Cancer Surgery in the Elderly

[Short-term results of video-assisted lung cancer surgery in octogenarians]

INTRODUCTION

Due to an increase in life expectancy, onco-pulmonologists and thoracic surgeons are more frequently faced with octogenarian patients with lung cancer. In this age group, treatment modalities may need to be revised because of the increasing presence of comorbidities. Surgery remains the reference treatment for early stage disease, but mortality rates and postoperative complications are higher in this group of patients. One of the solutions to reduce the operative risk would be to develop videoassisted thoracoscopic pulmonary resection surgery. The aim of this study was to evaluate the results of this form of lung cancer surgery in octogenarians.

METHODS

All patients 80 years old or more who underwent videoassisted lung cancer surgery from 2014 to 2018 at Lyon University Hospital were included. Wedge resections and diagnostic procedures were excluded.

RESULTS

Nineteen patients (13 men, 6 women) were included. The median age was 82 years old. All patients had undergone videoassisted lobectomy. Three patients required conversion to thoracotomy (15.8%). All patients underwent complete resection (R0). One patient had N1 lymph node involvement, all others were N0. The postoperative complication rate was 68.4%, the majority of which were grade II of the Clavien classification. Perioperative mortality was 5.3%.

CONCLUSIONS

Videoassisted lung cancer resection in a selected population of octogenarians is associated with satisfactory short-term results. It is reasonable to favour minimally invasive techniques in this population, even if the proof of their superiority has not yet been firmly established.

Age Nutrition Chirugie (ANC) study: impact of a geriatric intervention on the screening and management of undernutrition in elderly patients operated on for colon cancer, a stepped wedge controlled trial

Background

Undernutrition prior to major abdominal surgery is frequent and increases morbidity and mortality, especially in older patients. The management of undernutrition reduces postoperative complications. Nutritional management should be a priority in patient care during the preoperative period. However undernutrition is rarely detected and the guidelines are infrequently followed. Preoperative undernutrition screening should allow a better implementation of the guidelines.

Methods/design

The ANC (“Age Nutrition Chirurgie”) study is an interventional, comparative, prospective, multicenter, randomized protocol based on the stepped wedge trial design. For the intervention, the surgeon will inform the patient of the establishment of a systematic preoperative geriatric assessment that will allow the preoperative diagnosis of the nutritional status and the implementation of an adjusted nutritional support in accordance with the nutritional guidelines. The primary outcome measure is to determine the impact of the geriatric intervention on the level of perioperative nutritional management, in accordance with the current European guidelines. The implementation of the intervention in the five participating centers will be rolled-out sequentially over six time periods (every six months). Investigators must recommend that all patients aged 70 years or over and who are consulting for a surgery for a colorectal cancer should consider participating in this study.

Discussion

The ANC study is based on an original methodology, the stepped wedge trial design, which is appropriate for evaluating the implementation of a geriatric and nutritional assessment during the perioperative period. We describe the purpose of this geriatric intervention, which is expected to apply the ESPEN and SFNEP recommendations through the establishment of an undernutrition screening and a management program for patients with cancer. This intervention should allow a decrease in patient morbidity and mortality due to undernutrition.

Trial registration

This study is registered in ClinicalTrials.gov NCT02084524 on March 11, 2014 (retrospectively registered).

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

The onco-geriatric population is increasing and thus more and more elderly will require surgery; an important treatment modality for many cancer types. This population's heterogeneity demands preoperative risk stratification, which has led to the introduction of Geriatric Assessment (GA) and associated screening tools in surgical oncology. Many reviews have investigated the use of GA in onco-geriatric patients. Discrepancies in outcomes between studies currently hamper the implementation of a preoperative GA in clinical practice. A systematic review of systematic reviews was performed in order to investigate assessment tools of the most commonly included GA domains and their predictive ability regarding the adverse postoperative outcomes. All domains - except polypharmacy - were, to a varying degree, associated with different adverse postoperative outcomes. Functional status, comorbidity and frailty were assessed most frequently and were most often significant. The association between domain impairments and adverse postoperative outcomes appeared to be greatly influenced by the study population characteristics and selection bias, as well as the type of assessment tool used due to possible ceiling effects and its sensitivity to detect domain impairments. Frailty seems to be the most important predictor, which underpins the importance of an integrated approach. As it is unlikely that one universal GA will fit all, feasibility, based on the time, expertise, and resources available in daily clinical practice as well as the patient population to hand, should be taken into consideration, when tailoring the 'optimal GA'.

