Cancer

Introduction

Surgical intervention may not be appropriate in frail patients with new or recurrent bladder cancer. To ensure that their care is aligned to the principles of ‘Realistic Medicine’, we developed a structured programme of joint management between our Peri-Operative care of Older People undergoing Surgery (POPS), Anaesthetic and Urology teams. This analysis examines our experience.

Method

Patients listed for surgery and deemed to be frail at initial screening, underwent Comprehensive Geriatric Assessment, an anaesthetic review (if indicated) and surgical evaluations. Validated measures of frailty, cognition and function were used. Each patient had a joint consultation with a bladder cancer and POPS specialist. Patient details, clinical metrics were recorded prospectively on a POPS database, with clinical follow-up records maintained electronically.

Results

From a total of (approximately) 460 suspected or confirmed bladder cancer patients, 100 were reviewed in the joint POPS-bladder cancer specialist clinic between January 2017 and early January 2024. Moderate/severe frailty was noted in 55%. Only 23% of patients proceeded with their intended surgery (GA cystoscopy/TURBT/cystectomy). Most patients opted for no operative intervention instead choosing best supportive care (45%), repeat flexible cystoscopy (17%) or repeat diagnostics (14%). Over the follow up period (median 4 years), of those who opted for no operative intervention, most did not need to change from the recommended plan; 5% of patients required an emergency admission (bladder washouts only).

Conclusions

This novel joint working with POPS and bladder cancer specialists appears to be a safe, comprehensive, and patient-centred approach to the effective and efficient management of frail patients with bladder cancer. It allows various important factors to be carefully considered and balanced including frailty, patient priorities, symptom burden and tumour size/grade/number. This model of care means selected patients could avoid the burden of unnecessary procedures and surveillance.

Background: Prostate cancer and bladder outlet obstruction, often treated surgically, are increasing in the aging population, leading to more cases of stress urinary incontinence (SUI). While implantable continence devices are beneficial for many, a growing number of frail patients are unsuitable for surgery and rely on incontinence pads or penile clamps, which are limited to three-hour use to prevent tissue ischaemia. We present the first UK evaluation of the new PaceyCuff penile clamp, designed for 24-hour wear while maintaining blood flow, to assess its efficacy, safety, and impact on patient quality of life.

Methodology: Men with urodynamically-proven SUI were identified. Baseline penile and finger peripheral oxygen saturation (SpO2), three-hour pad weight, 24-hour pad count and patient-reported outcomes (ICIQ-UI, QoL) were measured. Participants were then fitted with the PaceyCuff, and reassessed immediately, at three hours post-application and (via telephone) after two weeks.

Results: 13 men (average age 74, range 62-82) were recruited. ICIQ-UI scores decreased from 17 to 10, and QoL scores from 13 to 9. Average three-hour pad weight dropped from 94g to 10g and daily pad usage decreased from 4 to 0.9 pads. Participants reported good tolerance, with an average pain score of 1.8/10 and only 2 minor adverse effects (skin abrasion, transient pain). Penile SpO2 remained stable before, immediately after, and three hours post-use (76%, 82%, and 81% respectively). Sub-group analysis of patients over the age of 80 (n=4) confirmed equal effectiveness. (ICIQ-UI decreased 18 to 10, QoL decreased 13 to 9, three-hour pad weight decreased 77g to 9g, daily pad usage decreased 4 to 1.5 pads, average pain 1.5/10).

Conclusions: The PaceyCuff has demonstrated both efficacy and tolerability in managing SUI in a UK cohort for the first time and offers a potential treatment option for elderly patients ineligible for surgical intervention.

Introduction:

The prevalence of older patients with Colorectal Cancer (CRC) is increasing. While surgery can offer benefits, older patients living with frailty undergoing Colorectal Surgery are more at risk of postoperative mortality and complications. The literature suggests comprehensive geriatric assessment (CGA) pre-operatively enhances shared decision making (SDM), equity of access to surgery, length of stay (LOS) and mortality. Our aim is to evaluate how a joint Geriatrician/Anaesthetic pre-assessment clinic would impact outcomes for elective colorectal surgery in older patients.

Method:

Patients aged >= 65 years had a CGA as part of the pre-operative assessment when undergoing Colorectal Surgery between September 2021 to December 2023. Data including Clinical Frailty Score (CFS), LOS, P-POSSUM Score, medication reconciliation, A&E Re-admissions and 30-day and 90-day mortality was analysed.

