BERKELEY, CA (UroToday.com) - Two fundamental changes will greatly impact the coming decades in health service in developed countries.
Firstly, the population is aging, and secondly, with an older population, the incidence of cancers will rise dramatically. More cancers mean more diagnostic and therapeutic approaches, which subsequently mean much greater outlays in a time where the public health care systems are on the verge of collapsing due to escalating costs. Saving money in a health service system seems feasible according to the Harvard Business School. “The cheapest and most effective way is to do it at the first time in the right way.“ Porter ME: Redefining competition in health care. Harvard Business Review, January 2011). It sounds very simple, but in reality it is quite difficult.
Medicine cannot and should not be reduced to simple economic principles. It is the patient and his illness that are the first priorities, and then the principal precepts of medical ethics: “First do not harm.“ This is in itself a real challenge if we look at old patients affected by invasive bladder cancer (BC). The peak incidence of BC is at 85 years, and this is the demographic that is increasing the most in the population (aged 85+ years). Age has been found to be an independent risk factor for the development of BC and is also connected with comorbidity. Aging itself results in a gradual, progressive loss of biological reserves necessary for the body to maintain physiological homeostasis under stress. This means that any kind of therapeutic approach targets a weakened body. The chronological age is not as important as the comorbidity for the decision-making process as shown in the recent publication of Mayr et al. (BJU Int. 2012 Feb). Currently a reliable risk assessment can be done with an accurate evaluation of the health status of the patient. Different tools are at our disposal to estimate the therapeutic risk such as: Adult Comorbidity Evaluation-27 (ACE-27), the Charlson Comorbidity Index (CCI), the Eastern Cooperative Oncology Group performance status (ECOG) and the American Society of Anesthesiologists (ASA) comorbidity scores. The simplest tool is surely the ASA score, with a good correlation with perioperative mortality in cystectomies in the elderly.
Nevertheless, octogenarians face many obstacles in receiving the right diagnosis in time, and then being directed to the right treatment. Handling the oldest patients however also means sometimes refraining from any kind of intervention. We physicians have to discuss not only the quality of life, but the quality of death if necessary, and it is the latter which we think is becoming more and more important. Thus we have to be prepared. We physicians are trained to treat with the intention to cure, and most frequently we are faced with patients younger than 75 years. For patients beyond age 75, we too often think that an intervention is not feasible and we should accept the natural history of the illness. But dying from BC is atrocious, and in our own series, we obtained disappointing results. Lodde et al. (Eur Urol. 47, 773-779; 2005) showed what happens when a conservative approach is chosen in potentially curable patients. 24 patients were treated with a trimodal therapy and then followed up. All patients complained of urgency, frequency, severe nocturia, and recurrent bleeding. The patient spent mean every fifth day at the hospital (days spent in nursing homes were not counted), in 16 cases, a salvage cystectomy due to bleeding was performed. We have seen intestinal occlusions, enterovesical fistulas, brain metastases and paraplegia caused by bone metastases. Only one patient experienced a peaceful death. We failed in giving our patients a good quality of life for the remaining life span, but we also failed in giving them a good quality of death.
Rational thinking is not driving our decision making process. Physicians avoid a curative approach with the following arguments:
- The comorbidity is too high to undergo radical cystectomy (RC);
- The competing comorbidity has a worse prognosis than BC;
- After radical cystectomy an assisted life in a social setting is not feasible;
- Full recovery after radical therapy is not probable;
- A more attending approach is equal regarding prognosis.
Is a systemic chemotherapy for BC maybe more appropriate in the? There are no reliable data available. Most data are taken from studies made on patients under 70 years and therefore lacking in evidence. Cisplatin-based chemotherapy, the most effective chemotherapy in BC, is associated with various toxicities such as nephrotoxicity, ototoxicity, neurotoxicity and vascular toxicity. The impaired physiological reserve in the elderly results in a dose reduction and a decreased efficacy of the chemotherapy. Nonplatinum-based chemotherapy has become an alternative for the elderly with BC despite its apparently inferior efficacy. In summary, a complete course of chemotherapy is as challenging as an RC. Therefore, in most cases, a suboptimal dose treatment is applied and leads to a disappointing result.
There is a substantial body of evidence that RC provides the best overall and cancer specific survival even in the eighth and ninth decade. However, most of the elderly with invasive BC will never be treated with RC. Hollenbeck et al. (Urology 64, 292-297;2004) showed that only 24,9% of septuagenarian with invasive BC are treated with RC. In the age group 80+ years, the rate drops to 11.5%, and when considering the cohort of >85 years the rate is 4%. 79% of octogenarians with invasive BC are treated with TUR alone. This implicates a cancer specific death within 5 years in 95% of the cases. It is true that the benefit of RC in octogenarians is less than in younger patients but the benefit compared to all other treatment options is 15 months as shown by Chamie et al. (BJU Int. 102,284-290;2008). If RC is performed in a N0 stadium then the survival benefit increases to 52 months, this provides one more reason not to delay diagnosis and definitive treatment. Advanced age itself should not be a reason for avoiding RC.
But everything has its price. Although mortality rates between 14-20% are historical, the RC carries a burden of substantial morbidity and mortality rates. Here we have to face another problem. Complications in the literature are not reported in a standardized fashion. Therefore studies are often not comparable. Not even the mortality rate is an irrevocable end point. There are different definitions: perioperative mortality, in-house mortality, short-term mortality, and 30-days mortality. Often the most favorable definition was chosen to lower the mortality rate. The intention was to give good results rather than true outcomes. With the widespread acceptance of the Clavien-Dindo Classification (Ann Surg 240: 205-213;2004) in the urological world, the real burden of RC becomes apparent, with complication rates up to 72% in octogenarians, in centres of excellence (Shabsigh et al. Eur Urol. 2009 Jan;55(1):164-74). But on analyzing the data in detail, it becomes evident that only 17% of the complications were grade 3 and 4, which were previously called “major complications.“ The mortality rates in different series oscillate between 1.2% to 12.7% (Morgan et al. J Urol. 186:829-834;2011) but compared to the patient group <65 years, the mortality in octogenarians was three times higher and the 90-days mortality in octogenarians 5.5 times higher than in patients younger than 65 years. It is evident that the older the patients are the higher the comorbidities are and as a consequence the mortality rate increases. The assessment of comorbidities is the key to the right indication for RC which can be cured, or at least palliated. In this context, clinical failures are often paid with lives, the lives of our patients. Therefore there is no room for error. Errors have to be avoided in a structural way creating environments where geriatric patients can be thoughtfully assessed, prepared, and assisted after surgery, and in a technical way guaranteed that the best and most experienced surgeons are performing RC following the latest standards available. RC in old and oldest patients is a team effort. We have to face this challenge in a proper and appropriate way, and we have to act in time. Otherwise we can only react to the major force, and this is only the second-best solution.
Armin Pycha and Evi Comploj as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc... of their research by referencing the published abstract.