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Knigin D, Brezinov Y, Salvador S, Lau S, Gotlieb WH. Surgery Advances in Gynecologic Tumors: The Evolution and Outcomes of Robotic Surgery for Gynecologic Cancers in a Tertiary Center. Curr Oncol 2024; 31:2400-2409. [PMID: 38785460 PMCID: PMC11120242 DOI: 10.3390/curroncol31050179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024] Open
Abstract
The integration of innovation into routine clinical practice is faced with many challenges. In 2007, we received the mandate to evaluate how the introduction of a robotic program in gynecologic oncology affected patient-centered care by studying its impact on clinical outcomes and hospital resource utilization. Here we summarize the history and experience of developing a robotic surgery program for gynecologic cancers over 16 years. Analysis of the data indicates that robotic surgery improved perioperative patient clinical parameters, decreased blood loss, complications, and hospital stay, maintained the oncologic outcome, and is cost-effective, resulting in it becoming the dominant surgical approach in gynecologic oncology in a tertiary cancer care institution.
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Affiliation(s)
- David Knigin
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada; (D.K.); (S.S.); (S.L.)
- Segal Cancer Center, Sir Mortimer B. Davis Institute of Medical Research, McGill University, Montreal, QC H3T 1E2, Canada
| | - Yoav Brezinov
- Segal Cancer Center, Sir Mortimer B. Davis Institute of Medical Research, McGill University, Montreal, QC H3T 1E2, Canada
| | - Shannon Salvador
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada; (D.K.); (S.S.); (S.L.)
- Segal Cancer Center, Sir Mortimer B. Davis Institute of Medical Research, McGill University, Montreal, QC H3T 1E2, Canada
| | - Susie Lau
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada; (D.K.); (S.S.); (S.L.)
- Segal Cancer Center, Sir Mortimer B. Davis Institute of Medical Research, McGill University, Montreal, QC H3T 1E2, Canada
| | - Walter H. Gotlieb
- Division of Gynecologic Oncology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada; (D.K.); (S.S.); (S.L.)
- Segal Cancer Center, Sir Mortimer B. Davis Institute of Medical Research, McGill University, Montreal, QC H3T 1E2, Canada
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Papachristou N, Kartsidis P, Anagnostopoulou A, Marshall-McKenna R, Kotronoulas G, Collantes G, Valdivieso B, Santaballa A, Conde-Moreno AJ, Domenech JR, Kokoroskos E, Papachristou P, Sountoulides P, Levva S, Avgitidou K, Tychala C, Bakogiannis C, Stafylas P, Ramon ZV, Serrano A, Tavares V, Fernandez-Luque L, Hors-Fraile S, Billis A, Bamidis PD. A Smart Digital Health Platform to Enable Monitoring of Quality of Life and Frailty in Older Patients with Cancer: A Mixed-Methods, Feasibility Study Protocol. Semin Oncol Nurs 2023; 39:151437. [PMID: 37149438 DOI: 10.1016/j.soncn.2023.151437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 03/29/2023] [Indexed: 05/08/2023]
Abstract
OBJECTIVES LifeChamps is an EU Horizon 2020 project that aims to create a digital platform to enable monitoring of health-related quality of life and frailty in patients with cancer over the age of 65. Our primary objective is to assess feasibility, usability, acceptability, fidelity, adherence, and safety parameters when implementing LifeChamps in routine cancer care. Secondary objectives involve evaluating preliminary signals of efficacy and cost-effectiveness indicators. DATA SOURCES This will be a mixed-methods exploratory project, involving four study sites in Greece, Spain, Sweden, and the United Kingdom. The quantitative component of LifeChamps (single-group, pre-post feasibility study) will integrate digital technologies, home-based motion sensors, self-administered questionnaires, and the electronic health record to (1) enable multimodal, real-world data collection, (2) provide patients with a coaching mobile app interface, and (3) equip healthcare professionals with an interactive, patient-monitoring dashboard. The qualitative component will determine end-user usability and acceptability via end-of-study surveys and interviews. CONCLUSION The first patient was enrolled in the study in January 2023. Recruitment will be ongoing until the project finishes before the end of 2023. IMPLICATIONS FOR NURSING PRACTICE LifeChamps provides a comprehensive digital health platform to enable continuous monitoring of frailty indicators and health-related quality of life determinants in geriatric cancer care. Real-world data collection will generate "big data" sets to enable development of predictive algorithms to enable patient risk classification, identification of patients in need for a comprehensive geriatric assessment, and subsequently personalized care.
