Introduction
The surgical population is aging at a faster rate than the general population. A significant proportion of this group will undergo cancer surgery; in 2030 it is estimated that more than 75% of cancer patients will be aged over 65 years. While there are clear benefits in terms of morbidity and mortality, older people undergoing cancer surgery remain at higher risk than younger patients of adverse postoperative outcomes. , With increasing age, the rate of surgical complications remains fairly static, with the excess observed morbidity seen in older patients related to higher rates of medical complications. , This is particularly relevant in oncological surgery where 90% of older patients with cancer live with multimorbidity, 40% have polypharmacy, and 70% are functionally dependent. Furthermore, the frequent exclusion of older people from cancer treatment studies has led to a paucity of evidence describing disease and treatment outcomes in this age cohort. As a result, treatment decisions in the older population can be complex, with uncertainty among professionals regarding the gold standard of care. Traditionally, treatment decisions have been based on age alone, without consideration of multimorbidity, frailty, and functional capacity as superior prognostic indicators. In response to these issues, guidelines from professional bodies outline surgical care standards for older patients including the recommendation to use a comprehensive, structured approach to assessment and management of older patients with cancer. ,
Patient Assessment
Treatment decisions for patients with cancer are traditionally made at multidisciplinary meetings between oncologists, surgeons, and radiologists, with other specialties contributing as necessary. For over 50 years, oncologists have used the Eastern Cooperative Oncology Group (ECOG) performance status as a method to assess function and guide treatment decisions. While the benefits of this performance status include face validity and clinical feasibility, it can be less discriminatory in older people because it does not distinguish between functional impairment, specifically attributable to malignancy and therefore potentially reversible through oncological treatment, and preexisting impairment secondary to frailty, multimorbidity, or dementia. An awareness of the limitation of this approach has led to the inclusion of Comprehensive Geriatric Assessment (CGA) and optimization in oncological assessment for older people. CGA is an established, evidenced-based methodology for multidomain assessment of medical, functional, psychological, and social issues using objective tools. The role of CGA in the medical setting is well established and there is an increasing evidence base for CGA in surgical and oncological cohorts.
Cancer treatment involves traditional chemotherapy and radiotherapy, often used in combination with biologic treatment and surgery. CGA is used to assess and optimize prior to oncological treatment, resulting in amended oncological treatment decisions in a quarter of cases (intensifying or reducing treatment intensity) and increased survival. , In surgical settings, CGA has resulted in a reduction in length of stay and postoperative morbidity and mortality in elective and emergency surgical patients across surgical subspecialties, , , , including colorectal cancer surgery.
Identifying patients most likely to benefit from CGA is important. The International Society of Geriatric Oncology (SIOG) recommends screening older patients with cancer using validated tools to identify patients requiring further assessment and optimization. Three of the most widely used tools include the G8, Vulnerable Elder Survey-13 (VES-13), and the abbreviated Comprehensive Geriatric Assessment (aCGA). The G8 is an eight-item questionnaire that takes less than 10 min to complete by any clinician, with a score <14 identifying a patient who may benefit from CGA. VES-13 is a self-administered 13-question survey that takes <10 min, with a score ≤3 suggesting an older person who may benefit from CGA. The third tool, the aCGA, is a 15-question survey assessing four domains, including functional status (e.g., activities of daily living [ADL]), independent ADL, depression, and cognition, with individual domain cutoffs identifying a need for further assessment. All three have been validated in the oncological setting but have not been studied in patients undergoing cancer surgery specifically. , ,
Core Components of Perioperative Care for Older Patients Undergoing Cancer Surgery
Models of perioperative care for older patients with cancer undergoing surgery vary. There are a number of core components appropriately tailored to the perioperative and oncological settings ( Table 36.1 ).
