Kate O'Rourke

March 07, 2016

BOSTON — Patients older than 65 years who experience serious perioperative complications from cancer surgery and who survive 6 months have significantly decreased long-term survival compared with those who do not have serious perioperative complications, according to results from a new study.

Researchers say the findings show that surgeons should be careful about premature celebration.

"Thirty-, 60-, 90-, and even 180-day measures of mortality do not capture the full impact of complications on long-term survival," said Hari Nathan, MD, PhD, a surgeon at the University of Michigan Health System, Ann Arbor.

Short-term survival is not a great indicator of how a patient will do down the road when serious complications arise from surgery.

Dr Nathan presented the study here at the Society of Surgical Oncology (SSO) 2016 Cancer Symposium.

He explained that research has indicated that high-mortality hospitals and low-mortality hospitals do not differ much with respect to the occurrence of complications; rather, they differ in how promptly and efficiently those complications are handled (N Engl J Med. 2009;361:1368-1375).

The phenomenon of inefficiency is known as the failure to "rescue." In recent years, researchers have focused on the ability to rescue patients and prevent short-term mortality.

In the new study, Dr Nathan and colleagues assessed the incidence of complications after cancer resection in elderly patients and the impact of those complications on long-term survival.

"The question we ask is whether rescue tells the whole story for cancer patients, or, in other words, is getting the patient through the operation a cause of premature celebration in surgical oncology," said Dr Nathan.

In a question-and-answer session that followed the presentation, Bridget Fahy, MD, a surgical oncologist at the University of New Mexico, in Albuquerque, who was not involved with research, called the study "super important."

The researchers analyzed data from the Surveillance, Epidemiology, and End Results Program–Medicare database from 2005 to 2009. They focused on patients aged 65 years or older who underwent curative-intent surgery for esophageal (n = 965), lung (n = 12,395), and pancreatic cancer (n = 1966).

The team used cox proportional hazards models with risk adjustment for age, sex, comorbidity, stage, and procedure. A serious complication was defined as one requiring a length of stay in the hospital of greater than the 75th percentile for that procedure. Serious complications ranged from 10% to 17%; 30-day mortality rates ranged from 3% to 6%.

Table. Complication Rates and 30-Day Mortality for Curative-Intent Surgeries

  Esophageal Cancer Lung Cancer Pancreatic Cancer
Mild complications 21% 8% 11%
Serious complications 17% 10% 12%
30-Day mortality 6.2% 3.3% 3.9%

 

In analyzing the survival of 30-day survivors only, patients who had serious perioperative complications had a significant decrease in 5-year survival compared with those with mild or no complications, after adjusting for sex, age, and procedure code. This was true for all three malignancies: esophageal cancer (hazard ratio [HR], 2.55), lung cancer (HR, 2.13), and pancreatic cancer (HR, 1.57). A similar trend was seen for patients who survived for 60 days, 90 days, and 180 days.

"We see a very consistent story that even going out to 6 months, patients with serious perioperative complications have decreased long-term survival compared with those who did not have a perioperative complication," said Dr Nathan.

The results defy conventional expectations, he suggested.

"At 6 months, you would think that all of those lingering effects of the perioperative complications should have washed out, and yet, even at 6 months, those patients who have a serious complication have decreased long-term survival."

Further analysis showed that patients who did not experience serious complications received chemotherapy at about twice the rate of those who did. Even taking this into account, patients with severe complications still had decreased survival.

"Although chemotherapy receipt does explain part of our findings, it does not explain all of them, and there is still a persistent impact of perioperative complications on long-term survival," said Dr Nathan.

He said the study emphasized the importance of appropriate patient selection for complex surgical procedures and demonstrated the need for improvements in quality metrics. "I think our work has important implications for quality assessment," Dr Nathan added.

"I think in cancer surgery in particular, we have to get away from these short-term metrics of survival. We have to think about the implications of complications for long-term survival, even if at a very-high-quality hospital, we are good at salvaging those patients who do experience those complications," he added.

Dr Fahy emphasized that the potential impact of surgery and complications on mortality should be discussed with patients. "Patient selection really starts with informed consent and an understanding of patient goals," she said. She also advocated for more patients receiving a palliative care consult.

Dr Nathan and Dr Fahy have disclosed no relevant financial relationships.

Society of Surgical Oncology (SSO) 2016 Cancer Symposium: Abstract 81, presented March 5, 2016.

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