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Abstract
Objectives The effectiveness and impact of any treatment on patients’ physical functions, especially in older patients, should be closely considered. This study aimed to evaluate activities of daily living (ADLs) after oncological surgery in patients with gastrointestinal and hepatobiliary-pancreatic cancers by age groups in Japan.
Design Retrospective observational study using health services utilisation data from 1 January 2015 to 31 December 2016.
Setting Data for patients with gastrointestinal and hepatobiliary-pancreatic cancers diagnosed in 2015 from 431 hospitals nationwide in Japan.
Participants Patients who underwent endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR) and laparoscopic or open surgery were included.
Outcome measures The proportion of ADL decline at discharge, death and unexpected readmission within 6 weeks postsurgery was calculated by age groups (40–74, 75–79 and ≥80 years).
Results Data for 68 032 patients were analysed. The difference in the proportion of ADL decline after ESD/EMR between patients aged ≥80 years and <75 years was marginal (0.8%–2.5%), whereas that after laparoscopic (4.8%–5.9%) or open surgery (4.6%–9.4%) was large, except for pancreatic cancer (3.0%). Among patients with gastric cancer who underwent laparoscopic or open surgery, the proportion of unexpected readmission tended to be higher in patients aged ≥80 years than in the remaining younger patients (laparoscopic surgery 4.8% vs 2.3% (p=0.001); open surgery 7.3% vs 4.4% (p<0.001)). The postoperative mortality rate was <3% (<10 cases) across all ages and cancer types.
Conclusions In ESD/EMR, postoperative ADL decline was almost the same between older and younger patients. Laparoscopic or open surgery is associated with increased rates of ADL decline in older patients, especially in those aged ≥80 years. The potential decline in ADLs should be carefully considered preoperatively to best maintain the patient’s quality of life postsurgery.
- adult oncology
- epidemiology
- surgery
Data availability statement
The data were only permitted for use in this study and are not publicly available.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
This study used nationwide data that covered approximately 49% of new cancer cases in Japan.
Activities of daily living (ADL) after oncological surgery were examined by age groups.
Information on ADLs was only available at the time of hospital admission and discharge.
The extent to which doctors’ judgements and patients’ preferences influenced their treatment choice remains unclear.
The impact of in-hospital rehabilitation on ADLs has not been considered.
Introduction
Age is associated with a progressive decline in the functional reserve of multiple organ systems and an increased incidence of chronic diseases, such as cancer.1 In 2020, approximately 37% of the global incidence of cancer was reported among patients aged ≥70 years.2 In Japan, 20%–40% of patients with gastrointestinal and hepatobiliary-pancreatic cancers treated at cancer care hospitals are aged ≥80 years.3 There is no standard age limit for patients to undergo surgery, as long as they can tolerate invasive procedures. A previous study reported that >90% of older patients undergoing tumour resection were independent in terms of their activities of daily living (ADLs) before surgery.4
Older patients have considerable concerns about the outcomes and physical burden of treatment.5 Even if surgery cures cancer, patients’ quality of life will decline if they are unable to regain full functionality. Amemiya et al reported that 24% of patients aged ≥75 years who underwent elective surgery for gastric and colorectal cancers often showed a transient decrease in ADLs 1 month postoperatively.6 By contrast, a Norwegian study of patients aged ≥70 years with colorectal cancer reported a decline in ADLs in approximately one-third of patients at the 16–28 months follow-up postoperatively.7 Both these studies indicate that surgery for gastric and colorectal cancers in older patients may at least temporarily reduce ADLs. Older patients are likely to show a high degree of variability in their tolerance of invasive surgery. Moreover, to the best of our knowledge, the impact of surgery for hepatobiliary-pancreatic cancer, which is common in older patients, on ADLs has not been reported to date. Therefore, this exploratory study assessed the proportion of ADL decline after surgery by age groups and evaluated the current status of older patients with gastrointestinal and hepatobiliary-pancreatic cancers in Japan using a nationwide database. This study aimed to determine whether the risk of postoperative ADL decline in older people, who would have been deemed to be clinically eligible for surgery, is comparable to that in younger people. Evaluating the impact of surgery on ADLs using large-scale real-world data will assist older patients and their families in decision-making about treatment options.
