Marguerite Palisoul, MD

As the proportion of the elderly in the US population continues to increase, with life expectancy trending upward, we can expect to see more gynecologic cancers in our patients.^1,2 At present, the most effective approach to these cancers commonly includes aggressive surgical resection with chemotherapy and, in some cases, radiation. It remains unclear whether elderly patients should be managed the same as younger patients, with minimal data to guide physicians. Some evidence suggests an increased risk of surgical complications in 
older adults.³

To optimize surgical care in our elderly patients, we need to understand the risks of perioperative mortality and morbidity in this population. For example, the current standard of care for advanced epithelial ovarian cancer is aggressive cytoreductive surgery followed by adjuvant chemotherapy,⁴ although neoadjuvant chemotherapy is gaining utility and popularity in certain circumstances. During pretreatment counseling, it is imperative that we communicate patient-specific outcomes so that patients and their families can make educated decisions in line with their goals. What should we know about age-dependent outcomes when counseling our patients?

To optimize surgical care in this population, we also need to develop and use new methods of surgical decision making. Although some data suggest that age is an independent risk factor for postoperative complications, not all elderly patients are the same in terms of comorbidities and functional status. In order to truly assess risks, we need to identify additional preoperative risk factors. Are there accurate scoring tools or predictors of outcomes available to help us assess the risks of postoperative mortality and morbidity?

In this article, we highlight recent developments in surgical treatment of the elderly, focusing on:

• postoperative mortality and morbidity in patients older than 80 years
• adjuncts to preoperative assessment for oncogeriatric surgical patients.

Risks rise sharply in older patients undergoing treatment for ovarian Ca

Moore KN, Reid MS, Fong DN, et al. Ovarian cancer in the octogenarian: does the paradigm of aggressive cytoreductive surgery and chemotherapy still apply? 
Gynecol Oncol. 2008;110(2):133–139.

Mahdi H, Wiechert A, Lockhart D, Rose PG. Impact of age on 30-day mortality and morbidity in patients undergoing surgery for ovarian cancer. Int J Gynecol 
Cancer. 2015;25(7):1216–1223.

The cornerstone of optimal survival from certain gynecologic cancers, such as advanced ovarian cancer, is aggressive debulking surgery. However, older adults are classically under-represented in clinical trials that guide this standard of care.

To determine whether patients aged 80 years or older respond differently from younger patients to conventional ovarian cancer management, Moore and colleagues retrospectively reviewed their institutional experience. They found that postoperative mortality increased from 5.4% in patients aged 80 to 84 years to 9.1% in those aged 85 to 89 and 14.4% in those older than 90. The rates for younger patients were 0.6% for patients younger than 60 years, 2.8% for those aged 60 to 69 years, and 2.5% for those aged 70 to 
79 years (P<.001).

Notably, 13% of patients aged 80 years or older who underwent primary surgery died during their primary hospitalization. Of those who survived, 50% were discharged to skilled nursing facilities. Of patients who underwent cytoreductive surgery, 13% were unable to undergo any intended adjuvant therapy, and only 57% completed more than 3 cycles of chemotherapy, either due to demise or toxicities. Two-month survival for patients 80 years or older was comparable between patients who underwent primary surgery and those who had primary chemotherapy (20% and 26%, respectively).

With a similar objective, Mahdi and colleagues identified 2,087 patients with ovarian cancer who underwent surgery. After adjusting for confounders with multivariable analyses, they found that octogenarians whose initial management was surgery were 9 times more likely than younger patients to die and 70% more likely to develop complications within 30 days. Among patients who underwent neoadjuvant chemotherapy, there were no significant differences between older and younger patients in 30-day postoperative mortality or morbidity.

When evaluating elderly patients for surgery, the use of multiple risk-assessment strategies may improve accuracy

Huisman MG, Audisio RA, Ugolini G, et al. Screening for predictors of adverse outcome in onco-geriatric surgical patients: a multicenter prospective cohort study. Eur J Surg Oncol. 2015;41(7):844–851.

