Association of Geriatric Comanagement and 90-Day Postoperative Mortality Among Patients Aged 75 Years and Older With Cancer

The effect of comprehensive geriatric assessment on treatment decisions, supportive care received, and postoperative outcomes in older adults with cancer undergoing surgery: A systematic review

INTRODUCTION

Surgery is an essential part of cancer treatment, particularly for localised solid tumours. Geriatric assessments (GA) with tailored interventions or comprehensive GA (CGA) can identify frailty factors and needs of older adults with cancer, assisting treatment decisions and care strategies to reduce postoperative complications. This systematic review summarises the effects of GA/CGA compared to usual care for older adults with cancer intended for surgery: their impact on treatment decisions, supportive care interventions, postoperative complications, survival, and health-related quality of life (HRQOL).

MATERIALS AND METHODS

We conducted a systematic search of MEDLINE, EMBASE, CINAHL, and PubMed (January 2000-October 2022) for randomised controlled trials (RCTs) or cohort studies with a comparison group on the effects of GA/CGA in older adults with cancer (≥65 years) intended for surgery. This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Due to heterogeneity in study designs and reporting, a meta-analysis was not possible; results are narratively described.

RESULTS

From 12,440 citations, 312 were selected for full-text review. Thirteen studies reporting on 12 trials were included for analysis: four RCTs and eight cohort studies with comparison groups (three prospective, five retrospective). RCTs ranged in sample size (122-475; mean 249), with variability in who performed GA/CGA, disciplines involved, and team integration. Primary outcomes included impact of GA/CGA on postoperative delirium (two studies), Clavien-Dindo (CD) grade II-V postoperative complications (one study), hospital length of stay (one study), and a composite criterion including mortality, functional impairment, and weight loss (one study). All RCTs scored high for risk of bias due to underpowering for their primary outcome; none met their primary endpoint. After adjustment for prespecified factors in secondary analyses, one RCT found GA/CGA significantly reduced the odds of postoperative complications (CD grade I-V) (adjusted-OR: 0.33, 95 %CI: 0.11-0.95; p = 0.05) due to fewer grade I-II complications. One RCT reported no significant difference between groups in HRQOL: intervention patients reported less pain at discharge, but this difference disappeared at three-month follow-up.

DISCUSSION

Well-powered, high-quality trials are needed to determine the impact of GA/CGA on optimising surgical treatment decisions, supportive care and postoperative outcomes for older adults with cancer.

Care pathways for patients with cognitive impairment and chronic kidney disease

Various epidemiological datasets and pathophysiological hypotheses have highlighted a significant link between chronic kidney disease (CKD) and cognitive impairment (CI); each condition can potentially exacerbate the other. Here, we review the mutual consequences of CKD and CI on health outcomes and care pathways and highlight the complexities due to the involvement of different specialists. Our narrative review covers (i) the burden of CI among patients with CKD, (ii) the impact of CI on kidney health, (iii) access to kidney replacement therapy for people with CI, (iv) resources in cognitive care and (v) potential models for integrated 'nephro-cognitive' care. CI (ranging from mild CI to dementia) has a significant impact on older adults, with a high prevalence and a strong association with CKD. Furthermore, CI complicates the management of CKD and leads to a higher mortality rate, poorer quality of life and higher healthcare costs. Due to difficulties in symptom description and poor adherence to medical guidelines, the presence of CI can delay the treatment of CKD. Access to care for patients with both CKD and CI is hindered by physical, cognitive and systemic barriers, resulting in less intensive, less timely care. Multidisciplinary approaches involving nephrologists, geriatricians, neurologists and other specialists are crucial. Integrated care models focused on person-centred approaches, shared decision-making and continuous co-management may improve outcomes. Future research should focus on the putative beneficial effects of these various strategies on both clinical and patient-reported outcomes.

Reducing in-hospital complications in older patients undergoing plastic surgery through a collaborative model of care

BACKGROUND

There is increasing evidence to support collaborative care and proactive comprehensive geriatric assessment and management in a number of surgical specialties. Data are lacking in older people under the care of plastic surgeons. This before/after study evaluates the impact of the introduction of a shared care model between geriatric medicine and plastic surgery in an Australian metropolitan teaching hospital.

METHODS

A shared care model was implemented for all patients aged 75 years and older admitted electively and emergently under the plastic surgery team with patients admitted jointly under a plastic surgeon and geriatrician. Comprehensive geriatric assessment and management was undertaken on admission with tailored intervention along with regular inpatient review. The primary outcome of interest was rate of in-hospital complications. Secondary outcome measures included individual complications, length of stay, readmission, and discharge disposition.

RESULTS

A total of 123 consecutive patients were eligible for inclusion (63 pre-intervention, 60 intervention). The rate of complications was significantly lower in the intervention group (47.6% vs. 28.3%, P = 0.03). There was a non-significant reduction in rate of delirium and new discharge to residential aged care facility. Subgroup analysis of frailer patients (Clinical Frailty Scale ≥4) demonstrated a significant reduction in rates of delirium (44.4% vs. 15.6%, P = 0.02) and new institutionalization (18.5% vs. 0.0%, P = 0.02).

CONCLUSION

A shared care model between geriatricians and plastic surgeons has the potential to improve patient outcomes with the greatest benefit likely to be seen in older patients with frailty.

Optimizing Pharmacotherapy During Implementation of Enhanced Recovery After Surgery (ERAS) in Ambulatory Urologic Oncology Surgery: Narrative Review

Adapting Enhanced Recovery After Surgery (ERAS) protocols to the ambulatory surgery setting is an ongoing need. While all surgical procedures necessitate the need for recovery protocols, urologists looking to perform outpatient surgical oncology procedures must be cognizant of the restrictive discharge criteria for an ambulatory procedure. Furthermore, a surgery being performed in the ambulatory setting should not imply that the procedure is without the risk of morbidity. With this in mind, ERAS protocols are paramount to ensuring optimal surgical outcomes. The individual components of such protocols encompass the perioperative period in its entirety. They include patient education, the stabilization of chronic medical conditions, perioperative nutrition, frailty mitigation, and the management of various postoperative sequalae. This review paper evaluates and summarizes the essential role of pharmacotherapy in ERAS protocols for ambulatory urologic oncology surgery.

Change and predictors of body composition after gastrectomy for gastric cancer during first postoperative year

PURPOSE

After gastrectomy for gastric cancer, patients often lose significant body weight because of decreased caloric intake and nutrient absorption. Body weight typically requires approximately 1 year to stabilize. This study aimed to examine the changes and predictors of body composition during the first postoperative year.

METHODS

A total of 230 patients underwent radical gastrectomy for stage I to III gastric cancers. Body composition was measured using bioelectrical impedance analysis, and changes were analyzed over 1 year. Multiple regression analysis was used to identify predictors of body composition changes.

RESULTS

Body composition changes and significant body weight and body fat mass reductions occurred primarily within the first 6 months postoperatively. Skeletal muscle mass initially decreased but improved after 6 months without significant changes related to adjuvant chemotherapy. Increased edema was observed at 6 and 12 months postoperatively in patients after total gastrectomy and adjuvant chemotherapy. Gastrectomy type and body mass index significantly affected postoperative body weight changes. In addition, gastrectomy type was associated with changes in skeletal muscle mass and bone mineral content. Adjuvant chemotherapy significantly affected the whole-body phase angle at 6 and 12 months.

CONCLUSION

Our findings emphasized the initial significant reductions postoperatively and subsequent adjustments over time and elucidated the complex interplay between surgical techniques, adjuvant treatment, and patient characteristics and midterm changes in body composition.

Association between geriatric co-management and receipt of rehabilitation services in the inpatient postoperative period among older adults with cancer

PURPOSE

Geriatric co-management is associated with a lower postoperative mortality among older adults with cancer. This might be due to a higher use of rehabilitation services such as physical therapy (PT) or occupational therapy (OT). In this study, we assess the relationship between geriatric co-management and PT /OT use.

