Page 148 - Risk quantification and modification in older patients with colorectal cancer

Chapter 7
(2012-2013). These controls fared much better than expected from previous research.34 For reference, in the Dutch ColoRectal Audit (DCRA) data, a gradual improvement is seen over the years in outcomes, i.e. less postoperative mortality, but no dramatic change between 2010-2011 and 2012-2013.36
Due to the small numbers of index events i.e. postoperative deaths, chance (such as a calamity with stapling) could have had a disproportionate impact on the results. This may have masked a positive effect of implementing the program. It could be argued that a weakness of our study is that prehabilitation and rehabilitation were not standardised for all patients in our program. In our opinion, the choice to allow for limited tailoring to a patient’s needs within our protocol ensures its applicability to daily practice. A fit elderly patient actively playing sports will be difficult to motivate for prehabilitation he or she is unlikely to benefit from. Likewise, an elderly patient that recovers very fast after surgery and can return home on day five is not going to benefit from staying in a rehabilitation facility. On the other end of the spectrum, very frail patients can be limited by their comorbidity to participate in an exercise program. These are the main reasons that not all patients in this study participated in all aspects of the program. Therefore we believe that prehabilitation and rehabilitation should both be facilitated in a comprehensive care program for elderly patients. This is in contrast to the suggestion that research should focus on preoperative interventions following research in younger counterparts.11,37
One of the problems in dealing with elderly patients is that there is no ultimate test to select patients. Age alone is not a predictor of outcome,38 but it could be regarded as a key determinant for the progressive functional inadequacy of physiological systems that leads to an impaired physical capacity to overcome stressors. Therefore in our program, we chose age 75 and up as a cut-off.
Philosophically there are two opposing ways to go about with research in this field. First, we could focus on the individual patient and completely individualise prehabilitation, rehabilitation and treatment. As a consequence, it will be very difficult to reach scientific evidence about what we are doing exactly. The other way would be to succumb every patient to a strict protocol, but as discussed earlier it would be difficult to include all patients; in the absence of reliable prognosticators to make a proper selection of patients. Therefore, we chose all consecutive patients
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