Practice Changes

Rather than reject surgery out-of-hand because of concerns about adverse outcomes, surgeons should discuss all options with patients, according to Al-Refaie, adding, “It would be highly informative for the patient to have this discussion.”If surgery remains an option after discussion with the patients, surgeons should be prepared for the likely complications of oncological surgery in an older patient. “The surgical service now has data to stand on to prepare for these more likely events, such as longer stays,” Al-Refaie said.

The colorectal cancer study found, for example, that 17% of patients over 80 developed major complications, and 29% experienced prolonged hospital lengths-of-stay (LOS). In addition, the study reported that older patients experienced higher rates of 30-day operative mortality (>80 years vs. 45-55 years; 6% vs. <1%); major complications (>80 years vs. 45-55 years; 21% vs. 14%); and prolonged LOS after open (>80 years vs. 45-55 years; 37% vs. 24%) and laparoscopic procedures (>80 years vs. 45-55 years; 40.5% vs. 18%). “This does not mean we shouldn’t perform the surgeries, but we should increase preparedness,” Al-Refaie asserted.He recommended trying to address some of the potential complications prior to surgery, when possible. “For example, if a patient presents with recent pneumonia or malnutrition, in some regards these are modifiable risk factors” and should be treated, Al-Refaie said.

Other co-morbidities cannot be altered, so surgeons must consider them when creating the post-surgical treatment plan. “[If] an 85-year-old who has some limited performance status will not leave the hospital as soon as a more active patient will, so you help the patient prepare,” he explained. In such a case, for example, a social worker can be told that rehabilitation will likely be required.. “The whole point of the research is, basically, if you can recognize this as an issue and find things that can predict these complications, you can essentially intervene with newer surgical techniques or more attention to other issues,” D'Cunha added.

Even if a patient has a successful recovery from operation, difficult questions remain, according to Al-Refaie. He noted that older patients typically are not enrolled in chemotherapy trials, so there are not many guidelines on further treatment options.“Do we give chemotherapy in light toxicity?” he questioned, explaining that there is simply not enough information in the literature to inform such a determination. “But our results shed slight on the importance of this issue.”