Delivering tailored surgery to older cancer patients: Preoperative geriatric assessment domains and screening tools - A systematic review of systematic reviews

Impact of age on elderly patients with oral cancer

INTRODUCTION

In this study we have tried to analyze the impact of age on various clinico-pathological parameters, treatment completion and subsequent survival in older patients.

MATERIALS AND METHODS

This is a retrospective analysis of 140 elderly (> 65 years) patients of oral cancer operated between January 2012 and December 2013. The patients were divided into two groups based upon their age that ≤ 70 years and > 70 years.Association of distribution of various clinico-pathological factors between different groups was assessed by using Chi-square test. Survival analysis was done using Kaplan Meir analysis. Univariate and multivariate analysis were performed.

RESULTS

The two groups had similar distribution of various clinico-pathological factors. Disease free survival for the group ≤ 70 and > 70 years was 37.6 months and 36.4 months (p < 0.594). 13.5% and 7.8% patients > 70 years and ≤ 70 years were either advised or received sub-optimal adjuvant therapy (p < 0.002).

CONCLUSION

There is no difference distribution of various clinico-pathological factors and survival in patients of oral cancer ≤ 70 and > 70 years of age. Age did not affect survival. Majority of patients could complete the adjuvant therapy advised. Still, significantly more number of patients > 70 years could not receive/complete appropriate adjuvant therapy. Thus treatment needs to be tailored keeping in mind the individual's performance status and the co-morbidities.

Low skeletal muscle mass as a risk factor for postoperative delirium in elderly patients undergoing colorectal cancer surgery

Background

Both low skeletal muscle mass (LSMM) and delirium are frequently seen in elderly patients. This study aimed to investigate the association between preoperative LSMM and postoperative delirium (POD) in elderly patients undergoing colorectal cancer (CRC) surgery and to design a model to predict POD.

Patients and methods

This is a retrospective observational cohort study. Patients aged 70 years or older undergoing CRC surgery from January 2013 to October 2015 were included in this study. The cross-sectional skeletal muscle area at the level of the third lumbar vertebra using computed tomography was adjusted for patients' height, resulting in the skeletal muscle index. The lowest quartile per sex was defined as LSMM. Short Nutritional Assessment Questionnaire for Residential Care and KATZ-Activities of Daily Living were used to define malnourishment and physical dependency, respectively. POD was diagnosed using the Delirium Observational Screening Scale and geriatricians' notes.

Results

Median age of the 251 included patients was 76 years (IQR, 73-80 years), of whom 56% of patients were males, 24% malnourished, and 15% physically impaired. LSMM and POD were diagnosed in 65 and 33 (13%) patients, respectively. POD occurred significantly more in patients with LSMM (25%) compared with patients without LSMM (10%), P=0.006. In the multivariate analysis, age, history of delirium, and LSMM were significantly associated with POD. In addition, this effect increased in patients with LSMM and malnourishment (P=0.019) or physical dependency (P=0.017).

Conclusion

Age, history of delirium, LSMM, and malnourishment or physical dependency were independently associated with POD. Our nomogram could be used to identify patients at an increased risk for delirium. These patients may benefit from intensive monitoring to prevent POD.

Preoperative Management of the Geriatric Patient: Frailty and Cognitive Impairment Assessment

As the population ages, more geriatric patients will be presenting for surgical procedures. Preoperative evaluation seeks to assess patients for geriatric syndromes: frailty, sarcopenia, functional dependence, and malnutrition. Age-related changes in physiology increase risk for central nervous system, cardiovascular, pulmonary, renal, hepatic, and endocrine morbidity and mortality. Identification of various comorbidities allows for preoperative optimization and for opportunities for intervention including nutritional supplementation and prehabilitation, which may improve postoperative outcomes.

Shared decision-making in older patients with colorectal or pancreatic cancer: Determinants of patients' and observers' perceptions

OBJECTIVE

To identify determinants of older patients' perceptions of involvement in decision-making on colorectal (CRC) or pancreatic cancer (PC) treatment, and to compare these with determinants of observers' perceptions.

METHODS

Patients' perceptions of involvement were constructed by the 9-item SDM questionnaire (SDM-Q-9) and a Visual Analogue Scale for Involvement (VAS-I). Observers' perceptions were constructed by the OPTION5, OPTION12, and MAPPIN'SDM. Convergent validities were calculated between the patient-sided and observer instruments using Spearman's correlation coefficient. Linear regression was used to identify determinants per criterion.

RESULTS

58 CRC and 22 PC patients were included (mean age: 71.8 ± 5.2 years, 45.0% female). No significant correlations were found between the patient-sided and observer instruments. Patients' impression of involvement was influenced by patient characteristics such as quality of life and satisfaction, while observers' perceptions mainly referred to encounter characteristics such as the mean duration of consultations and general communication skills.

