Comorbidity in older surgical cancer patients: influence on patient care and outcome. Eur J Cancer. 2007;43:2179-2193. [PMID: 17681780 DOI: 10.1016/j.ejca.2007.06.008]

Disparities in care of older adults of color with cancer: A narrative review

This review describes the barriers and challenges faced by older adults of color with cancer and highlights methods to improve their overall care. In the next decade, cancer incidence rates are expected to increase in the United States for people aged ≥65 years. A large proportion will be older adults of color who often have worse outcomes than older White patients. Many issues contribute to racial disparities in older adults, including biological factors and social determinants of health (SDOH) related to healthcare access, socioeconomic concerns, systemic racism, mistrust, and the neighborhood where a person lives. These disparities are exacerbated by age-related challenges often experienced by older adults, such as decreased functional status, impaired cognition, high rates of comorbidities and polypharmacy, poor nutrition, and limited social support. Additionally, underrepresentation of both patients of color and older adults in cancer clinical research results in a lack of adequate data to guide the management of these patients. Use of geriatric assessments (GA) can aid providers in uncovering age-related concerns and personalizing interventions for older patients. Research demonstrates the ability of GA-directed care to result in fewer treatment-related toxicities and improved quality of life, thus supporting the routine incorporation of validated GA into these patients' care. GA can be enhanced by including evaluation of SDOH, which can help healthcare providers understand and address the needs of older adults of color with cancer who face disparities related to their age and race.

Gastric adenocarcinoma location and postoperative complication rates in Asian patients: A 2014-2019 NSQIP analysis

BACKGROUND

Asian gastric cancer patients have higher long-term survival rates post-gastrectomy. This study compares 30-day post-gastrectomy outcomes between Asians and non-Asians.

METHODS

Gastric cancer patients undergoing elective gastrectomies were identified in 2014-2019 NSQIP datasets (n ​= ​1,438). Demographics, comorbidities, and postoperative outcomes were analyzed.

RESULTS

Asians had lower odds of total gastrectomy (AOR ​= ​0.52, p ​= ​0.003), age ≥65 (AOR ​= ​0.60, p ​= ​0.006), smoking history (AOR ​= ​0.35, p ​< ​0.001), dyspnea (AOR ​= ​0.25, p ​= ​0.01), and hypoalbuminemia (AOR ​= ​0.62, p ​= ​0.025); they also had lower BMI (p ​< ​0.001). Postoperative outcomes were not significantly different aside from a shorter median length of hospital stay in days (LOS) (Asians: 7 (6, 11); non-Asians: 8 (6, 11); p ​< ​0.001).

CONCLUSIONS

Asian gastric cancer patients have significantly lower odds of having select preoperative comorbidities and have shorter hospital LOS.

Vulvar squamous cell carcinoma in women 80 years and older: Treatment, survival and impact of comorbidities

BACKGROUND

Despite being a disease of mainly older women, little is known about the clinical management of older women with vulvar squamous cell carcinoma (VSCC). We evaluated their daily clinical management compared with younger women, and established the prevalence of comorbidities and its impact on overall survival (OS).

METHODS

All Dutch women diagnosed with VSCC from 2015 to 2020 (n = 2249) were selected from the Netherlands Cancer Registry. Women aged ≥80 years (n = 632, 28%) were defined as "older" patients, women <80 years were considered as "younger". Chi-square tests were performed to evaluate differences in treatment by age group and comorbidities. Differences in OS were evaluated using Kaplan-Meier Curves and log-rank test.

RESULTS

The vast majority of both older (91%) and younger (99%) patients with FIGO IA VSCC received surgical treatment of the vulva. Older FIGO IB-IV VSCC patients were less likely to undergo groin surgery than younger patients (50% vs. 84%, p < 0.01). Performance of surgical treatment of the vulva and groin(s) was not associated with the number of comorbidities in older patients (p = 0.67 and p = 0.69). Older patients with ≥2 comorbidities did have poorer OS compared to women with one or no comorbidities (p < 0.01).

CONCLUSION

The vast majority of older patients underwent vulvar/local surgery. Older patients less often received groin surgery compared to younger patients. The majority of older patients had at least one comorbidity, but this did not impact treatment choice. The poorer survival in older VSCC patients may therefore be due to death of competing risks instead of VSCC itself.

The impact of geriatric characteristics and comorbidities on distant metastases and other cause mortality in older women with non-metastatic breast cancer treated with primary endocrine therapy

INTRODUCTION

In recent years, primary surgical treatment of older women with non-metastatic breast cancer has decreased in favor of primary endocrine therapy (PET). PET can be considered in women with a remaining life expectancy of less than five years. The aim of this study was to (1) assess the risk of distant metastases and other cause mortality over ten years in women aged 65 and older with stage I-III breast cancer treated with PET, (2) whether this was associated with geriatric characteristics and comorbidities and to (3) describe the reasons on which the choice for PET was made.

METHODS

Women were included from the retrospective FOCUS cohort, which comprises all incident women diagnosed with breast cancer aged 65 or older between January 1997 and December 2004 in the Comprehensive Cancer Center Region West in the Netherlands. We selected women (N = 257) with stage I-III breast cancer and treated with PET from this cohort. Patient characteristics (including comorbidity, polypharmacy, walking, cognitive and sensory impairment), treatment and tumor characteristics were retrospectively extracted from charts. Outcomes were distant metastasis and other cause mortality. Cumulative incidences were calculated using the Cumulative Incidence for Competing Risks method (CICR); and subdistribution hazard ratios (SHR) were tested between groups based on age, geriatric characteristics and comorbidity with the Fine and Gray model.

RESULTS

Women treated with PET were on average 84 years old and 41% had one or more geriatric characteristics. Other cause mortality exceeded the cumulative incidence of distant metastasis over ten years (83 versus 5.6%). The risk of dying from another cause further increased in women with geriatric characteristics (SHR 2.06, p < 0.001) or two or more comorbidities (SHR 1.72, p < 0.001). Often the reason for omitting surgery was not recorded (52.9%), but if recorded surgery was omitted mainly at the patient's request (18.7%).

DISCUSSION

This study shows that the cumulative incidence of distant metastasis is much lower than other cause mortality in older women with breast cancer treated with PET, especially in the presence of geriatric characteristics or comorbidities. This confirms the importance of assessment of geriatric characteristics to aid counseling of older women.

The occurence of cancer in ageing populations at global and regional levels, 1990 to 2019

BACKGROUND

population ageing contributes to increased cancer cases and deaths and has profound implications for global healthcare systems. We estimated the trends of cancer cases and deaths in ageing populations at global and regional levels.

METHODS

using data from the Global Burden of Disease Study 2019, we analysed the change in cancer cases and deaths associated with population ageing, population growth and epidemiological factors from 1990 to 2019 using decomposition analysis. Additionally, we estimated the proportions of people aged 65 years and over accounting for total cases and deaths, and investigated relationships between the proportions and the Sociodemographic Index (SDI) using the Pearson correlation coefficient.

RESULTS

from 1990 to 2019, there was an increase of 128.9% for total cases and 74.8% for total deaths in all cancers combined; the percentages of older people increased from 48.6% to 56.4% for cases and from 52.0% to 61.9% for deaths. Population ageing contributed to the largest increase in global cancer occurrence, with 56.5% for cases and 63.3% for deaths. However, the changes attributed to epidemiological factors was 5.2% for cancer cases and -33.4% for cancer deaths. The proportions of total cases and deaths of older adults were positively correlated with socioeconomic development of the country.

CONCLUSION

our findings revealed that the main contributor to increased cancer cases and deaths has changed from comprehensive epidemiological factors to demographic shifts. To respond to the rapidly growing occurrence of cancer in ageing populations, the global health priority should focus on meeting the rising demand for cancer diagnosis, treatment and care services for older people.

Peritoneal metastases in elderly patients with colorectal cancer

BACKGROUND

With the introduction of cytoreductive surgery with intraperitoneal chemotherapy and the development of new systemic anti-cancer agents, the treatment of colorectal cancer (CRC) patients with peritoneal metastases has changed. Real-world data on the treatment of elderly patients and their clinical outcomes is lacking.

METHODS

All CRC patients diagnosed with synchronous peritoneal metastases (SPM) during 2008-2019 (n = 7,748) were identified from the Netherlands Cancer Registry. Trends in treatment and postoperative mortality were described by age category (<70, 70-74, 75-79, ≥80 years) and period of diagnosis (2008-2013, 2014-2019). Kaplan-Meier curves were constructed, and log-rank tests were performed to evaluate differences in overall survival (OS).

RESULTS

With increasing age, less patients received multimodality treatment and systemic treatment. Of the patients aged <70 years, 38% underwent multimodality treatment and 35% palliative systemic therapy, declining to 4% and 12% in patients ≥80 years. A large and increasing proportion of elderly patients did not receive cancer-directed treatment, this increased from 32% in 2008-2013 to 41% in 2014-2019 in 75-79 years old patients and from 52% to 65% in ≥80 years old. Postoperative mortality decreased in all age categories over time, OS remained stable. The median OS of elderly patients ranged from 8 months in 70-74 years old to 3 months in patients aged ≥80 years.

DISCUSSION

Age strongly affects treatment of patients with SPM, with a large and increasing proportion of elderly patients not receiving cancer-directed treatment. Their prognosis remains very poor. There is a need for therapeutic options that are well tolerable for elderly patients.