Use of the Barthel index, activities of daily living, in dermatologic surgery in patients aged 80 years and older

BACKGROUND

Dermatologists often attend elderly patients with non-melanoma skin cancer (NMSC). There is a lack of information regarding the optimum treatment for elderly patients with NMSC.

METHODS

The objective of this study was to describe changes in the Barthel Index (BI) after dermatologic surgery for NMSC in patients aged 80 years and older. A prospective observational study was carried out in patients aged 80 years and older diagnosed with NMSC and treated with conventional dermatologic surgery. BI was performed by direct interview with the patients and/or their caregiver before the surgery, seven and 30 days after the surgery.

RESULTS

A total of 180 dermatologic surgeries were performed in 144 patients. The average age of the patients was 84.2 years. There were 84 men (58.3%) and 60 women (41.7%). Mean BI score was 85.9 at baseline, 85.3 on day 7 after surgery, and 85.6 on day 30, showing minimal changes after dermatologic surgery. Changes in the BI occurred mainly in dressing, toilet use, transfers, mobility (on level surfaces) and walking stairs.

CONCLUSIONS

Activities of daily living were not significantly affected in patients aged 80 years and older, after dermatologic surgery for NMSC.

Total thyroidectomy in geriatric patients: a retrospective study

In the English literature there is no single definition that identifies elderly patients. In our retrospective study, we divided total thyroidectomized patients operated on from 2000 to 2010 in the Department of Surgical Sciences of the "Sapienza" University of Rome, in two groups: group 1 consists of 448 patients over 65 years and group 2 consists of 1275 patients under 65 years. We compared both groups in terms of indications for surgery, histological diagnoses, postoperative complications (laryngeal nerv palsy, hypocalcemia, bleeding and seroma) and mortality. The results showed no statistically significant differences between the two groups with respect to the type of surgical indication, the type of comorbidities, the incidence of postoperative complications and perioperative mortality. The only data discordant with those in the international literature was the incidence of neoplastic disease that is found to be slightly greater in group 2. In conclusion, total thyroidectomy in patients over 65 years is a safe procedure and is not burdened with a higher percentage of postoperative complications, even if requires a careful preoperative assessment of risk factors related to comorbidity.

Complications of ambulatory major dermatological surgery in patients older than 85 years

BACKGROUND

During the last decades, the progressive ageing of the population has resulted in a rising skin cancer incidence. Although previous studies detected no higher morbidity for dermatological surgery in senior patients, their exclusion from optimal surgical treatment remains as a common clinical practice.

OBJECTIVE

The aim of this study was to determine the diseases treated with ambulatory major dermatological surgery, the surgical morbidity and the associated variables in ≥ 85 year-old patients.

PATIENTS/METHODS

This is an observational study on 247 successive patients older than 85 years of age who underwent dermatological surgery in a single Ambulatory Mayor Surgery unit. Studied variables were age, gender, tobacco-alcohol exposure, co-morbid medical conditions, blood-thinning medication, antibiotic prophylaxis, number of lesions, location, histopathological diagnosis, area of skin removed, surgical technique, type of flap, length of surgery, entrance order, suture thread, surgical complications and need of post-operative admission.

RESULTS

The most common site was head and neck (82.7%). The most frequent tumour was basal cell carcinoma (45.1%), followed by squamous cell carcinoma (38.7%) and melanoma (8.3%). Direct closure was the most frequent procedure (55.6%). Of the total number of patients, 7.9% of patients suffered complications; necrosis followed by cellulitis were the most frequent. Length of surgical procedure, area of skin removed and reconstruction with skin-graft were significantly related to higher risk of post-operative complications.

CONCLUSIONS

No intra or post-surgical mortality or life-threatening local complications were detected. Most post-surgical local complications appeared after wide excisions and complex reconstruction techniques that prolonged the length of the surgery.

The influence of aging on the early detection, diagnosis, and treatment of breast cancer

Patterns of care for women with breast cancer vary substantially with patient age. Older patients with breast cancer frequently receive less than standard management, resulting in poorer outcome. At diagnosis, the health status of older women with breast cancer affects survival and treatment decisions. Age-related comorbidity may limit diagnostic tests, narrow treatment options, and significantly increase mortality not related to breast cancer. Yet, for healthy older women with early-stage breast cancer, stage-adjusted survival is similar to that of younger women. Calendar age is not sufficient to encompass the heterogeneity in health status of the elderly. Instead, management of older women with breast cancer should be based on anticipated survival, functional status, and the goals of the patient for treatment. In this review, we evaluate pertinent data and provide guidance for the management of older women with breast cancer.

