Page 82 - Risk quantification and modification in older patients with colorectal cancer

Chapter 4
Strengths of our study include its multicentre design, respectable sample size and the completeness of data. This study also has several limitations. First, we chose to include only patients with elective surgery. This may be a missed opportunity to obtain additional prognostic information and improve treatment decisions for patients in the emergency setting, who are especially at risk for complications and mortality.24,25 Second, patients were selected from the surgical audit, hence a decision to operate had been made. This introduced a possible selection bias, with patients highly dependent on care not being included in our analysis. The inability to report on preoperative instrumental ADL functioning (iADL) and iADL/ADL functioning as outcome is another limitation. It can be argued that, in addition to survival and complications, maintaining independence is a very relevant outcome after cancer surgery for older patients.26 Furthermore, the magnitude of the impact of preoperative impairments on adverse postoperative outcomes, might have weakened given the intervention attached to the risk scores. Lastly, we note that this tool could be used to discuss outcomes of treatment and shared decision making but does not replace a GA.
The older colorectal cancer population is growing, thus it is important to identify patients at risk of unfavourable outcomes. In addition, the colorectal cancer screening programs that have been introduced in recent years will increase the number of older patients with low stages of disease for whom surgical risk and cancer risk must be carefully weighed. Colorectal cancer surgery is now considered generally safe in older patients,27 with decreasing mortality rates over the past decades, but morbidity and mortality rates are still higher compared with the younger population.28 As the risk assessment tools used in our study have already been successfully introduced in many Dutch hospitals, the cumulative risk sumscore can provide valuable information, which can be used in shared decision making with patients regarding their prognosis and treatment.
Conclusions
A geriatric sumscore that reflects an individual’s risk for delirium, undernutrition, falls, and physical impairment has strong predictive value for morbidity and mortality after colorectal cancer surgery in older patients. This information can be used in shared decision making and may be included in risk models for morbidity and mortality in older colorectal cancer patients.
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