Page 205 - Risk quantification and modification in older patients with colorectal cancer

Within a care pathway for older patients with CRC, a risk model could replace current geriatric screening and CGA assessment for most patients. However, there are two major additions to such a care pathway: the risk for delirium should be assessed preoperatively because of the association of delirium with postoperative complications (Chapter 3) including a longer hospital stay, in-hospital mortality23 and reduced OS,24 and the strong evidence that (non-pharmacological) multicomponent delirium prevention is useful for hospitalised patients.25 Furthermore, because of the association between undernutrition and mortality,26 preoperative nutritional status should be assessed as soon as possible after CRC diagnosis to maximise the efficacy of nutritional interventions. Screening of undernutrition on the day of surgery then becomes obsolete. Moreover, pulmonary optimisation can be achieved for patients that smoke by advocating smoking cessation. Hence, smoking cessation for even four weeks before surgery can reduce the risk of wound-healing complications.27
Information from a risk model should then be presented during the MDT meeting. Theoretically, the advantage of using prognostic information during an MDT, is that it creates awareness among healthcare professionals of the risks of surgical treatment. The prognostic information can also be used in the decision-making process later on. Figure 2 depicts an example of a possible care pathway where our findings and suggestions are incorporated.
Postoperative colorectal cancer care
In addition to preoperative interventions, we should also give more attention to postoperative interventions that also might improve outcomes of CRC surgery. Reduction of postoperative immobilisation using ERAS and postoperative physiotherapy are well established and have shown to be useful for reducing complications and length of hospital stay.28-30 However, we do not advocate the implementation of prearranged rehabilitation into standard care for CRC; in contrast to the rehabilitation program from Chapter 7. The recent advancements in CRC care have likely contributed to the further shortening of the length of hospital stay and a reduction in complications, limiting the necessity of such a program.31 However, postoperative delirium preventive measures and early mobilisation can be initiated after screening (VMS) by the treating physician. In high-risk older patients, a multidisciplinary approach with geriatric co-management might be an additional strategy of further reducing postoperative complications (including delirium) and shortening the length of hospital stay of hospital stay.32
General discussion and future perspectives
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