Abstract
Simple SummaryThe benefit of major cancer surgery among older patients may be limited, and it remains unclear how to optimally select suitable patients. By combining very simple geriatric (gait speed, and weight loss) and cancer parameters (cancer site and cancer extension), the pre-operative GRADE score > 8 was significantly associated with severe post-operative complications, and overall post-operative mortality among older patients with digestive or non-breast gynaecological cancer undergoing surgery. At the time of the first consultation, the GRADE score could help surgeons to choose the most suitable treatment strategy, avoiding under- or over-treatment, especially when a geriatric assessment is not available. We aimed to assess the prognostic value of the pre-operative GRADE score for long-term survival among older adults undergoing major surgery for digestive or non-breast gynaecological cancers. Between 2013 and 2019, 136 consecutive older adults with cancer were prospectively recruited from the PF-EC cohort study before major cancer surgery and underwent a geriatric assessment. The GRADE score includes weight loss, gait speed at the threshold of 0.8 m/s, cancer site and cancer extension. The primary outcome was post-operative 5-year mortality. Patients were classified as low risk (GRADE ≤ 8) or high risk (GRADE > 8) on the basis of the median score. A Cox multivariate proportional hazards regression model was performed to assess the association between pre-operative factors and 5-year mortality expressed by adjusted hazard ratio (aHR) and 95% CI. The median age was 80 years, 52% were men, 73% had colorectal cancer. The 30-day post-operative severe complication rate (Clavien-Dindo ≥ 3) was 37%. The 5-year post-operative mortality rate was 34.5%. A GRADE score ≥ 8 (aHR = 2.64 [1.34–5.21], p = 0.0002) was associated with post-operative mortality after adjustment for Body Mass Index < 21 kg/m2 and Instrumental Activities of Daily Living <3/4. By combining very simple geriatric and cancer parameters, the pre-operative GRADE score provides a discriminant prognosis and could help to choose the most suitable treatment strategy for older cancer patients, avoiding under or over-treatment.
Highlights
With the aging of populations worldwide, the number of older people with cancer is increasing [1], challenging daily surgical practice
By 31 August 2019, 136 consecutive patients aged 65 and over with digestive or nonbreast gynecological cancer who were referred for Geriatric Assessment (GA) had been selected for major cancer surgery and were prospectively included in this study
This is the main strength of this score, since it does not require a geriatric assessment and it could be of great help to surgeons in the decision whether or not to perform cancer surgery among older adults, especially when a GA is not available
Summary
With the aging of populations worldwide, the number of older people with cancer is increasing [1], challenging daily surgical practice. The main challenge is to select the optimal treatment tailored to patient heterogeneity in terms of social environment, levels of dependency, comorbidities, nutrition, mobility, cognitive and mood status, all liable to lead to post-operative complications and shorter survival [10]. We developed and validated a simple and easy prognostic score (the GRADE score: https://grade.shinyapps.io/dynnomapp/) (accessed on 7 November 2021) to assist therapeutic decisions for older patients with cancer [14]. This score takes into account two geriatric parameters (weight loss and gait speed) and two cancer parameters (cancer site and extension), and predicts short-term mortality (i.e., ≤6 months). We hypothesized that the GRADE score could help decide whether or not to undertake radical cancer surgery in older patients
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