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Is Head & Neck Surgery in the Super-Old a Bad Idea?

Various preoperative clinical and demographic variables were found to predict worse outcomes in the oldest individuals undergoing surgery for head and neck cancer and could potentially guide patient counseling, a retrospective multi-institutional cohort study indicated.

In the analysis of over 375 patients ages 80 and up, those with moderate to severe comorbidities on a validated comorbidity instrument had a greater than threefold increased risk of death at 90 days (odds ratio [OR] 3.33, 95% CI 1.29-8.60), reported Jason Rich, MD, of Washington University School of Medicine in St. Louis, Missouri, and colleagues.

Patients ages 85 and older — the so-called oldest old — were 19% more likely to die within this timeframe (OR 1.19, 95% CI 1.14-1.26), with each additional year of age associated with a 20% increased risk of death, they wrote in JAMA Otolaryngology — Head & Neck Surgery.

Several factors were associated with serious postsurgical complications at 30 days:

  • Moderate to severe comorbidities (OR 1.80, 95% CI 1.34-2.41)
  • High frailty (OR 1.72, 95% CI 1.10-2.67)

Higher body mass index (BMI ≥25), meanwhile, appeared to be marginally protective against the risk of developing a serious complication (OR 0.95, 95% CI 0.91-0.99).

“This large, retrospective cohort study represents a major contribution to the literature by combining the multi-institutional experience of patients 80 years or older undergoing major head and neck surgery, as defined by reconstruction in the form of a free flap or a pedicle flap,” Rich and colleagues stated.

Certain postoperative factors also predicted worse patient outcomes. Need of additional surgeries was associated with higher 30-day complication rates (OR 5.40, 95% CI 3.09-9.43) and functional decline at 90 days (OR 2.94, 95% CI 1.81-4.79). For functional decline, the investigators found that 11% of patients who were independent at baseline had declined to a dependent status by 90 days post-surgery.

Flap failure was associated with a high 90-day mortality risk (OR 3.56, 95% CI 1.47-8.92), but the investigators “demonstrated that the type of flap (free vs pedicle) was not independently associated with higher risk of 30-day serious complications, 90-day mortality, or 90-day functional decline.”

Importantly, Rich’s group identified clinically important, preoperative variables including age, BMI, comorbidity, and frailty to create a risk stratification system that could help quantify individual patient risk for worse rates of complications at 30 days and mortality at 90 days.

Using this system, the researchers were able to categorize patients in class I, II, and III for 30 and 90-day complication and mortality risk.

“After controlling for other risk factors, patients in classes II and III had higher risk for 30-day complications and 90-day mortality as compared with patients in class I,” the authors wrote, “while only class III patients were at higher risk for 90-day functional decline after controlling for other risk factors.”

In an invited commentary, Steven Cannady, MD, of the University of Pennsylvania in Philadelphia, and Alexandra Kejner MD, of the University of Kentucky in Lexington, reiterated that the findings represent a “major contribution” to the literature on flap surgery in the elderly, noting that “to assemble 17 institutions and produce such an in-depth study with lengthy data collection requirements and thorough analysis is complex, commendable, and powerful.”

They also suggested that the findings will leave an indelible mark on patient counseling, although as reconstructive surgeons, they felt it was important to ask how they should use this information and whether class III patients should perhaps not be offered surgery at all or only a specific type of surgery.

In an accompanying viewpoint, Zhen Gooi, MD, and Everett Vokes, MD, both of the University of Chicago Medicine, called this study on the “so-called super-old” timely and said subjecting such patients to the stressors of major surgery is as much an ethical issue as it is a medical one.

“In the case of an elderly patient facing a malignant condition, a healthcare treatment preference to remove the cancer may incur a substantial price on the patient’s overall health goals to preserve their quality of life,” they pointed out.

Gooi and Vokes also questioned what the right course might actually be for elderly patients who are frail and at high risk for surgical complications and mortality. “In very elderly individuals who have already greatly exceeded mean life expectancy, perhaps quality-of-life measures should be the true gauge in determining what constitutes effective treatment, even if the goals of care are non-curative,” they observed.

“Ultimately, the maxim of primum non nocere should be the guiding principle in the case of these patients,” they concluded, calling the new evidence-based data from Rich and colleagues “a most welcome addition to the oncology field.”

For their study, Rich’s group included 376 patients from academic centers in the U.S. to examine factors associated with 30-day serious complication rates as well as the risk of both functional decline and mortality at 90 days. Inclusion criteria were patients 80 years and older undergoing free tissue transfer or pedicle flap reconstruction from 2015 through 2017.

Length of time for surgery and surgeries involving the maxilla, oral cavity, or oropharynx were also associated with worse outcomes at 30 and 90 days following surgery.

Moderate to severe comorbidities were defined as an Adult Comorbidity Evaluation-27 score of 2 to 3, while high frailty was defined as a Modified Frailty Index score of 0.25 or above. At 30 days, serious complications were reported in 51.3% of the group overall. Free flap failure rate in this study was 3.6%, similar to that seen in younger patients, the group noted.

Rich had no conflicts of interest to declare.

Cannady reported conducting a clinical trial on flap monitoring funded by Sonavex while Kejner reported receiving a research grant from ViOptix.

Gooi had no conflicts of interest to declare but Vokes reported receiving fees from AbbVie, Amgen, AstraZeneca, Bristol-Myers Squibb, Celgene, Eli Lilly, EMD Serono, Genentech, GlaxoSmithKline, Merck, Novartis, and Regeneron.


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