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Affiliation(s)
- Nikolaos Papachristou
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Panagiotis Kartsidis
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Anagnostopoulou
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Grigorios Kotronoulas
- School of Medicine, Dentistry and Nursing, University of Glasgow, Glasgow, United Kingdom
| | | | | | - Ana Santaballa
- University and Polytechnic La Fe Hospital of Valencia, Valencia, Spain
| | | | | | | | - Panagiotis Papachristou
- Academic Primary Health Care Centre, Region Stockholm, Stockholm, Sweden; Department of Neurobiology, Care Science and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
| | - Petros Sountoulides
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Sophia Levva
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Kelly Avgitidou
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece; Healthink (Medical Research & Innovation, PC), Thessaloniki, Greece
| | - Christiana Tychala
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece; Healthink (Medical Research & Innovation, PC), Thessaloniki, Greece
| | - Costas Bakogiannis
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panos Stafylas
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece; Healthink (Medical Research & Innovation, PC), Thessaloniki, Greece
| | | | | | | | | | | | - Antonios Billis
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis D Bamidis
- Medical Physics and Digital Innovation Laboratory, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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The impact of the modified frailty index on clinical outcomes for patients with stage IV non-small cell lung cancer receiving chemotherapy. J Geriatr Oncol 2022; 13:654-661. [DOI: 10.1016/j.jgo.2022.02.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/23/2021] [Accepted: 02/23/2022] [Indexed: 01/20/2023]
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Abstract
The majority of patients with common malignancies are older adults. Intrinsic complex biological changes of aging along with inflammation, immunosenescence, age-associated chronic diseases, and extrinsic environmental and psychosocial factors have significant impact on not only development and behavior of individual malignancies, but also physiologic reserve and vulnerability of older patients who suffer from them. As a result, clinical practice of geriatric oncology demands integration of careful geriatric assessment and management. This article provides an overview of basic biology of aging and its relationship with cancer. After a brief introduction about the definition and mechanisms of aging, as well as age-related biological and physiological changes, the discussion mainly focuses on recent development and insights into the relationship of frailty, inflammation, and immunity with cancer, highlighting how the new knowledge can help further improve assessment and treatment of older patients with malignancies and promote cancer research.
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Castellví Valls J, Borrell Brau N, Bernat MJ, Iglesias P, Reig L, Pascual L, Vendrell M, Santos P, Viso L, Farreres N, Galofre G, Deiros C, Barrios P. Resultados de morbimortalidad en cáncer colorrectal en paciente quirúrgico frágil. Implementación de un Área de Atención al Paciente Quirúrgico Complejo. Cir Esp 2018; 96:155-161. [DOI: 10.1016/j.ciresp.2017.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 09/15/2017] [Accepted: 09/25/2017] [Indexed: 12/11/2022]
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Konstantinidis IT, Chouliaras K, Levine EA, Lee B, Votanopoulos KI. Frailty Correlates with Postoperative Mortality and Major Morbidity After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2017; 24:3825-3830. [DOI: 10.1245/s10434-017-6111-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Indexed: 12/19/2022]
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Cheung KL, Morgan D, Brain E, Poortmans P, Parks R, Korc-Grodzicki B, Ugolini F, Shakir T, Tsang J, Stone H, Kenis C, Perks G, Wijayatunga R. 4th symposium on primary breast cancer in older women. Theme: putting personalized care into practice (Held: 3 March 2017). BREAST CANCER MANAGEMENT 2017. [DOI: 10.2217/bmt-2017-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Following the inception in 2010, the University of Nottingham hosted the 4th Symposium on Primary Breast Cancer in Older Women, under the auspices of the International Society of Geriatric Oncology, in March 2017, at East Midlands Conference Centre. This is the only meeting of its kind in the UK, now held biennially, aiming at a multidisciplinary audience, including patients, their carers and advocates. With a theme on ‘Putting personalising care into practice’, this Symposium included sessions on ‘local and systemic therapies’, ‘new ideas’, ‘patients and carers’, and ‘challenging areas’, covered by an international and local faculty, interviewing patients and carers, and abstract presentations. Topics covered were practical and wide-ranging, including selectng for chemotherapy, radiotherapy and breast reconstruction, treating HER2-positive disease, and the roles of the geriatrician and geriatric oncology nurse.
