Quality of Life in Older Adults After Major Cancer Surgery: The GOSAFE International Study

Impact of American College of Surgeons Geriatric Surgery Verification Program in Patients Undergoing Major Abdominal Oncologic Operation at a Cancer Center

BACKGROUND

Patients older than 65 years have unique needs and treatment outcome goals. The objective of this study was to evaluate the impact of Geriatric Surgery Verification (GSV) initiative in oncology patients 65 years or older undergoing major abdominal operation.

STUDY DESIGN

We implemented the American College of Surgeons GSV program protocols for patients 65 years and older starting in 2022. A retrospective review was conducted of patients undergoing major abdominal oncologic operation from January 2021 through December 2022 to create pre-GSV and post-GSV initiative cohorts. Main outcome variables were postoperative institutionalization and change in the patient's primary residence disposition (measured as Primary Residence Score as a proxy for loss of independence).

RESULTS

A total of 57 patients in the control group and 43 patients in the intervention group met inclusion criteria. The average age was 76.5 and 75 years, respectively. Patients were well matched for clinical and sociodemographic characteristics. The intervention group had a shorter mean length of stay (4.4 ± 2.5 days vs 6.5 ± 3.6 days in the control group [p < 0.01]) and were less likely to be newly discharged to an institution (7.3% vs 24.1%, p = 0.03). The GSV initiative was associated with 72% lower odds of increased Primary Residence Score (ie care needs) at time of discharge (odds ratio 0.28, 95% CI 0.1 to 0.81).

CONCLUSIONS

The GSV initiative intervention in geriatric oncology patients undergoing major abdominal operation was associated with reducing postoperative institutionalization and change in primary residence disposition. Further studies to explore different mechanisms within GSV that lead to improved outcomes in geriatric oncologic population will be informative.

Outcome of robotic colon surgery in older patients with colon cancer

INTRODUCTION

Older patients are less likely to undergo curative surgery for colon cancer (CC) because of a higher rate in comorbidities that increases the risk for complications and mortality. Robot-assisted surgery could be an alternative minimally invasive approach allowing surgical treatment in a higher percentage of patients above 70 years old. This study aims at evaluating the safety of robotic surgery in older patients with CC.

MATERIALS AND METHODS

Prospectively collected data from all patients receiving robot-assisted surgery for CC at a tertiary center between 2016 and 2022 were used for retrospective subgroup analysis based on age and tumor location (right-sided, left-sided). Perioperative outcome including 30-day major morbidity and 90-day mortality rate, overall survival (OS) and cancer-specific survival (CSS) were compared.

RESULTS

In total, 231 patients met inclusion criteria of the study: n = 89 < 70 years, n = 64 between 70 and 79 years, n = 72 between 80 and 89 years, and n = 6 ≥ 90 years. No differences in 90-day mortality or 30-day major morbidity were observed between age groups. Thirty-day overall morbidity, length of stay (LOS), and days to full mobility were increased in ≥70-year-olds for right- and left-sided surgery. One-, three-, and five-year CSS did not differ while the three- and five-year OS significantly decreased with age.

DISCUSSION

Robot-assisted surgery for resection of CC can be used safely in older patients.

The pervasive impact of frailty on ovarian cancer care and the role of prehabilitation: Qualitative perspectives of key stakeholders

INTRODUCTION

We performed a qualitative study to explore key stakeholders' perspectives about the impact of frailty on ovarian cancer care and evaluate a candidate prehabilitation intervention.

MATERIALS AND METHODS

We conducted semi-structured interviews with patient-caregiver dyads and multi-disciplinary clinicians. Patients were ≥ 50 years of age with a new diagnosis of advanced stage (III/IV) ovarian cancer who received cancer-directed treatment (chemotherapy and/or surgery) during the past year and met criteria as pre-frail or frail using the FRAIL scale. We used a semi-structured interview guide to elicit participants' views on frailty, nutrition, physical therapy, and a candidate prehabilitation intervention. We used inductive and deductive approaches to code and analyze interviews and identify emergent themes and patterns.

RESULTS

Ten patients and caregivers (five dyads) and 10 providers were interviewed. We identified four themes: (1) frailty screening is essential to prevent over- and under-treatment, but underused; (2) stakeholders preferred a multidisciplinary approach to providing tailored care for frail patients over a candidate prehabilitation intervention; (3) patient, family caregiver, and clinician stakeholders reported multiple barriers to prehabilitation programs, including concerns about selection bias, and (4) frail patients and family members are vulnerable and require more psychosocial support.

DISCUSSION

We identified significant barriers to prehabilitation interventions for frail patients with ovarian cancer; initiatives to increase frailty screening and provide tailored multi-disciplinary approaches may have a greater impact.

Health-Related Quality of Life After Colorectal Cancer Surgery in Older Patients Compared to the Young: A Prospective Multicentre Observational Study

Introduction: The impact of colorectal surgery on older adults' (≥65 years) health-related quality of life (HRQoL) is rarely reported. Methods: This prospective multi-institutional cohort study involving 217 participants investigated factors affecting older colorectal cancer (CRC) patients' HRQoL following surgery with the EORTC QLQ-C30 and the HADS. Results: The trend of the global QoL and individual subscales show an overall dip in QoL from baseline to pre-discharge, before slowly rising until the 6-month mark. Baseline score of individual outcome measures was the only constant predictor of the outcome measure over time. Conclusion: Age was not found to be a significant predictor of HRQoL in older adults undergoing colorectal surgery, while baseline scores of individual outcome measures consistently predicted post-operative HRQoL scores. Interventions should be targeted at specific subgroups of older adults scheduled for colorectal surgery, such as those with lower baseline scores.

Recovery trajectories after major abdominal surgery: A retrospective pooled cohort study

BACKGROUND

Recovery from major surgery can be difficult to predict given the many factors involved in treating disease and restoring preoperative function. Postoperative recovery metrics such as length of stay, complications, and mortality are typically described. However, large data quantities for patient-reported recovery are scarce. In this retrospective study, we aimed to describe the multidimensional recovery trajectory of patients undergoing major abdominal surgery 4-8 weeks after surgery and explore factors related to incomplete overall recovery.

METHODS

We retrospectively analysed pooled cohort data of adults undergoing elective major abdominal surgery between 2018 and 2024 across three tertiary-level hospitals. Recovery was measured at postoperative days 1, 3, 7, 14, weeks 4-8, and 3 months using the Postoperative Quality of Recovery Scale (PostopQRS). Physiological, nociceptive, emotive, activities of daily living (ADL), and cognitive domains were assessed, with recovery defined as a return to, or improvement of, preoperative baseline levels. Overall recovery was defined as recovery in all domains. Length of stay was assessed for patients who recovered overall, or did not recover, at postoperative weeks 4-8.