The clinical decision‐making process of healthcare professionals within a personalized home‐based rehabilitation during sequential chemoradiotherapy for stage III non‐small lung cancer: A case study

INTRODUCTION

The purpose of this case study was to demonstrate the clinical decision-making process of healthcare professionals within a rehabilitation program during chemoradiotherapy (CHRT) for a high-risk patient diagnosed with stage III non-small cell lung cancer (NSCLC). The course of CHRT and patient's preferences, facilitators, and barriers were considered.

CASE-DESCRIPTION

The patient was a 69-year-old man with a history of rheumatoid arthritis diagnosed with stage III NSCLC.

INTERVENTION

A home-based, personalized, and partly supervised rehabilitation program during CHRT, including aerobic, resistance, and breathing exercises, as well as nutritional counseling.

OUTCOMES

The patient suffered from side effects of CHRT, which required adjustments in the context and intensity of the exercises. An important facilitator for the patient was encouraged by his wife in following the home-based rehabilitation program. During home visits, the patient and physiotherapists performed the exercises together to help him to overcome the burden and motivate the patient to adhere to the rehabilitation program.

CONCLUSION

This case study demonstrates that physical exercise training could be performed by adjusting training intensity and the way in which the physical exercise training was delivered, while the patient experienced side effects from CHRT. In addition, the involvement and support of (in)formal caregivers seems essential for adherence to rehabilitation.

Impact of age and comorbidities on short- and long-term outcomes of patients undergoing surgery for colorectal cancer

Background

As the world population is progressively ageing, more and more elderly patients will require cancer surgery. Although curative surgery is the treatment of choice for resectable colorectal cancer (CRC), it is still debated whether elderly frail patients should undergo major cancer surgery due to the increased risk of postoperative and long-term mortality. The aim of this retrospective study was to evaluate the impact of age and comorbidities on postoperative mortality/morbidity and long-term outcomes, looking for potential age-related survival differences.

Methods

A total of 1,482 patients operated for CRC at our institution between January 2005 and October 2020 were analysed. The independent effect of age and comorbidities on postoperative complications was assessed by a logistic model, while the effect on overall survival (OS) and cancer-related survival (CRS) was estimated by a Cox regression model.

Results

The median age in the cohort was 67.8 years. Postoperative mortality was very low in the whole cohort (0.8%) and contained even in older age groups (3.2% in patients aged 80–84 years, 4% in the 85–90-year age group). The cumulative incidence of postoperative complications was doubled in patients with comorbidities (32.8% vs. 15.1%, p = 0.002). With regard to OS, as expected, it exponentially decreased with advancing age. Conversely, differences in CRS were less pronounced between age groups and absent in patients with stage 0–I CRC. Analysis of all causes and cancer-related mortality revealed a peak within 2 years from surgery, suggesting a prolonged impact of surgery. In patients aged 75 years and above, all-cause mortality showed a steep increase 1 year after surgery, while cancer-related mortality plateaued at about 4 years after surgery. On multivariable analysis, OS, but not CRS, was significantly influenced by age.

Conclusions

Although acceptable results of surgery in elderly patients, OS is strongly dependent on age: older people die more from competing causes than cancer-related treatments compared to younger age classes. The preoperative identification of risk factors for low OS may help the selection of those elderly patients who would benefit from curative CRC surgery.

Feasibility of Rehabilitation during Chemoradiotherapy among Patients with Stage III Non-Small Cell Lung Cancer: A Proof-of-Concept Study

Rehabilitation during chemoradiotherapy (CHRT) might (partly) prevent reduction in physical fitness and nutritional status and could improve treatment tolerance in patients with stage III non-small cell lung cancer (NSCLC). The aim of this proof-of-concept study was to investigate the feasibility of a multimodal program for rehabilitation during CHRT. A home-based multimodal rehabilitation program (partly supervised moderate-intensity physical exercise training and nutritional support) during CHRT was developed in collaboration with patients with stage III NSCLC and specialized healthcare professionals. A predetermined number of six patients with stage III NSCLC (aged > 50 years) who underwent CHRT and participated in this program were monitored in detail to assess its feasibility for further development and optimization of the program. The patient’s level of physical functioning (e.g., cardiopulmonary exercise test, six-minute walking test, handgrip strength, body mass index, fat free mass index, energy and protein intake) was evaluated in order to provide personalized advice regarding physical exercise training and nutrition. The program appeared feasible and well-tolerated. All six included patients managed to perform the assessments. Exercise session adherence was high in five patients and low in one patient. The performed exercise intensity was lower than prescribed for all patients. Patients were motivated to complete the home-based rehabilitation program during CHRT. Preliminary effects on physical and nutritional parameters revealed relatively stable values throughout CHRT, with inter-individual variation. Supervised and personalized rehabilitation in patients with stage III NSCLC undergoing CHRT seems feasible when the intensity of the physical exercise training was adjusted to the possibilities and preferences of the patients. Future research should investigate the feasibility of a supervised and personalized rehabilitation program during CHRT with a low-to-moderate exercise intensity with the aim to prevent physical decline during CHRT.

Surgical under-treatment of older adult patients with cancer: A systematic review and meta-analysis

BACKGROUND

Older patients with cancer often have lower surgery rates and survival than younger patients, but this may reflect surgical contraindications of advanced disease, comorbidities, and frailty - and not necessarily under-treatment.

OBJECTIVES

This review aims to describe variations in surgery rates and observed or net survival among younger (<75) and older (≥75) patients with breast, lung and colorectal cancer, while taking account of pre-existing health factors, in order to understand how under-treatment is defined and estimated in the literature.

METHOD

MEDLINE, EMBASE, Web of Science and PubMed databases were searched for studies reporting surgery rates and observed or net survival among younger and older patients with breast, lung, and colorectal cancer. Study quality was assessed using the Newcastle Ottawa Scale, and random effects meta-analyses were used to combine study results. The I-squared statistic and subgroup analyses were used to assess heterogeneity.

RESULTS

Thirty relatively high-quality studies of patients with breast (230,200; 71.9%), lung (77,573; 24.2%), and colorectal (12,407; 3.9%) cancers were identified. Compared to younger patients, older patients were less likely to receive surgical treatment for 1) breast cancer after adjusting for comorbidity, performance status (PS), functional status and patient choice, 2) lung cancer after accounting for stage, comorbidity, PS, and 3) colorectal cancer after adjusting for stage, comorbidity, and gender. The pooled unadjusted analyses showed lower surgery receipt in older patients with breast (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.13-0.78), lung (OR 0.54, 95% CI 0.39-0.75), and colorectal (OR 0.59, 95% CI 0.51-0.68) cancer. In separate analyses, older patients with breast, lung and colorectal cancer had lower observed and net survival, compared to younger patients.

CONCLUSIONS

Lower surgery rates in older patients may contribute to their poorer survival compared to younger patients. Future research quantifying under-treatment should include necessary clinical factors, patient choice, patient's quality of life and a statistically-robust approach, which will demonstrate how much of the survival deficit in older patients is due to their receiving lower surgery rates.

The Role of Ablative Radiotherapy in Older Adults With Limited Metastatic Disease

For patients with oligometastatic cancer, radiotherapy presents a promising avenue for achieving meaningful symptom relief and durable disease control. Data from recently published and ongoing randomized studies are helping to define the appropriate contexts for effective intervention with stereotactic ablative body radiotherapy (SABR) in the oligometastatic setting. Importantly, older adults represent a significant portion of patients with oligometastatic disease, yet often comprise a minority of patients in clinical trials. Moreover, older adults of the same chronologic age may have variable degrees of fitness and frailty. In this review, we highlight the specific challenges and considerations for the use of radiotherapy for older adults with oligometastatic disease-noting the importance of geriatric assessments in clinical decision-making about the appropriateness of SABR and other metastasis-directed therapies in this population. We then review data from existing trials, including a subset analysis of adverse events and survival estimates among older adults enrolled in the landmark SABR-COMET trial. Finally, we discuss future directions for research, including the need for focused clinical trials in older adult cohorts. Ultimately, a multidisciplinary approach is critical when carefully balancing the potential risks and benefits of this emerging treatment paradigm in the older adult population.

Effect of comorbidities on long-term outcomes of colorectal cancer patients

OBJECTIVE

The objective of this work is to evaluate the association of comorbidities with various outcomes in patients diagnosed with colon or rectal cancer.

METHODS

We conducted a prospective cohort study of patients diagnosed with colon or rectal cancer who underwent surgery. Data were gathered on sociodemographic, clinical characteristics, disease course, and the EuroQol EQ-5D and EORTC QLQ-C30 scores, up to 5 years after surgery. The main outcomes of the study were mortality, complications, readmissions, reoperations, and changes in PROMs up to 5 years. Multivariable multilevel logistic regression models were used in the analyses.

RESULTS

Mortality at some point during the 5-year follow-up was related to cardiocerebrovascular, hemiplegia and/or stroke, chronic obstructive pulmonary disease (COPD), diabetes, cancer, and dementia. Similarly, complications were related to cardiovascular disease, COPD, diabetes, hepatitis, hepatic or renal pathologies, and dementia; readmissions to cardiovascular disease, COPD, and hepatic pathologies; and reoperations to cerebrovascular and diabetes. Finally, changes in EQ-5D scores at some point during follow-up were related to cardiocerebrovascular disease, COPD, diabetes, pre-existing cancer, hepatic and gastrointestinal pathologies, and changes in EORTC QLQ-C30 scores to cardiovascular disease, COPD, diabetes, and hepatic and gastrointestinal pathologies.

