- Email: [email protected]
The surgical risk of elderly patients with cancer
ARTICLE IN PRESS
Surgical Oncology 13 (2004) 169–173 www.elsevier.com/locate/suronc
Editorial
The surgical risk of elderly patients with cancer 1. The surgical risk in the elderly: to operate or not Two out of three solid tumours occur in patients aged 65 years or older, and most cancer-related deaths occur within this age subgroup [1–3]. There is evidence that this expanding population receives substandard treatment when compared to the younger age group [4]. This is due to the perceived limitations to offer conventional treatments to the elderly [5,6] as there are concerns about associated medical conditions [7,8], reluctance to incorporate older patients either into clinical trials of novel agents, or into existing screening programs [9–12]. Although this concern refers to the overall management of the elderly with cancer involving multimodal treatment, surgery is probably the most successful treatment option at the present moment. It is our responsibility to alert the medical community and make sure we are prepared for a cultural, practical, and ethical change. Operating on the elderly and even very elderly for cardiac, orthopaedic or vascular diseases is increasingly accepted; there is, on the other hand, continued reluctance to recommend aggressive intervention for malignant conditions [1]; this is true for non-surgical treatment and surgery too, even though surgical resection has so far been accepted as the only curative therapy for solid tumours [2]. Elderly subjects are denied surgery because of their presumed higher mortality and morbidity rates, as it used to be stated at the beginning of last century [3]. Other reasons to receive sub-standard treatment are shorter life expectancy and active live expectancy. Reluctance to advise or accept an operation is often unrelated to the presence of co-existing debilitating conditions or impaired functional status [4]. In the first half of last century operative mortality under elective conditions was high for patients X70 (19% compared to 5% in modern series). The increasing elderly population and the frequency of surgical problems among the elderly was clearly focused by Brooks in 1937 [3]. It has been over 50 years since Welch reported a large series of abdominal operations in patients 470 years with a peri-operative mortality of 20.7% [5]: he 0960-7404/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.suronc.2004.09.012
concluded that the surgery itself was safe but that senior patients required greater attention in their peri-operative management. In 1975 Greenfield showed operative mortality was halved among the same age group how over a 40 year period [6], as the consequence of improvements in anaesthetic and surgical technique, availability of new drugs and optimised postoperative care. It is rather surprising that, in spite of this progress, it is still common clinical practice to exclude the aged from optimal surgical treatment [13]. Such a less-than-average management of oncogeriatric series prompted several surgical oncologist reviewing their series, resulting into two positive outcomes: first, authors reviewed their performance, audited their outcomes, and compared their results, providing evidence of superimposable long-term cancer-related outcomes, no matter the patient’s age [14,15]. Also, they noticed how, after accurate selection and expert management, short-term complication and death rates do not differ significantly. Surprisingly it was only during the last quarter of the century that we started realising the prognostic importance of comorbidities as a powerful prognosticator. Not only weight loss and obstructive conditions were noticed to negatively impact on short-term outcomes, but a number of medical conditions such as cardiovascular, pulmonary, renal, hepatic, metabolic, and so on [7–10]. Consequently, a direct impact of comorbidities on cancer management was hypothesised: geriatricians had been using comorbidities as a prognosticator for several years, and a significant step forward was made when a predictive value in toxicity and outcome of treatment was noticed among elderly cancer patients, mainly receiving non-surgical treatment [11,12,16,17]. Some studies seemed to indicate that the inclusion of a vast list of comorbidities to the patient’s pre-treatment assessment increases their prognostic value [18,19]. It was also suggested it is not a mere list of associated medical conditions to impact on prognosis, but it is actually the complexity of information that can be gathered through a comprehensive geriatric assessment (CGA) tool. CGA had proven useful in predicting
ARTICLE IN PRESS 170
Editorial / Surgical Oncology 13 (2004) 169–173
mortality and disability in several clinical settings, including hospital geriatric evaluation, inpatient geriatric consultation, home assessment service, hospital home assessment service, and outpatient assessment service and in a number of chronic diseases [20–24]. 