Methods
Design and data source
In this retrospective observational study, we used health utilisation data linked with hospital-based cancer registries (HBCR) collected for research on evaluating healthcare quality for patients with cancer (Quality Indicator Project).8 The National Cancer Centre collected the HBCR data from designated cancer care hospitals and some voluntary participating hospitals throughout Japan.9 Among these hospitals, 431 participated in the Quality Indicator Project,10 and the data of approximately 49% of incident cancer cases in Japan were included in this study.10 The health utilisation data reflected the effect of introducing the Diagnosis-Procedure Combination payment system. The survey data included information equivalent to fee-for-service insurance claims that cover the utilisation of all billable health services. They also included discharge summary information such as ADLs at hospital admission and discharge and the reasons for any readmission. The data of patients diagnosed with gastrointestinal and hepatobiliary-pancreatic cancers in 2015 were analysed from 1 January 2015 to 31 December 2016. All these data were linked to the HBCR data at individual patient level in the participating hospitals.
Identification of patients with cancer
Patients were selected as follows. First, we identified patients with cancer who were at least 40 years old at the time of diagnosis in 2015 and had started their first course of treatment at a hospital using the HBCR data. Those diagnosed with the following epithelial origin cancers were selected: gastric, colon, rectal, pancreatic, intrahepatic bile duct and biliary tract cancers and hepatocellular carcinoma. Second, patients who underwent tumour resection were identified using the health services utilisation data. Targeted surgical treatments included endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) and laparoscopic and open surgeries. However, as the number of patients who underwent laparoscopic surgery for pancreatic and biliary tract cancers was limited, we were unable to calculate the ADL decline for these patients. The classification of the degree of surgical invasiveness was based on the surgical difficulty classification of the Japanese Society of Gastroenterological Surgery11 and regulations for the implementation of highly skilled medical specialist system rules of the Japanese Society of Hepato-Biliary-Pancreatic Surgery (online supplemental material 1).12 Patients with colorectal cancer who had undergone colostomy augmentation were excluded from the analysis, as assessment of defecation was impossible in these patients. Patients with distant metastases or clinical stage IV disease as per the seventh edition of the Union for International Cancer Control tumour-node-metastasis staging system were also excluded from the analysis, owing to the risk of ADL decline from cancer progression. The length of hospital stays varies across hospitals in Japan. Patients with prolonged hospital stay, who stayed longer than twice of the median hospital stay, were excluded, as these patients could recover from the impact of surgery during their stay.
Supplemental material
Data analysis
Information on ADLs, death discharge and readmissions within 6 weeks from the date of discharge after surgery was extracted from the discharge summary data of the health services utilisation data. The Barthel index was used to evaluate the ADLs (100 points indicated independent ADLs). As mentioned above, patients undergoing tumour resection were assumed to have a high level of preoperative ADL independence.4 For these patients, the need for any assistance after surgery, even if temporary, can impair their quality of life. In this study, as in a previous study,13 we calculated the proportion of patients who had a decrease of ≥10 points in their ADLs.14 In calculating the proportion of ADL decline, the analysis was based on patients whose ADL information had been entered both on admission and at discharge. The number of postoperative in-hospital deaths and the proportion of unexpected hospital admissions within 6 weeks of postoperative discharge were also calculated. Patients with death discharges were excluded in the calculation of the proportion of ADL decline and unexpected readmissions. Age was categorised into three groups, 40–74, 75–79 and ≥80 years, as the health insurance system in Japan defines people aged ≥75 years as being ‘later-stage-older’ and are treated under a different insurance system.15 The number of patients aged ≥80 years is increasing in Japanese clinical practice, and it is often difficult to determine the indication for surgery for these patients.
Statistical analysis
Overall differences in distribution across categories were statistically tested using the χ2 test of independence or Kruskal-Wallis equality of populations rank test to analyse categorical data. When significant differences were found, Dunn’s test was used to determine which groups had the difference. If the number of patients was <10, the information was kept confidential for patient privacy considerations, in accordance with the Ministry of Health, Labour and Welfare Committee.16 All analyses were performed using the Stata (Texas, USA) software (V.15.0; Stata).
Patient and public involvement
None.
Results
Overall, 68 032 patients were included in the analysis (figure 1).
Patient selection process. *Patients with biliary tract cancer undergoing laparoscopic surgery were not included in the analysis. ADL, activities of daily living; EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection.
ESD and EMR for gastric, colon and rectal cancers
The data of 26 778 patients undergoing ESD or EMR were used for analysis. Online supplemental material 2 summarises the characteristics of patients undergoing ESD or EMR. The proportion of women in the ≥80 years age group was greater than that in all the other age groups for all selected cancers. The proportion of patients with independent ADLs at admission decreased with age (p<0.001).
