Frail patients with colorectal cancer (CRC) are at increased risk of complications after surgery. Prehabilitation seems promising to improve this outcome and therefore we evaluated the effect of ...physical prehabilitation on postoperative complications in a retrospective cohort of frail CRC patients.
The study consisted of all consecutive non-metastatic CRC patients ≥70 years who had elective surgery from 2014 to 2019 in a teaching hospital in the Netherlands, where a physical prehabilitation program was implemented from 2014 on. We performed both an intention-to-treat and per protocol analysis to evaluate postoperative complications in the physical prehabilitation (PhP) and non-prehabilitation (NP) group.
Eventually, 334 elective patients were included. The 124 (37.1%) patients in the PhP-group presented with higher age, higher comorbidity scores and walking-aid use compared to the NP-group. Medical complications occurred in 26.6% of the PhP-group and in 20.5% of the NP-group (p = 0.20) and surgical complications in 19.4% and 14.3% (p = 0.22) respectively. In all frailty subgroups, the medical complications were lower in the PhP-group compared to the NP-group (35.9% vs. 45.5% for patients with ≥2 comorbidities, 36.2% vs. 39.1% for ASA score ≥ III, 29.2% vs. 45.8% for walking-aid use). Differences were not significant.
In this study, patients selected for physical prehabilitation had a worse frailty profile and therefore a higher a priori risk of postoperative complications. However, the postoperative complication rate was not increased compared to patients who were less frail at baseline and without prehabilitation. Hence, physical prehabilitation may prevent postoperative complications in frail CRC patients ≥70 years.
Background
Elderly patients with pancreatic cancer are underrepresented in clinical trials, resulting in a lack of evidence.
Objective
The aim of this study was to compare treatment and overall ...survival (OS) of patients aged ≥ 70 years with stage I–II pancreatic cancer in the EURECCA Pancreas Consortium.
Methods
This was an observational cohort study of the Belgian (BE), Dutch (NL), and Norwegian (NOR) cancer registries. The primary outcome was OS, while secondary outcomes were resection, 90-day mortality after resection, and (neo)adjuvant and palliative chemotherapy.
Results
In total, 3624 patients were included. Resection (BE: 50.2%; NL: 36.2%; NOR: 41.3%;
p
< 0.001), use of (neo)adjuvant chemotherapy (BE: 55.9%; NL: 41.9%; NOR: 13.8%;
p
< 0.001), palliative chemotherapy (BE: 39.5%; NL: 6.0%; NOR: 15.7%;
p
< 0.001), and 90-day mortality differed (BE: 11.7%; NL: 8.0%; NOR: 5.2%;
p
< 0.001). Furthermore, median OS in patients with (BE: 17.4; NL: 15.9; NOR: 25.4 months;
p
< 0.001) and without resection (BE: 7.0; NL: 3.9; NOR: 6.5 months;
p
< 0.001) also differed.
Conclusions
Differences were observed in treatment and OS in patients aged ≥ 70 years with stage I–II pancreatic cancer, between the population-based cancer registries. Future studies should focus on selection criteria for (non)surgical treatment in older patients so that clinicians can tailor treatment.
Trends of surgical and non-surgical complications among the old, older and oldest patients after colorectal cancer (CRC) surgery could help to identify the best target outcome to further improve ...postoperative outcome.
All consecutive patients ≥70 years receiving curative elective CRC resection between 2011 and 2019 in The Netherlands were included. Baseline variables and postoperative complications were prospectively collected by the Dutch ColoRectal audit (DCRA). We assessed surgical and non-surgical complications over time and within age categories (70–74, 75–79 and ≥ 80 years) and determined the impact of age on the risk of both types of complications by using multivariate logistic regression analyses.
Overall, 38648 patients with a median age of 76 years were included. Between 2011 and 2019 the proportion of ASA score ≥3 and laparoscopic surgery increased. Non-surgical complications significantly improved between 2011 (21.8%) and 2019 (17.1%) and surgical complications remained constant (from 17.6% to 16.8%). Surgical complications were stable over time for each age group. Non-surgical complications improved in the oldest two age groups. Increasing age was only associated with non-surgical complications (75–79 years; OR 1.17 (95% CI 1.10–1.25), ≥80 years; OR 1.46 (95% CI 1.37–1.55) compared to 70–74 years), not with surgical complications.
The reduction of postoperative complications in the older CRC population was predominantly driven by a decrease in non-surgical complications. Moreover, increasing age was only associated with non-surgical complications and not with surgical complications. Future care developments should focus on non-surgical complications, especially in patients ≥75 years.
There is a growing body of evidence for a beneficial effect of prehabilitation on short-term outcomes after colorectal cancer (CRC) surgery in older patients. However, long-term effects on survival ...or hospital admissions have not been investigated. This study reports these long-term outcomes from a previously published observational cohort study.
