Surgical Care for Older Adults: The Importance of Patient-Centered Outcomes in Daily Practice

The population is aging, new cancer diagnoses are rising, and older adults are increasingly undergoing major cancer surgery (1). Frailty assessment is an important area for perioperative risk stratification in older adults. Frailty is associated with poor outcomes across most surgical specialties and is also potentially modifiable in the preoperative phase of care through prehabilitation programs, for example (2-4). Many surgical outcomes studies in older adults focus on traditional outcomes of perioperative morbidity and mortality; however, far fewer focus on patient-centered outcomes, such as discharge destination, functional status, or psychosocial well-being. Additionally, the emphasis is often on immediate 30-day postoperative outcomes, and it is important to note that longer-term outcomes are needed, as older adults are typically not undergoing major cancer surgery to increase their longevity by a mere 30 days. Thus, studies examining outcomes beyond 30 days are imperative to our understanding of frailty syndromes in older adults, especially those undergoing cancer surgery. In this issue of the Journal, Montroni and colleagues (5) report a study on an international prospective cohort of older adults undergoing major cancer surgery, aptly named the Geriatric Oncology Surgical Assessment and Functional rEcovery (GOSAFE) study. Frailty assessment was performed preoperatively using multiple screening tools, and there was a focus on patient-centered outcomes, such as quality of life and functional recovery. In this study, quality of life and functional recovery were assessed using the EQ-5D-3L metric preoperatively and then again at 3 and 6 months postoperatively. The EQ-5D-3L instrument includes the domains of mobility, self-care, usual activities, pain and/or discomfort, and anxiety and/or depression. The authors found that outcomes were not preserved at the 3-month mark but were, in fact, improved at the 6-month mark. A closer look at the data reveals that the improvements seen at the 6-month mark were primarily in the outcomes of pain and/or discomfort and depression and/or anxiety, whereas mobility, self-care, and ability to perform usual activities were worse than baseline. These findings suggest that outcomes should be reassessed multiple times throughout an older adult patient’s perioperative course and not solely in the immediate postoperative phase of care. Despite these mixed findings, the results of the GOSAFE study are clinically significant and have large implications when placed into context with preexisting literature. The GOSAFE study found associations between decreased postoperative quality of life and worse scores on the Flemish Version of the Triage Risk Screening Tool and Geriatric 8 Health Screening Tool, both of which include a measure of mood and depression. Likewise, a previous study by Tang et al. (6) revealed that cognitive and psychological factors, including depression, were statistically significantly associated with postoperative mortality in older adults. Similarly, a study by Blumenthal et al. (7) found a statistically significant association with mortality in patients with depression undergoing cardiac surgery. The results of each of these studies suggest that preoperative assessment of an older adult’s fitness for elective surgery should require more than just cardiopulmonary risk stratification and include evaluation of cognition, functional status, and mental health. This work by Montroni et al. (5) also underscores the necessity of in-depth discussions with older adults and their families, prior to surgery, regarding their goals of care and the impact of surgery on patient-centered outcomes such as quality of life and living location. The possibility of discharge to a nursing facility, which has been omitted from this study as a potential outcome, is a crucial patient-centered outcome measure of the utmost importance to older adults (8). The potential for discharge to a nursing facility should be part of preoperative informed consent discussions, as loss of independence not only is common in older adults after surgery but also has been found to be associated with postoperative readmissions and mortality (9). Although the current study is a remarkable foundation for integrating the study of patient-centered outcomes with respect to preoperative frailty in older adult cancer patients, future work should include expanded patient populations, as colorectal surgery patients accounted for nearly two-thirds of the cohort in this study. Areas of focus for future studies may include lung, breast, and prostate cancer operations, given their prevalence in older adults as the most common cancers. Additionally, studying these disease processes will also allow for the evaluation of cancer surgeries that span the inpatient and outpatient domains of surgical care (10). Studies examining the association of frailty with patient-centered and real-world perioperative outcomes, like this one, continue to emphasize the importance of, and need for, multidisciplinary care for older adults undergoing surgery. The American College of Surgeons (ACS) has recognized the relevance of perioperative multidisciplinary care for older adults and launched the Geriatric Surgery Verification (GSV) Program in 2019. The GSV program includes 32 standards that focus on goals of care, shared decision making, preoperative assessment of geriatric vulnerabilities, interdisciplinary care, and standardized postoperative care to prevent delirium, maintain function, and optimize nutrition (11). These GSV-verified centers serve as models of optimal care for older adults undergoing surgery. Furthermore, the ACS has added geriatric-specific predictor and outcome measures to their publicly available National Surgical Quality Improvement Program risk calculator. Examples of geriatric-specific predictors include impaired cognition, surrogate signed consent, and history of falls, and the geriatric-specific outcomes include postoperative delirium, functional decline, mobility aid use, development of pressure ulcers, and discharge to facility, which is already included as an outcome for all patients regardless of age (12,13). This publicly available resource allows clinicians to counsel older adult patients and their families accurately about anticipated geriatric-specific outcomes, even if their facility is not verified by the ACS GSV Program. The advent of the ACS GSV Program and evolution of the ACS National Surgical Quality Improvement Program risk calculator to include geriatric-specific predictors and outcomes represent true advancements that impact and improve the care of older adults on a daily basis. Research focused on long-term patient-centered outcomes for older adults undergoing surgery will continue to improve personalized care across surgical specialties. Future work must focus on diverse older adult populations across a wide range of inpatient and outpatient operations. Furthermore, frailty metrics and outcomes assessments (including both clinical and quality-of-life outcomes) must be developed such that they can be easily applied across patient populations and multiple time points without bias. Finally, providers caring for older adults undergoing surgery should aim to include routine assessment of frailty and counseling on patient-centered outcomes in their daily practice. No funding was used for this editorial. Role of the funder: Not applicable. Disclosures: GS has no disclosures. MR has the following disclosures: Consultant—American College of Surgeons; Consultant—Healthgrades. Author contributions: GAS: conceptualization, writing—original draft, writing—review & editing. MMR: conceptualization, supervision, writing—original draft, writing—review & editing. Acknowledgements: Dr. Salzman was supported by the VA Office of Academic Affiliations through the National Clinician Scholars Program. No new data were generated or analyzed in support of this editorial.