METHODS

This is a retrospective cohort study of adults aged 75 years and older with cancer who underwent elective surgery at Memorial Sloan Kettering Cancer Center between February 2015 and February 2018. We used two separate multivariable logistic regression models for PT and OT, adjusted for age at surgery, gender, American Society of Anesthesiology score, preoperative albumin, operative time, and estimated blood loss. We also evaluated the association between frailty and receipt of PT and or OT using separate models by additionally including frailty as a primary predictor.

RESULTS

Of the 1650 patients, 308 (19%) did not receive PT or OT, 747 (45%) received only PT, and 593 (36%) received both PT and OT. Geriatric co-management was significantly associated with higher PT use (OR = 1.58, 95% CI = 1.19, 2.11, p = 0.002) and higher OT use (OR = 1.36, 95% CI = 1.08, 1.71, p = 0.010). The associations between geriatric co-management and rehabilitation service remained after additional adjustment for frailty. Higher degree of frailty was also associated with higher PT use (OR = 1.11, 95% CI = 1.01, 1.22, p = 0.033) and higher OT use (OR = 1.25, 95% CI = 1.15, 1.34, p < 0.0001).

CONCLUSIONS

Geriatric co-management and frailty were associated with greater use of PT and OT. Future studies should investigate the impact of geriatric co-management on functional recovery.

Frailty and Renal Cell Carcinoma: Integration of Comprehensive Geriatric Assessment into Shared Decision-making

CONTEXT

Frailty, a geriatric syndrome characterized by decreased resilience and physiological reserve, impacts the prognosis and management of older adults significantly, particularly in the context of surgical and oncological care.

OBJECTIVE

To provide an overview of frailty assessment in the management of older patients with a renal mass/renal cell carcinoma (RCC), focusing on its implications for diagnostic workup, treatment decisions, and clinical outcomes.

EVIDENCE ACQUISITION

A narrative review of the literature was conducted, focusing on frailty definitions, assessment tools, and their application in geriatric oncology, applied to the field of RCC. Relevant studies addressing the prognostic value of frailty, its impact on treatment outcomes, and potential interventions were summarized.

EVIDENCE SYNTHESIS

Frailty is a poor prognostic factor and can influence decision-making in the management of both localized and metastatic RCC. Screening tools such as the Geriatric Screening Tool 8 (G8) and the Mini-COG test can aid clinicians to select older patients (ie, aged ≥65 yr) for a further comprehensive geriatric assessment (CGA) performed by dedicated geriatricians. The CGA provides insights to risk stratify patients and guide subsequent treatment pathways. As such, the involvement of geriatricians in multidisciplinary tumor boards emerges as an essential priority to address the complex needs of frail patients and optimize clinical outcomes. Herein, we propose a dedicated care pathway as a first key step to implement frailty assessment in clinical practice and research for RCC.

CONCLUSIONS

Frailty has emerged as a crucial factor influencing the management and outcomes of older patients with RCC. Involvement of geriatricians in diagnostic and therapeutic pathways represents a pragmatic approach to screen and assess frailty, fostering individualized treatment decisions according to holistic patient risk stratification.

PATIENT SUMMARY

Frailty, a decline in resilience and physiological reserve, influences treatment decisions and outcomes in elderly patients with renal cell carcinoma, guiding personalized care. In this review, we focused on pragmatic strategies to screen patients with a renal mass suspected for renal cell carcinoma, who are older than 65 yr, for frailty and on personalized management algorithms integrating geriatric input beyond patient- and tumor-related factors.

An anesthesiology-led perioperative outreach service: experience from a Canadian centre and a focused narrative literature review

Approximately 320 million surgeries occur annually worldwide, increasingly performed on an ageing, comorbid population in whom postoperative complications contribute significantly to mortality. While anesthesiologists have led advances in perioperative care, the optimal structure of the provision of postoperative care has lacked discourse. In this article, we describe the implementation, structure, role, and benefits of an Anesthesiology Perioperative Outreach Service (APOS) at a Canadian tertiary hospital, providing proactive daily review and management of high-risk surgical patients. The APOS involves routine reviews and care on surgical wards, emphasizing collaboration among anesthesiology, internal medicine, surgery, and geriatric medicine teams, with a specific screening pathway to identify patients experiencing myocardial injury after noncardiac surgery. We discuss case vignettes to illustrate common examples of how the APOS enabled early detection and treatment escalation for deteriorating patients and provide a focused narrative literature review. The anesthesiology-led perioperative outreach model described herein could provide an implementable framework for institutions seeking to enhance their quality of postoperative care-particularly among complex, comorbid patients at risk of postoperative morbidity.

Comprehensive Geriatric Assessment, Treatment Decisions, and Outcomes in Older Patients Eligible for Pancreatic Surgery

INTRODUCTION

Periampullary cancer has a poor prognosis. Surgical resection is a potentially curative but high-risk treatment. Comprehensive geriatric assessment (CGA) can inform treatment decisions, but has not yet been evaluated in older patients eligible for pancreatic surgery.

METHODS

This prospective observational study included patients ≥ 70 years of age eligible for pancreatic surgery. Frailty was defined as impairment in at least two of five domains: somatic, psychological, functional, nutritional, and social. Outcomes included postoperative complications, functional decline, and mortality.

RESULTS

Of the 88 patients included, 87 had a complete CGA. Sixty-five patients (75%) were frail and 22 (25%) were non-frail. Frail patients were more likely to receive nonsurgical treatment (43.1% vs. 9.1% p = 0.004). Fifty-seven patients underwent surgery, of which 52 (59%) underwent pancreaticoduodenectomy. The incidence of postoperative delirium was three times higher in frail patients (29.7% vs. 0%, p = 0.005). The risk of mortality was three times higher in frail patients (HR: 3.36, 95% CI: 1.43-7.89, p = 0.006).

CONCLUSION

Frailty is common in older patients eligible for pancreatic surgery and is associated with treatment decision, a higher incidence of delirium and a three times higher risk of all-cause mortality. CGA can contribute to shared decision-making and optimize perioperative care in older patients.

Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review

With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.

Interdisciplinary provider visits attenuate relationship between patient concerns and distress in older adults with cancer

PURPOSE

This study examined the relationship between multidimensional patient concerns and anxiety and depression in a national sample of older adults with cancer (OACs ≥ 65 years) and the buffering effect of visiting providers across disciplines (e.g., oncology, allied health, primary care, mental health) on these relationships.

METHODS

Participants completed a cross-sectional survey through the Cancer Support Community's Cancer Experience Registry (CER), an online community-based research initiative. Eligible participants were 65 years and older and diagnosed with cancer in the past five years. Participants completed self-report measures of (1) the severity of their concerns across multiple domains, (2) anxiety and depression, and (3) whether they received care for "symptoms and side effects" from various providers.

RESULTS

The sample consisted of 277 OACs; 45% endorsed elevated anxiety and 31% endorsed elevated depression. The most severe concerns were in the domains of body image and healthy lifestyle and symptom burden and impact. More severe concerns were associated with higher levels of anxiety and depression. The relationship between concern severity and distress was weaker in OACs who saw a palliative care, mental health, physical or occupational therapy provider, pharmacist, or primary care provider relative to OACs who did not. A visit with an oncology provider did not moderate most relationships between concerns and distress.

CONCLUSIONS

The relationship between OACs' concerns and distress was attenuated by treatment with a specialty provider. Interdisciplinary team care may be a vital component of comprehensive patient-centered care for OACs.

The impact of surgical intervention on religious coping, psychological well-being, and pain levels in older adult patients: A quasi-experimental study

AIM

This study aimed to determine the impact of surgical intervention on religious coping, psychological well-being, and pain levels in older adult patients.

METHOD

The data of the study, which used a one-group pretest-posttest quasi-experimental design without a control group, was collected between July 1, 2023, - January 30, 2024. Data collection involved the use of a Personal Information Form, the Religious Coping Scale, the Psychological Well-Being Scale, and the Visual Analog Scale.

