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Key Points Question Is collaboration between geriatricians and surgeons in the perioperative care of older patients with cancer associated with postoperative outcomes? Findings In this cohort study including 1892 patients aged 75 years and older, the adjusted probability of death within 90 days after surgery was 4.3% for patients who received geriatric comanagement of care, compared with 8.9% for patients who received care management from the surgical service only. Meaning These findings suggest that when feasible, older patients undergoing surgical treatment for cancer should receive geriatric care comanagement as part of their perioperative care., This cohort study examines outcomes associated with geriatric comanaged perioperative care vs care managed by the surgery team alone among patients aged 75 years and older with cancer., Importance Collaboration between geriatricians and surgeons in the perioperative treatment of older patients has been associated with improved outcomes in several nononcologic specialties. Similar associations may be possible among older patients with cancer. Objective To investigate the associations of geriatric comanagement of care for older patients undergoing cancer-related surgical treatment with 90-day postoperative mortality, rate of adverse surgical events, and postoperative use of inpatient supportive care services. Design, Setting, and Participants This retrospective cohort study assessed outcomes of patients who received geriatric comanaged care vs those who did not using multivariable logistic regression analysis, with 90-day mortality as the outcome and geriatric comanagement of care as the main variable, with adjustment for age, sex, American Society of Anesthesiology score, Memorial Sloan Kettering Frailty Index score, preoperative albumin level, operative time, and estimated blood loss. A similar model was used to assess the association of geriatric comanagement with adverse surgical events, defined as any major complication, readmission, or emergency department visit within 30 days. Patients aged 75 years and older who underwent an elective surgical procedure with a hospital stay of at least 1 day at a single tertiary-care cancer center between February 2015 and February 2018 were included. Data were analyzed from January to July 2019. Exposures Postoperative care comanaged by the geriatrics service and surgical service (geriatric comanagement group) vs by the surgical service only (surgical service group). Main Outcomes and Measures 90-day mortality, adverse surgical events, and use of supportive care services. Results Of 1892 patients included, 1020 (53.9%) received geriatric comanagement of care; these patients, compared with those who received care managed by the surgery service only, were older (mean [SD] age, 81 [4] years vs 80 [4] years; P

Background Delirium and pain are common and serious postoperative complications. Subanaesthetic ketamine is often administered intraoperatively for postoperative analgesia and to spare postoperative opioids. Some evidence also suggests that ketamine prevents delirium. The primary purpose of this trial was to evaluate the effectiveness of ketamine in preventing postoperative delirium in older adults after major surgery. Secondary outcomes, viewed as strongly related to delirium, were postoperative pain and opioid consumption. Methods This was a multicentre, international, randomised trial that enrolled adults older than 60 undergoing major cardiac and noncardiac surgery under general anaesthesia. Participants were enrolled prior to surgery and gave written informed consent. We used a computer-generated randomisation sequence. Patients at study sites were randomised to one of three study groups in blocks of 15 to receive intraoperative administration of (i) placebo (intravenous normal saline), (ii) low dose ketamine (0.5 mg/kg) or (iii) high dose ketamine (1 mg/kg). Study drug was administered following induction of anaesthesia, prior to surgical incision. Participants, clinicians, and investigators were all masked to group assignment. Delirium and pain were assessed twice daily in the first three postoperative days using the Confusion Assessment Method and Visual Analog Scale, respectively. Postoperative opioid use was recorded, and hallucinations and nightmares were assessed. Analyses were performed by intention-to-treat and adverse events were evaluated. The Prevention of Delirium and Complications Associated with Surgical Treatments [PODCAST] trial is registered in clinicaltrials.gov; NCT01690988 Findings Between February 6, 2014 and June 26, 2016, 1360 patients assessed and 672 were randomised, with 222 in the placebo group, 227 in the low dose ketamine group, and 223 in the high dose ketamine group. There was no difference in postoperative delirium incidence between those in the combined ketamine groups and those who received placebo (19.45% vs. 19.82%, respectively; absolute difference, 0.36%; 95% CI, −6.07% to 7.38%; p=0.92). There were no significant differences among the three groups in maximum pain scores (p=0.88) or median opioid consumption (p=0.47) over time. There were more postoperative hallucinations (p=0.01) and nightmares (p=0.03) with escalating doses of ketamine. Adverse events (cardiovascular, renal, infectious, gastrointestinal, bleeding), whether viewed individually (P value for each >0.40) or collectively (82/222 [36.9%] in placebo group, 90/227 [39.6%] in low dose ketamine group, 91/223 in high dose ketamine group [40.8%]; P=0.69), did not differ significantly across the three groups. Interpretation The administration of a single subanaesthetic dose of ketamine to older adults during major surgery did not show evidence of reducing postoperative delirium, pain, or opioid consumption, and might cause harm by inducing negative experiences. Given current evidence and guidelines related to ketamine and postoperative analgesia, the unexpected secondary findings regarding pain and opioid consumption warrant replication or refutation in subsequent research. Funding The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report. The principal investigators (MSA and GAM) had full access to all the data in the study and had final responsibility for the decision to submit for publication.

