To determine the predictive value of the "Timed Up & Go" (TUG), a validated assessment tool, on a prospective cohort study and to compare these findings to the ASA classification, an instrument ...commonly used for quantifying patients' physical status and anesthetic risk.
In the onco-geriatric surgical population it is important to identify patients at increased risk of adverse post-operative outcome to minimize the risk of over- and under-treatment and improve outcome in this population.
280 patients ≥70 years undergoing elective surgery for solid tumors were prospectively recruited. Primary endpoint was 30-day morbidity. Pre-operatively TUG was administered and ASA-classification was registered. Data were analyzed using multivariable logistic regression analyses to estimate odds ratios (OR) and 95% confidence intervals (95%-CI). Absolute risks and area under the receiver operating characteristic curves (AUC's) were calculated.
180 (64.3%) patients (median age: 76) underwent major surgery. 55 (20.1%) patients experienced major complications. 50.0% of patients with high TUG and 25.6% of patients with ASA≥3 experienced major complications (absolute risks). TUG and ASA were independent predictors of the occurrence of major complications (TUG:OR 3.43; 95%-CI = 1.14-10.35. ASA1 vs. 2:OR 5.91; 95%-CI = 0.93-37.77. ASA1 vs. 3&4:OR 12.77; 95%-CI = 1.84-88.74). AUCTUG was 0.64 (95%-CI = 0.55-0.73, p = 0.001) and AUCASA was 0.59 (95%-CI = 0.51-0.67, p = 0.04).
Twice as many onco-geriatric patients at risk of post-operative complications, who might benefit from pre-operative interventions, are identified using TUG than when using ASA.
OBJECTIVES
To evaluate long‐term survival and institutionalization in onco‐geriatric surgical patients, and to analyze the association between these outcomes and a preoperative risk score.
DESIGN
...Prospective cohort study with long‐term follow‐up.
SETTING
International and multicenter locations.
PARTICIPANTS
Patients aged 70 years or older undergoing elective surgery for a malignant solid tumor at five centers (n = 229).
MEASUREMENTS
We assessed long‐term survival and institutionalization using the Preoperative Risk Estimation for Onco‐geriatric Patients (PREOP) score, developed to predict the 30‐day risk of major complications. The PREOP score collected data about sex, type of surgery, and the American Society for Anesthesiologists classification, as well as the Timed Up & Go test and the Nutritional Risk Screening results. An overall score higher than 8 was considered abnormal.
RESULTS
We included 149 women and 80 men (median age = 76 y; interquartile range = 8). Survival at 1, 2, and 5 years postoperatively was 84%, 77%, and 56%, respectively. Moreover, survival at 1 year was worse for patients with a PREOP risk score higher than 8 (70%) compared with 8 or lower (91%). Of those alive at 1 year, 43 (26%) were institutionalized, and by 2 years, almost half of the entire cohort (46%) were institutionalized or had died. A PREOP risk score higher than 8 was associated with increased mortality (hazard ratio = 2.6; 95% confidence interval CI = 1.7‐4.0), irrespective of stage and age, but not with being institutionalized (odds ratios = 1 y, 1.6 95% CI = .7‐3.8; 2 y, 2.2 95% CI = .9‐5.5).
CONCLUSION
A high PREOP score is associated with mortality but not with remaining independent. Despite acceptable survival rates, physical function may deteriorate after surgery. It is imperative to discuss treatment goals and expectations preoperatively to determine if they are feasible. Using the PREOP risk score can provide an objective measure on which to base decisions. J Am Geriatr Soc 68:1235–1241, 2020.
Irreversible electroporation (IRE) is a non-thermal ablative technique for unresectable liver malignancies deemed unsuitable for traditional thermal ablation due to proximity to biliary and/or ...vascular structures. Needle tract tumour seeding is a well-recognised complication following thermal ablation, while little is known about its risk with IRE use. We present a case of tumour seeding after IRE for unresectable hepatocellular carcinoma in a man in his 70s. The procedure was complicated by bleeding from a pseudoaneurysm, which required coil embolisation and blood transfusion. He initially progressed well, however, imaging at 12 months indicated a new tumour in the right intercostal space along the tract of one of the IRE needles; consistent with seeding. Although the patient subsequently underwent systemic therapy with sorafenib, his disease progressed, and unfortunately he passed away 20 months following IRE. This report adds to mounting evidence of needle tract tumour seeding as a complication following IRE.
