Delivering Perioperative Care for Older Patients Undergoing Cancer Surgery

Introduction

The surgical population is aging at a faster rate than the general population. A significant proportion of this group will undergo cancer surgery; in 2030 it is estimated that more than 75% of cancer patients will be aged over 65 years. While there are clear benefits in terms of morbidity and mortality, older people undergoing cancer surgery remain at higher risk than younger patients of adverse postoperative outcomes. ^, With increasing age, the rate of surgical complications remains fairly static, with the excess observed morbidity seen in older patients related to higher rates of medical complications. ^, This is particularly relevant in oncological surgery where 90% of older patients with cancer live with multimorbidity, 40% have polypharmacy, and 70% are functionally dependent. Furthermore, the frequent exclusion of older people from cancer treatment studies has led to a paucity of evidence describing disease and treatment outcomes in this age cohort. As a result, treatment decisions in the older population can be complex, with uncertainty among professionals regarding the gold standard of care. Traditionally, treatment decisions have been based on age alone, without consideration of multimorbidity, frailty, and functional capacity as superior prognostic indicators. In response to these issues, guidelines from professional bodies outline surgical care standards for older patients including the recommendation to use a comprehensive, structured approach to assessment and management of older patients with cancer. ^,

Patient Assessment

Treatment decisions for patients with cancer are traditionally made at multidisciplinary meetings between oncologists, surgeons, and radiologists, with other specialties contributing as necessary. For over 50 years, oncologists have used the Eastern Cooperative Oncology Group (ECOG) performance status as a method to assess function and guide treatment decisions. While the benefits of this performance status include face validity and clinical feasibility, it can be less discriminatory in older people because it does not distinguish between functional impairment, specifically attributable to malignancy and therefore potentially reversible through oncological treatment, and preexisting impairment secondary to frailty, multimorbidity, or dementia. An awareness of the limitation of this approach has led to the inclusion of Comprehensive Geriatric Assessment (CGA) and optimization in oncological assessment for older people. CGA is an established, evidenced-based methodology for multidomain assessment of medical, functional, psychological, and social issues using objective tools. The role of CGA in the medical setting is well established and there is an increasing evidence base for CGA in surgical and oncological cohorts.

Cancer treatment involves traditional chemotherapy and radiotherapy, often used in combination with biologic treatment and surgery. CGA is used to assess and optimize prior to oncological treatment, resulting in amended oncological treatment decisions in a quarter of cases (intensifying or reducing treatment intensity) and increased survival. ^, In surgical settings, CGA has resulted in a reduction in length of stay and postoperative morbidity and mortality in elective and emergency surgical patients across surgical subspecialties, ^, ^, ^, including colorectal cancer surgery.

Identifying patients most likely to benefit from CGA is important. The International Society of Geriatric Oncology (SIOG) recommends screening older patients with cancer using validated tools to identify patients requiring further assessment and optimization. Three of the most widely used tools include the G8, Vulnerable Elder Survey-13 (VES-13), and the abbreviated Comprehensive Geriatric Assessment (aCGA). The G8 is an eight-item questionnaire that takes less than 10 min to complete by any clinician, with a score <14 identifying a patient who may benefit from CGA. VES-13 is a self-administered 13-question survey that takes <10 min, with a score ≤3 suggesting an older person who may benefit from CGA. The third tool, the aCGA, is a 15-question survey assessing four domains, including functional status (e.g., activities of daily living [ADL]), independent ADL, depression, and cognition, with individual domain cutoffs identifying a need for further assessment. All three have been validated in the oncological setting but have not been studied in patients undergoing cancer surgery specifically. ^, ^,

Core Components of Perioperative Care for Older Patients Undergoing Cancer Surgery

Models of perioperative care for older patients with cancer undergoing surgery vary. There are a number of core components appropriately tailored to the perioperative and oncological settings ( Table 36.1 ).

Table 36.1

Core Components of Perioperative Care for Older People Undergoing Cancer Surgery

	Component	Detail
Preoperative	Assessment	- Assessment of physiological reserve - Assessment of known comorbidities - Diagnosis of new comorbidities - Identification of geriatric syndromes - Assessment of functional capacity - Assessment of mental capacity - Assessment of psychosocial factors - Assessment of social situation
	Optimization	- Optimization of medical comorbidities - Comprehensive medication review - Optimization of geriatric syndromes - Optimization of malnutrition and obesity - Optimization of psychosocial factors and modifiable lifestyle risk factors - Optimization of functional reserve - Optimization of social situation
	Shared decision-making (SDM)	- Understanding patient goals and expectations - Counseling on risks, benefits, and alternatives to treatment - Collaboration across specialties to address specific aspects of SDM in older people - Planning the perioperative period - Advanced care planning
Intraoperative	Intraoperative care	- Following anesthetic and surgical guidelines
Postoperative	Prevention and treatment of medical complications	- Prevention of postoperative medical complications - Prompt identification of postoperative medical complications - Standardized treatment of postoperative medical complications
	Management of multidisciplinary issues	- Early mobilization to prevent functional decline and falls - Optimizing nutrition including early feeding - Prompt removal of urinary catheters - Ensuring pressure area care
	Discharge planning	- Early identification of potential barriers to discharge - Collaboration across disciplines and specialties to facilitate prompt discharge - Timely liaison with community services to support transitions of care - Appropriate follow up plan, with communication to primary care team
Organizational	Education and collaboration across disciplines and specialties	- Upskilled workforce - Perioperative medicine curricula - Structured teaching program - Avoidance of silo working -Joint clinical reflection through interdisciplinary, multispecialty morbidity and mortality review, development of guidelines and audit meetings, etc.
	Research	- Structured quality improvement projects - Collaborative multispecialty research programs -Use of “big data” to examine perioperative outcomes and inform local quality improvement (e.g., national audit)