11512 Background: We explored the association between geriatric comanagement and 90-day postoperative mortality of cancer patients aged 75 or older. Methods: A retrospective review of a prospectively maintained database was performed on patients over 75 years old who underwent elective surgery with hospital length of stay of ≥1 day at Memorial Sloan Kettering Cancer Center from 2015-2018. Geriatric comanagement group (GCG) patients had geriatric preoperative evaluation and inpatient geriatric comanagement. Patients in the surgical management group (SMG) did not have geriatric preoperative evaluation or postoperative geriatric comanagement. We utilized a multivariable logistic regression model with 90-day mortality as the outcome, geriatric co-management as the predictor, and adjusted for age, gender, American Society of Anesthesiology score, Memorial Sloan Kettering Frailty Index, preoperative albumin level, operation time, and estimated blood loss. The same logistic model was used to assess the association between adverse surgical events within 30-days (any major complication, readmission, or urgent care center visit) and geriatric comanagement. Results: Of 1,855 patients (median age 80), 1,009 patients (54%) were co-managed by geriatricians. GCG patients were slightly older, less likely to be male, had longer operation time, and stayed in the hospital longer. Adjusted rates of 90-day mortality was lower in GCG vs. SMG (4.3% and 9.2%, respectively; 95% CI around difference -7.3%, -2.5%; p-value < 0.0001). We did not find evidence of a difference in adverse surgical events between groups (OR 0.96, p-value = 0.8). A greater proportion of GCG patients received inpatient physical therapy (80% vs. 64%) and occupational therapy (37% vs. 25%) compared to SMG patients. Conclusions: Our study shows that geriatric comanagement is associated with reduced 90-day postoperative mortality in cancer patients aged ≥75. A randomized trial study is needed to confirm this finding.

As the number of older patients with cancer is increasing, oncology disciplines are faced with the challenge of managing patients with multiple chronic conditions who have difficulty maintaining independence, who may have cognitive impairment, and who also may be more vulnerable to adverse outcomes. National and international societies have recommended that all older patients with cancer undergo geriatric assessment (GA) to detect unaddressed problems and introduce interventions to augment functional status to possibly improve patient survival. Several predictive models have been developed, and evidence has shown correlation between information obtained through GA and treatment-related complications. Comprehensive geriatric evaluations and effective interventions on the basis of GA may prove to be challenging for the oncologist because of the lack of the necessary skills, time constraints, and/or limited available resources. In this article, we describe how the Geriatrics Service at Memorial Sloan Kettering Cancer Center approaches an older patient with colon cancer from presentation to the end of life, show the importance of GA at the various stages of cancer treatment, and how predictive models are used to tailor the treatment. The patient's needs and preferences are at the core of the decision-making process. Development of a plan of care should always include the patient's preferences, but it is particularly important in the older patient with cancer because a disease-centered approach may neglect noncancer considerations. We will elaborate on the added value of co-management between the oncologist and a geriatric nurse practitioner and on the feasibility of adapting elements of this model into busy oncology practices.

10035Background: Perioperative Geriatric Comanagement may improve surgical outcomes of older frail cancer patients. We present our 3 year experience with perioperative geriatric comanagement & the ...

10011Background: The relationship between age-related impairments in geriatric surgical patients and the need for postoperative intensive care unit (ICU) admission and subsequent outcomes is largel...