Uppal S, Igwe E, Rice L, Spencer R, Rose SL. Frailty index predicts severe complications in gynecologic oncology patients. Gynecol Oncol. 2015;137(1):98–101.

The National Comprehensive Cancer 
Network recommends that clinicians determine baseline life expectancy for older adults with cancer to aid in management decision making. The use of tools such as www.eprognosis.com, developed to determine anticipated life expectancy independent of cancer, can prove useful in determining a patient’s risk of dying or suffering from their cancer before dying of another cause.⁵

When it comes to the determination of risk related to a patient’s cancer diagnosis and selection of potential management options, many argue that the subgroup of elderly patients is not homogenous and that the use of age alone to guide management decisions may be unfair. Preoperative evaluation ideally should incorporate a global assessment of predictive risk factors.

Three assessment tools are 
especially useful

Huisman and colleagues set out to identify accurate preoperative assessment methods in elderly patients undergoing oncologic surgery. They prospectively recruited 328 patients aged 70 years or older and evaluated patients preoperatively using 11 well-known geriatric screening tools. They compared these evaluations with outcomes to determine which tools best predict the occurrence of major postoperative complications. They found the strongest correlation with outcomes when combining gender and type of surgery with the following 3 assessment tools:

• Timed Up and Go (TUG)—a walking test to measure functional status
• American Society of Anesthesiologists scale—a scoring system that quantifies preoperative physical status and estimates anesthetic risk
• Nutritional Risk Screening—an assessment of nutritional risk based on recent weight loss, overall condition, and reduction of food intake.

All 3 are simple and short screening tools. When used together, they can provide clinicians with accurate risk estimations.

The findings of Huisman and colleagues reinforce the importance of a global assessment of the patient’s comorbidities, functional status, and nutritional status when determining candidacy for oncologic surgery.

Functional index predicts need 
for postoperative ICU care 
and risk of death

Uppal and colleagues set out to quantify the predictive value of the modified Functional Index (mFI) in assessing the need for postoperative critical care support and/or the risk of death within 30 days after gynecologic cancer surgery. The mFI can be calculated by adding 1 point for each variable listed in the TABLE, with a score of 4 or higher representing a high-frailty cohort.

Of 6,551 patients who underwent gynecologic surgery, 188 were admitted to the intensive care unit (ICU) or died within 
30 days after surgery. The mFI was calculated, with multivariate analyses of additional variables. An mFI score of 3 or higher was predictive of the need for critical care support and the risk of 30-day mortality and was associated with a significantly higher number of complications (P<.001).

Predictors significant for postoperative critical care support or death were:

• preoperative albumin level less than 3 g/dL (odds ratio [OR] = 6.5)
• operative time (OR = 1.003 per minute of increase)
• nonlaparoscopic surgery (OR = 3.3)
• mFI score, with a score of 0 serving as the reference (OR for a score of 1 = 1.26; score of 2 = 1.9; score of 3 = 2.33; and score of 4 or higher = 12.5).

When they combined the mFI and albumin scores—both readily available in the preoperative setting—Uppal and colleagues were able to develop an algorithm to determine patients who were at “low risk” versus “high risk” for ICU admission and/or death postoperatively (FIGURE).

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Bottom line

Older patients are more commonly affected by multiple medical comorbidities, as well as functional, cognitive, and nutritional deficiencies, which contribute to their increased risk of morbidity and mortality after surgery. The elderly experience greater morbidity with noncardiac surgery in general.