Preoperative Care for Older Patients Undergoing Cancer Surgery

Regardless of patient age, the preoperative period is an opportunity to identify and modify conditions that may adversely impact a patient’s perioperative journey. Improving patient-reported and clinician-reported outcomes can be more challenging in older patients with cancer due to concurrent multimorbidity and geriatric syndromes requiring optimization in a short preoperative timeframe. In planned cancer surgery, the optimization period is often just 1 to 2 weeks (possibly longer if neoadjuvant treatment is being administered first) with a preoperative period <24 h in emergency cancer surgery (such as acute bowel obstruction secondary to a gastrointestinal malignancy).

Assessment of Frailty

This important component of assessment of older patients is addressed in the chapter on Frailty (see Chapter 15).

Assessment of Comorbidities

A comprehensive assessment begins with reviewing the patient’s known preexisting medical conditions, which in the older cohort will often include a number of pathologies. Common examples include ischemic heart disease, essential hypertension, anemia, chronic obstructive pulmonary disease (COPD), and osteoarthritis. This assessment involves an evaluation of severity, past and present treatments, and current disease control for each comorbidity, allowing identification of areas for optimization. Targeted investigations may be required to further assess these underlying conditions.

Older patients with cancer should also be routinely screened for the presence of undiagnosed comorbidities using history, examination, and routine investigations. Routine investigations may include a full blood profile, renal and liver function tests, electrocardiograph (ECG), and spirometry. These investigations may lead to new diagnoses. Multimorbidity is an independent predictor of reduced quality of life, adverse surgical outcomes, and mortality rates. ^, CGA provides an underpinning methodology with which to manage multimorbidity, cognizant of the interplay between individual comorbidities, and the necessary treatments with an understanding of the potential impact on the patient during the perioperative period.

Assessment of Geriatric Syndromes

Geriatric syndromes are distinct conditions occurring in older patients that do not stem from identifiable diseases but rather occur due to the accumulation of impairments across multiple systems affecting multiple domains in patient function. The most common geriatric syndromes and proposed tools for assessment are listed in Table 36.2 .

Table 36.2

Assessment Methods for Common Geriatric Syndromes

Geriatric Syndrome	Example Assessment Tool
Frailty	Clinical Frailty Scale (CFS) Edmonton Frail Scale (EFS)
Cognitive impairment	Montreal Cognitive Assessment (MoCA)
Delirium	4AT Rapid Assessment Test (4AT)
Falls/reduced mobility	Timed up and go Gait velocity
Incontinence	Clinical assessment
Pressure ulcers	Waterlow Braden Scale

The presence of geriatric syndromes, in particular frailty, is associated with worse postoperative outcomes in older patients with cancer and should therefore inform shared decision-making (SDM). Assessment of cognition is important to inform capacity assessment, appraise delirium risk, and facilitate SDM. There is no single cognitive assessment cutoff score that deems a patient to have “capacity” regarding the surgical decision. National legislation will inform the assessment of capacity and guide how decisions are made in patients deemed to lack capacity.

Assessment of Functional Capacity

Assessment of an older patient’s functional status is essential to:

Refine perioperative risk assessment
Identify areas for preoperative optimization
Inform SDM
Inform the postoperative plan to minimize functional deterioration
Facilitate proactive discharge planning

Functional status should be assessed using a multidisciplinary approach, often with the use of a validated tool such as the Nottingham Extended Activities of Daily Living (NEADL). Functional reserve can be appraised through self-reported exercise tolerance, scores such as 6-Minute Walk Test (6MWT), or an objective physiological assessment such as cardiopulmonary exercise testing (CPET). Other widely used scores such as the Duke Activity Status Index (DASI) estimate functional capacity using both a combination of ADL and estimated functional reserve.

Assessment of Psychological Factors and Social Situation

Appraising psychological and social domains using CGA is useful to identify areas that can be optimized and used to anticipate potential barriers to postoperative recovery. Mental health disorders, particularly anxiety, depression, and social isolation, can impact postoperative recovery, including timely discharge from hospital. Preoperative screening for these issues should be undertaken using validated tools such as the Hospital Anxiety and Depression Scale (HADS) to supplement a clinical history including detail of support networks and reliance on formal or informal carers. Finally, as part of assessing the psychological domain it is important to assess the patient’s understanding of their condition and expectations for ongoing treatment, e.g., managing a colostomy.

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