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

Inflammation-based prognostic scores in geriatric patients with rectal cancer

BACKGROUND

Morbidity/mortality and oncologic outcomes can be worsened in geriatric rectal cancer patients due to comorbidities and frailty. The aim of this study was to compare surgical and oncological results of geriatric rectal cancer patients using inflammation-based prognostic scores.

METHODS

The prospectively maintained database of 991 rectal cancer patients treated at our center between 2007 and 2020 were analyzed. All conventional clinicopathologic features, and oncologic outcomes are compared between patients ≥ 65 years old (geriatric patients: Group I) and < 65 years old (non-geriatric patients: Group II). The modified Glasgow Prognostic Score (mGPS) and the C-reactive protein-albumin ratio (CAR), were determined. The prognostic value of mGPS and CAR as well as the well-known clinico-pathologic factors to predict surgical morbidity, mortality, local and/or distant recurrence, and overall survival was assessed.

RESULTS

There were 567 (57.2%) patients who were ≥ 65 years old (Group I; 349 males, median age 74 [range 65-9]) years) and 424 (42.8%) who were < 65 years old (Group II; 252 males, median age 58 [range 20-64] years). The high-grade [Clavien-Dindo III-IV] complications rates of Group I and Group II patients sere 20% (n = 113), and 9% (n = 37), respectively. High-grade complications were related to mGPS (p < 0.001) and CAR (p < 0.001) values. The high-grade complication rate was found to be higher in Group I than in Group II, and this was statistically significant (p < 0.001). High preoperative mGPS and CAR values were significantly associated with postoperative mortality (p < 0.001). In Cox multivariate analysis, mGPS (p = 0.003) and CAR (p = 0.001) were significantly in correlation with lowered overall survival. The mGPS and CAR were found to be independent prognostic factors for overall survival.

CONCLUSIONS

The mGPS and CAR can predict severe postoperative complications and early mortality. mGPS, and CAR have a powerful prognostic value and the potential clinical usefulness to predict decreased overall survival in both geriatric and non-geriatric rectal cancer patients.

Geriatric Implications of Surgical Oncology

Surgical oncology is cancer care that focuses on using surgery to diagnose, stage, and treat cancer and is one of the main treatments for malignancy. Patients older than 65 years are generally considered geriatric. The incidence of cancer in geriatric patients is increasing annually. Candidacy for surgical intervention depends on factors such as cancer type, size, location, grade and stage of the tumor, and the patient's overall health status and age. Despite increasing agreement that age should not limit treatment options, geriatric patients tend to be undertreated. Cancer in geriatric patients has different features than in younger patients. As such, treatment options may be dissimilar in these 2 cohorts. Here, care of the geriatric patient undergoing surgical oncology interventions is discussed.

Age Is a Risk Factor for Postoperative Complications Following Excisional Laminectomy for Intradural Extramedullary Spinal Tumors

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

The incidence of intradural extramedullary (IDEM) spinal tumors is increasing. Excisional laminectomy for removal and decompression is the standard of care, but complications associated with patient age are unreported in the literature. Our objective is to identify if age is a risk factor for postoperative complications after excisional laminectomy of IDEM spinal tumors.

METHODS

A retrospective analysis was performed on the 2011 to 2014 ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database for patients undergoing excisional laminectomy of IDEM spinal tumors. Age groups were determined by interquartile analysis. Chi-squared tests, t tests, and multivariate logistic regression models were employed to identify independent risk factors. Institutional review board approval was not needed.

RESULTS

A total of 1368 patients met the inclusion criteria for the study. Group 1 (age ≤ 44) contained 372 patients, group 2 (age 45-54) contained 314 patients, group 3 (age 55-66) contained 364 patients, and group 4 (age > 66) contained 318 patients. The univariate analysis showed that mortality and unplanned readmission were highest among patients in group 4 (1.26%, P = .011, and 10.00%, P = .039, respectively). Postoperative wound complications were highest among patients in group 1 (2.15%, P = .009), and postoperative venous thromboembolism and cardiac complications were highest among patients in group 3 (4.4%, P = .007, and 1.10%, P = .032, respectively). Multivariate logistic regression revealed that elderly age was an independent risk factor for postoperative venous thromboembolism (group 3 vs group 1; odds ratio = 6.739, confidence interval = 1.522-29.831, P = .012).

CONCLUSIONS

This analysis revealed that increased age is an independent risk factor for postoperative venous thromboembolism in patients undergoing excisional laminectomy for IDEM spinal tumors.

