Page 14 - Risk quantification and modification in older patients with colorectal cancer

Chapter 1
chemotoxicity and lower overall survival after cancer treatment. Low physical performance and functional dependency are also associated with increased care needs after hospitalisation and readmission.23-25,26 In addition, patients with preoperative impairment in activities of daily living (ADL) are at increased risk of further functional decline after CRC surgery.27 Also, skeletal muscle mass and density (related to sarcopenia, physical functioning and functional decline) showed associations with postoperative complications, extended hospital stay28- 33 and chemotoxicity.34 Although, skeletal muscle mass and density as prognostic factors have not been studied in older colorectal cancer patients.
It is important to realise that impaired physical performance, comorbidity, undernutrition, and cognitive impairments are regularly missed during oncological workup,35 resulting in an incorrect assessment of performance status.36 Therefore, for individual risk assessment in older patients, Comprehensive Geriatric Assessment (CGA) has been advocated because it captures the considerable heterogeneity in health and functional ability of older patients. CGA can estimate the patient’s physical and cognitive reserves that are needed to tolerate cancer treatment and it can reduce the risk of under- and overtreatment.37 CGA has been shown to change the treatment decision in up to 40% of older cancer patients, especially those receiving chemotherapy.38
When CGA is not available, prognostic information for individual patients may be obtained from a Geriatric Assessment (GA)39 or even geriatric screening tools (such as ISAR-HP40 and G841) as outcomes of these screening are associated with treatment tolerance, overall survival and functional decline in haematological malignancies, head and neck cancer and lung cancer.42-44 Risk-prediction models may also be used to support treatment decisions because they can an estimate of individual treatment outcomes.
Prediction models need to be applicable, relevant and accurate for their intended use.45 Providing accurate prognostic information to older CRC patients concerning possible risk and benefits of treatment improves the likelihood that treatment decisions are consistent with individual needs, values, and preferences. Multiple risk prediction models are available for the prediction of morbidity and mortality after CRC surgery.46-51 However, it is unclear whether these prediction models are applicable and accurate for older, especially frail, patients. Ideally, prognostic
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