Older female cancer patients: importance, causes, and consequences of undertreatment

Despite increased interest in treatment of senior cancer patients, older patients are much too often undertreated. This review aims to present data on treatment practices of older women with breast and gynecologic cancers and on the consequences of undertreatment on patient outcome. We also discuss the reasons and validity of suboptimal care in older patients. Numerous studies have reported suboptimal treatment in older breast and gynecologic cancer patients. Undertreatment displays multiple aspects: from lowered doses of adjuvant chemotherapy to total therapeutic abstention. Undertreatment also concerns palliative care, treatment of pain, and reconstruction. Only few studies have evaluated the consequences of nonstandard approaches on cancer-specific mortality, taking into account other prognostic factors and comorbidities. These studies clearly showed that undertreatment increased disease-specific mortality for breast and ovarian cancers. For other gynecological cancers, data were insufficient to draw conclusions. Objective reasons at the origin of undertreatment were, notably, higher prevalence of comorbidity, lowered life expectancy, absence of data on treatment efficacy in clinical trials, and increased adverse effects of treatment. More subjective reasons were putative lowered benefits of treatment, less aggressive cancers, social marginalization, and physician's beliefs. Undertreatment in older cancer patients is a well-documented phenomenon responsible for preventable cancer deaths. Treatments are still influenced by unclear standards and have to be adapted to the older patient's general health status, but should also offer the best chance of cure.

Successful Treatment of Intraoperative Heart Failure Caused by Ampulla Cardiomyopathy by Intra-aortic Balloon Pumping and Percutaneous Cardiopulmonary Support: Report of a Case

An 82-year-old woman underwent total gastrectomy for advanced gastric cancer with invasion to the lower esophagus. Her blood pressure dropped alarmingly during the operation, which was performed via the transabdominal and left-side transthoracic approach. Using echocardiography, we diagnosed intraoperative-onset reversible heart failure caused by ampulla cardiomyopathy. Because the infusion of catecholamines is associated with secondary heart failure, we gave her calcium antagonists and nicorandil, then started intra-aortic balloon pumping (IABP) and the percutaneous cardiopulmonary support system (PCPS). On postoperative day (POD) 7, the IABP and PCPS were removed and on POD 12, she was extubated successfully. The patient was discharged on POD 54 and has remained well. The factors predisposing her to ampulla cardiomyopathy were left-side thoracotomy, hypoxia caused by one-lung ventilation, and the infusion of high-dose catecholamines. Prompt diagnosis and timely treatment of the heart failure with IABP and PCPS prevented any further complications.

Surgical treatment for multinodular goitres in geriatric patients

BACKGROUND

Although age is not a contraindication for thyroid surgery, few elderly patients undergo surgery due to the greater risk of morbidity. The aims of this study are to determine in patients aged >65 years: (1) whether the indications for surgery on multinodular goitre (MG) differ with respect to younger patients; (2) the surgical results; and (3) whether the postsurgery morbidity and mortality rates are higher.

PATIENTS AND METHOD

Eighty-one patients aged over 65 years who were receiving surgery for MG were analysed; 40 49%) presented with associated co-morbidities. Sixty percent had thyroid symptoms, either compressive and/or toxic. All underwent programmed surgery following stabilisation and strict control of their co-morbidities. As a control group we used 510 MG patients receiving surgery and aged between 30 and 65 years.

RESULTS

Compared with the control group the geriatric patients had a longer time of goitre evolution (P=0.032), greater presence of symptoms (P=0.001) and a higher percentage of intrathoracic component (P=0.001). Compressive symptoms were the major indication for surgery (P=0.001). Postoperative complications occurred in 40% of the patients, a higher rate than in the control group (28%; P=0.011), although a large percentage of those complications were transitory. Definitive complications included two recurrent laryngeal nerve injuries (2.5%). The preoperative symptoms remitted in all the patients, and only three were associated with a thyroid carcinoma, one of which was anaplastic.

CONCLUSIONS

MG operated on in elderly patients has a longer evolution and an intrathoracic component, and surgery is indicated restrictively. With close monitoring of the co-morbidities and a programmed operation the results with regard to morbidity and mortality are similar to those obtained at younger ages.

