Surgical Considerations for Older Adults With Cancer: A Multidimensional, Multiphase Pathway to Improve Care

INTRODUCTION

By 2040, the incidence of solid cancers among patients older than 70 years will increase from 1.2 million to 2.2 million in North America alone.¹ Older adults with cancer are at highest risk of poor or unwanted outcomes when treatments are insufficiently personalized.^2,3 For example, in the United Kingdom, older adults are less likely to undergo surgery for rectal cancer based on age alone and experience higher rates of cancer-related death at 1 year compared with younger patients.⁴ Failure to provide appropriate surgical cancer care to older adults may be driven by the unique complexities of balancing an individual's cancer diagnosis, preoperative assessment, decision for surgery, and perioperative care. Failure to directly address this complexity risks undertreatment by excluding patients from advanced care because of chronologic age or overtreatment by not accounting for the individual vulnerabilities and goals.³ It is imperative to base decisions on multidimensional health status and frailty rather than chronologic age with the overall goal of optimal cancer care and maintaining functional independence.^5,6

CONTEXT

• Key Objective

• How can I implement in my practice a comprehensive and efficient patient-centered pathway for older patients with cancer undergoing surgery?

• Knowledge Generated

• Age is just a number and should not guide oncologic care. Every clinical and organizational effort should revolve around measuring functional recovery and patients' quality of life together with oncologic appropriateness. The ideal solution to improve perioperative clinical outcomes in older adults should include a multidimensional, multidisciplinary, and multiphase pathway, rather than a single intervention.

• Relevance

• This review provides a roadmap prioritizing interventions in a stepwise manner based on importance and ease of implementation, and may be adjusted based on available local resources. We will discuss minimally invasive surgery, enhanced recovery protocols, frailty assessment and geriatric comanagement (including in the palliative setting), prehabilitation, and social frailty.

Current surgical literature regarding care of the older adult is dispersive (eg, more than 70 frailty screening tools have been published), leading to challenges in how to adequately approach care in this vulnerable population. Despite limited guidelines, it is crucial to acknowledge the substantial role of surgery in the care of solid cancer, especially in older adults.⁷

This review provides first an overview of frailty and physiologic stress; outlines outcomes of importance to patients, namely, quality of life and functional recovery; and describes care models. We then provide a stepwise guide for surgeons and multidisciplinary care teams to integrate older adult–specific care into their practices, outlined in Figure 1. This is a multidimensional, multiphase pathway composed of evidence-based elements, prioritized from one to six based on ease of implementation, which can be modified based on available resources.

FIG 1.

Multidimensional, multiphase pathway to optimize the care of older adults with cancer undergoing surgery. (1) MIS or good surgery. (2) Enhanced recovery protocols. (3) Modern frailty screening. (4) Geriatric comanagement. (5) Prehab. (6) Social support. ^aThe six steps are presented in a stepwise manner based on their importance and ease of implementation and may be adjusted based on local resources. Adj Rx, adjuvant treatment; comgmnt, comanagement; MDT, multidisciplinary tumor board; Med-Rad Onc, medical-radiation oncologist; MIS, minimally invasive surgery; Neoadj Rx, neoadjuvant treatment; Prehab, prehabilitation; PT-OT, physical therapist–occupational therapist; Rehab, rehabilitation.

