FARGO is a prospective cohort study that aims to determine the performance of preoperative frailty assessment based on the Frailty Phenotype (FP), compared to a perioperative cardiovascular risk assessment based on the combination of preoperative Revised Cardiac Risk Index (RCRI), age and occurrence of myocardial injury after noncardiac surgery (MINS), in predicting the composite of all-cause death or new disability at 6 months after surgery in patients aged 55 or older. Patients will have confirmed or suspected gynecologic cancer, undergoing cytoreductive or high-risk surgery with or without chemotherapy.
Little is known about how to best predict postoperative outcomes, recovery from complications, and chemotherapy tolerance in an increasingly older and medically complex GO population. Measuring frailty may represent a comprehensive tool for risk prediction. The study 1) will help fill the current gap in knowledge; 2) will translate into clinical practice changes both locally, and when replicated in a larger multi-centre study, elsewhere in Canada and worldwide; and 3) will inform future studies on shared decision-making strategies and interventions. By evaluating the role of frailty as a static or dynamic predictor of patient important outcomes, and by considering the complexity of these patients and also of their treatment trajectories, the study has the potential to fill those gaps and influence how care is delivered. By involving stakeholders in the evaluation of feasibility and acceptability of frailty assessment, this will inform a change in care that is sustainable, innovative, and patient-centred. There have been substantial knowledge advancements about perioperative risk factors and the long-term impact of postoperative complications; however, oncology patients and patient-reported outcomes have been insufficiently studied. There is increased literature on frailty assessment in noncardiac surgery; however, studies that included GO patients are few and of low-quality. The study will overcome the limitations of the current knowledge and practice, and will potentially change healthcare delivery.
Study Type
OBSERVATIONAL
Enrollment
280
A way to summarize the overall level of fitness or frailty of an older adult after they had been evaluated by an experienced clinician
Defined by the presence of three from the following five clinical features: weakness, slow walking speed, unintentional weight loss, exhaustion, and low physical activity
Juravinksi Hospital
Hamilton, Ontario, Canada
RECRUITINGCredit Valley Hospital
Mississauga, Ontario, Canada
RECRUITINGSunnybrook
Toronto, Ontario, Canada
RECRUITINGUniversity Health Network
Toronto, Ontario, Canada
RECRUITINGAll-cause death or new disability at 6 months
Disability status is determined using the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0). New disability at any time point is based according to the following criteria that account for baseline disability scores: 1. For individuals with a disability score of \<25% at baseline, new disability is defined as a disability score ≥25% at follow-up; 2. For individuals with a disability score ≥25%, new disability is defined an increase in disability score of ≥8%. Vascular death is defined as any death with a vascular cause and includes those deaths following a myocardial infarction, cardiac arrest, stroke, cardiac revascularization procedure (i.e., percutaneous coronary intervention \[PCI\] or coronary artery bypass graft \[CABG\] surgery), pulmonary embolus, hemorrhage, or deaths due to an unknown cause. Non-vascular death is defined as any death due to a clearly documented non-vascular cause (e.g. trauma, infection, malignancy).
Time frame: 6 months
All cause death
Vascular death is defined as any death with a vascular cause and includes those deaths following a myocardial infarction, cardiac arrest, stroke, cardiac revascularization procedure (i.e., percutaneous coronary intervention \[PCI\] or coronary artery bypass graft \[CABG\] surgery), pulmonary embolus, hemorrhage, or deaths due to an unknown cause. Non-vascular death is defined as any death due to a clearly documented non-vascular cause (e.g., trauma, infection, malignancy).
Time frame: 28 days and 1 year
Oncologic Outcomes: Progression Free Survival (PFS)
PFS, defined as the time from treatment initiation to tumor progression or recurrence or death from any cause, or to the date of censoring at the last time the subject was known to be alive. Cancer progression/recurrence will be defined as a measurable progression/recurrence documented on imaging.
Time frame: at 6 and 12 months
Oncologic Outcomes: Cancer-specific death
Cancer-specific death is death directly attributable to the primary gynecological cancer or directly related to its treatment, in the absence of other causes of death.
Time frame: at 6 and 12 months
New Disability
Disability status is determined using the 12-item World Health Organization Disability Assessment Schedule (WHODAS 2.0). New disability at any time point is based according to the following criteria that account for baseline disability scores: 1. For individuals with a disability score of \<25% at baseline, new disability is defined as a disability score ≥25% at follow-up; 2. For individuals with a disability score ≥25%, new disability is defined an increase in disability score of ≥8%. Definition of new disability at 28 days, 6 months, and 1 year after surgery will use as baseline disability score the WHODAS 2.0 score measured before surgery.
