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The Old-Old Under the Knife - VA Surgeons Research Treatment Options for Aging Cancer Patients
MINNEAPOLIS--Often, clinical research and resulting guidelines are based on studies of subjects much younger and healthier than typical patients. That is especially an issue at the VA which has an aging veteran population faced with cancer diagnoses late in life.
-Waddah B. Al-Refaie, MD
Staff Surgeon, Division of Surgical Oncology - Minneapolis VAMC
“Most solid tumors occur in patients over 65; [yet]; the interesting part is that the cutoff for screening is 80,” said Waddah B. Al-Refaie, MD, staff surgeon at the Division of Surgical Oncology at the Minneapolis VAMC.
Al-Refaie noted that many clinical cancer trials have limited applicability to the elderly because the majority of the patients studied are young, healthy, affluent and insured, explaining, “Most of our older patients are, smokers, co-morbid and of a lower socio-economic status.”
Research which focuses on operative mortality as a benchmark for quality or outcomes can paint an incomplete picture, he suggested. “As we know, colon-cancer procedures are very common at hospitals and overall mortality is not necessarily very high,” in the population traditionally studied. Inadequate information was available on indicators such as morbidity, complications and length of stay (LOS) in elderly patients, however.
To remedy that knowledge gap, he and his colleagues at the Minnesota Surgical Outcomes Workgroup are specifically researching oncology surgery outcomes in the older population. One recent study, published in the Annals of Surgery, reported that of 19,375 patients over 40 years old who received colorectal cancer procedures in the 2005 to 2008 American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, more than 20% of them were older than 80. 1
With such a large percentage of older veteran surgical patients, higher mortality rates take on even greater importance. Yet while still the greatest worry, death is not the only concern for the “oldest of the old.” That same study also “predicts an increased likelihood for major events and a greater likelihood of a longer stay in the hospital” after surgery, Al-Refaie said.
While colorectal cancer was the topic of the study, the risks extend to other oncological surgeries. Earlier research by the Minnesota workgroup, where Al-Refaie is co-director, looked at lung resection related to cancer. Again, higher mortality was shown. 2
The potential for “these adverse outcomes should not serve as a prohibitive,” Al-Refaie emphasized, saying that surgery sometimes remains the best option.
“Lung cancer is the No. 1 killer, and traditionally we have thought the elderly to be at higher risk for problems in treatment, once they get it,” added Jonathan D’Cunha, MD, PhD, a thoracic surgeon associated with the group and one of the study’s co-authors. Complicating treatment is that smoking-related lung cancer sometimes can take so long to develop that patients often have their initial diagnosis at an advanced age.
President Barack Obama shakes hands with a veteran during the 65th anniversary of D-Day in Normandy, France June 6, 2009. (Official White House photo by Pete Souza)
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