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Visser L, Prent A, Banning LBD, van Leeuwen BL, Zeebregts CJ, Pol RA. Risk Factors for Delirium after Vascular Surgery: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2021; 76:500-513. [PMID: 33905851 DOI: 10.1016/j.avsg.2021.03.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/05/2021] [Accepted: 03/16/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Vascular surgery is considered a risk factor for the development of postoperative delirium (POD). In this systematic review we provide a report on the incidence and risk-factors of POD after vascular surgery. METHODS A systematic literature search was conducted using Pubmed with the MeSH terms and key words "delirium" or "confusion", "vascular surgery procedures" and "risk factors or "risk assessment". Studies were selected for review after meeting the following inclusion criteria: vascular surgery, POD diagnosed using validated screening tools, and DSM-derived criteria to assess delirium. A meta-analysis was performed for each endpoint if at least two studies could be combined. RESULTS Sixteen articles met the abovementioned criteria. The incidence of delirium ranged from 5% to 39%. Various preoperative risk factors were identified that is, age (Random MD 3.96, CI 2.57-5.35), hypertension (Fixed OR 1.30, CI 1.05-1.59), diabetes mellitus (Random OR 2.15, CI 1.30-3.56), hearing impairment (Fixed OR 1.89, CI 1.28-2.81), history of cerebrovascular incident or transient ischemic attack (Fixed OR 2.20, CI 1.68-2.88), renal failure (Fixed OR 1.61, CI 1.19-2.17), and pre-operative low haemoglobin level (fixed MD -0.76, CI -1.04 to -0.47). Intra-operative risk factors were duration of surgery (Random MD 15.68; CI 2.79-28.57), open aneurysm repair (Fixed OR 4.99, CI 3.10-8.03), aortic cross clamping time (fixed MD 7.99, CI 2.56-13.42), amputation surgery (random OR 3.77, CI 2.13-6.67), emergency surgery (Fixed OR 4.84, CI 2.81-8.32) and total blood loss (Random MD 496.5, CI 84.51-908.44) and need for blood transfusion (Random OR 3.72, CI 1.57-8.80). Regional anesthesia on the other hand, had a protective effect. Delirium was associated with longer ICU and hospital length of stay, and more frequent discharge to a care facility. CONCLUSIONS POD after vascular surgery is a frequent complication and effect-size pooling supports the concept that delirium is a heterogeneous disorder. The risk factors identified can be used to either design a validated risk factor model or individual preventive strategies for high-risk patients.
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Brattinga B, Rutgers A, De Haan JJ, Absalom AR, van der Wal-Huisman H, de Bock GH, van Leeuwen BL. Preoperative Inflammatory Markers as a Predictor of Three-Year Overall Survival in Older Cancer Patients Undergoing Oncologic Surgery. Cancers (Basel) 2021; 13:cancers13081824. [PMID: 33920422 PMCID: PMC8069748 DOI: 10.3390/cancers13081824] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/03/2021] [Accepted: 04/08/2021] [Indexed: 01/08/2023] Open
Abstract
Simple Summary Older patients can have an increased expression of inflammatory cytokines due to ageing of the immune system. It is likely that older cancer patients with a low-grade inflammatory state are more at risk for an exaggerated inflammatory response to surgery and for poor outcome after surgery. The aim of this study was to examine whether preoperative inflammatory markers could be a predictor of overall survival in older patients undergoing oncologic surgery. In this prospective cohort study, a plasma level of C-reactive protein (CRP) ≥ 10 mg/L was a predictor of inferior three-year overall survival after oncologic surgery in older cancer patients, and also for the specific group of older patients with a colorectal tumor. Measuring preoperative plasma level of CRP might be useful in risk stratification for poor outcome after surgery in older cancer patients. Abstract Oncologic surgery results in substantially higher morbidity and mortality rates in older patients compared to younger patients, yet little is known about the relation between the preoperative inflammatory state and postoperative outcome in the specific group of older cancer patients. The aim of this study was to examine whether preoperative inflammatory markers could be a predictor of overall survival in older patients undergoing elective surgery for a solid malignant tumor. Patients 65 years and older undergoing surgery for a solid malignant tumor were included in a prospective cohort study. Inflammatory markers C-reactive protein (CRP), interleukin-1 beta (IL-1β), IL-6, IL10, IL-12 and tumor necrosis factor-alpha (TNF-α) were measured in plasma samples preoperatively. The main outcome was overall survival three years after surgery. Between 2010 and 2016, 328 patients with a median age of 71.5 years (range 65–89) were included. A significantly higher mortality rate three years after surgery, was found in patients with high preoperative plasma levels of CRP and IL-6 (p = 0.013 and p = 0.046, respectively). In multivariate analysis, corrected for variables such as age, disease stage, frailty, comorbidities, type of surgery and complications, a preoperative plasma level of CRP ≥ 10 mg/L was an independent prognostic factor for inferior overall survival three years after surgery (multivariate hazard ratio 1.50, 95% confidence interval 1.04–2.16, p = 0.031). Also, for the specific group of patients with colorectal cancer, a preoperative plasma level of CRP ≥ 10 mg/L was a prognostic factor for inferior survival three years after surgery (multivariate hazard ratio 2.40, 95% confidence interval 1.20–4.81, p = 0.014). Preoperative elevated plasma level of CRP is an independent unfavorable prognostic factor for overall survival three years after oncologic surgery. This gives more insight into the relationship between inflammation and survival in older cancer patients, and might contribute to risk stratification for poor outcome after surgery in older cancer patients.
