Co-managed care by geriatrics and surgical services improved 90-day mortality for older cancer patients

Older people with cancer face heightened risks of several unfavorable postoperative outcomes. Frailty is a key factor behind adverse postoperative events in this population—previous studies have shown that people who were deemed frail were more than 8 times more likely to die within 1 year following elective colectomy for colon cancer than those who were not. But a new study found that getting the geriatrics team paired with the surgical team for perioperative care can lower mortality risks for this patient population.

“This cohort study found that older patients whose care was comanaged by the geriatrics and surgical services had significantly lower 90-day postoperative mortality than patients whose care was managed by the surgical service only,” wrote study first author Armin Shahrokni, MD, MPH, a geriatrician and researcher with Memorial Sloan Kettering Cancer Center in New York, and colleagues, in JAMA Network Open. “To our knowledge, our study is the first to assess the association of 90-day postoperative mortality with geriatric co-management. Geriatric co-management can reduce postoperative mortality by various mechanisms…Such services may play a role in attenuating the adverse outcomes associated with surgical stress on these patients.”

The focus of this co-management of care is on the prevention and management of geriatric syndromes and complications. Previously demonstrated advantages of geriatric co-management included better preoperative assessments for frailty and other factors, reduced length of hospital stay, improved complication rates, and lower mortality.

Shahrokni and colleagues ultimately included 1,892 surgery patients in their analysis, with 1,020 (53.9%) receiving geriatric co-management. Compared with those who did not receive geriatric co-management, patients who did were older (mean [SD] age, 81 [4] years versus 80 [4] years; P<.001), had longer operative time (mean [SD], 203 [146] minutes versus 138 [112] minutes; P<.001), and stayed in the hospital longer (median [interquartile range], 5 [3-8] days versus 4 [2-7] days; P<.001). There were no significant differences in the proportions of men in the two groups (488 [47.8%] men versus 450 [51.6%] men; P=.11).

Adjusted probability of death within 90 days after surgical treatment was 4.3% for the geriatric co-management group compared with 8.9% for the surgical service group (difference, 4.6% [95% CI 2.3%-6.9%]; P<.001).

Adverse surgical events did not vary significantly between the two groups (OR 0.93 [95% CI 0.73-1.18]; P=.54).

Compared with their surgery-only counterparts, more patients in the geriatric co-management group received support services such as physical therapy (555 patients [63.6%] versus 820 patients [80.4%]; P<.001), occupational therapy (220 patients [25.2%] versus 385 patients [37.7%]; P<.001), speech and swallow rehabilitation (42 patients [4.8%] versus 86 patients [8.4%]; P=.002), and nutrition services (637 patients [73.1%] versus 803 patients [78.7%]; P=.004).

In an accompanying editorial, Nicole Saur, MD, and Isacco Montroni, MD, PhD, both surgeon-researchers with the University of Pennsylvania and Ospedale per gli Infermi in Italy, respectively, and neither of whom were affiliated with the study, wrote that the findings provided “important information” into the impact of geriatric involvement in this population.

“[The study] suggests that a simple intervention of including a geriatrician in the care team may dramatically improve outcomes,” the editorial authors wrote. “There is no doubt that this is a key ingredient in the care of geriatric patients…The obvious problem is that we do not have a crystal ball to determine who is fit enough to undergo surgery without complications related to their surgery or their comorbidities. Therefore, a multidisciplinary, multiphase approach is necessary for all patients.”

According to Shahrokni and colleagues, subsequent research should dive more deeply into the specific potential benefits or characteristics of effective geriatric co-management, both in this population and others.

“Future studies should assess how often such services are used and their effects on outcomes in the perioperative period,” the study authors wrote. “Other potential mechanisms warrant further study. A recent nonsurgical study in older adults with cancer found that geriatric assessment was associated with an increased number of conversations about aging-related concerns; therefore, the content and quality of perioperative communications between health care practitioners and older patients with cancer and their caregivers should be investigated.”

Chief among the limitations identified by the authors were that patients received referrals for preoperative evaluation based mainly on the surgeon’s or patient’s preference.

Montroni and Saur offered specific recommendations for better integrating the geriatrics team into various aspects of operative care.

“A care pathway for geriatric patients should include universal frailty screening,” Saur and Montroni wrote. “At a pre-chosen frailty screening threshold based on the patient population and resources at the institution, multidisciplinary optimization and prehabilitation should be undertaken. For patients with cancer, in addition to preoperative optimization with a geriatrician, a geriatrician should be present at the multidisciplinary tumor board and present for goals of care discussions. When possible, geriatric patients should be treated with minimally invasive surgery…We must continue to strive to find the optimal recipe in a multiphase program or we will continue to fall short in the care of these complex patients.”

  1. Geriatrician collaboration with surgery teams improved 90-day mortality rates among older cancer patients, researchers found.

  2. The study underscores previously demonstrated advantages of geriatric co-management and included better preoperative assessments for frailty and other factors, reduced length of hospital stay, improved complication rates, and lower mortality.

Scott Harris, Contributing Writer, BreakingMED™

No source appearing in this article disclosed any relevant financial relationship with industry.

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