RESULTS

Six hundred and fifty-three patients were included, with mean (SD) age of 57.8 (14.4) years. Of these, 36% were aged ≥65 years and 58% were male. The incidence of overall recovery at postoperative week 4-8 was 42%. Domain-level recovery at postoperative weeks 4-8 was 63% for nociception, 81% for emotion, 82% for ADLs, and 83% for cognition. Patients failing to achieve overall recovery at weeks 4-8 had longer mean (SD) lengths of stay compared to those who recovered (11.3 (10.3) vs. 7.3 (7.1) days, p < .001).

CONCLUSIONS

The incidence of overall recovery at postoperative week 4-8 was 42%. Patients with incomplete overall recovery had longer lengths of stay. Multidimensional strategies to improve the recovery trajectory warrant further investigation.

EDITORIAL COMMENT

Major surgical procedures are often followed by a lengthy and difficult recovery period. Traditional measures such as mortality and complications are usually analysed, but this 653-patient study investigated patient-reported recovery scores after major abdominal surgery. Novel findings include that only 42% of patients have recovered fully in all recovery domains at weeks 4-8, and these patients also had longer hospital stays. Preoperative risk factors were analysed for associations with recovery trajectories.

Exploring the role of health-related quality of life measures in predictive modelling for oncology: a systematic review

Health related quality of life (HRQoL) is increasingly assessed in oncology research and routine care, which has led to the inclusion of HRQoL in prediction models. This review aims to describe the current state of oncological prediction models incorporating HRQoL. A systematic literature search for the inclusion of HRQoL in prediction models in oncology was conducted. Selection criteria were a longitudinal study design and inclusion of HRQoL data in prediction models as predictor, outcome, or both. Risk of bias was assessed using the PROBAST tool and quality of reporting was scored with an adapted TRIPOD reporting guideline. From 4747 abstracts, 98 records were included in this review. High risk of bias was found in 71% of the publications. HRQoL was mainly incorporated as predictor (78% (55% predictor only, 23% both predictor and outcome)), with physical functioning and symptom domains selected most frequently as predictor. Few models (23%) predicted HRQoL domains by other or baseline HRQoL domains. HRQoL was used as outcome in 21% of the publications, with a focus on predicting symptoms. There were no difference between AI-based (16%) and classical methods (84%) in model type selection or model performance when using HRQoL data. This review highlights the role of HRQoL as a tool in predicting disease outcomes. Prediction of and with HRQoL is still in its infancy as most of the models are not fully developed. Current models focus mostly on the physical aspects of HRQoL to predict clinical outcomes, and few utilize AI-based methods.

Colonoscopy-Assisted Laparoscopic Wedge Resection for Colonic Lesions and Its Impact on Quality of Life: Results From the LIMERIC Study

BACKGROUND

The LIMERIC study has proven that colonoscopy-assisted laparoscopic wedge resection effectively and safely removes benign colonic lesions unsuitable for endoscopic removal, thereby avoiding the need for major surgery.

OBJECTIVE

To evaluate the impact of colonoscopy-assisted laparoscopic wedge on health-related quality of life of patients who participated in the LIMERIC study.

DESIGN

Prospective multicenter study.

SETTINGS

The LIMERIC study was performed between 2016 and 2020 in 13 Dutch hospitals. Five-level EuroQoL 5-dimension questionnaires were administered at baseline and 3 months after the procedure.

PATIENTS

Patients with incomplete pre- or postoperative questionnaires or those undergoing combined interventions were excluded from the intention-to-treat analysis. Those for whom CAL-WR was not feasible or who underwent completion surgery were excluded from the per-protocol analysis.

INTERVENTION

Colonoscopy-assisted laparoscopic wedge for either 1) colon polyp unsuitable for endoscopic resection; 2) nonlifting residual or recurrent polyp within scar tissue after previous polypectomy; or (3) Rx/R1 endoscopic removal of a low-risk pT1 colon carcinoma.

MAIN OUTCOME MEASURES

Three-month health-related quality of life.

RESULTS

Colonoscopy-assisted laparoscopic wedge did not affect health-related quality of life in the per-protocol analysis (n = 56) or in the intention-to-treat analysis (n = 67). The majority of patients reported no change in health status (57%). No significant differences were observed in the distribution of responses across all 5 dimensions before and after colonoscopy-assisted laparoscopic wedge. Patients'EuroQoL self-rated visual analog scale scores were also unaffected by a colonoscopy-assisted laparoscopic wedge, with a median score of 82.5 at baseline and 80 after surgery in the per-protocol analysis ( p = 0.63).

LIMITATIONS

Solely a patient-reported outcome measure evaluating global health-related quality of life was used, rather than one specifically assessing disease-related quality of life, such as the quality of life questionnaire colorectal cancer module 29.

CONCLUSIONS

Colonoscopy-assisted laparoscopic wedge has no significant impact on the health-related quality of life in patients with benign colonic lesions and should therefore be considered before major surgery is performed. See Video Abstract.

RESECCIN LAPAROSCPICA EN CUA ASISTIDA POR COLONOSCOPIA PARA LESIONES COLNICAS IMPACTO EN LA CALIDAD DE VIDA RESULTADOS DEL ESTUDIO LIMERIC