RESULTS

The results revealed a significant increase in psychological well-being and positive religious coping after surgical intervention compared to presurgical levels (p < 0.001). Multiple linear regression analysis revealed that male gender, younger age, enhanced psychological well-being, and positive religious coping were identified as factors contributing to a reduction in postsurgical pain levels.

CONCLUSION

The study's results indicate that surgical intervention serves as a significant variable influencing psychological well-being and religious coping among older adult patients.

Management of esogastric cancer in older patients

Although esogastric cancers often affect patients over 75, there are no specific age-related guidelines for the care of these patients. Esogastric cancers have a poor prognosis and require multimodal treatment to obtain a cure. The morbidity and mortality of these multimodal treatments can be limited if care is optimized by selecting patients for neoadjuvant treatment and surgery. This can include a geriatric assessment, prehabilitation, renutrition, and more extensive use of minimally invasive surgery. Denutrition is frequent in these patients and is particularly harmful in older patients. While older patients may be provided with neoadjuvant chemotherapy or radiotherapy, it must be adapted to the patient's status. A reduction in the initial dose of palliative chemotherapy should be considered in patients with metastases. These patients tolerate immunotherapy better than systemic chemotherapy, and a strategy to replace chemotherapy with immunotherapy whenever possible should be evaluated. Finally, better supportive care is needed in patients with a poor performance status. Prospective studies are needed to improve the care and prognosis of elderly patients.

How to compensate for frailty? The real life impact of geriatric co-management on morbi-mortality after colorectal cancer surgery in patients aged 70 years or older

In Europe, CRC is the second most common cause of cancer death, and surgery remains the mainstay curative treatment. Age and frailty are associated with an increased risk of postoperative morbidity and 1-year mortality. Chronological age is not sufficient to assess the risk of postoperative complications. The CGA has been developed to better identify frail patients. Geriatric co-management have been developed to optimize the post-operative outcomes. We analyzed the real-life of geriatric co-management within an ERAS program on surgical outcomes at 90 days and oncologic outcomes at 1 year in patients aged 70 years or older after surgery for CRC. This was a retrospective study based on a prospective cohort. Fifty-one patients with a G8 score ≤ 14 were referred to geriatricians for preoperative CGA (Frail Group). They were compared with 151 patients with a G8 score ≥ 15 (Robust Group). In the Frail Group, patients were significantly older with more comorbidities than the patients in the Robust Group. Oncologic characteristics, treatments and global post-operative outcomes were comparable between the two groups. One year after surgery mortality and recurrence rates were similar between the two groups. Our study suggests that geriatric co-management is feasible and contributes to the reduction of postoperative morbimortality. Moreover, performing the CGA after G8 score screening and completion of geriatric interventions resulted in similar 90-day postoperative outcomes, in frail patients than in robust patients. Our results confirmed the benefit of geriatric co-management, involving G8 screening, CGA, and ERAS, for frail older patients undergoing surgery for CRC.

Updates on the Management of Colorectal Cancer in Older Adults

Colorectal cancer (CRC) poses a significant global health challenge. Notably, the risk of CRC escalates with age, with the majority of cases occurring in those over the age of 65. Despite recent progress in tailoring treatments for early and advanced CRC, there is a lack of prospective data to guide the management of older patients, who are frequently underrepresented in clinical trials. This article reviews the contemporary landscape of managing older individuals with CRC, highlighting recent advancements and persisting challenges. The role of comprehensive geriatric assessment is explored. Opportunities for treatment escalation/de-escalation, with consideration of the older adult's fitness level. are reviewed in the neoadjuvant, surgical, adjuvant, and metastatic settings of colon and rectal cancers. Immunotherapy is shown to be an effective treatment option in older adults who have CRC with microsatellite instability. Promising new technologies such as circulating tumor DNA and recent phase III trials adding later-line systemic therapy options are discussed. Clinical recommendations based on the data available are summarized. We conclude that deliberate efforts to include older individuals in future colorectal cancer trials are essential to better guide the management of these patients in this rapidly evolving field.

New Onset Geriatric Syndromes and One-year Outcomes Following Elective Gastrointestinal Cancer Surgery

OBJECTIVE

To assess whether older adults who develop geriatric syndromes following elective gastrointestinal surgery have poorer 1-year outcomes.

BACKGROUND

Within 10 years, 70% of all cancers will occur in older adults ≥65 years old. The rise in older adults requiring major surgery has brought attention to age-related complications termed geriatric syndromes. However, whether postoperative geriatric syndromes are associated with long-term outcomes is unclear.

METHODS

A population-based retrospective cohort study using the New York State Cancer Registry and the Statewide Planning and Research Cooperative System was performed including patients >55 years with pathologic stage I-III esophageal, gastric, pancreatic, colon, or rectal cancer who underwent elective resection between 2004 and 2018. Those aged 55 to 64 served as the reference group. The exposure of interest was a geriatric syndrome [fracture, fall, delirium, pressure ulcer, depression, malnutrition, failure to thrive, dehydration, or incontinence (urinary/fecal)] during the surgical admission. Patients with any geriatric syndrome within 1 year of surgery were excluded. Outcomes included incident geriatric syndrome, 1-year days alive and out of the hospital, and 1-year all-cause mortality.

RESULTS

In this study, 37,998 patients with a median age of 71 years without a prior geriatric syndrome were included. Of those 65 years or more, 6.4% developed a geriatric syndrome. Factors associated with an incident geriatric syndrome were age, alcohol/tobacco use, comorbidities, neoadjuvant therapy, ostomies, open surgery, and upper gastrointestinal cancers. An incident geriatric syndrome was associated with a 43% higher risk of 1-year mortality (hazard ratio, 1.43; 95% confidence interval, 1.27-1.60). For those aged 65+ discharged alive and not to hospice, a geriatric syndrome was associated with significantly fewer days alive and out of hospital (322 vs 346 days, P < 0.0001). There was an indirect relationship between the number of geriatric syndromes and 1-year mortality and days alive and out of the hospital after adjusting for surgical complications.

CONCLUSIONS

Given the increase in older adults requiring major surgical intervention, and the establishment of geriatric surgery accreditation programs, these data suggest that morbidity and mortality metrics should be adjusted to accommodate the independent relationship between geriatric syndromes and long-term outcomes.

The association of postoperative morbidity and age on 5-year survival after colorectal surgery in the elderly population: a nationwide cohort study

AIM

This study aimed to evaluate the association of age and postoperative morbidity on 5-year overall survival (OS) after elective surgery for colorectal cancer.

METHOD

Patients undergoing elective, curatively intended surgery for colorectal cancer Union for International Cancer Control Stages I-III between January 2014 and December 2019 were selected from four Danish nationwide healthcare databases. Patients were divided into four groups: group I 65-69 years old; group II 70-74 years old; group III 75-79 years old; and group IV ≥80 years old. Propensity score matching was used to reduce potential confounding bias. The primary outcome was the association of age and postoperative morbidity with 5-year OS. The secondary outcome was conditional survival, given that the patient had already survived the first 90 days after surgery.

RESULTS

After propensity score matching with a 1:1 ratio, group II contained 2221 patients; group III 952 patients; and group IV 320 patients. There was no significant difference in 5-year OS between group I (reference) and groups II and III (P = 0.4 and P = 0.9, respectively). Patients with severe postoperative complications within 30 days after surgery had a significantly decreased OS (P < 0.01); however, when patients who died within the first 90 days were excluded from the analysis, the differences in 5-year OS were less pronounced across all age groups.

CONCLUSION

Postoperative morbidity, and not patient age, was associated with a lower 5-year OS. Long-term survival for patients who experience a complication is similar to patients who did not have a complication when conditioning on 90 days of survival.

