Patients aged 75 years and older face an increased risk of mortality and postoperative events when undergoing surgical treatment for cancer. In a study recently published in JAMA Network Open, a research team led by first author Armin Shahrokni, MD, MPH, found that patients whose care was managed by both the surgical and geriatric teams experienced significantly better outcomes compared with those whose care was provided by the surgical team alone. In this interview with i3 Health, Dr. Shahrokni, a geriatrician and oncologist at Memorial Sloan Kettering Cancer Center, discusses the significance of these findings and shares advice for optimizing collaboration between surgeons and geriatricians treating older patients with cancer.
What are some of the unique risk factors and challenges faced by older patients with cancer undergoing surgery?
Armin Shahrokni, MD, MPH: Older patients, in general, are at higher risk for poor surgical outcomes compared with younger patients. Among older patients, those who are frail face the highest risk. Cancer surgeries are usually just one part of the care. Following surgery, some patients need to proceed with additional treatment called adjuvant treatment, such as chemotherapy or radiation. If older frail patients experience poor surgical outcomes, they are less likely to receive these additional treatments, and as a result, their outcomes would further deteriorate.
Older patients with cancer can also experience impairments such as weight loss, due to either their cancer or an inability to prepare meals for themselves as a result of aging. The approaches to these two causes of weight loss are completely different, and they both require focused assessment and intervention for these patients.
Can you comment on the significance of your findings regarding geriatric comanagement of care for older patients undergoing surgery for cancer?
Dr. Shahrokni: Our study was done at a single institution, Memorial Sloan Kettering Cancer Center, which is considered to be one of the top cancer centers in the United States and the world. However, even in this situation—with our vast resources and the great expertise of our surgeons—when geriatricians were involved in the care of older adults with cancer before, during, and after surgery, these patients were less likely to die within 90 days of surgery. I do believe that except for emergent surgeries, zero 90-day postoperative mortality should be the goal that we should all aim to achieve.
Moreover, we assessed why geriatric comanagement is associated with such a decrease in mortality. We found that more patients who were in the geriatric comanagement group received supportive care services, such as physical therapy or occupational therapy, after surgery. This may not seem important to some, but imagine an older adult with cancer who stays in bed for days and weeks following major surgery. That amount of deconditioning would be very difficult to overcome. By performing their comprehensive assessments, the geriatricians in the study figured out the frailty of the patients, and then the inpatient geriatrics service made more effort to address those issues.
What strategies should be implemented to improve collaboration between geriatric and surgical teams in this patient population?
Dr. Shahrokni: I am a geriatrician who believes in the power of evidence and data. The most effective method for improving collaboration between surgeons and geriatricians is to generate more and better quality data that supports such collaboration. One of my surgeon friends once told me, "Surgeons are simple people: they would like great outcomes for their patients." So although there will always be a subset of surgeons who don't believe in the importance of such collaboration, many would cherish it.
I also think that both sides need to make an effort to understand and respect each other's discipline. The language of a geriatrician is completely different from the language of a surgeon. This can cause confusion. The only way that we can overcome this disparity is if geriatricians and surgeons form multidisciplinary teams and remain patient with each other. Eventually, you will see strong bonds form, and from there, this collaboration can expand to late adopters.
What further research needs to be done regarding the benefits of geriatric comanagement in older patients undergoing surgery for cancer?
Dr. Shahrokni: Our study is not the end of the story. Instead, it is the second chapter of the story. It started with many studies showing that frailty is associated with poorer surgical outcomes. Then we asked, how can we improve the outcomes of these frail patients? Our study, even with all its limitations, shows signs that the outcomes of frail patients can be improved by pairing frailty experts––geriatricians––with surgeons.
There are still many questions that remain, which need to be addressed in a randomized trial if possible. I also expect the emergence of various programs referred to as geriatric comanagement. But what are the components of those programs? Will they all be the same? What would the measure of success be for the program and for the patients? We showed that the mortality rate is lower, but what about those who survived? Maybe the functional recovery of those who were in the geriatric comanagement group was also faster. What about caregiver burden? What about the surgery team burden? All of these questions are important, as we are still facing an aging population. We had better be ready soon, or otherwise we will experience another crisis.
About Dr. Shahrokni
Armin Shahrokni, MD, MPH, is a geriatrician and oncologist at Memorial Sloan Kettering Cancer Center. He specializes in the treatment of patients with colorectal and other gastrointestinal cancers, as well as elderly patients who are undergoing surgery. He serves on the Scholar Advisory Committee of the Hartford Foundation, and he is a member of the Cancer and Aging Research Group and the Alliance Elderly Cancer Committee. Dr. Shahrokni's research focuses on the role of telemedicine to optimize the treatment of older patients with cancer and on improving collaboration among the multidisciplinary team in the treatment of these patients. He is currently leading a study investigating the rate of postoperative emergency room visits and hospital readmission in elderly patients with colorectal cancer.
For More Information
Shahrokni A, Tin AL, Sarraf S, et al (2020). Association of geriatric comanagement and 90-day postoperative mortality among patients aged 75 years and older with cancer. JAMA Netw Open. [Epub ahead of print] DOI:10.1001/jamanetworkopen.2020.9265Transcript edited for clarity. Any views expressed above are the speaker's own and do not necessarily reflect those of i3 Health.