Frailty and days at home in the year after surgery for ovarian cancer: A patient centered outcome for older adults.

Abstract

e13843 Background: Ovarian cancer debulking surgery is associated with improved survival but also with significant perioperative morbidity. Days at home (DAH) is a novel measure that reflects what many older adults value: being alive, returning home, and limiting facility stays, and is associated with self-rated quality of life. We evaluated the association between frailty and DAH one year after ovarian cancer surgery and determined modifiable predictors of low DAH to guide surgical decision-making in older adults with ovarian cancer. Methods: This population-based cohort study of fee-for-service Medicare beneficiaries receiving surgery for ovarian cancer between 2014-2019 examined associations between a frailty and DAH in the year after surgery. Frailty was identified using a validated claims-based frailty index (CFI) and patients were categorized as robust (CFI < 0.15), pre-frail (CFI 0.15 to < 0.25), and frail (CFI > = 0.25). DAH were calculated by subtracting hospital (inpatient, emergency department, and observation days), nursing home (long-term hospital, skilled nursing, and rehab facility days), and death days (days not alive in the year after surgery) from 365. Outcomes were stratified by frailty and age. A multivariate linear regression of DAH with patient and surgical covariates was performed. Results: Among 7,348 patients (mean [SD] age 74.1 [6.0] years), 44.0% were robust, 49.8% pre-frail, and 6.2% frail. The mean [SD] DAH for all patients was 322.6 [89.4] days; frail patients had significantly fewer DAH (269.0 [126.0]) as did pre-frail (314.5 [96.3]), compared with robust patients (330.4 [68.2]) (p < 0.001). Stratification by age and frailty indicated robust oldest (> = 80 years old) patients had more DAH than frail younger (< 70 years old) counterparts (329.6 [78.7] vs 274.5 [117.4]). Long-term mortality after 90 days contributed to loss in DAH in death days (25.7 [73.1]) rather than hospital (3.2 [7.9]) and nursing home days (1.7 [10.7]). Before 90-days, most DAH were lost to hospital (6.5 [8.0)] and nursing home (2.7 [9.2]) days rather than death (2.5 [12.4]). One year mortality rates were highest in frail patients (27.8%) and lowest in robust patients (8.8%). In adjusted models, frailty was the strongest predictor of fewer DAH (-51.8), followed by high-risk procedures (-29.9), and surgery without chemotherapy (-23.2); minimally invasive surgery was associated with an increase in DAH (+28.4 days, p < 0.001 all). Conclusions: Cancer-directed surgery in older adults is a high-stakes decision with limited data to guide surgical decision-making. In this study, frailty was the greatest predictor of fewer DAH, suggesting that frailty, above usual metrics of age and comorbidities, should be incorporated into surgical decision-making. Future studies should examine whether counseling older adults about outcomes beyond 90-days and tailoring surgical approaches to minimize surgical stress results in more personalized patient-centered surgical care.