Risk assessment for cancer surgery in elderly patients

Overall survival and morbidity are not associated with advanced age for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: a single centre experience

Objectives

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has enabled better prognosis for patients with peritoneal surface malignancies. However, in older age groups, short -and long-term outcomes are still perceived as poor. We evaluated patients aged 70 and over and determine if age is a predictor of morbidity, mortality and overall survival (OS).

Methods

A retrospective cohort analysis was performed on CRS/HIPEC patients and categorised by age. The primary outcome was overall survival. Secondary outcomes included morbidity, mortality, hospital and incentive care unit (ICU) stay and early postoperative intraperitoneal chemotherapy (EPIC).

Results

A total of 1,129 patients were identified with 134 aged 70+ and 935 under 70. There was no difference in OS (p=0.175) or major morbidity (p=0.051). Advanced age was associated with higher mortality (4.48 vs. 1.11 %, p=0.010), longer ICU stay (p<0.001) and longer hospitalisation (p<0.001). The older group was less likely to achieve complete cytoreduction (61.2 vs. 73 %, p=0.004) and receive EPIC (23.9 vs. 32.7 %, p=0.040).

Conclusions

In patients undergoing CRS/HIPEC, age of 70 and above does not impact OS or major morbidity but is associated with increased mortality. Age alone should not be a limiting factor in selecting CRS/HIPEC patients. Careful multi-disciplinary approach is needed when considering those of advanced age.

Timed up and go test and long-term survival in older adults after oncologic surgery

BACKGROUND

Physical performance tests are a reflection of health in older adults. The Timed Up and Go test is an easy-to-administer tool measuring physical performance. In older adults undergoing oncologic surgery, an impaired TUG has been associated with higher rates of postoperative complications and increased short term mortality. The objective of this study is to investigate the association between physical performance and long term outcomes.

METHODS

Patients aged ≥65 years undergoing surgery for solid tumors in three prospective cohort studies, 'PICNIC', 'PICNIC B-HAPPY' and 'PREOP', were included. The TUG was administered 2 weeks before surgery, a score of ≥12 seconds was considered to be impaired. Primary endpoint was 5-year survival, secondary endpoint was 30-day major complications. Survival proportions were estimated using Kaplan-Meier curves. Cox- and logistic regression analysis were used for survival and complications respectively. Hazard ratios (aHRs) and Odds ratios (aOR) were adjusted for literature-based and clinically relevant variables, and 95% confidence intervals (95% CIs) were estimated using multivariable models.

RESULTS

In total, 528 patients were included into analysis. Mean age was 75 years (SD 5.98), in 123 (23.3%) patients, the TUG was impaired. Five-year survival proportions were 0.56 and 0.49 for patients with normal TUG and impaired TUG respectively. An impaired TUG was an independent predictor of increased 5-year mortality (aHR 1.43, 95% CI 1.02-2.02). The TUG was not a significant predictor of 30-day major complications (aOR 1.46, 95% CI 0.70-3.06).

CONCLUSIONS

An impaired TUG is associated with increased 5-year mortality in older adults undergoing surgery for solid tumors. It requires further investigation whether an impaired TUG can be reversed and thus improve long-term outcomes.

TRIAL REGISTRATION

The PICNIC studies are registered in the Dutch Clinical Trial database at www.trialregister.nl: NL4219 (2010-07-22) and NL4441 (2014-06-01). The PREOP study was registered with the Dutch trial registry at www.trialregister.nl: NL1497 (2008-11-28) and in the United Kingdom register (Research Ethics Committee reference 10/H1008/59).  https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/?page=15&query=preop&date_from=&date_to=&research_type=&rec_opinion=&relevance=true .