UNDERSTANDING FRAILTY AND REDUCING PERIOPERATIVE STRESS

Traditionally, age has been a major factor in surgical decision making. However, emerging data indicate that consideration of age alone is insufficient to make decisions about pursuing surgical interventions.⁸ Indeed, age is a nonmodifiable factor with no intervention proven effective to lower it, so aging-related experts assert that “The Age of Talking About Age Alone is Over.”⁹ Instead, a focus on domains that result from the aging process should be considered. For example, impairments could present as cognitive impairment, difficulty in walking, or relying on others to perform daily tasks. Broadly, a patient with more aging-related impairments is characterized as frail, and a patient with fewer aging-related impairments is considered fit.¹⁰ The physiologic definition of frailty is a decreased tolerance for stress associated with negative outcomes such as mortality or health care utilization (eg, emergency room visit and hospital admission).¹¹ Stress in an older adult with cancer could arise from the aging process (eg, functional decline because of multiple falls), cancer, cancer treatment, or a combination of these factors.¹² Therefore, the overarching goal is to reduce stress and support a frail patient to optimize functional recovery. In the literature, there are three emerging themes on reducing perioperative stress: collaboration between geriatricians and surgeons (also known as geriatric comanagement), prehabilitation (alone or in addition to rehabilitation), and enhanced recovery protocols (ERPs). We will discuss these programs in detail in this review.

DEFINING THE ULTIMATE GOAL: FUNCTIONAL RECOVERY THROUGH PERSONALIZED CARE OF OLDER ADULTS

Evaluating success in surgical cancer care among older adults must go beyond survival, cancer control, and early postoperative outcomes to include disability, change in quality of life, and maintenance of function with particular attention to patient preferences.^13-15 Overall, these outcomes are important for the broader goal of recovery for older adults, which we refer to as functional recovery.

One of the more comprehensive definitions of functional recovery after surgery includes key attributes such as regaining control over physical, psychologic, social, and habitual functions; returning to preoperative levels of independency or dependency in activities of daily living; and regaining one's optimum level of well-being.¹⁶

To date, functional recovery has been incompletely measured. However, several patient-reported measures are currently in use and include activities of daily living, the WHO Disability Assessment Schedule, and physical performance tests such as gait speed, timed up and go, and grip strength.^14,17 Common measures of health-related quality of life are the EuroQol-5D, Patient-Reported Outcome Measurement Information System Global Health, and Short Form Health Survey–36).^18-20 Additional important outcomes include caregiver burden, autonomy, and emotional health.²⁰ Given the lack of granular data, studies using large databases frequently use factors associated with discharge (eg, time at home, homecare utilization, and long-term institutionalization) as surrogates for functional recovery.^13,20 However, only limited progress has been made to meaningfully measure functional recovery after surgery or hospitalization. The use of digital health technologies may allow improvements in both monitoring and understanding postoperative recovery.^21,22 In addition, attempts at longitudinal assessments up to 1 year after surgery may be useful to determine true recovery.²³ Understanding these outcomes may better support patient-centered perioperative and cancer care. Providers should consider how they monitor and support the recovery of their patients with attention to functional recovery.²⁰

CARE MODELS FOR OLDER ADULT–SPECIFIC SURGERY

Care models share many elements, but vary in what assessments are included, how the results are used, who delivers care, where care is delivered, outcomes targeted, resources needed, ease of implementation, and sustainability.²² With the aim of identifying frailty, reducing stress, and supporting functional recovery, a range of care models have been evaluated and reported across settings. Generally, care models can be categorized by degree of integration and shared responsibility between care providers.^24,25 Discretionary postoperative geriatric consultation is the simplest model in which a geriatric consultation is requested by the surgical team as needed.²⁶ Routine postoperative geriatric consultation models use a threshold, such as age, for routine geriatric consultation at the time of admission, and the surgical team maintains primary responsibility.²⁷ Geriatric colocation models arrange the institutional environment to provide all older adults within the same space multidisciplinary care teams, which include geriatric expertise.^26,27 Shared care models, also referred to as a comanagement or team-based care, emphasize collaborative care with shared responsibility between surgical and geriatric teams.^21,28 How preoperative geriatric-specific assessments are included also varies, usually based on resources available.²⁹ Assessments may include single screening tools or comprehensive geriatric assessment (GA), and the results may simply identify those at increased risk or be used for shared decision making, multidisciplinary tumor board discussions and treatment decisions, filtering for prehabilitation strategies, and informing fully integrated shared care. Considerations from these models are used to inform our multidimensional, multiphase pathway (Fig 1).