CONCLUSION

Due to evident differences in determinants, older CRC/PC patients' and observers' perceptions of involvement should both be collected in evaluating the quality of medical decision-making.

PRACTICE IMPLICATIONS

General communication skills should be integrated in SDM training interventions. New SDM measurement tools for patients are needed to sufficiently discriminate between the constructs of involvement and satisfaction.

Long-Term Survival in Octogenarians After Surgical Treatment for Colorectal Cancer: Prevention of Postoperative Complications is Key

Background

Whether to treat octogenarians with colorectal cancer (CRC) in the same manner as younger patients remains a challenging issue. The purpose of this study was to analyse postoperative complications and long-term survival in a consecutive cohort of octogenarians who were surgically treated for CRC.

Methods

Octogenarians with primary CRC suitable for curative surgery between January 2008 and December 2011 were included. Data about comorbidities, tumour stage, and complications were retrospectively collected from patient files. Data about survival were retrieved with use of the Dutch database for persons and addresses. To identify factors associated with severe postoperative complications and postoperative survival, logistic regression analyses, and Cox regression analyses were performed. Odds ratios and hazard ratios (HR) with 95% confidence intervals (CI) were estimated.

Results

In a series of 108 octogenarians, median age was 83 years (range 80–94 years). Median follow-up was 47 (range 1–107) months. Major postoperative complications occurred in 25% of the patients. No risk factors for development of severe postoperative complications could be identified. The 30-day mortality was 7%; 1- and 5-year mortality was 19% and 56%, respectively. Overall median survival was 48 months: 66 months in patients without complications versus 13 months in patients with postoperative complications. Postoperative complications were most predictive of decreased survival (HR 3.16; 95% CI 1.79–5.59), even including tumour characteristics, comorbidity, and emergency surgery.

Conclusions

Long-term survival in octogenarians deemed fit for surgery is reasonably good. Prevention of major postoperative complications could further improve clinical outcome.

Preventing Treatment-Related Functional Decline: Strategies to Maximize Resilience

The majority of patients with cancer are older adults. A comprehensive geriatric assessment (CGA) will help the clinical team identify underlying medical and functional status issues that can affect cancer treatment delivery, cancer prognosis, and treatment tolerability. The CGA, as well as more abbreviated assessments and geriatric screening tools, can aid in the treatment decision-making process through improved individualized prediction of mortality, toxicity of cancer therapy, and postoperative complications and can also help clinicians develop an integrated care plan for the older adult with cancer. In this article, we will review the latest evidence with regard to the use of CGA in oncology. In addition, we will describe the benefits of conducting a CGA and the types of interventions that can be taken by the interprofessional team to improve the treatment outcomes and well-being of older adults.

Searching for Clinically Relevant Biomarkers in Geriatric Oncology

Ageing, which is associated with a progressive decline and functional deterioration in multiple organ systems, is highly heterogeneous, both inter- and intraindividually. For this, tailored-made theranostics and optimum patient stratification become fundamental, when decision-making in elderly patients is considered. In particular, when cancer incidence and cancer-related mortality and morbidity are taken into account, elderly patient care is a public health concern. In this review, we focus on oncogeriatrics and highlight current opportunities and challenges with an emphasis on the unmet need of clinically relevant biomarkers in elderly cancer patients. We performed a literature search on PubMed and Scopus databases for articles published in English between 2000 and 2017 coupled to text mining and analysis. Considering the top insights, we derived from our literature analysis that information knowledge needs to turn into knowledge growth in oncogeriatrics towards clinically relevant biomarkers, cost-effective practices, updated educational schemes for health professionals (in particular, geriatricians and oncologists), and awareness of ethical issues. We conclude with an interdisciplinary call to omics, geriatricians, oncologists, informatics, and policy-makers communities that Big Data should be translated into decision-making in the clinic.

Frailty and quality of life among older people with and without a cancer diagnosis: Findings from TOPICS-MDS

Background

The number of older cancer patients is rising. Especially in older people, treatment considerations should balance the impact of disease and treatment on quality of life (QOL) and survival. How a cancer diagnosis in older people interacts with concomitant frailty to impact on QOL is largely unknown. We aimed to determine the association between frailty and QOL among community-dwelling older people aged 65 years or above with and without a cancer diagnosis cross-sectionally and at 12 months follow-up.

Methods

Data were derived from the TOPICS-MDS database. Frailty was quantified by a frailty index (FI). QOL was measured with the subjective Cantril’s Self Anchoring Ladder (CSAL, range: 0–10) and the health-related EuroQol-5D (EQ-5D, range:-0.33–1.00) at baseline and after 12 months. To determine associations, linear mixed models were used.