| Component | Detail | |
|---|---|---|
| Preoperative | Assessment | – Assessment of physiological reserve – Assessment of known comorbidities – Diagnosis of new comorbidities – Identification of geriatric syndromes – Assessment of functional capacity – Assessment of mental capacity – Assessment of psychosocial factors – Assessment of social situation |
| Optimization | – Optimization of medical comorbidities – Comprehensive medication review – Optimization of geriatric syndromes – Optimization of malnutrition and obesity – Optimization of psychosocial factors and modifiable lifestyle risk factors – Optimization of functional reserve – Optimization of social situation | |
| Shared decision-making (SDM) | – Understanding patient goals and expectations – Counseling on risks, benefits, and alternatives to treatment – Collaboration across specialties to address specific aspects of SDM in older people – Planning the perioperative period – Advanced care planning | |
| Intraoperative | Intraoperative care | – Following anesthetic and surgical guidelines |
| Postoperative | Prevention and treatment of medical complications | – Prevention of postoperative medical complications – Prompt identification of postoperative medical complications – Standardized treatment of postoperative medical complications |
| Management of multidisciplinary issues | – Early mobilization to prevent functional decline and falls – Optimizing nutrition including early feeding – Prompt removal of urinary catheters – Ensuring pressure area care | |
| Discharge planning | – Early identification of potential barriers to discharge – Collaboration across disciplines and specialties to facilitate prompt discharge – Timely liaison with community services to support transitions of care – Appropriate follow up plan, with communication to primary care team | |
| Organizational | Education and collaboration across disciplines and specialties | – Upskilled workforce – Perioperative medicine curricula – Structured teaching program – Avoidance of silo working -Joint clinical reflection through interdisciplinary, multispecialty morbidity and mortality review, development of guidelines and audit meetings, etc. |
| Research | – Structured quality improvement projects – Collaborative multispecialty research programs -Use of “big data” to examine perioperative outcomes and inform local quality improvement (e.g., national audit) |
Preoperative Care for Older Patients Undergoing Cancer Surgery
Regardless of patient age, the preoperative period is an opportunity to identify and modify conditions that may adversely impact a patient’s perioperative journey. Improving patient-reported and clinician-reported outcomes can be more challenging in older patients with cancer due to concurrent multimorbidity and geriatric syndromes requiring optimization in a short preoperative timeframe. In planned cancer surgery, the optimization period is often just 1 to 2 weeks (possibly longer if neoadjuvant treatment is being administered first) with a preoperative period <24 h in emergency cancer surgery (such as acute bowel obstruction secondary to a gastrointestinal malignancy).
Assessment of Frailty
This important component of assessment of older patients is addressed in the chapter on Frailty (see Chapter 15).
Assessment of Comorbidities
A comprehensive assessment begins with reviewing the patient’s known preexisting medical conditions, which in the older cohort will often include a number of pathologies. Common examples include ischemic heart disease, essential hypertension, anemia, chronic obstructive pulmonary disease (COPD), and osteoarthritis. This assessment involves an evaluation of severity, past and present treatments, and current disease control for each comorbidity, allowing identification of areas for optimization. Targeted investigations may be required to further assess these underlying conditions.
Older patients with cancer should also be routinely screened for the presence of undiagnosed comorbidities using history, examination, and routine investigations. Routine investigations may include a full blood profile, renal and liver function tests, electrocardiograph (ECG), and spirometry. These investigations may lead to new diagnoses. Multimorbidity is an independent predictor of reduced quality of life, adverse surgical outcomes, and mortality rates. , CGA provides an underpinning methodology with which to manage multimorbidity, cognizant of the interplay between individual comorbidities, and the necessary treatments with an understanding of the potential impact on the patient during the perioperative period.
Assessment of Geriatric Syndromes
Geriatric syndromes are distinct conditions occurring in older patients that do not stem from identifiable diseases but rather occur due to the accumulation of impairments across multiple systems affecting multiple domains in patient function. The most common geriatric syndromes and proposed tools for assessment are listed in Table 36.2 .
| Geriatric Syndrome | Example Assessment Tool |
|---|---|
| Frailty | Clinical Frailty Scale (CFS) Edmonton Frail Scale (EFS) |
| Cognitive impairment | Montreal Cognitive Assessment (MoCA) |
| Delirium | 4AT Rapid Assessment Test (4AT) |
| Falls/reduced mobility | Timed up and go Gait velocity |
| Incontinence | Clinical assessment |
| Pressure ulcers | Waterlow Braden Scale |
The presence of geriatric syndromes, in particular frailty, is associated with worse postoperative outcomes in older patients with cancer and should therefore inform shared decision-making (SDM). Assessment of cognition is important to inform capacity assessment, appraise delirium risk, and facilitate SDM. There is no single cognitive assessment cutoff score that deems a patient to have “capacity” regarding the surgical decision. National legislation will inform the assessment of capacity and guide how decisions are made in patients deemed to lack capacity.