CONCLUSIONS

Optimising the management of the comorbidities most strongly related to adverse outcomes may help to reduce those events in these patients.

Cancer epidemiology and treatment patterns for older persons in Japan: a review of nationwide data and statistics

Older patients tend to have comorbidities and physiological decline, which require adaptation in terms of standard treatment. Therefore, the care of older patients poses a unique challenge for healthcare providers. Their standard care is relatively less established than for younger patients because older patients are often excluded from clinical trials, resulting in limited representation. This review, using various data sources, such as cancer registries and national statistics, aims to describe the nationwide status of older patients in Japan and the care provided to them. Incidence statistics have revealed that each age group's most common types of cancers are different. Relevant data have also shown that older patients are more likely to be left without treatment compared with their younger counterparts, although the extent of such differences tends to depend on the cancer type. A survey of the general population has shown that older patients are more likely to be treated for common diseases; however, they are found to have undetected diseases when screened for the common diseases. Individuals' life expectancies may vary depending on their physical conditions. The social lives of older persons, which often revolve around their jobs and family structures, vary widely. Thus, clinicians and caregivers should consider the background information of older patients in order to accommodate their special needs.

Temporal Trends and Predictors of Opioid Use Among Older Patients With Cancer

OBJECTIVES

While opioids represent a cornerstone of cancer pain management, the timing and patterns of opioid use in the cancer population have not been well studied. This study sought to explore longitudinal trends in opioid use among Medicare beneficiaries with nonmetastatic cancer.

MATERIALS AND METHODS

Within a cohort of 16,072 Medicare beneficiaries ≥66 years old diagnosed with nonmetastatic cancer between 2007 and 2013, we determined the likelihood of receiving a short-term (0 to 6 mo postdiagnosis), intermediate-term (6 to 12 mo postdiagnosis), long-term (1 to 2 y postdiagnosis), and high-risk (morphine equivalent dose ≥90 mg/day) opioid prescription after cancer diagnosis. Multivariable logistic regression models were used to identify patient and cancer risk factors associated with these opioid use endpoints.

RESULTS

During the study period, 74.6% of patients received an opioid prescription, while only 2.66% of patients received a high-risk prescription. Factors associated with use varied somewhat between short-term, intermediate-term, and long-term use, though in general, patients at higher risk of receiving an opioid prescription after their cancer diagnosis were younger, had higher stage disease, lived in regions of higher poverty, and had a history of prior opioid use. Prescriptions for high-risk opioids were associated with individuals living in regions with lower poverty.

CONCLUSIONS

Temporal trends in opioid use in cancer patients depend on patient, demographic, and tumor characteristics. Overall, understanding these correlations may help physicians better identify patient-specific risks of opioid use and could help better inform future evidence-based, cancer-specific opioid prescription guidelines.

The significance of comorbidity burden among older patients undergoing abdominal emergency or elective surgery

BACKGROUND

Comorbidities may cause complications in perioperative care and affect treatment outcomes of older patients. The study aim was to analyse comorbidity burdens with respect to their predictive power in outcome prediction in elderly qualified for abdominal elective or emergency surgery.

METHODS

Consecutive patients undergoing major abdominal surgery between 2010 and 2017 at a secondary referral hospital were included in the retrospective study, for a total of 1586 patients. To explain the relationship between the comorbidity types and 30-day mortality and morbidity logistic regression analysis was performed. Morbidity was assessed using the Clavien-Dindo Score. Major complications were defined as a C-D score ≥ 3. We also presented the data concerning need for reoperation and ICU admission.

RESULTS

85.9% of patients had at least one comorbidity. In the group of emergency patients age and number of comorbidities were independent risk factors of 30-day mortality and major morbidity. In elective patients age, dementia (OR:3.52; 95%CI:1.35-9.20) and kidney disease (OR:1.64; 95%CI:1.04-2.57) were found to be independent risk factors of 30-day postoperative mortality. Age (1.04; 95%CI:1.00-1.08) and heart disease (OR:1.30, 95%CI:1.04-1.63) were found to be independent risk factors of 30-day major morbidity.

CONCLUSIONS

In patients undergoing elective surgery 30-day mortality and morbidity was associated with age. 30-day mortality, but not morbidity was associated with kidney disease and dementia. 30-day morbidity, but not mortality, was associated with heart disease.

Impact of Smoking-Related Chronic Obstruction Pulmonary Disease on Mortality of Invasive Ductal Carcinoma Patients Receiving Standard Treatments: Propensity Score-Matched, Nationwide, Population-Based Cohort Study

Simple Summary

This study is the first to estimate the impact of smoking-related chronic obstructive pulmonary disease (COPD) on invasive ductal carcinoma (IDC) patients receiving standard treatments. Smoking-related COPD was not a significant independent risk factor for all-cause mortality in women with stage I–III IDC receiving standard treatments. The frequency of hospitalization for COPD with at least one acute exacerbation within one year before breast surgery was highly associated with high mortality for women with IDC receiving standard treatments.

Abstract

Purpose: the survival effect of smoking-related chronic obstructive pulmonary disease (COPD) and COPD with acute exacerbation (COPDAE) is unclear for patients with invasive ductal carcinoma (IDC) receiving standard treatments. Methods: we recruited women with clinical stage I–III IDC from the Taiwan Cancer Registry Database who had received standard treatments between 1 January 2009 and 31 December 2018. The time-dependent Cox proportional hazards model was used to analyze all-cause mortality. To reduce the effects of potential confounders when all-cause mortality between Groups 1 and 2 were compared, 1:2 propensity score matching (PSM) was performed. We categorized the patients into two groups based on COPD status to compare overall survival outcomes: Group 1 (current smokers with COPD) and Group 2 (nonsmokers without COPD group). Results: PSM yielded 2319 patients with stage I–III IDC (773 and 1546 in Groups 1 and 2, respectively) eligible for further analysis. In the multivariate time-dependent Cox regression analyses, the adjusted hazard ratio (aHR; 95% confidence interval (CI)) of all-cause mortality for Group 1 compared with Group 2 was 1.04 (0.83–1.22). The aHRs (95% CIs) of all-cause mortality for ≥1 hospitalization for COPDAE within one year before breast surgery was 1.51 (1.18–2.36) compared with no COPDAE. Conclusion: smoking-related COPD was not a significant independent risk factor for all-cause mortality in women with stage I–III IDC receiving standard treatments. Being hospitalized at least once for COPDAE within one year before breast surgery is highly associated with high mortality for women with IDC receiving standard treatments. The severity of smoking-related COPD before treatments for breast cancer might be an important prognostic factor of survival. Thus, the information of the severity of COPD before treatment for breast cancer might be valuable for increasing the survival rate in treatment of breast cancer, especially in the prevention of progress from COPD to COPDAE.

Prevalence of multimorbidity in adults with cancer, and associated health service utilization in Ontario, Canada: a population-based retrospective cohort study

BACKGROUND

The majority of people with cancer have at least one other chronic health condition. With each additional chronic disease, the complexity of their care increases, as does the potential for negative outcomes including premature death. In this paper, we describe cancer patients' clinical complexity (i.e., multimorbidity; MMB) in order to inform strategic efforts to improve care and outcomes for people with cancer of all types and commonly occurring chronic diseases.

METHODS

We conducted a population-based, retrospective cohort study of adults diagnosed with cancer between 2003 and 2013 (N = 601,331) identified in Ontario, Canada healthcare administrative data. During a five to 15-year follow-up period (through March 2018), we identified up to 16 co-occurring conditions and patient outcomes for the cohort, including health service utilization and death.

RESULTS

MMB was extremely common, affecting more than 91% of people with cancer. Nearly one quarter (23%) of the population had five or more co-occurring conditions. While we saw no differences in MMB between sexes, MMB prevalence and level increased with age. MMB prevalence and type of co-occurring conditions also varied by cancer type. Overall, MMB was associated with higher rates of health service utilization and mortality, regardless of other patient characteristics, and specific conditions differentially impacted these rates.

CONCLUSIONS

People with cancer are likely to have at least one other chronic medical condition and the presence of MMB negatively affects health service utilization and risk of premature death. These findings can help motivate and inform health system advances to improve care quality and outcomes for people with cancer and MMB.

Indications for Emergency Abdominal Surgeries in Older Patients: 7-Year Experience of a Single Centre

The majority of patients undergoing emergency laparotomy are older adults that carry the highest mortality. More research into the development of targeted interventions is required. Therefore, the aim of the study was to analyse the indications for emergency abdominal surgery in patients aged ≥ 65 admitted to the Department of General Surgery. The study included consecutive patients aged ≥ 65 who underwent emergency abdominal surgery within 48 h after admission at one institution. In 2010–2017, 986 patients were enrolled in the study (female 57%, male 43%). Patients were divided into three age groups, 65–70, 71–84 and ≥ 85, with 255 patients (25.9%), 562 patients (57.0%) and 169 patients (17.1%) in each group, respectively. In the first and second age groups, the most common indications for surgery were acute cholecystitis, non-malignant ileus, colorectal cancer complications and acute appendicitis. In the oldest patients, the most common indications were complications of colorectal cancer, acute cholecystitis, non-malignant ileus and complications of diverticulosis. In the women, the biggest differences in indications between age groups were colorectal cancer (p = 0.025) and peptic ulcer disease complications (p = 0.005); in the men, the biggest difference was seen for complicated diverticulitis (p = 0.001). The most frequent comorbidities were heart diseases (81.0%), followed by endocrine (33.6%) and vascular diseases (22.7%). The three most common indications for emergency surgery in older patients at our institution were acute cholecystitis, colorectal cancer complications and non-malignant bowel obstruction, affecting 59.5% of this group of patients. Elective surgery and endoscopic screening have the potential to prevent major part of these acute diseases. However, further prospective research is necessary on this field, particularly among frail, older patients.

