Although medical frailty is a concept with a relatively short history, a frail state is clearly associated with poorer health outcomes in the elderly. Therefore, appropriate assessment of elderly patients is necessary to predict the risk of severe peri-treatment morbidities or an unexpected worse outcome when considering treatment for any type of cancer. Several systematic reviews have revealed that appropriate assessment has adequate feasibility and high sensitivity for predicting frailty in elderly patients with cancer. However, the types of assessment used have not always been useful for prediction of adverse outcomes or had high specificity or negative predictive value [73–75]. Therefore, it is possible that the assessment methods presently used to guide therapeutic decision-making may be inadequate for elderly patients with cancer.

Efforts to evaluate the effectiveness of the assessment protocols proposed for elderly patients with ovarian cancer are ongoing. The Modified Frailty Index (mFI) consists of 11 variables derived from the Canadian Study of Health and Aging Frailty Index and was reported to predict morbidities requiring ICU admission in patients scheduled for colectomy (Table 16.1) [76]. The usefulness of the mFI as a predictor of the risk of morbidities has also been investigated in a retrospective study of 6551 patients who were identified in the National Surgical Quality Improvement Program data for 2008–2011 as having undergone surgery for gynecologic cancer (although the exact number with ovarian cancer was not reported) [77]. One hundred and eighty-eight (2.9%) of these women developed life-threatening complications requiring management in ICU or resulting in death within 30 days postoperatively. The complication rates were 2, 2.7, 4.4, 7.4, and 24.4% for mFI scores of 0, 1, 2, 3, and ≥4, respectively, and were significantly higher in patients with a score ≥ 3 than those with a score ≤ 2 (P < 0.001). In multivariate analysis, significant predictors of severe complications were a preoperative albumin level < 3 g/dl (OR 6.5, 95% CI 4.31–9.96), longer operating time (OR 1.003 per minute increase, 95% CI 1.001–1.004), non-laparoscopic surgery (OR 3.3, 95% CI 1.56–8.83), and an mFI score ≥ 2 (score 2, OR 1.91, 95% CI 1.17–3.11; score 3, OR 2.33, 95% CI 1.05–5.19; score ≥ 4, OR 12.5, 95% CI 4.77–32.76). When the women were categorized as low-risk and high-risk groups on the basis of a preoperative albumin level ≤ 3 g/dl and/or an mFI score ≥ 4, the high-risk group showed a higher (≥10%) rate of severe perioperative complications when compared with the low-risk group (≤10%). The authors concluded that the mFI criteria could identify patients with gynecologic malignancy who were at high risk for perioperative complications that require management in ICU or are fatal.

An ovarian cancer-specific investigation has since been performed for 751 patients aged ≥65 years identified in the National Surgical Quality Improvement Program database as having undergone PCS between 2005 and 2016 [78]. One hundred and twenty-three (16.4%) of these patients encountered complications of the same level of severity as those described in the previous report [77]. A number of variables, including patient demographics (age, body mass index, race), preoperative laboratory values (creatinine, hematocrit, platelet count, white blood cell count, albumin), and comorbidities (hypertension, cigarette smoking, diabetes, chronic obstructive pulmonary disease, history of cerebrovascular accident, myocardial infarction within the previous 6 months, history of transient ischemic attack), were compared between patients with and without severe morbidities. Eight variables identified to be significant were chosen for a model to predict the probability of postoperative complications in patients aged ≥65 years undergoing PCS for ovarian cancer (Table.16.2). The variables chosen for the proposed predictive model were ascites (present or absent), current smoking (yes or no), race (white vs. nonwhite), preoperative creatinine (≥1.5 mg/dL or <1.5 mg/dL), preoperative platelet count (≥450 × 10⁹/L or <450 × 10⁹/L), preoperative hematocrit (≥30% or <30%), preoperative white blood cell count (≥10 × 10⁹/L or <10 × 10⁹/L), and preoperative albumin (≥3.5 g/dL or <3.5 g/dL). The area under the receiver-operating characteristic curve for the model was 0.725, indicating fair (not poor but not good) performance. This model could predict a 35% probability of severe postoperative complications with 21.8% sensitivity and 92.6% specificity. When the threshold of prediction was decreased to 50% probability, the sensitivity decreased to 9.8% although specificity increased to 98.0%. These findings indicate that preoperative evaluation to identify patients with the highest risk of severe postoperative complications is not easy. However, the high specificity of this model means that patients who can undergo PCS safely could be identified, including those who are elderly.

A GINECO study has reported a comprehensive geriatric assessment tool that can predict the risk of severe treatment-related toxicities in elderly patients with ovarian cancer [23]. Based on their study findings, the authors devised a geriatric vulnerability score (GVS), calculated from five criteria, namely, a low activities of daily living score (<6), a low instrumental activities of daily living score (<25), hypoalbuminemia (<3.5 g/dL), lymphopenia at inclusion (<1 × 10⁹/L), and a high Hospital Anxiety and Depression Scale score (>14). GVS is sum of these variables of each patient. The patients aged ≥70 years with ovarian cancer were separated into two groups using a cutoff point of 3. Patients with a GVS ≥3 were significantly less likely to complete their planned chemotherapy than those with a GVS <3 (OR 0.41, 95% CI 0.17–0.99; P = 0.044) and were significantly more likely to have more severe (grade ≥ 3) non-hematologic toxicities (OR 4.40; 95% CI 1.92–10.08; P = 0.0002), more serious adverse events (OR 2.79, 95% CI 1.27–6.11; P = 0.009), and more unplanned hospital admissions (OR 2.57, 95% CI 1.17–5.63; P = 0.017) [79]. Since the chemotherapy administered in this study was carboplatin alone, further investigation is needed to evaluate the predictive accuracy of the GVS in elderly patients with ovarian cancer who receive combination chemotherapy with a taxane and a platinum agent.