1.1. Comprehensive geriatric assessment In a previous experience of ours, investigating on nonsurgical elderly cancer patients [25], we demonstrated how the CGA adds substantial information to the functional assessment of elderly cancer patients routinely collected through the Performance Status (PS) index. Among elderly cancer patients, the role of PS as unique marker of functional status resulted unacceptable. Although there is no consensus on which instrument is preferable, CGA should be utilised in older cancer patients to ameliorate their functional status, detect unaddressed problems, and expand their survival. The decision whether to operate or not on a patient is one of the most important ones a surgeon is asked to make. This is obviously more relevant when dealing with a patient who is a poor surgical candidate. The older population is a large and heterogeneous group, ranging from competent, active and well individuals to frail, demented subjects. A number of factors (i.e. greater need for information, more effective use of available resources, advances in perioperative management and surgical techniques) demand an improved and individualised risk definition to be shared between the surgeon and the patient. Although this can be a difficult task in an emergency setting, risk prediction should be appreciated and disclosed to the patient while consenting her/him. The largest number of abnormal laboratory tests are not capable of predicting post-treatment/operative adverse outcomes. Consequently, a number of risk classifications aimed at predicting outcomes for specific conditions have been developed and tested; unfortunately, results have been relatively disappointing. Importantly, no scoring method relating to candidacy for surgery has ever been attempted specifically on the oncogeriatric population. 1.2. Estimating surgical risk Currently available assessment tools include the wellknown American Society of Anesthesiologists (ASA) physical status system [26]. ASA is not aimed to measuring the operative risk, rather to globally assess the degree of sickness or physical state prior to anaesthesia and surgery; ASA does not specifically refer to elderly individuals. Unfortunately, ASA is not sufficiently sensitive in differentiating the largest proportion of patients falling in the ASA II and III categories [1,27].
The assessment of cardiac risk was addressed by Goldman Cardiac Risk Index (CRI) [28], an instrument designed to assess cardiac risk in non-cardiac surgery but is rarely used by surgeons [29]. The modified cardiac risk index, and the algorithm for cardiac risk assessment laid down by the American College of Physicians, are applied by anaesthesiologists as determinants of outcome [30,31]. Respiratory complications were analysed by Kroenke [32] who described the following as associated with respiratory complications following thoracic and major abdominal surgery (a) age over 70, (b) peri-operative broncho-dilator use, (c) abnormal chest X-ray and (d) high ASA grade. Lawrence et al. [33] identified four preoperative variables that were associated with postoperative respiratory complications: (1) abnormal respiratory examination, (2) abnormal chest X-ray, (3) Goldman CRI, and (4) the Charlson co-morbidity index [34]. These have not been formalised as a score or validated. Undernourishment is high amongst the ‘‘healthy’’ geriatric population, as it can affect up to 12% males and 8% females. Moreover, nutritional deficiencies occur in 60% hospitalised elderly subjects in Europe. These figures have an impact on outcomes, since a sixfold increase in surgical complications was reported in patients who were malnourished preoperatively [35,36]. APACHE is probably the best known of the physiological scoring systems (Acute Physiological And Chronic Health Evaluation) [37]. It is based on 34 physiological variables taking the worst values in the first 24 hours from the patient’s admission to an intensive care unit. Various modifications of this APACHE system are now available: APACHE II [38] uses 12 physiological variables; it is currently being used in general and surgical intensive care patients. Its application in the intensive care unit seems very appropriate but its development to general surgical patients who may not require respiratory support in intensive care is limited. Another physiological scoring system originated in the UK is the Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) [39,40]. P POSSUM is a modification of the POSSUM [41]; this has been developed to attempt to counter over prediction of mortality that has been experienced in some diseases when POSSUM has been used. A different formula for the calculation of the risk value is made. Both these scoring systems consists of two parts: a physiological score, and an operative score. This second part is highly relevant to the final result; unfortunately the necessity to record per-operative variables compromises its usefulness as a preoperative assessment tool.
ARTICLE IN PRESS Editorial / Surgical Oncology 13 (2004) 169–173
In the lack of reliable instruments capable of predicting the risk, and allowing a fair comparison between series, it was felt appropriate auditing and presenting personal and institutional results. Series of Ivor-Lewis transthoracic-abdominal resections for oesophageal tumours, major abdominal procedures for large bowel malignancies or extensive liver cancer surgery, pancreatic resections and others were audited and published [42–59]. Reviews were also performed [60] as well as multi-institutional data collections [61]. Several lessons were drawn here. First and most importantly, long term cancer outcomes are ageindependent; whenever a surgical option is feasible, it should be considered and offered no matter the patients anagraphycal age. Second, it was shown how aggressive procedures can be undertaken on subjects 470 years. Unfortunately, a serious selection bias is noticeable all along this data collection, and such conclusions are not realistic; these findings are only representative of the restricted number of very fit patients who managed to reach the operative room. But, how do we select elderly patients for surgery?