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Affiliation(s)
- Kwok-Leung Cheung
- Division of Medical Sciences and Graduate Entry Medicine, School of Medicine, University of Nottingham, Royal Derby Hospital Centre, Derby DE22 3DT, UK
| | - David Morgan
- Department of Oncology, Nottingham University Hospitals, Nottingham NG5 1PB, UK
| | - Etienne Brain
- Department of Oncology, Institut Curie, Paris, France
| | | | - Ruth Parks
- Breast Unit, Royal Derby Hospital, Derby DE22 3NE, UK
| | | | - Fiammetta Ugolini
- Breast Unit, Brighton & Sussex University Hospital, Brighton BN1 6AG, UK
| | - Taner Shakir
- Peterborough Breast Unit, Peterborough PE3 9GZ, UK
| | - Janice Tsang
- Hong Kong Breast Cancer Registry, Hong Kong Breast Cancer Foundation, Hong Kong, SAR
| | - Heather Stone
- Breast Unit, Royal Derby Hospital, Derby DE22 3NE, UK
| | - Cindy Kenis
- Department of Geriatric Oncology, University Hospitals Leuven, Belgium
| | - Graeme Perks
- Department of Oncology, Nottingham University Hospitals, Nottingham NG5 1PB, UK
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Vermillion SA, Hsu FC, Dorrell RD, Shen P, Clark CJ. Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients. J Surg Oncol 2017; 115:997-1003. [PMID: 28437582 DOI: 10.1002/jso.24617] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 02/26/2017] [Accepted: 02/27/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Frailty disproportionately impacts older patients with gastrointestinal cancer, rendering them at increased risk for poor outcomes. A frailty index may aid in preoperative risk stratification. We hypothesized that high modified frailty index (mFI) scores are associated with adverse outcomes after tumor resection in older, gastrointestinal cancer patients. METHODS Patients (60-90 years old) who underwent gastrointestinal tumor resection were identified in the 2005-2012 NSQIP Participant Use File. mFI was defined by 11 previously described, preoperative variables. Frailty was defined by an mFI score >0.27. The postoperative course was evaluated using univariate and multivariate analysis. RESULTS 41 455 patients (mean age 72.4 years, 47.4% female) were identified. The most prevalent form of cancer was colorectal (69.3%, n = 28 708) and 2.8% of patients were frail (n = 1,164). Frail patients were significantly more likely to have increased length of stay (11.7 vs 9.0 days), major complications (29.1% vs 17.9%), and 30-day mortality (5.6% vs 2.5%), (all P < 0.001). Multivariate analysis identified mFI as an independent predictor of major complications (OR 1.52, 95%CI 1.39-1.65, P < 0.001) and 30-day mortality (OR 1.48, 95%CI 1.24-1.75, P < 0.001). CONCLUSIONS mFI was associated with the incidence of postoperative complications and mortality in older surgical patients with gastrointestinal cancer.
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Affiliation(s)
- Sarah A Vermillion
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Fang-Chi Hsu
- Division of Public Health Sciences, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Robert D Dorrell
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Perry Shen
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Clancy J Clark
- Division of Surgical Oncology, Department of General Surgery, Wake Forest Baptist Health, Winston Salem, North Carolina
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Huisingh-Scheetz M, Walston J. How should older adults with cancer be evaluated for frailty? J Geriatr Oncol 2016; 8:8-15. [PMID: 27318797 DOI: 10.1016/j.jgo.2016.06.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/21/2016] [Accepted: 06/01/2016] [Indexed: 12/11/2022]
Abstract
Traditionally used as a descriptive term, frailty is now a recognized medical syndrome identifying individuals with decreased physiologic reserve. Frailty is characterized by diminished strength, endurance, and reduced physiologic function. Several valid frailty screening tools exist in the literature, and these measures have been used to relate frailty to outcomes important to the older patient with cancer. Frail adults are at increased risk of adverse surgical outcomes and early findings suggest that frailty predicts poor chemotherapy tolerance. While much research is needed to explore the biologic relationships between frailty and cancer, there is an urgent need to implement frailty screening and management into the care of the older patient with cancer in order to improve outcomes in this vulnerable subset. The purpose of this paper is to provide an introduction of frailty to oncologists including a review of the definition, frailty screening tools, its clinical relevance to older patients with cancer, and a brief guide to frailty management.
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Affiliation(s)
| | - Jeremy Walston
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, USA
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Wagner D, DeMarco MM, Amini N, Buttner S, Segev D, Gani F, Pawlik TM. Role of frailty and sarcopenia in predicting outcomes among patients undergoing gastrointestinal surgery. World J Gastrointest Surg 2016; 8:27-40. [PMID: 26843911 PMCID: PMC4724585 DOI: 10.4240/wjgs.v8.i1.27] [Citation(s) in RCA: 142] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 09/19/2015] [Accepted: 10/20/2015] [Indexed: 02/06/2023] Open
Abstract
According to the United States census bureau 20% of Americans will be older than 65 years in 2030 and half of them will need an operation - equating to about 36 million older surgical patients. Older adults are prone to complications during gastrointestinal cancer treatment and therefore may need to undergo special pretreatment assessments that incorporate frailty and sarcopenia assessments. A focused, structured literature review on PubMed and Google Scholar was performed to identify primary research articles, review articles, as well as practice guidelines on frailty and sarcopenia among patients undergoing gastrointestinal surgery. The initial search identified 450 articles; after eliminating duplicates, reports that did not include surgical patients, case series, as well as case reports, 42 publications on the impact of frailty and/or sarcopenia on outcome of patients undergoing gastrointestinal surgery were included. Frailty is defined as a clinically recognizable state of increased vulnerability to physiologic stressors resulting from aging. Frailty is associated with a decline in physiologic reserve and function across multiple physiologic systems. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength. Unlike cachexia, which is typically associated with weight loss due to chemotherapy or a general malignancy-related cachexia syndrome, sarcopenia relates to muscle mass rather than simply weight. As such, while weight reflects nutritional status, sarcopenia - the loss of muscle mass - is a more accurate and quantitative global marker of frailty. While chronologic age is an important element in assessing a patient's peri-operative risk, physiologic age is a more important determinant of outcomes. Geriatric assessment tools are important components of the pre-operative work-up and can help identify patients who suffer from frailty. Such data are important, as frailty and sarcopenia have repeatedly been demonstrated among the strongest predictors of both short- and long-term outcome following complicated surgical procedures such as esophageal, gastric, colorectal, and hepato-pancreatico-biliary resections.
