Our study suggests that geriatric co-management is feasible and contributes to the reduction of postoperative morbimortality after CRC surgery within an ERAS program for frail older patients. Moreover, performing the CGA after G8 score screening and completion of geriatric interventions resulted in similar 90-day postoperative morbidity in frail older patients than in robust older patients. Our results are consistent with previous studies. CGA and geriatricians’ involvement in the perioperative care of older patients who underwent oncologic surgical treatment are becoming increasingly important to reduce post-operative morbi-mortality. This is a retrospective study based on a prospective cohort in which geriatric characteristics are prospectively recorded. This study was based on a monocentric cohort which allowed efficient co-management with full involvement of oncogeriatricians from the early stage of medical care and the surgical health care team. Considering that patients were consecutively included and that there were no exclusion criteria, this study can be considered as a real-life study.
Frailty increases post-operative morbi-mortality. This increased post-operative mortality in older patients has mainly been attributed to differences in early mortality.27 Early mortality might be mainly due to postoperative complications.8,28 Previous studies revealed that older patients with CRC who survive the first year after surgery may have the same overall cancer-related survival rates as younger patients. Correctly treating older patients is becoming increasingly challenging in an aging population, and geriatric co-management appears to be specifically interesting for elective surgery. The CGA allows the detection of frailty markers, which enables the implementation of appropriate measures to address each marker. This co-management benefits both frail and robust patients.
Geriatric co-management appears to improve postoperative outcomes in patients undergoing oncologic and non-oncologic surgery. Its benefits have been widely demonstrated in orthopedic surgery19,29 and, more recently, in vascular surgery,18,30 oncologic surgery,31,32 and in trauma centers30. This was the first study to report the 90-day surgical outcomes and 1-year oncologic outcomes following geriatric co-management. Our results revealed that pre-operative CGA after G8 score screening achieved similar outcomes for frail older patients than for robust older patients. These results are consistent with recent studies on geriatric co-management.31 In our study, the global post-operative morbidity in frail older patients was not only similar to that in robust older patients but similar, if not lower, than that in younger patients in the literature.10
A short-term consequence of reducing postoperative morbidity is shortening of the LOS. In our study, the LOS was only one day longer in the Frail Group than in the Robust Group (7 days vs 6 days), which is consistent with the literature.9,33 The LOS for older patients in the literature is still longer than that for younger patients (4–12 vs. 3.9–12 days).10
Frail Group patients were more often discharged to rehabilitation centers than robust older patients (34% vs. 8%). Although we expected the LOS of Frail Group patients to be longer, LOS was not correlated with the discharge mode. Considering discharge to rehabilitation centers only, the LOS for the Frail Group was shorter than that for the Robust Group (median 9 vs. 11 days). Compared with home discharge, the median LOS for the Robust Group was 5 days, whereas it was 7 days for the Frail Group. Rehabilitation was often indicated for the Frail Group patients during CGA, suggesting that performing CGA results in a reduced LOS for frail older patients anticipating rehabilitation. When rehabilitation was not recommended, home discharge was nevertheless optimized through nurse visits or social support and systematic telephonic follow-up at days 1, 7 and 30 after discharge.
To our knowledge, this is the first study to report the completion rates of geriatric interventions after CGA. We obtained very high completion rates; more than 80% of most of the recommended interventions were completed. We did not observe delirium syndrome or falls in the Frail Group despite the high risk of delirium and fall (85.1% and 72.5%, respectively). Moreover, delirium or falls were not observed in the Robust Group neither suggesting that the interventions benefited all patient; therefor, training of health care personnel and participation in perioperative protocols reduce frequent complications such as falls and delirium.
Additionally, CGA and support did not extend the median time from surgical consultation to surgery, as shown in a previous study.20 These results demonstrate that CGA and, more importantly, geriatric intervention completion are feasible before surgery. However, selection bias was present in our cohort as patient undergoing emergency and palliative surgeries were not included; however, this was a real-life consecutive cohort without exclusion criteria.
This is a retrospective study based on a prospective cohort in which geriatric characteristics are prospectively recorded. This study was based on a monocentric cohort which allowed efficient co-management with full involvement of oncogeriatricians from the early stage of medical care and the surgical health care team. Considering that patients were consecutively included and that there were no exclusion criteria, this study can be considered as a real-life study.
A limitation of this study is that the methodology did not allow for the assessment of the specific impact of CGA independently of the ERAS protocol. Another limitation is that the study was not designed as a randomized study. However, frailty has been identified as a post-operative complication risk increasing morbi-mortality.7,14,34 Moreover, CGA,35,36 the G8 score,15 and the ERAS protocol3 have been individually validated, and in this study, we evaluated the benefit of combining these tools. The strength of this study it was a real-world study that revealed that the completion rate of geriatric interventions is high globally.
An economic evaluation of this protocol could be interesting. On the one hand, geriatric assessment and corrective and preventative measures are time-consuming and represent additional costs. On the other hand, reducing LOS and avoiding post-operative complications represent a potential cost reduction. The costs associated with the geriatric perioperative unit have been evaluated for orthopedic surgery, and the results revealed a positive income statement regardless of emergency or standard procedures, even when paramedical staff was increased.37 The ERAS protocol appears cost-effective in the medium term as well. A study have shown that implementing an ERAS program is expensive; however, costs are offset by reduced postoperative resource utilization with an overall cost saving.38
When it comes to invasive treatment, older patients are more concerned about preserving their quality of life than their life expectancy. Consequently, a study to assess the quality of life and patient satisfaction following geriatric co-management might be of interest.
In conclusion, our results confirmed the benefit of geriatric co-management, involving G8 screening, CGA, and ERAS, for frail older patients undergoing surgery for CRC. Geriatric co-management appears to be specifically interesting for elective surgery. A prospective multicentric study is needed to validate our findings. Moreover, a randomized trial could be valuable; however, depriving frail patients of the ERAS protocol and geriatric care is likely to be unethical.