Patient-centered time-at-home outcomes in older adults after surgical cancer treatment
Chesney TR, Haas B, Coburn NG, Mahar AL, Zuk V, Zhao H, Wright FC, Hsu AT, Hallet J; Recovery After Surgical Therapy for Older Adults Research–Cancer (RESTORE-Cancer) Group. JAMA Surg. 2020; 155(11):e203754. Epub 2020 Oct 7. DOI: https://doi.org/10.1001/jamasurg.2020.3754
Importance — Functional outcomes are central to cancer care decision-making by older adults.
Objective — To assess the long-term functional outcomes of older adults after a resection for cancer using time at home as the measure.
Design, Setting, and Participants — This population-based cohort study was conducted in Ontario, Canada, using the administrative databases stored at ICES (formerly the Institute for Clinical Evaluative Sciences). The analysis included adults 70 years or older with a new diagnosis of cancer between January 1, 2007, and December 31, 2017, who underwent a resection 90 days to 180 days after the diagnosis. Patients were followed up until and censored at the date of death, date of last contact, or December 31, 2018.
Main Outcomes and Measures — The main outcome was time at home, dichotomized as high time at home (defined as ≤14 institution days annually) and low time at home (defined as >14 institution days) during the 5 years after surgical cancer treatment. Time-to-event analyses with Kaplan-Meier methods and multivariable Cox proportional hazards regression models were used.
Results — A total of 82 037 patients were included, with a median (interquartile range) follow-up of 46 (23-80) months. Of these patients, 52 119 were women (63.5%) and the mean (SD) age was 77.5 (5.7) years. The median (interquartile range) number of days at home per days alive per patient was high, at 0.98 (0.94-0.99) in postoperative year 1, 0.99 (0.97-1.00) in year 2, 0.99 (0.96-1.00) in year 3, 0.99 (0.96-1.00) in year 4, and 0.99 (0.96-1.00) in year 5. The probability of high time at home was 70.3% (95% CI, 70.0%-70.6%) at postoperative year 1 and 53.2% (95% CI, 52.8%-53.5%) at postoperative year 5. Advancing age (≥85 years: hazard ratio [HR], 2.11; 95% CI, 2.04-2.18); preoperative frailty (HR, 1.74; 95% CI, 1.68-1.80); high material deprivation (5th quintile: HR, 1.25; 95% CI, 1.20-1.29); rural residency (HR, 1.14; 95% CI, 1.10-1.18); high-intensity surgical procedure (HR, 2.04; 95% CI, 1.84-2.25); and gastrointestinal (HR, 1.23; 95% CI, 1.18-1.27), gynecologic (HR, 1.31; 95% CI, 1.18-1.45), and oropharyngeal (HR, 1.05; 95% CI, 0.95-1.16) cancers were associated with low time at home. Inpatient acute care was responsible for 76.0% and long-term care was responsible for 2.0% of institution days in postoperative year 1. Inpatient days decreased to 31.0% by year 3, but days in long-term care increased over time.
Conclusions and Relevance — This study found that older adults predominantly experienced high time at home after resection for cancer, reflecting the overall favorable functional outcomes in this population. The oldest adults and those with preoperative frailty and material deprivation appeared to be the most vulnerable to low time at home, and efforts to optimize and manage expectations about surgical outcomes can be targeted for this population; this information is important for patient counseling regarding surgical cancer treatment and for preparation for postoperative recovery.