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Pavel MC, Ferre A, Garcia-Huete L, Oliva I, Guillem L, Tomas I, Renzulli M, Jorba-Martin R. Preliminary results of the implementation of a Complex Surgical Patient Area as a tool to improve the quality of care. Cir Esp 2025; 103:287-294. [PMID: 40010565 DOI: 10.1016/j.cireng.2025.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2024] [Accepted: 01/05/2025] [Indexed: 02/28/2025]
Abstract
INTRODUCTION Given the increasing complexity of surgical patients, their evaluation within a Complex Surgical Patient Area (APQC) is essential. This study aims to present the functioning of the APQC and analyse its outcomes. METHODS Between 2022 and 2024, 73 patients were evaluated, with a mean age of 72.8 ± 10 years. Of these, 97.3% were ASA ≥ III, and 41.1% had a Clinical Frailty Score ≥4. The evaluation centered on a multidisciplinary committee responsible for determining the patient's operability and guiding the intrahospital circuit. During postoperative evolution, patient follow-up was carried out by two complementary teams in continuous communication. Failure to Rescue (FTR) was defined as the death of a patient following one or more serious complications. RESULTS The main reason for including patients in the CSPA was multimorbidity in 53.4% of cases and a specific pathology in 28.8%. In 31.5% of cases, the intervention was ruled out, with one-year survival below 40%. Among the 35 operated patients, the Comprehensive Complication Index (CCI) was 18.034 ± 21.94, the average hospital stay was 14.34 ± 20.15 days, and the readmission rate was 25.7%. The FTR rate was 12.5%. CONCLUSIONS Current data suggest a positive impact of the APQC on the evolution of complex patients. A larger patient sample is needed for a detailed analysis of the factors where APQC activities may have the greatest influence.
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Affiliation(s)
- Mihai-Calin Pavel
- Unidad de Cirugía HBP, Servicio de Cirugía General, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Grup de Recerca en Cirurgia General i Aparell Digestiu (RECERCGAD), Hospital Universitari de Tarragona Joan XXIII, Departament de Medicina i Cirurgia, Universitat Rovira i Virgili (URV), Institut d'Investigació de la Salut Pere Virgili (IISPV), Tarragona, Spain; Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain.
| | - Ana Ferre
- Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Lucia Garcia-Huete
- Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Servicio de Anestesiología y Reanimación, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Iban Oliva
- Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Unidad de Cuidados Intensivos, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Lluisa Guillem
- Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Servicio de Medicina Interna, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Ignacio Tomas
- Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Servicio de Geriatría y Cuidados Paliativos, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Marcela Renzulli
- Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Servicio de Rehabilitación, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
| | - Rosa Jorba-Martin
- Unidad de Cirugía HBP, Servicio de Cirugía General, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain; Grup de Recerca en Cirurgia General i Aparell Digestiu (RECERCGAD), Hospital Universitari de Tarragona Joan XXIII, Departament de Medicina i Cirurgia, Universitat Rovira i Virgili (URV), Institut d'Investigació de la Salut Pere Virgili (IISPV), Tarragona, Spain; Area del Paciente Quirúrgico Complejo, Hospital Universitari de Tarragona Joan XXIII, Tarragona, Spain
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Bhamidipaty M, Thillainadesan J, Rickard M, Keshava A, Lam V, Suen M. Non-home discharge in the octogenarian and nonagenarian colorectal cancer population: a retrospective cohort study. Int J Colorectal Dis 2025; 40:97. [PMID: 40259031 PMCID: PMC12011941 DOI: 10.1007/s00384-025-04891-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/08/2025] [Indexed: 04/23/2025]
Abstract
PURPOSE This study aims to determine the rate of non-home discharge (NHD) and identify factors associated with non-home discharge in a colorectal cancer (CRC) population of adults aged 80 years and older. This is the first study looking specifically at NHD as an outcome in the ≥ 80 years colorectal cancer cohort. METHODS This is a single-centre retrospective exploratory observational study from a high-volume colorectal cancer unit. Patients aged ≥ 80 years from a prospectively collected CRC database from 2013 to 2020 were included. Electronic medical records were assessed to obtain demographic, clinical, functional and discharge data. Univariable and multivariable logistic regression analyses were performed to identify factors associated with NHD the primary study outcome. Secondary outcomes included discharge disposition and functional decline. RESULTS Two hundred forty-two patients aged ≥ 80 years underwent CRC resection. Alo, 234 patients and 221 patients were included in the overall and subgroup non-home discharge analysis. The non-home discharge rate was 19.9% in the cohort that pre-operatively were from home. On multivariable logistic regression, after adjusting for other significant variables, frailty (odds ratio (OR) 2.91, 95% CI 1.25-6.75, p = 0.013), severe complications (OR 3.92, 95% CI 1.40-10.97, p = 0.009) and an open operation (OR 3.93, 95% CI 1.87-8.24, p < 0.001) were associated with a significantly higher rate of NHD. The incidence of functional decline from those at home was 72.4% in the non-home discharge group and 16.7% in those who returned home (p < 0.001). CONCLUSION This is the first paper describing the overall rate and identifying factors associated with non-home discharge specifically in the ≥ 80 years CRC population. Prospective studies are required to investigate causality and interventions to reduce non-home discharge rates.
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Affiliation(s)
- Madhu Bhamidipaty
- Department of Colorectal Surgery, Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia.
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia.
- Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia.
- Division of Colorectal Surgery, Department of Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia.
- Department of Colorectal Surgery, Launceston General Hospital, Launceston, TAS, Australia.
| | - Janani Thillainadesan
- Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Matthew Rickard
- Department of Colorectal Surgery, Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
- Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Discipline of Surgery, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Division of Colorectal Surgery, Department of Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Anil Keshava
- Department of Colorectal Surgery, Macquarie University Hospital, Macquarie University, Sydney, NSW, Australia
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
- Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Discipline of Surgery, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Division of Colorectal Surgery, Department of Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Vincent Lam
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Michael Suen
- Macquarie Medical School, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, NSW, Australia
- Concord Institute of Academic Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
- Discipline of Surgery, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Division of Colorectal Surgery, Department of Surgery, Concord Repatriation General Hospital, Sydney, NSW, Australia
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Schulz LN, Edwards S, Hamilton MG, Isaacs AM. Cerebrospinal Fluid Shunts to Treat Hydrocephalus and Idiopathic Intracranial Hypertension: Surgical Techniques and Complication Avoidance. Neurosurg Clin N Am 2025; 36:255-268. [PMID: 40054977 DOI: 10.1016/j.nec.2024.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2025]
Abstract
This article provides an in-depth review of cerebrospinal fluid (CSF) shunts for managing hydrocephalus and idiopathic intracranial hypertension, with a focus on advanced surgical techniques and strategies to prevent complications. It examines the placement of ventricular, lumbar, peritoneal, atrial, and pleural catheters, highlighting the benefits of neuro-navigation, endoscopic visualization, and laparoscopic-assisted approaches. Evidence-based methods to reduce shunt infections, malfunctions, and overdrainage are discussed, along with a comparative analysis of shunt types tailored to individual patient needs. The article also explores innovations such as programmable valves, antimicrobial coatings, and transesophageal echocardiography, offering insights into future directions for optimizing CSF shunting outcomes.
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Affiliation(s)
- Lauren N Schulz
- Department of Neurological Surgery, Ohio State University College of Medicine, 410 West 10th Avenue, Columbus, OH 43210, USA
| | - Sara Edwards
- Division of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, Foothills Hospital, 1403 - 29th Street Northwest, Calgary, Alberta T2N 2T9, Canada
| | - Mark G Hamilton
- Division of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, Foothills Hospital, 1403 - 29th Street Northwest, Calgary, Alberta T2N 2T9, Canada
| | - Albert M Isaacs
- Department of Neurological Surgery, Ohio State University College of Medicine, 410 West 10th Avenue, Columbus, OH 43210, USA; Department of Pediatric Neurosurgery, Nationwide Children's Hospital, 4th Floor Faculty Office Building, 700 Children's Drive, Columbus, OH 43205, USA.
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Antunes Santos R, Fraga T, Caetano AC, Póvoa S, Bonito N. Curative Management of Synchronous Lung and Pancreatic Adenocarcinomas in an Older Patient: A Multidisciplinary Case Report. Cureus 2025; 17:e79401. [PMID: 40125134 PMCID: PMC11929971 DOI: 10.7759/cureus.79401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2025] [Indexed: 03/25/2025] Open
Abstract
Synchronous primary malignancies are uncommon and represent diagnostic and therapeutic challenges, particularly for elderly patients with comorbidities. We report the case of a 78-year-old man with distinct primary adenocarcinomas of the lung and pancreas who was successfully treated with a curative-intent approach. Initially exhibiting unintentional weight loss, asthenia, and gastrointestinal complaints, the initial diagnostic workup, which included computed tomography (CT) and positron emission tomography/computed tomography (PET/CT), revealed a spiculated lesion in the left upper lobe and, incidentally, a hypermetabolic lesion in the pancreatic body. Due to the increased clinical suspicion and the potential for symptomatic progression, the pulmonary lesion was prioritized for further assessment investigation. Bronchial brush cytology indicated non-small cell lung adenocarcinoma, resulting in a left upper lobectomy with lymph node dissection. Histopathology confirmed a 31 mm mixed adenocarcinoma with pleural extension and mediastinal nodal involvement (stage IIIA). After adjuvant chemoradiotherapy, complicated by hematologic toxicity, further evaluation of the pancreatic lesion was conducted. A laparoscopic splenopancreatectomy revealed a 10 mm pancreatic ductal adenocarcinoma from an intraductal papillary mucinous neoplasm (stage IA). The patient underwent six cycles of adjuvant gemcitabine and capecitabine, showing no evidence of recurrence in follow-up imaging. This case features the importance of comprehensive imaging, multidisciplinary collaboration, and personalized treatment in managing synchronous malignancies, particularly considering the treatment approach for elderly patients.
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Affiliation(s)
- Rita Antunes Santos
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, Entidade Pública Empresarial (E.P.E), Coimbra, PRT
| | - Teresa Fraga
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, Entidade Pública Empresarial (E.P.E), Coimbra, PRT
| | - Ana Carlota Caetano
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, Entidade Pública Empresarial (E.P.E), Coimbra, PRT
| | - Sara Póvoa
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, E.P.E., Coimbra, PRT
| | - Nuno Bonito
- Medical Oncology, Instituto Português de Oncologia de Coimbra Francisco Gentil, Entidade Pública Empresarial (E.P.E), Coimbra, PRT
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Lam AB, Sorensen L, Moore VA, Bouvette MJ, Diaz Barba A, Clifton S, Wismann A, Keyser K, Shinall MC, Nipp RD. Perioperative Supportive Care Interventions to Enhance Surgical Outcomes for Older Adults With Cancer: A Systematic Review. JCO Oncol Pract 2025:OP2400762. [PMID: 39854660 DOI: 10.1200/op-24-00762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2024] [Revised: 10/30/2024] [Accepted: 12/09/2024] [Indexed: 01/26/2025] Open
Abstract
PURPOSE Older adults with cancer have unique needs, which likely influence surgical outcomes in the geriatric oncology population. We conducted a systematic review to describe the literature focused on perioperative supportive care interventions for older adults with cancer undergoing surgery. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we performed a comprehensive search using the Ovid MEDLINE, CINAHL, and Embase databases for literature published from January 2010 to October 2023. We included randomized controlled trials (RCTs) focusing on supportive care interventions that enrolled adults older than 60 years with cancer. RESULTS We included 11 RCTs with 2,177 patients in this review. Patients' age ranged from 60 to 95, and the median number of patients per study was 147 (range, 44-690). Most studies included patients with colorectal cancer (81.8%). Half of the studies (54.5%) evaluated exercise interventions, and the remaining assessed geriatric assessment-guided interventions (27.2%), nutrition optimization (9.1%), and patient empowerment (9.1%). Primary outcomes included postoperative complications, quality of life, feasibility of exercise programs, inspiratory muscle endurance, and hospital length of stay, among others. All studies had postoperative complications as a primary or secondary outcome. We found implementation challenges that influenced several studies, including high dropout rates and intervention fidelity. CONCLUSION We found 11 studies focused on perioperative supportive care interventions in older adults with cancer undergoing surgery. Notably, interventions involved exercise, geriatric assessment-guided care, nutrition optimization, and patient empowerment. We also found heterogeneity in intervention modality and outcome assessment, thus demonstrating a need for ongoing work to address the unique needs of the geriatric oncology population.
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Affiliation(s)
- Anh B Lam
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Luke Sorensen
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Vanessa A Moore
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Max J Bouvette
- College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Adolfo Diaz Barba
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Shari Clifton
- Robert M. Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Wismann
- Division of Geriatrics, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Katie Keyser
- Section of Hematology & Oncology, Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK
| | - Myrick C Shinall
- Division of General Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN
- Geriatrics Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, TN
| | - Ryan David Nipp
- Section of Hematology & Oncology, Department of Medicine, University of Oklahoma Health Sciences Center, Stephenson Cancer Center, Oklahoma City, OK
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Peters XD, Zhang LM, Liu Y, Cohen ME, Rosenthal RA, Ko CY, Russell MM. Octogenarians unable to return home by postoperative-day 30. Am J Surg 2024; 238:115926. [PMID: 39303481 DOI: 10.1016/j.amjsurg.2024.115926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/15/2024] [Accepted: 08/21/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND For older adults undergoing surgery, returning home is instrumental for functional independence. We quantified octogenarians unable to return home by POD-30, assessed geriatric factors in a predictive model, and identified risk factors to inform decision-making and quality improvement. METHODS This retrospective cohort study examined patients ≥80 years old from the ACS NSQIP Geriatric Surgery Pilot, using sequential logistic regression modelling. The primary outcome was non-home living location at POD-30. RESULTS Of 4946 patients, 19.8 % lived in non-home facilities at POD-30. Increased odds of non-home living location were seen in patients with preoperative fall history (OR 2.92, 95%CI 2.06-4.14) and new postoperative pressure ulcer (OR 2.66, 95%CI 1.50-4.71) Other significant geriatric-specific risk factors included mobility aid use, surrogate-signed consent, and postoperative delirium, with odds ratios ranging from 1.42 (1.19-1.68) to 1.97 (1.53-2.53). CONCLUSIONS These geriatric-specific risk factors highlight the importance of preoperative vulnerability screening and intervention to inform surgical decision-making.
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Affiliation(s)
- Xane D Peters
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago, IL, USA; Loyola University Medical Center, Department of Surgery, Maywood, IL, USA.
| | - Lindsey M Zhang
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago, IL, USA; University of Chicago Medical Center, Department of Surgery, Chicago, IL, USA; Washington University School of Medicine, Department of Surgery, St. Louis, MO, USA
| | - Yaoming Liu
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago, IL, USA
| | - Mark E Cohen
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago, IL, USA
| | - Ronnie A Rosenthal
- Yale University, Department of Surgery, New Haven, CT, USA; Veteran Affairs Connecticut Healthcare System, West Haven, CT, USA
| | - Clifford Y Ko
- American College of Surgeons, Division of Research and Optimal Patient Care, Chicago, IL, USA; David Geffen School of Medicine at the University of California Los Angeles, Department of Surgery, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Marcia M Russell
- David Geffen School of Medicine at the University of California Los Angeles, Department of Surgery, Los Angeles, CA, USA; VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Chang GJ, Gunn HJ, Barber AK, Lowenstein LM, Dohan D, Broering J, Dockter T, Tan AD, Dueck A, Chow S, Neuman H, Finlayson E. Improving Surgical Care and Outcomes in Older Cancer Patients Through Implementation of a Presurgical Toolkit (OPTI-Surg)-Final Results of a Phase III Cluster Randomized Trial (Alliance A231601CD). Ann Surg 2024; 280:623-632. [PMID: 39069901 PMCID: PMC11728768 DOI: 10.1097/sla.0000000000006458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
OBJECTIVE To assess the effect of a practice-level preoperative frailty screening and optimization toolkit (OPTI-Surg) on postoperative functional recovery and complications in elderly cancer patients undergoing major surgery. BACKGROUND Frailty is common in older adults. It increases the risk of poor postoperative functional recovery and complications. The potential for a practice-level screening/optimization intervention to improve outcomes is unknown. METHODS Thoracic, gastrointestinal, and urologic oncological surgery practices within the National Cancer Institute Community Oncology Research Program (NCORP) were randomized 1:1:1 to usual care (UC), OPTI-Surg, or OPTI-Surg with an implementation coach. OPTI-Surg consisted of the Edmonton Frail Scale and guided recommendations for referral interventions. Patients 70 years old or above undergoing curative intent surgery were eligible. The primary outcome was 8 weeks postoperative function (kcal/wk). The key secondary outcome was complications within 90 days. Mixed models were used to compare UC to the 2 OPTI-Surg arms combined. RESULTS From July 2019 to September 2022, 325 patients were enrolled in 29 practices. One hundred ninety-nine (64 UC, 135 OPTI-Surg) and 279 (78 UC, 201 OPTI-Surg) were evaluable for primary and secondary analysis, respectively. UC and OPTI-Surg patients did not significantly differ in total caloric expenditure (2.2 UC, 2.0 OPTI-Surg) after adjusting for baseline function ( P =0.53). UC and OPTI-Surg patients did not significantly differ in postoperative complications (25.6% UC, 35.3% OPTI-Surg, P =0.5). CONCLUSIONS Frailty assessment was successfully performed, but the OPTI-Surg intervention did not improve postoperative function nor reduce postoperative complications compared with UC. Future analysis will explore practice-level factors associated with toolkit implementation and the differences between the coaching and noncoaching arms.
