Nora Kovar, MD, MPH; and Melissa L. Teply, MD, give their perspective on research from Quirin Zangl, MD, published in ONCOLOGY regarding geriatric assessment in patients with genitourinary carcinoma.
The authors in the accompanying article employ function-based geriatric assessment in the pre- and postoperative evaluation of older adults. Traditionally, “preoperative risk assessment” refers to cardiac, pulmonary, or infectious risk, with mortality (for good reason) as the primary measure of surgical outcome. In geriatric patients, this approach often misses important aspects of the patient’s condition (eg, functional dependence) that are relevant not only for care teams as they make treatment plans but also for patients as they anticipate what their course of treatment might look like. Ongoing emphasis on more comprehensive assessment—including functional status—will help to refine the evaluation of geriatric patients across disciplines and could improve conversations with patients and families regarding their care.
For both patients and their families, good recovery is closely linked with function. In studies from various surgical disciplines, poor postoperative functional status has been associated with lower quality-of-life scores1 for patients, as well as increased burden for their caregivers.2 Functional recovery also has important implications from a systems-based perspective, because postoperative functional deficits have also been associated with increased healthcare utilization and costs.3
In recent years, geriatric assessment that is more comprehensive in scope has gained attention as part of preoperative evaluation4,5 and pretreatment evaluation of oncology patients more broadly,6,7 and it can be easily incorporated without abandoning more traditional outcome measures. For example, poor preoperative functional status has been associated with increased postoperative morbidity and mortality,8,9 higher rates of perioperative complications,10,11 increased length of stay,12 and discharge to a nonhome setting.13 Many researchers have also begun to explore “prehabilitation”—therapy aimed at enhancement of functional status before surgery—as an approach that might improve these outcomes.14-16
Fewer studies include functional status (eg, activities of daily living [ADL] dependence) among their postoperative measures; however, available results have yielded useful insights. In recent studies of older surgery patients,17 including oncologic surgery patients,18 higher scores from a preoperative geriatric assessment tool that included functional status, mood, cognition, and mobility were associated with increased probability of both geriatric and surgical complications, increased length of stay, and increased postdischarge needs, including new functional dependence. Of note, the tool employed was able to be administered in a clinic setting in less than 10 minutes.
Creating a shared understanding of likely outcomes—including less traditional outcomes such as functional status—among providers, patients, and families is an important part of surgical planning.
The accompanying article evaluated patients’ functional status at 3 time points: preoperatively, at postoperative day 8, and 12 months after hospital discharge. This approach adds clarity to what patients can expect in their postoperative course and would provide useful information for providers to reference in approaching shared decision-making. Also of note is the significant correlation between ADL status and lethality in the distal urinary tract surgery group, particularly given that ADL assessment requires little more than completion of a questionnaire.
As the population ages and becomes more comorbid, performing thorough but efficient preoperative assessment will become increasingly critical. Moreover, these higher-
complexity patients will require more nuanced conversations regarding potential risks and benefits of treatments. Incorporating more comprehensive geriatric assessment and focusing on practical, functional measures will aid providers not only in preparing to care for their patients but in setting realistic expectations for patients and families. Future research should include such measures not only preoperatively, but throughout the postoperative timeline.
Kovar is an internist who specializes in geriatrics at the University of Nebraska Medical Center.
Teply is an internist at the University of Nebraska Medical Center. She is Board Certified in Hospice and Palliative Medicine.