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Lavoué V, Gotlieb W. Benefits of Minimal Access Surgery in Elderly Patients with Pelvic Cancer. Cancers (Basel) 2016; 8:cancers8010012. [PMID: 26771641 PMCID: PMC4728459 DOI: 10.3390/cancers8010012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 12/10/2015] [Accepted: 01/05/2016] [Indexed: 12/12/2022] Open
Abstract
An increasing proportion of patients requiring treatment for malignancy are elderly, which has created new challenges for oncologic surgeons. Aging is associated with an increasing prevalence of frailty and comorbidities that may affect the outcome of surgical procedures. By decreasing complications and shortening length of hospital stay without affecting oncologic safety, surgery performed using the robot, rather than traditional laparotomy, improves the chances of a better outcome in our growing elderly populations. In addition to age, surgeons should take into account factors, such as frailty and comorbidities that correlate with outcome.
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Affiliation(s)
- Vincent Lavoué
- Service de chirurgie gynécologique, Centre Hospitalo-Universitaire de Rennes, Hôpital Sud, 16 Bd de Bulgarie, 35000 Rennes, France.
- Inserm, ER440-OSS, CRLCC Eugène Marquis, Avenue Bataille Flandre-Dunkerque, 35000 Rennes, France.
| | - Walter Gotlieb
- Division of Gynecologic Oncology, Segal Cancer Center, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2, Canada.
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Audisio RA. Tailoring surgery to elderly patients with cancer. Br J Surg 2015; 103:e10-1. [PMID: 26679284 DOI: 10.1002/bjs.9948] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 11/09/2022]
Abstract
Better assessments needed to assess frailty
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Affiliation(s)
- R A Audisio
- Department of Surgery, St Helens Teaching Hospital, University of Liverpool, Marshalls Cross Road, St Helens WA9 3DA, UK.
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Desai AM, Lichtman SM. Systemic therapy of non-colorectal gastrointestinal malignancies in the elderly. Cancer Biol Med 2015; 12:284-91. [PMID: 26779365 PMCID: PMC4706522 DOI: 10.7497/j.issn.2095-3941.2015.0078] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
In the coming years life expectancy is expected to increase and with this the percentage of the population above age 65 will grow. Patients above 65 make up more than two thirds of those currently diagnosed with gastrointestinal malignancies. Available evidence based medicine does not focus on the average patient, above the age 70, encountered in every day practice. Most guidelines and clinical trials are not designed to take into account the special considerations needed when treating the elderly such as functional status, comorbidities, polypharmacy, life expectancy, and social support. The majority of available data is based on retrospective reviews or subset analyses of larger studies where the elderly represent a fraction of the studied population. This review focuses on the toxicities and tolerability of current standard therapies for non-colorectal gastrointestinal malignancies, including gastroesophageal, pancreatic, bile duct and hepatocellular cancers in the elderly. With careful patient selection and geriatric assessment the elderly can safely benefit from standard therapies offered to younger patients.
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Affiliation(s)
- Avni M Desai
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 11725, USA
| | - Stuart M Lichtman
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 11725, USA
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Husain ZA, Kim AW, Yu JB, Decker RH, Corso CD. Defining the High-Risk Population for Mortality After Resection of Early Stage NSCLC. Clin Lung Cancer 2015; 16:e183-7. [DOI: 10.1016/j.cllc.2015.04.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 04/14/2015] [Indexed: 02/04/2023]
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Chen CCH, Lin MT, Liang JT, Chen CM, Yen CJ, Huang GH. Pre-surgical Geriatric Syndromes, Frailty, and Risks for Postoperative Delirium in Older Patients Undergoing Gastrointestinal Surgery: Prevalence and Red Flags. J Gastrointest Surg 2015; 19:927-34. [PMID: 25650167 DOI: 10.1007/s11605-015-2760-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 01/21/2015] [Indexed: 01/31/2023]
Abstract
OBJECTIVE We sought to identify and evaluate red flags for pre-surgical geriatric conditions (geriatric syndromes, frailty, and risks for postoperative delirium) in older patients undergoing gastrointestinal surgery. METHODS Older individuals (≥65 years) undergoing major elective gastrointestinal surgery from 2009 to 2012 were enrolled and assessed preoperatively. RESULTS Participants (N=379; mean age=74.5 ± 5.9 years) primarily underwent colorectal (54.3 %), gastric (21.9 %), and pancreatobiliary (12.6 %) surgery. Overall, 30.9 % had existing geriatric syndromes, 26.7 % were frail, and 22.8 % had >3 risk factors for postoperative delirium. The largest proportion (45.7 %) presented with at least one geriatric condition. Patients with or without geriatric conditions were discriminated with adequate sensitivity (67 %), specificity (84 %), and positive predictive value (77 %) by eight red flags: age ≥75 years (OR, 2.86; P<0.001), eating soft food (OR, 3.63; P=0.001), reported hypertension (OR, 2.8; P=0.001), weight loss >3 kg (OR, 4.79; P<0.001), fair-to-weak grip strength (OR, 2.53; P=0.001), sleeplessness (OR, 2.57; P=0.001), no-better-than-peer perceived health (OR, 1.88; P=0.022), and short-term inability to recall two of three common words (OR, 1.81; P=0.025). CONCLUSIONS Eight red flags covered as part of history and physical examination are well suited to screen patients for geriatric conditions indicating the need for preoperative geriatric assessments and optimization.