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Affiliation(s)
- George J. Chang
- Department of Colon and Rectal Surgery, the University of Texas MD Anderson Cancer Center, Houston, TX
- Department of Health Services Research, the University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Heather J. Gunn
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN
| | | | - Lisa M. Lowenstein
- Department of Health Services Research, the University of Texas, MD Anderson Cancer Center, Houston, TX
| | - Daniel Dohan
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA
| | | | - Travis Dockter
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN
| | - Angelina D. Tan
- Alliance Statistics and Data Management Center, Mayo Clinic, Rochester, MN
| | - Amylou Dueck
- Alliance Statistics and Data Management Center, Scottsdale, AZ
| | - Selina Chow
- Alliance Protocol Operations Office, University of Chicago, Chicago, IL
| | - Heather Neuman
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, CA
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Theodorakis N, Nikolaou M, Hitas C, Anagnostou D, Kreouzi M, Kalantzi S, Spyridaki A, Triantafylli G, Metheniti P, Papaconstantinou I. Comprehensive Peri-Operative Risk Assessment and Management of Geriatric Patients. Diagnostics (Basel) 2024; 14:2153. [PMID: 39410557 PMCID: PMC11475767 DOI: 10.3390/diagnostics14192153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2024] [Revised: 09/18/2024] [Accepted: 09/26/2024] [Indexed: 10/20/2024] Open
Abstract
Background: As the population ages, the prevalence of surgical interventions in individuals aged 65+ continues to increase. This poses unique challenges due to the higher incidence of comorbidities, polypharmacy, and frailty in the elderly population, which result in high peri-operative risks. Traditional preoperative risk assessment tools often fail to accurately predict post-operative outcomes in the elderly, overlooking the complex interplay of factors that contribute to risk in the elderly. Methods: A literature review was conducted, focusing on the predictive value of CGA for postoperative prognosis and the implementation of perioperative interventions. Results: Evidence shows that CGA is a superior predictive tool compared to traditional models, as it more accurately identifies elderly patients at higher risk of complications such as postoperative delirium, infections, and prolonged hospital stays. CGA includes assessments of frailty, sarcopenia, nutritional status, cognitive function, mental health, and functional status, which are crucial in predicting post-operative outcomes. Studies demonstrate that CGA can also guide personalized perioperative care, including nutritional support, physical training, and mental health interventions, leading to improved surgical outcomes and reduced functional decline. Conclusions: The CGA provides a more holistic approach to perioperative risk assessment in elderly patients, addressing the limitations of traditional tools. CGA can help guide surgical decisions (e.g., curative or palliative) and select the profiles of patients that will benefit from perioperative interventions to improve their prognosis and prevent functional decline.
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Affiliation(s)
- Nikolaos Theodorakis
- School of Medicine, National, and Kapodistrian University of Athens, 75 Mikras Asias, 11527 Athens, Greece;
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (C.H.); (D.A.)
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
| | - Maria Nikolaou
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (C.H.); (D.A.)
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
| | - Christos Hitas
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (C.H.); (D.A.)
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
| | - Dimitrios Anagnostou
- Department of Cardiology, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (C.H.); (D.A.)
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
| | - Magdalini Kreouzi
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
- Department of Internal Medicine, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Sofia Kalantzi
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
- Department of Internal Medicine, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Aikaterini Spyridaki
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
- Department of Internal Medicine, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece
| | - Gesthimani Triantafylli
- Geriatric Outpatient Clinic, Sismanogleio-Amalia Fleming General Hospital, 14 25is Martiou Str., 15127 Melissia, Greece; (M.K.); (S.K.); (A.S.); (G.T.)
| | - Panagiota Metheniti
- Second Department of Surgery, Aretaieion General Hospital, National and Kapodistrian University of Athens, 76 Vasilissis Sofias Ave., 11528 Athens, Greece; (P.M.); (I.P.)
| | - Ioannis Papaconstantinou
- Second Department of Surgery, Aretaieion General Hospital, National and Kapodistrian University of Athens, 76 Vasilissis Sofias Ave., 11528 Athens, Greece; (P.M.); (I.P.)
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Yao J, Zhao X, Chen J, Liu T, Song Y, Dang J. Treatment strategies for elderly patients with locally advanced esophageal cancer: a systematic review and meta-analysis. BMC Cancer 2024; 24:1101. [PMID: 39232734 PMCID: PMC11373433 DOI: 10.1186/s12885-024-12853-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2024] [Accepted: 08/26/2024] [Indexed: 09/06/2024] Open
Abstract
BACKGROUND Neoadjuvant chemoradiotherapy (nCRT) followed by surgery remains a standard of care for resectable esophageal cancer (EC), and definitive chemoradiotherapy (dCRT) is an alternative for unresectable diseases. However, it is controversial for the use of the two aggressive regimens in elderly patients. METHODS We systematically searched multiple databases for studies comparing overall survival (OS) and/or progression-free survival (PFS) between dCRT and surgery (nCRT + surgery or surgery alone) or between dCRT and radiotherapy (RT) alone in elderly patients (age ≥ 65 years) until March 28, 2024. Statistical analysis was performed using random-effects model. RESULTS Fourty-five studies with 33,729 patients were included. dCRT significantly prolonged OS (hazard ratio [HR] = 0.64, 95% confidence interval [CI]: 0.58-0.70) and PFS (HR = 0.67, 95% CI: 0.60-0.76) compared to RT alone for unresectable EC, and resulted in a worse OS compared to surgery for resectable cases (HR = 1.34, 95% CI: 1.23-1.45). Similar results of OS were also observed when the multivariate-adjusted HRs were used as the measure of effect (dCRT vs. RT alone: HR = 0.65, 95% CI: 0.58-0.73; dCRT vs. surgery: HR = 1.49, 95% CI: 1.28-1.74). Subgroup analyses according to age group (≥ 70, ≥ 75, or ≥ 80 years), study design, study region, histological type, radiation field, chemotherapy regimen revealed comparable results. CONCLUSIONS nCRT + surgery is likely a preferred strategy for elderly patients with good physiological conditions; and dCRT is a better alternative for unresectable cases. Advanced age alone does not appear to be a key predictor for the tolerability of the two aggressive treatments.
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Affiliation(s)
- Jiacheng Yao
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Xinyu Zhao
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China
| | - Jun Chen
- Department of Radiation Oncology, Shenyang Tenth People's Hospital, Shenyang, China
| | - Tingting Liu
- Department of Radiation Oncology, Anshan Cancer Hospital, Anshan, China
| | - Yaowen Song
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China.
| | - Jun Dang
- Department of Radiation Oncology, The First Hospital of China Medical University, Shenyang, China.
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10
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Boerner T, Sewell M, Tin AL, Vickers AJ, Harrington-Baksh C, Bains MS, Bott MJ, Park BJ, Sihag S, Jones DR, Downey RJ, Shahrokni A, Molena D. A Novel Frailty Index Can Predict the Short-Term Outcomes of Esophagectomy in Older Patients with Esophageal Cancer. Curr Oncol 2024; 31:4685-4694. [PMID: 39195332 PMCID: PMC11352928 DOI: 10.3390/curroncol31080349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 08/29/2024] Open
Abstract
Background: Frailty, rather than age, is associated with postoperative morbidity and mortality. We sought to determine whether preoperative frailty as defined by a novel scoring system could predict the outcomes among older patients undergoing esophagectomy. Methods: We identified patients 65 years or older who underwent esophagectomy between 2011 and 2021 at our institution. Frailty was assessed using the MSK-FI, which consists of 1 component related to functional status and 10 medical comorbidities. We used a multivariable logistic regression model to test for the associations between frailty and short-term outcomes, with continuous frailty score as the predictor and additionally adjusted for age and Eastern Cooperative Oncology Group performance status. Results: In total, 447 patients were included in the analysis (median age of 71 years [interquartile range, 68-75]). Most of the patients underwent neoadjuvant treatment (81%), an Ivor Lewis esophagectomy (86%), and minimally invasive surgery (55%). A total of 22 patients (4.9%) died within 90 days of surgery, 144 (32%) had a major complication, 81 (19%) were readmitted, and 31 (7.2%) were discharged to a facility. Of the patients who died within 90 days, 19 had a major complication, yielding a failure-to-rescue rate of 13%. The risk of 30-day major complications (OR, 1.24 [95% CI, 1.09-1.41]; p = 0.001), readmissions (OR, 1.31 [95% CI, 1.13-1.52]; p < 0.001), and discharge to a facility (OR, 1.86 [95% CI, 1.49-2.37]; p < 0.001) increased with increasing frailty. Frailty and 90-day mortality were not associated. Conclusions: Frailty assessment during surgery decision-making can identify patients with a high risk of morbidity.
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Affiliation(s)
- Thomas Boerner
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Marisa Sewell
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Amy L. Tin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Andrew J. Vickers
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Caitlin Harrington-Baksh
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Manjit S. Bains
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Matthew J. Bott
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Bernard J. Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Smita Sihag
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - David R. Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Robert J. Downey
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Armin Shahrokni
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Daniela Molena
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
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11
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Desouza C, Shetty V. Beyond one step: unveiling optimal approach for bilateral knee arthroplasty - a comprehensive meta-analysis. Arch Orthop Trauma Surg 2024; 144:3631-3639. [PMID: 39039313 DOI: 10.1007/s00402-024-05454-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 07/02/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Total knee arthroplasty (TKA) is an efficient and common procedure used to treat advanced osteoarthritis of the knee. Geriatric patients make up the majority of TKA patients. For the surgical management of bilateral knee arthritis, there is still debate regarding whether to do a simultaneous or staged TKA. We through this study have gathered data and aimed to assess the safety of simultaneous bilateral TKA in patients. MATERIALS AND METHODS We conducted a study according to the PRISMA guidelines by searching through various databases for the following search terms: total knee arthroplasty (TKA), complications following TKA, bilateral TKA, and bilateral vs. unilateral TKA. The search included case series and clinical trials and excluded review articles, yielding 24 articles from the original search. We extracted data upon the outcomes in patients undergoing simultaneous bilateral TKA. We performed additional bias assessments to validate our search algorithm and results. RESULTS One hundred and three published articles were identified, and twenty-four that included a total of 2, 18,385 patients were included in the meta-analysis. 93,074 patients underwent simultaneous bilateral TKA and 125,311 patients underwent staged bilateral TKA. Simultaneous bilateral TKA was associated with significantly increased mortality rate (P < 0.00001, Odd's ratio [OR] 1.86, 95% Confidence interval [CI] 1.53-2.26), increased incidence of pulmonary embolism (P < 0.00001, OR 1.58, 95% CI 1.30-1.91), deep venous thrombosis (P < 0.00001, OR 1.31, 95% CI 1.17-1.46), and neurological complications (P < 0.002, OR 1.44, 95% CI 1.14-1.82). There were no significant differences in cardiac complications between both the procedures (P = 0.60, OR 0.93, 95% CI 0.70-1.23). CONCLUSION Staged bilateral TKA is associated with less complication rates as compared to simultaneous bilateral TKA. Hence, patients should be counselled and selected based on the risks respective to each strategy.
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Affiliation(s)
- Clevio Desouza
- SAANVI Orthopaedics, Sorrento Building, High St, Hiranandani Gardens, Powai, Mumbai, 400076, Maharashtra, India.
- Centre for Bone and Joints, Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, Mumbai, India.
| | - Vijay Shetty
- SAANVI Orthopaedics, Sorrento Building, High St, Hiranandani Gardens, Powai, Mumbai, 400076, Maharashtra, India
- Dr L H Hiranandani Hospital, Powai, Mumbai, India
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12
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Yamada S, Oshima K, Nomoto K, Sunagawa Y, Oshima Y, Nakao A. The survival in octogenarians undergoing surgery for pancreatic cancer and its association with the nutritional status. Surg Today 2024; 54:734-742. [PMID: 38112860 DOI: 10.1007/s00595-023-02782-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/01/2023] [Indexed: 12/21/2023]
Abstract
PURPOSES This study explored the association between the nutritional status and survival outcomes after pancreatic cancer surgery and reconsidered surgical indications in octogenarians. METHODS Three hundred and ninety-three consecutive pancreatic cancer patients who underwent resection were analyzed and grouped according to age (< 70 years old; septuagenarians [70-79 years old], and octogenarians [80-89 years old]). The Charlson age comorbidity index and nutritional parameters were recorded. Survival outcomes and their association with nutritional parameters and prognostic factors were examined. RESULTS The overall survival was worse in the octogenarians than in other patients. The median overall survivals in the < 70 years old group, septuagenarians, and octogenarians were 27.2, 26.4, and 15.3 months, respectively (P = 0.0828). DUPAN-2 ≥ 150 U/mL, borderline resectable/unresectable tumors, blood loss volume ≥ 500 mL, and blood transfusion were predictors of the overall survival among octogenarians. Nutritional parameter values were worse in the octogenarians than in other patients. The octogenarian age group was not an independent predictor of postoperative complications in a univariate analysis. CONCLUSIONS Survival outcomes were poor in octogenarians. However, an age ≥ 80 years old alone should not be considered a contraindication for pancreatic cancer surgery. The maintenance of perioperative nutritional status is an important factor associated with the survival.
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Affiliation(s)
- Suguru Yamada
- Department of Gastroenterological Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan.
| | - Kenji Oshima
- Department of Gastroenterological Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Kosuke Nomoto
- Department of Gastroenterological Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Yuki Sunagawa
- Department of Gastroenterological Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Yukiko Oshima
- Department of Gastroenterological Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
| | - Akimasa Nakao
- Department of Gastroenterological Surgery, Nagoya Central Hospital, 3-7-7 Taiko, Nakamura-ku, Nagoya, 453-0801, Japan
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13
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Tomida R, Fukawa T, Kusuhara Y, Hashimoto K, Shiozaki K, Izumi K, Ninomiya I, Kadoriku F, Izaki H, Naroda T, Okamoto K, Kawanishi Y, Kanayama HO, Takahashi M. Robot-assisted partial nephrectomy in younger versus older adults with renal cell carcinoma: a propensity score-matched analysis. World J Urol 2024; 42:326. [PMID: 38748308 DOI: 10.1007/s00345-024-04917-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 01/17/2024] [Indexed: 06/15/2024] Open
Abstract
PURPOSE Our study aimed to compare the surgical outcomes of robot-assisted partial nephrectomy (RAPN) between younger and older patients after adjusting for their background differences. We particularly assessed RAPN outcomes and safety in older patients. METHODS We retrospectively evaluated 559 patients clinically diagnosed with T1 renal cell carcinoma (RCC) and treated with RAPN between 2013 and 2022 at five institutions in Japan. The patients were classified into two groups according to their age during surgery (younger group: < 75 years, older group: ≥ 75 years). Propensity score matching (PSM) was performed to adjust for the differences in the backgrounds between younger and older patients, and surgical outcomes were compared. RESULTS Among the 559 patients, 422 (75.5%) and 137 (24.5%) were classified into the younger and older groups, respectively; 204 and 102 patients from the younger and older groups were matched according to PSM, respectively. Subsequently, patient characteristics other than age were not significantly different between the two groups. In the matched cohort, the older group had more patients with major complications (younger, 3.0%; older, 8.8%; P = 0.045). CONCLUSION Surgical outcomes of RAPN in older patients with RCC were comparable with those in younger patients, although older patients experiencedsignificantly more complications than younger patients. These results suggest the need for further detailed preoperative evaluation and appropriate postoperative management in older patients receiving RAPN.