Assessment of Functional Capacity
Assessment of an older patient’s functional status is essential to:
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Refine perioperative risk assessment
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Identify areas for preoperative optimization
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Inform SDM
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Inform the postoperative plan to minimize functional deterioration
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Facilitate proactive discharge planning
Functional status should be assessed using a multidisciplinary approach, often with the use of a validated tool such as the Nottingham Extended Activities of Daily Living (NEADL). Functional reserve can be appraised through self-reported exercise tolerance, scores such as 6-Minute Walk Test (6MWT), or an objective physiological assessment such as cardiopulmonary exercise testing (CPET). Other widely used scores such as the Duke Activity Status Index (DASI) estimate functional capacity using both a combination of ADL and estimated functional reserve.
Assessment of Psychological Factors and Social Situation
Appraising psychological and social domains using CGA is useful to identify areas that can be optimized and used to anticipate potential barriers to postoperative recovery. Mental health disorders, particularly anxiety, depression, and social isolation, can impact postoperative recovery, including timely discharge from hospital. Preoperative screening for these issues should be undertaken using validated tools such as the Hospital Anxiety and Depression Scale (HADS) to supplement a clinical history including detail of support networks and reliance on formal or informal carers. Finally, as part of assessing the psychological domain it is important to assess the patient’s understanding of their condition and expectations for ongoing treatment, e.g., managing a colostomy.
Optimization
Optimization of Medical Comorbidities
Evidence-based approaches should be utilized but applied with an awareness of the interplay between coexisting conditions (both comorbidities and geriatric syndromes), and treatments in the individual patient scheduled to undergo cancer surgery. This process can be challenging in the context of multimorbidity, e.g., addressing uncontrolled hypertension in a patient with Parkinson’s disease who also has significant symptomatic postural hypotension. The approach to optimization must therefore be nuanced with clear instruction regarding preoperative interventions and planning for longer-term interventions to be instigated in the postoperative period.
Comprehensive Medication Review
Medication review is an integral component of preoperative CGA. The full medication list should be reviewed to identify:
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Drugs lacking a valid indication
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Adverse drug effects
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Drug-drug interactions
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Opportunities to optimize comorbidities
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Drugs to be withheld perioperatively (e.g., anticoagulants, oral hypoglycemic agents)
Additionally, medication adherence and use of medication aids should be assessed. This is important to prevent harm from introducing new agents or increasing doses of existing medications in the setting of poor disease control due to nonadherence as opposed to resistant disease.
Optimizing Geriatric Syndromes
Frailty is a common condition occurring frequently in older patients with cancer. Potential frailty modifiers include nutritional supplementation, exercise interventions, and pharmacological treatments (angiotensin-converting inhibitors and vitamin D). However, there are no studies to date examining these or other frailty modifiers in improving postoperative outcomes in cancer surgery.
Cognitive impairment can be difficult to assess and optimize in a single preoperative consultation. However, given the timelines from assessment to cancer surgery and the impact of cognitive impairment on delirium risk, capacity, and SDM, a systematic approach should be used. Following screening (using 4AT) and clinical history/examination, assessment should be completed using a brief multidomain tool. Optimization strategies include:
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Identification and management of comorbidities known to impact cognition (e.g., depression, electrolyte abnormalities, pain, etc.)
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Optimization of cerebrovascular risk (e.g., statins, antiplatelets)
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Clear verbal and written preoperative instructions for the patient and/or carer (e.g., regarding medicine cessation)
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Planning of the intraoperative period (e.g., depth of anesthesia, use of benzodiazepines)
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Planning of the patient journey (e.g., admission on day of surgery to avoid additional bed moves)
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Communication of delirium-prevention strategies preoperatively to patients, their families, and ward staff
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Modification of delirium risk using Hospital Elder Life Program (HELP)-type interventions (e.g., provision of sensory aids, cognitive stimulation, mobilization) to effectively reduce the incidence of delirium in hospitalized patients
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Communication regarding potential delirium related distress for patients, carers, and staff
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Signposting to long-term condition management (memory clinic assessment and follow-up)
Similarly, other geriatric syndromes such as falls and incontinence should be addressed and optimized using a multidisciplinary approach throughout the perioperative pathway.