Clearly, the decision to operate on an elderly patient should be approached with caution, and a critical assessment of the patient’s risk factors should be performed to inform counseling about the patient’s management options. Future randomized prospective data will help us better understand the relationship between age and surgical outcomes.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

As the proportion of the elderly in the US population continues to increase, with life expectancy trending upward, we can expect to see more gynecologic cancers in our patients.^1,2 At present, the most effective approach to these cancers commonly includes aggressive surgical resection with chemotherapy and, in some cases, radiation. It remains unclear whether elderly patients should be managed the same as younger patients, with minimal data to guide physicians. Some evidence suggests an increased risk of surgical complications in 
older adults.³

To optimize surgical care in our elderly patients, we need to understand the risks of perioperative mortality and morbidity in this population. For example, the current standard of care for advanced epithelial ovarian cancer is aggressive cytoreductive surgery followed by adjuvant chemotherapy,⁴ although neoadjuvant chemotherapy is gaining utility and popularity in certain circumstances. During pretreatment counseling, it is imperative that we communicate patient-specific outcomes so that patients and their families can make educated decisions in line with their goals. What should we know about age-dependent outcomes when counseling our patients?

To optimize surgical care in this population, we also need to develop and use new methods of surgical decision making. Although some data suggest that age is an independent risk factor for postoperative complications, not all elderly patients are the same in terms of comorbidities and functional status. In order to truly assess risks, we need to identify additional preoperative risk factors. Are there accurate scoring tools or predictors of outcomes available to help us assess the risks of postoperative mortality and morbidity?

In this article, we highlight recent developments in surgical treatment of the elderly, focusing on:

• postoperative mortality and morbidity in patients older than 80 years
• adjuncts to preoperative assessment for oncogeriatric surgical patients.

Risks rise sharply in older patients undergoing treatment for ovarian Ca

Moore KN, Reid MS, Fong DN, et al. Ovarian cancer in the octogenarian: does the paradigm of aggressive cytoreductive surgery and chemotherapy still apply? 
Gynecol Oncol. 2008;110(2):133–139.

Mahdi H, Wiechert A, Lockhart D, Rose PG. Impact of age on 30-day mortality and morbidity in patients undergoing surgery for ovarian cancer. Int J Gynecol 
Cancer. 2015;25(7):1216–1223.

The cornerstone of optimal survival from certain gynecologic cancers, such as advanced ovarian cancer, is aggressive debulking surgery. However, older adults are classically under-represented in clinical trials that guide this standard of care.

To determine whether patients aged 80 years or older respond differently from younger patients to conventional ovarian cancer management, Moore and colleagues retrospectively reviewed their institutional experience. They found that postoperative mortality increased from 5.4% in patients aged 80 to 84 years to 9.1% in those aged 85 to 89 and 14.4% in those older than 90. The rates for younger patients were 0.6% for patients younger than 60 years, 2.8% for those aged 60 to 69 years, and 2.5% for those aged 70 to 
79 years (P<.001).

Notably, 13% of patients aged 80 years or older who underwent primary surgery died during their primary hospitalization. Of those who survived, 50% were discharged to skilled nursing facilities. Of patients who underwent cytoreductive surgery, 13% were unable to undergo any intended adjuvant therapy, and only 57% completed more than 3 cycles of chemotherapy, either due to demise or toxicities. Two-month survival for patients 80 years or older was comparable between patients who underwent primary surgery and those who had primary chemotherapy (20% and 26%, respectively).

With a similar objective, Mahdi and colleagues identified 2,087 patients with ovarian cancer who underwent surgery. After adjusting for confounders with multivariable analyses, they found that octogenarians whose initial management was surgery were 9 times more likely than younger patients to die and 70% more likely to develop complications within 30 days. Among patients who underwent neoadjuvant chemotherapy, there were no significant differences between older and younger patients in 30-day postoperative mortality or morbidity.

When evaluating elderly patients for surgery, the use of multiple risk-assessment strategies may improve accuracy

Huisman MG, Audisio RA, Ugolini G, et al. Screening for predictors of adverse outcome in onco-geriatric surgical patients: a multicenter prospective cohort study. Eur J Surg Oncol. 2015;41(7):844–851.