State of the scientific evidence and recommendations for the management of older patients with gastric cancer

Gastric cancer is one of the most frequent and deadly tumours worldwide. However, the evidence that currently exists for the treatment of older adults is limited and is derived mainly from clinical trials in which older patients are poorly represented. In this article, a group of experts selected from the Oncogeriatrics Section of the Spanish Society of Medical Oncology (SEOM), the Spanish Group for the Treatment of Digestive Tumours (TTD), and the Spanish Multidisciplinary Group on Digestive Cancer (GEMCAD) reviews the existing scientific evidence for older patients (≥65 years old) with gastric cancer and establishes a series of recommendations that allow optimization of management during all phases of the disease. Geriatric assessment (GA) and a multidisciplinary approach should be fundamental parts of the process. In early stages, endoscopic submucosal resection or laparoscopic gastrectomy is recommended depending on the stage. In locally advanced stage, the tolerability of triplet regimens has been established; however, as in the metastatic stage, platinum- and fluoropyrimidine-based regimens with the possibility of lower dose intensity are recommended resulting in similar efficacy. Likewise, the administration of trastuzumab, ramucirumab and immunotherapy for unresectable metastatic or locally advanced disease is safe. Supportive treatment acquires special importance in a population with different life expectancies than at a younger age. It is essential to consider the general state of the patient and the psychosocial dimension.

Transplantation and Cellular Therapy for Older Adults-The MSK Approach

PURPOSE OF REVIEW

Hematologic malignances more commonly affect older individuals and often present with advanced, higher risk disease than younger patients. Allogeneic and autologous hematopoietic cell transplantation is well-established treatment modalities with curative potential following either frontline treatments for these diseases or salvage therapy in the relapsed or refractory setting. More recently, novel cellular immunotherapy such as chimeric antigen receptor T-cell therapy has been shown to lead to high response rate and durable remission in many patients with advanced blood cancers.

RECENT FINDINGS

Given unique characteristics of older patients, how best to deliver these higher-intensity and time sensitive treatment modalities for them remains challenging. Moreover, their short-term and potential long-term impact on their functional status, cognitive status, and quality of life may be significant considerations for many older patients. All these issues contributed to the lack of access and significant underutilization of these potential curative treatment strategies. In this review, we present up to date evidence to support potential benefits of transplantation and cellular therapy for older adults, their steady improving outcomes, and most importantly, highlight the use of geriatric assessment to help select appropriate older patients and optimize them prior to and following transplantation and cellular therapy. We specifically describe our approach at Memorial Sloan Kettering Cancer Center and encouraging early results from its implementation.

Esophageal cancer in octogenarians: Should esophagectomy be done?

INTRODUCTION

Esophagectomy is the treatment of choice for esophageal cancer. In octogenarians data is conflicting. We evaluated postoperative outcomes and long-term survival of octogenarians and their younger counterparts.

MATERIALS AND METHODS

A retrospective analysis of a prospectively maintained database including consecutive patients with esophageal cancer who underwent esophagectomy at a large referral, academic center between 2012 and 2021. Subgroups were designed according to age (<70, 70-79, and ≥ 80).

RESULTS

A total of 359 patients underwent esophagectomy for esophageal cancer, 223 (62%) aged <70, 107 (30%) aged 70-79 and 29 (8%) aged ≥80. Octogenarians had higher American Society of Anesthesiologists [ASA] scores (p = 0.001), and fewer received neoadjuvant therapy (p = 0.04). Octogenarians experienced more major complications (P < 0.001) with significantly higher 30-day mortality rate (P = 0.001). In a multivariable analysis, major complications were associated with higher risk of being discharged to a rehabilitation center (odds ratio [OR] 14.839, 95% confidence interval [CI] 4.921-44.747, p < 0.001) while age was not. Overall survival was reduced in octogenarians, with a 50th percentile survival of 10 months compared to 32 and 26 months in patients age < 70 and 70-79, respectively (p = 0.014). In a multivariable analysis, age ≥ 80 (hazard ratio [HR] 4.478 95% CI 2.151-9.322, p < 0.001), cancer stage (HR 1.545, 95% CI 1.095-2.179, p = 0.013), and postoperative major complications (HR 2.705 95% CI 1.913-3.823, p < 0.001) were independently associated with reduced survival.

DISCUSSION

Our study showed that octogenarians had significantly higher postoperative major complications compared to younger age groups. Overall survival was significantly reduced in these patients, probably due to an increased rate of perioperative mortality. Better patient selection and preparation may improve postoperative outcomes and increase long-term survival.

The perceived value of a geriatrics-surgery co-management program: Perspectives from three surgical specialties

BACKGROUND

Geriatrics-surgery co-management (GSCM) programs have improved patient outcomes, but little is known about how they change care and whether their value varies by surgical specialty. We aimed to assess GSCM's effects as perceived by Orthopedic Trauma, Trauma, and Neurosurgery clinicians.

METHODS

We conducted a mixed-methods study utilizing electronic survey and virtual interviews at Penn Presbyterian Medical Center, an academic trauma center, in Philadelphia, PA. Participants included physicians, advanced practice providers, nurses, social workers, and case managers in the aforementioned specialties. Key measures were perspectives on value of GSCM, its facilitators, specialty most appropriate to manage specified medical issues, and factors affecting use.

RESULTS

Of 71 eligible clinicians, 45 (63%) completed the survey and 12 (21%) of 56 purposefully sampled for specialty-role diversity were interviewed. Clinicians across specialties valued GSCM highly and similarly for impact on personal management of older adults (grand mean [standard error, SE] = 4.33 [0.24] out of 5; p = 0.80 for specialty means comparisons), patient care (mean [SE] = 4.47 [0.21]; p = 0.27), patient outcomes (mean [SE] = 4.26 [0.22]; p = 0.51), and specialty overall (mean [SE] = 4.55 [0.23]; p = 0.25) but less so for knowledge growth (mean [SE] = 3.47 [0.29]; p = 0.11). Interviewees across specialties reported that value derived from improved understanding of patient history, management of complex medical conditions, goals of care support, communication with families, and patient discharge facilitation. Interviewees also agreed on program facilitators: aligned stakeholders, shared data-driven goals, champion/administrative support, continuity and availability of geriatricians, and thorough communication. Specialties differed on three issues: (1) who should manage some medical concerns; (2) whether GSCM makes their job easier (significantly easier for Orthopedic Trauma: mean [SE] = 4.75 [0.29] vs. Trauma: mean [SE] = 4.01 [0.19]; p = 0.05); and (3) whether GSCM increases coordination difficulty (more for Neurosurgery: mean [SE] = 2.18 [0.0.58] vs. Orthopedic Trauma: mean [SE] = 0.51 [0.42]; p = 0.03 and Trauma: mean [SE] = 0.89 [0.28]; p = 0.07). Orthopedic Trauma had the most positive impression of GSCM overall.

CONCLUSIONS

Clinicians across diverse surgical specialties valued GSCM. Hospitals considering implementation or expansion of GSCM should attend to identified facilitators and may need to tailor to specialty.

Survival in Older Japanese Adults With Advanced Cancer Before and After Implementation of a Geriatric Oncology Service

PURPOSE

Research studies have demonstrated that comprehensive geriatric assessment (CGA) improves outcomes in older adults with cancer treated with chemotherapy. We compared survival outcomes on older adults with advanced cancer before and after the initiation of a geriatric oncology service (GOS) in a single Japanese cancer center.

METHODS

This was a comparative study of two groups of consecutive patients 70 years and older with advanced cancer who were referred to medical oncology for first-line chemotherapy before (controls; n = 151, September 2015-August 2018) and after (GOS; n = 191, September 2018-March 2021) implementation of the GOS. When the treating physician requested a consultation from the GOS, a geriatrician and an oncologist performed CGA and provided recommendations for cancer treatment and geriatric interventions. Time to treatment failure (TTF) and overall survival (OS) were compared between the two groups.

RESULTS

The median age for all patients was 75 (range, 70-95) years, and 85% had GI cancers. In the GOS group, 82 patients received the CGA before a treatment decision and oncologic treatment plans were changed in 49 patients (60%). The overall implementation rate of the CGA-based geriatric interventions was 45%. Two hundred and eighty-two patients received chemotherapy (controls; n = 128 and GOS; n = 154), and 60 patients were treated with best supportive care only (controls; n = 23 and GOS; n = 37). Among patients receiving chemotherapy, TTF event rates for the GOS group compared with the control group were 5.7% versus 14% at 30 days (P = .02) and 13% versus 29% at 60 days (P = .001). The GOS group had longer OS than the control group with a hazard ratio of 0.64 (95% CI, 0.44 to 0.93; P = .02).