Results:

197 patients were seen over 28 months. 147 (75%) of patients underwent surgery and 50 (25%) declined after SDM. 30-day and 90-day mortality was 0% and 0.5% respectively. The average age was 80 (65-94), compared to 74 (65-88) prior to clinic inception. The median CFS was 4. LOS with CFS <=4 averaged 7.7 days and CFS >=5 averaged 16.5 days (t-test -4.88, p 9.91e-06). 12 new diagnoses (5%) were made. Common diagnoses included Dementia and Atrial Fibrillation. 123 referrals were made, accounting for 49% of the cohort. 22% of the cohort’s medication were altered (16% of which were deprescriptions). A&E Reattendance was 18%, compared to 29% in other studies. 0 patients required ICU admission.

Conclusion:

Perioperative Frailty Involvement for patients undergoing CRC Surgery greatly improves outcomes and reduces postoperative mortality following Colorectal Surgery. CFS, LOS and P-POSSUM Score are major predictors of poor postoperative outcome in this population. There has been a reduction in A+E admissions and onward referrals. Further work needs to be completed on the financial implications and impact on other surgical specialties.

Introduction

The ongoing rise in prostate cancer rates and consequent prostatectomy have led to an increase in rates of male stress urinary incontinence. ATOMS is an adjustable sling requiring no manual input and suitable for frailer patients. We investigated the long term efficacy of the ATOMs in managing SUI and performed a subanalysis within the geriatric population (aged 75+).

Method

69 men (mean: 70.2, range 50-81) underwent an ATOMS insertion between 2015-2019. Follow up data for up to 9 years were analysed (mean: 5.8, range 5-9 years). Out of the 69 men in the original cohort, 19 were aged 75+ (mean: 76.5, range: 75-81). 17 had SUI post radical prostatectomy, 1 post TURP and 1 post AP resection.

Results

Out of the 19 men, 14 (74%) were dry post ATOMs implant insertion (ie using maximum one pad per day for reassurance). This rate is lower compared with the original cohort (79.7%). The average number of top ups to achieve dryness was 3 (same as the initial cohort). Out of the 14 men who remained incontinent in the initial cohort, 5 were 75+. Of these, 2 reported a significant improvement in their incontinence without meeting the ‘dry’ criteria. 1 had his ATOMs device removed due to infection. 1 was switched to an artificial urinary sphincter. 1 remains incontinent and is being managed with botox injections. There were no cases of mechanical failure.

Conclusions

ATOMS appears to be an efficacious and safe procedure in the geriatric population, with only marginal difference in dry rates compared to the non-geriatric cohort. The main benefit over an artificial sphincter is that it exerts a passive effect to prevent incontinence and requires no patient input for every void. This is especially prudent as geriatric patients may lose hand dexterity or cognitive ability over time.

Introduction

It is increasingly recognised within oncogeriatrics that standard fast-track pathways for suspected malignancy can be inappropriate for frail and elderly patients (Thomas et. al.; Age and Ageing; 2021; 50; ii8-ii13). Specifically for colorectal referrals, following standard pathways can mean undergoing invasive and expensive endoscopic investigations which may be unwanted and not alter overall management. Streaming frail patients to elderly medicine may increase opportunities for comprehensive geriatric assessment whilst reducing unwanted invasive tests and time spent on fast-track pathways.

Methods

A 3-month retrospective audit of frail patients seen in colorectal fast-track clinic was conducted to evaluate existing practice at Bradford Teaching Hospitals. This informed the design of a new pathway streaming frail patients directly to elderly clinic within 2 weeks. This was implemented in a 3-month pilot with data prospectively collected to compare outcomes. Cohorts:
- 26 patients (median age 79, WHO performance status 3) seen by colorectal team March-June 2022.
- 20 patients (median age 85, WHO performance status 2) streamed to elderly medicine clinic October 2022- March 2023.

Results

- Median time to fast-track pathway removal was 62 days for patients managed via colorectal clinic compared to 31 days via elderly medicine.
- Invasive tests and imaging (CT/endoscopy) fell from 1.4 tests per patient in colorectal clinic to 0.4 patients in the pilot. - 2 diagnoses of cancer made via colorectal clinic, but no further treatment for either patient. 1 diagnosis of lung cancer in pilot group, patient undergoing radiotherapy.
- Patients seen in elderly clinic had greater rates of positive diagnosis for symptoms (eg: infective/iatrogenic).

Conclusions

Streaming frail elderly patients referred via colorectal fast-track to elderly medicine reduced the number of invasive investigations undertaken and time spent on fast-track pathways. Expanding this successful pilot could improve long-term clinical quality in the service and more widely if disseminated.

Introduction: In the cancer setting, Comprehensive Geriatric Assessment (CGA) reduces chemotherapy toxicity, improves QOL and increases advance directive completion (ASCO 2020: The Geriatric Assessment Comes of Age; Soto-Perez-de-Celis et al; The Oncologist). We wanted to look at whether CGA improved symptomatology, as patients attending our oncogeriatric clinic complained of a range of symptoms, related to their cancer, as well as other co-morbidities and frailty.