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Banning LBD, Visser L, Zeebregts CJ, van Leeuwen BL, El Moumni M, Pol RA. Transition in Frailty State Among Elderly Patients After Vascular Surgery. World J Surg 2021; 44:3564-3572. [PMID: 32494998 PMCID: PMC7458900 DOI: 10.1007/s00268-020-05619-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Frailty in the vascular surgical ward is common and predicts poor surgical outcomes. The aim of this study was to analyze transitions in frailty state in elderly patients after vascular surgery and to evaluate influence of patient characteristics on this transition. METHODS Between 2014 and 2018, 310 patients, ≥65 years and scheduled for elective vascular surgery, were included in this cohort study. Transition in frailty state between preoperative and follow-up measurement was determined using the Groningen Frailty Indicator (GFI), a validated tool to measure frailty in vascular surgery patients. Frailty is defined as a GFI score ≥4. Patient characteristics leading to a transition in frailty state were analyzed using multivariable Cox regression analysis. RESULTS Mean age was 72.7 ± 5.2 years, and 74.5% were male. Mean follow-up time was 22.7 ± 9.5 months. At baseline measurement, 79 patients (25.5%) were considered frail. In total, 64 non-frail patients (20.6%) shifted to frail and 29 frail patients (9.4%) to non-frail. Frail patients with a high Charlson Comorbidity Index (HR = 0.329 (CI: 0.133-0.812), p = 0.016) and that underwent a major vascular intervention (HR = 0.365 (CI: 0.154-0.865), p = 0.022) had a significantly higher risk to remain frail after the intervention. CONCLUSIONS The results of this study, showing that after vascular surgery almost 21% of the non-frail patients become frail, may lead to a more effective shared decision-making process when considering treatment options, by providing more insight in the postoperative frailty course of patients.
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Steinkamp PJ, Pranger BK, Li MF, Linssen MD, Voskuil FJ, Been LB, van Leeuwen BL, Suurmeijer AJH, Nagengast WB, Kruijff S, van Ginkel RJ, van Dam GM. Fluorescence-Guided Visualization of Soft-Tissue Sarcomas by Targeting Vascular Endothelial Growth Factor A: A Phase 1 Single-Center Clinical Trial. J Nucl Med 2021; 62:342-347. [PMID: 32680922 DOI: 10.2967/jnumed.120.245696] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 06/23/2020] [Indexed: 02/05/2023] Open
Abstract
Resection of soft-tissue sarcoma (STS) is accompanied by a high rate of tumor-positive surgical margins (14%-34%), which potentially lead to decreased disease-free survival. Vascular endothelial growth factor A is overexpressed in malignant tumors, including STS, and can be targeted with bevacizumab-800CW during fluorescence-guided surgery for real-time tumor detection. In this phase 1 clinical trial, we determined the feasibility, safety, and optimal dose of bevacizumab-800CW for fluorescence-guided surgery in STS for in vivo and ex vivo tumor detection. Methods: Patients with a histopathologic diagnosis of STS were included. In the dose-escalation phase, patients received bevacizumab-800CW intravenously 3 d before surgery (10, 25, and 50 mg; n = 8). In the subsequent dose-expansion phase, 7 additional patients received bevacizumab-800CW at the optimal dose. Fluorescence images were obtained in vivo and ex vivo during all stages of standard care. The optimal dose was determined by calculating in vivo and ex vivo tumor-to-background ratios (TBR) and correlating these results with histopathology. Results: Fifteen patients with STS completed this study. All tumors could be visualized during in vivo and ex vivo imaging. The optimal bevacizumab-800CW dose proved to be 10 mg, with a median in vivo TBR of 2.0 (±0.58) and a median ex vivo TBR of 2.67 (±1.6). All 7 tumor-positive margins could be observed in real time after surgical resection. Conclusion: GS using 10 mg of bevacizumab-800CW is feasible and safe for intraoperative imaging of STS, potentially allowing tumor detection and margin assessment during surgery. An additional follow-up phase 2 study is needed to confirm the diagnostic accuracy.
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Jonker LT, Lahr MMH, Oonk MHM, de Bock GH, van Leeuwen BL. Post-discharge Telemonitoring of Physical Activity, Vital Signs, and Patient-Reported Symptoms in Older Patients Undergoing Cancer Surgery. Ann Surg Oncol 2021; 28:6512-6522. [PMID: 33641013 PMCID: PMC7914037 DOI: 10.1245/s10434-021-09707-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/22/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Postoperative home monitoring could potentially detect complications early, but evidence in oncogeriatric surgery is scarce. Therefore, we evaluated whether post-discharge physical activity, vital signs, and patient-reported symptoms are related to post-discharge complications and hospital readmissions in older patients undergoing cancer surgery. METHODS In this observational cohort study, we monitored older patients (≥65 years of age) undergoing cancer surgery, for 2 weeks post-discharge using tablet-based applications and connected devices. Outcome measures were post-discharge complications and readmissions; physical activity and patient-reported symptoms over time; and threshold violations for physical activity (step count <1000 steps/day), vital signs (temperature <36°C or >38°C; blood pressure <100/60 mmHg or >150/100 mmHg; heart rate <50 bpm or >100 bpm; weight -5% or +5% of weight at discharge); and patient-reported symptoms (pain score greater than the previous day; presence of dyspnea, vomiting, dizziness, fever). RESULTS Of 58 patients (mean age 72 years), 24 developed a post-discharge complication and 13 were readmitted. Measured parameters indicated 392 threshold violations out of 5379 measurements (7.3%) in 40 patients, mostly because of physical inactivity. Patients with readmissions had lower physical activity at discharge and at day 9 after discharge and violated a physical activity threshold more often. Patients with post-discharge complications had a higher median pain score compared with patients without these adverse events. No differences in threshold violations of other parameters were observed between patients with and without post-discharge complications and readmissions. CONCLUSION Our results show the potential of telemonitoring older patients after cancer surgery but confirm that detecting post-discharge complications is complex and multifactorial.