ANTECEDENTES:El estudio LIMERIC ha demostrado que la resección laparoscópica en cuña asistida por colonoscopia elimina de forma eficaz y segura las lesiones colónicas benignas inadecuadas para la extirpación endoscópica, evitando así la necesidad de cirugía mayor.OBJETIVO:Evaluar el impacto de la cuña laparoscópica asistida por colonoscopia en la calidad de vida relacionada con la salud de los pacientes que participaron en el estudio LIMERIC.DISEÑO:Estudio multicéntrico prospectivo.ENTORNO:El estudio LIMERIC se realizó entre 2016 y 2020 en 13 hospitales holandeses. Se administraron cuestionarios EQ-5D-5L al inicio y 3 meses después del procedimiento.PACIENTES:Los pacientes con cuestionarios pre o postoperatorios incompletos o aquellos sometidos a intervenciones combinadas fueron excluidos del análisis por intención de tratar. Aquellos en los que la CAL-WR no era factible o que se sometieron a cirugía de finalización fueron excluidos del análisis por protocolo.INTERVENCIÓN:Cuña laparoscópica asistida por colonoscopia para (1) pólipo de colon no apto para resección endoscópica; (2) pólipo residual o recidivante no elevable dentro de tejido cicatricial tras polipectomía previa; o (3) extirpación endoscópica Rx/R1 de un carcinoma de colon pT1 de bajo riesgo.MEDIDAS DE RESULTADO PRINCIPALES:Calidad de vida relacionada con la salud a los tres meses.RESULTADOS:La cuña laparoscópica asistida por colonoscopia no afectó a la calidad de vida relacionada con la salud en el análisis por protocolo (n = 56), ni en el análisis por intención de tratar (n = 67). La mayoría de los pacientes no informaron ningún cambio en su estado de salud (57%). No se observaron diferencias significativas en la distribución de las respuestas en las 5 dimensiones antes y después de la cuña laparoscópica asistida por colonoscopia. La EQ-VAS autoevaluada de los pacientes tampoco se vio afectada por la cuña laparoscópica asistida por colonoscopia, con una puntuación media de la VAS de 82,5 al inicio y 80 después de la cirugía en el análisis por protocolo (p = 0,63).LIMITACIONES:Se utilizó únicamente una medida de resultados comunicada por el paciente que evaluaba la calidad de vida global relacionada con la salud, en lugar de una que evaluara específicamente la calidad de vida relacionada con la enfermedad, como el QLQ-CR29.CONCLUSIONES:La cuña laparoscópica asistida por colonoscopia no tiene un impacto significativo en la calidad de vida relacionada con la salud en pacientes con lesiones colónicas benignas y, por lo tanto, debe considerarse antes de realizar una cirugía mayor. (Traducción-Dr. Aurian Garcia Gonzalez ).

Comparison of Modified Frailty Index, Clinical Frailty Scale, ECOG Score, and ASA PS Score in Predicting Postoperative Outcomes in Cancer Surgery: A Prospective Study

Multiple pre-operative risk assessment scores are available for risk stratification of cancer patients undergoing surgery. This is the first study comparing commonly used preoperative risk assessment tools of Eastern Cooperative Oncology Group Performance Scale (ECOG) and American Society of Anaesthesiologists Physical Status Scale (ASA PS) with frailty scores of Modified Frailty Index (MFI) and Clinical Frailty Scale (CFS). This is a prospective observational study of adult cancer patients undergoing oncosurgery in a tertiary cancer center over one year. Pre-operative risk stratification was done using CFS, MFI, ASA PS, and ECOG scales. All patients were followed up postoperatively for 30 days, and complications were documented. Univariate and multivariate analyses were performed. p value of ≤0.05 was considered significant. Of the 4107 patients studied, 12.6% had prolonged hospitalization, 6.1% had morbidity, 0.9% had readmission, and mortality was 0.6%. ASA PS, ECOG, and CFS were significantly associated with prolonged hospitalization, morbidity, and mortality. MFI was significantly associated with prolonged hospitalization and morbidity. No score could predict readmission. On multivariate analysis, morbidity and readmission were significantly associated with neoadjuvant therapy (p=0.001), mortality with emergency surgery (p=0.001), and prolonged hospitalization with stage III and IV cancer (p=0.001). In adult patients undergoing oncosurgery, ASA PS, ECOG, and CFS are predictors of prolonged hospitalization, morbidity, and mortality. MFI is predictive of prolonged hospitalization and morbidity. None of the studied pre-operative risk scores predict readmission. Newer predictive tools with cancer-specific factors are required for better risk stratification of cancer patients undergoing surgery.

The Aging Stomach: Clinical Implications of H. pylori Infection in Older Adults-Challenges and Strategies for Improved Management

Aging is a multifactorial biological process characterized by a decline in physiological function and increasing susceptibility to various diseases, including malignancies and gastrointestinal disorders. Helicobacter pylori (H. pylori) infection is highly prevalent among older adults, particularly those in institutionalized settings, contributing to conditions such as atrophic gastritis, peptic ulcer disease, and gastric carcinoma. This review examines the intricate interplay between aging, gastrointestinal changes, and H. pylori pathogenesis. The age-associated decline in immune function, known as immunosenescence, exacerbates the challenges of managing H. pylori infection. Comorbidities and polypharmacy further increase the risk of adverse outcomes in older adults. Current clinical guidelines inadequately address the specific needs of the geriatric population, who are disproportionately affected by antibiotic resistance, heightened side effects, and diagnostic complexities. This review focuses on recent advancements in understanding H. pylori infection among older adults, including epidemiology, diagnostics, therapeutic strategies, and age-related gastric changes. Diagnostic approaches must consider the physiological changes that accompany aging, and treatment regimens need to be carefully tailored to balance efficacy and tolerability. Emerging strategies, such as novel eradication regimens and adjunctive probiotic therapies, show promise for improving treatment outcomes. However, significant knowledge gaps persist regarding the impact of aging on H. pylori pathogenesis and treatment efficacy. A multidisciplinary approach involving gastroenterologists, geriatricians, and other specialists is crucial to providing comprehensive care for this vulnerable population. Future research should focus on refining diagnostic and therapeutic protocols to bridge these gaps, ultimately enhancing clinical outcomes and reducing the burden of H. pylori-associated diseases in the aging population.

Predictors of perioperative morbidity in elderly patients undergoing colorectal cancer resection

AIM

Colorectal cancer resection in the elderly may be associated with significant morbidity. This study aimed to assess perioperative morbidity in elderly patients undergoing colorectal cancer resection and to investigate risk factors for postoperative complications.

MATERIALS AND METHODS

Consecutive patients aged ≥ 75 years undergoing colorectal cancer resection with curative intent between January 2014 and December 2021 at our institution were included. We evaluated risk factors for postoperative complications, length of hospital stays (LOS), 30-day readmission, and 90-day mortality rates.

RESULTS

A total of 843 patients underwent colorectal cancer resection during the study period, of whom 202 patients were 75 years or older. Advanced age was associated with postoperative complications (Clavien-Dindo score > 3b, p = 0.001). Sarcopenia, preoperative plasma albumin < 3.5 g/dL, and open and urgent surgery were significantly correlated with major complications (p = 0.015, p = 0.022, p = 0.003, and p < 0.001, respectively). LOS was longer in elderly patients with a modified 5-item Frailty Index (5-mFI) ≥ 2 and low preoperative serum albumin levels, as well as following open surgery (p = 0.006, p = 0.001 and p < 0.001, respectively). Sarcopenia and preoperative plasma albumin < 3.5 g/dL were predictors for 90-day mortality (p = 0.004 and p > 0.001).

CONCLUSION

Advanced age, sarcopenia, preoperative hypoalbuminemia, 5-mFI ≥ 2, and open or urgent surgery may serve as predictors for postoperative morbidity in the elderly population.