Management issues for elderly patients with breast cancer

Fifty percent of breast cancers occur after the age of 65 years and 25% occur after the age of 75 years. Encountering a breast cancer in an older woman is frequent. After years of dearth of data specific to the elderly, some evidence is beginning to accumulate concerning breast cancer in the older woman. Recent data from mammography studies confirm its effective in women with 10 years or more of life expectancy (perhaps even 5 years). Epidemiologic and randomized studies demonstrate that a proper surgery and adjuvant treatment can decrease relapse and improve survival in patients older than 80 years. Radiation therapy studies show a decrease in local relapse even in patients older than 70 years. Adjuvant hormonal therapy has essentially the same effectiveness as in younger women. Chemotherapy has a role in patients older than 70 years. Consensus statements, such as the St. Gallen consensus, have dropped the age limit of 70 years from their recommendations. Comorbidity and life expectancy should be taken into account for proper selection of adjuvant treatment. The treatment of metastatic breast cancer has evolved significantly with the introduction of aromatase inhibitors, new chemotherapeutic agents, and targeted biologic agents. New chemotherapeutic agents are as effective as single agents compared to older and more toxic drug combinations. The cumulative result of the introduction of these new agents, at a population level, is a 7.5-month increase in the median survival time of patients with metastatic breast cancer over the past decade.

Prognostic significance of the age factor in the thyroid cancer: Statistical analysis

BACKGROUND AND OBJECTIVES

To determine whether thyroid carcinoma in elderly patients presents any peculiar characteristics, whether the greater biological aggressiveness of the neoplasm modifies the surgical treatment selected, and whether age greater than 70 years represents an independent prognostic factor.

METHODS

Retrospective analysis of case histories from the Department of Surgery of "La Sapienza" University of Rome; 403 patients subjected to total thyroidectomy between 1993 and 1999, with a minimum follow-up period of 3 years subdivided into three groups: group I (patients aged between 20 and 50 years), group II (patients aged between 51 and 70 years) and group III (patients aged >70 years). The surgical and postoperative treatment is uniform in all study groups.

RESULTS

Age greater than 70 years entails a significant increase in mortality; the mortality rate in the three groups was found to be 3%, 9% and 54%, respectively. Prognosis is significantly worse in the elderly patients group (group III) than in group I (P < or = 0.001) and in group II (P < or = 0.001); group II mortality was significantly higher than that of group I (P = 0.005); in group III, the neoplasm displays features of greater biological aggressiveness (greater incidence of undifferentiated forms, presence of lymph nodes at diagnosis and vascular invasion, locally advanced forms, greater incidence of stage IV).

CONCLUSIONS

Statistical analysis shows that the greater biological aggressiveness of the neoplasm in elderly patients worsens the prognosis, although an age exceeding 70 years itself represents an unfavourable prognostic factor; total thyroidectomy does not present any counter-indications in elderly patients.

Surgical considerations in the geriatric patient

The geriatric patient has a high incidence of foot deformities and may be considered a good surgical candidate if healthy and psychologically ready for the surgical procedure. Foot problems in the geriatric population that may require surgical intervention can be grouped into approximately five categories, including (1) localized orthopedic disorders (ie, bunions, hammer toes, and so on); (2) skin and nail problems (ie, onychomycosis); (3) degenerative and inflammatory arthritis; (4) diabetic foot disorders; and (5) neuromuscular disease. However, age-related changes in cardiovascular, pulmonary, and renal function increase the risk of perioperative complications. The higher rates of complications seen in the older surgical patients result in part from existing comorbidity and age-associated changes in organ function. Extensive procedures depending on good bone healing for success should usually not be attempted on older patients. Office surgery for the geriatric patient should involve only the simplest procedures and should be kept to a minimum because of the increased possibility of postoperative complications. In the hospital there is better preoperative evaluation, operating room conditions, and postoperative care.