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Jonker LT, van Leeuwen BL. ASO Author Reflections: Extending Postoperative Observation of Oncogeriatric Surgery Patients After Hospital Discharge by Using Telemonitoring. Ann Surg Oncol 2021; 28:6523-6524. [PMID: 33641014 PMCID: PMC8460574 DOI: 10.1245/s10434-021-09734-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/04/2021] [Indexed: 11/23/2022]
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van der Wal-Huisman H, Heineman E, van Leeuwen BL. Live bedside music in daily clinical practice of a surgical hospital ward among older patients: A controlled study design of an innovative practice. J Geriatr Oncol 2021; 12:960-963. [PMID: 33536156 DOI: 10.1016/j.jgo.2021.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/21/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE There is an increasing interest in the role of the arts, particularly music, in healthcare. Music seems an attractive non-pharmacological intervention for older patients to improve postoperative outcomes. Although live music elicits more meaningful responses from an audience than recorded music, the use of live music is still rare on hospital wards. In view of the positive effects of recorded music on older surgical patients, we designed, in collaboration with a conservatoire, an innovative practice named Meaningful Music in Health Care (MiMiC). The aim is to determine whether live bedside music implements into daily practice and allows improves patient outcomes. METHOD This manuscript provides an overview of a trial evaluating if live bedside music can improve postoperative outcomes in older patients. The MiMiC initiative is a non randomized controlled trial study among older surgical patients on three hospital wards. Live bedside music is performed by professional musicians, once a day for six or seven consecutive days. The primary outcome is experienced pain; secondary outcomes are anxiety, relaxation and physical parameters (heart rate, heart rate variability, blood pressure, respiratory rate and oxygenation). Measurements of these variables are collected before the intervention, 30 min afterwards and again after three hours. Daily evaluations determine whether this innovative practice can be implemented in daily practice. CONCLUSION This manuscript describes a new practice, live bedside music by professional musicians, on surgical hospital wards aiming to improve patient outcomes. It offers a new field of interprofessional collaboration for the benefit of patients. Further research must be conducted focussing on patient outcomes, including cost-effectiveness and the experiences of patients and healthcare professionals.
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Brattinga B, van Leeuwen BL. Senescent Cells: A Potential Target for New Cancer Therapies in Older Oncologic Patients. Cancers (Basel) 2021; 13:cancers13020278. [PMID: 33451087 PMCID: PMC7828542 DOI: 10.3390/cancers13020278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/02/2021] [Indexed: 01/26/2023] Open
Abstract
Cellular senescence is a complex process and is one of the key elements of ageing [...].
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Banning LBD, El Moumni M, Visser L, van Leeuwen BL, Zeebregts CJ, Pol RA. Frailty leads to poor long-term survival in patients undergoing elective vascular surgery. J Vasc Surg 2020; 73:2132-2139.e2. [PMID: 33387657 DOI: 10.1016/j.jvs.2020.10.088] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/29/2020] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Frailty has persistently been associated with unfavorable short-term outcomes after vascular surgery, including an increased complication risk, greater readmission rate, and greater short-term mortality. However, a knowledge gap remains concerning the association between preoperative frailty and long-term mortality. In the present study, we aimed to determine this association in elective vascular surgery patients. METHODS The present study was a part of a large prospective cohort study initiated in 2010 in our tertiary referral teaching hospital to study frailty in elderly elective vascular surgery patients (Vascular Ageing Study). A total of 639 patients with a minimal follow-up of 5 years, who had been treated from 2010 to 2014, were included in the present study. The Groningen Frailty Indicator, a 15-item self-administered questionnaire, was used to determine the presence and degree of frailty. RESULTS Of the 639 patients, 183 (28.6%) were considered frail preoperatively. For the frail patients, the actuarial survival after 1, 3, and 5 years was 81.4%, 66.7%, and 55.7%, respectively. For the nonfrail patients, the corresponding survival was 93.6%, 83.3%, and 75.2% (log-rank test, P < .001). Frail patients had a significantly greater risk of 5-year mortality (unadjusted hazard ratio, 2.09; 95% confidence interval, 1.572-2.771; P < .001). After adjusting for surgical- and patient-related risk factors, the hazard ratio was 1.68 (95% confidence interval, 1.231-2.286; P = .001). CONCLUSIONS The results of our study have shown that preoperative frailty is associated with significantly increased long-term mortality after elective vascular surgery. Knowledge of a patient's preoperative frailty state could, therefore, be helpful in shared decision-making, because it provides more information about the procedural benefits and risks.