Challenges in Geriatric Oncology—A Surgeon’s Perspective

As our global population ages, we will see more cancer diagnoses in older adults. Surgery is an important treatment modality for solid tumours, forming the majority of all cancers. However, the management of older adults with cancer can be more complex compared to their younger counterparts. This narrative review will outline the current challenges facing older adults with cancer and potential solutions. The challenges facing older adults with cancer are complex and include lack of high-level clinical trials targeting older adults and selection of the right patient for surgery. This may be standard surgical treatment, minimally invasive surgery or alternative therapies (no surgery) which can be local or systemic. The next challenge is to identify the individual patient’s vulnerabilities to allow them to be maximally optimised for treatment. Prehabilitation has been shown to be of benefit in some cancer settings but uniform guidance across all surgical specialties is required. Greater awareness of geriatric conditions amongst surgical oncologists and integration of geriatric assessment into a surgical clinic are potential solutions. Enhanced recovery programmes tailored to older adults could reduce postoperative functional decline. Ultimately, the greatest challenge an older adult with cancer may face is the mindset of their treating clinicians—a shared care approach between surgical oncologists and geriatricians is required.

Physical and Cognitive Function Assessment to Predict Postoperative Outcomes of Abdominal Surgery

BACKGROUND

Current evaluation methods to assess physical and cognitive function are limited and often not feasible in emergency settings. The upper-extremity function (UEF) test to assess physical and cognitive performance using wearable sensors. The purpose of this study was to examine the (1) relationship between preoperative UEF scores with in-hospital outcomes; and (2) association between postoperative UEF scores with 30-d adverse outcomes among adults undergoing emergent abdominal surgery.

METHODS

We performed an observational, longitudinal study among adults older than 40 y who presented with intra-abdominal symptoms. The UEF tests included a 20-sec rapid repetitive elbow flexion (physical function), and a 60-sec repetitive elbow flexion at a self-selected pace while counting backwards by threes (cognitive function), administered within 24-h of admission and within 24-h prior to discharge. Multiple logistic regression models assessed the association between UEF and outcomes. Each model consisted of the in-hospital or 30-d post-discharge outcome as the dependent variable, preoperative UEF physical and cognitive scores as hypothesis covariates, and age and sex as adjuster covariates.

RESULTS

Using UEF physical and cognitive scores to predict in-hospital outcomes, an area under curve (AUC) of 0.76 was achieved, which was 17% more sensitive when compared to age independently. For 30-d outcomes, the AUC increased to 0.89 when UEF physical and cognitive scores were included in the model with age and sex.

DISCUSSION

Sensor-based measures of physical and cognitive function enhance outcome prediction providing an objective practicable tool for risk stratification in emergency surgery settings among aging adults presenting with intra-abdominal symptoms.

The importance of geriatric and surgical co-management of elderly in muscoloskeletal oncology: A literature review

People over 65 years old are the fastestgrowing part of the population and also the most common population in oncological practice. The geriatric co-assessment when involved in the management of orthopedic elderly patients could improve the survival and clinical outcomes of the patients. The aim of this review is to understand the importance of comprehensive geriatric assessment in elderly cancer orthopaedic patients affected by bone and soft tissue sarcoma in order to apply it and identify the mean surgical prognostic factors of this population.

Mechanisms of decision-making in preoperative assessment for older adult prostate cancer patients-A qualitative study

BACKGROUND AND OBJECTIVE

Little research exists which investigates the contextual factors and hidden influences that inform surgeons and surgical teams decision-making in preoperative assessment when deciding whether to or not to operate on older adult prostate cancer patients living with aging-associated functional declines and illnesses. The aim of this study is to identify and examine the underlying mechanisms that uniquely shape preoperative surgical decision-making strategies concerning older adult prostate cancer patients.

METHODS

Qualitative methodologies were used that paired ethnographic field observations with semistructured interviews for data collection. An inductive thematic analysis approach was used to identify, analyze, and describe patterns in the data.

RESULTS

Factors underlining surgical decision-making originated from the context of two categories: (1) clinical and surgery-specific factors; and (2) non-patient factors. Thematic subcategories included personal experiences, methods of assessment during medical encounters, anticipation of outcomes, perceptions of preoperative assessment instruments for frailty and multimorbidity, routines and workflow patterns, microcultures, and indirect observation and second-hand knowledge.

