Frailty in Older Cancer Survivors: A Literature Review

Background/Purpose: Frailty is a multi-dimensional syndrome characterized by decreased physiologic reserve that results in increased vulnerability to stressors and adverse health outcomes. It has been hypothesized that cancer treatment is associated with accelerated aging and frailty; yet frailty in older cancer survivors is not well understood. The purpose of this literature review was to examine the nature and impact of frailty in this population.

Methods: We conducted a comprehensive search using CINAHL, PubMed, EMBASE, Psych INFO, and Proquest. Search terms included: cancer or neoplasms, cancer survivors, older adult, elderly, aged, frail elderly, frail and frail elder. Reference lists of retrieved articles were manually reviewed for additional articles. Included studies were published between 1990-2015, had a study population of older adults with a history of adult cancer, and frailty assessed as a primary or secondary outcome. Study designs could be randomized controlled trials or prospective or retrospective cohort studies. Review articles, case reports, editorials, and doctoral dissertations were excluded. Studies of patients currently receiving or planning to receive cancer treatment or survivors of childhood cancer were also excluded. Three research team members independently assessed the abstracts and identified articles meeting the inclusion and exclusion criteria. An evidence table detailing key study components was compiled.

Results: The initial search resulted in 70 titles and abstracts; 46 abstracts were retained after eliminating duplicates. Six studies meeting criteria were included in the review. The studies utilized prospective (n=5) and retrospective (n=1) designs and were conducted in community-based populations. The sample sizes ranged from 91 to 12,480 (2349 [18.8%] participating in this study had a history of cancer). Ages ranged from 53 to 95 years old, with average ages > 65 years. Frailty was measured using components of the Frailty Phenotype (n=3), Balducci Criteria (n=2), and Comprehensive Geriatric Assessment (n=1). The prevalence of frailty in patients with a history of cancer ranged from 13% to 29.2%. The prevalence of pre-frailty was up to 50%. In one study, older breast cancer survivors exhibited more frailty at a younger age than women in a population-based study (18%; 3%). In another, individuals with a cancer history had a higher prevalence of ADL limitations (31.9%; 26.9%), IADL limitations (49.5%; 42.3%), geriatric syndromes (60.8%; 53.9%), and vulnerability (45.8%; 39.5%). In a third, older cancer survivors who were frail had a greater risk of premature mortality than those who were non-frail (HR=2.79; 95% CI=1.34-5.81).

Conclusions: The effect of cancer and cancer treatment on the development of frailty in older adults is not well studied. Scant data indicate that a history of cancer is associated with increased prevalence of frailty, ADL/IADL limitations, presence of geriatric syndromes, and vulnerability. Frailty in older cancer survivors is also associated with increased risk of premature mortality.

Implications for Practice/Research: Studies on frailty in older adults with a history of cancer are limited. More research utilizing rigorous methods and standardized measures is needed. Implementation of screening and targeted interventions could minimize frailty, decrease disability, enhance quality of life, and improve survival in older cancer survivors.