We compared patients ≥75 years who received elective CRC surgery in Reinier de Graaf Hospital before (2010–2013: standard care) and after implementation of a multimodal prehabilitation program (2014–2015; prehabilitation). With a six-year follow-up period, we analyzed survival using the Kaplan-Meier method and the occurrence of one or more hospital admissions using logistic regression analyses.
Overall, 137 patients were included in the standard care group and 86 patients in the prehabilitation group. There were no differences in patients, tumor and treatment characteristics. After six years, 51.1% in the standard care group and 59.3% in the prehabilitation group (p = 0.167) were still alive. When corrected for confounders in the prehabilitation group less patients had one or more hospital admissions during follow-up (odds ratio (OR) 0.43 (95% CI 0.24–0.77).
Unfortunately these limited historical cohorts did not allow for strong conclusions concerning long-time survival. However, after prehabilitation less patients had hospital admissions during follow up. Hopefully, this first study into the long-term effects of multimodal prehabilitation will trigger more future research.
Purpose
Shared decision making calls for clinician communication strategies that aim to foster choice awareness and to present treatment options neutrally, such as by not showing a preference. ...Evidence for the effectiveness of these communication strategies to enhance patient involvement in treatment decision making is lacking. We tested the effects of 2 strategies in an online randomized video-vignettes experiment.
Methods
We developed disease-specific video vignettes for rheumatic disease, cancer, and kidney disease showcasing a physician presenting 2 treatment options. We tested the strategies in a 2 (choice awareness communication present/absent) by 2 (physician preference communication present/absent) randomized between-subjects design. We asked patients and disease-naïve participants to view 1 video vignette while imagining being the patient and to report perceived room for involvement (primary outcome), understanding of treatment information, treatment preference, satisfaction with the consultation, and trust in the physician (secondary outcomes). Differences across experimental conditions were assessed using 2-way analyses of variance.
Results
A total of 324 patients and 360 disease-naïve respondents participated (mean age, 52 ± 14.7 y, 54% female, 56% lower educated, mean health literacy, 12 ± 2.1 on a 3–15 scale). The results showed that choice awareness communication had a positive (Mpresent = 5.2 v. Mabsent = 5.0, P = 0.042, η2partial = 0.006) and physician preference communication had no (Mpresent = 5.0 v. Mabsent = 5.1, P = 0.144, η2partial = 0.003) significant effect on perceived room for involvement in decision making. Physician preference communication steered patients toward preferring that treatment option (Mpresent = 4.7 v. Mabsent = 5.3, P = 0.006, η2partial = 0.011). The strategies had no significant effect on understanding, satisfaction, or trust.
Conclusions
This is the first experimental evidence for a small effect of fostering choice awareness and no effect of physician preference on perceived room to participate in decision making. Physician preference steered patients toward preferring that option.
To study outcomes of adults with idiopathic thrombocytopenic purpura (ITP), we performed a follow-up study in a cohort of 152 consecutive patients who were treated according to a well-defined ...algorithm. Long-term outcomes were determined relative to the response 2 years after diagnosis, because most (93%) patients who ultimately attained platelet counts above 30.0 × 109/L (30 000/μL) did so within this time frame. Complete follow-up for mortality could be studied in 99% of patients and for morbidity in 95% of patients, with a mean of 10.5 years. Within 2 years after diagnosis, 4 patients died, 2 were lost to follow-up, and 12 were reclassified as having secondary immune thrombocytopenia. Of the remaining 134 patients, 114 (85%) had obtained platelet counts above 30.0 × 109/L while all therapies had been discontinued. These patients had a long-term mortality risk equal to the general population. Twelve of 134 patients (9%), all with severe thrombocytopenia, had refractory disease and suffered a mortality risk of 4.2 (95% confidence interval, 1.7-10.0). Bleeding and infection equally contributed to the death of these patients. Another 8 patients (6%) had platelet counts above 30.0 × 109/L while on maintenance therapy. Similar to patients with refractory disease, these latter patients had considerably increased ITP-related hospital admissions, but mortality was only slightly higher than in the general population. In conclusion, most adults with ITP have a good outcome with infrequent hospital admissions and no excess mortality. The absence of gross morbidity and mortality in patients with moderate thrombocytopenia supports clinical practice refraining from further treatment.
Older patients are at risk for adverse outcomes after surgical treatment of cancer. Identifying patients at risk could affect treatment decisions and prevent functional decline. Screening tools are ...available to select patients for Geriatric Assessment. Until now their predictive value for adverse outcomes in older colorectal cancer patients has not been investigated.