CONCLUSION

Surgeon's personal experiences has a significant impact on the decision-making processes during preoperative assessments. However, non-patient factors such as institutional microcultures passively and actively influence decision-making process during preoperative assessment.

Cognitive decline after major oncological surgery in the elderly

BACKGROUND

Elderly patients undergoing oncological surgery experience postoperative cognitive decline. The aims of this study were to examine the incidence of cognitive decline 3 months after surgery and identify potential patient-, disease- and surgery-related risk factors for postoperative cognitive decline in onco-geriatric patients.

METHODS

A consecutive series of elderly patients (≥65 years) undergoing surgery for the removal of a solid tumour were included (n = 307). Cognitive performance was assessed pre-operatively and 3 months postoperatively. Postoperative decline was defined as a decline in scores of cognitive tests of ≥25% on ≥2 of 5 tests.

RESULTS

Of the patients who had completed the assessments, 117 (53%, 95% confidence interval [CI]: 47-60) had improved cognitive test scores, whereas 26 (12%, 95% CI: 7.6-16) showed cognitive decline at 3 months postoperatively. In patients aged >75 years, the incidence of overall cognitive decline 3 months postoperatively was 18% (95% CI: 9.3-27). In patients with lower pre-operative Mini-Mental State Examination (MMSE) score (≤26) the incidence was 37% (95% CI: 18-57), and in patients undergoing major surgery it was 18% (95% CI: 10.6-26). Of the cognitive domains, executive function was the most vulnerable to decline.

CONCLUSION

About half of the elderly patients show improvement in postoperative cognitive performance after oncological surgery, whereas 12% show cognitive decline. Advanced age, lower pre-operative MMSE score and major surgery are risk factors for cognitive decline at 3 months postoperatively and should be taken into account in the clinical decision-making progress. Research to develop interventions to preserve quality of life should focus on this high-risk subpopulation.

Age-related Disparity: Breast Cancer in the Elderly

Aging poses an unique opportunity to study cancer biology and treatment in older adults. Breast cancer is often studied in young women; however, much investigation remains to be done on breast cancer in our expanding elderly population. Diagnostic and management strategies applicable to younger patients cannot be empirically used to manage older breast cancer patients. Lack of evidence-based data continues to be the major impediment toward delivery of personalized cancer care to elderly breast cancer patients. This article reviews the relevant literature on management of curable breast cancer in the elderly, the role of geriatric assessment, complex treatment decision making within the context of patient's expected life expectancy, comorbidities, physical function, socioeconomic status, barriers to health care delivery, goals of treatment, and therapy-related side effects. Continuing efforts for enrolling elderly breast cancer patients in contemporary clinical trials, and thus improving age-appropriate care, are emphasized.

Comprehensive geriatric assessment in 326 older women with early breast cancer

Background:

One-third of new early breast cancer diagnoses occur in women over 70 years old. However, older women are less likely to receive radical curative treatments. This study prospectively evaluated a cohort of older women using a Comprehensive Geriatric Assessment (CGA) to determine whether fitness explained the apparent under-treatment in this patient group.

Methods:

In this multi-centre prospective study, patients aged ⩾70 years with Stages I–III breast cancer underwent a pretreatment baseline CGA consisting of eight assessment tools. Patients were defined as ‘fit’ if they had normal score in seven out of eight of the assessment tools. ‘High risk’ patients were defined as those with grade 3, ER negative, HER2 positive, or node positive breast cancer.

Results:

Data on 326 patients were available for full analysis. The median age was 77 years. In all, 182 (56%) of the total population were defined as high risk, with 49%, 61% and 53% of those in the 70–74, 75–84 and ⩾85 years age groups respectively having high risk tumours. A total of 301 patients had sufficient CGA records of whom 131 (44%) were reported as fit, with 34%, 54% and 12% of them in the 70–74, 75–84 and ⩾85 years age groups respectively. More fit than unfit patients underwent primary breast surgery (100% vs 91%, P=0.0002), axillary surgery (92% vs 84%, P=0.0340), and adjuvant chemotherapy for high-risk disease (51% vs 20%, P=0.0001). Rates of adjuvant radiotherapy after wide local excision were not significantly different (88% vs 90% respectively, P=0.8195).

