Cancer surgery in elderly patients: risk assessment

Senior patients with cancer are more frequently referred for possible surgical resection. Surgeons must ask: Do we know how to assist them? Do we understand their needs? Are we able to assess and predict operative risks? This review article focuses on such aspects and aims to assist surgical oncologists in the decision-making process.

Modern decision-making is based on evidence. Unfortunately, there is often insufficient evidence guiding the choice of surgical options for senior patients with cancer.

It is generally believed that surgery is the most effective cancer-ablative therapy. However, complication rates, mortality, length of hospital stay, and intensive care unit admissions increase with patient age, which can offset oncologic advantages. Delay in cancer diagnosis can lead to a greater number of emergency presentations, and emergency surgery is associated with increased morbidity and mortality in this population. In the absence of clear guidelines and concerns about their ability to tolerate treatment, older patients are less likely to be offered standard cancer treatments that have been shown to improve survival. Nevertheless, high-profile centers have repeatedly demonstrated the feasibility of surgical treatment in this age group.

Poor understanding of frailty is, to a large degree, responsible for under-treatment. A particularly striking example of this is the nonsurgical treatment of older women with breast cancer. Only one in two older women have their cancer excised; too often, primary endocrine treatment is preferred. On the other hand, there can be overtreatment. When frailty is not identified, patients may be treated aggressively, resulting in poor oncologic outcomes, increased mortality, substandard quality of life, and high monetary costs. Alternative options should be discussed.

The decision of how to treat has to be thorough and honest. It should include the patient’s preferences because older patients are keen to participate in the decision-making process. Patients should be informed of the advantages and disadvantages of a surgical procedure. Too often, for cases in which the operation is likely to be successful, practitioners forget to reassure the patient that the operation is feasible, perhaps slightly risky, but certainly worth undertaking, and, most importantly, that the associated long-term prognosis is favorable. On the other hand, practitioners should not be swayed by a demanding family into offering an overwhelmingly risky operation to a frail patient who is unlikely to overcome multiple potential postoperative complications.

To guide these discussions, what is needed is clinical research that focuses not only on standard peri- and postoperative mortality and complication rates but also on longer-term outcomes and quality of life. Elderly patients who survive the first year after surgery have the same cancer-related survival as younger patients; therefore, decreased long-term survival in the elderly is mainly a result of differences in early mortality. The treatment of senior oncologic patients should focus on enhancing functional capacity preoperatively (prehabilitation), perioperative care, and 1-year outcomes after surgery.

SURGICAL CONSIDERATIONS IN THE OLDER ADULT WITH LUNG CANCER

Lung cancer is primarily a disease of the elderly. More than 65% of lung cancer patients are older than age 65 years when diagnosed.⁴¹ The percentage of patients with newly diagnosed lung cancer who are age ≥ 75 years is approximately 25% and the percentage of patients age ≥ 75 years who die of lung cancer is approximately 30%. Thus, the average patient with lung cancer is paradigmatic of the issues involved in the treatment of an elderly patient with cancer, which may be framed as the following: How should an elderly patient with cancer that, if left untreated, will likely cause his or her death to be offered treatment with the lowest risk of operative morbidity and mortality that, at the same time, aims at the longest life expectancy, with acceptable functional status and quality of life?

The information needed to guide such difficult clinical decisions for elderly patients with lung cancer remains incompletely collected. For example, the standard of care for patients of any age with resectable lung cancer has been anatomic lung lobectomy; the relative risks and efficacy of lesser resections (ie, segmentectomy) are being evaluated in clinical trials. In large randomized trials, lobectomy is associated with an operative mortality of 1.4%, and no increased risk was found to be associated with advanced age. However, this study and other smaller studies of elderly patients with lung cancer did not clearly characterize the population of patients considered for surgery. Some patients believed to have an increased perioperative risk, by use of unknown selection criteria, were referred for alternative ablative therapies such as radiation treatment.

It is possible that, in elderly patients who are not currently offered lobectomy, treatment with sublobar resection may have a better chance for cure with acceptable risks compared with nonsurgical ablative therapies. Conversely, some elderly patients undergoing lobectomy for lesions resectable by segmentectomy may not be offered a more extensive resection (and its benefits).

The effect of thoracic surgery on quality of life has been examined in only a few studies. They suggest that elderly patients experience a pattern of initial decrement followed by recovery similar to that seen in younger patients. Overall, patients with lung cancer have a baseline quality of life lower than that of their peers, and preoperative quality of life has been found to predict long-term survival after thoracic surgery.

Paralleling the efforts to preoperatively define patients at risk because of diminished quality of life has been the effort to define thoracic surgery patients at risk for postoperative complications because of frailty, disability, and multiple comorbidities. A geriatric preoperative assessment using these measures predicted both risks of postoperative institutionalization and 6-month survival.

Overall, intraoperative and postoperative management of patients undergoing lung cancer surgery has advanced considerably, such that the majority of patients can safely undergo effective surgery. The challenge now is to define the high-risk patient population, which will usually be a subgroup of the elderly.

Successful surgical treatment of the elderly patient, therefore, depends on a proactive, patient-centric, multidisciplinary program that involves a geriatrician and in which all stakeholders are committed to understanding the unique needs and expectations of the patients and their families.

In conclusion, surgery remains the best modality to treat solid tumors, regardless of patient age. Surgeons treating elderly patients with cancer should take into account that other factors, such as frailty, comorbidities, performance, and cognitive status, are important considerations when predicting outcomes. With adequate perioperative care, elderly patients can do as well in terms of morbidity and mortality as their younger counterparts. Therefore, if surgery is determined to be the appropriate treatment modality, patients should not be denied this option because of their age.