1. Liu Y, Hu A, Zhang M, Shi C, Zhang X, Zhang J. Correlation between functional status and quality of life after surgery in patients with primary malignant bone tumor of the lower extremities. Orthop Nurs. 2014;33(3):163-170. doi:10.1097/NOR.0000000000000050
2. Ariza-Vega P, Ortiz-Piña M, Kristensen MT, Castellote-Caballero Y, Jiménez-Moleón JJ. High perceived caregiver burden for relatives of patients following hip fracture surgery. Disabil Rehabil. 2019;41(3):311-318. doi:10.1080/09638288.2017.1390612
3. Serper M, Bittermann T, Rossi M, et al. Functional status, healthcare utilization, and the costs of liver transplantation. Am J Transplant. 2018;18(5):1187-1196. doi:10.1111/ajt.14576
4. Xue D-D, Cheng Y, Wu M, Zhang Y. Comprehensive geriatric assessment prediction of postoperative complications in gastrointestinal cancer patients: a meta-analysis. Clin Interv Aging. 2018;13:723-736. doi:10.2147/CIA.S155409
5. Dogrul RT, Dogrul AB, Konan A, et al. Does preoperative comprehensive geriatric assessment and frailty predict postoperative complications? World J Surg. 2020;44(11):3729-3736. doi:10.1007/s00268-020-05715-8
6. Wildiers H, Heeren P, Puts M, et al. International Society of Geriatric Oncology consensus on geriatric assessment in older patients with cancer. J Clin Oncol. 2014;32(24):2595-2603. doi:10.1200/JCO.2013.54.8347
7. Loh KP, Soto-Perez-de-Celis E, Hsu T, et al. What every oncologist should know about geriatric assessment for older patients with cancer: Young International Society of Geriatric Oncology position paper. J Oncol Pract. 2018;14(2):85-94. doi:10.1200/JOP.2017.026435
8. Curtis G, Hammad A, Anis HK, et al. Preoperative functional status predicts increased morbidity following total knee arthroplasty. Surg Technol Int. 2019;34:379-384.
9. Ko H, Ejiofor JI, Rydingsward JE, Rawn JD, Muehlschlegel JD, Christopher KB. Decreased preoperative functional status is associated with increased mortality following coronary artery bypass graft surgery. PLoS One. 2018;13(12):e0207883. doi:10.1371/journal.pone.0207883
10. Saraiva MD, Karnakis T, Gil-Junior LA, Oliveira JC, Suemoto CK, Jacob-Filho W. Functional status is a predictor of postoperative complications after cancer surgery in the very old. Ann Surg Oncol. 2017;24(5):1159-1164. doi:10.1245/s10434-017-5783-9
11. Curtis GL, Hammad A, Anis HK, Higuera CA, Little BE, Darwiche HF. Dependent functional status is a risk factor for perioperative and postoperative complications after total hip arthroplasty. J Arthroplasty. 2019;34(7S):S348-S351. doi:10.1016/j.arth.2018.12.037
12. Raad M, Amin RM, El Abiad JM, Puvanesarajah V, Best MJ, Oni JK. Preoperative patient functional status is an independent predictor of outcomes after primary total hip arthroplasty. Orthopedics. 2019;42(3):e326-e330. doi:10.3928/01477447-20190321-01
13. Hung Y-C, Wolf JH, D’Adamo CR, Demos J, Katlic MR, Svoboda S. Preoperative functional status is associated with discharge to nonhome in geriatric individuals. J Am Geriatr Soc. 2021;69(7):1856-1864. doi:10.1111/jgs.17128
14. Kim S, Hsu F-C, Groban L, Williamson J, Messier S. A pilot study of aquatic prehabilitation in adults with knee osteoarthritis undergoing total knee arthroplasty – short term outcome. BMC Musculoskelet Disord. 2021;22(1):388. doi:10.1186/s12891-021-04253-1
15. Daniels SL, Lee MJ, George J, et al. Prehabilitation in elective abdominal cancer surgery in older patients: systematic review and meta-analysis. BJS Open. 2020;4(6):1022-1041. doi:10.1002/bjs5.50347
16. Vermillion SA, James A, Dorrell RD, et al. Preoperative exercise therapy for gastrointestinal cancer patients: a systematic review. Syst Rev. 2018;7(1):103. doi:10.1186/s13643-018-0771-0
17. Min L, Hall K, Finlayson E, et al. Estimating risk of postsurgical general and geriatric complications using the VESPA preoperative tool. JAMA Surg. 2017;152(12):1126-1133. doi:10.1001/jamasurg.2017.2635
18. Pollock Y, Chan C-L, Hall K, Englesbe M, Diehl KM, Min L. A novel geriatric assessment tool that predicts postoperative complications in older adults with cancer. J Geriatr Oncol. 2020;11(5):866-872. doi: 10.1016/j.jgo.2019.09.013