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Affiliation(s)
- Ryotaro Tomida
- Department of Urology, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Tomoya Fukawa
- Department of Urology, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan.
| | - Yoshito Kusuhara
- Department of Urology, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
| | | | - Keito Shiozaki
- Tokushima Prefectural Central Hospital, Tokushima, Japan
| | | | - Iku Ninomiya
- Ehime Prefectural Central Hospital, Matsuyama, Japan
| | | | - Hirofumi Izaki
- Tokushima Prefectural Central Hospital, Tokushima, Japan
| | | | | | | | - Hiro-Omi Kanayama
- Department of Urology, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Masayuki Takahashi
- Department of Urology, Tokushima University Graduate School of Biomedical Sciences, 3-18-15, Kuramoto-cho, Tokushima, 770-8503, Japan
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14
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Chumdermpadetsuk RR, Garland M, Polanco-Santana JC, Callery MP, Kent TS. Predictors of non-home discharge after pancreatoduodenectomy in patients aged 80 years and above. HPB (Oxford) 2024; 26:410-417. [PMID: 38129275 DOI: 10.1016/j.hpb.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 11/22/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Pancreatic cancer has the highest growth in incidence among patients aged ≥80 years. Discharge destination after hospitalization is increasingly recognized as a marker of return to baseline functional status. Our aim was to identify the preoperative and intraoperative predictors of non-home discharge in those aged 80 or older. METHODS The ACS-NSQIP pancreas-targeted database was queried to identify patients aged ≥80 years who underwent pancreatoduodenectomy (PD) from 2014 to 2020. Home discharge (HD) versus non-HD cohorts were compared using univariate logistic regression. Multivariable logistic regression was used to identify predictors of non-HD. RESULTS Non-HD was over twice as likely to occur in patients aged ≥80 years than in those aged 65-79 years (p < 0.01). Comorbidity factors significantly associated with non-HD in patients aged ≥80 years included COPD, hypertension, HF, lower preoperative albumin, but not obesity. Non-comorbidity factors included older age, female gender, ASA III-IV, preoperative dependent functional status, and transfer origin before PD. CONCLUSION Individuals ≥80 years have possibly delayed or lower rate of return to baseline functional status following PD compared to those aged 65-79 years. Predictors of non-HD can be identified to facilitate preoperative counseling and discharge planning, thus enhancing care workflow efficiency.
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Affiliation(s)
- Ritah R Chumdermpadetsuk
- Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Ave, Boston, MA 02215, USA.
| | - Mateo Garland
- Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Ave, Boston, MA 02215, USA
| | | | - Mark P Callery
- Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Ave, Boston, MA 02215, USA
| | - Tara S Kent
- Beth Israel Deaconess Medical Center, Department of Surgery, 330 Brookline Ave, Boston, MA 02215, USA
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15
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Chen SY, Radomski SN, Stem M, Papanikolaou A, Gabre-Kidan A, Gearhart SL, Efron JE, Atallah C. Factors associated with not undergoing surgery for locally advanced rectal cancers: An NCDB propensity-matched analysis. Surgery 2023; 174:1323-1333. [PMID: 37852832 DOI: 10.1016/j.surg.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 08/01/2023] [Accepted: 09/05/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The traditional treatment paradigm for patients with locally advanced rectal cancers has been neoadjuvant chemoradiation followed by curative intent surgery and adjuvant chemotherapy. This study aimed to assess surgery trends for locally advanced rectal cancers, factors associated with forgoing surgery, and overall survival outcomes. METHODS Adults with locally advanced rectal cancers were retrospectively analyzed using the National Cancer Database (2004-2019). Propensity score matching was performed. Factors associated with not undergoing surgery were identified using multivariable logistic regression. Kaplan-Meier and log-rank tests were used for 5-year overall survival analysis, stratified by stage and treatment type. RESULTS A total of 72,653 patients were identified, with 64,396 (88.64%) patients undergoing neoadjuvant + surgery ± adjuvant therapy, 579 (0.80%) chemotherapy only, 916 (1.26%) radiation only, and 6,762 (9.31%) chemoradiation only. The proportion of patients who underwent surgery declined over the study period (95.61% in 2006 to 92.29% in 2019, P trend < .001), whereas the proportion of patients who refused surgery increased (1.45%-4.48%, P trend < .001). Factors associated with not undergoing surgery for locally advanced rectal cancers included older age, Black race (odds ratio 1.47, 95% CI 1.35-1.60, P < .001), higher Charlson-Deyo score (score ≥3: 1.79, 1.58-2.04, P < .001), stage II cancer (1.22, 1.17-1.28, P < .001), lower median household income, and non-private insurance. Neoadjuvant + surgery ± adjuvant therapy was associated with the best 5-year overall survival, regardless of stage, in unmatched and matched cohorts. CONCLUSION Despite surgery remaining an integral component in the management of locally advanced rectal cancers, there is a concerning decline in guideline-concordant surgical care for rectal cancer in the United States, with evidence of persistent socioeconomic disparities. Providers should seek to understand patient perspectives/barriers and guide them toward surgery if appropriate candidates. Continued standardization, implementation, and evaluation of rectal cancer care through national accreditation programs are necessary to ensure that all patients receive optimal treatment.
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Affiliation(s)
- Sophia Y Chen
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shannon N Radomski
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Miloslawa Stem
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Angelos Papanikolaou
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, NYU Langone Health, NYC, NY
| | - Alodia Gabre-Kidan
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Susan L Gearhart
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan E Efron
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chady Atallah
- Colorectal Research Unit, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, NYU Langone Health, NYC, NY.
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16
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Ahmed N, Tankel J, Asselah J, Alcindor T, Alfieri J, David M, Najmeh S, Spicer J, Cools-Lartigue J, Mueller C, Ferri L. Survival and perioperative outcomes of octo- and nonagenarians with resectable esophageal carcinoma. Dis Esophagus 2023; 36:doad043. [PMID: 37448141 DOI: 10.1093/dote/doad043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Indexed: 07/15/2023]
Abstract
The outcomes of different treatment modalities for patients aged 80 and above with locally advanced and resectable esophageal carcinoma are not well described. The aim of this study was to explore survival and perioperative outcomes among this specific group of patients. A retrospective, cohort analysis was performed on a prospectively maintained esophageal cancer database from the McGill regional upper gastroinestinal cancer network. Between 2010 and 2020, all patients ≥80 years with cT2-4a, Nany, M0 esophageal carcinoma were identified and stratified according to the treatment modality: Neoadjuvant chemotherapy (nCT) or chemoradiotherapy (nCRT); definitive CRT (dCRT); upfront surgery; palliative CT/RT; or best supportive care (BSC). Of the 162 patients identified, 79 were included in this study. The median age was 83 years (80-97), most were cT3 (73%), cN- (56%), and had adenocarcinoma (62%). Treatment included: nCT/nCRT (16/79, 20%); surgery alone (19/79, 24%); dCRT (12/29, 15%); palliative RT/CT (27/79, 34%); and BSC (5/79, 6%). Neoadjuvant treatment was completed in 10/16 (63%). Of the 35/79 who underwent surgery, major complications occurred in 13/35 (37%) and 90-day mortality in 3/35 (9%). Overall survival (OS) for the cohort at 1- and 3-years was 58% and 19%. Among patients treated with nCT/nCRT, this was 94% and 46% respectively. Curative intent treatment (nCT/nCRT/upfront surgery/dCRT) had significantly increased 1- and 3- year OS compared with non-curative treatment (76%/31% vs. 34%/3.3%). Multimodal standard of care treatment is feasible and safe in select octo/nonagenarians, and may be associated with improved OS. Age alone should not bias against treatment with curative intent.
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Affiliation(s)
- Nabeel Ahmed
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - James Tankel
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jamil Asselah
- Division of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Thierry Alcindor
- Division of Medical Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joanne Alfieri
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Marc David
- Department of Radiation Oncology, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sara Najmeh
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Spicer
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Jonathan Cools-Lartigue
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Carmen Mueller
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
| | - Lorenzo Ferri
- Division of Thoracic and Upper Gastrointestinal Surgery, McGill University Health Centre, Montreal General Hospital, Montreal, Quebec, Canada
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17
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Sykes DAW, Waguia R, Abu-Bonsrah N, Price M, Dalton T, Sperber J, Owolo E, Hockenberry H, Bishop B, Kruchko C, Barnholtz-Sloan JS, Erickson M, Ostrom QT, Goodwin CR. Associations between urbanicity and spinal cord astrocytoma management and outcomes. Cancer Epidemiol 2023; 86:102431. [PMID: 37478632 DOI: 10.1016/j.canep.2023.102431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND The management of spinal cord astrocytomas (SCAs) remains controversial and may include any combination of surgery, radiation, and chemotherapy. Factors such as urbanicity (metropolitan versus non-metropolitan residence) are shown to be associated with patterns of treatment and clinical outcomes in a variety of cancers, but the role urbanicity plays in SCA treatment remains unknown. METHODS The Central Brain Tumor Registry of the United States (CBTRUS) analytic dataset, which combines data from CDC's National Program of Cancer Registries (NPCR) and NCI's Surveillance, Epidemiology, and End Results Programs, was used to identify individuals with SCAs between 2004 and 2019. Individuals' county of residence was classified as metropolitan or non-metropolitan. Multivariable logistic regression models were used to evaluate associations between urbanicity and SCA. Cox proportional hazard models were constructed to assess the effect of urbanicity on survival using the NPCR survival dataset (2004-2018). RESULTS 1697 metropolitan and 268 non-metropolitan SCA cases were identified. The cohorts did not differ in age or gender composition. The populations had different racial/ethnic compositions, with a higher White non-Hispanic population in the non-metropolitan cohort (86 % vs 66 %, p < 0.001) and a greater Black non-Hispanic population in the metropolitan cohort (14 % vs 9.9 %, p < 0.001). There were no significant differences in likelihood of receiving comprehensive treatment (OR=0.99, 95 % CI [0.56, 1.65], p = >0.9), or survival (hazard ratio [HR]=0.92, p = 0.4) when non-metropolitan and metropolitan cases were compared. In the metropolitan cohort, there were statistically significant differences in SCA treatment patterns when stratified by race/ethnicity (p = 0.002). CONCLUSIONS Urbanicity does not significantly impact SCA management or survival. Race/ethnicity may be associated with likelihood of receiving certain SCA treatments in metropolitan communities.
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Affiliation(s)
- David A W Sykes
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Romaric Waguia
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Nancy Abu-Bonsrah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mackenzie Price
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA; Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Tara Dalton
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Jacob Sperber
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Edwin Owolo
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | | | - Brandon Bishop
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA; Trans-Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, MD, USA; Center for Biomedical Informatics & Information Technology (CBIIT), National Cancer Institute, Bethesda, MD, USA
| | - Melissa Erickson
- Department of Orthopedic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Quinn T Ostrom
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA; Central Brain Tumor Registry of the United States, Hinsdale, IL, USA; The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, NC, USA; Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - C Rory Goodwin
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA.
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18
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Maier CF, Schölch C, Zhu L, Nzomo MM, L’hoest H, Marschall U, Reißfelder C, Schölch S. Weekday-dependent long-term outcomes in gastrointestinal cancer surgery: a German population-based retrospective cohort study. Int J Surg 2023; 109:3126-3136. [PMID: 37418560 PMCID: PMC10583906 DOI: 10.1097/js9.0000000000000580] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/26/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND For most solid cancers, surgery represents the mainstay of curative treatment. Several studies investigating the effects of the weekday of surgery (WOS) on patient outcomes have yielded conflicting results. Barmer, the second-largest health insurance company in Germany, serves roughly 10% of the German population. The authors have used the Barmer database to evaluate how the weekday on which the surgery is performed influences long-term oncologic outcomes. METHODS For this retrospective cohort study, the Barmer database was used to investigate the effect of the WOS (Monday-Friday) on outcomes following oncological resections of the colorectum ( n =49 003), liver ( n =1302), stomach ( n =5027), esophagus ( n =1126), and pancreas ( n =6097). In total, 62 555 cases from 2008 to 2018 were included in the analysis. The endpoints were overall survival (OS), postoperative complications, and the necessity for therapeutic interventions or reoperations. The authors further examined whether the annual caseload or certification as a cancer center influenced the weekday effect. RESULTS The authors observed a significantly impaired OS for patients receiving gastric or colorectal resections on a Monday. Colorectal surgery performed on Mondays was associated with more postoperative complications and a higher probability of reoperations. The annual caseload or a certification as a colorectal cancer center had no bearing on the observed weekday effect. There is evidence that hospitals schedule older patients with more comorbidities earlier in the week, possibly explaining these findings. CONCLUSION This is the first study investigating the influence of the WOS on long-term survival in Germany. Our findings indicate that, in the German healthcare system, patients undergoing colorectal cancer surgery on Mondays have more postoperative complications and, therefore, require significantly more reoperations, ultimately lowering the OS. This surprising finding appears to reflect an attempt to schedule patients with higher postoperative risk earlier in the week as well as semi-elective patients admitted on weekends scheduled for surgery on the next Monday.
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Affiliation(s)
- Christopher F. Maier
- JCCU Translational Surgical Oncology (A430), German Cancer Research Center (DKFZ), Heidelberg
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | - Caroline Schölch
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | - Lei Zhu
- JCCU Translational Surgical Oncology (A430), German Cancer Research Center (DKFZ), Heidelberg
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | | | | | | | - Christoph Reißfelder
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
| | - Sebastian Schölch
- JCCU Translational Surgical Oncology (A430), German Cancer Research Center (DKFZ), Heidelberg
- DKFZ-Hector Cancer Institute, University Medical Center Mannheim
- Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim
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19
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Reddavid R, Sofia S, Puca L, Moro J, Ceraolo S, Jimenez-Rodriguez R, Degiuli M. Robotic Rectal Resection for Rectal Cancer in Elderly Patients: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:5331. [PMID: 37629373 PMCID: PMC10456068 DOI: 10.3390/jcm12165331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/01/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
Rectal cancer is estimated to increase due to an expanding aging population, thus affecting elderly patients more frequently. The optimal surgical treatment for this type of patient remains controversial because they are often excluded from or underrepresented in trials. This meta-analysis aimed to evaluate the feasibility and the safety of robotic surgery in elderly patients (>70 years old) undergoing curative treatment for rectal cancer. Studies comparing elderly (E) and young (Y) patients submitted to robotic rectal resection were searched on PubMed, Embase, and the Cochrane Library. Data regarding surgical oncologic quality, post-operative, and survival outcomes were extracted. Overall, 322 patients underwent robotic resection (81 in the E group and 241 in the Y group) for rectal cancer. No differences between the two groups were found regarding distal margins and the number of nodes yielded (12.70 in the E group vs. 14.02 in the Y group, p = 0.16). No differences were found in conversion rate, postoperative morbidity, mortality, and length of stay. Survival outcomes were only reported in one study. The results of this study suggest that elderly patients can be submitted to robotic resection for rectal cancer with the same oncologic surgical quality offered to young patients, without increasing postoperative mortality and morbidity.
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Affiliation(s)
- Rossella Reddavid
- University of Turin, Department of Oncology, Division of Surgical Oncology and Digestive Surgery, San Luigi University Hospital, 10043 Turin, Italy; (S.S.); (L.P.); (J.M.)
| | - Silvia Sofia
- University of Turin, Department of Oncology, Division of Surgical Oncology and Digestive Surgery, San Luigi University Hospital, 10043 Turin, Italy; (S.S.); (L.P.); (J.M.)
| | - Lucia Puca
- University of Turin, Department of Oncology, Division of Surgical Oncology and Digestive Surgery, San Luigi University Hospital, 10043 Turin, Italy; (S.S.); (L.P.); (J.M.)
| | - Jacopo Moro
- University of Turin, Department of Oncology, Division of Surgical Oncology and Digestive Surgery, San Luigi University Hospital, 10043 Turin, Italy; (S.S.); (L.P.); (J.M.)
| | - Simona Ceraolo
- Nursing Degree Program, Department of Clinical and Biological Sciences, University of Turin, 10124 Torino, Italy;
| | | | - Maurizio Degiuli
- University of Turin, Department of Oncology, Division of Surgical Oncology and Digestive Surgery, San Luigi University Hospital, 10043 Turin, Italy; (S.S.); (L.P.); (J.M.)
