not routinely assess the frailty of their patients. This made the talk all the more useful for the urologists and oncologists present.

Definition and implications for treatment

In its broadest sense, Capitanio defined patient frailty as a state of reduced resilience and increased vulnerability and also one in which minor events can trigger disproportionate adverse outcomes. “Frailty is related to, but distinct from ageing, comorbidity and disability.” Capitanio identified two main theoretical concepts of frailty: the frailty phenotype and the accumulation of deficits.

The frailty phenotype is based on five criteria: shrinking (weight loss), weakness (declining grip strength), self-reported fatigue, a decrease in walking speed and self-reported low activity.

The “accumulation” model sees an increase of deficits as people age, with a variety of symptoms collecting in a patient over time. The rate and the deficits will vary between people. The frailty index will count these deficits and generate a score.

There is a variety of ways to establish frailty, some based on measurements. There is also a quicker way that a urologist or oncologist might first identify the characteristics of frailty: “You might be familiar with the Geriatric 8 (G8) screening tool. This survey takes mere minutes to fill out, offering a score between 0 and 17. The EAU PCa Guidelines, for example, use anything below 14 as the cut-off point, requiring a simplified geriatric evaluation.”

Capitanio also pointed to developments in the use of imaging as an objective way to measure frailty. “Cross-sectional imaging can be used to identify lean-muscle cross-sectional surface area in screening for sarcopenia or several skeletal muscle wasting.”

Frailty of the patient has direct implications when it comes to RCC treatment. For instance, frailty means that the toxic effects of treatment are greater, and adverse events are more dangerous. Frail patients may also be less willing to accept the toxic side effects of their treatment.

“A correct evaluation and management can avoid minor events triggering adverse outcomes,” Capitanio concluded. “A baseline evaluation of frailty is mandatory in RCC, especially in elderly patients. Always consider referring the patient to a geriatrician once frailty is identified.”