Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: A prospective observational cohort study

https://doi.org/10.1016/j.critrevonc.2009.11.002Get rights and content

Abstract

Objective

To examine the association between the outcomes of a pre-operative comprehensive geriatric assessment (CGA) and the risk of severe post-operative complications in elderly patients electively operated for colorectal cancer.

Methods

One hundred seventy-eight consecutive patients ≥70 years electively operated for all stages of colorectal cancer were prospectively examined. A pre-operative CGA was performed, and patients were categorized as fit, intermediate, or frail. The main outcome measure was severe complications within 30 days of surgery.

Results

Twenty-one patients (12%) were categorized as fit, 81 (46%) as intermediate, and 76 (43%) as frail. Eighty-three patients experienced severe complications, including three deaths; 7/21 (33%) of fit patients, 29/81 (36%) of intermediate patients and 47/76 (62%) of frail patients (p = 0.002). Increasing age and ASA classification were not associated with complications in this series.

Conclusion

CGA can identify frail patients who have a significantly increased risk of severe complications after elective surgery for colorectal cancer.

Introduction

Colorectal cancer is a common cause of morbidity and the second most common cause of cancer death in the Western world. Sixty percent of patients are more than 70 years old at diagnosis [1]. With an increasingly aging population, the number of elderly patients presenting with the disease will grow.

The resection rate in colorectal cancer is high even in advanced age, and elective surgery is generally safe with mortality rates around 3% [2]. The reported rate of post-operative complications, on the other hand, lies between 30% in the general patient population and 60% in patients older than 70 years of age [3], [4]. Growing evidence indicates that post-operative complications, in addition to influencing patients’ well-being and mortality post-operatively, also may have important effects on long-term survival and recovery to pre-operative levels of independence [5], [6]. Although many studies have attempted to link pre-surgical risk factors to morbidity, most of these lack information about common risk factors among elderly patients (e.g. malnutrition, depression, and dementia) as well as important complications (e.g. delirium). Thus, there is an urgent need for better risk stratification tools in this patient group, as a means to target prophylactic interventions towards those with the highest risk.

Comprehensive geriatric assessment (CGA) is a systematic approach aiming to assess physical functioning, co-morbidity, polypharmacy, nutrition, cognition, and emotional status in elderly patients. Extensive and solid evidence supporting this approach is provided by randomized controlled trials demonstrating that a geriatric intervention guided by CGA has positive effects on health, functional status and mortality [7], [8]. A large number of review articles advocate the introduction of CGA as a routine assessment in elderly patients with cancer, and some observational studies suggest that the evaluated domains have predictive value in elderly cancer patients receiving chemotherapy or undergoing surgery [4], [9], [10], [11], [12], [13]. However, it still remains unclear whether CGA may shape interventions and clinical decisions in geriatric oncology, and the task force on CGA of the International Society of Geriatric Oncology states that “there is an urgent need to validate in multicentric prospective trials CGA-based approaches in older cancer patients” [14].

In the present study, patients aged 70 years or more undergoing elective surgery for colorectal cancer were pre-operatively assessed with a standardized CGA. The objectives were to determine whether CGA could predict complications within 30 days of surgery, and to compare the predictive value of CGA with that of age, tumor stage, and American Society of Anesthesiologists Physical Status Classification System (ASA classification). Complications were extensively registered, and the patients were followed up with a telephone interview three months post-operatively. To our knowledge this is the largest study to date reporting the predictive value of CGA in a homogeneous group of surgical cancer patients.

Section snippets

Data collection procedure and inclusion and exclusion criteria

In Norway, all operations for colorectal cancer are performed in public hospitals. The patients in the present study were recruited from three hospitals, i.e. Ullevål University Hospital (UUS), Aker University Hospital, and Akershus University Hospital, all of which serve designated catchment areas in Oslo and Akershus county. UUS is also a referral hospital for more complicated cases from a larger part of Eastern Norway. From the routinely scheduled surgical programs at each hospital, patients

Statistical methods

Complications occurring within 30 days of surgery were defined as the main outcome, and estimation of sample size was based on reports of complication rates of about 30% [3], [26]. Comparing the two groups fit and frail, we assumed a lower rate of 20% complications in the fit group versus a higher rate of 50% complications in the frail group. With power 80% and a 5% level of significance; 36 patients were needed in each of these two groups. According to the literature, the majority of elderly

Study recruitment

During the inclusion period, 296 patients ≥70 years were scheduled for elective colorectal surgery in the three hospitals. A total of 185 of these patients were included in the study, among which 178 were available for analyses of early outcome and 159 for assessment of living conditions and level of dependency at three months (Fig. 1). The time spent on completing CGA ranged from 20 to 80 min.

Baseline characteristics

Baseline characteristics are given in Table 2. The age ranged from 70 to 94 years, and 10 patients were

Discussion

Our study confirmed that a comprehensive geriatric assessment-based stratification predicts complications in elderly patients electively operated for colorectal cancer. Frail patients had a significantly higher morbidity than patients in the fit and intermediate groups. Moreover, the rate of post-operative complications was not related to increasing age, ASA classification or tumor stage.

When making treatment decisions in elderly cancer patients, an overall categorization based on CGA, as

Conclusion

Comprehensive geriatric assessment is a valuable tool for predicting complications in elderly patients undergoing elective surgery for colorectal cancer. Patients categorized as frail have a significantly increased risk of morbidity, and a focus of attention in future studies should be to reduce risk by optimizing these patients perioperatively. In this study, increasing age and ASA classification failed to predict complications.

Conflict of interest statement

SRK, AN, MJ, ES, HOJ, AB, and TBW declare that there is no conflict of interest. RAA has been reimbursed by AstraZeneca and Pfeizer, manufacturers of aromatase inhibitors, for attending and lecturing at the 109th annual meeting of the Japanese Surgical Society and the 2008 ESSO meeting in the Hague, respectively. He also acts as an expert witness on a consulting basis for several law firms in the UK. There are no competing interests with the statements made in this article.

Reviewers

Barbara L. van Leeuwen, MD, PhD, Surgeon, University Medical Center Groningen, Hanzeplein 1, Groningen, Netherlands.

Professor Margot Gosney, University of ReadingInstitute of Health Sciences, Building 22, London Road, Reading, RG1 5AQ, United Kingdom.

Professor Malcolm Reed, University of Sheffield, Royal Hallamshire Hospital, Academic Surgical Oncology Unit, Sheffield, S10 2JF, United Kingdom.

Acknowledgements

The study is supported by a research grant from the Norwegian Cancer Society (to SRK). The Norwegian Cancer Society had no role in the study design, data collection, analysis and interpretation of data; in the writing of the manuscript; or in the decision to submit the manuscript for publication.

Dr. Kristjansson is a research fellow at the Department of Geriatric Medicine, Oslo University Hospital, Ullevål and at the University of Oslo. She is specializing in internal medicine and geriatric medicine. The focus of her research is the integration of a comprehensive geriatric assessment in the pre-operative evaluation of elderly cancer patients, and the identification of frailty in elderly patients.

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    Dr. Kristjansson is a research fellow at the Department of Geriatric Medicine, Oslo University Hospital, Ullevål and at the University of Oslo. She is specializing in internal medicine and geriatric medicine. The focus of her research is the integration of a comprehensive geriatric assessment in the pre-operative evaluation of elderly cancer patients, and the identification of frailty in elderly patients.

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