CONCLUSION

In this study, older adults with advanced cancer managed after the implementation of a GOS had improved survival outcomes compared with a historical control of patients.

Predictors of mortality in patients with isolated gastrointestinal perforation

Gastrointestinal (GI) perforation is common in the emergency department and has a high mortality rate. The present study aimed to identify risk factors for mortality in patients with GI perforation. The objective was to assess and prognosticate the surgical outcomes of patients, aiming to ascertain the efficacy of the procedure for individual patients. A retrospective cohort study of patients with GI perforation who underwent surgery in a public tertiary hospital in China from January 2012 to June 2022 was performed. Demographics, clinical characteristics, laboratory and imaging results, and outcomes were collected from electronic medical records. The primary outcome measure was in-hospital mortality, and patients were divided into survivor and non-survivor groups based on this measure. Univariate and multivariable logistic regression analyses were performed to obtain independent factors associated with mortality. A total of 529 patients with GI perforation were eligible for inclusion. The in-hospital mortality rate after emergency surgery was 10.59%. The median age of the patients was 60 years (interquartile range, 44-72 years). Multivariable logistic regression analysis indicated that age, shock on admission, elevated serum creatinine (sCr) and white blood cell (WBC) count <3.5x109 or >20x109 cells/l were predictors of in-hospital mortality. In conclusion, advanced age, shock on admission, elevated sCr levels and significantly abnormal WBC count are associated with higher in-hospital mortality following emergency laparotomy.

Perioperative mortality among geriatric patients in Ethiopia: a prospective cohort study

Background

With the dramatic growth in the aged population observed in developed and developing nations, the older population burdened by unmet demand for surgical treatment has become a significant yet unnoticed public health concern in resource-limited countries. Studies are limited regarding surgical mortality of geriatric patients in Africa. Therefore, this study aims to estimate the incidence and identify predictors of postoperative mortality using prospective data in a low-income country, Ethiopia.

Methods and materials

A prospective cohort study was conducted from June 01, 2019, to June 30, 2021, at a tertiary-level hospital in Ethiopia. Perioperative data were collected using an electronic data collection tool. Cox regression analysis was used to identify predictor variables. The association between predictors and postoperative mortality among geriatrics was computed using a hazard ratio (HR) with a 95% confidence interval (CI); p-value <0.05 was a cutoff value to declare statistical significance.

Results

Of eligible 618 patients, 601 were included in the final analysis. The overall incidence of postoperative mortality among geriatrics was 5.16%, with a rate of 1.91 (95% CI: 1.34, 2.72) deaths per 1,000 person-day observation. Age ≥ 80 years (Adjusted hazard ratio (AHR) = 2.59, 95% CI: 1.05, 6.36), ASA physical status III/IV (AHR = 2.40, 95%CI 1.06, 5.43), comorbidity (AHR = 2.53, 95% CI: 1.19, 7.01), and emergency surgery (AHR = 2.92, 95% CI: 1.17, 7.27) were the significant predictors of postoperative mortality among older patients.

Conclusion

Postoperative mortality among geriatrics was high. Identified predictors were age ≥ 80 years, ASA status III/IV, comorbidity, and emergency surgery. Target-specific interventions should be addressed to improve high surgical mortality in these patients.

An evaluation of postoperative outcomes and treatment changes after frailty screening and geriatric assessment and management in a cohort of older patients with colorectal cancer

INTRODUCTION

Adequate patient selection is crucial within the treatment of older patients with colorectal cancer (CRC). While previous studies report increased morbidity and mortality in older patients screened positive for frailty, improvements in the perioperative care and postoperative outcomes have raised the question of whether older patients screened positive for frailty still face worse outcomes. This study aimed to investigate the postoperative outcomes of older patients with CRC screened positive for frailty, and to evaluate changes in treatment after frailty screening and geriatric assessment.

MATERIALS AND METHODS

Patients ≥70 years with primary CRC who underwent frailty screening between 1 January 2019 and 31 October 2021 were included. Frailty screening was performed by the Geriatric-8 (G8) screening tool. If the G8 indicated frailty (G8 ≤ 14), patients were referred for a comprehensive geriatric assessment (CGA). Postoperative outcomes and changes in treatment based on frailty screening and CGA were evaluated.

RESULTS

A total of 170 patients were included, of whom 74 (43.5%) screened positive for frailty (G8 ≤ 14). Based on the CGA, the initially proposed treatment plan was altered to a less intensive regimen in five (8.9%) patients, and to a more intensive regimen in one (1.8%) patient. Surgery was performed in 87.8% of patients with G8 ≤ 14 and 96.9% of patients with G8 > 14 (p = 0.03). Overall postoperative complications were similar between patients with G8 ≤ 14 and G8 > 14 (46.2% vs. 47.3%, p = 0.89). Postoperative delirium was observed in 7.7% of patients with G8 ≤ 14 and 1.1% of patients with G8 > 14 (p = 0.08). No differences in 30-day mortality (1.1% vs. 1.5%, p > 0.99) or one-year and two-year survival rates were observed (log rank, p = 0.26).

DISCUSSION

Although patients screened positive for frailty underwent CRC surgery less often, those considered eligible for surgery can safely undergo CRC resection within current clinical care pathways, without increased morbidity and mortality. Efforts to optimise perioperative care and minimise the risk of postoperative complications, in particular delirium, seem warranted. A multidisciplinary onco-geriatric pathway may support tailored decision-making in patients at risk of frailty.

Differential use of postoperative psychosocial and physical services among older adults with head and neck cancer

INTRODUCTION

Older adults undergoing head and neck cancer (HNC) surgery often have significant functional and mental health impairments. We examined use of postoperative physical, nutritional, and psychosocial services among a cohort of older adults with HNC comanaged by geriatricians and surgeons.

MATERIALS AND METHODS

Our sample consisted of older adults who were referred to the Geriatrics Service at Memorial Sloan Kettering Cancer Center between 2015 and 2019 and took a geriatric assessment (GA) prior to undergoing HNC surgery. Physical, nutritional, and psychosocial service utilization was assessed. Physical services included a physical, occupational, or rehabilitation consult during the patient's stay. Nutritional services consisted of speech and swallow or nutritional consult. Psychosocial services consisted of psychiatry, psychology, or a social work consult. Relationships between each service use, geriatric deficits, demographic, and surgical characteristics were assessed using Wilcoxon rank-sum test or Chi-square test.

RESULTS

In total, 157 patients were included, with median age of 80 and length of stay of six days. The most common GA impairments were major distress (61%), depression (59%), social activity limitation (SAL) (54%), and deficits in activities of daily living (ADL) (44%). Nutritional and physical services were used much more frequently than psychosocial services (80% and 85% vs 31%, respectively). Receipt of services was associated with longer median length of hospital stay, operation time, and greater deficits in ADLs. SAL was associated with physical and psychosocial consult and lower Timed Up and Go (TUG) score; instrumental ADL (iADL) deficits were associated with physical services; and depression and distress were associated with psychosocial services.

DISCUSSION

The burden of psychosocial deficits is high among older adults with HNC. Future work is needed to understand the limited utilization of psychosocial services in this population as well as whether referral to psychosocial services can reduce the burden of these deficits.

Survey and Interview Findings of an Environmental Scan of Perioperative Geriatric Models of Care in Canada

Background

Best practice recommendations support the implementation of perioperative geriatric care models that tailor to the specific needs of older adults undergoing surgery. The objective of this study was to describe the current proactive perioperative geriatric programs and pathways in Canadian hospitals.

Methods

A survey of geriatricians, surgeons, and anesthesiologists practicing in Canada combined with phone interviews of a subset of participants were used to determine characteristics of perioperative geriatric pathways or programs including eligibility, team composition, and intervention elements.