Elderly Patients Have Better Quality of Life but Worse Survival Following Pelvic Exenteration: A 25-Year Single-Center Experience

OBJECTIVE

To describe quality of life (QOL) and survival outcomes following pelvic exenteration (PE) in old and young patients.

BACKGROUND

PE is a management option for complete resection in locally advanced pelvic cancers. Few studies have examined the impact of age on the outcome in elderly patients following PE.

PATIENTS AND METHODS

Prospective cohort of consecutive patients undergoing partial and complete PE between 1994 and 2019. Patients were divided into a younger (< 65 years) or older cohort (≥ 65 years) based on their age. QoL was assessed using the SF-36 and FACT-C questionnaires and survival estimated using the Kaplan-Meier method.

RESULTS

For 710 patients who underwent PE during the study period, FACT-C total score was significantly better in the elderly during the whole follow-up period of 5 years. Mental component score (SF-36) was significantly better at baseline (p = 0.008) and at 24 months postoperatively (p = 0.042), in the elderly group. Median overall survival was 75 months in the younger cohort and 53 months in the older cohort (p = 0.004). In subgroup analysis, older patients with recurrent or primary rectal cancer had a median survival of 37 and 70 months, respectively. Postoperative cardiovascular complications were greater in the elderly cohort (p < 0.001).

CONCLUSIONS

Elderly patients had better overall QoL but lower survival that is probably related to cardiovascular complications rather than to cancer as both groups had similar R0 resection rate. Hence, the elderly population should be considered equally for PE.

Cost analysis of inguinal hernia repair: the influence of clinical and hernia-specific factors

Introduction

As in the rest of the world, in Germany, inguinal hernia operations are among the most common operations. From an economic standpoint, very little is known about the influence of demographic, clinical or hernia-related parameters on the cost of inguinal hernia repair. We, therefore, evaluated individual patient parameters associated with higher costs with a special focus on multimorbidity.

Methods

A total of 916 patients underwent hernia repair for primary or recurrent inguinal hernia between 2014 and 2017 at a single university center and were included in the analysis. The clinical and financial data of these patients were analyzed to identify cost-increasing parameters.

Results

A majority of patients were male (90.7%), with a mean age of 55 years. The surgical methods utilized were mainly the TAPP (57.2%) and Lichtenstein (41.7%) procedures, with an average duration of surgery of 85 min and an average duration of anesthesia of 155 min. The mean cost of all procedures was 3338.3 € (± 1608.1 €).

Older age, multimorbidity, emergency operations with signs of incarceration, longer hospital stays and postoperative complications were significant cost-driving factors. On the other hand, sex, the side of the hernia (left vs. right) and the presence of recurrent hernias had no influence on the overall direct costs.

Conclusion

From a purely economic point of view, older age and multimorbidity are demographic cost-driving factors that cannot be influenced. The national hospital reimbursement system needs to consider and compensate for these factors. Emergency operations need to be prevented by early elective treatment. Long postoperative stays and postoperative complications need to be prevented by proper preoperative check-ups and accurate treatment.

Muscle invasion in oropharyngeal carcinoma undergoing transoral robotic surgery

BACKGROUNDS

Pathologic features of oropharyngeal squamous cell carcinoma (OPSCC) treated with trans-oral robotic surgery predict prognosis and adjuvant therapy. We hypothesized that pathologic muscle invasion (pMI) is associated with poor pathological markers.

METHODS

Retrospective review of surgically treated OPSCC to identify pMI and its association with poor pathologic markers.

RESULTS

pMI was present in 12/37 patients, and compared to non-pMI, was associated with higher rates of lymphovascular invasion (75% vs. 36%, p = 0.03), perineural invasion (16.7% vs. 0%, p = 0.04), extranodal extension (66.7% vs. 20%, p < 0.01), and tumor stage (8.3% vs. 48% pT1, 75% vs. 52% pT2 and 16.7% vs. 0% pT3). pMI was associated with having a positive margin on main specimen (41.7% vs. 12%, p = 0.04) but not after considering additional margins.

CONCLUSIONS

Muscle invasion was associated with higher pathologic tumor staging, poor pathologic factors, and higher rates of positive margin on main specimen.

Oncologic Outcomes Following Transoral Robotic Surgery for Human Papillomavirus-Associated Oropharyngeal Carcinoma in Older Patients

Importance

While early epidemiologic studies ascribed increases in the incidence of human papillomavirus-associated oropharyngeal cancers to middle-aged patients, recent analyses have demonstrated an increasing median age of diagnosis. Treatment of patients older than 70 years is controversial as their inclusion in the practice-defining clinical trials has been limited and the survival benefit conferred by chemotherapy may be outweighed by treatment toxic effects.

Objective

To assess the oncologic outcomes of older adults with human papillomavirus-associated oropharyngeal cancer who underwent upfront transoral robotic surgery and pathologic characteristics-guided adjuvant therapy in a large cohort of patients with close follow-up.

Design, Setting, and Participants

A retrospective cohort analysis was conducted in a tertiary care academic medical center between January 1, 2010, and December 30, 2017. Patients aged 70 years or older at time of diagnosis with biopsy-proven and surgically resectable p16-positive oropharyngeal cancers were included. Data analysis was conducted from March 1 to June 1, 2020.

Exposures

Transoral robotic surgery oropharyngeal resection and neck dissection with pathologic characteristic-guided adjuvant therapy.

Main Outcomes and Measures

Three-year estimates of disease-specific survival, overall survival, and disease-free survival, as well as rates of adjuvant therapy (radiotherapy and chemoradiotherapy) and perioperative complications.

Results

Seventy-seven patients were included (median age, 73.0; interquartile range, 71.0-76.0; range, 70-89 years); of these, 58 were men (75.3%). Perioperative mortality was 1.3% and the rate of oropharyngeal hemorrhage was 2.6%. Twenty-seven patients (35.1%) underwent postoperative radiotherapy and 20 patients (26.0%) underwent postoperative chemoradiotherapy. The median length of follow-up was 39.6 (range, 0.1-96.2) months, and the 3-year estimates of survival were 92.4% (95% CI, 82.4%-96.9%) for disease-specific survival, 90.0% (95% CI, 79.4%-95.0%) for overall survival, and 84.3% (95% CI, 73.4%-91.0%) for disease-free survival.

Conclusions and Relevance

The findings of this cohort study suggest that transoral robotic surgery and pathologic characteristic-guided adjuvant therapy can provide beneficial survival outcomes, infrequent perioperative mortality, and, for most carefully selected older adults, obviate the need for chemotherapy.

Real-world implementation of a geriatric-specific ERAS protocol in patients undergoing colonic cancer surgery

BACKGROUND

The aim of this single-center observational study was to evaluate the impact of implementing Enhanced Recovery After Surgery (ERAS) protocols, combined with systematic geriatric assessment and support, on surgical and oncological outcomes in patients aged 70 or older undergoing colonic cancer surgery.

METHODS

Two groups were formed from an actively maintained database from all patients undergoing laparoscopic colonic surgery for neoplasms during a defined period before (standard group) or after (ERAS group) the introduction of an ERAS program associated with systematic geriatric assessment. The primary outcome was postoperative 90-day morbidity. Secondary outcomes were total length of hospital stay, initiated and completed adjuvant chemotherapy (AC) rate, and 1-year mortality rate.

RESULTS

A total of 266 patients (135 standard and 131 ERAS) were included in the study. Overall 90-day morbidity and mean hospital stay were significantly lower in the ERAS group than in the standard group (22.1% vs. 35.6%, p = 0.02; and 6.2 vs. 9.3 days, p < 0.01, respectively). There were no differences in readmission rates and anastomotic complications. AC was recommended in 114 patients. The rate of initiated treatment was comparable between the groups (66.6% vs. 77.7%, p = 0.69). The rate of completed AC was significantly higher in the ERAS group (50% vs. 20%, p < 0.01) with a lower toxicity rate (57.1% vs. 87.5%, p = 0.002). The 1-year mortality rate was higher in the standard group (7.4% vs. 0.8%, p < 0.01).

CONCLUSIONS

The combination of ERAS protocols and geriatric assessment and support reduces the overall morbidity rate and improves 12-month oncologic outcomes.

Diabetes mellitus and colorectal carcinoma outcomes: a meta-analysis

OBJECTIVES

The impact of diabetes mellitus (DM) on colorectal cancer (CRC) outcomes remains unknown. We studied this by conducting a meta-analysis to evaluate (1) CRC outcomes with and without DM and (2) treatment patterns.

METHODS

We searched PubMed, EMBASE, Google Scholar, and CINAHL for full-text English studies from 1970 to 12/31/2017. We searched keywords, subject headings, and MESH terms to locate studies of CRC outcomes/treatment and DM. Studies were evaluated by two oncologists. Of 14,332, 48 met inclusion criteria. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method, we extracted study location, design, DM definition, covariates, comparison groups, outcomes, and relative risks and/or hazard ratios. We utilized a random-effects model to pool adjusted risk estimates. Primary outcomes were all-cause mortality (ACM), disease-free survival (DFS), relapse-free survival (RFS), and cancer-specific survival (CSS). The secondary outcome was treatment patterns.