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20
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Kim SW. Surgical management for elderly patients with pancreatic cancer. Ann Surg Treat Res 2023; 105:63-68. [PMID: 37564946 PMCID: PMC10409631 DOI: 10.4174/astr.2023.105.2.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 06/01/2023] [Accepted: 06/04/2023] [Indexed: 08/12/2023] Open
Abstract
Pancreatic cancer, one of the diseases of the elderly, has dismal prognosis, demanding major surgery with high risk and life quality problems, especially in the elderly. Therefore, treatment selection, whether or not to undergo surgery, preoperative risk assessment, and perioperative management of the elderly are becoming critical issues. Although the elderly are expected to have higher morbidity and mortality and lower long-term survival outcomes, surgery is becoming safer over time. Appropriate surgical indication selection, patient-centered decision-making, adequate prehabilitation and postoperative geriatric care are expected to improve surgical outcomes in the elderly. Surgeons must have the concept of geriatric care, and efforts based on institutional systems and academic societies are required. If well selected and prepared, the same surgical principle as non-elderly patients can be applied to elderly patients. In this paper, the surgical treatment of elderly patients with pancreatic cancer is reviewed.
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Affiliation(s)
- Sun-Whe Kim
- Department of Surgery, Chung-Ang University Gwangmyeong Hospital, Gwangmyeong, Korea
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21
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Ma M, Peters XD, Zhang LM, Hornor M, Christensen K, Coleman J, Finlayson E, Flood KL, Katlic M, Lagoo-Deenadayalan S, Robinson TN, Rosenthal RA, Tang VL, Ko CY, Russell MM. Multisite Implementation of an American College of Surgeons Geriatric Surgery Quality Improvement Initiative. J Am Coll Surg 2023; 237:171-181. [PMID: 37185633 DOI: 10.1097/xcs.0000000000000723] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) Coalition for Quality in Geriatric Surgery (CQGS) identified standards of surgical care for the growing, vulnerable population of aging adults in the US. The aims of this study were to determine implementation feasibility for 30 selected standards, identify barriers and best practices in their implementation, and further refine these geriatric standards and verification process. STUDY DESIGN The CQGS requested participation from hospitals involved in the ACS NSQIP Geriatric Surgery Pilot Project, previous CQGS feasibility analyses, and hospitals affiliated with a core development team member. Thirty standards were selected for implementation. After implementation, site visits were conducted, and postvisit surveys were distributed. RESULTS Eight hospitals were chosen to participate. Program management (55%), immediate preoperative and intraoperative clinical care (62.5%), and postoperative clinical care (58%) had the highest mean percentage of "fully compliant" standards. Goals and decision-making (30%), preoperative optimization (28%), and transitions of care (12.5%) had the lowest mean percentage of fully compliant standards. Best practices and barriers to implementation were identified across 13 of the 30 standards. More than 80% of the institutions reported that participation changed the surgical care provided for older adults. CONCLUSIONS This study represents the first national implementation assessment undertaken by the ACS for one of its quality programs. The CQGS pilot testing was able to demonstrate implementation feasibility for 30 standards, identify challenges and best practices, and further inform dissemination of the ACS Geriatric Surgery Verification Program.
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Affiliation(s)
- Meixi Ma
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of Alabama at Birmingham Medical Center, Birmingham, AL (Ma)
| | - Xane D Peters
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, Loyola University Medical Center, Maywood, IL (Peters, Hornor)
| | - Lindsey M Zhang
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of Chicago Medical Center, Chicago, IL (Zhang)
| | - Melissa Hornor
- Department of Surgery, Loyola University Medical Center, Maywood, IL (Peters, Hornor)
| | - Kataryna Christensen
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
| | - JoAnn Coleman
- Sinai Center for Geriatric Surgery, Sinai Hospital, Baltimore, MD (Coleman, Katlic)
| | - Emily Finlayson
- Department of Surgery, University of California San Francisco, San Francisco, CA (Finlayson)
| | - Kellie L Flood
- Department of Medicine, Division of Geriatrics, Hospice, and Palliative Medicine, University of Alabama at Birmingham Medical Center, Birmingham, AL (Flood)
| | - Mark Katlic
- Sinai Center for Geriatric Surgery, Sinai Hospital, Baltimore, MD (Coleman, Katlic)
| | | | - Thomas N Robinson
- Department of Surgery, University of Colorado Denver, Aurora, CO (Robinson)
| | | | - Victoria L Tang
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, CA (Tang)
| | - Clifford Y Ko
- From the Division of Research and Optimal Patient Care, American College of Surgeons, Chicago, IL (Ma, Peters, Zhang, Christensen, Ko)
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA (Ko, Russell)
| | - Marcia M Russell
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA (Ko, Russell)
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22
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Lehtomäki K, Soveri LM, Osterlund E, Lamminmäki A, Uutela A, Heervä E, Halonen P, Stedt H, Aho S, Muhonen T, Ålgars A, Salminen T, Kallio R, Nordin A, Aroviita L, Nyandoto P, Kononen J, Glimelius B, Ristamäki R, Isoniemi H, Osterlund P. Resectability, Resections, Survival Outcomes, and Quality of Life in Older Adult Patients with Metastatic Colorectal Cancer (the RAXO-Study). J Clin Med 2023; 12:jcm12103541. [PMID: 37240646 DOI: 10.3390/jcm12103541] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Older adults are underrepresented in metastatic colorectal cancer (mCRC) studies and thus may not receive optimal treatment, especially not metastasectomies. The prospective Finnish real-life RAXO-study included 1086 any organ mCRC patients. We assessed repeated centralized resectability, overall survival (OS), and quality of life (QoL) using 15D and EORTC QLQ-C30/CR29. Older adults (>75 years; n = 181, 17%) had worse ECOG performance status than adults (<75 years, n = 905, 83%), and their metastases were less likely upfront resectable. The local hospitals underestimated resectability in 48% of older adults and in 34% of adults compared with the centralized multidisciplinary team (MDT) evaluation (p < 0.001). The older adults compared with adults were less likely to undergo curative-intent R0/1-resection (19% vs. 32%), but when resection was achieved, OS was not significantly different (HR 1.54 [CI 95% 0.9-2.6]; 5-year OS-rate 58% vs. 67%). 'Systemic therapy only' patients had no age-related survival differences. QoL was similar in older adults and adults during curative treatment phase (15D 0.882-0.959/0.872-0.907 [scale 0-1]; GHS 62-94/68-79 [scale 0-100], respectively). Complete curative-intent resection of mCRC leads to excellent survival and QoL even in older adults. Older adults with mCRC should be actively evaluated by a specialized MDT and offered surgical or local ablative treatment whenever possible.
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Grants
- 2016, 2018, 2019, 2020, 2021, 2022, 2023 Finska Läkaresällskapet
- 2019-2020, 2021, 2022-23 Finnish Cancer Foundation
- 2023 Swedish Cancer Society
- 2022-2023 Radium Hemmets Research Funds
- 2020-2022 Relander's Foundation
- 2016, 2017, 2018, 2019, 2020, 2021,2022, 2023 Competitive State Research Financing of the Expert Responsibility Area of Tampere, Helsinki and Turku
- Tukisäätiö 2019, 2020; OOO 2020 Tampere University Hospital
- 2019, 2020, 2021, 2022 Helsinki University Hospital
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Affiliation(s)
- Kaisa Lehtomäki
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Leena-Maija Soveri
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
- Home Care, Joint Municipal Authority for Health Care and Social Services in Keski-Uusimaa, 05850 Hyvinkää, Finland
| | - Emerik Osterlund
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185 Uppsala, Sweden
| | - Annamarja Lamminmäki
- Department of Oncology, Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1A, 70210 Kuopio, Finland
| | - Aki Uutela
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Eetu Heervä
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Päivi Halonen
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Hanna Stedt
- Department of Oncology, Kuopio University Hospital, Puijonlaaksontie 2, 70210 Kuopio, Finland
- Faculty of Health Sciences, University of Eastern Finland, Yliopistonranta 1A, 70210 Kuopio, Finland
| | - Sonja Aho
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Timo Muhonen
- Department of Oncology, South Carelia Central Hospital, Valto Käkelän Katu 1, 53130 Lappeenranta, Finland
| | - Annika Ålgars
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Tapio Salminen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
| | - Raija Kallio
- Department of Oncology, Oulu University Hospital, Kajaanintie 50, 90220 Oulu, Finland
| | - Arno Nordin
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Laura Aroviita
- Department of Oncology, Kanta-Häme Central Hospital, Ahvenistontie 20, 13530 Hämeenlinna, Finland
| | - Paul Nyandoto
- Department of Oncology, Päijät-Häme Central Hospital, Keskussairaalankatu 7, 15850 Lahti, Finland
| | - Juha Kononen
- Docrates Cancer Centre, Docrates Hospital, Saukonpaadenranta 2, 00180 Helsinki, Finland
- Department of Oncology, Central Finland Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland
| | - Bengt Glimelius
- Department of Immunology, Genetics and Pathology, Uppsala University, 75185 Uppsala, Sweden
| | - Raija Ristamäki
- Department of Oncology, Turku University Hospital, Hämeentie 11, 20520 Turku, Finland
- Department of Oncology, University of Turku, Kiinanmyllynkatu 10, 20520 Turku, Finland
| | - Helena Isoniemi
- Transplantation and Liver Surgery, Abdominal Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Surgery, Clinicum, University of Helsinki, 00014 Helsinki, Finland
| | - Pia Osterlund
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön Katu 34, 33520 Tampere, Finland
- Department of Oncology, Tays Cancer Centre, Tampere University Hospital, Teiskontie 35, 33520 Tampere, Finland
- Department of Oncology, Comprehensive Cancer Center, Helsinki University Hospital, 00290 Helsinki, Finland
- Department of Oncology, Clinicum, University of Helsinki, 00014 Helsinki, Finland
- Department of Gastrointestinal Oncology, Tema Cancer, Karolinska Universitetssjukhuset, Eugeniavägen 3, 17176 Solna, Sweden
- Department of Oncology-Pathology, Karolinska Institutet, Solnavägen 1, 17177 Solna, Sweden
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23
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Roeder F, Jensen AD, Lindel K, Mattke M, Wolf F, Gerum S. Geriatric Radiation Oncology: What We Know and What Can We Do Better? Clin Interv Aging 2023; 18:689-711. [PMID: 37168037 PMCID: PMC10166100 DOI: 10.2147/cia.s365495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Elderly patients represent a growing subgroup of cancer patients for whom the role of radiation therapy is poorly defined. Older patients are still clearly underrepresented in clinical trials, resulting in very limited high-level evidence. Moreover, elderly patients are less likely to receive radiation therapy in similar clinical scenarios compared to younger patients. However, there is no clear evidence for a generally reduced radiation tolerance with increasing age. Modern radiation techniques have clearly reduced acute and late side effects, thus extending the boundaries of the possible regarding treatment intensity in elderly or frail patients. Hypofractionated regimens have further decreased the socioeconomic burden of radiation treatments by reducing the overall treatment time. The current review aims at summarizing the existing data for the use of radiation therapy or chemoradiation in elderly patients focusing on the main cancer types. It provides an overview of treatment tolerability and outcomes with current standard radiation therapy regimens, including possible predictive factors in the elderly population. Strategies for patient selection for standard or tailored radiation therapy approaches based on age, performance score or comorbidity, including the use of prediction tests or geriatric assessments, are discussed. Current and future possibilities for improvements of routine care and creation of high-level evidence in elderly patients receiving radiation therapy are highlighted.
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Affiliation(s)
- Falk Roeder
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Alexandra D Jensen
- Department of Radiation Oncology, University Hospital Marburg-Giessen, Giessen, Germany
| | - Katja Lindel
- Department of Radiation Oncology, Städtisches Klinikum, Karlsruhe, Germany
| | - Matthias Mattke
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Frank Wolf
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
| | - Sabine Gerum
- Department of Radiation Therapy and Radiation Oncology, Paracelsus Medical University Hospital, Salzburg, Austria
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24
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Aslakson RA, Rickerson E, Fahy B, Waterman B, Siden R, Colborn K, Smith S, Verano M, Lira I, Hollahan C, Siddiqi A, Johnson K, Chandrashekaran S, Harris E, Nudotor R, Baker J, Heidari SN, Poultsides G, Conca-Cheng AM, Cook Chapman A, Lessios AS, Holdsworth LM, Gustin J, Ejaz A, Pawlik T, Miller J, Morris AM, Tulsky JA, Lorenz K, Temel JS, Smith TJ, Johnston F. Effect of Perioperative Palliative Care on Health-Related Quality of Life Among Patients Undergoing Surgery for Cancer: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2314660. [PMID: 37256623 PMCID: PMC10233417 DOI: 10.1001/jamanetworkopen.2023.14660] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 03/31/2023] [Indexed: 06/01/2023] Open
Abstract
Importance Involvement of palliative care specialists in the care of medical oncology patients has been repeatedly observed to improve patient-reported outcomes, but there is no analogous research in surgical oncology populations. Objective To determine whether surgeon-palliative care team comanagement, compared with surgeon team alone management, improves patient-reported perioperative outcomes among patients pursuing curative-intent surgery for high morbidity and mortality upper gastrointestinal (GI) cancers. Design, Setting, and Participants From October 20, 2018, to March 31, 2022, a patient-randomized clinical trial was conducted with patients and clinicians nonblinded but the analysis team blinded to allocation. The trial was conducted in 5 geographically diverse academic medical centers in the US. Individuals pursuing curative-intent surgery for an upper GI cancer who had received no previous specialist palliative care were eligible. Surgeons were encouraged to offer participation to all eligible patients. Intervention Surgeon-palliative care comanagement patients met with palliative care either in person or via telephone before surgery, 1 week after surgery, and 1, 2, and 3 months after surgery. For patients in the surgeon-alone group, surgeons were encouraged to follow National Comprehensive Cancer Network-recommended triggers for palliative care consultation. Main Outcomes and Measures The primary outcome of the trial was patient-reported health-related quality of life at 3 months following the operation. Secondary outcomes were patient-reported mental and physical distress. Intention-to-treat analysis was performed. Results In total, 359 patients (175 [48.7%] men; mean [SD] age, 64.6 [10.7] years) were randomized to surgeon-alone (n = 177) or surgeon-palliative care comanagement (n = 182), with most patients (206 [57.4%]) undergoing pancreatic cancer surgery. No adverse events were associated with the intervention, and 11% of patients in the surgeon-alone and 90% in the surgeon-palliative care comanagement groups received palliative care consultation. There was no significant difference between study arms in outcomes at 3 months following the operation in patient-reported health-related quality of life (mean [SD], 138.54 [28.28] vs 136.90 [28.96]; P = .62), mental health (mean [SD], -0.07 [0.87] vs -0.07 [0.84]; P = .98), or overall number of deaths (6 [3.7%] vs 7 [4.1%]; P > .99). Conclusions and Relevance To date, this is the first multisite randomized clinical trial to evaluate perioperative palliative care and the earliest integration of palliative care into cancer care. Unlike in medical oncology practice, the data from this trial do not suggest palliative care-associated improvements in patient-reported outcomes among patients pursuing curative-intent surgeries for upper GI cancers. Trial Registration ClinicalTrials.gov Identifier: NCT03611309.
