Study Highlights Gaps in Supportive Care for Older Patients With Cancer Undergoing Surgery

Older patients with cancer who undergo surgery experience moderate-to-severe symptoms, highlighting the need to address potential gaps in supportive care, according to data presented at the Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care.

“Older Adults are expected to account for a large majority of new cancer diagnoses over the next 10 years. Because of advances in patient selection in perioperative management demand-driven therapies, older adults are increasingly likely to have cancer surgery,” Jesse Zuckerman, MDCM, from the University of Toronto, Toronto, explained during a presentation at the virtual meeting, adding that it has become evident that many older adults place a higher importance on post-operative outcomes, such as functional independence or quality-of-life, compared with short-term outcomes, such as morbidity and mortality.

“Understanding [older adults’] symptom burden after cancer surgery is, therefore, necessary for patient-centered preoperative decision-making, counseling, and expectation management,” he added. “This information, however, is lacking.”

Therefore, the investigators conducted a population-level study of 48,748 patients aged 70 years or older with a new diagnosis of a solid malignancy who underwent surgery between January 1, 2007 to December 31, 2017, to determine symptom trajectories and factors associated with high symptom burden after cancer surgery in older adults.

The investigators collected data prospectively from Edmonton Symptom Assessment System (ESAS) scores to calculate the monthly prevalence of moderate-to-severe symptoms (ESAS >4) for anxiety, depression, drowsiness, lack of appetite, nausea, pain, shortness of breath, tiredness, and poor well-being over 1 year after surgery. Symptoms were analyzed 90 days prior to surgery and 180 days after surgery.

Twenty-eight percent of patients were 80 years or older, 64% were female, 54% underwent a high surgical intensity procedure, and 51% of patients underwent adjuvant therapy.

Of the 234,420 ESAS recorded over 1 year after surgery, moderate-to-severe tiredness (57.8%), poor well-being (51.9%), and lack of appetite (39.3%) were the most common symptoms reported.

However, of note, the investigators reported that the proportion of patients with moderate-to-severe symptoms was stable over the first year after surgery, with <5% variation for each symptom, meaning surgery neither improved nor worsened patients’ cancer symptoms.

“However, these trajectories may be influenced by common, yet less intense, procedures such as breast and prostate resections,” Zuckerman said.

Therefore, the investigators also examined patients who underwent higher intensity procedures. Although similar patterns were observed for all procedures, those who underwent high-intensity procedures for lung and upper gastrointestinal/hepato-pancreato-biliary resections showed an initial rise in symptoms 1 month after surgery. However, these symptoms were resolved by 3 months after surgery.

Moreover, symptoms like tiredness, drowsiness, and nausea increased when coinciding with median time to first adjuvant treatment (64 days; IQR 48-87) compared with patients who underwent surgery only. However, the investigators noted this was not statistically significant (<5% change) and resolved by the end of adjuvant therapy.

Lastly, the investigators found that older age, female sex (increase from 0% to 38%), lower socioeconomic status, frailty (increase from 15% to 37%), high comorbidities (increase from 24% to 52%), receipt of adjuvant chemotherapy within 2 weeks (increase from 0% to 101%), and high-intensity surgery (increase from 24% to 75%) were associated with higher risk of moderate-to-severe symptoms among older adults who underwent surgery. Living in a rural area was the only factor that was associated with a lower risk of moderate-to-severe symptom burden (decrease from 26% to 0%).

“These findings are encouraging as neither surgery nor adjuvant therapies lead to important symptom worsening, even among patients who required high intensity surgery and experienced higher initial symptom burden. Their trajectory stabilized in the long-term, suggesting either that surgery and adjuvant therapies do not significantly increase older adults’ experience of symptoms, or that current support mechanisms are effective in getting patients back to their perceived baseline,” Zuckerman said.

However, he added, patients are still experiencing a certain level of moderate-to-severe symptoms for up to a year after surgery, “highlighting potential gaps in supportive care for older adults after surgery. We should therefore aim to effectively lessen this remaining symptom burden by identifying preoperative factors associated with significant symptom burden. We can identify those groups of older adults and have routine symptom assessment and better targeted longitudinal support systems and more effectively improve their quality of life after cancer treatment.”

Reference:

Zuckerman J. Patient-Reported Symptom Burden After Cancer Surgery in Older Adults: A Population-Level Analysis. Presented at: Society of Surgical Oncology 2021 International Conference on Surgical Cancer Care; March 18-19, 2021; Virtual. Abstract 74.