Preparing for Future Challenges in Geriatric Surgical Oncology


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Ruth Mary Parks, BMBS, MRCS, MSc

Ruth Mary Parks, BMBS, MRCS, MSc

Kwok-Leung Cheung, MD, FRCS, FACS

Kwok-Leung Cheung, MD, FRCS, FACS

In the past decade, advances in surgical oncology have been echoed in the field of geriatric oncology. The current literature regarding older people with cancer includes mainly retrospective cohort studies, focusing on alternatives to radical surgery in comorbid patients. More recently, work has focused on the addition of geriatric assessment as an adjunct to decision-making in the older person with cancer. Compared with the plethora of evidence-based medicine available in the literature as a whole, the older person is still underrepresented, despite being at the greatest risk of cancer.

Ms. Parks is Core Surgical Trainee, East Midlands North Deanery, Nottingham, UK, and Dr. Cheung is Clinical Associate Professor, School of Medicine, University of Nottingham, UK.

Alternatives to Radical Surgery 

WE ACCEPT that the treatment goals of the older person with cancer may differ from those of their younger counterparts. Overall “cure” of the cancer may not be realistic, and greater emphasis is placed on quality of life and control of symptoms. An online survey of European Society of Surgical Oncology (ESSO) and Society of Surgical Oncology (SSO) members conducted by the Surgical Task Force of the International Society of Geriatric Oncology (SIOG) received responses from 251 surgeons regarding opinions on geriatric oncology assessment.1 Respondents to the survey identified good quality of life and a satisfying recovery—not survival—as the primary endpoints for their surgical intervention. One in three surgeons would proceed to surgery regardless of cognitive function, as long as functional capacity is conserved.

Stuart M. Lichtman, MD

Stuart M. Lichtman, MD

GUEST EDITOR

Geriatrics for the Oncologist is guest edited by Stuart M. Lichtman, MD, and developed in collaboration with the International Society of Geriatric Oncology (SIOG). Dr. Lichtman is an Attending Physician at Memorial Sloan Kettering Cancer Center, Commack, New York, and Professor of Medicine at Weill Cornell Medical College, New York. He is also President of SIOG. For more information about geriatric oncology, visit www.siog.org and the ASCO Geriatric Oncology website (www.asco.org/practice-guidelines/cancer-care-initiatives/geriatric-oncology/geriatric-oncology-resources).

Therefore, many older patients who previously would have been faced with the challenging decision of whether or not to undergo radical surgery are now being given alternative options, such as minimally invasive surgery, nonoperative treatment, or even no treatment (supportive care only). For example, in the field of prostate cancer, it is accepted that endocrine therapy is an alternative form of treatment, with the aim to suppress testosterone, mimicking surgical castration,2 for patients who do not want or are not suitable for surgery. In rectal cancer, a viable alternative to total mesorectal excision for an older adult with a high risk of morbidity may be chemoradiotherapy.3 Other notable examples include primary endocrine therapy in breast cancer4 and stereotactic radical radiotherapy in non–small cell lung cancer. 

Minimally invasive surgery is becoming more popular with surgeons and patients. In the field of colorectal and urologic cancers, we have progressed from conventional open techniques to laparoscopic/robotic surgery.5 In head and neck cancer, we have moved from open radical surgery to minimal access surgery including endoscopic techniques.6 Thoracoscopic and/or laparoscopic surgeries have also been successfully utilized in many other types of cancer, such as lung7 and gastrointestinal.8 The benefits of minimally invasive surgery include less blood loss, shorter recovery time and length of hospital stay,5 and decreased rates of postoperative hospital-acquired infection.7 Future challenges in surgical management include further refinement of minimally invasive techniques and selection of surgical candidates. 

“The potential benefits of delaying surgery must be weighed against the risk of cancer progression as well as the psychological burden on the patient.”
— Ruth Mary Parks, BMBS, MRCS, MSc, and Kwok-Leung Cheung, MD, FRCS, FACS

Selection of Surgical Candidates 

MULTIPLE PREOPERATIVE factors have been shown to contribute to postoperative complications in the older population, including age,9 comorbidities,10 and preoperative cognitive function.11 

In 2014, SIOG published an updated consensus on geriatric assessment in older patients with cancer.12 They concluded geriatric assessment can be valuable for detection of impairment not routinely identified; prediction of overall survival; and ability to influence treatment choice and intensity. It should include domains concerning functional status, comorbidity, cognition, mental health, fatigue, social status, nutrition, and the presence of geriatric syndromes. They could not, however, yet recommend one specific geriatric assessment model among all those models available. 