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Affiliation(s)
- Rebecca A. Aslakson
- Department of Anesthesiology, Lerner College of Medicine at the University of Vermont, Burlington
| | - Elizabeth Rickerson
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Bridget Fahy
- Department of Surgery, Divisions of Surgical Oncology and Palliative Medicine, University of New Mexico, Albuquerque
| | - Brittany Waterman
- Department of Internal Medicine, Division of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus
| | - Rachel Siden
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Kathryn Colborn
- Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Shelby Smith
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora
| | - Mae Verano
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Isaac Lira
- Clinical Research Department, University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Caroline Hollahan
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Amn Siddiqi
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Kemba Johnson
- Clinical Research Center, Ohio State University Wexner Medical Center, Columbus
| | | | - Elizabeth Harris
- Harvard Medical School, Boston, Massachusetts
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Richard Nudotor
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Joshua Baker
- Clinical Research Department, University of New Mexico Comprehensive Cancer Center, Albuquerque
| | - Shireen N. Heidari
- Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - George Poultsides
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | | | | | - Anna Sophia Lessios
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Laura M. Holdsworth
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
| | - Jillian Gustin
- Department of Internal Medicine, Division of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus
| | - Aslam Ejaz
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center, Columbus
| | - Timothy Pawlik
- Department of Surgery, Division of Surgical Oncology, Ohio State University Wexner Medical Center, Columbus
| | - Judi Miller
- Patient Family Advocate, Baltimore, Maryland
| | - Arden M. Morris
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
- Division of Palliative Medicine, Department of Medicine, Brigham & Women’s Hospital, Boston, Massachusetts
| | - Karl Lorenz
- Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Stanford, California
- VA Palo Alto Healthcare System, Palo Alto, California
| | - Jennifer S. Temel
- Department of Medicine, Division of Hematology/Oncology, MGH, Boston, Massachusetts
| | - Thomas J. Smith
- Departments of Medicine and Oncology, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
| | - Fabian Johnston
- Department of Surgery, Johns Hopkins Medical Institutions Campus, Baltimore, Maryland
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Iwamoto SJ, Defreyne J, Kaoutzanis C, Davies RD, Moreau KL, Rothman MS. Gender-affirming hormone therapy, mental health, and surgical considerations for aging transgender and gender diverse adults. Ther Adv Endocrinol Metab 2023; 14:20420188231166494. [PMID: 37113210 PMCID: PMC10126651 DOI: 10.1177/20420188231166494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 03/13/2023] [Indexed: 04/29/2023] Open
Abstract
As the transgender and gender diverse (TGD) population ages, more transfeminine and transmasculine individuals present to clinic to initiate or continue their gender-affirming care at older ages. Currently available guidelines on gender-affirming care are excellent resources for the provision of gender-affirming hormone therapy (GAHT), primary care, surgery, and mental health care but are limited in their scope as to whether recommendations require tailoring to older TGD adults. Data that inform guideline-recommended management considerations, while informative and increasingly evidence-based, mainly come from studies of younger TGD populations. Whether results from these studies, and therefore recommendations, can or should be extrapolated to aging TGD adults remains to be determined. In this perspective review, we acknowledge the lack of data in older TGD adults and discuss considerations for evaluating cardiovascular disease, hormone-sensitive cancers, bone health and cognitive health, gender-affirming surgery, and mental health in the older TGD population on GAHT.
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Affiliation(s)
- Sean J. Iwamoto
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 E 17th Avenue, Aurora, CO 80045, USA
- Endocrinology Service, Medicine Service, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Justine Defreyne
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Christodoulos Kaoutzanis
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Robert D. Davies
- Department of Psychiatry, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- CUMedicine LGBTQ Mental Health Clinic, University of Colorado Hospital, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
| | - Kerrie L. Moreau
- Division of Geriatric Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Eastern Colorado Geriatric Research Education and Clinical Center, Rocky Mountain Regional VA Medical Center, Aurora, CO, USA
| | - Micol S. Rothman
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- UCHealth Integrated Transgender Program – Anschutz Medical Campus, Aurora, CO, USA
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Radiomics and Artificial Intelligence Can Predict Malignancy of Solitary Pulmonary Nodules in the Elderly. Diagnostics (Basel) 2023; 13:diagnostics13030384. [PMID: 36766488 PMCID: PMC9914272 DOI: 10.3390/diagnostics13030384] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
Solitary pulmonary nodules (SPNs) are a diagnostic and therapeutic challenge for thoracic surgeons. Although such lesions are usually benign, the risk of malignancy remains significant, particularly in elderly patients, who represent a large segment of the affected population. Surgical treatment in this subset, which usually presents several comorbidities, requires careful evaluation, especially when pre-operative biopsy is not feasible and comorbidities may jeopardize the outcome. Radiomics and artificial intelligence (AI) are progressively being applied in predicting malignancy in suspicious nodules and assisting the decision-making process. In this study, we analyzed features of the radiomic images of 71 patients with SPN aged more than 75 years (median 79, IQR 76-81) who had undergone upfront pulmonary resection based on CT and PET-CT findings. Three different machine learning algorithms were applied-functional tree, Rep Tree and J48. Histology was malignant in 64.8% of nodules and the best predictive value was achieved by the J48 model (AUC 0.9). The use of AI analysis of radiomic features may be applied to the decision-making process in elderly frail patients with suspicious SPNs to minimize the false positive rate and reduce the incidence of unnecessary surgery.
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Sasaki A, Tachimori H, Akiyama Y, Oshikiri T, Miyata H, Kakeji Y, Kitagawa Y. Risk model for mortality associated with esophagectomy via a thoracic approach based on data from the Japanese National Clinical Database on malignant esophageal tumors. Surg Today 2023; 53:73-81. [PMID: 35882654 DOI: 10.1007/s00595-022-02548-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/24/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE Postoperative complications after esophagectomy can be severe or fatal and impact the patient's postoperative quality of life and long-term outcomes. The aim of the present study was to develop the best possible model for predicting mortality and complications based on the Japanese Nationwide Clinical Database (NCD). METHODS Data registered in the NCD, on 32,779 patients who underwent esophagectomy via a thoracic approach for malignant esophageal tumor between January, 2012 and December, 2017, were used to create a risk model. RESULTS The 30-day mortality rate after esophagectomy was 1.0%, and the operative mortality rate was 2.3%. Postoperative complications included pneumonia (13.8%), anastomotic leakage (13.2%), recurrent laryngeal nerve palsy (11.1%), atelectasis (4.9%), and chylothorax (2.5%). Postoperative artificial respiration for over 48 h was required by 7.8% of the patients. Unplanned intubation within 30 postoperative days was performed in 6.2% of the patients. C-indices evaluated using the test data were 0.694 for 30-day mortality and 0.712 for operative mortality. CONCLUSIONS We developed a good risk model for predicting 30-day mortality and operative mortality after esophagectomy based on the NCD. This risk model will be useful for the preoperative prediction of 30-day mortality and operative mortality, obtaining informed consent, and deciding on the optimal surgical procedure for patients with preoperative risks for mortality.
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Affiliation(s)
- Akira Sasaki
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan.,Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hisateru Tachimori
- Endowed Course for Health System Innovation, Keio University School of Medicine, Tokyo, Japan.,Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yuji Akiyama
- Department of Surgery, Iwate Medical University School of Medicine, 2-1-1 Idaidori, Yahaba-cho, Shiwa-gun, Iwate, 028-3695, Japan. .,Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan.
| | - Taro Oshikiri
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Health Policy and Management, Keio University School of Medicine, Tokyo, Japan
| | - Yoshihiro Kakeji
- Database Committee, The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
| | - Yuko Kitagawa
- The Japanese Society of Gastroenterological Surgery, Tokyo, Japan
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Stereotactic body radiotherapy compared with video‐assisted thoracic surgery after propensity‐score matching in elderly patients with pathologically‐proven early‐stage non‐small cell lung cancer. PRECISION RADIATION ONCOLOGY 2022. [DOI: 10.1002/pro6.1175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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Gill TM, Vander Wyk B, Leo-Summers L, Murphy TE, Becher RD. Population-Based Estimates of 1-Year Mortality After Major Surgery Among Community-Living Older US Adults. JAMA Surg 2022; 157:e225155. [PMID: 36260323 PMCID: PMC9582971 DOI: 10.1001/jamasurg.2022.5155] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 07/16/2022] [Indexed: 01/26/2023]
Abstract
Importance Despite their importance to guiding public health decision-making and policies and to establishing programs aimed at improving surgical care, contemporary nationally representative mortality data for geriatric surgery are lacking. Objective To calculate population-based estimates of mortality after major surgery in community-living older US adults and to determine how these estimates differ according to key demographic, surgical, and geriatric characteristics. Design, Setting, and Participants Prospective longitudinal cohort study with 1 year of follow-up in the continental US from 2011 to 2018. Participants included 5590 community-living fee-for-service Medicare beneficiaries, aged 65 years or older, from the National Health and Aging Trends Study (NHATS). Data analysis was conducted from February 22, 2021, to March 16, 2022. Main Outcomes and Measures Major surgeries and mortality over 1 year were identified through linkages with data from the Centers for Medicare & Medicaid Services. Data on frailty and dementia were obtained from the annual NHATS assessments. Results From 2011 to 2017, of the 1193 major surgeries (from 992 community-living participants), the mean (SD) age was 79.2 (7.1) years; 665 were women (55.7%), and 30 were Hispanic (2.5%), 198 non-Hispanic Black (16.6%), and 915 non-Hispanic White (76.7%). Over the 1-year follow-up period, there were 206 deaths representing 872 096 survey-weighted deaths and 13.4% (95% CI, 10.9%-15.9%) mortality. Mortality rates were 7.4% (95% CI, 4.9%-9.9%) for elective surgeries and 22.3% (95% CI, 17.4%-27.1%) for nonelective surgeries. For geriatric subgroups, 1-year mortality was 6.0% (95% CI, 2.6%-9.4%) for persons who were nonfrail, 27.8% (95% CI, 21.2%-34.3%) for those who were frail, 11.6% (95% CI, 8.8%-14.4%) for persons without dementia, and 32.7% (95% CI, 24.3%-41.0%) for those with probable dementia. The age- and sex-adjusted hazard ratios for 1-year mortality were 4.41 (95% CI, 2.53-7.69) for frailty with a reduction in restricted mean survival time of 48.8 days and 2.18 (95% CI, 1.40-3.40) for probable dementia with a reduction in restricted mean survival time of 44.9 days. Conclusions and Relevance In this study, the population-based estimate of 1-year mortality after major surgery among community-living older adults in the US was 13.4% but was 3-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery.
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Affiliation(s)
- Thomas M. Gill
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Brent Vander Wyk
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Linda Leo-Summers
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Terrence E. Murphy
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert D. Becher
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
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Ojha S, Darwish MB, Benzie AL, Logarajah S, McLaren PJ, Osman H, Cho E, Jay J, Jeyarajah DR. Esophagectomy in octogenarians: Is it at a cost? Heliyon 2022; 8:e11945. [DOI: 10.1016/j.heliyon.2022.e11945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/08/2022] [Accepted: 11/21/2022] [Indexed: 11/29/2022] Open
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Laurent A, Marechal R, Farinella E, Bouazza F, Charaf Y, Gay F, Van Laethem JL, Gonsette K, El Nakadi I. Esophageal cancer: Outcome and potential benefit of esophagectomy in elderly patients. Thorac Cancer 2022; 13:2699-2710. [PMID: 36000335 PMCID: PMC9527164 DOI: 10.1111/1759-7714.14596] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/08/2022] [Accepted: 07/11/2022] [Indexed: 12/04/2022] Open
Abstract
Background This analysis evaluated the morbimortality and the potential benefit of esophagectomy for cancer in elderly patients. Methods Patients who underwent esophagectomy for EC were divided into elderly (≥70 years) and nonelderly (<70 years) groups. The groups were compared regarding patient and tumor characteristics, postoperative morbimortality, and disease‐free, overall and cancer‐specific survival. Results Sixty‐one patients were classified into elderly, and 187 into nonelderly groups. The elderly were characterized by a higher rate of WHO score (p < 0.0001), higher cardiac (p < 0.004) and renal (p < 0.023) comorbidities. The rate of neoadjuvant therapy and especially of neoadjuvant CRT was significantly lower in elderly patients (p < 0.018 and p < 0.007). Operative morbidity was also higher in this group (p < 0.024). The 30‐ and 90‐day mortality was 8.2 and 11.5%, respectively in elderly patients and 0.5 and 3.2% in nonelderly patients (p < 0.004 and p < 0.012). This 90‐day mortality decreased when specific surgery‐related deaths were taken into consideration. OS and DFS were significantly better in the nonelderly group (p < 0.003 and p < 0.005) while no difference was observed for cancer‐specific survival (CSS). Conclusion No difference in CSS was observed. Although elderly patients with EC had higher postoperative morbimortality, the age should not be a criterion whether to perform, or not to perform, esophagectomy. This decision must be based on the balance between the patient's general condition and aggressive disease.
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Affiliation(s)
- Adeline Laurent
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Raphael Marechal
- Department of Gastroenterology, University Hospital Center of Tivoli, La louvière, Belgium
| | - Eleonora Farinella
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Fikri Bouazza
- Department of Digestive Surgical Oncology, Faculty of Medicine (ULB), Institut Jules Bordet, Brussels, Belgium
| | - Yassine Charaf
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - France Gay
- Department of Gastroenterology and Digestive Oncology, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Jean-Luc Van Laethem
- Department of Gastroenterology and Digestive Oncology, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Kimberly Gonsette
- Department of Anesthesiology, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
| | - Issam El Nakadi
- Department of Digestive Surgery, Faculty of Medicine (ULB), Erasme University Hospital Center, Brussels, Belgium
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Hackner D, Hobbs M, Merkel S, Siepmann T, Krautz C, Weber GF, Grützmann R, Brunner M. Impact of Patient Age on Postoperative Short-Term and Long-Term Outcome after Pancreatic Resection of Pancreatic Ductal Adenocarcinoma. Cancers (Basel) 2022; 14:cancers14163929. [PMID: 36010922 PMCID: PMC9406071 DOI: 10.3390/cancers14163929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/04/2022] [Accepted: 08/09/2022] [Indexed: 12/02/2022] Open
Abstract
(1) Purpose: to evaluate the impact of age on postoperative short-term and long-term outcomes in patients undergoing curative pancreatic resection for PDAC. (2) Methods: This retrospective single-center study comprised 213 patients who had undergone primary resection of PDAC from January 2000 to December 2018 at the University Hospital of Erlangen, Germany. Patients were stratified according the age into two groups: younger (≤70 years) and older (>70 years) patients. Postoperative outcome and long-term survival were compared between the groups. (3) Results: There were no significant differences regarding inhospital morbidity (58% vs. 67%, p = 0.255) or inhospital mortality (2% vs. 7%, p = 0.073) between the two groups. The median overall survival (OS) and disease-free survival (DFS) were significantly shorter in elderly patients (OS: 29.2 vs. 17.1 months, p < 0.001, respectively; DFS: 14.9 vs. 10.4 months, p = 0.034). Multivariate analysis revealed that age was a significant independent prognostic predictor for OS and DFS (HR 2.23, 95% CI 1.58−3.15; p < 0.001 for OS and HR 1.62, 95% CI 1.17−2.24; p = 0.004 for DFS). (4) Conclusion: patient age significantly influenced overall and disease-free survival in patients with PDAC undergoing primary resection in curative intent.
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Affiliation(s)
- Danilo Hackner
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
- Division of Health Care Sciences, Dresden International University, 01067 Dresden, Germany
| | - Mirianna Hobbs
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Susanne Merkel
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Timo Siepmann
- Division of Health Care Sciences, Dresden International University, 01067 Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, 01069 Dresden, Germany
| | - Christian Krautz
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Georg F. Weber
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Robert Grützmann
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Maximilian Brunner
- Department of General and Visceral Surgery, Friedrich-Alexander-University (FAU) Erlangen-Nuremberg, 91054 Erlangen, Germany
- Correspondence: ; Tel.: +49-09131-85-33296
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Scarsi S, Martin D, Halkic N, Demartines N, Roulin D. Enhanced recovery in elderly patients undergoing pancreatic resection: A retrospective monocentric study. Medicine (Baltimore) 2022; 101:e29494. [PMID: 35687782 PMCID: PMC9276327 DOI: 10.1097/md.0000000000029494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 05/05/2022] [Indexed: 01/04/2023] Open
Abstract
Enhanced recovery after surgery (ERAS) pathway for pancreas has demonstrated its value in clinical practice. However, there is a lack of specific evidence about its application in elderly patients. The aim of the present study was to assess the impact of age on compliance and postoperative outcomes. Patients ≥70 years old that underwent pancreatic resection within an ERAS pathway between 2012 and 2018 were included, and divided into three groups: 70-74, 75-79, and ≥80 years old. Compliance with ERAS items, length of stay, mortality, and complications were analyzed. 114 patients were included: 49, 37, and 28 patients aged 70-74, 75-79, and ≥80 years, respectively. Overall compliance to ERAS items between groups was not different (66%, 66%, and 62%, P = .201). No significant difference was observed in terms of median length of stay (14, 17, and 17 days, P = .717), overall complications (67%, 78%, and 71%, P = .529), major complications (26%, 32%, and 39%, P = .507), or mortality (0%, 3%, and 4%, P = .448) with increasing age. Application of an ERAS pathway is feasible in elderly patients with pancreatic resection. Increasing age was neither associated with poorer compliance nor worse postoperative outcomes.