Results

Analysis of 132 survey respondents and 24 interviews showed 47% (40 out of 85) of hospitals described had elements of a perioperative geriatrics program and 20% had two or more elements. Eleven themes emerged including: how perioperative geriatric care programs built geriatric competencies in other health-care providers; geriatric assessment identified risks not captured in standard perioperative risk assessment; perceived value for patients and the health-care team; delirium prevention was addressed; most programs were reactive; most programs were informal; virtual care may be used to meet demand; successful implementation required system buy-in with collaboration across subspecialties; mechanisms to drive improvement were accountability and data evaluation; few clinicians with geriatric expertise; and other priorities limited program implementation.

Conclusions

There were few hospitals in Canada with perioperative geriatric care models and even fewer with elements spanning the entire perioperative pathway. Strengths, weaknesses, opportunities, and threats to inform the implementation and sustainability of perioperative geriatric care in the Canadian context were identified in this national environmental scan.

Assessing and managing frailty in emergency laparotomy: a WSES position paper

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty-an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions.

Supporting SURgery with GEriatric Co-Management and AI (SURGE-Ahead): A study protocol for the development of a digital geriatrician

INTRODUCTION

Geriatric co-management is known to improve treatment of older adults in various clinical settings, however, widespread application of the concept is limited due to restricted resources. Digitalization may offer options to overcome these shortages by providing structured, relevant information and decision support tools for medical professionals. We present the SURGE-Ahead project (Supporting SURgery with GEriatric co-management and Artificial Intelligence) addressing this challenge.

METHODS

A digital application with a dashboard-style user interface will be developed, displaying 1) evidence-based recommendations for geriatric co-management and 2) artificial intelligence-enhanced suggestions for continuity of care (COC) decisions. The development and implementation of the SURGE-Ahead application (SAA) will follow the Medical research council framework for complex medical interventions. In the development phase a minimum geriatric data set (MGDS) will be defined that combines parametrized information from the hospital information system with a concise assessment battery and sensor data. Two literature reviews will be conducted to create an evidence base for co-management and COC suggestions that will be used to display guideline-compliant recommendations. Principles of machine learning will be used for further data processing and COC proposals for the postoperative course. In an observational and AI-development study, data will be collected in three surgical departments of a University Hospital (trauma surgery, general and visceral surgery, urology) for AI-training, feasibility testing of the MGDS and identification of co-management needs. Usability will be tested in a workshop with potential users. During a subsequent project phase, the SAA will be tested and evaluated in clinical routine, allowing its further improvement through an iterative process.

DISCUSSION

The outline offers insights into a novel and comprehensive project that combines geriatric co-management with digital support tools to improve inpatient surgical care and continuity of care of older adults.

TRIAL REGISTRATION

German clinical trials registry (Deutsches Register für klinische Studien, DRKS00030684), registered on 21st November 2022.

Impact of Medical Specialties on Diagnostic and Therapeutic Management of Elderly Cancer Patients

The management (diagnostic and therapeutic) of cancer in the geriatric population involves a number of complex difficulties. The aim of this study was to assess the impact of a medical specialty on the diagnostic and therapeutic management of elderly cancer patients. Four clinical scenarios of cancer in the geriatric population, with a dedicated survey to gather information regarding each clinical case's diagnostic and therapeutic approaches, as well as the different criteria influencing physicians' therapeutic decisions, were exposed to geriatricians, oncologists, and radiotherapists in Saint-Etienne. The surveys were filled out by 13 geriatricians, 11 oncologists, and 7 radiotherapists. There was a homogeneity of responses regarding the confirmation of cancer diagnostics in the elderly. There were strong disparities (inter- and intra-specialties) for several clinical situations regarding the therapeutic management of cancer. There were significant disparities in terms of surgical management, the implementation of a chemotherapy protocol, and the adaptation of the chemotherapy dosage. Contrary to oncologists, who primarily consider the G8 and the Karnofsky score, geriatric autonomy scores and frailty with cognitive assessment were the key factors determining diagnostic/therapeutic therapy for geriatricians. These results raise important ethical questions, requiring specific studies in geriatric populations to provide the homogenous management of elderly patients with cancer.

Development and implementation of an interdisciplinary telemedicine clinic for older patients with cancer-Preliminary data

BACKGROUND

Frailty assessment is an important marker of the older adult's fitness for cancer treatment independent of age. Pretreatment geriatric assessment (GA) is associated with improved mortality and morbidity outcomes but must occur in a time sensitive manner to be useful for cancer treatment decision making. Unfortunately, time, resources and other constraints make GA difficult to perform in busy oncology clinics. We developed the Cancer and Aging Interdisciplinary Team (CAIT) clinic model to provide timely GA and treatment recommendations independent of patient's physical location.

METHODS

The interdisciplinary CAIT clinic model was developed utilizing the surge in telemedicine during the COVID-19 pandemic. The core team consists of the patient's oncologist, geriatrician, registered nurse, pharmacist, and registered dietitian. The clinic's format is flexible, and the various assessments can be asynchronous. Patients choose the service method-in person, remotely, or hybrid. Based on GA outcomes, the geriatrician provides recommendations and arrange interventions. An assessment summary including life expectancy estimates and chemotoxicity risk calculator scores is conveyed to and discussed with the treating oncologist. Physician and patient satisfaction were assessed.

RESULTS

Between May 2021 and June 2022, 50 patients from multiple physical locations were evaluated in the CAIT clinic. Sixty-eight percent was 80 years of age or older (range 67-99). All the evaluations were hybrid. The median days between receiving a referral and having the appointment was 8. GA detected multiple unidentified impairments. About half of the patients (52%) went on to receive chemotherapy (24% standard dose, 28% with dose modifications). The rest received radiation (20%), immune (12%) or hormonal (4%) therapies, 2% underwent surgery, 2% chose alternative medicine, 8% were placed under observation, and 6% enrolled in hospice care. Feedback was extremely positive.

CONCLUSIONS

The successful development of the CAIT clinic model provides strong support for the potential dissemination across services and institutions.

Frailty Assessment and Prehabilitation as Part of a PeRioperative Evaluation and Planning (PREP) Program for Patients Undergoing Colorectal Surgery

Frailty assessment and prehabilitation can be incrementally implemented in a multidisciplinary, multiphase pathway to improve patient care. To start, modifications can be made to a surgeon's practice with existing resources while adapting standard pathways for frail patients. Frailty screening can identify patients in need of additional assessment and optimization. Personalized utilization of frailty data for optimization through prehabilitation can improve postoperative outcomes and identify patients who would benefit from adapted care. Additional utilization of the multidisciplinary team can lead to improved outcomes and a strong business case to add additional members of the team.

Surgical and non-surgical complications after colorectal cancer surgery in older patients; time-trends and age-specific differences

BACKGROUND

Trends of surgical and non-surgical complications among the old, older and oldest patients after colorectal cancer (CRC) surgery could help to identify the best target outcome to further improve postoperative outcome.

MATERIALS AND METHODS

All consecutive patients ≥70 years receiving curative elective CRC resection between 2011 and 2019 in The Netherlands were included. Baseline variables and postoperative complications were prospectively collected by the Dutch ColoRectal audit (DCRA). We assessed surgical and non-surgical complications over time and within age categories (70-74, 75-79 and ≥ 80 years) and determined the impact of age on the risk of both types of complications by using multivariate logistic regression analyses.

RESULTS

Overall, 38648 patients with a median age of 76 years were included. Between 2011 and 2019 the proportion of ASA score ≥3 and laparoscopic surgery increased. Non-surgical complications significantly improved between 2011 (21.8%) and 2019 (17.1%) and surgical complications remained constant (from 17.6% to 16.8%). Surgical complications were stable over time for each age group. Non-surgical complications improved in the oldest two age groups. Increasing age was only associated with non-surgical complications (75-79 years; OR 1.17 (95% CI 1.10-1.25), ≥80 years; OR 1.46 (95% CI 1.37-1.55) compared to 70-74 years), not with surgical complications.