STEPWISE GUIDE TO IMPLEMENTING OLDER ADULT–SPECIFIC CANCER CARE FOR SURGEONS

Here, we detail our six-step multidimensional, multiphase pathway. These are presented in a stepwise manner to guide surgeons in integrating these elements into their practices over time and based on local resources.

Step 1: Use Minimally Invasive Surgical Approaches to Reduce Surgical Stress

Minimally invasive approaches have long been associated with reductions in complications, postoperative pain, and length of stay (LOS), as well as improvements in return to normal activity. However, multiple concerns about the safety of such approaches among older adults have been raised, namely, the need for pneumoperitoneum and head-down (ie, Trendelenburg) positioning, which may inhibit ventilation and reduce venous return, and longer operating times that may offset any potential benefit of a minimally invasive surgical approach.³⁰

Despite these initial reservations, emerging data indicate that minimally invasive surgery is safe for older adults who may in fact derive the most benefit from such approaches.³¹ Three recent meta-analyses comparing laparoscopy and open colorectal surgery for both benign and malignant conditions among older adults all demonstrate lower complication rates in the laparoscopic group.^32-34 Only two randomized controlled trials (RCTs) exist examining laparoscopic colorectal surgery specifically among older adults with conflicting results—the ALCCaS trial found overall fewer complications (50.7% v 36.8%, P = .02), whereas the CLASICC trial demonstrated no differences in complication rates.^35-37 Regarding added benefit among older adults, a retrospective cohort study comparing minimally invasive colorectal surgery between older (≥ 70 years) and younger adults reported a greater reduction in deaths among older adults (absolute difference 7.0% v 2.1%, adjusted odds ratio [OR] 3.01; 95% CI, 1.31 to 7.33 v adjusted OR 0.31; 95% CI, 0.05 to 1.38).³¹

Although the current literature may suggest that such approaches are not contradicted for older adults with pancreatic or gastric cancers, these may be best performed at specialty centers with experienced surgeons given the complexity and demands of these specific operations.^38,39 Finally, it is important to note that frailty assessments were not performed in these studies and patients were grouped based on age alone. Therefore, we are left to extrapolate that frailty is also not a contraindication to minimally invasive surgery and that frail patients derive a benefit, but this should be specifically studied. Nevertheless, the existing data are compelling and minimally invasive approaches have been jointly advocated for by the American College of Surgeons and the American Geriatrics Society with the goal of minimizing postoperative complications.⁴⁰

Step 2: Use Enhanced Recovery Protocols to Reduce Immediate Postoperative Stress

In an effort to moderate the physiologic stress of surgery, ERPs, multidisciplinary care bundles consisting of evidence-based components, were implemented.⁴¹ The number of interventions varies between programs, but all protocols encompass at minimum early mobilization and oral intake after surgery, early removal of urinary catheters, avoidance of nasogastric tubes, and opioid-sparing analgesia.⁴² Widespread acceptance and adoption are due to compelling evidence demonstrating improved outcomes including fewer complications, earlier return of bowel function, and reduced LOS without negative impact on readmission rates and mortality.⁴²

For older adults specifically, minimizing physiologic stress and reducing narcotic use and LOS may prevent delirium, cognitive decline, and hospitalization-associated disability. However, some worry that ERPs cannot be safely applied to the older adult populations as standardized protocols may fail to account for age-related changes in pharmacokinetics, slower recovery (eg, inability to comply with early ambulation or early oral intake), and potential for late complications in the context of earlier discharge from the hospital.^42,43 Indeed, much of the literature regarding ERPs does not focus on older adults or include frailty assessments nor is there a focus on the impact on geriatric syndromes or geriatric-specific outcomes.

