Surgery and the elderly: when an apparent overtreatment becomes safe and effective

Abstract

Background: There are unique issues to consider when caring for an older with cancer. Since older patients with cancer are under-represented in clinical trials, there are less evidence-based data to guide the treatment. The challenge of managing older patients is to assess whether the expected benefits of treatment are superior to the risk in peoples with decreased life expectancy and tolerance to stress. Methods: Our approach for identification of fit patients match the comprehensive geriatric assessment with a multidisciplinary evaluation of older patients. At the roundtable there were the oncologist and the surgeon, a radiologist, internist with expertise in pulmonology, geriatrician, anesthesiologist with expertise in nutrition, psychologist, physiatrist, oncologic nurse, the general practitioner and caregiver of the specific patient, social worker. Starting from a careful analysis of medical history, physical examination, biochemical and instrumental exams the team proceeded applying the comprehensive geriatric assessment and balancing risks and benefits of all possible therapeutic options; the final decision was made taking into account the opinion of general practitioner and caregiver. Thereafter, the decision-making process was completed through a discussion with the patient in order to explain the risk-to-benefit ratio of surgery and to better understand wishes, hopes and unmet needs. Results: In the last year we were able to identify as fit, forty-five very old oncologic patients. Whit an aggressive surgical approach all the patients are free of disease and their quality of life is ameliorated. Notably, for six patients the surgical approach was firstly excluded for age and tumor burden as evidenced on Computed Tomography at another oncologic hospital with high surgical volumes. After our re-evaluation, all six patients were deemed as fit and surgery was radical for all. The length of hospital stay was of three days for two of them, seven days for other three; for a patient with nutritional problem, the total parenteral nutritional support was prolonged for ten days. Conclusions: Aging and increased life expectancy mean that cancer in the older is becoming an increasingly common problem. Proper selection of patients is mandatory to administering effective and safe oncologic treatment. Advanced age alone should not preclude an effective cancer option that could improve quality of life or extend survival.