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Affiliation(s)
- Cheryl Chia-Hui Chen
- Department of Nursing, College of Medicine, National Taiwan University, National Taiwan University Hospital, Taipei, Taiwan,
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Audisio R, Wyld L. No standard is set for older women with breast cancer. Eur J Surg Oncol 2015; 41:607-9. [DOI: 10.1016/j.ejso.2015.01.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/09/2015] [Accepted: 01/05/2015] [Indexed: 01/10/2023] Open
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Huisman MG, Audisio RA, Ugolini G, Montroni I, Vigano A, Spiliotis J, Stabilini C, de Liguori Carino N, Farinella E, Stanojevic G, Veering BT, Reed MW, Somasundar PS, de Bock GH, van Leeuwen BL. Screening for predictors of adverse outcome in onco-geriatric surgical patients: A multicenter prospective cohort study. Eur J Surg Oncol 2015; 41:844-51. [PMID: 25935371 DOI: 10.1016/j.ejso.2015.02.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Revised: 02/20/2015] [Accepted: 02/24/2015] [Indexed: 10/23/2022] Open
Abstract
AIMS The aim of this study was to investigate the predictive ability of screening tools regarding the occurrence of major postoperative complications in onco-geriatric surgical patients and to propose a scoring system. METHODS 328 patients ≥ 70 years undergoing surgery for solid tumors were prospectively recruited. Preoperatively, twelve screening tools were administered. Primary endpoint was the incidence of major complications within 30 days. Odds ratios (OR) and 95% confidence intervals (95% CI) were estimated using logistic regression. A scoring system was derived from multivariate logistic regression analysis. The area under the receiver operating characteristic curve (AUC) was applied to evaluate model performance. RESULTS At a median age of 76 years, 61 patients (18.6%) experienced major complications. In multivariate analysis, Timed Up and Go (TUG), ASA-classification and Nutritional Risk Screening (NRS) were predictors of major complications (TUG>20 OR 3.1, 95% CI 1.1-8.6; ASA ≥ 3 OR 2.8, 95% CI 1.2-6.3; NRS impaired OR 3.3, 95% CI 1.6-6.8). The scoring system, including TUG, ASA, NRS, gender and type of surgery, showed good accuracy (AUC: 0.81, 95% CI 0.75-0.86). The negative predictive value with a cut-off point >8 was 93.8% and the positive predictive value was 40.3%. CONCLUSIONS A substantial number of patients experience major postoperative complications. TUG, ASA and NRS are screening tools predictive of the occurrence of major postoperative complications and, together with gender and type of surgery, compose a good scoring system.
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Affiliation(s)
- M G Huisman
- University of Groningen, University Medical Center Groningen, Department of Surgery, Hanzeplein 1, 9713 GZ Groningen, The Netherlands.