Nevertheless, an increasing number of well-conducted studies examining the safety of ERPs among older adults exist, and consensus has been reached across numerous surgical subspecialties.^44,45 A recent meta-analysis comparing ERPs with conventional care for colorectal cancer surgery among patients older than 65 years identified six studies with 1,174 patients, including three RCTs, which reported a lower incidence of morbidity (OR 0.38; 95% CI, 0.25 to 0.59), shorter LOS (mean difference –2.5 days; 95% CI, 4.1 to 0.9), and time to first flatus (mean difference –20.0 hours; 95% CI, –36.2 to 3.8) with ERPs, and no differences in postoperative ileus, readmissions, and mortality.⁴² Regarding geriatric-specific outcomes, an RCT comparing ERP with standard care among 240 older adults (≥ 70 years) with colorectal cancer demonstrated a lower incidence of postoperative delirium with ERP (3.4% v 12.9%, P = .01).⁴⁶ In another RCT of 150 older adults (≥ 70 years) undergoing elective colorectal surgery, ERP led to better independence preservation when compared with standard care (home discharge 87% v 67%, P = .005).⁴⁷

Step 3: Include Preoperative Frailty Assessment to Identify Those Most at Risk and Include Frailty Expert at Cancer-Specific Multidisciplinary Meetings

The gold standard for assessing frailty is a comprehensive GA, a multidimensional assessment that may take more than 60 minutes, best performed by geriatric care providers.⁴⁸ Impairments detected during GAs are associated with poorer surgical outcomes of older adults with cancer, so some argue it is time well spent.^49,50 Nonetheless, given the expansion of web-based and digital technologies, various research teams have explored methods of improving the feasibility and/or utility of such assessments.⁵¹ At Memorial Sloan Kettering Cancer Center, the GA has been transformed into the electronic Rapid Fitness Assessment (eRFA).⁵² The eRFA is a web-based GA largely completed directly by patients and/or caregivers, with nurses completing assessments of cognition by Mini-Cog and gait speed by timed up and go.^53,54 A study of 637 patients (median age 80) examining the feasibility of eRFA (completion time 11 minutes) demonstrates that a significant majority of patients completed it without assistance and with a high-level satisfaction.⁵² In a large cohort of older adults with cancer, the eRFA score was more strongly associated with 6-month postoperative mortality compared with the American Society of Anesthesiologist-Physical Status classification.⁵⁵ Finally, another benefit of web-based platforms is the opportunity to create unique and much-needed data infrastructures while performing routine care, reducing the need for dedicated research support or use of less meaningful surrogates within existing data sources.

For groups without access to a web-based GA, filtering patients for conventional GA based on an age cutoff (such as 70) or after a screening frailty assessment may be used based on available resources and geriatric providers.⁵⁶ It is important to note that currently other than comprehensive GA, which is the gold standard for assessing frailty, there are a large number of frailty screening tools. A systematic review identified at least 21 frailty screening tools evaluating the association of frailty with postoperative outcomes in older adults with and without cancer.⁵⁷ Some of these instruments were based on accumulation of aging-related impairments, and some were based on the physiologic model such as the physiologic frailty phenotype.^10,58 Regardless of the chosen assessment or screening system, it is essential to systematically address and determine the patient's fitness for surgery, the most appropriate surgical procedure, and whether any preoperative optimization is needed. In addition, it is paramount to obtain information about cognition (including history of delirium), independence in daily activities, living situation, and physical status such as sarcopenia, mobility, and nutrition.⁵⁹

In multidisciplinary meetings, frailty should also be discussed and interpreted with the help of a frailty expert. Integrating frailty expertise has been shown to be beneficial in clinical settings. One study examining the addition of a frailty expert in tumor board meetings demonstrates a significant decrease in the days spent in hospital (median 5 v 8.5 days, P = .02) and grade ≥ II postoperative complications (13.3% v 35.5%, P = .005) in patients who had their cancer management modified based on frailty assessment.⁶⁰

Step 4: Share the Care of Older Adults With a Multidisciplinary Team Throughout the Perioperative Period

After assessing for frailty, it is important to reduce perioperative stress and support functional recovery through comanagement. There is considerable benefit to co-management in all aspects of the care pathway.

Comanagement in the perioperative period.