Results

7493 older people (78.6±6.4 years, 58.4% female) were included. Dealing with a cancer diagnosis (n = 751) was associated with worse QOL both at baseline (CSAL:-0.25 (95%-CI:-0.36;-0.14), EQ-5D:-0.03 (95%-CI:-0.05;-0.02)) and at follow-up (CSAL:-0.13 (95%-CI:-0.24;-0.02), EQ-5D:-0.02 (95%-CI:-0.03;-0.00)). A ten percent increase in frailty was also associated with a decrease in QOL at baseline (CSAL:-0.35 (95%-CI:-0.38;-0.32), EQ-5D:-0.12 (95%-CI:-0.12;-0.11)) and follow-up (CSAL:-0.27 (95%-CI:-0.30;-0.24), EQ-5D:-0.07 (95%-CI:-0.07;-0.06)). When mutually adjusting for frailty and a cancer diagnosis, associations between a cancer diagnosis and QOL only remained significant for CSAL at baseline (-0.14 (95%-CI:-0.25;-0.03)), whereas associations between frailty and QOL remained significant for all QOL outcomes at baseline and follow-up. No statistical interactions between cancer and frailty in their combined impact on QOL were found.

Conclusions

Cancer diagnosis and frailty were associated with worse health-related and self-perceived QOL both at baseline and at follow-up. Differences in QOL between older people with and without a cancer diagnosis were explained to a large extent by differences in frailty levels. This stresses the importance to take into account frailty in routine oncologic care.

Risk Factors for Adverse Outcome for Elderly Patients undergoing Curative Oncological Resection for Gastrointestinal Malignancies

BACKGROUND

The incidence of gastrointestinal cancer increases with age, with approximately 20% of these cases in people over 80 years of age. Due to pre-existing comorbidities, this onco-geriatric population often presents diagnostic and therapeutic challenges.

METHODS

A systematic review of articles on PubMed was performed to determine the predictive ability of screening tools and their components regarding the occurrence of adverse outcomes in elderly onco-surgical patients with gastrointestinal malignancies.

RESULTS

Surgical procedures in this patient cohort, particularly complex resections, may result in increased morbidity and mortality. The decision to treat an elderly patient with curative intent requires sound clinical judgment based on knowledge, consideration of objective parameters, and experience. These patients could potentially be optimized for surgery with the improvement of nutritional and overall performance status as well as with stabilizing comorbidities.

CONCLUSION

Various geriatric assessment and screening tools have been developed to identify risk factors to assist the surgeon and the interdisciplinary team in treatment planning, including the Frailty Assessment Score, Timed Up and Go test, nutritional status, and Activities of Daily Living test. It is important to emphasize that transparent and open communication between the treating surgeon and the patient is crucial in that the patient fully understands the implications of the treatment plan.

Performance of a capnodynamic method estimating effective pulmonary blood flow during transient and sustained hypercapnia

The capnodynamic method is a minimally invasive method continuously calculating effective pulmonary blood flow (CO_EPBF), equivalent to cardiac output when intra pulmonary shunt flow is low. The capnodynamic equation joined with a ventilator pattern containing cyclic reoccurring expiratory holds, provides breath to breath hemodynamic monitoring in the anesthetized patient. Its performance however, might be affected by changes in the mixed venous content of carbon dioxide (C_vCO₂). The aim of the current study was to evaluate CO_EPBF during rapid measurable changes in mixed venous carbon dioxide partial pressure (P_vCO₂) following ischemia–reperfusion and during sustained hypercapnia in a porcine model. Sixteen pigs were submitted to either ischemia–reperfusion (n = 8) after the release of an aortic balloon inflated during 30 min or to prolonged hypercapnia (n = 8) induced by adding an instrumental dead space. Reference cardiac output (CO) was measured by an ultrasonic flow probe placed around the pulmonary artery trunk (CO_TS). Hemodynamic measurements were obtained at baseline, end of ischemia and during the first 5 min of reperfusion as well as during prolonged hypercapnia at high and low CO states. Ischemia–reperfusion resulted in large changes in P_vCO₂, hemodynamics and lactate. Bias (limits of agreement) was 0.7 (−0.4 to 1.8) L/min with a mean error of 28% at baseline. CO_EPBF was impaired during reperfusion but agreement was restored within 5 min. During prolonged hypercapnia, agreement remained good during changes in CO. The mean polar angle was −4.19° (−8.8° to 0.42°). Capnodynamic CO_EPBF is affected but recovers rapidly after transient large changes in P_vCO₂ and preserves good agreement and trending ability during states of prolonged hypercapnia at different levels of CO.

Modified frailty index predicts postoperative outcomes in older gastrointestinal cancer patients

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.