Supplemental material
The proportion of ADL decline was <3% in all the groups (figure 2). The proportion of unexpected hospitalisation for gastric cancer was slightly higher in the ≥80 years age group than that in the other age groups (p<0.001). In all the groups, <10 patients died after ESD or EMR, and the proportion of death was similar across all age groups.
Proportion of patients with a decrease in activities of daily living of 10 points or more at discharge after endoscopic submucosal dissection/endoscopic mucosal resection and laparoscopic and open surgeries *p<0.05, **p<0.01 for differences in ADL declines among patients with independent ADLs at admission. ADL, activities of daily living; EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection.
Laparoscopic surgery for gastric, colon, and rectal cancers and hepatocellular carcinoma
Overall, 10 048 patients underwent laparoscopic surgery. Patients aged ≥80 years with gastric cancer were slightly more likely to have clinical stage II disease (15.8%) than patients aged <75 years (8.5%) and those aged 75–79 years (9.6%) (p<0.001) (online supplemental material 3). Among patients with hepatocellular carcinoma, 20% aged ≥80 years underwent moderately invasive surgery (p=0.164). For all selected cancers, the proportion of patients with independent ADLs on admission decreased with increasing age.
Supplemental material
For gastric cancer, even among patients with independent ADLs at admission, the proportion of patients with ADL decline by ≥10 points in the ≥80 years group was 4.2% (95% CI 3.0% to 5.6%). The proportion of unexpected readmissions for gastric cancer was slightly higher in the ≥80 years group than in the other age groups. The number of patients with hepatocellular carcinoma and colon and rectal cancers who were unexpectedly readmitted was <10 in all the age groups. Overall, the proportion of death before discharge from the hospital was small in all the studied groups.
Open surgery for gastric, colon, rectal, pancreatic, and biliary tract cancers and hepatocellular and intrahepatic cholangiocarcinoma
The data of 31 206 patients undergoing open surgery were used for analysis. For all selected cancers, the proportion of female patients tended to increase with age (online supplemental material 4). For gastric cancer, the proportion of partial resection was slightly higher in the ≥80 years group (67.8%) than in younger groups (57.3%, 40–74 years; 59.8%, 75–79 years) (p<0.001) (online supplemental material 5). Patients with biliary tract cancer and those aged ≥80 years tended to have undergone less invasive surgery (p<0.001). The proportion of those with independent ADLs during admission decreased with increasing age for all selected cancers.
Supplemental material
Supplemental material
The postoperative ADL decline tended to increase with age even if patients had independent ADLs on admission, except for those with intrahepatic bile duct cancer. For colon and rectal cancer, >10% of patients aged ≥80 years had a decline in ADL of >10 points at discharge. For gastric and rectal cancers, the proportion of unexpected readmission tended to be slightly higher in older patients, especially in those aged ≥80 years, than in younger patients. The proportion of deaths before discharge from the hospital in all the age groups was <2%, except for biliary tract cancer.
Discussion
To the best of our knowledge, this is the first exploratory study to use the nationwide database in Japan and analyse ADL decline after oncological surgery for gastrointestinal and hepatobiliary-pancreatic cancers by age groups. The results of this study revealed an actual decline in postoperative ADLs in older people, who would have been deemed to be clinically eligible for surgery, compared with that noted in younger people. Although significant differences were observed in the proportion of ADL decline after ESD or EMR owing to a large number of participants, the difference in this proportion was <3% between the <75 and ≥80 years age groups. ESD or EMR is less invasive and more tolerable than laparoscopic or open surgery in older patients. However, regarding laparoscopic and open surgeries for patients aged ≥80 years, with the exception of colon, rectal and pancreatic cancers, the difference in the proportion of ADL decline between the <75 and ≥80 years age groups was >3%. As this study assessed patients’ ADLs during discharge from the hospital, our results cannot simply be compared with those of previous studies. Given that most patients recovered from their transient decline and only few patients showed declined ADLs at 6 weeks postoperatively,6 13 the majority of the ADL decline observed in this study may subsequently resolve. However, a certain number of older patients required assistance during discharge from the hospital. Therefore, we should carefully assess in advance the need for postdischarge assistance among older patients undergoing laparoscopic and open surgeries, especially those aged ≥80 years.