Age Stratification of 30-Day Postoperative Outcomes Following Excisional Laminectomy for Extradural Cervical and Thoracic Tumors

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate age as an independent predictive factor for perioperative morbidity and mortality in patients undergoing surgical decompression for metastatic cervical and thoracic spinal tumors using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2011 to 2014.

METHODS

We identified 1673 adult patients undergoing excisional laminectomy of cervical and thoracic extradural tumors. Patients were stratified into quartiles based on age, with Q1 including patients aged 18 to 49 years, Q2 including patients aged 50 to 60 years, Q3 including patients aged 61 to 69 years, and Q4 including patients ≥70 years. Univariate and multivariate regression analyses were performed to examine the association between age and 30-day perioperative morbidity and mortality.

RESULTS

Age was an independent risk factor for 30-day venous thromboembolism (VTE) and reoperation. Patients in Q3 for age had nearly a 4 times increased risk of VTE than patients in Q1 (odds ratio [OR] 3.97; 95% CI 1.91-8.25; P < .001). However, there was no significant difference in VTE between patients in Q4 and Q1 (P = .069). Patients in Q2 (OR 1.99; 95% CI 1.06-3.74; P = .032) and Q4 (OR 2.18; 95% CI 1.06-4.52; P = .036) for age had a 2 times increased risk of reoperation compared with patients in Q1.

CONCLUSIONS

Age was an independent predictive factor for perioperative VTE and reoperation, but there was no clear age-dependent relationship between increasing age and the risk of these perioperative complications.

Multicenter Study of Presentation, Management, and Postoperative and Long-Term Outcomes of Septegenerians and Octogenerians Undergoing Gastrectomy for Gastric Cancer

BACKGROUND

The optimal treatment strategy for elderly patients with gastric cancer is still controversial. This study aimed to assess the impact of age on short- and long-term outcomes after treatment for primary gastric cancer.

METHODS

From January 2004 to December 2014, a total of 507 patients underwent gastrectomy for gastric adenocarcinoma at two high-volume upper gastrointestinal (GI) centers. The patients were classified into three groups as follows: group A (patients ≤ 69 years old, n = 266), group B (patients 70-79 years old, n = 166), and group C (patients ≥ 80 years old, n = 75). Clinicopathologic characteristics as well as, short- and long-term outcomes were compared between the groups.

RESULTS

The patients in groups B and C had more comorbidities, whereas the younger subjects (group A) had more advanced tumor stages. Less extensive surgery was performed in the groups B and C. Older patients (age ≥ 70 years) had more postoperative medical complications. Moreover, group C had a higher postoperative mortality rate (8.1%) than group A (1.8%) or group B (1.9%). In the multivariable analysis, age older than 80 years (group C) was a negative independent factor for overall survival (OS) (hazard ratio [HR], 2.36) compared with group A, whereas group B seemed to have a comparable risk (HR, 1.37). Notably, the three groups did not show significant differences in disease-related survival (DRS).

CONCLUSION

The data suggest that patients 70-79 years of age show a risk of postoperative death comparable with that of younger subjects. However, patients older than 80 years should be carefully selected for surgical treatment due to the increased risk of postoperative mortality.

Enhanced Recovery After Colorectal Surgery (ERAS) in Elderly Patients Is Feasible and Achieves Similar Results as in Younger Patients

Aim: Enhanced recovery after surgery (ERAS) is a multimodal approach that aims to optimize perioperative treatment. Whether elderly patients receiving colorectal surgery can adhere to and benefit from an ERAS approach is uncertain. The aim of this study was to compare patients in different age groups participating in an ERAS program. Method: In this substudy of a randomized controlled trial, we analyzed the interventional ERAS arm of adult patients eligible for laparoscopic or open colorectal resection with regard to the importance of age. Patients were divided into three groups based on age: ≤65 years (n = 79), 66-79 years (n = 56), and ≥80 years (n = 19). The primary end point was total postoperative hospital stay (THS). Secondary end points were postoperative hospital stay, postoperative complications, postoperative C-reactive protein levels, readmission rate, mortality, and patient adherence to the different ERAS elements. All parameters and measuring the adherence to the ERAS protocol were recorded before surgery, on the day of the operation, and daily until discharge. Results: There were no significant differences in length of THS between age groups (≤65 years, median 5 [range 2-47] days; 66-79 years, median 5.5 [range 2-36] days; ≥80 years, median 7 [range 3-50] days; p = .53). All secondary outcomes were similar between age groups. Patient adherence to the ERAS protocol was as good in the elderly as it was in the younger patients. Conclusion: Elderly patients adhered to and benefited from an ERAS program, similar to their younger counterparts.