Table 3:
Expanded summary of evidence demonstrating statistically significant, negative associations between systemic variables and postoperative clinical outcomes
| Study design | Sample size | Age* | Men (%) | Primary cancer site (% by type) | Significance in univariate analysis | Significance in multivariate analyses | |
|---|---|---|---|---|---|---|---|
|
| |||||||
| Cheung et al (2019)7 | Retrospective | 2202 | NR | 63% | NR | Pulmonary complications: increased among patients with obesity (p=0·046); VTE: increased among patients with obesity (p=0·014); duration of hospital stay: decreased among patients with obesity (p=0·0010); and RBC transfusion: decreased among patients with obesity (p<0·001) | VTE: obesity, OR 1·75 (95% CI 1·2–2·6, p=0·0070); and UTI: obesity, 0·38 (0·15–0·95, p=0·038) |
| De la Garza Ramos et al (2016)8 | Retrospective | 4583 | 62 (54–70) | 59% | Lung (34%), breast (21%), prostate (21%), kidney (20%), and thyroid (4%) | More than one major complication: anaemia, CHF, chronic lung disease, coagulopathy, electrolyte imbalance, pulmonary circulation disorders, renal failure, malnutrition, and pathological fracture (all more likely, p<0·001); association between frailty (mild, moderate, or severe) and inpatient mortality: moderate (OR 5·15 [95% CI 2·4–10·9]) and severe (5·74 [2·7–12·2], both p<0·001); association between frailty (mild, moderate, or severe) and major inpatient complications: mild (1·88 [1·33–2·66]), moderate (3·83 [2·71–5·41]), and severe (6·97 [4·98–9·74], all p<0·001); and association between frailty (mild, moderate, or severe) and LOS: mild (mean 3·3 [SD 0·4] days, p<0·001), moderate (5·6 [0·4] days, p<0·001), and severe (6·4 [0·4] days, p<0·001) | More than one major complication: anaemia, OR 1·36 (95% CI 1·1–1·7, p=0·0010); CHF, 1·83 (1·2–2·7, p=0·0090); chronic lung disease, 1·64 (1·3–2·0); coagulopathy, 1·98 (1·5–2·6); electrolyte imbalance, 2·66 (2·2–3·2); pulmonary disease, 3·19 (2·3–4·4); renal failure, 1·79 (1·2–2·7); malnutrition, 2·11 (1·5–2·99, all six p<0·001); and pathological fracture, 1·23 (1·01–1·5, p=0·033) |
| De la Garza Ramos et al (2020)9 | Retrospective | 1601 | 61·2 | 62% | NR | RBC transfusions: men (p=0·034), coagulopathy (p=0·090), hypoalbuminaemia (p=0·0080), previous transfusion, preoperative anaemia, decreased preoperative haematocrit (all three p<0·001), increased preoperative international normalised ratio (p=0·065), and higher ASA physical status class (p=0·0010) | RBC transfusions: higher ASA physical status class, OR 1·5 (95% CI 1·2–2·1, p=0·0030); preoperative anaemia, 3·1 (2·1–4·56, p<0·001); any complications: red blood cell transfusion, 1·65 (1·1–2·6, p=0·022); and hypoalbuminaemia, 1·53 (1·01–2·3, p=0·042) |