1.3. Preoperative assessment of cancer in the elderly (PACE) To minimise the risk of a major selection bias in recruiting and presenting surgical data on elderly cancer patients, an international project has been launched with the aim of defining the general health condition of oncogeriatric surgical candidates PACE. PACE is a new instrument generated from the previous experience [23], this time focusing on the surgical candidate. In addition, PACE incorporates other instruments currently used for surgical risk assessment (PS, ASA, Possum, and P Possum). Specifically PACE entails:
171
Results are now available from an interim analysis on 215 patients entered from 7 recruiting centres from the UK, Italy, the Netherlands and Japan. Participation rate was 99% (2 patients refused the interview for personal reasons). Patient’s age ranges from 70 to 92 years (median age 76 years). Patients affected by breast, urogenital, colorectal, head & neck, and upper GI malignancies were recruited. The administration of the questionnaire took an average of 20 minutes. Patients demonstrated a clear comprehension of what they were required in completing the various components of PACE. Patients developing postoperative complications had a higher number of comorbidities (p ¼ 0:024), and a higher GDS (p ¼ 0:018). A significant difference was also noticed between the 2 groups when PS is taken into account: 81.9% of the non-complicated group had PS=0 vs. 46.9% of the ones who underwent complications (po0:0001). ADL and IADL dependency were also significantly associated to the complication rate (p ¼ 0:005 and 0:043; respectively). There was no evidence of association between scores on the Mini Mental State, the Brief Fatigue Index, and ASA. We can provisionally conclude that the aspects of PACE relating to psychological wellbeing do not appear to be significantly associated with post-operative complications. To the opposite, aspects relating to physical frailty and morbidity (i.e. PS, ADL and IADL) seem to show a significant association. These interesting early results should be rehinforced with figures from a much larger sample. This cooperative project is ongoing at present under the auspices of SIOG–International Society of Geriatric Oncology [64], and further expressions of interest in actively participating to this investigation are welcome.
References MMS—Mini Mental State [62] Satariano’s modified index of co-morbidities [25] ADL—Activities of Daily Living [33] IADL—Instrumental Activities of Daily Living [34] GDS—Geriatric Depression Scale [36] BFI—Brief Fatigue Inventory [37] PS—ECOG Performance Status [38] ASA—American Society Anaesthesiologists [26] POSSUM—Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity [39,40] P POSSUM—Portsmouth POSSUM Modification [41]
A pilot study has been completed on a sample of 73 patients; it has proven PACE to be feasible and inexpensive [63].
[1] Alexander HR, Turnbull AD, Salomone J, et al. Upper abdominal cancer surgery in the very elderly. Journal of Surgical-Oncology 1991;47:82–6. [2] Wallach CB, Kurtz RC. Gastrointestinal cancer in the elderly. Gastroenterology Clinics of North America 1990;19:419–32. [3] Brookes B. Surgery in patients of advanced age. Annals of Surgery 1937;105:481–501. [4] Samet J, Hunt WC, Key C, Goodwin JS. Choice of cancer therapy varies with age of patient. Journal of American Mathematical Association 1986;255:3385–90. [5] Welch CS. Surgery in the aged. New England Journal of Medicine 1948;238:821–32. [6] Greenfield LJ. Surgery of the aged. Philadelphia: WB Saunders (ed); 1975. [7] Boyd JB, Bradford Jr B, Watne AL. Operative risk factors of colon resection in the elderly. Annals of Surgery 1980;192:743–6. [8] Brown SCW, Walsh S, Abrahm JS, Sykes PA. Risk factors and operative mortality in surgery for colorectal cancer. Annals of the Royal College of Surgeons of England 1991;73:269–72.