Uppal S, Igwe E, Rice L, Spencer R, Rose SL. Frailty index predicts severe complications in gynecologic oncology patients. Gynecol Oncol. 2015;137(1):98–101.

The National Comprehensive Cancer 
Network recommends that clinicians determine baseline life expectancy for older adults with cancer to aid in management decision making. The use of tools such as www.eprognosis.com, developed to determine anticipated life expectancy independent of cancer, can prove useful in determining a patient’s risk of dying or suffering from their cancer before dying of another cause.⁵

When it comes to the determination of risk related to a patient’s cancer diagnosis and selection of potential management options, many argue that the subgroup of elderly patients is not homogenous and that the use of age alone to guide management decisions may be unfair. Preoperative evaluation ideally should incorporate a global assessment of predictive risk factors.

Three assessment tools are 
especially useful

Huisman and colleagues set out to identify accurate preoperative assessment methods in elderly patients undergoing oncologic surgery. They prospectively recruited 328 patients aged 70 years or older and evaluated patients preoperatively using 11 well-known geriatric screening tools. They compared these evaluations with outcomes to determine which tools best predict the occurrence of major postoperative complications. They found the strongest correlation with outcomes when combining gender and type of surgery with the following 3 assessment tools:

• Timed Up and Go (TUG)—a walking test to measure functional status
• American Society of Anesthesiologists scale—a scoring system that quantifies preoperative physical status and estimates anesthetic risk
• Nutritional Risk Screening—an assessment of nutritional risk based on recent weight loss, overall condition, and reduction of food intake.

All 3 are simple and short screening tools. When used together, they can provide clinicians with accurate risk estimations.

The findings of Huisman and colleagues reinforce the importance of a global assessment of the patient’s comorbidities, functional status, and nutritional status when determining candidacy for oncologic surgery.

Functional index predicts need 
for postoperative ICU care 
and risk of death

Uppal and colleagues set out to quantify the predictive value of the modified Functional Index (mFI) in assessing the need for postoperative critical care support and/or the risk of death within 30 days after gynecologic cancer surgery. The mFI can be calculated by adding 1 point for each variable listed in the TABLE, with a score of 4 or higher representing a high-frailty cohort.

Of 6,551 patients who underwent gynecologic surgery, 188 were admitted to the intensive care unit (ICU) or died within 
30 days after surgery. The mFI was calculated, with multivariate analyses of additional variables. An mFI score of 3 or higher was predictive of the need for critical care support and the risk of 30-day mortality and was associated with a significantly higher number of complications (P<.001).

Predictors significant for postoperative critical care support or death were:

• preoperative albumin level less than 3 g/dL (odds ratio [OR] = 6.5)
• operative time (OR = 1.003 per minute of increase)
• nonlaparoscopic surgery (OR = 3.3)
• mFI score, with a score of 0 serving as the reference (OR for a score of 1 = 1.26; score of 2 = 1.9; score of 3 = 2.33; and score of 4 or higher = 12.5).

When they combined the mFI and albumin scores—both readily available in the preoperative setting—Uppal and colleagues were able to develop an algorithm to determine patients who were at “low risk” versus “high risk” for ICU admission and/or death postoperatively (FIGURE).

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and modified Functional Index","field_file_image_credit[und][0][value]":"6"},"type":"media","attributes":{"height":"316","width":"665","class":"media-element file-medstat-image-full-text"}}]]
Bottom line

Older patients are more commonly affected by multiple medical comorbidities, as well as functional, cognitive, and nutritional deficiencies, which contribute to their increased risk of morbidity and mortality after surgery. The elderly experience greater morbidity with noncardiac surgery in general.