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Festen S, van der Wal-Huisman H, van der Leest AHD, Reyners AKL, de Bock GH, de Graeff P, van Leeuwen BL. The effect of treatment modifications by an onco-geriatric MDT on one-year mortality, days spent at home and postoperative complications. J Geriatr Oncol 2020; 12:779-785. [PMID: 33342722 DOI: 10.1016/j.jgo.2020.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/30/2020] [Accepted: 12/02/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Decision-making in older patients with cancer can be complex, as benefits of treatment should be weighed against possible side-effects and life-expectancy. A novel care pathway was set up incorporating geriatric assessment into treatment decision-making for older cancer patients. Treatment decisions could be modified following discussion in an onco-geriatric multidisciplinary team (MDT). We assessed the effect of treatment modifications on outcomes. MATERIALS AND METHODS This retrospective study was performed in the surgical department of a University Hospital. Patients of 70 years and older with a solid malignancy were included. All patients underwent a nurse-led geriatric assessment (GA) and were discussed in an onco-geriatric MDT. This could result in a modified or an unchanged treatment advice compared to the regular tumor board. Primary outcome was one-year mortality. Secondary outcomes were post-operative complications and days spent in hospital in the first year after inclusion. RESULTS For the 184 patients in the analyses, the median age was 77.5 years and 41.8% were female. For 46 patients (25%), the treatment advice was modified by the onco-geriatric MDT. There was no significant difference in one-year mortality between the unchanged and modified group (29.7% versus 26.1%, p = 0.7). There were, however, significantly fewer days spent in hospital (median 5 vs 8.5 days p = 0.02) and fewer grade II or higher postoperative complications (13.3% versus 35.5% p = 0.005) in the modified group. CONCLUSION Incorporating geriatric assessment in decision-making did not lead to excess one-year mortality, but did result in fewer complications and days spent in hospital.
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Jonker LT, Hendriks S, Lahr MMH, van Munster BC, de Bock GH, van Leeuwen BL. Postoperative recovery of accelerometer-based physical activity in older cancer patients. Eur J Surg Oncol 2020; 46:2083-2090. [DOI: 10.1016/j.ejso.2020.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/13/2020] [Accepted: 06/09/2020] [Indexed: 12/20/2022] Open
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Jonker LT, Lahr MMH, Festen S, Oonk MHM, de Bock GH, van Leeuwen BL. Perioperative telemonitoring of older adults with cancer: Can we connect them all? J Geriatr Oncol 2020; 11:1244-1249. [PMID: 32893182 PMCID: PMC7472980 DOI: 10.1016/j.jgo.2020.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/23/2020] [Accepted: 08/19/2020] [Indexed: 12/22/2022]
Abstract
Objectives Although the increasing cancer incidence in older patients is widely recognised, older patients remain underrepresented in clinical cancer trials and eHealth studies. The aim of this research is to identify technological and patient-related barriers to inclusion of this population in a clinical eHealth study. Material and Methods This is a retrospective analysis of a prospective cohort study with older patients (≥ 65 years) undergoing cancer-related surgery, who were identified for a perioperative telemonitoring study. Reasons for ineligibility and refusal had been prospectively registered. Characteristics and postoperative outcomes were compared between participants and non-participants. Results Between May 2018 and March 2020, 151 patients were assessed for eligibility, resulting in 65 participants and 86 non-participants. The main reason for ineligibility was lack of internet access at home (n = 16), while main reasons for refusal were perceived high mental burden (n = 46) and insufficient digital skills (n = 12). Compared with participants, non-participants were significantly older (mean age 75 vs. 73, p = 0.01); more often female (64% vs. 35%, p = 0.00), unmarried (42% vs. 8%, p = 0.01) living alone (38% vs. 19%, p = 0.02); had a higher ASA classification (43% vs. 19%, p = 0.00); often had polypharmacy (67% vs. 43%, p = 0.00); and were more often discharged to skilled nursing facilities (0% vs. 15%, p = 0.00). Conclusion Our results confirm the underrepresentation of older female patients with little support from a partner and higher comorbidity. We should be aware of technological and patient-related barriers to including older adults with cancer, in order to avoid further dividing patients with low and high digital health literacy.
