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Reduction in Postoperative Complications Found in Older Patients After Personalized Assessment

Older adults who had colorectal surgery were found to have reduced postoperative complications if they started the Geriatric Oncology Service.

Starting the Geriatric Oncology Service (GOS) was found to improve outcomes in older patients who had colorectal surgery, according to a study published in Journal of Surgical Oncology.1 The reduction in complications after the surgery indicates that personalized assessment of surgical outcomes can have a positive effect on care.

Older adults are the demographic primarily diagnosed with colorectal cancer (CRC), with a median age of diagnosis of 66 years in the United States.2 Comprehensive geriatric assessment (CGA) for older adults has been provided to help provide individualized care for each of the patients. The GOS aimed to incorporate comprehensive assessments, recommendations for treatment, and interventions based on a patient’s vulnerabilities. However, it is unknown if the GOS has any effect on surgical outcomes.

Diagram of colon | Image credit: Orawan - stock.adobe.com

Diagram of colon | Image credit: Orawan - stock.adobe.com

The retrospective study used data from the NHO Kyushu Cancer Center (NKCC) in Fukuoka, Japan. Patients who were considered for surgical treatment for CRC between January 1, 2015, and May 31, 2023, and aged 75 years and older were eligible for the study. Patients were excluded if they had emergency surgery or had indications of local resection. Patients who were treated prior to the implementation of GOS (January 2015 to October 2018) acted as the controls for the patients treated after the implementation of the GOS in November 2018.

The reduction of postoperative complications was the primary outcome that was evaluated in this study with secondary objectives to assess the effect of the implementation of the GOS on treatment strategies and interventions.

The comprehensive assessment was done at the recommendation of a primary care physician. The frailty and fitness of the older adult was evaluated based on the 10-item Frailty Index Based on a CGA (FI-CGA-10). The GOS can provide recommendations on treatment plans and other interventions based on the results of the health assessments, including referral to physical therapists, dietitians, and visiting nurse services. Any surgical operations were conducted for either curative surgery or non-curative surgery for symptom improvement. Electronic medical records were used to collect data on the characteristics of the surgery, including operation time, postoperative complications, and discharge location.

There were 314 patients included in this study. Both the control and implementation groups had 128 patients after propensity score matching (PSM), with the control group having surgery prior to potential GOS implementation. Patients who were referred to the GOS who had a FI-CGA-10 test were found to be fit in 31.7% of the population, pre-frail in 38.6% of the population, and frail in 29.7% of the population. After evaluation, patients who were considered fit or pre-frail had a higher rate of being recommended for and undergoing surgery compared with frail patients (97.8% and 96.4% vs 79.1%; P = .0023).

The proportion of patients who had ASA-PS 3 or more was higher in the GOS period group compared with the controls prior to PSM (17.1% vs 8.9%; P = .0369), though the difference was reduced after PSM. The GOS group had a higher rate of consultation in the CGA (90.6%) compared with the control group, who did not undergo consultation. Perioperative rehabilitation was also higher in the GOS group compared with the control group (78.1% vs 59.4%). Pharmacist referral was also higher in the GOS group (7.8% vs 0%).

The control group had a higher rate of surgical complications of CD Grade 2 or higher compared with the GOS group (32.8% vs 21.9%; P = .0496). The GOS group had a higher rate of being discharged to home compared with the control group (85.2% vs 77.3%) but the difference was not significant after PSM and no major difference was found in the length of hospital stay. There was 1 death in the control group compared with none in the GOS group.

Postoperative complications were found to be most associated with being male (OR, 2.35; 95% CI, 1.32-4.29; P = .0013), not having a CGA performed (OR, 1.75; 95% CI, 1.00-3.10; P = .0218), or having intraoperative bleeding of 50 mL or more (OR, 3.23; 95% CI, 1.81-5.80; P = .0002).

There were some limitations to this study. The study design used a before and after model, which could lead to unmeasured characteristics. The sample size was relatively small. Survival data did not have as much follow-up, which led to the impact of CGA on survival not being properly accounted for. The study was also done at a single center, which could limit generalizability.

The researchers concluded that CGA as a part of the GOS, particularly in evaluating fitness and frailty, was effective in lowering the incidence of postoperative complications. Older patients would benefit from such a program being implemented prior to their own surgery for CRC.

References

  1. Sugiyama M, Nishijima TF, Kasagi Y, et al. Impact of comprehensive geriatric assessment on treatment strategies and complications in older adults with colorectal cancer considering surgery. Published online June 16, 2024. J Surg Oncol (Tallinn). doi:10.1002/jso.27736
  2. Colorectal Cancer Facts & Figures 2020-2022. American Cancer Society. 2020. Accessed June 17, 2024. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/colorectal-cancer-facts-and-figures/colorectal-cancer-facts-and-figures-2020-2022.pdf
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