Clinical Review

2015 Update on cancer

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When the cancer patient is elderly, how do you weigh the risks of surgery?

IN THIS ARTICLE

  • Preoperative
 risk-assessment 
strategies
  • The 11-item
 modified 
Functional Index
  • Using the
 Functional Index 
in practice


 

References

As the proportion of the elderly in the US population continues to increase, with life expectancy trending upward, we can expect to see more gynecologic cancers in our patients.1,2 At present, the most effective approach to these cancers commonly includes aggressive surgical resection with chemotherapy and, in some cases, radiation. It remains unclear whether elderly patients should be managed the same as younger patients, with minimal data to guide physicians. Some evidence suggests an increased risk of surgical complications in 
older adults.3

To optimize surgical care in our elderly patients, we need to understand the risks of perioperative mortality and morbidity in this population. For example, the current standard of care for advanced epithelial ovarian cancer is aggressive cytoreductive surgery followed by adjuvant chemotherapy,4 although neoadjuvant chemotherapy is gaining utility and popularity in certain circumstances. During pretreatment counseling, it is imperative that we communicate patient-specific outcomes so that patients and their families can make educated decisions in line with their goals. What should we know about age-dependent outcomes when counseling our patients?

To optimize surgical care in this population, we also need to develop and use new methods of surgical decision making. Although some data suggest that age is an independent risk factor for postoperative complications, not all elderly patients are the same in terms of comorbidities and functional status. In order to truly assess risks, we need to identify additional preoperative risk factors. Are there accurate scoring tools or predictors of outcomes available to help us assess the risks of postoperative mortality and morbidity?

In this article, we highlight recent developments in surgical treatment of the elderly, focusing on:

  • postoperative mortality and morbidity in patients older than 80 years
  • adjuncts to preoperative assessment for oncogeriatric surgical patients.

Risks rise sharply in older patients undergoing treatment for ovarian Ca

Moore KN, Reid MS, Fong DN, et al. Ovarian cancer in the octogenarian: does the paradigm of aggressive cytoreductive surgery and chemotherapy still apply? 
Gynecol Oncol. 2008;110(2):133–139.

Mahdi H, Wiechert A, Lockhart D, Rose PG. Impact of age on 30-day mortality and morbidity in patients undergoing surgery for ovarian cancer. Int J Gynecol 
Cancer. 2015;25(7):1216–1223.

The cornerstone of optimal survival from certain gynecologic cancers, such as advanced ovarian cancer, is aggressive debulking surgery. However, older adults are classically under-represented in clinical trials that guide this standard of care.

To determine whether patients aged 80 years or older respond differently from younger patients to conventional ovarian cancer management, Moore and colleagues retrospectively reviewed their institutional experience. They found that postoperative mortality increased from 5.4% in patients aged 80 to 84 years to 9.1% in those aged 85 to 89 and 14.4% in those older than 90. The rates for younger patients were 0.6% for patients younger than 60 years, 2.8% for those aged 60 to 69 years, and 2.5% for those aged 70 to 
79 years (P<.001).

Notably, 13% of patients aged 80 years or older who underwent primary surgery died during their primary hospitalization. Of those who survived, 50% were discharged to skilled nursing facilities. Of patients who underwent cytoreductive surgery, 13% were unable to undergo any intended adjuvant therapy, and only 57% completed more than 3 cycles of chemotherapy, either due to demise or toxicities. Two-month survival for patients 80 years or older was comparable between patients who underwent primary surgery and those who had primary chemotherapy (20% and 26%, respectively).

With a similar objective, Mahdi and colleagues identified 2,087 patients with ovarian cancer who underwent surgery. After adjusting for confounders with multivariable analyses, they found that octogenarians whose initial management was surgery were 9 times more likely than younger patients to die and 70% more likely to develop complications within 30 days. Among patients who underwent neoadjuvant chemotherapy, there were no significant differences between older and younger patients in 30-day postoperative mortality or morbidity.

What this EVIDENCE 
means for practiceThese data reinforce the care warranted when counseling older adult patients with gynecologic cancer about their initial management options. Some patients and their families may be willing to accept different risks for postoperative morbidity and mortality, whereas others may not. We need randomized data comparing outcomes of primary cytoreductive surgery with neoadjuvant chemotherapy in this age group. Nevertheless, it seems clear that the older patient cannot be treated the same as the younger patient.

When evaluating elderly patients for surgery, the use of multiple risk-assessment strategies may improve accuracy

Huisman MG, Audisio RA, Ugolini G, et al. Screening for predictors of adverse outcome in onco-geriatric surgical patients: a multicenter prospective cohort study. Eur J Surg Oncol. 2015;41(7):844–851.

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