RESULTS

Forty-eight studies were included, 42 in the meta-analysis, and 6 in the descriptive analysis, totaling > 240,000 patients. ACM was 21% worse (OR 1.21, 95% CI 1.15-1.28) and DFS was 75% worse (OR 1.75, 95% CI: 1.33-2.31) in patients with DM. No differences were detected in CSS (OR 1.10, 95% CI 0.98-1.23) or RFS (OR 1.12, 95% CI 0.91-1.38). Descriptive analysis of treatment patterns in CRC and DM suggested potentially less adjuvant therapy use in cases with DM and CRC.

CONCLUSIONS

Our meta-analysis suggests that patients with CRC and DM have worse ACM and DFS than patients without DM, suggesting that non-cancer causes of death in may account for worse outcomes.

Relative importance of clinical and sociodemographic factors in association with post-operative in-hospital deaths in colorectal cancer patients in New South Wales: An artificial neural network approach

RATIONALE, AIMS AND OBJECTIVES

Co-morbidities in colorectal cancer patients complicate hospital care, and their relative importance to post-operative deaths is largely unknown. This study was conducted to examine a range of clinical and sociodemographic factors in relation to post-operative in-hospital deaths in colorectal cancer patients and identify whether these contributions would vary by severity of co-morbidities.

METHODS

In this multicentre retrospective cohort study, we used the complete census of New South Wales inpatient data to select colorectal cancer patients admitted to public hospitals for acute surgical care, who underwent procedures on the digestive system during the period of July 2001 to June 2014. The primary outcome was in-hospital death at the end of acute care. Multilayer perceptron and back-propagation artificial neural networks (ANNs) were used to quantify the relative importance of a wide range of clinical and sociodemographic factors in relation to post-operative deaths, stratified by severity of co-morbidities based on Charlson co-morbidity index.

RESULTS

Of 6288 colorectal cancer patients, approximately 58.3% (n = 3669) had moderate to severe co-morbidities. A total of 464 (7.4%) died in hospitals. The performance for ANN models was superior to logistic models. Co-morbid musculoskeletal and mental disorders, adverse events in health care, and socio-economic factors including rural residence and private insurance status contributed to post-operative deaths in hospitals.

CONCLUSION

Identification of relative importance of factors contributing to in-hospital deaths in colorectal cancer patients using ANN may help to enhance patient-centred strategies to meet complex needs during acute surgical care and prevent post-operative in-hospital deaths.

Cancer mortality in the oldest old: a global overview

BACKGROUND

As a higher proportion of adults live beyond 85 years, their cancer burden is expected to increase. While trends among the oldest old are established for major epithelial cancers (breast, prostate, lung, and colorectal cancers), they are less studied for minor cancers. This study describes age trends of cancer mortality, with emphasis on individuals aged 85+ years.

RESULTS

Overall cancer mortality peaked at 85 years old and decreased or stabilized for all countries except the USA, France, and Japan, in which mortality continued to increase after age 85 years. For most countries, cancers of the oesophagus, stomach, liver, and larynx have a similar flat trend patterns across all ages. Bladder and kidney cancers as well as non-Hodgkin lymphoma, multiple myeloma, and leukemia showed a decreasing pattern after 85 years for UK, Germany, Italy and Poland. Lung cancer peaked at 80 years, although the age-specific peak among women did not follow the same pattern among all countries. Breast and prostate cancers increased after 85 years.

CONCLUSION

Mortality stabilized or decreased after age 85, particularly for non-hormonal cancers. Whether this reflects a true biological levelling of mortality rates, or lower validity of cancer registration among the oldest old, remains open to discussion.

METHODS

Completed death data were obtained from the World Health Organization (WHO) for eight countries (2000 to 2014). Age-specific mortality rates were calculated for each 5-year age group above age 64. Joinpoint regression models were used to identify significant changes in mortality trends by age.

Cervical Cancer Treatment Delays and Associated Factors in a Cohort of Women From a Developing Country

PURPOSE

To estimate treatment delays and associated factors among women diagnosed with cervical cancer who were treated at the main cancer center in Rio de Janeiro, Brazil.

MATERIALS AND METHODS

A retrospective cohort study was performed comprising 865 women newly diagnosed with cervical cancer between 2012 and 2014. Times from diagnosis to treatment initiation (less than or equal to 60 days) and from diagnosis to treatment ending (less than or equal to 120 days) were analyzed according to the Brazilian law for the treatment of patients with cancer. Associations between treatment delays and sociodemographic, economic, lifestyle, clinical, and treatment variables were estimated using logistic regression models, with 95% CIs.

RESULTS

The average age was 48 (± 13.7) years, and the median age was 47 years; 36.2% of patients had stage IIIB to IVA disease. The median time from diagnosis to treatment initiation was 114 days, which was statistically higher among women with stage IIB to IVA (105.5 days) compared with those with earlier stages (119 days). The delay in treatment initiation occurred in 92.8% of participants; the median time from diagnosis to treatment ending was 274 days, with a delay (more than 120 days) for 92.6% of patients. The median time interval from diagnosis to the first visit to the cancer center was 28 days, with a delay of more than 30 days for 46.6% of patients. Age (odds ratio [OR], 1.05; 95% CI,1.02 to 1.08), stage IIIB to IVA (OR, 0.38; 95% CI, 0.16 to 0.90), time to first visit to the cancer center (OR, 11.52; 95% CI, 4.32 to 30.66), chemoradiation treatment (OR, 4.56; 95% CI, 1.81 to 11.47), and adequate treatment (OR, 2.57; 95% CI, 1.26 to -5.40) were independently associated with delay of treatment initiation.

CONCLUSION

Significant delays in treatment initiation and ending were observed in this studied population. The treatment initiation delay was positively associated with age, time interval more than 30 days from diagnosis to first specialist assessment at the cancer center, treatment with chemoradiation, and adequate treatment.

Treatment patterns and outcomes change in early-stage non-small cell lung cancer in octogenarians and older: a SEER database analysis

BACKGROUND

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer death in the world.

AIMS

We used the Surveillance, Epidemiology, and End Results (SEER) database to investigate the changes in the incidence, treatment patterns, and outcomes of early-stage non-small cell lung cancer (NSCLC) in octogenarians and older from 1995 to 2015.

METHODS

Using the SEER database, we identified patients ≥ 80 years stage I-IIa NSCLC diagnosed from 1995 to 2015. Changes in the treatment patterns, incidence and proportion, and survival were assessed by years of diagnosis.

RESULTS

In total, 25,394 patients were identified. The incidence number sharply increased from 260 in 1995 to 2120 in 2015. There was a tremendous increase in the proportion who underwent radiotherapy from 22.7% in 1995 to 50% in 2015 (P < 0.0001), with a corresponding decrease in surgical treatment, from 50 to 28.6% (P < 0.0001). The 2-year cancer-specific survival (CSS) and overall survival (OS) improved for patients treated with radiation alone and relatively subtly for those who received surgery alone.

CONCLUSION

At present, RT has replaced surgery as the most commonly used modality in early-stage NSCLC in patients ≥ 80 years in the United States. An improvement was observed in CSS and OS for patients treated with definitive RT and surgery.

When and how should surgery be performed in senior colorectal cancer patients?

Older studies reported high rates of postoperative morbidity and mortality in the senior population, which lead to a tendency to withhold curative surgery in the older population. However, more recent studies showed impressing developments in postoperative outcomes in seniors. Probably, these improvements are due to enhancements in both surgical and non-surgical aspects in the pre-, peri- and postoperative period, such as minimally invasive techniques and anesthesiological insights. The postoperative survival gap seen earlier between younger and older patients is fading. For optimal treatment in the older population, special awareness and care on several aspects is needed. As only a minority of the seniors are frail, a quick frailty assessment is crucial to distinguish the fit from the frail in the decision-making process. In addition, it could be valuable to improve the lacks in physical condition in the preoperative period with the use of prehabilitation programs. Furthermore, it is important to evolve an emergency to an elective setting by postponing emergency surgery to prevent any high-risk situation. In conclusion, based on modern insights, surgery is a valid option in the curative treatment of colorectal cancer in seniors, however individual attention and care is required.

Influence of primary tumour and patient factors on survival in patients undergoing curative resection and treatment for liver metastases from colorectal cancer

Background

Resection of the primary tumour is a prerequisite for cure in patients with colorectal cancer, but hepatic metastasectomy has been used increasingly with curative intent. This national registry study examined prognostic factors for radically treated primary tumours, including the subgroup of patients undergoing liver metastasectomy.

Methods

Patients who had radical resection of primary colorectal cancer in 2009–2013 were identified in a population‐based Swedish colorectal registry and cross‐checked in a registry of liver tumours. Data on primary tumour and patient characteristics were extracted and prognostic impact was analysed.

Results

Radical resection was registered in 20 853 patients; in 38·7 per cent of those registered with liver metastases, surgery or ablation was performed. The age‐standardized relative 5‐year survival rate after radical resection of colorectal cancer was 80·9 (95 per cent c.i. 80·2 to 81·6) per cent, and the rate after surgery for colorectal liver metastases was 49·6 (46·0 to 53·2) per cent. Multivariable analysis identified lymph node status, multiple sites of metastasis, high ASA grade and postoperative complications after resection of the primary tumour as strong risk factors after primary resection and following subsequent liver resection or ablation. Age, sex and primary tumour location had no prognostic impact on mortality after liver resection.