Review of frailty in geriatric surgical oncology

Frailty is a common phenomenon in older adult population and associated with an elevated risk of adverse health outcomes. Recent studies have demonstrated that patients with frailty undergoing surgery had a significantly higher morbidity and mortality compared to those without frailty. This is particularly important in patients with cancer because the prevalence of frailty is persistently high across a spectrum of primary cancers. Identifying frailty in oncological patients undergoing surgery may provide an important preoperative intervention opportunity to mitigate operative risks. In this review, we provide an overview of frailty and its association with other geriatric syndromes. We will also review the impact of frailty on postoperative outcomes focusing on the field of surgical oncology. We then describe currently available tools to objectively measure frailty to provide clinicians with various practical tools that may be adopted in their clinical practice. Finally, we will describe potential interventional programs, including the recently introduced Geriatric Surgery Verification program by the American College of Surgeons, that may be institutionally adopted to mitigate postoperative complications and improve meeting patient-centered goals in the frail patient population.

Outcomes reported in elective colorectal cancer surgery research for older patients: A scoping review

AIM

Colorectal cancer rates are increasing in older populations, who often have comorbidities and face higher surgical risks and mortality rates. Therefore, surgical outcomes, such as 5-year mortality rates, may not be appropriate, necessitating a focus on postoperative quality of life. However, determining optimal postoperative outcome measures for older colorectal cancer patients poses a challenge. This scoping review aimed to explore currently available data describing postoperative outcomes used to assess older patients undergoing elective colorectal cancer surgery.

METHOD

We conducted a comprehensive literature search of major electronic databases from inception to March 2023. Studies exploring frail or older individuals with colorectal cancer undergoing elective surgical procedures, and which reported postoperative outcomes, were included. Outcomes were categorized as surgery-specific versus person-centred and summarized using narrative synthesis. The type and rate of surgery-specific outcomes were tabulated.

RESULTS

Of 1366 identified citations, 16 studies focused on person-centred outcomes and 66 reported exclusively on surgery-specific outcomes. Nine 'person-centred outcome' studies reported discharge destination, primarily home discharge. Postoperative delirium ranged from 8.2% to 18.1% in six studies. Four studies explored geriatric syndromes, three analysed activities of daily living, and three studies reported significant quality of life improvement. The 66 'surgery-specific outcome' studies assessed mortality (N = 61); length of stay (N = 40); postoperative complications (N = 47); readmission (N = 18); reoperation (N = 16); and survival (N = 42).

CONCLUSION

Person-centred outcomes are underreported, but crucial for guiding patient management. Older patients require adequate information about their postoperative recovery period to enhance wellbeing. Future research must address this gap to improve care for older people undergoing elective colorectal cancer surgery.

A critical analysis of surgical outcomes indicators in hepato-pancreato-biliary surgery: From crude mortality to composite outcomes

BACKGROUND

Indicators of surgical outcomes are designed to objectively evaluate surgical performance, enabling comparisons among surgeons and institutions. In recent years, there has been a surge in complex indicators of perioperative short-term and long-term outcomes. The aim of this narrative review is to provide an overview and a critical analysis of surgical outcomes indicators, with a special emphasis on hepato-pancreato-biliary (HPB) surgery.

METHODS

A narrative review of outcome measures was conducted using a combined text and MeSH search strategy to identify relevant articles focused on perioperative outcomes, specifically within HPB surgery.

RESULTS

The literature search yielded 624 records, and 94 studies were included in the analysis. Included papers were classified depending on whether they assessed intraoperative or postoperative specific or composite outcomes, and whether they assessed purely clinical or combined clinical and socio-economic indicators. Specific indicators included in composite outcomes were categorized into three main domains: intraoperative metrics, postoperative outcomes, and oncological outcomes. While postoperative mortality, complications, hospital stay and readmission were the indicators most frequently included in composite outcomes, oncological outcomes were rarely considered.

CONCLUSIONS

The evolution of surgical outcomes has shifted from the simplistic assessment of crude mortality rates to complex composite outcomes. Whether the recent explosion of publications on these topics has a clinical impact in real life is questionable. Outcomes from the patient perspective, integrating social and financial indicators, are not yet integrated into most of these composite analytical tools but should not be underestimated.

Association between Geriatric 8 frailty and health-related quality of life in older patients with cancer (PROGNOSIS-G8): a Danish single-centre, prospective cohort study

BACKGROUND

Health-related quality of life (HRQoL) is highly valued among older adults with cancer. The Geriatric 8 screening tool identifies individuals with frailty, but its association with HRQoL remains sparsely investigated. Herein, we evaluate whether Geriatric 8 frailty is associated with short-term and long-term HRQoL in older patients with cancer.

METHODS

In this Danish single-centre, prospective cohort study, patients aged 70 years and older, referred to oncological assessment for solid cancers, were screened with the Geriatric 8. Patients completed the European Organisation for Research and Treatment of Cancer (EORTC) Quality-of-Life Core 30 (QLQ-C30) and Elderly 14 (ELD14) questionnaires at baseline, 3 months, 6 months, 9 months, and 12 months. Patient characteristics were obtained from medical records. Differences in mean global health status and QoL (GHS), measured using the two seven-point Likert scale questions from the EORTC QLQ-C30 regarding overall health and QoL during the past week, between patients with frailty (defined as a Geriatric 8 score of ≤14) and without frailty within 12 months were the primary outcome. Secondary outcomes were differences in the mean EORTC Summary Score comprised of all questions from the QLQ-C30 except for those included in the GHS and a question concerning financial difficulties, and five functional (physical, role, and social functioning, maintaining purpose, and family support from the EORTC QLQ-C30 and the EORTC-QLQ-ELD14), and five symptom scales (fatigue, pain, mobility, future worries, and burden of illness from the EORTC-QLQ-C30 and the EORTC-QLQ-ELD14). Analyses were done using linear mixed models. All primary and secondary outcomes were adjusted for gender, treatment intent, and cancer type and the primary outcome was also assessed by means of a responder analysis.