Frail older adults with cancer are at the highest risk for poor or unwanted outcomes after surgery, either related to surgery (eg, intra-abdominal abscess) or because of nonsurgery factors (eg, postoperative delirium after receiving a benzodiazepine for insomnia).⁵⁷ Both place the body of an older frail adult with cancer under greater stress. Early detection and proper management of such events may mitigate negative outcomes. For instance, the effects of geriatric comanagement have been studied in a cohort of 1,020 patients who underwent cancer surgery compared with 872 similar patients with standard surgical service management. The adjusted probability of death within 90 days was less than half in the geriatric comanagement group (4.3% v 8.9%; 95% CI, 2.3%-6.9%; P < .001). Despite similar complication rates, the geriatric co-management group had greater utilization of supportive care services, which might have contributed to the decreased mortality rate.²⁵

Comanagement in the long term.

Recovery of older adults with cancer continues after hospital discharge. Underassessed and undertreated signs and symptoms at this point lead to emergency room visits and hospital readmissions.⁶¹ To improve the care gap from inpatient to outpatient care, Medicare promoted transitional care management (TCM) where care teams follow patients through phone calls and in-person visits in the first 30 days following hospital discharge.⁶² TCM led to a reduction in 30-day mortality and cost in the first three years of implementation among older adults with or without cancer.⁶³ In the cancer surgery setting, TCM can be performed by either geriatric care providers or the patient's primary care provider. When postoperative stress is protracted, patients may benefit from rehabilitation programs, which should be comanaged. Rehabilitation should be reconsidered both in the way it is achieved and where it is obtained. The goal is to regain independence and not simply discharge from the hospital as the implications of nonindependence are important and perhaps underappreciated. A retrospective analysis from 97,455 patients shows that readmission rate varies tremendously depending on discharge location after colorectal surgery. The hospital readmission rate varied from 16% for home with organized home health services, 19% for skilled nursing facility, 34% for rehabilitation facility, and 22% for long-term care hospital (P < .01). All locations besides long-term care were associated with a higher risk of readmission even after adjusting for confounders.⁶⁴

Palliative or supportive care comanagement.

Palliative or supportive care is a multidisciplinary approach focused on relief from suffering for any patient with serious illness and at any stage of disease. Such an approach may be beneficial among older adults who frequently prioritize quality of life over life prolongation.⁶⁵ Data suggest that surgical patients are less likely to receive palliative care consultations than those with chronic medical conditions despite the risks of postoperative morbidity and mortality, burdensome pre- and postoperative symptoms, and need for assistance with complex decision making.⁶⁶ Because of an underappreciation of prolonged recovery and persistent disability after surgery, it is not uncommon for older adults to undergo surgical interventions with unrealistic expectations and inadequate consultation.⁶⁷ Older adults may also experience higher rates of unwanted invasive procedures following a postoperative complication rather than treatments focused on comfort and quality of life.^66,68 Furthermore, even in the presence of advance directives, patient preferences are frequently inaccurately recorded or overlooked.⁶⁹ With this knowledge, patients may benefit from discussions about nonsurgical options and earlier introductions to palliative care.⁷⁰ Palliative care should be considered an important adjunct to the standard of care and offered at any point along the cancer care continuum, from diagnosis to end of life. Whereas geriatric medicine focuses on the prevention and management of specific health problems in older adults, palliative care focuses on quality of life and symptom relief among patients of all ages. Together, these approaches can be complementary with the overall goal of improving the quality of life of an older adult patient facing a serious illness.⁷¹ In addition, in the absence of a specific geriatric service, a palliative care specialist may serve as an important partner in ensuring outcomes that are most meaningful to older adults and addressing issues related to the psychologic, social, and spiritual domains.⁷²

The perioperative care of an older adult with cancer is complex and multidimensional, and interventions may occur in different phases. Comprehensive holistic care for older adults requires collaboration among multiple services, and comanagement should be a goal for the entire care pathway to ensure that all aspects of care are addressed to the fullest extent possible.