Conclusions:

In this study, all women ⩾70 years deemed fit by CGA underwent primary surgery. Nearly 50% of fit women with high-risk disease did not receive adjuvant chemotherapy suggesting under treatment in this group.

Quality of life among survivors of early-stage cervical cancer in Taiwan: an exploration of treatment modality differences

PURPOSE

Women with early-stage cervical cancer may experience changes in their quality of life (QoL) due to treatment or to the effects of the cancer. In this study, we examined differences in QoL by treatment modality between women who underwent surgery only and those treated with concurrent chemoradiation (CCRT).

METHODS

The sample of 290 women had been diagnosed with stage I-II cervical cancer. Data were collected on these women's demographic and disease characteristics, general QoL, and cancer-specific QoL using an author-designed demographic-disease survey, the European Organization for Research and Treatment of Cancer QoL questionnaire, and the Taiwanese-version Cervical Cancer Module 24 questionnaire, respectively. Data were analyzed by descriptive statistics and analysis of covariance.

RESULTS

Women with cervical cancer who underwent surgery only had significantly worse constipation and body image than those treated with CCRT. Women who underwent CCRT had worse physical and role functioning than those who underwent surgery only. Women who had CCRT also reported worse symptoms, such as fatigue, appetite loss, diarrhea, financial difficulties, sexual enjoyment, and sexual/vaginal functioning, than those who had only surgery.

CONCLUSIONS

Our results add knowledge about QoL in women with early-stage cervical cancer who receive different treatment modalities. When suggesting treatment modalities for women with cervical cancer, health professionals should also consider changes in women's QoL after cancer treatment. To improve women's QoL after treatment, professionals should also offer timely and individualized interventions based on women's cervical cancer treatment.

Access to Cancer Specialist Care and Treatment in Patients With Advanced Stage Lung Cancer

BACKGROUND

Access to specialty care is critical for patients with advanced stage lung cancer. This study assessed access to cancer specialists and cancer treatment in a broad population of patients with advanced stage lung cancer.

MATERIALS AND METHODS

Two study samples were extracted from 2 claims databases and analyzed independently: patients aged ≥ 18 years with de novo diagnosis of metastatic lung cancer in the MarketScan database between 2008 and 2014 (commercially insured adult patients; n = 22,268); and patients aged ≥ 65 years in the Surveillance, Epidemiology, and End Results-Medicare database with a diagnosis of advanced non-small-cell lung cancer between 2007 and 2011 (Medicare-insured elderly patients; n = 9651). The study period spanned from 6 weeks before the first lung biopsy tied to the initial lung cancer diagnosis until the end of continuous health insurance enrollment, or data availability, or death.

RESULTS

Among the commercially insured adults (MarketScan), most patients were seen by a cancer specialist within a month of first lung biopsy (80%), 12% were never seen by a cancer specialist, and 6% did not receive cancer-directed therapy. Among the Medicare-insured elderly patients (SEER-Medicare), the proportions were 79%, 4%, and 10%, respectively. Patients seen by a cancer specialist were more likely to receive cancer-directed therapy (95% vs. 92%, P < .001 and 92% vs. 38%, P < .001, respectively).

CONCLUSION

Between 4% and 12% of patients with advanced stage lung cancer do not have appropriate access to cancer specialist, which appears to negatively affect access to optimal and timely treatment.

Emergency Abdominal Surgery in the Elderly: Can We Predict Mortality?

BACKGROUND

The United Kingdom population is ageing. Half of patients requiring an emergency laparotomy are aged over 70, 20 % die within 30 days, and less than half receive good care. Frailty and delay in management are associated with poor surgical outcomes. P-POSSUM risk scoring is widely accepted, but its validity in patients aged over 70 undergoing emergency laparotomy is unclear.

AIMS

To assess if P-POSSUM risk stratification reliably predicts inpatient mortality in this group and establish whether those who died within 30 days received delayed care.