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[9] Greenburg AG, Saik RP, Pridham D. Influence of age on mortality of colon surgery. American Journal of Surgery 1985;150(1):65–70. [10] Fallahzadeh H, Mays ET. Preexisting disease as a predictor of the outcome of colectomy. American Journal of Surgery 1991;162(5): 497–8. [11] Firat S, Bousamra M, Gore E, Byhardt RW. Comorbidity and KPS are independent prognostic factors in stage I non-small-cell lung cancer. International Journal of Radiation Oncology Biology Physics 2002;52(4):1047–57. [12] Firat S, Byhardt RW, Gore E. Comorbidity and Karnofksy performance score are independent prognostic factors in stage III non-small-cell lung cancer: an institutional analysis of patients treated on four RTOG studies. Radiation Therapy Oncology Group. International Journal of Radiation Oncology Biology Physics 2002;54(2):357–64. [13] Audisio RA, Bozzetti F, Gennari R, Jaklitsch MT, Koperna T, Longo WE, Wiggers T, Zbar AP. The surgical management of elderly cancer patients: recommendations of the SIOG surgical task force. European Journal of Cancer 2004;40:926–38. [14] Vercelli M, Quaglia A, Casella C, Parodi S, Capocaccia R, Martinez Garcia C. Relative survival in elderly cancer patients in Europe. European Journal of Cancer 1998;34:2264–70. [15] Vercelli M, Capocaccia R, Quaglia A, Casella C, Puppo A, Coebergh JW. Relative survival in elderly European cancer patients: evidence for health care inequalities. The EUROCARE Working Group. Critical Reviews in Oncology/Hematology 2000;35:161–79. [16] Frasci G. On behalf of the Southern Italy Cooperative Oncology Group (SICOG). Chemotherapy of lung cancer in the elderly. Critical Reviews in Oncology/Hematology 2002;41(3):349–61. [17] Piccirillo JF. Inclusion of comorbidity in a staging system for head and neck cancer. Oncology (Huntingt) 1995;9(9):831–6 841, 845-8. [18] Rochon PA, Katz JN, Morrow LA, McGlinchey-Berroth R, Ahlquist MM, Sarkarati M, Minaker KL. Comorbid illness is associated with survival and length of hospital stay in patients with chronic disability. A prospective comparison of three comorbidity indices. Medical Care 1996;34(11):1093–101. [19] Fried LP, Bandeen-Roche K, Kasper JD, Guralnik JM. Association of comorbidity with disability in older women: the Women’s Health and Aging Study. Journal of Clinical Epidemiology 1999;52(1):27–37. [20] Repetto L, Granetto C, Venturino A, et al. Prognostic evaluation of the older cancer patient. In: Balducci L, Lyman GH, Ershler WB, editors. Comprehensive geriatric oncology, 20. Amsterdam: Harwood Academic Publisher; 1998. p. 287–300. [21] Stuck AE, Siu AL, Wieland GD, et al. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342: 1032–6. [22] Bernabei R, Landi F, Gambassi G, et al. British Medical Journal 1998;316:1348–51. [23] National Institutes of Health Consensus Developement Conference Statement. Geriatric assessment methods for clinical decision-making. Journal of the American Geriatrics Society 1988;36:342–7. [24] Rich MW, Beckham W, Wittenberg C, et al. A multidisciplinary intervention to prevent readmission of elderly patients with congestive heart failure. New England Journal of Medicine 1995;333:1190–5. [25] Repetto L, Fratino L, Audisio RA, Venturino A, Gianni W, Vercelli M, Parodi S, Dal Lago D, Gioia F, Monfardini S, Aapro MS, Serraino D. Zagonel V Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group Performance Status in elderly cancer patients: an Italian Group for Geriatric Oncology Study. J Clin Oncol. 2002;20(2): 494–502.
