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Comparing the association between multiple chronic conditions, multimorbidity, frailty, and survival among older patients with cancer

  • Wyatt P. Bensken
    Correspondence
    Corresponding author at: Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America.
    Affiliations
    Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America

    Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States of America
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  • Nicholas K. Schiltz
    Affiliations
    Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America

    Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, United States of America
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  • David F. Warner
    Affiliations
    Department of Sociology, University of Alabama at Birmingham, Birmingham, AL, United States of America

    Center for Family & Demographic Research, Bowling Green State University, Bowling Green, OH, United States of America
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  • Dae H. Kim
    Affiliations
    Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, United States of America

    Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America
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  • Melissa Y. Wei
    Affiliations
    Division of General Internal Medicine and Health Services Research, Department of Internal Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States of America

    Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, CA, United States of America
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  • Ana R. Quiñones
    Affiliations
    Department of Family Medicine, Oregon Health & Science University, Portland, OR, United States of America

    OHSU-PSU School of Public Health, Oregon Health & Science University, Portland, OR, United States of America
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  • Vanessa P. Ho
    Affiliations
    Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America

    Department of Surgery, MetroHealth Medical Center, Cleveland, OH, United States of America
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  • Amy S. Kelley
    Affiliations
    Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
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  • Cynthia Owusu
    Affiliations
    Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States of America

    Division of Hematology/Oncology, Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, OH, United States of America
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  • Erin E. Kent
    Affiliations
    Gillings School of Global Public Health, Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America

    Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
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  • Siran M. Koroukian
    Affiliations
    Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America

    Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States of America
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      Abstract

      Introduction

      The high prevalence of multiple chronic conditions (MCC), multimorbidity, and frailty may affect treatment and outcomes for older adults with cancer. The goal of this study was to use three conceptually distinct measures of morbidity to examine the association between these measures and mortality.

      Materials and Methods

      Using Medicare claims data linked with the 2012–2016 Ohio Cancer Incidence Surveillance System we identified older adults with incident primary cancer sites of breast, colorectal, lung, or prostate (n = 29,140). We used claims data to identify their Elixhauser comorbidities, Multimorbidity-Weighted Index (MWI), and Claims Frailty Index (CFI) as measures of MCC, multimorbidity, and frailty, respectively. We used Cox proportional hazard models to examine the association between these measures and survival time since diagnosis.

      Results

      Lung cancer patients had the highest levels of MCC, multimorbidity, and frailty. There was a positive association between all three measures and a greater hazard of death after adjusting for age, sex (colorectal and lung only), and stage. Breast cancer patients with 5+ comorbidities had an adjusted hazard ratio (aHR) of 1.63 (95% confidence interval [CI]: 1.38, 1.93), and those with mild frailty had an aHR of 3.38 (95% CI; 2.12, 5.41). The C statistics for breast cancer were 0.79, 0.78, and 0.79 for the MCC, MWI, and CFI respectively. Similarly, lung cancer patients who were moderately or severely frail had an aHR of 1.82 (95% CI: 1.53, 2.18) while prostate cancer patients had an aHR of 3.39 (95% CI: 2.12, 5.41) and colorectal cancer patients had an aHR of 4.51 (95% CI: 3.23, 6.29). Model performance was nearly identical across the MCC, multimorbidity, and frailty models within cancer type. The models performed best for prostate and breast cancer, and notably worse for lung cancer. The frailty models showed the greatest separation in unadjusted survival curves.

      Discussion

      The MCC, multimorbidity, and frailty indices performed similarly well in predicting mortality among a large cohort of older cancer patients. However, there were notable differences by cancer type. This work highlights that although model performance is similar, frailty may serve as a clearer indicator in risk stratification of geriatric oncology patients than simple MCCs or multimorbidity.

      Keywords

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