Too Frail for Surgery? Initial Results of a Large Multidisciplinary Prospective Study Examining Preoperative Variables Predictive of Poor Surgical Outcomes

Surgical considerations in older adults with cancer

PURPOSE

The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment.

METHODS

This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality.

RESULTS

Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization.

CONCLUSION

Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.

Prevalence of frailty and its association with mortality in general surgery

BACKGROUND

We assessed the prevalence of frailty in an older acute general surgical population and its correlation with length of hospital stay, readmission to hospital, and 30- and 90-day mortality.

METHODS

In 3 acute surgical admission units, we assessed consecutive participants aged over 65 years with general surgical conditions. We measured the prevalence of frailty using a 7-point frailty score. We measured length of hospital stay, readmission to hospital, and mortality at both 30 and 90 days.

RESULTS

We studied 325 participants with an average age of 77.3 years 8.2 (standard deviation), 185 (57%) women. There were 88 (28%) participants who were classified as being mildly, moderately, or severely frail. The frail group spent longer in hospital (7.6 days, 95% confidence interval [CI] 6.1 to 9.2 vs 11.1, 95% CI 7.2 to 15.0; P = .03). They also were more likely to die at both 30 and 90 days (adjusted odds ratio [OR] 4.0, 95% CI 1.1 to 15.2, P = .04; OR 3.0, 95% CI 1.3 to 7.4, P = .02). Readmission to hospital did not differ (OR 1.1, 95% CI .5 to 2.3).

CONCLUSIONS

Over 1 in 4 people were frail. These individuals spent longer in hospital and were more likely to die.

Thoracic surgeons' perception of frail behavior in videos of standardized patients

Background

Frailty is a predictor of poor outcomes following many types of operations. We measured thoracic surgeons' accuracy in assessing patient frailty using videos of standarized patients demonstrating signs of physical frailty. We compared their performance to that of geriatrics specialists.

Methods

We developed an anchored scale for rating degree of frailty. Reference categories were assigned to 31 videos of standarized patients trained to exhibit five levels of activity ranging from “vigorous” to “frail.” Following an explanation of frailty, thoracic surgeons and geriatrics specialists rated the videos. We evaluated inter-rater agreement and tested differences between ratings and reference categories. The influences of clinical specialty, clinical experience, and self-rated expertise were examined.

Results

Inter-rater rank correlation among all participants was high (Kendall's W 0.85) whereas exact agreement (Fleiss' kappa) was only moderate (0.47). Better inter-rater agreement was demonstrated for videos exhibiting extremes of behavior. Exact agreement was better for thoracic surgeons (n = 32) than geriatrics specialists (n = 9; p = 0.045), whereas rank correlation was similar for both groups. More clinical years of experience and self-reported expertise were not associated with better inter-rater agreement.

Conclusions

Videos of standarized patients exhibiting varying degrees of frailty are rated with internal consistency by thoracic surgeons as accurately as geriatrics specialists when referenced to an anchored scale. Ratings were less consistent for moderate degrees of frailty, suggesting that physicians require training to recognize early frailty. Such videos may be useful in assessing and teaching frailty recognition.

Sarcopenia in patients with bladder cancer undergoing radical cystectomy: impact on cancer-specific and all-cause mortality

BACKGROUND

The authors evaluated sarcopenia as a predictor of cancer-specific survival (CSS) and overall survival (OS) among patients with urothelial cancer of the bladder undergoing radical cystectomy (RC).

METHODS

The lumbar skeletal muscle index (SMI) of 205 patients treated with RC for urothelial cancer between 2000 and 2007 was measured. Sarcopenia was classified according to international consensus definitions (SMI of < 55 cm(2)/m(2) for men and < 39 cm(2)/m(2) for women). The CSS and OS were estimated using the Kaplan-Meier method and compared with the log-rank test. Variables associated with CSS and all-cause mortality were summarized with hazard ratios (HRs).

RESULTS

Of 205 patients, 141 (68.8%) were sarcopenic. Patients with sarcopenia were older, but were otherwise similar to patients without sarcopenia with respect to sex, Charlson comorbidity index, American Society of Anesthesiologists score, Eastern Cooperative Oncology Group performance status, receipt of neoadjuvant chemotherapy, TNM stage of disease, and tumor grade (P > .05 for all). The median follow-up was 6.7 years, during which time 135 patients died, including 91 who died of bladder cancer. Sarcopenic patients had significantly worse 5-year CSS (49% vs 72%; P = .003) and OS (39% vs 70%; P = .003) compared with patients without sarcopenia. Moreover, sarcopenia was found to be independently associated with both increased CSS (HR, 2.14; P = .007) and all-cause mortality (HR, 1.93; P = .004) on multivariable analysis.