| | - R A Audisio
- University of Liverpool, St. Helens Teaching Hospital, Department of Surgery, Marshalls Cross Road, St. Helens, WA9 3DA, United Kingdom
| | - G Ugolini
- University of Bologna, S. Orsola Malpighi Hospital, Department of Surgery, Via Pietro Albertoni, 15, 40138 Bologna, Italy
| | - I Montroni
- University of Bologna, S. Orsola Malpighi Hospital, Department of Surgery, Via Pietro Albertoni, 15, 40138 Bologna, Italy
| | - A Vigano
- McGill University Health Center, Montreal General Hospital, Department of Oncology, 1650 Cedar Avenue, Montreal, Quebec H3G 1A4, Canada
| | - J Spiliotis
- Metaxa Cancer Hospital, Department of Surgery, Mpotasi 51, 185 37 Piraeus, Greece; Regional University Hospital of Patras, Department of Surgery, Patras, Greece
| | - C Stabilini
- San Martino University Hospital, Department of Surgery, Largo Rosanna Benzi, 10, 16132 Genua, Italy
| | - N de Liguori Carino
- Central Manchester University Hospitals, Manchester Royal Infirmary, Department of Hepato-Pancreato-Biliary Surgery, Oxford Road, Manchester M13 9WL, United Kingdom
| | - E Farinella
- S. Maria Hospital, Department of Surgery, Azienda Ospedaliera di Perugia Via Brunamonti, 51 06122 Perugia, Italy
| | - G Stanojevic
- Clinic for General Surgery, Clinical Center Nis, Bulevar Zorana Djindjica 48, 1800 Nis, Serbia
| | - B T Veering
- University of Leiden, Leiden University Medical Center, Department of Anesthesiology, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - M W Reed
- University of Sheffield, Department of Oncology, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, United Kingdom
| | - P S Somasundar
- Roger Williams Medical Center, Division of Surgical Oncology, Affiliate of Boston University, 50 Maude Street, Providence, RI 02908, United States
| | - G H de Bock
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - B L van Leeuwen
- University of Groningen, University Medical Center Groningen, Department of Surgery, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
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19
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Abstract
Frailty is a clinical syndrome initially characterized in geriatric populations with a hallmark of age-related declines in physiologic reserve and function and increased vulnerability to adverse health outcomes. Recently, frailty has increasingly been recognized as a common and important HIV-associated non-AIDS (HANA) condition. This article provides an overview of our current understanding of frailty and its phenotypic characteristics and evidence that they are related to aging and to chronic inflammation that is associated with aging and also with long-term treated HIV infection. The etiology of this chronic inflammation is unknown but we discuss evidence linking it to persistent infection with cytomegalovirus in both geriatric populations and people living with HIV infection.
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Affiliation(s)
- Sean X. Leng
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21224, USA
| | - Joseph B. Margolick
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21224, USA
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20
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The potential value of comprehensive geriatric assessment in evaluating older women with primary operable breast cancer undergoing surgery or non-operative treatment — A pilot study. J Geriatr Oncol 2015; 6:46-51. [DOI: 10.1016/j.jgo.2014.09.180] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 06/24/2014] [Accepted: 09/12/2014] [Indexed: 12/27/2022]
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21
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Korc-Grodzicki B, Downey RJ, Shahrokni A, Kingham TP, Patel SG, Audisio RA. Surgical considerations in older adults with cancer. J Clin Oncol 2014; 32:2647-53. [PMID: 25071124 DOI: 10.1200/jco.2014.55.0962] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
PURPOSE The aging of the population is a real concern for surgical oncologists, who are increasingly being asked to treat patients who would not have been considered for surgery in the past. In many cases, decisions are made with relatively little evidence, most of which was derived from trials in which older age was a limiting factor for recruitment. METHODS This review focuses on risk assessment and perioperative management. It describes the relationship between age and outcomes for colon, lung, hepatobiliary, and head and neck cancer, which are predominantly diseases of the elderly and are a major cause of morbidity and mortality. RESULTS Effective surgery requires safe performance as well as reasonable postoperative life expectancy and maintenance of quality of life. Treatment decisions for potentially vulnerable elderly patients should take into account data obtained from the evaluation of geriatric syndromes, such as frailty, functional and cognitive limitations, malnutrition, comorbidities, and polypharmacy, as well as social support. Postoperative care should include prevention and treatment of complications seen more frequently in the elderly, including postoperative delirium, functional decline, and the need for institutionalization. CONCLUSION Surgery remains the best modality for treatment of solid tumors, and chronologic age alone should not be a determinant for treatment decisions. With adequate perioperative risk stratification, functional assessment, and oncologic prognostication, elderly patients with cancer can do as well in terms of morbidity and mortality as their younger counterparts. If surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.
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Affiliation(s)
- Beatriz Korc-Grodzicki
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom.
| | - Robert J Downey
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Armin Shahrokni
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - T Peter Kingham
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Snehal G Patel
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
| | - Riccardo A Audisio
- Beatriz Korc-Grodzicki, Robert J. Downey, Armin Shahrokni, T. Peter Kingham, and Snehal G. Patel, Memorial Sloan-Kettering Cancer Center, New York, NY; Riccardo A. Audisio, St Helens Teaching Hospital, University of Liverpool, St Helens, United Kingdom
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22
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Abstract
Frailty is a common and important geriatric syndrome characterized by age-associated declines in physiologic reserve and function across multiorgan systems, leading to increased vulnerability for adverse health outcomes. Two major frailty models have been described in the literature. The frailty phenotype defines frailty as a distinct clinical syndrome meeting three or more of five phenotypic criteria: weakness, slowness, low level of physical activity, self-reported exhaustion, and unintentional weight loss. The frailty index defines frailty as cumulative deficits identified in a comprehensive geriatric assessment. Significant progress has recently been made in understanding the pathogenesis of frailty. Chronic inflammation is likely a key pathophysiologic process that contributes to the frailty syndrome directly and indirectly through other intermediate physiologic systems, such as the musculoskeletal, endocrine, and hematologic systems. The complex multifactorial etiologies of frailty also include obesity and specific diseases. Major clinical applications include risk assessment and stratification. This can be applied to the elderly population in the community and in a variety of care settings. Frailty may also be useful for risk assessment in surgical patients and those with cardiovascular diseases, cancer, or human immunodeficiency virus infection, as well as for assessment of vaccine effectiveness in older adults. Currently, exercise and comprehensive geriatric interdisciplinary assessment and treatment are key interventions for frailty. As understanding of the biologic basis and complexity of frailty further improves, more effective and targeted interventional strategies and innovative geriatric-care models will likely be developed.