[26] New classification of physical status. American Society of Anesthesiologists, Anesthesiology 1963;24:111 http://www.asahq. org/ProfInfo/PhysicalStatus.html. [27] Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients. J Am Geriatr Soc 2001;49(8):1080–5. [28] Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. New England Journal of Medicine 1977;297:845–50. [29] Michaels JA, Payne SPK, Galland RB. A study of methods used for cardiac risk assessment prior to major vascular surgery. European Journal of Vascular and Endovascular Surgery 1996;11:221–4. [30] Detsky AS, Abrams HB, McLaughlin JR, et al. Predicting cardiac complications in patients undergoing non-cardiac surgery. Journal of General Internal Medicine 1986;1(4):211–9. [31] Guidelines for assessing and managing the perioperative risk from coronary artery disease associated with major noncardiac surgery. American College of Physicians. Annals of Internal Medicine 1997;127(4):309–12. [32] Kroenke K, Lawrence VA, Theroux J, et al. Postoperative complications after thoracic and major abdominal surgery in patients with and without obstructive lung disease. Chest 1993;104:1445–51. [33] Lawrence VA, Dhanda R, Hilsenbeck SG, Page CP. Risk of pulmonary complications after elective abdominal surgery. Chest 1996;110:744–50. [34] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of Chronic Disease 1987;40:373–83. [35] Bozzetti F. Surgery in the elderly: the role of nutritional support. Clinical Nutrition 2001;20(2):103–16. [36] Detsky AS, Baker JP, O’Rourke K, et al. Predicting nutritionassociated complications for patients undergoing gastrointestinal surgery. Journal of Parental and Enteral Nutrition 1987;11(5):440–6. [37] Knaus WA, Zimmerman JE, Wagner DP, Draper EA, Lawrence DE. APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Critical Care Medicine 1981;9(8):591–7. [38] Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Critical Care Medicine 1985;13(10):818–29. [39] Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. British Journal of Surgery 1991;78(3):355–60. [40] Copeland GP. The POSSUM system of surgical audit. Archives of Surgery 2002;137(1):15–9. [41] Prytherch DR, Whiteley MS, Higgins B, et al. POSSUM and Portsmouth POSSUM for predicting mortality. Physiological and Operative Severity Score for the enumeration of Mortality and morbidity. British Journal of Surgery 1998;85(9):1217–20. [42] Karl RC, Smith SK, Fabri PJ. Validity of major cancer operations in elderly patients. Annals of Surgical Oncogy 1995; 2:107–13. [43] Plotnikov VI, Kulish VL, Malaev SG. Surgery for elderly patients with cancer of the cardia. Seminars in Surgical Oncology 1992;8:41–5. [44] Yamanaka H, Hiramatsu Y, Kawaguchi Y, et al. Surgical treatment for poor-risk patients with carcinoma of the oesophagus. Japanese Journal of Surgery 1991;21:178–83. [45] Hirano T, Yamamoto S, Miura T, et al. Cancer of the stomach in the elderly. Research in Surgery 1990;2:53–7. [46] Rohde H, Bauer P, Stu¨tzer H, et al. Proximal compared with distal adenocarcinoma of the stomach: differences and consequences. British Journal of Surgery 1991;78:1242–8.
ARTICLE IN PRESS Editorial / Surgical Oncology 13 (2004) 169–173 [47] Bandoh T, Isoyama T, Toyoshima H. Total gastrectomy for gastric cancer in the elderly. Surgery 1991;109:136–42. [48] Fortner JG, Lincer RM. Hepatic resection in the elderly. Annals of Surgery 1990;211:141–5. [49] Takenaka K, Shimada M, Higashi H, et al. Liver resection for hepatocellular carcinoma in the elderly. Archives of Surgery 1994;129:846–50. [50] Fong Y, Blumgart LH, Fortner JG, Brennan MF. Pancreatic or liver resection for malignancy is safe and effective for the elderly. Annals of Surgery 1995;4:426–37. [51] Yanaga K, Kanematsu T, Takenaka K, et al. Hepatic resection for hepatocellular carcinoma in the elderly patients. American Journal of Surgery 1988;155:238–41. [52] Nuzzo G, Giovannini I, Giuliante F, Boldrini G, Chiarla C, Tebala GD. The surgical risk of liver resections for neoplasms in the elderly patient. Chir Ital 1994;46(1):23–9. [53] Saunders K, Tompkins R, Longmire Jr W, Roslyn J. Bile duct carcinoma in the elderly-a rationale for surgical management. Archives of Surgery 1991;126:1186–91. [54] Spencer MP, Sarr MG, Nagorney DM. Radical pancreatectomy for pancreatic cancer in the elder. Is it safe and justified? Annals of Surgery 1991;212:140–3. [55] Katoh H, Hirano S, Satoh K. Surgical treatment of pancreatobiliary carcinoma in the elderly. Nippon Ronen Igakkai Zasshi 1994;31:33–7. [56] Kayahara M, Nagakawa T, Ueno K, et al. Pancreatic resection for periampullary carcinoma in the elderly. Surgery Today 1994;24:229–33.