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Baggett ND, Schulz K, Buffington A, Marka N, Hanlon BM, Zimmermann C, Tucholka J, Fox D, Clapp JT, Arnold RM, Schwarze ML. Surgeon Use of Shared Decision-making for Older Adults Considering Major Surgery: A Secondary Analysis of a Randomized Clinical Trial. JAMA Surg 2022; 157:406-413. [PMID: 35319737 PMCID: PMC8943640 DOI: 10.1001/jamasurg.2022.0290] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Because major surgery carries significant risks for older adults with comorbid conditions, shared decision-making is recommended to ensure patients receive care consistent with their goals. However, it is unknown how often shared decision-making is used for these patients. Objective To describe the use of shared decision-making during discussions about major surgery with older adults. Design, Setting, and Participants This study is a secondary analysis of conversations audio recorded during a randomized clinical trial of a question prompt list. Data were collected from June 1, 2016, to November 31, 2018, from 43 surgeons and 446 patients 60 years or older with at least 1 comorbidity at outpatient surgical clinics at 5 academic centers. Interventions Patients received a question prompt list brochure that contained questions they could ask a surgeon. Main Outcomes and Measures The 5-domain Observing Patient Involvement in Decision-making (OPTION5) score (range, 0-100, with higher scores indicating greater shared decision-making) was used to measure shared decision-making. Results A total of 378 surgical consultations were analyzed (mean [SD] patient age, 71.9 [7.2] years; 206 [55%] male; 312 [83%] White). The mean (SD) OPTION5 score was 34.7 (20.6) and was not affected by the intervention. The mean (SD) score in the group receiving the question prompt list was 36.7 (21.2); in the control group, the mean (SD) score was 32.9 (19.9) (effect estimate, 3.80; 95% CI, -0.30 to 8.00; P = .07). Individual surgeon use of shared decision-making varied greatly, with a lowest median score of 10 (IQR, 10-20) to a high of 65 (IQR, 55-80). Lower-performing surgeons had little variation in OPTION5 scores, whereas high-performing surgeons had wide variation. Use of shared decision-making increased when surgeons appeared reluctant to operate (effect estimate, 7.40; 95% CI, 2.60-12.20; P = .003). Although longer conversations were associated with slightly higher OPTION5 scores (effect estimate, 0.69; 95% CI, 0.52-0.88; P < .001), 57% of high-scoring transcripts were 26 minutes long or less. On multivariable analysis, patient age and gender, patient education, surgeon age, and surgeon gender were not significantly associated with OPTION5 scores. Conclusions and Relevance These findings suggest that although shared decision-making is important to support the preferences of older adults considering major surgery, surgeon use of shared decision-making is highly variable. Skillful shared decision-making can be done in less than 30 minutes; however, surgeons who engage in high-scoring shared decision-making are more likely to do so when surgical intervention is less obviously beneficial for the patient. Trial Registration ClinicalTrials.gov Identifier: NCT02623335.
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Affiliation(s)
- Nathan D. Baggett
- HealthPartners Institute/Regions Hospital Emergency Medicine, St Paul, Minnesota
| | - Kathryn Schulz
- University of Wisconsin School of Medicine and Public Health, Madison
| | | | - Nicholas Marka
- Biostatistical Design and Analysis Center, University of Minnesota, Minneapolis
| | - Bret M. Hanlon
- Department of Surgery, University of Wisconsin, Madison
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison
| | | | | | - Dan Fox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Justin T. Clapp
- Department of Anesthesia and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert M. Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Xu Y, Zhang Y, Han S, Jin D, Xu X, Kuang T, Wu W, Wang D, Lou W. Prognostic Effect of Age in Resected Pancreatic Cancer Patients: A Propensity Score Matching Analysis. Front Oncol 2022; 12:789351. [PMID: 35433408 PMCID: PMC9008824 DOI: 10.3389/fonc.2022.789351] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 03/04/2022] [Indexed: 01/11/2023] Open
Abstract
Background While the elderly population account for an indispensable proportion in pancreatic ductal adenocarcinoma (PDAC), these patients are underrepresented in clinical trials. Whether surgery offered the same benefit for elderly patients as that for younger cohort and which factors affected long-term outcome of elderly population remained unclear. Aims This study aims to evaluate long-term prognosis of elderly PDAC patients (≥70 years old) after surgery and to investigate potential prognostic factors. Methods This retrospective study included PDAC patients receiving radical resection from January 2012 to July 2019 in Zhongshan Hospital Fudan University. Patients were divided into young (<70) and old groups (≥70). Propensity score matching (PSM) was conducted to eliminate the confounding factors. We investigated potential prognostic factors via Cox proportional hazards model and Kaplan–Meier estimator. Nomogram model and forest plot were constructed to illustrate the prognostic value of age. Results A total of 552 PDAC patients who received radical resection were included in this research. Elderly patients showed poorer nutritional status and were less likely to received adjuvant treatment. After matching, although age [hazard ratio (HR)=1.025, 95%CI 0.997–1.054; p=0.083] was not statistically significant in the multivariate cox regression analysis, further survival analysis showed that patients in the old group had poorer overall survival (OS) when compared with young group (p=0.039). Furthermore, reception of adjuvant chemotherapy (HR=0.411, 95%CI 0.201-0.837; p=0.014) was the only independent prognostic factor among elderly patients and could significantly improve OS. Subgroup analysis indicated that age had better prognostic value in PDAC patients with good preoperative nutritional status and relative low tumor burden. Finally, a prognostic prediction model contained age, reception of adjuvant chemotherapy, American Joint Committee on Cancer (AJCC) 8th T and N stage was constructed and presented in nomogram, whose Harrell’s concordance index was 0.7478 (95%CI, 0.6960–0.7996). The calibration curves at 1 and 3 years indicated an optimal conformity between actual and nomogram-predicted survival probability in the PDAC patient who received surgery. Conclusion The elderly PDAC patients were associated with worse OS survival after radical resection, and the noticeable negative effect of age was observed among PDAC patients with better preoperative nutritional status and less aggressive tumor biology. Adjuvant chemotherapy was essential to improve survival outcome of elderly PDAC patients following radical resection.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Wenhui Lou
- *Correspondence: Dansong Wang, ; Wenhui Lou,
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Dezube AR, Cooper L, Mazzola E, Dolan DP, Lee DN, Kucukak S, De Leon LE, Dumontier C, White A, Swanson SJ, Jaklitsch MT, Frain LN, Wee JO, Ademola B, Polhemus E. Perioperative Esophagectomy Outcomes in Older Esophageal Cancer Patients in Two Different Time Eras. Semin Thorac Cardiovasc Surg 2022; 35:412-426. [PMID: 35248724 PMCID: PMC10049881 DOI: 10.1053/j.semtcvs.2021.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022]
Abstract
To investigate perioperative outcomes of esophagectomies by age groups. Retrospective analysis of esophageal cancer patients undergoing esophagectomy from 2005 to 2020 at a single academic institution. Baseline characteristics and outcomes were analyzed by 3 age groups: <70, 70-79, and ≥80 years-old. Sub-analysis was done for 2 time periods: 2005-2012 and 2013-2020. Of 1135 patients, 789 patients were <70, 294 were 70-79, and 52 were ≥80 years-old. Tumor characteristics, and operative technique were similar, except positive longitudinal margins rates (all <3%) (P = 0.008). Older adults experienced increased complications (53.6% vs 69.7% vs 65.4% respectively; P < 0.001) attributable to grade II complications (41.4% vs 62.2% vs 63.5% respectively; P < 0.001). Hospital length of stay (LOS) and rehabilitation requirements were higher in older adults (both P < 0.05). 30-day readmissions, reoperation, and 30-day mortality rates (all <2%) showed no association with age group. Overall complications, LOS, discharge disposition and re-operative rates improved from 2005 to 2012 to 2013-2020 for all (P < 0.05). Increasing age was an independent risk factor for cardiovascular complications (OR 1.7, 95% CI 1.23-2.46 for ages 70-79 and OR 2.7, 95% CI 1.37-5.10 for ages ≥80 ), inpatient rehabilitation (OR 3.3, 95% CI 2.26-5.05 for ages 70-79 and OR 12.1 95% CI 5.83-25.04 for ages ≥80), and prolonged LOS (OR 1.64 95% CI 1.16-2.31 for ages 70-79 and OR 3.6 95% CI 1.71-7.67 for ≥80. After adjusting for time period, older age remained associated with complications (P < 0.05). Highly selected older adults at a large volume esophagectomy center can undergoesophagectomy with increased minor complication and rehabilitation needs.
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Affiliation(s)
- Aaron R Dezube
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Lisa Cooper
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emanuele Mazzola
- Division of Data Sciences, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Daniel P Dolan
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Daniel N Lee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Suden Kucukak
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Luis E De Leon
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Clark Dumontier
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts; New England GRECC, VA Boston Healthcare System, Boston, Massachusetts
| | - Abby White
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Scott J Swanson
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael T Jaklitsch
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Laura N Frain
- Division of Aging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jon O Wee
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bayonle Ademola
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily Polhemus
- Division of Thoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Quero G, Pecorelli N, Paiella S, Fiorillo C, Petrone MC, Capretti G, Laterza V, De Sio D, Menghi R, Kauffmann E, Nobile S, Butturini G, Ferrari G, Rosa F, Coratti A, Casadei R, Mazzaferro V, Boggi U, Zerbi A, Salvia R, Falconi M, Alfieri S. Pancreaticoduodenectomy in octogenarians: The importance of "biological age" on clinical outcomes. Surg Oncol 2022; 40:101688. [PMID: 34844071 DOI: 10.1016/j.suronc.2021.101688] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/01/2021] [Accepted: 11/22/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION With the prolongation of life expectancy, an increasing number of elderly patients are evaluated for pancreatic surgery. However, the influence of increasing age on outcomes after pancreaticoduodenectomy (PD) is still unclear, especially in octogenarians. Aim of this study is to evaluate the perioperative characteristics and outcomes of octogenarians undergoing PD. METHODS Data for 812 patients undergoing PD between 2019 and 2020 in 10 referral centers in Italy were reviewed. Patients aged 80 years or older were matched based on nearest neighbor propensity scores in a 1:1 ratio to patients younger than 80 years. Propensity scores were calculated using 7 perioperative variables including gender, ASA score, neoadjuvant treatment (NAT), biliary stent positioning, type of surgical approach (open, laparoscopic, robot-assisted), associated vascular resections, type of lesion. Perioperative characteristics and short-term postoperative outcomes were compared before and after matching. RESULTS Overall, 81 (10%) patients had 80 years or more. Before matching, octogenarians had a higher rate of ASA score≥ 3 (n = 35, 43.2% vs. n = 207, 28.3%; p = 0.005) and less frequently underwent NAT (n = 11, 13.6% vs. n = 213, 29.1%; p = 0.003). Matching was successfully performed for 70 octogenarians. After matching, no differences in preoperative and intraoperative characteristics were found. Postoperatively, ICU admission was more frequent in octogenarians (50% vs 30%; p = 0.01). Although in-hospital mortality was higher in octogenarians before matching (7.4% vs 2.9% in the younger cohort; p = 0.03), no difference was noted between the matched cohorts (p = 0.36). Postoperative morbidity was comparable between groups in the whole and selected populations. At the multivariate analysis, chronological age was not recognized as a prognostic factor for cumulative major complications, while ASA ≥3 was the only confirmed influencing feature (OR 2.98; 95%CI: 1.6-6.8; p = 0.009). CONCLUSIO In high-volume centers, PD in octogenarians shows similar outcomes than younger patients. Age itself should not be considered an exclusion criterion for PD, but a focused preoperative assessment is essential for adequate patient selection.
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Affiliation(s)
- Giuseppe Quero
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Nicolò Pecorelli
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Paiella
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy.
| | - Maria Chiara Petrone
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Capretti
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy
| | - Vito Laterza
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Emanuele Kauffmann
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Via Paradisa, 2, 56124, Pisa, Italy
| | - Sara Nobile
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Giovanni Butturini
- Casa di Cura Pederzoli, Via Monte Baldo 24, 37019, Peschiera del Garda, Verona, Italy
| | - Giovanni Ferrari
- ASST Grande Ospedale Metropolitano Niguarda, Division of Minimally-invasive Surgical Oncology, Piazza Ospedale Maggiore, 3 20162, Milan, Italy
| | - Fausto Rosa
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
| | - Andrea Coratti
- Division of Surgical Oncology and Robotics, Department of Oncology, Careggi University Hospital, Florence, Italy
| | - Riccardo Casadei
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vincenzo Mazzaferro
- HPB Surgery and Liver Transplantation, Department of Oncology, University of Milan, Milan, Italy; Istituto Nazionale Tumori, Fondazione IRCCS, Milan, Italy
| | - Ugo Boggi
- Chirurgia Generale Universitaria dell'Ospedale di Cisanello, Via Paradisa, 2, 56124, Pisa, Italy
| | - Alessandro Zerbi
- Humanitas Clinical and Research Center - IRCCS, Rozzano, MI, Italy; Humanitas University, Department of Biomedical Sciences, Pieve Emanuele, MI, Italy
| | - Roberto Salvia
- Department of General and Pancreatic Surgery, The Pancreas Institute, University of Verona Hospital Trust, Italy
| | - Massimo Falconi
- Division of Pancreatic Surgery, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy; Pancreato-Biliary Endoscopy and EUS Division, Pancreas Translational & Clinical Research Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sergio Alfieri
- Gemelli Pancreatic Center, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; CRMPG (Advanced Pancreatic Research Center), Largo Agostino Gemelli, 8, 00168, Rome, Italy; Università Cattolica del Sacro Cuore di Roma, Largo Francesco Vito 1, 00168, Rome, Italy
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Nipp RD, Qian CL, Knight HP, Ferrone CR, Kunitake H, Castillo CFD, Lanuti M, Qadan M, Ricciardi R, Lillemoe KD, Temel B, Hashmi AZ, Scott E, Stevens E, Williams GR, Fong ZV, O'Malley TA, Franco-Garcia E, Horick NK, Jackson VA, Greer JA, El-Jawahri A, Temel JS. Effects of a perioperative geriatric intervention for older adults with Cancer: A randomized clinical trial. J Geriatr Oncol 2022; 13:410-415. [PMID: 35074322 PMCID: PMC9058195 DOI: 10.1016/j.jgo.2022.01.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/27/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Older adults with gastrointestinal cancers undergoing surgery often experience poor outcomes, such as prolonged postoperative hospital length of stay (LOS), intensive care unit (ICU) use, hospital readmissions, and complications. Involvement of geriatricians in the care of older adults with cancer can improve outcomes. We conducted a randomized trial of a perioperative geriatric intervention (PERI-OP) in older patients with gastrointestinal cancer undergoing surgery. METHODS From 9/2016-4/2019, we randomly assigned patients age ≥ 65 with gastrointestinal cancer planning to undergo surgical resection to receive PERI-OP or usual care. Patients assigned to PERI-OP met with a geriatrician preoperatively in the outpatient setting and postoperatively as an inpatient consultant. The primary outcome was postoperative hospital LOS. Secondary outcomes included postoperative ICU use, 90-day hospital readmission rates, and complication rates. We conducted intention-to-treat (ITT) and per-protocol (PP) analyses. RESULTS ITT analyses included 137/160 patients who underwent surgery (usual care = 68/78, intervention = 69/82). PP analyses included the 68 usual care patients and the 30/69 intervention patients who received the preoperative and postoperative intervention components. ITT analyses demonstrated no significant differences between intervention and usual care in postoperative hospital LOS (7.23 vs 8.21 days, P = 0.374), ICU use (23.2% vs 32.4%, P = 0.257), 90-day hospital readmission rates (21.7% vs 25.0%, P = 0.690), or complication rates (17.4% vs 20.6%, P = 0.668). In PP analyses, intervention patients had shorter postoperative hospital LOS (5.90 vs 8.21 days, P = 0.024), but differences in ICU use (13.3% vs 32.4%, P = 0.081), 90-day hospital readmission rates (16.7% vs 25.0%, P = 0.439), and complication rates (6.7% vs 20.6%, P = 0.137) remained non-significant. CONCLUSIONS In this randomized trial, PERI-OP did not have a significant impact on postoperative hospital LOS, ICU use, hospital readmissions, or complications. However, the subgroup who received PERI-OP as planned experienced encouraging results. Future studies of PERI-OP should include efforts, such as telehealth, to ensure the intervention is delivered as planned.