Time frame: 28 days, 6 months and 1 year after surgery
Major vascular complications
defined as a composite of vascular death, and non-fatal myocardial infarction (or myocardial injury for the 28-day time point), stroke, symptomatic proximal venous thromboembolism, and cardiac arrest
Time frame: at 28 days, 6 months, and 1 year after surgery
Infection, and infection with sepsis
Infection is defined as a pathologic process caused by the invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic organisms. The Third International Consensus Definitions Task Force defines sepsis as a "life-threatening organ dysfunction due to a dysregulated host response to infection." Based on the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria, sepsis will require a quick Sequential Organ Failure Assessment (qSOFA) Score ≥2 points due to infection. The qSOFA includes the following items and scoring system: 1. Altered mental status (1 point) 2. systolic blood pressure of 100 mm Hg or less (1 point), and 3. respiratory rate of 22 breaths/min or more (1 point).
Time frame: at 28 days, 6 months, and 1 year after surgery
In-hospital delirium
Delirium during the first 3 days after surgery or before discharge from the hospital, based on Confusion Assessment Method (CAM). According to CAM, patients are diagnosed with delirium if they meet the first 2 criteria (acute onset with fluctuating course, AND attention deficit), and at least one of the second 2 criteria (disorganized thinking OR altered level of consciousness). Participants will be screened for postoperative delirium while in hospital, twice daily, during the first 3 days after surgery or until discharge (if before 3 days), by research personnel, using the 3D-CAM, or the CAM-ICU any time the participants are in the PACU or in ICU
Time frame: During the index hospital admission for surgery up to the first 3 days after surgery or before discharge from hospital
Bleeding Independently Associated with Mortality after noncardiac Surgery
BIMS is a bleeding meeting any of the following 3 criteria: 1. Leading to a postoperative hemoglobin \<70 g/L 2. Requiring transfusion of one or more units of red blood cells 3. Judged to be the immediate cause of death
Time frame: 28 days after surgery
Acute congestive heart failure
The definition of congestive heart failure requires at least one of the following clinical signs (i.e. any of the following signs: elevated jugular venous pressure, respiratory rales/crackles, crepitations, or presence of S3) and at least one of the following: 1. Radiographic findings (i.e., vascular redistribution, interstitial pulmonary edema, or frank alveolar pulmonary edema) OR 2. Heart failure treatment implemented with diuretics with documented clinical improvement.
Time frame: 28 days after surgery, 6 months and 1 year after surgery
Unplanned admission to ICU
admission to the ICU that was not planned
Time frame: during index hospitalization for surgery
New clinically important atrial fibrillation
The definition of new clinically important atrial fibrillation requires the documentation of atrial fibrillation or atrial flutter of any duration on an ECG or rhythm strip, which results in angina congestive heart failure, symptomatic hypotension, or requires treatment with a rate controlling drug, antiarrhythmic drug, or electrical cardioversion.
Time frame: 28 days after surgery, 6 months and 1 year after surgery
Length of stay
time spent in hospital immediately after surgery
Time frame: during index hospitalization for surgery
Chemotherapy-related outcomes: total dose received
This will be measured at the end of any chemotherapy treatment when considered terminated: Total dose received, defined as Relative Dose Intensity (RDI), as calculated as the percentage of the standard dose that was administered
Time frame: Before Surgery, 6-months post-surgery
Chemotherapy-related outcomes: time to completion of all chemotherapy cycles
This will be measured at the end of any chemotherapy treatment when considered terminated: Time to completion of all chemotherapy cycles (number of days)
Time frame: Before Surgery, 6-months post-surgery
Chemotherapy-related outcomes: patient's decisional regret
This will be measured at the end of any chemotherapy treatment when considered terminated: Patient's decisional regret, defined as "distress or remorse after a (health care) decision," assessed using the Decisional Regret scale, a validated a 5-item scale
Time frame: Before Surgery, 6-months post-surgery
Chemotherapy-related outcomes: Change in health-related function or well-being
This will be measured at the end of any chemotherapy treatment when considered terminated: Change in health-related function or well-being, defined as the difference in WHODAS 2.0 score after chemotherapy compared to before chemotherapy.
Time frame: Before Surgery, 6-months post-surgery
Chemotherapy-related outcomes
This will be measured at the end of any chemotherapy treatment when considered terminated: Change in health-related quality of life, defined as the difference in FACT-G7 score after chemotherapy compared to before chemotherapy.
Time frame: Before Surgery, 6-months post-surgery
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