Prostate Cancer Surgery Complications More Likely Among Older Men

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Patient age 70 years and above is an independent risk factor for perioperative morbidity, according to data from a national cohort.
Patient age 70 years and above is an independent risk factor for perioperative morbidity, according to data from a national cohort.

Prostate cancer (PCa) patients aged 70 years and older who undergo radical prostatectomy (RP) experience significantly higher rates of perioperative morbidity than those younger than 60 years, according to a new study.

The study, which included 35,968 men aged 18 to 89 years who underwent RP from 2010 to 2015 in the National Surgical Quality Improvement Program (NSQIP) database, found that the perioperative blood transfusions rates were 6.0% among patients aged 70 to 89 years compared with 3.7% among those younger than 60 years, a team led by Boris Gershman, MD, of The Miriam Hospital and Brown University in Providence, Rhode Island, reported in Urologic Oncology. The older group also had higher rates of 30-day complications (6.4% vs 4.4%), readmissions (4.9% vs 3.9%), and 30-day mortality (0.3% vs 0.1%). The most common complications overall were infectious complications (2.4%), followed by surgical site infection/wound complications (1.5%), and thromboembolic complications (1.1%).

In multivariable analyses, patients aged 70 to 89 years had a significant 31% increased risk of any complication, 39% increased risk of requiring a blood transfusion, and 2.7-fold increased risk of 30-day mortality, according to the investigators.

“These results have implications for preoperative risk-stratification and counseling given potential for increased utilization of surgery as definitive local therapy for older men,” the authors wrote. “Moreover, they identify patients for whom perioperative interventions may reduce morbidity.”

They noted, for example, that closer follow-up after surgery with telephone calls or nursing visits may decrease readmission rates or preventable complications.

The study's finding of a nonlinear relationship between age and perioperative outcomes, with increasing rates of 30-day complications, readmission, and blood transfusion beginning at about age 70 years, “suggest that even after adjusting for patient features including comorbidities, older age remains an independent risk factor for perioperative morbidity,” Dr Gershman's team wrote. “In this context, age may reflect the generally decreased physiologic reserve (i.e., fraility) of older patients.”

In a discussion of study limitations, the investigators noted that they were unable to adjust for a number of clinicopathologic characteristics not available in the NSQIP database, including pathologic features that reflect case mix, socioeconomic status, hospital and surgeon volume, and preoperative functional assessment. The team also could not assess complication severity using Clavien grading. Information about specific complications such as lymphocele formation, urinary leak, and anastomotic stricture were not contained in the NSQIP and therefore could not be assessed.

In addition, the investigators did not examine oncologic or functional outcomes or endpoints beyond 30 days postoperatively, “which are relevant for patients counseling and treatment selection.” Lastly, Dr Gershman and his colleagues noted, their results may reflect selection bias related to the decision to pursue surgical intervention in older men, “as RP may be preferentially offered to healthier older men.”

Reference

Pereira JF, Golijanin D, Pareek G, et al. The association of age with perioperative morbidity and mortality among men undergoing radical prostatectomy. Urol Oncol. doi: 10.1016/j.urolonc.2017.11.019

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