Outcomes in Octogenarians Undergoing High-Risk Cancer Operation: A National Study

Department of Surgery, University of Michigan, Ann Arbor, Michigan, United States
Journal of the American College of Surgeons (Impact Factor: 5.12). 12/2007; 205(6):729-34. DOI: 10.1016/j.jamcollsurg.2007.06.307
Source: PubMed


Current information about outcomes in octogenarians undergoing cancer operations is limited largely to case series from selected centers. Population-based data can provide more realistic estimates of the risks and benefits of operations in this group.
We performed a retrospective cohort study of patients undergoing major resections for lung, esophageal, and pancreas cancer. Using the Nationwide Inpatient Sample (1994 to 2003), we examined operative mortality and discharge disposition in octogenarians (aged 80+ years), relative to younger patients (aged 65 to 69 years) (n = 272,662). We then used the Surveillance and End Results-Medicare-linked database (1992 to 2001) to measure late survival in the elderly (n = 14,088).
Operative mortality among octogenarians was substantially higher than that of younger patients (aged 65 to 69 years) for all three cancers (esophagectomy, 19.9% versus 8.8%, p < 0.0001; pancreatectomy, 15.5% versus 6.7%, p < 0.0001; lung resection, 6.9% versus 3.7%, p < 0.0001). A large proportion of octogenarians were transferred to extended care facilities after operation, ranging from 24% after lung resection to 44% after esophagectomy. Five-year survival in octogenarians was low for all three cancers: 11% after pancreatectomy, 18% after esophagectomy and 31% after lung cancer resection. Survival among octogenarians with two or more comorbidities was worse than those with fewer comorbid diagnoses--10% versus 14% for pancreatectomy, 15% versus 23% for esophagectomy, and 27% versus 37% for lung resection.
Population-based outcomes after high-risk cancer operation in octogenarians are considerably worse than typically reported in case series and published survival statistics. Such information might better inform clinical decision making in this high-risk group.

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    • "There is a difference between the mortality rate (mean 15.0%, range 4.7—15.5%) reported by cohort studies [10] [11] [20] and that reported by institutional reports (mean 3.9% range 0—13%) [8,9,12—19,21] and our own series (0%). The difference was ascribed mainly to a reporting bias [13], but, as reported by Riall [2], the mortality rate following surgery in octogenarians, is nearly twice as high at low-volume facilities compared to highvolume facilities. "
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    ABSTRACT: Pancreatic and perampullary neoplasms in patients aged 80 or older trouble the surgeons because of the risk of surgical treatment. We have reviewed our experience and literature's reports of pancreaticoduodenectomy in octogenarians, evaluating early results and long-term survival in pancreatic cancer group. Three hundred eighty-five patients who underwent pancreaticoduodenectomy for neoplasms from 1998 to 2011 were included in the study, and were divided in two groups: group 1, patients younger than 80years of age, and group 2, patients 80years of age and older. Operative morbidity, mortality, disease-free and long-term survival were analysed. English literature was systematically searched for pancreatic resection's outcome in octogenarians. There were 385 pancreaticoduodenectomies: 362 patients were in group 1 and 23 patients in group 2. There was no significant difference regarding gender, and pathologic findings between the two groups. Complications' rate (40 vs. 43%), mortality rate (4% vs. 0%), and overall median survival for pancreatic cancer patients were not statistically different in the two groups (median 21 vs. 19months). Literature's review showed 14 reports of pancreatic resection in octogenarians. Most of the studies (particularly in centres with high-volume pancreatic surgery) showed that outcome after pancreatectomy was not different in octogenarians or in younger patients. Pancreaticoduodenectomy is an acceptable option for elderly patients. Age alone should not be considered a contraindication to major pancreatic resection, but a careful preoperative evaluation and an accurate postoperative management are mandatory. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
    Journal of Visceral Surgery 06/2015; DOI:10.1016/j.jviscsurg.2015.06.004 · 1.75 Impact Factor
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    • "In spite of this improvement, there are inherent risks associated with any surgery, and complications, including death, may occur [3-6]. While high-risk surgeries performed by high volume surgeons and hospitals are associated with better patient outcomes [4,7], a subset of patients will still experience complications [3-7]. Facing such complications, it would be advantageous for patients preparing for high-risk surgery to engage in advance care planning—a process by which patients make preparations for medical decision making and engage in behaviors to guide medical decisions made on their behalf in the event that they cannot make their own decisions at a future time [8-11]. "
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    ABSTRACT: Background High-risk surgery patients may lose decision-making capacity as a result of surgical complications. Advance care planning prior to surgery may be beneficial, but remains controversial and is hindered by a lack of appropriate decision aids. This study sought to examine stakeholders’ views on the appropriateness of using decision aids, in general, to support advance care planning among high-risk surgery populations and the design of such a decision aid. Methods Key informants were recruited through purposive and snowball sampling. Semi-structured interviews were conducted by phone until data collected reached theoretical saturation. Key informants were asked to discuss their thoughts about advance care planning and interventions to support advance care planning, particularly for this population. Researchers took de-identified notes that were analyzed for emerging concordant, discordant, and recurrent themes using interpretative phenomenological analysis. Results Key informants described the importance of initiating advance care planning preoperatively, despite potential challenges present in surgical settings. In general, decision aids were viewed as an appropriate approach to support advance care planning for this population. A recipe emerged from the data that outlines tools, ingredients, and tips for success that are needed to design an advance care planning decision aid for high-risk surgical settings. Conclusions Stakeholders supported incorporating advance care planning in high-risk surgical settings and endorsed the appropriateness of using decision aids to do so. Findings will inform the next stages of developing the first advance care planning decision aid for high-risk surgery patients.
    BMC Palliative Care 06/2014; 13:32. DOI:10.1186/1472-684X-13-32 · 1.78 Impact Factor
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    • "Similarly, although large population-based studies in the pancreatic literature suggest worse short-term outcomes in older, compared to younger, patients [74, 75], it is likely that “age” in these population-based studies was simply a surrogate for chronic illness. When large series of elderly patients undergoing major pancreatic and hepatobiliary operations are analyzed, chronological age turns out not to be a meaningful risk factor, although all agree that physiologic age as described above is essential to consider [76–80]. "
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    ABSTRACT: The proportions both of elderly patients in the world and of elderly patients with cancer are both increasing. In the evaluation of these patients, physiologic age, and not chronologic age, should be carefully considered in the decision-making process prior to both cancer screening and cancer treatment in an effort to avoid ageism. Many tools exist to help the practitioner determine the physiologic age of the patient, which allows for more appropriate and more individualized risk stratification, both in the pre- and postoperative periods as patients are evaluated for surgical treatments and monitored for surgical complications, respectively. During and after operations in the oncogeriatric populations, physiologic changes occuring that accompany aging include impaired stress response, increased senescence, and decreased immunity, all three of which impact the risk/benefit ratio associated with cancer surgery in the elderly.
    The Scientific World Journal 01/2012; 2012(7):303852. DOI:10.1100/2012/303852 · 1.73 Impact Factor
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