Randomized trial of a perioperative geriatric intervention for older adults with cancer.

Abstract

12012 Background: Older adults with gastrointestinal (GI) cancers undergoing surgery often experience poor outcomes, such as prolonged postoperative (post-op) length of stay (LOS), intensive care unit (ICU) use, and readmissions. Involvement of geriatricians in the care of older adults with cancer can improve outcomes. We conducted a randomized trial of a perioperative geriatric intervention in older adults with GI cancers undergoing surgery. Methods: We randomly assigned patients age ≥65 with GI cancers planning to undergo surgical resection to receive a perioperative geriatric intervention or usual care. Intervention patients met with a geriatrician preoperatively in the outpatient setting and post-op as an inpatient consultant. The geriatrician conducted a geriatric assessment and made recommendations to the surgical/oncology teams. The primary end point was post-op LOS. Secondary end points included post-op ICU use, readmission risk, and patient-reported symptom burden (Edmonton Symptom Assessment System [ESAS]) and depression symptoms (Geriatric Depression Scale). We conducted both intention-to-treat (ITT) and per protocol (PP) analyses. Results: From 9/13/16-4/30/19, we randomized 160 patients (72.4% enrollment rate; median age = 72 [65-92]). The ITT analyses included 137/160 patients who underwent surgery (usual care = 68/78, intervention = 69/82). The PP analyses included the 68 usual care patients and the 30/69 intervention patients who received both pre- and post-op intervention components. In ITT analyses, we found no significant differences between intervention and usual care in post-op LOS (7.2 v 8.2 days, P = .37), ICU use (23.3% v 32.4%, p = .23), and readmission rates within 90 days of surgery (21.7% v 25.0%, p = .65). Intervention patients reported lower depression symptoms (B = -1.39, P < .01) at post-op day 5 and fewer moderate/severe ESAS symptoms at post-op day 60 (B = -1.09, P = .02). In PP analyses, intervention patients had significantly shorter post-op LOS (5.9 v 8.2 days, P = .02) and lower rates of post-op ICU use (13.3% v 32.4%, p < .05), but readmission rates were not significantly different (16.7% v 25.0%, p = .36). Conclusions: Although this perioperative geriatric intervention did not have a significant impact on the primary end point in ITT analysis, we found encouraging results in several secondary outcomes and for the subgroup of patients who received the planned intervention. Future studies of this perioperative geriatric intervention should include efforts, such as telehealth visits, to ensure the intervention is delivered as planned. Clinical trial information: NCT02810652 .

A nationwide web-based survey of oncologic surgeons to clarify the current status of preoperative assessment for elderly cancer surgery patients in Japan

“…The results showed that interventions based on preoperative GA did not reduce the incidence of grade II-IV adverse events 15 . Currently, there are several randomized controlled trials evaluating the usefulness of preoperative GA for elderly cancer surgery patients, and the results are promising 16 , 17 . However, differences in the background of the study population, selection bias, surgical techniques and assessment tools used, as well as endpoints, make it difficult to build evidence, and this is an issue that should be investigated in the future.…”

Randomized controlled trial of geriatric consultation versus standard care in older adults with hematologic malignancies

“…Emerging evidence from other trials of predominantly solid tumors suggests that GAdriven interventions improve meaningful outcomes other than survival in older patients with cancer, including decreased treatment toxicity and improvements across multiple domains of quality of life. 16,17,27,28,36,37 Varying models of GA-driven interventions were studied in these trials, ranging from a GA summary with recommended interventions carried out by the treating hematologic oncologist, to an embedded co-management model led by a geriatrician (as described above). Future trials in older adults with blood cancers should investigate not only the effectiveness of different models of geriatrics-driven interventions in terms of mortality, but also their impact on treatment decisions and patient-centered outcomes such as function and quality of life-outcomes often valued by older patients just as much as if not more than survival.…”

Current Status and Problems of Preoperative Assessment for Elderly Cancer Surgery Patients in Japan: A Nationwide Survey

“…Although GA observational studies and case control studies in elderly cancer surgery patients are increasing, differences in study population background, selection bias, surgical techniques and evaluation tools used, and endpoint settings make it di cult to build the evidence. In such a situation, four randomized control studies as new evidence for GA were reported at the ASCO 2020 annual meeting [ [12][13][14][15] ]. Three of the four studies were chemotherapeutic studies and the remaining was a surgical study; all showed the usefulness of the GA.…”