Surgery more common in the elderlyDoctors, who traditionally have been hesitant to perform major surgery on patients aged 80 or older, are beginning to revise the standard of care.
By: Sam McManis, McClatchy Newspapers
SACRAMENTO, Calif. — At 82, retired engineer Leonard Thompson is out to show he still has a few good years left.
Years? What’s this bunk about mere years, sonny?
More like decades. Why the heck not?
Thompson, after all, exercises body and mind daily, even developing his own workout program for seniors that emphasizes stretching, deep breathing, light aerobics and modified sit-ups and push-ups. And, six months ago, he recovered from invasive bladder and prostate cancer surgery quicker than some patients half his age.
“He is a fairly remarkable individual,” says Thompson’s urologist, Dr. Ralph deVere White, director of the University of California Davis Cancer Center.
Not an anomaly
Doctors, who traditionally have been hesitant to perform major surgery on patients aged 80 or older, are beginning to revise the standard of care. More and more, patients inching toward the century mark are undergoing cancer operations, open-heart surgery and joint replacements at an age when previously they might have been told to take it easy and let nature take its course.
Credit improvements in medical technology, coupled with a fast-growing aging population skewing healthier than previous generations, for the shift.
But such advances have not arrived without controversy in the medical community. Much of the concern deals with bioethics issues such as quality-vs.-quantity of life and the growing monetary burden on Medicare. There also is the specter of ageism. To wit: Is it appropriate to put a shelf life on procedures based on a patient’s chronological age?
Far from an academic discussion, this situation was all too real for Thompson.
Thompson, of Roseville, Calif., was diagnosed a year ago with bladder cancer, the fourth-most-common cancer among American men. He said his original doctor took what charitably could be called the conservative, wait-and-see approach. Surgery was not even considered. Chemotherapy was discouraged. Thompson considered it like throwing in the towel before even starting the fight.
“It was the wrong approach for someone like me,” he says.
Too stubborn, not too old, Thompson sought another opinion.
That led him to deVere White, the UC Davis urologist who coincidentally had just concluded a research study with colleague Dr. Karim Chamie showing that otherwise healthy octogenarians can tolerate invasive surgery - radical cystectomy, to be precise - to treat bladder cancer.
The study, published in August in the British Journal of Urology International, showed as much as a 52-months-of-life benefit for many elderly who had surgery, provided they did not die from an unrelated disease. However, the overall survival rate for all octogenarian bladder cancer patients differed only slightly (18 months to 15 months) for those who had surgery compared to radiotherapy.
“I think you could absolutely argue that putting anyone through the surgery and recovery for three months of extra life when you’re 80 years old is not worth it for the patient,” deVere White says. “On the other hand, if you look at the patients who had the surgery and got their lymph nodes (removed) and did not die of some other disease, then you’re looking at over four years of extra life. That, I think, is worth it.”
So, after Thompson had three rounds of chemotherapy that failed to help his condition, deVere White recommended surgery.
“A lot of doctors still feel hesitant (to operate),” deVere White says. “And there’s no doubt that a patient’s comorbities (other risks) clearly play a big factor. Life is finite. Obviously, as you get to some age, the threshold becomes quality of life being maybe more important than quantity.
“I think this has been interpreted by a number of people as, ‘OK, we really shouldn’t be operating on octogenarians.’ The first I read about this was a few years ago from the public health school at Harvard. They said an awfully lot of elderly people appear to be undertreated and you really cannot generalize about age.”
Thompson didn’t have to be persuaded. He wanted the surgery.
“It’s the right thing to do and let’s do it now,” he told deVere White.
In June, he had the operation to remove his bladder, 13 pelvic lymph nodes and related urinary organs. DeVere White also ended up removing Thompson’s cancer-ridden prostate.
Thompson was told he would need a 10-day postoperative hospital stay. He made it out in four.
“They said if you can get up and walk around the hall, which I did with no problem at all, I could go. I was told that some people in their 40s and 50s have to stay the whole 10 days after surgery.
“So, see, a lot depends more on your overall health, not just your age.”
DeVere White hastens to add that Thompson is something of a star patient. Not every octogenarian responds so well to surgery.
“We are not advocating, wholesale, that everyone at 80 with bladder cancer should have their bladders out,” deVere White says. “But just because you’re 80 does not mean that you should not have surgery.”
For heart patients, surgery to replace valves or perform angioplasty no longer is rare, says Dr. Robert Kincade, cardiac surgeon with the Sutter Heart & Vascular Institute in Sacramento.
“There’s been a shift toward older patients, because people are living longer and staying healthier longer,” he says. “And there are new techniques that make surgery safer.”
Not for everyone
“We don’t operate on everybody in their 80s who needs surgery,” Kinkade says. “Sometimes the thing to do is not operate on them. In general, we look at their overall health and physical condition.”
Patients often receive a mixed message, deVere White says, depending on the medical malady. Among elderly men seen by urologists, prostate cancer is even more common than bladder cancer. The latest treatment philosophy for prostate cancer is that early detection in the elderly should not result in surgery. The thinking: Elderly patients will die of something else before the prostate becomes an issue.
“With the prostate, all the risks from surgery and radiation aren’t being offset by the increased longevity,” deVere White says. “There’s been a tendency to carry that same feeling across to bladder cancer. But (bladder cancer) is much more deadly. You can get good results from surgery.”
This is where the ethical concerns come in. Just because you can prolong an elderly patient’s life, should you?
“There’s no question that at some point the issue of who’s going to pay for this has to come into it,” says Dr. Ben Rich, the endowed chair of bioethics at UC Davis Medical School. “Nobody’s saying this kind of allocation decision based largely or entirely on age is something that should be done at the bedside. It should be done as a matter of public policy.”
Among the longtime advocates of rationing health care for the elderly to ease the burden on Medicare is Dr. Daniel Callahan, co-founder of the Hastings Center, a bioethics think tank in New York.
Callahan once suggested that, to save Medicare, patients over 80 should not have invasive surgeries. Such a stance has proven controversial, especially considering that the Census Bureau reports that 85-plus is the fastest-growing age demographic in the United States.
In a recent essay on a New York Times health blog, Callahan wrote, “Doctors endlessly complain to me that excessive patient expectations of medical miracles, or those of their family members, make it harder, not easier, these days to curtail aggressive treatment.”
He later added: “There’s nothing we can’t do for an older person, and there’s a lot of pressure to do it. This is considered progress, and it’s considered ageism to be skeptical.”