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[57] Jensen HE, Nielsen J, Baslev I. Carcinoma of the colon in the oo`d age. Annals of Surgery 1970;171:107–15. [58] Bader TF. Colorectal cancer in patients older than 75 years of age. Diseases of the Colon and Rectum 1986;29:728–32. [59] Huguet C, Harb J, Bona S. Coloanal anastomosis after resection of low rectal cancer in the elderly. World Journal of Surgery 1990;14:619–23. [60] Audisio RA, Veronesi P, Ferrario L, Cipolla C, Andreoni B, Aapro MS. Elective surgery in gastrointestinal tumours in the aged. Annals of Oncology 1997;8(4):317–27. [61] Colorectal Cancer Collaborative Group. Surgery for colorectal cancer in the elderly patients: a systematic review. Lancet 2000;356:968–74. [62] Folstein MF, Folstein SE, McHugh PR. Mini Mental State. A practical method for grading the cognitive state of patients for the clinicians. Journal of Psychiatric Research 1975;12: 189–98. [63] Audisio RA, Gennari R, Sunouchi K, Nair HR, Sestini A, Pope D, West C. Preoperative assessment of cancer in the elderly: a pilot study. Supportive Cancer Therapy 2003;1(1): 55–60. [64] http://www.cancerworld.com/siog/default.asp.
Riccardo A. Audisio University of Liverpool, Liverpool, UK Whiston Hospital, Prescot, Merseyside, UK E-mail address: [email protected]
Surgical Oncology 13 (2004) 169–173 www.elsevier.com/locate/suronc
Editorial
The surgical risk of elderly patients with cancer 1. The surgical risk in the elderly: to operate or not Two out of three solid tumours occur in patients aged 65 years or older, and most cancer-related deaths occur within this age subgroup [1–3]. There is evidence that this expanding population receives substandard treatment when compared to the younger age group [4]. This is due to the perceived limitations to offer conventional treatments to the elderly [5,6] as there are concerns about associated medical conditions [7,8], reluctance to incorporate older patients either into clinical trials of novel agents, or into existing screening programs [9–12]. Although this concern refers to the overall management of the elderly with cancer involving multimodal treatment, surgery is probably the most successful treatment option at the present moment. It is our responsibility to alert the medical community and make sure we are prepared for a cultural, practical, and ethical change. Operating on the elderly and even very elderly for cardiac, orthopaedic or vascular diseases is increasingly accepted; there is, on the other hand, continued reluctance to recommend aggressive intervention for malignant conditions [1]; this is true for non-surgical treatment and surgery too, even though surgical resection has so far been accepted as the only curative therapy for solid tumours [2]. Elderly subjects are denied surgery because of their presumed higher mortality and morbidity rates, as it used to be stated at the beginning of last century [3]. Other reasons to receive sub-standard treatment are shorter life expectancy and active live expectancy. Reluctance to advise or accept an operation is often unrelated to the presence of co-existing debilitating conditions or impaired functional status [4]. In the first half of last century operative mortality under elective conditions was high for patients X70 (19% compared to 5% in modern series). The increasing elderly population and the frequency of surgical problems among the elderly was clearly focused by Brooks in 1937 [3]. It has been over 50 years since Welch reported a large series of abdominal operations in patients 470 years with a peri-operative mortality of 20.7% [5]: he 0960-7404/$ - see front matter r 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.suronc.2004.09.012
concluded that the surgery itself was safe but that senior patients required greater attention in their peri-operative management. In 1975 Greenfield showed operative mortality was halved among the same age group how over a 40 year period [6], as the consequence of improvements in anaesthetic and surgical technique, availability of new drugs and optimised postoperative care. It is rather surprising that, in spite of this progress, it is still common clinical practice to exclude the aged from optimal surgical treatment [13]. Such a less-than-average management of oncogeriatric series prompted several surgical oncologist reviewing their series, resulting into two positive outcomes: first, authors reviewed their performance, audited their outcomes, and compared their results, providing evidence of superimposable long-term cancer-related outcomes, no matter the patient’s age [14,15]. Also, they noticed how, after accurate selection and expert management, short-term complication and death rates do not differ significantly. Surprisingly it was only during the last quarter of the century that we started realising the prognostic importance of comorbidities as a powerful prognosticator. Not only weight loss and obstructive conditions were noticed to negatively impact on short-term outcomes, but a number of medical conditions such as cardiovascular, pulmonary, renal, hepatic, metabolic, and so on [7–10]. Consequently, a direct impact of comorbidities on cancer management was hypothesised: geriatricians had been using comorbidities as a prognosticator for several years, and a significant step forward was made when a predictive value in toxicity and outcome of treatment was noticed among elderly cancer patients, mainly receiving non-surgical treatment [11,12,16,17]. Some studies seemed to indicate that the inclusion of a vast list of comorbidities to the patient’s pre-treatment assessment increases their prognostic value [18,19]. It was also suggested it is not a mere list of associated medical conditions to impact on prognosis, but it is actually the complexity of information that can be gathered through a comprehensive geriatric assessment (CGA) tool. CGA had proven useful in predicting
