Frailty and long-term survival among patients in Australian intensive care units with metastatic cancer (FRAIL-CANCER study): a retrospective registry-based cohort study

Background Recent advances in cancer therapeutics have improved outcomes, resulting in increasing candidacy of patients with metastatic cancer being admitted to intensive care units (ICUs). A large proportion of patients also have frailty, predisposing them to poor outcomes, yet the literature reporting on this is scarce. We aimed to assess the impact of frailty on survival in patients with metastatic cancer admitted to the ICU.Methods In this retrospective registry-based cohort study, we used data from the Australia and New Zealand Intensive Care Society Adult Patient (age >= 16 years) database to identify patients with advanced (solid and haematological cancer) and a documented Clinical Frailty scale (CFS) admitted to 166 Australian ICUs. Patients without metastatic cancer were excluded. We analysed the effect of frailty (CFS 5-8) on long-term survival, and how this effect changed in specific subgroups (cancer subtypes, age [<65 years or >= 65 years], and those who survived hospitalisation). Because estimates tend to cluster within centres and vary between them, we used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty on survival time up to 4 years after ICU admission between groups.Findings Between Jan 1, 2018, and March 31, 2022, 30 026 patients were eligible, and after exclusions 21 174 patients were included in the analysis; of these, 6806 (32<middle dot>1%) had frailty, and 11 662 (55<middle dot>1%) were male, 9489 (44<middle dot>8%) were female, and 23 (0<middle dot>1%) were intersex or self-reported indeterminate sex. The overall survival was lower for patients with frailty at 4 years compared with patients without frailty (29<middle dot>5% vs 10<middle dot>9%; p<0<middle dot>0001). Frailty was associated with shorter 4-year survival times (adjusted hazard ratio 1<middle dot>52 [95% CI 1<middle dot>43-1<middle dot>60]), and this effect was seen across all cancer subtypes. Frailty was associated with shorter survival times in patients younger than 65 years (1<middle dot>66 [1<middle dot>51-1<middle dot>83]) and aged 65 years or older (1<middle dot>40 [1<middle dot>38-1<middle dot>56]), but its effects were larger in patients younger than 65 years (p(interaction)<0<middle dot>0001). Frailty was also associated with shorter survival times in patients who survived hospitalisation (1<middle dot>49 [1<middle dot>40-1<middle dot>59]).Interpretation In patients with metastatic cancer admitted to the ICU, frailty was associated with poorer long-term survival. Patients with frailty might benefit from a goal-concordant time-limited trial in the ICU and will need suitable post-intensive care supportive management.Copyright (c) 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license.