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EDITORIALS |
From the Department of Surgery, The Permanente Medical Group, Kaiser Medical Center, Walnut Creek, California.
Correspondence: Address correspondence to: Pascal R. Fuchshuber, MD, PhD, Department of Surgery, The Permanente Medical Group, 1425 South Main Street, Walnut Creek, CA 94596; Fax: 925-295-4766; E-mail: pascal.fuchshuber{at}kp.org
Effective utilization of health care resources has gained prominent attention with the dramatic shift in the population pyramid towards the elderly, the tightening of available health care dollars, and the increased regulation of access to health care. The search for an adequate surrogate for quality and outcome has dominated this debate. Inextricably linked to it is the question of fair and appropriate allotment of those precious health care resources to the elderly. This is particularly true for the treatment of cancer. Exorbitant cost of multimodality cancer therapy combined with a rapidly expanding affected elderly population has increased the possibility of under use of cancer therapy. Several studies have already examined the appropriate use of cancer directed radiation and chemotherapy and have demonstrated under use in the elderly.1,2
In this issue of the Annals of Surgical Oncology, O’Connell et al.3 provide us with a much-needed study on the utilization of cancer surgery in the elderly. The scope and broadness of this study makes it unique. Utilization of cancer surgery in over 200,000 cancer patients 40 years of age and older from the SEER database was analyzed. Nine different cancer sites were included. The study was restricted to localized, i.e. potentially curative cancers. The results are provocative. The multivariate analysis reveals significantly decreased odds of receiving cancer directed surgery in the elderly patient (60 to 90 years of age) with lung, liver, breast, pancreas, esophageal, gastric cancers, sarcoma and rectal cancer. No differences were seen only for colon cancers. In addition, unfavorable hazard ratios were found for African-American patients and larger tumor sizes. An increase in survival was seen in all patients that did undergo surgery, regardless of ethnicity, race or tumor size.
The authors appropriately point out several critical issues with this study.
First, the validity of this study hinges on the accuracy of the SEER database. Coding errors, insufficient information on treatment and comorbidities as well as inaccurate cancer staging data may limit the value of the results. It would be important to corroborate these results by performing similar analysis in other large datasets that include precise clinical information on treatment, (co)morbidity and staging.
Second, the reasons for the observed under use of cancer directed surgery in the elderly remain elusive. Whether surgical therapy is intentionally withheld in the elderly because of the perceived increased operative risk or the absence of perceived long-term benefits by both patient and physician remains speculative. The evidence addressing the influence of age on the operative risk is controversial. For nearly every retrospective review that claims no increased risk due to age of the patient a similar study with opposite results can be found.4–6 Studies comparing surgical outcome in high versus low volume centers do not address the issues of utilization and age. They do provide evidence, however, that for procedures with higher surgical complexity such as large cancer operations outcome depends on the expertise and volume of the operating team.6,7 As the authors point out, future surgical outcome studies need to elucidate whether varying rates of utilization for the elderly surgical cancer patient are due to differences in expertise, volume and standards of care.
Third, this study raises the question whether lower cancer directed surgery rates in the elderly are due to inadequate preoperative evaluation of these patients. A recent review of the assessment of preoperative risk in elderly patients demonstrates that a specific physiologic status leading to increased surgical risk exists in the elderly patient.8 Khuri et al. developed a preoperative scoring system for the operative risk assessment with a high positive predictive accuracy.9 Interestingly, out of nine variables, age came in only as the sixth most important predictive factor. Specific guidelines and scoring systems for cancer directed surgery in the elderly need to be developed and tested for improving surgical utilization and outcome in these patients.
Last but not least, this study raises the relevant issue whether ethnic and racial differences are in part responsible for the observed differences in cancer surgery use in the elderly. This question reminds us of the importance of culturally competent care, particularly in the context of cancer care and elderly patients.
This work by O’Connell and colleagues raises a number of provocative questions on the utilization and outcome of cancer directed surgery in the elderly. Clearly, further research is warranted. As we are threatened by an explosion of both the population of elderly cancer patients as well as the costs of providing multimodality cancer treatment to them, the most provocative question remains: Is the observed use of cancer directed surgery in the elderly due to judicious, evidence based selection or discrimination based on age, ethnicity and tumor stage? No dataset in existence will bear the answer to the latter part of the question. However, future studies can provide us with increasingly better tools to insure the implementation of its first part. As academic clinicians it is our responsibility to conduct these studies. The analysis of the SEER data by O’Connell and associates has laid the groundwork by providing us with a set of relevant questions.
Received for publication September 5, 2004. Accepted for publication September 22, 2004.
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