To study the predictive value of the Geriatric 8 (G8) and Identification of Seniors at Risk for Hospitalized Patients (ISAR-HP) screening tools for adverse outcomes after elective colorectal surgery in patients older than 70years. Primary outcomes were 30-day complication rates, secondary outcomes were the length of hospital stay and six-month mortality.
Multicentre cohort study from two hospitals in the Netherlands. Frail was defined as a G8 ≤14 and/or ISAR-HP ≥2. Odds ratio (OR) is given with 95% CI.
Overall, 139 patients (52%) out of 268 patients were included; 32 patients (23%) were ISAR-HP-frail, 68 (50%) were G8-frail, 20 were frail on both screening tools. Median age was 77.7years. ISAR-HP frail patients were at risk for 30-day complications OR 2.4 (CI 1.1–5.4, p=0.03), readmission OR 3.4 (1.1–11.0), cardiopulmonary complications OR 5.9 (1.6–22.6), longer hospital stay (10.3 versus 8.9day) and six-months mortality OR 4.9 (1.1–23.4). When ISAR-HP and G8 were combined OR increased for readmission, 30-day and six-months mortality. G8 alone had no predictive value.
ISAR-HP-frail patients are at risk for adverse outcomes after colorectal surgery. ISAR-HP combined with G8 has the strongest predictive value for complications and mortality.
Patients screening frail on ISAR-HP are at increased risk for morbidity and mortality. Screening results of G8 alone was not predictive for postoperative outcomes. Predictive value increased when G8 and ISAR-HP were combined.
Introduction Older patients have an increased risk of morbidity and mortality after colorectal cancer (CRC) surgery. Existing CRC surgical prediction models have not incorporated geriatric ...predictors, limiting applicability for preoperative decision-making. The objective was to develop and internally validate a predictive model based on preoperative predictors, including geriatric characteristics, for severe postoperative complications after elective surgery for stage I–III CRC in patients ≥70 years. Patients and Methods: A prospectively collected database contained 1088 consecutive patients from five Dutch hospitals (2014–2017) with 171 severe complications (16%). The least absolute shrinkage and selection operator (LASSO) method was used for predictor selection and prediction model building. Internal validation was done using bootstrapping. Results: A geriatric model that included gender, previous DVT or pulmonary embolism, COPD/asthma/emphysema, rectal cancer, the use of a mobility aid, ADL assistance, previous delirium and polypharmacy showed satisfactory discrimination with an AUC of 0.69 (95% CI 0.73–0.64); the AUC for the optimism corrected model was 0.65. Based on these predictors, the eight-item colorectal geriatric model (GerCRC) was developed. Conclusion: The GerCRC is the first prediction model specifically developed for older patients expected to undergo CRC surgery. Combining tumour- and patient-specific predictors, including geriatric predictors, improves outcome prediction in the heterogeneous older population.
Summary
Objective
To investigate the efficacy of bevacizumab and trastuzumab combined with docetaxel, oxaliplatin, and capecitabine (B-DOCT) as first-line treatment of advanced human epidermal growth ...factor receptor 2 (HER2)-positive gastric cancer (GC).
Methods
In this multicentre, single-arm, phase II study, tumor HER2 status was determined centrally prior to treatment. Patients with advanced HER2-positive adenocarcinoma of the stomach or gastroesophageal junction (immunohistochemistry 3+ or immunohistochemistry 2+/silver in-situ hybridization positive) were treated with six cycles of bevacizumab 7.5 mg/kg (day 1), docetaxel 50 mg/m
2
(day 1), oxaliplatin 100 mg/m
2
(day 1), capecitabine 850 mg/m
2
b.i.d. (days 1–14), and trastuzumab 6 mg/kg (day 1) every three weeks, followed by maintenance with bevacizumab, capecitabine, and trastuzumab until disease progression. The primary objective was to demonstrate an improvement of progression-free survival (PFS) to >7.6 months (observed in the ToGA trial) determined according to the lower limit of the 95 % confidence interval (CI). Secondary endpoints were safety, objective response rate (ORR), and overall survival (OS).
Results
Twenty-five patients with HER2-positive tumors were treated with B-DOCT between March 2011 and September 2014. At a median follow-up of 17 months, median PFS was 10.8 months (95%CI: 9.0–NA), OS was 17.9 months (95%CI: 12.4–NA). One-year PFS and OS were 52 % and 79 %, respectively. The ORR was 74 % (95%CI: 52–90 %). Two patients became resectable during treatment with B-DOCT and achieved a pathological complete response. The most common treatment-related grade ≥ 3 adverse events were: neutropenia (16 %), diarrhoea (16 %), and hypertension (16 %).
Conclusions
B-DOCT is a safe and active combination in HER2-positive GC, supporting further investigations of DOC with HER2/vascular endothelial growth factor (VEGF) inhibition in HER2-positive GC.
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