FINDINGS

Between June 1, 2020 and Oct 15, 2021, 1398 eligible patients were screened with the Geriatric 8 (908 [65%] with frailty and 490 [35%] without frailty) and provided medical record data. Of these patients, 707 (51%) also provided HRQoL data (437 [62%] with frailty and 270 [38%] without frailty). When adjusted, patients with frailty had poorer GHS (-15·1, 95% CI -18·5 to -11·6; p<0·0001) at baseline and throughout follow-up (3 months -7·4, -11·0 to -3·7, p=0·0001; 6 months -11·7, -15·5 to -7·9, p<0·0001; 9 months -10·4, -14·3 to -6·5, p<0·0001; 12 months -10·4, -14·6 to -6·2, p<0·0001) compared to patients without frailty. Adjusted summary scores were also poorer for patients with frailty (-9·9, 95% CI -12·1 to -7·6; p<0·0001) compared to patients without frailty at baseline and throughout follow-up (3 months -8·2, -10·5 to -5·8, p=0·0001; 6 months -9·0, -11·4 to -6·6, p<0·0001; 9 months -9·2, -11·7 to -6·8, p<0·0001; 12 months -8·9, -11·5 to -6·3, p<0·0001). Patients with frailty had significantly worse physical and role functioning, mobility, and fatigue outcomes, with no differences in family support within 12 months, at all timepoints.

INTERPRETATION

Older patients with cancer and frailty have significantly poorer HRQoL than those without frailty within the 12 months following an oncology referral. Thus, by identifying and treating frailty, we can ultimately improve patient HRQoL.

FUNDING

The Danish Cancer Society, Academy of Geriatric Cancer Research (AgeCare), Odense University Hospital, University of Southern Denmark, Dagmar Marshalls Fond, and Agnes and Poul Friis Fond.

Non-operative management after immune checkpoint inhibitors for early-stage, dMMR/MSI-H gastrointestinal cancers

Surgery is a standard treatment for early-stage gastrointestinal cancers, often preceded by neoadjuvant chemo(radio)therapy or followed by adjuvant therapy. While leading to cure in a proportion of patients, it has some drawbacks such as intra/post-operative complications, mutilation and life-long functional sequelae. Further to the unprecedented efficacy data from studies of immune checkpoint inhibitors for advanced mismatch repair deficient/microsatellite instable (dMMR/MSI-H) tumours, a strong interest has recently emerged for the investigation of such agents in the neoadjuvant setting. Although limited by the exploratory design and small sample size, trials of neoadjuvant immune checkpoint inhibitors for early-stage dMMR/MSI-H gastrointestinal cancers have consistently reported complete response rates ranging from 70 % to 100 %. As a result, the question has arisen as to whether surgery is still needed or organ-preserving strategies should be offered to this especially immuno-sensitive population. In this article, we discuss the available evidence for neoadjuvant immune checkpoint inhibitors in dMMR/MSI-H gastrointestinal cancers and analyse opportunities and challenges to the implementation of non-operative management approaches in this setting.

Evaluation and Application of Frailty Index in Colorectal Cancer: A Comprehensive Review

Colorectal cancer (CRC) is a common malignant tumor that primarily affects the elderly population. Surgery is one of the main treatment modalities for CRC. Frailty is a prevalent characteristic among the elderly and a leading cause of mortality. The frailty index (FI) is a comprehensive tool for assessing patients' frailty status, quantifying indicators such as weight loss, fatigue, and nutritional status, to reflect the degree of frailty. In recent years, the FI has undergone modifications to more accurately evaluate the risk of surgical complications and prognosis in CRC patients. This review summarizes the methods for frailty assessment, the development and modifications of the FI, and compiles the research findings and applications of the FI in predicting surgical complications, postoperative recovery, and survival rates in CRC patients. Furthermore, limitations in the current modified frailty index (mFI) and future research directions are discussed. This review provides essential references for further understanding the role of frailty in CRC patients and the clinical application of the mFI.

Updates on the Management of Colorectal Cancer in Older Adults

Colorectal cancer (CRC) poses a significant global health challenge. Notably, the risk of CRC escalates with age, with the majority of cases occurring in those over the age of 65. Despite recent progress in tailoring treatments for early and advanced CRC, there is a lack of prospective data to guide the management of older patients, who are frequently underrepresented in clinical trials. This article reviews the contemporary landscape of managing older individuals with CRC, highlighting recent advancements and persisting challenges. The role of comprehensive geriatric assessment is explored. Opportunities for treatment escalation/de-escalation, with consideration of the older adult's fitness level. are reviewed in the neoadjuvant, surgical, adjuvant, and metastatic settings of colon and rectal cancers. Immunotherapy is shown to be an effective treatment option in older adults who have CRC with microsatellite instability. Promising new technologies such as circulating tumor DNA and recent phase III trials adding later-line systemic therapy options are discussed. Clinical recommendations based on the data available are summarized. We conclude that deliberate efforts to include older individuals in future colorectal cancer trials are essential to better guide the management of these patients in this rapidly evolving field.

Predictive value of the G8 screening tool for postoperative complications in older adults undergoing cancer surgery: A systematic review and meta-analysis

INTRODUCTION

Older adults with cancer who are being considered for cancer surgery are heterogenous, with variation in their physical, mental, and social baselines and risk of postoperative complications. Due in part to the complex nature of this population, the optimal preoperative evaluation method is not clearly defined. In this study we investigated whether geriatric-8 (G8), a screening tool for older patients with cancer that determines the need for a full geriatric assessment, is suitable for assessing the risk of postoperative complications in this population being considered for surgery.

MATERIALS AND METHODS

Studies that enrolled older patients undergoing cancer surgery and compared prevalence of postoperative complications in G8 "high" (≥15) patients and G8 "low" (<15) patients were identified using PubMed and EMBASE. A meta-analysis was conducted to calculate the risk ratio of postoperative complication rate. Postoperative mortality was systematically reviewed.

RESULTS

Eleven studies published between 2017 and 2022 were included in our analysis with a total of 2,691 older patients who underwent various types of cancer surgery and were characterized by their G8 scores: 1,255 G8 high (≥15) patients and 1,436 G8 low (<15) patients. G8 low patients had a significantly higher prevalence of postoperative complications than G8 high patients (risk ratio [95% confidence interval]: 1.56 [1.18-2.07], p = 0.002, I2 = 79%).

DISCUSSION

G8 can be an effective and efficient preoperative tool to assess risk of postoperative complications in older adults undergoing cancer surgery and identify potential need for further evaluation of an individual's risk with a comprehensive geriatric assessment.

Assessing the mFI-5 frailty score and functional status in geriatric patients undergoing inguinal hernia repairs

PURPOSE

The modified 5-factor frailty index (mFI-5) is a prognostic tool based on five comorbidities from the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database-hypertension, congestive heart failure, chronic obstructive pulmonary disease (COPD), diabetes, and non-independent functional status. Our study investigates the mFI-5 index's ability to predict morbidity, length of stay (LOS), and discharge destination in geriatric patients undergoing inguinal hernia repairs, as well as assesses the interplay of baseline functional status.

