Page 138 - Risk quantification and modification in older patients with colorectal cancer

Chapter 7
Introduction
Colorectal cancer is an age-related disease, disproportionally affecting older patients with an expected increase of 52% in the next two decades.1,2 While survival for all cancer types increases, improvement of cancer outcome has been relatively limited in older patients.3 Comorbidity, social and cognitive functioning, nutritional status and physical performance level contribute to daily functioning and patient’s resilience to withstand or adapt to stressors. As surgery is a major stressor, this also explains why elderly have a fourfold increase in major postoperative complications.4 Comorbidity, functional dependency and older age are associated with early postoperative mortality.5 Surgery also seems to have a prolonged impact on elderly patients, as early postoperative mortality highly underestimates 1-year mortality in these patients.6,7 Besides this prolonged risk of mortality, elderly patients experience a decline in self-care capacity up to 60% in the first year after surgery.8 Preventing functional decline and optimizing patient’s preoperative condition are possible strategies to increase treatment outcomes and increase patients’ chance of retaining independence. Earlier studies focused on improving physical performance using exercise training were only moderately successful and did not improve self-reported performance but dealt with low adherence.9
Conceptually there are three ways to limit the impact of colorectal cancer (CRC) surgery in elderly patients. First, through prehabilitation, by optimising functional capacity prior to surgery using exercise training, nutritional support and optimising comorbidity resulting in increased resilience.10,11 Second, by limiting the impact of surgery through minimally invasive and enhanced recovery strategies reducing perioperative stress response, tissue injury and metabolic response12,13 potentially resulting in fewer complications and less postoperative pain. Third, by means of early discharge to a rehabilitation centre, thereby countering the negative effects of hospital stay i.e. low daily activity and reducing the risk for hospital-acquired infections. With rehabilitation, we try to restore preoperative levels of functioning, thereby limiting the susceptibility to other illnesses and to restore a patient’s quality of life.
With this concept in mind, a multimodality care program for elderly colorectal cancer patients was initiated in a teaching hospital in the western part of the
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