Clearly, the decision to operate on an elderly patient should be approached with caution, and a critical assessment of the patient’s risk factors should be performed to inform counseling about the patient’s management options. Future randomized prospective data will help us better understand the relationship between age and surgical outcomes.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

As the proportion of the elderly in the US population continues to increase, with life expectancy trending upward, we can expect to see more gynecologic cancers in our patients.^1,2 At present, the most effective approach to these cancers commonly includes aggressive surgical resection with chemotherapy and, in some cases, radiation. It remains unclear whether elderly patients should be managed the same as younger patients, with minimal data to guide physicians. Some evidence suggests an increased risk of surgical complications in 
older adults.³

To optimize surgical care in our elderly patients, we need to understand the risks of perioperative mortality and morbidity in this population. For example, the current standard of care for advanced epithelial ovarian cancer is aggressive cytoreductive surgery followed by adjuvant chemotherapy,⁴ although neoadjuvant chemotherapy is gaining utility and popularity in certain circumstances. During pretreatment counseling, it is imperative that we communicate patient-specific outcomes so that patients and their families can make educated decisions in line with their goals. What should we know about age-dependent outcomes when counseling our patients?

To optimize surgical care in this population, we also need to develop and use new methods of surgical decision making. Although some data suggest that age is an independent risk factor for postoperative complications, not all elderly patients are the same in terms of comorbidities and functional status. In order to truly assess risks, we need to identify additional preoperative risk factors. Are there accurate scoring tools or predictors of outcomes available to help us assess the risks of postoperative mortality and morbidity?

In this article, we highlight recent developments in surgical treatment of the elderly, focusing on:

• postoperative mortality and morbidity in patients older than 80 years
• adjuncts to preoperative assessment for oncogeriatric surgical patients.

Risks rise sharply in older patients undergoing treatment for ovarian Ca

Moore KN, Reid MS, Fong DN, et al. Ovarian cancer in the octogenarian: does the paradigm of aggressive cytoreductive surgery and chemotherapy still apply? 
Gynecol Oncol. 2008;110(2):133–139.

Mahdi H, Wiechert A, Lockhart D, Rose PG. Impact of age on 30-day mortality and morbidity in patients undergoing surgery for ovarian cancer. Int J Gynecol 
Cancer. 2015;25(7):1216–1223.

The cornerstone of optimal survival from certain gynecologic cancers, such as advanced ovarian cancer, is aggressive debulking surgery. However, older adults are classically under-represented in clinical trials that guide this standard of care.

To determine whether patients aged 80 years or older respond differently from younger patients to conventional ovarian cancer management, Moore and colleagues retrospectively reviewed their institutional experience. They found that postoperative mortality increased from 5.4% in patients aged 80 to 84 years to 9.1% in those aged 85 to 89 and 14.4% in those older than 90. The rates for younger patients were 0.6% for patients younger than 60 years, 2.8% for those aged 60 to 69 years, and 2.5% for those aged 70 to 
79 years (P<.001).

Notably, 13% of patients aged 80 years or older who underwent primary surgery died during their primary hospitalization. Of those who survived, 50% were discharged to skilled nursing facilities. Of patients who underwent cytoreductive surgery, 13% were unable to undergo any intended adjuvant therapy, and only 57% completed more than 3 cycles of chemotherapy, either due to demise or toxicities. Two-month survival for patients 80 years or older was comparable between patients who underwent primary surgery and those who had primary chemotherapy (20% and 26%, respectively).

With a similar objective, Mahdi and colleagues identified 2,087 patients with ovarian cancer who underwent surgery. After adjusting for confounders with multivariable analyses, they found that octogenarians whose initial management was surgery were 9 times more likely than younger patients to die and 70% more likely to develop complications within 30 days. Among patients who underwent neoadjuvant chemotherapy, there were no significant differences between older and younger patients in 30-day postoperative mortality or morbidity.

When evaluating elderly patients for surgery, the use of multiple risk-assessment strategies may improve accuracy

Huisman MG, Audisio RA, Ugolini G, et al. Screening for predictors of adverse outcome in onco-geriatric surgical patients: a multicenter prospective cohort study. Eur J Surg Oncol. 2015;41(7):844–851.