METHODS

Patients aged ≥ 65 years who underwent inguinal or femoral hernia repairs from the 2018-2020 NSQIP database were studied. Separate analyses were performed for emergent and elective cohorts. Stratification was performed according to the sum of mFI-5 variables: mFI = 0, mFI = 1, mFI ≥ 2.

RESULTS

A total of 41,897 consisted of 92.9% elective and 7.1% emergent cases. The sample was 37.8% mFI = 0, 47.2% mFI = 1, and 15.0% mFI ≥ 2. Median age was 73 (IQR 68-78). Of emergent mFI ≥ 2 cases, 24.2% had non-independent functional status, versus only 4.8% in elective cases. Area under the curve was calculated for emergent and elective groups, including mortality (0.86, 0.80), pneumonia (0.82, 0.77), discharge destination not home (0.78, 0.73), prolonged LOS (0.69, 0.66), and infection (0.71, 0.62). Of index variables, dependent functional status was correlated with increased complications in elective and emergent cohorts, while COPD was significant in elective cases (OR > 2.0, p < 0.05).

CONCLUSION

The mFI-5 is predictive of complications in geriatric inguinal hernia repairs, especially in emergent cases. Frail patients with non-independent functional status are most at risk and, thus require proactive and watchful perioperative care.

A 10-year review on older patients undergoing colorectal cancer surgery: surgeon-led geriatric service and good quality surgery are drivers of good outcomes

BACKGROUND

Older age and frailty are associated with worse postoperative outcomes and prolonged length of stay (LOS). In this study, we aimed to analyze the long-term outcomes after the implementation of our geriatric surgical service (GSS).

METHODS

This was a single-center retrospective study from July 2010 to December 2021 on patients aged ≥75 years or patients aged ≥65 years with frailty. Our GSS includes multidisciplinary assessment and optimization by specialized nurses, physiotherapists, anesthetists, dietitians, and geriatricians. Cumulative sum (CUSUM) analysis was used to assess the performance of our GSS. Our primary outcome was defined as the presence of 30-day mortality, prolonged LOS ≥ 14 days, and/or >10% decrease in the modified Barthel Index at 6 weeks, which depicts the failure of GSS. A downsloping CUSUM curve implies consecutive cases of success.

RESULTS

There were 233 patients with a mean age of 79.0 ± 4.9 years; of these, 73 patients (31.3%) were frail. The overall 30-day mortality (1.7%), Clavien-Dindo ≥ grade IIIA complications (12.0%), and LOS (median, 7.0 days) were low. The CUSUM analysis showed 3 phases with overall sustained improvement in outcomes. Transient inconsistency in the second phase (during midimplementation of GSS) may be due to the early adoption of laparoscopic surgery (44.6% vs 24.1%; adjusted P =.031) and expansion of service to include patients with higher perioperative risks (weighted Charlson Comorbidity Index score ≥4: 64.9% vs 38.0%; adjusted P =.002) in the second period compared with the first period. The outcomes subsequently improved in the third phase after overcoming the learning curve.

CONCLUSION

Our GSS showed sustained performance over the past decade. Good quality surgery and surgeon-led geriatric service are paramount for good postoperative outcomes.

Predicting Functional Recovery and Quality of Life in Older Patients Undergoing Colorectal Cancer Surgery: Real-World Data From the International GOSAFE Study

PURPOSE

The GOSAFE study evaluates risk factors for failing to achieve good quality of life (QoL) and functional recovery (FR) in older patients undergoing surgery for colon and rectal cancer.

METHODS

Patients age 70 years and older undergoing major elective colorectal surgery were prospectively enrolled. Frailty assessment was performed and outcomes, including QoL (EQ-5D-3L) recorded (3/6 months postoperatively). Postoperative FR was defined as a combination of Activity of Daily Living ≥5 + Timed Up & Go test <20 seconds + MiniCog >2.

RESULTS

Prospective complete data were available for 625/646 consecutive patients (96.9%; 435 colon and 190 rectal cancer), 52.6% men, and median age was 79.0 years (IQR, 74.6-82.9 years). Surgery was minimally invasive in 73% of patients (321/435 colon; 135/190 rectum). At 3-6 months, 68.9%-70.3% patients experienced equal/better QoL (72.8%-72.9% colon, 60.1%-63.9% rectal cancer). At logistic regression analysis, preoperative Flemish Triage Risk Screening Tool ≥2 (3-month odds ratio [OR], 1.68; 95% CI, 1.04 to 2.73; P = .034, 6-month OR, 1.71; 95% CI, 1.06 to 2.75; P = .027) and postoperative complications (3-month OR, 2.03; 95% CI, 1.20 to 3.42; P = .008, 6-month OR, 2.56; 95% CI, 1.15 to 5.68; P = .02) are associated with decreased QoL after colectomy. Eastern Collaborative Oncology Group performance status (ECOG PS) ≥2 is a strong predictor of postoperative QoL decline in the rectal cancer subgroup (OR, 3.81; 95% CI, 1.45 to 9.92; P = .006). FR was reported by 254/323 (78.6%) patients with colon and 94/133 (70.6%) with rectal cancer. Charlson Age Comorbidity Index ≥7 (OR, 2.59; 95% CI, 1.26 to 5.32; P = .009), ECOG ≥2 (OR, 3.12; 95% CI, 1.36 to 7.20; P = .007 colon; OR, 4.61; 95% CI, 1.45 to 14.63; P = .009 rectal surgery), severe complications (OR, 17.33; 95% CI, 7.30 to 40.8; P < .001), fTRST ≥2 (OR, 2.71; 95% CI, 1.40 to 5.25; P = .003), and palliative surgery (OR, 4.11; 95% CI, 1.29 to 13.07; P = .017) are risk factors for not achieving FR.

CONCLUSION

The majority of older patients experience good QoL and stay independent after colorectal cancer surgery. Predictors for failing to achieve these essential outcomes are now defined to guide patients' and families' preoperative counseling.

Identifying risk factors for poor multidimensional recovery after major surgery: A systematic review

Traditional risk factors used for predicting poor postoperative recovery have focused on postoperative complications, adverse symptoms (nausea, pain), length of hospital stay, and patient quality of life. Despite these being traditional performance indicators of patient postoperative "status," they may not fully define the multidimensional nature of patient recovery. The definition of postoperative recovery is thus evolving to include patient-reported outcomes that are important to the patient. Previous reviews have focused on risk factors for the above traditional outcomes after major surgery. Yet, there remains a need for further study of risk factors predicting multidimensional patient-focused recovery, and investigation beyond the immediate postoperative period after patients are discharged from the hospital. This review aimed to appraise the current literature identifying risk factors for multidimensional patient recovery.