METHODS

Observational study of consecutive patients aged 70 and over fulfilling the National Emergency Laparotomy Audit criteria from a tertiary hospital. The predictive value of pre-operative P-POSSUM, ASA, lactate and other routine variables was assessed. Surgical review, decision to operate, consultant surgical review, antibiotic prescription, laparotomy and discharge or death time points were assessed by 30-day survival.

RESULTS

One hundred and ninety-three patients were included. This represented 46.28 % of those undergoing an emergency laparotomy in our centre. Pre-operative P-POSSUM scoring, ASA grade and lactate were moderate predictors of mortality (AUC 0.784 and 0.771, respectively, lactate AUC 0.705, all p ≤ 0.001). No correlation existed between pre-operative P-POSSUM and days to death (p = 0.209), nor were there delays in key management timings in those who died in 30 days.

CONCLUSIONS

P-POSSUM scoring may predict inpatient mortality with moderate discrimination. Addition of frailty scoring in this high-risk group might better identify those with a high risk of mortality after emergency laparotomy and would be a fertile area for further research.

Skilled nursing facility placement in hospitalized elderly patients with colon cancer

BACKGROUND

The current study sought to determine predictive risk factors and inpatient resource utilization associated with discharge to skilled nursing facility (SNF) in hospitalized elderly patients with colon cancer.

MATERIALS AND METHODS

Inpatient data from U.S. community hospital discharges from 2003 to 2011 was analyzed in a retrospective cohort study using the Healthcare Cost and Utilization Project, National Inpatient Sample (HCUP-NIS). Subjects included hospitalized postoperative colon cancer patients over age of 65 (N = 98,797).

RESULTS

The proportion of elderly colon cancer patients discharged to a SNF increased by 16.67% from 2003 to 2011 (18-21%). Elderly patients discharged to a SNF had increased hospitalization costs (+$10,293.70, p < 0.01) compared to elderly colon cancer patients discharged home. Hospitalization predictive risk factors associated with SNF placement include age above 75 (OR, 4.07; 95% CI, 3.90, 4.25; p < 0.01), paralysis (OR, 3.60; 95% CI, 3.06-4.23; p < 0.01), length of stay (LOS) 10 days or more (OR, 3.00; 95% CI, 2.88-3.13; p < 0.01), psychoses (OR, 2.91; 95% CI, 2.56-3.32; p < 0.01), and neurological disorders (OR, 2.34; 95% CI, 2.17-2.52; p < 0.01).

CONCLUSIONS

Despite increased costs and worse clinical outcomes associated with SNF placement, over 40% increase of hospital discharge to SNF should be anticipated from this population over the next 20 years. Neurologic and psychiatric comorbidities have significantly negative clinical impacts and increase the likelihood of colon cancer patients' discharge to a SNF.

Peri-Operative Management of Older Adults with Cancer-The Roles of the Surgeon and Geriatrician

Optimal surgical management of older adults with cancer starts pre-operatively. The surgeon plays a key role in the appropriate selection of patients and procedures, optimisation of their functional status prior to surgery, and provision of more intensive care for those who are at high risk of post-operative complications. The literature, mainly based on retrospective, non-randomised studies, suggests that factors such as age, co-morbidities, pre-operative cognitive function and intensity of the surgical procedure all appear to contribute to the development of post-operative complications. Several studies have shown that a pre-operative geriatric assessment predicts post-operative mortality and morbidity as well as survival in older surgical cancer patients. Geriatricians are used to working in multidisciplinary teams that assess older patients and make individual treatment plans. However, the role of the geriatrician in the surgical oncology setting is not well established. A geriatrician could be a valuable contribution to the treatment team both in the pre-operative stage (patient assessment and pre-operative optimisation) and the post-operative stage (patient assessment and treatment of medical complications as well as discharge planning).

Symptom distress in older adults following cancer surgery

BACKGROUND

Symptom distress remains a significant health problem among older adults with cancer following surgery. Understanding factors influencing older adults' symptom distress may lead to early identification and interventions, decreasing morbidity and improving outcomes.