Step 5: Employ Prehabilitation to Enhance Resilience to Stress and Promote Functional Recovery

Prehabilitation is a multidisciplinary, multifaceted, and preoperative intervention to prevent or minimize surgery-related functional decline and improve perioperative outcomes. Multimodal prehabilitation typically involves optimization of activity, nutrition, and anxiety or depression, along with comorbidity optimization and smoking or alcohol cessation.⁷³ In cancer surgery, the surgical team must balance oncologic outcomes with postsurgical outcomes and, recently, additional focus has been placed on functional outcomes.⁷⁴ Unfortunately, many studies on prehabilitation have not addressed functional outcomes as important end points. Because previous work failed to demonstrate robust improvement in traditional postoperative surgical outcomes, many surgeons question the value of prehabilitation, particularly in the context of potential harm with delayed surgical intervention.⁷⁵ However, recent evidence suggests that delays in treatment, up to 60 days, do not affect long-term oncologic outcomes.⁷⁶

A recent randomized superiority trial evaluated preoperative prehabilitation versus postoperative rehabilitation; both regimens included exercise, nutrition, and psychologic interventions in frail patients before and after colorectal cancer surgery.⁷⁷ No differences were found between groups with regard to 30-day complication rate, LOS, hospital readmissions, recovery of walking capacity, and patient-reported outcome measures. This may be explained, in part, by the fact that patients were treated with a protocolized, multiphase surgical pathway to decrease the stress of the perioperative period (eg, minimally invasive surgery and ERP). The conflicting results regarding the effects of prehabilitation on perioperative outcomes suggest that prehabilitation is likely not a standalone intervention, but part of a multiphase pathway for frail, older patients. The same authors proposed methods to identify these third variables in studies evaluating prehabilitation, which will aid in further defining and studying particular components of the pathway.⁷⁸ For example, another study evaluating only frail patients receiving prehabilitation found that those who could not achieve a 400-m 6-minute walking distance during the prehabilitation period had an increased risk of postoperative complications (61 v 21% with at least one complication within 30 days, P < .01).⁷⁹ As such, in addition to the previously described potential benefits, prehabilitation can also be used as an adjunct frailty test. If frail patients cannot achieve improved functional status preoperatively, this implies that they may not tolerate surgical stress and a modified treatment plan should be considered.

Without evidence supporting a single unified prehabilitation regimen, surgeons may be tempted to avoid adopting a formal program as it can be costly, time-consuming, and difficult to implement. Table 1 reports the steps of an evidence-based approach to implement prehabilitation initiatives.^80-83 At this time, the evidence is limited and guidelines are lacking. As such, additional studies are needed to further define what interventions will be optimally suited for each patient. In the meantime, prehabilitation should be initiated incrementally in all surgical practices and integrated into routine perioperative management. Finally, appropriate preoperative interventions should be considered throughout the perioperative and postoperative periods to achieve maximum benefit.

TABLE 1.

Evidence-Based Approach to Implementation of Prehabilitation Initiatives for Older Adults

Step 6: Address Social Frailty Proactively Instead of Reactively

The increased complexity of cancer treatments (eg, multistep neoadjuvant therapies, surgery, and adjuvant treatments) poses a substantial challenge not only for older adults but also for their support network. Limited education and low health literacy, a lack of financial and tangible resources, and insufficient support networks are well-established risk factors for inferior clinical outcomes after cancer care.⁸⁴ This is a complex area to assess for and requires an integrated comanagement approach, the addition of social work, and other hospital-level support.

Social frailty (SF) is “a continuum of being at risk of losing, or having lost, resources that are important for fulfilling one or more basic social need during the lifespan.”^85(p326) Identifying and intervening on SF, arguably the least explored dimension of frailty, is intricate, especially when considering cultural contexts.

As a baseline, all clinicians should elicit key information regarding SF.