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Jonker LT, Plas M, de Bock GH, Buskens E, van Leeuwen BL, Lahr MMH. Remote Home Monitoring of Older Surgical Cancer Patients: Perspective on Study Implementation and Feasibility. Ann Surg Oncol 2020; 28:67-78. [PMID: 32602060 PMCID: PMC7752881 DOI: 10.1245/s10434-020-08705-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Indexed: 12/12/2022]
Abstract
Background Remote home monitoring might fill the perceived surveillance gap after hospital discharge. However, it is unclear whether older oncologic patients will be able to use the required new digital technologies. The study aimed to assess the feasibility of postoperative remote home monitoring for this population. Methods This observational cohort study recruited patients aged 65 years or older scheduled for oncologic surgery. The study patients used a mobile application and activity tracker preoperatively until 3 months postoperatively. A subset of the patients used additional devices (thermometer, blood pressure monitor, weight scale) and completed electronic health questionnaires 2 weeks after hospital discharge. Feasibility was assessed by the study completion rate, compliance in using components of the information technology system, acceptability [Net Promotor Score (NPS)] and usability [System Usability Scale (SUS)]. The NPS score varied from − 100 to + 100. An SUS higher than 68 was considered above average. Results Of 47 participants (mean age, 72 years; range, 65–85 years), 37 completed a follow-up assessment, yielding a completion rate of 79%. Compliance in using the activity tracker (n = 41) occurred a median of 81 days [interquartile range (IQR), 70–90 days] out of 90 post-discharge days. Compliance in measuring vital signs and completing health questionnaires varied from a median of 10.5 days (IQR, 4.5–14.0 days) to 12 days (IQR, 5–14 days) out of 14 days. The NPS was + 29.7%, and the mean SUS was 74.4 ± 19.3. Conclusion Older oncologic patients in the study considered postoperative home monitoring acceptable and usable. Once they consented to participate, the patients were compliant, and the completion rate was high. Electronic supplementary material The online version of this article (10.1245/s10434-020-08705-1) contains supplementary material, which is available to authorized users.
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Weerink LB, van der Hoorn A, van Leeuwen BL, de Bock GH. Low skeletal muscle mass and postoperative morbidity in surgical oncology: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle 2020; 11:636-649. [PMID: 32125769 PMCID: PMC7296274 DOI: 10.1002/jcsm.12529] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 09/17/2019] [Accepted: 11/14/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Sarcopenia might function as an indicator for frailty, and as such as a risk factor for the development of postoperative complications. The aim of this study was to meta-analyse the relation between preoperative sarcopenia and the development of severe postoperative complications in patients undergoing oncological surgery. METHODS PubMed and Embase databases were systematically searched from inception until May 2018. Included were studies reporting on the incidence of severe postoperative complications and radiologically determined preoperative sarcopenia. Studies reporting the skeletal muscle as a continuous variable only were excluded. Data were extracted independently by two reviewers. Random effect meta-analyses were applied to estimate the pooled odds ratio (OR) with 95% confidence intervals (95% CI) for severe postoperative complications, defined as Clavien-Dindo grade ≥3, including 30-day mortality. Heterogeneity was evaluated with I2 testing. Analyses were performed overall and stratified by measurement method, tumour location and publication date. RESULTS A total of 1924 citations were identified, and 53 studies (14 295 patients) were included in the meta-analysis. When measuring the total skeletal muscle area, 43% of the patients were sarcopenic, versus 33% when measuring the psoas area. Severe postoperative complications were present in 20%, and 30-day mortality was 3%. Preoperative sarcopenia was associated with an increased risk of severe postoperative complications (ORpooled : 1.44, 95% CI: 1.24-16.8, P<0.001, I2 =55%) and 30-day mortality (ORpooled : 2.15, 95% CI: 1.46-3.17, P<0.001, I2 =14%). A low psoas mass was a stronger predictor for severe postoperative complications compared with a low total skeletal muscle mass (ORpooled : 2.06, 95% CI: 1.37-3.09, ORpooled : 1.32, 95% CI: 1.14-1.53, respectively) and 30-day mortality [ORpooled : 6.17 (95% CI: 2.71-14.08, ORpooled : 1.80 (95% CI: 1.24-2.62), respectively]. The effect was independent of tumour location and publication date. CONCLUSIONS The presence of low psoas mass prior to surgery, as an indicator for sarcopenia, is a common phenomenon and is a strong predictor for the development of postoperative complications. The presence of low total skeletal muscle mass, which is even more frequent, is a less informative predictor for postoperative complications and 30-day mortality. The low heterogeneity indicates that the finding is consistent over studies. Nevertheless, the value of sarcopenia relative to other assessments such as frailty screening is not clear. Research is needed in order to determine the place of sarcopenia in future preoperative risk stratification.
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Verver D, Rekkas A, Garbe C, van Klaveren D, van Akkooi ACJ, Rutkowski P, Powell BWEM, Robert C, Testori A, van Leeuwen BL, van der Veldt AAM, Keilholz U, Stadler R, Eggermont AMM, Verhoef C, Leiter U, Grünhagen DJ. The EORTC-DeCOG nomogram adequately predicts outcomes of patients with sentinel node-positive melanoma without the need for completion lymph node dissection. Eur J Cancer 2020; 134:9-18. [PMID: 32454396 DOI: 10.1016/j.ejca.2020.04.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 04/14/2020] [Accepted: 04/18/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Based on recent advances in the management of patients with sentinel node (SN)-positive melanoma, we aimed to develop prediction models for recurrence, distant metastasis (DM) and overall mortality (OM). METHODS The derivation cohort consisted of 1080 patients with SN-positive melanoma from nine European Organization for Research and Treatment of Cancer (EORTC) centres. Prognostic factors for recurrence, DM and OM were studied with Cox regression analysis. Significant factors were incorporated in the models. Performance was assessed by discrimination (c-index) and calibration in cross-validation across centres. The models were externally validated using a prospective cohort consisting of 705 German patients with SN-positive: 473 trial participants of the German Dermatologic Cooperative Oncology Group study (DeCOG-SLT) and 232 screened patients. A nomogram was developed for graphical presentation. RESULTS The final model for recurrence and the calibrated models for DM and OM included ulceration, age, SN tumour burden and Breslow thickness. The models showed reasonable calibration. The c-index for the recurrence, DM and OM model was 0.68, 0.70 and 0.70, respectively, and 0.70, 0.72 and 0.74, respectively, in external validation. The EORTC-DeCOG model identified a robust low-risk group, with all identified low-risk patients (approximately 4% of the entire population) having a 5-year recurrence probability of <25% and an overall 5-year recurrence rate of 13%. A model including information on completion lymph node dissection (CLND) showed only marginal improvement in model performance. CONCLUSIONS The EORTC-DeCOG nomogram provides an adequate prognostic tool for patients with SN-positive melanoma, without the need for CLND. It showed consistent results across validation. The nomogram could be used for patient counselling and might aid in adjuvant therapy decision-making.