ARTICLE IN PRESS 170
Editorial / Surgical Oncology 13 (2004) 169–173
mortality and disability in several clinical settings, including hospital geriatric evaluation, inpatient geriatric consultation, home assessment service, hospital home assessment service, and outpatient assessment service and in a number of chronic diseases [20–24]. 1.1. Comprehensive geriatric assessment In a previous experience of ours, investigating on nonsurgical elderly cancer patients [25], we demonstrated how the CGA adds substantial information to the functional assessment of elderly cancer patients routinely collected through the Performance Status (PS) index. Among elderly cancer patients, the role of PS as unique marker of functional status resulted unacceptable. Although there is no consensus on which instrument is preferable, CGA should be utilised in older cancer patients to ameliorate their functional status, detect unaddressed problems, and expand their survival. The decision whether to operate or not on a patient is one of the most important ones a surgeon is asked to make. This is obviously more relevant when dealing with a patient who is a poor surgical candidate. The older population is a large and heterogeneous group, ranging from competent, active and well individuals to frail, demented subjects. A number of factors (i.e. greater need for information, more effective use of available resources, advances in perioperative management and surgical techniques) demand an improved and individualised risk definition to be shared between the surgeon and the patient. Although this can be a difficult task in an emergency setting, risk prediction should be appreciated and disclosed to the patient while consenting her/him. The largest number of abnormal laboratory tests are not capable of predicting post-treatment/operative adverse outcomes. Consequently, a number of risk classifications aimed at predicting outcomes for specific conditions have been developed and tested; unfortunately, results have been relatively disappointing. Importantly, no scoring method relating to candidacy for surgery has ever been attempted specifically on the oncogeriatric population. 1.2. Estimating surgical risk Currently available assessment tools include the wellknown American Society of Anesthesiologists (ASA) physical status system [26]. ASA is not aimed to measuring the operative risk, rather to globally assess the degree of sickness or physical state prior to anaesthesia and surgery; ASA does not specifically refer to elderly individuals. Unfortunately, ASA is not sufficiently sensitive in differentiating the largest proportion of patients falling in the ASA II and III categories [1,27].
The assessment of cardiac risk was addressed by Goldman Cardiac Risk Index (CRI) [28], an instrument designed to assess cardiac risk in non-cardiac surgery but is rarely used by surgeons [29]. The modified cardiac risk index, and the algorithm for cardiac risk assessment laid down by the American College of Physicians, are applied by anaesthesiologists as determinants of outcome [30,31]. Respiratory complications were analysed by Kroenke [32] who described the following as associated with respiratory complications following thoracic and major abdominal surgery (a) age over 70, (b) peri-operative broncho-dilator use, (c) abnormal chest X-ray and (d) high ASA grade. Lawrence et al. [33] identified four preoperative variables that were associated with postoperative respiratory complications: (1) abnormal respiratory examination, (2) abnormal chest X-ray, (3) Goldman CRI, and (4) the Charlson co-morbidity index [34]. These have not been formalised as a score or validated. Undernourishment is high amongst the ‘‘healthy’’ geriatric population, as it can affect up to 12% males and 8% females. Moreover, nutritional deficiencies occur in 60% hospitalised elderly subjects in Europe. These figures have an impact on outcomes, since a sixfold increase in surgical complications was reported in patients who were malnourished preoperatively [35,36]. APACHE is probably the best known of the physiological scoring systems (Acute Physiological And Chronic Health Evaluation) [37]. It is based on 34 physiological variables taking the worst values in the first 24 hours from the patient’s admission to an intensive care unit. Various modifications of this APACHE system are now available: APACHE II [38] uses 12 physiological variables; it is currently being used in general and surgical intensive care patients. Its application in the intensive care unit seems very appropriate but its development to general surgical patients who may not require respiratory support in intensive care is limited. Another physiological scoring system originated in the UK is the Physiological and Operative Severity Score for enUmeration of Mortality and morbidity (POSSUM) [39,40]. P POSSUM is a modification of the POSSUM [41]; this has been developed to attempt to counter over prediction of mortality that has been experienced in some diseases when POSSUM has been used. A different formula for the calculation of the risk value is made. Both these scoring systems consists of two parts: a physiological score, and an operative score. This second part is highly relevant to the final result; unfortunately the necessity to record per-operative variables compromises its usefulness as a preoperative assessment tool.