| De la Garza Ramos et al (2021)10 | Retrospective | 1226 | Non-Hispanic White: 62 (SD 12); Black: 60 (SD 11) | Non-Hispanic White: 62%; Black: 68% | NR | Black race: overall complications, increased (p=0·013) and minor complications, increased (p=0·0080) | Minor complications: Black race, OR 1·87 (95% CI 1·2–3·01, p=0·010); older age: 1·02 (1·0–1·03, p=0·026); and dependent functional status (partly or fully dependent for ADLs), 1·84 (1·1–3·2, p=0·027); major complications: smoking, 2·56 (1·60–4·10); dependent functional status (partly or fully dependent for ADLs), 2·93 (1·7–5·1); and hypoalbuminaemia, 1–67 (1·1–2·6, all three p<0·001) |
| Dea et al (2014)11 | Prospective | 101 | 62 (33–85) | 49% | Lymphoma (5%), breast (22%), NSCLC (20%), kidney (17%), colorectal (11%), prostate (7%), and other (19%) | NR | Complications (any): increased age (p=0·035); pressure sores: motor score (p=0·031); increased LOS: preoperative motor score (p<0·0001); worse overall survival: Frankel grade (statistically significant; p value NR); and sex: male (statistically significant, p value NR)† |
| Dea et al (2020)12 | Retrospective | 253 | 57·5 (SD 11·2) | 49% | Breast (18%), lung (20%), prostate (6%), kidney (16%), and other (40%) | Less than 3-month survival for men (p<0·001): worse ECOG-PS score (p=0·038), worse AIS score (p<0·001), worse NRS score (p=0·044), and worse EQ-5D score (p=0·0010) | NR |
| Elsamadicy et al (2020)13 | Retrospective | 4423 | 30-day readmission: 60 (SD 15); 90-day readmission: 60 (SD 13); and no readmission: 62 (SD 14) | 30-day readmission: 61%; 90-day readmission: 60%; and no readmission: 61% | NR | NR | 30-day readmission: hypertension, OR 1·45 (95% CI 1·2–1·8, p=0·0020), and renal failure, 1·53 (1·1–2·2, p=0·025); 31–90-day readmission: rheumatoid arthritis or collagen vascular disease, 4·08 (1·5–11·5, p=0·0080) and coagulopathy, 0·50 (0·3–0·97, p=0·040) |
| Hussain et al (2019)14 | Retrospective | 1498 | Normoalbuminaemic (>3·5 g/dL): 41% ≥65 years of age; hypoalbuminaemic (<3·5 g/dL): 36% ≥65 years of age | Normoalbuminaemic (>3·5 g/dL): 65%; hypoalbuminaemic (<3·5 g/dL): 64% | NR | Association between hypoalbuminaemia and 30-day survival; any complications; sepsis; RBC transfusion; LOS ≥10 days; or non-home discharge (all p<0·001) | Association between hypoalbuminaemia and 30-day survival, OR 5·2 (95% CI 3·4–8·0, p<0·001); any complications, 3·2 (2·4–4·1, p<0·001); sepsis, 3·1 (1·9–4·9, p<0·001); RBC transfusion, 1·4 (1·1–1·8, p<0·001); LOS ≥10 days, 4·3 (3·3–5·6, p<0·001); or non-home discharge, 2·9 (2·3–3·7, p<0·001) |