CONCLUSION

The reduction of postoperative complications in the older CRC population was predominantly driven by a decrease in non-surgical complications. Moreover, increasing age was only associated with non-surgical complications and not with surgical complications. Future care developments should focus on non-surgical complications, especially in patients ≥75 years.

Geriatric assessment and treatment decision-making in surgical oncology

PURPOSE OF REVIEW

Present an approach for surgical decision-making in cancer that incorporates geriatric assessment by building upon the common categories of tumor, technical, and patient factors to enable dual assessment of disease and geriatric factors.

RECENT FINDINGS

Conventional preoperative assessment is insufficient for older adults missing important modifiable deficits, and inaccurately estimating treatment intolerance, complications, functional impairment and disability, and death. Including geriatric-focused assessment into routine perioperative care facilitates improved communications between clinicians and patients and among interdisciplinary teams. In addition, it facilitates the detection of geriatric-specific deficits that are amenable to treatment. We propose a framework for embedding geriatric assessment into surgical oncology practice to allow more accurate risk stratification, identify and manage geriatric deficits, support decision-making, and plan proactively for both cancer-directed and non-cancer-directed therapies. This patient-centered approach can reduce adverse outcomes such as functional decline, delirium, prolonged hospitalization, discharge to long-term care, immediate postoperative complications, and death.

SUMMARY

Geriatric assessment and management has substantial benefits over conventional preoperative assessment alone. This article highlights these advantages and outlines a feasible strategy to incorporate both disease-based and geriatric-specific assessment and treatment when caring for older surgical patients with cancer.

Intrinsic capacity and resilience: Taking frailty to the next level

In addition to frailty, two novel concepts have been introduced in the field of geriatrics to capture the heterogeneous ageing process: the first is intrinsic capacity, which uses a community-based, holistic approach and is propagated by the World Health Organization (WHO); and the second is resilience, which provides a more dynamic perspective on the individual's reserves, injury and recovery. While both concepts are linked to frailty, with all three focusing on reserves in relation to ageing, each approaches this issue from a different point of view. In this paper, we will compare and contrast these three concepts - frailty, intrinsic capacity and resilience - and assess their relevance to future geriatric oncology research as well as daily clinical practice.

Frailty Predicts Loss of Independence After Liver Surgery

BACKGROUND

Loss of independence (LOI) is a significant concern in patients undergoing liver surgery. Although the risks of morbidity and mortality have been well studied, there is a dearth of data regarding the risk of LOI. Therefore, this study aimed to assess predictors of LOI after liver surgery.

METHODS

This study utilized the National Surgical Quality Improvement Program (NSQIP) data from 2015 to 2018 from a retrospective cohort study of patients undergoing liver resections. LOI was defined as the change from preoperative functional independence to the postoperative discharge requirement in a post-care facility. Frailty was defined using the modified frailty index-5 (mFI-5).

RESULTS

A total of 22,463 patients underwent hepatectomy via the NSQIP during the study period. In total, 22,067 participants were included in the analysis. A total of 4.7% of patients had LOI after surgery and were discharged to a rehabilitation center or nursing facility. mFI-1 was an independent predictor of LOI (OR:2.2 [1.9-4.3]). However, the odds for LOI were higher (OR:5.1[2.5-8.2]) in patients with mFI ≥ 2.

CONCLUSION

LOI is an important outcome of liver surgery. Frailty is a predictor of LOI and should be used as a guide to inform patients about the potential outcomes.

Association Between Frailty and Time Alive and At Home After Cancer Surgery Among Older Adults: A Population-Based Analysis

BACKGROUND

Although frailty is known to impact short-term postoperative outcomes, its long-term impact is unknown. This study examined the association between frailty and remaining alive and at home after cancer surgery among older adults.

METHODS

Adults aged ≥70 years undergoing cancer resection were included in this population-based retrospective cohort study using linked administrative datasets in Ontario, Canada. The probability of remaining alive and at home in the 5 years after cancer resection was evaluated using Kaplan-Meier methods. Extended Cox regression with time-varying effects examined the association between frailty and remaining alive and at home.

RESULTS

Of 82,037 patients, 6,443 (7.9%) had preoperative frailty. With median follow-up of 47 months (interquartile range, 23-81 months), patients with frailty had a significantly lower probability of remaining alive and at home 5 years after cancer surgery compared with those without frailty (39.1% [95% CI, 37.8%-40.4%] vs 62.5% [95% CI, 62.1%-63.9%]). After adjusting for age, sex, rural living, material deprivation, immigration status, cancer type, surgical procedure intensity, year of surgery, and receipt of perioperative therapy, frailty remained associated with increased hazards of not remaining alive and at home. This increase was highest 31 to 90 days after surgery (hazard ratio [HR], 2.00 [95% CI, 1.78-2.24]) and remained significantly elevated beyond 1 year after surgery (HR, 1.56 [95% CI, 1.48-1.64]). This pattern was observed across cancer sites, including those requiring low-intensity surgery (breast and melanoma).

CONCLUSIONS

Preoperative frailty was independently associated with a decreased probability of remaining alive and at home after cancer surgery among older adults. This relationship persisted over time for all cancer types beyond short-term mortality and the initial postoperative period. Frailty assessment may be useful for all candidates for cancer surgery, and these data can be used when counseling, selecting, and preparing patients for surgery.

Thoracic surgery with geriatric assessment and collaboration can prepare frail older adults for lung cancer surgery

BACKGROUND AND OBJECTIVES

We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients.

METHODS

Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA > 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 < FI-CGA < 0.4. A qualitative analysis of geriatric interventions was performed.

RESULTS

Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18).

CONCLUSION

Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.

Quality of Life in Older Adults After Major Cancer Surgery: The GOSAFE International Study

BACKGROUND

Accurate quality of life (QoL) data and functional results after cancer surgery are lacking for older patients. The international, multicenter Geriatric Oncology Surgical Assessment and Functional rEcovery after Surgery (GOSAFE) Study compares QoL before and after surgery and identifies predictors of decline in QoL.

METHODS

GOSAFE prospectively collected data before and after major elective cancer surgery on older adults (≥70 years). Frailty assessment was performed and postoperative outcomes recorded (30, 90, and 180 days postoperatively) together with QoL data by means of the three-level version of the EuroQol five-dimensional questionnaire (EQ-5D-3L), including 2 components: an index (range = 0-1) generated by 5 domains (mobility, self-care, ability to perform the usual activities, pain or discomfort, anxiety or depression) and a visual analog scale.

RESULTS

Data from 26 centers were collected (February 2017-March 2019). Complete data were available for 942/1005 consecutive patients (94.0%): 492 male (52.2%), median age 78 years (range = 70-95 years), and primary tumor was colorectal in 67.8%. A total 61.2% of all surgeries were via a minimally invasive approach. The 30-, 90-, and 180-day mortality was 3.7%, 6.3%, and 9%, respectively. At 30 and 180 days, postoperative morbidity was 39.2% and 52.4%, respectively, and Clavien-Dindo III-IV complications were 13.5% and 18.7%, respectively. The mean EQ-5D-3L index was similar before vs 3 months but improved at 6 months (0.79 vs 0.82; P < .001). Domains showing improvement were pain and anxiety or depression. A Flemish Triage Risk Screening Tool score greater than or equal to 2 (odds ratio [OR] = 1.58, 95% confidence interval [CI] = 1.13 to 2.21, P = .007), palliative surgery (OR = 2.14, 95% CI = 1.01 to 4.52, P = .046), postoperative complications (OR = 1.95, 95% CI = 1.19 to 3.18, P = .007) correlated with worsening QoL.

CONCLUSIONS

GOSAFE shows that older adults' preoperative QoL is preserved 3 months after cancer surgery, independent of their age. Frailty screening tools, patient-reported outcomes, and goals-of-care discussions can guide decisions to pursue surgery and direct patients' expectations.