OBJECTIVE

We conducted this study to identify factors associated with symptom distress following surgery among 326 community-residing patients 65 years or older with a diagnosis of thoracic, digestive, gynecologic, and genitourinary cancers.

METHODS

This secondary analysis used combined subsets of data from 5 nurse-directed intervention clinical trials targeting patients after surgery at academic cancer centers in northwest and northeastern United States. Symptom distress was assessed by the Symptom Distress Scale at baseline and at 3 and 6 months.

RESULTS

A multivariable analysis, using generalized estimating equations, showed that symptom distress was significantly less at 3 and 6 months (3 months: P < .001, 6 months: P = .002) than at baseline while controlling for demographic, biologic, psychological, treatment, and function covariates. Thoracic cancer, comorbidities, worse mental health, and decreased function were, on average, associated with increased symptom distress (all P < .05). Participants 75 years or older reported increased symptom distress over time compared with those aged 65 to 69 years (P < .05).

CONCLUSIONS

Age, type of cancer, comorbidities, mental health, and function may influence older adults' symptom distress following cancer surgery.

IMPLICATIONS FOR PRACTICE

Older adults generally experience decreasing symptom distress after thoracic, abdominal, or pelvic cancer surgery. Symptom management over time for those with thoracic cancer, comorbidities, those with worse mental health, those with decreased function, and those 75 years or older may prevent morbidity and improve outcomes of older adults following surgery.

High-grade glioma in elderly patients: can the oncogeriatrician help?

Gliomas are the most frequent primary brain tumors in adults. As the population ages in Western countries, the number of people being diagnosed with glioblastoma is expected to increase. Clinical management of elderly patients with primary brain tumors is difficult, owing to multiple comorbidities, polypharmacy, decreased tolerance to chemotherapy, and an increased risk of radiation-induced neurotoxicity. A few specific randomized studies have shown a benefit for radiotherapy in elderly patients with good performance status. For patients with poor performance status, chemotherapy (temozolomide) has been shown to be associated with prolonged duration of response. Patients with methylated O⁶-alkylguanine deoxyribonucleic acid alkyltransferase promoter seem to have better outcomes. Oncogeriatrics proposes the geriatric evaluation of elderly patients to improve therapeutic choices and optimize the management of treatment toxicities and comorbidities.

Frailty predicts outcome of elective laparoscopic cholecystectomy in geriatric patients

BACKGROUND

Frailty is a phenotype characterized by complex and challenging medical problems and higher susceptibility to adverse health outcomes. It can be derived at by a multidimensional process known as comprehensive geriatric assessment (CGA), which assesses the functional reserves of the elderly. In this study we report for the first time on a prospective evaluation of the association between CGA and postoperative complications after elective laparoscopic cholecystectomy for biliary disease.

METHODS

Fifty-seven patients older than 65 years who were to undergo elective laparoscopic cholecystectomy for uncomplicated biliary disease were prospectively examined. Preoperative CGA was performed and the patients were categorized as fit or frail. The main outcome of the study was the rate of any postoperative complication within 30 days of surgery.

RESULTS

There were 29 women (50.9 %) and the median (interquartile range) age of the cohort was 73 (8.8) years. Thirty-two patients (56.1 %) were categorized as frail and 25 (43.9 %) as fit. The overall incidence of postoperative complications was 23.7 %, most of which were grade I and II (18.8 %). Frail patients, according to the CGA assessment, experienced a significantly higher incidence of postoperative complications compared to their fit counterparts (84.6 vs. 15.4 %, p = 0.023). Frail patients experienced a significantly higher frequency of prolonged (more than 2 days) postoperative hospital stay compared with their fit counterparts (p = 0.023).

CONCLUSIONS

Preoperative CGA may predict postoperative complications and prolonged postoperative hospital stay of elderly patients who undergo elective laparoscopic cholecystectomy. Larger-scale studies independently assessing this association are warranted.

Cancer surgery in the elderly

The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.