Optimizing Malnutrition
Malnutrition affects more than 50% of older patients with cancer due to a catabolic state secondary to malignancy, and depression and reduced appetite secondary to the physical tumor burden or adverse treatment effects. Malnutrition should be assessed using a validated tool cognizant of the overlap with cachexia. Contributing factors, such as poor dentition, poor oral health care, dysphagia, and access to food, require a multidisciplinary approach to assessment and optimization. Oral nutritional supplements are often adequate to address malnutrition; however, more invasive methods such as enteral or parenteral feeding may be required preoperatively particularly when the timeframe to cancer surgery is short. Enlisting the help of a dietician with oncology experience as part of the multidisciplinary team (MDT) can be helpful.
Optimizing Psychosocial Factors and Lifestyle Risk Factors
Addressing psychosocial issues to improve patient-reported outcomes after cancer surgery might involve a variety of interventions. These range from pharmacological management of untreated mental health issues, psychology/counseling referral to address cancer-related distress, or occupational therapy and social work input to improve social engagement, ensure home support, and address financial issues.
Modifiable lifestyle risk factors should also be addressed in the preoperative period. These include support with smoking cessation, alcohol consumption, weight management, and exercise. Such risk factor management is relevant for all ages, noting that the “teachable moment” is also relevant in the management of older people.
Optimizing Functional Reserve
As discussed in Chapter 35 , there is emerging evidence that prehabilitation with exercise, nutrition, and psychological support may improve cancer surgery outcomes. Evidence in the older patient cohort, however, is limited and further research is needed with regard to acceptability, feasibility, and impact of exercise on short- and long-term postoperative outcomes.
Shared Decision-Making
SDM is a collaborative process between health care professionals, patients, and their families used to inform a health-related decision. The clinician’s role in SDM is to provide insight regarding the diagnosis and potential risks and benefits of relevant treatment options. In the setting of cancer surgery, discussion of treatment options should include proceeding with surgery, alternative surgeries (less radical), alternative treatments (chemotherapy, radiotherapy), palliative management, or “do nothing” options. In older people, the risk of cancer progression should be considered in the context of prognosis from coexistent frailty or multimorbidity, which may convey a shorter life expectancy than the cancer for which surgical treatment is being considered.
Preoperative risk assessment is essential to inform SDM and a number of validated tools are available. Examples include the American Society of Anesthetists (ASA) physical status, the Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (P-POSSUM), and the Surgical Outcome Risk Tool (SORT). The limitations of these population-based measures should be acknowledged when used to inform the SDM process, but coupled with clinical assessment can provide a systematic approach to risk assessment and planning of the perioperative period (e.g., ensuring appropriate use of level 2 and 3 care).
Advanced Care Planning
Advanced care planning is a crucial component of SDM in cancer surgery in older people and should be routinely undertaken with patients and their families. Timely incorporation of this into the discussion empowers patients to outline their wishes for future care and treatments, including planning for situations where the patient may no longer have capacity to make independent decisions. Important points to address in this discussion include ceilings of treatment, including what interventions would be offered and would be acceptable to patients (e.g., levels of care, single-organ support) and resuscitation status. This discussion is particularly important in oncology patients where the intent of treatment may not be curative, and prognosis is often uncertain.
Postoperative Care for Older Patients Undergoing Cancer Surgery
While intraoperative care for the particular surgery falls under the jurisdiction of the anesthetist and surgeon, standardizing postoperative care to minimize the incidence and severity of common postoperative medical complications is essential to provide value both for individual patients and for health care services. In the case of emergency cancer presentations (e.g., bowel obstruction secondary to malignancy), the postoperative period may often afford the first point of contact with CGA-based services. In such circumstances there may be an increased reliance on collateral history to inform the clinical team regarding premorbid status.
Prevention and Treatment of Medical Complications
Postoperative medical complications that commonly affect older people and examples of methods to reduce the incidence or severity of these are presented in Table 36.3 . These examples do not represent exhaustive management strategies.
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