Socioeconomic deprivation is associated with poorer short- and long-term outcomes after both elective and urgent surgery.⁸⁶ In a nationwide cohort study from Northern Europe, low socioeconomic position was associated with an increased likelihood of undergoing acute cancer surgery and with a reduced 1-year overall survival.⁸⁷

Social deprivation (ie, inadequate opportunity for social experience) is inversely and dynamically related to frailty.⁸⁸ Older adults with less income and education at baseline are more likely to experience health degradations (eg, increase in frailty) and less likely to experience health improvements in the future.⁸⁹

SF is multifaceted and includes but is not limited to socioeconomic and social deprivation.

An eight-item questionnaire (SF-8) was developed to assess SF (Fig 2).⁹⁰ The SF-8 has been shown to demonstrate very good correlation with frailty phenotype and is associated with an increased odds ratio of adverse health outcomes including depressive symptoms, risk of malnutrition, and poor physical performance.⁹⁰ The SF-8 provides a simple survey that can be easily administered preoperatively to highlight the immediate and ongoing needs for social support.

FIG 2.

Defining and measuring the fulfillment of basic social needs in older adults. ^aSF-8 items are added up to a total score that defines three subgroups: social nonfrailty (0-1 point), social prefrailty (2-3 points), and social frailty (4-8 points). SF-8, social frailty 8-item questionnaire. Adapted from Bunt et al⁸⁵ and Pek et al.⁹⁰ Reprinted by permission from Springer Nature. © 2021 European Journal of Ageing. Bunt S, Steverink N, Olthof J, et al. Social frailty in older adults: A scoping review. Eur J Ageing 14:323–334, 2017.

There are a number of interventions or support systems (ie, health assets) that can be enacted to mitigate the risk of SF.⁹¹ Table 2 outlines different types of health assets and the direct effects on clinical outcomes.^92-99 Although several items of SF cannot be improved in a timely manner or at all, providing basic social support has been found to be effective in enabling health-related behavioral changes compared with usual care in a study of frail older patients.¹⁰⁰ Three techniques may improve SF: (1) instructions on how to perform a behavior (eg, follow a heathier diet), (2) adding objects to an environment (eg, a medication dispenser), and (3) restructuring the physical environment (eg, making housing modifications to reduce fall risks). Two functions, education and enablement, may improve physical function and behaviors.

TABLE 2.

Relationship Between Social Frailty Health Assets and Clinical Outcomes in Older Adults

Encouraging productive behaviors and providing appropriate social services may optimize social functioning and general or physical health.¹⁰⁰ Indeed, addressing SF through a multidisciplinary comanagement strategy will mitigate perioperative stress and promote functional recovery.

In conclusion, for surgeons, inconsistent literature with critical methodologic limitations makes it challenging to integrate older adult-oriented processes into cancer surgery. The rising numbers of older adults with cancer and increasing complexity of cancer care require multidisciplinary care throughout the care pathway. In this review, we highlight the importance of frailty assessment and efforts to reduce perioperative stress with a primary goal of functional recovery. We provide an evidence-based, multidimensional, multiphase pathway that surgeons can implement in a stepwise manner to optimize care of these vulnerable patients.

AUTHOR CONTRIBUTIONS

Conception and design: Isacco Montroni, Nicole M. Saur, Armin Shahrokni, Tyler R. Chesney

Collection and assembly of data: Pasithorn A. Suwanabol, Tyler R. Chesney

Data analysis and interpretation: Tyler R. Chesney

Manuscript writing: All authors

Final approval of manuscript: All authors

Accountable for all aspects of the work: All authors

AUTHORS' DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST

Surgical Considerations for Older Adults With Cancer: A Multidimensional, Multiphase Pathway to Improve Care

The following represents disclosure information provided by the authors of this manuscript. All relationships are considered compensated unless otherwise noted. Relationships are self-held unless noted. I = Immediate Family Member, Inst = My Institution. Relationships may not relate to the subject matter of this manuscript. For more information about ASCO's conflict of interest policy, please refer to www.asco.org/rwc or ascopubs.org/jco/authors/author-center.

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