Age No Barrier to Preserved QoL, Functional Recovery After Surgery for CRC

Most older patients who had surgery for colorectal cancer (CRC) had functional recovery (FR) with preserved quality of life (QoL), a large prospective study showed.

Three-fourths of patients had functional recovery 3-6 months after surgery and 70% had equivalent or better QoL as compared with before surgery. The data revealed multiple risk factors associated with not achieving functional recovery and with worse QoL after surgery.

The findings should help inform decisions about surgical strategies for older patients with CRC, reported Flavia Foca, BStat, of the IRCCS Istituto Romagnolo per lo Studio dei Tumori “Dino Amadori” in Meldola, Italy, and co-authors in the Journal of Clinical Oncology.

“The GOSAFE shows that [a] majority of older patients can experience a restored QoL and FR 3 months after colorectal cancer surgery,” the authors concluded. “Those were much needed but previously unknown data about outcomes that truly matter to patients. Frailty screening tools, history of delirium, and postoperative complications correlate with worse QoL and FR. These items and their correlation with the restoration of QoL and function should guide the conversation about the possible surgical strategies.”

The findings can serve as a benchmark for surgeons and others who counsel older adults considering elective colorectal surgery, which would contribute toward a more holistic approach to surgical decision making, according to Anthony Loria, MD, and Fergal J. Fleming, MD, of the University of Rochester in New York, in an accompanying editorial.

They added that the study raised questions that require further exploration:

• Choice of preoperative screening instruments, proper group to screen, and the most efficacious interventions
• Standardization of the screening population with respect to age thresholds
• Additional therapeutic interventions (geriatric assessment, postoperative rehabilitation, etc.)

“This study provides valuable evidence-based information for patient counseling, but it also highlights the significance of stability in quality of life and functional recovery outcomes between 3 and 6 months,” Loria and Fleming stated. “[P]atients experiencing significant disruptions in quality of life … and functional recovery … at 3 months are unlikely to see spontaneous improvements by 6 months.”

“This study serves as a stepping stone toward shared decision making, patient-centered care, and development of pragmatic, comprehensive, and cost-effective strategies tailored to the unique needs of this patient population,” they added.

The surgical community only recently recognized that certain traditional oncologic outcomes (such as progression-free survival and disease-free survival) have limited value to older patients, for whom paramount objectives include surviving surgery, regaining independence, and having a satisfactory postoperative QoL, Foca and co-authors noted in their introduction. The GOSAFE study was specifically designed to examine and gain insights into the outcomes that matter most to patients in the real world.

As previously reported, the primary results of the GOSAFE population pertained to patients with different types of cancer. Foca and colleagues presented findings for the subgroup of patients with colon and rectal cancer. The primary outcome was restoration of QoL after surgery. Secondarily, they wanted to identify correlations between patient status and patient-reported outcomes and functional recovery.

The analysis involved 646 patients 70 or older who underwent elective major colorectal surgery. Patients underwent a frailty assessment prior to surgery and QoL outcomes (by the EQ-5D-3L instrument) were assessed at 3 and 6 months after surgery. Functional recovery was defined by a combination of an Activity of Daily Living score ≥5, Timed Up & Go test <20 seconds, and a MiniCog score >2.

Investigators had complete data for 625 patients who had a median age of 79. Surgery involved the colon in 435 cases and the rectum in 190. Three-fourths of the procedures were minimally invasive. At 3-6 months, 73% of the patients who had colon surgery attained equivalent or better QoL as compared with baseline, as did 60-64% of the patients who had surgery for rectal cancer. Overall, 69% of patients met the outcome at 3 months and 70% at 6 months.

Logistic regression analysis identified two factors that predicted worse QoL at 3 and 6 months colectomy: Flemish Triage Risk Screening Tool (fTRST) ≥2 (OR 1.68, P=0.034; OR 1.71, P=0.027) and postoperative complications (OR 2.03, P=0.008; OR 2.56, P=0.02). For patients with rectal cancer, worse QoL was associated with ECOG performance status ≥2 (OR 3.81, P=0.006).

The authors found that 78.6% of patients with colon cancer and 70.6% of those with rectal cancer met criteria for functional recovery. Factors associated with functional decline after colectomy were severe surgical complications (OR 10.32, P<0.001), palliative surgery (OR 4.11, P<0.001), and fTRST ≥2 (OR 2.71, P=0.003). The only factor significantly associated with functional decline after rectal surgery was ECOG score ≥2 (OR 4.61, P=0.009).