Page 203 - Risk quantification and modification in older patients with colorectal cancer

risk, and risk for delirium that are part of the nationwide implemented Dutch National Patient Safety Program (“veiligheid management systeem” or “VMS”)20 and the national guideline for detection of undernutrition for all patients with CRC. These efforts to improve (postoperative) outcomes of CRC patients also coincide with ERAS.
Where Geriatric Assessment (GA) is used to identify patients at risk of geriatric deficits, a comprehensive GA (CGA) can confirm or negate the presence of geriatric impairments, and subsequently direct interventions aimed at improving outcomes, the discussion of treatment goals and treatment preferences to improve quality of life, and improving treatment adherence.21,22 Interventions initiated by the VMS program include a comprehensive nutritional evaluation of high-risk patients, physiotherapy in case of ADL dependence of previous falls, and postoperative delirium prevention in high-risk patients.20 Where geriatric screening and assessment are usually performed before treatment decisions are made, in current clinical practice the VMS is assessed on the day of hospital admission. Concurrently, the Enhanced recovery after surgery (ERAS) guideline also has been implemented in many Dutch hospitals. To illustrate the current clinical practice, Figure 1 shows a care pathway for older CRC patients used in multiple Dutch Hospitals.
Preoperative colorectal cancer care
Disadvantages of the current clinical practice with geriatric screening and assessment, VMS and preoperative care components of ERAS, are the overlap of these methods with respect to detection of (geriatric) deficits and introduction of interventions. Additionally, timing of screening and interventions (including CGA) can be optimised. The resources needed for a CGA are still scarce in many hospitals, or even non-existing. In current practice, screening tools are used to select patients for CGA, but especially for the G8, the low specific results in an unnecessary referral for CGA. In addition, patients with only an impairment of single geriatric domains might be managed accordingly, without the need for a CGA. A CGA is then preserved for high-risk patients who may benefit the most (multiple geriatric impairments) or patients with metastatic disease where alternative therapy or even best-supportive care is considered.
General discussion and future perspectives
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