Can POPS (proactive care of older people undergoing surgery) solve “An Age Old Problem” in colorectal surgery?

Australia is aging, with over 16% of our current population ≥65 years; a percentage that will further increase over the coming years, resulting in a larger number of older patients with colorectal cancer (CRC).1, 2 Old age is associated with reduced patient functionality, increased frailty, increased post-operative complications, worsened quality of life and reduced independence.3, 4 The 2010 UK National Confidential Enquiry into Patient Outcome and Death coined the phrase “An Age Old Problem” to emphasize the need of multidisciplinary input for all patients ≥65 years undergoing surgery, in order to identify risk factors which clinicians can help optimize in the pre- and post-operative period.5 The proactive care of older people undergoing surgery (POPS) care model involves early multidisciplinary involvement of clinicians and relevant allied health personnel.6 As with ERAS (enhanced recovery after surgery), POPS bridges both pre-, peri and post-operative care. Pre-operative screening is performed via validated screening tools, such as the G8 Geriatric Screening Tool, to identify patients at risk of frailty who would benefit from a comprehensive geriatric assessment (CGA).2 CGA is a systematic assessment performed by geriatricians to assess patients' medical, psychosocial, and functional capabilities and therefore allow the formulation of a medical and drug optimization plan, including a discussion regarding goals of patient care.2 The Australian and New Zealand Society for Geriatric Medicine has recently advocated for this two-step approach of using validated tools for geriatric screening in all elderly cancer patients, followed by a CGA in patients identified who may likely benefit from optimization.7 This process would also provide an avenue for increased multidisciplinary shared decision making regarding the decision to proceed to surgery, and identify patients for which operative management may be a disservice or lead to a “futile” surgical outcome. Supervised pre-habilitation is a multi-faceted program aimed at improving patient functionality with exercise and resistance training, respiratory physiotherapy, optimisation of nutritional status by dieticians, and psychosocial support.6 Pre-habilitation as part of POPS can still be a useful adjunct to existing ERAS programs for elderly patients undergoing surgery, in particular with regards to surgical resilience, which is defined as the time to return to homeostasis after surgery.8 However, the literature in this domain can be difficult to analyse as much of this evidence is heterogenous, making data challenging to summarize and interpret. In particular, pre-habilitation can involve several different forms of exercise and nutritional optimisation programs and utilize a range of different outcome assessments.9 Recent randomized prospective studies, such as the GEPOC trial (geriatric assessment and intervention in older vulnerable patients undergoing surgery for colorectal cancer) are currently recruiting to further elucidate on this topic.2 Peri- and post-operative POPS involves a geriatric liaison team providing direct patient care in terms of fluid management, treatment of any medical complications and organization of discharge planning. Ongoing outpatient clinic reviews and CGAs would be offered to patients as required.6 Analysis of the National Emergency Laparotomy Audit (NELA) data for example has found that post-operative CGA for elderly patients is associated with a reduction in 30 day mortality.10 However, the implementation of a POPS program is still challenging due to several reasons. For emergency patients, and many elective patients being offered upfront semi-elective surgery, there is insufficient time to undertake clinically meaningful pre-habilitation programs. CRC patients undergoing joint oncological and surgical therapy (such as Total Neoadjuvant Therapy) may therefore be ideal candidates for pre-habilitation. These exercise programs also need to be supervised to ensure patient compliance. To avoid further burdening the hospital system, telehealth sessions have been used, where there is promising evidence that these are effective at ensuring patient engagement.11 The provision of a dedicated and readily accessible multidisciplinary team will require both expertise and extra funding in order to provide a comprehensive POPS service. Although it has been shown to decrease overall costs in overseas health systems,12 given the current resource constraints on our health networks, cost–benefit analyses on a POPS model for CRC patients will need to be performed before widespread adoption in Australia is possible. Whilst questions remain regarding widespread implementation of a POPS care model for elderly patients undergoing CRC surgery, there is promising evidence in the literature for such a program, and similar programs are already being utilized for other surgical specialties, in particular orthopedic surgery. With the expected rise in this patient demographic, now may be the time to adopt a POPS to address the “Age Old Problem”. Open access publishing facilitated by The University of Melbourne, as part of the Wiley - The University of Melbourne agreement via the Council of Australian University Librarians. Matthew Yuan-Kun Wei: Writing – original draft; writing – review and editing. Alex Besson: Writing – review and editing. Gordana Popovska: Writing – review and editing. Justin Yeung: Conceptualization; supervision; writing – original draft; writing – review and editing.