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Affiliation(s)
- Xujiao Chen
- Department of Geriatrics, Zhejiang Hospital, Hangzhou, People's Republic of China
| | - Genxiang Mao
- Department of Geriatrics, Zhejiang Hospital, Hangzhou, People's Republic of China
| | - Sean X Leng
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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23
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Bhangu A, Kiran RP, Audisio R, Tekkis P. Survival outcome of operated and non-operated elderly patients with rectal cancer: A Surveillance, Epidemiology, and End Results analysis. Eur J Surg Oncol 2014; 40:1510-6. [PMID: 24704032 DOI: 10.1016/j.ejso.2014.02.239] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2013] [Revised: 02/12/2014] [Accepted: 02/19/2014] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND With an ageing population, surgery is increasingly offered to elderly patients with rectal cancer, although outcomes for the oldest patients remain poorly defined. This study aimed to determine whether operative intervention improves outcome in elderly patients. METHOD Patients aged 18+ years diagnosed with rectal adenocarcinoma between 1998 and 2009 were identified from the Surveillance, Epidemiology, and End Results database. The primary endpoint was adjusted hazard ratios (HR) for 5-year cancer specific survival (CSS); the secondary endpoint was 5-year overall survival (OS). RESULTS With increasing age, patients were less likely to undergo surgery, receive a complete stage or receive neoadjuvant radiotherapy. CSS and OS increasingly diverged with age in patients undergoing surgery. Those aged 80+ had reduced CSS compared to those aged 70-79 years (stages I-III, respective adjusted HR 2.14, 1.58, 1.48, all p < 0.001). However, stage II patients aged 80+ treated with resection and neoadjuvant therapy had similar survival to those aged 70-79 years (adjusted HR 1.26, p = 0.149). For only patients aged 80+ years, those treated non-operatively had lower survival than those undergoing surgery, who in turn had the best survival when treated with neoadjuvant radiotherapy (adjusted HR 0.74, p = 0.001). CONCLUSION Contrary to common expectation, in patients aged over 80 with rectal cancer, surgery with or without other modalities was associated with better survival than non-operative treatment. Despite selection bias in this observational study, these findings support consideration of maximal therapy regardless of age in selected patients deemed to be fit, since this leads to outcomes equivalent to younger patients.
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Affiliation(s)
- A Bhangu
- Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK; Division of Surgery, Imperial College, Chelsea and Westminster Campus, London, UK
| | - R P Kiran
- Division of Colorectal Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, USA
| | - R Audisio
- Department of Surgery, University of Liverpool, Liverpool, UK
| | - P Tekkis
- Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, UK; Division of Surgery, Imperial College, Chelsea and Westminster Campus, London, UK.
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24
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Hamaker M, Seynaeve C, Nortier J, Wymenga M, Maartense E, Boven E, van Leeuwen-Stok A, de Rooij S, van Munster B, Smorenburg C. Slow accrual of elderly patients with metastatic breast cancer in the Dutch multicentre OMEGA study. Breast 2013; 22:556-9. [DOI: 10.1016/j.breast.2012.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/06/2012] [Accepted: 12/17/2012] [Indexed: 10/27/2022] Open
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25
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Bennett JA, Winters-Stone KM, Dobek J, Nail LM. Frailty in older breast cancer survivors: age, prevalence, and associated factors. Oncol Nurs Forum 2013; 40:E126-34. [PMID: 23615146 PMCID: PMC3988495 DOI: 10.1188/13.onf.e126-e134] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To describe frailty and associated factors in breast cancer survivors (BCSs) and evaluate whether BCSs are frail at an earlier age than female participants from in two large epidemiological studies. DESIGN Descriptive, cross-sectional. SETTING School of Nursing at Oregon Health and Science University. SAMPLE 216 BCSs aged 53-87 years who were a mean 5-7 years post-treatment and not currently participating in exercise. METHODS Performance tests, clinical measures, and self-reported questionnaires provided baseline data on five criteria for frailty. MAIN RESEARCH VARIABLES Frailty was defined as meeting three of the five criteria of the frailty phenotype: shrinking, exhaustion, low activity, slowness, and weakness. Data were compared to published data from women in the Cardiovascular Health Study (CHS) and Women's Health and Aging Study (WHAS). FINDINGS Eighteen percent of BCSs aged 70-79 years were frail compared to 11% of women of the same age in the CHS and WHAS. Frailty was more common at a younger age in BCSs, and more BCSs were frail in all age groups compared to women in the CHS study until about age 80 years, when prevalence of frailty was similar in the two groups. Fifty percent of BCSs were classified as prefrail because they met one or two of the five frailty criteria. Higher body mass index increased the odds of frailty, and higher physical activity decreased the odds of frailty (odds ratio [OR] = 1.12, p = 0.003, and OR = 0.99, p = 0.000, respectively). CONCLUSIONS Frailty and prefrailty may be common in BCSs and may occur at an earlier age than in adults without a history of breast cancer. IMPLICATIONS FOR NURSING Nurses should be alert to prefrailty or frailty at a younger age in BCSs. Awareness and early intervention may delay or prevent frailty. KNOWLEDGE TRANSLATION BCSs may be frail even when they are not yet considered older adults. Prefrailty in BCSs is important to recognize because it suggests impending frailty that could lead to reduced physical functioning or poor health. Prefrailty and frailty could be assessed in BCSs aged 50 years and older in a clinical setting using a few questions about weight, fatigue, and activity levels, in addition to simple tests of walking speed and grip strength, if warranted.