| Karhade et al (2019)15 | Retrospective | 732 | 61 (53–69) | 58% | NR | Overall survival: BMI <18 (vs 18–30), HR 1·8 (95% CI 1·1–2·9, p=0·010); Charlson comorbidity other than metastases, 1·3 (1·1–1·5, p=0·0070); ECOG-PS 3–4, 2·7 (2·1–3·4, p<0·001); ASIA score (A-D), 1·5 (1·3–1·8, p<0·001); anaemia (haemoglobin <13 g/dL), 1·7 (1·4–2·0, p<0·001); thrombocytopenia (<150 × 103 cells/μL), 1·5 (1·1–1·9, p=0·0040); thrombocytosis (>450×103 cells/μL), 1·4 (1·1–2·0, p=0·020); absolute lymphocyte count (×103 cells/μL) <1, 1·6 (1·3–1·9, p<0·001); absolute neutrophil count (×103 cells/μL) >6, 1·3 (1·1–1·6, p=0·010); neutrophil-to-lymphocyte ratio ≥4·7, 1·8 (1·5–2·2, p<0·001); platelet-to-lymphocyte ratio ≥408, 1·7 (1·4–2·0, p<0·001); albumin <3·5 g/dL, 2·0 (1·6–2·4, p<0·001); ALP (IU/L) ≥100, 1·8 (1·5–2·2, p<0·001); calcium (mg/dL) ≥9, 0·7 (0·6–0·9, p<0·001); creatinine (mg/dL) ≥1, 0·8 (0·6–0·9, p=0·0090) | Overall survival, HR (95% CI): Charlson comorbidity other than metastases, 1·2 (1·02–1·4, p=0·030); ECOG-PS 3–4, 2·7 (2·1–3·3, p<0·001); anaemia (haemoglobin) <13 g/dL: 1·4 (1·1–1·7, p=0·0010); albumin <3·5 g/dL: 2·0 (1·7–2·5, p<0·001); ALP (IU/L) ≥100: 1·3 (1·1–1·5, p=0·0060) |
| Nater et al (2018)16 | Prospective | 142 | 59 (47–71) | 58% | Lung (34%), kidney (22%), breast (21%), and prostate (19%) | Overall survival: men, HR 1·59 (95% CI 1·0–2·5, p=0·038); elevated BMI, 0·945 (0·91–0·98, p=0·0062); ODI, 10·014 (1·0–1·0, p=0·012); EQ-5D, 0·300 (0·1–0·7, p=0·0049); SF-36 PCS, 0·95 (0·92–0·97, p<0·001); and metastases to other organs with or without extraspinal bone metastases, 2·2 (1·4–3·4, p<0·001) | Overall survival: SF-36 PCS, HR 0·95 (95% CI 0·92–0·97, p<0·0001); metastases to other organs: 1·9 (1·3–3·2, p<0·001) |
| Park et al (2016)17 | Prospective | 50 | 58 (26–79) | 54% | Lung (100%) | Postoperative non-ambulatory status: pre-operative non-ambulatory status, OR 17·7 (95% CI 1·6–203·1, p=0·021) | NR |
| Prost et al (2020)18 | Prospective | 264 | 64 (SD 19) | 56% | Lung (21%), breast (19%), kidney (13%), prostate (10%), gastrointestinal (4%), head and neck (3%), thyroid (3%), hepatic (3%), melanoma (2%), gynaecological (2%), bladder (2%), and other (20%) | NR | 12-month survival: CRP >10 mg/L, 2·7 (p<0·01); albumin (>35 g/L), 0·5 (p<0·001); hypercalcaemia (>2·6 nmol/L): 2·3 (p<0·001); any complications: CRP >10 mg/L, 1·7 (p<0·01)‡ |
| Schoenfeld et al (2016)19 | Retrospective | 318 | 60·2 (SD 13·2) | 58% | Lung (16%), breast (13%), lymphoma or multiple myeloma (12%), and other (58%) | 30-day survival: ambulatory preoperative, OR 9·6 (95% CI 2·2–41·1, p value NR); albuminaemia ≥3·5 g/dL, 8·0 (3·0–21·7, p value NR); BMI <18·5, 0·2 (0·1–0·7, p value NR); 90-day survival: ambulatory status, 3·0 (1·7–5·4, p value NR); albuminaemia ≥3·5 g/dL, 3·5 (2·1–5·9, p value NR); BMI <18·5, 0·6 (0·2–1·8, p value NR)§ | 30-day survival, OR (95% CI): albuminaemia ≥3·5 g/dL, 9·0 (3·1–26·6, p<0·001); normal ambulatory status at the time of surgery, 6·8 (1·5–30·7, p=0·010); BMI <18·5, 0·18 (0·04–0·8, p=0·020, decreased odds of survival); 90-day survival, OR (95% CI): albuminaemia ≥3·5 g/dL: 3·9 (2·2–6·8, p<0·001); ambulatory status, 2·4 (1·3–4·5, p=0·0060) |
| Sebaaly et al (2018)20 | Retrospective | 297 | 61 (SD 10·9) | 54% | NR | NR | SSI: ASA ≥3, OR 1·1 (95% CI 1·03–1·2, p=0·020) and smoking, 2·4 (1·06–7·2, p=0·040) |
