Does the Veterans Affairs Risk Analysis Index Overestimate Frailty in Patients With Localized Prostate Cancer?

The Veterans Affairs Health System recently implemented the Risk Analysis Index (RAI) to assess frailty before surgery. Elevated RAI scores trigger a surgical pause and geriatric consultation to reduce short-term morbidity. However, any cancer diagnosis, including localized prostate cancer (PCa), increases RAI, potentially overstating frailty in otherwise healthy patients. We hypothesized that low-risk or intermediate-risk PCa does not correlate with 30-day morbidity and mortality predicted by RAI.

We retrospectively reviewed patients with low-risk or intermediate-risk PCa who underwent radical prostatectomy at a single institution over 5 years. RAI-administrative (RAI-A) scores were calculated with and without including PCa. Thirty-day postoperative complications and mortality were compared with rates predicted by RAI-A using data from the original Veterans Affairs Surgical Quality Improvement Program study.

Among 130 patients (median age 61), 53.4% had favorable intermediate-risk, 41.2% unfavorable intermediate-risk, and 5.3% low-risk PCa. Mean RAI-A excluding PCa was 8.58, and including PCa it was 24.95. Corresponding Veterans Affairs Surgical Quality Improvement Program-predicted complication rates were 4.6% (2.5% grade IV-V) and 11.2% (5.6% grade IV-V). In our cohort, 6 patients (4.6%) experienced complications, none grade IV-V.

Including localized PCa in RAI-A calculations overestimates frailty and predicted morbidity. Excluding the PCa diagnosis may better reflect surgical risk in low-risk or intermediate-risk patients, preventing unnecessary delays in treatment.