Effectiveness of Geriatric Assessment-Driven Interventions on Survival and Functional and Nutritional Status in Older Patients with Head and Neck Cancer: A Randomized Controlled Trial (EGeSOR)

Simple Summary

Due to population ageing, there is an increasing number of older patients with head and neck cancers (HNC). Management of HNCs is complex. This population may be frailer than other patients with solid cancer. The Geriatric Assessment (GA) is a multidimensional diagnostic and therapeutic tool focused on frailty to propose a coordinated treatment plan and long-term follow-up. Several trials assessed the efficacy of GA-driven interventions on diverse outcomes but no recent randomized controlled trial demonstrated the impact on mortality, functional, or nutritional status as a primary outcome in this particular population. This trial highlighted several difficulties in implementation of geriatric interventions and suggested that the assessment of other models as co-management with oncologists and/or experienced practice nurses could be useful in clinical routine practice.

Abstract

This study assesses the efficacy of Geriatric Assessment (GA)-driven interventions and follow-up on six-month mortality, functional, and nutritional status in older patients with head and neck cancer (HNC). HNC patients aged 65 years or over were included between November 2013 and September 2018 by 15 Ear, Nose, and Throat (ENT) and maxillofacial surgery departments at 13 centers in France. The study was of an open-label, multicenter, randomized, controlled, and parallel-group design, with independent outcome assessments. The patients were randomized 1:1 to benefit from GA-driven interventions and follow-up versus standard of care. The interventions consisted in a pre-therapeutic GA, a standardized geriatric intervention, and follow-up, tailored to the cancer-treatment plan for 24 months. The primary outcome was a composite criterion including six-month mortality, functional impairment (fall in the Activities of Daily Living (ADL) score ≥2), and weight loss ≥10%. Among the patients included (n = 499), 475 were randomized to the experimental (n = 238) or control arm (n = 237). The median age was 75.3 years [70.4–81.9]; 69.5% were men, and the principal tumor site was oral cavity (43.9%). There were no statistically significant differences regarding the primary endpoint (n = 98 events; 41.0% in the experimental arm versus 90 (38.0%); p = 0.53), or for each criterion (i.e., death (31 (13%) versus 27 (11.4%); p = 0.48), weight loss of ≥10% (69 (29%) versus 65 (27.4%); p = 0.73) and fall in ADL score ≥2 (9 (3.8%) versus 13 (5.5%); p = 0.35)). In older patients with HNC, GA-driven interventions and follow-up failed to improve six-month overall survival, functional, and nutritional status.

Exploring Cost-Effectiveness of the Comprehensive Geriatric Assessment in Geriatric Oncology: A Narrative Review

The Comprehensive Geriatric Assessment (CGA) and the corresponding geriatric interventions are beneficial for community-dwelling older persons in terms of reduced mortality, disability, institutionalisation and healthcare utilisation. However, the value of CGA in the management of older cancer patients both in terms of clinical outcomes and in cost-effectiveness remains to be fully established, and CGA is still far from being routinely implemented in geriatric oncology. This narrative review aims to analyse the available evidence on the cost-effectiveness of CGA adopted in geriatric oncology, identify the relevant parameters used in the literature and provide recommendations for future research. The review was conducted using the PubMed and Cochrane databases, covering published studies without selection by the publication year. The extracted data were categorised according to the study design, participants and measures of cost-effectiveness, and the results are summarised to state the levels of evidence. The review conforms to the SANRA guidelines for quality assessment. Twenty-nine studies out of the thirty-seven assessed for eligibility met the inclusion criteria. Although there is a large heterogeneity, the overall evidence is consistent with the measurable benefits of CGA in terms of reducing the in-hospital length of stay and treatment toxicity, leaning toward a positive cost-effectiveness of the interventions and supporting CGA implementation in geriatric oncology clinical practice. More research employing full economic evaluations is needed to confirm this evidence and should focus on CGA implications both from patient-centred and healthcare system perspectives.

Patterns of Treatment and Outcomes in Older Men With Penile Cancer: A SEER Dataset Analysis

Purpose

To evaluate clinicopathologic and treatment characteristics from a population-based cohort of penile cancer, with an emphasis in older adults, due to incomplete evidence to guide therapy in this age subgroup.

Materials and Methods

Patients with malignant penile tumors diagnosed 2004-2016 were identified in the Surveillance, Epidemiology and End Results Program (SEER)-18 dataset. Demographic and treatment characteristics were obtained. Population was analyzed by age at diagnosis (<65 vs ≥65 years). We examined univariate associations between age groups with Chi-square analysis. To study survival, we calculated Kaplan-Meier survival curves, but due to the high number of competing events, we also performed a univariate competing risk analysis using the cumulative incidence function, and a multivariate analysis using the Fine-Gray method. We also described competing mortality due to penile cancer and other causes of death.

Results

We included 3,784 patients. Median age was 68 years, 58.7% were aged ≥65. Older patients were less likely to have received chemotherapy (p<0.001), primary site surgery (p = 0.002), or therapeutic regional surgery (p <0.001). Median overall survival (OS) in patients <65 years was not reached (95% CI incalculable) vs 49 months in those ≥65 years (95% CI 45-53, p <0.0001). On univariate analysis, age was associated with a lower incidence of penile cancer death. On multivariate analysis, stage at diagnosis, and receipt of primary site surgery were associated with a higher incidence of penile cancer death. Estimated penile cancer-specific mortality was higher in patients <65 years in stages II-IV. Estimated mortality due to other causes was higher in older patients across all stages.

Conclusions

Older patients are less likely to receive surgery, chemotherapy and radiotherapy for penile cancer. Primary surgical resection was associated with better penile cancer-specific mortality on multivariate analysis. Competing mortality risks are highly relevant when considering OS in older adults with penile cancer. Factors associated with undertreatment of older patients with penile cancer need to be studied, in order to develop treatment strategies tailored for this population.

Ageing and cancer: a research gap to fill

The complex mechanisms of ageing biology are increasingly understood. Interventions to reduce or delay ageing‐associated diseases are emerging. Cancer is one of the diseases promoted by tissue ageing. A clockwise mutational signature is identified in many tumours. Ageing might be a modifiable cancer risk factor. To reduce the incidence of ageing‐related cancer and to detect the disease at earlier stages, we need to understand better the links between ageing and tumours. When a cancer is established, geriatric assessment and measures of biological age might help to generate evidence‐based therapeutic recommendations. In this approach, patients and caregivers would include the respective weight to give to the quality of life and survival in the therapeutic choices. The increasing burden of cancer in older patients requires new generations of researchers and geriatric oncologists to be trained, to properly address disease complexity in a multidisciplinary manner, and to reduce health inequities in this population of patients. In this review, we propose a series of research challenges to tackle in the next few years to better prevent, detect and treat cancer in older patients while preserving their quality of life.

Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies

We conducted a randomized controlled trial in older adults with hematologic malignancies to determine the impact of geriatrician consultation embedded in our oncology clinic alongside standard care. From February 2015 to May 2018, transplant-ineligible patients aged ≥75 years who presented for initial consultation for lymphoma, leukemia, or multiple myeloma at Dana-Farber Cancer Institute (Boston, MA, USA) were eligible. Pre-frail and frail patients, classified based on phenotypic and deficit-accumulation approaches, were randomized to receive either standard oncologic care with or without consultation with a geriatrician. The primary outcome was 1-year overall survival. Secondary outcomes included unplanned care utilization within 6 months of follow-up and documented end-of-life (EOL) goals-of-care discussions. Clinicians were surveyed as to their impressions of geriatric consultation. One hundred sixty patients were randomized to either geriatric consultation plus standard care (n=60) or standard care alone (n=100). The median age of the patients was 80.4 years (standard deviation = 4.2). Of those randomized to geriatric consultation, 48 (80%) completed at least one visit with a geriatrician. Consultation did not improve survival at 1 year compared to standard care (difference: 2.9%, 95% confidence interval: -9.5% to 15.2%, P=0.65), and did not significantly reduce the incidence of emergency department visits, hospital admissions, or days in hospital. Consultation did improve the odds of having EOL goals-of-care discussions (odds ratio = 3.12, 95% confidence interval: 1.03 to 9.41) and was valued by surveyed hematologic-oncology clinicians, with 62.9%-88.2% of them rating consultation as useful in the management of several geriatric domains.