Program improves surgical outcomes, preserves independence for older adults with cancer
Key takeaways:
- The American College of Surgeons’ Geriatric Surgery Verification program significantly reduced hospital stays.
- Older adults prioritize functional independence as a key surgical goal.
An American College of Surgeons initiative reduced postoperative hospitalization among older adults with cancer, according to study findings.
The strategy also resulted in increased likelihood that patients would be discharged home and helped patients achieve independence.
Researchers evaluated the American College of Surgeons’ Geriatric Surgery Verification (GSV) initiative among 43 patients with cancer aged 65 years or older (average age, 75 years) who underwent major oncological abdominal operations in 2022.
To create a comparison group, they retrospectively reviewed 57 patients (average age, 76.5 years) matched for clinical and sociodemographic characteristics who underwent the same type of operations between January 2021 and December 2022.
Postoperative institutionalization and change in a patient’s primary residence served as the main outcomes.
Patients in the intervention group had shorter mean length of hospital stay (4.4 ± 2.5 days) than the control group (6.5 ± 3.6 days). They also had lower likelihood of being discharged to an institution (7.3% vs. 24.1%; P =.03). Those in the GSV program cohort had a 72% lower likelihood of having increased care needs at discharge (OR = 0.28; 95% CI, 0.1-0.81), suggesting higher levels of independence.
The findings are particularly important given the increasing number of people with cancer in the 65-and-older age group, according to Steve (Sung) Kwon, MD, MPH, FACS, surgical oncologist at Roger Williams Medical Center and director of Roger Williams Surgery and Cancer Outcomes Research and Equity Center.
“We need to be ready and able to improve outcomes for these patients,” Kwon told Healio. “Especially when older and frail patients are undergoing multimodal therapy, it’s important to be able to think about their needs preoperatively in order to improve and maximize their outcomes.”
Healio spoke with Kwon about the origins of this initiative, what it entails, the benefits it may offer, and the next steps in its evolution and implementation.
Healio: What unique challenges do older patients with cancer face in terms of surgery?
Kwon: The older patient population experiences higher risk for postoperative complications and mortality. There is a group of changes that occur with aging called geriatric syndromes. Those may involve sarcopenia (ie, muscle loss), frailty, increased risk of falls and cognitive impairment. Older patients also are faced with increased number of medical comorbidities associated with aging, such as hypertension, hyperlipidemia, heart disease and pulmonary disease.
Accordingly, there is also an increased frequency of polypharmacy. Some patients require a walker or a wheelchair secondary to reduced functional capacity and mobility. These geriatric syndromes are known to be risk factors for postoperative complications and poor functional recovery.
These patients also often have different perspectives in terms of goals of care, and physicians often overlook that. As cancer physicians, we have a single goal of curing them of their pathology, and perhaps we aren’t as focused on the individual patient’s needs. We found in our study that the number one goal for these patients is to recover the functional independence they had prior to surgery. That outweighed the goal of being cured of cancer. Their desire to return to their normal lives surpasses the desire to achieve cure and extend life.
Healio: What is the GSV program, and how does it address the needs of older patients undergoing surgery for cancer?
Kwon: The American College of Surgeons recognizes that the older patient population has different needs and elevated risks that can be mitigated. They developed a comprehensive program in which they address a multitude of these geriatric syndromes preoperatively. They address issues like nutrition, prehabilitation, preoperative polypharmacy management, and minimizing the risk for delirium and postoperative confusion. It involves patients earlier in the process, from the preoperative phase to the hospital to the postoperative phase. This comprehensive program addresses a multitude of issues that require attention prior to surgery.
It is notable that patients who are undergoing surgery for cancer have even more complexity, due to their need for multimodal therapies like chemotherapy and radiation in addition to surgery. They may be even more deconditioned and need to be optimized during the surgical and postsurgical process. This program addresses their preoperative phase and prepare them for optimal functional recovery so that they can return to their preoperative functional status quicker.
Healio: How did you evaluate the efficacy of the GSV program?
Kwon: We are still in the evaluation phase. We are looking at patients’ recovery process at 30, 60, 90, and 180 days, and at 1 year. We’re using multiple questionnaires and surveys to assess their postoperative functional recovery among those who were in the GSV program vs. those who were not.
For this paper, we looked at more short-term outcomes. As mentioned before, we noted that the primary goal of care was to return to their normal lives and functional independence. Therefore, we wanted to see the impact of GSV on patients returning to their homes or going to a rehabilitation or skilled nursing facility after surgery. We created a primary residence score based on the dispositions of patients pre- and postoperatively. We used that as a surrogate marker for whether we are helping patients achieve their primary postoperative goal of returning to their functional independence. In the long term, we will look at health-related quality of life and functional recovery over the course of 1 year after surgery.
Healio: What are the potential long-term implications of this research?
Kwon: A program built around trying to achieve the best outcomes for these patients will be very important as we go forward. A recent paper looked at community dwelling Medicare beneficiaries aged older than 65 years, and it showed inpatient mortality from an elective surgery is about 7.4%. That figure increased to more than 20% for non-elective surgeries. The number of surgeries performed in this population is high, and the outcome is not what we want it to be — that mortality risk is still fairly high. We want to be able to successfully address some of these issues in this growing population.
References:
- Gill TM, et al. JAMA Surg. 2022;doi:10.1001/jamasurg.2022.5155.
- Jiminez M, et al. J Am Coll Surg. 2024;doi:10.1097/XCS.0000000000001247.
For more information:
Steve (Sung) Kwon, MD, MPH, FACS, can be reached at steve.kwon@chartercare.org.
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