| Tatsui et al (2014)21 | Retrospective | 267 | 59·2 (17–86) | 77% | Renal (100%) | Overall survival: progressive systemic disease, HR 4·1 (95% CI 3·1–5·4, p<0·001) and preoperative neurological deficit, 2·3 (1·6–3·1, p<0·001) | Overall survival: progressive systemic disease, HR 4·1 (95% CI 2·9–5·8, p<0·001) and preoperative neurological deficit 1·8 (1·2–2·7, p<0·002) |
| Zairi et al (2016)22 | Retrospective | 271 | Smallest psoas tertile (n=90): 61 (SD 13); middle psoas tertile (n=90): 61 (SD 9·3); largest psoas tertile (n=91): 57·4 (SD 12) | Smallest psoas tertile (n=90): 59%; middle psoas tertile (n=90): 58%; largest psoas tertile (n=91): 57% | Lung (23%), prostate (15%), renal (14%), breast (13%), haematological (8%), gastrointestinal (7%), nasopharynx (6%), thyroid (4%), hepatic (2%), skin (2%), and other (7%) | Ambulatory status: KPS (p<0·001), Frankel grade (p=0·022); non-discharge home: KPS <80 (p=0·016), Frankel grade (p=0·0087), Tokuhashi score (p=0·039) | NR |
| Zakaria et al (2020); 30-day survival23 | Retrospective | 247 | 60 (25–87) | 52% | Lung (23%), prostate (15%), kidney (14%), breast (13%), haematopoietic (8%), gastrointestinal (7%), nasopharynx (6%), thyroid (4%), liver (2%), skin (2%), and other (7%) | Stroke: OR 4·8 (95% CI 1·4–16·4, p=0·013); liver disease: 5·8 (1·6–20·3; p=0·0060); middle versus smallest psoas tertile: 0·6 (0·4–0·8; p<0·001); largest vs smallest psoas tertile: 0·4 (0·3–0·6; p<0·001); Tokuhashi score: 0·8 (0·6–0·9, p=0·0010); and KPS: 0·96 (0·94–0·99; p=0·0010) | Liver disease: OR 7·6 (95% CI 1·2–47·0, p=0·029);Tokuhashi score: 0·7 (0·5–0·98, p=0·039) |
| Zakaria et al (2020); 90-day survival23 | Retrospective | 247 | 60 (25–87) | 52% | Lung (23%), prostate (15%), kidney (14%), breast (13%), hematopoietic (8%), gastrointestinal (7%), nasopharynx (6%), thyroid (4%), liver (2%), skin (2%), and other (7%) | Older age: OR 1·3 (95% CI 1·1–1·7, p=0·014); diabetes: 2·7 (1×·1, p=0·0030); middle versus smallest psoas tertile: 0·3 (0·2–0·6, p=0·0010); largest versus smallest psoas tertile: 0·2 (0·1–0·4, p<0·001); Tokuhashi score: 0·7 (0·7–0·8, p<0·001); Tomita score: 1·3 (1·1–1·4, p<0·001); KPS: 0·97 (0·96–0·99, p<0·001) | Diabetes: OR 2·8 (95% CI 1·01–7·8, p=0·046); middle versus smallest psoas tertile: 0·2 (0·09–0·6, p=0·0030); largest versus smallest psoas tertile: 0·16 (0·05–0·4, p<0·001); Tokuhashi score: 0·7 (0·6–0·9, p=0·0020) |
| Zakaria et al (2020); overall survival23 | Retrospective | 247 | 60 (25–87) | 52% | Lung (23%), prostate (15%), kidney (14%), breast (13%), hematopoietic (8%), gastrointestinal (7%), nasopharynx (6%), thyroid (4%), liver (2%), skin (2%), and other (7%) | Myocardial infarction or CAD: 1·7 (1·2–2·5, p=0·0040); COPD: 1·7 (1·2–2·5, p=0·0050); low BMI: 0·97 (0·94–0·99, p=0·012); middle versus smallest psoas tertile: 0·6 (0·4–0·8, p<0·001); largest versus smallest psoas tertile: 0·4 (0·3–0·6, p<0·001), Tokuhashi score: 0·9 (0·86–0·93, p<0·001); Tomita score: 1·2 (1·1–1·2, p<0·001) | COPD: 1·7 (1·1–2·7, p=0·19); middle versus smallest psoas tertile: 0·5 (0·4–0·7, p<0·001); largest versus smallest psoas tertile: 0·5 (0·3–0·7, p<0·001); Tokuhashi score: 0·9 (0·85–0·97, p=0·010) |