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Leimkühler M, Hentzen JEKR, Hemmer PHJ, Been LB, van Ginkel RJ, Kruijff S, van Leeuwen BL, de Bock GH. Systematic Review of Factors Affecting Quality of Life After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2020; 27:3973-3983. [PMID: 32335752 PMCID: PMC7471142 DOI: 10.1245/s10434-020-08379-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Previous studies have shown that, overall, quality of life (QoL) decreases within the first 3-6 months after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC), returning to baseline levels by 6-12 months. This systematic review aims to evaluate the factors affecting QoL after CRS + HIPEC within 12 months of surgery. METHODS Electronic databases were investigated searching for articles reporting QoL with validated questionnaires up to September 2019. Risk of bias was assessed with the methodological index for non-randomized studies tool. The primary outcomes were short-term (< 6 months after surgery) and medium-term (6-12 months after surgery) determinants of QoL after CRS + HIPEC. Secondary outcomes were QoL and reported symptoms over time. RESULTS We included 14 studies that used 12 different questionnaires. The reported data were collected prospectively or retrospectively for 1556 patients (dropout < 50% in four studies). Overall, studies showed diminished QoL within 3 months after surgery and a recovery to baseline or greater by 12 months. QoL was negatively influenced by higher age, female sex, prolonged operation time, extensive disease, residual disease, adjuvant chemotherapy, complications, stoma placement, and recurrent disease. QoL results were comparable between studies, with dropout rates above and below 50%. CONCLUSIONS QoL returns to baseline levels within 12 months after CRS + HIPEC provided the disease does not recur, and this recovery process is influenced by several factors.
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Huisman MG, Ghignone F, Ugolini G, Sidorenkov G, Montroni I, Vigano A, de Liguori Carino N, Farinella E, Cirocchi R, Audisio RA, de Bock GH, van Leeuwen BL. Long-Term Survival and Risk of Institutionalization in Onco-Geriatric Surgical Patients: Long-Term Results of the PREOP Study. J Am Geriatr Soc 2020; 68:1235-1241. [PMID: 32155289 PMCID: PMC7318670 DOI: 10.1111/jgs.16384] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/30/2019] [Accepted: 01/16/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To evaluate long-term survival and institutionalization in onco-geriatric surgical patients, and to analyze the association between these outcomes and a preoperative risk score. DESIGN Prospective cohort study with long-term follow-up. SETTING International and multicenter locations. PARTICIPANTS Patients aged 70 years or older undergoing elective surgery for a malignant solid tumor at five centers (n = 229). MEASUREMENTS We assessed long-term survival and institutionalization using the Preoperative Risk Estimation for Onco-geriatric Patients (PREOP) score, developed to predict the 30-day risk of major complications. The PREOP score collected data about sex, type of surgery, and the American Society for Anesthesiologists classification, as well as the Timed Up & Go test and the Nutritional Risk Screening results. An overall score higher than 8 was considered abnormal. RESULTS We included 149 women and 80 men (median age = 76 y; interquartile range = 8). Survival at 1, 2, and 5 years postoperatively was 84%, 77%, and 56%, respectively. Moreover, survival at 1 year was worse for patients with a PREOP risk score higher than 8 (70%) compared with 8 or lower (91%). Of those alive at 1 year, 43 (26%) were institutionalized, and by 2 years, almost half of the entire cohort (46%) were institutionalized or had died. A PREOP risk score higher than 8 was associated with increased mortality (hazard ratio = 2.6; 95% confidence interval [CI] = 1.7-4.0), irrespective of stage and age, but not with being institutionalized (odds ratios = 1 y, 1.6 [95% CI = .7-3.8]; 2 y, 2.2 [95% CI = .9-5.5]). CONCLUSION A high PREOP score is associated with mortality but not with remaining independent. Despite acceptable survival rates, physical function may deteriorate after surgery. It is imperative to discuss treatment goals and expectations preoperatively to determine if they are feasible. Using the PREOP risk score can provide an objective measure on which to base decisions. J Am Geriatr Soc 68:1235-1241, 2020.