Methods: We retrospectively analysed follow up clinic letters of patients who had attended the oncogeriatric clinic, between June 2022 and June 2023. We used a Lirkert scale, to see whether symptoms they had complained of had 1 – got worse, 2 – stayed the same, 3 – improved or 4 – resolved.

Results: 32 patients with a wide range of malignancies were included. 59 patients were excluded because they: died before the 2nd appointment, did not require a second appointment, had their second appointment outside the analysis window, DNA or in 1 case the follow up letter could not be found. On average each patient complained of 3 symptoms. 30 different symptoms were noted (2 excluded as there was no mention of them in the 2nd visit.) The top presentations were pain, constipation, low mood, breathlessness, reduced mobility, falls and dizziness. 68% of the symptoms complained of showed improvement – including all the top presentations. The average score on the Lirkert scale was 2.76 78% of patients had shown improvement or resolution in at least some of their symptoms.

Conclusions: Our retrospective review shows that older, cancer patients, have a high burden of varied symptomatology, because of their cancer, co-morbidities and frailty. Attendance at an oncogeriatric clinic results in improvement in the symptom burden for the majority of older adults, and an improvement in some symptoms, whether they are related to cancer, or other frailty syndromes.

Introduction

Oncogeriatrics is relatively new concept aligning geriatric services with oncology, whereby older cancer patients have a comprehensive geriatrics assessment (CGA) to support oncology decision-making and improve outcomes and quality of care. Despite the rationale, evidence for effective oncogeriatric services are largely based upon specialist centres. We initiated a feasibility study February 2021, to establish criteria and pathway implications for an Acute Trust without oncology beds.

Method

Following an iterative process, a pathway was established between the Lung MDT and the established frailty unit. Patients with lung cancer who met criteria would be seen within a week and underwent a CGA by a frailty practitioner, consultant geriatrician, physiotherapist, occupational therapist. Referrals were made as appropriate to allied services eg dietician, pharmacy, continence teams etc.

Results

We refined the referral criteria and process, identifying the presence of a geriatrician at Lung MDT as key to ensuring incorporation of CFS (Rockwood) for effective MDT case discussion. Defining the cohort and pathway was challenging given the complex interplay of cancer symptom burden and comorbidity set against COVID, workforce pressures and cancer targets. Final referral criteria was age over 70, Rockwood 4 or more, a formal lung cancer diagnosis, and a plan to undergo active treatment. Referral numbers were low during the feasibility phase. Only 38 patients were referred and we saw 23 patients over a 2 year period. Referral rates increased in the final 3 months of the pilot although only 9 of 22 who met criteria were referred.

Conclusion

Establishment of an effective oncogeriatrics service is challenging. The feasibility study has established a baseline for potential activity and job planning. Analysis of individual patient benefit is ongoing. Longer term we aim to extend the service to support patients after treatment has started, provide prehab, and include patients with all types of cancer.

Introduction:

Faecal-immunochemical test is employed as a screening tool for colorectal cancer. Our observational study examined the FIT in primary care as a risk stratification tool in frail patients.

Method:

The records of 217 frail patients over a 24-month period were analysed. Patients with haematological indices of anaemia were offered FIT to detect GI haemorrhage as part of assessment for selection for lower GI investigations. Patients were risk stratified based on FIT results based on the presence or absence of red flags. Patients who were FIT positive were referred for urgent lower GI endoscopy versus those who were FIT negative were managed without bowel investigations unless there were red flags such as abdominal mass, changed bowel habits or family history of bowel cancer.

Results:

Of 217 patients over a 24-month period of these 42 patients (19.4%) were FIT positive. All of these (n = 42) underwent colonoscopy of which 9 (normal )18 ( colonic polyps ) 12 ( diverticulosis ) 3 ( colorectal cancer ). Of the 42 FIT positive patients 16 were on direct oral anticoagulant (DOAC). Patients on DOACs and those on dual anti platelet agents were more likely to be FIT positive. We also found a positive correlation between higher frailty indices, HAS BLED scores and chronic kidney disease and low creatinine clearance r=0.68, p=0.001. Despite the small numbers in this study the correlation is statistically significant.

Conclusion

There is a statistically significant positive correlation of FIT positive and frailty indices with DOACs, Dual anti platelet agents, CKD, low creatinine clearance ( r=0.68 and p=0.001 ). Following this the HASBLED scores increased, hence our practices implemented an enhanced surveillance of monitoring these patients quarterly due to the increased risk. We advocate frailty indices should be incorporated in the HAS BLED scores for improved patient safety.