Uppal S, Igwe E, Rice L, Spencer R, Rose SL. Frailty index predicts severe complications in gynecologic oncology patients. Gynecol Oncol. 2015;137(1):98–101.

The National Comprehensive Cancer 
Network recommends that clinicians determine baseline life expectancy for older adults with cancer to aid in management decision making. The use of tools such as www.eprognosis.com, developed to determine anticipated life expectancy independent of cancer, can prove useful in determining a patient’s risk of dying or suffering from their cancer before dying of another cause.⁵

When it comes to the determination of risk related to a patient’s cancer diagnosis and selection of potential management options, many argue that the subgroup of elderly patients is not homogenous and that the use of age alone to guide management decisions may be unfair. Preoperative evaluation ideally should incorporate a global assessment of predictive risk factors.

Three assessment tools are 
especially useful

Huisman and colleagues set out to identify accurate preoperative assessment methods in elderly patients undergoing oncologic surgery. They prospectively recruited 328 patients aged 70 years or older and evaluated patients preoperatively using 11 well-known geriatric screening tools. They compared these evaluations with outcomes to determine which tools best predict the occurrence of major postoperative complications. They found the strongest correlation with outcomes when combining gender and type of surgery with the following 3 assessment tools:

• Timed Up and Go (TUG)—a walking test to measure functional status
• American Society of Anesthesiologists scale—a scoring system that quantifies preoperative physical status and estimates anesthetic risk
• Nutritional Risk Screening—an assessment of nutritional risk based on recent weight loss, overall condition, and reduction of food intake.

All 3 are simple and short screening tools. When used together, they can provide clinicians with accurate risk estimations.

The findings of Huisman and colleagues reinforce the importance of a global assessment of the patient’s comorbidities, functional status, and nutritional status when determining candidacy for oncologic surgery.

Functional index predicts need 
for postoperative ICU care 
and risk of death

Uppal and colleagues set out to quantify the predictive value of the modified Functional Index (mFI) in assessing the need for postoperative critical care support and/or the risk of death within 30 days after gynecologic cancer surgery. The mFI can be calculated by adding 1 point for each variable listed in the TABLE, with a score of 4 or higher representing a high-frailty cohort.

Of 6,551 patients who underwent gynecologic surgery, 188 were admitted to the intensive care unit (ICU) or died within 
30 days after surgery. The mFI was calculated, with multivariate analyses of additional variables. An mFI score of 3 or higher was predictive of the need for critical care support and the risk of 30-day mortality and was associated with a significantly higher number of complications (P<.001).

Predictors significant for postoperative critical care support or death were:

• preoperative albumin level less than 3 g/dL (odds ratio [OR] = 6.5)
• operative time (OR = 1.003 per minute of increase)
• nonlaparoscopic surgery (OR = 3.3)
• mFI score, with a score of 0 serving as the reference (OR for a score of 1 = 1.26; score of 2 = 1.9; score of 3 = 2.33; and score of 4 or higher = 12.5).

When they combined the mFI and albumin scores—both readily available in the preoperative setting—Uppal and colleagues were able to develop an algorithm to determine patients who were at “low risk” versus “high risk” for ICU admission and/or death postoperatively (FIGURE).

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and modified Functional Index","field_file_image_credit[und][0][value]":"6"},"type":"media","attributes":{"height":"316","width":"665","class":"media-element file-medstat-image-full-text"}}]]
Bottom line

Older patients are more commonly affected by multiple medical comorbidities, as well as functional, cognitive, and nutritional deficiencies, which contribute to their increased risk of morbidity and mortality after surgery. The elderly experience greater morbidity with noncardiac surgery in general.

Clearly, the decision to operate on an elderly patient should be approached with caution, and a critical assessment of the patient’s risk factors should be performed to inform counseling about the patient’s management options. Future randomized prospective data will help us better understand the relationship between age and surgical outcomes.

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.