Conclusion

Lymph node status and complications have a negative impact on outcome after both primary resection and liver surgery. Older age and female sex were underrepresented in the liver surgical cohort, but these factors did not influence prognosis significantly.

Worse lung cancer outcome in patients with lower respiratory tract infection confirmed at time of diagnosis

Background

Pulmonary malignancy is one of the most frequent and fatal cancers in older patients. As data on lower respiratory tract infection (LRTI) and the outcome of lung cancer are scarce, our objective was to determine the impact of LRTI on therapeutic possibilities and one‐year mortality.

Methods

Patients undergoing bronchoscopy in 2017 who had bronchial microbial sampling at the time of the lung cancer diagnosis (n = 143) were included. Group 1 (LRTI+) included patients with confirmed infection (n = 74) while Group 2 (LRTI‐) included patients without infection (n = 69). Clinical characteristics, pathogen profile and one‐year survival were analyzed.

Results

Age, gender, TNM stage, histology type, comorbidities or underlying lung disease did not differ among groups. The most common LRTI pathogens included aerobic (n = 49), anaerobic (n = 14) and fungal (n = 26) infections. Chemo/immune/target therapy alone, or in combination with radiotherapy were significantly less frequently used, whilst palliative care was more common in Group 1 (LRTI+). Multiple pathogen LRTI patients were significantly older, less frequently diagnosed with adenocarcinoma and had worse performance status compared to solitary pathogen LRTI patients. One‐year median survival was 274 days (235 vs. 305 days Group 1 vs. Group 2). Risk factors for increased one‐year mortality included performance status ≥2 (OR 30.00, CI 95% 5.23–313.00), performance status 1 (OR 11.87, CI 95% 4.12–33.78), male gender (OR 4.04, CI 2.03–8.04), LRTI with multiple pathogens (OR 2.72, CI 1.01–6.81) and nonadenocarcinoma histology (OR 2.26, CI 1.15–4.56).

Conclusion

LRTIs in lung cancer patients, especially multiple pathogen infections, are associated with less oncotherapeutic possibilities and significant risk for lower one‐year median survival.

Stereotactic Body Radiotherapy Versus Surgery for Early-Stage Non-Small-Cell Lung Cancer

BACKGROUND

Surgery is the gold standard therapy for patients with early-stage non-small-cell lung cancer (NSCLC). However, stereotactic body radiotherapy (SBRT) may provide as an alternative for patients who are medically inoperable or refuse surgical resection. The optimal treatment (SBRT or surgery) for patients with early-stage NSCLC is not clear.

METHODS

A systematic search was performed from PubMed, MEDLINE, Embase, and the Cochrane Library. Study heterogeneity and publication bias were estimated.

RESULTS

Fourteen cohort studies involving 1438 participants (719 who received SBRT and 719 who received surgery) were included in the meta-analysis. The main bias sources between the two groups, such as age, gender, tumor diameter, forced expiratory volume in 1 s, and Charlson comorbidity index were matched. The surgery was associated with a better overall survival (OS) and long-term distant control (DC) for early-stage NSCLC. The pooled OR and 95% confidence interval (CI) for 1-y, 3-y, 5-y OS, and 5-y DC were 1.56 (1.12-2.15), 1.86 (1.50-2.31), 2.43 (1.80-3.28), and 2.74 (1.12-6.67), respectively. No difference was found between the treatments in the 1-y and 3-y disease-free survival; 1-y, 3-y and 5-y locoregional control; or 1-y and 3-y DC.

CONCLUSIONS

Our results found a superior OS and long-term DC for early-stage NSCLC after surgery compared with SBRT after propensity score matching.

Rectal cancer in old age -is it appropriately managed? Evidence from population-based analysis of routine data across the English national health service

BACKGROUND

There is significant debate as to where to draw the line between undertreating older rectal cancer patients and minimising treatment risks. This study sought to examine the use of radical rectal cancer treatments and associated outcomes in relation to age across the English NHS.

METHODS

Patient, tumour and treatment characteristics for all patients diagnosed with a first primary rectal cancer in England between 1st April 2009 and 31st December 2014 were obtained from the CORECT-R data repository. Descriptive analyses and adjusted logistic regression models were undertaken to examine any association between age and the use of major resection and post-surgical outcomes. Funnel plots were used to show variation in adjusted rates of major resection.

RESULTS

The proportion of patients who underwent a major surgical resection fell from 66.5% to 31.7%, amongst those aged <70 and aged ≥80 respectively. After adjustment, 30-day post-operative mortality, failure to rescue and prolonged length of stay were significantly higher among the oldest group when compared to the youngest. Patient reported outcomes were not significantly worse amongst older patients. Significant variation was observed in adjusted surgical resection rates in the oldest patients between NHS Trusts. The probability of death due to cancer was comparable across all age groups.

CONCLUSIONS

Older patients who are selected for surgery have good outcomes, often comparable to their younger counterparts. Significant variation in the treatment of older patients could not be explained by differences in measured characteristics and required further investigation.

Multimodal prehabilitation to reduce the incidence of delirium and other adverse events in elderly patients undergoing elective major abdominal surgery: An uncontrolled before-and-after study

Background

Delirium is a common and serious complication in elderly patients undergoing major abdominal surgery, with significant adverse outcomes. Successful strategies or therapies to reduce the incidence of delirium are scarce. The objective of this study was to assess the role of prehabilitation in reducing the incidence of delirium in elderly patients.

Methods

A single-center uncontrolled before-and-after study was conducted, including patients aged 70 years or older who underwent elective abdominal surgery for colorectal carcinoma or an abdominal aortic aneurysm between January 2013 and October 2015 (control group) and between November 2015 and June 2018 (prehabilitation group). The prehabilitation group received interventions to improve patients’ physical health, nutritional status, factors of frailty and preoperative anaemia prior to surgery. The primary outcome was incidence of delirium, diagnosed with the DSM-V criteria or the confusion assessment method. Secondary outcomes were additional complications, length of stay, unplanned ICU admission, length of ICU stay, readmission rate, institutionalization, and in-hospital or 30-day mortality.

Result

A total of 360 control patients and 267 prehabilitation patients were included in the final analysis. The mean number of prehabilitation days was 39 days. The prehabilitation group had a higher burden of comorbidities and was more physically and visually impaired at baseline. At adjusted logistic regression analysis, delirium incidence was reduced significantly from 11.7 to 8.2% (OR 0.56; 95% CI 0.32–0.98; P = 0.043). No statistically significant effects were seen on secondary outcomes.

Conclusion

Current prehabilitation program is feasible and safe, and can reduce delirium incidence in elderly patients undergoing elective major abdominal surgery. This program merits further evaluation.

Trial registration

Dutch Trial Registration, NTR5932.

The advanced radiotherapy network (ART-NET) UK lung stereotactic ablative radiotherapy survey: national provision and a focus on image guidance

OBJECTIVE

Stereotactic ablative radiotherapy (SABR) has become the standard of care for suitable patients with peripherally located early stage non-small cell lung cancer. Lung SABR requires strict image-guided radiotherapy (IGRT) protocols to ensure its safe delivery. The aim of this survey was to provide an assessment of current lung SABR practice in the UK.

METHODS

An online semi-structured survey containing a maximum of 32 questions regarding lung SABR, focussing on treatment image verification processes was piloted, developed and disseminated to the radiotherapy managers of 62 National Health Service centres across the UK.

RESULTS

The survey had a 100% complete response from NHS centres. 36 centres (58%) currently deliver lung SABR, with half treating fewer than 50 patients per year. Six centres deliver SABR despite not being commissioned by the NHS to provide this service. There is wide variation in the use of IGRT. Eight different permutations of cone beam CT order within the workflow were reported. Almost half of lung centres (17/36, 47%) believe there is a need to update national image guidance associated with lung SABR, such as the use of 'day zero', mid treatment and post treatment cone beam CTs.

CONCLUSION

Our results demonstrate wide variation in IGRT for lung SABR. There is an opportunity to develop existing IGRT workflows and the optimal approach to image guidance. Further work is required to investigate lung SABR provision and potential barriers to its implementation.

ADVANCES IN KNOWLEDGE

This survey represents the most comprehensive and accurate assessment of lung SABR practice in the UK since the 2014 SABR consortium survey.

The gap in postoperative outcome between older and younger patients with stage I-III colorectal cancer has been bridged; results from the Netherlands cancer registry

AIM OF THE STUDY

Previous studies have shown that older patients benefited less than younger patients from surgical treatment for colorectal cancer (CRC). However, CRC care has advanced over time, and it is time to assess whether the difference in postoperative mortality between older and younger CRC patients is still present.

METHODS

Patients with primary stage I-III CRC diagnosed between 2005 and 2016 were selected from the Netherlands Cancer Registry (N = 111,778). Trends in postoperative mortality and 1-year postoperative relative survival (RS) were analysed, stratified according to age (<75 versus ≥75 years) and tumour location (colon versus rectum). One-year postoperative RS was analysed to correct for background mortality in the older population.