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Mehtsun WT, McCleary NJ, Maduekwe UN, Wolpin BM, Schrag D, Wang J. Patterns of Adjuvant Chemotherapy Use and Association With Survival in Adults 80 Years and Older With Pancreatic Adenocarcinoma. JAMA Oncol 2022; 8:88-95. [PMID: 34854874 PMCID: PMC8640950 DOI: 10.1001/jamaoncol.2021.5407] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Patients 80 years and older with pancreatic ductal adenocarcinoma (PDAC) have not consistently received treatments that have established benefits in younger older adults (aged 60-79 years), yet patients 80 years and older are increasingly being offered surgery. Whether adjuvant chemotherapy (AC) provides additional benefit among patients 80 years and older with PDAC following surgery is not well understood. OBJECTIVE To describe patterns of AC use in patients 80 years and older following surgical resection of PDAC and to compare overall survival between patients who received AC and those who did not. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study among patients 80 years or older diagnosed with PDAC (stage I-III) between 2004 to 2016 who underwent a pancreaticoduodenectomy at hospitals across the US reporting to the National Cancer Database. EXPOSURES AC vs no AC 90 days following diagnosis of PDAC. MAIN OUTCOMES AND MEASURES The proportion of patients who received AC was assessed over the study period. Overall survival was compared between patients who received AC and those who did not using Kaplan-Meier estimates and multivariable Cox proportional hazards regression. A landmark analysis was performed to address immortal time bias. A propensity score analysis was performed to address indication bias. Subgroup analyses were conducted in node-negative, margin-negative, clinically complex, node-positive, and margin-positive cohorts. RESULTS Between 2004 and 2016, 2569 patients 80 years and older (median [IQR] age, 82 [81-84] years; 1427 were women [55.5%]) underwent surgery for PDAC. Of these patients, 1217 (47.4%) received AC. Findings showed an 18.6% (95% CI, 8.0%-29.0%; P = .001) absolute increase in the use of AC among older adults who underwent a pancreaticoduodenectomy comparing rates in 2004 vs 2016. Receipt of AC was associated with a longer median survival (17.2 months; 95% CI, 16.1-19.0) compared with those who did not receive AC (12.7 months; 95% CI, 11.8-13.6). This association was consistent in propensity and subgroup analyses. In multivariable analysis, receipt of AC (hazard ratio [HR], 0.72; 95% CI, 0.65-0.79; P < .001), female sex (HR, 0.88; 95% CI, 0.80-0.96; P < .001), and surgery in the more recent time period (≥2011) (HR, 0.90; 95% CI, 0.82-0.99; P = .02) were associated with a decreased hazard of death. An increased hazard of death was associated with higher pathologic stage (stage II: HR, 1.68; 95% CI, 1.43-1.97; P < .001; stage III: HR, 2.39; 95% CI, 1.88-3.04; P < .001), positive surgical margins (HR, 1.49; 95% CI, 1.34-1.65; P < .001), length of stay greater than median (10 days) (HR, 1.17; 95% CI, 1.07-1.28; P < .001), and receipt of oncologic care at a nonacademic facilities (Community Cancer Program: HR, 1.20; 95% CI, 1.07-1.35; P < .001; Integrated Network Cancer Program: HR, 1.25; 95% CI, 1.07-1.46; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, the use of AC among patients who underwent resection for PDAC increased over the study period, yet it still was administered to fewer than 50% of patients. Receipt of AC was associated with a longer median survival.
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Affiliation(s)
- Winta T. Mehtsun
- Division of Surgical Oncology, Department of Surgery, University of California San Diego
| | - Nadine J. McCleary
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Ugwuji N. Maduekwe
- Division of Surgical Oncology, Department of Surgery, University of North Carolina at Chapel Hill
| | - Brian M. Wolpin
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Deborah Schrag
- Department of Medical Oncology, Gastrointestinal Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jiping Wang
- Division of Surgical Oncology, Department of Surgery, Dana-Farber Cancer Institute, Mass General Brigham, Boston, Massachusetts
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Hue JJ, Bingmer K, Sugumar K, Ocuin LM, Rothermel LD, Winter JM, Ammori JB, Hardacre JM. Mortality and Survival Among Octogenarians with Localized Pancreatic Head Cancer: a National Cancer Database Analysis. J Gastrointest Surg 2021; 25:2582-2592. [PMID: 33634421 DOI: 10.1007/s11605-021-04949-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/25/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) has historically poor outcomes. Difficult decisions must be made by patients and providers, especially in the elderly for whom treatment morbidities may not be tolerable. Herein, we report treatment-dependent outcomes of octogenarians with localized PDAC. METHODS The National Cancer Database identified patients ≥60 years with localized PDAC of the pancreatic head (2011-2016). Patients were grouped by age (60-79 and ≥80 years) and categorized by treatment regimen: no treatment, chemotherapy, pancreaticoduodenectomy, pancreaticoduodenectomy with perioperative chemotherapy, or pancreaticoduodenectomy with adjuvant chemotherapy. Postoperative outcomes and survival were analyzed. RESULTS A total of 35,409 patients were included, 8745 (24.7%) of which were ≥80 years. Over 52% of octogenarians did not receive any treatment, compared to 19.1% of younger patients (p<0.001). Patients ≥80 years who underwent a pancreaticoduodenectomy had a significantly greater 90-day mortality rate compared to patients 60-79 years (11.0% vs. 6.7%, p<0.001). Only 42.2% of octogenarians who underwent upfront pancreatectomy received adjuvant chemotherapy. Median survival for octogenarians was 3.3 months without any treatment, 9.7 months with chemotherapy, 12.0 months with pancreaticoduodenectomy, and greater than 20 months with either perioperative or adjuvant chemotherapy in addition to pancreaticoduodenectomy. Age ≥80 was associated with poor survival relative to ages 60-79 when adjusting for treatment regimen (HR=1.19, p<0.001). CONCLUSION Increasing age is associated with worse overall survival in PDAC, but select octogenarians can achieve reasonable survival with multimodal therapy. Given the poor survival and increased perioperative mortality of octogenarians, patient selection for surgery and consideration of neoadjuvant therapy may be increasingly important.
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Affiliation(s)
- Jonathan J Hue
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Katherine Bingmer
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Kavin Sugumar
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Lee M Ocuin
- Department of Surgery, Division of Hepatobiliary and Pancreatic Surgery, Atrium Health
- , Charlotte, NC, USA
| | - Luke D Rothermel
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Jordan M Winter
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - John B Ammori
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA
| | - Jeffrey M Hardacre
- Department of Surgery, Division of Surgical Oncology, University Hospitals Cleveland Medical Center, 11100 Euclid Ave, Cleveland, OH, 44106, USA.
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Cloos-v.Balen M, Portier ESH, Fiocco M, Hartgrink HH, Langers AMJ, Neelis KJ, Lips IM, Peters FP, Slingerland M. Neoadjuvant chemoradiotherapy followed by resection for esophageal cancer: clinical outcomes with the 'CROSS-regimen' in daily practice. Dis Esophagus 2021; 35:6374655. [PMID: 34557905 PMCID: PMC9016892 DOI: 10.1093/dote/doab068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 07/19/2021] [Accepted: 09/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Since the first results of the Dutch randomized CROSS-trial, neoadjuvant chemoradiotherapy (CRT) using carboplatin and paclitaxel followed by resection for primary resectable nonmetastatic esophageal cancer (EC) has been implemented as standard curative treatment in the Netherlands. The purpose of this retrospective study is to evaluate the clinical outcomes of this treatment in daily practice in a large academic hospital. METHODS Medical records of patients treated for primary resectable nonmetastatic EC between May 2010 and December 2015 at our institution were reviewed. Treatment consisted of five weekly courses of carboplatin (area under the curve 2) and paclitaxel (50 mg/m2) with concurrent external beam radiotherapy (23 fractions of 1.8 Gy), followed by transthoracic or transhiatal resection. Data on survival, progression, acute and late toxicity were recorded. RESULTS A total of 145 patients were included. Median follow-up was 43 months. Median overall survival (OS) and progression-free survival (PFS) were 35 (95% confidence interval [CI] 29.8-40.2) and 30 (95% CI 19.7-40.3) months, respectively, with corresponding 3-year OS and PFS of 49.6% (95% CI 40.4-58.8) and 45.6% (95% CI 36.6-54.6). Acute toxicity grade ≥3 was observed in 25.5% of patients. Late adverse events grade ≥3 were seen in 24.8%, mostly esophageal stenosis. CONCLUSION Neoadjuvant CRT followed by resection for primary resectable nonmetastatic EC in daily practice results in a 3-year OS of 49.6% (95% CI 40.4-58.8) and PFS of 45.6% (95% CI 36.6-54.6), compared with 58% (51-65%) and 51% (43-58%) within the CROSS-trial. The slightly poorer survival in our daily practice group might be due to the presence of less favorable patient and tumor characteristics in daily practice, as is to be expected in daily practice. Toxicity was comparable with that in the CROSS-trial and considered acceptable.
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Affiliation(s)
- Marissa Cloos-v.Balen
- Address correspondence to: Marissa Cloos-van Balen, MD, Department of Medical Oncology, Leiden University Medical Center and Groene Hart Ziekenhuis Gouda, C7, PO Box 9600, 2300 RC Leiden, the Netherlands.
| | - Edmée S H Portier
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marta Fiocco
- Department of Biomedical Science, Medical Statistical Section, Leiden University Medical Center, Leiden, the Netherlands
| | - Henk H Hartgrink
- Department of Surgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexandra M J Langers
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Karen J Neelis
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Irene M Lips
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, the Netherlands
| | - Femke P Peters
- Department of Radiation Oncology, Leiden University Medical Center and The Netherlands Cancer Institute, Leiden, the Netherlands
| | - Marije Slingerland
- Department of Medical Oncology, Leiden University Medical Center, Leiden, the Netherlands
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Rubin DS, Huisingh-Scheetz M, Ferguson MK, Nagele P, Peden CJ, Lauderdale DS. U.S. trends in elective and emergent major abdominal surgical procedures from 2002 to 2014 in older adults. J Am Geriatr Soc 2021; 69:2220-2230. [PMID: 33969889 PMCID: PMC8373714 DOI: 10.1111/jgs.17189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The U.S. population is aging and projected to undergo an increasing number of general surgical procedures. However, recent trends in the frequency of major abdominal procedures in older adults are currently unknown as improvements in non-operative interventions may obviate the need for major surgery. Thus, we evaluated the trends of major abdominal surgical procedures in older adults in the United States. METHODS We performed a retrospective cohort study using the National Inpatient Sample from 2002 to 2014 with trend analysis using National Cancer Institute's Joinpoint Trend Analysis Software. We identified the average annual percent change (AAPC) in the yearly frequency of major abdominal surgical procedures in older adults (≥50 years of age). RESULTS Our cohort included a total of 3,951,947 survey-weighted discharges that included a major abdominal surgery in adults ≥50 years of age between 2002 and 2014. Of these discharges, 2,529,507 (64.0%) were for elective abdominal surgeries, 2,062,835 (52.0%) were for female patients, and mean (SD) age was 61.4 (15.9) years. The frequency of major abdominal procedures (elective and emergent) decreased for adults aged 65-74 (AAPC: -1.43, -1.75, -1.11, p < 0.0001), 75-84 (AAPC: -2.75, -3.33, -2.16, p < 0.001), and ≥85 (AAPC: -4.07, -4.67, -3.47, p < 0.0001). The AAPC for elective procedures decreased for older adults aged 75-84 (AAPC = -1.65; -2.44, -0.85: p = 0.0001) and >85 (AAPC = -3.53; -4.57, -2.48: p < 0.0001). All age groups showed decreases in emergent procedures in 50-64 (AAPC = -1.76, -2.00, -1.52, p < 0.0001), 65-74 (AAPC = -3.59, -4.03, -3.14, p < 0.0001), 75-84 (AAPC = -3.90, -4.34, -3.46, p < 0.0001), ≥85 (AAPC = -4.58, -4.98, -4.17, p < 0.0001) age groups. CONCLUSIONS AND RELEVANCE In this cohort of older adults, the frequency of emergent and elective major abdominal procedures in adults ≥65 years of age decreased with significant variation among individual procedure types. Future studies are needed to identify the generalizability of our findings to other surgical procedures.
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Affiliation(s)
- Daniel S Rubin
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois, USA
| | - Mark K Ferguson
- Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Peter Nagele
- Department of Anesthesia and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Carol J Peden
- Department of Anesthesiology, University of Southern California, Los Angeles, California, USA
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Diane S Lauderdale
- Department of Public Health Sciences, University of Chicago, Chicago, Illinois, USA
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Motoyama S, Maeda E, Iijima K, Anbai A, Sato Y, Wakita A, Nagaki Y, Fujita H, Minamiya Y, Higashi T. Differences in treatment and survival between elderly patients with thoracic esophageal cancer in metropolitan areas and other areas. Cancer Sci 2021; 112:4281-4291. [PMID: 34288283 PMCID: PMC8486216 DOI: 10.1111/cas.15070] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/04/2021] [Accepted: 07/16/2021] [Indexed: 12/25/2022] Open
Abstract
To address the major issue of regional disparity in the treatment for elderly cancer patients in an aging society, we compared the treatment strategies used for elderly patients with thoracic esophageal cancer and their survival outcomes in metropolitan areas and other regions. Using the national database of hospital‐based cancer registries in 2008‐2011, patients aged 75 years or older who had been diagnosed with thoracic esophageal cancer were enrolled. We divided the patients into two groups: those treated in metropolitan areas (Tokyo, Kanagawa, Osaka, Aichi, Saitama, and Chiba prefectures) with populations of 6 million or more and those treated in other areas (the other 41 prefectures). Compared were patient backgrounds, treatment strategies, and survival curves at each cancer stage. In total, 1236 (24%) patients from metropolitan areas and 3830 (76%) patients from nonmetropolitan areas were enrolled. Patients in metropolitan areas were treated at more advanced stages. There was also a difference in treatment strategy. The 3‐year survival rate among cStage I patients was better in metropolitan areas (71.6% vs. 63.7%), and this finding mainly reflected the survival difference between patients treated with radiotherapy alone. For cStage II‐IV patients, there were no differences. Multivariable Cox proportional hazard analysis including interaction terms between treatment areas, cStage, and the first‐line treatments revealed that treatments in the metropolitan areas were significantly associated with better survival among patients treated with radiotherapy alone for cStage I cancer. Treatment strategies for elderly patients with thoracic esophageal cancer and its survival outcomes differed between metropolitan areas and other regions.