METHODS

A systematic review without meta-analysis was performed to qualitatively summarize preoperative risk factors for multidimensional recovery 4-6 weeks after major surgery (PROSPERO, CRD42022321626). We reviewed three electronic databases between January 2012 and April 2022. The primary outcome was risk factors for multidimensional recovery at 4-6 weeks. A GRADE quality appraisal and a risk of bias assessment were completed.

RESULTS

In total, 5150 studies were identified, after which 1506 duplicates were removed. After the primary and secondary screening, nine articles were included in the final review. Interrater agreements between the two assessors for the primary and secondary screening process were 86% (k = 0.47) and 94% (k = 0.70), respectively. Factors associated with poor recovery were found to include ASA grade, recovery tool baseline score, physical function, number of co-morbidities, previous surgery, and psychological well-being. Mixed results were reported for age, BMI, and preoperative pain. Due to the observational nature, heterogeneity, multiple definitions of recovery, and moderate risk of bias of the primary studies, the quality of evidence was rated from very low to low.

CONCLUSION

Our review found that there were few studies assessing preoperative risk factors as predictors for poor postoperative multidimensional recovery. This confirms the need for higher quality studies assessing risk for poor recovery, ideally with a consistent and multi-dimensional definition of recovery.

Prevention and treatment of noncognitive complications

Patients aged 65 and older are the fastest growing segment in the population of many countries. Based on evolving demographics showing increasing life expectancies, it is expected that there will be a concurrent rise in the demand for a large variety of surgical and anesthesia services. Surgery offers definitive management of many age-related diseases and provides symptom-relieving (morbidity) and life-extending (mortality) benefits. However, elderly adult surgical patients, especially the frail ones, often require a different level of care than younger patients during the perioperative period. As many have chronic illnesses and acquired deconditioning and functional decline, older patients are prone to develop untoward outcomes such as postoperative complications and loss of independence. This manuscript focuses on the holistic quality person-centered care, supported by a wide stakeholder team of health-care workers, ensuring fidelity to comprehensive geriatric assessment and optimization services where possible, offering a systematic approach to early health risk assessment and risk modification in the perioperative period, with the ultimate goal of reducing postoperative complications and health-care costs. The "comprehensive geriatric assessment and optimization" cost-effective approach builds on robust evidence with older people more likely to be alive, a shorter length of hospital stay due to fewer postoperative medical complications, and improved rates of return to usual residence. Prehabilitation programs are delivered focusing on primary (through counseling) and secondary prevention (through screening) with an aim to improve fitness for surgery, by evaluating functional capacity, nutritional and psychological health, prompting interventions, targeting physical exercise, lifestyle and nutritional advice, and psychological support.

Prospective, Multi-Institutional Observational Study of Deterioration in Activities of Daily Living in Elderly Patients After Lung Cancer Surgery

Introduction

To determine the rate of deteriorating activities of daily living (ADL) and to investigate predictive factors in elderly patients undergoing surgery for NSCLC.

Methods

Patients with NSCLC aged 75 years or older who underwent curative surgical resection were evaluated using the Tokyo Metropolitan Institute of Gerontology Index of Competence Instrumental ADL (TMIG-IADL) and the Japanese version of EuroQol 5-dimensions 5-level (EQ-5D-5L) quality-of-life scale administered at baseline and at 6 months postoperative. The primary end point was the rate of living patients without substantial deterioration of TMIG-IADL, defined as a decline greater than or equal to three points. Multivariable logistic regression was performed to determine risk factors for deteriorating ADL.

Results

Between May 2019 and May 2020, 876 of the 986 screened patients enrolled from 47 institutions were eligible and included in the analysis. TMIG-IADL and EQ-5D-5L scores were obtained from 96.0% and 92.6% of the patients, respectively. At 6 months postoperative, 745 patients (85.1%, 95% confidence interval: 82.5%-87.3%) reported no significant ADL deterioration, and 96 of 841 patients (11.4%) with postoperative score data reported significant deterioration. The social domain was the most frequently affected activity. In multivariable analysis, poor performance status, low G8 geriatric screening score, segmentectomy (versus wedge resection), and surgery lasting less than 3 hours were associated with deteriorating ADL. Worsening EQ-5D-5L scores by minimally important difference or more were observed in 22.1% of the patients. Changes in TMIG-IADL and EQ-5D-5L scores were poorly correlated.

Conclusions

Approximately 15% of elderly patients with NSCLC experienced significant ADL deterioration at 6 months postoperative.

Minimally Invasive Surgery for Perihilar Cholangiocarcinoma: A Systematic Review of the Short- and Long-Term Results

Surgery and postoperative systemic chemotherapy represent the standard treatment for patients with perihilar cholangiocarcinoma (PHC). Minimally Invasive Surgery (MIS) for hepatobiliary procedures has spread worldwide in the last two decades. Since resections for PHC are technically demanding, the role of MIS in this field is yet to be established. This study aimed to systematically review the existing literature on MIS for PHC, to evaluate its safety and its surgical and oncological outcomes. A systematic literature review on PubMed and SCOPUS was performed according to the PRISMA guidelines. Overall, a total of 18 studies reporting 372 MIS procedures for PHC were included in our analysis. A progressive increase in the available literature was observed over the years. A total of 310 laparoscopic and 62 robotic resections were performed. A pooled analysis showed an operative time ranging from 205.3 ± 23.9 and 840 (770-890) minutes, and intraoperative bleeding between 101.1 ± 13.6 and 1360 ± 809 mL. Minor and major morbidity rates were 43.9% and 12.7%, respectively, with a 5.6% mortality rate. R0 resections were achieved in 80.6% of patients and the number of retrieved lymph nodes ranged between 4 (3-12) and 12 (8-16). This systematic review shows that MIS for PHC is feasible, with safe postoperative and oncological outcomes. Recent data has shown encouraging results and more reports are being published. Future studies should address differences between robotic and laparoscopic approaches. Given the management and technical challenges, MIS for PHC should be performed by experienced surgeons, in high-volume centers, on selected patients.

Comparison of changes in health-related quality of life between elderly and non-elderly patients undergoing elective surgery for colorectal cancer

PURPOSE

Elderly people are thought to be more likely than their non-elderly counterparts to experience a decline in activities of daily living (ADL) and quality of life (QOL) due to the onset and treatment of disease. In this study, we investigated whether there was an age-related difference in changes in health-related QOL indices after surgical resection of colorectal cancer (CRC).