After laparoscopic and open surgery, the proportion of ADL decline was higher in the ≥80 years group than in the <75 years group, even if patients had independent ADLs on admission. For gastric and biliary tract cancers, despite a larger proportion of patients aged ≥80 years who underwent partial resection or minimally invasive surgery, the proportion of ADL decline was higher and more significant in older patients than in younger patients. However, the difference in the proportion of ADL decline after pancreatic cancer surgery in patients with independent ADL at admission between the ≥80 and <75 years age groups was small (2.5%). Pancreatic cancer has a poor prognosis, and many older patients with pancreatic cancer are not actively treated.17 Therefore, the older patients with pancreatic cancer in this study may be relatively fit and healthy. Meanwhile, the number of older patients aged ≥75 years undergoing laparoscopic surgery for colon and rectal cancers is small; thus, further studies are required.
Previous studies reported that mortality rate and postoperative complications of older surgical patients are comparable with those of other age group patients.18–20 In this study, the mortality rate after surgery in older patients was similar to that in younger patients. The proportion of unexpected postoperative readmission in the ≥80 years group undergoing ESD/EMR and laparoscopic or open surgery for gastric cancer was significantly higher than that in the <75 years group, but the difference was small (<3%). The proportion of unexpected readmission in the ≥80 years group for other cancers was similar to that in younger patients. These results suggest that older patients with operable gastrointestinal and hepatobiliary-pancreatic cancers can be viable candidates for standard surgical resection. Further research should be conducted to determine the eligibility of older patients with cancers for surgery.
This study has some limitations. First, as this study was conducted retrospectively, we did not consider cognitive function and other conditions in older patients who had undergone surgery. Therefore, it is unclear to what extent the doctors’ judgements and patients’ preferences have influenced their treatment choice. Second, we excluded patients with prolonged hospital stay, as they have been shown to recover from their transient decline in ADLs during their hospital stay6 13; thus, the impact of surgery on these patients’ ADLs could be underestimated. Third, this study’s proportion of unexpected readmissions only accounted for admissions to the same hospital where the operation was performed. Admissions to other hospitals were not considered, which may have led to an underestimation of the readmission rate. Fourth, the impact of in-hospital rehabilitation on ADLs has not been considered. Hence, further research is needed to determine whether rehabilitation on admission can prevent the decline in ADLs. Finally, as ADLs were assessed during hospital discharge, it was unclear to what extent the ADLs had been recovered with postdischarge rehabilitation and other measures. Further studies should assess long-term ADL changes in the older patients postoperatively.
Conclusions
This study reported the impact of surgery on ADLs for patients with gastrointestinal and hepatobiliary-pancreatic cancers using real-world data. When making treatment choices for older patients with cancer, it is important to consider the effectiveness and impact of treatment on patients’ physical functions. The proportion of ADL decline at discharge after open surgery was higher in patients aged ≥80 years than in those aged <75 years. However, the difference in the proportion of ADL decline after ESD or EMR between the <75 and ≥80 years groups was marginal. This suggests that even those aged ≥80 years are eligible for aggressive surgery if the benefits of surgery outweigh the risks. However, careful preoperative consideration should be given regarding the potential decline in ADLs to best maintain the patient’s quality of life after surgery.
Data availability statement
The data were only permitted for use in this study and are not publicly available.
Ethics statements
Patient consent for publication
Ethics approval
Ethical approval for data analysis was obtained from the Institutional Review Board of the National Cancer Center in Japan (2019-064), which waived the requirement for patient consent. Owing to the retrospective nature of the database analysis, the project outlines were made public to provide patients with an opportunity for refusal according to the national ethics guidelines for medical research on human subjects. This study was also approved by the review committee of the Quality Indicator Project at the National Cancer Center.
Acknowledgments
We would like to thank Dr Tomonori Mizutani and Dr Tetsuya Hamaguchi for their advice on our analysis. We would also like to thank the tumour registrars in the hospitals for registering data that enabled our analysis.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors AOk, HK, MK and AOg contributed to the conception and design of the study. AOk, HK, MK, TH and AOg contributed to data analysis and interpretation. AOk drafted the manuscript. All authors critically reviewed the manuscript. All authors had final responsibility for the decision to submit for publication. AOg is the guarantor for the study.
Funding This work was supported by the Grants-In-Aid for Scientific Research (grant number KAKENHI20EA1011).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.