With an expanding elderly population and median rectal cancer detection age of 70 years, the prevalence of rectal cancer in elderly patients is increasing. Management is based on evidence from ...younger patients, resulting in substandard treatments and poor outcomes. Modern management of rectal cancer in the elderly demands patient-centered treatment, assessing frailty rather than chronological age. The heterogeneity of this group, combined with the limited available data, impedes drafting evidence-based guidelines. Therefore, a multidisciplinary task force convened experts from the European Society of Surgical Oncology, European Society of Coloproctology, International Society of Geriatric Oncology and the American College Surgeons Commission on Cancer, with the goal of identifying the best practice to promote personalized rectal cancer care in older patients.
A crucial element for personalized care was recognized as the routine screening for frailty and geriatrician involvement and personalized care for frail patients. Careful patient selection and improved surgical and perioperative techniques are responsible for a substantial improvement in rectal cancer outcomes. Therefore, properly selected patients should be considered for surgical resection. Local excision can be utilized when balancing oncologic outcomes, frailty and life expectancy. Watch and wait protocols, in expert hands, are valuable for selected patients and adjuncts can be added to improve complete response rates. Functional recovery and patient-reported outcomes are as important as oncologic-specific outcomes in this age group. The above recommendations and others were made based on the best-available evidence to guide the personalized treatment of elderly patients with rectal cancer.
Older age is a risk factor for the development of HCC. However, the treatment options available for older patients with HCC, their safety, efficacy and utility, are poorly understood resulting in ...challenging decision-making. In this review, we aim to report the best available evidence to facilitate optimal decision making for older patients with HCC. We report that surgical resection for HCC is equally safe (90-day mortality ~3%) and effective (five-year disease free survival ~40%) for older patients as it is for younger patients. Five-year survival after ablation therapy for HCC is in excess of 50% in older patients, whilst morbidity rates are in the region of 3%. Survival rates of 30% after chemoembolisation reflects its role as a non-curative treatment. Transplantation is an option that may be helpful for a minority of patients, but the high risks of in-hospital mortality and lower likelihood of receiving a transplant should be duly considered before committing to this approach. We therefore advocate an individualised assessment for older patients based on these risk profiles and probabilities of optimal outcomes. In patients with a projected life-span ≥ 3 years, and who have sufficient physiological and functional reserve, surgical resection should be the treatment of choice. Patients with a projected life-span < 3 years are better served with loco-regional therapies, and tumour size, at a threshold of 3 cm, should guide the choice between ablation and chemoembolisation therapies.
Contemporary management of pancreas cancer in older people Baltatzis, Minas; Rodriquenz, Maria Grazia; Siriwardena, Ajith K. ...
European journal of surgical oncology,
March 2021, 2021-Mar, 2021-03-00, 20210301, Letnik:
47, Številka:
3
Journal Article
Recenzirano
As the population of western countries is aging, the number of patients diagnosed with cancer is growing. Therefore older people, more susceptible to develop pancreatic malignancy, will likely ...represent the prototype of a pancreatic cancer patient in the near future. Diagnostic modalities utilised for younger patients are also applicable for older individuals. There is accumulative evidence that biological age is not an independent factor predicting poor outcome in elderly patients with resectable disease undergoing surgery, however increased postoperative morbidity and mortality within the elderly group has also been reported. Adjuvant chemotherapy should be offered in all patients with good performance status regardless of their age. Palliative measures for unresectable tumours including relief from biliary and duodenal obstruction as well as chemotherapy should be considered in non-frail patients with reasonable life expectancy. Palliative chemotherapy options are FOLFIRINOX or gemcitabine/nab-paclitaxel for patients with good performance status (0–1) and gemcitabine alone for patients with performance status 2–3.
The cornerstone for improving the outcomes of the elderly age group is careful patient selection and perioperative optimization of those who have indication for surgery. Patients and their carers should be involved in the decision making process with emphasis on the expected functional recovery after the proposed treatment modality. The presence of geriatricians in the multidisciplinary team meetings is crucial in order to identify the optimal treatment pathway for elderly patients. Geriatric input regarding peri-habilitation pathways to improve surgical outcomes, to decrease mortality and to expedite patients’ functional recovery is highly recommended.
•Diagnostic modalities should be the same for elderly patients as in younger population.•Age is not an independent contraindication for surgery.•Geriatric specialists have a crucial role in designing the appropriate management and in optimising the patients for surgery, chemotherapy or both.•FOLFIRINOX, gemcitabine and nab-paclitaxel are well tolerated by the elderly population.•Holistic care is recommended to facilitate elderly patients’ functional recovery after treatment.
