Principles of surgical oncology in the elderly.
Elderly patients constitute the largest group in oncologic medical practice, despite the fact that in solid cancers treated operatively, many patients are denied standard therapies and where such decision making is based solely on age. The “natural” assumptions that we have are often misleading; namely, that the elderly cannot tolerate complex or difficult procedures, chemotherapy, or radiation schedules; that their overall predictable medical health determines survival (and not the malignancy); or that older patients typically have less aggressive tumors. Clearly, patient selection and a comprehensive geriatric assessment is key where well-selected cases have the same cancer-specific survival as younger cohorts in a range of tumors as outlined including upper and lower gastrointestinal malignancy, head and neck cancer, and breast cancer. The assessment of patient fitness for surgery and adjuvant therapies is therefore critical to outcomes, where studies have clearly shown that fit older patients experience the same benefits and toxicities of chemotherapy as do younger patients and that when normalized for preexisting medical conditions,that older patients tolerate major operative procedures designed with curative oncological intent. At present, our problem is the lack of true evidence-based medicine specifically designed with age in mind, which effectively limits surgical decision making in disease-based strategies. This can only be achieved by the utilization of more standardized, comprehensive geriatric assessments to identify vulnerable older patients, aggressive pre-habilitation with amelioration of vulnerability causation, improvement of patient-centered longitudinal outcomes, and an improved surgical and medical understanding of relatively subtle decreases in organ functioning, social support mechanisms and impairments of health-related quality of life as a feature specifically of advanced age.
Department of Surgery and Transplantation, Chaim Sheba Medical Center, Tel-Aviv, Israel 52621. apzbar1355@yahoo.com
Andrew P
AP
Zbar
Aviad
A
Gravitz
Riccardo A
RA
Audisio
D000368:Aged; D000369:Aged, 80 and over; D000375:Aging; D003131:Combined Modality Therapy; D003657:Decision Making; D019317:Evidence-Based Medicine; D005260:Female; D015577:Geriatric Assessment / Q000379:methods*; D005853:Geriatrics; D006801:Humans; D008495:Medical Oncology; D009369:Neoplasms / Q000601:surgery*; D010347:Patient Care Planning