Optimization of Medical Status 

FOR THOSE PATIENTS who have been selected for surgery, the challenge will be to optimize their medical status, and this may be accomplished through prehabilitation to improve functional capacity. However, the potential benefits of delaying surgery for prehabilitation must be weighed against the risk of cancer progression as well as the psychological burden on the patient. Optimization through prehabilitation is not a new concept to surgery as a whole, and examples are listed in Table 1.13 

TABLE 1: Examples of Optimization of Medical Status Through Prehabilitation 

Comorbidity 

Optimization 

Heart failure 

Consider beta-blocker ± ACE inhibitor 

Ischemic heart disease 

Consider statins, antiplatelet, beta-blocker 

Arrhythmia 

Consider anticoagulant, pacemaker 

Chronic obstructive pulmonary disease 

Optimize antiobstructive therapy 

Smoking 

Advise cessation program 

Diabetes 

Optimize glucose-lowering regimen 

Anemia 

Assess cause, supplement, or transfuse 

ACE = angiotensin-converting enzyme. Source: Parks et al.13 

The previously mentioned SIOG survey on surgeons’ attitudes on the geriatric oncology patient noted that 71% of surgeons would be prepared to delay surgery in favor of prehabilitation (for up to 4 weeks) if better functional recovery could be achieved.1 

Changing Mindset 

THE SAME SURVEY1 found that more than 90% of surgeons offered surgery regardless of the patient’s age. Therefore, it seems the concept of geriatric surgical oncology is already accepted to some degree within this community. 

Moving forward, the most important challenge is to change the mindset that patients may be “too old” for surgery. In the past few decades, we have seen the role of the multidisciplinary team flourish. Now we must extend this role to include collaboration with our geriatric oncology colleagues (both geriatricians with a special interest in cancer and oncologists with a special interest in geriatric oncology) who can provide a different perspective in terms of setting achievable treatment goals for our older patients and working with us to accomplish these goals. 

Future Directions 

WE NEED TO CONTINUE to build a strong evidence base, select the right patient for the right procedure, optimize high-risk patients, and change our mindset in terms of treatment goals and collaboration with colleagues. The future of nonoperative management should also involve the development of personalized medicine in selecting optimal therapies based on biology. It is our responsibility to educate our colleagues, extending the surgical multidisciplinary team to oncologists and geriatricians where possible. Further work needs to be done to help better understand how to use the results of geriatric assessment. ■

DISCLOSURE: Ms. Parks reported no conflicts of interest. Dr. Cheung has received honorarium from Chugal, research funding from AstraZeneca, and served as an advisory board member for AstraZeneca and Genomic Health. 

REFERENCES 

1. Ghignone F, van Leeuwen BL, Montroni I, et al: The assessment and management of older cancer patients. Eur J Surg Oncol 42:297-302, 2016. 

2. Reese DM: Choice of hormonal therapy for prostate cancer. Lancet 355:1474-1475, 2000. 

3. Appelt AL, Ploen J, Harling H, et al: High-dose chemoradiotherapy and watchful waiting for distal rectal cancer. Lancet Oncol 16:919-927, 2015. 

4. Hind D, Wyld L, Reed MW: Surgery, with or without tamoxifen, vs tamoxifen alone for older women with operable breast cancer. Br J Cancer 96:1025-1029, 2007. 

5. Veldkamp R, Kuhry E, Hop WC, et al: Laparoscopic surgery versus open surgery for colon cancer. Lancet Oncol 6:477-484, 2005. 

6. Holsinger FC, Ferris RL: Transoral endoscopic head and neck surgery and its role within the multidisciplinary treatment paradigm of oropharynx cancer. J Clin Oncol 33:3285- 3292, 2015. 

7. Paul S, Isaacs AJ, Treasure T, et al: Long term survival with thoracoscopic versus open lobectomy. BMJ 349:g5575, 2014. 

8. Zhao Y, Jiao W, Zhao J, et al: Anastomosis in minimally invasive Ivor Lewis esophagectomy via two ports provides equivalent perioperative outcomes to open. Indian J Cancer 51:25-28, 2015. 

9. Rocco N, Rispoli C, Pagano G, et al: Breast cancer surgery in elderly patients. BMC Surg 13:(suppl 2):S25, 2013. [article retracted]

10. Pei G, Zhou S, Han Y, et al: Risk factors for postoperative complications after lung resection for non-small cell lung cancer in elderly patients at a single institution in China. J Thorac Dis 6:1230-1238, 2014. 

11. Inouye SK, Bogardus ST Jr, Charpentier PA, et al: A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 340:669-676, 1999. 

12. Wildiers H, Heeren P, Puts M, et al: International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol 32:2595-2603, 2014. 

13. Parks RM, Rostoft S, Ommundsen N, et al: Peri-operative management of older adults with cancer. Cancers (Basel) 7:1605-1621, 2015.



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