Peri-operative outcomes following major surgery for head and neck cancer in the elderly: institutional audit and case–control study

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.

Traditional risk factors and cancer-related factors associated with cardiovascular disease risk in head and neck cancer patients

Background

Risk of incident cardiovascular disease (CVD) in head and neck squamous cell carcinoma (HNSCC) patients is under-reported. We assessed the association of HNSCC-related factors and traditional risk factors with 1- and 5-year CVD risk in HNSCC patients without prevalent CVD at cancer diagnosis.

Methods

A clinical cohort of 1,829 HNSCC patients diagnosed between 2012 and 2018, at a National Cancer Institute (NCI)-designated cancer center was included. Information on HNSCC-related factors [HNSCC anatomical subsite, stage at diagnosis, treatment, and tumor human papillomavirus (HPV) status] were extracted from the tumor registry. Data on traditional risk factors (hypertension, dyslipidemia, diabetes, tobacco smoking status, and obesity) were extracted from the electronic health records system (EHR) at baseline (HNSCC diagnosis). A composite of ischemic heart disease, heart failure, and ischemic stroke was the outcome of interest in time to event analysis. Hazard ratio (HR) (95% CI) were reported with death as a competing risk.

Results

In patients diagnosed with HNSCC, 10.61% developed incident CVD events by 1-year post cancer diagnosis. One-year CVD risk was lower in patients using antihypertensive medications at baseline, compared to patients without baseline hypertension [HR (95% CI): 0.41 (0.24-0.61)]. One-year CVD risk was high in patients receiving HNSCC surgery. Patients receiving radiation therapy had a higher 5-year CVD risk than surgery patients [HR (95% CI): 2.17 (1.31-3.04)]. Patients using antihypertensive medications had a lower 5-year CVD risk than patients without baseline hypertension [HR (95% CI): 0.45 (0.22-0.75)]. Older age and diabetes were associated with increased 1- and 5-year CVD risk. HPV-negative patients were older (p 0.006) and had a higher 5-year cumulative incidence of CVD (p 0.013) than HPV-positive patients.

Conclusion

Traditional risk factors and cancer-related factors are associated with CVD risk in HNSCC patients. Future research should investigate the role of antihypertensive medications in reducing CVD risk in HNSCC patients.

Outcomes following head and neck cancer surgery among older adults as determined by an electronic geriatric assessment

PURPOSE

Older adults with head and neck cancer have increased postoperative complications, longer hospital stays, and higher rates of mortality. Geriatric assessment (GA) provides a measure of overall health status and is preferable to using age alone for assessing fitness for surgery. We sought to determine whether a patient's frailty as determined by a novel electronic GA is associated with outcomes after head and neck cancer (HNC) surgery.

METHODS

We conducted a retrospective review of 159 patients aged 75 and older referred to the Geriatrics Service at Memorial Sloan Kettering Cancer Center for pre-operative evaluation prior to undergoing HNC surgery. All patients completed the electronic Rapid Fitness Assessment (eRFA) within 60 days prior to surgery. The accumulated geriatric deficit (AGD) score includes twelve domains from the eRFA with a point assigned for each domain in which there is a deficit and a final point related to comorbidities. Three other metrics were individually assessed: age, Karnofsky Performance Scale (KPS), and number of comorbidities. We utilized multivariable linear regression and t-tests to determine whether frailty is associated with longer length of hospital stay, 30-day intensive care unit (ICU) admission, and 30-day and 90-day postoperative mortality.

RESULTS

Patients with a higher AGD score spent more time in the hospital post-operatively (1.0 day increase per unit increase in AGD; 95% CI: 0.21-1.9; p = 0.015). Lower KPS was also associated with statistically significant longer length of stay (-2.70 day change per increasing index KPS; 95% CI: -4.30 - -1.00; days; p = 0.002), while age and comorbidity were not found to be statistically associated with length of stay. Higher AGD score remained significantly associated with longer length of stay on multivariable analysis (0.93 day increase per unit increase in AGD; 95% CI 0.15-1.71; p = 0.019). AGD was the only metric associated with increased risk of ICU admission (6.6 vs 5.0 geriatric deficits for those admitted vs not admitted to ICU; p = 0.024).

CONCLUSIONS

Frailty is associated with increased length of hospital stay and ICU admission in older adults with HNC undergoing surgery. GA can be used to counsel patients on the expected postoperative course.

Cancer in the older Indian population: Understanding the current context in an emerging economy

India is considered a demographically young country with over 65% of the population aged below 35 years. However, improvements in maternal and child health, and infectious diseases, have created a rapid epidemiological transition with an aging population (8.6% in 2011) with a projected increase (19% by 2050), equating to 104 million. In addition to the well-articulated issues surrounding the care of the older patients with cancer, the Indian context as an emerging economy provides additional social, political, economic and clinical challenges. This review addresses the key issues and possible solutions germane to both policymakers in India and other emerging economies. Extension of cancer prevention, equal, optimal treatment opportunities, and inclusion in clinical trials, akin to the younger population, must be encouraged. Various national health initiatives require effective implementation, to provide uniform, evidence-based, cancer care across India. Designated geriatric oncology departments, and required care at the primary healthcare level are essential.

Microvascular reconstruction of head and neck defects in the elderly

BACKGROUND

Microvascular free-flap reconstruction of the head and neck is a common technique utilized across many ages. The purpose of this study was to identify if advanced age or comorbidity was associated with worse post-operative outcomes in patients undergoing free-flap reconstruction.

METHODS

A retrospective analysis was performed on 344 consecutive patients undergoing free-flap surgery of the head and neck. Demographic, clinical and pathological factors were considered along with Charlson Comorbidity Index (CCI) scores and American Society of Anesthesiologists (ASA) status. Logistic regression analysis was used to investigate the association of age, CCI or ASA with post-operative complications.

RESULTS

Elderly patients (≥75 years) had a higher overall complication rate (odds ratio (OR) 1.7, P = 0.04) that was restricted to medical complications (OR 2.1, P = 0.05) and not surgical complications (OR 1.4, P = 0.14). Reconstructions of defects from cutaneous malignancy predominated in the elderly cohort (48% versus 29%, P < 0.01), but there was no difference in complication rate when cutaneous or mucosal subgroups were separated by age. ASA IV status was weakly associated with surgical complications (OR 3.89, P = 0.053), but CCI and elderly age were not associated with any outcome. Median length of stay was similar between age groups.

CONCLUSION

Free-flap reconstruction in older patients was associated with increased medical complications, and surgical complications were weakly associated with ASA status. Advanced age or comorbidity should not preclude microvascular reconstruction, but comorbid status should be optimized pre-operatively and factors predisposing to medical complications minimized where possible.