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Affiliation(s)
- Jill A Bennett
- School of Nursing, Oregon Health and Science University, Portland, USA.
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26
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Abstract
Colorectal cancer (CRC) largely affects older individuals; almost half of cases occur in patients >75 years old. The incidence increases with advancing age, doubling every 7 years in patients aged ≥50 years. The medical and societal burdens of CRC will probably worsen over the coming decades as the number of older individuals (>70) continues to grow. No evidence-based guidelines are available for this age group, as older patients with CRC are generally excluded from randomized clinical trials and the fit ones who are recruited are not representative of the general elderly population. When feasible, surgery is the most successful treatment option for eradicating the primary lesion, as well as any metastases. The operative risk under elective conditions is not markedly different in older than in younger patients; however, the acute setting is to be avoided as it is associated with high operative death rates. Well-selected older patients can tolerate chemotherapy, but benefits need to be balanced against potentially limited life expectancy and reduced quality of life. The use of combination chemotherapy is an area of much controversy, but this treatment should not necessarily be withheld because of the age of the patient. Careful monitoring of toxicities and early intervention is essential in older patients undergoing chemotherapy.
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Affiliation(s)
- Riccardo A Audisio
- University of Liverpool, St Helens Teaching Hospital, Department of Surgery, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK.
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27
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Swaminathan V, Spiliopoulos MK, Audisio RA. Choices in surgery for older women with breast cancer. Breast Care (Basel) 2012; 7:445-51. [PMID: 24715825 DOI: 10.1159/000345402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Breast cancer is a major cause of mortality worldwide. As the population ages and life expectancy increases, the burden of cancer on health services will increase. Older patients with breast cancer are becoming more suitable for surgery; tailored surgical techniques and increasing healthy life expectancy alongside improved assessment of patients are aiding this trend. Surgery is also becoming a favoured treatment of personal choice for older patient with breast cancer. Evidence shows that surgery is almost always feasible for the older patient with outcomes (survival, progression, and recurrence rates) comparable to younger groups and superior to non-surgical treatments. We aim to describe the current status of surgery for the older patient with breast cancer, showing it is an option that should not be denied. Surgery should always be considered regardless of age, after evaluation of co-morbidities.
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Affiliation(s)
| | | | - Riccardo A Audisio
- Consultant Breast Oncological Surgeon, St Helens Teaching Hospital, St Helens, UK
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28
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Swaminathan V, Audisio R. Cancer in older patients: an analysis of elderly oncology. Ecancermedicalscience 2012; 6:243. [PMID: 22423250 PMCID: PMC3298408 DOI: 10.3332/ecancer.2012.243] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Indexed: 12/03/2022] Open
Abstract
Is it possible to define when someone is elderly? The worldwide population is growing not only in number but also in age; it is estimated that the population will increase to around 750 million by 2021. Two thirds of cancer occurs in the over 65 age groups. With an increasing elderly population, it can be derived that cancer will become a more prevalent condition. The burden of cancer on the medical profession will be even more apparent than before. In addition the elderly age group has different needs compared with younger oncology patients; there can be no ‘rule of thumb’ with the management of elderly illness. Factors such as frailty are significant when treating cancer in the older patients. The assessment of quality of life in older patients with cancer is also an important factor. Is it best for a patient to enjoy life as it is with cancer or aim for increased life expectancy by undertaking treatment with the threat of morbidity however severe during that period? The volume of scientific evidence currently available to support all the issues in geriatric oncology is greatly limited; almost all treatments designed for oncology are being tested in randomized clinical trials preferentially using younger cohorts of patients. Changes need to be made in order to further this field of medicine. Geriatric oncology is no longer a palliative field, as a healthy active life can now be expected by some older patients. The burden of oncology in the elderly will need to take a modern approach regarding the management of these patients.
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Affiliation(s)
- V Swaminathan
- Mersey Deanery, FY1 Southport DGH, Town Lane, Kew, Southport, PR8 6PN, UK
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29
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Abstract
Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.
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Affiliation(s)
- Andrew P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Aviv, Israel 52621.
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