Elderly patients undergoing colorectal cancer surgery : can care be further improved?

Introduction: Colorectal cancer (CRC) is one of the most common malignancies affecting approximately 6 400 new patients/year in Sweden of which 44% are 75 years and older at diagnosis. In order to identify potential predictors for surgical outcome and areas of improvement, this thesis aims to illuminate different aspects in the care of patients aged 75 years and older, undergoing CRC surgery.

Methods: The studies in this thesis make use of a wide range of methods such as epidemiological methods: register based in study I and II, and prospective observational cohort study (IV). Qualitative methods with inductive content analysis were used in study III.

Aims and Results: Study I investigated the characteristics of elderly colon cancer patients and how they are managed and treated compared to their younger counterparts when undergoing resection. Elderly patients were less often completely staged, and less often evaluated at a multidisciplinary team conference (MDT) prior to surgery. Furthermore, fewer elderly patients underwent curative resection and were more often subjected to emergency surgery. Study II investigated if there is an association in elderly CRC patients between use of potentially inappropriate medication (PIM) at the time of surgery, and postoperative mortality and length of hospital stay (LOS). Results showed a significant association between use of PIM and increased postoperative mortality and LOS. Study III investigated elderly CRC patients’ experience of healthcare and the information given pre-, peri- and postoperatively. The results showed that feelings of vulnerability, uncertainty, disappointment, loss of control, and exposure were evident during the various phases of surgical care. This was the result of poor information about their cancer and planned treatment, potential impact on daily life and independency, as well as a negative perception of the hospital environment, need for support, and worries about the future. Rehabilitation was perceived as lacking individualisation, and persistent difficulties in regaining appetite and nutritional status prevented a quick recovery. Perception of unclear division of responsibility between care providers was evident after discharge. Study IV investigated if geriatric risk factors identified by a comprehensive geriatric assessment (CGA) performed preoperatively could predict postoperative complications and LOS in elderly patients undergoing CRC surgery. Although no association was seen between the results of individual instruments used in the CGA and postoperative outcome, it was observed that elderly patients tolerated surgery well, and in general regained their preoperative functional status during the follow-up period.

Conclusions: Elderly patients are capable of recovering well from elective surgery but there are several areas for improvement. The results revealed age-dependent differences in the surgical care of CRC patients, to the disadvantage of older patients. PIM is associated with worsened outcome and elderly patients perceive the care and information received as lacking individual adaptations. We therefore believe that elderly patients could benefit from a thorough geriatric assessment prior to surgery in order to identify risk patients and adapt and improve peri-operative care in elderly CRC patients.

List of scientific papers

I. Egenvall M., Schubert Samuelsson K., Klarin I., Lökk J., Sjövall A., Martling, A., Gunnarsson U. Management of colon cancer in the elderly: a population-based study. Colorectal Dis. 2014 Jun;16(6):433-41.
https://doi.org/10.1111/codi.12575

II. Schubert Samuelsson K., Egenvall M., Klarin I., Lökk J., Gunnarsson U. Inappropriate drug use in elderly patients is associated with prolonged hospital stay and increased postoperative mortality after colorectal cancer surgery: a population-based study. Colorectal Dis. 2016 Feb;18(2):155-62.
https://doi.org/10.1111/codi.13077

III. Schubert Samuelsson K., Iwarzon M., Egenvall M., Klarin I., Lökk J., Gunnarsson U. Elderly peoples’ experiences of health care process and information when undergoing colorectal cancer surgery. [Submitted]

IV. Schubert Samuelsson K., Egenvall M., Klarin I., Lökk J., Gunnarsson U. Preoperative geriatric assessment and follow-up of patients 75 years and older undergoing colorectal cancer surgery. [Manuscript]