RESULTS

Between 2005 and 2016, 30-day postoperative mortality showed a stronger decrease for older patients (from 10.0% to 4.0% for colon cancer [p < 0.001] and from 8.3% to 2.7% for rectal cancer [p < 0.001]) compared with younger patients (from 2.0% to 0.9% for colon cancer [p < 0.001] and from 1.4% to 0.7% for rectal cancer [p = 0.01]). Between 2005 and 2016, also 1-year RS increased more for older patients (from 84.8% to 94.6% for colon cancer and from 86.1% to 97.2% for rectal cancer) compared with younger patients (from 94.0% to 97.8% for colon cancer and from 96.3% to 98.8% for rectal cancer).

CONCLUSION

Between 2005 and 2016, differences in postoperative mortality between older and younger CRC patients decreased. One-year postoperative RS was almost equal for older and younger patients in 2015-2016. This information is crucial for shared decision-making on surgical treatment.

Cancer incidence in older adults in selected regions of sub-Saharan Africa, 2008-2012

Although the countries of Sub-Sharan Africa represent among the most rapidly growing and aging populations worldwide, no previous studies have examined the cancer patterns in older adults in the region as a means to inform cancer policies. Using data from Cancer Incidence in Five Continents, we describe recent patterns and trends in incidence rates for the major cancer sites in adults aged ≥60 years and in people aged 0-59 for comparison in four selected population-based cancer registries in Kenya (Nairobi), the Republic of South Africa (Eastern Cape Province), Uganda (Kyadondo country), and Zimbabwe (Harare blacks). Over the period 2008-2012, almost 9,000 new cancer cases were registered in older adults in the four populations, representing one-third of all cancer cases. Prostate and esophageal cancers were the leading cancer sites in older males, while breast, cervical and esophageal cancers were the most common among older females. Among younger people, Kaposi sarcoma and non-Hodgkin lymphoma were common. Over the past 20 years, incidence rates among older adults have increased in both sexes in Uganda and Zimbabwe while rates have stabilized among the younger age group. Among older adults, the largest rate increase was observed for breast cancer (estimated annual percentage change: 5% in each country) in females and for prostate cancer (6-7%) in males. Due to the specific needs of older adults, tailored considerations should be given to geriatric oncology when developing, funding and implementing national and regional cancer programmes.

Cardiorespiratory fitness and site-specific risk of cancer in men: A systematic review and meta-analysis

BACKGROUND

Cardiorespiratory fitness is a strong predictor of all-cause morbidity and mortality; nevertheless, the association between cardiorespiratory fitness and the risk of cancer remains unclear. Thus, the aim of this study was to synthetize the evidence on the relationship between cardiorespiratory fitness and the risk of several sites of cancer in men.

METHODS

A computerised search in MEDLINE, EMBASE and Web of Science databases from their inception to 13th February 2019 was performed. Both fixed and random-effects models were used to calculate the pooled hazard ratio (HR) estimates and their 95% confidence intervals (CIs) to examine the effect of high and moderate versus low cardiorespiratory fitness on site-specific cancer (lung, colon/rectum, prostate) and all-sites cancer.

RESULTS

Ten studies were included in the qualitative review, and seven of them were included in the meta-analysis. Using low cardiorespiratory fitness as the reference group, moderate and high levels of cardiorespiratory fitness were associated with a lower risk (HRs) of lung cancer, 0.53 (95% confidence interval [CI], 0.39 to 0.68) and 0.52 (95% CI, 0.42 to 0.61); colorectal cancer, 0.74 (95% CI, 0.55 to 0.93) and 0.77 (95% CI, 0.62 to 0.92) and all cancer sites, 0.86 (95% CI, 0.79 to 0.93) and 0.81 (95% CI, 0.75 to 0.87), respectively.

CONCLUSIONS

Among men, cardiorespiratory fitness plays an important role in protecting against the risk of lung and colorectal cancer. Additionally, this protective effect was observed for all-sites cancer risk. These results show the importance of good cardiorespiratory fitness as a potential factor in cancer prevention.

Time trends of short-term mortality for octogenarians undergoing a colorectal resection in North Europe

BACKGROUND

Decreased cancer specific survival in older colorectal patients is mainly due to mortality in the first year, emphasizing the importance of the first postoperative year. This study aims to gain an overview and time trends of short-term mortality in octogenarians (≥80 years) with colorectal cancer across four North European countries.

METHODS

Patients of 80 years or older, operated for colorectal cancer (stage I-III) between 2005 and 2014, were included. Population-based cohorts from Belgium, Denmark, the Netherlands, and Sweden were collected. Separately for colon- and rectal cancer, 30-day, 90-day, one-year, and excess one-year mortality were calculated. Also, short-term mortality over three time periods (2005-2008, 2009-2011, 2012-2014) was analyzed.

RESULTS

In total, 35,158 colon cancer patients and 10,144 rectal cancer patients were included. For colon cancer, 90-day mortality rate was highest in Denmark (15%) and lowest in Sweden (8%). For rectal cancer, 90-day mortality rate was highest in Belgium (11%) and lowest in Sweden (7%). One-year excess mortality rate of colon cancer patients decreased from 2005 to 2008 to 2012-2014 for all countries (Belgium: 17%-11%, Denmark: 21%-15%, the Netherlands: 18%-10%, and Sweden: 10%-8%). For rectal cancer, from 2005 to 2008 to 2012-2014 one-year excess mortality rate decreased in the Netherlands from 16% to 7% and Sweden: 8%-2%).

CONCLUSIONS

Short-term mortality rates were high in octogenarians operated for colorectal cancer. Short-term mortality rates differ across four North European countries, but decreased over time for both colon and rectal cancer patients in all countries.

Surgical approach and geriatric evaluation for elderly patients with colorectal cancer

This review aims to define the most appropriate surgical approach and geriatric evaluation for elderly patients with colorectal cancer (CRC). Surgery represents the main treatment for CRC, but elderly cancer patients still represent a challenge for the surgeon due to frequent comorbidities such as cardiovascular and pulmonary diseases, which increase operative risk as well as the risk of postoperative morbidity and mortality. Cancer patients with comorbidities show lower survival rates and quality of life, together with higher healthcare costs. There is also evidence that patients with comorbidities sometimes receive modified treatment, compromising optimal care. To optimize treatment, the approach to elderly cancer patients needs a multidisciplinary team to assess preoperative conditions, prevent post-surgical complications and improve outcome, especially for frail patients. Laparoscopic surgery for CRC shows a number of advantages compared to conventional surgery such as less postoperative pain, rapid return to prior activities and a decrease in costs. Recent studies confirm that laparoscopic procedures could be performed safely on both older and younger patients with no difference compared with open surgery as regards morbidity or length of hospital stay.

Aging and the cancer burden in Latin America and the Caribbean: Time to act

OBJECTIVE

To describe the cancer burden in adults aged 65 years and older in Latin America and the Caribbean to serve as rational for improving cancer control planning among region's older population.

MATERIALS AND METHODS

Using the up-to-date GLOBOCAN estimates for 2018, we describe the cancer burden including key patterns for the major cancer sites among adults aged 65 years and older in Latin America and the Caribbean. We also predict the future burden in 2040 by applying population projections, assuming no changes in incidence rates over time.

RESULTS

In 2018, an estimated 679,000 new cancer cases occurred among older adults in LAC, representing almost half (48%) of the total incidence burden (43% in Central America, 49% in South America, and 52% in the Caribbean). Prostate, colorectum, and lung were the most common cancers among older males in South America and the Caribbean, with non-melanoma skin cancer ranking third in Central America. Among older females, the most common sites were breast, colorectum, and non-melanoma skin cancer, except in the Caribbean, where lung cancer ranked third. Overall, the number of new cancer cases among older adults in the region is expected to double by 2040, reaching 1.6 million new cases.

CONCLUSION

Our findings highlight the need for an urgent adaptation of healthcare systems across LAC by improving training in geriatrics for the oncology workforce, and by including older adults in clinical guidelines, insurance schemes, and cancer prevention policies.

The association between the Nutrition-Related index and morbidity following head and neck microsurgery

OBJECTIVES/HYPOTHESIS

Despite consensus that preoperative nutritional assessment is of importance in the head and neck surgical oncology population, it remains unclear how exactly malnutrition is associated with perioperative morbidity especially among those undergoing microvascular surgery. We aimed to study this association to help inform preoperative risk stratification, guide the use of nutritional interventions, and ultimately help prevent malnutrition related morbidity.

STUDY DESIGN

Database analysis.

METHODS

Retrospective, linked analysis of the 2011 to 2016 National Surgical Quality Improvement Program. After identifying eligible patients and stratifying according to the Nutrition-Related Index, a univariate screen of preoperative demographic and clinical covariates was performed. Subsequently, propensity score matching was utilized to control for differences in baseline covariates. Perioperative complications and mortality were then analyzed using the propensity score-matched cohorts.

RESULTS

Among 977 identified patients, 276 (28.2%) were malnourished. Malnourished patients had higher rates of comorbidity, were more likely to actively smoke, and were more likely to have primaries in the oropharynx or hypopharynx/larynx. After propensity score matching to control for confounders, malnourished patients had higher rates of pulmonary complications (21.5% vs. 11.6%, P < .01), higher rates of bleeding or need for transfusion (56.6% vs. 43.0%, P < .01), higher rates of venous thromboembolism (3.7% vs. 0.8%, P = .03), and a higher 30-day mortality rates (3.7% vs. 0.0%, P < .01).

