Correlation of Preoperative Geriatrics 8 Score and Postoperative Complications in Older Adult Patients with Head and Neck Cancer: A Prospective Observational Study

Introduction

The care of older adult patients with head and neck cancer is a growing challenge for otolaryngologists. Overall, the world is experiencing a growth in the population aged ≥ 65 years, which is predicted to be above 1.5 billion by 2050 [1]. In Thailand the population of older adults increased from 17.6% in 2018 to 18% in 2020 [2], and the number of head and neck cancer cases also increased in this group. Standard treatment for head and neck cancer generally involves major surgery, which is accompanied by concerns regarding postoperative complications in older patients, because of underlying disease and physiological changes that affect capacity to tolerate stress, particularly in those with advanced stage tumors.

Chronological age alone is not a reliable predictor of postoperative complications, as it does not capture the physiological heterogeneity in the older adult population [3, 4]. Hence, in the absence of appropriate tools to predict patient prognosis, treatment plans tend to deviate from standard guidelines, due to age-related patient factors.

To identify older adults who are fit to undergo surgery and those who need special care, preoperative assessment tools are essential. There are concerns that the traditional assessment conducted for all patients is insufficient to predict postoperative complications in older adults. Frailty is a term used to describe older adults with limited overall reserve to withstand stressors, representing a state of reduced physiological reserves associated with increased susceptibility to disability [5]. By definition, a frail individual is highly susceptible to poor healthcare outcomes. The Comprehensive Geriatric Assessment (CGA) for frailty has been recommended by The Society for International Oncology in Geriatrics for administration to older patients who are receiving cancer care [6]. The CGA is a multidimensional, multidisciplinary process, including assessment of physical, functional, co-morbidity, cognitive, nutrition, polypharmacy, social support, and mental status, as well as evaluation of mobility/balance, and is time consuming to administer [7, 8]. Bellera, et al. [9] reported a Geriatric 8 (G8) score cut-off value of 14 for older adult patients with cancer who were scheduled to undergo chemotherapy, with sensitivity of 85% relative to a reference exam, consisting of seven comprehensive geriatric assessment questionnaires. The G8 has the advantage of being relatively simple to administer; however, the predictive value of the G8 score for postoperative complications following surgery has yet to be explored. Many studies have reported high accuracy for prediction of postoperative complications in treatment of other cancers [10, 11, 12]; however, some reports suggest that the G8 may not be a useful predictive tool [13], and there have been few studies of application of the G8 in patients undergoing surgery for head and neck cancer. So the G8 score is chosen for study of feasibility to be a preoperative assessment tool instead of CGA in the situation of large workload in everyday practice.

The objective of this study was to examine the correlation between preoperative G8 score and major postoperative complications in older adult patients with head and neck cancer that whether can apply for practical routine assessment or not.

Results

A total of 104 cases were included in the study, with mean age 68.84 ± 6.99 years and 71 (68.3%) were male. Among patients, 68 (65.4%) had a history of underlying disease, of which were 46 (67.6%) had hypertension, 21 (30.9%) diabetes mellitus, 17 (25%) dyslipidemia, 12 (17.6%) pulmonary disease, 5 (7.4%) cardiovascular diseases, and 8 (11.8%) others conditions. Overall mean BMI was 22.21 ± 4.3 kg/m2. Further, 53 (51%) and 67 (64.4%) patients had histories of alcohol consumption and smoking, respectively. Regarding cancer site, 56 cases (53.8%) had oral cancer. Advanced stage was present in 86 (82.7%) cases, reconstruction operations were mainly non-free flap (97 cases; 93.3%), and mean duration of operation was 5.31 ± 2.41 h and > 4 h in 75 (72.1%) cases. American Society of Anesthesiologists score was < 3 in 78 (75%) cases and G8 score was ≤ 14 in 73 (70.2%) cases, who were defined as the frail group. Patient characteristics are summarized in Table 1.

