Oncology/Endocrine
Geriatric assessment in surgical oncology: A systematic review

https://doi.org/10.1016/j.jss.2014.07.004Get rights and content

Abstract

Background

The comprehensive geriatric assessment (CGA) has developed as an important prognostic tool to risk stratify older adults and has recently been applied to the surgical field. In this systematic review, we examined the utility of CGA components as predictors of adverse outcomes among geriatric patients undergoing major oncologic surgery.

Materials and methods

MEDLINE, Embase, and the Cochrane Library were searched for prospective studies examining the association of components of the CGA with specific outcomes among geriatric patients undergoing elective oncologic surgery. Outcome parameters included 30-d postoperative complications (POC), mortality, and discharge to a nonhome institution.

Results

The initial search identified 178 potentially relevant articles, with six studies meeting inclusion criteria. Deficiencies in instrumental activities of daily living, activities of daily living, fatigue, cognition, frailty, and cognitive impairment were associated with increased POC. No CGA predictors were identified for postoperative mortality whereas frailty, deficiencies in instrumental activities of daily living, and depression predicted discharge to a nonhome institution.

Conclusions

Across a variety of surgical oncologic populations and cancer types, components of the CGA appear to be predictive of POC and discharge to a nonhome institution. These results argue for inclusion of focused geriatric assessments as part of routine preoperative care in the geriatric surgical oncology population.

Introduction

The growth of the elderly population in the United States parallels the proportional increase in geriatric surgical patients over the past decade. Aging affects a patient's functional, physiologic, and social wellbeing, and these challenges have profound impacts on treatment and care. Geriatric patients typically have a greater burden of comorbid medical conditions; however, these may incompletely represent the spectrum of physiologic age and vulnerability. The challenge of balancing these comorbidities with the need for surgery is compounded with the addition of a cancer diagnosis. Currently, the median age of cancer diagnosis (for all sites) is 66 y [1]. By 2030, the American Cancer Society predicts that the population aged >64 will increase to 20%, representing 70% of all prevalent cancers [1]. This suggests a growing need for risk stratification assessments that address geriatric cancer care, but innovative approaches have yet to enter into standard clinical practice.

There are currently a number of assessments used by geriatricians and primary care providers to measure older patients' physiologic fitness. In geriatric clinics, a comprehensive geriatric assessment (CGA) is often used to assess components of a patient's physical, mental, and social wellbeing providing a complete picture of the patient's physiological age and capabilities regardless of chronologic age. A full CGA can take several hours to complete, and it includes standard assessments such as activities of daily living (ADL), geriatric depression score, and a timed “get-up and go” test [2]. Although useful, a CGA may not be feasible due to time constraints, especially in a busy surgical clinic [3].

Shorter, more efficient geriatric assessments can address these time constraints while adequately assessing surgical eligibility among geriatric cancer patients [4]. By analyzing different components of the CGA, investigators have sought to categorize patients as frail, moderately frail, or fit. Intuitively, frail patients will experience worse outcomes than those who are fit. However, for the intermediate (or moderately) frail, additional assessments could improve the decision-making process regarding treatment. Studies examining the predictive value of different screening tests have found relatively consistent benefits of using these assessments for general surgery and surgical oncology across different types of cancer [1], [3], [5], [6], [7], [8], [9].

Recognizing the need for synthesis of the burgeoning body of geriatric surgical oncology literature evaluating the potential utility of these assessments, we performed a systematic review of existing studies to assess which components of the CGA may be the most robust predictors of clinically relevant outcomes in this context. The results of this study will provide support and direction in developing new screening protocols and possibly identify actionable targets of the CGA for future preoperative intervention studies to mitigate the risk of adverse outcomes.

Section snippets

Materials and methods

We aimed to identify prospective cohort studies including patients scheduled to undergo elective surgery for cancer treatment and investigated the association of components of the CGA and postoperative outcomes.

Characteristics of included studies

The literature search yielded 178 citations (84 from MEDLINE, 94 from Embase, and none from the Cochrane Library) (Figure). After screening abstracts, 45 potentially relevant articles were selected for further examination, excluding non-English articles, those with abstracts alone, review articles, and duplicate citations. The remaining articles were further reviewed for inclusion criteria by reading the full text. After exclusion of 39 further studies due to failure to meet inclusion criteria

Discussion

With the aging population, the burden of cancer in the elderly has increasing public health significance. For older adults presenting with solid tumors, recommended surgical therapies are often potentially substantial physiologic stressors, and there is significant heterogeneity in patients' ability to tolerate and recover from these treatments. Building on the well-established role of CGA as an adjunct to clinical care management from the gerontology literature, a number of investigators have

Acknowledgment

Author's contributions: M.A.F., D.T.M., K.C., and A.B.S. did the data collection. M.A.F., D.T.M., and K.C. did the analysis and interpretation, M.A.F., D.T.M., and A.B.S. did the writing of the article. K.C., H.M., M.E.N., and A.B.S. did the conception and design of the project. M.E.N. and A.B.S. did the critical revisions of the article.

The project described was supported by the Medical Student Training in Aging Research program in conjunction with the University Cancer Research Fund and the

Cited by (127)

  • Surgery for chronic otitis media in the elderly

    2023, American Journal of Otolaryngology - Head and Neck Medicine and Surgery
View all citing articles on Scopus

An earlier version of this review was presented at the American Geriatrics Society Annual Scientific Meeting in Seattle, Washington on May 4–5, 2012.

1

First and second authors are considered co-first authors for this article.

View full text