Page 202 - Risk quantification and modification in older patients with colorectal cancer
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Chapter 11
endurance training combined with sufficient dietary intake (proteins).11 However, due to the considerable heterogeneity of the prehabilitation programs and the heterogeneity of patients under scrutiny, sound interpretation of the study results is difficult.11 In addition, the impact of prehabilitation on outcomes such as quality of life is scarce or even absent, and this needs further investigation. Prehabilitation as a preventive strategy for delirium in older frail patients is of interest and was recently investigated, however evidence is still limited.12
One of the largest challenges for prehabilitation research is who to select for such a program. Better patient selection for prehabilitation is needed, because of the limited effect shown in a non-selective population.11,13 However, there are no optimal selection methods yet. Patient selection based on age (≥75 years) and patient motivation, was not shown to significantly improve outcomes (Chapter 7). However, selection based on ASA score III-IV (severe systemic disease or life- threatening disease) of patients scheduled for major abdominal surgery (50% CRC surgery) and allocated prehabilitation resulted in 20% fewer complications in comparison to standard treatment.14
However, we showed that ASA score alone is not the best selection method for older patients (Chapter 4, 6), and more patients might benefit from prehabilitation when better selection criteria are used. A trial is underway for a 4-week training program with selection based on the Clinical Frailty Scale.15,16 However, the clinical frailty score does not take into account important prognostic factors such as tumour characteristics or comorbidity,17,18 limiting its use for a large number of patient. Therefore, the GerCRC model, which also uses tumour and comorbidity, might serve as a possible instrument to select patients for prehabilitation (after validation). Ideally, a Net Benefit (NB) of the prediction model is calculated that compares prediction model based treatment with default policies of ‘’treat none’’ or ‘’treat all’’.6
Implications for clinical practice
Since 2014, a (Comprehensive) Geriatric Assessment of high-risk patients with CRC has been mandatory in the Netherlands.19 This is in addition to the standard evaluation of the four geriatric domains: undernutrition, physical impairment, fall
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