Frailty tied to poor emotional health in older patients with advanced cancer

In older patients with advanced cancer, frailty is associated with poorer emotional health, a cluster randomized trial has shown.

A recent review found that increased mortality, postoperative mortality, and chemotherapy intolerance were associated with frailty in older patients with cancer. [Ann Oncol 2015;26:1091-1101] However, there was no discussion on emotional health, thus highlighting the paucity of trials evaluating the link between frailty and emotional health in this patient subgroup.

“Our study expands on this body of literature by describing the association between frailty and depression, anxiety, and distress in older adults with advanced cancer and, to the best of our knowledge, we are the first to describe this relationship,” said the researchers. “[W]e showed that, as frailty increased in older patients with advanced cancer, patients’ symptoms of depression and anxiety worsened, and levels of distress rose.”

The team evaluated 541 patients (mean age 76.6 years, 51 percent male) with incurable stage III/IV solid tumours or lymphomas. Participants were categorized as robust, prefrail, or frail (27, 41, and 32 percent, respectively). Twenty-two percent screened positive for depression, 8 percent screened positive for anxiety, and 36 percent screened positive for distress. [Oncologist 2021;26:e2181-e2191]

As the frailty level increased (robust vs prefrail vs frail), so did the mean scores for depression (1.7 vs 2.6 vs 4.9), anxiety (1.9 vs 2.1 vs 4.6), and distress (1.9 vs 2.7 vs 3.9; p<0.001 for all).

The frailer the participants were (frail vs prefrail vs robust), the more likely they were to screen positive for depression (44 percent vs 14 percent vs 8 percent), anxiety (16 percent vs 5 percent vs 4 percent), and distress (55 percent vs 31 percent vs 20 percent; p<0.001 for all).

Compared with robust participants, prefrail participants were more likely to screen positive for depression (adjusted odds ratio [aOR], 2.2) and distress (aOR, 1.7; p<0.05 for both), as were frail participants (aORs, 12.8 and 4.6, respectively; p<0.001 for both). The likelihood of screening positive for anxiety was also greater among frail vs robust participants (aOR, 6.6; p<0.001).

“[These findings imply that] the frailer a patient becomes, the greater the effect on mental health, and the less likely patients may be to engage in activities that reduce frailty, thus leading to worsened mental health,” the researchers explained. “Understanding these pathways or cycles would provide a foundation for refining and adapting both mental health and frailty interventions, and perhaps combining interventions that might specifically be applied to older patients with advanced cancer at increased risk of frailty.”

Integrated care approach

“Overall, the [findings] indicate a need for an integrated care approach to treating older patients with cancer,” said the researchers. “Including mental health in screening, assessing, and coordinating healthcare could have implications for mitigating the progression of frailty and improving the overall quality of life for these individuals.” 

“Our study also underscores the need for a multidisciplinary approach when treating older adults with cancer,” they added. Oncologists are encouraged to consider the aid of other specialists (eg, geriatricians, psychiatrists, psychologists, social workers, physical therapists) to facilitate an integrative approach geared towards improving the emotional health and frailty in older patients with advanced cancer. [J Clin Oncol 2020;38:885-904]

Further exploration is warranted to identify interventions that can effectively address frailty in this setting. “[I]dentifying areas of frailty can prompt screening for emotional health and guide delivery of appropriate interventions … Future studies should build upon [the current] findings to identify specific pathways between frailty and depression, anxiety, and distress,” said the researchers.