Associations of a claims-based frailty index with perioperative outcomes and survival among older adults undergoing radical cystectomy for bladder cancer

Boris Gershman; John Ernandez; Sumedh Kaul; Agustin Perez-Londoño; Aaron Fleishman; Ruslan Korets; Peter Chang; Andrew A Wagner; Simon Kim; Joaquim Bellmunt; Nima Aghdam; Ellen P McCarthy; Dae Hyun Kim; Aria F Olumi

doi:10.1016/j.urolonc.2025.04.009

Associations of a claims-based frailty index with perioperative outcomes and survival among older adults undergoing radical cystectomy for bladder cancer

Urol Oncol. 2025 May 27:S1078-1439(25)00168-1. doi: 10.1016/j.urolonc.2025.04.009. Online ahead of print.

Authors

Affiliations

¹ Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA. Electronic address: bgershma@bidmc.harvard.edu.
² Department of Urology, Brigham and Womens Hospital, Boston, MA.
³ Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
⁴ Division of Urologic Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
⁵ Urology Associates, Colorado Springs, CO, USA.
⁶ Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA.
⁷ Department of Radiation Oncology, Beth Israel Deaconess Medical Center, Boston, MA.
⁸ Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA; Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.

PMID: 40436688
DOI: 10.1016/j.urolonc.2025.04.009

Abstract

Objective: Frailty is increasingly recognized as an important component of geriatric assessment in older adults and an important predictor of clinical outcomes. Bladder cancer (BC) is a potentially lethal disease, and treatments like radical cystectomy (RC) are associated with high rates of morbidity. We examined the associations of baseline frailty with perioperative outcomes and survival in a population-based cohort of older adults undergoing RC.

Materials and methods: We identified older adults aged 66 to 89 years with Tany Nany cM0 urothelial carcinoma of the bladder who underwent RC from 2000 to 2017 in SEER-Medicare. Baseline frailty was assessed using the claims-based frailty index (CFI), a validated deficit accumulation frailty measure, within the 12-months preceding surgery. The associations of CFI with perioperative outcomes and survival were evaluated using multivariable regression models.

Results: A total of 6,041 patients were included in the study cohort, including 2,640 (44%) who were robust (CFI <0.15), 2,980 (49%) who were prefrail (CFI 0.15-<0.25), and 421 (7%) who were mildly to severely frail (CFI ≥0.25). Increasing CFI was associated with statistically significantly higher rates of prolonged hospitalization, 90-day emergency department utilization, 90-day complications, and 90-day hospital readmission, and fewer healthy days at home (HDAH). CFI remained independently associated with an increased risk of perioperative outcomes and worse mortality in multivariable regression models.

Conclusions: In a national, contemporary cohort of older adults with BC undergoing RC, increasing frailty was independently associated with a higher risk of perioperative morbidity, fewer HDAH, and worse mortality. The CFI provides an objective assessment to improve decision-making in older adults with bladder cancer.

Keywords: Bladder cancer; Cystectomy; Frail Elderly; Insurance claims.