Page 147 - Risk quantification and modification in older patients with colorectal cancer

Prehabilitation in a multidisciplinary care program
could not demonstrate a clear improvement in 1-year mortality after the start of the program. What we noticed, however, was that improvements in outcomes already started during the development of our program. This could imply that dedicated multidisciplinary care was the main driver of the improved outcomes for our elderly CRC patients and that the actual program did not add to that significantly. However, a further decrease in cardiac complications and a lower number of patients with a prolonged length of stay was seen after implementation of the complete program, which could be regarded a merit of the program.
To our knowledge, this is the first study to assess the usefulness of a comprehensive multidisciplinary care program for older colorectal cancer patients that included both prehabilitation and rehabilitation. There are however multiple studies that investigated these components separately, most of them in a much younger population. These studies found that prehabilitation positively influenced functional capacity,11,29-31 only one study showing a benefit on morbidity32 as was also shown in a meta-analysis.33 Other studies of rehabilitation and fast-track surgery in elderly patients demonstrated a shortened length of stay without increasing readmission rates.22 Further comparison with other studies is difficult as the inclusion of older, more high-risk patients in these studies was low or even absent.33 However, one publication showed a promising effect of a prehabilitation program for older ASA III-IV patients and elective abdominal surgery with a reduction of complications of 20%.32 Despite 51% of patients having significant comorbidity in our study, our mortality rates from 2012 onwards could be considered low.6,34
Our study did not show the clear benefit we had expected from a comprehensive multidisciplinary care program. Several possible explanations can be put forward, which are interconnected to its strengths and limitations. Already in 2012, we started our multidisciplinary Delphi rounds to develop a comprehensive multidisciplinary care program for elderly CRC patients in our hospital. The increased focus on elderly CRC patients is likely to have improved treatment outcomes in a way similar to the so-called Hawthorne effect.35 During the development of the program, clinicians were probably more aware of the specific problems, and demands of elderly CRC patients and other caregivers such as dieticians and physiotherapists were more regularly involved. That could explain why there was a dramatic decrease in 1-year mortality in our most recent controls
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