The major complications which were Clavien-Dindo grade VI-V were death in 2 cases, septic shock in 8 cases, myocardial infarction in 2 cases, upper airway obstruction due to bilateral vocal cord paralysis in 2 cases and pneumothorax in 1 case. All of Clavien-Dindo grade III was complications of surgical wound that needed debridement in 15 cases as shown in (Table 3).

Discussion

Care of older adult patients with head and neck cancer undergoing planned resection of primary cancer is challenging due to increases in the number of patients and high rates of postoperative complications. In many centers, routine preoperative assessment of the fitness of older adult patients scheduled for surgery for head and neck cancer is the same as that used for the general population, and does not categorize patients according to frailty. The objective of preoperative assessment is to identify older adult patients who are at risk of post operative complications and need intensive care, or to inform reconsideration of the surgical management plan. All of the older adult patients who participated in this study were evaluated as low to intermediate risk by routine preoperative assessment; however, the complication rate differed among groups. The CGA [16] is accepted as the standard of care for evaluation the status of older adult patients and comprises a set of six questionnaires: Activities of Daily Living, Instrumental Activities of Daily Living, 4-item Geriatric Depression Scale, Mini Mental State Examination, Mini Nutritional Assessment Short Form, and questions about any falls in the previous year. CGA results are considered abnormal when a patient has an impaired score on at least one questionnaire. The CGA is time consuming in practical application, whereas the G8 takes 3–5 min to administer and consists of seven items, dealing with food intake, weight loss, mobility, neuropsychological problems, BMI, prescription drugs, and self-perception of health which making it simpler to apply in practice [17].

The main finding of the present study was that G8 score ≤ 14 can predict postoperative complications, underlining the practical utility of this alternative preoperative assessment method for older adult patients. Conventional assessment of the older adults scheduled for surgery to treat head and neck cancer in our department indicated that they were all low risk for surgery; however, we found that 70.2% of patients were classified as frail, which was higher than expected, as the patients had already been selected for surgery by traditional assessment. Handforth, et al. reported that median overall prevalence of frailty across studies that identified frailty using the CGA was 43% (range 7%–68%) [18, 19]. In this study, patients in the frailty group according to G8 score had higher rates of complication than those in the non-frailty group, consistent with previous reports [18, 19, 20, 21], including a recent investigation by Nakayama, et al. [21] of older adults patients undergoing free-flap reconstruction following head and neck cancer [22].

As our department is a super-tertiary center that performs a high volume of surgery for cases with head and neck surgery annually, a preoperative assessment tool that can predict postoperative outcomes is important for making appropriate care plans to prevent postoperative complications in older adults who experience surgical and non-surgical complications. Non-surgical complications, such as postoperative delirium, heart failure, myocardial infarction, and pneumonia, are usually of less concern in patients with normal results of physical assessment, such as ECG, blood chemistry, and chest x-ray. Here, we report application of an additional assessment tool in older adult patients with head and neck cancer, which provides more information for otolaryngologists and other team members to inform counselling regarding morbidity and mortality from surgery and individual treatment plans; for example, reconsideration of surgical plan or preparation of a multidisciplinary team for intensive care during the postoperative period.

This study has limitations. The study subjects included few cases of free-flap reconstruction, which involves an extended operation duration and severe stress for older adult patients; therefore, it is unclear whether G8 score can predict postoperative complications under these circumstances. Further the variation in cancer sites and surgeons included in this study may have influenced the observed complications and should be controlled for in future investigations.

Conclusion

G8 score is a geriatric assessment tool that can be applied for routine preoperative evaluation of older adult patients with head and neck cancer to predict postoperative complications and inform management plans for those classified in the frail group, with the aim of reducing postoperative morbidity and mortality.

Acknowledgements

We thank all staff members at the Division of Medical Research, Rajavithi Hospital and acknowledge publication of a preprint on MedRxiv, the preprint server for health sciences.