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Leimkühler M, de Haas RJ, Pol VEH, Hemmer PHJ, Been LB, van Ginkel RJ, Kruijff S, de Bock GH, van Leeuwen BL. Adding diagnostic laparoscopy to computed tomography for the evaluation of peritoneal metastases in patients with colorectal cancer: A retrospective cohort study. Surg Oncol 2020; 33:135-140. [PMID: 32561078 DOI: 10.1016/j.suronc.2020.02.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 01/13/2020] [Accepted: 02/13/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Despite its widespread use, computed tomography (CT) is not perfect for evaluating peritoneal metastases of colorectal origin before cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). We therefore evaluated the value of adding diagnostic laparoscopy to CT when assessing patient eligibility for CRS + HIPEC. METHODS This was a retrospective study of a consecutive series of 112 patients evaluated systematically by diagnostic laparoscopy and CT between January 2012 and January 2018. Patient eligibility for CRS + HIPEC was assessed by the peritoneal cancer index (PCI) both at the time of initial diagnostic laparoscopy and during the retrospective review of CT images. Two experienced radiologists who were blinded to the PCI result at laparoscopy then independently estimated the PCI based on CT imaging. The primary outcome was the number of patients eligible for CRS + HIPEC by each method. RESULTS We identified 112 patients, of whom 95 (85%) were eligible for CRS + HIPEC based on diagnostic laparoscopy and 84 underwent CRS + HIPEC. Overall, 14 patients (17%) experienced an "open-and-close" procedure. In contrast to diagnostic laparoscopy, 100 patients (89%) were identified as being eligible for CRS + HIPEC by CT (p = 0.13), which would have resulted in an additional five open-and-close procedures. CONCLUSIONS Adding diagnostic laparoscopy to CT produced a clinically relevant, but statistically non-significant, reduction in the number of patients eligible for CRS + HIPEC. We conclude that diagnostic laparoscopy may be of use in preoperative assessments when systematic analysis by CT scores the PCI as greater than ten. Future research should focus on the cost-effectiveness of this approach.
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Plas M, Rutgers A, van der Wal-Huisman H, de Haan JJ, Absalom AR, de Bock GH, van Leeuwen BL. The association between the inflammatory response to surgery and postoperative complications in older patients with cancer; a prospective prognostic factor study. J Geriatr Oncol 2020; 11:873-879. [PMID: 32035801 DOI: 10.1016/j.jgo.2020.01.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 01/26/2020] [Accepted: 01/26/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Accurate prognostic biomarkers would substantially improve surgical planning and decisions making yet no studies have been reported exploring the inflammatory response in surgically treated older patients with cancer. The aim of this study was to explore inflammatory biomarkers as potential prognostic factors for postoperative complications within 30 days in older patients with cancer. METHOD Patients 65 years and older undergoing surgery for removal of a solid malignant tumour were included in an observational cohort study. All complications occurring up to 30 days postoperatively were documented prospectively. Inflammatory markers were measured in plasma samples pre- and postoperatively: C-reactive protein (CRP), Interleukin-1 beta (IL-1β), IL-6, IL-10, IL-12, and Tumour necrosis factor-alpha (TNF-α). Associations between inflammatory markers and postoperative complications were explored using logistic regression analysis. RESULTS Between July 2010 and April 2014, plasma samples of 224 patients were collected. Median age was 72 (65-89) years and 116 (51.8%) patients were female. Approximately half of the patients developed postoperative complications (49.6%) of whom 62 patients (55.9%) developed >1 complication. An independent prognostic effect was observed for the inflammatory biomarkers IL-6 and IL-10 for the occurrence of postoperative complications. CONCLUSION The perioperative inflammatory response is associated with complications, independently from patient and surgical factors which are also associated with outcome. Research is warranted towards further exploration of the perioperative inflammatory response with the aim to improve perioperative care and outcome, and might help to improve surgical planning and decision making for older patients with cancer.
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Jonker L, Plas M, de Bock GH, Lahr MMH, van Leeuwen BL. Implementing eHealth for Postoperative Home Monitoring of Elderly Cancer Patients: A Feasibility Study. Eur J Surg Oncol 2020. [DOI: 10.1016/j.ejso.2019.11.420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Du J, Plas M, Absalom AR, van Leeuwen BL, de Bock GH. The association of preoperative anxiety and depression with neurocognitive disorder following oncological surgery. J Surg Oncol 2020; 121:676-687. [PMID: 31930514 PMCID: PMC7064888 DOI: 10.1002/jso.25836] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/31/2019] [Indexed: 01/02/2023]
Abstract
Background The proposed underlying mechanisms of anxiety and depression, and of postoperative neurocognitive disorder (NCD), each include immune system involvement. Therefore, the aims of this study were to investigate the incidence of postoperative NCD 3 months after surgery among oncological patients undergoing surgery and to evaluate the role of preoperative anxiety and depression. Method A consecutive series of patients (age ≥ 18 years) undergoing surgery for the removal of solid tumors were included (n = 218). Cognitive performance was assessed preoperatively and at 3 months postoperatively. Preoperative anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale. Results NCD affected 12.3% of elderly patients (age ≥ 70 years, n = 57) at 3 months after surgery, with executive function mostly affected. By contrast, 8.4% of younger patients (age < 70 years, n = 107) were affected, with information processing speed mostly affected. Low educational attainment was a risk factor (OR, 6.0; 95% CI, 1.9–19.0) of overall NCD, whereas preoperative anxiety was associated with decline in the domain of executive function. Conclusion Postoperative NCD is a complication of oncological surgery for all adults instead of the elderly only. Preoperative anxiety was associated with an increased risk of executive function decline, and low educational attainment was a key factor for overall NCD.