CONCLUSIONS

The presence of sarcopenia was found to significantly increase a patient's risk of CSS and all-cause mortality after undergoing RC for bladder cancer.

Preoperative quality of life and surgical outcomes in gynecologic oncology patients: a new predictor of operative risk?

OBJECTIVE

Quality of life (QoL) for women with gynecologic malignancies is predictive of chemotherapy related toxicity and overall survival but has not been studied in relation to surgical outcomes and hospital readmissions. Our goal was to evaluate the association between baseline, pre-operative QoL measures and 30-day post-operative morbidity and health resource utilization by gynecologic oncology patients.

METHODS

We analyzed prospectively collected survey data from an institution-wide cohort study. Patients were enrolled from 8/2012 to 6/2013 and medical record data was abstracted (demographics, comorbid conditions, and operative outcomes). Responses from several validated health-related QoL instruments were collected. Bivariate tests and multivariable linear and logistic regression models were used to evaluate factors associated with QoL scores.

RESULTS

Of 182 women with suspected gynecologic malignancies, 152 (84%) were surveyed pre-operatively and 148 (81%) underwent surgery. Uterine (94; 63.5%), ovarian (26; 17.5%), cervical (15; 10%), vulvar/vaginal (8; 5.4%), and other (5; 3.4%) cancers were represented. There were 37 (25%) cases of postoperative morbidity (PM), 18 (12%) unplanned ER visits, 9(6%) unplanned clinic visits, and 17 (11.5%) hospital readmissions (HR) within 30days of surgery. On adjusted analysis, lower functional well-being scores resulted in increased odds of PM (OR 1.07, 95%CI 1.01-.1.21) and HR (OR 1.11, 95%CI 1.03-1.19). A subjective global assessment score was also strongly associated with HR (OR 1.89, 95%CI 1.14, 3.16).

CONCLUSION

Lower pre-operative QoL scores are significantly associated with post-operative morbidity and hospital readmission in gynecologic cancer patients. This relationship may be a novel indicator of operative risk.

Identifying predictors of a difficult thyroidectomy

BACKGROUND

A Thyroidectomy Difficulty Scale (TDS) was previously developed that identified more difficult operations, which correlated with longer operative times and higher complication rates. The purpose of this study was to identify preoperative variables predictive of a more difficult thyroidectomy using the TDS.

METHODS

A four item, 20-point TDS, was used to score the difficulty of thyroid operations. Patient and disease factors were recorded for each patient. Difficult thyroidectomy and non-difficult thyroidectomy (NDT) patients were compared. A final multivariate logistic regression model was constructed with significant (P<0.05) variables from a univariate analysis.

RESULTS

A total of 189 patients were scored using TDS. Of them, 69 (36.5%) suffered from hyperthyroidism, 42 (22.2%) from Hashimotos, 34 (18.0%) from thyroid cancer, and 36 (19.0%) from multinodular goiter. Among hyperthyroid patients, the DT group had a greater number preoperatively treated with Lugols potassium iodide (81.6% DT versus 58.1% NDT, P=0.032), presence of ophthalmopathy (31.6% DT versus 9.7% NDT, P=0.028), and presence of (>4 IU/mL) antithyroglobulin antibodies (34.2% DT versus 12.9% NDT, P=0.05). Using multivariate analysis, hyperthyroidism (odds ratio [OR], 4.35, 95% confidence interval [CI], 1.23-15.36, P=0.02), presence of antithyroglobulin antibody (OR, 3.51, 95% CI, 1.28-9.66, P=0.015), and high (>150 ng/mL) thyroglobulin (OR, 2.61, 95% CI, 1.06-6.42, P=0.037) were independently associated with DT.

CONCLUSIONS

Using TDS, we demonstrated that a diagnosis of hyperthyroidism, preoperative elevation of serum thyroglobulin, and antithyroglobulin antibodies are associated with DT. This tool can assist surgeons in counseling patients regarding personalized operative risk and improve OR scheduling.

Role of neoadjuvant therapy in the multimodality treatment of older patients with pancreatic cancer

BACKGROUND

A well-defined treatment strategy for elderly patients with resectable pancreatic cancer is lacking. Multiple reports have described highly selected older cancer patients who have successfully undergone pancreatectomy. However, multimodality therapy is essential for long-term survival, and elderly patients are at high risk for not receiving adjuvant therapy postoperatively. We sought to describe the treatment patterns and outcomes of a series of elderly patients with pancreatic cancer who were treated with a multimodality strategy that liberally used neoadjuvant therapy.

STUDY DESIGN

We retrospectively reviewed treatment plans, short-term outcomes, and overall survival of all patients 70 years old and older, presenting to our institution over a 9-year period, who were treated for potentially resectable or borderline resectable pancreatic cancer.