ARTICLE IN PRESS Editorial / Surgical Oncology 13 (2004) 169–173
In the lack of reliable instruments capable of predicting the risk, and allowing a fair comparison between series, it was felt appropriate auditing and presenting personal and institutional results. Series of Ivor-Lewis transthoracic-abdominal resections for oesophageal tumours, major abdominal procedures for large bowel malignancies or extensive liver cancer surgery, pancreatic resections and others were audited and published [42–59]. Reviews were also performed [60] as well as multi-institutional data collections [61]. Several lessons were drawn here. First and most importantly, long term cancer outcomes are ageindependent; whenever a surgical option is feasible, it should be considered and offered no matter the patients anagraphycal age. Second, it was shown how aggressive procedures can be undertaken on subjects 470 years. Unfortunately, a serious selection bias is noticeable all along this data collection, and such conclusions are not realistic; these findings are only representative of the restricted number of very fit patients who managed to reach the operative room. But, how do we select elderly patients for surgery?
1.3. Preoperative assessment of cancer in the elderly (PACE) To minimise the risk of a major selection bias in recruiting and presenting surgical data on elderly cancer patients, an international project has been launched with the aim of defining the general health condition of oncogeriatric surgical candidates PACE. PACE is a new instrument generated from the previous experience [23], this time focusing on the surgical candidate. In addition, PACE incorporates other instruments currently used for surgical risk assessment (PS, ASA, Possum, and P Possum). Specifically PACE entails:
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Results are now available from an interim analysis on 215 patients entered from 7 recruiting centres from the UK, Italy, the Netherlands and Japan. Participation rate was 99% (2 patients refused the interview for personal reasons). Patient’s age ranges from 70 to 92 years (median age 76 years). Patients affected by breast, urogenital, colorectal, head & neck, and upper GI malignancies were recruited. The administration of the questionnaire took an average of 20 minutes. Patients demonstrated a clear comprehension of what they were required in completing the various components of PACE. Patients developing postoperative complications had a higher number of comorbidities (p ¼ 0:024), and a higher GDS (p ¼ 0:018). A significant difference was also noticed between the 2 groups when PS is taken into account: 81.9% of the non-complicated group had PS=0 vs. 46.9% of the ones who underwent complications (po0:0001). ADL and IADL dependency were also significantly associated to the complication rate (p ¼ 0:005 and 0:043; respectively). There was no evidence of association between scores on the Mini Mental State, the Brief Fatigue Index, and ASA. We can provisionally conclude that the aspects of PACE relating to psychological wellbeing do not appear to be significantly associated with post-operative complications. To the opposite, aspects relating to physical frailty and morbidity (i.e. PS, ADL and IADL) seem to show a significant association. These interesting early results should be rehinforced with figures from a much larger sample. This cooperative project is ongoing at present under the auspices of SIOG–International Society of Geriatric Oncology [64], and further expressions of interest in actively participating to this investigation are welcome.
References MMS—Mini Mental State [62] Satariano’s modified index of co-morbidities [25] ADL—Activities of Daily Living [33] IADL—Instrumental Activities of Daily Living [34] GDS—Geriatric Depression Scale [36] BFI—Brief Fatigue Inventory [37] PS—ECOG Performance Status [38] ASA—American Society Anaesthesiologists [26] POSSUM—Physiological and Operative Severity Score for enUmeration of Mortality and Morbidity [39,40] P POSSUM—Portsmouth POSSUM Modification [41]
A pilot study has been completed on a sample of 73 patients; it has proven PACE to be feasible and inexpensive [63].
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Riccardo A. Audisio University of Liverpool, Liverpool, UK Whiston Hospital, Prescot, Merseyside, UK E-mail address: [email protected]