METHODS

Patients who underwent elective surgery for primary CRC at our hospital between September 2017 and November 2021 were enrolled. Changes in QOL after surgery were evaluated after dividing the study population into a non-elderly (NE) group (younger than 75 years) and an elderly (E) group. A Short-Form 36-Item Health Survey was used as an index of QOL. The subscale and component summary scores before and 6 months after surgery were compared.

RESULTS

Forty-seven patients were included in the E group and 166 patients were the NE group. The E group had significantly worse preoperative performance and physical status than the NE group. However, indices of physical function were not worsened after surgery in either group. In the NE group, there were significant decreases in role physical and role component summary scores and significant increases in general health, mental health, and mental component summary scores. In the E group, there were no significant changes in the subscale or component summary scores after surgery.

CONCLUSION

Our study demonstrated elderly patient did not necessarily show a decline in QOL more than non-elderly patients after CRC surgery. Surgical resection for CRC should be considered even for elderly patients, while considering possible risk factors for worsening ADL and QOL.

Frailty Assessment and Prehabilitation as Part of a PeRioperative Evaluation and Planning (PREP) Program for Patients Undergoing Colorectal Surgery

Frailty assessment and prehabilitation can be incrementally implemented in a multidisciplinary, multiphase pathway to improve patient care. To start, modifications can be made to a surgeon's practice with existing resources while adapting standard pathways for frail patients. Frailty screening can identify patients in need of additional assessment and optimization. Personalized utilization of frailty data for optimization through prehabilitation can improve postoperative outcomes and identify patients who would benefit from adapted care. Additional utilization of the multidisciplinary team can lead to improved outcomes and a strong business case to add additional members of the team.

Health-related quality-of-life trajectories during/after surgery and adjuvant chemotherapy in patients with colon cancer

PURPOSE

This study aims to evaluate quality of life trajectory during the first year after surgical treatment in patients with resectable primary colon cancer.

METHODS

Patients with resectable primary colon cancer diagnosed between 2013 and 2019 who received surgical treatment and adjuvant chemotherapy if indicated were selected from the Prospective Dutch ColoRectal Cancer cohort study (PLCRC). Health-related quality of life (HR-QoL) was assessed using EORTC-QLQ-C30 questionnaire before surgery, and three and twelve months after surgery. HR-QoL scores varied between 0 and 100 and outcomes were compared according to age (< 70 years, ≥ 70 years), comorbidity (yes, no) and treatment type (adjuvant chemotherapy, surgical treatment only). The extent of resilience, defined as a recovery of HR-QoL to baseline level after a clinically relevant decline in HR-QoL at months, was calculated twelve months post-surgery.

RESULTS

For all 458 patients, the mean age was 66.4 years (SD 9.5), 40% were aged 70 years and older and 68% were men. Baseline level of HR-QoL summary score was relatively high with a mean of 87.9 (SD 11.5), and did not significantly differ between older and younger patients. The strongest decline of HR-QoL compared to baseline was observed at three months with a gradual recovery over time. Fourteen percent of all patients were non-resilient or showed a late decline at twelve months post-surgery. Compared to younger patients, older patients who received adjuvant chemotherapy were less resilient (respectively, 53 and 32%, p = 0.07) and at risk of a late decline in HR-QoL 1 year post-surgery (respectively, 3% versus 16%, p = 0.02). Comorbidity status had no significant impact on the HR-QoL trajectory.

CONCLUSION

Colon cancer treatment was associated with a decline in HR-QoL three months post-surgery, but most patients return to baseline level within twelve months. Still, particularly older patients who received adjuvant chemotherapy were less resilient and at risk of a late decline in HR-QoL. These data could help in patients counselling regarding colon cancer treatment.

Frailty and Cancer: Current Perspectives on Assessment and Monitoring

Frailty, an age-related condition of increased vulnerability to acute endogenous or exogenous stressors, is a key barrier to successful treatment of cancer in older people. In this group of patients, assessment of frailty is required before starting a new treatment. According to guidelines, the gold standard to assess frailty in older adults with cancer is geriatric screening followed by geriatric assessment (GA) across essential GA-domains (social status, physical function, nutrition, cognition, emotion, co-morbidity, polypharmacy). GA enables tailoring of both oncological therapy and non-oncological interventions to the patient's vulnerabilities. Large clinical trials recently have demonstrated that the feasibility and tolerability of systemic cancer treatment in older patients are significantly improved by such GA-guided management. Indications and optimal tools for frailty monitoring during the course of cancer treatment have not yet been defined in greater detail. New technologies such as wearable sensors or apps offer promising new opportunities to further develop frailty monitoring. This review describes the current standards and perspectives for the assessment and monitoring of frailty in elderly patients with cancer.

Impact of age and comorbidities on short- and long-term outcomes of patients undergoing surgery for colorectal cancer

Background

As the world population is progressively ageing, more and more elderly patients will require cancer surgery. Although curative surgery is the treatment of choice for resectable colorectal cancer (CRC), it is still debated whether elderly frail patients should undergo major cancer surgery due to the increased risk of postoperative and long-term mortality. The aim of this retrospective study was to evaluate the impact of age and comorbidities on postoperative mortality/morbidity and long-term outcomes, looking for potential age-related survival differences.

Methods

A total of 1,482 patients operated for CRC at our institution between January 2005 and October 2020 were analysed. The independent effect of age and comorbidities on postoperative complications was assessed by a logistic model, while the effect on overall survival (OS) and cancer-related survival (CRS) was estimated by a Cox regression model.

Results

The median age in the cohort was 67.8 years. Postoperative mortality was very low in the whole cohort (0.8%) and contained even in older age groups (3.2% in patients aged 80–84 years, 4% in the 85–90-year age group). The cumulative incidence of postoperative complications was doubled in patients with comorbidities (32.8% vs. 15.1%, p = 0.002). With regard to OS, as expected, it exponentially decreased with advancing age. Conversely, differences in CRS were less pronounced between age groups and absent in patients with stage 0–I CRC. Analysis of all causes and cancer-related mortality revealed a peak within 2 years from surgery, suggesting a prolonged impact of surgery. In patients aged 75 years and above, all-cause mortality showed a steep increase 1 year after surgery, while cancer-related mortality plateaued at about 4 years after surgery. On multivariable analysis, OS, but not CRS, was significantly influenced by age.

Conclusions

Although acceptable results of surgery in elderly patients, OS is strongly dependent on age: older people die more from competing causes than cancer-related treatments compared to younger age classes. The preoperative identification of risk factors for low OS may help the selection of those elderly patients who would benefit from curative CRC surgery.