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Affiliation(s)
- Satoru Motoyama
- Division of Esophageal Surgery, Akita University Hospital, Akita, Japan.,Department of Comprehensive Cancer Control, Akita University Graduate School of Medicine, Akita, Japan
| | - Eri Maeda
- Environmental Health Science and Public Health, Akita University Graduate School of Medicine, Akita, Japan
| | - Katsunori Iijima
- Department of Gastroenterology, Akita University Graduate School of Medicine, Akita, Japan
| | - Akira Anbai
- Department of Radiology, Akita University Graduate School of Medicine, Akita, Japan
| | - Yusuke Sato
- Division of Esophageal Surgery, Akita University Hospital, Akita, Japan.,Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Akiyuki Wakita
- Division of Esophageal Surgery, Akita University Hospital, Akita, Japan.,Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Yushi Nagaki
- Division of Esophageal Surgery, Akita University Hospital, Akita, Japan.,Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Hiromu Fujita
- Division of Esophageal Surgery, Akita University Hospital, Akita, Japan.,Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Yoshihiro Minamiya
- Department of Thoracic Surgery, Akita University Graduate School of Medicine, Akita, Japan
| | - Takahiro Higashi
- Division of Health Services Research, Center for Cancer Control and Information Services, National Cancer Center, Akita University Graduate School of Medicine, Akita, Japan
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Kalbfell E, Kata A, Buffington AS, Marka N, Brasel KJ, Mosenthal AC, Cooper Z, Finlayson E, Schwarze ML. Frequency of Preoperative Advance Care Planning for Older Adults Undergoing High-risk Surgery: A Secondary Analysis of a Randomized Clinical Trial. JAMA Surg 2021; 156:e211521. [PMID: 33978693 DOI: 10.1001/jamasurg.2021.1521] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance For patients facing major surgery, surgeons believe preoperative advance care planning (ACP) is valuable and routinely performed. How often preoperative ACP occurs is unknown. Objective To quantify the frequency of preoperative ACP discussion and documentation for older adults undergoing major surgery. Design, Setting, and Participants This secondary analysis of data from a multisite randomized clinical trial testing the effects of a question prompt list intervention on preoperative communication for older adults considering major surgery was performed at 5 US academic medical centers. Participants included surgeons who routinely perform high-risk surgery and patients 60 years or older with at least 1 comorbidity and an oncological or vascular (cardiac, peripheral, or neurovascular) problem. Data were collected from June 1, 2016, to November 30, 2018. Interventions Patients received a question prompt list brochure with 11 questions that they might ask their surgeon. Main Outcomes and Measures For patients who had major surgery, any statement related to ACP from the surgeon, patient, or family member during the audiorecorded preoperative consultation was counted. The presence of a written advance directive (AD) in the medical record at the time of the initial consultation or added preoperatively was recorded. Open-ended interviews with patients who experienced postoperative complications and family members were conducted. Results Among preoperative consultations with 213 patients (122 men [57%]; mean [SD] age, 72 [7] years), only 13 conversations had any discussion of ACP. In this cohort of older patients with at least 1 comorbid condition, 141 (66%) did not have an AD on file before major surgery; there was no significant association between the presence of an AD and patient age (60-69 years, 26 [31%]; 70-79 years, 31 [33%]; ≥80 years, 15 [42%]; P = .55), number of comorbidities (1, 35 [32%]; 2, 18 [33%]; ≥3, 19 [40%]; P = .62), or type of procedure (oncological, 53 [32%]; vascular, 19 [42%]; P = .22). There was no difference in preoperative communication about ACP or documentation of an AD for patients who were mailed a question prompt list brochure (intervention, 38 [35%]; usual care, 34 [33%]; P = .77). Patients with complications were enthusiastic about ACP but did not think it was important to discuss their preferences for life-sustaining treatments with their surgeon preoperatively. Conclusions and Relevance Although surgeons believe that preoperative discussion of patient preferences for postoperative life-sustaining treatments is important, these preferences are infrequently explored, addressed, or documented preoperatively. Trial Registration ClinicalTrials.gov Identifier: NCT02623335.
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Affiliation(s)
- Elle Kalbfell
- Department of Surgery, University of Wisconsin-Madison
| | - Anna Kata
- Department of Surgery, Georgetown University Hospital, Washington, DC
| | | | | | - Karen J Brasel
- Department of Surgery, Oregon Health & Science University, Portland
| | - Anne C Mosenthal
- Department of Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
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45
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Schwarze ML, Buffington A, Tucholka JL, Hanlon B, Rathouz PJ, Marka N, Taylor LJ, Zimmermann CJ, Kata A, Baggett ND, Fox DA, Schmick AE, Berlin A, Glass NE, Mosenthal AC, Finlayson E, Cooper Z, Brasel KJ. Effectiveness of a Question Prompt List Intervention for Older Patients Considering Major Surgery: A Multisite Randomized Clinical Trial. JAMA Surg 2021; 155:6-13. [PMID: 31664452 DOI: 10.1001/jamasurg.2019.3778] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Poor preoperative communication can have serious consequences, including unwanted treatment and postoperative conflict. Objective To compare the effectiveness of a question prompt list (QPL) intervention vs usual care on patient engagement and well-being among older patients considering major surgery. Design, Setting, and Participants This randomized clinical trial used a stepped-wedge design to randomly assign patients to a QPL intervention (n = 223) or usual care (n = 223) based on the timing of their visit with 1 of 40 surgeons at 5 US study sites. Patients were 60 years or older with at least 1 comorbidity and an oncologic or vascular (cardiac, neurosurgical, or peripheral vascular) problem that could be treated with major surgery. Family members were also enrolled (n = 263). The study dates were June 2016 to November 2018. Data analysis was by intent-to-treat. Interventions A brochure of 11 questions to ask a surgeon developed by patient and family stakeholders plus an endorsement letter from the surgeon were sent to patients before their outpatient visit. Main Outcomes and Measures Primary patient engagement outcomes included the number and type of questions asked during the surgical visit and patient-reported Perceived Efficacy in Patient-Physician Interactions scale assessed after the surgical visit. Primary well-being outcomes included (1) the difference between patient's Measure Yourself Concerns and Well-being (MYCaW) scores reported after surgery and scores reported after the surgical visit and (2) treatment-associated regret at 6 to 8 weeks after surgery. Results Of 1319 patients eligible for participation, 223 were randomized to the QPL intervention and 223 to usual care. Among 446 patients, the mean (SD) age was 71.8 (7.1) years, and 249 (55.8%) were male. On intent-to-treat analysis, there was no significant difference between the QPL intervention and usual care for all patient-reported primary outcomes. The difference in MYCaW scores for family members was greater in usual care (effect estimate, 1.51; 95% CI, 0.28-2.74; P = .008). When the QPL intervention group was restricted to patients with clear evidence they reviewed the QPL, a nonsignificant increase in the effect size was observed for questions about options (odds ratio, 1.88; 95% CI, 0.81-4.35; P = .16), expectations (odds ratio, 1.59; 95% CI, 0.67-3.80; P = .29), and risks (odds ratio, 2.41; 95% CI, 1.04-5.59; P = .04) (nominal α = .01). Conclusions and Relevance The results of this study were null related to primary patient engagement and well-being outcomes. Changing patient-physician communication may be difficult without addressing clinician communication directly. Trial Registration ClinicalTrials.gov identifier: NCT02623335.
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Affiliation(s)
| | - Anne Buffington
- Department of Surgery, University of Wisconsin-Madison, Madison
| | | | - Bret Hanlon
- Department of Biostatistics & Medical Informatics, University of Wisconsin-Madison, Madison
| | - Paul J Rathouz
- Department of Population Health, The University of Texas at Austin, Austin
| | - Nicholas Marka
- Department of Surgery, University of Wisconsin-Madison, Madison
| | - Lauren J Taylor
- Department of Surgery, University of Wisconsin-Madison, Madison
| | | | - Anna Kata
- Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | | | - Daniel A Fox
- School of Medicine, Northwestern University, Evanston, Illinois
| | - Andrea E Schmick
- Department of Medicine, University of Wisconsin-Madison, Madison
| | - Ana Berlin
- Division of General Surgery, Department of Surgery, Columbia University Medical Center, New York, New York.,Adult Palliative Medicine Service, Division of Hematology/Oncology, Department of Medicine, Columbia University Medical Center, New York, New York
| | - Nina E Glass
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Anne C Mosenthal
- Department of Surgery, Rutgers New Jersey Medical School, Newark
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland
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46
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Kalbfell EL, Buffington A, Kata A, Brasel KJ, Mosenthal AC, Cooper Z, Finlayson E, Schwarze ML. Expressions of conflict following postoperative complications in older adults having major surgery. Am J Surg 2021; 222:670-676. [PMID: 34218931 DOI: 10.1016/j.amjsurg.2021.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/17/2021] [Accepted: 06/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND After serious postoperative complications, patients and families may experience conflict about goals of care. METHODS We performed a multisite randomized clinical trial to test the effect of a question prompt list on postoperative conflict. We interviewed family members and patients age ≥60 who experienced serious complications. We used qualitative content analysis to analyze conflict and characterize patient experiences with complications. RESULTS Fifty-six of 446 patients suffered a serious complication. Participants generally did not report conflict relating to postoperative treatments and expressed support for the care they received. We did not appreciate a difference in conflict between intervention and usual care. Respondents reported feeling unprepared for complications, witnessing heated interactions among team members, and a failure to develop trust for their surgeon preoperatively. CONCLUSION Postoperative conflict following serious complications is well described but its incidence may be low. Nonetheless, patient and family observations reveal opportunities for improvement.
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Affiliation(s)
- Elle L Kalbfell
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Anne Buffington
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Anna Kata
- Department of Surgery, Georgetown University Hospital, Washington D.C, USA
| | - Karen J Brasel
- Department of Surgery, Oregon Health and Science University, Portland, OR, USA
| | - Anne C Mosenthal
- Department of Surgery, Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Zara Cooper
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
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47
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Paolini C, Bencini L, Gabellini L, Urciuoli I, Pacciani S, Tribuzi A, Moraldi L, Calistri M, Coratti A. Robotic versus open pancreaticoduodenectomy: Is there any difference for frail patients? Surg Oncol 2021; 37:101515. [PMID: 33429323 DOI: 10.1016/j.suronc.2020.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Old age and frailty are predictors of early postoperative results after pancreatic surgery. We analysed the results of robotic and open pancreatoduodenectomy in elderly and frail patients. METHODS Data from the local robotic pancreatoduodenectomy database were reviewed and matched with those from open operations during the same period (2014-2020). Both old age and frailty were used to determine any correlation with postoperative outcomes. Elderly patients were defined as patients aged 70 years or more, while frailty was classified according to the validated modified Frailty Index. RESULTS A total of 118 pancreatoduodenectomies were included in the analysis: 65 (55.1%) robotic and 53 (44.9%) open. More than 50% of patients were frail. Overall, 7.6% of patients experienced grade IV Clavien-Dindo complications, and 3.4% died within 90 days after surgery. Frail patients experienced a similar rate of severe complications after robotic vs. open operations (5.3 vs. 11.6; p = 0.439) but earlier refeeding (3 days vs. 4 days; p = 0.006) and earlier drain removal (6 days vs. 7 days; p = 0.046) when operated on by a robotic approach. The oncological outcomes, including limphnodes retrieval, residual disease, recurrences, and survival, were not influenced by the surgical approach. Non-elderly patients also showed more benefits with the robotic approach (lower complication index, earlier refeeding, and drain removal). CONCLUSIONS Robotic pancreatoduodenectomy is associated with risks of major complications that are comparable to those of open operation in frail patients. Some perioperative parameters (refeeding, drain removal) seem to favour robotics in frail patients and younger patients, although at the price of longer operating times.
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Affiliation(s)
- Claudia Paolini
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Lapo Bencini
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy.
| | - Linda Gabellini
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Irene Urciuoli
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Sabrina Pacciani
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Angela Tribuzi
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Luca Moraldi
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Massimo Calistri
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
| | - Andrea Coratti
- Surgical Oncology and Robotics, Careggi University Hospital, Florence, Italy
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48
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Chen C, Kolbe J, Christmas T. Surgical treatment of non-small-cell lung cancer in octogenarians: a single-centre retrospective study. Intern Med J 2021; 51:596-599. [PMID: 33890378 DOI: 10.1111/imj.15268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
Lung resection in patients aged ≥80 years is considered high risk and contributes to the low rates of resection in this population. This review of 79 octogenarians who underwent curative surgery for non-small-cell lung cancer demonstrated no intraoperative mortality, 30-day mortality of 1.3% and 12-month mortality of 10%. In this selected cohort of octogenarians, surgery resulted in acceptable short- to medium-term outcomes.
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Affiliation(s)
- Charlotte Chen
- Respiratory Services, Auckland District Health Board, Auckland, New Zealand
| | - John Kolbe
- Respiratory Services, Auckland District Health Board, Auckland, New Zealand.,Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Tim Christmas
- Respiratory Services, Auckland District Health Board, Auckland, New Zealand
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49
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Parray A, Bhandare MS, Pandrowala S, Chaudhari VA, Shrikhande SV. Peri-operative, long-term, and quality of life outcomes after pancreaticoduodenectomy in the elderly: greater justification for periampullary cancer compared to pancreatic head cancer. HPB (Oxford) 2021; 23:777-784. [PMID: 33041206 DOI: 10.1016/j.hpb.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 09/08/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Pancreaticoduodenectomy (PD) is more challenging in the elderly. METHODS Data of patients undergoing PD above 70 years of age was analysed to study short and long-term outcomes along with the quality of life parameters (QOL). RESULTS Out of 1271 PDs performed, 94 (7%) patients were 70 years or more. American Society of Anaesthesiology (ASA) scores were higher in comparison to patients below 70 years (ASA 1;20% vs. 54% and ASA 2&3;80% vs. 46%, p < 0.001). The postoperative 90-day mortality rate of 5.3% and morbidity (Clavein Grade III and IV of 27%) was higher but non-significant compared to 3.9% (p = 0.50) and 20% (p = 0.11) in patients less than 70 years. The median survival of 40 months was significantly better for periampullary carcinoma when compared to 15 months in pancreatic ductal adenocarcinoma (PDAC) (p < 0.0001). Patients, less than 70 years had significantly better 3-year survival; 64% vs 43% with periampullary etiology (p < 0.01) and 29% vs 0% with PDAC (p < 0.0001). QLQ-PAN 26 questionnaire responses were suggestive of good long term QOL in these patients. CONCLUSION Although PD is safe and feasible in the elderly population with good long-term QOL, postoperative morbidity and mortality can be slightly higher and long-term survival significantly lower.
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Affiliation(s)
- Amir Parray
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Manish S Bhandare
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India.
| | - Saneya Pandrowala
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Vikram A Chaudhari
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
| | - Shailesh V Shrikhande
- Gastrointestinal and Hepato-Pancreato-Biliary Service, Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, 400012, Maharashtra, India
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50
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Esophageal Cancer in Elderly Patients, Current Treatment Options and Outcomes; A Systematic Review and Pooled Analysis. Cancers (Basel) 2021; 13:cancers13092104. [PMID: 33925512 PMCID: PMC8123886 DOI: 10.3390/cancers13092104] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/17/2021] [Accepted: 04/21/2021] [Indexed: 12/26/2022] Open
Abstract
Simple Summary Any given treatment may provide improve survival for elderly patients with oesophageal cancer compared to best supportive care. Although surgery may be related to a higher rate of complications in these patients, it also offers the best chance for survival, especially when combined with perioperative chemo-or chemoradiation. Definitive chemoradiation remains also a valid and widely used curative approach in this population. Quality of life after oesophageal cancer treatment does not seem to be particularly compromised in elderly patients, although the risk of loss of autonomy after the disease is higher. Based on the available data, excluding a priori elderly patients from curative treatment based on age alone cannot be supported. A thorough general health status and geriatric assessment is necessary to offer the optimal treatment, tailored to the individual patient. Abstract Esophageal cancer, despite its tendency to increase among younger patients, remains a disease of the elderly, with the peak incidence between 70–79 years. In spite of that, elderly patients are still excluded from major clinical trials and they are frequently offered suboptimal treatment even for curable stages of the disease. In this review, a clear survival benefit is demonstrated for elderly patients treated with neoadjuvant treatment, surgery, and even definitive chemoradiation compared to palliative or no treatment. Surgery in elderly patients is often associated with higher morbidity and mortality compared to younger patients and may put older frail patients at increased risk of autonomy loss. Definitive chemoradiation is the predominant modality offered to elderly patients, with very promising results especially for squamous cell cancer, although higher rates of acute toxicity might be encountered. Based on the all the above, and although the best available evidence comes from retrospective studies, it is not justified to refrain from curative treatment for elderly patients based on their age alone. Thorough assessment and an adapted treatment plan as well as inclusion of elderly patients in ongoing clinical trials will allow better understanding and management of esophageal cancer in this heterogeneous and often frail population.
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