Advanced hepatocellular cancer (HCC) is the fourth leading cause of cancer-related death globally and is most common in elderly patients with a peak incidence in the UK at ages 85–89 years. In ...addition to the well-established risk factors of alcohol and viral hepatitis B and C, rising obesity and associated non-alcoholic fatty liver disease is projected to contribute to increased incidence of advanced HCC in elderly patients. The management of advanced HCC is changing rapidly; for over a decade the multi-kinase inhibitor sorafenib has been the only treatment option that offered a proven survival advantage, but in the last 4 years other treatment options have emerged including other kinase inhibitors, and monoclonal antibodies targeting angiogenesis and immune checkpoint inhibitors. Recent clinical trials have recruited older patients with no maximum age exclusion criteria, and age has not been found to be predictive for treatment effect in subgroup analyses. Chronological age is an unreliable measure of fitness for treatment and frailty may be a more apt descriptor, but the lack of a unified assessment tool has limited its use in current practice. Development of unified frailty assessments and prospective large-scale studies of novel systemic therapies where age and frailty are evaluated would be informative.
Older age represents a major risk factor for developing colorectal cancer and the disease disproportionately affects patients older than 60 years of age. However, knowledge regarding the optimal ...management of older patients with metastatic colorectal cancer (mCRC) remains limited. The challenge of treating older patients arises in tailoring treatments to a heterogeneous cohort whilst adjusting for individuals with a wide variation of physiological reserve, a reduced tolerance to treatment side-effects and morbidity, and often different priorities as compared with younger patients. Data from the published literature supports the premise that older age alone is not an acceptable determinant of treatment options. In particular, patients aged 65–70 years with mCRC ought to be considered similarly to younger patients and patients aged 70–74 also stand to benefit from both hepatic resection and systemic therapy notwithstanding the higher rates of morbidity and mortality. Patients aged 75–79, and with sufficient physiological reserve ought to be considered for curative treatment options which are proportional to the extent of metastatic disease. Meanwhile, in patients aged ≥80 years, life-extending or life-enhancing benefit ought to be demonstrable prior to embarking upon major surgery as a curative treatment option. Older patients who meet the physiological eligibility criteria to enter clinical trials of systemic chemotherapy appear to gain similar benefit as younger patients and should not be excluded on the basis of age alone. Clinical trials that are specifically designed for older patients are feasible and could yield valuable information to guide clinical practice.
Accurate quality of life (QoL) data and functional results after cancer surgery are lacking for older patients. The international, multicenter Geriatric Oncology Surgical Assessment and Functional ...rEcovery after Surgery (GOSAFE) Study compares QoL before and after surgery and identifies predictors of decline in QoL.
GOSAFE prospectively collected data before and after major elective cancer surgery on older adults (≥70 years). Frailty assessment was performed and postoperative outcomes recorded (30, 90, and 180 days postoperatively) together with QoL data by means of the three-level version of the EuroQol five-dimensional questionnaire (EQ-5D-3L), including 2 components: an index (range = 0-1) generated by 5 domains (mobility, self-care, ability to perform the usual activities, pain or discomfort, anxiety or depression) and a visual analog scale.
Data from 26 centers were collected (February 2017-March 2019). Complete data were available for 942/1005 consecutive patients (94.0%): 492 male (52.2%), median age 78 years (range = 70-95 years), and primary tumor was colorectal in 67.8%. A total 61.2% of all surgeries were via a minimally invasive approach. The 30-, 90-, and 180-day mortality was 3.7%, 6.3%, and 9%, respectively. At 30 and 180 days, postoperative morbidity was 39.2% and 52.4%, respectively, and Clavien-Dindo III-IV complications were 13.5% and 18.7%, respectively. The mean EQ-5D-3L index was similar before vs 3 months but improved at 6 months (0.79 vs 0.82; P < .001). Domains showing improvement were pain and anxiety or depression. A Flemish Triage Risk Screening Tool score greater than or equal to 2 (odds ratio OR = 1.58, 95% confidence interval CI = 1.13 to 2.21, P = .007), palliative surgery (OR = 2.14, 95% CI = 1.01 to 4.52, P = .046), postoperative complications (OR = 1.95, 95% CI = 1.19 to 3.18, P = .007) correlated with worsening QoL.
GOSAFE shows that older adults' preoperative QoL is preserved 3 months after cancer surgery, independent of their age. Frailty screening tools, patient-reported outcomes, and goals-of-care discussions can guide decisions to pursue surgery and direct patients' expectations.
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