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Novel Approaches to Perioperative Assessment and Intervention May Improve Long-term Outcomes after Colorectal Cancer Resection in Older Adults

Scope of Problem

Cancer is often described as a disease of the elderly; in fact 60 to 70% of new cancer diagnoses occur in patients aged 65 years or older.1 Colorectal cancer (CRC) remains the second and third most commonly occurring cancer for both sexes and the second and third leading cause of death for men and women living in developed countries.2 Although chemotherapy and radiation may be used in the treatment of this patient population, surgical resection with curative intent is often the treatment of first choice.  In the older population, needs become more complex as multiple comorbidities can have the potential to affect outcomes. Patient-centered outcomes, such as quality of life, reintegration into the community, physical performance after cancer surgery and avoidance of treatment related complications, have not been well-studied.1 Cheema and colleagues aimed to study outcomes of surgical treatment in CRC for the geriatric population. A review of the literature to evaluate trends in CRC surgery was conducted with specific attention to patient-centered outcomes of therapy for CRC. The researchers then proposed adaptations from the geriatrics literature to improve the prediction of both short and long-term outcomes after surgery for this population of patients. The literature review provided several interesting results.1

Results1

  • Epidemiology: It is predicted that the prevalence of CRC will rise significantly in the coming years, with an even higher rate in the older population; the median age at diagnosis is 71 years according to the Surveillance, Epidemiology and End Results (SEER) data
  • Changing Nature of Comorbidity in Surgical Patients: Geriatric patients range from highly functional and cognitively intact individuals to frail and impaired individuals; multimorbidity is a significant predictor of longitudinal functional outcomes, disability, and need for health services
  • Trends on Surgical Resection and Outcomes Among Complex, Older Cancer Patients: Surgery is used increasingly on frail and comorbid patients with cancer; although there are studies that evaluate 30 day morbidity and mortality, few studies examine patient-centered outcomes
  • Long-Term Survivorship Outcomes: Both the American Cancer Society (ACS) and the National Cancer Institute (NCI) are increasing focus on survivorship and community reintegration following cancer therapy; the perioperative period is underexplored. Geriatric assessment markers may help to predict six month postoperative mortality
  • Preoperative Assessment and Intervention: Preoperative assessments are currently designed to predict 30 day postoperative mortality and morbidity; comprehensive geriatric assessments (CGAs) may help to more accurately determine important factors beyond the chronological age of the patient

The authors of the paper note that many older patients with cancer are not functionally impaired and that screening for the more vulnerable patients is imperative.1 Interventions designed to prevent disability associated with increased rates of adverse outcomes can generate health care savings but also lead to important improvements in patient-centered outcomes. Cheema et al. conclude that the ideal timing for the development of a CGA based prehabilitation plan would be the preoperative assessment period for surgical procedures. Future studies should focus on the appropriate window for assessment and devise a risk stratification model.1

ManageCRC Commentary

Cancer occurs more frequently in the older patient, yet this population is not well-represented in clinical trials.  A more specifically tailored and comprehensive assessment for the geriatric population is needed.  The authors of this paper note that patient-centered outcomes are rarely if ever studied in regard to the older population of patients with cancer, yet these same outcomes can make a significant difference to the patient.  As our population continues to age and cancer diagnoses become more frequent, prediction of increased morbidity and improved patient-centered outcomes are needed.  As noted in a previous study, geriatric assessment is essential to capture the differences between chronological age and functional age in this group of patients.3 The authors rightly point out that future studies should focus on this population of patients, helping to identify the vulnerable older patient with CRC.

References

  1. Cheema, J.N., Abraham, N.S., Berger, D.H. et al. Novel approaches to perioperative assessment and intervention may improve long-term outcomes after colorectal cancer resection in older adults. Ann Surg 2011; 253: 867-874  doi:10.1097/SLA.0b013e318208faf0  Link to abstract at: http://www.ncbi.nlm.nih.gov/pubmed?term=cheema%2C%20abraham%2C%20berger

  2. Jemal, A., Bray, F., Center, M.M., Ferlay, J., Ward, E., & Forman, D. Global cancer statistics. CA Cancer J Clin 2011; 61: 69-90. doi: 10.3322/caac.20107   Link to free full text at: http://onlinelibrary.wiley.com/doi/10.3322/caac.20107/pdf

  3. Hurria, A, Cirrincione, CT, Muss, HB. Implementing a geriatric assessment in Cooperative Group clinical cancer trials: CALBG 360401. J Clin Oncol 29: 1290-1296. doi:10.1200/JCO.2010.30.6985  Link to abstract at: http://www.ncbi.nlm.nih.gov/pubmed/21357782 


Article Created On : 5/9/2011 9:07:03 AM             Article Updated On : 5/9/2011 9:07:03 AM