CONCLUSIONS

This nationwide analysis finds that 28.2% of patients undergoing surgery for head and neck cancers with free flap reconstruction are malnourished. Malnourishment was found to be independently associated with postoperative pulmonary complications, bleeding or need for transfusion, and 30-day mortality.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:375-380, 2020.

Preoperative geriatric assessment and follow-up of patients older than 75 years undergoing elective surgery for suspected colorectal cancer

OBJECTIVES

We investigated the predictive value of specific tools used in a Comprehensive Geriatric Assessment (CGA) with regard to postoperative outcome in patients 75 years and older undergoing elective colorectal cancer (CRC) surgery. Furthermore, recovery was followed over the first postoperative year using the same assessment tools.

MATERIAL AND METHODS

Baseline clinical and CGA variables including functional and nutritional status, pressure sore risk, fall risk, cognition, depression, polypharmacy, comorbidity, and health-related quality-of-life (HRQoL) were prospectively recorded. Outcome variables were postoperative complications and length of stay (LOS). Patients were likewise followed up at one, three and twelve months postoperatively.

RESULTS

Forty-nine patients underwent surgery (median age 81 years). Forty-three per cent had ASA (American Society of Anesthesiologists) class 2 47% had ASA class 3. Postoperative complications occurred in 32.7%. Median LOS was eight days. In univariate analyses, none of the parameters tested predicted postoperative complication or LOS. During follow-up, all patients recovered to baseline values apart from HRQoL which was still reduced at three and twelve months (p = .017). Nutritional status had improved twelve months after surgery (p = .011).

CONCLUSIONS

No association could be found in this study between the results of a comprehensive geriatric assessment and prolonged length of stay or postoperative complication rate after elective surgery for colorectal cancer. Patients recovered well during the first year after surgery. Quality of life, however, was still lower than prior to surgery.

A conditional model predicting the 10-year annual extra mortality risk compared to the general population: a large population-based study in Dutch breast cancer patients

Objective

Many cancer survivors are facing difficulties in getting a life insurance; raised premiums and declinatures are common. We generated a prediction model estimating the conditional extra mortality risk of breast cancer patients in the Netherlands. This model can be used by life insurers to accurately estimate the additional risk of an individual patient, conditional on the years survived.

Methodology

All women diagnosed with stage I-III breast cancer in 2005–2006, treated with surgery, were selected from the Netherlands Cancer Registry. For all stages separately, multivariable logistic regression was used to estimate annual mortality risks, conditional on the years survived, until 10 years after diagnosis, resulting in 30 models. The conditional extra mortality risk was calculated by subtracting mortality rates of the general Dutch population from the patient mortality rates, matched by age, gender and year. The final model was internally and externally validated, and tested by life insurers.

Results

We included 23,234 patients: 10,101 stage I, 9,868 stage II and 3,265 stage III. The final models included age, tumor stage, nodal stage, lateralization, location within the breast, grade, multifocality, hormonal receptor status, HER2 status, type of surgery, axillary lymph node dissection, radiotherapy, (neo)adjuvant systemic therapy and targeted therapy. All models showed good calibration and discrimination. Testing of the model by life insurers showed that insurability using the newly-developed model increased with 13%, ranging from 0%-24% among subgroups.

Conclusion

The final model provides accurate conditional extra mortality risks of breast cancer patients, which can be used by life insurers to make more reliable calculations. The model is expected to increase breast cancer patients’ insurability and transparency among life insurers.

Global cancer incidence in older adults, 2012 and 2035: A population-based study

Population ageing has substantially contributed to the rising number of new cancer cases worldwide. We document cancer incidence patterns in 2012 among older adults globally, and examine the changing magnitude of cancer in this age group over the next decades. Using GLOBOCAN 2012 data, we presented the number and proportion of new cancer cases, and the truncated age-standardised incidence rates among adults aged 65 years and older for all cancer sites combined and for the five most common cancer sites by world region. We calculated the incidence in 2035 by applying population projections, assuming no changes in rates. In 2012, 6.7 million new cancer cases (47.5% of all cancers) were diagnosed among older adults worldwide, with marked regional disparities. Nearly 48% of these cases occurred in less developed regions. Lung, colorectal, prostate, stomach and breast cancers represented 55% of the global incidence, yet distinct regional patterns were observed. We predict 14 million new cancer cases by 2035, representing almost 60% of the global cancer incidence. The largest relative increase in incidence is predicted in the Middle East and Northern Africa (+157%), and in China (+155%). Less developed regions will see an increase of new cases by 144%, compared to 54% in more developed regions. The expected increase in cancer incidence at older ages will have substantial economic and social impacts globally, posing considerable and unique challenge to healthcare systems in every world region, especially in those with limited resources and weaker health systems.

Impact of Age, Comorbidity, and FIGO Stage on Treatment Choice and Mortality in Older Danish Patients with Gynecological Cancer: A Retrospective Register-Based Cohort Study

Background

The number of older patients with cancer is increasing in general, and ovarian and endometrial cancer are to a large extent cancers of the elderly. Older patients with cancer have a high prevalence of comorbidity. Comorbidity and age may be predictive of treatment choice and mortality in older patients with cancer along with stage and performance status.

Objectives

The aim of this study was to describe comorbidity in a population of older Danish patients with gynecological cancer, and to evaluate the predictive value of comorbidity and age on treatment choice and cancer-specific and all-cause mortality.

Materials and methods

In this retrospective study, we included 459 patients aged ≥ 70 years. Patients were diagnosed with cervical, endometrial, or ovarian cancer from 1 January, 2007 to 31 December, 2011 and were evaluated and/or treated at Odense University Hospital. Comorbidity was assessed using the Charlson Comorbidity Index. Treatment was classified as curative intended, palliative intended, or no treatment.

Results

Age, International Federation of Gynecology and Obstetrics (FIGO) stage, and performance status were found to be significant predictors of treatment choice, while comorbidity was not. Multivariate analyses showed that both cancer-specific and all-cause mortality were significantly associated with treatment choice, FIGO stage, and performance status. Age was not associated with mortality, with the exception of ovarian cancer, where age was associated with all-cause mortality. Comorbidity was not an independent predictor of treatment choice or mortality.

Conclusions

In our population of older Danish patients with gynecological cancer, age, FIGO stage, and performance status were predictors of treatment choice, while comorbidity was not. Treatment choice, FIGO stage, and performance status were significantly associated with both cancer-specific and all-cause mortality. Age was only associated with mortality in ovarian cancer, while comorbidity was not associated with mortality.

Prevalence of Cardiac Disease in Breast Cancer Patients at Time of Diagnosis Compared to the General Female Population in Germany

Background

Advances in oncological therapy have significantly improved breast cancer survival; therefore comorbid conditions are becoming more relevant. We investigated the prevalence of prior cardiovascular diseases and risk factors in patients with breast cancer compared to those in the general female population in Germany.

Methods

The PASSOS heart study is a retrospective multicenter cohort study on cardiac late effects in breast cancer patients treated between 1998 and 2008. We analyzed the frequencies of cardiac diseases and cardiovascular risk factors in patients from this cohort as documented in anesthesia protocols compared to self-reported frequencies in the general female population in Germany.

Results

3,496 patients aged between 40 and 79 years who underwent breast surgery were considered for analysis. The age-standardized prevalence of cardiac diseases or cardiovascular risk factors was 6.75 versus 7.52% and 69 versus 80.92%, respectively. Coronary heart disease (3.96 vs. 5.18%) and angina pectoris (0.37 vs. 1.03%) prevalence was lower in breast cancer patients, while non-fatal myocardial infarction (2.06 vs. 1.81%) and stroke (2.64 vs. 2.34%) were more frequent (not statistically significant).

Conclusion

Pre-existing cardiac diseases and cardiovascular risk factors are common in both study populations, being slightly less frequent in the PASSOS cohort. When making therapy decisions, the cardiac risk profile should be carefully monitored and taken into account.

The age-adjusted Charlson comorbidity index as a predictor of survival in surgically treated vulvar cancer patients

Objective

To evaluate the impact of age-adjusted Charlson comorbidity index (ACCI) in predicting disease-free survival (DFS), overall survival (OS), and cancer-specific survival (CSS) among surgically treated patients with vulvar carcinoma. The secondary aim is to evaluate its impact as a predictor of the pattern of recurrence.

Methods

We retrospectively evaluated data of patients that underwent surgical treatment for vulvar cancer from 1998 to 2016. ACCI at the time of primary surgery was evaluated and patients were classified as low (ACCI 0–1), intermediate (ACCI 2–3), and high risk (>3). DFS, OS and CSS were analyzed using the Kaplan-Meir and the Cox proportional hazard models. Logistic regression model was used to assess predictors of distant and local recurrence.

Results

Seventy-eight patients were included in the study. Twelve were classified as low, 36 as intermediate, and 30 as high risk according to their ACCI. Using multivariate analysis, ACCI class was an independent predictor of worse DFS (hazard ratio [HR]=3.04; 95% confidence interval [CI]=1.54–5.99; p<0.001), OS (HR=5.25; 95% CI=1.63–16.89; p=0.005) and CSS (HR=3.79; 95% CI=1.13–12.78; p=0.03). Positive nodal status (odds ratio=8.46; 95% CI=2.13–33.58; p=0.002) was the only parameter correlated with distant recurrence at logistic regression.

Conclusion

ACCI could be a useful tool in predicting prognosis in surgically treated vulvar cancer patients. Prospective multicenter trials assessing the role of ACCI in vulvar cancer patients are warranted.