RESULTS

There were 179 (76%) of 236 patients treated with curative intent. Of these patients, 153 (85%) initiated neoadjuvant therapy: 74 (48%) subsequently underwent pancreatectomy and 79 did not due to disease progression (n = 46), insufficient performance status (n = 23), or other reasons (n = 10). Eleven (42%) of 26 patients who underwent surgery first received postoperative therapy. Among patients treated with curative intent, the median overall survival of all patients initiating neoadjuvant therapy (16.6 months [range 2.1 to 142.7 months]) was similar to that of patients undergoing resection primarily (15.1 months [range 5.4 to 100.8 months]), p = 0.53. After pancreatectomy, patients had a 2% in-hospital mortality rate and 91% were discharged home.

CONCLUSIONS

Eighty-five percent of all patients 70 years old and older, who underwent pancreatectomy for potentially resectable or borderline resectable pancreatic cancer, received multimodality therapy. More than 90% were discharged home. These data demonstrate a potential role for neoadjuvant therapy in selecting elderly patients for surgery, and support further studies to refine individualized treatment protocols for this high-risk population.

Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance, Epidemiology, and End Results analysis

BACKGROUND

With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients.

METHOD

Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS).

RESULTS

With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70-79 years (stages I-III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70-79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001).

CONCLUSION

Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.

Sarcopenia as a predictor of complications and survival following radical cystectomy

PURPOSE

Patients undergoing radical cystectomy face substantial but highly variable risks of major complications. Risk stratification may be enhanced by objective measures such as sarcopenia. Sarcopenia (loss of skeletal muscle mass) has emerged as a novel biomarker associated with adverse outcomes in many clinical contexts relevant to cystectomy. Based on these data we hypothesized that sarcopenia would be associated with increased 30-day major complications and mortality after radical cystectomy for bladder cancer.

MATERIALS AND METHODS

We performed a retrospective study of patients treated with radical cystectomy at our institution from 2008 to 2011. Sarcopenia was assessed by measuring cross-sectional area of the psoas muscle (total psoas area) on preoperative computerized tomography. Cutoff points were developed and evaluated using ROC curves to determine predictive ability in men and women for outcomes of major complications and survival.

RESULTS

Of 224 patients with bladder cancer 200 underwent preoperative computerized tomography within 1 month of surgery. Total psoas area was calculated with a mean score of 712 and 571 cm2/m2 in men and women, respectively. A clear association was noted between major complications and lower total psoas area in women using a cutoff of 523 cm2/m2 to define sarcopenia (AUC 0.70). Sarcopenia was not significantly associated with complications in men. There was a nonsignificant trend of sarcopenia with worse 2-year survival.

CONCLUSIONS

Sarcopenia in women was a predictor of major complications after radical cystectomy. Further research confirming sarcopenia as a useful predictor of complications would support the development of targeted interventions to mitigate the untoward effects of sarcopenia before cancer surgery.

A prospective study examining the association between preoperative frailty and postoperative complications in patients undergoing minimally invasive surgery

BACKGROUND AND PURPOSE

Current surgical decision-making is overly subjective and often misjudges a patient's physiologic state. The concept of frailty has gained recent recognition and potentially represents a measureable phenotype, which can quantify a patient's physiologic reserve and risk of an adverse surgical outcome. We sought to investigate the relationship between preoperative markers of frailty and postoperative complications in patients undergoing minimally invasive surgery (MIS).

METHODS

Frailty, using the methodology described by Fried and coworkers, was prospectively measured in patients who presented to urology, general surgery, and surgical oncology clinics where major MIS (endoscopic, laparoscopic, or robotic) was planned. The relationship between preoperative markers of frailty and 30-day postoperative complications was our primary outcome measure.

RESULTS

Our cohort includes 80 patients. Mean age and body mass index were 60.0 (range 19-87) years and 29.2 (range 18.4-53.1) kg/m(2), respectively. The majority of patients were male (57.5%) and Caucasian (65.0%). Thirteen patients were deemed "intermediately frail" or "frail," and the remaining 67 were classified as "not frail." Thirteen (16.25%) patients experienced any postoperative complication. Five (38.5%) of the intermediately frail and frail patients experienced a complication, compared with eight (11.9%) of the not frail patients (odds ratio=5.914; 95% confidence interval=1.25-27.96; P=0.025).

CONCLUSION

The advent of MIS has potentially lured surgeons into thinking older and patients with comorbidities may more easily tolerate this surgical approach compared with traditional open techniques. Our data suggest, however, that intermediately frail or frail patients are at increased risk of experiencing postoperative complications compared with not frail patients.