As more and more older adults face cancer, it’s important that oncologists study and understand how best to have conversations to help patients make decisions about treatment, says surgical oncologist and researcher Dr. Julie Hallet.
“The majority of cancer patients will be over the age of 70 in the next 10 years. That will be 75 per cent of all patients with cancer,” she says. “We need to make treatment decisions according to the needs and values of this aging population.”
Traditionally, these older adults haven’t been considered for aggressive surgery or treatment, Dr. Hallet says.
“But older adults are changing: they are more active and have a different lifestyle until an older age than in the past.”
Oncologists are becoming expected to offer more aggressive treatments, she says, but the decisions can be difficult and there’s often much more to consider: is the person frail? Are there co-morbidities and what are they? How will these impact surgical outcomes?
“There’s a lot of research into complications and death after treatment but we wanted to look at other functional outcomes that are important to older adults: independence, quality of life and staying out of the hospital.
“Using these measures, we hope to develop a guide for shared decision-making that reflects a patient’s wishes and values.”
In a new study published in JAMA Surgery, Dr. Hallet and her team looked at time in hospital for older adults after cancer surgery.
What did this research look at?
With grants from OICR and CIHR, the team looked at data from 82,037 adults over age 70 who underwent cancer surgery to examine days spent at home versus days in the hospital in the five years after surgery.
“Avoiding hospital stays is an important patient-centred outcome that shows the global burden that treatment may place on patients in the long-term” Dr. Hallet said.
What did you find?
The good news is that most older adults spent most of their time at home and very few days in the hospital in the few years after cancer surgery.
“Ninety-eight percent of people spent the majority of their time at home,” Dr. Hallet said.
“What this data allowed us to do is drill down to examine who typically spends more time in the hospital,” she explained. “The oldest adults who also had pre-operative frailty and material deprivation — difficultly accessing basic needs like food or heating — were most vulnerable to spending more time in hospital.”
What does this mean for patients and care providers?
This information can help care providers better set up supports after surgery, Dr. Hallet says.
“For the most vulnerable, we can provide counselling, set expectations for surgery and put systems in place — like homecare or more frequent follow up — that can help with reducing future ER visits and hospitalizations,” she explains.
And this information will also allow oncologists to better advise patients what to expect after surgery in an effort to help decision-making, she adds.
Any other key takeaways?
It’s really important that we don’t dismiss older people because they might have some complications, Dr. Hallet says. Quality of life is important and these measures are still high.
“Chronological age is not a reason to treat someone differently; their individual values are – that’s patient-centred care,” she adds.
What’s next on this research path?
The team will continue to look at other functional measures in this population: where do they live? Do they move to long-term care faster? Who uses home care services after surgery? How do the outcomes of minimally invasive versus open surgery differ?
“All of this population-based research is moving toward the goal of making a predictive tool for patients, families and clinicians. This tool would help guide decision-making by providing evidence-based predictions: So if you are an 83-year-old with pancreas cancer undergoing whipple surgery, what’s the predicted time at home or need for long-term care? It will be a tool to help informed decision making and preparation for surgery,” Dr. Hallet says. “With all of this information, patients can make better informed decisions and oncologists can honour each patient’s values. It can also help us determine where to put resources and allow for a better transition of care to improve longer-term outcomes.
“If someone doesn’t have all the information when they make a decision, they often regret it and that regret is actually associated with poorer outcomes,” Dr. Hallet says. “We want to make sure that everyone, including older adults, have all the information they need to make a decision that’s right for them and be supported accordingly.”
