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Frailty, advanced age tied to less time at home after cancer resection

JAMA Surgery
Reuters Health - 21/10/2020 - Elderly, frail and low-income adults may have less time at home after cancer resection than patients who are younger and more affluent, a Canadian study suggests.

Researchers examined data on 82,037 adults aged 70 years and older in Ontario, Canada, who had a new cancer diagnosis from 2007 to 2017 and underwent resection within 90 to 180 days. Overall, the median number of days at home per days alive was 0.98 in postoperative year 1 and 0.99 in postoperative year 5.

Across the entire study population, the probability of high time at home, defined as 14 days or less in an institutional setting annually, was 70.3% in postoperative year 1 and 53.2% by postoperative year 5, according to the results in JAMA Surgery.

Several factors, however, were associated with low time at home, defined as more than 14 institutional days per year. These included age of at least 85 years (hazard ratio 2.11); preoperative frailty (HR 1.74); highest level of material deprivation (HR 1.25); rural residency (HR 1.14); and high-intensity surgical procedure (HR 2.04).

"Some groups of older adults have lower time at home, for example those who are older and who are frail, however, even those higher risk older adults have a lot of days at home," said study coauthor Dr. Julie Hallet, an assistant professor of surgery at the University of Toronto and surgical oncologist at Sunnybrook Health Sciences Centre.

This means that all groups of older adults can have good performance and function after surgery, Dr. Hallet said by email.

"They should be considered and offered surgery, and we should not write off patients because they are older or frailer," Dr. Hallet added.

The chance that patients might have high time at home after cancer surgery increased during the study period, with people treated near the end of the study less likely (HR 0.83) to have low time at home than those treated early in the study period.

People with certain tumors were also at lower risk of low time at home. Compared to those with bronchopulmonary cancers, used as a reference in the analysis, patients with breast cancer (HR 0.82), melanoma (HR 0.88), and genitourinary cancers (HR 0.71) were less likely to have low time at home.

With other tumor types, low time at home was more common than with bronchopulmonary cancers, including gastrointestinal (HR 1.23), gynecologic (HR 1.31), and oropharyngeal (1.05) cancers.

One limitation of the study is that researchers lacked data on certain factors that might influence time at home including preoperative performance, cognitive function, and burden of cancer, the study team notes.

Still, "these findings will help tailor decision-making for patients and their caregivers," said Dr. Jennifer Watt, a geriatrician at St. Michael's Hospital-Unity Health Toronto who wasn't involved in the study.

"Patients value time at home and now we can provide them with estimates of how much time they can anticipate spending at home versus in a care setting," Dr. Watt said by email.

The results also underscore the importance of physicians identifying the patients most vulnerable to low time at home, particularly the oldest adults, frail patients, and those with low socioeconomic status, said Dr. Bellal Joseph, professor and chief of trauma, acute care, burn and emergency surgery at the University of Arizona - Banner Health in Tucson.

"Physicians should incorporate this information while counseling patients before their surgeries, and then optimize their care post-surgery to maximize their time-at-home," Dr. Joseph, who wasn't involved in the study, said by email.

By Lisa Rapaport

SOURCE: https://bit.ly/2HoYAPf JAMA Surgery, online October 7, 2020.

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