| Zakariaetal (2020); any complications and postoperative neurological function23 | Retrospective | 247 | 60 (25–87) | 52% | Lung (23%), prostate (15%), kidney (14%), breast (13%), hematopoietic (8%), gastrointestinal (7%), nasopharynx (6%), thyroid (4%), liver (2%), skin (2%), and other (7%) | Any complications: middle versus smallest psoas fertile, OR 0·5 (95% CI 0·3–0·9, p=0·030); Tokuhashi score, 1·1 (1·0–1·3, p=0·024); KPS: 1·0 (1·0–1·1, p=0·0010) | Postoperative neurological function: previous stroke, OR 0·2 (95% CI 0·04–0·95, p=0·044); largest versus smallest psoas fertile, 4·1 (1·3–13·3, p=0·018); any complications: myocardial infarction or CAD, 2·9 (1·2–7·4, p=0·021); chronic renal disease, 3·0 (1·1–8·8, p=0·040) |
| Zhang et al (2021)24 | Retrospective | 411 | 58 (SD 11) | 56% | NR | VTE: Frankel grade (A–C vs D–E), OR 5·6 (95% CI 3·0–11·1, p=0·0010); CCI >7 (vs 7 or less), 5·8 (1·4–24·8, p=0·017) | VTE: Frankel grade (A–C vs D–E), OR 5·6 (95% CI 3·0–11·1, p=0·0010); CCI >7 (vs 7 or less), 2·3 (1·3–4·2, p=0·017) |
The table lists prospective studies (any sample size) and retrospective studies (>200 patients). BMI reported as kg/m2. AIS=ASIA Impairment Scale. ADL=activities of daily living. ALP=alkaline phosphatase. ASA=American Society of Anesthesiologists. ASIA=American Spinal Injury Association. BMI=body-mass index. CAD=coronary artery disease. CHF=congestive heart failure. CCI=Charlson Comorbidity Index. COPD=chronic obstructive pulmonary disease. CHF=congestive heart failure. CRP=C-reactive protein. ECOG-PS=Eastern Cooperative Oncology Group Performance Status. EQ-5D=EuroQoL-5 dimensions. HR=hazard ratio. KPS=Karnofsky performance score. LOS=length of stay. NSCLC=non-small-cell lung cancer. NR=not reported. NRS=Numeric Rating Scale. ODI=Oswestry Disability Index. OR=odds ratio. RBC=red blood cell. SF-36 PCS=Short-Form 36 physical component summary. SSI=surgical site infection. UTI=urinary tract infection. VTE=venous thromboembolism.
*
Median or mean age in years (range, or SD if no range).
†
In their paper, Dea and colleagues state that statistically significant associations were found. However, they do not report p values.
‡
HR, OR, and associated CIs were not reported for any of these data.
§
Schoenfeld and colleagues do not cite p values in this paper, but state in their methodology that only variables that maintained p<0·02 in initial bivariate testing were subsequently included into a multivariate logistic regression analysis.