A case for geriatric oncology

The increase in cancer incidence with increasing age is becoming more obvious and more important as the average age of the population increases. The close link between old age and cancer development is the result of three main factors: the substantial length of time required for carcinogenesis; the occurrence of age-related molecular changes that mimic carcinogenesis; and, changes in bodily environment that favour cancer progression, which is a consequence of increasing age. The clinical behaviour of common malignant diseases, eg, breast, ovarian, and lung cancers, lymphomas, and acute leukaemias, may change with age because of intrinsic variation of the neoplastic cells and the ability of the tumour host to support neoplastic growth. Therapeutic decisions should be based on an estimation of the patient's life expectancy, and risks and benefits should be weighted up accordingly. A comprehensive geriatric assessment of function, comorbidity, cognition, depression, social support, nutrition, and polypharmacy, would allow interventions to be tailored to individual needs. In developed countries, the numbers of older people who develop cancer are increasing and many questions remain unanswered. These issues include: the causes of the association of cancer and ageing; the age-related differences in cancer biology; the goals of cancer treatment in the aged; and the effectiveness of cancer prevention. We review the biological and clinical interactions of cancer and ageing and discuss the skills and knowledge necessary for caring for older patients.

Cancer and age in the USA

Cancer in the older person has become an increasingly common problem with the aging of the population. The goal of this paper is to review the influence of age on cancer biology and cancer management. Specific interactions of cancer and aging include: Increased incidence of cancer with the age: This association may be reported to three factors: duration of carcinogenesis; increased susceptibility of older tissues to late stage carcinogens, and systemic effects of aging, including immune-senescence and enhanced cytokine production. Biological behavior of cancer: With aging, the prognosis of certain neoplasms, including acute myelogenous leukemia and large-cell non-Hodgkin's lymphoma worsens, whereas the behavior of other tumors becomes more indolent. In these biologic variations one may recognize both a 'seed" effect (different tumor cells) and a "soil" effect (different ways in which the older tumor host handles tumor growth. Goals of prevention and treatment: Given the limited life-expectancy of older individuals and reduced tolerance of clinical intervention, the main goal is compression of morbidity, rather than prolongation of survival. Cancer prevention in the older person: In virtue of increased susceptibility to environmental carcinogens, the older person appears an ideal candidate for primary prevention of cancer, including chemoprevention; though randomized controlled studies have not been performed, the older person may benefit from secondary prevention (screening), when the average life-expectancy is 3 years or longer. Cancer treatment: The risk of surgical complications increases only slightly with age for elective surgery, but increases dramatically for emergency surgery. Radiation therapy appears a valuable method of cancer treatment in patients of all ages. Chemotherapy can be made safer by the following provisions: use of hemopoietic growth factors for patients aged 70 and older receiving moderately toxic chemotherapy (CHOP and CHOP-like); maintenance of hemoglobin levels at 12 g/dl with erythropoietin; adjustment of the dose of renally excreted agents to the glomerular filtration rate; selection of the best candidates for chemotherapy based on comprehensive geriatric assessment.

Geriatric oncology: challenges for the new century

The management of cancer in the older aged person represents one of the major immediate challenges of medicine. The response to this challenge involves answers to the following questions: I. Who is old? Currently. 70 years of age may he considered the lower limit of senescence because the majority of age-related changes occur after this age. Individual estimates of life expectancy and functional reserve may be obtained by a comprehensive and time-consuming multidimensional geriatric assessment. The current instrument may be fine-tuned and new instruments, including laboratory tests of ageing. may be developed. 2. Why do older persons develop more cancer? It is clear that ageing tissues are more susceptible to late-stage carcinogen. Older persons may represent a natural monitor system for new environmental carcinogens, and may also represent a fruitful ground to study the late stages of carcinogenesis. 3. Is cancer different in younger and older persons? Clearly. the behaviour of some tumors. including acute myeloid leukaemia, non-Hodgkin's lymphoma and breast cancer change with the age of the patient. The mechanisms of these changes that may involve both the tumour cell and the tumour host are poorly understood. 4. Can cancer he prevented in older individuals? Chemoprevention offers a new horizon of possibilities for cancer prevention: older persons may benefit most from chemoprevention due to increased susceptibility to environmental carcinogens. Screening tests may become more accurate in older individuals due to increased prevalence of cancer. hut may he less beneficial due to more limited patient life expectancy. 5. Do older persons benefit from cytotoxic treatment? The answer to this question partly stands on proper patient selection. partly on the development of safer forms of cancer treatment and prudent use of antidotes to chemotherapy toxicity. 6. What is the cost of treating older cancer patients? The treatment of older patients is generally more costly. This cost should be assessed against the cost of not treating cancer and promoting functional dependence. which by itself is extremely costly. 7. What are the endpoints of clinical trials in older cancer patients? With more limited life expectancy. the effect of treatment on quality of life is paramount. Reliable assessment of quality of life is essential for interpreting clinical trials in older individuals. 2000 Elsevier Science Ltd. All rights reserved.