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Bras L, Driessen DAJJ, de Vries J, Festen S, van der Laan BFAM, van Leeuwen BL, de Bock GH, Halmos GB. Patients with head and neck cancer: Are they frailer than patients with other solid malignancies? Eur J Cancer Care (Engl) 2019; 29:e13170. [PMID: 31571340 PMCID: PMC7063690 DOI: 10.1111/ecc.13170] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/06/2019] [Accepted: 09/04/2019] [Indexed: 12/16/2022]
Abstract
Objective We aimed to compare frailty status between patients with head and neck cancer (HNC) and other solid malignancies. Methods Data collection was prospective, and the following were compared between cohorts at baseline: patient and tumour characteristics, Charlson Comorbidity Index (CCI), Groningen Frailty Indicator (GFI), Mini Mental State Examination (MMSE), Activities of Daily Living (ADLs), Instrumental ADLs (IADLs), Timed Up and Go (TUG) and Quality of Life (QoL). Univariate and multivariate logistic regression analyses were performed, and odds ratios (ORs) with their 95% confidence intervals (95% CIs) were estimated. Results In total, 242 patients with HNC and 180 with other oncology diagnoses were enrolled, of whom 32.6% and 21.8% were frail according to the GFI respectively. Comorbidity scores were not significantly different between the cohorts (7.4% vs. 13.1%; OR 0.54; 95% CI 0.28–1.02). In the univariate analysis, the GFI was significantly worse in the HNC cohort (OR 1.74; 95% CI 1.11–2.71). However, in the multivariate analysis, the MMSE, TUG and global QoL were significantly worse in the HNC cohort, with ORs of 20.03 (95% CI 2.44–164.31), 11.56 (95% CI 1.86–71.68) and 0.98 (95% CI 0.97–1.00) respectively. Conclusion Patients with HNC appear to be frailer than patients with other solid malignancies despite comparable levels of comorbidity.
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Deckers EA, Wevers KP, Muller Kobold AC, Damude S, Vrielink OM, van Ginkel RJ, Been LB, van Leeuwen BL, Hoekstra HJ, Kruijff S. S-100B as an extra selection tool for FDG PET/CT scanning in follow-up of AJCC stage III melanoma patients. J Surg Oncol 2019; 120:1031-1037. [PMID: 31468535 PMCID: PMC6851671 DOI: 10.1002/jso.25682] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 08/05/2019] [Indexed: 11/13/2022]
Abstract
Background and Objectives This current study assessed the value of S‐100B measurement to guide fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scanning for detecting recurrent disease in stage III melanoma patients. Methods This study included 100 stage III melanoma patients in follow‐up after curative lymph node dissection. Follow‐up visits included physical examination and S‐100B monitoring. FDG PET/CT scanning was indicated by clinical symptoms and/or elevated S‐100B. Results Of 100 patients, 13 (13%) had elevated S‐100B without clinical symptoms, of whom 7 (54%) showed disease evidence upon FDG PET/CT scanning. Twenty‐six patients (26%) had clinical symptoms with normal S‐100B and FDG PET/CT revealed metastasis in 20 (77%). Three patients had clinical symptoms and elevated S‐100B, and FDG PET/CT revealed metastasis in all three (100%). Overall, FDG PET/CT scanning revealed metastasis in 30 of the 42 patients (71.4%). For seven recurrences, elevated S‐100B prompted early detection of asymptomatic disease; 10% of all asymptomatic patients in follow‐up, 23% of all patients with recurrent disease. Conclusion S‐100B cannot exclude recurrent disease during follow‐up of stage III melanoma. However, adding S‐100B measurement to standard clinical assessment can guide FDG PET/CT scanning for detecting recurrent melanoma.
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Portielje JEA, Hamaker ME, Maas HAAM, van Leeuwen BL, van den Bos F. [American guideline for geriatric oncology; applicable to Dutch clinical practice?]. NEDERLANDS TIJDSCHRIFT VOOR GENEESKUNDE 2019; 163:D3614. [PMID: 31361408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
American guideline for geriatric oncology; applicable to Dutch clinical practice? The American Society of Clinical Oncology (ASCO) has recently issued a guideline for geriatric oncology that provides guidance regarding the practical assessment and management of vulnerabilities in older patients undergoing chemotherapy. The recommendations are discussed and a practical framework for implementation in Dutch oncology practice is described.
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Vrielink OM, Kruijff S, van Leeuwen BL, Roodenburg JL. Application of CO 2 laser evaporation in locally advanced melanoma. Melanoma Manag 2019; 6:MMT14. [PMID: 31236206 PMCID: PMC6582456 DOI: 10.2217/mmt-2018-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 02/18/2019] [Indexed: 11/21/2022] Open
Abstract
Aim This study aims to investigate the role of CO2 laser evaporation in the treatment of melanoma patients with satellite or in-transit metastases. Materials & methods Patients who underwent CO2 laser evaporation were retrospectively included between November 2002 and August 2018. The Sharplan 40C CO2 laser was used with a high pulse wave mode. Data concerning patient and tumor characteristics, CO2 laser evaporation and subsequent therapies were collected. Results A total of 26 patients were included. Median duration of local control was 5.5 months. The median number of lesions evaporated per treatment was three (1-16); patients received a median of three (1-19) treatments. Conclusion In a selected group of melanoma patients with satellite or in-transit metastases, CO2 laser evaporation should be considered as treatment for local control.
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