Updates in surgical oncology from SIOG 2020

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Published: 2 Nov 2020
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Dr Isacco Montroni - Ospedale per gli Infermi, Faenza, Italy

Dr Isacco Montroni speaks to ecancer about the updates in surgical oncology from the SIOG 2020 meeting.

He explains that part of the main updates relate to the impact of the COVID-19 pandemic on the surgical care of cancer patients and the worry that there will be more mortality due to delayed diagnosis.

Dr Montroni notes some bright news in that there has been a high rate of applications to join the SIOG surgical task force, showing that more and more people are interested in caring for geriatric cancer patients.

He also highlights a number of important pieces of literature for surgical oncology in geriatric patients.

We focussed our updates on four major things: two are substantial facts that happened over the last year and one is, as you know, the impact of COVID-19 in the surgical care of cancer patients. What we saw was that, first of all, we will have to deal with delayed diagnosis in our service; I’m a colorectal surgeon, as I said, but in every surgical service. So there is a chance that we have to deal with more advanced cancer coming up so with increased mortality and decreased overall survival because of delayed diagnosis.

Second of all, unfortunately the fear that COVID put into surgeons and scientists forced many people to come up with unclear or not exactly evidence-based guidelines, above all during the first months of the pandemic so that suboptimal treatment of cancer was unfortunately performed. We have proof of that and also we have attended a number of publications when, above all four, the fear that minimally invasive surgery could have been related to spreading the virus led surgeons to perform the wrong procedure or the suboptimal procedure, mostly out of fear for what we didn’t know and what we now know slightly better. But that left a scar in the treatment, in the surgical treatment of cancer patients for months.

There is also great news coming from the surgical fields. Number one is that more and more people are interested in caring for geriatric cancer patients, as we have seen in the rates of the number of applications for joining the SIOG surgical taskforce. Not just in number but on the quality of the member that we are incorporating now, which is young and eager scientists who really want to improve the care of geriatric patients.

But also we had two very important pieces of literature coming up. One comes from the Memorial Sloan Kettering Cancer Centres and Armin Shahrokni, a geriatrician and medical oncologist, is the first author but this is a substantial publication for every surgeon. Because what it was able to show is that adding a geriatrician into the surgical care of older cancer patients improves mortality of an astonishing 57% over the first three months after surgery. He basically compared a group of patients treated at the Memorial Sloan Kettering, which is an excellent centre, undergoing cancer surgery from excellent surgeons but they had only surgical care after, only carried out by surgeons, to a group of patients who, instead, not only had great surgeons taking care of them but they had the add of geriatricians of Armin’s team. Again, despite the same amount of complications in the post-op period, the group of patients who were treated by a geriatrician had a way better survival at three months. This is unprecedented and it’s an important piece of data because it established the highest cut in mortality that we have been witnessing in recent care.

The last publication I wanted to speak, and then a hypothesis, is about prehabilitation. We presented data from McGill University and Professor Carli who ran a randomised controlled study comparing a group of patients, of frail patients who had colorectal cancer surgery, before a prehabilitation programme. Comparing this group to a group of patients who didn’t undergo prehabilitation but just had rehabilitation, so after surgery. He was not able to show a cut in the complication rate in the group who underwent the prehabilitation protocol before the procedure.

Now, there is high expectation on the role of prehabilitation above all in older and frail patients. But what prehabilitation is showing more and more is that it’s a system that helps you not just cutting complications but it helps people going back to their independent site of living that they had before the surgery. So in one word it promotes functional recovery and not just a cut in the complication rate.

Now, based on this publication and based on Armin’s publication on what is called geriatric co-management, we are reaching a point that we see that in order to treat older cancer patients there is not one magical ingredient that you have to have to add to the recipe in order to make it magical. But there are a number of instruments, a number of strategies, that you have to put in place at all times. So starting from a good, early diagnosis, to frailty assessment, to prehabilitation, to optimally adjuvant chemoradiation therapy when needed, to optimal surgery carried out minimally invasive when possible, to rehabilitation and having a geriatrician helping you in a geriatric co-management and then, again, medical oncologists titrating adjuvant treatment and physical therapies for your rehabilitation and case managers that can help guiding you throughout all of the process, then you put in place a multiphase, multidisciplinary system that really can add on to the final outcome which is, for older patients, an improved quality of life and an improved functional recovery. So it’s not just one ingredient but we’re talking about an entire recipe that we need to embrace and put in place in order to improve our standards of care.

How can the papers presented at SIOG have an impact on the future of medical oncology, especially in terms of geriatric oncology?

The Memorial Sloan Kettering manuscript has a direct impact, immediate, because it tells you that you have to add a geriatrician in your care, in your surgical care, of geriatric cancer patients. This is simple, quote-unquote, when it comes to scientific questions adding a geriatrician helps. It’s less simple when you practically have to add somebody and you need to convince not only surgeons that they need a new collaborator, there’s a new cook in the kitchen, but also administration to hire these people and that’s not simple. It’s not simple but we now have evidence that it’s mandatory, it’s needed, because it really improves our patient’s life, it really saves lives, at least from the data that we presented. So that’s a practical, immediate thing that you should do.

Then we added a piece of literature, Nicole Saur and the ACRS  group showing that it’s also possible on an economical base, showing us a business case to hiring a geriatrician and that’s a publication from BCR that recently came out. So, again, Nicole Saur presenting the business case for hiring a geriatrician in high level institutions in order to improve your outcomes.

Carli’s manuscript also has direct implications because it tells you that it’s not just one thing that you need to implement but if you wanted to embrace the care of older patients you need a number of systems, a number of pathways in place. It’s not, again, just one thing but it’s a number of people that need to work together. So that also adds an immediate impact that when we think about these programmes or these projects because we now know that without everybody we cannot achieve our ultimate goal.

There are new data coming out about functional recovery and about quality of life in geriatric patients as soon as the GOSAFE final result will come out. The GOSAFE is a real world prospective multicentre study that is just focussed on quality of life and functional recovery in older patients affected by cancer who had major surgery. We are all eager in the scientific community to be able to share this data once and for all because, again, we have focussed our research this time on what are called patient-reported outcomes. So those outcomes that really matter to patients so that we will be able to show how surgical care can actually improve patient reported outcomes, can improve quality of life. That will be not a historic event but a very important event because it will help us also not just in the discussion with our patient where we can present data about a topic that was neglected before, but it also can improve the level of personalising surgical care because it can tell you that doing this type of procedure will improve patients’ quality of life rather than the opposite.