GERIATRIC CO-MANAGED CARE OF OLDER ADULTS ADMITTED TO A SURGICAL SERVICE FOR GASTROINTESTINAL CANCER. A PROPENSITY SCORE ANALYSIS

Surgery represents the key treatment for the majority of g.i. cancers and the advances in anaesthesia, perioperative medicine, pain medicine and postoperative critical care, as well as surgical techniques, have changed the risk-to-benefit balance of surgery in many high-risk patients. Many more medically complex patients have become eligible for surgical interventions, including those who are older, frail, or have multiple comorbidities, a decline in physiological reserve, impaired nutrition or cognition and are at higher risk for poor outcomes. Geriatric patients require multimodality and multispecialty interventions to improve their care geriatric but geriatric comanagement (GC) in general surgery is rarely implemented. A single-centre observational study was performed within an Italian teaching hospital with a tertiary referral practice for oncological surgery between January 2015 and December 2019. Eligibility criteria were patients aged at least 70 years, with colorectal, gastric, and hepatopancreaticobiliary cancer, admitted to the Oncological Surgery of Policlinico San Martino of Genoa, who underwent elective surgical procedures or palliative treatments and required a hospital stay of at least 1 day. This before and after study aimed to examine the effectiveness of the GC by comparing patient outcomes before and after the implementation of a dedicated geriatric service in November 2018. During the first three years older cancer patients underwent a CGA in order to stratify patients’ frailty and performance status prior to surgery. Starting from November 1st 2018, a GC was implemented in the surgical ward following the appointment of a fulltime consultant geriatrician. This upgraded model of geriatric care consisted of the initiation of daily targeted geriatrician-led ward rounds focusing on older cancer patients. A total of 235 patients were admitted to the oncological surgery ward during the entire study period: 122 (52%) before November 1st 2018 (control group) and 113 (48%) between November 1st 2018 and November 1st 2019 (GC group). Comparison of the two cohorts demonstrated that patients in the control group were older (median age [IQR] 81.50 [78.00, 85.00] years vs 79.00 [76.00, 83.00] years; p < 0.004) and predominantly male (79 [64.8%] vs 59 [52.2%]; p < 0.05). Average Frailty Index scores were 0.12 in the control group and 0.18 in the intervention group (p <0.01), corresponding to a pre-frail phenotype in both cases. Patients from the GC group demonstrated a significant decrease in grade I-V postoperative complications (OR = 0.53 (95%CI 0.32, 0.87), p <. 0.012), which was also confirmed by our adjusted analysis according to the propensity score (weighted OR = OR = 0.37 (95%CI 0.27, 0.50), p < 0.001). Indeed, the GC group exhibited significantly lower CCI scores (β coefficient [SE], GC vs control group -10.2 (95%CI -17.3, -3.8), p < 0.009) as compared to the patient from the control group. Specifically, in those patients who received GC, mean CCI score was lower by 12 points, which represents a statistically significant decrease after adjustment (β coefficient [SE], intervention vs controls -15.6 (95%CI -23.8, -7.33), p < 0.001). No significant differences between the two groups were observed when considering 90-day and 1-year mortality. Of note, the majority of deaths in the GC group were cancer related (i.e., due to progression of disease). A higher number of patients were deemed eligible to start anticancer treatment in the GC group as compared to the patient from the control group [21 (48%) vs. 35 (69%), p = 0.063]. In conclusion, GC can improve the perioperative management of older cancer patients undergoing elective g.i. surgery by potentially reducing postoperative complications. To our knowledge, amongst the few studies analysing the effectiveness of GC in patient who are candidate to major oncological surgery, this is one of the few ones showing positive results in terms of reduction of postoperative complications.